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Modern  Surgery 


GENERAL  AND  OPERATIVE 


BY 

JOHN  CHALMERS  DA  COSTA,  M.D.,  LL.  D. 

samuel  d.  gross  professor  of  surgery,  jefferson  medical  college,  philadelphia; 

surgeon  to  the  jefferson  medical  college  hospital;   surgeon  to  st. 

Joseph's  hospital,  Philadelphia;  fellow  of  the  American  surgical 

ASSOCIATION;      member     OF      THE      AMERICAN     PHILOSOPHICAL 

society;  membre  de  la  societk  international  de 

chirurgie;  member  of  the  medical  reserve 

corps,   u.   s.  navy,  etc. 


Seventh  Edition,  Revised,  Enlarged,  and  Reset 
With  1085  Illustrations,  Some  of  Them  in  Colors 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1915 


Copyright,  1894,  by  W.  B.  Saunders.     Reprinted  March,  1895,  and  August,  1896.     Revised,  entirely  reset, 
reprinted,  and  recopyrighted  June,   1898.     Reprinted   October,    1898,   and  June,    1899.     Revised, 
reprinted,  and  recopyrighted  August,  1900.     Reprinted   August,   1901;   August,  1902,  and 
November,  1902.     Revised,  entirely  reset,    reprinted,   and  recopyrighted   August, 
1903.     Reprinted  July,  1904;  October,  1905;  September,  1906,  and  October 
1906.     Revised,  reprinted,  and  recopyrighted  January,  1907.     Re- 
printed April,  1907;  March,  1908,  and  July,  1909.    Revised, 
reprinted,  and  recopsrrighted  January,  1910.     Re- 
printed    September,    1910;    May,    i9ri; 
August,   1912,  and  August  1913. 
Revised,  entirely  reset,  re- 
printed, and  recopy- 
righted   April, 
1914. 


Copyright,  1914,  by  W.  B.  Saunders  Company 


Reprinted  January,  1915,  and  September,  1915 


3> 


ni^ 


?  ESS      OF 

SI  DERS      cor 


"  Yet  each  man,  following  his  S3Tnpathies, 
Unto  himself  assimilating   all, 

Using  men's  thoughts  and  forms  as  steps  to  rise, 
Who   speaks   at  last  his   individual   word, 
The  free  result  of  all  things  seen  and  heard, 
Is  in  the  noblest  sense  original. 
Each  to  himself  must  be  his  final  rule, 
Supreme  dictator,   to  reject  or  use, 
Employing  what  he  takes  but  as  his  tool. 
But  he  who,  self-sufficient,   dares  refuse 
All  aid  of  men,  must  be  a  god  or  fool." 

W.  W.  Story   ("A  Contemporary  Criticism  "). 


THIS    BOOK   IS    DEDICATED    TO    THE    CHIEF    SURGEON   AND   INSPIRA- 
TION   OF    ONE    OF    THE    GREATEST,    MOST    PROGRESSIVE,    AND 
MOST    INFLUENTIAL    SURGICAL    CLINICS   IN  THE   WORLD. 
A    CLINIC    FROM    WHICH    COME    IMPORTANT    FACTS, 
REAL    IDEAS,    AND    BRILLIANT    MEN. 

TO    THE    OPERATOR,    THE    TEACHER,    THE    INVESTIGATOR,    AND    THE 
SURGICAL    PHILOSOPHER.       TO 

DR.    WILLIAM    STEWART   HALSTED, 

THE    DISTINGUISHED    PROFESSOR    CF    SURGERY    IN 

JOHNS    HOPKINS    UNIVERSITY. 


PREFACE  TO  SEVENTH  EDITION 


It  is  the  custom  to  have  a  preface  in  a  medical  book.  So  this  book,  too, 
shall  have  its  preface.  The  natural  tendency  is  to  do  the  customary  thing  in 
the  conventional  way.  Were  I  to  do  this  I  would  tell  how  many  volumes  of 
previous  editions  have  been  sold,  would  claim  appreciation  as  the  due  of  the 
seventh  edition,  give  a  list  of  the  attractive  novelties  it  contains,  and  express 
the  conviction  that  the  latest  edition  (like  the  newest  baby)  is  superior  to  all  of 
its  predecessors.  I  have  done  this  sort  of  thing  in  the  past,  but  I  shall  do  it  no 
more,  because  such  a  preliminary  proclamation  has  in  it  an  unpleasant  sugges- 
tion of  the  shopkeeper  advertising  his  stock  or  the  peddler  vending  his  wares. 

A  man  w^ho  has  worked  long  and  earnestly  in  the  completion  of  a  book  has 
upon  him  a  sense  of  disenchantment  and  has  within  him  a  host  of  misgivings. 
Hope  is  seldom  a  constant  companion  of  the  solitary  worker.  No  one  can 
be  more  conscious  than  the  author  that  there  are  defects  in  this  book.  I 
have  done  my  best  to  correct  them  and  have  corrected  many  of  them,  but 
others  are  uncorrectable  without  writing  an  entirely  new  book. 

In  the  making  of  this,  as  of  previous  editions,  I  have  again  and  again  been 
in  profound  perplexity  as  to  whether  an  alleged  discovery  is  a  fragment  of 
eternal  truth  or  a  nebulous  emanation  of  chaos.  To  make  many  mistakes  of 
judgment  in  regard  to  such  matters  would  mean  a  book  rich  in  misinforma- 
tion. If  all  of  the  alleged  improvements  of  recent  years  were  gathered  to- 
gether, the  company  would  be  decidedly  mixed,  and  one  would  have  to  be 
cautious  in  receiving  and  in  making  introductions.  In  that  company  we  would 
find  the  productions  of  the  mistaken  enthusiast,  of  the  brilliant  confidence 
man,  of  the  deluded  observer,  of  the  conscientious  worker,  of  the  dull  pre- 
tender, of  the  man  with  occasional  flashes  of  genius,  of  the  profound  scholar, 
and  of  the  grandee  of  science. 

In  a  book  like  this  the  author  is  held  by  a  short  tether.  He  must  strive  to 
attain  a  happy  medium  between  undue  length  and  undue  brevity.  The  for- 
mer tends  to  become  prolixity,  the  latter  a  Gradgrind  catalogue  of  undi- 
gested and  unexplained  facts.  Almost  every  very  long  book,  like  almost 
every  very  long  congressional  speech,  contains  many  words  which  tell  little. 
Too  brief  a  book  is  like  Mrs.  General's  mind,  free  from  opinions.  She  had 
"a  little  circular  set  of  mental  grooves  or  rails  on  which  she  started  little 
trains  of  other  people's  opinions,  which  never  overtook  one  another  and  never 
got  anywhere."    Many  times  I  have  set  forth  opinions,  but  as  want  of  space 


12  '  Preface  to  Seventh  Edition 

has  forbidden  argument  and  discussion,  the  imperative  mood  has  dominated 
the  text,  and  many  of  the  views  must  appear  dogmatic  and  oracular. 

I  have  tried  to  keep  out  of  these  pages  the  ornaments  of  plagiarism.  I 
have  sought  to  do  so  by  giving  the  authority  for  every  important  statement. 
When  possible  I  have  used  the  author's  words,  believing  that  his  description 
of  his  own  work  must  be  better  than  any  description  that  could  be  written  for 
him.  In  consequence,  the  book  contains  numerous  quotations.  As  I  must 
use  other  men's  work,  it  is  only  fair  that  I  should  acknowledge  it.  The  vital 
necessity  for  using  the  work  of  others  is  emphasized  in  Mr.  Story's  lines, 
which  are  printed  on  page  7. 

The  author  wishes  to  thank  warmly  several  gentlemen  who  have  given 
able,  unselfish,  and  highly  valuable  aid.  To  the  sections  on  Orthopedic  Sur- 
gery, The  Surgery  of  the  Bones,  of  the  Joints,  of  the  Muscles,  and  of  the  Ten- 
dons, Dr.  J.  Torrance  Rugh,  Associate  in  Orthopedic  Surgery  in  the  Jefferson 
Medical  College,  contributed  some  of  the  results  of  his  extensive  experience. 

The  section  on  Rontgenology  was  revised  by  that  most  skilful  operator. 
Dr.  Willis  F.  Manges,  the  Rontgenologist  of  the  Jefferson  College  Hospital. 
Dr.  Thomas  C.  Stellwagen,  Jr.,  assistant  Genito-urinary  Surgeon  of  the 
Jefferson  College  Hospital,  was  of  great  help  to  me  in  the  revision  of  the  sec- 
tions on  Genito-urinary  Diseases. 

Dr.  Hubley  R.  Owen,  Surgeon  to  the  Philadelphia  Hospital,  has  efl&ciently 
and  in  many  ways  lessened  the  burdens  of  the  author. 

To  Dr.  Chevalier  Jackson,  of  Pittsburgh,  the  distinguished  laryngologist, 
I  extend  sincere  acknowledgments.  He  did  me  the  honor  to  contribute  to 
this  book.  He  wrote  a  section  upon  Tracheobronchoscopy  and  Esophagoscopy, 
describing  the  very  valuable  methods  he  devised. 

A  contemplation  of  the  achievements  of  modern  surgery  must  fill  the 
surgical  student  with  hope  and  confidence,  must  inspire  him  with  the  con- 
viction that  we  are  on  the  threshold  of  great  events,  and  that  the  first  few  hesi- 
tating words  of  truth  have  as  yet  but  scarce  been  lisped  by  the  baby  lips  of 
Science. 

John  Chalmers  DaCosta. 
2045  Walnut  Street,  Philadelphia.     . 


CONTENTS 


PAGE 

I.  Bacteriology 17 

n.  Asepsis  and  Antisepsis 57 

III.  Inflammation 78 

IV.  Repair 115 

V.  Surgical  FE\rERS 128 

VI.   Suppuration  and  Abscess 132 

VII.   Ulceration  and  Fistula 151 

Vni.  Mortification,  Gangrene,  or  Sphacelus 163 

IX.  Thrombosis  and  Embolism 184 

X.   Septicemia  and  Pyemia 194 

XI.  Erysipelas  (St.  Anthony's  Fire) 199 

XII.  Tetanus  or  Lockjaw 203 

Xm.  Tuberculosis 213 

XIV.  Rachitis  or  Rickets 252 

XV.   Contusions  and  WoL^^^DS 258 

XVI.   Bl"rns  and  Scalds;  Effects  of  Cold 312 

XVII.   Syphilis 316 

XVIII.  Tl^mors,  or  Morbid  Growths 345 

XIX.  Diseases  and  Injuries  of  the  Heart  and  Vessels 404 

Hemorrhage  or  Loss  of  Blood 436 

Operations  On  the  Vascular  System 459 

Ligation  of  Arteries  in  Continuity 468 

XX.  Diseases  and  Injuries  of  Bones  and  Joints 493 

Diseases  of  the  Bones 493 

Fractures 513 

Diseases  of  the  Joints 617 

Liixations  or  Dislocations 655 

Operations  Upon  Bones  and  Joints 688 

XXI.  Diseases  .and  Injuries  of  Muscles,  Tendons,  and  Burs^ 712 

Operations  Upon  Muscles  and  Tendons 732 

XXII.  Orthopedic  Surgery 736 

XXIII.  Diseases  and  Injuries  of  Ner\'f:s 747 

Diseases  of  Ner\'es 747 

Wotmds  and  Injuries  of  Nerves 749 

Operations  Upon  Nerves 75^ 

13 


14  Contents 

PAGE 

XXrV.  Diseases  and  I^7XIRIES  of  the  Head 769 

Diseases  of  the  Head 769 

Injuries  of  the  Head 779 

XXV.    StJKGERY   OF  THE   SpESTE 835 

XXVI.   Surgery  of  the  Respiratory  Organs 863 

Diseases  and  Injuries  of  the  Nose  and  Antnun 877 

Diseases  and  Injuries  of  the  Larynx  and  Trachea 879 

Operations  On  the  Larynx  and  Trachea 883 

Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs 890 

Operations  On  Pleura  and  Limgs 904 

XXVII.  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 912 

XXVIII.  Diseases  and    Injuries  of  the  Abdomen 943 

Stomach  and  Intestines 956 

The  Peritoneum 1021 

The  Liver,  Gall-bladder,  and  Bile-ducts 1032 

The  Pancreas 1054 

The  Spleen 1063 

Operations  Upon  the  Abdomen 1066 

XXIX.  Diseases  and  Injuries  of  the  Rectum  and  .Anus 1165 

XXX.  Anesthesia  and  Anesthetics iigr 

XXXI.  Diseases  of  the  Skin  and  Nails 1226 

XXXII.  Diseases  and  Injuries  of  the  Thyroid  Gland 1227 

XXXni.  The  Carotid  Gland;  the  Thymus  Gland 1 246 

XXXTV.   Diseases  and  Injuries  of  the  Lymphatics 1 248 

XXXV.  Bant)Ages 1253 

XXXVI.   Plastic  Surgery 1261 

XXXVII.  Diseases  ant)  Injuries  of  the  Genito-urinary  Organs 1266 

Diseases  and  Injuries  of  the  Kidney  and  Ureter 1273 

Diseases  and  Injuries  of  the  Bladder 1312 

Diseases   and   Injiiries   of   the   Urethra,   Penis,   Testicles,   Prostate, 
Seminal  Vesicles,  Spermatic  Cord,  and  Timica  Vaginalis 1339 

XXXVni.  Amputations 1401 

Special  Amputations 1406 

XXXIX.  Diseases  of  the  Mammary  Gland 1423 

XL.  Skiagraphy,  or  the  Employment  of  the  Rontgen  Rays;  The  Finsen 

Light;  Becquerel's  Rays;  Radium  Rays i447 

XLI.  Injuries  By  Electmcity 1471 


INDEX 1477 


MODERN  SURGERY 


MODERN   SURGERY 


I.  BACTERIOLOGY 

Bacteriology  is  the  science  of  micro-organisms.  Though  a  science  in 
the  youth  of  its  years,  bacteriology^  has  not  only  profoundly  altered,  but  it 
has  also  revolutionized,  patholog}',  and  our  ^'iews  of  surgery-  would  be  incom- 
plete, misleading,  and  erroneous  -^"ithout  its  aid. 

Micro=organisms,  or  microbes,  are  minute  non-nucleated  vegetable 
cells  closely  connected  with  fungi  and  algte,  many  of  them  bemg  ^•isible  only 
by  means  of  a  highly  powerful  microscope  and  after  they  have  been  brightly 
stained.  The  contents  of  these  cells  are  protoplasm  and  nuclear  chromatin 
enclosed  by  an  albuminous  structure  which  in  some  cases  contains  cellulose. 
There  is  considerable  e^•idence  that  certain  diseases  are  caused  b}'  micro-organ- 
isms so  minute  as  to  escape  detection  even  by  the  most  powerful  microscope. 
The  French  Yellow  Fever  Commission  asserted  that  the  yellow  fever  micro- 
organism (which  is  perhaps  protozoal)  passes  through  a  porcelain  filter  ("An- 
nals of  the  Pasteur  Institute.*'  Xov.,  1903).  The  micro-organism  of  rabies 
probably  does  the  same  thing. 

Simon  Flexner  believes  that  many  diseases  are  due  to  subniicroscopical 
parasites  (Ether  Day  Address,  1911). 

Even  in  the  most  remote  times  some  have  believed  that  "the  mj'sterious 
cause  of  contagious  and  epidemic  diseases  must  be  sought  in  liA-ing  entities" 
(Monti  on  "Modern  Patholog>^") ,  but  all  such  behefs  were  mgenious  guesses 
or  improved  theories,  unsustained  by  a  scrap  of  experimental  demonstration. 
Bacteria  were  discovered  in  16S3  by  the  Dutch  optician  Leeuwenhoek,  of 
Deht.  In  his  researches  he  used  the  simple  microscope,  that  is,  single  lenses  of 
short  focal  length.  B3-  means  of  this  primitive  instrument  he  saw  spermato- 
zoids,  capillaries,  blood-corpuscles,  the  structure  of  the  cr\-stalline  lens,  yeast- 
cells,  and  certam  large  bacteria.  The  Dutch  observer  regarded  bacteria  as 
animalculge. 

In  1762  Plenciz,  of  Ylenna,  impressed  by  the  publications  of  Leeuwenhoek, 
asserted  that  each  disease  is  caused  by  a  special  organism,  that  decomposition 
is  caused  by  micro-organisms,  and  that  bacteria  can  grow  m  H\'ing  tissue. 

In  I  S3  2  Bassi  claimed  that  a  certam  disease  of  silkworms  was  due  to  a  fungus. 
In  1S39  Schonlein  discovered  the  vegetable  parasite  causative  of  favus. 

In  1S40  Henle  came  to  the  conclusion  that  fungi  cause  all  infectious  diseases. 
In  1S43  Ohver  Wendell  Holmes  published  his  famous  essay  on  the  Contagious- 
ness of  Puerperal  Fever,  and  in  1S47  Semmelweiss,  of  Yienna,  strongly  main- 
tained the  same  thesis. 

In  1847  Professor  John  K.  Mitchell  put  forth  the  theor\-  that  malarial  and 
epidemic  fevers  have  a  "cr\-ptogamic  origin."  In  1S49  jSIalmsten  pointed  to 
a  fungus  as  the  cause  of  ring\\"orm. 

Cohn,  who  for  over  twenty  years  subsequent  to  1850  contributed  actively 
to  science,  described  round  bacteria  (cocci),  rod-shaped  bacteria  (baciUi),  and 
in  1872  admitted  disease-producing  bacteria  to  his  classification. 
2  17 


1 8  Bacteriology 

In  1863  Davaine  found  bacilli  in  the  blood  of  victims  of  splenic  fever  and 
made  a  strong  argument  to  prove  that  the  bacilli  caused  the  disease.  Absolute 
proof  was  furnished  by  Koch  in  1876.  He  inoculated  animals  with  pure  cul- 
tures of  the  bacilli  and  produced  the  disease  ("Bacteria  and  Their  Products," 
by  Sims  Woodhead). 

The  first  delinite  knowledge  of  bacteria  and  their  products  came  from  a 
chemist  and  not  a  physician,  and  dates  from  the  study  of  fermentation  by  the 
illustrious  Frenchman  Pasteur. 

Before  his  day  "bacteria  were  known,  theories  of  infection  had  been  elabo- 
rated, and  vaccination  practised,"  but  he  "definitely  established  the  import- 
ance of  bacteria  in  putrefaction,  fermentation,  and  disease,  and  gave  to  vac- 
cination a  scientific  basis"  ("Research  in  Medicine,"  by  Prof.  Richard  M. 
Pearce,  in  "Popular  Science  Monthly,"  July,  191 2). 

In  1858  Pasteur  asserted  that  every  fermentation  has  invariably  its  specific 
ferment;  that  this  ferment  consists  of  living  cells;  that  these  cells  produce 
fermentation  by  absorbing  the  oxygen  of  the  substance  acted  upon;  that 
putrefaction  is  caused  by  an  organized  ferment;  that  all  organized  ferments 
are  carried  about  in  the  air;  and  that  the  entire  exclusion  of  air  prevents 
putrefaction  or  fermentation. 

In  i860  Pasteur  published  the  observation  that  sterile  liquids  will  not 
be  contaminated  by  air  if  the  air  gains  entry  only  through  a  long  curved  tube, 
the  reason  being  that  dust  and  growths  fall  from  the  entering  air  by  gravity 
("Comptes  rendus,"  i860). 

In  1863  Pasteiir  published  experiments  which  proved  that  beer  cannot 
ferment  without  yeast  and  that  wine  received  in  sterile  vessels  and  defended 
from  external  contamination  will  not  undergo  ammoniacal  change. 

Most  of  the  subsequent  life  of  Pasteur  was  passed  in  seeking  the  causes,  the 
prevention,  and  the  cure  of  infectious  diseases  in  man  and  animals. 

The  views  of  Pasteur,  which  were  radical  departures  from  accepted  belief, 
inaugurated  a  bitter  controversy,  and  in  that  controversy  were  born  the 
microbic  theory  of  disease,  the  doctrine  of  preventive  inoculation,  antiseptic 
surgery,  and  serum-therapy. 

The  word  microbe,  which  signifies  a  small  living  being,  was  introduced 
in  1878  by  the  late  Professor  Sedillot,  of  Paris.  At  that  time  the  nature  of 
these  bodies  was  in  doubt ;  some  thought  them  animal,  and  called  them  micro- 
zoaria;  others  thought  them  vegetable,  and  called  them  microphyta;  the  designa- 
tion "microbe"  does  not  commit  us  to  either  view.  We  now  know  them  to  be 
vegetable,  but  the  term  "microbe"  has  remained  in  use. 

The  micro-organisms  connected  with  disease  in  man  are  divided  into: 

1.  Yeasts,  Saccharomyces,  or  Blastomycetes; 

2.  Molds,  or  Hyphomycetes; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts,  or  budding  fungi,  include  most  of  those  fungi  which  can  cause 
alcoholic  fermentation  in  saccharine  matter.  They  consist  of  small  round  or 
oval  cells,  which  are  devoid  of  chlorophyl,  which  can  live  without  free  oxygen, 
and  which  multiply  by  gemmation  or  budding.  Definite  nuclei  are  not  demon- 
strable in  the  cells.  When  a  cell  multiplies  a  small  bud  of  protoplasm  projects 
from  or  near  the  end,  or  buds  project  from  or  near  both  ends  of  the  cell.  Buds 
increase  progressively  in  size  and  a  constriction  appears  between  each  bud  and 
the  parent-cell.  Each  constriction  deepens  as  the  corresponding  projection 
enlarges,  until  the  bud  attains  a  considerable  size  and  is  cast  off  as  a  daughter- 
cell.  In  some  cases  buds  are  not  cast  off,  but  remain  attached,  a  chain  or 
series  of  rounded  yeast-cells  being  formed.  Yeast-cells  contain  spores  when 
nourishment  is  insufficient.  Under  certain  conditions  yeast  fungi  can  form 
interwoven  threads  called  mycelial  threads. 


Schizomycetes,   or  Bacteria  19 

Molds,  or  filamentous  fungi,  consist  of  filaments,  each  filament  being  com- 
posed of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments  springing 
from  a  germinal  tube  which  grows  from  a  germinating  spore.  A  thread  grows 
by  increase  at  the  apex,  and  this  area  eventually  gives  origin  to  new  spores. 
The  yeast  fungi  are  the  common,  but  not  the  only  cause  of  fermentation. 
]Mold  fungi  are  cormected  with  processes  of  decomposition.  Putrefaction  is 
due  to  bacteria  and  retards  the  growth  of  yeasts  and  molds. 

^lost  yeasts  and  molds  grow  best  upon  dead  organic  matter,  some  attack 
plants,  a  few  the  lower  animals,  and  a  ver>'  few  grow  upon  or  in  the  tissues 
of  the  hiunan  body.  The  term  mycosis  means  an  infection  with,  budding  fungi 
or  with  filamentous  fimgi. 

The  o'idium  albicans  is  a  fungus  which  by  growing  in  the  mucous  membrane 
produces  the  disease  known  as  thrush.  Some  observers  believe  that  the  thrush 
fungus  is  a  mold.  Others  maintain  that  it  is  a  budding  fungus  which  may 
develop  filaments.  Thrush  attacks  especially  the  mucous  membrane  of  the 
tongue,  Hps,  cheeks,  gums,  and  phar_\Tix,  but  occasionally  the  grow^th  takes 
place  upon  the  esophagus,  the  vocal  cords,  the  stomach,  the  vagina  of  a  preg- 
nant woman,  the  respirator}-  tract,  and  the  areola  of  the  breast  of  a  nursing 
woman.  The  fimgus  has  been  foujid  in  areas  of  bronchopneumonia.  The 
proliferating  fungus  presents  the  appearance  of  milky  white  spots  which  by 
thickening  and  coalescence  form  curd-like  masses,  the  superficial  layer  of  epi- 
theliiun  being  raised  and  cast  off.  Thrush  is  particularly  common  in  infants 
during  the  second  week  of  life,  and  in  infants  suffering  from  marasmus,  but  it 
may  occur  in  older  children  and  even  in  adults  who  have  been  weakened  by 
some  exhausting  disease  like  t^-phoid  fever  or 
tuberculosis. 

BJastomycetes  dermatitis  is  an  inflammation 
of  the  skin  due  to  yeast  fungi  and  bearing  a 
resemblance  to  tuberculosis  or  s^-philis.  Pharyn- 
gomy coses,  keratomy coses,  otomycoses,  pneumo- 
mycoses, and  mycoses  of  the  fiver,  kidney,  etc., 
have  been  reported.  Sanfehce  and  others  main- 
tain that  pathogenic  yeasts  are  responsible  for  Fig.  i. — ^Actinomyces  (Ziegler). 
the  growth  of  malignant  tumors.      It  is  certain 

that  yeasts  may  exist  in  a  carcinoma  and  can  be  cultivated,  but  proof  is 
entirely  lacking  that  they  are  anything  but  a  contamination.  Many  skin 
diseases  are  due  to  fungi;  among  them  should  be  mentioned  fa\njs,  pitjnriasis 
versicolor,  herpes  tonsurans,  parasitic  sycosis,  and  eczema  marginatum. 

Actinomycosis  i  streptotrichosis)  is  a  disease  due  to  infection  with  some 
variety  of  streptothrix.  Usually  the  streptothrices  are  regarded  as  molds,  but 
they  possibly  constitute  a  sort  of  transition  stage  between  filamentous  fungi  and 
bacteria. 

It  was  long  befieved  that  the  ray  fungus  (Fig.  i)  was  the  only  cause  of 
actinomycosis.  We  now  know  that  other  members  of  the  streptothrix  group 
may  be  responsible  (see  page  309). 

Madura-foot,  or  mycetoma,  is  due  to  the  Streptothrix  madurce. 

Schizomycetes,  or  bacteria,  chiefly  claim  our  attention.  It  is  important 
to  remember  that  the  term  "bacteria,"  though  applied  to  the  class  schizomycetes, 
has  also  a  more  restricted  appHcation — that  is,  to  a  di\ision  of  the  class;  it 
may  mean  either  schizomycetes  in  general,  or  rod-shaped  schizomycetes,  whose 
length  is  not  more  than  twice  their  breadth.  In  this  work  it  is  employed  to 
designate  schizomycetes  as  a  class. 

Bacteria  are  minute,  unbranched,  non-nucleated,  vegetable  cells,  free 
from  chlorophyl,  varying  in  shape  and  occasionally  presenting  locomotive 
flagella.     Though  devoid  of  chlorophyl  (leaf  coloring-matter),  many  of  them 


20  Bacteriology 

produce  pigment.  The  cell  consists  of  a  cell  membrane,  a  layer  of  protoplasm, 
and  some  central  fluid.  No  true  nucleus  has  yet  been  demonstrated,  but 
granules  are  found  within  the  cells  which  some  call  metachromatic  bodies  (Babes) 
and  others  nuclei  (Ernst).  The  cell  membrane  varies  greatly  in  thickness, 
and  when  it  is  very  thick  the  cell  is  said  to  have  a  capside.  The  round  cells 
have  a  smooth  outer  surface,  but  some  of  the  rod-shaped  cells  show  many 
flagella  or  at  the  end  a  single  flagellum  (Fig.  2) .  Flagella  enable  some  bacteria 
to  move  (motile  bacteria) ,  but  all  organisms  which  possess  them  are  not  motile, 
and  under  certain  conditions  bacteria  without  flagella  may  develop  them,  or 
organisms  which  possess  flagella  may  lose  the  power  to  develop  them. 

Some  bacteria,  known  as  non- pathogenic,  cannot  grow  and  produce  poison 
either  in  the  tissues,  in  wound-fluid,  or  in  the  fluid  moistening  a  mucous  surface. 
Others  grow  upon  dead  organic  matter,  but  are  not  able  to  invade  living 
tissues.  They  can  live  and  multiply  in  dead  material,  as  the  discharge  from  a 
wound  or  in  the  fluid  covering  a  mucous  surface,  and  are  called  saprophytes, 
saprophytic  microbes,  or  putrefactive  bacteria.  Obligate  saprophytes  only  Hve 
in  dead  matter  and  never  become  parasites.  Facultative  saprophytes  can 
become  parasites  under  certain  circumstances,  but  normally  grow  in  dead 
organic  matter.  '  Bacteria,  known  as  the  pathogenic,  under  certain  conditions 
invade  living  tissue  and  cause  various  diseases.  Harmless  bacteria  are  non- 
pathogenic.    Parasitic  bacteria  can  grow  on  or  in  the  tissues  of  the  body. 


^^^^ 


^i^' 


Fig.  2. — Types  of  flagella:  a,  Vibrio  cholerse,  one  flagellum  at  the  end — monotrichia  type;  h,  Bact. 
syncyaneum  tuft  of  flagella  at  the  end,  rarely  at  the  side — Lopotrichia  type;  c,  Bact.  vulgare,  flagella 
arranged  all  about — Peritrichia  type  (Lehmann  and  Neumann). 

Obligate  parasites  are  those  which  have  not  been  cultivated  outside  of  the 
body  (as  the  spirilla  of  relapsing  f everj .  Facidtative  parasites  usually  live  out- 
side the  body,  but  may  enter  into  the  body  and  produce  disease.  The  schizo- 
mycetes  vary  much  in  shape,  size,  color,  arrangement,  mode  of  growth,  and 
action  upon  the  body.  One  form  cannot  be  transformed  into  another,  but 
each  maintains  its  specific  identity.  Ever}^  organism  comes  from  a  pre-existing 
organism,  this  being  true  of  all  forms.  Pasteur  proved  that  spontaneous  gen- 
eration is  impossible.  Although  numerous  attempts  have  been  made  to  over- 
throw this  view  it  still  stands  imshaken.  The  protoplasm  of  these  cells  can 
be  stained  with  anilin  colors,  and  the  cell- wall  is  more  readily  detected  after 
treating  it  with  water,  which  causes  it  to  swell. 

.Many  bacteria  are  colored;  others  are  colorless.  Some  move  {motile 
bacteria) ;  others  do  not  move  (amotile  bacteria) .  The  bacilli  of  anthrax  and 
tuberculosis  and  all  cocci  are  amotile.  Most  bacteria  can  change  from  motile 
to  amotile,  or  from  amotile  to  motile,  when  subjected  to  certain  changes  of 
soil  and  en\dronment.  The  oscillations  of  cocci  are  physical  in  natiu-e,  not 
vital;  they  are  Brunonian  or  Brownian  movements,  movements  due  to  altera- 
tions in  equihbriimi  because  of  ciu-rents  or  changes  of  level  in  the  fluid  in  which 
the  micro-organisms  are  contained.  Bacteria  seem  to  possess  the  power  of 
attracting  elements  necessarv"  for  their  nutrition  (positive  chemiotaxis  or  chemo- 
taxis)  and  of  repelling  harmful  elements  (negative  chemiotaxis  or  chemotaxis) . 


Forms  of  Bacteria  21 

Bacterial  Products. — Bacteria  when  active  produce  many  different  prod- 
ucts. Among  them  are  gases  (H,  HoS,  CO2,  NH3),  water,  alcohols,  fatty  acids, 
carbohydrates,  phenol,  coloring-matter,  toxins,  enz\Tnes,  etc.  Some  of  these 
materials  are  gi\-en  off  from  the  hving  cell,  some  are  found  only  when  the  cell 
is  dead.  Some  of  them  are  excretions,  some  of  them  secretions.  Some  are 
formed  within  the  cell  (intracellular) ,  others  are  excreted  by  the  bacteria  into 
the  material  in  which  the  cell  lies  (extracellular). 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria  are — 

1.  The  Coccus  or  Micrococcus — the  bernv'-shaped,  oval,  or  roimd  bacterium 

(Fig.  3); 

2.  The  Bacillus — the  rod-shaped  bacteriimi  (Fig.  4); 

3.  The  Spirillum  or  Vibrio — the  corkscrew-shaped  or  spiral  bacterium 
(Fig.  5).  A  short  spiral  organism  is  called  a  comma  bacillus.  Spirochetes  are 
sharply  bent  curved  rods  twisted  like  the  thread  of  a  screw. 


Fig.  3. — Micrococci.  Fig.  4. — Bacilli.  Fig.  5. — Spirilla. 

De  Ban*'  compares  these  forms,  respectively,  to  the  billiard-ball,  the  lead- 
pencil,  and  the  corkscrew. 

Cocci  and  Bacilli. — ^As  surgeons  we  have  to  do  chiefly  "n-ith  cocci  and  bacilli. 
Cocci  may  be  designated  according  to  their  arrangement  ^^ith  one  another; 
namely,  when  existing  singly  they  are  called  monococci  (Fig.  3) :  in  pairs  they 
are  called  diplococci  (Fig.  8,  a)  ;  arranged  end  to  end  in  a  chain  they  are  called 
streptococci  (Fig.  8,  c) ;  in  group  side  by  side  clustered  Hke  a  bunch  of  grapes 
they  are  called  staphylococci  (Fig.  8,  b)  ;  in  groups  of  four  they  are  called  plate 
cocci  or  tetracocci;  in  cubic  groups  they  are  called  sarcincB  or  wool-sack 
cocci  (Fig.  6).  Irregular  masses,  resembling  frog-spa-mi,  constitute  zooglea 
masses  (Fig.  9).     The  gelatinous  matter  in  such  a  mass  is  formed  by  a  trans- 


Fig.  6. — SarcinjE  formiag  bales  of  packets.  Fig.  7. — ^.\scococcus  BHlrothii  Cohn  (after  F. 
Single     packets     regularlj-     grouped     together  Cohn). 

(Lehmann  and  Xeumann). 

formation  in  the  walls  of  the  bacteria.  The  term  ascococci  is  appHed  to  a  group 
of  cocci  enclosed  in  a  capsule  (G.  S.  Woodhead)  (Fig.  7). 

The  cocci  are  often  named  according  to  their  function,  as,  for  example, 
"pyogenic,"  or  pus-forming.  Cocci  may  be  named  according  to  the  color  of 
the  culture.  The  name  may  embody  the  form,  arrangement,  color  of  culture, 
and  function:  for  instance.  Staphylococcus  pyogenes  aureus  signifies  a  round 
micro-organism,  which  arranges  itself  vrith  its  fellows  in  the  form  of  a  bimch 
of  grapes,  which  produces  pus,  and  which  gives  golden-yeUow  cultures. 

The  bacilli  are  long,  staff-shaped  organisms.  Long,  deHcate,  jointed  ba- 
cilli ha^•ing  wa\y  outlines  are  kno-nm  as  leptothrix  forms.  Chain-like  bacilli 
are  called  streptobacilli.     BaciUi  give  origin  to  many  surgical  diseases. 

Dichotomy  or  Branching. — It  is  ver}-  seldom  that  a  side  bud  appears  upon 
bacteria  except  in  the  bacteria  of  tuberculosis  and  diphtheria. 


22 


Bacteriology 


Pseudodichotomy  is  by  no  means  unusual.  It  occurs  when  one  end  of  a 
bacillus  grows  by  the  end  of  the  adjacent  bacillus  or  when  a  bacillus  in  a  chain 
divides  in  a  line  parallel  to  the  chain  and  thus  begins  another  chain  (Fig.  lo). 


^ 

%# 


^^ 


Fig.  8. — ^Formsof  cocci:  A,  Diplococci;  B,  staphy- 
lococci; C,  streptococci. 


Fig.  g. — Zooglea  (Ball). 


Multiplication  of  Bacteria. — Bacteria  multiply  with  great  rapidity 
when  placed  under  suitable  conditions.  They  can  multiply  by  transverse 
fission  or  by  spore-formation.     Some  bacteria  multiply  by  both  methods.     In 


1 1 


/ 


a 


^6> 
8 


a  b 

Fig.  ID. — Pseudodichotomy:  a,  In  bacilli;  b,  in  streptococci  (Lehmann  and  Neumann). 


fission,  or  segmentation,  a  bacillus  undergoes  an  increase  in  size  and  length; 
a  coccus  does  not  increase  in  size,  but  slightly  elongates.  In  either  case  about 
the  middle  of  the  cell  a  transverse  constriction  begins,  which  deepens  until  the 

cell  has  divided  into  two 
^  /'  .trssv  .*3s».  *  parts,  each  of  which  soon 
grows  as  large  as  its  parent 
(Figs.  II,  12).  As  a  rule, 
the  micro-organisms  separate 
after  division  of  the  cell; 
but  they  may  not  do  so; 
and  if  they  do  not  separate, 
the  special  grouping  receives 
a  particular  name  (diplococci, 
streptococci,  etc.).  If  the 
division  is  invariably  in  the 
same  direction,  and  if  the  new 
cells  remain  in  contact,  strep- 
tococci or  streptobacilli  are  formed.  Tetracocci  and  sarcinae  are  formed  when  a 
number  of  cocci  "divide  in  two  or  three  successively  vertical  directions"  ("Clin- 
ical Bacteriology,"  by  Levy  and  Klemperer),  forming  four  quadrants  (tetracocci) 
or  eight  octants  (sarcince).     All  cocci  and  most  bacilli  multiply  by  fission. 


Fig.  12. — Divisions  of  a  bacillus  (after  Mace). 


Spores 


23 


Hence  the  common  term  oi  fission  fungi.  The  time  required  for  the  multipli- 
cation of  a  bacterium  varies.  Some  varieties,  when  placed  under  favorable 
conditions,  undergo  fission  in  two  hours.  The  cholera  bacillus  requires  only- 
twenty  minutes  to  divide.  The  tubercle  bacillus  requires  several  days.  If 
segmentation  of  a  single  cell  and  the  growth  to  maturity  of  its  products  require 
one  hour,  a  single  cell  in  a  single  day,  if  the  conditions  for  increase  were  ideally 
favorable,  would  have  16,000,000  descendants,  and  in  three  days  the  mass  of 
new  cells  would  weigh  7500  tons  (Cohn).  In  order,  however,  for  such  enormous 
multiplication  to  occur  conditions  would  have  to  be  absolutely  favorable  for  the 
cells,  and  conditions  are  never  absolutely  favorable.  Were  it  otherwise,  all 
other  forms  of  life  would  be  destroyed.  During  growth  in  a  culture-medium 
inhibitory  substances  are  formed,  and  these  substances  are  detrimental  to  the 
bacteria  themselves  and  to  all  bacteria  of  the  same  type.  Such  substances  are 
known  as  autotoxins  (Conradi  and  Kurpjuweweit,  in  "Muenchen.  med.  Woch.," 
No.  32,  September  12,  1905).  In  a  culture  of  cholera  bacilli  the  number  of 
living  microbes  begins  to  lessen  after  twenty- four  hours,  and  after  forty-eight 
hours  the  diminution  is  distinct. 

Spores. — ^A  spore  is  a  germ,  and  corresponds  with  the  seed  of  a  plant. 
Some  bacilli,  a  few  spirilla,  and  it  may  be  sarcinae,  multiply  by  spore-formation. 
Cocci  do  not  undergo  spore-formation  after  the  manner  of  bacilli,  though  some 
observers  maintain  that  cocci  occasionally 
undergo  an  alteration  that  makes  them 
very  resistant  to  any  destructive  influences. 
When  spore-formation  is  about  to  occur  in 
a  bacillus,  a  point  of  cloudiness  or  an  area  of 
bright  refraction  appears  in  the  protoplasm 
and  the  cell  generally  elongates.  When  a 
row  of  cells  sporulate,  the  segments,  each 
of  which  contains  a  lustrous  area  or  a  region 
of  cloudiness,  look  like  parts  of  a  necklace 
of  beads  (Fig.  13).  The  spore  enlarges,  the 
cell  membrane  bursts,  and  the  young  bacillus 
emerges  through  the  opening.  A  cell  usually 
contains  but  one  spore,  which  may  be  situated 
at  the  end  of  the  cell  (endspore)  or  in  the 
middle  of  the  cell  (endospore).  Sometimes 
a  single  cell  contains  several  spores.  If  an  endspore  exists,  the  end  of  the  cell 
containing  the  spore  is  swollen  or  club  shaped  (drumstick  bacterium).  If  an 
endospore  exists,  the  cell  becomes  spindle  shaped  {Clostridium).  When  mul- 
tiplication is  by  a  single  endospore,  the  bacillus  does  not  elongate.  When 
multiplication  takes  place  by  a  process  of  combined  spore-formation  and 
fission,  the  mother-cell  divides  into  a  number  of  daughter-cells,  which  are  called 
arthrospores.  Organisms  which  when  active  multiply  by  fission  take  on  spore- 
formation  when  subjected  to  certain  conditions. 

Spore-formation  tends  to  occur  when  bacilh  are  about  to  die  for  want  of 
nourishment  or  when  there  is  an  excess  of  oxygen  present.  The  spore  has  a 
dense  envelope  or  covering  which  is  very  resistant  to  destructive  agents.  So 
resistant  is  the  covering  that  twice  the  amount  of  heat  is  necessary  to  kill  a 
spore  as  to  kill  an  active  adult  cell.  Spores  when  placed  under  conditions 
imfavorable  for  development  may  remain  inactive  for  an  indefinite  period,  just 
as  seeds  remain  inactive  when  unplanted.  Drying,  even  drying  for  years,  may 
not  destroy  them.  A  dry  temperature  of  nearly  300°  F.  destroys  the  spores  of 
anthrax,  but  only  after  acting  for  three  hours.  Steam  or  boiling  water  kills 
most  spores  in  a  few  minutes.  Some  spores  are  able  to  withstand  the  action 
of  live  steam  for  several  or  perhaps  for  many  hours.     Direct  sunlight  quickly 


Fig.  13. — Sporulation  (after  De  Bary). 


24  Bacteriology  / 

destroys  spores  ("Clinical  Bacteriology,"  by  Levy  and  Klemperer).  When 
spores  encounter  favorable  conditions,  they  develop  very  rapidly  into  adult 
cells,  just  as  seeds  develop  when  planted.  It  seems  probable  that  spores  occa- 
sionally remain  dormant  in  the  human  body  for  long  periods,  and  finally  awaken 
into  activity  because  of  injury  or  disease  of  the  tissue  in  which  they  lie. 

Chemical  Composition  of  Bacteria. — The  protoplasm  of  bacteria  consists 
of  water,  salts,  albimiinous  material,  extractives  soluble  in  alcohol,  and  extrac- 
tives soluble  in  ether. 

Life=conditions  of  Bacteria. — In  order  to  grow  and  to  multiply, 
bacteria  require  a  suitable  soil  and  the  favoring  influences  of  heat  and  moisture. 
The  soil  demanded  consists  of  highly  organized  compounds  rather  than  crude 
substances,  and  slight  modifications  in  it  may  prove  fatal  to  some  forms  of 
bacterial  Hfe,  but  highly  advantageous  to  others.  Some  organisms  require 
albuminous  matter,  others  need  carbohydrates;  they  all  require  water,  carbon, 
nitrogen,  oxygen,  hydrogen,  and  certain  inorganic  materials,  especially  lime 
and  potassium  (Woodhead).  All  organisms  require  water.  If  dried,  no 
micro-organisms  will  multiply,  and  many  forms  will  die.  The  fluids  and 
tissues  of  the  individual  may  or  may  not  afford  a  favorable  soil  for  the  germs 
of  a  disease,  or,  in  the  same  person,  may  afford  it  at  one  time  and  not  at  an- 
other. Some  individuals  seem  to  possess  indestructible  immunity  from, 
and  others  are  especially  prone  to,  certain  bacterial  diseases,  and  these  im- 
munities and  predispositions  may  be  hereditary.  The  Japanese  show  high 
immunity  to  scarlet  fever  and  negroes  to  yellow  fever.  Drimkards  are  pre- 
disposed to  pneumonia.  Some  families  exhibit  high  susceptibihty  to  scarlet 
fever.  Negroes  are  very  susceptible  to  tuberculosis  and  small-pox.  Impair- 
ment of  health,  by  altering  some  subtle  condition  of  the  soil,  may  make  a  person 
liable  who  previously  was  exempt.  The  insane  are  predisposed  to  infections. 
Injury  or  disease  of  a  tissue  may  increase  local  Hability. 

Again,  some  bacteria  which  under  normal  conditions  are  harmless  m.ay 
become  virulent  under  certain  conditions.  Colon  bacilli,  which  under  nor- 
mal conditions  seem  to  be  putrefactive  organisms  inhabiting  the  intestine,  may 
attack  a  point  of  least  resistance  in  the  intestine  itself:  this  point  being  estab- 
lished by  congestion,  strangulation,  inflammation,  or  injury,  and  descendants 
of  the  bacteria  which  attacked  the  point  of  least  resistance  may  become  so 
virulent  that  they  can  live  and  develop  in  tissues  distant  and  apparently  normal 
and  cause  disease  in  them. 

The  presence  of  oxygen  influences  microbic  growth.  Most  organisms  thrive 
best  when  exposed  to  the  oxygen  of  the  air,  and  they  are  known  as  aerobic. 
The  term  anaerobic  is  employed  to  designate  organisms  that  can  grow  and 
multiply  and  produce  particular  products  only  when  air  is  absent,  free  oxygen 
being  fatal  to  them.  They  may  need  oxygen;  but  if  they  do,  they  are  able  to 
obtain  it  from  the  tissues  when  air  is  excluded.  Tetanus  bacilli  and  the  bacilli 
of  malignant  edema  are  anaerobic.  An  organism  which  grows  as  well  in  the 
presence  as  in  the  absence  of  oxygen  is  called  a  facultative-anaerobic  bacterium. 
Most  microbic  diseases  in  man  are  due  to  facultative-anaerobic  bacteria. 

Effect  of  Motion,  Sunlight,  the  X=rays,  Radium,  Cold,  and  Heat.— 
The  majority  of  fungi  grow  best  when  at  rest;  violent  agitation  retards  the 
growth  of  some.  Sunlight  antagonizes  the  growth  of  certain  bacteria,  especially 
tubercle  baciUi  and  the  bacilli  of  typhoid  fever.  Direct  sunlight  even  destroys 
spores.  Ordinary  daylight  is  very  slowly  germicidal  to  bacteria.  Direct  sun- 
light is  quickly  fatal  to  them.  Sunlight  is  bactericidal  even  when  heat  rays  are 
intercepted.  The  active  agent  is  the  light.  The  blue  and  violet  are  the  most 
active,  while  the  rays  of  the  red  end  of  the  spectrum  are  devoid  of  power  to 
kill  bacteria.  The  electric  arc-light  acts  on  bacteria  like  sunlight.  It  is  claimed 
by  some  that  the  x-rays  retard  bacterial  growth.     Radium  rays  are  bactericidal. 


Latent  Bacteria  25 

Sunlight,  the  arc-Hght,  radium  emanations,  and  .v-rays  stimulate  tissue  activi- 
ties, and  so  aid  the  tissues  to  rid  themselves  of  bacteria.  Temperature  influ- 
ences bacterial  growth.  Some  organisms  will  grow  only  within  narrow  tem- 
perature limits,  while  others  can  sustain  sweeping  alterations,  but  most  grow- 
best  between  the  limits  of  from  86°  to  104°  F.  Freezing  renders  bacteria 
motionless  and  incapable  of  multiplication,  but  it  does  not  kill  them;  they 
again  become  active  when  the  temperature  is  raised.  Prudden  showed  that 
t^Tphoid  bacilli  can  live  in  ice  one  hundred  and  three  days.  The  absurdity 
of  employing  cold  as  a  germicide  is  evident  when  the  fact  is  known  that  a 
temperature  of  200°  F.  below  zero  is  not  fatal  to  germ-life,  cell-acti\dties  by 
such  a  temperatiu'e  only  being  rendered  dormant.  Bacteria  have  been  placed 
in  hermetically  sealed  tubes  and  the  tubes  immersed  in  liquid  air  for  seven 
days.  The  germs  were  thus  subjected  to  a  temperature  of  — 190°  C,  but  there 
was  no  change  produced  in  their  virulence  (A.  MacFayden  and  S.  Roland,  in 
"Lancet,"  March  24,  1900).  High  temperatures  are  fatal  to  bacteria;  moist 
heat  is  more  destructive  than  dry  heat,  and  adult  cells  are  more  easily  killed 
than  spores.  A  temperature  less  than  212°  F.  ■^ill  kill  mam'  organisms,  and 
boiling  will  kill  every  pathogenic  organism  that  does  not  form  spores.  Some 
spores  are  not  destroyed  after  prolonged  boUing,  and  some  '^ill  withstand  a 
temperature  of  120°  C.  As  a  practical  fact,  however,  boiling  water  kills  in  a 
few  minutes  all  cocci,  most  baciUi,  and  all  pathogenic  spores;  though  the  spores 
of  antlirax,  tetanus,  and  malignant  edema  are  killed  with  more  difficulty  than 
are  the  spores  of  other  bacteria. 

Effect  of  Bacteria  Upon  Bacteria. — Some  bacteria  are  antagonistic  to 
others,  some  are  synergistic  to  others.  When  certain  bacteria  favor  the  growth 
of  other  bacteria  the  process  is  called  symbiosis.  WTien  certain  bacteria  retard 
the  growth  of  other  bacteria  the  process  is  known  as  antibiosis. "  The  strepto- 
coccus of  erysipelas  is  antagonistic  to  the  bacillus  of  anthrax  and  also  to  syphi- 
lis and  tuberculosis.  The  Bacillus  prodigiosus  makes  the  streptococcus  of  ery- 
sipelas more  active,  and  the  bacillus  of  anthrax  less  active.  The  growth  of 
some  microbes  in  culture-media  makes  a  soil  favorable  or  imfavorable  for  other 
microbes,  and  the  same  process  may  occur  in  the  human  body.  Influenza 
renders  the  lungs  prone  to  infection  with  pneiunococci.  Aerobic  organisms 
prepare  a  wound  for  tetanus  bacilH.  Saprophytes  on  mucous  surfaces  are  an- 
tagonistic to  certain  pathogenic  bacteria.  The  organisms  productive  of  lactic 
acid  fermentation  are  destructive  to  many  injurious  intestinal  bacteria.  We 
are  not  yet  able  to  cure  a  microbic  disease  by  inoculatrng  the  sufferer  with 
antagonistic  microbes,  on  the  principle  of  sending  a  thief  to  catch  a  thief, 
although  Hankin  ("British  Medical  Journal,"  August  14,  1897)  suggests  puri- 
fying water  infected  with  colon  bacilli  or  t>-phoid  bacilH  by  means  of  the  jSIicro- 
coccus  Ghadiallii,  which  is  fatal  to  them. 

Latent  Bacteria. — Sometimes  pathogenic  organisms  remain  latent  in  the 
body  for  a  considerable  time.  They  are  not  destroyed,  but  produce  no  s}Tiip- 
toms,  or  only  local  sAonptoms,  possibly  because  the  indi\ddual  is  immune  for 
the  time  being.  Pneumococci,  staphylococci,  and  t^'phoid  bacilli  may  become 
latent.  Tubercle  bacilli  may  remain  long  latent  in  a  l}Tnph-gland  or  in  any  old 
area  of  caseation.     S^T^hilis  may  remain  latent  for  a  long  time. 

Latent  bacteria  may  take  on  active  growth  when  the  tissue  containing 
them  is  damaged  by  injur\'  or  disease.  I  have  seen  active  disease  arise  in 
an  apparently  cured  and  stiff  tuberculous  joint  as  a  result  of  forcibly  breaking 
up  adhesions.  An  attack  of  bronchitis  may  light  up  an  old  and  latent  area  of 
pulmonary  tuberculosis.  The  administration  of  ether  or  chloroform  by  in- 
halation may  render  active  a  pre^dously  inactive  tuberculous  focus  in  the  limg. 
A  partial  or  incomplete  operation  on  a  quiescent  tuberculous  lesion  is  apt  to  be 
followed  by  active  spread  and  may  result  in  wide  dissemination  of  disease 


26  Bacteriology 

Mixed  Infection. — A  fact  of  practical  importance  to  the  surgeon  is 
that  an  area  infected  by  one  form  of  micro-organism  may  be  invaded  by 
another  form.  This  is  known  as  a  mixed  infection,  and  consists  in  a  primary 
infection  with  one  variety  of  organism,  and  a  secondary  infection  with  another, 
or  in  an  infection  at  the  same  time  with  different  micro-organisms.  Mixed 
infection  is  .especially  common  on  surfaces  exposed  to  air  and  wound  infec- 
tion is  usually  mixed.  Koch  found  both  bacilli  and  micrococci  in  the  same 
lesion  of  tuberculosis.  A  soil  filled  with  pneumococci  favors  the  growth  of  pus 
cocci  and  tubercle  bacilli.  Tuberculous  or  syphilitic  lesions  may  be  attacked 
by  erysipelas.  Chancre  and  chancroid  can  exist  together.  A  syphilitic  ulcer 
is  a  good  culture-soil  for  tubercle  bacilli  (Schnitzler) .  Suppuration  in  lesions 
of  tuberculosis  is  due  to  secondary  infection  with  pus  organisms.  Occasionally 
in  empyema  and  other  conditions  due  to  pus  organisms  the  diseased  process 
ceases  to  be  active,  the  pyogenic  bacteria  having  lost  much  of  their  virulence, 
but  a  mixed  infection  with  some  germ  usually  harmless  may  break  down  sur- 
rounding barriers,  intensify  the  virulence  of  bacteria,  and  aggravate  the  disease 
into  an  acute  outburst.  When  secondary  infection  occurs  the  primary  in- 
fection may  remain  as  before,  may  be  aggravated,  may  be  mitigated  in  inten- 
sity, may  be  destroyed,  or  may  be  disseminated. 

Intra=uterine  or  Placental  Infection. — The  infection  of  the  embryo 
from  the  diseased  ovum  or  the  diseased  sperm-cell  occurs  only  in  syphiHs.  Such 
an  embryo  is  diseased  at  the  first  moment  of  life.  The  direct  transmission  of 
bacteria  from  parent  to  fetus  is  a  problem  still  in  course  of  solution.  Certain 
it  is  that  some  diseases  may  follow  the  transmission  of  the  micro-organism 
through  the  septum  of  separation  between  the  circulations  of  the  mother  and 
child.  Placental  transmission  may  occur  in  syphilis,  scarlatina,  pneumonia, 
anthrax,  measles,  pyogenic  conditions,  and  tuberculosis  (Hektoen).  A  child 
born  of  a  woman  recently  the  subject  of  pneumonia  may  be  born  with  that 
disease,  and  a  child  may  be  born  with  pnemnonia  when  the  mother  has  never 
had  it.  Mothers  free  from  infectious  disease  may  give  birth  to  infected  chil- 
dren. It  is  stated  that  Mauriceau  (a  noted  French  obstetrician  of  the  17th  cen- 
tury) was  born  with  small-pox,  though  his  mother  had  never  had  a  sign  of  the  dis- 
ease. Few  cases  of  congenital  tuberculosis  have  been  reported,  but  Rosenberger 
claims  to  have  found  the  bacilli  in  the  umbilical  vein  from  the  placenta  of  a 
tuberculous  mother.  A  child  of  a  tuberculous  parent  may  not  be  born  tuber- 
culous, but  may  have  weakened  tissue-cells  that  easily  fall  a  prey  to  the  tubercle 
bacillus  when  it  reaches  them  by  any  avenue.  Placental  transmission  of  bac- 
teria is  favored  by  disease  or  injury  of  the  placenta. 

Chemical  Antiseptics  and  Germicides  and  Aseptic  Agents. — It  is 
necessary  to  make  a  distinction  between  deodorizers,  antiseptics,  and  germi- 
cides, although  the  two  latter  terms  are  usually  regarded  as  being  interchang- 
able.     In  the  methods  of  antiseptic  surgery  we  use  germicides. 

A  deodorizer  is  an  agent  which  destroys  an  offensive  odor.  It  is  true  that 
an  offensive  odor  may  be  due  to  microbic  growth.  It  is  also  true  that  nasty 
odors  may  prove  injurious  to  those  who  inhale  them.  But,  nevertheless,  the 
odor  is  the  resiilt  of  microbic  action,  and  destroying  an  odor  does  not  render 
harmless  the  bacteria  which  caused  it.     Charcoal  is  a  well-known  deodorizer. 

An  antiseptic  is  an  agent  which  retards  or  prevents  putrefaction.  It  acts 
by  weakening  or  killing  saprophytic  organisms,  but  is  not  fatal  to  spores. 

A  germicide  or  disinfectant  is  an  agent  which  is  fatal  to  adult  bacteria 
and  spores.  The  destruction  of  the  germs  of  disease  on  the  skin,  in  clothing, 
in  excreta,  in  a  wound,  etc.,  is  known  as  disinfection.  Disinfection  of  the  skin, 
of  a  wound,  of  dressings,  or  of  instruments  is  called  also  sterilization. 

Antiseptics  and  germicides  should  not  be  used  in  surgically  clean  wounds. 
Repair  will  occur  more  quickly  if  they  are  not  used.     Tillmanns  has  pointed 


Corrosive  Sublimate  27 

out  that  when  antiseptics  are  used  cell-division  begins  late  and  progresses 
slowly.  Germicides  are  not  efficient  in  fatty  tissue,  as  bacteria  surrounded 
with  oil  cannot  be  reached  by  the  drug,  and  the  chemical  is  irritant  and  apt 
to  induce  fat  necrosis  (Haenel,  in  "Deutsch.  med.  Woch.,"  1895,  No.  8). 

Corrosive  Sublimate. — Many  chemical  agents  will  idll  bacteria,  one  of 
the  most  popular  of  them  all  being  corrosive  sublimate.  Koch  showed  that 
corrosive  sublimate  is  an  efficient  test-tube  germicide  when  present  in  the 
proportion  of  only  i  part  to  50,000.  It  is  used  in  surgery  in  strengths  of  i 
part  of  the  salt  to  1000,  2000,  3000,  or  more  parts  of  water.  Badly  infected 
wounds  are  occasionally  irrigated  with  solutions  of  a  strength  of  i  :  500. 
Contact  with  albumin  precipitates  from  a  solution  of  corrosive  sublimate  an 
insoluble  albiuninate  of  mercury  which  forms  a  white  layer  upon  the  surface 
of  the  wound,  is  not  a  germicide,  and  prevents  deep  diffusion  of  the  mer- 
curial fluid.  In  surgical  operations  by  the  antiseptic  method  the  mercurial  salt 
should  be  combined  with  tartaric  acid  in  the  proportion  of  i  to  5,  which  com- 
bination prevents  the  formation  of  the  insoluble  albuminate  of  mercury. 

But  though  corrosive  sublimate  under  certain  conditions  is  extremely  pow- 
erful, it  is  not  always  absolutely  rehable.  Many  spores  are  very  resistant  to  its 
action.  Even  a  i  per  cent,  solution  of  bichlorid  of  mercury  is  not  certainly 
destructive  to  the  spores  of  anthrax.  Geppert  tells  us  that  anthrax  spores 
may  be  active  after  a  twenty-five-hour  immersion  in  a  i  :  100  solution  of 
sublimate  (Schimmelbusch) .  In  the  presence  of  hydrogen  sulphid  corrosive 
sublimate  is  useless,  inert  and  insoluble  sulphid  of  mercury  being  precipitated; 
hence  corrosive  sublimate  is  without  value  as  a  rectal  antiseptic;  in  fact, 
Gerloczy  has  proved  that  a  concentrated  aqueous  solution  of  sublimate  will 
not  disinfect  an  equal  quantity  of  feces.  Corrosive  sublimate  contained  in 
dressings  after  a  time  undergoes  decomposition  and  ceases  to  be  a  germicide. 
It  is  not  germicidal  in  fatty  tissues  because  it  is  unable  to  attack  bacteria 
which  are  coated  with  oil.  Corrosive  sublimate  is  very  irritating  to  the  tissues 
and  causes  copious  exudation.  Hence,  if  an  extensive  wound  has  been  irri- 
gated with  this  agent,  drainage  must  be  employed  to  obtain  exit  for  the  wound 
fluid.  In  some  wounds  which  have  been  irritated  by  corrosive  sublimate  the 
tissues  seem  to  loose  to  a  great  extent  their  power  of  resistance  to  bacteria  and 
infection  may  be  actually  facilitated  by  irrigation  with  bichlorid  of  mercury. 
In  rare  instances  corrosive  sublimate  is  absorbed  and  produces  poisoning. 
In  spite  of  these  shortcomings  and  drawbacks  it  is  a  valuable  aid  to  the  sur- 
geon and  is  very  frequently  used,  especially  upon  the  skin  of  the  patient 
and  the  hands  of  the  operator  and  his  assistants.  It  should  be  dissolved  in 
distnied  water.  Ordinary  water  causes  a  precipitate  to  form  (common  salt 
prevents  the  formation  of  this  precipitate). 

Because  of  the  fact  that  corrosive  sublimate  is  poisonous  and  very  irritant, 
it  should  not  be  used  upon  serous  membranes.  It  is  absorbed  quickly  from 
serous  membranes  and  destroys  the  endothelial  cells  and  should  not  be  in- 
troduced into  the  pleural  sac,  into  joints,  or  into  the  peritoneal  cavity.  It 
should  never  be  put  within  the  dura,  and  should  not  be  applied,  in  strong 
solution  at  least,  to  mucous  membranes.  It  should  not  be  introduced  into  the 
rectrmi  for  three  reasons:  First,  it  is  intensely  irritant  and  causes  pain  and 
inflammation.  Second,  it  is  useless,  being  largely  and  promptly  converted  into 
insoluble  and  inert  sulphid  of  mercury.  Third,  a  poisonous  dose  may  be 
absorbed.  Instruments  cannot  be  placed  in  corrosive  sublimate  without  being 
dulled,  stained,  and  corroded.  It  is  better  to  make  the  solution  at  the  time  it  is 
needed,  so  as  to  have  it  fresh,  for  in  old  solutions  much  of  the  soluble  corrosive 
sulbimate  has  been  converted  into  insoluble  ox^xhlorid  of  mercury,  and  the  fluid 
has  ceased  to  be  germicidal.  In  order  to  make  up  fresh  solutions  use  tablets, 
€ach  of  which  contains  about  7  J  grains  of  the  drug — one  of  these  tablets  added 


28  Bacteriology 

to  a  pint  of  water  makes  a  solution  of  a  strength  of  i  :  looo.  Tablets  which 
also  contain  ammonium  chlorid  are  more  soluble  than  those  which  contain 
corrosive  sublimate  only.  Hot  solutions  of  the  drug  are  more  powerfully 
germicidal  than  cold  solutions.  As  corrosive  sublimate  is  irritant,  leads  to 
profuse  exudation,  and  may  produce  tissue  necrosis,  it  should  never  be  in- 
troduced into  an  aseptic  wound.  In  such  a  wound  it  can  do  no  good  and  may 
do  much  harm. 

Griffin,  in  Foster's  "Practical  Therapeutics,"  sets  forth  the  strengths  of 
solutions  applicable  to  different  regions: 

For  disinfection  of  the  surgeon's  hands  and  the  patient's  skin,  i  :  looo* 
for  irrigating  trivial  wounds,  i  :  2000;  for  irrigating  larger  wounds  and  cavi- 
ties, I  :  10,000  to  I  :  5000;  for  irrigating  vagina,  i  :  10,000  to  i  :  5000;  for 
irrigating  urethra,  i  :  40,000  to  i  :  20,000;  for  irrigating  conjunctiva,  i  :  5000; 
for  gargling,  i  :  10,000  to  i  :  5000. 

Corrosive  Sublimate  Poisoning. — Corrosive  sublimate  may  be  absorbed 
from  a  wound,  a  serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury  may  be  followed  by 
cramp  in  the  limbs  and  belly,  feeble  pulse,  cold  skin,  extreme  restlessness,  and 
even  collapse  and  death.  At  the  first  sign  of  trouble  withdraw  the  drug  and 
treat  the  ptyalism  (see  page  338). 

Lithiomercuric  lodid. — This  material  was  prepared  and  tested  by  Dr. 
Rosenberger  and  Mr.  England  ("American  Medicine,"  1904,  p.  1021).  It  is 
asserted  that  the  iodid  of  mercury  and  lithium  is  more  powerfully  germicidal 
than  corrosive  sublimate,  does  not  form  inert  albuminate  when  placed  in  a 
wound,  and  is  not  precipitated  by  alkalis.  It  is  not  nearly  so  irritant  nor  is 
it  so  poisonous  as  corrosive  sublimate.  I  have  given  it  an  extensive  trial  in 
my  clinic  and  am  satisfied  that  it  is  superior  to  corrosive  sublimate  as  a  germ- 
icide, is  less  irritant,  and  is  less  poisonous.  Its  only  objection  is  that  it  is  more 
expensive. 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of  from  1:40  to  i:  20. 
It  is  certainly  fatal  to  pus-organisms,  but  weak  solutions  fail  to  kill  most  bac- 
teria and  do  not  destroy  spores.  Unfortunately,  this  acid  attacks  the  hands  of 
the  surgeon;  consequently  in  the  United  States  dilute  carbolic  acid  is  chiefly 
employed  as  a  solution  in  which  to  place  the  sterilized  operating  instruments, 
or  as  a  germicide  to  prepare  the  skin  of  the  patient  before  the  operation  is  per- 
formed. 

Carbolic  acid  is  very  irritant  to  tissues,  and  carbolized  dressings  may  be 
responsible  for  sloughing  of  the  wound  or  dry  gangrene  (see  p.  182).  Because 
of  its  irritant  properties  wounds  which  have  been  irrigated  with  it  should  be 
well  drained.     Carbolic  acid,  like  corrosive  sublimate,  is  inert  in  fatty  tissues. 

Pure  carbolic  acid  is  a  reliable  disinfectant  for  certain  conditions.  It  is 
used  to  destroy  chancroids,  to  purify  infected  wounds  and  abscess  cavities,  to 
disinfect  the  medullary  cavity  in  osteomyelitis,  to  stimulate  granulation  after 
the  open  operation  for  hydrocele,  or  to  purify  sloughing  burns  and  ulcerated 
areas.  The  pure  acid  rarely  produces  constitutional  symptoms,  but  it  occa- 
sionally causes  sloughing.  Its  application  causes  pain  for  a  moment  only, 
and  then  analgesia  ensues.  Even  dilute  solutions  of  carbolic  acid  greatly 
reheve  pain  when  applied  to  raw  surfaces.  The  local  action  of  carbolic  acid 
can  be  at  once  antidoted  by  the  application  of  alcohol  (Seneca  D.  Powell). 
When  carbolic  acid  is  applied  to  a  wound,  the  area  about  the  wound  should 
first  be  moistened  with  alcohol.  After  the  application  of  pure  carbolic  acid 
to  the  interior  of  a  joint,  a  wound,  the  medullary  canal,  or  an  infected  area 
the  surgeon  should  wait  about  one  minute  and  then  apply  alcohol. 

Dilute  carbolic  acid  acts  more  slowly  and  less  certainly  than  corrosive  sub- 
limate.    It  requires  twenty-four  hours  for  a  5  per  cent,  solution  to  kill  anthrax 


Alcohol 


29 


spores.  Pus  or  blood  (albuminous  matter)  greatly  weakens  the  germicidal 
power  of  carbolic  acid,  and  fatty  tissue  cannot  be  disinfected  by  it.  It  is  not 
even  the  best  of  agents  in  which  to  place  instruments,  as  it  dulls  them.  After 
operation  upon  the  mouth  it  may  be  used  as  a  wash  or  gargle,  i  to  2  per  cent, 
being  a  suitable  strength.  It  is  used  sometimes  to  irrigate  the  bladder  and 
often  to  cleanse  sinuses,  but  is  not  employed  in  the  peritoneal  cavity,  the 
pleural  sac,  the  rectum,  or  the  brain.  It  is  occasionally  injected  into  tubercu- 
lous joints.     Carbolic  solution  should  never  be  used  in  clean  wounds. 

Carbolic  Acid  Poisoning. — Carbolic  acid  is  readily  absorbed,  and  may  thus 
produce  toxic  symptoms.  Absorption  is  not  uncommon  when  the  weaker 
solutions  are  used,  but  seldom  occurs  when  a  wound  has  been  brushed  over 
with  pm-e  acid,  because  the  pure  acid  at  once  forms  an  extensive  zone  of  co- 
agulated albumin,  which  acts  as  a  barrier  to  absoprtion.  One  of  the  early  indi- 
cations of  the  absorption  of  carboHc  acid  is  the  assiunption  by  the  urine  of  a 
smoky,  greenish,  or  blackish  hue.  This  hue  appears  a  little  time  after  the  urine 
has  been  voided,  whereas  the  smoky  hue  of  hematuria  is  noted  in  urine  at  once 
after  it  has  been  passed.  The  condition  produced  by  carbolic  acid  is  known  as 
carboluria,  and  examination  of  such  urine  shows  a  great  diminution  or  entire 
absence  of  sulphates  when  the  acidulated  imne  is  heated  with  chlorid  of  barivmi. 
The  diminution  of  precipitable  siilphates  is  explained  by  the  fact  that  these 
salts  are  combined  A\ith  carbolic  acid,  forming  soluble  sulphocarbolates. 
Such  urine  is  apt  to  contain  albiunin.  If  during  the  use  of  carbolized  dress- 
sing  or  the  emplo}Tnent  of  carbolic  solutions  the  urine  becomes  smoky,  the 
use  of  the  drug  in  any  form  must  be  at  once  discontinued,  otherwise  dangerous 
S}'mptoms  will  soon  appear.  These  s\Tnptoms  are  subnormal  temperature, 
feeble  pulse  and  respiration,  muscular  weakness,  and  vertigo.  If  death  occiurs, 
it  is  due,  as  a  rule,  to  respiratory-  failure.  The  treatment  of  slow  poisoning 
by  carbolic  acid  consists  in  at  once  withdrawing  the  drug,  gi^ing  stimulants 
and  nourishing  food,  administering  sulphate  of  sodium  several  times  a  day, 
and  atropin  in  the  morning  and  evening.  (For  Carbolic  Acid  Gangrene,  see 
page  1S2.) 

Boric  Acid. — This  drug  is  a  very  rmld  antiseptic.  It  is  used  to  dust  woimds. 
A  solution  of  it  is  used  to  irrigate  woimds  and  as  the  fluid  for  hot  antiseptic 
fomentations.     The  solution  should  be  concentrated. 

Acetate  of  Aluminum. — This  is  a  mild  antiseptic,  useful  as  a  constituent 
of  irrigating  fluids  and  of  hot  fomentations.  Its  prolonged  use  hardens  the 
tissues.     A  strength  of  i  or  2  per  cent,  is  employed. 

Saline  Solution. — Sodium  chlorid  solution  of  normal  strength  (0.9  of  i 
per  cent.)  does  not  damage  the  cells  of  serous  surfaces  or  of  a  woimd,  hence 
it  is  used  as  an  irrigating  fluid,  and  it  is  the  best  fluid  for  such  a  purpose.  In 
intravenous  infusion,  in  shock,  or  hemorrhage  it  is  verv^  valuable.  It  does  not 
damage  the  blood-corpuscles  as  plain  water  does.  It  is,  however,  irritant  to 
the  kidneys  when  used  by  hj^odermoclysis  or  intravenous  infusion;  hence 
if  the  kidneys  are  diseased  saline  fluid  of  one-half  normal  strength  should  be 
used  for  either  of  the  latter  purposes.  Normal  salt  solution  is  prepared  as 
follows:  A  quart  of  water  is  filtered  and  sterilized  and  in  this  i^  drams  of 
table  salt  are  dissolved,  and  the  fluid  is  again  boiled  (see  pages  466  and  467). 

Thiersch's  Flmd. — This  fluid  is  used  upon  mucous  and  serous  surfaces 
and  is  employed  to  irrigate  woimds.  It  is  non-toxic  and  non-irritant.  It 
consists  of  I  gr.  of  salicyHc  acid  and  6  gr.  of  boric  acid  to  i  oz.  of  sterile  water. 

Alcohol  is  a  germicidal  agent,  which  is  most  powerful  when  of  the  strength 
of  70  per  cent.  It  may  be  used  on  the  hands  of  the  surgeon  or  the  skin  of  the 
patient  in  a  strength  of  70  per  cent,  and  may  be  used  plain  or  mixed  with  cor- 
rosive sublimate,  of  the  strength  of  i  part  of  corrosive  to  1000  parts  of  alcohol. 
Pure  alcohol  is  used  to  arrest  the  local  action  of  pure  carbolic  acid. 


3©  Bacteriology 

Boiled  water  is  used  to  dissolve  antiseptic  materials;  to  inject  by  hypo- 
dermoclysis;  to  irrigate  wounds,  mucous  cavities  or  serous  surfaces,  and  as  a 
fluid  in  which  to  keep  instruments  during  the  operation.  It  damages  somewhat 
the  tissue-cells  of  the  surface  of  a  wound  and  injures  the  cells  of  serous  surfaces, 
hence  for  irrigation  and  h3q3odermoclysis  salt  solution  is  to  be  preferred. 

Creolin,  which  is  a  preparation  made  by  the  dry  distillation  of  English  coal, 
is  a  germicide  without  irritant  or  powerful  toxic  effects.  It  is  less  powerful 
than  carboHc  acid,  but  acts  similarly.  It  is  not  soluble  in  water,  but  is  used 
in  emvilsion  of  a  strength  of  from  i  to  5  per  cent.  It  does  not  irritate  the  skin 
like  carbolic  acid. 

Peroxid  or  dioxid  of  hydrogen  is  an  excellent  agent  for  cleansing  a  purulent 
or  putrid  area,  but  it  is  never  applied  to  a  sterile  wound.  It  is  prepared  in  a 
10- volume  solution,  which  should  be  diluted  one-half  to  two-thirds  before  using. 
A  30  per  cent,  solution  is  known  as  perhydrol.  It  probably  destroys  the  al- 
buminous element  upon  which  bacteria  live,  and  thus  starves  the  fungi.  When 
peroxid  of  hydrogen  is  applied  to  a  purulent  area  ebullition  occurs,  liberated 
oxygen  bubbling  up  through  the  fluid  and  the  pus  being  oxidized.  The  per- 
oxid reaches  every  cranny  and  diverticulum  containing  pus.  The  peroxid 
of  hydrogen  is  not  fatal  to  tetanus  bacilli;  in  fact,  tetanus  bacilH  can  be  culti- 
vated in  a  strong  solution  of  it.  It  is  very  valuable  as  a  mouth-wash  to  cleanse 
the  mouth  before  and  after  operations  in  the  oral  cavity.  Some  surgeons  use 
it  to  wash  out  appendiciilar  abscesses  (R.  T.  Morris).  It  must  not  be  injected 
into  a  deep  abscess  in  any  region  unless  a  large  opening  exists,  as  otherwise  the 
evolved  gas  may  tear  apart  structures,  dissect  up  the  cellular  tissue,  and  spread 
infection.  The  use  of  peroxid  should  not  be  too  long  continued,  for  if  used  for 
a  considerable  period  it  makes  the  granulations  edematous  and  retards  healing. 
In  fact,  its  continued  use  may  actually  prevent  a  sinus  closing. 

Iodoform  is  largely  used  by  surgeons  in  spite  of  the  fact  that  laboratory 
workers  have  assured  us  it  is  not  truly  a  germicide,  as  bacteria  wiU  grow  upon 
it.  Clinical  evidence,  however,  is  in  its  favor  and  surgeons  long  ago  concluded 
that  it  at  least  hinders  the  development  of  bacteria,  directly  antagonizes  the 
action  of  the  toxic  products  of  germ-life,  and  stimulates  the  production  of 
connective  tissue.  It  is  of  the  greatest  value  when  applied  to  putrid  foci, 
suppurating  areas,  and  tuberculous  processes.  In  putrid  foci  it  probably 
combines  with  toxins  and  renders  them  less  poisonous  or  even  inert. 

It  attenuates  the  virulence  of  pus  cocci  and  organisms  of  putrefaction.  It 
renders  its  greatest  service  in  tuberculous  processes  and  is  infinitely  more 
powerful  when  oxygen  is  excluded  than  when  it  is  present.  The  laboratory 
workers  who  condemn  it  have  in  many  cases  used  nutrient  material  in  which 
it  does  not  dissolve  (P.  F.  Lomry,  "Archiv  fiir  khn.  Chir.,"  1896).  D.  B. 
Heile  ("Proceedings  of  the  German  Surgical  Congress  of  1903")  insists  that 
iodoform  is  a  valuable  germicide  if  oxygen  is  excluded.  He  says,  if  iodoform 
is  mixed  with  tissue  juice,  oxygen  being  excluded,  the  mLxture  becomes  power- 
ftdly  germicidal,  even  to  streptococci,  in  from  three  to  five  days,  although,  as  he 
maintains,  neither  constituent  of  the  mixture  when  alone  is  germicidal.  Tissue 
juice  decomposes  iodoform,  liver  juice  decomposing  it  most  rapidly,  brain  and 
fat  decomposing  it  slowly.  Granulation  tissue  decomposes  it  and  tuberculous 
granulation  tissue  acts  upon  it  most  rapidly. 

The  conclusion  of  Hefle  is  that  this  study  confirms  the  clinical  observation 
that  iodoform  is  valuable  in  cavities,  but  not  in  free  surfaces.  My  own  belief 
is  that  it  is  more  valuable  in  cavities  than  upon  free  surfaces,  but  when  we  are 
dealing  with  putrefactive  areas,  even  on  free  surfaces,  it  is  of  great  value. 
When  iodoform  decomposes  on  a  free  surface  it  sets  free  I,  which  we  now  know 
is  a  powerful  germicide.  When  it  decomposes  in  tissue  juice  Heile  says  it 
forms  a  powerful  germicide  which  is  rendered  inert  by  oxygen.     Clinically, 


Iodoform  31 

no  real  substitute  for  iodoform  has  yet  been  found.  It  can  be  rendered  sterile 
by  several  washings  with  a  solution  of  corrosive  sublimate.  It  need  not  be 
applied  to  clean  wounds,  but  the  powder  is  ven*-  useful  when  dusted  into  infected 
woimds.  It  prevents  wound  discharges  from  decomposing  and  distinctly  allays 
pain.  Gauze  impregnated  with  iodoform  is  used  to  keep  abscesses  open  after 
evacuation,  to  drain  the  belly  after  certain  operations,  to  pack  giside  the  intes- 
tines and  prevent  their  infection  during  some  abdominal  operations,  and  as 
packing  to  arrest  intracranial  hemorrhage.  Iodoform  gauze  will  drain  serum 
well,  but  will  not  drain  pus.  In  fact,  it  blocks  up  a  pus-cavity,  and  if  long  re- 
tained leads  to  the  collection  of  purulent  matter  behind  and  about  the  supposed 
drain.  If  used  in  an  abscess,  it  must  be  replaced  in  twenty-four  or  thirtv-six 
hours.  Tuberculous  joints  and  cold  abscesses  are  injected  with  iodoform  emul- 
sion, which  is  made  by  adding  the  drug  to  sterile  glycerin  or  olive  oil.  The 
emulsion  contains  from  4  to  10  per  cent,  of  iodoform.  Dunham's  iodoform 
emulsion  is  valuable  in  suppurating  ca^dties  ("Annals  of  Surger>^,"  May,  1909). 
In  order  to  prepare  it  he  adds  to  100  c.c.  of  glycerin,  i  gm.  of  iodin,  and  i  gm.  of 
iodid  of  potassium,  sets  the  mixture  in  an  Arnold  sterilizer,  and  boils  the  fluid 
in  the  sterilizer.  By  shaking  the  mixture  the  iodin  goes  into  solution  in  the 
glycerin.  When  the  mixture  cools,  10  gm.  of  iodoform  are  added  and  ground 
into  the  mixture  by  use  of  a  sterile  mortar.  A  solution  in  ether  of  a  strength 
of  10  per  cent,  may  be  used  to  inject  the  ca\'ity  of  a  cold  abscess,  but  it  is  dan- 
gerous, may  rupture  the  wall,  and  is  more  apt  to  produce  poisoning  than  is  the 
emulsion.     Iodoform  wax  is  used  to  fill  cavities  in  bone  (see  p.  502). 

I odoform-poisoning. — The  drug  must  be  used  with  some  caution.  Ab- 
sorption from  a  wound  sometimes  happens,  producing  toxic  s^Tuptoms.  These 
S}"mptoms  are  frequently  misinterpreted,  being  usually  attributed  to  infec- 
tion. R.  T.  Morris  has  pointed  out  that  in  iodoform-poisoning  the  wound 
seems  to  be  in  excellent  condition,  whereas  in  sepsis  the  wound  appears  un- 
healthy. The  symptoms  in  some  cases  are  acute  and  arise  suddenly,  and  con- 
sist of  hallucinatory  delirium,  nausea,  fever,  watery  eyes,  contracted  pupils, 
metallic  taste  in  the  mouth,  yellowness  of  the  skin  and  eyes,  an  odor  of  iodoform 
upon  the  breath,  the  presence  of  the  drug  in  the  urine,  the  outbreak  of  a  skin 
eruption  resembling  measles  or  one  which  is  er\-thematous,  vesicular,  bullous, 
or  petechial.  There  is  often  nephritis  and  always  excessive  loss  of  flesh  and 
strength.  Patients  \dth  such  acute  s}Tnptoms  usually  pass  into  coma  and  die 
within  a  week.  Such  attacks  are  most  apt  to  arise  in  those  beyond  middle  life 
(see  Gerster  and  Lilienthal,  in  Foster's  "Practical  Therapeutics'')-  Iodin  can 
be  recognized  in  urine  by  adding  a  few  drops  of  commercial  nitric  acid  and  a 
little  chloroform.  \\Tien  the  mixture  is  shaken  the  chloroform  will  take  up  the 
free  iodin  and  become  purple,  and  on  standing  the  purple  layer  -vsiU  settle  to  the 
bottom  of  the  tube.  Another  method  is  as  follows:  Put  a  little  iu"ine  in  a  saucer, 
add  a  little  calomel,  and  stir.  If  the  urine  contains  iodoform  a  brown  color  will 
be  noted  (R.  T.  Morris).  The  finding  of  iodin  in  the  urine,  however,  is  not 
proof  that  the  patient  is  poisoned.  We  may  find  it  when  no  sign  of  poisoning 
exists.  In  chronic  cases  of  iodoform-poisoning  the  first  s}Tnptoms  usually 
observ^ed  are  moroseness,  bewilderment,  and  irritability,  followed  by  depression, 
with  unsystematized  persecutors*  delusions,  delirium,  coma,  and  even  death. 

In  systemic  poisoning  by  iodoform,  discontinue  the  use  of  the  drug,  sus- 
tain the  strength  of  the  patient,  and  favor  the  elimination  of  the  poison. 

Iodoform  sometimes  produces  great  local  irritation  of  the  cutaneous  sur- 
face, the  dermatitis  being  eczematous  or  else  being  manifested  by  crops  of 
vesicles  filled  with  turbid  yellow  senun  or  even  bloody  serum.  These  vesicles 
rupture  and  expose  a  raw,  oozing  surface,  looking  not  unlike  a  burn.  The 
dermatitis  usually  exists  only  in  the  region  with  which  iodoform  was  in  con- 
tact, but  in  some  cases  it  spreads  widely.     The  use  of  the  drug  must  be  at 


32  Bacteriology 

once  abandoned,  for  to  continue  it  will  not  only  increase  the  dermatitis,  but  may 
produce  constitutional  symptoms.  Wash  the  vesiculated  area  with  a  stream 
of  normal  salt  solution  to  remove  iodoform,  open  each  vesicle,  and  dress  the 
part  for  several  days  wdth  gauze  wet  with  normal  salt  solution.  After  acute 
inflammation  ceases  apply  zinc  ointment  or  cosmolin. 

Aristol  is  an  odorless  iodin  compound  used  by  some  as  an  antiseptic  dust- 
ing-powder. 

Loretin  is  an  antiseptic  powder  which  is  odorless,  germicidal,  non-irritant, 
and  which  is  said  to  be  non-toxic. 

Euphoren  is  a  powder  containing  iodin,  and  the  iodin  separates  from 
it  slowly  when  the  powder  is  applied  to  wounds  or  burns.  It  does  not  produce 
toxic  s}Tiiptoms  readily,  if  at  all,  and  is  a  valuable  substitute  for  iodoform. 
It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale-yellow  powder  containing  60  per  cent,  of  iodin.  Its 
bismuth  salt  is  known  as  antinosin.  Nosophen  is  not  toxic,  is  free  from 
odor,  and  is  the  best  of  the  substitutes  for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform.  It  is  of  value 
when  applied  to  suppurating,  ulcerating,  or  sloughing  areas,  but  it  does  not 
benefit  tuberculous  conditions.  Sometimes  absorption  takes  place  to  a  suffi- 
cient extent  to  cause  cyanosis,  sweating,  and  weakness  of  the  pulse  and  respi- 
ration. If  cyanosis  arises,  suspend  the  administration  of  the  drug  and  admin- 
ister stimulants  by  the  stomach. 

Airol  is  a  substitute  for  pure  iodoform,  and  is  composed  of  gaUic  acid, 
bismuth,  and  iodoform.     It  is  non-irritant  and  non-toxic. 

Among  other  powders  we  may  mention  iodol,  amyloform,  subiodid  of 
bismuth,  and  dermatol  or  subgallate  of  bismuth. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have  shown  that 
metalHc  silver  exerts  an  inhibitive  action  upon  the  growth  of  micro-organisms 
and  does  not  irritate  the  tissues.  Crede  has  also  demonstrated  the  same  facts. 
These  statements  indicate  one  great  reason  why  silver  wire  is  such  a  useful 
suture  material  (see  page  74).  Halsted  is  accustomed  to  place  silver  foil  over 
wounds  after  they  have  been- sutured,  and  Crede  employes  as  a  dressing  a 
fabric  in  which  metalUc  silver  is  intimately  incorporated. 

Crede  considers  silver  lactate  (actol)  an  admirable  antiseptic.  It  does 
not  form  an  insoluble  albimiinate  when  introduced  into  the  tissues  and  is 
not  an  irritant.  Silver  citrate  (itrol)  is  said  to  be  even  a  better  preparation 
than  silver  lactate,  and  it  is  a  useful  dusting-powder.  A  preparation  of 
metallic  silver,  known  as  colloidal  silver  or  collargolum,  is  made.  This  prepa- 
ration is  soluble  in  water  and  in  albuminous  fluids.  It  is  said  to  remain  as 
metallic  silver  when  in  solution  and  to  be  powerfully  germicidal.  It  certainly 
seems  to  cause  temporary  leukocytosis,  but  so  do  some  other  drugs  which  are 
not  antagonistic  to  infections.  It  comes  put  up  in  i-  and  2-gr.  tablets.  A 
solution  of  the  strength  of  from  i  to  5  per  cent,  is  used.  In  severe  cases  of  sepsis 
some  advocate  injecting  this  solution  into  a  vein  which  has  been  rendered  promi- 
nent by  applying  a  bandage  above  the  elbow.  The  dose  is  from  i  to  2  gr. 
of  the  drug.  One  injection  or  more  may  be  given.  I  have  never  seen  it  do  the 
slightest  good  and  I  believe  that  intravenous  injections  are  dangerous.  Some 
have  given  it  subcutaneously,  some  by  the  mouth,  others  by  enema.  Sub- 
cutaneous injections  are  often  very  irritant  and  it  is  doubtful  if  the  drug  is 
absorbed  from  either  the  stomach  or  rectima.  The  most  extraordinary  claims 
have  been  put  forth  regarding  the  therapeutic  value  of  collargolum.  Its  use 
has  been  advocated  in  the  most  diverse  general  infections.  I  believe  it  is  of 
no  real  value.  Its  claims,  in  my  opinion,  have  been  shattered  by  the  majority 
report  of  the  committee  of  the  American  Medical  Association  ("Jour.  Am.  Med. 
Assoc,"  March  13,  1909).     Crede's  ointment  of  silver,  I  beheve,  is  of  use  in 


lodin 


33 


infections  of  the  skin  and  lymphatic  vessels.  I  have  used  it  repeatedly  in  such 
cases.  In  a  child,  15  gr.,  in  an  adult,  45  gr.  of  the  ointment  are  rubbed 
into,  the  skin  at  one  time,  and  the  rubbing  should  be  kept  up  from  ten  to  thirty 
minutes.  There  is  said  to  be  no  risk  of  argyria.  Protargol  is  a  silver  salt 
much  used  in  gonorrhea.  A  solution  in  water  is  made.  It  is  not  precipitated 
by  albumin,  alkaUs,  nor  acids.  In  gonorrhea  a  i  to  5  per  cent,  solution  is 
used.  Argyrol  is  a  new  and  valuable  preparation  of  silver  \Yhich  I  have  used 
freciuently  with  much  satisfaction.  It  is  known  as  silver  \dtelline,  is  not  irritant, 
and  contains  30  per  cent,  of  metallic  silver.  It  is  not  precipitated  by  albvunin. 
In  a  strength  of  5  per  cent,  it  is  a  very  useful  injection  for  gonorrhea,  as  it  has 
powerful  gonococcidal  properties.  In  some  t}^es  of  chronic  c^^stitis  several 
drams  of  a  3  per  cent,  solution  may  be  injected  into  the  bladder  from  time  to 
time,  and  much  stronger  solutions  can  be  used  vnih  safety.  Inflamed  mucous 
membranes  may  be  painted  with  a  solution  of  a  strength  of  from  20  to  50  per 
cent.  A  sinus  or  a  sluggish  area  of  granulation  may  be  stimulated  by  touching 
with  a  solution  of  a  strength  of  from  25  to  50  per  cent.  I  have  found  it  of  much 
ser\dce  in  sinuses. 

Formaldehyd,  or  formic  aldehyd,  has  valuable  antiseptic  properties. 
Formalin  (liquor  formaldehydi)  is  a  37  per  cent,  solution  of  the  gas  in  water. 
Solutions  of  this  strength  cauterize  the  tissues,  but  i  per  cent,  solutions  can  be 
used  to  disinfect  wounds.  A  solution  of  a  strength  of  0.5  per  cent,  is  used  to 
irrigate  sinuses,  tuberculous  areas,  abscess  ca^dties,  and  suppiirating  joints. 
A  strong  solution  is  used  to  asepticize  chancroids  and  other  ulcers.  A  2 
per  cent,  solution  disinfects  instruments.  The  vapor  of  formalin  can  be  so 
applied  as  to  disinfect  wounds,  and  Wood  suggested  its  emploAinent  in  septic 
peritonitis  as  a  means  of  disinfection  after  the  abdomen  has  been  opened. 
Formic  aldehyd  gas  thoroughly  disinfects  catheters. 

Formalin-gelatin  was  introduced  by  Schleich  as  an  antiseptic  powder. 
The  commercial  preparation  is  known  as  glutei.  When  appHed  to  a  clean 
wound  it  gives  off  formahn  and  keeps  the  wound  aseptic.  WTien  it  is  applied 
to  a  sloughing  surface  it  ■^iU  not  give  off  formahn  imless  it  is  mixed  -v^ith 
pepsin  and  hydrochloric  acid.  Formalin-gelatin  has  been  used  to  fill  bone 
ca\dties. 

Lysol  is  a  clear,  brownish,  oily  fluid  Vvith  an  odor  like  creasote.  It  is  a 
A'aluable  germicidal  agent.  It  is  saponified  phenol  and  is  used  in  a  solution 
of  a  strength  of  from  i  to  3  per  cent.  It  does  not  attack  the  hands  Like  carbolic 
acid  and  is  much  less  poisonous. 

Mustard  is  an  exceUent  emergency  germicide.  Its  value  has  been  demon- 
strated by  RosweU  Park,  who  uses  a  mixture  of  soap,  cornmeal,  and  mus- 
tard flour  to  scrub  the  surgeon's  hands  or  the  patient's  skin.  I  have  used 
it  repeatedly  T\-ith  entire  satisfaction.  Mustard  removes  the  odor  of  decay  at 
once. 

Commercial  gasolene  is  used  by  Riordan  and  others  to  clean  wounds 
and  ulcers,  and  to  prepare  the  field  of  operation.  Its  vapor  is  sc>  inflammable 
that  the  material  must  not  be  used  when  gas  or  lamp  fight  is  necessary.  It  is 
used  only  in  the  daytime  or  in  a  room  fighted  by  electricity,  and  on  free  sur- 
faces where  evaporation  is  rapid.  It  is  sterile,  non-irritant,  and  on  evapora- 
tion leaves  a  dr\',  clean  surface. 

lodin. — ^This  drug  was  strongly  endorsed  by  the  late  Prof.  Nicholas  Senn 
("Surger}^,  Gynecolog>^,  and  Obstetrics,"  July,  1905).  He  regarded  it  as  the 
most  powerfiil  and  the  safest  of  antiseptics,  and  claimed  that  in  solutions  of  a 
strength  of  i  per  cent,  it  is  non-irritant  and  causes  a  protective  phagocytosis. 
It  may  be  used  in  great  dilution  or  the  tincture  may  be  applied  to  an  infected 
woimd  in  the  same  manner  as  is  pure  carbofic  acid;  a  method  advocated  by 
Carl  Beck.     In  dilute  solution  it  is  used  to  irrigate  sinuses.     The  proper  dilu- 


34  Bacteriology 

tion  for  irrigation  of  a  sinus  is  obtained  when  the  tincture  is  diluted  to  the 
color  of  sherry  wine.  Its  employment  for  sterilizing  the  skin  is  described 
on  page  68. 

Nucleins,  especially  protonuclein,  possess  germicidal  powers.  Nuclein  is 
composed  of  nucleinic  acid  and  protein  material.  When  injected  hypodermat- 
ically  and  to  a  less  degree  when  taken  by  the  mouth  it  increases  the  germicidal 
power  of  the  blood-serum,  causes  leukocytosis  and  increased  phagocytosis,  and 
thus  prevents  or  opposes  infection.  MikuHcz  has  used  nucleinic  acid  to  in- 
crease vital  resistance  as  a  preliminary  to  operation  (see  page  42).  A  i  per 
cent,  solution  of  nucleinic  acid  is  on  the  market.  This  acid  is  made  from 
yeast.  The  dose  of  the  preparation  is  from  10  to  60  minims  hypodermatically, 
once  or  several  times  a  day.  Protonuclein  probably  contains  nucleinic  acid 
and  is  of  some  value  when  applied  locally  to  areas  of  infection,  particularly 
when  sloughing  exists. 

Heat. — The  best  germicide  is  heat,  and  the  best  form  in  which  to  apply 
heat  is  by  means  of  boiling  water  (which  is  even  better  than  steam) .  One  can 
use  boiling  water  upon  instruments  and  dressings,  but  seldom  upon  a  patient. 
Jeannel,  of  Toulouse,  uses  boiling  salt  solution  in  abscess  cavities,  and  some 
other  surgeons  employ  steam  or  boiling  water  to  disinfect  the  medullary  canal 
in  osteomyelitis.  Nevertheless,  boiling  water  is  seldom  applied  to  a  patient, 
and  in  many  cases  a  chemical  germicide  must  be  used. 

Among  other  antiseptics  and  germicides  of  more  or  less  value  we  may 
mention  trichlorid  of  iodin,  chlorid  of  zinc  (10  per  cent,  solution),  chlorid  of 
iron,  salol,  oxycyanid  of  mercury,  fluorid  of  sodiimi,  argonin,  sugar,  lannaiol, 
bichlorid  of  palladium  (in  very  dilute  solution),  thymol,  potash  soap,  salicylic 
acid,  sulphate  of  copper,  arsenite  of  copper,  camphor,  eucalyptol,  cinnamon, 
bromin,  chlorin  (as  gas  or  as  chlorin- water) ,  cinnamic  acid,  permanganate 
of  potassium  or  of  calcium,  chlorate  of  potassium,  and  oxalic  acid.  The  sur- 
geon before  operating  should  always  scrub  his  hands  in  a  germicidal  solution. 

Distribution  of  Bacteria.- — Microbes  are  very  widey  distributed  in 
nature.  They  are  found  in  all  water  except  that  which  comes  from  very 
deep  springs;  in  all  soil  to  the  depth  of  3  ft.;  and  in  air,  except  that  over  the 
desert,  over  the  open  sea,  and  that  about  lofty  mountains.  Dust-free  air 
does  not  contain  them;  the  more  dust,  the  more  microbes,  hence  they  are  present 
in  greatest  number  in  the  air  of  towns.  There  are  more  in  narrow  courts 
than  in  broad  highways,  more  in  crowded  attics  than  in  roomy  apartments. 
Bacteria  are  present  on  and  in  the  skin,  in  the  alimentary  canal,  in  the  nose, 
mouth,  and  pharynx,  and  in  the  blood  and  lymph.  As  Adami  points  out,  under 
normal  conditions  the  bacteria  which  enter  the  blood  are  very  quickly  killed. 

Microbes  may  be  useful.  Some  of  them  are  scavengers,  and  clean  the 
surface  of  the  earth  of  its  dead  by  the  process  known  as  ^^ putrefaction,''^  in 
which  complex  organic  matter  is  reduced  to  harmless  gases  and  to  a  mineral 
condition.  The  gases  are  taken  up  from  the  air  by  vegetables,  and  the  mineral 
matter  is  dissolved  in  rain-water  and  passes  into  the  soil  from  which  it  came, 
there  again  to  be  food  for  plants,  which  plants  will  become  food  for  animals. 
Other  organisms  purify  rivers;  others  cause  bread  to  rise;  still  others  give  rise 
to  fermentation  in  liquors.  Microbes  may  be  harmful.  They  may  poison 
rivers  and  soils ;  they  may  be  parasites  on  vegetable  life ;  they  cause  diseases  of 
the  growing  vine,  and  also  of  wine;  they  produce  the  mold  on  stale,  damp 
bread;  they  occasionally  form  poisonous  matter  in  sausages,  in  ice-cream,  and 
in  canned  goods;  and  they  produce  many  diseases  among  men  and  the  lower 
animals. 

With  so  universal  a  distribution  of  these  fungi,  man  must  constantly  take 
them  into  his  organism.  They  are  upon  the  surface  of  his  body,  he  inhales 
them  with  every  breath,  and  he  swallows  them  with  his  food  and  drink.     Most 


Infection  or  Disease  Production  by  Micro-organisms  35 

of  them,  fortunately,  are  entirely  harmless;  others  cannot  act  on  the  living 
tissues;  but  some  are  virulent,  and  these  are  generally,  but  not  always, 
destroyed  by  the  cells  of  the  human  body.  The  alimentary  canal  always 
contains  bacteria  of  putrefaction,  which  act  only  upon  the  dead  food,  and  not 
upon  the  living  body;  but  when  a  man  dies  these  organisms  at  once  attack 
the  tissues,  and  postmortem  putrefaction  begins  in  the  abdomen.  Even 
pathogenic  bacteria  may  exist  for  long  periods  in  the  tissues  without  causing 
illness  in  the  host,  but  when  such  bacteria  do  persist,  they  may  at  any  time 
and  from  a  variety  of  causes  become  active  in  producing  disease  in  the  carrier, 
or  when  they  pass  from  the  host  they  may  perhaps  infect  other  people  (see 
Typhoid  Carriers,  page  38).  Sternberg  found  pneumococci  in  healthy  sputum. 
In  fact,  pneumococci  can  be  found  in  the  mouths  of  25  per  cent,  of  people  free 
from  pneiimonia.  Pneumococci  obtained  from  the  mouth  of  an  individual 
free  from  pneimionia  "are  just  as  pathogenic  as  the  diplococci  obtained  from  a 
culture  from  the  sputum  of  a  pneumonic  patient"  (Sir  Thomas  Oliver,  in  "Brit- 
ish Medical  Journal,"  April  30, 1910) .  If  the  lungs  become  irritated,  insufflation 
of  diplococci  from  the  mouth  may  be  followed  by  pneumonia.  Every  infection 
is  at  first  local.  Some  infections  remain  local,  but  others  become  general. 
In  a  general  infection  the  micro-organisms  are  in  the  blood,  though  often  we 
cannot  find  them  because  of  imperfect  methods  (Ball,  in  "Lancet,"  June  8,1912). 

Welch  long  ago  pointed  out  that  the  human  skin  normally  contains  the 
Staphylococcus  epidermidis  albus,  even  after  the  most  careful  surgical  cleans- 
ing. Dudgeon,  in  the  Horace  Dobell  Lecture  for  1908  ("Lancet,"  Dec.  5,  1908, 
"Latent  Persistence  and  the  Reactivation  of  Pathogenic  Bacteria  in  the  Body"), 
says  that  healthy  organs  may  contain  various  bacteria,  that  the  tissues  of  the 
fetus  are  sterile,  but  in  childhood  and  adult  life  "bacteria  are  found  in  various 
parts  of  the  human  body;  that  Staphylococcus  albus  can  be  cultivated  from  the 
human  omentum  in  cases  in  which  the  peritoneal  cavity  is  apparently  healthy"; 
that  pus  cocci  may  persist  for  long  periods  in  a  scar;  that  virulent  diphtheria 
bacilli  may  be  "found  in  the  throats  of  persons  who  have  come  in  contact  with 
diphtheria  patients,  but  show  no  signs  of  the  disease" ;  that  the  Bacillus  proteus 
is  frequently  found  in  the  urine;  that  colon  bacilli  normally  inhabit  the  in- 
testinal tract  and  appends  and  frequently  exist  in  the  urinary  tract  without 
giving  rise  to  inflammation  or  symptoms  of  disease,  and  that  t;y^hoid  bacilli 
tend  notably  to  persist  (see  page  38).  As  previously  stated,  the  organisms  of 
tuberculosis  and  of  syphilis  may  long  rest  latent. 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause  of  a  disease  it 
must  fulfil  Koch's  circuit.  It  must  always  be  foimd  associated  with  the 
disease;  it  must  be  capable  of  forming  pure  cultures  outside  the  body;  these 
cultures  must  be  capable  of  reproducing  the  disease;  and  the  microbe  must 
again  be  foimd  associated  with  the  artificially  produced  morbid  process. 

Infection  or  Disease  Production  by  Micro=organisms. — Most  infec- 
tions are  caused  by  bacteria,  some  result  from  molds,  a  few  from  protozoa. 
Pathogenic  organisms  cannot  enter  through  the  soimd  skin  and  the  imbroken 
skin  without  causing  the  formation  of  lesions  at  the  point  of  entrance.  The 
sound  skin  is  the  very  best  antiseptic  covering  for  tissue,  as  ordinary  bacteria 
cannot  pass  it  at  all.  Some  bacteria  by  entering  the  ducts  of  cutaneous  glands 
may  cause  disease.  Disease-producing  organisms  which  enter  the  body  may 
reach  the  focus  in  which  they  act  from  outside  of  the  body,  entering  by  inocu- 
lation, inhalation,  or  ingestion.  In  most  instances  organisms  which  enter  the 
body  from  without  are  rapidly  destroyed.  When  they  enter  in  large  numbers, 
or  when  they  are  very  virulent,  or  when  the  vital  resistance  of  the  indi^ddual 
is  at  a  low  ebb  they  cause  disease.  Bacteria  may  reach  the  region  in  which 
they  become  active  from  some  other  part  of  the  body.  Bacteria  seldom  dwell 
in  the  body  long  without  inducing  disease,  but  spores  can  lie  dormant  in  the 


36  Bacteriology 

system  for  years.  When  bacteria  or  spores  from  some  other  part  of  the  body 
reach  a  region  of  injury  or  disease  they  may  become  active;  this  area  is  a  dam- 
aged and  weakened  part,  in  it  the  circulation  is  abnormal,  it  is  a  so-called  point 
of  least  resistance  (a  locus  minoris  resistentice)  which  affords  a  nest  for  them  to 
develop  and  to  multiply,  the  cellular  activities  of  the  weakened  part  being 
unable  to  cope  with  the  activities  of  the  germs.  Even  large  numbers  of  patho- 
genic organisms  may  induce  no  trouble  in  a  healthy  man;  but  let  them  reach 
a  damaged  spot,  and  mischief  is  apt  to  arise.  Kocher  established  subcutaneous 
bone  injuries  in  dogs,  and  these  injuries  pursued  a  healthy  course  until  the 
animal  was  fed  upon  putrid  meat,  whereupon  suppuration  took  place.  This 
experiment  proves  that  micro-organisms  can  reach  a  damaged  area  by  means 
of  the  blood,  and  it  enables  us  to  imderstand  how  a  knee-joint  can  suppurate 
when  we  merely  break  up  adhesions,  and  how  osteomyelitis  can  follow  traimia 
when  the  skin  is  intact.  A  given  number  of  organisms  might  produce  no  effect 
on  a  healthy  man,  whereas  the  same  number  might  produce  disease  in  an  indi- 
vidual who  was  weak  or  ill-nourished,  suffering  from  depression  or  fear,  or 
debilitated  by  the  habitual  use  of  alcohol.  The  personal  equation  plays  a  great 
part  in  disease  production.  Some  individuals  seem  to  be  immune  to  certain 
diseases;  and  these  immunities  and  liabilites  may  be  hereditary  or  acquired, 
temporary  or  permanent. 

The  local  infection  may  be  violent  and  yet  never  be  generalized.  Sometimes 
the  local  reaction  at  the  point  of  bacterial  entry  is  so  trivial  as  to  be  overlooked, 
or  by  the  time  general  infection  occurs  the  initial  point  of  local  infection  may 
have  healed. 

It  is  not  at  all  unusual  to  observe  lymphangitis  or  lymphadenitis  "above  a 
healed  focus"  (J.  C.  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1911).  A 
few  infections  generalize  primarily  by  way  of  the  blood — most  do  so  by  the 
lymphatics.  From  the  moment  there  is  lymphangitis  or  lymphadenitis  the 
infection  is  to  be  regarded  as  general,  and  the  blood  contains  toxins  or  bacteria, 
the  lymph-glands  filtering  out  and  holding  comparatively  few  micro-organisms. 
(See  J.  C.  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1911,  and  Noetzel,  in 
"Beitr.  z.  klin.  Chir.,"  1909,  Ixv). 

A  general  infection  in  which  the  blood  contains  toxins  but  not  bacteria  is 
called  a  toxemia.  A  general  infection  in  which  the  blood  contains  bacteria  is 
called  a  bacteremia. 

The  intensity  of  an  infection  may  often  be  estimated  by  the  degree  of 
leukocytosis  and  anemia  (see  page  42). 

Enzymes. — Bacteria  contain  and  excrete  ferments,  and  these  ferments 
are  known  as  enzymes.  Bacterial  ferments  resemble  pepsin  and  trypsin,  the 
digestive  ferments.  The  digestive  ferments  convert  albimiin  into  peptone, 
starch  into  sugar,  and  break  up  fat.  Some  enzymes  are  proteolytic  (dissolve 
albumin);  some  are  diastatic  (change  starch  into  sugar);  some  convert  cane- 
sugar  into  grape-sugar;  some  coagulate  mUk.  When  microbic  infection  of  the 
tissues  occurs  the  enzymes  of  the  bacteria  act  upon  the  tissues  just  as  the  digest- 
ive ferments  act  upon  the  food,  and  form  microbic  albumoses.  The  enzymes 
are  the  weapons  of  micro-organisms.  By  means  of  these  ferments  bacteria 
not  only  prepare  substances  for  assimilation,  but  seek  to  destroy  antagonists 
and  cell  enemies.  It  is  probable  that  enzymes  when  absorbed  are  frequently 
productive  of  toxemia. 

Toxins  are  poisons  produced  by  microbic  action.  The  action  of  patho- 
genic bacteria  upon  the  tissues  is  of  great  importance.  In  the  first  place,  they 
invade  the  tissue,  the  capacity  for  invasion  varying  greatly  and  depending  on 
their  power  to  sweep  aside  the  defenses  of  the  body.  When  they  invade  the 
tissues  they  abstract  from  the  blood,  the  lymph,  and  the  cells  certain  elements 
necessary  to  the  body — as  water,  oxygen,  albumins,  carbohydrates,  etc. — 


Immunity  37 

and  thus  cause  body  wasting  and  exhaustion  from  want  of  food.  In  the  second 
place,  bacteria  produce  a  vast  niunber  of  compounds,  some  harmless  and  others 
highly  poisonous.  The  s\Tnptoms  of  a  microbic  disease  are  largely  due  to  the 
absorption  of  poisonous  materials  from  the  area  of  infection.  These  poisons 
may  be  formed  from  the  tissues  by  the  action  upon  them  of  the  bacterial  fer- 
ments (see  page  36),  may  be  excreted  by  the  bacteria  (extracellular  toxins),  or 
may  be  liberated  from  the  bodies  of  degenerating  microbes  (bacterial  protein, 
intracellular  toxins,  or  endotoxins).  Intracellular  toxins  are  ver\^  insoluble. 
Bacteria  contain  and  secrete  ferments;  and  as  albumoses  are  formed  in  the 
alimentary  canal  by  the  action  of  digestive  ferments  upon  proteins,  sugars, 
and  starches,  so  microbic  albumoses  are  formed  by  the  action  of  microbic 
ferments  upon  tissues.  Just  as  the  albimioses  formed  in  digestion  are  poisonous 
when  injected,  so  the  albumoses  of  microbic  action  are  poisonous  when  ab- 
sorbed. The  albumoses  of  microbic  action  are  called  toxalbumins,  and  these 
albvmioses  often  operate  as  \drulent  poisons  to  the  body-cells. 

A  number  of  compounds  formed  during  the  microbic  destruction  of  tissue  are 
alkaloidal  in  nature.  These  poisonous  alkaloids  are  readily  diffusible  and, 
many  of  them,  very  virulent.  It  is  probable  that  every  pathogenic  organism 
has  its  owTi  special  toxin  which  produces  its  characteristic  effects,  although 
the  effects  are  modified  by  the  nature  of  the  soil — that  is  to  say,  by  the  condi- 
tion of  the  tissues.  Again,  one  micro-organism  may  produce  several  toxins. 
The  absorption  of  toxins  may  be  very^  rapid;  for  instance,  the  toxins  of  cholera 
may  kiU  a  man  before  the  baciUi  have  migrated  from  the  intestine.  Brieger 
uses  the  term  toxin  to  designate  all  of  the  poisonous  products  of  bacterial  action. 
He  di\ides  toxins  into  alkaloidal  or  crystaUizable  and  amorphous,  the  latter 
being  called  toxalbumins. 

Ptomains. — By  many  WTiters  the  term  "ptomain"  is  used  to  designate 
these  toxins,  but,  in  reality,  a  ptomain  is  a  form  of  toxin  produced  by  the  action 
of  saprophytic  bacteria.  A  ptomain  is  a  putrefactive  alkaloid  and  a  toxin 
is  any  poison  of  microbic  origin.  Among  these  putrefactive  alkaloids  may 
be  mentioned  tetanin,  t\^hotoxin,  sepsin,  putrescin,  tyrotoxicon,  muscarin, 
and  spasmotoxin.  The  poison  which  occasionally  forms  in  cheese,  ice-cream, 
sausage,  and  canned  goods  is  composed  of  ptomains.  Poisoning  by  any  putrid 
food  is  called  ptomain-poisoning. 

Leukomains  must  not  be  confoimded  with  the  above-mentioned  bodies. 
Leukomains  are  alkaloidal  substances  existing  normally  in  the  tissues  and 
not  produced  by  bacteria,  but  arising  from  physiologic  fermentations  or  ret- 
rograde chemical  changes.  They  are  natural  body  constituents,  in  contrast 
to  toxins,  which  are  morbid  constituents.  Leukomains  are  foimd  in  ex- 
pired air,  saUva,  urine,  feces,  tissues,  and  the  venom  of  serpents.  If  not 
excreted,  these  bodies  may  induce  illness,  and  when  injected  may  act  as 
poisons.  Ordinary-  colds  and  some  fevers  result  from  leukomains;  they  play 
a  great  part  in  uremia,  and  when  excretion  is  deficient  the  retained  leuko- 
mains make  the  system  a  hospitable  host  for  pathogenic  bacteria.  Sickness 
due  to  the  retention  and  absorption  of  leukomains  is  known  as  auto-intoxication. 
Among  leukomains  may  be  mentioned  adenin,  hj'poxanthin,  and  xanthin, 
allied  to  uric  acid,  and  other  substances  allied  to  creatin  and  creatinin.  The 
surgeon  should  never  forget  the  possibility  of  harm  being  done  by  retained 
leukomains,  and  should  endeavor  to  prevent  auto-intoxication  in  all  cases  by 
keeping  the  skin,  the  bowels,  and  the  kidneys  active. 

Immunity. — Resistance  is  the  fight  of  the  body  against  bacteria.  Even  a 
person  with  high  resistance  may  be  infected,  but  even  though  infected  the  body 
still  fights  the  bacteria.  If  a  person  cannot  be  infected  with  a  certain  disease, 
he  is  said  to  be  immune  to  it.  Some  persons  seem  naturally  immune  to  certain 
diseases  {natural  immunity).     Immunity  to  some  diseases  may  be  produced 


38  Bacteriology 

artificially.  When  the  body  itself  produces  the  materials  which  render  it 
immune  the  immunity  is  called  active.  When  immunity  is  produced  by  the 
introduction  of  substances  artificially  produced  the  immunity  is  called  passive 
or  artificial.  It  has  long  been  known  that  when  a  person  recovers  from  certain 
diseases  he  has  become  immune  to  the  disease  from  which  he  siiffered  {acquired 
immunity).  Immunity  may  be  transitory,  prolonged,  or  permanent.  Acquired 
immunity  may  be  compared  to  fermentation.  When  fermentation  ceases,  the 
addition  of  more  ferment  is  without  result.  When  a  person  recovers  from 
certain  diseases,  the  addition  to  his  blood  of  more  of  the  causative  bacteria  is 
also  void  of  result. 

Immunity  was  long  believed  to  arise  from  the  exhaustion  of  some  unknown 
constituent  of  tissue  necessary  to  the  life  of  the  bacteria.  This  theory  was 
advanced  by  Pasteur.  It  has  been  abandoned  because  of  the  demonstration 
that  though  an  animal  may  become  immune  to  a  disease  caused  by  certain 
bacteria,  these  bacteria  may  continue  to  live  in  the  host.  It  is  true  that  when 
recovery  ensues  upon  infections,  as  a  rule,  the  causative  bacteria  disappear, 
but  there  are  enough  exceptions  to  this  rule  to  invalidate  the  theory  of  Pasteur. 
It  is  well  known  that  even  for  years  after  an  attack  of  typhoid  fever  the  bacilli 
may  exist  in  the  gall-bladder  or  the  bone-marrow,  or  be  passed  in  the  urine  or 
feces.  A  person  apparently  well,  yet  holding,  for  instance,  in  his  gall-bladder 
infectious  bacteria,  is  called  a  "bacteria  carrier."  From  i  to  2  per  cent,  of  per- 
sons who  have  had  typhoid  fever  years  ago  pass  bacilli  in  the  stools,  and  such 
carriers  are  often  responsible  for  the  spread  of  the  disease.  Hutchinson 
("British  Medical  Journal,"  March  26,  1910)  reports  a  "carrier"  whose  attack 
had  been  fifteen  years  before.  Gregg  ("Boston  Med.  and  Surg.  Jour.,"  July 
16,  1908)  reported  the  case  of  a  typhoid  carrier  fifty- two  years  after  recovery 
from  typhoid.  Some  carriers  never  knew  they  had  had  typhoid,  the  attack 
having  been  very  mild.  Some  have  never  had  it,  but  have  been  in  contact  with 
it.  Such  people  were  immune.  A  carrier  may  give  the  disease  to  others,  but 
is  practically  immune.  "Certain  protective  immune  bodies,  such  as  opsonins 
and  stimulins,  are  augmented  by  the  attack;  others,  such  as  the  bactericidins 
and  bacteriolysins,  are  not  augmented  to  the  point  of  destruction  of  the 
bacilli"  (Willard  J.  Stone,  in  "American  Journal  of  Medical  Sciences,"  April, 
1 91 2).  Fromme  operated  upon  4  typhoid  carriers.  In  each  case  he  removed 
the  gall-bladder.  In  the  bile  of  each  he  found  baciUi.  After  operation  the 
bacilli  disappeared  from  the  feces  of  each  woman  ("Deutsch.  Zeitsch.  f.  Chir.," 
Nov.,  1910).  A  theory  proposed  by  Chauveau  is  known  as  the  "retention 
theory,"  and  is  the  opposite  of  Pasteur's  "exhaustion  theory."  According  to 
Chauveau,  bacteria  growing  within  the  body  leave  as  a  legacy  excrementitious 
material,  and  the  accumulation  and  retention  of  excrementitious  products  pro- 
duce immunity. 

Until  very  recently  one  set  of  investigators  maintained  that  immunity  de- 
pends upon  the  activity  of  certain  body  cells  which  attack,  consume,  and 
destroy  bacteria,  this  is  the  theory  of  phagocytosis  (see  page  41).  Another  set 
asserted  the  claims  of  Nuttal  and  Buchner,  that  normal  fresh  blood-serum 
is  germicidal,  the  power  varying  for  different  bacteria  and  being  limited.  A 
fixed  amount  of  serum  is  capable  of  destroying  a  fixed  number  of  bacteria  of 
a  certain  variety.  Vaughan  and  others  states  that  the  germicidal  agent  is 
probably  a  nuclein  furnished  chiefly  by  the  white  cells  and  held  in  solution  by 
the  alkaline  serum.  This  germicidal  agent  of  normal  serum  Buchner  called 
"alexin"  or  defensive  protein,  and  explained  immunity  by  its  presence.  This 
theory  is  known  as  the  "humoral  theory."  According  to  this  theory  as  originally 
maintained,  when  an  animal  is  naturally  immune  to  a  bacterial  disease  it  is 
assumed  that  the  blood-serum  and  body  fluids  contain  enough  of  this  alexin  to 
dissolve  or  destroy  the  bacteria.     Neither  method  of  defense  is  the  only  one. 


Agglutinins  and  Precipitins  39- 

In  all  probability  both  phagocytosis  and  bacterial  solution  are  occurring  in  the 
same  patient  at  the  same  time,  phagocytosis  being  impossible  but  for  the  serum 
and  bacteriolysis  being  impossible  without  leukocytes. 

Since  the  above  theories  were  set  forth  it  has  been  found  that  when  an  ani- 
mal recovers  from  some  bacterial  diseases  the  blood-serum  and  body  fluids  con- 
tain new  protective  materials  called,  in  general,  antibodies.  The  toxins  of  bac- 
teria stimulate  body  cells  to  the  production  of  antibodies,  and  antibodies  bring 
the  disease  to  an  end  and  secure  immunity.  It  is  thus  seen  that  the  very  poi- 
sons produced  by  bacteria  cause  the  body  cells  to  produce  poison  antidotes. 
The  bacteria  may  be  so  virulent  or  the  patient  so  susceptible  that  poison  over- 
whelms the  cells,  antibodies  are  not  formed  in  sufficient  quantity,  and  death 
ensues.  The  cells  may  be  badly  poisoned  and  the  patient  may  become  very  ill, 
and  yet  after  a  time  the  cells  may  regain  enough  vitality  to  furnish  antibodies  in 
sufficient  quantity  to  bring  about  cure  and  to  secure  immunity.  The  bacteria 
may  be  so  few  in  number  or  so  attenuated  in  virulence  or  the  cells  of  the  patient 
may  be  so  active  that  quantities  of  antibodies  are  quickly  formed  under  mild 
stimulation,  and  the  individual  does  not  take  the  disease  at  all  or  takes  it  very 
mildly. 

The  lytic  or  bacteriolytic  antibodies  or  lysins  destroy  and  dissolve  bac- 
teria. All  bacteria  are  not  susceptible  to  lysis,  for  instance,  streptococci,  tu- 
bercle bacilli,  and  pneumococci.  When  recovery  ensues  the  causative  bacteria 
usually  but  not  always  disappear  (see  page  38).  These  lytic  bodies  are  formed 
by  the  leukocytes,  bone-marrow,  spleen,  and  lymph-glands  (Wassermann,  in 
''Berlin,  klin.  Woch.,"  No.  4,  1898,  and  Levaditi,  in  "Annales  de  ITnst.  Pas- 
teur," 1904). 

Agglutinins  and  precipitins  gather  in  the  blood-serum  of  an  animal  when 
the  animal  has  been  injected  with  bacteria  or  certain  cells.  When  these  anti- 
bodies appear  in  blood  after  an  animal  has  been  injected  with  bacteria  they 
agglutinate  and  precipitate  the  bacteria  injected.  It  is  probable  that  agglu- 
tinins and  precipitins  are  formed  by  the  endothelium  of  vessels  walls  (Kraus 
and  Schiffman,  in  "Annales  de  ITnst.  Pasteur.,"  1906).  These  materials  only 
appear  after  certain  infections. 

Opsonins  are  materials  which  by  attaching  themselves  to  certain  bacteria 
so  alter  the  bacteria  that  they  easily  become  the  victims  of  phagocytosis  (see 
Phagocytosis,  page  41). 

Antitoxins  are  specific  bodies  secreted,  as  Roux  says,  by  the  body  cells. 
They  pass  into  the  serum  and  body  fluids.  They  fix  and  neutralize  the  bac- 
terial toxin  by  combining  with  it,  but  do  not  dissolve,  kill,  precipitate,  or  ag- 
glutinate the  bacteria.  The  first  antitoxin  to  be  discovered  was  that  of  diph- 
theria. The  discovery  was  made  by  Behring  in  1890.^^  He  found  that  if  an 
animal  is  injected  with  gradually  increasing  amounts  of  diphtheria  toxin  the 
serum  comes  to  contain  an  antitoxic  material.  Very  soon  after  this  discovery 
was  announced  Behring  and  Kitasato  made  a  like  discovery  in  regard  to  tetanus 
toxin.  It  was  pointed  out  by  Kitasato  and  Behring  that  animals  can  be  ren- 
dered immune  to  tetanus  by  artificial  means  and  that  the  blood-serum  of  im- 
mune animals  will,  if  injected  into  other  animals,  render  them  immmie,  or 
perhaps  cure  the  disease  if  injected  into  animals  suffering  from  tetanus.  The 
same  statements  were  also  proved  to  be  true  of  diphtheria.  Now  many  experi- 
menters are  endeavoring  to  find  the  antitoxin  of  each  microbic  disease  for  the 
purpose  of  using  it  therapeutically  and  also  as  a  preventive  agent. 

In  some  infections  soluble  toxins  are  not  formed  and  the  body  resistance 
depends  largely  on  the  formation  by  the  bacteria  of  substances  which  finally, 
when  present  in  sufficient  amounts,  destroy  bacteria. 

Surely  one  of  the  most  important  of  modern  discoveries  is  that  certain 
1 "  Deutsche  Med.  Wochenschrift,"  1890,  Nos.  49  and  50. 


40  Bacteriology 

substances  introduced  into  the  body  cause  a  reaction  which  results  in  the  forma- 
tion of  antibodies.  Any  material  which  causes  antibodies  to  form  is  called 
an  antigen.  In  the  preceding  section  we  have  spoken  of  bacterial  products  as 
the  antigens.  But  other  antigens  exist,  for  instance,  blood-corpuscles  and 
other  cells,  blood-serum,  some  vegetable  poisons,  and  some  animal  poisons. 
Thought  is  now  directed  to  treating  bacterial  diseases  by  the  introduction  of  the 
proper  antigen  to  produce  lysins,  opsonins,  antitoxins,  as  the  case  may  be. 
Streptococci  produce  no  antigen  which  leads  to  lysin  formation,  but  do  produce 
antigens  which  lead  to  antitoxin  and  opsonin  formation. 

The  subject  is  of  enormous  importance  and  is  vastly  complicated. 

EhrlicJi's  Theory  of  the  Mechanism  of  Immunity  by  Antitoxins. — Ehrlich's 
theory  was  advanced  in  1898  and  is  generally  accepted  at  the  present  time. 
"Ehrlich's  theory  of  the  mechanism  of  immunity  is  based  upon  Weigert's 
teaching  of  the  process  of  tissue  repair.  It  is  a  matter  of  universal  observation 
that  nature  is  prodigal  in  her  attempts  to  repair  an  injury.  This  is  shown 
in  the  healing  process  in  an  ordinary  wound.  A  much  larger  amount  of  mate- 
rial is  thrown  out  to  bridge  the  chasm  than  is  really  utilized  in  the  formation  of 
new  tissue.  The  presence  of  an  excessive  amount  of  new  material  is  shown  by 
the  fact  that  the  part  is  raised  above  the  level  of  the  surrounding  sound  tissue, 
and  this  excess  is  removed  gradually  as  the  new-formed  tissue  becomes  stronger 
and  stronger,  until  finally  the  wound  is  marked  by  a  line  of  white  scar-tissue, 
the  excess  gradually  passing  into  the  blood-current. 

"Ehrlich  believed  that  the  mechanism  of  immunity  was  explainable  on  a 
similar  basis.  It  had  become  evident  from  the  experiments  of  Wassermann 
with  the  tetanus  bacillus  that  its  toxin  had  an  especial  affinity  for  the  cells 
of  the  central  nervous  system.  Experiments  with  other  bacteria  pointed  to 
the  fact  that  the  toxins  of  different  species  of  bacteria  had  an  especial  affinity 
for  the  cells  of  different  organs  of  the  body.  When  the  amount  of  poison 
entering  the  body  is  not  sufficient  to  destroy  the  cells  which  have  an  especial 
affinity  for  it,  these  cells  may  be  injured  only  to  such  an  extent  as  to  permit 
subsequent  repair.  In  order  to  comprehend  Ehrlich's  hypothesis  it  is  neces- 
sary to  conceive  the  cells  of  the  body  as  having  a  complex  structure  which 
may  be  stated  diagrammatically  as  consisting  of  a  central  mass  or  nucleus 
from  which  radiate  a  number  of  'lateral  chains,'  or  bonds,  each  of  which 
serves  to  bind  the  cell  to  other  substances.  In  the  case  of  the  cells  of  the 
central  nervous  system  one  of  these  lateral  bonds  has  an  especial  affinity  for 
tetanus  toxin  and  suffers  destruction.  The  cell  now  finds  itself  in  unstable  equi- 
Hbrium,  and  at  once  proceeds  to  repair  the  damage  wrought.  As  in  the  case 
of  tissue  repair,  the  new  material  produced  is  far  in  excess  of  the  required 
amount.  The  excess  finds  its  way  into  the  blood-current.  This  material 
now  circulating  in  the  blood-current  has  the  same  affinity  for  tetanus  toxin  as 
when  united  with  the  central  mass  of  a  cell  as  its  lateral  bond,  and  can,  there- 
fore, combine  with  tetanus  toxin  floating  in  the  blood-current,  thus  preserving 
other  cells  from  injury.  The  union  formed  between  the  lateral  bond  of  the 
cell  (which  is  really  the  antitoxin)  and  the  tetanus  toxin  results  in  the  forma- 
tion of  a  compound  which  is  physiologically  inert.  According  to  Ehrlich's 
idea,  therefore,  the  antitoxin  is  simply  the  excess  of  lateral  bonds  floating 
in  the  blood-current.  This  substance  can  neutralize  the  effect  of  the  tetanus 
toxin  in  a  test-tube  just  as  readily  as  it  does  within  the  body"  (D.  H.  Bergey, 
"American  Medicine,"  October  11,  1902). 

Phagocytes. — It  was  generally  believed  after  Metschnikoff's  important 
discoveries  that  leukocytes  were  the  agents  which  protected  the  body  from 
infection.  When  other  observers  found  that  in  blood-serum  is  material  that 
damages  or  destroys  bacteria,  opinion  swung  to  the  veiw  that  the  blood-serum 
contains  the  protective  element,  and  that  the  leukocytes  are  simply  scavengers 


The  Process  of  Phasocs'tosis 


41 


m 


m 


and  remove  dead  bacteria,  but  do  not  destroy  li\-ing  ones.  It  has  recently  been 
shown  that  under  some  circumstances  leukocytes  destroy  li\-ing  bacteria  and 
under  other  circumstances  they  do  not.  and  that  the  presence  or  absence  of 
this  property  depends  in  most  instances  upon  the  presence  or  absence  in  the 
blood-serum  of  substances  which  act  upon  bacteria  and  render  them  susceptible 
to  the  phagocytic  action  of  leukocytes.  We  say  in  most  instances,  not  in  all 
instances,  because  certain  bacteria,  for  instance,  influenza  baciUi,  are  phago- 
o,i:able  without  the  presence  of  opsonic  serum  iLud\ig  Hektoen,  address  in 
''Section  of  Physiology-  and  Experimental  Medicine,  American  Assoc,  for 
Advancement  of  Science,"  190S;  '"Science,"  Feb.  12,  1909).  The  existence  of 
substances  in  the  serum  provocative  of  phagocytosis  was  demonstrated  bv 
Wright  and  Douglas  in  1903,  and  they  named  them  opsonins.  If  opsonins 
are  present,  they  act  upon  bacteria,  and  render  the  bacteria  susceptible  to 
phagocytosis.  (See  Lud^-ig  Hektoen.  in  •"Jour.  Am.  Med.  Assoc,"  Mav  12, 
1906.)  Opsonins  act  upon  bacteria  and  alter  them,  and  the  altered  bacteria 
are  easil}'  eaten  up  by  leukocytes.  "\'er\-  Airulent  bacteria  resist  phagoc^-tosis 
because  they  have  little  affinity  for  opsonin,  and  such  Airulent  bacteria  may 
grow  in  opsonic  serum.  The  source  of  opsonins  is  not  known,  but  serum 
normally  contains  "opsonins  for  many  different  bacteria'"  (Hektoen.  in  "Jour. 
Am.  Med.  Assoc,"  May  12,  1906).  \^Tien  experiment  determines  the  fact  that 
an  indi^'idua^s  leukoc}i:es  are  highly  phagoc}idc  toward  particular  bacteria. 
we  believe  that  a  quantit^•  of 
opsonin  for  that  variety-  of  bac- 
teria is  present,  and  we  may 
say  the  iadiA-idual  has  a  high 
opsonic  index  as  regards  them. 
Under  opposite  conditions  we 
say  he  has  a  low  opsonic  index. 
"The  opsonic  index  of  Wright 
with  respect  to  a  given  bac- 
terium is  obtained  by  compar- 
ing the  number  of  the  bacteria 
taken  up  imder  the  influence 
of  the  sermn  of  the  person  or 
animal  in  question  with  the 
number  taken  up  under  the  in- 
fluence of  the  corresponding 
standard  of  normal  senmi  under 

conditions  that  are  as  comparable  as  they  possibly  can  be  made"  (Lud^ig 
Hektoen.  address  in  "Section  of  Advancement  and  Physiology-  and  Experi- 
mental ]SIedicine  in  Am.  Assoc,  for  Science."'  1909;  "Science.""  Feb.  12.  1909). 
The  Process  of  Phagocytosis. — We  have  just  seen  how  opsonins 
stimulate  phagocytosis.  The  process  of  destruction  of  bacteria  by  ceUs  is 
known  as  phagocytosis,  and  the  destro}-ing  cells  are  called  phagocytes.  The 
cells  active  in  phagoc}tosis  are  the  endothelial  ceUs  of  the  blood-vessels, 
htnph-channels  and  h-mph-spaces,  and  particularly  the  leukoc^tes.  "WTien 
infection  occurs,  the  white  blood-ceUs  gather  in  enormous  numbers  at  the  seat 
of  disease,  encompass  and  surround  the  bacteria,  and  binld  a  barrier  to  prevent 
dissemination  of  the  microbes  and  general  iofection  of  the  -s-ictim.  The  force 
which  draws  leukoc}tes  to  a  region  of  infection  also  tends  to  draw  them  to  an 
area  where  there  is  cellular  degeneration  or  death.  This  force  is  called  positive 
chemiota.xis  and  is  greatly  stimulated  by  opsonins.  In  ver}-  %-irulent  infections 
the  leukocytes  may  fail  to  collect  and  may  actually  be  repelled  and  scattered 
under  the  influence  of  what  has  been  called  negative  chemiota.xis.  PhagocAtes 
at  the  seat  of  infection  tr\-  to  eat  up,  can*}-  away  to  a  gland,  and  there  digest 


^^i 


s«k 


■PhagocjTosii:  A,   Succesifiil;  B,  unsuccessful 

vSenn ) . 


42  Bacteriology 

and  destroy  bacteria.  A  battle  royal  occurs,  the  microbes  fighting  the  body 
cells  with  most  active  ferments  and  destroying  the  opsonic  power  of  the  blood- 
liquor;  the  body  cells  endeavoring  to  devom*  and  destroy  the  bacteria  (Fig.  14), 
in  which  effort  opsonins  give  them  aid.  In  some  cases  the  bacteria  win  abso- 
lutely and  the  patient  dies.  In  other  cases  they  win  for  a  time  and  over- 
whelm the  system;  but  presently  the  body  cells,  whose  movements  were 
inhibited  by  the  poison,  regain  their  activity  and  are  then  immune  to  the 
bacterial  poison.  It  is  probable  that  the  materials  thrown  out  by  the  white  cells 
during  the  combat  with  the  microbes  tend  to  destroy  bacterial  products  and 
to  neutralize  toxic  products  of  tissue  destruction.  These  materials,  which  neu- 
tralize toxic  products,  are  known  as  antitoxins  (see  page  39).  After  the  attack 
of  disease  has  passed  away  the  body  cells  have  been  educated  to  withstand  this 
poison,  and  new  cells  in  the  future  retain  this  capacity;  the  weak  cells  were 
killed,  the  fittest  survived,  and  the  body  fluids  contain  antitoxin.  The  new 
cells  formed  in  the  body  are  insusceptible  to  the  poison  and  the  indi\'idual  is 
said  to  be  insusceptible  or  immune.  The  theory  of  phagocytosis  immunity 
assimies  an  educated  white  corpuscle  and  body  ceU.  This  view  originated 
with  Sternberg,  but  it  is  usually  accredited  to  Metschnikoff.  Lankester  gave 
us  the  term  "educated  corpuscle." 

Leukocjrtosis. — In  a  number  of  infectious  and  inflammatory  diseases  leuko- 
cytosis occiirs.  By  this  term  we  mean  a  notable  increase  of  leukocytes  in  the 
blood,  the  polynuclear  neutrophiles  being  increased  relatively  and  absolutely. 
Leukocytosis  in  an  infection  indicates  that  the  body  is  trying  to  protect  itself 
against  poisons  by  furnishing  more  phagocytes  to  attack  bacteria.  The  degree 
of  the  leukocytosis  is  a  sort  of  gauge  of  the  virulence  of  the  infection  and  of  the 
reacting  or  resisting  powers  of  the  individual.  In  a  very  trivial  infection  there 
may  be  a  slight  leukocytosis  or  no  leukocytosis  at  all.  A  violent  infection,  if 
resistance  is  high,  is  accompanied  by  a  high  degree  of  leukocytosis;  if  resist- 
ance is  low,  there  is  a  low  degree  or  no  leukocytosis  at  all. 

In  a  virulent  infection  absence  of  leukocytosis  is  of  unfavorable  import. 
It  means  that  tissue  resistance  is  at  an  end  and  that  the  body  cells  have  ceased 
to  fight  the  bacteria. 

Normally,  the  blood  should  contain  about  7500  leukocytes  per  c.mm. 
From  60  to  75  per  cent,  of  the  cells  are  polynuclear  neutrophiles.  If  the  cells 
number  well  above  10,000,  and  if  the  percentage  of  polynuclear  neutrophiles  is 
increased,  the  condition  is  regarded  as  leukocytosis. 

In  most  cases  the  leukocyte  count  is  below  20,000.  Over  20,000  is  high 
leukocytosis.  It  is  very  seldom  that  a  count  of  over  30,000  is  obtained  (see 
page  93). 

Artificial  Stimulation  of  Phagocytosis. — When  active  hyperemia  is  induced 
by  heat,  when  irritants  are  applied  to  an  inflamed  surface,  or  when  an  inflamed 
joint  is  treated  by  Bier's  method  of  passive  hyperemia,  local  leukocytosis  is 
stimulated  and  phagocytosis  becomes  more  active.  A  few  years  ago 
Issaeff  ai£rmed  that  the  introduction  of  certain  materials,  as  salt  solution, 
into  the  peritoneal  cavity,  lead,  for  a  time,  to  great  increase  in  the  resistance  to 
abdominal  infection.  This  period  of  increased  resistance  he  called  the  resist- 
ance period.  It  begins  a  few  hours  after  the  injection  and  terminates  by  the 
end  of  the  fifth  day.  During  this  period  the  great  increase  in  intraperitoneal 
leukocytes  saves  the  animal  from  infection  with  bacteria,  which  would  other- 
wise cause  a  dangerous  or  fatal  inflammation.  Mikulicz  believed  it  possible 
to  establish  this  resistance  period  before  abdominal  operations  and  was  working 
on  the  problem  just  before  his  lamented  death.  MikuUcz  used  diluted  nucleinic 
acid  injected  twenty-four  to  forty-eight  hours  previous  to  operation  (Mikulicz, 
"Verhandl.  d.  2>2)-  Congress  d.  Deutsch.  Ges.  f.  Chir.,"  1904).  Graf's  studies  of 
nucleinic  acid  used  to  secure  immunity  from  puerperal  sepsis  were  inconclusive 


Protective  and  Pre\entive  Inoculations  43 

(" Zentralblatt  fiir  G>Tiakologie/'  1910,  Xo.  27;.  Some  s'jjseons  have  in- 
jected fresh  warm  horse-serum  for  the  same  purpose  Peiie.  Jayle,  and 
Federmann;  see  "'Le  Presse  Medicale,''  1905;.  The  agents  used  must  not 
be  of  a  nature  to  damage  opsonins,  for  leukoo-tosis  without  plenty-  of  opsonins 
would  do  no  good.  A  true  infectious  or  inflammatory-  leukoo-tosis  is  much 
more  protective  than  an  artificial  leukoc\i:osis,  however  induced.  In  fact 
Ieukoc\-tosis  induced,  for  instance,  by  injecting  such  a  material  as  nuclein  is  of 
ver\-  little  use  against  an  established  infection.  It  is  probably  of  more  value 
as  a  protective  against  infection.  How  sUght  or  how  great  this  value  may  be 
is  not  yet  certainly  determined. 

Vital  Resistance. — ^Local  resistance  is  lowered  by  injury  or  disease  of  the 
skin  or  mucous  membrane.  Soxmd  skin  and  mucous  membrane  are  most 
important  elements  in  resistance.  For  instance,  disease  of  the  intestinal  mucosa 
may  permit  colon  bacilli  or  other  micro-organisms  to  be  taken  through  the 
damaged  mucous  membrane  and  be  carried  to  distant  regionSj,  in  which  regions 
of  arrest  disease  may  arise. 

In  the  same  maimer  pulmonary  tuberculosis  may  devel(^  subsequent  to 
disease  of  the  bronchial  mucous  membrane.  The  general  vital  resistance 
to  infection  depends  in  part  upon  germicidal  and  opsonic  blood-liquor  and  in 
part  upon  active  leukocytes. 

Vital  resistance  is  increased  by  agents  which  cause  active  phagocytosis 
without  destruction  of  opsonins. 

An\"thing  that  lessens  the  germicidal  and  opsonic  power  of  blood-serum  or 
the  phagoc\"tic  actL"vit}^  of  corpuscles  lessens  general  vital  resistance.  Among 
these  causes  are  ill  health,  worry,  unhygienic  life,  chronic  drug  intoxications, 
alcoholism,  chronic  \"isceral  diseases,  diabetes,  Br^^t's  disease,  gout,  rheiuna- 
tism,  \iolent  and  sudden  fluctuations  of  temperature,  bodily  or  mental  over- 
work, improper  food,  insufficient  food,  too  little  sleep,  fear,  antec«ient  illness, 
exfjosure  to  cold,  and  the  creation  of  points  of  least  resistance  (see  page  36). 
The  general  ^dtal  resistance  to  infection  is  also  lowered  by  inordinate  prolonga- 
tion of  a  surgical  operation,  by  shock,  by  hemorrhage,  by  protraction  of  the  an- 
esthetic state  with  ether  or  diloroform.  Kxham  ("'BriL  Med.  Jour.,"  Jan.  27, 
191 2)  points  out  that  inOammation  is  a  factor  in  resistance  (this  is  seen  by 
pus  limitation  in  appendiceal  abscess),  and  so  is  fever.  Elevated  temperature 
means  that  the  body  is  fighting  the  infection  (see  page  129). 

Different  tissues  in  the  same  indi\ddual  show  great  differences  in  resistance. 
We  know  that  certain  bacteria  have  a  predisposition  to  attack  certain  tissues. 
This  is  notably  true  of  tubercle  bacillL  The  resistance  of  an  individual  varies 
at  different  times.  Heredity  often  plays  a  rirt  ::.  r)rediq)osition  and  resist- 
ance and  sex  has  some  influence  upon  ::.  R  ;r  :-  :_duential  r^arding  some 
diseases  (see  page  24).  Resistance  vanes  -:  iif:  :rr.:  ajes.  Exham  ("'Brit. 
Med.  Jour.,"'  Jan.  27,  1912)  points  c  a:  :ha:  liailar-:.  ar-  7  articilarly  prone  to 
acute  infections,  but  are  less  arr  ::  ale  ::  aaen:  tJa  :   ^re  :■  ia  a 

Protective  and  Preventive  Inoculations. — (Jar  aa.v  rize  of  pro- 
tective inoculations  for  contagious  diseases  dates  fr;n:  Jeaar:  s  aisaiaer;.- 
of  vaccination  against  smaU-pox  in  179S.  Preventive  'aa  a.aa  a :  a;  "  i :a  a::ra  a- 
ated  \-iru5  are  due  to  the  experiments  of  Pasteur.  Tans  :  :st-  rr  as:  nrrl 
the  cause  of  chicken-cholera,  and  cultivated  the  mi::  --aaaira.  :  nar  as  se 
outside  the  body.  He  found  that  by  keying  his  aaaar-  :  r  -  a-  arar  aty 
became  attenuated  in  \Trulence,  and  that  these  atteiiua:r  a  a.  a  a  7-  a  aa  . a.r  a 
in  fowls,  caused  a  mild  attack  of  the  disease,  which  at:  a  a    a  -    :  r   :    1 

rendered  the  fowl  immune  to  the  most  virulent  cuitar^s      aa  a  rcr   : 
attenuated  by  keeping  them  for  some  time,  by  e:qK)sing  :acra  :  r  a  sa : ::  a  r:  ;  a 
to  a  temperature  just  below  that  necessary-  to  kiU  the  organisms,  or  by  treating 
them  with  certain  antiseptics.     It  has  further  been  shown  that  injection  of  the 


44  Bacteriology 

blood-serum  of  an  animal  rendered  immune  by  inoculation  is  capable  of  making 
a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  may  be  rendered  immune  to  certain 
diseases  by  inoculating  them  with  filtered  cultures  of  the  microbes  of  the  dis- 
ease, the  filtrate  containing  microbic  products,  but  not  living  microbes.  By 
this  method  animals  can  be  rendered  immune  to  tetanus  and  diphtheria. 
Pasteur's  protective  inoculations  against  hydrophobia  owe  their  power  to 
microbic  products,  and  Koch's  lymph  contains  them  as  its  active  ingredients. 
Injections  of  dead  bacteria  is  the  basis  of  inoculation  against  typhoid  fever. 
Inoculation  with  dead  bacteria  is  called  vaccination  and  the  dead  bacteria 
constitute  the  vaccine  (see  pa.ge  47). 

Vaccination  against  typhoid  has  been  notably  successful  in  the  army  and  navy 
of  the  United  States.  Surgeon-General  Stokes  of  the  U.  S.  Navy  reports  the  en- 
tire disappearance  of  typhoid  from  the  navy  as  the  result  of  vaccination.  During 
the  summer  of  191 1  an  army  division  of  nearly  13,000  men  was  stationed  in  Texas 
for  four  months.  It  was  in  a  region  where  typhoid  existed.  Every  man  was 
vaccinated  and  only  one  developed  typhoid.  The  chief  feature  in  acquired  im- 
munity is  the  presence  in  the  blood  and  tissues  of  elements  which  can  neutralize 
the  toxic  products  of  bacteria.  These  elements  are  "antitoxins"  (see  page  39). 
Microbic  products  are  dead  and  cannot  multiply  as  can  living  bacteria,  hence 
the  human  organism  is  not  overwhelmed  unless  the  dose  is  too  large,  but  the 
microbic  products  cause  the  development  of  antitoxin  as  certainly  as  do  the 
living  microbes.  The  above  facts  are  of  immense  importance,  for  on  these 
lines  may  be  solved  the  problems  of  the  prevention  and  treatment  of  microbic 
maladies. 

Orrhotherapy,  or  serum=therapy,  is  an  attempt  to  utilize  therapeu- 
tically the  germicidal  properties  of  blood-sermn.  It  is  believed  that  when 
a  person  recovers  from  an  infectious  disease  the  alkahne  blood-seriun  is  satu- 
rated with  protective  material,  particularly  with  antitoxin.  If  this  belief  is 
true,  a  proper  deduction  is,  that  blood-serimi  containing  protective  material 
should  cure  the  disease  if  injected  into  a  patient  suffering  from  an  attack. 
Some  sera  used  therapeutically  are  antitoxic  (antitoxin),  that  is,  they  do  not 
kill  bacteria,  but  merely  neutralize  the  toxin.  Others  are  bacteriolytic, 
destroying  and  dissolving  bacteria.  An  antitoxic  serum  is  made  by  injecting 
a  horse  with  toxin.  The  horse-serum  comes  to  contain  antitoxin.  Antibac- 
terial serum  is  obtained  by  injecting  an  animal  first  with  the  dead  and  then 
with  the  living  bacteria.  The  serum  contains  the  bacteriolytic  material. 
Instead  of  using  the  blood-serum  itself,  some  observers  have  precipitated  the 
supposed  cmrative  material  from  the  serimi,  have  dissolved  this  material,  and 
have  administered  the  solution  in  fixed  amounts.  Instead  of  using  the  serum 
of  persons  rendered  immune  by  an  attack  of  the  disease,  many  physicians  have 
employed  the  serum  of  animals  rendered  artificially  immune  by  injections  of 
attenuated  cultures  of  the  bacteria  or  injections  of  bacterial  products.  Some 
experimenters  have  even  employed  the  serum  of  animals  naturally  immime 
to  the  disease.  In  some  cases  the  serum  is  given  hypodermatically,  in  some 
intravenously,  in  some  by  lumbar  puncture,  in  some  by  intracerebral,  and 
in  others  by  intraneural,  injection.  Claims  have  been  made  that  serums  are 
efi&cient  when  given  by  the  mouth  or  by  the  rectum.  Paten,  of  Melbourne, 
claimed  in  1906  that  the  oral  administration  of  immune  serum  raises  the  opsonic 
index  ("Med.  Press  and  Circular,"  Jan.  31  and  Feb.  7,  1906). 

Latham  ("Lancet,"  Feb.  15,  1908)  and  others  claim  that  clinical  and  bac- 
teriologic  evidences  are  in  favor  of  the  view  that  serums  are  efficient  when  given 
by  the  mouth.  If  these  views  are  proved  to  be  true  serum-therapy  "^dll  receive 
an  enormous  impetus.  Calmette  has  perfected  an  antivenomous  serum  (anti- 
venene)  for  use  after  cobra  bites.     Pasteur  has  devised  a  method  which  wiU  usu- 


Orrhotherapy,  or  Serum-therapy  45 

ally  prevent  hydrophobia  (see  page  306).  That  Murri,  of  Bologna,  has  appar- 
ently cured  a  case  of  hydrophobia  seems  proved  (see  page  307).  Hosts  of  ob- 
servers believe  in  the  utility  of  diphtheria  antitoxin  and  many  are  convinced  of 
the  value  of  tetanus  antitoxin.  The  earlier  in  the  disease  the  injection  of  an 
antitoxic  serum  is  practised  and  the  larger  the  dose,  the  more  apt  it  is  to  prove 
curative.  When  the  toxin  has  not  yet  combined  with  cells,  antitoxin  may  keep 
it  from  doing  so,  and  when  it  has  recently  combined  and  the  combination  is  still 
vmstable,  antitoxin  may  cause  dissociation  of  the  combination.  When  the 
disease  is  well  established  and  the  cell  combination  of  toxin  is  firm,  antitoxin 
will,  in  all  probability,  fail  to  cure.  If  we  decide  to  give  serum  in  an  acute 
infection,  give  it  early  and  as  advised  by  Ball  ("Lancet,"  June  8,  1912). 

A  rapid  effect  will  be  obtained  by  mixing  the  serum  with  normal  salt 
solution  and  throwing  100  c.c.  of  the  mixture  into  a  vein.  Each  day  after 
this  50  to  100  c.c.  are  given  subcutaneously. 

Ball  advises  that  we  obtain  the  serimi  which  is  most  nearly  autogenous. 
The  best  is  obtained  from  the  blood  of  one  who  has  recently  recovered  from  the 
identical  infection.  The  next  best  is  obtained  from  a  person  who  has  been  arti- 
ficially immunized.  Make  a  vaccine  at  once,  and  as  soon  as  it  is  made,  sub- 
stitute it  for  the  serimi  injections. 

It  is  very  important  to  remember  that  the  water  of  the  salt  solution  must 
have  been  recently  distilled.  Otherwise  an  intravenous  injection  of  serum  and 
salt  solution  will  be  followed  by  a  chill  in  from  one-half  to  two  hours  after  the 
injection  (Ball,  in  "Lancet,"  June  8,  1912).  In  order  to  make  diphtheria 
antitoxin  a  horse  is  immunized  to  diphtheria  toxin  by  injecting  subcutaneously 
increasing  doses  of  diphtheria  toxin.  It  requires  two  or  three  months  for  the 
blood  of  the  animal  to  acquire  siif&cient  potency.  The  blood  containing  anti- 
toxin is  withdrawn  by  bleeding,  the  serum  is  separated  from  the  clot,  and  its 
antitoxic  potency  is  determined  by  complicated  methods.  We  signify  the  de- 
gree of  potency  of  a  serum  by  saying  that  it  is  of  so  many  "immunizing  units," 
a  unit  being  an  arbitrary  standard.  The  average  dose  for  a  child  is  1000  units 
and  for  an  adult  2000  units.  (Tetanus  Antitoxin  is  considered  on  page  208; 
Antivenene  is  considered  on  page  300.) 

Anthrax  in  animals  and  himian  beings  has  been  treated  with  success  by 
Sclavo's  serum  (the  serum  of  an  actively  immunized  animal).  The  antimenin- 
gococcus  serum  of  Flexner  and  Jobling  seems  to  possess  distinct  power  in  the 
treatment  of  epidemic  cerebrospinal  meningitis.  It  is  given  by  lumbar  punc- 
ture. Cholera  serum  seems  of  no  avail  therapeutically.  Shiga's  antidysenteric 
serimi  is  of  value.  Claims  are  made  for  plague  serum.  Inconclusive  experi- 
ments have  been  made  in  the  treatment  of  syphiUs  by  the  serum  of  dog's 
blood  and  by  the  blood-serimi  of  men  laboring  under  tertiary  syphilis;  in  the 
treatment  of  pneumonia  by  the  blood-serima  of  persons  convalescent  from 
pneumonia;  and  in  the  treatment  of  sufferers  from  septic  diseases  by  anti- 
streptococcic serum — blood-serum  of  horses  rendered  immune  to  virulent 
streptococci.  The  serum  treatment  of  pneumonia  is  a  failure.  The  real  value 
of  antistreptococcic  serum  is  yet  uncertain.  Occasionally  it  seems  to  do  great 
good;  at  other  times  it  appears  to  produce  no  benefit  whatever.  Some  ob- 
servers claim  remarkable  resiilts  in  erysipelas.  In  several  cases  of  phlegmonous 
erysipelas  and  in  2  cases  of  malignant  endocarditis  I  thought  it  was  of  benefit. 
Tavel,  in  an  elaborate  research  ("Klinische-therapeutische  Wochenschrift," 
Vienna,  August,  1902),  states  that  he  obtained  brilliant  results  in  some  cases, 
but  no  results  in  others.  He  does  not  undertake  to  explain  this  variabiHty  of 
action.  He  thinks  the  serimi  benefits  staphylococcus  as  well  as  streptococcus 
infections.  Antistreptococcic  serum  often  fails  completely.  This  is  supposed 
to  be  due  to  the  fact  that  there  are  many  different  families  of  streptococci.  It 
"was  hoped  that  a  polyvalent  serum  would  prove  eflScient,  but  the  hope  is  still 


46  Bacteriology 

only  a  hope.  It  has  been  proved  that  some  antistreptococcic  sera  have  not  as 
high  an  opsonic  index  for  streptococci  as  has  normal  horse-serum,  and  "the 
opsonin  content  of  an  antistreptococcic  serum  seems  to  be  the  factor  that 
gives  the  serum  whatever"  value  it  possesses  (Jordan's  "General  Bacteriology"). 
Tavel  and  Moser,  believing  that  scarlatina  is  a  streptococcic  malady,  prepare 
serum  by  using  cultures  of  streptococci  obtained  from  a  number  of  cases  of 
scarlet  fever.  Van  de  Velde  uses  cultures  of  streptococci  obtained  from  various 
streptococcic  infections.  According  to  Burkard  antistreptococcic  serum  de- 
stroys neutrophiles  in  the  blood.  This  destruction  is  not  harmful  if  leukocytosis 
follows  the  injections,  and  it  does  follow  them  in  aU  cases  when  the  body  is  able 
to  react  to  the  serum  ("Archiv.  f.  Gynak.,"  Ixxx,  No.  3).  Before  remo\'ing  a 
tongue  or  an  upper  jaw  it  is  my  custom  to  give  antistreptococcic  serum,  and  I 
beheve  that  it  lessens  the  tendency  to  toxemia  and  to  septic  bronchopneumonia. 
Malignant  tumors  (both  sarcomata  and  carcinomata)  have  been  treated  with 
the  blood-serum  of  dogs,  which  animals  had  been  injected  with  fluid  expressed 
from  malignant  growths  fRichet  and  Hericourt).  Von  Leyden  and  Blumen- 
thal  obtain  a  serum  by  compression  of  a  recent  cancerous  growth  and  treat 
human  \dctims  of  cancer  with  it.  They  claim  that  the  results  are  encouraging 
("Deutsche  medicinische  Wochenschrift,"  Sept.  4,  1902).  Many  claims  made 
for  serimi- therapy  in  surgical  diseases  are  exaggerated,  sensational,  and  un- 
scientific. It  does  not  seem  possible  to  obtain  an  antitoxin  for  each  bacterial 
malady,  and  the  bacteria  of  most  specific  diseases  are  potent  for  harm  for  more 
reasons  than  because  they  form  crystalloidal  toxic  matter.  That  there  is  truth 
in  the  method  seems  highly  probable,  but  how  much  truth  there  is,  is  not  yet 
definitely  ascertained.  It  is  our  duty  to  study,  experiment,  and  observe,  and  to 
reach  a  conclusion  only  after  honest,  careful,  and  thorough  investigation.  A 
httle  skepticism  is  as  yet  a  safe  rule. 

Anaphylaxis,  or  Untoward  Effects  of  Serum  Injections. — Anaphylaxis  is  a 
term  introduced  by  Richet  in  1904  to  designate  a  state  of  h}-persusceptibiHty 
(congenital  or  acquired)  "to  a  strange  protein  or  antigen  with  a  reaction  body 
formed  in  the  body  of  the  organism  undergoing  immunity"  (St.  George  T. 
Grinnan,  in  "Jour.  Amer.  Med.  Assoc,"  Jan.  20,  191 2).  It  has  been  known 
for  a  considerable  time  that  guinea-pigs  which  had  been  injected  -^-ith  anti- 
toxin frequently  died  when  injected  with  the  serum  again  some  time  later; 
the  curious  fact  is  that  the  first  dose  does  no  harm,  but  the  second  dose, 
given  after  several  days,  produces  the  trouble.  In  man  unpleasant  or  even 
dangerous  effects  may  follow  the  injection  of  any  serum.  They  occur  in  certain 
hypersensitive  individuals.  They  may  occur  from  a  first  dose,  but  are  far  more 
apt  to  arise  from  the  second,  the  third,  or  some  later  injection.  They  are 
most  apt  to  occur  when  there  has  been  an  interval  of  two  or  three  weeks  be- 
tween injections.  In  some  cases  where  death  followed  a  first  injection  an 
enlarged  thymus  existed.  In  a  recent  case  in  Philadelphia  this  was  proved  by 
autopsy. 

The  symptoms  may  be  trivial  and  not  arise  for  several  hours.  The  most 
common  ones  are  joint  pains,  weakness,  depression,  dyspnea,  urticaria  or 
erythema,  cough,  itching,  sneezing,  edema'  of  the  face,  and  swelling  of  the 
tongue  ("Progressive  Medicine,"  Dec.  i,  1908). 

The  symptoms  may  be  serious  and  arise  in  a  few  minutes.  In  such  a  con- 
dition any  of  the  previously  mentioned  symptoms  may  exist,  but  the  dysp- 
nea is  urgent,  the  face  is  often  cyanosed,  and  collapse  occurs.  In  some  cases 
death  occurs  in  a  few  minutes  after  an  injection.  When  untoward  results 
foUow  a  first  injection  the  condition  is  regarded  as  hyper  susceptibility  to  serum. 
When  it  follows  a  later  injection  it  is  called  serum  disease.  We  fear  fatahty 
from  an  initial  dose  when  there  is  hypersusceptibihty.  Serimi  disease  is 
usually  made  manifest  by  minor  symptoms  developing  from  eight  to  thirteen 


Vaccine  Therapy,  or  Treatment  of  Infections  by  Bacterial  Vaccines     47 

days  after  a  first  injection  or  almost  at  once  after  an  injection  given  from  four- 
teen days  to  four  months  after  the  first  one.  There  is  no  way  of  knowing 
beforehand  that  a  person  is  hypersensitive  or  that  he  is  Uable  to  serum  disease 
except  that  asthma  is  ominous  and  makes  us  fear  some  untoward  effect.  The 
dyspnea  in  some  cases  may  have  been  due  to  enlarged  thymus.  In  using 
diphtheria  antitoxin  or  tetanus  antitoxin  the  serima  should  be  given  at  close 
intervals  and  not  at  intervals  of  several  days. 

Vaccine  Therapy,  or  Treatment  of  Infections  by  Bacterial  Vac= 
cines  (Bacterines,  as  S.  Solis  Cohen  calls  them).^ — The  studies  of  Wright  and 
Douglas  upon  opsonins  led  to  the  adoption  of  this  plan  of  treating  certain 
infections. 

By  the  injection  of  an  antitoxic  sertun  w^e  seek  to  directly  neutralize  toxic 
products.  By  the  injection  of  the  bacterial  vaccines  we  seek  to  stimulate  the 
body  cells  to  produce  antibodies  and  particularly  opsonin.  An  injection  of 
antitoxic  serum  has  only  a  temporary  effect.  Injections  of  bacterial  vaccine 
cause  a  much  more  enduring  effect.  After  such  an  injection  the  opsonic  index 
usually  begins  to  rise  in  from  twelve  to  twenty-four  hours.  Additional  doses 
gain  more  pronounced  response.  The  injections  appear  to  be  free  from  all 
danger.  Bacterial  vaccine  consists  of  dead  bacteria  and  their  endotoxins 
made  into  emulsion  in  normal  salt  solution.  Each  individual  has  his  own  re- 
sponse to  such  an  injection,  but  this  response  varies  at  different  times.  An 
antitoxic  serum  contains  other  antibodies  besides  antitoxin.  Bacterial  vac- 
cine is  made  up  with  salt  solution  and  is  truly  specific.  A  vaccine  made 
up  from  a  certain  variety  of  organisms  is  valuable  only  in  infections  from 
that  variety  of  organism.  In  some  cases  stock  cultures  are  used,  but  it  is 
better  whenever  possible  to  obtain  the  bacteria  from  the  infected  person  and 
obtain  our  cultures  from  them  (autogenous  vaccine).  In  some  cases,  how- 
ever, we  cannot  wait  for  the  development  of  a  culture  and  must  then  use 
stock  vaccines.  In  erysipelas  we  cannot  use  autogenous  vaccine.  In  a  mixed 
infection  it  is  sometimes  uncertain  which  organism  is  the  main  factor  in  causing 
the  trouble  and  danger,  and  yet  that  is  the  main  factor  agamst  which  the  vaccine 
must  be  leveled.  Until  recently  it  was  beheved  that  the  dose  must  be  deter- 
mined by  the  opsonic  index.  This  plan  is  now  seldom  followed.  Each  cubic 
centimeter  of  Wright's  stock  vaccine  contains  600,000,000  dead  bacteria. 
The  first  dose  is  |  c.c.  and  the  second  dose  is  i  c.c.  HartweU  and  Lee  repeat 
the  fuU  dose  every  fourth  or  fifth  day  until  the  lesions  are  cleared  up  ("Pub- 
lications of  Mass.  General  Hosp.,"  Oct.,  1908).  Each  injection  is  made  in  the 
subcutaneous  tissue,  the  skin  having  been  previously  scrubbed  with  soap  and 
water  and  washed  with  alcohol.  In  many  cases  there  is  a  trivial  reaction  after 
injection.  This  reaction  is  not  febrile,  is  of  brief  diiration,  and  is  manifested 
by  headache,  backache,  and  languor.  It  might  weU  be  asked,  Why  inject  dpad 
bacteria  to  stimulate  resistance  when  live  bacteria  in  the  individual  have  failed 
to  do  it?  The  theory  is  that  the  bacteria  causing  the  disease  have  died  too 
quickly  in  the  blood  or,  for  some  other  reason,  have  failed  to  produce  enough 
stimulation  to  result  in  the  copious  production  of  antibodies. 

There  is  much  testimony  as  to  the  value  of  this  plan  of  treatment.  The 
temperature  of  some  cases  of  streptococcic  infection  may  be  rapidly  lowered  by 
vaccine  treatment,  pus  formation  may  be  lessened,  and  delirivun  be  abohshed. 
It  is  particularly  serviceable  in  superficial  infections  from  the  Staphylococcus 
aureus  (boils  and  carbuncles).  In  many  cases  pain  and  tenderness  begin  to 
abate  a  few  horn's  after  the  first  injection,  a  profuse  discharge  flows  from  the 
lesion  if  it  is  open,  and  gathers  in  the  tissues  if  there  is  no  opening.      If  the  focus 

^  In  this  connection  see  particularly  article  by  Roger  J.  Lee  and  article  by  H.  F.  Hart- 
weU and  Roger  J.  Lee  in  "  Publications  of  Mass.  General  Hosp.,"  October,  1908;  also  article 
by  Ball,  in  "  Lancet,"  June  8,  191 2.     I  have  used  these  articles  freely. 


48  Bacteriology 

of  infection  is  closed  it  should  be  incised,  but  Wright  insists  that  antiseptics 
must  not  be  used,  as  they  destroy  the  activity  of  opsonins.  The  treatment  is  of 
little  or  no  value  in  abscess,  pyemia,  septicemia,  and  mixed  infections.  It 
seems  certain  that  in  an  overwhelming  infection  a  vaccine  can  do  no  possible 
good.  In  such  a  condition  it  cannot  possibly  cause  the  patient's  tissues  to  pro- 
duce antibodies.  We  may  lay  it  down  as  a  rule  that  vaccines  are  particularly 
indicated  for  chronic  and  for  local  infections,  and  serums  for  general  infections. 
In  an  acute  infection  give  serum  at  once  and  autogenous  vaccine  as  soon  as  it 
can  be  made  (Ball's  rule). 

Tuberculin. — (See  page  220.) 

Special  Surgical  Microbes. — Suppuration  (see  page  132)  is  caused  by 
microbes.  Does  it  ever  exist  without  them?  The  answer  is,  "Practically  no." 
Injection  of  a  sterile  fluid  containing  dead  organisms,  or  the  injection  of  the 
sterile  products  of  the  growth  of  pyogenic  cocci,  will  form  a  limited  amount  of 
pus.  Injection  of  an  irritant  causes  the  formation  of  a  thin  fluid  which  may 
resemble  pus,  but  is  not  pus.  In  surgery  pus  very  seldom  forms  without  the 
actual  presence  of  living  micro-organisms  (see  page  133),  and  the  presence  of 
pus  is  regarded  as  proving  the  presence  of  Hving  micro-organisms. 

Pyogenic  Bacteria. — Pus  microbes,  or  pyogenic  microbes,  are  strongly 
proteolytic,  that  is,  they  possess  the  property  of  peptonizing  albumin,  and 
thus  forming  pus.  The  peptonizing  action  is  brought  about  by  bacterial 
products.  Some  believe  that  pus  is  not  formed  by  a  peptonizing  action  of 
the  bacteria,  but  that  the  bacteria  furnish  a  poison  (leukolysin)  which  breaks 
up  the  leukocytes,  and  that  the  breaking  up  of  leukocytes  Hberates  an  enzyme 
which  dissolves  albumin.  The  inflammation  which  surrounds  an  area  of 
pyogenic  infection  is  caused  by  the  irritant  products  of  bacterial  action  (tox- 
albimiins,  ammonia,  etc.).  In  the  presence  of  the  pyogenic  peptones  the 
coagulation  of  inflammatory  exudate  is  retarded  or  prevented.  Bacteria 
which  ordinarily  cause  suppuration  may  fail  to  cause  it,  producing  instead 
a  non-suppurative  inflammation.  Non-suppurating  inflammation  may  arise 
if  bacteria  are  present  in  small  numbers  or  if  the  tissue  resistance  is  at  a 
high  level,  or  if  the  virulence  of  the  bacteria  has  been  modified  by  adverse 
antecedent  conditions.  Bacteria  which  ordinarily  do  not  cause  suppuration 
may  do  so  under  certain  conditions  of  increased  bacterial  virulence  or  lessened 
tissue  resistance.  The  typhoid  bacillus  is  at  times  pyogenic,  but,  as  a  rule, 
it  is  not  pyogenic.  The  usual  causes  of  suppuration  are  the  following  micro- 
organisms. 

The  term  Micrococcus  pyogenes  (Fig.  15)  includes  the  Staphylococcus 
aureus,  the  Staphylococcus  albus,  and  the  Staphylococcus  citreus.  These 
forms  are  deviations  from  one  form  and  are  not  specifically  different.  The 
albus  and  citreus  may  be  grown  from  the  aureus,  and  they  may  remain  white 
and  yellow  or  may  revert  in  part  to  the  aureus  form  ("Atlas  of  Bacteriology," 
by  Lehmann  and  Neimiann) .  Some  observers  maintain  that  these  forms  vary 
greatly  in  virulence  and  hence  are  specifically  different,  but  the  varying 
virulence  has  been  disputed,  and  it  seems  to  have  been  proved  that  virulence 
may  be  lessened  greatly  even  when  the  color  does  not  change.  Eighty  per 
cent,  of  acute  abscesses  are  due  to  staphylococci.  Staphylococci  are  found 
also  in  osteomyeHtis,  in  carbuncle,  in  boil,  in  acne,  in  pemphigus,  in  perios- 
titis, in  septicemia,  and  in  pyemia,  and  in  some  cases  of  empyema  and  perito- 
nitis. Some  toxic  products  of  staphylococci  destroy  leukocytes.  AU  of  the 
staphylococci  are  non-motile. 

Staphylococcus  pyogenes  aureus  (Plate  i.  Figs,  i  and  15),  is  the  golden- 
yeUow  coccus.  When  grown  in  the  air  it  produces  orange-yellow  pigment. 
This  is  the  most  usual  cause  of  abscesses  (circumscribed  suppurations) .  _  The 
Staphylococcus  pyogenes  aureus  grows  best  in  air,  but  can  grow  when  air  is  ex- 


BACTERIOLOGY, 


Plate  i. 


1.  Staphylococcus  pyogenes  aureus. 

2.  Staphylococcus  pyogenes  albus. 

3.  Bacillus  tuberculosis  on  glycerin-agai'. 

(Warren's  Surgical  Pathology.^ 


Pyogenic  Bacteria  49 

eluded.  As  it  can  thus  grow  it  is  a  facultative  anaerobic  parasite.  It  is 
widely  distributed  in  nature,  and  is  found  in  the  soil,  the  dust  of  air,  water,  the 
alimentary  canal,  under  the  nails,  on  and  in  the  superficial  layers  of  skin, 
especially  in  the  axillae  and  perineum,  in  the  mouth,  the  nasal  cavities,  the  va- 
gina, and  human  milk.  It  forms  the  characteristic  color  only  when  it  grows 
in  air  (Plate  i,  Fig.  i).  It  is  killed  in  ten  minutes  by  a  moist  temperature  of 
58°  C.  and  is  instantly  killed  by  boiling  water.  Carbolic  acid  (i  :  40)  and 
corrosive  sublimate  (i  :  2000)  are  quickly  fatal  to  this  coccus. 

Staphylococcus  pyogenes  albus  (Plate  i,  Fig.  2),  the  white  staphylococcus, 
acts  like  the  aureus,  but  is  usually  more  feeble  in  power.  When  this  organism 
is  found  upon  and  in  the  skin  it  is  called  the  Staphylococcus  epidermidis  albus, 
an  organism  which  Welch  proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreus,  the  lemon-yellow  coccus,  is  found  occa- 
sionally in  acute  circumscribed  suppurations,  but  less  often  than  are  the 
other  two  forms.     Its  pyogenic  power  is  even  weaker  than  that  of  the  albus. 

The  Staphylococcus  cereus  albus  and  the  Staphylococcus  cereus  flavus  are 
found  occasionally  in  acute  abscesses,  but  these  forms  cannot  be  sharply  dif- 
ferentiated from  the  Micrococcus  pyogenes  and  the  names  should  be  abandoned. 

Staphylococcus  flavescens  is  occasionally  found  in  abscesses.  It  is  inter- 
mediate between  the  aureus  and  albus. 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a  bunch  of  grapes. 
It  is  occasionally  found  in  the  pus  of  acute  abscesses. 


Fig.  15. — Micrococcus  pyogenes  anreus  (X  looo)  Fig.  i6. — Streptococcus  pyogenes  (X  700)  (Leh- 

(Lehmann  and  Neumann).  mann  and  Neumann). 


The  Micrococcus  tetragenus  is  thought  to  be  the  bacterium  chiefly  respon- 
sible for  the  suppuration  of  tuberculous  pulmonary  lesions. 

Streptococcus  pyogenes  (Fig.  16). — This  coccus,  known  as  the  chain  coccus, 
grows  best  in  air  and  can  also  grow  when  air  is  excluded.  It  is  non-motile  and 
does  not  bear  spores.  It  is  found  in  the  healthy  human  body  in  the  nasal 
ca\dties,  urethra,  mouth,  vagina,  and  on  the  skin.  It  has  been  found  in  spread- 
ing inflammation  and  suppuration,  erysipelas,  pneumonia,  otitis,  puerperal 
fever,  pyemia,  septicemia,  lymphangitis,  some  very  acute  abscesses,  and  some 
cases  of  meningitis,  empyema,  peritonitis,  ulcerative  endocarditis,  pericarditis, 
osteomyelitis,  diarrhea,  and  in  certain  sore  throats.  It  varies  very  greatly 
in  virulence  and  the  intensity  of  its  action  is  strongly  influenced  by  the  natiire 
of  the  soil  in  which  it  is  implanted.  Streptococci  are  apt  to  cause  serious  local 
lesions,  violent  constitutional  involvement,  and  frequently  death.  Not  only  do 
streptococci  produce  virulent  toxins,  but  they  also  produce  a  non-toxic  material 
called  hemolysin,  which  dissolves  red  corpuscles.  Some  bacteria  always  get 
in  the  blood  drnring  the  existence  of  a  streptococcic  infection.  In  a  mild  case 
those  w^hich  enter  the  blood  are  soon  killed.  Even  in  a  very  severe  case  we  may 
be  unable  to  demonstrate  them,  but  they  are  surely  there.  Woodhead  tells 
us  (Treves's  "System  of  Surgery")  that  six  organisms,  each  of  which  bears  a 
separate  name,  are  discussed  under  this  designation.     Three  of  these  organ- 


50  Bacteriology 

isms  he  places  in  one  group,  two  in  another,  and  says  the  sixth  may  be  a  sepa- 
rate species. 

ist  Group. — Streptococcus  pyogenes  (Fig.  i6),  found  especially  in  spreading 
suppuration.  Such  suppurations  spread  because  streptococci  only  feebly 
attract  leuiocytes  and  prevent  the  coagulation  of  exudate.  Streptococci 
are  also  found  in  very  acute  abscesses.  About  15  per  cent,  of  acute  abscesses 
contain  streptococci.  The  Streptococcus  pyogenes  is  easily  killed  by  boiling, 
and  can  be  destroyed  by  carbolic  acid  and  corrosive  subhmate.  These  organ- 
isms are  normally  present  in  the  nasal  passages,  vagina,  mouth,  and  urethra. 

Streptococcus  pyogenes  malignus,  an  uncommon  organism  found  in  splenic 
abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up  into  diplococci. 

2d  Group. — Streptococcus  of  erysipelas  is  found  in  the  capillary  lymph- 
spaces  in  erysipelas.  Many  bacteriologists  believe  it  to  be  identical  with  the 
Streptococcus  pyogenes.  These  bacteria  tend  particularly  to  gather  in  the 
lymph-spaces.  They  rarely  produce  pus  and  when  they  do  it  is  usually  watery. 
When  ordinary  thick  pus  forms  there  is  a  mixed  infection  with  staphylococci. 

Streptococcus  of  Septicemia  and  Pyemia. — Most  observers  maintain  that 
it  is  identical  with  the  Streptococcus  pyogenes  and  the  streptococcus  of  ery- 
sipelas. 

3d  Group. — Streptococcus  articulorum,  found  in  the  false  membrane  of 
diphtheria  (see  the  article  by  Woodhead  in  the  "System  of  Surgery,"  by  Sir 
Frederick  Treves). 

Other  Pyogenic  Organisms. — The  various  forms  of  colon  bacillus,  the 
typhoid  bacillus,  the  Streptococcus  intracellularis,  the  Micrococcus  tetragenus, 
and  the  pneumococcus,  are  at  times  pyogenic.  Pneumococci  may  produce  ar- 
thritis (see  page  638),  peritonitis  (see  page  1030),  cholecystitis,  empyema,  necro- 
sis of  bone,  or  wound  infection.  A  case  of  wound  infection  due  to  pneumococci 
was  reported  by  J.  H.  Beaty  ("Northwestern  Lancet,"  July  i,  1907).  In  many 
persons  pneumococci  exist  in  the  mouth.  A  common  form  of  colon  bacillus  is 
the  Bacillus  pyogenes  fetidus:  it  is  found  in  stinking  peritoneal  pus  and  in  the 
pus  of  ischiorectal  abscesses.     The  gonococcus  is  also  pyogenic. 

The  Bacillus  pyocyaneus  maybe  the  sole  cause  of  a  suppuration,  but  usually 
when  it  appears  it  constitutes  a  secondary  infection  in  a  suppurating  area.  It 
causes  a  blue  or  blue-green  hue  in  pus  and  wound  discharges. 

It  is  normally  found  in  water  and  exists  in  the  mouth,  intestine,  and  skin. 

'Other    Surgical    Microbes. — Streptococcus    of    erysipelas    (Fehleisen's 

coccus),  as  stated  before,  is  thought  by  many  to  be  identical  with  the  Strep to- 

coccus  pyogenes.     Their  difference  in  action  is  believed  by 

^  Sternberg  to  be  due  to  difference  in  virulence  induced  by 

^^^  external  conditions  and  by  the  state  of  the  tissues  of  the 

Sm   fiB  host.     The  coccus  of  erysipelas  is  somewhat  larger  than 

Fig  if_MSococci     t^®  ordinary  form  of  Streptococcus  pyogenes.     Infection 

gonorrhoeEe,       highly     takes  place  by  a  wound,  often  a  very  trivial  wound  of 

magnified,    schematic     ^-j^g  gkin  or  mucous  membrane.     The  cocci  multiplv  in  the 

mS^^"^  ^^'''     small  lymph-channels.     This  coccus_  wih  cause  puerperal 

fever  in  a  woman  in  childbed  when  it  gains  access  to  any 

area  in  the  genital  tract  from  which  absorption  can  occur.     The  streptococcus 

seldom  causes  suppuration  in  erysipelas;  when  it  does  so  the  pus  is  usually 

watery.     Thick  pus  means  mixed  infection. 

The  gonococcus,  or  the  Micrococcus  gonorrhoea  (the  bacillus  of  Neisser)  (Fig. 
18),  is  the  diplococcus  which  causes  gonorrhea.  Neisser,  in  1879,  observed  this 
bacillus  in  pus  from  gonorrheal  ophthalmia  and  urethral  gonorrhea.  Bumm, 
in  1887,  proved  the  causative  influence  of  the  gonococcus.  He  reproduced  the 
disease  in  a  healthy  female  urethra  by  inoculation  with  the  twentieth  genera- 


Other  Surgical  Microbes  51 

tion  in  descent  from  a  pure  culture.  These  micrococci  are  in  pairs,  and  each 
member  of  a  pair  is  kidney  shaped  (Fig.  17).  Gonococci  grow  best  in  air, 
but  can  grow  when  air  is  excluded.  Diplococci  are  found  often  in  the  secretions 
of  apparently  healthy  mucous  membranes,  and  simulate  very  closely  gonococci, 
but  genuine  gonococci  are  not  so  found.  The  gonococcus  is  a  pure  parasite 
and  is  not  found  outside  of  the  organism  except  upon  articles  contaminated 
with  gonorrheal  discharge.  In  male  gonorrhea  the  gonococci  are  in  the  urethra 
and  prostate;  in  female  gonorrhea  they  are  in  the  urethra,  glands  of  Bartholin, 
and  cervLx  uteri.  These  cocci  may  cause  gonorrheal  conjunctivitis,  lymphan- 
gitis, lymphadenitis,  rhinitis,  otitis,  proctitis,  endometritis,  salpingitis,  oophori- 
tis, cystitis,  peritonitis,  bursitis,  thecitis,  pleuritis,  malignant  endocarditis, 
arthritis,  periostitis,  abscess,  and  parotitis.  In  chronic  urethral  gonorrhea  the 
gonococci  may  at  times  be  absent  from  the  discharge,  returning  when  there  has 
been  sexual  or  alcoholic  excess,  traumatism,  or  contact  with  an  irritant  secre- 
tion. In  such  a  case  there  could  have  been  but  a  very  few  gonococci  in  the 
urethra  before  the  irritation  was  applied,  and  the  discharge  was  kept  up,  in 
part  at  least,  by  irritant  toxins.  If  a  part  in  such  a  condition  is  irritated,  active 
multiplication  begins  and  the  cocci  reappear  in  the  discharge.  Gonococci 
cannot  be  cultivated  upon  ordinary  media,  but  grow  best  upon  humaij  blood  or 
hmnan  blood-serum.  In  gonorrhea 
the  organisms  are  found  both  within  ^  .j,#<i 

and  outside  of  pus-cells  and  on  mucous  *V*  •  •••        •  «  • 

cells  (Fig.  18).     The  gonococci  infect  *v"**  ^,,%^ 

a    surface    covered    with    cylindrical  »         •  ,';«e*»'  JS^ 

epithelium  much  more  readily  than  a  «►  yj** , ,  *  „ 

surface    covered   with  pavement-epi-      .  -~    *         *  •*  •*•»••?  '^ 

thehiun.      They  pass   into    the   sub-        ^,»e*,  *  •  *  * 
mucous    tissue,    cause    inflammation,      %•''***'        • 
and  spread    by    way  of   the  lymph-       '••*y/ 
paths.      It  seems    certain    that    the 

gonococcus      is      pyogenic,      although  Fig.  18.— Gonococci  from  gonorrheal  pus. 

mLxed  infection  with  other  pyogenic 

organisms  may  exist  in  this  disease.  Their  presence  inside  of  pus-cells  means 
phagocytosis.  Gonococci  stain  easily  by  methylene-blue  and  are  readily 
decolorized  by  Gram's  method. 

In  noma  streptococci  are  found.  No  specific  organism  has  been  isolated 
for  traumatic  spreading  gangrene  or  hospital  gangrene. 

The  bacillus  of  tetanus  or  the  Bacillus  tetani  (Nicolaier's  bacillus)  (Fig. 
19)  was  discovered  by  Nicolaier  in  1884.  In  1889  Kitasato  obtained  a  pure 
culture.  It  is  an  obligate  anaerobic  organism.  In  recent  cultures  at  least 
it  ceases  to  grow  in  the  presence  of  free  oxyg&a.  It  grows  within  the  tissues 
of  the  animal  body.  In  a  wound  to  which  air  has  access  the  bacilli  may  lie 
so  surrounded  by  fluid  that  air  cannot  reach  the  bacteria.  Pyogenic  or 
saprophytic  bacteria  may  consume  the  air  or  the  bacUli  may  lie  in  a  laceration 
of  the  tissue  the  outlet  of  which  is  sealed  by  exudate  or  blood.  The  bacillus 
of  tetanus  is  a  facultative  saprophyte,  that  is,  under  certain  conditions  it  can 
grow  in  dead  organic  material.  It  is  possible  to  develop  by  cultivation  bacilli 
which  will  live  in  air,  but  such  bacilli  have  lost  their  virulence. 

The  baciUi  of  tetanus  are  widely  distributed.  They  are  found  particularly 
in  hay,  in  the  soil  of  gardens,  in  the  dust  of  old  buildings,  in  street  dust  and 
dirt,  and  in  the  sweepings  of  stables.  The  feces  of  healthy  horses,  cattle,  and 
men  may  contain  the  bacilli.  Tetanus  develops  after  a  wound  and  the  baciUi 
remain  in  the  wound  and  do  not  enter  the  blood.  They  furnish  deadly  toxms 
which  are  absorbed.  The  symptoms  are  due  to  intoxication,  not  to  infection. 
The  toxin  of  tetanus  is  alkaloidal,  not  albuminoidal.     These  baciUi  stain  by 


52 


Bacteriology 


Fig.  ig. — Bacillus  of  tetanus,  with  spores. 


Gram's  method.  Cultures  are  made  in  agar-agar  punctures,  the  air  being 
excluded,  or  on  gelatin-containing  glucose  and  in  an  atmosphere  of  hydrogen. 
These  bacilU  when  placed  under  somewhat  unfavorable  conditions  sporulate 
with  great  rapidity,  and  the  spores  are  seen  at  the  ends  (Fig.  19).  The  spores 
are  far  more  resistant  than  the  adult  bacilli,  and  it  is  dif&cult  to  kill  them  in  a 
wound.     A  drug  which  is  very  fatal  to  tetanus  bacilli  is  bromin. 

The  Bacillus  tuberculosis  (Koch's 
bacillus)  (Fig.  20).  This  bacillus 
is  the  cause  of  all  tuberculous  pro- 
cesses. It  was  discovered  and  cul- 
tivated by  Koch  in  1882. 

It  is  non-motile  and  requires 
oxygen  in  order  to  grow,  but  may 
obtain  this  from  the  body  cells  or 
fluids.  It  stains  by  Gram's  method 
and  by  fuchsin.  These  bacilli  are 
cultivated  upon  glycerin-agar  or 
solid  blood-serum  (Plate  i,  Fig.  3). 
They  are  found  in  dust  contain- 
ing the  dried  sputum  of  victims  of 
phthisis  and  dried  discharges  and 
secretions  of  tuberculous  patients. 
This  infected  dusty  air  is  influential 
in  conveying  infection  (inhalation 
tuberculosis).  Infection  can  also 
be  conveyed  by  inoculation  of  bacilli 
(inoculation  tuberculosis)  and  by  eating  the  meat  and  drinking  the  milk  of 
tuberculous  animals  (ingestion  tuberculosis).  Tuberculin  is  discussed  on 
page  220. 

Koch  maintains  that  the  human  type  of  bacilli  is  almost  altogether 
responsible  for  tuberculosis  in  himian  beings.  Behring  and  many  other  ob- 
servers dispute  this  statement,  and  assert  that  bovine  bacilli  are  frequently 
responsible  for  tuberculosis  in  human  beings.  It  seems  certain  that  in  children 
many  cases  of  glandular  tuberculosis  and  abdominal  tuberculosis  are  due  to 
bovine  bacilli.  The  bacilli  of  cattle  are 
not  so  long  or  thick  and  are  straighter 
than  human  bacilli.  It  is  not  yet  quite 
certain  that  the  bovine  bacilli  are  iden- 
tical with  human  bacilli.  They  are  at 
least  very  close  blood  relations. 

Bacillus  anthracis,  or  the  bacillus  of 
anthrax  (Fig.  2 1) ,  is  the  cause  of  malignant 
pustule,  anthrax,  or  splenic  fever.  This 
bacillus  was  first  observed  by  PoUender 
in  1849,  ^^'^  its  causal  influence  was  first 
strongly  asserted  by  Davaine  in  1863. 
Davaine's  contention  was  proved  by 
Koch  in  1876.  It  is  non-motile.  Tissue 
containing  it  is  stained  by  Gram's  method, 
by  a  watery  solution  of  an  analine  dye.  It  will  grow  without  oxygen,  but  grows 
best  in  air.  In  the  presence  of  air  sporulation  occurs,  but  it  does  not  occur  in 
the  infected  animal.  It  grows  upon  or  in  gelatin  or  agar.  Only  outside  of 
the  diseased  body  are  spores  found,  and  they  exist  in  the  hides  and  hair  of 
infected  animals  and  in  stalls  and  pastures  in  which  diseased  animals  were  kept. 
Bacillus  mallei,  or  the  bacillus  of  glanders,  is  the  cause  of  glanders.     It  was 


\"- 

'   V  ^ 

V    ^ 

-- 

'a'' 

0. 

^- 

^ 

^          V 

<S 

.^_ 

■^ 

^     ^-^ 

\^--. 

~f 

\ 

\ 

;\^ 

\ 

Fig.  20. — Tubercle  bacilli  in  sputum  (Ziegler). 

Cover-glass  preparations  are  stained 


Other  Surgical  Microbes  53 

discovered  by  Loffler  and  Schlitz  in  1882.  It  is  non-motile  and  grows  best  in 
air,  growing  with  great  difficulty  when  air  is  excluded.  It  grows  well  upon 
glycerin-agar  and  does  not  stain  by  Gram's  method.  It  is  never  found  except  in 
the  body  of  a  diseased  man  or  other  animal.  It  is  best  cultivated  in  solid  blood- 
serum.     Under  certain  circumstances  some  few  of  the  bacilli  contain  spores. 

The  pneumococcus,  called  also  the  Diplococcus  pnenmonice,  FrdnkeVs  bacillus, 
and  the  Streptococcus  lanceolatus,  was  discovered  by  Sternberg  in  1880.  It  is 
often  found  in  the  saliva  of  healthy  individuals.    It  is  not  found  outside  of  the 


Fig.  21.— Bacillus  anthracis  (X  1000)  (Lehmann        Fig.  22.— Bacillus  of  malignant  edema  (Lehmann 
and  Neumann).  and  Neumann). 

body.  It  varies  greatly  in  virulence,  but  when  virulent  can  establish  inflamma- 
tion and  even  suppuration,  particiilarly  of  mucous  and  serous  surfaces.  It  is 
especially  apt  to  lodge  and  multiply  in  the  lung,  but  it  may  lodge  in  a  joint, 
in  the  brain  membranes,  in  the  peritoneum,  or  in  other  parts.  It  may 
cause  croupous  pneimionia,  catarrhal  pneumonia,  pleuritis,  meningitis,  con- 
junctivitis, arthritis,  peritonitis,  periostitis,  osteomyelitis,  parotitis,  salpingitis, 
empyema,  cholecystitis,  perinephric  and  other  abscesses,  nephritis,  tonsillitis, 
mastoiditis,  and  septicemia.  In  any  of  these  conditions  it  may  appear  in 
the  blood.  Pneumococci  in  the 
blood  constitute  pneimiococcemia. 
In  fact,  it  may  appear  in  the  blood 
when  the  lungs  have  not  been 
diseased.  Pneumococcic  arthritis, 
peritonitis,  cholecystitis,  or  em- 
pyema may  arise  without  coexist- 
ing or  antecedent  pneumonia.  The 
pneumococcus  grows  best  in  bouil- 
lon cultures,  in  blood-serum  and 
in  glycerin-agar.  Sir  Thomas 
Oliver  ("Brit.  Med.  Jour.,"  April 
30,  1910)  points  out  the  interest- 
ing fact  that  in  pneumococcic 
meningitis,  although  symptoms  are 
largely  cerebral,  the  patient  looks 
like  one  suffering  from  pneumonia. 

The  Bacillus  coli  communis,  called  also  the  Bacterium  coli  commune,  the 
colon  bacillus,  or  the  bacillus  of  Escherich  (Fig.  23),  was  discovered  in  feces  by 
Emmerich  in  1885.  Under  ordinary  conditions  this  is  a  putrefactive  bacillus 
inhabiting  the  intestinal  canal  and  feces  invariably  contain  it.  It  is  found  in 
the  mouth,  nose,  and  vagina,  on  the  skin,  and  under  the  nails.  The  bacillus  is 
normally  found  in  water,  even  in  water  regarded  by  the  users  as  pure.  It  has 
already  been  stated  that  this  ordinarily  harmless  micro-organism  may,  under  cer- 
tain conditions,  acquire  pathogenic  power  and  enter  the  circulation.  This  bacte- 
rivim  grows  best  in  air,  but  it  can  also  grow  when  air  is  excluded.     It  is  not 


>» 

<*  r 

*■   i 

'             1         , 
< 

Fig.  23. — Bacillus  coli  communis. 

54  Bacteriology 

stained  by  Gram's  method  and  has  pyogenic  power.  It  stains  with  anilin  dyes 
and  is  decolorized  by  iodin  solution.  There  are  numerous  forms  of  colon  bacilH, 
and  some  of  them  are  motile,  some  are  amotile.  This  bacillus  may  be  respon- 
sible for  appendicitis,  peritonitis,  inflammation  of  the  genito-urinary  tract, 
pneumonia,  inflammation  of  the  intestine,  leptomeningitis,  perineal  abscess, 
cholangitis,  cholecystitis,  myelitis,  puerperal  fever,  wound  infection,  and 
septicemia.  It  is  the  cause  of  many  abscesses  about  the  intestine,  and  is 
responsible  for  many  ischiorectal  abscesses.  From  the  pus  of  an  appendiceal 
abscess  we  may  perhaps  obtain  a  pure  culture  of  Escherich's  bacillus,  but  usu- 
ally find  also  streptococci  or  staphylococci,  and  sometimes  pneumococci. 
Colon  bacilli  introduced  into  the  system  by  tainted  food  may  be  responsible 
for  epidemic  pneumonia.  A  few  years  ago  there  was  such  an  epidemic  in 
Middlesbrough,  England  (Oliver,  in  "Brit.  Med.  Jour.,"  April  30,  1910). 

Lehmann  and  Neumann  point  out  that  there  are  occasionally  encountered 
"gaseous  phlegmons  and  similar  diseases  of  internal  organs,  in  which  are  found 
the  bacterium  coli  alone  or  usually  in  combination  with  other  varieties,  but 
without  any  anaerobes  being  present"  ("Atlas  and  Principles  of  Bacteriology," 
vol.  ii,  edited  by  Geo.  H.  Weaver). 

The  Bacillus  cedematis  maligni,  the  bacillus  of  malignant  edema,  or  the 
vibrione  septique  of  Pasteur  (Fig.  22),  was  discovered  by  Pasteur  in  1875. 
This  bacillus  is  found  especially  in  stagnant  water  and  certain  varieties  of  soil 
and  exists  in  putrefying  material.  It  is  sometimes  motile,  but  is  often  amotile, 
and  multiplies  by  spore  formation.  It  is  anaerobic  and  in  its  growth  produces 
bubbles  of  gas.  In  the  disease  known  as  malignant  edema  there  is  usually  a 
mixed  infection  with  the  bacilli  of  malignant  edema  and  saprophytic  organisms, 
and  the  latter  also  form  considerable  quantities  of  gas  in  the  tissues.  The 
bacilli  of  mahgnant  edema  may  cause  either  spreading  bloody  edema  contain- 
ing gas-bubbles  or  spreading  emphysematous  gangrene.  The  bacilli  enter  the 
blood  and  produce  septicemia.  The  bacillus  is  grown  in  the  interior  of  a  stab 
in  gelatin  aga,r-agar  or  solid  blood-serum  when  the  mouth  of  the  stab  has  been 
sealed  up. 

The  Bacillus  aerogenes  capsulatus  of  Welch  was  described  by  Welch  and 
Nuttal  in  1892.  This  bacillus  is  found  sometimes  in  abscesses  containing  gas. 
It  is  causative  of  some  cases  of  gangrenous  cellulitis,  which  is  a  spreading  gan- 
grene with  gas  formation. 

It  has  a  capsule  and  very  seldom  forms  spores.  It  stains  by  Gram's 
method  and  grows  Vv^ell  upon  blood-serimi. 

The  Bacterium  typhi,  the  typhoid  bacillus,  or  Eberth's  bacillus,  was  discovered 
by  Eberth  in  1880.  It  is  sometimes  found  in  water  or  soil  contaminated  by 
typhoid  fecal  matter.  It  never  exists  in  the  healthy  human  body  (except  in 
typhoid  carriers).  It  causes  typhoid  fever  and  in  this  disease  can  be  obtained 
and  cultivated,  particularly  from  the  spleen  and  lymphatic  glands  and  fre- 
quently from  the  blood.  It  has  been  found  in  the  urine,  kidney,  bone-marrow, 
and  bile.  It  is  difficult  to  cultivate  typhoid  bacilH  from  feces  because  of  the 
presence  of  multitudes  of  other  bacteria.  The  bacillus  of  typhoid  is  motile, 
does  not  stain  by  Gram's  method,  and  grows  best  in  air,  but  can  grow  when 
air  is  excluded.  It  grows  upon  all  the  ordinary  nutrient  media.  This  bacillus 
is  particularly  apt  to  be  confounded  with  the  colon  bacillus,  and  it  is  even  possi- 
ble that  the  former  develops  from  the  latter.  Besides  typhoid  fever  the  typhoid 
bacillus  may  cause  peritonitis,  chronic  osteomyelitis,  epididymitis,  orchitis,  gan- 
grene, cholecystitis,  thrombosis,  embolism,  synovitis,  arthritis,  and  pulmonary- 
inflammation.  If  pneimionia  is  caused  by  the  typhoid  bacillus,  there  are  the 
ordinary  physical  signs  of  pneumonia  and  there  are  no  abdominal  symptoms, 
but  the  appearance  of  the  patient  and  the  duration  of  the  disease  are  suggestive 
of  t)^hoid  fever.     It  is  interesting  to  note  that  relapse  may  occur  (Oliver,  in 


Infections  by  Protozoa  55 

"Brit.  Med.  Jour./'  April  30,  1910).  This  bacillus,  under  certain  conditions,  is 
pyogenic.  T\^hoid  bacilli  are  agglutinated  and  lose  motion  by  contact  with  a 
I  to  50  dilution  of  the  blood-serum  of  a  patient  with  tyhpoid  fever  or  conva- 
lescent from  typhoid  fever  (the  Widal  reaction) . 

Putrefactive  Bacteria. — By  putrefaction  we  mean  the  decomposition 
of  albuminous  matter  with  the  production  of  materials  possessed  of  a  foul  odor. 
The  bacilli  of  putrefaction  act  upon  dead  tissue  exposed  to  air  and  are  most 
active  when  the  supply  of  air  is  somewhat  limited.  The  surgeon  encounters 
these  bacteria  in  areas  of  necrosis  or  in  tissues  previously  destroyed  by  other 
microbes.  In  the  latter  case  they  cause  a  mixed  infection.  An  instance  of  such 
a  mLxed  infection  is  putrid  pus.  Some  of  the  products  of  putrefactive  bac- 
teria are  highly  poisonous  (ptomains).  Absorption  of  a  small  amount  of 
putrid  toxin  causes  surgical  fever  and  absorption  of  a  large  amoimt  causes 
putrid  intoxication. 

The  chief  putrefactive  bacteria  are:  The  colon  bacillus  (when  imder  normal 
conditions) ;  the  bacillus  of  malignant  edema;  the  Proteus  vulgaris;  the  Proteus 
nairabihs;  the  three  forms  of  the  BacUlus  saprogenes;  and  the  Proteus  zenkeri. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical  importance  the 
bacillus  of  influenza,  bacillus  of  diphtheria,  bacillus  of  bubonic  plague,  bacillus 
of  leprosy,  bacillus  of  rhinoscleroma,  bacillus  of  fetid  ozena,  bacillus  of  hemor- 
rhagic septicemia,  and  the  Bacillus  lactis  aerogenes,  which  is  an  unusual  cause 
of  peritonitis. 

The  ray-fungus  is  considered  on  page  309. 

Infections  by  Protozoa. — Protozoa  is  the  name  given  to  the  lowest 
forms  of  animal  life.  This  group  of  organisms  shows  transitions  from  forms 
certainly  animal  toward  forms  certainly  vegetable.  The  protozoa  are  minute 
unicellular  organisms.  The  cell  has  a  definite  nucleus  and  is  composed  of 
protoplasm  and  a  more  or  less  dense  cell  wall.  Many  species  have  organs  of 
locomotion  (cHia  or  flageUa).  Most  parasitic  protozoa  are  sporozoa.  The 
sporozoa  multiply  by  spore  formation,  feed  by  osmosis,  and,  when  freely  formed, 
possess  neither  cUia  nor  flagella.  Pebrine  or  silkworm  disease  is  due  to  protozoa, 
so  is  trvpanosomiasis.  Protozoa  are  known  to  cause  malaria  (the  plasmodium 
malariae),  tropical  dysentery'  (the  Entameba  histolytica),  and  syphilis.  Some 
observers  maintain  that  they  cause  cancer,  others  assert  that  they  are  respon- 
sible for  hydrophobia;  and  it  is  thought  probable  that  they  may  produce 
measles,  small-pox,  yeUow  fever,  scarlatina,  and  spotted  fever. 

The  SpirochcBta  Pallida  (the  Treponema  Pallidum). — ^A  bacterial  cause  of 
syphilis  has  long  been  sought.  Lustgarten  thought  he  had  found  it  in  a 
bacillus  resembling  the  tubercle  bacillus,  but  this  view  has  been  disproved. 
Schaudinn  and  Hoffmann  have  described  an  organism  constantly  present  in  the 
initial  lesion  of  s\phLlis  and  in  secondary^  lesions  and  w^hich  they  call  the  Spiro- 
chseta  pallida  ("Arbeiten  aus  dem  KaiserHchen  gesimdheitsamte,"  Berhn, 
April  10,  Heft  2).  The  studies  of  Schaudinn  and  Hoffmann  were  confirmed  by 
Metchnikoff  ("Bull.  Acad,  de  med.  de  Paris,"  May  16, 1905).  These  organisms 
are  found  in  great  numbers  in  the  juice  of  syphilitic  glands,  in  condylomata,  and 
in  chancres.  They  are  motile,  are  without  fiageUa,  curve  from  three  to  twelve 
times,  are  stained  mth  difiSculty,  and  are  transported  by  the  lymph  and  blood 
(Blaschko,  in  "Berlin  klin.  Woch.,"  No.  11,  1907).  The  organism  is  thought 
by  many  to  be  a  protozoon.  The  fact  that  the  cell  di\ides  longitudinally  and 
not  transversely  suggests  that  it  is  not  a  bacterium  (Noguchi).  Many  ob- 
serv^ers  place  the  organism  with  bacteria.  The  matter  is  still  in  doubt.  The 
spirochetes  were  originally  discovered  by  Bordet  and  Gengou  in  1903.  These 
observers  found  them  in  chancres,  but  thought  their  presence  was  inconstant. 
Schaudinn  and  Hoffmann  show  that  it  is  constant.  Very  positive  claims  are 
now  made  as  to  the  causal  influence  of  the  pale  spirochete,  and  it  seems  prac- 


56  Asepsis  and  Antisepsis 

tically  certain  that  syphilis  is  a  chronic  spirillosis.  The  micro-organism  is  present 
in  primary  syphilis  and  all  early  secondary  lesions  and  in  congenital  syphilis. 
It  is  not  found  in  gummata.  Noguchi  obtained  pure  cultures  of  the  spirochete, 
and  inoculation  of  monkeys  with  these  cultures  caused  the  development  of 
sores  resembling  chancres. 


II.  ASEPSIS  AND   ANTISEPSIS 

The  effort  in  all  operations  is  to  secure  and  maintain  scrupulous  surgical 
cleanliness.  What  is  known  as  the  antiseptic  method  we  owe  to  the  splendid 
labors  of  Lord  Lister,  and  the  aseptic  method  is  but  a  natural  evolution  of 
the  antiseptic  method.  It  is  true  that  Agostino  Bassi,  over  half  a  century  ago, 
convinced  that  various  maladies  w^ere  due  to  parasites,  treated  wounds  with 
a  solution  of  corrosive  sublimate.  It  is  true  that  Oliver  Wendell  Holmes  in 
1843  insisted  on  the  contagiousness  of  puerperal  fever.  It  is  also  true  that 
Semmelweiss  in  1847  demonstrated  the  infectiousness  of  puerperal  fever  and  the 
method  of  preventing  it;  that  Jules  Lemaire  in  1863  published  a  treatise  on  car- 
bolic acid  and  advocated  the  use  of  this  drug  in  the  treatment  of  w^ounds  in  order 
to  destroy  Hving  germs;  and  that  Bottini  in  1866  employed  carbolic  acid  in  the 
treatment  of  putrid  and  suppurating  wounds  because  he  believed  germs  to  be 
responsible  for  such  conditions  (Monti,  on  "Modern  Pathology")-  In  spite  of 
the  above  facts.  Lister  is  the  real  father  of  asepsis  and  taught  all  nations  how  to 
prevent  infection.  Monti  says:  "But  Lister,  with  that  practical  spirit  which 
forms  one  of  the  best  characteristics  of  English  genius,  from  the  scientific 
studies  of  Pasteur  deduced  the  general  laws  of  antisepsis  and  the  rules  for 
their  methodical  application  to  practical  surgery."  Lister  called  the  attention 
of  the  profession  to  a  new  method  of  treating  woiinds,  compound  fractures, 
and  abscesses  in  1867.^  The  processes  first  employed  were  extremely  com- 
plicated, but  have  been  made  in  the  last  few  years  simple  and  easy  of  per- 
formance. Lister  believed  the  chief  danger  to  be  from  air.  It  is  now  believed 
that  the  chief  danger  is  from  actual  contact  of  hands,  instruments,  dressings, 
oir  foreign  bodies  with  a  wound.  Air  carries  but  few  micro-organisms  unless 
it  is  filled  with  dust.  Infection  through  air  is  most  apt  to  occur  if  the  air  is 
dusty,  and  is  more  common  after  an  aseptic  than  an  antiseptic  operation. 

Of  course,  some  bacteria  from  the  air  must  settle  in  every  wound,  but 
the  majority  of  the  air  fungi  are  harmless.  Comparatively  few  reach  the  wound 
unless  the  air  is  dusty,  and  these  few  the  tissues  are  usually  able  to  destroy. 
Schimmelbusch  made  experiments  in  v.  Bergmann's  clinic  when  the  stu- 
dents were  present.  He  found  that  "the  number  of  bacteria  which  settle  upon 
the  surface  of  a  wound  a  square  decimeter  in  extent,  in  the  course  of  half  an 
hour,  is  about  60  or  70,"  and  thousands  are  usually  reqiiired  to  produce  infec- 
tion. 

There  is  no  danger  of  infection  being  produced  by  the  breath  of  spectators. 
Air  which  comes  from  the  lungs  is  germ  free,  and  even  a  large  class  will  not 
infect  the  air  by  breathing,  but  will  rather  help  to  free  it  from  bacteria,  for  the 
lungs  are  filters  for  air  laden  with  micro-organisms.  If  a  surgeon  talks  while  he 
is  operating,  he  may  spray  droplets  of  saliva  into  the  wound  and  thus  produce 
infection.  In  order  to  obviate  this  danger  some  surgeons  wear  masks  of  gauze 
before  the  nose  and  mouth.  A  conversational  assistant  is  a  danger,  and  a  sur- 
geon should  direct  his  remarks  away  from  the  wound  and  not  toward  it.  The 
surgeon  and  his  assistant  should  wear  caps  to  keep  hair  from  falling  in  the 
wound.  The  clean  shaven  face  is  not  a  peril  to  the  patient,  the  face  "bearded 
like  the  pard"  may  be.     A  bearded  man  should  wear  a  mask. 

1 "  Lancet,"  March  16,  1867  ;  "  Brit.  Med.  Jour.,"  August  9,  1867. 


Asepsis  and  Antisepsis  57 

The  more  simple  the  operative  technic,  the  better  and  the  more  certain  is 
it  to  be  carefully  carried  out.  Desault  said,  "The  simplicity  of  an  operation 
is  the  measure  of  its  perfection."  This  is  as  true  to-day  as  when  the  great 
French  surgeon  said  it.  The  fewer  assistants  that  are  used  the  better,  and  no 
hands  but  the  surgeons  should  enter  the  wound  unless  others  are  absolutely 
required. 

In  performing  any  surgical  operation  cutting  is  better  than  tearing  by 
blunt  dissection.  The  former  method  makes  an  incised  wound,  the  latter  a 
lacerated  wound.  In  an  incised  wound  there  is  a  minimum  amount  of  dam- 
age and  there  will  be  rapid  repair.  In  a  lacerated  wound  some  necrosis  occurs 
and  there  is  great  lowering  of  tissue  resistance,  hence  a  lacerated  woimd  is  much 
more  apt  to  become  infected  than  an  incised  wound. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic  or  the  antiseptic 
method.  In  the  aseptic  method^  heat,  chemical  germicides,  or  both  are  used 
to  cleanse  the  instruments,  the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants,  the  surface  being  freed  from  the  chemical  germicide  by 
washing  with  boiled  water  or  with  saline  solution.  After  the  incision  has  been 
made  no  chemical  germicide  is  used,  the  woimd  being  simply  sponged  with 
gauze  sterilized  by  heat;  if  irrigation  is  necessar\',  boiled  water  or  normal  salt 
solution  (at  1 10°  F.)  is  used,  and  the  wound  is  dressed  ^^i\h.  gauze  which  has  been 
rendered  sterile  by  heat.  The  effort  of  the  surgeon  is  simply  to  prevent  the 
entrance  of  micro-organisms  into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  they  \\ill  be  destroyed  by  healthy 
tissues.  The  aseptic  method  should  be  used  only  in  non-infected  areas.  If 
chemical  germicides  are  not  used  in  the  wound,  there  will  be  a  minimum 
amount  of  irritation,  few  cells  wiU  be  destroyed,  the  amount  of  wound-fluid 
will  be  small,  the  surgeon  can  often  dispense  with  drainage,  and  repair  will 
be  rapid.  If  a  wound  is  to  be  closed  without  drainage,  every  point  of  bleed- 
ing must  be  ligated.  Many  wounds  are  closed  by  interrupted  through-and- 
through  sutures  of  silkworm-gut.  Some  wounds  are  closed  in  layers  by 
catgut  sutures.  If  a  wound  is  closed  in  layers,  muscle  being  against  muscle, 
fascia  against  fascia,  etc.,  the  skin  may  be  closed  by  interrupted  sutures  or 
by  Halsted's  subcuticular  stitch  (Fig.  116).  If  this  stitch  is  emplo^^ed,  the  skin 
staphylococcus  does  not  obtain  access  to  stitch-holes,  and  stitch-abscesses  are 
not  apt  to  arise.  This  suture  may  consist  of  catgut,  silk,  or,  preferably,  silver 
wire,  this  latter  agent  being  capable  of  certain  sterilization  by  heat  and  exercis- 
ing a  definite  inhibitor}^  action  on  micro-organisms.  If  a  wound  is  closed 
without  drainage,  firm  compression  is  applied  over  the  wound  to  obliterate  any 
cavity  which  may  exist.  Such  a  ca^dty  is  called  a  dead  space.  If  a  dead 
space  is  allowed  to  remain  wound-fluid  will  gather,  tissue  resistance  w^ill  be 
lowered,  and  the  wound-fluid,  the  tissue,  or  both  may  become  infected.  Drain- 
age must  be  used  if  the  wound  is  ver\^  large,  if  its  shape  or  structure  prevents 
the  obliteration  of  the  ca^dty  by  pressure,  if  there  is  any  doubt  as  to  the  perfect 
cleanliness  of  the  part,  if  the  patient  is  very  fat  (for  in  such  indi\aduals  fat 
necrosis  predisposes  to  sepsis  and  to  fat  embolism),  or  if  the  skin  is  so  thin 
that  we  fear  pressm-e  -^-ill  produce  sloughing  ("A  Manual  of  Sm-gical  Treat- 
ment," by  Cheyne  and  Burghard).  In  some  regions  of  the  body  wounds  are 
sealed  with  collodion  or  iodof  orm-collodion.  If  irrigation  is  not  practised  and  the 
wound  is  dressed  with  dry  sterile  gauze,  the  procedure  is  said  to  be  by  the  "c?ry" 
aseptic  method.  In  the  antiseptic  method  the  same  preparations  are  made  for  the 
operation  as  in  the  aseptic  method,  but  during  the  operation  gauze  sponges 
impregnated  with  a  chemical  germicide  are  used,  and  the  wound  is  dressed  "nith 
gauze  containing  corrosive  sublimate  or  some  other  chemical  germicide.  If  the 
wound  is  not  flushed  with  a  chemical  germicide,  and  is  dressed  with  dry  antisep- 
tic gauze,  the  operation  is  said  to  be  by  the  "^/ry"  antiseptic  method.     The  anti- 


5^  Asepsis  and  Antisepsis 

septic  method  is  preferred  in  infected  areas.  Dry  dressings  are  usually  prefer- 
able to  moist  dressings  in  treating  aseptic  wounds,  because  they  are  more 
absorbent  and  do  not  act  as  poultices,  and  dry  dressings  may  be  used,  even  when 
the  wound  has  been  flushed.  Some  surgeons  question  the  value  of  antiseptic 
irrigation  in  a  septic  wound,  but  I  believe  it  removes  many  bacteria  and 
much  poisonous  matter  and  also  antidotes  toxic  material.  In  suppurating, 
areas  it  is  often  best  to  use  moist  dressings  in  the  form  of  antiseptic  fomen- 
tations. Year  by  year  the  aseptic  method  becomes  more  popular.  Surgeons 
have  learned  that  the  most  important  factor  in  asepsis  is  mechanical  cleans- 
ing by  means  of  soap  and  water.  The  chemical  germicide  plays  a  secondary 
rather  than  a  vital  part.  By  mechanical  cleansing  of  the  skin  great  numbers  of 
micro-organisms  are  removed  along  with  dirt,  grease,  and  epithehum.  Many 
bacteria  remain,  but  vast  hordes  are  washed  away,  and  the  danger  of  infec- 
tion is  greatly  lessened  by  thus  diminishing  the  number  of  bacteria.  If  a 
chemical  germicide  is  used  without  preliminary  mechanical  cleansing  it  is 
useless,  because  it  cannot  destroy  bacteria  in  the  epithelium  and  in  masses 
of  oily  matter.  After  mechanical  cleansing  the  germicide  is  active  in  destroy- 
ing the  comparatively  few  bacteria  which  are  naked  on  the  surface.  In  many 
regions  a  strong  chemical  germicide  must  not  be  used  (in  the  abdomen,  in 
the  brain,  in  joints,  in  the  pleural  sac,  and  in  the  bladder),  and  in  other  regions 
(mucous  surfaces  and  fatty  tissue)  it  is  productive  of  harm  rather  than  good. 

Preparation  for  an  Operation. — If  the  operation  is  to  be  performed 
in  a  hospital  there  is,  of  course,  an  operating  room  always  ready.  If  it  is  to 
be  done  in  a  private  house,  much  careful  preparation  is  desirable.  The 
operating  room  should  be  warm,  but  not  too  warm.  The  desirable  tempera- 
ture is  78°  to  80°  F.  Over  80°  F.  is  too  warm,  it  causes  vascular  relaxation  in  the 
patient,  and  makes  the  surgeon  perspire  and  wear  out.  The  patient  is  kept 
warm  by  certain  special  methods.  He  may  be  placed  on  a  table  heated  by  hot 
water  or  electricity  or  he  may  be  surrounded  by  hot-water  bags.  Any  large 
raw  surface  is  kept  covered  as  far  as  possible  with  pads  of  gauze  wrung  out  of 
hot  salt  solution  and  frequently  changed.  Protruding  intestines  are  treated  in 
the  same  way.  Every  effort  is  made  to  avoid  soaking  the  patient's  skin  with 
fluids,  because  as  they  cool  they  will  chill  him.  A  room  in  which  an  operation 
is  to  be  performed  should  be  well  lighted  and  well  ventilated.  The  northern 
light  is  the  best.  It  is  advantageous  to  have  an  open  grate  in  the  room,  for  then 
a  wood  fire  can  be  quickly  made  to  take  a  chill  off  the  air  and  ventilation  is  im- 
proved. The  morning  before  the  operation  the  furniture  should  be  removed, 
the  carpet  taken  up,  and  the  curtains  and  hangings  taken  down.  If  the  ceiling 
and  walls  are  papered,  they  must  be  thoroughly  brushed.  If  they  are  painted, 
they  must  be  washed  with  soap  and  water.  Dust  is  thus  removed  and  the  dan- 
ger of  dust  falling  into  the  wound  is  averted.  The  floor  is  scrubbed  with  soap 
and  water.  The  windows  should  be  opened  for  many  hours  to  thoroughly  dry 
and  freshen  the  room.  On  the  morning  of  the  operation  the  windows  are 
closed  and  newspapers  are  tacked  up  so  as  to  cover  the  lower  half  of  each  win- 
dow. Plenty  of  Hght  is  admitted  and  the  curiosity  of  neighbors  across  the 
street  cannot  be  satisfied.  The  patient's  bed  is  brought  into  the  room  and 
placed  in  a  position  where  there  will  be  plenty  of  light  for  future  dressings,  and 
where  the  siirgeon  will  have  access  from  either  side.  In  order  that  there  may  be 
access  from  each  side  the  bed  must  not  be  in  a  corner  or  against  the  waU. 
Never  use  a  big  broad  bed;  use  a  narrow  bed.  Never  have  a  feather  bed,  but 
insist  on  Treves's  advice  being  followed,  and  employ  a  metal  bed  with  a  wire 
netting  and  hair  mattress. 

A  piece  of  carpet  or  rug  is  spread  upon  a  portion  of  the  floor  and  the  table 
is  set  upon  it.  The  table .  should  be  so  placed  that  there  will  be  a  good  light 
on  the  field  of  operation.     There  are  several  tables  which  are  very  satisfac- 


Preparation  for  an  Operation 


59 


tory.  The  best  for  a  private  house  operation  is  LiHenthal's  (Figs.  24  and 
25).  This  table  can  be  folded  into  a  small  compass,  can  be  carried  in  a  case 
with  a  handle,  and  is  comparatively  light  and  easily  transportable.     It  can  be 


Fig.  24. — Lilienthal's  portable  operating  table. 

rapidly  set  up,  is  firm,  and  it  enables  the  surgeon  to  obtain  the  Trendelenburg 
position  at  any  moment.  A  kitchen  table  does  very  well.  If  a  kitchen  table  is 
used  and  the  abdomen  is  to  be  opened  a  frame  should  be  at  hand  which, 


Fig.  25. — LUienthal's  portable  operating  table,  folded. 

when  shpped  under  the  patient,  enables  the  surgeon  to  obtain  the  Trendelen- 
burg position.  Dr.  Joseph  Price  was  accustomed  to  use  two  trestles  and  a 
board  like  an  ironing  board.     In  hospital  work  I  use  Boldt's  table  (Figs.  26 


6o 


Asepsis  and  Antisepsis 


and  27).     On  the  table  or  board  is  placed  a  folded  comfortable  or  several 
folded  blankets.     A  rolled  blanket  is  placed  under  the  hollow  of  the  back  to 


Fig.  26. — Boldt's  operating  table. 

prevent  strain  of  the  sacro-iliac  joints  and  postoperative  backache.      Kelly's 
pad  to  catch  fluids  is  laid  upon  the  blankets  and  is  so  placed  that  fluid  used  in 


Fig.  27. — Boldt's  operating  table. 

irrigation   will   flow   into   it   and   will    be   conducted   by   it   to   a    suitable 
receptacle. 


Preparation  for  an  Operation 


6i 


Around  the  operating  table  at  proper  distances  are  arranged  a  table  for 
instruments,  ligatures  and  sutures,  a  table  for  dressings,  a  table  for  pads,  packs, 
gauze  sponges,  and  a  basin  of  bichlorid,  and  a  table  for  soap  and  a  basin  of 
water.  Ordinary'  wooden  tables  may  be  used  if  they  are  covered  with  towels 
wet  in  corrosive  sublimate  solution.  In  a  hospital  special  tables  are  used. 
They  are  of  iron  with  glass  tops.  Ordinary-  basins  may  be  used,  but  enameled 
or  glass  basins  in  stands  (Figs.  28  and  29)  are  the  most  satisf acton.-.  A  couple 
of  buckets  should  be  placed  on  the  floor  near  at  hand.     Enameled  buckets  are 

the  best  ones  to  use.  The  nurses  and 
assistants  should  have  ready  the  ether 
cone,  wrapped  in  a  clean  towel,  sterile 
sheets,  sterile  go-s^"ns,  sterile  towels,  sterile 
gauze  for  sponges  and    dressings,   trays 


S. — Revohins  vrash-stand. 


Fie.  2  0. — Plain  double  wash-stand. 


for  instruments  (Figs.  30  and  3i\.  iodoform  gauze,  catgut,  siLk.  silkworm-gut, 
hot  normal  salt  solution,  etc.,  according  to  the  nature  of  the  operation.  The 
surgeon  should  pick  out  the  instruments  required.  The  anesthetist  should 
lay  out  a  mouth-gag.  tongue-forceps.  h}-podermatic  s}Tinge  in  uvrking  order, 
ether  or  chloroform,  brandy,  tablets  of  str\-chnin  and  also  of  atropin,  and  a 
c}'linder  of  osy-gen. 

INIost  surgeons  have  the  operation  field  sterilized  the  day  before  the  opera- 
tion, except  in  an  emergency  case.     For  several  years  I  have  been  doing  it  in 


30. — Porcelain  surgical  tray. 


I. — Glass  surgical  Uay. 


most  cases  after  the  patient  has  been  anesthetized,  and  find  this  plan  more 
comfortable  for  the  patient,  less  troublesome,  and  equally  efiective. 

\MLen  the  time  for  the  operation  arrives,  the  siugeon  and  his  assistants 
remove  their  clothing  and  put  on  duck  trousers  and  thin,  short-sleeved  shirts  of 
white  muslin.  After  sterilizing  the  hands  and  forearms  they  envelop  themselves 
in  aseptic  or  antiseptic  sheets  or  gowns,  to  protect  the  patient  and  themselves. 
The  gowns  should  have  sleeves  long  enough  to  cover  the  forearms  and  wrists. 
SteriTe  muslin  caps  should  always  be  worn.  The  caps  prevent  hair,  dandrufi, 
and  sweat  from  falling  into  the  womid.  Many  operators  wear  over  the  mouth 
and  nose  a  respirator  or  piece  of  gauze  in  order  to  prevent  saliva  or  mucus  being 
projected  into  the  wound  while  the  surgeon  talks. 


62 


Asepsis  and  Antisepsis 


Danger  from  the  Hands. — It  is  a  difficult  or  impossible  matter  to  abso- 
lutely sterilize  the  hands,  but  it  is  fortunate,  as  Mikulicz  and  Fliigge  say,  that 
most  of  the  bacteria  of  the  skin  are  harmless.  The  Staphylococcus  epidermidis 
albus,  however,  is  constantly  present  in  the  epidermis.  The  hands  of  some 
persons  are  more  easily  sterilized  than  those  of  others.  For  instance,  a  hairy, 
creased  hand  is  more  difficult  to  sterilize  than  a  smooth  and  almost  hair- 
less one;  a  hand  grossly  neglected,  than  one  reasonably  clean.  Germs  abound 
in  the  epidermis,  in  the  fissures  and  creases,  under  and  around  the  nails,  on 
hairs,  and  in  ducts  of  glands.  The  surface  of  the  hands  may  be  thoroughly 
sterile  at  the  beginning  of  an  operation  and  become  infected  later,  because 
germs  in  gland  ducts  are  forced  to  the  surface.  Hence,  in  a  prolonged  opera- 
tion the  surgeon,  if  he  does  not  wear  gloves,  should  from  time  to  time  stop 
operating  and  wash  his  hands,  first  in  alcohol  and  then  in  corrosive  sublimate 
solution  (Leonard  Freeman). 

In  view  of  the  difficulty  of  cleansing  the  hands,  every  student  must  be 
taught  how  to  do  it,  and  he  must  become  impressed  with  the  fact  that  the 
surgical  hand  is  to  be  regarded  as  reaching  to  the  elbow.  The  more  the  fingers 
enter  a  wound,  the  greater  is  the  danger  of  infection  of  the  wound.  The 
surgeon  uses  retractors  and  forceps  whenever  possible,  but  in  most  cases  his 
fingers  must  at  times  enter  the  wound.  The  fingers  of  no  other  person  should 
enter  unless  absolutely  necessary.  The  basis  of  all  plans  of  sterilization  and  the 
most  important  part  of  any  plan  is  mechanical  cleansing  by  scrubbing  with  soap 
and  water.  By  this  means  a  quantity  of  loose  epidermis  is  removed  and  with 
it  great  numbers  of  bacteria. 

Mechanical  Cleansing  of  the  Hands  and  Forearms. — The  hands  and 
forearms  may  be  sterilized  in  several  ways.     Any  method  is  preceded  by 

mechanical  cleansing,  which  is  carried  out 
as  follows:  Scrub  for  five  minutes  with 
soap  and  hot  running  water,  giving  special 
attention  to  the  nails  and  creases  in  the 
skin.  The  water  should  be  as  hot  as  can 
be  borne  with  comfort,  as  hot  water  stimu- 
lates the  sweat  glands  and  the  flow  of  sweat 
washes  out  the  ducts.  If  the  ducts  are 
washed  out  before  the  operation  by  copious 
sweating,  during  the  operation  the  secretion 
will  be  slight.  The  brush  is  rubbed  both 
in  the  long  axis  of  the  extremity  and  trans- 
versely. The  creases  on  the  back  of  the 
hands  and  fingers  will  be  partially  opened  by  flexing  the  fingers,  and  transverse 
scrubbing  will  clean  the  furrows.  The  furrows  on  the  palmar  surface  will  be 
opened  by  extending  the  fingers,  and  will  be  best  cleaned  by  transverse  scrub- 
bing (George  Ben  Johnston).  An  exceUent  soap  is  ethereal  soap,  which  is  a 
solution  of  castile  soap  in  ether.  Castile  soap  can  be  used.  I  am  accustomed 
to  use  green  soap.  Some  surgeons  prefer  to  use  green  soap  in  the  form  of  a 
tincture.  Synol  soap  has  advocates.  There  is  no  particular  advantage  in 
using  soap  containing  a  germicide,  as  such  soap  is  practically  without  germicidal 
power.  The  brush  employed  should  be  kept  in  a  i  :  looo  solution  of  cor- 
rosive sublimate  or  should  have  been  recently  sterilized  with  steam  and  kept 
in  a  sterile  glass  box  (Fig.  32).  The  nafls  are  cut  short,  are  cleansed  with  an 
orange-wood  stick,  which  does  not  scratch  them,  and  the  hands  are  again 
scrubbed.  Very  prolonged  or  very  rough  scrubbing,  especially  with  harsh 
agents  like  marble  dust  or  sand,  is  actually  harmful,  as  it  tends  to  crack  the  hands 
and  make  them  rough  and  it  extensively  loosens  epidermis  which  may  drop  into 
the  wound.    Epidermis  may  contain  bacteria  within  it  and  may  infect  the  wound. 


Fig.  32. — Glass  brush-box  with  coverc 


Sterilization  of  the  Hands  and  Forearms  63 

Sterilization  of  the  Hands  and  Forearms. — After  mechanical  cleans- 
ing a  germicide  is  employed  to  render  the  parts  sterile.  Whatever  method 
is  adopted  it  is  desirable  that  it  shall  not  unduly  irritate  the  skin.  An  occa- 
sional operator  may  use  without  injury  tolerably  strong  chemicals,  but  the 
busy  hospital  surgeon,  who  operates  perhaps  several  times  or  many  times  a 
day,  cannot  use  them.  Any  method  which  inflames,  cracks,  or  roughens  the 
skin  makes  future  sterilization  difficult  or  impossible,  hence  such  a  method  is 
undesirable.     Four  methods  are  described  here: 

Furbringer^s  Method. — After  washing  off  the  soap  in  sterile  water  the  hands 
are  dipped  in  95  per  cent,  alcohol  and  held  there  for  two  or  three  minutes  while 
the  forearms,  hands,  fingers,  and  nails  are  being  rubbed  with  alcohol.  Alcohol 
removes  the  soap  which  has  entered  into  follicles  and  creases,  removes  desqua- 
mated epithelium,  enters  under  and  about  the  nails,  is  germicidal,  and  favors 
the  diffusion  of  the  corrosive  sublimate  under  the  nails  and  into  the  follicles, 
when  the  hands  are  placed  later  in  the  mercurial  solution.  Alcohol  also  hardens 
epithelium  and  keeps  it  from  desquamating  into  the  wound.  After  using  the 
alcohol  the  hands  are  then  dipped  in  a  hot  solution  of  corrosive  sublimate 
(i  :  1000),  and  with  the  forearms  are  scrubbed  for  at  least  a  minute,  the  nails 
receiving  especial  care. 

The  Welch-Kelly  Method: — ^Af ter  the  hands  and  forearms  have  been  cleansed 
mechanically  and  have  been  rinsed  in  sterile  water  they  are  immersed  for 
two  minutes  in  a  warm  solution  of  permanganate  of  potassium  (a  saturated 
solution 'in  distilled  water).  This  solution  causes  the  cutaneous  surface  to 
assume  a  very  dark  brown  color.  The  hands  and  forearms  are  then  immersed 
in  a  warm  saturated  solution  of  oxalic  acid  and  are  held  there  until  decolor- 
ized. They  are  then  well  washed  in  sterile  water,  are  next  immersed  for 
two  minutes  in  a  i :  500  solution  of  corrosive  sublimate,  and  finally  are  rinsed 
in  sterile  water  and  dried  on  a  sterile  towel.  The  solutions  for  use  in  the  above 
method  should  be  contained  in  jars  of  the  shape  of  a  druggist's  percolator, 
so  that  both  the  hands  and  forearms  can  be  immersed  at  the  same  time.  In 
this  method  the  permanganate  of  potash  is  merely  an  oxidizer  and  the  oxalic 
acid  is  the  active  germicide.  Some  persons  find  that  the  skin  tolerates  the  plan 
very  well,  others,  among  whom  is  the  author,  find  the  oxalic  acid  decidedly 
irritant  when  used  several  times  in  a  day. 

The  Weir-Stimson  Method. — This  method  was  suggested  by  Mr.  Rausch- 
enberg,  the  pharmacist  of  the  New  York  Hospital,  and  it  w^as  appHed  prac- 
tically by  Doctors  Weir  and  Stimson.  The  process  is  as  follows:  The  hands 
should  be  cleansed  mechanically  as  previously  directed.  Place  about  a  table- 
spoonful  of  chlorinated  lime  in  the  palm  of  the  hand,  place  upon  the  lime  a 
piece  of  crystalline  carbonate  of  soda  (washing  soda)  i  inch  square  and  J  inch 
thick,  add  a  Httle  water,  and  rub  the  creamy  mixture  over  the  arms  and  hands 
until  the  rough  granules  of  sodium  carbonate  are  no  longer  felt.  This  requires 
from  three  to  five  minutes.  At  first  there  is  a  sensation  of  heat  usually  fol- 
lowed by  a  sensation  of  coolness.  Place  the  paste  under  and  around  the  nails 
by  means  of  a  bit  of  sterile  orange  wood.  Wash  the  arms  and  hands  in  hot 
sterile  water.^  Remove  the  odor  of  chlorin  by  washing  the  hands  and  arms 
in  sterile  ammonia  water  of  a  strength  of  from  i  to  i  per  cent.  (McBurney, 
Collins,  and  Oastler,  in  "International  Text-Book  of  Surgery").  The  com- 
bination of  carbonate  of  sodium  and  chlorinated  lime  is  said  to  set  free  nascent 
chlorin,  a  most  efiicient  germicide.  I  used  this  method  for  several  years  in 
the  clinic  of  the  Jefferson  Medical  College  Hospital  and  found  it  efficient. 
When  employed  several  times  a  day  it  may  prove  decidedly  irritant.  It  is 
important  that  crystalline  washing-soda  be  employed.  If  the  bicarbonate 
is  used,  nascent  chlorin  will  not  be  produced,  but  hydrochloric  acid  gas  will 
1 "  Medical  Record,"  April  3,  1897. 


64  Asepsis  and  Antisepsis 

be  formed,  and  the  latter  gas  irritates  the  skin  and  is  not  a  satisfactory  ger- 
micide. 

The  Sublimate-alcohol  Method. — This  is  the  method  I  personally  prefer. 
It  is  rapid,  efficient,  and  reasonably  non-irritant.  It  is  as  follows:  Cleanse 
the  hands  with  soap  and  water  as  previously  directed.  Use  95  per  cent,  alco- 
hol as  in  Fiirbringer's  method  (see  p.  63).  Dip  the  hands  in  70  per  cent,  al- 
cohol containing  i  part  to  1000  of  corrosive  sublimate,  and  rub  the  hands,  fore- 
arms, and  nails  with  a  piece  of  sterile  gauze  wet  wdth  this  fluid  for  three  min- 
utes.   Rinse  these  parts  in  the  fluid  and  then  rinse  in  sterile  water. 

The  Use  of  Gloves. — Most  surgeons  are  so  impressed  with  the  impos- 
sibility of  sterilizing  the  hands  that  they  w^ear  gloves  in  operations.  Over 
sixty  years  ago,  at  King's  College,  Sir  Thomas  Watson  in  a  lecture  on  puer- 
peral fever  suggested  that  obstetricians  wear  gloves.  He  said:  "In  these  days 
of  ready  invention  a  glove,  I  think,  might  be  de^dsed  which  should  be  im- 
pervious to  fluids,  and  yet  so  thin  and  pHant  as  not  to  interfere  materially 
with  the  delicate  sense  of  touch  required  in  these  manipulations.  One  such 
glove,  if  such  shall  ever  be  fabricated  and  adopted,  might  well  be  sacrificed 
to  the  safety  of  the  mother  in  every  labor"  ("Watson's  Lectures  on  Physic"). 


Fig.  33. — Showing  rubber  glove  applied. 

Professor  Halsted  was  a  pioneer.  He  began  to  use  rubber  gloves  in  1889. 
Some  surgeons  used  cotton  and  others  silk  gloves,  but  it  has  been  proved 
that  cotton  and  silk  are  not  impervious  to  micro-organisms,  and  that  rubber 
is.  The  thin,  seamless  rubber  gloves  which  are  now  made  are  very  satisfactory. 
They  are  sterilized  by  boiling,  are  then  dried,  and  are  "^Trapped  in  a  sterile 
towel.  In  order  to  insert  the  hand  in  them  the  hand  should  be  dried,  the 
interior  of  the  glove  should  be  dusted  with  sterile  starch  or  talc  powder,  and 
then  the  niu"se  should  fold  forward  the  wrist  part  and  hold  the  glove  open 
while  the  surgeon  inserts  his  fingers  into  the  proper  compartments  and  pushes 
the  hand  in.  The  custom  of  filling  the  glove  wdth  sterile  fluid  and  then  in- 
serting the  hand  is  troublesome  and  objectionable,  because  the  fingers  soon 
become  sodden  Hke  those  of  a  washwoman,  the  sense  of  touch  is  unpaired, 
considerable  discomfort  is  occasioned,  and  the  skin  is  apt  to  crack. 

If,  during  an  operation,  a  glove  becomes  infected,  a  clean  one  can  be  sub- 
stituted for  it.  Gloves  somewhat  impair  the  sense  of  touch,  but  a  surgeon  soon 
learns  to  work  with  them.  If  they  are  to  be  used,  the  hands  should  be  sterihzed 
just  as  carefully  as  when  they  are  not  to  be  used,  because,  during  the  opera- 
tion, the  gloves  may  tear  or  be  punctured  by  a  needle.  I  always  wear  gloves, 
but  that  it  is  absolutely  necessary  to  wear  gloves  in  aU  cases  has  not  been 


Metal  Instruments 


65 


A  surgeon  should  wear 


proved.  Their  use  does  contribute  to  success  in  brain  operations,  abdominal 
operations,  and  joint  operations.  They  are  of  great  value  in  military-  surger}-, 
for  the  military-  surgeon  may  not  have  time  to  prepare  his  hands,  and  sterile 
gloves  can  be  always  kept  ready  prepared. 

\Mien  a  surgeon  is  obliged  to  place  his  lingers  in  an  area  of  \irulent  infec- 
tion he  may  be  poisoned.  Gloves  \\'ill  save  him  from  this  danger.  Again, 
a  surgeon  should  iv}'  to  avoid  bringing  his  hands  unnecessarily  in  contact 
with  putrid  or  purulent  matter.  Though  it  may  not  poison  him,  it  grossly 
infects  the  surface,  renders  subsequent  cleansing  difficult,  and  endangers 
other  patients.  Gloves  wUl  prevent  this  danger. 
gloves  if  he  is  making  an  examination  or  per- 
forming an  operation  which  is  sure  to  infect  the 
bare  hands,  and  he  should  wear  gloves  in  an 
operation  if  in  a  prcA^ious  operation  his  hands 
were  infected.  A  surgeon  whose  hands  are  ver\- 
hairv  or  sweat  much  -oill  contribute  to  the  patient's 
safety  by  wearing  gloves.  ^^-  34.-Hali-long  rubber  glove. 

Gloves  should  be  worn  if  the  surgeon  has  a  woimd  or  sore  upon  his  hand 
or  chapped  hands,  ^^^len  using  gloves  in  a  prolonged  operation  dip  the  cov- 
ered hands  now  and  then  in  corrosive  subHmate  solution,  because  the  glove 
may  have  been  punctured  or  dust  may  have  settled  upon  it  from  the  air. 

Gloves  make  the  hands  sweat,  and  if  one  should  be  ptmctured  considerable 
sweat  may  emerge  from  the  puncture  and  enter  the  wound,  and  sweat  contains 
bacteria.  The  entr\-  of  any  considerable  amoimt  of  sweat  is  more  dangerous 
to  the  patient  than  are  well  cleaned  naked  hands,  hence  gloves  may  actually 

favor  the  infection  they  are  meant  to 
„  __  ^/^_^- -,-_-.-.  prevent.  When  they  are  used  the  sur- 
geon must  take  scrupulous  care  not  to 
pimcture  them  with  a  needle,  cUp  them 
with  forceps,  or  tear  them  with  a  liga- 
ture or  suture. 


fl:»  •>  i  3   »  a  i  i  e   •  •! 


Fig. 


a,  ScMmmelbusch's  gas-heated  apparatus  for  sterilizing  instruments:  b,  wire  basket. 


The  closer  they  lit  the  less  the  danger  of  puncture,  and  one  should  know 
accurately  what  size  he  requires  to  fit  closely  and  smoothly  without  being  so 
tight  as  to  make  the  fingers  numb. 

Preparation  of  Gloves. — Wash  -^-ith  soap  and  water  containing  a  little  am- 
monia, rinse  in  sterile  water,  boil  for  thirty  minutes  in  a  i  per  cent,  solution 
of  carbonate  of  soda.  Dr\'  the  glove  and  wrap  in  a  dn,-  sterile  towel  and  keep 
untn  it  is  needed.  A  glove  should  stand  about  twenty  boilings.  The  surgeon 
should  carr}^  a  number  of  pairs  of  prepared  gloves  in  his  bag.  for  the  use  of 
himself  and  assistants  in  private  house  operations. 

Metal  instruments  are  disinfected  by  subjecting  them  to  the  action  of 
steam  in  a  special  sterilizer  or,  better,  by  boiling  them  for  fifteen  minutes  in  a 
I  per  cent,  solution  of  carbonate  of  sodium.  They  are  wrapped  into  a  bundle 
by  means  of  a  towel  or  piece  of  gauze  and  are  dropped  into  the  solution.  The 
blades  of  knives  should  first  be  wrapped  in  cotton  to  prevent  scratching  and 
dulling.  After  boiling,  the  instruments  should  be  rinsed  in  hot  sterile  water 
or  in  a  .5  per  cent,  solution  of  carboUc  acid  and  be  kept  until  needed  in  pans 


66  Asepsis  and  Antisepsis 

of  sterUe  water.  The  carbonate  of  sodium  prevents  rusting.  In  a  clinic  the 
boiling  is  carried  out  in  a  Schimmelbusch  sterilizer  (Fig.  35).  In  a  private 
house  it  can  be  done  in  a  sterilizer  such  as  that  shown  in  Fig.  36,  or  in  a  pan, 
a  kettle,  or  a  wash-boiler.  A  sterilizer  with  a  tray  is  better  than  an  ordinary- 
pan  or  kettle,  because,  when  the  latter  is  used,  the  metal  instruments  lie  in 
the  bottom  of  the  vessel,  where  the  heat  is  very  great  and  the  temper  may  be 
impaired.  Boiling,  unfortunately,  destroys  to  some  extent  the  keenness  of  cut- 
ting instruments,  the  ebullition  throwing  them  about.  After  the  completion  of 
the  operation  the  instruments  should  be  scrubbed  with  soap  and  water,  boiled  in 
soda  solution,  dried,  and  placed  in  a  closet  with  glass  shelves  so  that  they  wiU 
be  protected  from  moisture  and  dust.    Instruments  can  be  partially  disinfected 

by  keeping  them  for  thirty  min- 
utes in  a  5  per  cent,  solution  of 
carbolic  acid  or,  better,  in  a  2 
per  cent,  solution  of  formalin. 
Instruments  with  handles  of 
wood,  bone,  ivory,  or  tortoise 
shell  must  not  be  boiled.  Such 
instruments  should  not  be  used. 
Fig.  36.— Portable  steriUzer.  If   such   instruments   are   used, 

they  can  be  partially  disinfected 
by  the  use  of  carbolic  acid  or  formalin.  Metal  instruments,  whenever  possible, 
should  consist  of  one  smooth  piece.  Grooves  and  letters  are  objectionable,  as 
dirt  gathers  in  such  depressions. 

Preparation  of  the  Patient. — Whenever  possible  give  the  patient  some 
days'  rest  in  bed  before  a  severe  operation.  This  is  not  possible  in  an  emer- 
gency. It  is  seldom  desirable  in  the  case  of  a  highly  nervous  and  excitable 
woman.  Such  a  patient  is  sleepless  and  frightened  and  loses  ground  by  delay. 
In  most  cases  this  preliminary  rest  is  advisable.  It  is  particularly  desirable  in 
a  strong,  active  working  man  suddenly  translated  from  labor  to  bed.  We  wish 
to  prepare  him  to  meet  operative  shock.  During  the  wait  the  patient  is  apt  to 
adjust  himself  to  his  surroundings,  he  becomes  accustomed  to  diminished 
activity  and  to  sick-room  routine,  forms  an  acquaintance  with  his  nurses  and 
physicians,  and,  as  a  rule,  becomes  less  nervous  and  more  calmly  confident  of 
the  result.  He  also  learns  to  use  the  bed-pan  and  to  micturate  while  re- 
cumbent. A  patient  while  waiting  is  to  have  a  general  bath  several  times. 
Some  weak  and  emaciated  patients  are  treated  and  built  up  for  weeks  before 
the  operation  is  attempted.  During  this  preliminary  rest  the  surgeon  should 
study  the  disease,  and  study  the  individual  in  order  to  learn  his  tendencies, 
peculiarities,  etc.  The  condition  of  the  lungs,  the  heart,  the  blood,  and  the 
kidneys  should  be  accurately  determined.  The  amount  of  urine  passed  in 
twenty-four  hours  should  be  ascertained,  and  the  percentage  of  urea  should 
be  estimated  from  a  sample  of  the  twenty-four-hour  urine.  The  urine  is 
carefully  examined  for  sugar,  albumin,  casts,  acetone,  diacetic  acid,  indican, 
etc.  By  the  above  examinations  the  surgeon  may  be  able  to  anticipate  and 
provide  against  certain  calamities.  Sometimes  such  a  study  leads  us  to  post- 
pone or  abandon  an  operation.  Furthermore,  such  a  study  gives  the  informa- 
tion which  is  necessary  in  order  to  intelligently  select  the  proper  anesthetic. 
The  presence  in  the  urine  of  acetone  and  diacetic  acid  forbids  any  but  an 
emergency  operation.  Sugar  or  granular  and  fatty  casts  in  the  urine,  or  a 
considerable  quantity  of  albumin,  make  us  hesitate  to  operate.^  A  hemo- 
globin percentage  of  under  50  makes  us  seek  to  avoid  operation  in  most  cases 
not  associated  with  bleeding.  The  anesthetist  should,  during  this  preliminary 
period,  examine  the  heart,  pulse,  and  blood-pressure,  so  as  to  know  the  natural 
1  The  question  of  operation  on  diabetics  is  discussed  on  p.  69. 


Preparation  of  the  Patient  67 

character  of  each  when  the  patient  is  free  from  excitement.  Without  this  pre- 
liminary knowledge  he  cannot  accurately  appreciate  or  intelligently  interpret 
some  changes  induced  by  the  anesthetic.  Constipation  must  be  amended  by 
mild  laxatives  or  enemas,  and  all  fermented  matter  should  be  removed  from 
the  alimentary  canal.  Constipation  increases  the  probability  of  wound  infec- 
tion and  greatly  impairs  the  comfort  of  the  patient.  As  previously  shown,  the 
putrefactive  bacteria  in  the  intestinal  canal,  which  are  usually  harmless  and 
are  what  Adami  calls  "potential  parasites,"  may  escape  into  the  tissues. 
The  retention  of  fermented  matter  causes  catarrhal  inflammation  and  bacteria 
escape  more  easily.  If  they  escape  they  may  lead  to  damage  in  the  wound,  and 
even  if  wound  infection  from  within  does  not  occur,  constipation  lessens 
\dtal  resistance  and  increases  the  liability  to  wound  infection  from  without. 
Purgatives  must  not  be  -violent,  as  anything  which  greatly  depresses  a  person 
lessens  vital  resistance,  and  powerful  purgatives  are  powerful  depressants. 
The  diet  should  be  bland  and  nutritious,  but  not  bulky.  The  night  before 
the  operation  give  a  saline  cathartic,  and  the  morning  of  the  operation  em- 
ploy an  enema.  Not  only  do  we  empty  the  bowel  to  lessen  the  liability  to 
woimd  infection,  but  we  wish  the  rectum  empty  at  the  time  of  operation  for 
another  reason.  It  is  desirable  that  the  rectum  be  empty  because  in  shock 
the  absorbing  power  of  the  stomach  is  greatly  diminished  or  is  even  abolished 
for  the  time,  and  it  may  be  necessary  to  utilize  the  absorbing  power  of  the 
rectum  to  take  up  stimiilants  given  by  enema.  When  a  patient  is  under 
the  iniiuence  of  an  anesthetic  or  when  he  is  profoundly  shocked,  of  course  no 
attempt  is  made  to  give  stimulants  by  the  mouth.  WTienever  possible  give  a 
general  warm  bath  the  day  before  the  operation.  It  is  a  common  custom  the 
evening  before  the  operation  to  shave  the  region  if  hairy,  scrub  the  entire 
field  of  operation,  as  well  as  the  adjoining  regions,  mth  soap  and  water;  wash 
with  alcohol;  scrub  \\dth  hot  corrosive  sublimate  solution  (1:1000);  apply 
a  layer  of  moist  corrosive  sublimate  gauze,  and  place  over  this  dry  antiseptic 
gauze,  a  rubber  dam,  and  a  bandage.  Many  surgeons  apply  a  poultice  of  green 
soap  for  many  hours  before  applying  a  chemical  germicide,  in  order  to  separate 
masses  of  epithelium  and  with  them  many  germs.  This  method  is  particularly 
useful  in  cleansing  the  scalp.  On  removing  the  dressings  to  perform  the  opera- 
tion, the  part  is  scrubbed  with  soap  and  water,  washed  mth  sterile  water,  then 
\\dth  alcohol,  and  then  with  corrosive  sublimate  solution.  I  have  become  con- 
vinced that  the  teachers  in  Johns  Hopkins  Hospital  are  right,  and  that  cleansing 
the  day  before  operation  is  not  necessary  except  for  a  brain  case.  Neither  is  it 
desirable,  as  it  often  gives  the  patient  a  restless  night.  It  is  my  custom  to  have 
a  hairv'  region  shaved  the  day  before  operation.  In  all  cases  the  field  of  opera- 
tion is  disinfected  the  morning  of  the  operation.  Disinfection  is  again  practised 
when  the  patient  is  on  the  operating  table,  after  anesthetization.  In  emergency 
cases  disinfection  can  only  be  practised  just  previous  to  the  operation.  When 
the  field  of  operation  has  been  prepared,  surround  it  with  dry  sterile  sheets 
and  towels.  In  a  head  operation  I  stitch  the  towels  to  the  skin  to  keep  them 
in  place  and  at  the  termination  of  the  operation  remove  these  stitches.  IVIurphy 
prevents  infection  from  the  cutaneous  surface  by  spreading  a  specially  prepared 
sterile  solution  of  rubber  over  the  sterilized  operation  area.  The  rubber  is 
dissolved  in  acetone.  The  incisions  are  made  through  the  artificial  skin  of 
rubber  and  the  rubber  is  removed  w^hen  the  surgeon  is  ready  to  introduce  the 
sutures.  Thus  infection  of  the  wound  with  contaminated  secretion  of  the  skin 
glands  is  prevented.  If  iodin  has  been  used  upon  the  abdomen,  the  surgeon 
must  be  scrupulously  careful  not  to  bring  intestine  in  contact  with  the  skin. 
If  iodin  comes  in  contact  with  intestine,  it  irritates  the  gut  and  becomes 
responsible  for  subsequent  adhesions. 

If  disinfecting  an  emergency  case  in  which  a  wound  exists,  tincture  of 


68  Asepsis  and  Antisepsis 

iodin,  unless  well  diluted,  should  not  be  put  in  the  wound.  Hindenburg  had  a  case 
in  which  local  gangrene  followed  such  an  application  f "  Miinchener  medizinische 
Wochen.,"  July  5,  191  ij.  It  is  not  probable  that  the  very  dilute  alcoholic  solu- 
tion of  iodin  used  by  many  to  prepare  the  skin  would  endanger  a  wound. 

Of  recent  years  iodin  has  been  largely  used  and  warmly  praised  as  a  dis- 
infectant for  the  skin.  It  was  introduced  by  Grossich  in  1908.  If  iodin  is  to 
be  used  the  skin  may  be  scrubbed  and  shaved  the  night  before,  but  must  never 
be  scrubbed  within  several  hours  of  the  impending  operation.  Were  it  done,  it 
would  swell  the  surface  epitheUimi  and  keep  the  iodin  from  entering  into  the 
skin.  Two  hours  before  operation  apply  iodin,  and  apply  it  again  when  the 
patient  is  on  the  table.  In  an  emergency  case  the  skin  is  dry  shaved,  the  field 
of  operation  is  painted  with  a  2  per  cent,  alcoholic  solution  of  iodin  (which  is 
allowed  to  dr\'  and  is  not  wiped  away) ,  and  covered  with  sterile  towels  or  gauze. 
WTien  the  patient  is  placed  upon  the  table  the  field  is  again  painted  with  iodin. 
This  method  is  of  great  value  in  emergency  cases,  especially  in  out-patient 
■  and  accident  work.  I  have  abandoned  it  in  the  axilla  and  perineimi  because 
the  constant  moisture  of  those  regions  makes  iodin  inefficient.  The  method  is 
less  efficient  in  summer  than  in  winter,  because  in  siunmer  the  skin  is  apt  to 
be  wet  with  sweat. 

During  an  operation  the  patient  must  be  carefully  protected  from  cold 
by  wrapping  him  in  blankets,  and  often  by  ha\'ing  him  wear  specially  pre- 
pared drawers  with  feet.  After  the  completion  of  an  operation  and  the  ap- 
pHcation  of  the  dressings  the  patient  is  returned  to  his  room  or  the  ward, 
care  being  taken  to  protect  him  from  cold  or  drafts. 

Disinfection  of  Mucous  Membranes. — It  is  impossible  to  thoroughly 
disinfect  mucous  membranes.  We  must  not  scrub  forcibly  and  we  must  not 
use  powerful  germicides,  because  they  are  irritant  and  also  because  they  may 
be  absorbed.  The  best  that  can  be  done  in  the  vagina  is  to  rub  lightly,  when 
possible,  -^dth  a  bit  of  moist  absorbent  cotton  and  irrigate  with  a  solution 
of  boric  acid  or  with  normal  salt  solution.  Another  method  is  to  sponge  the 
vagina  with  creoUn  and  ethereal  soap  (i  and  i6j  and  irrigate  vidth  hot  saline 
fluid  or  boric  acid. 

The  rectum  is  prepared  by  washing  out  all  retained  feces  by  the  use  of 
copious  high  injections  and  by  irrigating  with  salt  solution  or  boric  acid. 

The  mouth  is  prepared  by  ha\dng  snags  of  teeth  and  tartar  removed  and 
decayed  teeth  removed  or  plugged.  For  several  days  before  the  operation 
scrub  the  teeth  twice  a  day  wdth  a  soft  brush  and  castile  soap ;  and  every  three 
hours,  w^hen  the  patient  is  awake,  rinse  the  mouth  with  peroxid  of  hydrogen 
and  spray  the  nares  and  nasopharv^nx  with  a  saturated  solution  of  boric  acid. 

The  urethra  is  prepared  by  administering  by  the  mouth  for  several  days 
salol  or  urotropin  and  by  frequent  irrigation  of  the  urethra  \\\\h  boric  acid 
solution,  normal  salt  solution,  a  solution  of  permanganate  of  potash  ( i :  6000), 
or  a  1 :  5000  solution  of  silver  nitrate. 

Preparation  of  a  Patient  for  An  Operation  Upon  the  Stomach. — (See  p.  1079.) 

The  Time  of  Day  to  Operate. — A  hard-and-fast  rule  cannot  be  set  as  to  the 
time  of  day  when  operations  should  be  done.  Emergency  operations  must  be 
performed  at  once  "vsithout  any  consideration  as  to  time.  It  is  often  necessary, 
because  of  other  professional  obligations,  to  set  an  afternoon  hour  for  an  opera- 
tion. WTienever  possible,  however,  if  the  nature  of  the  case  admits  of  it,  operate 
in  the  morning  and,  preferably,  in  the  early  morning.  By  doing  this  the  patient 
is  saved  some  hours  of  dread  and  worry  and  the  surgeon  is  enabled  to  operate 
when  he  is  fresh,  active,  and  alert:  in  other  words,  when  he  is  at  his  best.  A 
tired  mind,  like  a  tired  hand,  tends  to  become  shaky,  and  a  tired  mind  may 
mean  incorrect  observ-ation,  careless  technic,  impaired  judgment,  disastrous 
timidity,  or  calamitous  recklessness. 


The  Dry  Method  69 

Operations  on  Diabetics. — Surgical  operations  upon  diabetics  are  regarded 
as  very  dangerous  and  are  employed  by  most  surgeons  only  in  emergencies. 
In  operations  upon  such  subjects  gangrene  may  arise  in  the  wound  or  diabetic 
coma  may  develop.  It  is  important  to  remember  that  glycosuria  may  result 
from  a  surgical  condition  (head  injury,  sepsis,  etc.),  and  this  temporary  dia- 
betes may  be  relieved  by  operation.  'I  have  seen  it  in  appendicitis,  and  in 
such  cases  operation  is  not  contra-indicated,  but  is  imperative.  Llewellyn 
Phillips  ("Lancet,"  May  10  and  17,  1902)  refers  to  the  temporary  glycosuria 
produced  by  injury  and  sepsis.  He  thinks  that  diabetes  may  directly 
cause  cataract  and  balanoposthitis,  but  produces  gangrene  indirectly  by 
causing  nerve  degeneration  and  arteriosclerosis.  Phillips  points  out  that 
a  surgical  condition  and  glycosuria  may  exist  independent  of  and  uninfluenced 
by  each  other,  and  many  such  cases  can  be  operated  upon,  although  operation 
should  be  avoided  if  there  is  serious  disease  of  some  important  organ  (the  liver, 
for  instance).  Phillips,  in  the  valuable  article  referred  to,  insists  that  the 
percentage  of  sugar  is  not  a  measure  of  the  degree  of  danger;  that  albuminuria 
adds  greatly  to  the  danger;  that  the  presence  of  acetone  in  the  urine,  and  also 
the  presence  of  ammonia,  gives  a  bad  prognosis.  Phillips's  conclusions  as  to 
when  to  operate  and  when  to  refuse  operation  are  as  follows  ("Lancet,"  May 
10  and  17,  1902):  An  operation  for  malignant  disease  in  a  diabetic  can  be 
performed  if  the  operation  would  be  proper  on  a  non-diabetic  individual. 
Large  abdominal  tumors  can  be  removed.  Cosmetic  operations  are  justi- 
fiable if  the  general  health  is  good  and  there  is  not  marked  arterial  disease  or 
nerve  degeneration.  Operation  is  justifiable  in  all  emergencies  without  regard 
to  the  condition  of  the  urine.  In  a  diabetic  with  a  surgical  malady  it  is  often 
possible  to  lessen  danger  by  preliminary  treatment.  Only  an  operation  of  the 
greatest  urgency  should  be  performed  if  over  i  gm.  of  ammonia  is  excreted 
during  twenty-four  hours;  and  if  aceto-acetic  acid  or  much  albumin  is  present, 
every  case  but  the  most  urgent  should  be  postponed  and  subjected  to  medical 
treatment. 

I  would  add  to  the  conclusions  of  Phillips  that  the  anesthetic  is  a  danger 
to  the  kidneys  irritated  by  the  secretion  of  sugar,  and  it  is  desirable,  when 
possible,  to  use  local  anesthesia,  or,  as  Robt.  T.  Morris  advises,  nitrous  oxid 
and  oxygen  ("Medical  News,"  June  29,  1901),  or  spinal  anesthesia,  or  to  block 
the  nerves  with  cocain.  In  3  cases  I  used  spinal  anesthesia,  but  in  i  of  them 
the  patient  died  in  coma.  If  sugar  diminishes  in  the  urine  but  increases 
in  the  blood,  the  condition  is  one  of  danger.  Further,  if  the  urine  contains 
sugar,  but  neither  acetone  nor  diacetic  acid,  we  should  restrict  carbohydrates  and 
administer  opium  or  codein.  Too  strict  and  too  prolonged  exclusion  of  carbo- 
hydrates is  not  justifiable,  because  it  favors  the  occurrence  of  acetonuria. 
If  acetonuria  exists  or  arises,  a  pure  meat  diet  is  inadmissible,  as  it  favors  dia- 
betic coma.  The  risk  of  coma  is  diminished  by  giving  bicarbonate  of  soda  by 
the  mouth,  before  and  after  operation.  If  coma  arises  give  carbonate  of  soda 
intravenously. 

Irrigation  is  often  practised  in  septic  wounds,  but  is  not  required  in  aseptic 
wounds.  In  a  septic  wound  gentle  irrigation  is  often  desirable.  Irrigation 
removes  many  bacteria  and  much  toxin  and  antiseptic  irrigation  perhaps 
antidotes  retained  toxins.  Irrigation  must  never  be  forcible  for  fear  it  may  dis- 
seminate infection.  Among  irrigating  fluids  we  may  mention  corrosive  subli- 
mate, carbolic  acid,  peroxid  of  hydrogen,  boric  acid  solution,  acetate  of  alu- 
minum, and  normal  salt  solution.  Hot  normal  salt  solution  is  the  best  agent 
with  which  to  irrigate  the  peritoneal  cavity,  the  pleural  sac,  the  interior  of 
joints,  and  the  surface  of  the  brain.  This  solution  contains  0.9  per  cent,  of 
sodium  chlorid. 

The  Dry  Method. — Many  surgeons  employ  Landerer's  dry  method  in  oper- 


7©  Asepsis  and  Antisepsis 

ating  aseptically,  no  fluid  being  applied  to  the  wound.  As  the  wound  is  en- 
larged gauze  sponges  are  packed  in  to  arrest  hemorrhage.  On  the  completion  of 
the  operation  the  sponges  are  removed,  bleeding  points  are  Hgated,  and  the 
wound  is  often  closed  without  drainage. 

Ligatures  and  Sutures. — In  using  sutures  always  remember  that  they 
must  be  tied  firmly,  but  never  tightly.  A  tight  suture  will  cut  when  the 
woimd  swells  and  will  thus  fail  of  its  purpose;  further,  it  produces  an  area 
of  tissue  necrosis,  which  is  a  point  of  least  resistance  in  and  about  which 
infection  is  prone  to  occur.  We  had  far  better  use  many  very  fine  sutures 
than  a  less  number  of  thick  ones.  The  individual  fine  suture  is  weak,  but  in 
numbers  they  give  firm  support.  A  fine  suture  cannot  be  tied  too  tight. 
If  we  try  to  make  it  tight  the  attempt  is  frustrated  by  the  breaking  of  the 
suture. 

Catgut. — The  favorite  Hgature  material  is  catgut.  Catgut  undergoes  ab- 
sorption in  the  tissues.  Years  ago  attempts  were  made  by  Scarpa,  Crampton, 
and  Physick  to  use  absorbable  ligatures.  Sir  Astley  Cooper  tried  catgut. 
These  attempts  failed  because  the  material  employed  was  septic,  suppuration 
ensued,  the  wound  gaped,  and  the  ligature  was  cast  off  prematurely.  Surgeons 
remained  content  with  non-absorbable  ligatures  of  silk  or  Hnen.  These  liga- 
tures were  not  cut  short,  but  a  long  end  was  left  to  each  one,  and  the  ends 
were  allowed  to  hang  out  of  the  wound.  The  ligatures  were  Hghtly  pulled 
upon  from  time  to  time,  and  when  they  loosened  or  cut  through  were  removed. 
Catgut  is  the  submucous  coat  of  the  intestine  of  the  sheep,  and  is  the  material 
from  which  violin  strings  are  made.  It  was  reintroduced  into  surgery  by 
Lister.  It  is  usually  obtained  in  the  following  manner:  The  small  intestine, 
after  separation  from  the  mesentery,  is  washed  in  water,  laid  upon  a  board, 
and  scraped  by  a  metal  instrument.  Thus  the  mucous  coat  and  the  muscular 
coat  are  scraped  away,  and  the  submucous  coat  only  remains.  The  submu- 
cous coat  is  cut  into  strips,  and  each  strip  is  twisted  into  a  coil.  Raw  catgut  is 
an  infected  material.  It  is  difficult  to  sterilize,  because  in  the  twdsting  many 
organisms  get  into  the  interior  of  the  strand,  where  it  is  impossible  for  anti- 
septics to  reach  them.  Raw  catgut  obtained  from  animals  dead  of  splenic  fever 
contains  spores  of  anthrax.  If  not  thoroughly  disinfected  catgut  is  dan- 
gerous, and  some  surgeons  consider  its  cleanliness  always  a  matter  of  grave 
question  and  will  not  use  it.  Cases  of  tetanus  after  operation  have  been  traced 
directly  to  infected  catgut.  The  safest  raw  catgut  is  obtained  from  fresh 
intestines  (as  advised  by  Kuhn),  is  not  twisted,  is  made  into  strands  in  sterile 
machines  so  as  to  prevent  handling,  and  is  put  up  in  aseptic  bundles.  Surgeons' 
catgut  is  usually  obtained  from  the  dealer  in  skeins  containing  30  yards.  It 
should  be  rough  and  yellow.  The  smooth  white  variety  should  not  be  pur- 
chased. It  has  been  rubbed  smooth  with  a  piece  of  glass  and  bleached  with  a 
chemical,  and  in  consequence  is  weak  and  unreliable.  The  smallest  size  is 
known  as  double  zero,  then  come  single  zero,  No.  i.  No.  2,  No.  3,  and  No.  4. 
The  usual  ligature  size  is  No.  2.  Nos.  3  and  4  are  only  used  for  tying  thick 
pedicles.  Nos.  i  and  2  are  used  for  suturing  the  dura  and  peritoneum  and  No.  i 
for  tying  smaU  vessels  in  the  brain.  When  catgut  is  used  to  tie  deHcate  tissue 
(omental  masses,  intestinal  surfaces,  etc.)  it  must  first  be  softened  by  im- 
mersing for  half  a  minute  in  normal  salt  solution.  If  this  precaution  is  neglected 
and  wiry  catgut  is  used,  the  ligature  or  suture  will  cut  and  hemorrhage  will 
occur.  The  greater  the  diameter  of  the  gut,  the  more  uncertain  is  the  steriliza- 
tion. Nos.  3  and  4  are  of  doubtful  cleanHness,  no  matter  what  method  of 
sterilization  is  employed,  and  a  strand  though  clean  upon  the  surface  may  be 
infected  in  its  interior.  When  a  strand  which  is  infected  within  is  used  by  the 
surgeon  the  tissues  are  not  infected  promptly,  but  after  some  days  when  the 
catgut  has  been  partially  absorbed  and  the  spores  or  bacteria  within  the 


Ligatures  and  Sutures  71 

strand  have  been  set  free.  Many  late  infections  are  due  to  catgut  infected 
in  the  interior  of  the  strand.  The  smaller  sizes  I  believe  can  usually  be  satis- 
factorily sterilized.  I  am  very  uncertain  as  to  the  surgical  cleanliness  of  the 
larger  sizes. 

If  catgut  is  thoroughly  freed  from  bacteria  and  the  wound  in  which  it  is 
used  is  aseptic,  it  is  a  most  satisfactory  ligature  material,  is  absorbed  in  the 
wound  after  being  cut  off  short,  and  produces  no  trouble,  although  it  does 
increase  wound  secretion  slightly.  The  smaller  sizes  are  absorbed  in  four  or 
five  days,  No.  2  lasts  from  nine  to  ten  days,  Nos.  3  and  4  from  ten  days  to 
three  weeks.     Chromicized  catgut  is  absorbed  far  less  rapidly  than  plain  gut. 

One  of  the  following  methods  of  preparation  may  be  used: 

Boiling  in  Alcohol. — The  catgut  is  soaked  in  ether  for  twenty-four  hours 
to  remove  fat.  It  is  then  wound  on  glass  spools,  transferred  to  alcohol,  and 
boiled  under  pressure.  The  boiling  is  conducted  in  a  heavy  metal  jar  with 
a  well-fitting  screw-top.  The  jar  is  half  filled  with  alcohol.  The  spools  of 
catgut  are  placed  in  the  jar,  the  lid  of  the  jar  is  screwed  down,  and  the  ap- 
paratus is  immersed  in  boiling  water  for  half  an  hour.  The  gut  is  kept  in 
this  jar  until  needed.  Fowler's  catgut  is  prepared  by  boiling  in  alcohol.  It 
is  placed  in  hermetically  sealed  U-shaped  glass  tubes.  Each  tube  contains 
alcohol  and  twelve  ligatures.  The  alcohol  is  boiled  by  immersing  the  tube  in 
boiling  water. 

The  cumol  method  is  employed  by  Kelly  in  the  Johns  Hopkins  Hospital, 
and  is  known  as  Kronig's  method.  Cumol  is  a  fluid  hydrocarbon  which  boils 
at  179°  C.  Catgut  is  wound  upon  spools  of  glass,  and  these  are  placed  in  a 
beaker  glass,  the  bottom  of  which  is  covered  with  cotton.  A  bit  of  cardboard 
is  placed  on  top  of  the  beaker,  and  through  a  small  perforation  in  the  card- 
board a  thermometer  is  introduced.  The  beaker  is  placed  in  a  sand-bath 
and  the  bath  is  heated  by  means  of  a  Bunsen  burner.  The  temperature  is 
gradually  raised  to  80°  C,  and  is  kept  at  this  point  for  one  hour,  in  order 
entirely  to  remove  moisture  from  the  gut.  Cumol,  at  a  temperature  of  100°  C, 
is  poured  into  the  glass,  and  the  heat  is  increased  until  the  temperature  of  the 
cumol  is  165°  C,  which  is  a  few  degrees  below  its  boiHng-point.  For  one  hour 
this  temperature  is  maintained.  Then  the  cumol  is  poured  off  and  the  catgut  is 
allowed  to  remain  for  a  time  in  the  sand-bath,  at  a  temperature  of  100°  C.,  in 
order  to  dry.  It  is  transferred  for  keeping  into  sterile  glass  jars  or  test- 
tubes.^ 

The  Claudius  Method. — ^The  iodin  catgut  is  prepared  by  the  Claudius 
method.  Mr.  Moynihan,  of  Leeds,  makes  Claudius  catgut  as  follows:  In  10 
oz.  of  sterile  water  dissolve  i  oz.  of  crystals  of  iodid  of  potassium.  When  all 
the  crystals  are  dissolved  add  10  oz.  of  sterile  water,  and  then  add  i  oz.  of 
iodin  in  crystalline  form.  Dilute  the  mixture  with  4  pints  of  sterile  water. 
The  result  is  a  i  per  cent,  solution  of  iodin  and  potassium  iodid.  After  the 
usual  preliminary  preparation,  place  the  gut  in  the  mixture  and  keep  it  in  it  for 
for  at  least  eight  days  before  using.  It  can  be  kept  in  it  without  harm  for  a 
number  of  months.  Salkindsohn  has  modified  the  Claudius  method  as  follows: 
Use  I  part  of  tincture  of  iodin  and  1 5  parts  of  proof  spirits  and  immerse  the  cat- 
gut for  eight  days  (J.  S.  Riddell,  in  "Brit.  Med.  Jour.,"  April  6,  1907). 

Silverized  Catgut. — Blake  advocates  this  form  of  gut  ("Annals  of  Surgery," 
January,  1907).  He  prepares  it  as  follows:  He  winds  four  coils  of  gut  on  four 
glass  plates,  places  the  plates  in  a  jar  containing  a  2  per  cent,  solution  of 
collargolum  and  keeps  them  immersed  for  a  week,  the  jar  being  shaken  once 
or  twice  during  the  period  of  immersion.  At  the  end  of  a  week  the  plates  are 
removed  from  the  silver  solution  and  are  placed  for  from  fifteen  to  thirty 

^See  McBurney  and  Collins,  in  "International  Text-Book  of  Surgery,"  and  Clark,  in 
"  Johns  Hopkins  Hospital  Bulletin,"  March,  1896. 


72  Asepsis  and  Antisepsis 

minutes  in  95  per  cent,  alcohol,  then  the  gut  is  wound  -^ath  aseptic  care  on 
glass  spools  and  is  kept  until  wanted  in  95  per  cent,  alcohol. 

The  formalin  method  was  advocated  by  the  late  Prof.  Senn.  The  catgut 
is  wound  on  glass  test-tubes  and  is  immersed  in  an  aqueous  solution  of  formalin 
(2-4  per  cent.)  for  twenty-four  to  forty-eight  hours.  It  is  placed  in  rimning 
water  for  twelve  hoiirs  to  get  rid  of  the  formalin.  It  is  boiled  in  water  for 
fifteen  minutes,  is  cut  in  pieces  and  tied  in  bundles,  is  placed  in  a  glass-stop- 
pered jar,  and  is  kept  ready  for  use  in  the  following  mixture:  950  parts  of 
absolute  alcohol,  50  parts  of  glycerin,  and  100  parts  of  pulverized  iodoform. 
Every  few  days  the  mixture  should  be  shaken. 

Senn's  process  is  a  modification  of  Hoft'meister's.  Even  sterile  catgut 
contains  a  toxic  substance,  which  increases  woimd  secretion,  has  a  poisonous 
effect  on  body  cells,  and  favors  to  some  extent  limited  suppuration.  Senn 
maintains  that  to  counteract  this  influence  gut  should  not  only  be  sterile, 
but  should  be  antiseptic,  to  inhibit  the  growth  of  pyogenic  organisms  which 
reach  the  wound  from  without  during  operation  or  subsequently  by  the  blood. 

Dry  Heat  Method. — Boeckman  wraps  catgut  inparaffiji  paper,  seals  it  in  a 
paper  envelope,  puts  it  in  the  sterilizer,  and  subjects  it  to  dty  heat.  For  three 
hoiirs  it  is  heated  to  a  temper atrnre  of  284°  F.,  and  for  four  hours  to  a  tempera- 
ture of  290°  F.  The  envelope  can  be  carried  in  the  pocket  or  the  instrument 
bag.  When  the  gut  is  wanted  the  end  of  the  envelope  is  torn  off,  an  assistant 
T\dth  sterilized  hands  unwraps  the  paraffin  paper,  and  the  gut  is  dipped  for  a 
moment  in  sterile  water  to  make  it  pliable.^ 

Corrosive  Sublimate  Method. — A  method  which  has  been  largely  used  is 
to  take  raw  catgut,  keep  it  in  ether  for  twenty-four  hours,  soak  it  for  twenty- 
foiu:  hours  in  an  alcohoHc  solution  of  corrosive  sublimate  (i:  500),  -uindit  on 
sterilized  glass  rods,  and  place  it  for  keeping  in  ether  or  in  alcohol. 

Johnston's  quick  method  of  preparing  catgut  is  as  follows:  Place  it  for 
twenty-four  hours  in  ether;  at  the  end  of  this  period  place  it  in  a  solution 
containing  20  gr.  of  corrosive  sublimate,  100  gr.  of  tartaric  acid,  and  6  oz. 
of  alcohol.  The  small  gut  is  kept  in  this  for  ten  or  fifteen  minutes,  the  larger 
gut  from  twenty  to  thirty  minutes,  but  never  longer.  It  is  placed  for  keeping 
in  a  mixture  containing  i  drop  of  chlorid  of  palladium  to  8  oz.  of  alcohol. 
This  gut  is  strong  and  reliable.  At  the  time  of  operation  the  gut  is  placed 
in  a  solution  one-third  of  which  is  5  per  cent,  carbolic  acid  solution  and  two- 
thirds  of  which  is  alcohol. 

Preparatio7i  of  Chromicized  Catgut. — Chromicized  catgut  is  absorbed  less 
rapidly  by  the  tissues  than  ordinary  catgut.  It  is  used  to  tie  thick  pedicles 
and  large  arteries,  to  suture  nerves  and  tendons,  and  as  a  suture  material  in 
the  radical  cure  of  hernia.  Chromicized  gut,  No.  3  and  No.  4,  T^-iU  remain 
imabsorbed  in  the  tissues  from  four  to  six  weeks.  The  gut  should  be  soaked  in 
ether  for  twent3^-four  hours,  and  be  immersed  for  twenty-four  hours  in  a  4  per 
cent,  solution  of  chromic  acid  in  water.  The  gut  is  then  dried  in  a  hot-air 
sterilizer  and  is  disinfected  by  one  of  the  several  methods.  The  cumol  method 
is  satisfactory. 

How  to  Tie  Catgut. — Catgut  is  tied  in  a  reef  knot  (square  knot)  and  dis- 
tinct ends  are  left  on  cutting.  The  second  knot,  if  puUed  too  tightly,  may 
break  the  hgature.  Moist  catgut  is  sUppen,^  and  is  hard  to  tie.  If  a  large 
vessel  is  tied  by  catgut,  a  third  knot  should  be  used  and  the  ends  cut  close  to 
the  knot.  In  tying  a  vessel  in  the  brain  or  omentum  be  sure  the  gut  is  not 
wiry;  if  it  is  it  "udll  tear  the  vessel  and  permit  renewed  bleeding.  Wir\^  gut 
must  be  dipped  in  salt  solution  for  a  moment  just  before  using.  Really  strong 
catgut  can  be  tied  in  a  surgeon's  knot. 

Kangaroo-tendon  and  Its  Preparation. — This  material  is  said  to  be  obtained 
1  James  E.  Moore,  in  "  Phila.  Med.  Jour.,"  June  22,  1898. 


Ligatures  and  Sutures  73 

from  the  tail  of  the  great  kangaroo.  It  is  hard  to  beUeve  that  kangaroos  are 
sufficiently  cheap  and  plentiful  to  furnish  us  with  it  in  quantity.  It  is  cer- 
tainly a  tendonous  material.  It  is  especially  useful  fl^r  buried  sutures  in 
hernia  operations;  it  will  be  absorbed  in  the  tissues,  but  only  after  a  long  time 
(sixty  to  seventy  days).  Kangaroo-tendon  is  not  grossly  infected  as  is  catgut. 
The  material  is  obtained  from  a  recently  killed  animal  and  is  promptly  dried 
in  the  sun.  This  suture  material  was  introduced  by  Dr.  Henry  O.  Marcy. 
It  can  be  prepared  in  the  same  manner  as  the  chromicized  catgut,  and  it 
ought  always  to  be  chromicized. 

The  following  method  of  preparation  is  recommended  by  Charles  Truax 
("Mechanics  of  Surgery"):  Soak  the  dried  tendon  until  it  becomes  supple 
in  a  1 :  1000  solution  of  corrosive  sublimate.  Separate  the  material  into  in- 
dividual tendons,  place  them  lengthwise  between  two  towels;  dry  them; 
make  them  aseptic  by  soaking  in  a  solution  of  formalin,  as  we  would  do  with 
catgut  (see  above).  After  washing  out  the  formalin  chromicize  the  tendon 
by  placing  it  in  a  fresh  5  per  cent,  solution  of  carbolic  acid  containing  i :  4000 
parts  of  chromic  acid.  When  the  tendons  become  "dark  golden  brown"  in 
color,  they  are  removed  from  the  chromic  acid  solution,  dried  between  sterile 
towels,  and  placed  for  keeping  in  10  per  cent.  carboHzed  oil.  When  wanted, 
they  are  removed  from  the  oil,  and  wiped  with  a  sterile  towel  saturated  with 
bichlorid  solution  (i :  1000).  Kangaroo-tendon  is  tied  in  a  reef  knot.  It  must 
be  tied  firmly,  else  the  knot  will  slip. 

Silk. — This  material  can  be  used  for  both  hgatures  and  sutures;  many 
sizes  should  be  kept  on  hand.  Silk  is  very  strong,  soft,  extremely  supple, 
and  does  not  swell  or  irritate  the  tissue.  It  can  be  tied  into  very  firm  knots. 
Ordmary  surgical  silk  is  a  form  of  tmsted  silk — that  is,  several  or  many  strands 
are  twisted  into  one.  Cable  twist  or  Tait's  silk  is  very  strong  and  is  used  for 
t3dng  large  pedicles.  Braided  silk  is  extremely  strong  and  is  made  by  plaiting 
together  several  strands  of  twisted  silk.  Floss  silk  is  "a  straight  fiber  slightly 
twisted"  (Truax).  Silk  is  usually  tied  in  a  reef  knot,  but  occasionally  in  a  sur- 
geon's knot.  White  silk  may  be  used,  or  black  silk,  which  is  more  easily  visible. 
Silk  becomes  encapsulated  in  the  tissues.  It  is  not  absorbed  at  all  or  only  after 
a  very  long  time.  It  is  not  a  good  material  for  buried  sutures,  as  in  the  long 
run  it  mav  form  a  sinus.     Fine  silk  Hgatures  do  not  cause  sinuses. 

Preparation  of  Silk. — Sutures  of  silk  should  be  boiled  for  half  an  hour  before 
using  in  a  I  per  cent,  solution  of  carbonate  of  sodium.  Some  surgeons  keep 
the  silk  after  boiling  in  sublimated  alcohol  (i  :  1000)  or  carbolic  solution  (5 
per  cent.),  but  it  is  better  to  prepare  it  just  before  usmg.  A  convenient  method 
of  preparation  is  to  wind  the  silk  on  a  glass  spool,  place  the  spool  in  a  large 
test-tube,  close  the  mouth  of  the  tube  with  jeweler's  cotton,  introduce  the  tube 
into  a  steam  sterilizer,  and  subject  it  to  a  pressure  of  10  pounds  for  twenty 
minutes,  repeating  the  process  the  next  day.  These  tubes  are  carried  in 
wooden  boxes  sealed  with  rubber  corks. 

Horsehair  and  Its  Preparation. — This  is  used  for  effecting  very  neat  approxi- 
mation when  only  light  sutures  are  required;  for  instance,  in  wounds  of  the 
face.  Its  chief  use  is  for  capillary  drainage.  It  is  prepared  by  washing  and 
then  boiling  for  fifteen  minutes  in  -a  4  per  cent,  solution  of  carbonate  of  soditun. 
It  is  kept  until  needed  in  sublimated  alcohol  (i  :  1000). 

Silkworm-gut  and  Its  Preparation. — This  material  contains  fewer  bacteria 
than  catgut  and  does  not  swell  when  introduced  into  a  wound.  It  is  strong, 
sohd,  smooth,  non-irritating,  can  be  drawn  through  the  tissues  with  slight 
force,  and  does  not  tend  to  cut  the  tissue  as  does  a  metaUic  suture.  The 
designation  silkworm-gut  is  a  misnomer;  the  material  is  not  gut  at  all,  but 
is  obtamed  from  the  silk-producing  glands.  Italy  supplies  most  of  the  gut 
used  by  fishermen,  but  the  gut  used  by  the  surgeon  comes  chiefly  from  Murcia, 


74 


Asepsis  and  Antisepsis 


in  Spain.  When  the  silkworms  are  just  ready  to  spin  they  are  placed  in  vine- 
gar and  water  for  a  number  of  hours  and  are  thus  killed.  Each  worm  is  opened 
and  the  silk-producing  glands  are  clearly  exposed  and  each  gland  is  drawn 
by  its  ends  into  a  single  thread.  The  threads  are  dried  in  the  air  and  assume 
a  reddish  color  (M.  J.  Triollet,  in  "Bulletin  des  Sciences  Pharmacologiques," 
1905,  No.  5.  Quoted  in  "Lancet,"  Feb.  3,  1906).  "This  crude  silkworm-gut 
is  sold  to  the  manufacturer  and  further  treated.  It  is  first  boiled  in  alkaUne 
water  to  remove  fat  and  blood  and  is  then  dried  in  the  sun,  being  protected 
from  dust.  It  is  next  poHshed  by  means  of  slightly  oiled  pumice  stone.  The 
gut  is  then  bleached  with  sulphurous  acid  and  rubbed  vigorously  wdth  chamois 
leather  to  remove  dust  and  sulphur"  ("Lancet,"  Feb.  3,  1906).  It  is  a  very 
valuable  material,  but  is  not  used  for  ligatures,  as  it  cannot  be  tied  as  firmly  as 
catgut  and  because  w^hen  left  buried  in  the  tissues  the  sharp  ends  may  stick 
and  irritate  and  a  point  of  least  resistance  may  be  created.  Silkworm-gut  is 
prepared  by  placing  it  in  ether  for  forty-eight  hours  and  in  a  solution  of  corro- 
sive sublimate  (i  :  1000)  for  one  hour,  or  it  can  be  boiled  in  plain  water  for  half 

an  hour.  It  is  carried  in  a  long  tube  filled 
with  alcohol.  A  few  minutes  before  using 
the  gut  is  placed  in  carbolic  acid  and  al- 
cohol (one-third  of  the  solution  is  a  3  per 
cent,  solution  of  acid,  two-thirds  of  it  is 
alcohol).  Silkworm-gut  is  tied  by  the 
surgeon's  knot. 

Celluloid  Thread  atid  Its  Preparation. 
— This  material  is  warmly  advocated  by 
Pagenstecher.  He  calls  it  celluloid  yarn, 
and  prepares  it  from  English  gray  linen 
thread.  I  have  used  it  with  much  satis- 
faction. It  is  strong,  smooth,  flexible, 
and  the  knot  holds  firmly;  it  can  be 
sterilized  by  any  method  used  for  raw 
silk,  and  sterilization  by  dry  heat  actu- 
ally increases  its  strength.  Its  one  dis- 
advantage is  that  it  absorbs  about  40 
per  cent,  of  fluid,  but  it  does  not  soften. 
The  celluloid  is  added  after  the  thread 
has  been  boiled  in  a  i  per  cent,  solution 
of  carbonate  of  soda,  mped  on  or  wrapped 
in  a  sterile  towel,  and  dried  in  hot  air 
or  steam.  It  is  then  dipped  in  a  solu- 
tion of  celluloid  heated  in  a  hot-air 
sterilizer,  and  is  packed  in  sterile  boxes 
(Schlutius,  in  "Pacific  Med.  Journal," 
Jan.,  1900;  Keen  and  Rosenberger,  in 
"Phila.  Med.  Journal,"  May  10,  1900). 
Celluloid  thread  can  be  used  for  sutiires 
or  ligatures. 
Silver  wire  is  prepared  by  boiling.  It  is  a  very  useful  suture  material,  as  it 
can  be  thoroughly  sterilized  and  has  a  mild  inhibitory  effect  on  the  growth  of 
bacteria.  Some  surgeons  use  it  for  buried  sutures,  but  many  are  opposed 
to  using  it  thus  on  the  ground  that  it  is  apt  to  lead  to  sinus  formation.  Copper, 
brass,  and  bronze  have  a  very  distinct  inhibitory  effect  on  bacteria  (C.  L. 
Green,  in  the  "Practitioner,"  March,  1907),  and  wire  made  of  any  one  of 
these  metals  is  useful.  Gold,  tin,  platinum,  magnesium,  aluminum,  and  nickel 
are  devoid  of  inhibitory  power.     If  iron  oxidizes  freely  it  has  decided  inhibitory 


Fig.  37. — Small  steam-pressure  sterilizer  and 
instrument  boiler  (Fowler). 


Dressings 


75 


power;  if  it  is  so  coated  that  it  cannot  oxidize  it  has  no  inhibitory  power. 
Copper  is  more  powerfully  inhibitory  than  any  other  metal  (C.  L.  Green,  in  the 
"Practitioner,"  March,  1907).  I  have  used  copper  wire  and  brass  screws  in 
bone  and  have  used  wire  of  aluminum  bronze  for  various  purposes. 

Most  wounds  are  closed  by  interrupted  sutures  of  silkworm-gut,  but  silk, 
catgut,  chromic  catgut,  or  silver  wire  can  be  used.  The  old  continuous 
suture  (glovers'  stitch)  is  rarely  used  except  as  a  buried  suture.  An  admir- 
able closure  can  be  effected  by  Halsted's  subcuticular  stitch,  and  scarcely  any 
scar  results  (see  page  57).  Marcy's  buried  tendon  sutures  are  much  used,  espe- 
cially in  hernia  operations  and  in  various  other  operations  upon  the  abdomen. 

Dressings  are  made  of  cheese-cloth.  In  order  to  make  antiseptic  gauze 
the  cheese-cloth  is  boiled  in  a  solution  of  carbonate  of  sodiimi,  rinsed  out, 
and  dried;  it  is  then  soaked  for  twenty-four  hours  in  a  solution  containing  i" 
part  of  corrosive  sublimate,  2  parts  of  table  salt,  and  500  parts  of  w^ater.  It 
is  placed  in  clean  jars  with  glass  lids,  and  it  may  be  kept  moist  or  dry. 

Sterilized  or  aseptic  gauze  is  prepared  by  boiling  in  carbonate  of  sodium 
solution,  etc.,  as  described  under  Antiseptic  Gauze.      The  gauze  is  then 


Fig.  38. — Lautenschlager's  steam  sterilizer  for  dressings:  A,  Exterior  view;  B,  cross-section. 

-wrapped  in  a  towel  and  is  placed  in  a  steam  sterilizer  (Figs.  37  and  38)  for 
an  hour.     It  is  kept  until  wanted  in  sterile  glass  jars  with  glass  lids. 

Sterile  absorbent  cotton  is  prepared  in  the  same  manner  as  gauze.  Cotton 
is  useful  as  a  dressing  to  supplement  gauze,  being  placed  on  the  outside  of  the 
gauze.     It  absorbs  quantities  of  serirni,  but  will  take  up  very  Httle  pus. 

Iodoform  gauze  is  very  useful  for  packing  in  the  brain  and  abdomen,  for 
packing  abscesses  and  tuber ciilous  areas,  and  for  dressing  foul  wounds.  It 
is  prepared  as  follows:  Make  an  emiilsion  composed  of  equal  parts  by  weight 
of  iodoform,  glycerin,  and  alcohol,  and  add  corrosive  sublimate  in  the  pro- 
portion of  I  part  to  1000  of  the  mixture.  This  mixture  stands  for  three 
days.  Take  moist  bichlorid  gauze,  saturate  it  with  the  emulsion,  let  it  drip 
for  a  time,  and  keep  it  in  sterilized  and  covered  glass  jars  (Johnston) . 

Lister's  cyanid  gauze  (double  cyanid  of  zinc  and  mercury)  is  not  certainly 
.antiseptic,  and  must  be  dipped  into  a  corrosive  sublimate  solution  (i  :  2000) 
before  using.  All  forms  of  gauze  can  be  bought  ready  prepared  from  reliable 
firms. 

Some  surgeons  place  silver  foil  upon  a  wound  before  applying  the  gauze 
(Halsted,  page  32).     Very  small  wounds  in  which  drainage  is  not  employed  may 


76  Asepsis  and  Antisepsis 

be  dressed  by  laying  a  film  of  aseptic  absorbent  cotton  over  the  wound  and 
applying,  by  means  of  a  clean  camel's-hair  brush,  iodoform  collodion  (48  gr.  of 
iodoform  to  i  6z.  of  collodion).  Among  other  materials  sometimes  used  for 
dressing  wounds  the  following  should  be  mentioned:  Wood  wool,  absorbent 
wool,  moose  pappe,  oakum,  jute,  peat,  and  sawdust. 

Protectives. — A  protective  is  a  material  placed  directly  upon  wounds  to 
shield  them  from  irritation  and  infection.  The  commonly  used  protectives  are 
Lister's  oiled  silk  protective,  gutta-percha  tissue,  rubber  dam,  waxed  paper, 
paraffin  paper,  mackintosh,  Cargile  membrane,  and  silver  foil.  Undoubtedly, 
many  antiseptic  agents  destroy  young  cells  and  in  this  way  hinder  repair.  The 
same  is  true  of  certain  rough  dressings. 

R.  T.  Morris  showed  us  that  gauze  and  particularly  cotton  are  injurious 
to  a  healing  wound.  A  non-irritant  protective  laid  directly  upon  a  wound 
may  be  useful  by  saving  new  cells  from  injury  by  an  irritant  germicide  and 
from  being  pulled  away  at  each  change  of  dressings. 

Among  the  best  protectives  in  common  use  are  Lister's  protective,  gutta- 
percha tissue,  silver  foil,  and  Cargile  membrane.  Morris  condemns  gutta- 
percha tissue  as  irritant.  He  uses  thin  gold-beaters'  skin  made  from  the 
peritoneum  of  the  ox,  which  material  he  calls  Cargile  membrane,  after  an  Arkan- 
sas physician  who  introduced  it  into  practice.  The  advantage  of  this  material 
is  that  moisture  cannot  penetrate  and  new  cells  do  not  adhere.  I  have  used 
it  with  satisfaction  in  many  cases,  but  in  wounds  and  ulcers  prefer  silver 
foil. 

Silver  foil.  Lister's  protective,  or  gutta-percha  tissue  is  laid  directly  upon 
a  wound,  the  dressing  being  placed  above  it.  Silver  foil  comes  in  books  and 
is  sterilized  by  dry  heat.  Gutta-percha  tissue  should  be  sterilized  by  wash- 
ing with  soap  and  water,  rinsing  in  sterile  water,  and  soaking  in  a  solution  of 
corrosive  sublimate.  Lister's  protective  is  employed  to  save  the  wound  from 
the  irritation  of  carbolized  dressings. 

Impermeable  Material  Over  Dressings. — In  the  United  States,  if  it  is  desired 
to  place  an  impermeable  material  over  a  dressing,  a  rubber  dam  is  usually  em- 
ployed. A  rubber  dam  before  being  used  should  be  washed  with  soap  and 
water  and  soaked  in  a  solution  of  corrosive  sublimate. 

The  use  of  an  impermeable  material  on  the  outside  of  the  gauze  dressing 
is  not  nearly  so  common  as  formerly.  In  an  aseptic  wound  dry  dressing  im- 
covered  by  rubber  is  the  most  useful  plan.     When  a  dressing  is  covered  by  an 

impermeable  material  it  becomes 
moist,  acts  as  a  poultice,  and  the 
discharges  on  the  dressing  may 
undergo  decomposition. 

Drainage  is  used  in  all  in- 
fected wounds,  in  most  very  large 
wounds,  in  wounds  to  which  irri- 
tant antiseptics  have  been  applied, 
in  cases  in  which  large  abnormal 
Fig.  39.— Drainage-tubes:  A,  Glass;  B,  rubber.  cavities   exist,   in  very  fat  people, 

and  in  individuals  whose  skin  is  so 
thin  that  we  dare  not  apply  firm  pressure  (see  page  57).  Drainage,  when  needed, 
is  obtained  by  rubber  or  glass  tubes  (Fig.  39),  by  strands  of  horsehair,  silkworm- 
gut  or  catgut,  by  pieces  of  gauze,  and  occasionally  in  the  abdomen  by  Mikulicz's- 
bag  or  tampon  by  which  we  obtain  pressure  to  arrest  hemorrhage  and  also- 
secure  drainage  (Fig.  42).  Gauze  drainage  is  satisfactory  for  the  removal  of 
serum,  but  not  pus.  An  objection  to  the  gauze  drain  is  the  suffering  caused  by 
its  removal.  Before  removal  it  should  be  thoroughly  moistened  and  carefully 
separated  from  the  wound  edges  to  which  it  is  apt  to  adhere.     Sometimes  it  is- 


Removal  of  Stitches 


77 


removed  a  little  at  a  time.  If  pus  is  plentiful,  especially  if  it  is  thick,  rubber 
tubes  should  be  used.  The  caliber  of  the  tube  must  be  sufficient  to  permit  the 
pus  to  flow  freely.  Rubber  drainage-tubes  (Fig.  39,  B)  are  rendered  sterile  by 
boiling  in  plain  water.  They  are  kept  until  wanted  in  a  mercurial  solution. 
This  solution  should  be  changed  every  few  days,  because  the  mercury  is  apt 
to  be  precipitated  as  sulphid.  Glass  tubes  are  sterilized  by  boiling.  A  bit  of 
rubber  tissue  is  sometimes  used  for  drainage.  The  cigarette  drain  is  useful  in 
many  cases.  It  drains  serum  well  and  is  easily  removed.  It  is  made  by  folding 
up  a  piece  of  gauze  and  surrounding  it,  except  at  each  extremity,  with  gutta- 
percha tissue.  Gauze,  catgut,  etc.,  are  known  as  capillary  drains.  When  moist 
they  drain  serum  excellently,  but  pus  very  badly  or  not  at  all.  Pus  requires 
tubular  drainage.  Drainage-tubes  or  strands  are  brought  out  at  a  portion 
of  the  wound  which  will  be  dependent  when  the  patient  is  recumbent. 

Sponges. — Marine  sponges  are  never  used  to-day;  instead  we  use  gauze 
rolled  into  balls,  the  edges  and  ends  being  turned  in. 

Pads  and  Packs. — ^Ashton's  gauze  pads  are  very  useful  to  push  away 
structures  during  an  abdominal  operation  and  to  temporarily  pack  a 
wound.  Several  layers  of 
sterile  gauze  are  taken. 
Each  piece  is  about  6  in. 
long  and  4  in.  wide.  A 
stitch  is  run  round  the 
margins.  A  piece  of  tape 
is  sewed  in  one  corner. 
During   the    operation    the 

tape     protrudes     from     the  Fig.  40.— Smith's  dressing  basin. 

wound  and  is  clamped  with 

forceps.  This  plan  saves  the  pad  from  being  lost  or  forgotten  in  the  abdomen. 
Long  narrow  pieces  of  gauze  make  the  safest  and  best  packs  (Halsted's  packs), 
as  then  a  long  end  always  protrudes  from  the  wound  during  the  operation. 

Change  of  Dressing. — Dressing  should  not  be  changed  xmless  indications 
call  for  change.  To  unnecessarily  meddle  with  a  wound  is  stupid  and  harmful. 
In  many  cases  dressings  are  not  renewed  mitil  the  wound  has  healed.  When  a 
change  of  dressings  is  determined  upon  the  surgeon  should  carefully  sterilize 
his  hands  and  forearms  and  should  have  at  hand  a  warm  solution  of  corrosive 

sublimate,  normal  salt  solution,  an 
irrigator,  iodoform,  iodoform  gauze, 
scissors,  forceps,  basins  (Figs.  40  and 
41),  etc.  Dressings  should  be  moist- 
ened before  removal  with  salt  solu- 
tion or  corrosive  sublimate  solution. 
If  they  stick  to  the  part,  a  spray  of 
hydrogen  dioxid  projected  from  an 
atomizer  between  the  skin  and  dress- 
ings win  soon  loosen  them.  Dressings  must  be  changed  as  soon  as  soaking 
with  blood  or  wound-fluid  is  apparent.  If  the  wound  becomes  uneasy  and 
painful,  or  if  constitutional  symptoms  of  wound  infection  arise,  the  dressings 
must  be  removed  to  permit  of  inspection  of  the  wound.  A  change  of  dressings 
must  be  effected  with  all  of  the  aseptic  care  employed  in  a  surgical  operation. 
Dressings  are  not  dispensed  with  until  the  wound  is  soundly  healed. 

Removal  of  Stitches. — Buried  stitches  of  animal  material  are  not  removed 
by  the  surgeon,  but  are  gradually  absorbed  in  the  tissues.     Buried  stitches  of 
silk  or  silver  wire,  which  are  used  by  some  surgeons,  although  they  are  nof 
absorbed  in  the  tissues,  may  never  require  removal,  but  in  some  cases  cause 
sinuses  to  form,  and  a  sinus  from  a  suture  or  ligature  will  not  heal  until  the 


Fig.  41. — Plain  dressing  basin. 


78 


Inflammation 


suture  or  ligature  is  cast  out  or  removed.     Sutures  of  aluminum-bronze  wire 
are  absorbed  after  a  long  stay  in  the  tissues. 

If  a  catgut  stitch  is  passed  through  the  skin  and  tied  externally  the  loop 
in  the  tissue  is  absorbed,  but  the  knot  and  remainder  of  the  loop  is  on  the 
surface  and  is  not  absorbed,  but  remains  adherent  to  the  wound  and  the  sur- 
geon needs  only  to  lift  it  off  with  forceps.  Catgut  is  used  as  a  material  for 
cutaneous  suturing  in  the  operation  of  circumcision.  When  a  skin  wound  is 
closed  by  unabsorbable  sutures,  as  it  usually  is,  the  surgeon  at  the  proper 
time  takes  forceps  and  scissors  and  removes  the  stitches.  There  is  no  day 
after  an  operation  immutably  fixed  as  the  proper  day  to  remove  stitches. 

Stitches  may  usually  come  out  from  the  sixth 
to  the  eighth  day,  although  if  there  is  much 
tension  on  the  edges  of  the  wound  they  are 
allowed  to  remain  several  days  longer.  In 
large  wounds  half  of  the  stitches  are  taken  out 
at  one  time,  the  remainder  being  allowed  to  re- 
main for  a  couple  of  days  longer.  When  a  stitch 
begins  to  cut,  it  is  doing  no  good,  and  it  should 
be  removed,  no  matter 
how  short  a  time  it  has 
been  in  place.  If  it  is 
allowed  to  remain  it  will 
cut  into  the  wound,  make 
a  stitch- abscess,  and  cause 
an  irregular  suture-line. 
In  order  to  remove  a 
stitch  pick  up  an  end 
distal  from  the  knot  with 
forceps,  lift  it  lightly,  cut  one  side  of  the  suture  close  to  the  skin  by  scissors, 
and  remove  it  by  piilling  in  the  direction  of  the  side  on  which  the  suture 
was  cut  (Fig.  43). 

Bandages. — For  retaining  dressings  upon  wounds  unbleached  muslin 
bandages  may  be  used,  but  in  most  cases  gauze  bandages  are  employed. 
Gauze  bandages  may  be  applied  when  dry  or  wet;  normally,  they  are  applied 
when  dry.  Gauze  bandages  soaked  in  corrosive  sublimate  solution  are  anti- 
septic, do  not  seal  the  dressing,  hence  do  not  act  like  rubber  dam;  can  be  applied 
firmly,  evenly  and  rapidly,  and  are  very  comfortable. 


Fig.  42. — Mikulicz's  bag:  a,  Ab- 
dominal sutures;  b,  gauze  bag;  c, 
abdominal  wound;  d,  loops  in  the 
abdominal  wall;  e,  gauze  strip. 


Fig.  43. — Method  of  ex- 
traction of  a  suture  (Es- 
march  and  Kowalzig). 


III.  INFLAMMATION 

Definition. — When  the  tissues  are  injured  they  react  or  respond,  and 
this  reaction  or  response  is  known  as  inflammation.  The  process  of  inflam- 
mation was  defined  by  the  late  Sir  John  Burdon-Sanderson  as  "the  succession 
of  changes  which  occur  in  a  living  tissue  when  it  is  injured,  provided  that  the  in- 
jury is  not  of  such  a  degree  as  at  once  to  destroy  its  structure  and  vitality." 
Professor  Adami,  in  his  article  upon  inflammation  in  Allbutt's  "System  of 
Medicine,"  points  out  that  this  definition  really  includes  too  much.  He  alludes 
to  the  hemorrhage  which  occurs  in  the  liver  after  a  traumatism,  and  the  sub- 
sequent changes  in  the  extravasated  corpuscles,  and  points  out  that  these 
changes  are  not  inflammatory  phenomena.  This  definition,  however,  includes 
all  inflammatory  conditions,  is  largely  employed,  is  very  useful,  indicates  the 
cause,  and,  as  Burdon-Sanderson  says,  makes  clear  that  inflammation  is  a 
process  and  not  a  state  (Adami).  Adami's  definition  is  as  follows:  "The 
series  of  changes  constituting  the  local  manifestation  of  the  attempt  at  repair 


Active  Hyperemia 


79 


of  actual  or  referred  injury  to  a  part,  or,  briefly,  the  local  attempt  at  repair  of 
actual  or  referred  injury."  The  changes  alluded  to  in  Burdon-Sanderson's 
definition  comprise  (i)  changes  in  the  vessels  and  the  circulation,  (2)  depart- 
ure of  fluids  and  solids  from  the  vessels,  and  (3)  changes  in  the  perivascular 
tissues. 

Vascular  and  circulatory  changes  were  formerly  thought  to  be  abso- 
lutely essential  to  inflammation  in  both  vascular  and  non-vascular  tissues. 
In  the  former  they  occur  in  the  inflamed  tissues;  in  the  latter  (cornea  and 
cartflage)  they  are  manifest  in  neighboring  tissues  from  which  the  non-vascular 
area  derives  its  nutritive  material.  As  a  matter  of  fact,  in  inflammation 
vascular  changes  are  almost  always  present;  but  in  a  rather  trivial  corneal 
inflammation  the  episcleral  vessels  may  not  dilate,  and  the  only  white  corpus- 
cles which  gather  in  the  damaged  area  are  those  which  come  from  the  lymph- 
spaces  of  the  cornea.  Inflammation  in  any  tissue  will  not  be  accompanied 
by  vascular  dilatation  unless  the  process  reaches  a  certain  stage  of  severity. 


Fig.  44. — Normal  vessels  and  blood-stream. 


Fig.  45. — Dilatation  of  the  vessels  in  inflammation. 


Active  Hyperemia. — ^When  an  irritant  is  applied  to  tissue  there  may 
be  a  momentary  arterial  contraction  due  to  irritation  of  the  nerves,  but  this 
contraction  is  transitory,  and  is  not  an  inflammatory  phenomenon.  The 
first  vascular  phenomenon  is  dilatation  of  all  the  vessels — capillaries,  venifles, 
and  arterioles — appearing  first  and  being  most  pronounced  in  the  small 
arteries.  As  a  result  of  the  dilatation  there  are  increased  rapidity  of  circula- 
tion and  increased  determination  of  blood  to  the  part,  and  the  area  of  hyper- 
emia becomes  warmer  than  is  normal.  This  condition  of  increased  circulatory 
activity  is  known  as  "active  hyperemia"  (Fig.  45). 

Active  hyperemia  is  an  increase  in  the  amount  of  moving  blood  in  a  part. 
Passive  hyperemia  is  an  increase  in  the  amount  of  blood  in  a  part,  but  not  of 
moving  blood,  as  passive  hyperemia  or  congestion  is  due  to  venous  obstruction, 
and  the  blood  is  stagnated.  Diminution  in  the  amount  of  blood  in  a  part  is 
ischemia.  Local  anemia  is  the  complete  cutting  off  of  the  blood-supply  of  a 
part. 

In  active  hyperemia  more  blood  goes  to  the  part  and  more  blood  passes 
through  it,  an  increased  amount  of  venous  blood  comes  from  the  hyperemic 


8o 


Inflammation 


area,  the  venous  tension  is  increased,  and  the  veins  may  even  pulsate.  The 
capillaries,  which  under  ordinary  circumstances  contain  but  few  blood-cells 
(Fig.  44),  become  filled  with  corpuscles  (Fig.  45),  and  even  the  smallest  capil- 
laries pulsate.  The  blood  in  the  veins  adjacent  to  th^e  area  of  inflammation 
is  of  a  much  lighter  red  than  in  health.  Many  capillaries  which  were  invisible 
under  normal  conditions  become  visible  when  active  hyperemia  exists.  The 
capillaries  contain  no  muscle-fiber,  and  hence  these  tubes  cannot  actively  con- 
tract, except  so  far  as  the  cahber  of  the  tubes  is  altered  by  the  contraction  or 
expansion  of  the  endothehal  ceUs  of  the  capillary  wall.  Contraction  and 
dilatation  of  the  capillaries  depend  chiefly  on  the  amount  of  blood  sent  to  or 
retained  in  them.  In  active  hyperemia  the  increased  amount  of  blood  sent  to 
the  part  causes  capillary  dilatation.  As  a  result  of  the  dilatation  the  endo- 
thelial ceUs  become  thinner  than  before,  the  cells  in  consequence  of  irritation  lose 
some  of  their  power  to  restrain  exudation,  and  some  observers  assert  that  open- 
ings are  formed  between  the  ceUs  or 
that  previously  existing  openings  enlarge 
(page  82).  Fluid  elements  rarely  leave 
the  blood-vessels  dming  active  hyper- 
emia, but  they  occasionaUy  do.  The 
wheals  of  urticaria  are  thus  formed 
(Warren).  Active  hyperemia  is  often 
the  first  stage  of  an  inflammation,  but  it 
is  not  of  necessity  followed  by  other  in- 
flammatory changes,  and  it  can  be  caused 
by  nerve  section  or  nerve  stimulation. 

The  duration  of  active  h\^eremia  is 
variable.  If  the  irritation  was  brief, 
the  hyperemia  is  very  transitory.  In 
some  cases  dilatation  with  accelerated 
circulation  is  scarcely  more  than  momen- 
tary, giving  way  almost  immediately  to 
dilatation  with  retardation.  If  the  irri- 
tation is  prolonged,  hyperemia  may  last 
some  time  before  giving  way  to  retarda- 
tion. In  the  web  of  a  frog's  foot,  if  an 
irritant  is  applied,  hyperemia  lasts  from 
one-half  hour  to  two  hours  before  it  is 
replaced  by  retardation. 
Clinical  Signs  of  Active  Hyperemia. — ^A  hyperemic  part,  if  on  or  near 
the  surface,  is  red  in  color,  imparts  a  sense  of  heat  to  the  examining  hand, 
the  color  quickly  disappears  on  pressure  and  quickly  returns  when  press\n*e 
is  released.  In  a  congested  part  the  temperatme  is  diminished,  the  surface 
is  purple,  the  congested  veins  are  visible,  there  are  edema  and  a  sensation  of 
coldness  and  numbness.  When  congestion  is  purely  local  the  lividity  dis- 
appears quickly  when  pressure  is  applied  and  returns  quickly  when  pressm^e 
is  removed.  When  due  to  disease  of  the  heart  or  lungs,  lividity  disappears  and 
returns  slowly.  When  a  local  congestion  is  about  to  give  way  to  gangrene 
the  hvidity  disappears  very  slowly  on  pressure  and  crawls  back  very  slowly 
when  pressure  is  released. 

Retardation. — ^After  active  h3^eremia  has  existed  for  a  variable  time  the 
blood-current  begins  to  lessen  in  velocity,  until  it  becomes  more  tardy  than 
in  health.  This  is  known  as  "retardation  of  the  circulation."  Retardation 
is  first  noted  in  the  venules,  next  in  the  capiUaries,  and  last  in  the  arterioles; 
but  arterial  pulsation  continues.  The  red  cells  take  the  center  of  the  blood- 
stream, which  is  known  as  the  axial  current.     The  white  corpuscles  settle  out 


Fig.  46. — Retardation  of  blood  and  migration 
of  white  corpuscles  in  inflammation. 


Exudation  of  Fluids  8i 

of  the  central  stream,  separate  from  the  red  cells,  and  float  lazily  along  near  the 
vessel  wall,  and  they  are  accompanied  by  many  third  corpuscles.  The  white 
cells  show  a -strong  tendency  to  adhere  to  the  venule  walls,  and,  as  a  result, 
accumulate  against  the  inside  of,  and  stick  to,  these  walls  and  to  one  another, 
until  the  venules  are  entirely  lined  with  layers  of  leukocytes  (Fig.  46).  The 
third  corpuscles  act  in  a  similar  manner  and  take  the  peripheral  current.  In 
the  capillaries  some  leukocytes  gather,  but  not  so  many.  In  the  arterioles  they 
adhere  during  cardiac  dilatations,  but  are  swept  away  by  the  force  of  the 
heart's  contractions.  Retardation  is  believed  to  be  chiefly  due  to  paresis  of 
the  muscular  walls  of  the  arterioles.  This  causation  seems  probable  when 
we  recall  Lord  Lister's  experiments  upon  the  pigment-cells  of  the  frog's  foot. 
Lister  proved  that  inflammation  paralyzes  the  pigment-cells,  and  concluded 
that  dilatation  at  the  focus  of  an  inflammation  is  due  to  the  paralyzing  action 
of  an  irritant.  Dilatation  at  a  distance  from  the  focus  is  a  reflex  phenomenon 
(W.  Watson  Cheyne).  When  the  vessels  are  weakened  or  paralyzed  the 
contractions  of  the  arterioles  are  feeble  or  absent,  and  the  blood  is  no  longer 
urged  forward  by  arterial  power.  The  endothelial  cells  of  the  small  vessels 
enlarge  distinctly  during  retardation  and  develop  a  condition  of  stickiness,which 
leads  the  white  cells  to  adhere  to  them,  and  thus  increases  resistance  to  the 
current  of  blood  and  adds  to  retardation.  Fluids  pass  through  the  wall  of  a 
vessel  in  this  condition  more  readily  than  through  a  healthy  vessel,  and  white 
corpuscles  leave  the  vessel  in  large  numbers. 

Oscillation  and  Stagnation.^By  the  accumulation  of  leukocytes  the 
blood-stream  is  progressively  narrowed  and  the  axial  current  is  impeded. 
The  red  blood-cells  begin  to  stick  to  one  another,  forming  aggregations  like 
rouleaux  of  coin,  which  masses  increase  the  difficulty  the  axial  current  has  to 
contend  with,  until  progressive  movement  ceases  and  the  contents  of  the  vessels 
sway  to  and  fro  with  each  heart-beat.  This  is  the  stage  of  oscillation.  In  a 
short  time  oscillation  ceases  and  the  vessels  are  filled  with  blood  w^hich  does 
not  move,  and  the  vessel  walls  become  irregular  in  outline  or  even  pouched. 
This  stage  is  known  as  "stasis''  or  "stagnation.'"  Stasis  is  chiefly  due  to 
paralysis  and  damage  of  the  vessel  walls.  Migration  ceases  when  stasis 
takes  place.  If  stasis  persists,  coagulation  occurs,  because  the  vessel  walls 
have  been  so  injured  by  the  irritant  as  to  be  practically  dead  material,  and 
they  are  no  longer  able  to  prevent  clotting  of  their  contents.  Finally,  in  per- 
sisting stasis  the  vessel  walls  rupture  or  are  entirely  destroyed. 

Resume  of  the  Vascular  Changes  of  Inflammation.- — We  can  sum  up  the 
vascular  changes  of  inflammation  by  stating  that  they  consist  in  a  dilatation 
of  the  small  vessels  and  a  primary  acceleration,  a  secondary  retardation,  and  a 
subsequent  stagnation  of  the  blood-current,  exudation  of  blood-liquor,  adhe- 
sion of  leukocytes  to  the  walls  of  veins  and  capillaries,  migration  of  leukocytes, 
the  aggregation  of  the  red  blood-cells  into  intravascular  masses,  and  coagula- 
tion of  the  material  remaining  in  the  vessel. 

Exudation  of  Fluids. — It  is  to  be  remembered  that  in  the  process 
of  nutrition  blood-liquor  and  also  white  cells  pass  into  the  tissues  through  the 
walls  of  veins  and  capillaries,  and  during  this  process  certain  other  materials 
are  passing  from  the  tissues  into  the  vessels.  Hence,  a  diffusible  irritant  in 
the  vessels  may  pass  into  the  tissues  and  a  diffusible  irritant  in  the  tissues  may 
pass  into  the  vessels.  Whenever  retardation  of  the  circiflation  arises  there 
is  an  increase  in  the  amount  of  plasma  which  passes  out  of  the  vessels,  but  in 
inflammation  the  exudation  into  the  lymph-spaces  is  vastly  greater  in  amoimt 
and  is  different. in  composition.  In  a  slight  inflammation,  and  in  the  early 
stage  of  any  inflammation,  there  is  an  increase  in  the  fluid  exudate,  and  we 
speak  of  the  condition  as  "serous  inflammation."  This  fluid  is  reafly  not  serum, 
but  is  liquor  sanguinis.  We  find  true  serum  in  passive  congestion,  not  in  active 
6 


82  Inflammation 

inflammation.  The  fluid  of  a  serous  exudation  contains  very  few  white  cells, 
and  hence  little  or  no  fibrin  can  form  in  it,  and  coagulation  does  not  take  place 
in  the  perivascular  tissues;  and  if  the  inflammation  goes  no  further,  the  exudate 
is  absorbed  by  the  lymphatics.  A  blister  is  an  example  of  serous  inflamma- 
tion. If  the  inflammation  continues  to  intensify,  the  exudation  is  altered 
in  character — it  becomes  thicker,  turbid  and  very  coagulable,  and  exhibits 
a  greatly  increased  bactericidal  power.  It  contains  many  white  cells  and 
fibrin  elements,  and  coagulates  in  the  tissues,  because  some  of  the  leukocytes 
break  up  and  set  free  fibrin  ferment,  and  fibrin  ferment  causes  the  union  of 
calcium  and  fibrinogen  and  the  formation  of  fibrin.  This  fluid  exudate  is 
known  as  ''lymph,'"  or  plastic  exudation,  and  when  it  is  present  we  speak  of  the 
condition  as  "plastic  inflammation.'"  Lymph  can  be  seen  in  the  anterior 
chamber  of  the  eye  in  cases  of  plastic  iritis.  Coagulated  fibrin  in  a  recent 
wound  causes  the  edges  to  adhere  or  glazes  the  raw  surface.  In  inflammation 
of  a  mucous  surface  it  may  appear  as  a  false  membrane.  In  inflammation  of 
serous  surfaces  it  may  glue  the  surfaces  together  and  lessen  motion,  the  fibrin- 
ous masses  which  effect  the  gluing  being  called  fibrinous  or  plastic  adhesions. 
Such  adhesions  within  the  abdomen  may  seal  a  perforation,  may  cover  a  raw 
spot,  or  may  encompass  an  area  of  infection  and  prevent  fatal  diffusion. 
Further,  fibrin  surrounds  and  entangles  bacteria  and  retards  their  diffusion. 
Pyogenic  cocci  lessen,  retard,  or  prevent  fibrin  formation  or  destroy  fibrin  pre- 
viously formed.  Fibrinous  adhesions  may,  of  course,  do  harm.  They  may 
retard  or  prevent  the  absorption  of  exudate;  they  may  narrow  and  obstruct 
important  structures  (bowel,  urethra,  larynx) ;  they  may  bind  up  and  cripple  an 
important  viscus  (liver,  heart,  or  brain).  Fibrinous  adhesions  may  be  succeeded 
by  dense  contracting  and  constricting  bands  of  fibrous  tissue.  The  lymphatics 
endeavor  to  absorb  the  fluid  exudate  in  inflammation,  but  become  occluded 
by  coagulation,  and  the  area  they  drain  becomes  swollen,  hard,  and  "brawny." 
The  slighter  the  inflammation,  the  less  albuminous  is  the  fluid;  the  more  in- 
tense the  inflammation,  the  more  albuminous  is  the  fluid.  The  focus  of  a 
severe  inflammation  feels  brawny  because  of  coagulation  of  a  highly  albumin- 
ous exudate;  the  periphery  of  an  inflammation  is  soft  and  edematous  because 
of  the  presence  there  of  thin  and  non-coagulated  exudate.  Inflammatory 
lymph  contains  proteins  and  other  substances.  "Of  these  the  more  important 
are  ferments,  the  results  of  proteolysis  (notably  fibrin  and  its  precursors  and 
peptones),  and  in  many  cases  mucin,  together  with  bactericidal  substances,  and, 
where  bacteria  are  present,  the  products  of  their  growth."^  The  amount  of 
the  exudation  varies  with  the  violence  of  the  irritation,  the  nature  of  the  irri- 
tant, the  general  condition  of  the  organism,  and  the  state  of  the  tissues  which  are 
involved.  In  dense  tissue  (bone,  periosteum,  etc.)  the  exudation  is  scanty. 
In  loose  tissue  (subcutaneous  tissue)  it  is  profuse.  Profuse  exudation  may 
take  place  into  a  joint,  the  pleural  sac,  the  peritoneal  cavity,  or  the  peri- 
cardium. In  such  cases  the  exudation  is  profuse  because  the  serous  mem- 
brane has  a  thin  covering  of  endotheliimi,  contains  quantities  of  vessels,  and 
the  vessels  receive  but  a  thin  covering  and  obtain  but  a  scant  support  toward 
the  cavity. 

Does  the  plasma  leave  the  vessels  as  a  simple  filtrate?  Some  maintain 
that  it  does.  Heidenhain  and  others  claim  that  it  does  not,  and  believe  that 
the  endothelial  cells  play  an  active  part  in  the  process.  Heidenhain  likens 
exudation  to  secretion,  because  some  materials  from  the  plasma  pass  out 
and  others  do  not.  Adami  is  inclined  to  agree  with  Heidenhain,  that  the 
endothelium  plays  "not  a  passive  but  an  active  role."  Are  there  spaces  between 
the  endothelial  cells  of  the  capillary?  It  was  long  taught  positively  that  there 
are  no  open  spaces  between  the  endothehal  cells  of  the  vessel  wall  and  that 
1  Adami,  in  Allbutt's  "  System  of  Medicine." 


Migration  and  Diapedesis 


83 


these  cells  are  held  close  together  by  a  cement  substance.  It  is  now  believed 
by  some  obser\-ers  that  spaces  exist  between  the  protoplasmic  strands  which 
hold  the  cells  together,  these  spaces  being  closed  when  the  vessel  is  contracted 
and  open  when  the  vessel  is  dilated.  When  these  spaces  are  open  fluid  passes, 
and  through  these  doorways  leukocytes  emerge. 


Fig.  47. — Stages  of  the  migration  of  a  single  white  blood-corpuscle  through  the  wall  of  a  vein  (Caton). 

Migration  and  Diapedesis. — Even  early  in  an  inflammation  a  number 
of  white  corpuscles  pass  through  the  vessel  waUs;  but  when  the  inflammation 
is  weU  estabhshed,  large  numbers,  and  when  it  is  severe  vast  hordes,  pass  into 
the  perivascular  tissues.  This  process  is  known  as  "migration"  (Figs.  46  and 
47).  The  leukocytes  throw  out  protoplasmic  arms,  insert  themselves  between 
the  cells  of  the  walls  of  the 
vessel,  and  pifll  themselves 
through  by  their  power  of 
ameboid  movement  (Fig.  48). 
Some  observers  claim  that 
they  do  not  pass  through  exist- 
ing open  doors,  but  force  open- 
ings which  close  after  them. 
This  is  readily  accomplished, 
because  the  vessel  waU  is  itself 
damaged,  weakened,  and  con- 
voluted. Others  claim  that 
stomata  exist  between  the 
endothelial  cells,  the  vessel 
wall  being  porous  like  a  filter 
(see  page  82).  The  escape  of  leukocytes  takes  place  chiefly  from  the  venules, 
though  some  migrate  through  the  capillaries  and  even  the  arterioles  (Fig.  46). 

The  leukocytes  are  influenced  to  move  toward  the  damaged  tissue  by  the 
attractive  force  known  as  positive  "chemiotaxis,''  a  force  which  draws  them  to- 
ward invading  bacteria,  to  regions  of  irritation,  and  to  areas  of  tissue  death. 
Leukocytes  ma}^  move  from  very  \^rulent  organisms,  influenced  by  what  is 
known  as  negative  "chemiotaxis."  The  migration  of  a  leukocyte  requires 
but  a  short  time.  Figure  47  shows  the  migration  of  a  white  blood-ceU  through 
a  vein  waU.  the  process  requiring  one  hour  and  fifty  minutes.  In  very  acute 
inflammations  red  corpuscles  also  pass  into  the  tissues.  Red  corpuscles  are  not 
capable  of  ameboid  movements,  and  if  they  do  escape  from  the  vessels  the 
process  is  passive  on  their  part  and  not  active.  This  passive  escape  happens 
because  the  capillar}^  walls  have  been  destroyed  or  because  stomata  have  been 
greatly  enlarged  by  vascular  dilatation.     If  red  corpuscles  do  pass  into  the 


Fig.  48. — ^Ameboid  movements  of  a  leukocyte  (Warner). 


84  Inflammation 

exudate,  as  happens  in  pneumonia,  the  inflammation  is  a  very  severe  one,  and 
is  called  a  hemorrhagic  inflammation.  The  escape  of  corpuscles  by  a  passive 
process  is  known  as  "diapedesis,"  in  contradistinction  to  the  escape  of  leuko- 
cytes by  active  ameboid  movements,  a  process  known  as  "migration."  The 
white  corpuscles  usually  greatly  increase  in  number  in  the  blood  of  a  person 
who  has  an  acute  inflammation,  and  the  blood-making  organs,  such  as  the 
spleen  and  lymphatic  glands,  are  often  enlarged.  An  increase  of  white  cor- 
puscles in  the  blood  of  an  individual  is  called  leukocytosis  (see  page  92). 

Blood-plaques. — Blood-plates,  blood-plaques,  or  third  corpuscles,  may  be 
discovered  in  freshly  drawn  blood,  but  unless  they  are  present  in  unusual  num- 
bers they  will  rarely  be  seen  in  specimens  prepared  in  the  usual  way.  The 
third  corpuscles  can  be  seen  by  a  high-power  microscope  in  the  moving  blood 
of  the  web  of  a  frog's  foot.  In  blood  outside  of  the  body  they  are  destroyed  as 
soon  as  coagulation  begins,  and  in  order  to  see  them  coagulation  must  be 
prevented.  Some  observers  maintain  that  the  third  corpuscles  are  the  real 
fibrin-formers.  The  blood-plaques,  or  third  corpuscles,  are  found  to  be  present 
in  increased  numbers  in  inflammation.  In  health  their  usual  proportion  to 
red  cells  is  as  i  to  20.  They  are  especially  numerous  at  the  height  of  fever 
processes  and  during  convalescence  from  an  extensive  abscess. 

Changes  in  the  Perivascular  Tissues. — The  cells  of  the  perivascu- 
lar tissue  are  phagocytes,  and  when  stimulated  they  enlarge,  become  more 
actively  phagocytic,  and  undergo  reproduction.  The  liquor  sanguinis  which 
exudes  during  an  acute  inflammation  coagulates  unless  prevented  by  virulent 
bacteria.  It  has  often  been  asserted  that  exudation  is  Nature's  method 
of  supplying  nutriment  to  the  ceUs  of  the  damaged  region.  Adami  points 
out  the  apparently  contradictory  observation  that  the  amount  of  exudate  is 
in  direct  proportion  to  the  rapidity  of  cell  destruction,  but,  nevertheless,  con- 
cludes that  exudation  stands  in  close  relation  to  cell  proliferation.^  From 
whatever  cause,  tissue-ceUs  multiply,  and  this  process  is  known  as  "cell 
proliferation.^^ 

When  a  tissue  is  injured  it  inflames,  and,  as  Adami  points  out,  the  reaction 
we  caU  inflammation  is  an  attempt  tp  repair  injury. 

Irritation  may  lead  to  degeneration  and  death  of  cells;  it  may  lead  to 
growth  and  multiplication.  In  many  cases  both  processes  are  active  in  the 
acute  stage,  the  cells  at  the  focus  of  the  inflammation  undergoing  degeneration 
and  destruction,  and  those  at  the  boundary  undergoing  growth  and  prolifera- 
tion. 

If  tissue-cells  have  been  seriously  damaged  they  perish,  and  new  cells  are 
required  to  replace  them.  The  inflammatory  process  has  led  to  exudation 
of  plasma  and  migration  of  leukocytes  into  the  perivascular  tissues.  The 
connective-tissue  cells  mifltiply  and  produce  young  cells,  which  are  known 
as  "fibroblasts,'"  and  which  eat  up  many  leucocytes.  Early  in  an  inflammation 
polynuclear  leukocytes  preponderate,  later  mononuclear  phagocytic  cells 
predominate  (Opie).  The  leukocytes  contain  two  enzymes.  One  is  derived 
from  bone-marrow  and  digests  protein  in  an  alkaline  medium ;  the  other  is  de- 
rived from  lymph-glands  and  digests  protein  in  an  acid  medium  (Opie).  The 
migrated  leukocytes  in  part  surround  the  inflamed  region  and  retard  diffusion 
of  the  process.  Many  enter  the  diseased  area  and  attack  bacteria.  Some 
undergo  degenerative  changes  and  liberate  fibrin  ferment  which  makes  the 
exudate  clot.  Some  move  out  of  the  inflamed  area,  each  one  carrying  within 
it  tissue  debris  or  a  dead  bacterium,  and  many  are  eaten  up  by  the  fibroblasts. 
There  is  no  real  proof  that  leukocytes  proUferate  and  help  directly  to  form  new 
tissue.  This  mass  of  young  cells,  taking  origin  from  the  fixed  cells,  has  been 
called  embryonic  tissue,  because  of  a  fancied  resemblance  to  the  cells  of  the 
1  Adami,  in  AUbutt's  "  System  of  Medicine." 


Inflammation  in  Non-vascular  Tissue  85 

embn-o.  John  Hunter  called  it  Juvenile  tissue.  It  has  also  been  called  indiffer- 
ent tissue,  because  of  the  behef  that  it  could  be  converted  indifferently  into  vari- 
ous tissue  according  to  circumstances.  It  is  also  spoken  of  as  inflammatory 
new  formation.  The  cells  of  embrv'onic  tissue  are  called  fibroblasts  because 
they  form  fibrous  tissue. 

An  exudation  may  be  absorbed  by  the  lymphatics.  It  may  be  converted 
into  pus  if  infected  with  pyogenic  bacteria,  or  be  replaced  by  cells  from  the 
proliferation  of  fixed  tissue-cells,  the  cellular  mass  being  subsequently  vascu- 
larized by  the  extension  into  it  of  capillary  loops  derived  from  adjacent  capil- 
laries. When  embr\-onic  tissue  is  filled  with  blood-vessels — that  is  to  say, 
when  it  is  vascularized — it  is  called  granulation  tissue.  Granulation  tissue 
is  finally  converted  into  fibrous  tissue.  The  above  complicated  processes, 
vascular  and  perivascular,  are  not  accidents  nor  haphazard  freaks,  but  are 
Nature's  efforts  to  bring  about  a  ciire. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon  the  muscle  or  its 
ner\-e-elements.  Retardation  and  stasis  are  due  to  paralysis  of  the  vessel 
wall,  which  paralysis  causes  resistance  to  the  passage  of  the  blood-stream 
and  adhesion  of  the  leukocytes  to  the  vessel  wall.  The  blood-liquor  exudes 
and  the  leukocytes  migrate.  Often  these  efforts  of  Natiure  succeed.  Accel- 
eration of  the  circulation  may  succeed  in  washing  away  an  irritant  from  the 
vessel  wall.  By  bringing  quantities  of  blood  to  the  part  copious  exudation  of 
plasma  is  rendered  certain.  The  exudation  may  wash  and  remove  irritants 
from  the  tissues,  and  the  germicidal  blood-liquor  may  destroy  bacteria  in  the 
damaged  area.  The  migration  of  corpuscles  may  prove  of  great  service. 
The  leukocytes  siu"roi.md  an  area  of  infection  and  tend  to  limit  its  spread. 
Leukocytes  have  phagocytic  properties,  and  energetically  attack  and  often 
destroy  bacteria,  and  they  fiu^nish  enz^ines  which  may  digest  proteins  and 
antitoxins,  which  antagonize  and  may  neutralize  the  poisons  produced  by 
micro-organisms.  Leukocytes  aid  in  forming  fibrin.  Fibrin  formation  is  of 
ser\dce  by  helping  immobilization  and  by  hindering  the  spread  of  bacteria. 
Leukocytes  also  aid  in  separating  dead  tissue  from  liA^ing,  and  they  remove 
tissue  debris  from  the  area  of  inflammation.  The  mifltiplication  of  the  fixed 
connective-tissue  cells  leads  to  the  formation  of  fibroblasts,  and  fibroblasts  are 
converted  into  fibrous  tissue,  which  eff'ects  permanent  repair  (these  changes 
will  be  alluded  to  again  in  the  section  on  Repair). 

Nature  may  fail  in  her  efforts.  For  instance,  an  enormous  exudate  in- 
creases stasis  and  may  cause  such  tension  that  gangrene  results. 

Inflammation  in  Non=vascular  Tissue. — A  t^-pe  of  non-vascular 
tissue  is  the  cornea,  and  the  cornea  can  inflame.  The  healthy  cornea  contains 
no  blood-vessels.  It  is  formed  of  many  layers  of  fibers,  each  layer  rvmning 
parallel  with  the  corneal  siu-face  and  forming  angles  ^"ith  the  fibers  of  the 
adjacent  layers.  Between  the  layers  are  communicating  honph-spaces  con- 
taining connective-tissue  cells  known  as  corneal  corpuscles.  It  obtains  its 
noiu-ishment  in  part  from  the  vessels  of  the  conjunctiva,  but  chiefly  from  the 
vessels  of  the  ciliar}'  body  and  sclera.  WTien  the  cornea  inflames  the  epi- 
scleral, conjvmctival,  and  ciliary  vessels  usuaUy  dilate  and  pour  out  exudate, 
and  the  fluid  exudate  and  the  leukocytes  enter  into  the  corneal  h-mph-spaces. 
The  exudate  coagiflates  and  ceU  multiplication  ensues  as  in  any  other  in- 
flammation. In  mild  inflammations  the  vessels  about  the  cornea  may  not  dilate. 
Leukocytes,  from  the  hTnph-spaces,  reach  the  seat  of  injurv"  in  smaU  nmnbers, 
and  the  fixed  cells  multiply.  De  Nancrede  points  out  that  in  trivial  inflamma- 
tion, which  injures  but  does  not  destroy  the  epithehum,  leukocytes  may  not 
go  to  the  seat  of  inflammation,  the  only  change  being  enlargement  and  multi- 
plication of  corneal  corpuscles.  If  new  formation  takes  place,  a  permanent 
opacity  mars  the  cornea  as  a  consequence. 


86  Inflammation 

Cartilage  has  no  blood-vessels  except  in  regions  where  growth  is  very  active 
or  where  ossification  is  taking  place.  Cartilage  has  no  spaces,  like  the  cornea, 
for  a  free  circulation  of  lymph.  In  man  canals  have  not  been  demonstrated 
and  it  is  thought  that  fibrils  conduct  nutritive  fluids,  the  nutritive  plasma  flow- 
ing between  the  cells,  but  there  is  no  direct  connection  with  blood-vessels.  The 
plasma  is  furnished  by  the  vessels  at  the  margin  of  the  perichondrium.  Carti- 
lage can  inflame,  and  an  inflammation  of  this  structure  is  slow  in  evolution  and 
of  long  duration.  When  inflammation  occurs  the  cartilage  cells  enlarge  and 
their  nuclei  proliferate,  the  intercellular  substance  softens  and  cartilage  cells 
may  be  cast  off.  After  a  long  time  vessels  may  invade  the  inflamed  cartilage 
and  fibrous  tissue  forms  from  the  perichondrium,  but  in  some  cases  a  loss  of 
substance  is  not  repaired. 

Inflammation  of  Mucous  Membrane. — It  may  be  catarrhal,  suppura- 
tive, croupous,  or  diphtheritic.  In  a  catarrhal  inflammation  the  increased 
blood-supply  causes  an  excessive  flow  of  mucus.  The  submucous  tissues 
present  the  ordinary  changes  of  inflammation  and  quantities  of  epithelial 
cells  are  cast  off  from  the  surface.  Fibrous  tissues  may  form  in  the  sub- 
mucous tissue  and  thus  cause  permanent  thickening  (strictures,  etc.). 

Suppurative  inflammation  is  usually  preceded  by  catarrhal  inflammation. 
In  this  condition  there  is  a  discharge  of  mucopurulent  fluid  and  ulcers  are  apt 
to  form.  A  trivial  loss  of  substance  permits  of  regeneration,  but  a  considerable 
loss  is  repaired  by  fibrous  tissue,  which  by  its  bulk  and  by  contracting  may 
interfere  greatly  with  the  functional  usefulness  of  an  organ  or  a  canal. 

A  croupous  inflammation  is  one  in  which  quantities  of  epithelial  cells  are 
cast  off  the  surface  and  there  forms  upon  the  surface  a  highly  fibrinous  ex- 
udate (false  membrane). 

In  diphtheritic  inflammation  the  mucous  membrane  is  destroyed  and  the 
false  membrane  invades  the  submucous  tissue.  Diphtheritic  inflammation 
is  due  to  a  specific  bacillus. 

Classification  of  Inflammations. — The  various  forms  of  inflamma- 
tions are — (i)  Simple  or  common,  that  which  is  due  to  any  ordinary  traumatic, 
chemical,  thermal,  or  actinic  cause,  and  not  to  bacteria.  An  instance  of  simple 
inflammation  is  traumatic  periostitis  or  sun  dermatitis.  It  does  not  tend  par- 
ticularly to  spread.  Often  the  cause  of  a  simple  inflammation  is  momentary 
in  action;  (2)  infective  or  speciflc,  that  which  is  due  to  micro-organisms,  as  the 
streptococcus  of  erysipelas.  An  unsuccessful  attempt  has  been  made  to  charge 
all  inflammations  to  bacteria.  It  is  true  that  bacteria  can  generally  be  found 
in  inflammatory  areas,  but  that  they  are  the  only  causes  of  inflammation  is 
accepted  by  few.  Infective  inflammations  often  tend  to  spread  widely;  (3) 
traumatic,  which  is  due  to  a  blow  or  an  injury;  (4)  idiopathic,  which  is  without 
an  ascertainable  cause.  There  is  certainly  a  cause,  even  if  it  cannot  be  pointed 
out,  and  the  term  "idiopathic"  means  that  we  do  not  know  the  cause;  (5) 
acute,  which  is  rapid  in  course  and  violent  in  action;  (6)  chronic,  which  follows  a 
prolonged  course;  (7)  subacute,  which  is  intermediate  in  violence  and  dura- 
tion between  acute  and  chronic;  (8)  sthenic,  characterized  by  high  action; 
it  occurs  in  strong  young  subjects;  (9)  asthenic  or  adynamic,  occurring  in  the 
old,  the  debilitated,  and  the  broken  down.  In  such  an  inflammation  there 
is  no  certain  limitation  of  the  inflammation  by  leukocytes,  and  there  is  an 
indisposition  on  the  part  of  the  tissue-cells  to  form  fibroblasts;  (10)  paren- 
chymatous, affecting  the  "parenchyma,"  or  active  cells  of  an  organ;  (11) 
interstitial,  affecting  the  connective-tissue  stroma  of  an  organ;  (12)  serous, 
characterized  by  profuse  non-coagulating  exudation  (as  in  pleuritis)  or  by 
marked  inflammatory  edema;  (13)  plastic,  adhesive,  or  fibrinous,  character- 
ized by  an  exudation  which  glues  together  adjacent  surfaces,  as  in  peritonitis; 
(14)  purulent,  phlegmonous,  or  suppurative,  when  pyogenic  cocci  are  present 


Causes  of  Inflammation  87 

and  multiply;  (15)  hemorrhagic,  when  the  exudate  contains  many  red  blood- 
cells,  as  in  strangulated  hernia  and  in  the  pustules  of  black  small-pox;  (16) 
croupous,  when  an  inflammation  produces  upon  the  surface  of  a  tissue  a  fibrin- 
ous exudate  which  cannot  be  organized  into  tissue,  and  which  is  due  to  the 
action  of  micro-organisms.  An  exudate  of  this  character  was  called  by  the 
older  surgeons  ^'aplastic  lymph.'^  It  occurs  most  usually  on  mucous  mem- 
brane; (17)  diphtheritic,  which  differs  from  croupous  in  the  fact  that  the 
false  membrane  is  in  the  tissue  rather  than  upon  it;  (18)  gangrenous,  an  in- 
flammation resulting  in  death  of  the  part,  the  gangrene  being  due  to  the 
tension  of  the  exudate  or  the  virulence  of  the  poison;  (19)  healthy,  when  the 
tendency  is  to  repair;  (20)  unhealthy,  when  the  tendency  is  to  destruction; 
(21)  latent,  an  mflammation  which  for  some  time  does  not  announce  itself  by 
any  obvious  s^Tiiptoms,  as  the  inflammation  of  Peyer's  patches  in  tx'phoid 
fever;  (22)  contagious,  when  its  own  secretions  can  propagate  it;  (23)  dry, 
without  exudation;  (24)  hypostatic,  arising  in  a  region  of  passive  congestion 
(as  a  bed-sore);  (25)  malignant,  due  to  a  malignant  growth;  (26)  catarrhal, 
afl'ecting  a  mucous  membrane;  (27)  neuropathic,  due  to  impairment  of  the 
trophic  functions  of  the  nervous  system,  as  in  perforating  ulcer;  and  (28) 
sympathetic  or  reflex,  due  to  disease  or  injury  of  a  distant  part,  as  when  orchitis 
follows  mumps. 

Extension  of  Inflammation. — Inflammation  extends  by  continuity 
of  structure,  by  contiguity  of  structure,  by  the  blood,  and  by  the  lymphatics. 
Extension  by  continuity  is  seen  in  phlebitis.  Extension  by  contiguity  is 
seen  when  a  cutaneous  inflammation  advances  and  attacks  deeper  struc- 
tiires.  Extension  by  the  blood  is  seen  in  the  formation  of  the  smaU-pox  ex- 
anthem.  Extension  by  the  lymphatics  is  witnessed  in  a  bubo  foUo'sving  chan- 
croid. 

Terminations  of  Inflammation.- — Inflammation  may  be  followed  by 
a  return  of  the  tissues  to  health,  and  this  return  may  take  place  by  delites- 
cence, by  resolution,  or  by  new  growth.  By  delitescence  is  meant  abrupt 
termination  at  an  early  stage,  as  when  quinsy  is  aborted  by  the  administra- 
tion of  quinin  and  morphin,  and  the  production  of  a  sweat;  resolution  means 
the  gradual  disappearance  of  the  s}Tnptoms  when  inflammation  has  passed 
through  its  regular  stages;  and  new  groivth  means  that  an  inflammation  has 
lasted  a  considerable  time,  with  ample  blood-supply  and  without  suppuration, 
and  has  gone  on  to  the  formation  of  fibroblasts,  granulation  tissue,  and  fibrous 
tissue.  Inflammation  may  be  followed  by  death  of  the  inflamed  part  or 
necrosis.  Death  of  the  part  may  be  due  to  suppuration,  ulceration,  or  gan- 
grene. 

The  causes  of  inflammation  are — predisposing,  or  those  residing  in 
the  tissues,  and  rendering  them  liable  to  inflame;  and  exciting,  or  those  which 
directly  awake  the  process  into  activity.  The  first  may  be  thought  of  as 
furnishing  mflammable  material;  the  second  may  be  regarded  as  sparks  of  fire. 

Predisposing  causes  are  those  which  impair  the  general  vigor,  injure  the 
blood,  weaken  the  tissues,  or  lower  nutritive  activities.  Among  these  causes 
are  shock,  hemorrhage,  nerv'ous  irritation,  gout,  rheumatism,  diabetes,  Bright's 
disease,  alcohoHsm,  and  s^-phihs.  Plethora  renders  a  person  liable  to  sthenic 
inflammations  (those  characterized  by  high  action) .  Tissue  debility  renders 
one  prone  to  adynamic  or  asthenic  inflammations.  Nerve  injury  predisposes 
to  inflammation,  either  from  damage  to  trophic  nerv^es  and  consequent  failure 
in  tissue  nutrition  and  resistance  or  because  analgesia  exists  and  irritants 
which  reach  the  region  are  not  recognized  and  are  allowed  to  remain.  For 
instance,  if  the  conjunctiva  is  in  a  condition  of  analgesia,  the  presence  of 
foreign  bodies  is  not  noticed  and  destructive  inflammation  may  result  from 
their  non-removal. 


88  Inflammation 

After  removal  of  the  Gasserian  ganglion  the  cornea  is  devoid  of  sensation, 
the  flow  of  tears  is  lessened,  dust  gathers  in  the  eye,  and  if  not  removed  by 
irrigation  or  kept  out  by  a  shield,  inflammation  and  disastrous  ulceration  will 
ensue. 

Exciting  Causes. — The  exciting  causes  of  inflammation  are — traumatic, 
as  blows  and  mechanical  irritation;  chemical,  as  the  stings  of  insects,  the 
rubefacient  effects  of  mustard,  venom  of  serpents,  products  of  bacteria,  ivy 
poison,  etc.;  thermal,  heat  and  cold;  specific,  the  micro-organisms,  causing, 
for  instance,  tuberculous  peritonitis  or  erysipelas;  and  nervous,  nerve  stimula- 
tion certainly  being  ~  capable  of  producing  hyperemia  and  sometimes  even 
inflammation.  Inflammation  due  to  nerve  stimulation  is  seen  in  herpes  zoster 
and  in  the  swollen  and  discolored  skin  over  an  inflamed  joint  (Adami) .  Inflam- 
mation may  also  be  induced  by  electric  currents,  by  the  a;-rays,  by  radium 
rays,  and  by  the  actinic  rays  of  sunlight  and  of  electric  light. 

Some  writers  insist  that  every  inflammation  is  due  to  the  action  of  micro- 
organisms, but  this  statement  lacks  proof.  They  maintain  that  inflammation 
is  a  destructive  microbic  process  which  cannot  bring  about  repair,  and  that 
repair  begins  only  when  inflammation  ends.  As  Adami  points  out,  the  advo- 
cates of  this  view  argue  that  swelling,  pain,  and  discoloration  point  to  the 
existence  of  inflammation ;  that  repair  can  take  place  when  these  phenomena 
are  absent,  hence  inflammation  is  not  present  when  repair  begins.  As  a  matter 
of  fact,  swelling,  discoloration,  and  pain  are  phenomena  often  but  not  inva- 
riably associated  with  inflammation;  and  in  inflammation  one  or  all  of  these 
phenomena  may  be  absent.  Because  these  signs  are  not  discovered  is  no 
proof  that  inflammation  does  not  exist.  I  believe  that  inflammation  is  not 
always  due  to  microbes  and  is  not  always  a  destructive  process,  but  may  be 
from  the  start  conservative  and  reparative.  It  is  the  reaction  of  the  tissue 
to  injury  and  is  the  first  step  on  the  road  to  repair.^ 

Symptoms  of  Acute  Inflammation. — Inflammation,  if  at  aU  severe, 
announces  its  presence  by  symptoms  which  are  both  local  and  constitutional. 

Local  Symptoms  of  Acute  Inflammation. — ^The  most  prominent  local 
symptoms  were  known  centuries  ago  to  the  famous  Roman,  Celsus,  who  stated 
them  as  "rubor,  calor  cum  tumor e  et  dolore" — redness  and  heat  with  swelling  and 
pain.  As  set  forth  to-day,  the  local  symptoms  are:  (i)  heat;  (2)  pain;  (3) 
discoloration;  (4)  sweUing;  (5)  disordered  function ;  and  (6)  muscular  rigidity, 
which  is  noted  in  inflammation  of  certain  regions  and  structures. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of  blood  through  the 
damaged  area  and  to  the  arrival  at  the  surface  of  the  body  of  warm  blood 
from  internal  parts.  Although  an  inflamed  part  may  be,  and  usually  is, 
warmer  than  the  surrounding  parts,  its  temperature  is  never  greater  than  the 
temperature  of  the  blood.  This  increase  of  heat  is  especially  noticeable  when 
we,  for  instance,  touch  an  arm  affected  with  erysipelas  and  contrast  the  sensa- 
tion obtained  with  that  obtained  by  placing  the  hand  on  the  sound  arm. 
The  diseased  arm  feels  much  warmer  to  the  examining  hand  than  does  the 
sound  arm,  but  its  temperature  is  not  above  the  general  body  temperature. 
An  extremity  in  health,  as  is  well  known,  shows  on  the  surface  a  temperature 
below  that  of  the  blood ;  in  an  inflamed  state  the  temperature  may  nearly  equal 
that  of  the  blood.  Heat  is  always  present  in  inflammation  of  a  superficial 
part.  The  surgeon  examines  for  heat  by  placing  his  hand  upon  the  suspected 
area  and  then  placing  the  same  hand  upon  a  corresponding  portion  of  the  op- 
posite side  of  the  patient  in  order  to  note  the  contrast.  If  great  accuracy  is 
desired,  a  surface  thermometer  is  used. 

Pain  is  a  constant  and  conspicuous  symptom.  It  is  due  to  stretching 
of  or  pressure  upon  nerves  from  exudate;  to  irritation  of  nerves;  or  to  inflam- 
1  See  Adami's  masterly  article  in  AUbutt's  "  System  of  Medicine." 


Local  Symptoms  of  Acute  Inflammation  89 

mation  of  the  ner\-es  themselves,  producing  cellular  changes.  Pain  is  asso- 
ciated with  tenderness  (pain  on  pressure),  it  is  aggravated  by  motion  and  by 
a  dependent  position  of  the  part,  and  it  varies  in  degree  and  in  character.  In 
serous  membranes  it  is  acute  and  lancinating,  like  dagger- thrusts;  in  connect- 
ive tissue  it  is  acute  and  throbbing;  in  large  organs  it  is  dull  and  hea\y;  in 
the  bone  it  is  gnawing  or  boring;  in  the  skin  and  mucous  membrane  it  is  itch- 
ing, burning,  smarting,  or  stinging;  in  the  urethra  it  is  scalding;  in  the  testicle 
it  is  sickening  or  nauseating;  in  the  teeth  it  is  throbbing;  and  in  inflammation 
imder  dense  fascia  it  is  pulsatile.  Pain  in  inflammation  after  presenting  itself 
in  one  form  may  change  in  character.  If  a  pain  becomes  markedly  throbbing, 
suppuiration  may  be  anticipated.  Pain  does  not  always  occur  only  at  the  seat 
of  trouble,  but  may  be  felt  also  at  some  distant  point.  Usually  there  is  also 
pain  at  the  seat  of  disease.  Sometimes  no  pain  is  complained  of  in  that  region. 
I  have  seen  pain  in  the  right  sciatic  region  dependent  upon  a  chronically  in- 
flamed appendix,  no  complaint  ha\ing  been  made  of  pain  in  the  abdomen. 
This  is  known  as  a  "sympathetic^'  or  referred  pain,  and  is  due  to  the  fact  that 
the  area  to  which  pain  is  referred  receives  its  nerve-supply  from  the  same 
spinal  segment  as  does  the  inflamed  area;  in  other  words,  there  is  a  ner\-ous 
communication  between  the  inflamed  part  and  a  distant  area.  In  many  cases 
of  s}Tnpathetic  pain  a  nerve-trunk  refers  the  sense  of  pain  to  its  peripheral 
distribution,  but  sometimes  pain  is  referred  to  an  adjacent  ner\'e,  a  distant 
nerve,  or  even,  perhaps,  to  a  ner\-e  on  the  opposite  side  of  the  body.  Tender- 
ness, however,  is  detected  at  the  seat  of  trouble,  whether  or  not  it  exists  at 
the  seat  of  referred  pain. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  Pain  at  the  point  of 
the  right  shoulder  or  in  the  shoulder-blade  is  felt  also  in  gall-stones,  cholecys- 
titis, and  in  cancer  of  the  liver.  The  pain  arises  in  filaments  of  the  pneumo- 
gastric  from  the  hepatic  plexus. 

Pain  of  coxalgia  is  often  felt  on  the  inside  of  the  knee,  because  the  obtmator 
nerA^e,  which  sends  a  branch  to  the  ligamentimi  teres,  also  sends  a  branch  to 
the  interior  and  to  the  inner  side  of  the  knee-joint. 

Inflammation  of  an  eye  vnXh  increased  tension  causes  browache.  Inflam- 
mation of  the  anus,  uterus,  tubes,  or  ovaries  may  cause  sacral  backache.  Pain 
of  rectal  inflammation  may  be  referred  to  the  back  of  the  sacrum,  down  the 
thighs,  to  the  penis  and  to  the  perineimi.  I  have  seen  pain  in  the  heel  as  a 
S}Tnptom  of  rectal  cancer.  Pain  of  inflammation  of  the  sacro-iliac  joint  may  be 
referred  to  the  sciatic  nen.^e  and  its  branches.  Inflammation  of  the  prostate 
and  neck  of  the  bladder  causes  pain  in  the  head  of  the  penis,  and  often  pain  in 
the  lower  abdomen  and  loin.  Inflammation  of  a  testicle  or  epididymis  cause 
pain  in  the  groin,  and  often  also  in  the  abdomen,  back,  and  thighs.  Renal 
calcidus  and  pyelitis  cause  pain  in  and  retraction  of  the  testicle,  and  pain  in  the 
loin,  groin,  or  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes  more  ^dolent;  for 
instance,  hepatitis  becomes  much  more  painful  when  the  perihepatic  structures 
are  attacked.  Inflammation  without  pain  is  known  as  "latent"  (as  the  in- 
flammation of  Peyer's  patches  in  t}-phoid).  The  sudden  disappearance  of 
inflammatory  pain,  when  not  due  to  the  administration  of  opiates,  suggests 
the  possibility  of  gangrene,  because  analgesia  exists  in  gangrene.  The  char- 
acteristics of'inflammator>'  pain  are  that  it  comes  on  gradually,  has  a  fixed 
seat,  is  continuous,  is  attended  by  other  inflammatorv'  sATuptoms,  and  is  in- 
creased by  motion,  by  pressure,  and  by  a  dependent  position  of  the  part.  If 
there  be  no  tenderness  in  a  part,  the  source  of  the  pain  is  not  local  inflam- 
mation; but  tenderness  may  exist  when  there  is  no  local  inflammation,  as  in 
an  area  to  which  pain  is  referred  from  a  distant  part.  Pain  of  an  inflammation 
which  does  not  involve  a  nerve  does  not  correspond  to  an  exact  ner\-ous  dis- 


90 


Inflammation 


tribution.  If  pain  corresponds  exactly  to  the  area  of  a  nerve's  distribution,  the 
cause  of  it  is  acting  on  the  nerve-trunk  or  on  its  roots.  If  the  cutaneous  sur- 
face is  involved,  the  lightest  touch  causes  pain.  The  surface  may  be  extremely 
hyperesthetic  even  when  it  is  not  inflamed,  the  condition  resulting  from  deep- 
seated  or  distant  inflammation.  Areas  of  hyperesthesia  of  the  skin  of  the  ab- 
domen are  noted  in  various  visceral  inflammations.  Such  hyperesthesia  is  due 
to  referred  impressions.  If  touching  the  skin  produces  no  pain,  but  deep  pres- 
sure does  produce  it,  the  deeper  structures  are  the  source.  Pain  in  muscle  and 
ligament  is  developed  by  motion ;  in  muscle,  by  contraction,  but  not  by  passive 
movements  with  the  muscle  relaxed;  in  ligament  pain  is  developed  by  active  or 
passive  movements  which  stretch  the  ligament.  If,  for  example,  a  man  with  a 
stiff  neck  has  pain  on  the  right  side  of  the  back  of  his  neck  on  voluntarfly 
turning  his  face  toward  the  left  shoulder,  but  is  without  pain  when  his  face 
is  turned  by  the  surgeon,  who,  conversely,  induces  pain  by  turning  the  patient's 
face  far  to  the  right,  this  condition  indicates  the  trouble  to  be  muscular.  If, 
however,  no  pain  arises  on  turning  the  face  to  the  right,  but  it  is  manifest  on 
turning  the  face  actively  or  passively  to  the  left,  the  pain  is  in  those  ligaments 
which  stretch  when  the  face  is  turned  to  the  left.^  In  inflammation  of  the 
synovial  membrane  even  gentle  passive  motion  in  any  direction  causes  pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is  sudden  in  onset, 
intermits,  recurs  in  paroxysms,  and  is  relieved  by  pressure.  The  pain  of 
inflammation  is  gradual  in  onset,  is  continuous,  and  is  made  worse  by  pressure. 
The  pain  of  neuralgia  is  often  preceded  by  cutaneous  anesthesia  of  the  skin 
of  the  part,  is  very  paroxysmal,  comes  on  suddenly,  darts  through  recognized 
nerve-areas,  the  attack  lasts  some  hours,  and  is  apt  to  recur  at  a  certain  hour. 
It  presents  no  general  tenderness,  as  does  inflammation,  but  there  may  be 
several  points  which  are  acutely  sensitive  to  pressure  (Valleix's  points  dou- 
loureux) .  The  tender  spots  of  Valleix  are  met  with  in  inveterate  neuralgia,  and 
occur  at  points  where  nerves  "pass  from  a  deeper  to  a  more  superficial  level, 
and  particularly  where  they  emerge  from  bony  canals  or  pierce  fibrous  fasciae."^ 

Pain  is  often  of  great  value  by  calling  attention  to  parts  diseased;  but  it 
may  be  a  terrible  evfl,  racking  the  organism  and  even  causing  death.  If  pain 
continues  long,  it  becomes  in  itself  formidable:  it  prevents  sleep,  it  destroys 
appetite,  and  it  deteriorates  the  mind,  and  one  of  the  surgeon's  highest  duties 
is  to  relieve  it.  The  physiognomy  or  expression  of  physical  pain  presents  the 
foUowing  characteristics:  Heavy  fulness  about  the  eyes,  dropping  of  the 
angles  of  the  mouth,  and  the  aspect  of  fatigue.  The  victim  of  pain  may  be 
restless,  but  in  severe  inflammation  he  is  apt  to  assume  some  fixed  posture. 
He  may  be  anemic.  There  may  be  widespread  tremor,  muscular  twitches,  or 
muscular  rigidity.  The  absence  of  the  physiognomy  of  pain  in  a  person  who 
complains  of  great  agony  is  a  strong  indication  that  the  patient  exaggerates 
the  gravity  of  his  sufferings  or  deliberately  deceives. 

Discoloration  arises  from  determination  of  blood  to  the  part;  hence  the 
more  vascular  the  tissue,  the  greater  the  discoloration.  A  non-vasciflar  tissue 
presents  no  discoloration,  though  we  usually  find  discoloration  adjacent  in  the 
zone  of  blood-vessels  which  furnish  the  tissue  with  nutriment.  Discoloration  in 
vascular  tissue  is  most  intense  at  the  focus  or  center  of  the  inflammation.  Dis- 
coloration varies  in  tint  and  in  character  according  to  the  tissue  implicated  and 
the  nature  of  the  inflammation.  It  may  be  circumscribed  or  diffuse.  Arborescent 
redness  means  a  distribution  in  dendritic  lines.  Linear  discoloration  signifies 
redness  running  in  straight  lines,  as  in  phlebitis.  Punctiform  discoloration 
occurs  in  points,  and  is  due  to  vascular  rupture.  Maculiform  redness  re- 
sembles an  ecchymosis  or  blotch.     Dusky  discoloration  points  to  suppuration. 

1 "  Surgical  Diagnosis,"  by  A.  Pearce  Gould. 

2  Anstie,  "  Neuralgia  and  Diseases  which  Resemble  It." 


Local  Symptoms  of  Acute  Inflammation  91 

Inflammation  of  the  throat  and  skin  produces  scarlet  discoloration;  in- 
flammation of  the  sclerotic  coat  of  the  eye  and  of  the  fibrous  coat  of  muscle 
produces  lilac  or  bluish  discoloration;  inflammation  of  the  iris  produces  brick- 
dust,  grayish,  or  brown  discoloration;  er^-sipelas  causes  a  yellowish-red  dis- 
coloration; secondan,-  s}"philis  causes  a  copper-hued  discoloration;  and  ton- 
sillitis causes  a  livid  discoloration.  A  tuberculous  ulcer  is  of  a  purple  color 
on  the  edge.  Gangrene  is  shown  by  a  black  discoloration.  A  scorbutic  ulcer 
is  surrounded  by  an  area  of  ^•iolet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent  and  joined  with 
other  s}Tnptoms.  Redness  due  to  inflammation  disappears  on  pressure,  but 
returns  when  the  pressure  has  been  removed.  If  redness  is  due  to  staining  of 
the  surface  by  dye,  pigmentation,  or  extravasation  of  blood,  pressure  will  not 
blanch  the  spot.  If  on  takmg  oft'  pressure  the  redness  of  inflammation  rapidly 
returns,  the  circulation  is  active;  if,  on  the  contrar\-,  it  xer\-  slowly  reappears, 
the  circulation  is  ver\'  sluggish  and  gangrene  is  threatened.  Subcutaneous 
hemorrhage  gi^'es  rise  to  a  purple-red  color  which  does  not  fade  when  sub- 
jected to  pressure.  Stains  of  the  surface  by  dyes  fail  to  disappear  on  pressure, 
are  distributed  over  a  considerable  surface,  show  a  hue  which  is  uniform 
throughout,  are  ob\'iously  superficial,  are  not  associated  with  other  signs  of 
inflammation,  and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  exceUent  little  work  upon  ■'Surgical  Diagnosis," 
tells  us  that  the  color  of  a  h^-peremic  surface  may  furnish  important  informa- 
tion. Li^■idity  may  mean  failure  of  the  heart  and  lungs,  or  simply  venous 
congestion  in  the  part.  In  li\-idity  from  obstruction  of  the  lungs  or  heart  the 
color  slowly  returns  after  pressure  has  driven  it  out.  In  n\'idity  due  to  local 
congestion  the  color  quickly  returns  when  pressure  is  released  and  the  dilated 
veins  are  often  distinctly  ^•isible.  Of  course,  in  a  local  trouble,  when  the 
circulation  becomes  impaired  to  such  a  degree  that  gangrene  is  threatened, 
the  li\-iditv  fades  ver^'  slowly  on  pressure  and  reappears  very  slowly  on  the 
release  of  pressure. 

Swellijig  or  tumefaction  is  due  in  smaU  part  to  vascular  distention,  but 
chieflv  to  eft'usion  and  cell  multiphcation.  The  more  loose  ceflular  mate- 
rial a'  part  contains,  the  more  it  sweUs;  hence  the  eyehds,  scrotum,  Aiflva, 
tonsils,  glottis,  and  conjunctiva  sweU  ver\'  greatly  when  inflamed.  A  swelling 
is  soft  or  edematous  when  due  to  uncoagiilated  effusion;  is  brawny  and  doughy 
when  due  to  coagiflated  effusion;  is  hard  and  elastic  when  produced  by  pro- 
liferating ceUs.  SweUing  may  do  good  by  imloading  the  vessels  and  acting 
like  a  bhster  or  local  bleeding',  or  it  may  do  great  harm  by  pressing  upon  the 
vessels  and  cuttmg  off  the  blood-supply.  Swelling  of  the  conjunctiva,  or 
chemosis,  may  cause  sloughing  of  the  cornea,  and  swelling  of  the  prepuce 
mav  cause  gangrene.  A  swelling  may  do  harm  by  obstructing  an  aperture, 
as  in  edema  of  the  glottis,  when  the  lar\-nx  becomes  blocked;  or  by  com- 
pression of  a  normal  channel,  as  in  the  swelling  of  the  perineimi  when  the 
urethra  is  compressed.  The  cutaneous  siuiace  over  a  swollen  area  may  become 
covered  with  bhsters  or  blebs.  This  condition  is  noted  particularly  after  bums 
and  fractures. 

Disordered  function  is  always  present  in  inflammation.  It  may  be  mani- 
fested by  increased  tenderness  or  sensibility;  a  shght  touch,  it  maybe,  pro- 
ducing torturing  pain.  This  condition  is  caUed  hyperesthesia.  Parts  almost  or 
enthely  destitute  of  feehng  when  healthy  (as  tendons,  Hgaments,  and  bones) 
become  highly  sensitive  when  inflamed.  It  may  be  manifested  by  increased 
irritability.  In  dysenter\'  the  colon  repeatedly  contracts  and  expels  its  con- 
tents; the  stomach  does  likewise  in  gastritis;  and  the  bladder  acts  similarly  in 
cystitis.  Spasmodic  tTsitching  of  the  eyehds  occurs  in  conjimcti^dtis,  and 
t^-itching  of  the  muscles  of  a  hmb  after  fracture  and  amputation. 


Q2  Inflammation 

Impairment  of  Special  Function. — In  inflammation  of  the  eye,  when  an 
attempt  is  made  to  look  at  objects  the  lids  close  spasmodically,  and  even  a 
little  light  causes  great  pain  and  lacrimation  (photophobia).  In  inflamma- 
tion of  the  ear  noises  cause  great  suffering,  and  even  when  in  a  quiet  room  the 
patient  has  subjective  buzzing  and  roaring  in  his  ears  (tinnitus  aurium). 
In  coryza  the  sense  of  smell,  in  glossitis  the  sense  of  taste,  in  dermatitis  the 
sense  of  touch,  and  in  laryngitis  the  voice  may  be  lost.  In  inflammation  oi 
the  brain  the  mind  is  disordered;  in  arthritis  the  joints  can  scarcely  be  moved; 
and  in  myositis  it  is  difiicult  and  painful  to  employ  the  muscles. 

Derangement  of  Secretions. — In  dermatitis  the  sweat  is  not  thrown  off;  in 
hepatitis  bile  is  not  properly  secreted;  and  in  nephritis  urea  is  not  satisfac- 
torily removed.  The  secretions  may  undergo  important  changes  of  compo- 
sition. The  sputum  in  pneiunonia  is  rusty,  and  dysentery  causes  a  discharge 
of  bloody  mucus. 

Derangement  of  Absorbents. — In  the  height  of  an  inflammation  the  absorb- 
ents are  blocked  and  clogged  by  coagulated  exudate,  and  they  cannot  perform 
their  offices. 

Muscular  rigidity  is  sometimes  an  important  sign  of  inflammation.  If 
a  joint  is  inflamed,  the  muscles  which  move  the  joint  are  rigid  and  the  joint 
is  more  or  less  immobile.  In  inflammation  of  the  peritoneum  the  abdominal 
muscles  are  rigid,  and  the  respirations  become  shallow,  frequent,  and  thoracic. 
In  pleuritis  the  intercostal  muscles  of  the  inflamed  side  become  rigid  and  the 
respiratory  excursion  of  the  chest  is  limited.  Rigidity  serves  to  lessen  motio;i, 
prevent  pain,  protect  the  part,  and  so  gives  physiological  rest. 

Constitutional  S3nnptoms  of  Acute  Inflammation. — The  chief  constitutional 
symptoms  of  acute  inflammation  are  elevated  temperature  and  leukocytosis. 
Constitutional  symptoms  may  be  absent,  and  often  are  in  moderate  or  .limited 
inflammations;  but  in  severe,  extensive,  or  infective  inflammations  the  symp- 
tom group  known  as  fever  is  certain  to  exist.  This  is  known  as  symptomatic ^ 
or  inflammatory  fever,  and  it  arises  in  non-septic  cases  from  the  absorption  of 
aseptic  pyrogenous  exudate,  and  in  microbic  inflammations  from  the  absorption 
of  pyrogenous  toxic  products  of  bacterial  action.  In  young  and  robust  indi- 
viduals an  acute  non-microbic  inflammation  causes  a  fever  characterized  by 
full,  strong  pulse,  flushed  face,  coated  tongue,  dry  skin,  nausea,  constipation, 
and  possible  acute  delirium  (the  sthenic  type  of  the  older  authors) .  In  broken- 
down  and  exhausted  individuals  an  ordinary  inflammation,  and  in  any  individ- 
ual a  bacterial  inflammation,  may  cause  a  fever  with  typhoid  symptoms 
(the  typhoid,  asthenic,  or  adynamic  type) .  Fibrin  ferment  is  obtained  from  the 
white  corpuscles;  it  is  liberated  as  the  corpuscles  break  up  in  the  exudate,  and 
acting  on  the  liquor  sanguinis  cause  the  union  of  calcium  and  fibrinogen  and  the 
formation  of  fibrin.  The  absorption  of  fibrin  ferment  many  believe  causes 
aseptic  fever  (see  page  1 29) .  Inflammatory  blood  contains  an  increased  amount 
of  albumin  and  salts.  If  a  person  with  inflammatory  fever  is  bled,  the  blood  co- 
agulates rapidly,  the  clot  sinks,  and  there  is  found  on  the  surface  a  cup-shaped 
coat,  made  up  of  liquor  sanguinis  and  white  cells,  known  as  the  "buffy  coaf;  but 
this  is  not  really  a  sign  of  inflammation,  and  occurs  normally  in  the  blood  of 
the  horse.  The  buffy  coat  forms  when  blood  contains  a  great  nimiber  of  leu- 
kocytes, because  these  leukocytes  sink  more  slowly  than  do  the  red  corpuscles. 
Cupping  occurs  because  the  white  corpuscles  sink  more  slowly  by  the  side 
of  the  tube  than  far  from  the  sides. 

Leukocytosis. — In  many  inflammatory  and  infectious  diseases  leukocy- 
tosis is  noted.  It  probably  indicates  an  attempt  on  the  part  of  the  organism 
to  protect  itself  from  noxious  materials.  Leukocytosis  is  usually  much  more 
marked  if  pus  exists  than  if  the  exudation  is  serous  or  fibrinous. 

"The  degree  of  leukocytosis  may  be  considered  a  general  index  to  the  in- 


Chronic  Inflammation  93 

tensity  of  the  infection  and  to  the  strength  of  the  individual's  resisting  powers 
in  reacting  against  it.  It  follows,  therefore,  that  intense  infections  occurring 
in  indi\'iduals  whose  resisting  powers  are  strong,  produce  a  decided  increase; 
but  the  presence  of  an  infection  of  like  intensity  in  one  whose  resisting  powers 
are  greatly  crippled  fails  to  cause  leukocytosis,  for  in  such  an  instance  the  organ- 
ism is  so  overpowered  by  the  effects  of  the  morbid  process  that  it  is  incapable 
of  reacting"  ("CHnical  Hematology',"  by  J.  C.  DaCosta,  Jr.).  We  see  from 
the  above  that  gangrene  or  any  other  virulent  infection  may  be  accompanied 
by  a  low  leiikocyte  count,  and  when  pus  is  surrounded  by  a  thick  wall  the  leu- 
kocytes may  he  normal  or  nearly  normal  in  nimiber.  An  increased  proportion 
of  polyrnorphonuclear  leukocytes  strongly  suggests  body  reaction  against  in- 
fection, and  an  increase  of  eosinophUes  aids  us  in  recognizing  deep-seated  pus 
when  the  leukocyte  count  is  normal  or  but  slightly  increased. 

The  introduction  of  salt  solution  into  the  peritoneal  cavity  leads  to  the 
gathering  of  nimibers  of  white  cells,  and  the  resistance  of  the  serous  mem- 
brane to  infection  is  increased.  Horse-serum  that  has  been  boiled  is  said  by 
Petit  to  be  a  valuable  material  to  draw  polynuclear  leukocytes  to  a  part 
("Med.  Record,"  June  22,  1907).  It  has  been  injected  into  the  peritoneal 
ca\dty  the  evening  before  an  operation  (30  c.c);  it  has  been  poured  into  the 
cavity  at  the  termination  of  an  operation;  the  gauze  used  for  drainage  after 
an  appendicitis  operation  has  been  soaked  in  it. 

There  is  no  fixed  numlDer  of  leukocytes  which  causes  us  to  affirm  the  pres- 
ence or  absence  of  gangrene  or  pus.  Most  serious  inflammations  show 
marked  inflammatory^  leukocytosis  and  an  increase  in  the  relative  proportion 
of  polynuclear  cells.  Typhoid  shows  no  leukocytosis  and  even  a  mixed  in- 
fection shows  comparatively  little  increase  of  polynuclear  cells.  The  same 
is  true  of  tuberculosis.  The  same  man  should  make  all  the  counts  on  one 
patient;  at  least  five  himdred  cells  should  be  counted  and  several  examina- 
tions ought  to  be  made. 

Chronic  Inflammation. — This  condition  results  from  the  action  on  the 
iissnes  of  some  mild  but  long-acting  irritant.  It  progresses  slowly  and  does  not 
produce  s\Tnptoms  of  severity  either  in  the  part  or  the  body  at  large. 

Causes. — Blood  diseases,  as  rheumatism  and  gout;  infective  diseases,  as 
tuberculosis  and  syphilis;  retained  pus  in  an  ill-drained  abscess;  blocking 
of  the  duct  of  a  gland;  the  retention  of  a  foreign  body  ki  a  part;  the  flow  of  an 
irritant  secretion  (as  saliva  from  a  fistula);  repeated  identical  traumatisms 
of  an  occupation,  etc.  W.  Watson  Cheyne  tells  us  that  chronic  inflammation 
is  not  due  to  the  ordinary  pyogenic  organisms  (see  Cheyne's  article  on  Treves's 
"System  of  Surgery"). 

Tissue  Changes. — ^These  changes  are  practically  the  same  as  in  acute 
inflammation,  but  take  place  far  less  rapidly.  Vasciilar  dilatation,  exudation, 
and  leukocytic  migration  are  often  trivial.  Cell  proliferation  is  always  con- 
spicuously marked.  It  is  maintained  by  Cheyne  and  others  that  typical  granu- 
lation tissue  does  not  form,  the  tissues  of  the  part  being  replaced  directly  by 
fibrous  tissue.  Th.e  amount  of  fibrous  tissue  produced  is  relatively  very  great. 
This  tissue  may  cause  permanent  thickening,  or  may  contract  and  thus  dimin- 
ish the  size  of  a  part.  Contraction  is  very  considerable  in  cirrhosis  of  the  liver 
and  in  interstitial  nephritis. 

Symptoms. — Pain  varying  in  intensity  and  character;  tenderness;  great 
sweUing,  which  in  some  cases  is  followed  by  shrinking,  and  is  usually  indurated 
or  bra-UTiy.  As  a  matter  of  fact,  great  swelling  is  the  most  usual  sAonptom. 
Sometimes  there  is  a  tri\dal  amount  of  heat.  There  is  rarely  discoloration 
unless  the  skin  is  itself  inflamed,  but  usually  the  surface  veins  are  distinctly, 
and  sometimes  they  are  greatly,  distended.  There  are  no  constitutional 
.symptoms  attributable  purely  to  the  inflammation.     If  there  are  such  s\Tnp- 


94 


Inflammation 


toms,  they  are  due  to  the  disease  which  induced  the  inflammation  or  to  inter- 
ference with  the  function  of  an  organ  because  of  the  fibrous  mass.  (For  the 
treatment  of  chronic  inflammation  see  articles  upon  special  regions  and  par- 
ticular structures.) 

Treatment  of  Acute  Inflammation. — The  first  rule  in  treating  an 
inflammation  must  be  to  remove  the  exciting  cause.  If  this  cause  is  a  splinter 
in  the  part,  take  out  the  splinter;  if  it  is  a  foreign  body  in  the  eye,  remove  the 
foreign  body;  if  urine  is  extravasated,  open  and  drain;  take  off  pressure  from 
a  corn;  pull  out  an  ingrown  nail ;  and  remove  microbes  from  an  infected  area 
by  draining,  irrigating,  and  perhaps  by  appljdng  antiseptics.  The  rule,  remove 
the  cause,  applies  to  a  chronic  as  well  as  to  an  acute  inflammation.  If  fhe  cause 
of  an  inflammation  was  momentary  in  action  (as  a  blow) ,  we  cannot  remove  it, 
for  it  has  already  ceased  to  exist.  After  removing  the  cause,  endeavor  to  bring 
about  a  cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remembered  that  the 
division  of  inflammation  into  stages  is  natural,  and  not  artificial,  and  that  a 
remedy  which  does  good  in  one  stage  may  do  harm  in  another.  Certain  agents 
are  suited  to  aU  stages  of  an  acute  inflammation,  namely,  rest  and  elevation.  In 
many  inflammatory  conditions  nature  seeks  to  immobilize,  protect,  and  rest 
the  part  by  increasing  the  tension  of  adjacent  muscles.  By  this  muscular 
rigidity  inflamed  joints  are  fixed  and  rested.  Rigidity  of  the  intercostal  mus- 
cles in  pleuritis  limits  chest  motion  and  pain;  rigidity  of  the  abdominal  mus- 
cles in  peritonitis  limits  abdominal  movements  and  lessens  suffering. 

Rest. — Physiological  rest  is  of  infinite  importance,  and  is  always  indicated 
in  acute  inflammation.  In  the  exercise  of  function  blood  is  taken  to  a  part 
and  an  existing  inflammation  is  aggravated.  Further,  as  BiUroth  has  pointed 
out,  rest  prevents  the  dissemination  of  infection,  because  motion  exposes 
fresh  surfaces  to  inoculation  and  breaks  down  protective  barriers  of  leiiko- 
cytes.  Its  principles  were  first  thoroughly  studied  by  Hflton.^  Baron  Larrey, 
the  celebrated  military  surgeon  of  the  Napoleonic  Empire,  anticipated  many 
modern  views  on  this  subject.  He  insisted  on  the  necessity  of  rest  in  the 
treatment  of  wounds;  he  beheved  that  rest  permitted  Nature  to  perform 
her  work  unhampered;  he  was  accustomed  to  leave  a  "first  dressing,"  if 
properly  applied,  undisturbed  for  several  or  even  for  many  days.  He  believed 
it  advisable  to  associate  with  rest  weU  adjusted  and  judicious  compression 
made  by  bandages,  especially  flannel  bandages.  (The  author,  on  Baron 
Larrey,  in  "Johns  Hopkins  Hospital  Bulletin,"  July,  1906.)  The  means  of 
securing  rest  differ  with  the  structure  or  the  part  diseased.  When  rest  is 
used,  do  not  employ  it  too  long.  Rest  in  bed  diminishes  the  amount  of  blood 
sent  to  an  inflamed  part  and  lessens  the  force  of  the  circulation;  hence  it 
antagonizes  stasis.  It  has  been  shown  that  the  heart  beats  at  least  fifteen 
times  per  minute  less  when  the  patient  is  recumbent  than  when  he  is  erect. 
The  saving  of  strength  and  the  benefit  of  the  local  condition  are  thus  seen  to 
be  enormous.  In  fact,  the  heart  saves  at  least  twenty-one  thousand  beats  a 
day.     In  every  severe  inflammation  insist  on  the  patient  going  to  bed. 

In  cerebral  concussion  rest  must  be  secured  by  quiet,  by  darkness,  by  the 
avoidance  of  stimiilants  and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and  the  circulation  of 
poisons  in  the  blood.  In  inflamed  joints  rest  must  be  obtained  by  proper 
position,  associated  in  many  cases  with  the  adjustment  of  spUnts  or  plaster 
of  Paris,  or  the  employment  of  extension. 

In  pleuritis  partial  rest  can  be  secured  by  strapping  the  affected  side  with 
adhesive  plaster,  or  by  using  a  bandage  or  a  binder  to  limit  respiratory  move- 
ments. In  fractures  Nature  procures  rest  by  her  spHnts — the  callus — and 
^ "  Lectures  upon  Rest  and  Pain." 


Local  Bleeding  95. 

the  surgeon  procures  rest  by  his  splints — firm  dressings  or  extension.  In 
cancer  of  the  rectum  and  intractahle  rectitis  a  colostomy  secures  rest  for  the 
inflamed  and  damaged  bowel.  In  enteritis  opium  gives  rest  to  the  bowel  by 
stopping  peristalsis.  In  cystitis  rest  is  obtained  by  the  administration  of  opium 
and  belladonna,  which  paralyze  the  muscular  fibers  of  the  bladder.  The  use 
of  the  catheter  gives  rest  to  the  bladder  by  removing  urine.  A  cystostomy 
allows  complete  rest  by  permitting  the  bladder  to  suspend  its  function  as  a 
reser\-oir  of  urine.  In  cystitis  from  vesical  calculus  rest  is  obtained  by  incising 
the  bladder,  removing  the  stone,  and  draining,  or  by  crushing  and  evacuating 
the  stone.  In  inflamed  mucous  membrane  rest  from  the  contact  of  irritants  is 
secured  by  touching  the  membrane  with  silver  nitrate,  which  forms  a  protective 
coat  of  coagulated  albiunin.  Opening  an  abscess  gives  its  walls  rest  from  ten- 
sion. In  inflammations  of  the  eye  light  must  be  excluded  to  obtain  complete 
rest,  but  tolerably  satisfactory  rest  is  given  in  some  cases  by  the  use  of  glasses 
of  a  peacock-blue  tint.  In  aneurysm  the  operation  of  Hgation  cuts  oft"  the  blood- 
current  and  gives  rest  to  the  sac.  In  hernia  the  operation  gives  rest  from  pres- 
sure.    Instances  of  the  value  of  rest  could  be  multiplied  indefinitely. 

Relaxation  is  in  reahty  a  form  of  rest,  and  consists  in  placing  the  part  in  an 
easy  position.  In  synovitis  of  the  knee  semiflexion  of  the  knee-joint  lessens 
the  pain.     In  muscular  inflammation  relaxation  relieves  the  pain. 

Elevation  partly  restores  circulator}-  equiHbrium.  A  felon  is  less  painful 
when  the  hand  is  held  up  in  a  sling  than  when  it  is  dependent.  A  congestive 
headache  is  worse  during  recumbency.  A  gouty  inflammation  in  the  great  toe 
is  more  painful  with  the  foot  lowered  than  when  it  is  raised.  A  toothache 
becomes  worse  on  King  down. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorgement,  increased 
arterial  tension,  and  beginning  eftusion.  These  agents  are — (i)  local  bleed- 
ing or  depletion;  (2)  cold. 

Local  Bleeding. — Local  bleeding,  or  depletion,  is  the  abstraction  of  blood 
from  the  inflamed  area.  This  abstraction  relieves  circulator}'  retardation 
and  causes  the  blood  to  move  rapidly  onward.  The  corpuscles  clinging  to  the 
vessel  walls  are  washed  away,  the  capillaries  shrink  to  their  natural  size,  and 
the  exudate  is  absorbed.  In  other  words,  local  blood-letting  increases  the 
rate  of  the  circulation,  though  not  its  force. 

The  methods  of  bleeding  locally  are — (o)  pimcture;  {b)  scarification;  (c) 
leeching;  {d)  cupping. 

Puncture  is  recommended  in  inflammation,  not  only  because  it  abstracts 
blood  locally,  but  also  because  it  gives  an  exit  to  eft'usion  under  fibrous  mem- 
branes. It' is  verv^  useful  in  relie\ing  tension — for  instance,  in  epididymitis. 
It  is  performed  vath  a  tenotome  and  ^-ith  aseptic  precautions.  If  numerous 
punctures  are  made,  the  procedure  is  termed  "multiple  puncture."  This  is 
ver\^  useful  when  appHed  to  the  inflamed  area  around  a  leg  ulcer.  The  late 
Pro'f.  Joseph  Pancoast  was  very  fond  of  employing  multiple  punctures,  desig- 
nating the  operation  "the  antiphlogistic  touch  of  the  therapeutic  knife." 

Scarification  or  Incision. — By  means  of  scarification  we  bleed  locally, 
evacuate  exudate,  and  relieve  tension.  One  cut  or  many  cuts  may  be  made, 
and  these  cuts  may  be  deep  or  may  not  go  entirely  through  the  skin,  according 
to  circumstances.'  Alultiple  incisions  are  useful  when  applied  to  inflamed 
ulcers,  tissues  in  danger  of  gangrene,  and  to  almost  any  condition  of  great  ten- 
sion. Scarification  is  of  notable  value  when  edema  of  the  glottis  exists.  Free 
incision  is  of  great  benefit  in  periostitis  and  in  threatened  gangrene.  In  osteo- 
myelitis the  medullary  canal  must  be  promptly  opened. 

Leeching. — Leeches  must  not  be  appHed  to  a  region  plentifully  endowed 
with  loose  cellular  tissue,  as  great  swelling  and  discoloration  are  sure  to  ensue. 
These  regions  are  the  prepuce,  labia  majora,  scrotum,  and  eyehds.     Leeches 


96  Inflammation 

should  never  be  applied  to  the  face  (because  of  the  scar),  near  specific  sores 
or  inflammations,  nor  over  a  superficial  artery,  vein,  or  nerve.  A  leech  is  best 
applied  at  the  periphery  of  an  inflammation  and  between  an  inflammation 
and  the  heart.  To  leech  at  the  inflammatory  focus  only  aggravates  the  trouble. 
Before  applying- leeches,  wash  the  part  and  shave  it  if  hairy.  Place  the  leech 
in  a  test-tube  or  an  inverted  wine-glass,  inserting  the  tail  or  thick  end  first, 
and  invert  the  tube  so  that  the  leech's  head  will  come  in  contact  with  the  pre- 
pared skin.  The  leech  is  restrained  in  the  tube  until  it  ''takes  hold"  and 
begins  to  feed,  when  the  tube  is  removed.  If  the  leeches  will  not  bite,  smear 
the  part  with  milk  or  a  little  blood.  Never  pull  off  a  leech;  let  it  drop  off. 
It  will  usually  drop  off  when  full,  but  if  it  refuses  to  do  so,  sprinkle  it  with  salt. 
After  removing  a  leech,  employ  warm  fomentations  if  continued  bleeding  is 
desired.  Sometimes  the  bleeding  persists  or  recurs.  Weill  and  Mouriquand 
("Press.  Medicale,"  Paris,  No.  i,  1911)  report  6  cases  of  severe  bleeding. 
Bleeding  can  usually  be  arrested  by  styptic  cotton  and  pressure.  In  some  rare 
cases  the  bleeding  continues  in  spite  of  pressure.  This  is  due  to  the  fact  that 
the  tissue  contains  a  considerable  quantity  of  a  material  secreted  from  the 
throat  of  the  leech,  which  material  prevents  coagulation  of  blood.  In  such  a 
case  excise  the  bite  and  the  area  of  tissue  adjacent  to  it,  and  suture  the  wound. 
Leeching  leaves  permanent  triangular  scars.  The  Swedish  leech,  which  is 
preferred  to  the  American,  draws  from  2  to  4  drams  of  blood.  After  a  leech  has 
been  removed,  if  we  desire  to  use  it  again,  place  it  in  salt  water.  This  causes  it 
to  vomit  the  blood  which  it  has  taken  up.  Leeching  has  both  a  constitutional 
and  a  local  effect.  It  is  at  present  used  comparatively 
rarely,  but  it  is  employed  by  some  practitioners  over  the 
spermatic  cord  in  epididymitis,  on  the  temple  in  ocular 
inflammation,  and  over  the  right  fliac  region  to  relieve  pain 
in  mild  cases  of  appendicitis. 

Cupping. — Dry  cups  deviate  blood  from  a  deeply  placed 
inflamed  area  to  the  surface.  Wet  cups  actually  remove 
blood. 

Dry  cups  are  applied  without  first  incising  the  skin. 

One  or  more  may  be  applied.      A  special  instrument  is 

sold   in   the   shops    for   the  performance  of  dry  cupping. 

It  consists  of  a  glass  bell,  with  a  globular  and  hollow  top 

F"  ^~~^R  bb^  lb     °^   rubber   (Fig.  49).     The  rubber  is   emptied  of  air  by 

cupper.  squeezing.     The  glass  bulb,  the  edges  of  which  have  been 

greased,  is  pushed  upon  the  skin,  and  the  compression  is 

relaxed  upon  the  rubber  bulb.     A  partial  vacuum  is  created,  and  an  area  of 

skin  and  subcutaneous  tissue  full  of  blood  rises  into  the  glass  bell. 

Cupping  can  be  easily  performed  by  means  of  a  tumbler.  The  edge  of  the 
glass  is  greased ;  a  bit  of  blotting-paper  wet  with  alcohol  is  placed  in  the  bottom 
of  the  tumbler  and  lighted.  After  a  brief  period  the  glass  is  inverted  and  placed 
upon  the  skin,  which  has  been  dampened  with  warm  water.  As  the  air  in  the 
glass  cools  the  tissues  rise  into  the  partial  vacuum. 

Wet  cups  draw  blood,  and  the  skin  should  be  cleansed  before  they  are 
applied.  In  wet  cupping  apply  a  cup  for  a  moment,  remove  it,  incise  or 
puncture  the  skin,  and  replace  the  cup  to  draw  the  requisite  amount  of  blood. 
Incisions  may  be  made  by  an  ordinary  scalpel,  a  lancet,  or  a  scarificator,  a  cup 
being  then  applied.  An  excellent  scarificator  is  shown  in  Fig.  50.  In  this 
instrument  concealed  blades  are  thrown  out  by  touching  a  spring.  Baron 
Heurteloup  devised  an  instrimient  (Fig.  51)  in  which  the  incision  is  made  by  a 
scarificator.  The  blood  is  drawn  out  by  a  pump,  the  tube  being  placed  upon 
the  cut  area  and  the  withdrawal  of  the  piston  creating  a  vacuum.  This  instru- 
ment is  known. as  the  "artificial  leech."     After  scarification  and  the  application 


Cold  in  Treatment  of  Inflammation 


97 


of  the  cup.  the  partial  vacuum  draws  blood  into  the  cup:  when  the  wounds 
cease  to  bleed  the  cup  is  removed,  and  if  further  bleeding  is  thought  desirable, 
the  clots  are  wiped  away  and  the  cup  is  again  appUed.  and  after  its  removal 
warm  fomentations  are  used.  Wet  cupping  is  of  value  in  pleuritis.  pericarditis, 
and  nephritis. 

Cold  is  a  ven.-  powerful  and  useful  agent  if  used  judiciously  and  applied 
at  the  proper  time.  It  is  valuable  because  of  its  reflex  effect  upon  the  vessels 
of  the  inflamed  area  rather  than  becaiise  of  direct  action  upon  the  cells  of  a 
part.  It  shoifld  only  be  used  early  in  the  case,  that  is,  before  stasis  occurs.  It 
is  not  to  be  used  in  the  later  stages  of  inflammation,  for  it  vriti.  then  only  ag- 
gravate the  existing  state;  in  fact,  when  there  is  considerable  exudation  cold 
does  actual  harm. 

Cold  acts  by  constricting  the  vessels  of  a  h}-peremic  area,  thus  lessening 
the  amount  of  blood  sent  to  the  part,  and  preventing  the  evolution  of  the  proc- 
ess into  the  stage  of  stasis  and  exudation.  Further,  it  prevents  the  migra- 
tion of  leukocytes,  retards  cell-proliferation,  relieves  pain  and  tension,  and 
lowers  temperatiu"e.  If  cold  is  too  intense,  if  it  is  kept  too  long  apphed,  if  it 
is  used  too  late  in  an  inflammation,  if  it  is  used  upon  an  old  or  feeble  patient,  or 
if  it  is  employed  when  there  is  much  exudation  or  a  condition  of  tissue  strangu- 
lation, it  does  actual  harm.    It  lessens  the  nutritive  acti\-itv  of  cells,  constricts 


Fig.  50. — Scarificator. 


Fig.  51. — ^Heurteloup's  artificial  leech. 


the  h-mph-spaces  and  channels,  increases  existing  stasis,  hence  lowers  the  ^-ital- 
it>-  of  the  tissues,  and  may  cause  gangrene.  If  the  parts  are  constricted,  as  m 
strangulated  hernia,  or  if  thev  are  compressed  by  a  large  exudate  or  fed  by  dis- 
eased" blood-vessels,  or  if  the  patient  is  old  or  exhausted,  cold  is  particularly 
apt  to  cause  gangrene.  Cold  should  not  be  used  in  a  bacterial  inflammation. 
In  such  an  inflammation  it  is  desirable  that  quantities  of  active  leukoc}-tes 
should  come  to  the  part.  These  phagoc}-tes  destroy  bacteria  and  circumscribe 
the  inflammatory-  focus.  Cold  keeps  much  blood  and  hence  many  leukoQ-tes 
out  of  the  part.' lessens  the  ameboid  activity,  and  prevents  migration  of  the 
leukoc\-te5  which  do  succeed  in  arriving.  Hence,  cold  actuaUy  favors  the 
spread'  of  a  microbic  process.  Fiirthermore,  it  lessens  leukocytosis  and  thus 
lessens  the  protective  reaction  of  the  tissues.  De  Xancrede,  in  his  'Trinciples 
of  Surger}-."  points  out  that  in  an  inflammation  stasis  soon  arises  at  the  focus 
of  the^'inflammation.  and  there  is  an  area  of  stasis  surroimded  by  a  zone  pf 
h\-peremia.  Cold  benefits  the  h\-peremic  zone,  but  aggravates_  the  stasis. 
De  Xancrede  cautions  us  as  foUows:  ■•Judgment  is,  therefore,  requisite  to  decide 
whether  the  e\-il  at  the  focus  wiU  not  outweigh  the  good  exerted  at  the  periph- 
er\'."-^  De  Xancrede  further  points  out  that  cold  must  not  be  used  intermit- 
tentlv;  but  if  emploved  at  aU,  must  be  continuously  appHed.  If  cold  is  appKed 
intermittently,  there  wfll  be  a  reaction  whenever  it  is  removed,  and  this  reac- 

1"  Principles  of  Surgerj-." 


98 


Inflammation 


tion  causes  increased  hyperemia.  Hence,  cold  must  be  "continued  in  action  to 
prevent  reaction."  If  during  the  employment  of  cold  the  skin  becomes  purple 
and  congested  and  the  circulation  feeble,  at  once  discontinue  the  use  of  it,  as 
its  continuance  will  be  dangerous. 

Cold  may  be  used  as  wet  cold  or  as  dry  cold. 

Wet  cold  is  easily  appUed,  but  it  is  much  more  depressing  than  dry  cold, 
is  likely  to  produce  discomfort,  macerates  the  skin,  and  may  lead  to  the  forma- 
tion of  excoriations,  etc.  A  part  can  be  subjected  to  wet  cold  by  the  applica- 
tion of  evaporating  fluids  or  the  use  of  a  siphon.  When  wet  cold  is  used  inspect 
the  part  at  frequent  intervals,  and  discontinue  the  treatment  if  evidences  of 
stasis  become  positive.  Evaporating  fluids  are  extensively  employed.  If 
such  a  fluid  is  used,  never  cover  the  part  with  a  thick  dressing.  If  this  shoiild 
be  done,  the  fluid  will  not  evaporate  ^dth  sufficient  rapidity  to  produce  cold. 

A  piece  of  thin  muslin 
or  flannel  should  be 
moistened  with  the  fluid 
and  laid  upon  the  part, 
and  be  kept  constantly 
moist  by  the  apphca- 
tion  from  time  to  time 
of  small  quantities  of 
the  liquid.  Lead-water 
and  laudanum  is  used 
extensively,  and  prob- 
ably owes  its  chief  value 
to  the  fact  that  it  pro- 
duces cold  on  evapora- 
tion. Lead-water  and 
laudanum  is  composed 
of  I  oz.  of  laudamun, 
I  oz.  of  Hquor  plumbi 
subacetatis,  i  pint  of 
water.  Liquor  plumbi 
subacetatis  dilutus  may 
be  used  without  lau- 
danum. It  is  thought 
that  the  addition  of  lau- 
danum tends  to  allay 
pain.  Coplin  demon- 
strated by  a  series  of 
laboratory  experiments 
that  lead-water  and  laudamma  is  a  germicide.  A  solution  of  ammoniimi 
chlorid  may  be  used  in  the  strength  of  i  oz.  of  the  drug  to  2  quarts  of 
water.  If  ammonium  chlorid  is  used  for  more  than  a  short  period  of  time, 
it  is  prone  to  cause  the  formation  of  blisters,  which  are  irritable  and  pain- 
fifl.  Cheyne  and  Burghard  use  the  following  formula:  h  oz.  of  ammonium 
chlorid,  i  oz.  of  alcohol,  and  7  oz.  of  water.  Plain  spring-water,  iced  water,  or 
a  mixture  of  alcohol  and  water  may  be  used.  The  siphon  is  occasionally  used. 
If  there  is  a  wound,  the  fluid  which  comes  in  contact  with  it  must  be  aseptic  or 
antiseptic.  We  may  use  sterile  water,  sterile  salt  solution,  a  solution  of  boric 
acid,  or  a  solution  of  acetate  of  aluminum.  In  conjunctivitis,  cold  is  applied 
to  the  eye  by  means  of  hnen  or  muslin  soaked  in  iced  water,  laid  upon  the 
closed  lids,  and  changed  frequently. 

To  apply  wet  cold  by  means  of  a  siphon,  the  part  is  covered  with  one  layer 
of  wet  linen  or  muslin,  and  is  laid  upon  a  rubber  sheet  folded  like  a  trough  and 


■Siphon  (Esmarch). 


Cold  in  Treatment  of  Inflammation 


99 


Fig.  53. — Ice-bag  (W.  E.  Ashton). 


emptying  into  a  bucket.  A  vessel  filled  with  cold  water  is  placed  upon  a 
higher  level  than  the  bed.  A  wet  lamp-wick  is  now  taken,  one  end  is  inserted 
into  the  water  of  the  vessel,  and  the  other  end  is  laid  upon  the  part.  Capillary 
action  and  gravity  combine  to  keep  the  part  moist.  A  rubber  tube  may  be 
used  instead  of  a  wick.  If  a  tube  is  employed,  tie  it  in  a  knot  or  clamp  it  so 
that  the  fluid  is  delivered  drop  by  drop  (Fig.  52).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be  reduced  to  about  45°  F. 
by  adding  i  part  of  alcohol  to  every  4  parts  of  water.  A  mixture  of  5  parts  of 
nitrate  of  potassium,  5  parts  of 
chlorid  of  ammonium,  and  16  parts 
of  water  produces  great  cold. 

Dry  cold  is  more  manageable 
and  more  generally  useful  than 
wet  cold.  It  is  applied  by  means 
of  a  rubber  bag  or  a  bladder 
filled  mth  ground  or  finely  cracked 
ice,  several  folds  of  flannel  bemg 
first  laid  over  the  part.  The  flannel 
coUects  the  moistiu-e  from  the  "sweating"  bag  and  thus  prevents  maceration 
of  the  skin.  Further,  it  saves  the  tissue  from  being  subjected  to  too  much 
direct  cold  and  enables  us  to  obtain  the  beneficial  reflex  eft'ect.  The  ice-bag 
of  India-rubber  is  widely  used.  We  can  venture  to  apply  by  means  of  the 
ice-bag  a  greater  degree  of  cold  than  it  is  proper  to  apply  by  the  use  of  fluids, 
as  dry  cold  is  not  so  likely  to  induce  gangrene  as  is  moist  cold.  If  there  is 
much  tenderness,  the  weight  of  an  ice-bag  causes  pain,  and  it  is  best  to  suspend 
it  from  a  frame,  so  that  it  lightly  touches  the  part.    The  frame  is  the  same  as  is 

used  to  keep  the  bedclothes 
from  contact  viith  a  fractured 
leg,  and  can  be  easily  made 
from  barrel-hoops.  During 
the  time  an  ice-bag  is  being 
used  the  part  must  be  in- 
spected at  brief  intervals  to 
see  that  the  circulation  is  not 
unduly  depressed.  The  ice- 
bag  is  frequently  used  in 
joint  inflammation,  in  intra- 
cerebral inflammation,  in  epi- 
did\Tnitis,  in  acute  myelitis, 
and  by  many  in  the  earhest 
stage  of  appendicitis  (see 
page  1 01 6,  where  the  author 
expresses  his  disapproval  of 
such  a  method  of  treatment). 
If  a  joint  is  sprained,  the  im- 
mediate application  of  an  ice- 
bag  is  of  great  ser\dce.  A 
part  can  be  encircled  with  a 
rubber  tube  through  which  iced  water  is  made  to  flow  (Fig.  54) .  Even  when 
this  apparatus  is  used  the  part  should  first  be  wrapped  in  flannel.  Leiter's 
tubes,  which  are  tubes  of  lead  made  to  fit  various  regions  and  which  carry  a 
stream  of  cold  water,  can  also  be  used.  A  piece  of  flannel  must  be  placed 
between  the  tube  and  the  skin.  The  temperature  of  these  tubes  can  be  low- 
ered to  any  desired  degree  by  lowering  the  temperature  of  the  circulating  fluid. 
Cheyne  and  Burghard  wisely  caution  us  to  use  a  fluid  at  a  temperature  not 


Fig.  54. — The  Esmarch  cooling  coil. 


loo  Inflammation 

under  50°  or  60°  F.,  to  inspect  the  part  every  three  or  four  hours,  and  not  to 
employ  the  tubes  longer  than  twenty-four  hours. 

Heat  is  employed  by  some  early  in  an  inflammation.  It  is  rarely  beneficial 
at  this  stage,  except  when  applied  by  a  hot-air  apparatus  for  the  treatment  of 
an  injured  joint.  It  is  true  that  a  degree  of  heat  which  does  not  actually  de- 
stroy the  tissues  will  contract  the  vessels  as  does  cold;  but  this  degree  of  heat 
will  not  be  borne  by  the  patient  unless  but  a  limited  portion  of  a  superficial 
part  is  involved. 

Certain  agents  are  suited  to  the  stage  of  fully  developed  inflammation, 
when  there  is  a  great  deal  of  swelling  due  to  effusion  and  cell-proliferation. 
The  indication  in  this  stage  is  to  abate  swelling  by  promoting  absorption. 
This  is  accomplished  by  (i)  compression;  (2)  local  use  of  astringents  and 
sorbefacients;  (3)  the  douche;  (4)  massage;  (5)  heat. 

Compression  is  especially  beneficial  in  fully  developed  or  in  chronic  in- 
flammation, but  it  will  do  good  even  in  the  early  stages.  Compression  is 
of  great  usefulness;  it  supports  the  vessels  and  causes  them  to  drink  up  ef- 
fusion, and  it  strongly  rouses  the  absorbents.  This  agent  is  valuable  in 
most  external  inflammations  with  marked  swelling,  and  is  particularly  bene- 
ficial in  chronic  inflamniation.  In  erysipelas  of  an  extremity  the  part  should 
be  elevated  and  the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use  of  Martin's  elastic 
bandage  or  of  straps  of  adhesive  plaster  gives  decided  relief.  In  chronic  in- 
flammation of  a  joint  elastic  compression  is  of  great  value.  In  epididymitis, 
after  the  acute  stage,  the  testicle  may  be  strapped  with  adhesive  plaster.  In 
lymphadenitis  compression  by  a  weight  or  by  a  bandage  is  very  generally 
employed.  In  fractures  compression  not  only  antagonizes  spasm,  but  also 
combats  the  swelling  and  pain  of  inflammation.  Compression  must  be  judi- 
cious; it  must  never  be  forcible,  and  it  must  not  be  applied  to  a  limb  without 
including  the  distal  portion  of  the  extremity  (never,  for  instance,  strongly 
compress  the  elbow  without  including  the  hand,  nor  the  palm  without  band- 
aging the  fingers).  Injudicious  compression  causes  severe  pain  and  great 
edema,  and  may  produce  gangrene. 

Astringents  and  Sorbefacients. — Astringents  may  have  direct  value  in 
inflammation  of  the  skin,  but  it  is  not  likely  that  they  have  any  effect  on  deep- 
seated  inflammation.  When  used  in  evaporating  lotions  in  an  earlier  stage 
of  inflammation  the  cold  does  good  rather  than  the  drug.  Lead-water  and 
laudanum  is  extensively  employed  and  it  is  thought  to  somewhat  aUay  in- 
flammatory pain.  The  mixture  certainly  gives  comfort  in  cutaneous  erysipelas. 
It  is  very  doubtful  if  lead-water  is  of  any  service  at  any  stage  of  a  deep-seated 
inflammation  or  in  any  fully  developed  inflammation.  If  used  after  the  first 
stage  it  must  not  be  applied  as  an  evaporating  lotion,  because  cold  will  do 
harm.  Pieces  of  lint  are  soaked  in  the  fluid  and  placed  upon  the  part,  and  a 
bandage  is  applied.  The  wet  lint  which  has  been  placed  upon  the  part  is  cov- 
ered with  ofled  silk  or  a  rubber-dam  before  the  bandage  is  applied.  If  used  in 
the  latter  manner,  the  body-heat  is  retained  in  the  part.  If  greater  heat  is 
required,  a  hot- water  bag  can  be  placed  outside  of  the  bandage.  Lead-water, 
though  germicidal,  is  seldom  used  in  treating  wounds,  and  hot  lead-water 
should  not  be  applied  to  an  area  of  cutaneous  inflammation,  as  heat  increases 
congestion  and  does  harm  to  a  cutaneous  inflammation. 

Saturated  watery  solution  of  Epsom  salt  is  of  real  value  in  inflammation. 
It  is  applied  as  a  wet  compress  covered  with  rubber-dam.  It  is  moistened 
every  two  or  three  hours  and  renewed  in  twenty-four  hours,  the  skin  being 
washed  at  the  time  of  renewal.  In  many  cases  it  allays  pain  and  abates  swell- 
ing. Its  use  was  suggested  by  Tucker  ("Jour.  Experimental  Med.,"  May  25, 
1907). 


Astringents  and  Sorbefacients  loi 

Tincture  of  iodin  is  astringent,  sorbefacient,  counterirritant,  and  germicidal. 
It  must  not  be  used  pure.  For  application  to  adults  it  should  be  diluted  with 
an  equal  amount  of  alcohol,  and  for  children  with  3  parts  of  alcohol.  In  using 
iodin,  paint  it  upon  the  part  with  a  camels'-hair  brush  and  fan  it  dry,  applying 
one  or  more  coats.  The  repeated  application  of  iodin  to  the  skin  is  of  great 
benefit  in  inflammation  of  the  glands,  muscles,  tendons,  joints,  and  perios- 
teum. Iodin  is  apt,  after  a  time,  to  vesicate,  and  must  not  be  used  in  full 
strength,  because  it  is  irritant.  It  is  of  special  value  in  chronic  inflammation. 
In  deep-seated  inflammation  it  acts  as  a  counterirritant. 

Xitrate  of  silver  is  a  non-irritating  astringent  of  considerable  value  in 
inflammation  of  mucous  membranes.  It  forms  a  protective  coat  of  coagulated 
albumin,  and  is  much  used  in  treating  the  throat,  mouth,  and  genital  organs. 
In  urethral  inflammation  a  protein  compound  of  silver  known  as  protargol 
may  be  used. 

IchUiyoI  is  a  drug  of  decided  efiiciency  in  reducing  inflammatory  swelling. 
It  is  usuaUy  employed  in  ointments,  the  strength  being  from  25  to  50  per  cent. 
It  is  best  exhibited  with  lanolin.  When  rubbed  in  over  inflamed  glands, 
joints,  and  h-mphatic  enlargements,  it  is  of  great  value.  In  children  a  25  per 
cent.,  and  in  adults  a  50  per  cent.,  ointment  should  be  rubbed  in  thoroughly 
twice  a  day.  In  inflammatory'  skin  disease,  syno\atis,  thecitis,  frost-bite, 
bubo,  chilblam,  and  in  many  other  conditions,  acute  or  chronic,  the  use  of 
ichthyol  is  indicated.  The  odor  of  ichthyol  is  highly  disagreeable,  and  when 
ordered  for  a  refined  person  it  had  better  be  deodorized.  For  this  purpose 
Hare  uses  oil  of  citronella,  20  minims  to  i  oz.  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various  strengths,  is  ex- 
tremely valuable.  It  is  spread  upon  lint  and  kept  appUed  over  areas  of  fully 
developed  mflammation.  It  is  especially  useful  in  acutely  or  chronically 
inflamed  joints,  glands,  tendons,  etc.  Blue  ointment  is  strongly  irritant,  and 
will  soon  bhster  or  excoriate  a  tender  skin.  It  is  very  beneficial  in  periostitis, 
and  is  employed  by  many  surgeons  in  chronic  inflammations. 

The  douche  consists  of  a  stream  of  water  falling  upon  a  part  from  a  height. 
The  water  may  be  poured  from  a  receptacle  or  may  run  through  a  tube,  and 
may  be  either  hot  or  cold.  Alternating  hot  and  cold  streams  are  very  popular 
in  inflammations  of  joints  and  tendons,  especially  in  chronic  inflammation. 
This  mode  of  application  is  known  as  the  "Scotch  douche."  It  restores  the 
tone  of  the  blood-vessels  and  plasma-channels  and  promotes  the  absorption  of 
inflammatory-  exudate.  If  the  part  is  very  tender,  the  water  should  be  squeezed 
upon  it  froni  sponges.  In  a  sprain  of  a  joint,  after  a  tune,  when  thickening 
has  occiu-red,  pour  upon  the  part  daily,  from  a  height,  first  a  pitcherful  of 
ver\'  warm  water,  then  a  pitcherful  of  Y&ry  cold  water;  then  dry  the  part  and 
use'  friction  with  a  hand  greased  with  cosmoHn.  Hot  vaginal  douches  are 
generally  employed  in  pehac  inflammations. 

Massage  is  a  procedure  not  employed  frequently  enough.  It  is  ver\-  useful 
in  some  acute  inflammations,  though  in  these  it  must  be  gentle.  It  is  of  great 
ser\dce  in  the  treatment  of  sprains  of  joints  and  fractures  of  bones.  It  is  in- 
fluential for  good  in  chronic  inflammations  at  the  period  when  rest  is  aban- 
doned. It  acts  by  promoting  the  movements  of  tissue-fluids  (blood,  h-mph, 
and  areolar  fluid)',  stimulating  the  absorbents,  strengthening  local  nervous 
control,  and  thus  impro\-ing  nutrition.  Passive  motion  in  jomts  acts  as 
massage. 

Heat  may  be  used  continuously  or  mtermittently,  and  may  be  either 
moist  or  dry.  A  considerable  degree  of  heat  vr^\  act  like  cold  and  contract 
the  vessels. '  The  degree  necessars^  to  cause  vascular  contraction  ^TOuld  not 
destroy  the  tissue,  but  would  produce  discomfort,  which  discomfort  would 
becom'e  unbearable  during  the  continuance  of  the  application.     Therefore, 


I02  Inflammation 

heat  is  rarely  used  in  the  earliest  stage  of  an  acute  inflammation.  It  is  hard 
to  state  exactly  when  heat  should  be  substituted  for  cold.  Certainly  when 
retardation  and  stasis  are  manifest  it  is  to  be  preferred.  Moderate  heat 
should  be  used  when  inflammation  is  not  very  superficial.  In  a  cutaneous  in- 
flammation heat  usually  does  harm,  because  it  increases  the  congestion  of  an 
inflamed  superficial  part.  In  deep-seated  inflammations  heat  to  the  surface 
acts  as  a  revulsive  or  counterirritant.  Thus  a  poultice  to  the  chest  may  do 
good  in  the  first  stage  of  pneumonia,  and  cauterization  of  the  skin  near  a  joint 
may  benefit  an  acute  synovitis.  The  use  of  heat  for  purposes  of  counterirrita- 
tion  will  be  discussed  under  the  head  of  Counterirritants.  A  moderate  de- 
gree of  heat  applied  over  a  fully  developed  and  not  too  superficial  inflamed 
area  dilates  the  vessels,  especially  the  veins,  of  the  skin  and  superficial  tissues. 
Thus  circulation  is  re-estabUshed  in  an  area  fiUed  with  stagnant  blood  or 
blood  which  is  scarcely  moving  and  the  inflamed  region  is  drained,  fluid  exu- 
date is  absorbed,  tension  is  lessened,  the  lymph-spaces  and  vessels  distend, 
and  lymphatic  absorption  becomes  active.  The  application  of  heat  increases 
the  ameboid  activity  and  the  migratory  tendency  of  the  leukocytes,  phago- 
cytes gather  in  great  numbers  and  surround  an  area  of  infection,  and  those 
which  have  taken  up  bacteria  or  tissue  debris  hurry  aw^ay.  Heat  also,  in  all 
probability,  causes  antibodies  to  escape  from  the  leukocytes  and  enter  the 
blood-serum.  Furthermore,  heat  favors  leukocytosis.  Thus,  we  see,  that  heat 
tends  to  help  the  building  of  protective  barriers  about  an  area  of  infection  and 
aids  the  protective  reactions  of  the  body.  Heat  notably  lessens  the  pain  of 
inflammation.     It  is  often  used  purely  to  relieve  pain. 

The  forms  of  heat  are — (i)  fomentations;  (2)  poultices;  (3)  water-bath; 
(4)  dry  heat. 

Fomentation  is  the  application  to  the  skin  of  a  piece  of  flannel  containing 
a  hot  liquid.  A  basin  is  warmed  and  over  the  top  of  the  basin  a  towel  is  placed. 
A  piece  of  flannel  folded  in  two  or  three  thicknesses  is  laid  upon  the  towel  and 
boiling  water  is  poured  upon  it.  By  twisting  the  towel  the  water  is  squeezed 
out  of  the  flannel.  Great  care  must  be  taken  to  squeeze  the  water  thoroughly 
out  of  the  flannel,  otherwise  the  skin  may  be  scalded.  The  hot  flannel  is  laid 
upon  the  skin  over  the  disordered  part.  A  rubber-dam  larger  than  the  flannel 
is  placed  over  it,  a  mass  of  cotton  is  laid  upon  the  rubber-dam,  and  a  bandage 
is  applied.  The  fomentation  must  be  changed  within  an  hour  unless  a  hot- 
water  bag  has  been  placed  outside  the  bandage,  in  which  case  it  need  not  be 
changed  for  two  hours  or  more.  The  flannel  which  is  dipped  into  the  hot 
liquid  is  known  as  a  "stupe."  The  turpentine  stupe  is  made  by  wringing  out 
the  flannel  as  above  and  then  putting  upon  it  from  10  to  20  drops  of  turpentine. 
Instead  of  fomenting  the  part,  steam  may  be  thrown  upon  it.  Fomentations 
are  used  chiefly  for  their  reflex  influence  over  deep  congestions  or  inflamma- 
tions. The  liquid  of  a  fomentation  may,  if  desired,  contain  corrosive  sublimate, 
carbolic  acid,  or  other  agents.  A  fomentation  containing  an  antiseptic  is 
known  as  an  antiseptic  fomentation.  An  antiseptic  fomentation  or,  as  it  is  often 
called,  an  antiseptic  poultice  is  made  and  applied  as  follows:  Gauze  is  used 
instead  of  flannel,  and  is  laid  upon  the  towel  over  the  basin  as  previously  de- 
scribed. A  very  warm  solution  of  corrosive  sublimate  (1:1000)  of  concen- 
trated boric  acid  solution,  or  a  2  per  cent,  solution  of  acetate  of  aluminimi,  is 
poured  upon  the  gauze,  the  material  is  partly  wrung  out,  placed  upon  the  part, 
covered  with  a  rubber-dam,  and  upon  it  a  hot-water  bag  is  placed.  Fomenta- 
tions are  very  useful  in  relieving  pain  in  any  stage  of  an  inflammation  and  act 
also  as  counterirritants.  Fomentations  are  used  in  preference  to  ordinary 
poultices  if  there  is  any  probability  of  a  surgical  operation  becoming  neces- 
sary, because  skin  to  which  an  old-fashioned  poultice  has  been  apphed  cannot 
be  satisfactorfly  sterilized.    The  antiseptic  fomentation  is  of  great  service  in 


Heat  in  Treatment  of  Inflammation  103 

removing  sloughs  from  foul  wounds  and  ulcers.  It  is  the  only  form  of  poultice 
which  is  admissible  when  the  skin  is  broken. 

Poultice  or  Cataplasm. — ^A  poultice  is  a  soft  mass  apphed  to  a  part  to  bring 
heat  and  moisture  to  bear  upon  it.  Poultices  can  be  made  of  ground  flaxseed, 
of  sUpper>--elm  bark,  of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips, 
etc.  The  poultice  should  be  placed  upon  the  part  and  be  covered  outside  with 
oiled  silk,  a  rubber-dam,  or  waxed  paper.  A  mass  of  cotton  is  apphed  outside 
of  the  rubber  and  the  poultice  is  held  in  place  by  a  bandage  or  binder.  It  can 
be  kept  xexy  warm  for  a  considerable  period  by  placing  upon  it  a  bag  filled 
with  hot  water.  If  a  hot-water  bag  is  not  employed,  a  poultice  should  be 
changed  even,-  two  hours.  Spongiopflin,  when  moistened  with  hot  water,  is  a 
good  substitute  poultice.  Lint  soaked  with  hot  water  and  covered  with  some 
impermeable  material  does  ver\"  well.  A  poultice  containing  opium  is  known  as 
a  "sedative""  poultice.  About  2  gr.  of  opium  to  the  ounce  of  poultice-mass 
may  reheve  pain.  Flaxseed  is  a  vegetable  material,  adheres  to  the  skin,  enters 
the  mouths  of  glands  and  foUicles.  undergoes  decay,  can  be  removed  only  with 
great  difficulty,  and  is  a  ver\"  objectionable  material  to  use  if  there  is  any 
breach  of  surface  continuity  or  if  it  is  possible  that  an  incision  will  be  required. 
The  preparation  of  an  antiseptic  poultice  or  fomentation  is  described  above. 
Poultices  must  not  be  kept  on  the  part  too  long,  as  they  will  cause  vesication, 
especially  in  ad}Tiamic  conditions.  If  a  poultice  is  causing  vesication,  remove 
it  and  do  not  replace  it,  or  replace  it  after  sprinkling  the  part  and  the  poultice 
with  powdered  oxid  of  ziuc.  If  suppuration  exists  or  is  seriously  threatened, 
do  not  waste  time  by  using  poultices,  but  incise  at  once.  Incision  may  pre- 
vent suppuration  by  relieAiiig  tension,  affording  drainage,  and  permitting  the 
local  use  of  antiseptics.  If  pus  exists,  it  cannot  be  evacuated  too  soon.  To 
iise  poultices  and  delay  incision  is  often  productive  of  irreparable  harm.  After 
incision  of  a  purulent  focus  it  is  common  practice  to  apply  an  antiseptic  fomen- 
tation in  order  to  draw  quantities  of  leukoc\-tes  to  the  part  and  thus  limit  the 
spread  of  infection  and  stimulate  granulation. 

Hot-water  Bath. — The  continuous  warm  bath  is  now  rarely  employed  except 
in  bums  and  cases  of  phagedena,  when  it  often  proves  curative.  In  these 
cases  an  antiseptic  agent  may  be  dissolved  in  the  water.  Continuous  immer- 
sion in  a  warm  bath  is  regarded  favorably  by  some  surgeons  for  the  treatment 
of  sloughing  wounds  and  large  purulent  areas.  The  immersion  of  a  part 
from  time  to  time  in  water  as  hot  as  can  be  tolerated  is  useful  in  fuUy  developed 
and  in  chronic  inflammation.  Such  immersion  benefits  an  inflamed  joint, 
lessening  the  pain,  swelling,  and  stiffness. 

Dry  heat  is  applied  by  a  metalhc  object  dipped  in  hot  water  and  laid  upon 
the  part;  by  Leiter's  tubes,  through  which  hot  water  flows:  by  the  hot- water 
bag  or  by  the  hot-air  apparatus.  Some  surgeons  use  the  hot-water  bag  m. 
cases  of  mild  appendicitis  in  order  to  favor  the  limitation  of  the  area  of  infec- 
tion. The  hot-water  bag  is  often  soothing  and  beneficial  when  laid  upon  an 
inflamed  joint,  or  on  the  perineum  or  the  h>"pogastric  region  in  c\-stitis.  A 
bag  of  hot  sand,  a  hot  brick,  or  a  bottle  or  can  of  hot  water  may  be  used  in- 
stead of  the  water-bag.  The  hot-air  apparatus  is  of  ver}-  great  service  in  the 
treatment  of  chronic  inflammation,  and  particularly  of  inflamed  joints  {vide 
dry  hot-air  apparatus). 

Treatment  When  Suppuration  is  Threatened. — When  suppuration  is  threat- 
ened, ordinarily  hot  fomentations  or  antiseptic  fomentations  must  be  tised, 
and  the  part  must  be  kept  at  rest.  As  previously  explained,  the  flaxseed 
poultice  is  inadmissible.  VkTien  suppuration  is  threatened,  the  use  of  heat 
causes  the  coUection  of  multitudes  of  leukoc\-tes.  which  tend  to  limit  the  area 
of  infection  and  destroy  bacteria.  Even  when  suppuration  is  not  prevented, 
heat  aids  in  the  rapid  breaking  down  of  the  diseased  tissue  at  the  focus  of 


104  Inflammation 

the  inflammation  and  causes  hordes  of  leukocytes  to  gather  and  encompass  the 
suppurating  tissue,  and  these  leukocytes  prevent  the  spread  of  the  infection. 

In  most  cases,  when  suppuration  is  obviously  inevitable  or  seriously 
threatened,  a  free  incision  will  be  of  greatest  benefit. 

Irritants  and  Counterirritants  in  Inflammation. — Irritants  attract  an 
increased  supply  of  blood  to  the  part  whereon  they  are  applied,  and  are  used 
for  their  local  effects.  Counterirritants  are  used  to  affect  by  reflex  influence 
some  distant  part.  In  chronic  inflammation  irritants  may  do  good  by  pro- 
moting the  blood-supply,  thus  favoring  the  removal  of  exudates  (liniment 
for  rheumatism  and  synovitis,  and  nitrate  of  silver  for  ulcers).  Counter- 
irritants  are  powerful  pain-relievers  when  used  over  an  inflamed  structure; 
they  bring  blood  to  the  surface,  and  are  thought  by  many  writers  to  cause 
anemia  of  internal  parts,  the  site  and  area  of  anemia  depending  on  the  site, 
the  area,  and  the  duration  of  the  surface  irritation.  Some  recent  studies  seem 
to  suggest  that  counterirritation  produces  hyperemia  of  the  superficial  part, 
compensatory  anemia  of  surrounding  regions,  and  anemic  edema  of  the  sub- 
cutaneous tissue  and  muscles  (W.  Wecksberg,  "Zeit.  f.  klin.  Med.,"  Bd. 
xxxvii,  H.  3  u.  4).  Nancrede  dissents  from  the  statement  that  counterirritants 
cause  anemia  of  internal  parts ;  and  he  maintains  that  they  irritate  deeper  parts 
and  cause  more  external  blood  to  be  taken  to  them.  He  claims  that  a  blister 
applied  to  the  chest  produces  a  hyperemic  area  in  the  pleura,  and  refers  to 
Furneaux  Jordan's  opinion  that  direct  irritation  to  the  surface  over  a  joint 
adds  to  synovial  hyperemia,  and  that  consequently  in  joint  inflammation 
counterirritants  should  be  applied  above  and  below  a  joint,  but  not  directly 
over  it.  As  a  matter  of  fact,  we  know  clinically  that  powerful  counterirritation 
directly  over  an  inflamed  superficial  joint  is  occasionally  followed  by  an  aggra- 
vation of  the  trouble,  and  that  in  pericarditis  blistering  directly  over  the  peri- 
cardium may,  as  pointed  out  by  Brunton,  make  the  condition  worse.  Coun- 
terirritants not  only  relieve  pain  in  the  earlier  stages  of  inflammation,  but  they 
also  promote  absorption  of  exudate  in  the  later  stages,  and  are  particularly 
valuable  in  chronic  inflammations.  Great  benefit  is  obtained  by  bhstering 
old  thickened  ulcers,  and  by  painting  the  chest  with  iodin  to  relieve  pleuritic 
effusion.  Frictions,  besides  their  pressure  effects,  act  as  counterirritants. 
Frictions  may  relieve  skin  pain,  and  are  associated  with  the  application  of 
stimulating  liniments  in  the  treatment  of  stiff  joints.  A  mustard  plaster  is  a 
valuable  coimterirritant  in  an  acute  deeply  seated  inflammation.  Tincture 
of  iodin  is  extensively  used  in  chronic  inflammation. 

There  is  no  more  efificient  method  of  relieving  pleural  effusion  than  by 
the  application  of  a  succession  of  blisters.  Blisters  are  also  used  in  the  treat- 
ment of  inflamed  joints,  pericarditis,  pneumonic  consolidation  of  the  lung, 
acute  and  chronic  rheumatism,  etc. ;  and  are  applied  back  of  the  ears  or  at  the 
nape  of  the  neck  in  congestive  coma  or  meningitis.  A  blister  can  be  produced 
in  a  few  minutes  by  soaking  a  bit  of  lint  in  chloroform,  and  after  applying  it 
to  the  surface,  covering  it  with  oiled  silk  or  with  a  watch-glass.  Equal  parts 
of  lard  and  ammonia  will  blister  in  five  minutes.  It  is  easier  to  bHster  with 
cantharidal  collodion  or  bhstering  paper.  Before  applying  a  blister,  shave 
the  part  if  it  be  hairy;  then  grease  the  plaster  with  olive  oil  and  apply  it. 
Blistering  plaster  is  left  in  place  six  hours  in  the  case  of  an  adult,  but  only  two 
hours  in  the  case  of  an  old  person  or  a  child;  the  plaster  is  then  removed,  and 
if  a  blister  has  not  formed,  the  part  must  be  poulticed  for  a  few  hours.  When 
a  blister  is  obtained,  open  it  with  a  needle  which  has  been  dipped  in  boiling 
water.  If  the  surgeon  wishes  the  blister  to  heal,  it  should  be  covered  with  a 
piece  of  lint  smeared  with  cosmolin  or  with  zinc  ointment.  If  it  is  to  be  kept 
open  for  a  time,  cut  away  the  stratum  corneum  and  dress  with  cosmohn,  each 
ounce  of  which  contains  6  drops  of  nitric  acid. 


General  Bleeding,  Venesection,  or  Phlebotomy  105 

Pustulation  can  be  effected  with  tartar-emetic  ointment  or  with  Vienna 
paste.  Tartar-emetic  ointment  was  formerly  used  on  the  scalp  in  meningitis. 
Vienna  paste  consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime  made  into 
a  paste  with  alcohol.  It  is  applied  for  five  minutes,  and  is  then  washed  off 
with  vinegar. 

The  actual  cautery  is  the  most  powerful  of  counterirritants.  It  is  chiefly  used 
in  chronic  inflammation  of  joints,  bone,  nerves,  and  the  spinal  cord.  The  appli- 
cation is,  of  course,  very  painful,  and  it  is  best  to  give  an  anesthetic  before  using 
the  cautery.  The  Paquelin  cautery  is  the  instrument  used.  This  is  a  hollow 
platinum  point  which,  after  being  heated  in  the  flame  of  an  alcohol  lamp,  is  kept 
hot  by  forcing  through  it  the  vapor  of  gasolene  (Fig.  226).  The  point  is  used 
at  a  white  heat.  One  area  or  several  may  be  seared.  The  cautery  is  drawn 
lightly  two  or  three  times  over  each  spot  we  wish  to  burn.  The  object  is  to 
destroy  only  the  superficial  layers  of  the  skin.  After  the  cauterization  is  com- 
pleted, lint  wet  with  iced  water  is  applied  for  several  hours  to  allay  pain,  and 
then  hot  antiseptic  fomentations  are  used  until  the  slough  separates. 

If  the  wish  is  to  prevent  healing  after  separation  of  the  slough,  dress  the  sore 
with  cosmolin,  each  ounce  of  which  contains  6  drops  of  nitric  acid.  It  is  not 
wise  to  cauterize  deeply  directly  over  a  superficial  joint. 

Constitutional  Treatment  of  Inflammation. — Certain  remedies  are  used 
in  inflammation  for  their  general  or  constitutional  effects;  these  remedies 
are — (i)  general  bleeding;  (2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphor- 
etics; (5)  diuretics;  (6)  anodynes;  (7)  antipyretics;  (8)  emetics;  (9)  mercury 
and  iodids;  (10)  stimulants;  (11)  tonics. 

General  Bleeding,  Venesection,  or  Phlebotomy, — Venesection  is  suited 
to  the  early  stages  of  an  acute  inflammation  in  a  young  and  robust  subject. 
The  indication  for  its  employment  is  increased  arterial  tension,  as  shown  by  a 
strong,  full,  rapid,  and  incompressible  pulse  in  a  vigorous  young  patient. 
General  blood-letting  diminishes  blood-pressure  and  increases  the  speed  of  the 
blood-current,  thus  amends  stasis,  causes  the  absorption  of  exudate,  and  the 
washing  of  adherent  white  corpuscles  from  the  vessel  waU;  furthermore,  it 
reduces  the  whole  amount  of  body  blood  and  thus  forces  a  greater  rapidity  of 
circulation,  decreases  the  amount  of  fibrin  and  albumin,  lowers  the  tempera- 
ture, arrests  cell-proliferation,  and  stops  effusion. 

This  procedure  was  in  former  days  so  highly  esteemed  that  it  settled  into 
a  routine  formula  to  be  applied  to  every  condition  from  yellow  fever  to  dislo- 
cation. The  terrible  mortality  of  the  cholera  epidemics  from  1830  to  1835. 
led  practitioners  to  question  the  belief  that  bleeding  was  a  general  panacea, 
and  from  this  doubt  there  was  born  in  the  next  generation  violent  opposition 
to  blood-letting  in  any  disease.  Like  most  reactions,  opposition  has  gone  too 
far,  the  pendulum  of  condemnation  has  swung  beyond  the  line  of  truth  and 
sense,  and  thus  is  universally  neglected  or  broadly  condemned  a  powerful  and 
valuable  resource.  Many  physicians  of  long  experience  have  never  seen  a 
person  bled;  its  performance  is  not  demonstrated  in  most  schools,  and  but 
few  patients  and  families  will  permit  it  to  be  done;  but  when  properly  used 
it  is  occasionally  beneficial.  It  is  applicable,  however,  only  to  the  young, 
strong,  and  robust,  and  not  to  the  old,  weak,  or  feeble.  It  is  used  for  violent 
acute  inflammations  of  important  organs  or  tissues,  and  not  for  low  inflam- 
mations or  for  slight  affections  of  unimportant  parts.  It  is  used  in  the  early, 
but  not  in  the  late,  stages  of  an  inflammation.  It  is  used  when  the  pulse  is 
frequent,  full,  hard,  and  incompressible,  but  not  when  it  is  slow,  small,  soft, 
compressible,  and  irregular.  It  is  used  when  the  face  is  flushed,  but  not  when 
it  is  palHd.  It  is  not  used  in  fat  persons,  drunkards,  very  nervous  people,  or 
the  sufferers  from  adynamic,  septic,  or  epidemic  diseases.  It  is  of  value  in 
some  few  cases  of  congestion  of  the  lungs,  pneumonitis,  pleuritis,  meningitis, 


io6  Inflammation 

prostatitis,  cystitis,  and  other  acute  inflammatory  conditions.  It  is  particularly 
valuable  in  any  subject  when  uremia  exists,  or  when  there  is  distention  of 
the  right  side  of  the  heart.    The  method  of  bleeding  is  described  on  page  462. 

After  bleeding  the  patient  should  be  put  on  arterial  sedatives,  diuretics, 
diaphoretics,  anodynes,  and,  if  necessary,  purgatives.  A  favorite  mixture  of 
Prof.  S.  D.  Gross  was  the  antimonial  and  saline,  40  gr.  of  Epsom  salt,  -^  gr. 
of  tartar  emetic,  2  drops  of  tincture  of  aconite,  and  i  dram  of  sweet  spirits  of 
niter,  in  enough  ginger  syrup  and  water  to  make  h  oz. ;  given  every  four  hours. 

Arterial  Sedatives. — Drugs  of  this  character  are  of  great  use  before  stasis 
is  pronounced;  but  if  used  after  stasis  is  established  they  will  increase  it.  If 
stasis  exists  it  may  be  relieved  by  blood-letting,  local  or  general,  and  then 
arterial  sedatives  can  be  given.  Either  local  bleeding  or  venesection  abolishes 
stasis  and  lowers  tension,  and  arterial  sedatives  maintain  the  effect  and  hold 
the  ground  which  is  gained.  The  arterial  sedatives  employed  are  aconite, 
veratrum  viride,  gelsemiimi,  and  tartar  emetic.  These  sedatives  lessen  the 
force  and  the  frequency  of  the  heart-beats,  and  thus  slow  and  soften  the  pulse, 
and  are  suited  to  a  robust  person  with  an  acute  inflammation,  but  are  not 
suited  to  a  weak  individual  in  an  adynamic  state. 

Aconite  is  given  in  smaU  doses,  never  in  large  amounts.  One  drop  of 
the  tincture  in  a  little  water  is  given  every  half  hour  until  its  effect  is  manifest 
on  the  pulse,  when  it  may  be  given  every  two  or  three  hours.  Large  doses 
of  aconite  produce  pronounced  depression,  and  are  dangerous.  Aconite 
lowers  the  temperature,  slows  the  pulse,  and  produces  diaphoresis. 

Veratrum  viride  is  a  powerful  agent  to  slow  the  pulse  and  to  lower  blood- 
pressure;  it  produces  moisture  of  the  skin,  and  often  nausea.  It  is  given  in 
i-drop  doses  of  the  tincture  every  half  hour  until  its  physiologic  effects  are 
manifested,  when  the  period  between  doses  is  extended  to  two  or  three  hours. 
Ten  drops  of  laudanum  given  a  quarter  of  an  hour  before  each  dose  of  vera- 
trum viride  will  prevent  nausea. 

Gelsemium  is  an  arterial  sedative.  It  is  given  in  doses  of  5  to  10  drops  of  the 
tincture  ever}^  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse-rate.  This 
drug  is  not  generaUy  employed;  if  it  is  used  with  the  greatest  care  it  is  no 
better  than  some  other  agents,  and  if  it  is  not  so  used  it  will  cause  dangerous 
depression.  The  dose  is  from  -^  to  y-Q  gr.,  given  in  water  every  three  hours 
imtil  the  physiological  effects  are  manifest. 

Cathartics. — Purgation  is  of  great  value  in  inflammation.  By  it  putrid 
material  is  removed  from  the  intestine,  fluid  containing  poisonous  elements 
is  drawn  from  the  blood,  and  the  Lability  to  infection  of  the  tissues  is  lessened. 
Purgation  is  a  powerful  aid  in  removing  serous  effusions  and  other  exudates. 
The  administration  of  purgatives  is,  of  course,  not  to  be  a  routine  procedure 
in  inflammatory  states.  The  bowels  may  be  acting  so  freely  that  no  cathartic 
is  required.  Treatment  in  an  inflammation  should  be  inaugurated,  if  con- 
stipation exists,  by  giving  a  cathartic.  The  tongue  affords  important  indica- 
tions as  to  the  necessity  for  purgation.  Castor  oil  can  be  given  in  capsules, 
or  in  the  froth  of  beer,  or  the  juice  of  half  a  lemon  is  squeezed  into  a  tumbler, 
I  oz.  of  oil  poured  in,  and  the  rest  of  the  lemon  is  squeezed  on  top,  thus  making 
a  not  unpalatable  mixture.  Aloin,  podophyllum,  the  salines,  and  calomel  in 
3-  or  5-gr.  doses,  followed  by  a  saline,  have  their  advocates.  In  threat- 
ened peritonitis  the  salines  are  used  by  some  surgeons,  a.  teaspoonful  of  Epsom 
salt  and  a  teaspoonful  of  RocheUe  salt  being  given  hourly  untfl  a  movement 
occurs.  In  this  condition,  however,  purging  may  prove  disastrous.  In  the 
course  of  inflammation,  from  time  to  time,  if  there  be  constipation,  a  coated 
tongue,  and  foiflness  of  the  breath,  there  should  be  ordered  i  gr.  of  calomel 
with  24  gr.  of  bicarbonate  of  sodium,  made  into  twelve  powders,  one  being  given 


Antipyretics  107 

every  hour;  if  the  bowels  are  not  moved  by  the  time  the  powders  are  all  taken, 
a  saline  should  be  given.  If  a  violent  purgative  effect  is  desired,  as  in  menin- 
gitis, croton  oil  or  elaterium  may  be  ordered.  If  constipation  is  persistent,  give 
lluidextract  of  cascara  sagrada  daily  (20  to  40  drops),  or  a  pill  at  night  contain- 
ing i  gr.  of  extract  of  belladonna,  I  gr.  of  extract  of  nux  vomica,  y^  gr.  of  aloin, 
I  gr.  of  extract  of  physostigma,  and  h  drop  of  oil  of  cajuput.  Enemas  or  clysters 
may  be  used  in  some  cases.  A  very  useful  enema  is  composed  of  i  fl.oz.  of 
oil  of  turpentine,  i^  fl.oz.  of  olive  oil,  ^  fl.oz.  of  mucilage  of  acacia,  in  10  fl.oz. 
of  water.  Soap  and  turpentine  is  very  satisfactory.  Soapsuds  and  vinegar  in 
equal  parts  make  a  serviceable  clyster.  A  combination  of  oil  of  turpentine, 
castor  oil,  the  yolk  of  an  egg,  and  water  can  be  used.  Asafetida,  30  gr.  to  the 
yolk  of  I  egg,  makes  a  good  enema  to  amend  flatulence.  An  ounce  of  alum  in  i 
quart  of  water  is  valuable  for  the  same  purpose. 

Diaphoretics. — These  agents  are  very  useful.  A  profuse  sweat  removes 
much  toxic  material  from  the  blood  and  in  the  beginning  of  an  acute  inflam- 
mation, such  as  tonsillitis,  may  abort  the  disease.  Dover's  powder  is  commonly 
used,  but  pilocarpin  is  preferred  by  some.  Camphor  in  doses  of  from  i  to 
5  gr.  is  diaphoretic,  and  so  are  antimony  and  ipecac.  Acetate  and  citrate 
of  ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the  surface  (baths,  hot  bricks, 
hot-water  bags),  serpentaria,  and  guaiac  are  diaphoretic  agents. 

Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and  high-colored, 
and  are  valuable  aids  in  removing  serous  effusions  and  other  exudates. 
Among  the  diuretics  may  be  mentioned  calomel  in  repeated  large  doses, 
cocain,  alcohol,  infusion  of  digitalis,  the  nitrites,  squill,  tiupentine,  copaiba, 
and  cantharides.  The  liquor  potass^  and  the  acetate  of  potassium  are  the 
best  agents  to  increase  the  solids  in  the  urine.  The  liquor  potassii  citratis 
in  doses  of  i  to  4  fl.dr.  is  efficient.  Large  drafts  of  water  wash  out  the 
kidneys.  If  the  heart  is  weak,  citrate  of  caffein  is  a  good  stimulant  diu- 
retic, and  hot  coffee  is  very  serviceable  in  promoting  the  secretion  of  urine. 
The  injection  of  hot  salt  solution  into  the  rectiun  and  under  the  skin  favors 
diuresis,  and  the  intravenous  infusion  of  salt  solution  is  a  very  powerful  diuretic 
(see  page  465).  The  application  of  heat  to  the  loins  promotes  the  secretion  of 
urine.  Sodiotheobromin  salicylate  (diuretin)  is  an  uncertain  but  often  valuable 
diiuretic,  in  doses  of  10  gr.,  every  two  or  three  hours. 

Anodynes  and  Hypnotics. — Drugs  may  be  required  to  aUay  pain  or  procure 
sleep.  Dover's  powder,  besides  being  diaphoretic,  is  anodyne.  Opium  acts  well 
after  bleeding  or  purgation.  If  it  causes  nausea,  it  should  be  preceded  one  hour 
by  the  administration  of  30  gr.  of  bromid  of  potassiimi.  Opium  is  given  by 
the  mouth  or  by  the  rectimi.  Morphin  is  given  by  the  mouth  or  hypodermatic- 
ally.  Opium  is  used  when  there  is  pain,  but  its  use  is  not  to  be  long  persisted 
in  if  it  can  be  avoided.  It  is  given  in  doses  measured  purely  by  the  necessities 
of  the  case.  If  opiiun  disagrees,  try  the  combination  of  morphin  with  atropin. 
After  an  operation  antipyrin  or  phenacetin  will  often  quiet  pain  and  secure  sleep. 
When  a  person  feels  "so  tired  he  can't  sleep,"  alcohol  in  the  form  of  whisky 
or  brandy  must  be  given.  Sleeplessness  not  due  to  pain  is  met  by  chloral, 
trional,  veronal,  the  bromids,  or  sulphonal.  Chloral  is  dangerous  in  conditions 
of  weak  heart  or  exhaustion.  Bromids  must  be  given  m  large  doses  to  be 
efficient.  Sulphonal  must  be  given  about  four  or  five  hours  before  sleep  is 
expected,  in  doses  of  from  10  to  20  gr.  in  hot  mOk  or  hot  mint-water.  Trional 
is  safe  and  ver)^  satisfactory.    It  is  given  in  doses  of  15  to  25  gr.  in  hot  water. 

Antipjn-etics. — Arterial  sedatives,  diaphoretics,  and  purgatives  lower  tem- 
perature, and  have  previously  been  alluded  to  (see  page  106).  There  are  two 
great  classes  of  febrifuges — those  which  lessen  heat-production  and  those 
which  increase  heat-elimination.  In  the  first  group  we  find  quinin,  saHcyHc 
acid  and  the  saHcylates,  kairin,  alcohol,  antimony,  aconite,  digitaHs,  cupping, 


io8  Inflammation 

and  bleeding.  In  the  second  group  we  find  alcohol,  nitrous  ether,  antipyrin, 
acetanilid,  phenacetin,  opium,  ipecac,  cold  to  the  surface,  and  cold  drinks. 
In  surgical  inflammations  it  is  rarely  necessary  to  employ  heroic  means  to 
lower  temperature.  Quinin  is  but  a  feeble  antipyretic  for  non-malarial  fevers, 
and  that  it  shall  be  one  at  all  requires  a  dose  of  20  gr.  or  more.  SalicyHc  acid 
is  not  advisable  unless  there  is  hyperpyrexia  or  unless  the  patient  has  acute 
rheumatism.  If  30  or  40  minims  of  guaiacol  are  painted  on  the  skin  of  the  ab- 
domen, it  will  cause  a  notable  but  brief  drop  in  a  febrile  temperatm-e.  After 
a  short  period  of  lowered  temperature  there  is  commonly  a  chill  and  a  rapid 
rise.  Cardiac  depression  may  arise  after  giving  an  antipyretic,  and  such  an  agent 
as  antipyrin  is  dangerous  to  the  weak  and  adynamic.  In  truth,  all  of  the  coal- 
tar  derivatives  are  dangerous  when  used  as  antipyretics.  As  a  matter  of  fact, 
fever  is  a  condition  in  which  the  animal  organism  is  endeavoring  to  oxidize 
and  render  inert  certain  poisonous  materials,  and  antipyretic  drugs  lessen 
oxidation  and  actually  make  the  patient  worse.  It  is  a  suggestive  fact  that 
bacteria  are  said  to  multiply  more  rapidly  when  kept  at  about  the  normal 
body  temperature  than  when  kept  at  fever  heat  (102°  F.  or  more).  The  mere 
discomfort  of  fever  may  be  much  mitigated  by  antipyretic  drugs,  but  the  fever 
process  is  not  benefited  by  them.  No  attempt  should  be  made  to  lower  tem- 
perature by  cold  or  antipyretic  drugs,  unless  with  the  high  temperature  there 
are  the  nervous  phenomena  of  hyperpyrexia. 

Emetics  may  do  good  when  the  patient  suffers  from  a  parched,  coated 
tongue,  a  dry  and  hot  skin,  nausea,  and  gastric  oppression,  but  it  is  very 
rarely  in  these  days  that  we  employ  them. 

Mercury  and  the  lodids. — Mercury  is  an  alterative,  that  is,  an  agent 
which  favorably  affects  body  nutrition  without  causing  any  recognizable 
change  in  the  fluids  or  the  solids  of  the  body.  Mercury  lessens  blood  plas- 
ticity, hinders  the  exudation  of  Uquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  cell-proliferation.  Further, 
by  a  stimulant  action  on  the  absorbents  it  promotes  the  breaking  up  of  an 
existing  inflammatory  exudation,  and  hence  limits  damage  from  excess  of 
new  formation.  The  time  at  which  mercury  is  best  given  is  when  violent 
symptoms  have  abated,  the  guides  being  a  reduced  temperature  and  a  moist 
skin.  Mercury  is  often  given  in  conjunction  with  the  local  use  of  sorbefacients 
(ichthyol  or  mercurial  ointment).  When  possible,  the  administration  of 
mercury  is  associated  with  compression  of  the  inflamed  part.  Mercury  is 
sometimes  given  until  the  gums  are  slightly  touched,  but  it  is  not  given  to  the 
point  of  salivation.  When  the  breath  becomes  offensive  and  the  gums  tender  on 
snapping  the  teeth,  or  when  griping  and  diarrhea  begin,  the  dose  should  be 
reduced  or  the  drug  should  be  stopped  (see  Ptyalism).  In  iritis  mercury  is 
used  to  get  rid  of  the  plastic  effusion  which  is  causing  pupiUary  fixation  and 
opacity.  In  keratitis  the  gums  should  be  touched  slightly.  In  orchitis,  after 
the  subsidence  of  the  acute  symptoms,  mercury  should  be  employed.  In 
pericarditis,  meningitis,  and  in  many  chronic  and  fingering,  and  in  aU  syphil- 
itic inflammations,  this  drug  can  be  used. 

Some  persons  wfll  be  salivated  by  very  minute  doses  of  mercury,  either 
because  of  idiosyncrasy  or  previous  satiuration.  Others  can  take  enormous 
doses  without  any  appreciable  constitutional  effect.  The  action  of  mercurials 
can  be  favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  3  gr.  of  calomel  every 
three  hours  until  a  metallic  taste  is  noted  in  the  mouth.  If  the  case  is  not  so 
ui'gent,  gray  powder  is  a  good  combination.  Children  are  given  calomel  and 
sugar  or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug  for  some  time, 
corrosive  sublimate  is  a  suitable  form,  and  small  doses  wiU  actually  increase 
the  number  of  red  blood-corpuscles.    Corrosive  sublimate  is  to  be  given  alone- 


Remedies  Directed  Against  Special  Morbid  States  109 

or  combined  only  with  iodid  of  potassium.  The  green  iodid  of  mercury  is  a  dnio' 
suitable  for  prolonged  administration.  During  a  prolonged  course  of  mercvuy 
it  will  often  be  necessary-  to  give  at  the  same  time  a  little  opium  to  prevent 
diarrhea  and  griping.  A  rapid  effect  can  be  obtained  by  rubbing  daily  with 
a  gloved  hand  i  dr.  of  the  oleate  of  mercury-  or  h  dr.  of  the  ointment  into  the 
groins,  the  axillae,  or  the  inside  of  the  thighs.  Suppositories  of  mercmial 
ointment  induce  rapid  ptyaUsm.  H}-podermatic  injections  of  corrosive  sub- 
limate or  gray  oil  may  be  used,  and  must  be  thro-v\-n  deeply  into  the  muscles 
of  the  buttock  or  back.  Old  people,  those  who  are  exhausted,  anemic,  and 
broken  do-uTi,  and  the  tuberculous  bear  mercury-  badlv.  If  it  be  given  to  them 
at  all,  it  must  only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  remo\-ing  the  products  of  inflammation:  they 
can  be  given  for  a  long  time,  and  admirably  supplement  mercurials.  Iodid 
of  potassimn  can  be  prescribed  in  combination  with  corrosive  sublimate  as 
follows: 

R.     Hydraxg.  cHor.  corros gr.  ij; 

Potass,  iodidi 0 v  et  9 j; 

S>-r.  sarsaparillas  comp q.  s.  ad  f  o  ^■iii. — ^I. 

Sig. — ^Two  fluidrams  in  water,  after  meals. 

Iodid  of  potassivun.  well  diluted,  is  given  on  a  full  stomach;  it  is  never 
given  concentrated  or  before  meals.  A  convenient  mode  of  administration 
is  to  procure  a  concentrated  solution  of  the  iodid  of  potassium,  remembering 
that  ever\-  drop  equals  about  i  gr.  of  the  drug,  and  give  as  many  drops  as  may 
be  desired  in  half  a  glass  of  water  after  meals.  If  the  medicine  disagrees,  add 
to  each  dose,  after  it  is  put  in  water,  i  dr.  of  the  aromatic  spirit  of  ammonia. 
Extract  of  Hcorice  is  a  good  vehicle  for  the  iodid.  If  the  mixture  in  water 
disagrees,  the  drug  should  be  given  in  milk.  Capsules  are  satisfacton.*,  but 
a  drink  of  water  should  be  taken  just  before  and  again  just  after  taking  a 
capsule,  to  protect  the  stomach  from  the  concentrated  drug.  Iodid  of  sodium 
may  agree  when  iodid  of  potassium  does  not.  WTien  the  iodids  disagree  they 
produce  iodism.  The  first  indications  of  iodism  are  a  bad  taste  in  the  mouth, 
nmning  of  the  eyes  and  nose  and  sneezing,  followed  by  a  feeling  of  exhaustion,  _ 
absolute  loss  of  appetite,  nausea,  tremor,  and  skin  eruptions  (acne,  hemor- 
rhages, blebs,  hydroa,  etc.).  If  iodism  occins,  stop  the  drug  and  give  the 
patient  Fowler's  solution  in  increasing  doses,  laxatives,  diuretic  waters  and 
also  nutritious  food,  and  stimulants  if  depression  is  great.  Sometimes  bella- 
donna does  good  in  obstinate  cutaneous  disorders  induced  by  the  iodids. 

Remedies  Directed  Against  Special  Morbid  States. — If  inflammation 
is  associated  with  rheumatism,  gout,  scur\-^',  s}-philis,  tuberculosis,  or  any 
other  constitutional  disease  or  predisposition,  appropriate  treatment  should  be 
instituted  to  control  the  disease  or  combat  the  predisposition,  and  at  the  same 
time  the  area  of  inflammation  should  be  locally  treated.  S^-phihs  is  treated  by 
the  internal  use  of  mercur}- ;  in  some  cases  the  iodids  are  also  given ;  scurfy,  by 
vegetable  juices  and  potash  salts;  rheiunatism,  by  the  alkalis  or  salicylates; 
gout,  bv  colchicimi  or  piperazin;  tuberculosis,  bv  the  fats,  tonics,  and  open-air 
Hfe. 

Stimulants. — The  chief  stimulants  used  are  hot  black  coffee  by  the  stomach 
or  bowel:  hot  normal  salt  solution  by  the  bowel,  beneath  the  skin,  or  in  a  vein, 
alcohol  by  the  mouth  or  rectum:  and  str}-chnin  or  atropin  h\-podermatically. 
The  use  of  akoholic  stimulants  is  called  for  by  conditions  rather  than  by  dis- 
eases, being  indicated  by  the  state  of  the  patient  rather  than  by  the  name 
of  the  malady.  For  a  brief  acute  inflammation  in  a  robust  young  person 
alcohol  is  not  needed:  but  all  who  are  weak  or  exhausted,  be  they  young  or 
old,  all  who  are  aged,  those  who  are  accustomed  to  alcohoHc  beverages,  those 


no  Inflammation 

who  have  high  temperature  or  failure  of  circulation,  and  those  who  labor 
under  septic  inflammations  or  adynamic  processes  require  alcohol,  and  it 
should  be  given  with  a  free  hand.  In  an  acute  malady,  a  feeble,  compressible, 
rapid,  or  irregular  pulse,  and  great  weakness  of  the  first  sound  of  the  heart  are 
indications  that  alcohol  is  required.  Low,  muttering  delirium  is  a  strong  in- 
dication for  stimulation.  There  is  no  dose  of  alcohol  for  these  states;  it  is  given 
for  its  effect.  Two  ounces  of  brandy  or  whisky  may  be  needed  in  a  day,  or 
perhaps  many  ounces.  If  the  breath  of  the  patient  smells  strongly  of  the 
alcohol,  he  is  getting  too  much.  If  delirium  increases  after  each  dose,  alcohol 
is  doing  harm.  Alcohol  is  contra-indicated  in  acute  meningitis.  In  acute  illness 
use  whisky,  brandy,  champagne,  or  alcohol  and  water.  During  convalescence 
there  may  be  used  a  little  port,  claret,  or  sherry  wine,  or  malt  liquor.  These 
agents  will  promote  appetite,  digestion,  and  sleep. 

Strychnin  is  a  very  valuable  stimulant.  It  can  be  given  in  doses  of  -3V  to 
aV  gr.  three  times  a  day,  but  after  a  few  days  seems  to  lose  its  stimulant  effect, 

A  tropin  is  one  of  the  best  remedies  for  exhaustion  of  the  vasomotor  sys- 
tem.   The  dose  is  i^q  gr.  hypodermatically. 

Tonics. — The  use  of  tonics  is  indicated  during  convalescence  from  acute 
and  throughout  the  course  of  chronic  inflammations.  There  may  be  used 
iron,  quinin,  and  strychnin  in  the  form  of  elixir;  iron  alone,  as  in  the  tincture 
of  the  chlorid;  quinin  in  tonic  doses  (6  to  8  gr.  daily);  or  Fowler's  solution 
of  arsenic.    An  excellent  pill  consists  of — 

R.     Acid,  arsenos gr-  J; 

Strychnini gr.  ss; 

Quinini gr.  xlviij; 

Ferri  reduct gr.  vj. — M. 

Ft.  in  pil.  No.  xxiv. 

Sig. — One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the  best  tonics  is 
tincture  of  nux  vomica  in  gradually  increasing  doses. 

Antiphlogistic  Regimen. — This  term  comprises  the  necessary  directions 
relating  to  diet,  ventilation,  cleanliness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation,  the  patient 
cannot  eat,  there  must  be  administered  a  cathartic  before  food  is  given.  Nausea 
is  combated  by  calomel  and  soda,  drop-doses  of  a  6  per  cent,  solution  of 
cocain,  iced  champagne,  iced  brandy,  chloroform-water,  hot  water,  and  coun- 
terirritation  of  the  epigastric  region.  Sucking  ice  may  check  nausea,  but  it 
often  makes  the  patient  uncomfortable,  because  he  sucks  in  air  with  the  melted 
ice.  Sucking  ice  does  not  quench  thirst.  When  the  process  is  depressive  from 
the  start,  and  in  any  case  after  the  earliest  stage,  feeding  is  of  vital  moment. 
The  great  tissue  waste  calls  for  large  quantities  of  nutritive  material,  but  the 
impaired  digestion  demands  that  the  food  shall  be  easily  assimflable;  hence 
it  is  taken  in  liquid  form,  small  quantities  being  frequently  given.  Albimiin- 
water  is  an  agreeable  beverage  of  some  nutritive  value.  Milk  contains  all  the 
elements  required  by  the  body,  and  is  the  food  of  foods.  If  it  disagrees,  it  should, 
be  mixed  with  lime-water,  or  to  each  dose  an  equal  amount  of  Vichy  or  soda- 
water  may  be  added.  Peptonized  milk  is  a  valuable  agent.  Some  people  can 
take  boiled  milk  who  cannot  take  cold  unboiled  milk.  Some  patients,  how- 
ever, digest  raw  better  than  boiled  milk.  Peptonized  milk  has  been  to  a  great 
extent  superseded  by  pancreatinized  milk.  It  is  given  cold,  either  alone  or 
mixed  with  a  carbonated  water.  Kotmiiss  is  retained  in  some  cases  when  the 
stomach  rejects  afl  other  foods.  This  fermented  milk  is  nutritious,  stimulant, 
and  very  useful.  One  part  of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water 
make  a  nutritious  and  digestible  mixture.    Milk  punch  is  largely  used.    Whey 


Antiphlogistic  Regimen  iii 

may  be  used  when  plain  milk  cannot  be  taken.  Eggs  are  highly  nutritious,  but 
are  apt  to  disturb  the  stomach;  they  may  be  given  as  egg-nog,  or  simply  soft- 
boiled,  or  the  yolk  can  be  beaten  up  in  a  cup  of  tea,  or  raw  eggs  may  be  given  in 
sherrv  or  brandy.  When  considerable  nausea  exists  the  yolk  of  an  egg  may  be 
added  to  i  oz.  of  lemon-juice  and  2  dr.  of  sugar,  the  glass  being  filled  with 
carbonated  water.  Beef-tea  is  certainly  a  stimulant,  but  it  is  not  a  food.  It 
contains  the  excrementitious  elements  of  the  beef.  It  is  prepared  by  cutting 
up  I  pound  of  lean  beef,  adding  to  it  a  quart  of  water,  and  then  simmering, 
but  not  boiling,  down  to  a  pint,  finally  filtering  and  skimming  the  liquid.  The 
dose  is  a  wineglassful  seasoned  to  taste.  Beef  juice  is  nutritious.  It  is  pre- 
pared as  follows :  A  thick  and  tender  beefsteak  is  partly  broiled  over  a  hot  fire, 
the  outside  is  browned  and  the  juice  is  retained  within  the  meat.  The  steak 
is  cut  into  pieces  to  fit  a  lemon  squeezer  or  meat-press  (the  instrument  having 
been  warmed  by  previously  dipping  it  in  hot  water) .  The  juice  is  expressed  by 
squeezing  and  may  be  given  warm,  seasoned  with  salt  and  pepper,  or  may  be 
taken  after  it  has  been  frozen.  Fresh  meat  juice  may  be  used  plain  or  pan- 
creatinized.  The  meat  juices  obtained  in  the  shops  have  little  nutritive  value. 
Bouillon  and  beef  extracts  have  slight  nutritive  value.  Meat  jellies  (calf's  foot 
being  the  one  conmionly  used)  have  some  though  little  nutritive  value  by  pro- 
ducing a  certain  amount  of  energy  which,  were  they  not  given,  would  of  neces- 
sitv  be  furnished  by  protein.  Hence,  meat  jelly  saves  or  spares  protein  (Bauer). 
Clam-juice  and  clam-broth  are  palatable  and  slightly  nutritious.  They  are 
retained  in  many  cases  when  any  other  food  would  be  rejected.  The  broth  is 
to  be  given  hot  and  the  juice  either  hot  or  cold.  Coffee  is  a  valuable  stimulant  in 
febrile  conditions.  When  the  stomach  entirely  rejects  food  day  after  day,  nutri- 
tive enemata  are  given.  There  is  dispute  as  to  their  value,  because  it  is  certain 
that  the  large  intestine  does  not  digest  by  juices  of  its  own  manufacture,  and 
no  protein  matter  can  be  absorbed  without  previous  digestion.  If  undigested 
protem  matter  is  introduced  it  undergoes  putrefaction,  causes  irritation,  and 
Hberates  toxins  which  are  absorbed.  It  seems  equally  certain,  however,  that 
the  large  bowel  does  absorb  water  as  part  of  its  physiological  duty  and  that  it 
can  absorb  alcohol,  saHne  fluid,  grape-sugar,  certain  drugs,  and  perhaps  digested 
albmnin  and  fat.  Undigested  albumin  and  fat  should  never  be  given  by  enema. 
These  materials  should  be  pancreatinized  before  injection  or  should  be  nuxed 
with  pancreas  and  then  injected,  the  peptones  being  formed  in  the  bowel.  Nutri- 
tive enemata  are  given  at  a  temperatmre  of  90°  to  95°  F.  They  should  not  be 
bulky  (not  over  7  or  8  oz.),  because  a  large  enema  is  usually  quickly  expelled. 
They  should  not  be  given  oftener  than  three  or  perhaps  four  times  a  day,  be- 
cause too  frequent  administration  irritates  the  rectum  and  enemas  will  not  be 
retained  by  an  irritated  rectum.  During  the  period  that  rectal  enemata  con- 
stitute the'  method  of  feeding  the  rectum  should  be  washed  out  once  a  day  by 
a  high  enema  of  warm  salt  solution;  this  cleansing  enema  is  given  one  hour  be- 
fore a  nutritive  enema.  A  useful  enema  is  Leube's  meat  and  pancreas — 3  oz. 
of  pancreas  and  8  oz.  of  meat  are  rubbed  together  by  a  pestle,  tepid  water 
is  added,  and  the  mixture  is  injected.  It  undergoes  digestion  in  the  large  bowel. 
Bidwell's  formula  is  as  follows:  2  oz.  of  milk,  2  oz.  of  strong  beef-tea,  yolk  of  i 
egg,  I  dr.  of  pancreatic  solution,  prepared  one  hour  before  using  and  kept  during 
the  interim  at  a  temperature  of  100°  F.  Brandy  can  be  added  just  before  using. 
Enemata  of  salt  solution  greatly  reHeve  thirst.  When  the  sufferer  feels  able 
to  eat  a  Httle,  any  good  soup,  strained  and  skimmed,  should  be  ordered.  As 
the  patient  gets  better  he  may  be  fed  on  scraped  meat,  broth  containing  crumbs, 
tapioca  ^ith  cream,  custard,  milk- toast,  sweetbreads,  chops,  oysters,  chicken, 
etc.,  imtil  he  gradually  reaches  ordinary  diet. 

The  temperature  should  be  taken  at  regular  intervals,  and  the  condition  of 
the  gastro-intestinal  tract  should  be  observed.    The  urine  must  be  examined 


112  Inflammation 

at  intervals,  and  the  daily  amount  passed  must  be  known.  If  insufficient 
urine  is  being  passed,  increase  the  amount  of  fluid,  particularly  of  water,  given 
by  the  mouth.  If  the  urine  is  scanty  and  the  patient  is  nauseated  by  drinking 
water,  give  enemata  of  hot  saline  fluid  or  employ  hypodermoclysis.  The 
pulse  and  heart  must  be  frequently  observed,  and  cardiac  weakness  must  be 
combated  by  suitable  stimulants. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apartment  is  of  the 
greatest  importance.  Every  day  the  windows  should  be  opened  widely  for  a 
time,  the  patient,  of  course,  being  protected  from  chilling  and  kept  out  of  a 
draft.  When  the  windows  are  open  the  air  of  a  room  can  be  quickly  changed 
by  swinging  the  door  to  and  fro.  A  constant  access  of  fresh  air  must  be  secured, 
and  the  temperature  kept  as  near  as  possible  to  68°  F.  If  high  fever  exists,  the 
sick  man  must  be  cleaned  and  be  sponged  off  with  alcohol  and  water  every 
day.  It  is  important  that  the  bed-clothing  be  clean  and  that  the  sheet  be  un- 
wrinkled,  as  otherwise  bed-sores  may  form. 

Treatment  of  Chronic  Inflammation. — The  subject  of  chronic  inflam- 
mation has  been  referred  to  previously.  The  local  treatment  comprises  rest, 
relaxation,  elevation,  counterirritation,  massage,  passive  movements,  the 
douche,  the  appHcation  of  sorbefacients,  the  use  of  compression,  incision,  and, 
perhaps,  certain  special  methods,  as  the  induction  of  passive  hyperemia  by 
Bier's  method,  or  baking  the  part  in  a  hot-air  oven.  The  patient  should  be 
placed  under  proper  hygienic  and  climatic  conditions;  the  diet  must  be  judi- 
ciously regulated;  drugs  are  given  symptomatically  or  to  combat  some  con- 
stitutional tendency  or  disease  (see  articles  upon  Special  Regions  and  Diseases). 

Bier's  Hyperemic  Treatment  of  Inflammation. — Years  ago  Laennec 
asserted  that  cyanosis  is  antagonistic  to  tubercle.  Rokitansky  emphatically 
supported  the  contention  that  people  with  marked  valvular  disease  of  the  heart 
are  seldom  attacked  by  pulmonary  tuberculosis.  Such  lesions,  of  course,  dam 
back  the  blood  in  the  lungs.  Farre  and  Travers  point  out  the  great  hability 
to  pulmonary  tuberculosis  of  patients  with  anemic  lungs  because  of  stenosis  of 
the  pulmonary  artery  (Edward  Adams,  in  "N.  Y.  Med.  Jour.,"  February  26, 
1910).  The  discovery  of  how  to  utiHze  this  knowledge  in  treatment  was  made 
by  Professor  Bier,  of  Berlin.  Bier  beheves  that  hyperemia  in  inflammation  is 
a  reaction  on  the  part  of  the  organism;  that  it  is  Nature's  effort  to  remove  an 
irritant  and  to  supply  increased  nutritive  material,  hence  that  it  is  desirable 
and  should  not  be  combated  by  cold,  but  should  be  favored  by  every  means 
in  our  power.  Bier  endeavors  to  increase  the  hyperemia  of  an  inflamed  region, 
or  to  produce  hyperemia  in  an  area  of  disease.  He  regards  hyperemia  as 
beneficial,  stasis  as  harmful;  hence  he  causes  or  increases  hyperemia  and  com- 
bats stasis.  Stasis  lowers  tissue  resistance  and  may  cause  gangrene.  The 
increase  in  the  amount  of  moving  blood  in  a  part  means  an  increase  in  the 
munber  of  phagocytes  and  the  amount  of  germicidal  blood  liquor.  By  the 
method  of  treatment  recommended  by  Bier  the  surgeon  induces  venous,  pas- 
sive, or  obstructive  h3p)eremia  by  means  of  an  elastic  band  or  a  cupping  glass, 
active  or  arterial  hyperemia  by  means  of  hot  air. 

Obstructive  Hyperemia  by  Means  of  the  Elastic  Bandage. — The  constrictor 
should  be  the  soft  broad  bandage  of  an  Esmarch  apparatus.  Figure  55  shows 
it  apphed  around  the  arm.  The  bandage  must  not  be  so  tight  as  to  cut  off  the 
pulse  at  the  wrist  or  to  cause  unpleasant  sensations,  pain,  or  very  rapid  dis- 
tention of  the  subcutaneous  veins  (Meyer  and  Schmieden).  When  edematous 
swelling  arises  we  may  be  unable  to  feel  the  pulse.  Then  our  guide  must  be 
the  sensations  of  the  patient.  If  the  treatment  causes  pain  or  increases  existing 
pain,  at  once  discontinue  it  (Waterhouse,  "Brit.  Med.  Jour.,"  December  16, 
1 911).  The  part  below  the  band  should  become  bluish  red  and  warm,  but 
never  white  under  the  influence  of  the  constriction.     When  the  bandage  is  in 


Obstructive  Hyperemia  by  Means  of  the  Cupping  Glass  113 


place  an  area  of  inflammation  shows  an  increase  of  redness,  heat  and  swelling, 
and  a  diminution  of  pain.  If  pain  was  not  present  before,  the  bandage  must  not 
produce  it.  Should  it  do  so  it  is  too  tight.  In  chronic  conditions  the  bandage 
is  usually  employed  daily  and  for  two,  three,  or  four  hours  at  a  seance.  When 
used  for  three  hours  or  longer  temporary  edema  may  arise.  In  acute  cases  it  is 
used  for  twelve,  fifteen,  or  twenty  hours  a  day.  Prolonged  application  may 
make  the  skin  sore  unless  a  flannel  bandage  is  applied  before  the  band  is  used, 
unless  the  site  of  application  is  shifted  daily,  and  unless  the  skin  during  each 
intermission  is  well  rubbed  with 
alcohol.  The  bandage  is  always 
applied  well  above  the  inflamed 
region,  and  that  region  is  ex- 
posed free  from  dressings  in 
order  that  its  condition  during 
treatment  may  be  observed.  If 
edema  occurs,  the  band  must  be 
removed  and  the  edema  relieved 
by  elevation  and  massage.  If 
the  inflammation  is  accom- 
panied by  marked  edema,  inci- 
sions are  required.  Treatment 
by  the  bandage  may  prevent 
pus  formation.  If  pus  forms  it 
must,  of  course,  be  evacuated. 

Obstructive  Hyperemia  by 
Means  of  the  Cupping  Glass, — 
Endeavor  to  make  the  skin 
bluish  red,  but  not  white.  Cup- 
ping glasses  are  used  not  only 
to  treat  areas  of  inflammation, 
but  to  aid  in  emptying  sinuses 
and  abscesses  which  have  rup- 
tured or  have  been  incised.  Fig- 
ures 56-59  show  cupping  glasses. 

I  am  satisfied  from  personal 
experience  that  Bier's  method 
of  treatment  is  of  great  value 
in  acute  inflammation  as  well 
as  in  chronic  inflammation, 
and  that  it  is  not  used  as  often 
as  it  should  be.  I  have  used 
it  with  success  in  several  cases 
of  unimited  fracture.  It  is  an 
improvement  on  the  method  of 


Fig.  55. — Shows  elastic  bandage  in  place  around  the 
arm,  its  ends  tied  with  tapes  which  are  attached  to  the 
bandage.  This  is  the  style  of  bandage  usually  found  upon 
the  market.  If  the  bandage  is  to  remain  on  for  a  number 
of  hours,  it  is  advisable  to  apply  a  strip  of  adhesive  plaster, 
to  guard  against  the  tapes  becoming  undone.  Note  the 
engorgement  of  the  subcutaneous  veins  of  the  forearm, 
showing  the  effect  it  is  desired  to  produce  by  the  bandage 
(Meyer  and  Schmieden) . 


Thomas,  of  Liverpool,  for  inducing  hyperemia  about  the  ends  of  the  fragments. 
He  did  it  by  repeated  percussion  with  a  mallet.  Barker  has  recently  advocated 
Bier's  treatment  for  ununited  fracture.  I  have  never  used  it  for  purulent 
affections  of  large  joints,  a  condition  in  which  Bier  finds  it  highly  useful 
(Bier  andBaetzner,  in  "Practitioner,"  Jan.,  191 2).  He  empties  the  joint  with  a 
trocar,  washes  it  with  carbolic  solution,  puts  on  dressing,  but  does  not  immobilize. 
Bier  retains  the  band  from  twenty  to  twenty-two  hours  a  day.  As  soon  as  acute 
symptoms  subside  he  uses  hot  air.  The  reduction  of  the  daily  period  of  hyper- 
emia is  brought  about  gradually  before  substituting  hot  air.  I  have  seen  very 
gratifying  results  from  the  Bier  treatment  of  gonorrheal  joints.  I  beHeve 
that  this  treatment  gives  the  best  chance  of  cure  without  deformity  and  with 


114 


Inflammation 


retained  function.  It  is  valuable  for  joint  tuberculosis,  although  very  numer- 
ous brief  applications  are  necessary.  It  is  beneficial  for  thecitis,  areas  of  sup- 
puration after  incision,  and  chilblains.     Waterhouse  suggests  its  use  to  prevent 


Fig.  56. — The  simplest  form 
of  suction  glass.  The  rubber 
bulb  is  attached  directly  to 
the  glass.  This  glass  is  used 
in  the  treatment  of  furuncles 
of  smaller  size  and  sinuses 
(Meyer  and  Schmieden). 


Fig.  57. — Illustrating  an  ordinary  suction  ap- 
paratus for  the  finger  (felon,  etc.)  with  a  con- 
vexity at  the  lower  surface,  designed  to  receive 
the  pus  (Meyer  and  Schmieden). 


suppuration  in  a  crushed  limb.     The  treatment  is  contra-indicated  in  spreading 
inflammation — for  instance,  erysipelas. 

Bier  claims  that  arterial  hyperemia  induced  by  hot  air  is  particularly 
useful  in  chronic  inflammation,  as  it  favors  the  absorption  of  exudates  and  of 


j?ig_  58.— Shows  glass  of  simpler  configuration;  a  rubber  tube  connects  glass  with  bulb:  the  same 
can  be  readilv  detached,  thus  rendering  easy  the  sterilization  of  the  glass  by  boiling.  In  the  tube  a 
three-way  stop-cock  is  inserted.  This  cup  is  used  for  treating  furuncles  of  larger  dunensions,  etc. 
(Meyer  and  Schmieden). 

adhesions.  It  will  hasten  the  separation  of  sequestra.  Venous  hyperemia 
produced  by  the  elastic  band  or  the  cupping  glass  is  claimed  to  be  of  great 
value  in  infections.  It  may  abolish  the  infection,  prevent  suppuration,  and 
hasten  the  process  to  a  conclusion.     It  does  certainly  lessen  pain  and  favor 


Repair 


115 


absorption.  The  elastic  band  may  be  used  upon  an  extremity,  a  testicle,  the 
scrotiun,  and  the  head.  In  other  regions  cupping  glasses  are  used,  a  partial 
vacuum  being  established  in  the  glass  by  means  of  a  pump  or  a  rubber  bulb. 

Sir  Almroth  Wright's  Views  Upon  Inflammation  and  Its  Treat= 
ment. — Wright  mamtains  that  a  free  supply  of  blood  and  lymph  is  necessary 
for  repair,  that  both  the  blood  and  lymph  should  contain  a  sufficiency  of  pro- 
tective materials,  and  that  it  is  essential  that  numerous  active  leukocytes  enter 
the  area  of  disease. 

When  there  is  a  large  serous  effusion  and  few  leukocytes,  a  condition 
met  with  often  in  tuberculous  pleurisy,  repair  does  not  take  place. 

In  abscess  the  leukocytes  are  dead  and  the  material  obtained  from  dead 
leukocytes  retards  healing.  If  the  fluid  exudate  does  not  contain  protective 
material  the  process  extends. 


Fig.  59. — Constructed  for  the  treatment  of  the  hand.     A  soft-rubber  band  wound  around  the  cuff 
makes  it  fit  air-tight  around  the  arm  (Meyer  and  Schmieden). 

Repair  is  retarded  by  induration,  or  by  the  formation  of  a  fistula  or  a 
sinus. 

If  there  is  a  small  amount  of  fluid  exudate,  there  is  little  protective  sub- 
stance thrown  into  the  inflamed  part  and  repair  is  retarded. 

If  there  be  a  large  effusion  and  few  leukocytes,  cure  is  favored  by  removing 
the  fluid.  This  is  done  in  abscess  and  in  serous  effusion.  If  there  is  too 
little  lymph  in  the  part  salt  solution  and  citric  acid  should  be  used  locally, 
and  citric  acid  should  be  administered  internally.  The  administration  of 
proper  bacterial  vaccines  will  increase  the  protective  qualities  of  the  lymph. 
(See  Wright,  "The  Pathology  of  Inflammation,"  and  the  resume  of  his  views 
in  "Progressive  Medicine,"  Sept.  i,  1908,  p.  31.) 


IV.  REPAIR 

A  damaged  tissue  reacts  to  the  injury  and  Nature  attempts  to  effect 
repair.  It  is  held  by  many  that  inflammation  is  a  destructive  process 
and  repair  is  a  constructive  process;  that  repair  is  constantly  effected  in  an 
aseptic  wound  without  many  of  the  evidences  of  inflammation;  that  repair 
does  not  proceed  from  inflammation,  but  is  retarded  or  prevented  if  inflam- 
mation occurs.  As  before  stated,  we  agree  with  Adami,  that  inflammation 
is  reaction  to  injury  and  the  effort  of  Nature  to  repair  the  injury.  As  Adami 
points  out,  the  attempt  to  repair  may  fail,  the  reaction  to  injury  being  excess- 
ive or  not  powerful  enough;  but  even  should  the  attempt  fafl,  the  conserva- 
tive intention  exists.  "What  is  the  development  of  cicatricial  tissue  but  an 
attempt  at  repair?  What  other  meaning  can  be  ascribed  to  the  increased 
bactericidal  power  of  the  inflammatory  exudate  as  compared  with  that  of 
ordinary  lymph  and  blood-serum?  Why  do  leucocytes  accumulate  in  a 
region  of  injury?  Why  do  some  of  them  incorporate  bacteria  and  irritant 
particles,  and  others  bring  about  the  destruction  of  these  without  necessarily 


ii6  Repair 

ingesting  them?     All  these  are  means  whereby  irritants  are  antagonized  or 
removed,  and  reparation  and  return  to  the  normal  sought  after.  "^ 

Repair  is  favored  by  good  general  health,  asepsis  of  the  wound,  coaptation  of 
woimd  edges,  and  rest.  It  is  retarded  or  prevented  by  infection,  gaping  of  the 
wound,  frequent  or  forcible  motion,  and  impairment  of  the  general  health. 

Albuminuria  and  diabetes  particularly  obstruct  repair.  R.  T.  Morris 
points  out  that  sugar  in  the  blood  is  hygroscopic,  removes  water  from  the 
tissues,  and  thus  obstructs  repair;  and  also  that  the  wound  fluids  contain 
sugar  and  are  good  culture-media  ("Med.  News,"  June  29,  1901). 

Healing  By  First  Intention. — ^A  wound  may  "heal  by  first  inten- 
tion." This  mode  of  heahng,  which  is  known  as  "primary  union,"  occurs 
without  suppuration,  and  is  observed  in  the  healing  of  an  aseptic  wound.  If 
infection  occurs,  primary  union  will  not  take  place.  The  phrase  "by  first 
intention"  comes  down  to  us  from  the  past.  It  was  properly  thought  that 
Nature  intends  to  repair  a  wound,  and  first  intention  signifies  the  first,  best, 
the  most  desirable  way  in  which  it  can  be  accomplished.  In  a  small  aseptic 
incision,  in  which  no  considerable  vessels  are  cut,  repair  will  take  place  very 
rapidly  after  the  edges  have  been  approximated  and  the  wound  dressed.  In 
fact,  the  wound  edges  may  be  held  firmly  together  in  twenty-four  hours.  In 
such  a  Wound  a  small  amount  of  blood  flows  from  the  capillaries  between  the 
edges  of  the  wound,  and  this  blood  clots.  A  trivial  amount  of  exudate  and 
some  few  migrated  corpuscles  pass  into  the  clot  and  into  the  tissues.  The 
fixed  connective-tissue  cells  and  the  endothehal  cells  of  the  vessels  multiply, 
and  form  embryonic  or  juvenile  tissue.  The  ceUs  are  epitheloid  cells  and  are 
known  as  fibroblasts.  The  fibroblasts  eat  up  many  of  the  leukocytes  and 
multiply,  so  that  the  new  cells  from  one  side  of  the  wound  finally  interlace 
with  the  new  cells  from  the  other  side.  Nearby  capillaries  become  irregular 
in  outline;  at  certain  points  bulging  occurs,  and  at  these  points  new  capillaries 
..^^ develop,  extend  into  the  mass  of  fibroblasts,  and 

^''^,-..<:^^i^y^^:'f^s:!^^       join  new  capillaries  of  the  opposite  side.      The 

■'■^^S^^^%' .      =  i "V^        reparative  material  is  now  said  to  be  organized; 

■^^^^'■:0&^y-:^M'~h&iy^      it  has  become  granulation  tissue.     The  fibroblasts 

y^^^^^M^^;S$$§/  J        become  spindle  shaped  and  develop  into  interlac- 

'^'^T'^J^^^^^'M^^i         ing  fibers  (Fig.  60).      The  tissue  is  now  fibrous 
y(i^^%0^?^Bl /f^  ^^^      tissue;  it  contracts  strongly,  and  finally  most  of 

"1^s^''[^^^0^  J^  the  capillaries  are  obliterated   by  pressure.      In 

^^-    ■-:.-.--/  g^^j^  ^  slight  wound  the   reaction  to  injury  is 

^'^'  ^°'fib2s"(BSettr^  ^*°  chiefly  noted  in  the  cells  of  the  part,  and  the  ves- 
sels and  leiJiocytes  play  but  a  small  part  in  repair. 
The  exudation  is  so  scanty  that  there  is  practically  no  swelling  unless  it 
arises  from  venous  obstruction.  The  vessels  are  so  slightly  affected  that  there 
is  no  redness.  The  final  step  in  healing  is  contraction  of  the  fibrous  tissue  and 
the  covering  of  the  surface  with  epithelium,  which  springs  from  the  epithelial 
cells  upon  the  edges.  This  final  process  is  called  "cicatrization,"  and  con- 
sists in  the  formation  from  fibroblasts  of  new  fibrous  tissue  and  the  contraction 
of  the  new  tissue.  The  "immediate  union"  of  some  writers  never  occurs.  This 
term  means  the  union  of  microscopic  parts  to  their  counterparts  without  any 
effort  at  repair.  A  first  union  is  effected  always  by  clotted  blood  and  coagulated 
exudate,  next  by  proliferating  cefls,  and  finally  by  fibrous  tissue.  A  wound 
healing  by  first  intention  exhibits  no  evidence  of  inflammation.  There  is  some 
slight  tenderness,  but  no  actual  pain.  A  certain  amount  of  sweUing  arises  be- 
cause of  exudation  of  fluid  from  the  blood,  and  the  coagulation  of  this  fluid 
makes  the  wound  edges  hard.  Venous  obstruction  leads  in  some  cases  to  a  con- 
siderable fluid  swelling.  A  wound  may  heal  by  first  intention  even  though  some 
1  Adami,  in  Allbutt's  "System  of  Medicine." 


Healing  by  Second  Intention  117 

bacteria  are  present,  if  the  part  has  a  good  blood-supply  and  the  patient  is  in 
good  health.  Active  leukocytes  and  germicidal  blood  liquor  may  prevent 
infection.  In  a  more  extensive  incised  wound  many  vessels  are  cut.  After 
oozing  ceases  the  vessels  are  closed  by  clots  continuous  with  the  clot  between  the 
sides  of  the  wound.  An  exudation  of  plasma  from  the  blood-vessels  and  of 
lymph  from  the  lymph-spaces  takes  place.  Leukocytes  in  great  numbers  in- 
vade the  wound  edges  and  the  exudate,  and  the  exudate  clots.  Thus,  an  infec- 
tion may  be  surrounded  and  limited.  This  mass  of  blood-clot,  plasma-clot,  and 
leukocytes  used  to  be  kno-mi  as  "coagulable  lymph.''  The  leukoc>^tes  actively 
eat  up  the  clot,  and  by  the  end  of  the  third  day  occupy  the  space  formerly 
occupied  by  the  clot.  Embny^onic  tissue  is  formed  by  multiplication  of  the 
fLxed  connective-tissue  cells  and  endothehal  cells.  These  cells  are  called 
fibroblasts.  They  multiply  and  grow  into  the  mass  of  leukocytes,  eating  up 
many  of  the  leukocytes,  and  finally  join  the  fibroblasts  of  the  other  side  of  the 
wound.  Some  leukocytes  enter  uito  the  lymph-spaces.  New  capillaries  form 
from  the  capillaries  at  the  wound  margins.  By  the  end  of  the  first  week  the 
fibroblasts  begin  to  assume  various  outlines,  sending  out  poles  or  branches  or 
becoming  spindle  shaped.  These  spindle-shaped  cells  become  fibers,  and  the 
fibers  of  the  new  tissue  interlace  and  strongly  contract.  Thus  the  edges  are 
pulled  firmly  together.  Finally,  new  epitheliimi,  derived  from  epithelium  at 
the  wound  edges,  forms  and  grows  over  the  woimd  (Figs.  61-63).  In  order  to 
obtain  primary  union  the  surgeon  ought  to  cleanse  the  wound,  and  all  his  pro- 
cedures must  be  thoroughly  aseptic  and  bleeding  should  be  carefully  arrested. 
The  parts  are  then  accurately  coaptated  by  sutures,  aseptic  or  antiseptic  dress- 
ings are  applied,  and  special  care  is  taken  to  secure  rest.  In  a  large  wound  spe- 
cial methods  to  secure  drainage  are  required  (page  76).  In  a  small  wound 
the  spaces  between  the  stitches  give  exit  to  the  tri^^al  quantity  of  wound  fluid. 
The  use  of  irritant  germicides  in  a  wound  greatly  increases  the  amount  of 
discharge  and  renders  necessary  the  introduction  of  material  for  drainage. 
Even  a  comparatively  small  woimd  requires  drainage  for  the  first  twenty- 
fotu-  hours.  During  the  first  twenty-four  hours  after  a  large  woimd  begins  to 
heal  by  first  intention  the  discharge  of  bloody  serum  is  most  plentiful,  but  after 
this  period  it  becomes  ven,'  scanty  and  soon  ceases  entirely,  and  can  be  much 
diminished  in  quantit}'  on  the  first  day  by  the  apphcation  of  pressure.  Warren 
says  that  after  a  hip-joint  amputation  over  a  pint  of  bloody  serum  flows  out 
during  the  first  twenty-four  hours.  In  an  aseptic  wound,  as  a  rifle,  one-half  of 
the  stitches  are  removed  on  the  sLxth  or  seventh  day  and  the  remainder  on  the 
eighth  day,  but  for  two  weeks  more  the  wound  should  be  rested  and  supported, 
as  the  new  tissue  is  not  ven,^  resistant  to  infection.  Aseptic  fever  always  arises 
when  much  exudation  is  poured  out  and  it  is  slowly  and  imperfectly  drained. 
Aseptic  fever  is  due  to  the  absorption  of  aseptic  pyrogenous  material  (see  page 
129).  If  an  incised  woimd  becomes  infected,  the  pyogenic  organisms,  by  lique- 
f}dng  the  interceUular  substance,  destroy  the  bond  of  union  which  is  forming 
between  the  wound  edges.  As  a  consequence,  the  wound  edges  are  soon  T\idely 
separated  by  pus. 

WTiat  used  to  be  knov^Ti  as  ''healing  by  blood-clot"  is  heaHng  by  first  in- 
tention. If  there  is  a  considerable  gap  between  the  edges  of  an  aseptic  wound, 
and  the  gap  is  filled  "udth  a  blood-clot,  healing  goes  on  in  the  same  manner  as 
when  the  gap  is  narrow,  although  more  corpuscles,  more  exudate,  and  more 
fibroblasts  are  required  to  effect  repair. 

Healing  By  Second  Intention. — Healing  of  a  wound  in  which  there  is  a 
large  cavity  in  the  tissue  or  in  which  the  edges  have  gaped  apart  is  known  as 
heaHng  b}^  granulation,  or  "healing  by  second  intention."  It  is  called  healing 
by  granulation  because  the  granulations  (areas  of  vascularized  embr^'onic 
tissue)  are  \dsible.     It  is  eft"ected  in  the  same  manner  as  "healing  by  first 


ii8 


Repair 


intention,"  the  processes  in  the  two  cases  being  practically  identical  if  pus  is 
absent.  As  a  matter  of  fact,  in  healing  by  granulation  there  is  usually  wound 
infection.  As  a  result  of  infection  intercellular  substance  is  peptonized,  many 
reparative  cells  are  cast  off,  and  repair  can  be  effected  only  after  the  formation 


Fisr.  6i. 


Fig.  63. 

Figs.  61-63. — ^Healing  by  first  intention:  a,  Skin;  I,  fibroblasts;  c,  d,  e,  capillaries.  Fig.  61,  Clot 
in  the  vessels  continuous  with  clot  between  the  edges  of  the  wound.  Fig.  62,  Migration  of  leukocytes 
into  the  perivascular  tissues  and  into  the  clot  between  the  edges  of  the  wound.  Fig.  63,  Formation  of 
new  capillaries  (after  Pick). 

of  enormous  numbers  of  fibroblasts  and  the  expenditure  of  considerable  time. 
It  requires  much  longer  for  an  infected  wound  to  heal  than  for  an  incised  woimd 
to  be  repaired,  and  an  infected  wound  can  heal  only  by  granulation.  A  short 
time  after  the  infliction  of  a  wound  the  oozing  ceases,  because  thrombi  form  in 


Healing  by  Second  Intention 


119 


the  vessels  and  clot  gathers  in  tissue-gaps  and  interstices.  Exudation  begins 
and  leukocytes  migrate  into  the  exudate  and  into  the  walls  of  the  wound.  In 
an  hour  or  two  the  surface  of  the  wound  becomes  distinctly  glazed  or  glistening, 
because  of  the  formation  and  coagulation  of  fibrin.  The  exudation  is  at  first 
thin  and  red,  and  it  soon  becomes  so  profuse  as  to  wash  away  the  discolored 
fibrin  coat.  Usually,  in  a  few  days  the  discharge  becomes  purulent.  The 
connective-tissue  cells,  especially  the  endothelial  cells  of  the  vessels,  pro- 
liferate and  form  fibroblasts,  and  the  fibroblasts  multiply  to  close  the  wound. 
From  adjacent  capillaries  new  capillaries  form.  This  formation  takes  place  as 
follows:  A  portion  of  a  capillary  thickens  and  a  whip-like  process  comes  off 
from  the  thickened  part.  This  process  fuses  with  a  second  filament  budded 
from  another  or  from  the  same  capillary,  or  runs  straight  out  as  a  terminal  ves- 
sel. The  filaments  after  a  time  are  hollowed  out  from  within,  protoplasmic 
tubes  are  formed,  and  endothelial  cells  develop  from  the  protoplasm.  In 
some  cases  a  tubular  prolongation  comes  off  from  a  capillary  directly.  Figures 
63  and  64  show  the  formation  of  a  capillary.     In  a  wound  healing  by  granula- 


Fig.  64. — Development  of  a  blood-vessel  in  mesentery  of  an  embryo  (Warren). 

tion  these  newly  formed  capillaries  run  among  the  fibroblasts,  and  some  of 
them  run  perpendicularly  to  the  surface,  or  a  loop  forms  and  reaches  the  sur- 
face. The  surface  of  a  granulating  wound  is  covered  with  migrated  leukocytes, 
and  directly  under  these  are  fibroblasts  covering  the  new  vascular  strings  or 
loops.  Vascular  strings  or  loops  coated  with  fibroblasts  are  called  granulations 
(Fig.  65  shows  a  granulating  surface).  When  the  discharge  becomes  purulent, 
many  leukocytes  and  fibroblasts  are  destroyed,  inflammation  increases,  exuda- 
tion becomes  profuse,  and  cellular  multiplication  widespread  and  rapid  in  order 
to  make  up  for  the  cells  lost  by  microbic  action.  Gradually  the  gap  is  filled. 
As  it  is  being  filled  the  older  fibroblasts  in  the  deeper  layers  of  the  edges  and  base 
of  the  wound  are  converted  into  cicatricial,  fibrous,  or  scar  tissue  (Fig.  66) . 
As  the  granulations  rise  to  a  higher  level  at  the  surface  the  area  of  fibrous  tissue 
becomes  broader  at  the  base  and  margins,  and  this  young  fibrous  tissue  con- 
tracts. By  contracting  it  draws  the  edges  of  the  wound  nearer  together,  and 
thus  lessens  the  area  of  the  surface  which  must  be  covered  with  epithelium. 


I20 


Repair 


When  the  graniilations  reach  the  level  of  the  cutaneous  surface  the  epithelial 
cells  at  the  margin  of  the  Avound  proliferate,  and  young  epithelial  cells,  consti- 
tuting a  bluish  or  opalescent  film,  grow  over  the  granulations.  Epithelium 
comes  only  from  epithelium.  Granulations  are  never  converted  into  epithe- 
lium. The  epithelial  covering  comes  only  from  the  epithelium  at  the  wound 
margins,  unless  there  be  epithelial  remains  in  the  wound;  for  instance,  an  un- 
destroyed  papilla,  sweat-duct,  or  hair-follicle.  The  process  of  covering  the 
surface  with  epitheliimi  is  known  as  epidermization.  The  epidermization  of 
a  large  area  always  consumes  considerable  time  and  sometimes  Nature  fails 
to  accomplish  it.  In  such  cases  skin-grafting  is  employed  {q.  v.).  Before,  dur- 
ing, and  for  a  time  after  epidermization  the  fibrous  tissue  of  the  walls  and 
base  of  the  wound  contracts.  Thus  the  wound  margins  are  pulled  and  held 
nearer  together,  the  gap  to  be  bridged  is  diminished  in  size,  the  danger  of 
tearing  apart  of  the  epithelial 
layer  is  lessened,  many  capillaries 
are  destroyed   by  pressure,  and 


Fig.-  65. — Blood-vessels  in  granulation 
(Gross) . 


Fig.  66. — Cicatricial  tissue;  X  670  (Fowler). 


the  scar  becomes  firm,  white,  and  puckered.  Cicatrization  consists  in  the  con- 
version of  immature  connective  tissue  into  mature  fibrous  tissue  and  in  the 
contraction  of  the  new  fibrous  tissue.  Cicatrization  is  hurried  in  a  healthy 
granulating  wound  by  the  application  of  an  8  per  cent,  ointment  of  scarlet  red. 
It  is  kept  in  place  only  twenty-four  hours.  To  keep  it  longer  will  irritate  the 
wound  edges.  If  infection  is  severe,  destruction  will  exceed  repair  and  healing 
will  not  occur.  In  such  a  case  there  is  coagulation  necrosis  of  granulation 
tissue,  and  the  wound  becomes  covered  Tvith  tissue  remains  (aplastic  honph). 
If  granulations  rise  above  the  cutaneous  level,  healing  -^ill  not  take  place, 
because  the  epithelium  cannot  then  grow  over  the  raw  surface.  A  wound  in 
this  condition  is  said  to  possess  exuberant  granulations,  or  proud  flesh.  In 
some  cases  the  granulations  are  pale  from  insufiicient  lalood-supply,  and  in 
others  edematous  from  venous  congestion.  Contraction  of  the  fibrous  tissue 
may  be  insufficient  because  there  is  adhesion  to  deep  unyielding  fascia  or  to 
periostemn.  Excessive  contraction  is  frequent  after  burns  and  often  produces 
terrible  deformity.  The  scars  or  cicatrices  of  biirns  contain  much  elastic 
tissue  derived  from  cell  protoplasm.  Infected  w^oimds  and  ulcers  heal  by 
second  intention. 

Healing  By  Third  Intention. — This  consists  in  the  union  of  two  granu- 
lating sru-faces,  the  granulations  of  one  side  fusing  with  the  granulations  of 
the  other  side.  It  is  seen  in  the  union  of  collapsed  abscess-walls.  The  sur- 
geon occasionally  seeks  to  obtain  union  of  a  wound  several  days  old  by  third 
intention  by  approximating  two  granulating  surfaces.  If  the  surfaces  are 
aseptic,  he  will  often  succeed.  The  procedure  of  approximation  is  known  as 
secondary  suturing.  It  is  not  imusual  to  pack  a  woimd  with  iodoform  gauze  to 
control  oozing.  When  this  is  done  it  is  customary  to  pass  the  sutures,  but 
not  to  tie  them.     After  a  few  days  the  gauze  is  removed  and  the  sutures  are 


Healing  of  Subcutaneous  Wounds  121 

tied.  This  plan  renders  healing  much  more  rapid  than  would  be  possible  by 
the  process  of  heahng  by  second  intention. 

Cicatrices,  or  Scars. — The  newly  formed  connective  tissue  which  con- 
stitutes a  scar  ^ill  be  present  in  large  amount  if  more  granulations  were  formed 
than  were  really  necessan.-  for  repair  or  if  a  considerable  defect  was  repaired. 

A  recent  scar  contains  fibrous  tissue,  many  fibroblasts,  and  numerous 
blood-vessels,  but  no  nen-es,  h-mphatics.  or  elastic  fibers.  The  skin  above 
recent  scars  is  usually  red  because  of  the  numerous  vessels  beneath  it  and  the 
layer  of  epidermis  is  well  developed.  In  old  scars  fibroblasts  have  disappeared 
and  fibrous  tissue  reaJly  constitutes  the  cicatrix.  Some  blood-vessels  disappear 
and  the  diameters  of  those  remaining  are  much  reduced.  These  vascular 
changes  result  from  contraction  of  the  cicatrix.  Delicate  elastic  fibers  appear 
in  old  scars.  They  appear  at  the  end  of  the  second  month  in  wounds  healed 
by  first  intention,  at  the  end  of  the  third  or  fourth  month  in  woimds  healed  by 
second  intention,  and  they  take  origin  directly  from  cell  protoplasm  and  not 
from  fibrous  tissue  (]SIiner\Tni,  in  ''Virchow's  Archiv,''  vol.  clxx\-,  Xo.  2).  Xo 
genuine  h-mphatics  exist  in  old  scars,  but  occasionally  ner\-e  filaments  are 
present.  Some  dermal  papilla  are  found  after  a  time,  but  skin  glands,  skin 
muscle,  and  hair-follicles  remain  absent. 

An  old  scar  is  smooth,  whiter  than  the  surrounding  skin,  somewhat  creased 
or  wrinkled,  and  deficient  in  tactile  sense.  The  scar  of  a  healed  tuberculous 
ulcer  is  irregular.  li\-id,  and  often  actually  corrugated.  The  scar  of  a  healed 
S}'philitic  ulcer  is  at  first  copper}-  red  and  then  glistening  white  and  depressed. 
The  scar  of  an  old  ulcer  of  the  leg  and  of  the  skin  about  it  is  often  darkened 
by  pigmentation. 

A  cicatrix  may  be  discolored  by  retained  foreign  bodies,  for  instance. 
grains  of  gtmpowder. 

During  scar  formation  shreds  of  epidermis  may  be  displaced  and  included 
in  granulation  tissue.  Subsequently  they  are  included  in  fibrous  tissue,  and 
may  then  give  rise  to  transplantation  (J?npIantation}  dermoids  or  to  epithelial 
tiunors  (see  page  379).  A  scar  may  be  deformed,  for  instance,  may  be  greatly 
depressed  and  adherent  to  imderh-ing  bone,  and  in  certain  situations  such  a 
scar  will  fix  the  jaws  or  any  other  joint.  The  vicious  cicatrix  is  a  great  excess  of 
scar  tissue  and  results  from  delayed  healing  by  second  intention.  Such  cica- 
trices are  particularly  common  after  bums  and  tuberculous  ulcerations.  Iq 
some  cases  the  scar  is  irregular  and  lumpy,  in  other  cases  it  is  thickened  at 
certain  parts  and  discolored  and  resembles  keloid. 

A  cicatrix  may  block  a  natin-al  orifice,  as  the  mouth  or  nostril:  may  pro- 
duce great  deformity,  for  instance,  the  head  may  be  drawn  upon  the  chest 
or  shoulder  by  a  contracting  scar  in  the  neck,  fingers  may  be  grown  together 
after  a  bum,  or  a  hideous  depression  may  exist  on  the  forehead  after  an  iujiuy, 
or  the  face  may  be  fearfully  contorted  by  contracting  cicatrices.  A  scar  may 
produce  great  disabilit}-  by  blocking  the  jaws,  obstructing  the  rectum  or  -ore- 
thra.  or  fixing  a  joint  or  certain  muscles  of  an  extremit}-. 

]SIost  scars  are  insensitive,  some  are  hA-persensitive.  The  h\-per sensitive 
scars  are  usually  thin  and  pale.  The  itching,  burning,  or  tingling  appreciated 
in  a  sensitive  scar  are  located,  as  a  rule,  at  the  junction  of  sound  skin  and 
newly  formed  epidermis.  Sometimes  acute  nein-algic  pain  exists  in  and  about 
a  scar  due  to  pressure  upon  nen,-e  filaments. 

A  scar  may  inflame  or  ulcerate,  warts  may  spring  from  its  cutaneous  sur- 
face, keloid  may  arise  from  the  fibrous  tissue,  carcinoma  may  come  from  the 
epithelial  elements  (^MarjoHn's  ulcer),  sarcoma  from  the  connective-tissue 
elements. 

Healing  of  Subcutaneous  \\'ounds. — Blood  fills  the  tissue  gap  and  the 
blood  clots.     Plasma  exudes  and  corpuscles  migrate  into  the  clot  and  the 


122 


Repair 


tissue  about  it.  The  clot  is  eaten  up  by  the  leukocytes.  The  connective-tissue 
cells  and  the  endothelial  cells  of  the  adjacent  tissue  proHferate  and  form  fibro- 
blasts, and  fibroblasts  multiply  and  replace  the  clot.  The  area  of  fibroblasts 
is  vascularized  by  the  formation  of  new  capillaries,  fibrous  tissue  forms  and 
strongly  contracts. 

Healing  of  Wounds  In  the  Non=vascular  Tissues. — After  a  tri\'ial 
injun.'  of  the  cornea  a  few  leukocytes  gather  from  the  lymph-spaces  and  a  few  of 
the  fixed  cells  proliferate.  WTien  the  cornea  is  more  severely  wounded,  an 
increased  flow  of  l}Tnph  occurs.  The  nerves  are  irritated,  vessels  adjacent  to 
the  cornea  distend,  and  many  leukocytes  invade  the  l}Tnph-spaces.  The  cor- 
neal corpuscles  multiply  and  alter  in  shape.  The  product  of  the  process  may  be 
transparent  if  fibrin  is  absorbed  and  leukocytes  pass  away,  because  proUf erating 
corneal  corpuscles  form  transparent  tissue.  The  surface  epitheHum  is  re- 
placed by  proliferation  of  the  deep  layer  of  corneal  epithelium.  If  the  wound 
has  penetrated  the  posterior  portion  of  the  cornea,  it  becomes  fiUed  by  proHf era- 
ting  epitheHum  from  the  membrane  of  Descemet.  In  a  severe  injur}-  of  the 
cornea  endothelial  ceUs  and  corneal  corpuscles  proliferate,  vessels  grow  in  from 
the  corneal  margins  toward  the  seat  of  inflammation,  fibrous  tissue  forms,  and 
permanent  opacity  results. 

Repair  in  cartilage,  w^hen  it  occurs  at  all,  is  very  slow  and  is  accomplished  in 
the  same  way  as  repair  in  the  cornea.  Any  severe  injury  is  repaired  by  white 
fibrous  tissue,  furnished  by  the  cells  of  the  perichondrium,  and  the  scar  is 
permanent. 

Cell=division. — The  muJtiplication  of  connective-tissue  cells  in  repair 
may  be  by  direct,  but  is  usually  by  indirect,  cell-di\dsion.  Direct  cell-division 
consists  in  division  of  the  nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  takes  place  after  remarkable  changes 
in  the  nucleus.  The  membrane  of  the  nucleus  disappears;  the  nuclear  net- 
work becomes  first  close 
and  then  more  open;  and 
the  cell  becomes  roimd,  if 
not  so  before.  The  net- 
work of  the  nucleus,  now 
consisting  of  one  long  fiber, 
takes  the  shape  of  a  rosette; 
next  it  takes  a  star  form 
— the  aster  stage;  two  V's 
next  form — the  equatorial 
stage;  an  equatorial  line 
appears  and  \\idens,  and 
each  one  of  the  V's  retreats 
toward  a  pole.  Thus  two 
new  nuclei  are  formed,  each 
polar  V  passing  in  inverse 
order  through  the  previous  changes  of  shape,  and  the  protoplasm  of  the 
original  ceU  collecting  about  each  nucleus  (Fig.  67). 

Repair  of  Nerves. — ^A  nerve-fiber  consists  of  a  core  known  as  the  axis- 
cylinder,  which  is  the  essential  element  in  function.  About  the  axis-cylinder 
is  an  ahnost  Hquid  material,  known  as  the  medullar^'  sheath  or  white  substance 
of  Schwann,  or  myelin.  The  myelin  is  surrounded  by  a  firm  sheath  known 
as  the  neurilemma  (sheath  of  Schwann,  primitive  sheath,  neurilemma).  On 
the  inner  surface  of  the  sheath  of  Schwann,  or  between  it  and  the  white  sub- 
stance of  Schwann,  are  nuclei  which  are  supposed  by  some  to  be  peripheral 
ner\'e-cells  (neuroblasts).  The  neurilemma  is  absent  in  the  brain  and  cord. 
The  continuitv  of  the  white  substance  of  Schwann  is  interrupted  at  frequent 


Fig.  67. 


-Forms  assumed  by  a  nucleus  dividing  CGreen,  from 
Flemming). 


Repair  of  Nen'es  123 

inten-als,  and  these  breaks  in  the  myeUn  are  called  nodes  of  Ranvier.  Num- 
bers of  fibers  of  the  kind  just  described,  bound  in  bundles  by  connective  tissue 
and  surrounded  by  a  fibrous  sheath,  constitute  a  nerve.  It  is  known  that  a 
nerve  ma}^  regenerate  and  completely  regain  function  after  di^'ision;  that  regen- 
eration is  strongly  favored  by  suturing  the  ends  together;  and  that  if  the  ends 
of  a  divided  nerve  are  more  than  i  inch  apart,  regeneration  will  rarely  take  place 
unless  they  are  sutured  together.  The  method  by  which  regeneration  is  affected 
has  been  much  disputed  and  is  still  involved  in  uncertainty.  If  a  nerv'e  is 
di\'ided,  the  peripheral  segment  at  once  loses  its  fmiction  and  then  undergoes 
degeneration  (Wallerian  degeneration).  The  degeneration  begins  within 
twenty-four  to  forty-eight  hours  and  affects  the  entire  peripheral  segment. 
The  axis-cylinder  perishes,  the  myelin  runs  into  globules  and  is  absorbed, 
leaving  an  almost  empty  sheath;  the  nuclei  of  the  inner  surface  of  the  neuri- 
lemma proliferate  for  a  time,  but  cease  to  do  so  before  the  myelin  is  completely 
absorbed.  The  sheath  shrinks  and  looks  empty,  but  here  and  there  are  col- 
lected masses  of  proliferated  nuclei  and  protoplasm.  Degeneration  takes 
place  in  days,  but  regeneration  requires  months.  Regeneration  takes  place 
by  the  multiplication  of  pre-existing  nerve-fibers,  and  not  by  the  transforma- 
tion of  connective  tissue  into  nerA'e  structure.  The  ends  of  a  diA'ided  nerve,  it 
is  true,  become  united  by  connective  tissue  formed  by  the  proliferation  of  fibro- 
blasts, but  this  connective  tissue  is  only  a  bridge  to  carr\'  ner\"e  elements  across 
the  gap  between  the  proximal  and  peripheral  segments.  The  common  view 
is  that  regeneration  takes  place  as  follows:  The  new  axis-cylinder  of  the  per- 
ipheral segment  is  a  prolongation  of  the  old  axis-cylinder  of  the  proximal  seg- 
ment, projected  in  the  foUouing  mianner:  A  fiber,  which  is  at  first  devoid  of 
myelin,  is  prolonged  from  a  proximal  axis-cylinder;  it  di\'ides  into  many  cylin- 
ders, which  pierce  the  granulation  tissue  between  the  separated  ends  and  enter 
into  the  empty  sheaths  of  Schwann  of  the  distal  segment  or  insinuate  themselves 
between  these  sheaths  (Ran\der,  Reclus,  Senn).  The  above  is  the  view  enter- 
tained by  those  who  teach  that  the  new  axis-cylinders  come  entirely  and  only 
from  the  prolongation  of  old  axis-cylinders  of  the  proximal  segment,  that 
the  distal  segment  is  passive  in  the  process  until  "neurotised"  (Vanlair),  and 
that  regeneration  is  impossible  in  the  distal  segment  unless  it  is  in  approxima- 
tion with  the  proximal  segment  or  within  easy  reach  of  the  prolongations  of 
the  axis-cylinders  from  above.  Another  view  is  that  the  axis-cylinders,  myelm, 
and  neurilemma  are  formed  from  cells  which  exist  in  the  distal  segment,  and 
that  juvenile  axis-cylinders  and  medullar}-  sheaths  are  formed  in  the  peripheral 
portion  and  then  effect  a  junction  vn.th.  like  structures  of  the  central  segment. 
The  last-mentioned  \-iew  is  advocated  by  jNIayer  and  Eichhorst,  Tizzoni, 
Cattani,  and  others,  and  Ballance  and  Stewart  have  published  a  most  valuable 
monograph  advocating  it  ("The  Healing  of  Nerv^es")-  The  nuclei  proliferate 
and  form  a  mass  of  protoplasm  within  the  old  sheath,  which  protoplasm 
subsequently  joins  the  proximal  segment.  Such  a  protoplasmic  fiber  has  "con- 
duction and  irritability"  (Raymond's  "Human  Physiolog}-") ,  but  there  is  as 
yet  neither  myelin  nor  axis-cylinder.  "The  fiber  is  responsive  to  mechanical 
stimuli,  but  not  to  induction  shocks,  which  latter  property  retinns  only  after 
the  axis-cyhnder  is  developed.  The  medullary  substance  later  appears  and 
forms  a  tube;  and  still  later  the  axis-cylinder  is  formed,  having  its  origin  in 
the  central  end  of  the  nerv^e"  (Ibid.).  The  ^^ews  of  Ballance  and  Stewart 
may  be  set  forth  as  follows:  WTien  a  ner\^e-trunk  is  di\'ided,  the  peripheral 
segment  degenerates  whether  it  has  been  sutured  to  the  proximal  segment 
or  not,  and  the  portion  of  the  proximal  segment  near  the  wound  also  degen- 
erates. The  injur}-  produces  at  once  an  effusion  of  blood,  migration  of  leuko- 
cytes takes  place  into  and  about  the  woxmd  at  the  proximal  segment,  but 
leukocytic  invasion  of  the  entire  distal  segment  is  noted.     After  three  days 


124  Repair 

connective-tissue  cells  begin  to  replace  the  leukocytes,  and  after  two  weeks 
the  excess  of  leukocytes  is  no  longer  observed,  proHferated  connective-tissue 
cells  having  taken  their  place  (Ballance  and  Stewart,  "Healing  of  Ner\"es," 
page  94).  The  proximal  segment  in  the  neighborhood  of  the  wound  and 
the  entire  distal  segment  are  invaded  by  proliferating  connective-tissue  cells. 
The  connective-tissue  cells  completely  absorb  the  fatty  myelin  and  axis- 
cylinders.  The  cells  of  the  neurilemma  actively  multiply,  and  connective- 
tissue  cells  lying  among  chains  of  neurilemma  cells  become  spindle-shaped 
and  "the  degenerated  nerve-trunk  therefore  becomes  hard,  fibrous,  and  cir- 
rhosed"  (Ibid.). 

In  the  proximal  end  of  a  divided  nerve  an  "end-bulb''  is  formed.  This 
was  long  supposed  to  be  due  to  the  prolongation  of  nerve-fibers  from  the  cen- 
tral fibers  and  a  turning  backward  because  they  could  not  cross  the  gap.  As 
a  matter  of  fact,  the  ends  of  the  divided  fibers  curl  up ;  on  and  in  this  scaff old- 
Like  arrangement  new  fibers  are  placed,  they  having  been  produced  by  the 
neurilemma  cells  which  have  taken  on  "neuroblastic  function"  (Ballance  and 
Stewart).  When  a  nerve  has  been  sutured,  the  earliest  signs  of  regeneration 
"occur  at  the  end  of  three  weeks"  (Ibid.).  Short  lengths  of  new  fibers  are 
laid  down  within  old  neurilemma  sheaths.  The  new  axis-cylinder  "is  seen  to 
consist  in  the  deposition  along  one  side  of  a  spindle-shaped  neurilemma  cell,  of 
a  thin  thread  which  grows  in  length  untU  it  projects  beyond  the  limits  of  the 
parent  cell  and  stretches  on  toward  its  next  neighbor  in  the  same  longitudinal 
row"  (Ibid.).  The  new  medullary  sheath  is  "laid  down  by  a  process  of  secre- 
tion" (Ibid.)  along  the  sides  of  the  neurilemma  cells. 

BaUance  and  Stewart  go  on  to  point  out  that  if  the  central  theory  of  regen- 
eration is  true,  not  a  trace  of  regeneration  could  occur  in  the  distal  segment 
when  the  two  segments  have  not  been  uiiited  by  sutures,  and  yet  such  regen- 
eration does  occur,  although  slowly,  the  new  axis-cyhnders  and  medullary 
sheaths  not  attaining  full  size.  "Evidently  some  stimulus  afforded  by  the 
conduction  of  impiilses  is  necessary  in  order  to  permit  of  their  full  develop- 
ment" (Ibid.).  In  the  notable  study  quoted  at  such  length  are  some 
experiments  on  the  "conduct  and  fate  of  transplanted  nerve."  When  the 
gap  is  wide  between  the  two  ends,  a  portion  of  fresh  nerve- trunk  may  be 
inserted  to  bridge  it.  The  transplanted  piece  degenerates;  it  is  invaded  by 
leukocytes,  and  proliferating  connective-tissue  cells,  medullary  sheaths,  and 
axis-cylinders  are  destroyed,  but  regeneration  may  subsequently  occur;  "but 
when  it  does  occur,  it  is  not  from  the  activity  of  the  cells  of  the  graft  itself." 
Blood-vessels  enter  the  degenerated  graft  at  each  end  and  they  are  accom- 
panied by  chains  of  neurilemma  cells,  which  form  axis-cyhnders  and  medul- 
lary sheaths.  The  graft  is  merely  a  scaffold.  Verga  (quoted  "Journal  de 
Chiriirgie,"  April,  1910)  opposes  the  notion  that  the  peripheral  end  plays 
any  part  in  regeneration  and  advocates  the  view  that  all  regeneration  comes 
from  the  central  end. 

The  studies  of  BaUance  and  Stewart  persuade  us  that  regeneration  does 
occur  in  the  distal  part  independently  of  the  proximal  part,  although  full  de- 
velopment does  not  take  place  unless  there  is  a  junction  with  the  central 
part.  As  to  the  exact  method  of  regeneration  we  still  feel  somewhat 
uncertain.  When  we  remember  that  the  nerve-fibers  of  the  spinal  cord 
are  devoid  of  neurilemma  and  that  the  cord  can,  to  some  extent  at  least, 
regenerate,  we  must  conclude  that  regeneration  can  take  place  in  the  cord 
without  the  aid  of  neurilemma  cells,  and  must  infer  that  the  same  may  be 
true  in  a  nerve. 

Repair  of  the  Spinal  Cord  and  Brain. — Can  the  spinal  cord  regenerate? 
Many  observers  have  doubted  it.  But  there  is  no  doubt  of  the  fact  that  some- 
times, after  the  subsidence  of  an  acute  myehtis  or  after  the  relief  of  a  pressure 


Repair  of  IVIuscles  125 

wliich  produced  complete  and  prolonged  paralysis,  there  is  a  return  of  func- 
tional power.  It  is  usually  assumed  that  restoration  is  possible  in  fibers  which 
have  not  been  hopelessly  damaged,  but  is  not  possible  in  those  which  have  been 
destroyed;  but,  as  Gow^ers  says,  there  are  cases  in  which  "we  can  scarcely 
believe  that  the  axis-cylinders  retain  their  continuity,  although  conducting 
capacity  is  ultimately  restored."  Clinical  evidence  indicates  strongly  that 
the  pyramidal  fibers  may  regenerate.  Mills  ("The  Nervous  System  and  Its 
Diseases")  says:  "Nerve-tracts  in  the  spinal  cord  and  brain  have  power  to 
regenerate,  but  this  is  not  so  great  as  in  the  peripheral  nerves,  and  yet  even  old 
cases  of  compression  of  the  spinal  cord  may  make  great  improvement  after  a 
long  time,  largely  through  the  regeneration  of  the  columns  of  the  cord." 
jNIills  aflirms  that  although  ner\^e-cells  sometimes  appear  to  regenerate,  the 
destruction  in  these  cases  was  not  complete.  Recently  I  showed  in  my  clinic  a 
man  who  had  had  complete  paraplegia  with  paralysis  of  the  bladder  and 
rectum  for  nineteen  years.  The  condition  was  due  to, a  bullet  lodged  within 
the  spinal  canal.  Removal  of  the  bullet  was  foUow^ed  in  a  few  weeks  by  restora- 
tion of  control  over  the  bladder  and  rectum.  In  a  few  months  spastic  paraplegia 
was  substituted  for  flaccid  paralysis. 

WTien  axis-cylinders  have  been  destroyed  in  the  cord  and  yet  some  power 
returns,  we  ask  oiu-selves:  Does  this  occur  because  new  fibers  have  grown  down 
from  above?  Gowers  says  that  such  a  growth  has  been  proved  to  occur  in  the 
lower  animals,  but  has  not  as  yet  been  demonstrated  in  man;  although  speci- 
mens have  been  described  which  strongly  suggest  such  an  occurrence  in  the 
human  subject.  That  the  cord  can  regenerate  to  some  extent  seems  highly 
probable  from  the  report  of  a  case  operated  upon  by  my  colleague.  Professor 
Francis  T.  Stew^art,  of  Philadelphia.  He  sutinred  a  completely  divided  spinal 
cord  and  extraordinary^  restoration  of  function  took  place  (Francis  T.  Stewart 
and  Richard  H.  Harte,  in  "Phila.  Med.  Journal,"  June  7,  1902).  This  case  is 
commented  on  at  some  length  in  the  section  of  Injuries  on  the  Spinal  Cord. 
Another  somewhat  similar  case  was  reported  by  George  Ryerson  Fowler  in  the 
"Annals  of  Surgery,"  Oct.,  1905. 

Man}^  claim  that  a  brain  injury  cannot  be  followed  by  repair  with  restora- 
tion of  function;  some  think  that  complete  regeneration  can  take  place;  others, 
that  partial  regeneration  may  occur.  Vitzon  and  Tedeschi  even  believe  that 
nerv^e-cells  in  the  brain  can  regenerate.  It  seems  probable  that  extensive 
injm-ies  are  not  repaired,  but  slighter  ones  may  be,  new  ganglion-cells  and 
neuroglia  being  formed.  Tedeschi  describes  the  process  of  repair  after  a 
woimd  of  the  brain  as  follows:  Degeneration  occurs  and  a  limited  focus  of 
necrosis  forms  and  then  the  adjacent  tissue  shows  evidences  of  repair.  Capil- 
laries form  from  the  endothelial  cells,  glia  tissue  from  the  neuroglia,  ganglion- 
cells  present  karyokinetic  changes,  and  some  nerve-fibers  appear  in  the  scar 
(Senn's  "Principles  of  Surgery"). 

Repair  of  Muscles. — It  has  long  been  taught  that  the  repair  of  muscle 
by  muscle  is  impossible,  and,  as  a  matter  of  fact,  it  does  not  take  place  if  the 
ends  of  a  di\dded  muscle  are  separated  to  the  extent  of  an  inch  or  more.  When 
a  muscle  is  di\ided  transversely  by  a  cut  of  considerable  extent,  the  ends  of 
the  di\'ided  fibers  retract  and  a  \\ade  space  is  left  between  them.  Blood  flow^s 
into  the  space  between  the  ends,  and  also  betw^een  individual  fibers  of  the  in- 
jured muscle  and  the  blood-clots.  Exudation  of  plasma  occurs  and  migration 
of  corpuscles  takes  place.  Fibroblasts  are  produced  by  proliferation  of  con- 
nective-tissue cells  and  a  mass  of  fibroblasts  soon  replaces  the  blood-clot. 
Granulation  tissue  is  formed  by  vascularization  of  the  mass  of  fibroblasts,  and 
granulation  tissue  is  converted  into  scar  tissue,  but  not  at  all  into  muscle. 
After  sHght  injuries  a  trivial  amount  of  muscular  regeneration  does  occur  by  the 
multipKcation  of  li\dng  muscle-cells,  but  not  by  metamorphosis  of  fibroblasts. 


126  Repair 

Fibroblasts  are  incapable  of  transformation  into  muscular  tissue.  When  the 
ends  of  a  divided  muscle  are  separated  only  to  a  very  slight  degree  or  when  they 
have  been  brought  together  and  sutured,  some  muscular  regeneration  occurs. 
After  an  injury  a  number  of  the  muscular  fibers  always  wither,  perish,  and  are 
absorbed.  The  process  of  regeneration  arises  from  the  remaining  fibers.  The 
nuclei  of  the  muscle-fiber  proliferate  and  so  do  the  nuclei  of  the  perimysium. 
The  muscle-cells  are  called  myoblasts,  and  the  nuclei  of  the  perimysium  are 
called  sarcoblasts.  About  the  juvenile  muscle-cells  a  deposit  of  protoplasm 
takes  place  (Weber).  The  embryonal  cells  gradually  become  spindle-shaped, 
and  muscular  fiber  is  formed  by  cellular  fusion  or  by  elongation  of  individual 
cells. 

The  above  remarks  refer  to  striated  muscle.  Unstriated  muscle-fibers 
are  repaired  solely  by  "indirect  multiplication  of  their  nuclei"  (Senn). 

If  a  muscle  has  been  divided,  it  should  be  sutured.  This  process  insures 
more  rapid  repair  and  secures  a  better  functional  result,  and  is  followed  by  a 
much  greater  amount  of  muscular  regeneration. 

Repair  of  Tendon. — ^When  a  tendon  is  divided,  the  ends  retract,  and  the 
sheath,  as  a  rule,  becomes  filled  with  blood-clot.  The  blood-clot  is  rapidly 
removed,  fibroblasts  replacing  it.  This  new  tissue  arises  from  the  sheath, 
the  cut  ends  of  the  tendon  not  participating  in  its  formation.  Granulation 
tissue  is  formed;  this  is  converted  into  fibrous  tissue,  and  after  a  time  the 
fibrous  tissue  becomes  true  tendon.  If  no  blood-clot  forms  in  the  sheath,  the 
walls  of  this  structure  collapse  and  adhere,  and  the  separated  tendon-ends 
are  held  together  by  a  flat  fibrous  band  formed  from  the  collapsed  sheath 
(Warren's  "Surgical  Pathology"). 

Repair  of  Bone. — When  a  bone  is  broken  a  blood-clot  quickly  forms  in 
the  medullary  cavity,  between  the  broken  ends  and  under  and  outside  the  peri- 
osteum. Leukocytes  invade  and  destroy  the  clot.  The  cells  outside  the  peri- 
osteum, the  cells  of  the  periosteum  and  of  the  medullary  tissue,  particularly 
the  endothelial  cells,  proliferate  and  produce  cells  which  are  practically  fibro- 
blasts. The  osteoblasts  in  the  medullary  tissue,  and  perhaps  in  the  deeper 
layers  of  the  periosteum,  multiply  and  are  distributed  through  the  mass  of 
fibroblasts.  The  osteoblasts  may  form  bone  directly  or  may  form  cartilage 
first.  Some  teach  that  fibroblasts  can  be  converted  into  bone;  others  positively 
deny  such  a  conversion.  The  point  is  not  settled,  but  it  is  well  to  remember 
that  in  myositis  ossificans  a  muscle  is  converted  into  bone,  and  hence  that  it  is 
probable  that  fibroblasts,  which  are  formed  from  periosteum  and  medullary 
tissue,  are  more  prone  to  undergo  such  a  development.  During  regeneration 
the  bone  ends  soften  and  are  partially  absorbed  by  osteoclasts.  Osteoclasts  are 
large  osteoblasts  which  have  lost  the  power  of  bone  production  and  furnish  a 
secretion  which  dissolves  osseous  matter.  The  excess  of  callus  is  finally  ab- 
sorbed by  osteoclasts.  (For  a  more  extended  description  see  Repair  of  Frac- 
tures.) Sir  William  Macewan  has  recently  denied  that  the  periosteum  plays  a 
leading  role  in  bone  production  ("Brit.  Med.  Jour.,"  June  22,  1907).  He 
beheves  that  the  periosteum  is  a  membrane  to  limit  and  control  the  osteoblasts 
and  that  new  bone  is  formed  purely  from  bone  cells.  There  is  much  experimen- 
tal evidence  to  confirm  Sir  WiUiam's  assertion.  If  he  is  correct,  a  considerable 
osseous  defect  could  not  be  filled  up  by  new  bone  even  if  the  periosteum  were 
intact.  As  a  clinical  fact,  we  see  this  very  thing  occur.  In  a  more  recent 
article  ("Lancet,"  August  3,  191 2)  Sir  William  claims  that  osteoblasts  are  the 
essential  elements  in  repair,  that  they  come  from  cartilage  cells,  that  when 
growing  bone  is  stripped  of  periosteum  growth  continues,  that  when  bone 
is  removed  and  periosteiun  is  left  no  growth  occurs,  and  that  transplantation 
of  spicules  offers  the  best  chance  of  repair  because  each  fragment  furnishes 
peripheral  growth.    During  the  last  few  years  many  surgeons  have  utilized  bone 


Repair  of  Blood-vessels 


127 


transplantation,  for  instance,  transplanting  a  portion  of  a  rib  or  the  crest  of 
the  tibia  of  the  same  individual  to  fix  an  ununited  fracture,  to  fill  a  bone  gap  the 
result  of  osteomyelitis,  or  to  anchor  vertebrae  as  in  Albee's  operation  for  verte- 
bral caries.  John  B.  Murphy  in  many  respects  disagrees  with  IMacewan.  (See 
"Practical  Med.  Series,"  vol.  ii,  191 2.)  He  believes  that  a  bit  of  periosteum 
completely  detached  from  the  bone  of  a  young  individual  and  placed  in  the  fat 
or  muscle  of  the  same  individual  may  make  new  permanent  bone.  If  one  end 
of  the  strip  is  allowed  to  retain  attachment  to  the  bone,  the  transplanted  end 
practically  always  makes  new  bone.  Bone  with  or  without  periosteum  trans- 
planted in  the  same  indi\ddual  and  placed  in  contact  with  growing  bone  unites 
to  the  living  bone,  acts  as  a  scaffold  for  blood-vessels  and  osteogenetic  cells,  and 
is  eventually  absorbed. 


Fig.  68. — Fracture  one  week:  blood- 
clot  containing  fragment  of  bone  (War- 
ren). 


Fig.  69. — Callus  of  fracture 
(dog),  four  weeks:  commenc- 
ing ossiiicatioa  of  external 
callus  (Warren). 


Fig.  70. — Femur  of  a  child 
fifth  week  after  fracture 
(Warren). 


Repair  of  BIood=vessels. — If  an  arterv^  is  cut  across  and  ligated,  a  clot 
forms  T^athin  its  lumen  and  about  its  divided  end,  and  the  circulation  in  the 
vessel  at  this  point  is  permanently  arrested.  The  proximal  clot,  it  used  to  be 
thought,  always  reaches  the  first  collateral  branch.  This  statement  was  true 
before  the  days  of  asepsis;  it  is  not  always  true  now.  Often  a  clot  stops  far 
short  of  the  branch  above.  Exudation  of  plasma  and  migration  of  corpuscles 
take  place  from  the  vasa  vasorum.  The  clot  becomes  filled  with  leiikocytes, 
VN^hich  gradually  destroy  it,  and  it  plays  no  active  part  in  repair.  Fibroblasts 
form  by  the  multipHcation  of  the  cells  of  the  vessel  wall  and  the  clot  is  soon 
replaced  by  fibroblasts.  The  fibroblasts  are  converted  into  granulation  tissue, 
granulation  tissue  becomes  fibrous  tissue,  the  fibrous  tissue  contracts,  and  the 


128  Surgical  Fevers 

artery  is  transformed  into  a  fibrous  cord.  Warren  insists  that  the  muscle- 
cells  of  the  middle  coat  play  an  active  part  in  repair.  Usually,  when  a  liga- 
ture is  applied  to  an  artery  in  continuity,  a  deliberate  attempt  is  made  to 
rupture  the  internal  and  middle  coats,  in  order  to  permit  of  contraction  and 
retraction  above  and  below  the  seat  of  Hgature,  and  a  turning  inward  of  the 
inner  coat.  Such  a  sequence  of  events  happens  when  an  artery  is  completely 
divided  across  and  not  tied,  and  favors  the  rapid  formation  of  a  clot. 

Ballance  and  Edmunds  ("Ligation  in  Continuity")  maintain  that  repair 
is  obtained  most  rapidly  when  the  artery  is  tied  with  two  ligatures,  the  vessel 
at  this  point  being  deprived  of  blood,  but  the  internal  and  middle  coats  being 
kept  intact.  Cell-proliferation  forms  a  spindle-shaped  mass  of  new  cells  and 
the  lumen  is  obliterated  at  the  seat  of  ligation  by  fibroblasts  obtained  from 
the  fixed  cells  of  the  wall  of  the  artery.  Senn  advocates  the  employment  of 
two  ligatures,  not  placed  side  by  side  as  in  the  method  of  Ballance  and  Ed- 
mimds,  but  so  apphed  as  to  include  "a  bloodless  space  about  ^  inch  in 
length"  ("Principles  of  Surgery"). 

When  a  lateral  ligature  is  applied  to  a  vein  or  when  a  small  woimd  in  a 
vein  or  artery  is  sutured,  the  circulation  in  the  vessel  is  not  completely  cut  off, 
a  thrombus  of  small  size  is  formed  on  the  vessel  walls,  the  fixed  cells  of  the 
vessel  wall  proliferate,  and  a  scar  of  fibrous  tissue  effects  repair.  A  com- 
pletely divided  vein  heals  as  does  a  completely  divided  artery.  The  clot 
after  the  aseptic  application  of  a  ligature  to  a  vein  may  be  of  slight  extent, 
but  in  some  cases  the  proximal  clot  reaches  the  first  collateral  branch  and  in 
others  goes  far  above  it. 

Repair  of  Skin. — ^The  fibrous  structure  is  repaired  by  fibrous  tissue.  Hair- 
follicles,  sweat-glands,  and  sebaceous  glands  are  not  re-formed.  The  epitheHal 
layer  is  regenerated  by  the  proliferation  of  adjacent  epithelial  cells. 

Repair  of  Lymphatic  Tissue. — ^Lymphatic  tissue  can  regenerate  either 
from  the  fatty  tissue,  the  divided  ends  of  the  lymph-ducts,  or  both  structures. 

Repair  of  the  Kidney  and  Testicle. — These  organs  when  damaged  can 
undergo  some  regeneration. 

Repair  of  the  Liver  and  Spleen. — Each  of  these  organs,  after  injury,  is 
capable  of  considerable  regeneration. 


V.  SURGICAL   FEVERS 

The  surgeon  encounters  fever  as  a  result  of  an  inflammation  or  an  aseptic 
wound,  in  consequence  of  infection,  as  a  result  of  poisoning  by  certain  drugs, 
and  in  several  maladies  of  the  nervous  system.  It  is  important  to  remember 
that,  while  elevated  temperature  is  generally  taken  as  a  gauge  of  the  intensity 
of  fever,  it  is  not  a  certain  index.  There  may  be  fever  with  subnormal  tem- 
perature (as  in  the  collapse  of  typhoid  or  pneumonia),  and  there  may  be 
elevated  temperature  without  true  fever  (as  in  certain  diseases  of  the  nervous 
system).  It  is  true,  however,  that  elevation  of  temperature  is  almost  always 
noted,  and  is  usually  accepted  as  the  measure  of  the  severity  of  the  fever. 

Elevated  temperature  is  only  a  symptom.  The  elevated  temperature  of  an 
infection  may  be  regarded  as  evidence  that  the  body  is  fighting  the  infection. 
An  acute  infection  with  a  low  or  subnormal  temperature  is  a  far  graver  condi- 
tion than  an  acute  infection  with  a  high  temperature.  The  low  temperature 
shows  that  the  body  is  abandoning  the  contest;  the  subnormal  temperature 
shows  that  it  has  abandoned  it.  Exham  ("Brit.  Med.  Jour.,"  January  27, 
191 2)  points  out  that  the  worst  cases  of  pneumonia,  peritonitis,  and  diph- 
theria are  those  with  subnormal  temperature,  and  that  in  some  of  the  most 
malignant  cases  of  scarlet  fever  the  temperature  does  not  rise  much  above 


Aseptic  Traumatic  Fever  129 

100°  F.  As  Exham  says:  elevated  temperature  is  a  defence  and  subnormal 
temperature  means  that  body  resistance  is  at  an  end  (see  page  43).  If  in 
doubt  as  to  the  cause  of  fever,  count  the  leukocytes;  make  a  blood-culture,  a 
Widal  test,  and  a  Wassermann  test. 

The  essential  phenomena  of  fever,  according  to  Maclagan,  are — (i)  wasting 
of  nitrogenous  tissue;  (2)  increased  consumption  of  water;  (3)  increased 
elimination  of  urea;  (4)  increased  rapidity  of  circulation;  (5)  preternatural 
heat. 

Traumatic  fevers  follow  a  traumatism  and  attend  the  healing  or  infection 
of  a  wound.  The  forms  are — (i)  benign  traumatic  fever;  (2)  malignant  trau- 
matic fever. 

Benign  traumatic  fever  is  divided  into  two  forms — the  aseptic  and  the 
septic.  There  is  but  one  form  of  aseptic  fever,  the  postoperation  rise.  The 
septic  benign  fevers  are  surgical  fever  and  suppurative  fever.  The  malignant 
traumatic  fevers  are  sapremia,  septic  infection,  and  pyemia.  In  this  section 
we  discuss  only  the  benign  fevers. 

Aseptic  traumatic  fever,  or  the  postoperation  rise,  often,  but  not  always, 
appears  after  a  thoroughly  aseptic  operation  and  after  a  simple  fracture  or  a 
contusion.  It  is  not  preceded  by  a  chill,  by  chilliness,  or  by  a  feeling  of  illness. 
It  may  appear  during  the  evening  of  the  da}'  of  operation  or  not  until  the  next 
day,  and  reaches  its  highest  point  by  the  evening  of  the  second  day  (ioo°-io3° 
F.).  This  elevation  is  spoken  of  as  the  "postoperation  rise"  because  it  is 
usually  encountered  after  an  operation.  Besides  the  elevated  temperature 
there  are  no  ob^dous  symptoms;  the  patient  feels  well,  sleeps  well,  and  often 
wants  to  sit  up;  there  are  no  rigors  and  there  is  no  delirium.  The  woimd  is 
free  from  pain  and  appears  entirely  normal.  Blood  examination  may  show 
moderate  leukocytosis.  This  fever  is  due  to  absorption  of  pyrogenous  material 
from  the  woimd  area,  the  material  being  obtained  from  clot  or  inflammatory 
exudate,  or  from  both.  IVIany  observ^ers  believe  that  the  pyrogenous  element 
is  fibrin  ferment,  which  is  absorbed  from  disintegrating  blood-clot  and  coagu- 
lating exudate.  Warren  thinks  the  fever  is  due  to  fibrin  ferment,  and  "also 
to  other  substances  sHghtly  altered  from  their  original  composition  during  life." 
Some  have  asserted  that  the  fever  is  due  to  nerv^ous  shock. 

Schnitzler  and  Ewald  have  studied  aseptic  fever.^  These  observers  main- 
tain that  aseptic  fever  can  exist  when  no  fibrin  ferment  is  free  in  the  blood,  that 
fibrin  ferment  can  be  free  in  the  blood  when  there  is  no  fever,  and,  in  conse- 
quence, that  fibrin  ferment  is  not  the  cause  of  the  elevation  of  temperature. 
They  rule  out  of  consideration  nerv^ous  shock  as  a  cause,  and  assert  that  a 
combination  of  several  factors  is  responsible,  nucleins  and  albumoses  which 
are  set  free  by  traumatism  being  looked  upon  as  the  most  active  causative 
agents.  The  presence  of  nuclein  in  the  blood  in  aseptic  fever  is  indicated  by 
leukocytosis  and  by  the  increase  of  the  alloxur  bodies  (including  uric  acid)  in 
the  urine.  The  capacity  of  nucleins  and  albumoses  to  cause  elevated  tempera- 
ture is  greater  in  the  tuberculous  than  in  the  non-tuberculous,  and  we  know 
clinically  that  a  tuberculous  patient  is  apt  to  exhibit  a  more  \dolent  postopera- 
tion rise  than  is  a  non-tuberculous  subject.  The  diagnosis  of  aseptic  traimiatic 
fever  is  only  to  be  made  after  a  careful  examination  has  assured  the  sturgeon 
that  there  is  no  obscure  or  hidden  area  of  infection. 

In  some  cases  aseptic  fever  may  appear  after  an  operation,  and  later  be 
replaced  by  a  septic  fever.  If  the  temperature  remains  elevated  more  than  a 
day  or  so,  if  other  s^onptoms  appear,  or  if  after  the  temperature  has  become 
normal  it  again  rises,  the  wound  should  be  examined  at  once,  as  trouble  almost 
certainly  exists. 

^  See  "Archiv  fiir  klinische  Medicin,"  Bd.  liii,  H.  3,  1896;  also  statement  of  their  \-iews 
in  "Medical  Record,"  Dec.  19,  1896. 


130  Surgical  Fevers 

True  traumatic,  or  genuine  surgical  fever,  is  seen  as  a  result  of  infected 
wounds  in  which  there  is  decided  inflammation,  but  no  pus.  The  real  cause 
is  the  presence  of  fermentative  bacteria  in  the  wound  and  the  absorption  of  a 
moderate  amount  of  their  toxic  products.  The  most  active  and  commonly 
present  organisms  are  those  of  putrefaction.  Surgical  fever  ceases  as  soon  as 
free  discharge  occurs,  and  the  appearance  of  such  a  fever  is  an  indication  for 
instant  drainage.  The  condition  is  ushered  in  two  or  three  days  after  the 
operation  by  chilly  sensations  and  general  discomfort.  The  temperature  rises 
pretty  sharply,  ascends  with  evening  exacerbations  and  morning  remissions, 
and  reaches  its  height  about  the  third  or  fourth  day,  when  suppuration  sets  in; 
the  temperature  begins  to  drop  when  pus  forms,  if  the  pus  has  free  exit,  and 
reaches  normal  at  the  end  of  a  week.  (See  Suppurative  Fever.)  The  tempera- 
ture may  reach  104°  F.  or  more,  but  rarely  rises  above  103°  F.  The  patient  has 
the  general  phenomena  of  fever,  that  is  to  say,  thirst,  anorexia,  nausea,  dry  and 
coated  tongue,  constipation,  pain  in  the  back  and  legs,  and  headache.  The 
urine  is  scanty  and  high  colored.  Blood  examination  usuaUy  shows  decided 
leukocytosis.  The  wound  is  painful,  tender,  swollen,  discolored,  and  often 
foul,  and  stitch-abscesses  may  form.  Some  or  all  of  the  stitches  must  be  cut, 
the  area  should  be  asepticized,  the  wound  edges  separated  by  iodoform  gauze, 
or  the  wound  drained  by  a  tube.  The  fact  that  this  fever  is  apt  to  cease  when 
discharge  of  pus  begins  led  the  older  surgeons  to  hope  for  pus  and  to  endeavor 
to  cause  it  to  form.  A  severe  grade  of  surgical  fever,  such  as  arises  when  there 
is  putrefaction  in  a  large  and  ill-drained  wound,  is  due  to  the  absorption  of  a 
large  quantity  of  the  toxic  products  of  putrefactive  bacteria,  and  is  known  as 
sapremia  (see  p.  194). 

Suppurative  Fever. — ^This  fever,  which  is  due  to  the  absorption  of  the 
toxins  of  pyogenic  organisms,  occurs  after  suppuration  has  begun,  is  found 
when  the  pus  has  not  free  exit,  and  is  an  intoxication  rather  than  an  infection, 
that  is  to  say,  toxins  enter  the  blood,  but  no  bacteria.  It  can  follow  or  be 
associated  with  surgical  fever,  or  may  arise  in  cases  in  which  surgical  fever  has 
not  existed.  Suppuration  in  a  wound  is  indicated  by  a  rapid  rise  of  tempera- 
ture— possibly  by  a  chill.  The  temperature  rises  to  a  considerable  height, 
shows  morning  remissions  and  evening  exacerbations,  and  as  it  begins  to  fall 
toward  morning  sweating  occurs.  The  patient  is  much  exhausted  and  presents 
the  phenomena  of  fever  previously  described.  The  skin  about  the  wound  be- 
comes swollen,  dusky  in  color,  and  edematous,  pain  becomes  pulsatile,  and  much 
tenderness  develops.  Blood  examination  shows  very  marked  leukocytosis. 
The  wound  must  at  once  be  drained  and  asepticized.  In  a  chronic  suppuration, 
such  as  occurs  when  there  is  pyogenic  infection  of  a  tuberculous  area,  there  ex- 
ists a  fever  with  marked  morning  remissions  and  vesperal  exacerbations,  at- 
tended with  drenching  night-sweats,  emaciation,  diarrhea,  and  exhaustion. 
This  is  known  as  hectic  fever;  it  is  reaUy  a  chronic  suppurative  fever.  The  treat- 
ment of  hectic  fever  consists  in  the  drainage  and  disinfection,  if  possible,  the 
excision  of  the  infected  area,  the  employment  of  a  nutritious  diet,  stimulants, 
tonics,  remedies  for  the  exhausting  sweats,  and  free  access  of  fresh  air. 

Some  Other  Forms  of  Fever  Seen  by  the  Surgeon. — Fever  of 
Tension. — ^When  there  is  great  tension  upon  the  stitches,  the  spots  where  the 
stitches  perforate  ulcerate  and  some  fever  arises.  To  reheve  the  fever  of 
tension  cut  one  or  several  stitches.  This  fever  is  in  some  cases  surgical,  and 
in  some  suppurative,  according  as  to  whether  the  infective  organisms  cause 
fermentation  or  suppuration. 

Fever  of  Iodoform  Absorption. — (See  page  31.) 
Fever  of  Ptyalism,  or  Mercurial  Fever. — (See  page  338.) 
Fever  Due   to  Awakening  of  An  Area  of  Pulmonary  Tuberculosis. — A 
quiet,  non-progressive  area  of  pulmonary  tuberculosis  may  burst  into  activity 


Svirgical  Scarlet  Fever  131 

after  an  operation,  and  is  particularly  apt  to  if  ether  was  administered.  The 
surgeon  must  be  watchful  of  this  condition.  Several  times  I  have  seen  a 
person  vdth  signs  suggesting  bronchitis  at  the  base  of  one  lung  develop  a  moder- 
ate and  prolonged  fever.  Such  a  condition  is  not  bronchitis  because  it  is  uni- 
lateral. The  sputum  shows  pus  cocci,  but  no  tubercle  bacilli.  I  formerlv  re- 
garded it  as  tuberculosis,  but  it  is  always  recovered  from  and  is  probably 
bronchopneiunonia  of  one  lobe  of  one  lung. 

Fever  of  Morphinism. — Sometimes  a  morphin  habitue  suffers  from  severe 
chills  and  intermittent  fever  of  the  quotidian  or  tertian  type.  The  condition 
is  usually  thought  to  be  malarial,  a  \dew  which  is  strengthened  by  the  common 
association  T\-ith  neuralgia;  but  quinin  proves  futile  as  a  remedy  and  blood 
examination  gives  a  negative  result.  If  we  have  reason  to  suspect  that  the 
patient  is  using  morphin,  examine  the  urine  for  the  drug  and  wash  out  the 
stomach  and  examine  the  washing.  The  latter  test  is  of  value  even  when 
morphin  is  used  hx-podermatically,  because  some  of  the  drug  is  excreted  into 
the  stomach. 

Fever  of  Cocam-poisoning. — (See  Local  Anesthesia.) 

Hepatic  Fever. — (See  section  on  Liver  and  Gall-bladder.) 

Neurotic  or  Hysterical  Fever. — This  remarkable  condition  is  occasionally, 
though  seldom,  encountered.  It  is  unusual  for  the  temperature  to  rise  above 
101°  F.  Most  of  the  reported  cases  of  great  h>7)erpyrexia  are  instances  of 
simulation  and  fraud.  That  very  great  elevation  can  occur  is  shown  by  the 
case  seen  by  Mr.  J.  W.  Teale,  which  case  was  also  observed  by  Sir  Clifford 
AUbutt.  The  temperatm-e  rose  again  and  again  to  118°  F.  In  such  cases  the 
temperature  rises  ven,-  rapidly,  remains  at  its  height  but  a  short  time,  and  then 
falls  as  rapidly  as  it  arose.  It  may  happen  that  elevated  temperature  is  the 
sole  e\'idence  of  iUness.  there  being  no  wasting,  thirst,  or  other  febrile  s}Tnp- 
toms.  Cold  sponging  rapidly  lowers  the  temperatiu^e.  Such  elevated  tempera- 
ture may  occur  irregularly  or  be  attained  daily  for  months.  As  a  rule,  hys- 
terical stigmata  can  be  detected.  Osier  points  out  that  cases  of  hysterical 
fever  ''with  spurious  local  manifestations"  are  verv^  deceptive.  The  case  may 
resemble  meningitis,  peritonitis,  or  some  other  acute  inflammatory'  condition; 
but  the  course  of  the  supposed  malady  is  found  to  be  atypical  and  the  symptoms 
are  observed  to  be  variable  and  often  anomalous.  There  is  no  leukocytosis; 
frequently  there  is  an  apparent  increase  in  red  cells,  because  of  vasomotor 
distiurbance,  a  faU  in  hemoglobin,  and  an  increased  proportion  of  lymphocytes 
and  eosinophiles  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.).  It  is 
dangerous  to  make  a  diagnosis  of  neurotic  fever;  it  must  not  be  done  unless 
aU  other  possible  causes  have  been  excluded.  Some  supposed  cases  depend 
upon  imrecognized  tuberculosis,  some  on  visceral  syphilis,  some  on  imdiscov- 
ered  malignant  disease,  some  on  toxin  absorption  from  the  alimentary  canal. 

An  emotional  fever  sometimes  occurs  after  accidents  or  operations.  The 
patient  may  have  a  chill,  and  then  develop  \dolent  headache,  photophobia,  and 
hysterical  excitement,  with  elevated  temperature.  Inexplicable  elevations  of 
temperature  may  occur  in  neurasthenia. 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed  septic  fevers,  for 
only  by  this  means  can  malaria  be  excluded.  It  is  more  common  to  mistake 
sepsis  for  malaria  than  malaria  for  sepsis.  In  malaria  the  spleen  is  enlarged, 
the  febrile  attacks  exhibit  periodicity,  neuralgias  are  common  associates,  and 
quinin  cures  the  condition. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  wTiters  (notably  Sir 
Victor  Horsley  and  Sir  James  Paget)  that  a  child  is  rendered  especially  sus- 
ceptible to  scarlet  fever  by  the  shock  of  a  siu-gical  operation.  Scarlet  fever 
which  develops  after  a  wound,  a  burn,  or  an  operation  is  spoken  of  as  surgical 
scarlet  fever.    Warren  quotes  Thomas  Smith  as  ha\'ing  had  10  cases  of  scarlet 


132  Suppuration  and  Abscess 

fever  in  43  operations  of  lithotomy  in  children.  The  puerperal  state  is 
supposed  also  to  predispose  to  scarlet  fever.  It  is  not  certain  whether  the 
poison  enters  by  the  wound,  or  whether  shock  and  exhaustion  predispose  to 
ordinary  scarlatina,  or  whether  ordinary  scarlatina  was  incubating  before 
the  accident  or  operation.  Some  surgeons  hold  that  an  attack  of  scarlet  fever 
after  an  operation  is  a  mere  coincidence.  Others  maintain,  and  with  great 
show  of  reason,  that  a  red  scarlatiniform  eruption  appearing  after  an  operation 
rarely  indicates  genuine  scarlet  fever,  but  usually  points  to  infection,  as  such 
eruptions  are  known  occasionally  to  arise  in  septicemia.  It  rarely  indicates 
scarlet  fever,  and  yet  it  sometimes  does.  There  is  such  a  condition  as  surgical 
scarlet  fever,  as  is  proved  by  the  facts  that  victims  of  the  disease  have  been 
known  to  communicate  it,  and  that  it  is  often  followed  by  "nephritis  and 
usually  by  desquamation"  (Holt's  "Diseases  of  Infancy  and  Childhood"). 

Hoffa  has  discussed  this  subject  elaborately.  He  concludes  that  four  types 
of  eruption  can  follow  operation:  (i)  a  vasomotor  disturbance  due  to  irrita- 
tion of  sensory  nerves,  and  manifested  by  a  transient  urticaria  or  erythema; 
(2)  a  toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  material  from 
the  injured  area — the  absorption  of  carbolic  acid,  iodoform,  of  corrosive 
sublimate,  or  the  effect  of  ether;  (3)  an  infectious  rash,  which  is  sometimes 
found  in  septicemia  or  pyemia,  and  is  due  to  minute  emboli  composed  of  bac- 
teria, which  emboli  lodge  in  the  capillaries;  (4)  true  scarlet  fever,  with  the  usual 
symptoms  and  complications,  the  micro-organisms  having  entered  by  way  of 
the  wound  and  the  eruption  often  beginning  at  the  wound  edges  (quoted  in 
Warren's  "Surgical  Pathology").  Surgical  scarlatina  is  aberrant.  It  develops 
rapidly,  the  period  of  incubation  is  extremely  brief,  and  the  throat  may  or  may 
not  be  involved.  Holt  tells  us  that  the  rash  is  usually  atypical  and  that  "the 
general  symptoms,  particularly  those  relating  to  the  nervous  system,"  are 
"especially  severe"  ("Diseases  of  Infancy  and  Childhood").  The  infection 
is  believed  to  be  due  to  a  specific  germ,  but  it  has  not  been  certainly  identi- 
fied. Streptococci  have  been  found  in  the  throat,  skin,  and  the  pus  from 
secondary  otitis  media. 

If  surgical  scarlet  fever  develops  the  wound  should  be  drained  and  asepti- 
cized, and,  if  the  situation  admits  of  it,  dressed  with  hot  antiseptic  fomentations. 
The  general  treatment  is  the  same  as  for  ordinary  scarlatina. 

Fever  of  Malignant  Disease. — Elevation  of  temperature  may  occur  during 
the  course  of  sarcoma  or  carcinoma.  It  is  particularly  apt  to  if  growth  is  very 
rapid  or  if  ulceration  exists.  Malignant  growths  of  the  liver  are  especially  apt 
to  cause  elevation  of  temperature  and  leukocytosis. 

Fever  of  malignant  disease  usually  appears  as  irregular  elevations  of  tem- 
perature of  short  duration.  In  some  cases  there  is  a  continuous  or  remittent 
fever;  in  some  an  intermittent  fever.    Even  the  hectic  type  is  met  with. 

Urinary  Fever  and  Urethral  Fever. — (See  section  on  Disease  of  Genito- 
urinary Organs.) 

Syphilitic  Fever. — (See  page  322.) 

Thyroid  Fever. — (See  section  on  ThjToid  Gland.) 


VI.  SUPPURATION   AND   ABSCESS 

Suppuration  is  a  process  in  which  damaged  living  tissues  and  inflamma- 
tory exudates  are  liquefied  by  the  action  of  pyogenic  organisms,  and  it  is  a  com- 
mon result  of  microbic  inflammation.  The  organisms  which  are  responsible 
are  referred  to  on  page  48.  Staphylococci  tend  to  produce  local  suppuration; 
streptococci  tend  to  cause  spreading  suppuration.  It  is  generally  taught  that 
pyogenic  bacteria  liquefy  damaged  tissues  and  exudates  by  peptonizing  them, 


Suppuration  133 

the  active  agent  in  effecting  the  chemical  change  being  poison  furnished  by 
the  bacteria.  There  is  some  evidence  that  white  corpuscles  by  disintegration 
set  free  enzymes,  which  dissolve  or  aid  in  dissolving  albumin.  Streptococci 
and  staphylococci  vary  greatly  in  virulence,  and  the  intensity  and  diffusion  of 
a  pyogenic  infection  depends  upon  the  virulence  and  nimiber  of  the  bacteria 
and  the  level  of  vital  resistance.  Streptococci  and  staphylococci  may  both  be 
present  in  one  focus,  and  there  may  be  secondary  infection  with  bacteria  of 
putrefaction  or  other  bacteria.  The  pyogenic  infection  may  be  primary  or  it 
may  be  secondarily  implanted  in  a  disease  area  containing  other  micro-organ- 
isms. The  pyogenic  organisms  are  very  irritant,  and  when  deposited  cause  in- 
flammation; inflammation  leads  to  exudation,  but  the  exudate  cannot  co- 
agulate or  coagulates  but  imperfectly,  because  it  is  peptonized  by  the  fer- 
ment of  the  micro-organisms  and  also  perhaps  because  albumin  is  dissolved 
by  leukolysin  from  the  white  corpuscles.  If  an  area  of  embryonic  tissue  is 
invaded  by  many  pyogenic  micro-organisms,  it  is  promptly  peptonized.  The 
peptonizing  action  is  upon  the  fibrinous  elements  of  an  exudate  and  upon  the 
intercellular  substance  of  embryonic  or  granulation  tissue.  Cells  are  separated 
from  intercellular  substance,  and  in  consequence  degenerate  and  die.  Pep- 
tonized exudate  or  peptonized  embryonic  tissue  is  called  pus.  In  suppurations 
induced  by  staphylococci  a  barrier  of  leukocytes  is  first  formed  around  the  re- 
gion of  irritation ;  this  barrier  is  reinforced  by  fibroblasts,  the  pus  is  imprisoned, 
and  rapid  spreading  and  wide  diffusion  are  prevented.  In  inflammations  in- 
duced by  streptococci  the  peptonizing  action  of  the  organisms  is  so  great  that 
no  barrier  of  white  blood-cells  or  of  proliferating  connective-tissue  cells  forms  in 
time  to  imprison  the  micro-organisms,  hence  the  suppuration  spreads  rapidly 
and  widely.  During  the  existence  of  a  streptococcic  infection  some  bacteria 
always  enter  the  blood.  Suppuration  can  be  induced  by  the  injection  of  pyo- 
genic bacteria,  by  their  entry  through  a  wound,  and  by  rubbing  them  into  the 
skin.  In  some  rare  instances,  especially  when  the  diet  has  been  putrid,  they 
may  enter  through  the  blood  and  lodge  at  a  point  of  least  resistance.  When  a 
medullary  canal  suppurates  after  a  chill  to  the  surface  or  after  a  blow  that  does 
not  cause  a  wound,  we  know  that  the  bacteria  must  have  arrived  by  means  of 
the  blood.  Bacteria  which  reach  a  point  of  least  resistance  through  the  blood 
come  from  some  atrium  of  infection  which  may  be  discoverable  or  which  may 
not  be  foimd.  The  entry  of  pyogenic  bacteria  does  not  necessarily  cause 
suppuration,  as  the  healthy  human  body  can  destroy  a  considerable  number, 
even  if  given  in  one  "dose";  but  a  large  number  in  a  healthy,  or  even  a  small 
number  in  an  unhealthy,  body  almost  certainly  leads  to  pus  formation.  The 
pus  of  aU  acute  abscesses  contains  bacteria  of  suppuration,  but  the  pus  of 
tuberculous  abscesses  does  not,  unless  there  be  a  mixed  infection;  in  other 
words,  pure  tuberculous  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  the  actual  presence  of  bacteria?  It  is 
true  that  the  injection  of  irritants  can  cause  the  formation  of  a  thin  fluid  which 
contains  no  bacteria,  but  this  non-bacterial  fluid  is  not  pus.  A  purulent  fluid 
is  formed  by  injecting  cultures  of  pus  cocci  which  have  been  rendered  sterile 
by  heat,  the  bacteria  having  been  killed,  a  ferment  contained  in  the  bacterial 
cells  being  the  active  agent.  Purulent  material  also  results  from  the  injection 
simply  of  the  sterile  products  of  the  growth  of  pyogenic  cocci.  This  purulent 
or  sterile  fluid  is  known  as  spurious  or  aseptic  pus.  An  area  of  such  aseptic 
suppm-ation  does  not  tend  to  spread  and  the  process  concerns  us  but  little  as 
surgeons,  except  in  cases  of  pyemia,  in  which  thrombi  containing  toxins  alone 
may  occasionally  induce  limited  secondary  abscesses. 

Impaired  health  or  an  area  of  lowered  \dtality  predisposes  to  suppura- 
tion. Diabetes  and  albuminuria  are  common  and  influential  predisposing 
causes,  because  in  these  diseases  tissue  resistance  is  always  at  a  low  ebb.     In 


134 


Suppuration  and  Abscess 


amyloid  disease  resistance  to  pus  cocci  is  greatly  impaired.  It  is  lessened  in 
lithemia  and  in  any  condition  of  ill  health.  The  lymphatic  glands,  medulla 
of  bones,  serous  membranes,  and  connective  tissue  are  especially  prone  to  sup- 
purate. 

Pus  may  form  within  twenty-four  hours  after  bacteria  have  been  deposited, 
or  it  may  not  be  formed  for  days.  The  older  surgeons  claimed  that  pus  could 
do  good  by  protecting  granulations  and  separating  disorganized  tissue.  It 
is  now  held  that  it  is  absolutely  harmful  by  melting  down  sound  tissue  and 
poisoning  the  entire  organism.  Modern  surgery  has  to  a  great  degree  abohshed 
pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — (i)  a  watery  por- 
tion, the  liquor  puris  or  pus-serum,  containing  peptone,  fat,  microbic  products, 
osmazone,  and  salts,  and  not  tending  to  coagulate;  (2)  a  solid  portion,  or 
sediment  composed  of  dead  and  living  micro-organisms  of  suppuration,  connect- 
ive-tissue cells,  often  epithehal  cells,  perhaps  red  blood-cells,  lymphocytes, 
pus-corpuscles  (Fig.  71),  debris  of  tissue,  and  shreds  of  dead  tissue.     The 


Fig.  71. — Fragmentation  of  nucleus  in  leukocytes  undergoing  transformation  into  pus-corpuscles  (Senn). 

pus-corpuscles  are  either  pol)niuclear  white  blood-cells  or  altered  connective- 
tissue  cells  containing  many  nuclei.  Some  of  them  are  dead,  some  have  ame- 
boid movements,  some  are  fatty,  others  are  granular  and  contain  more  than  one 
nucleus,  and  all  are  degenerating.  A  pus-ceU  is  waste  matter,  and  it  cannot 
aid  in  repair.  Very  exceptionally  pus  disappears  by  absorption,  by  caseation, 
or  by  calcification. 

Pus  in  General. — The  color  of  pus  is  variable  and  depends  upon  the  nature 
of  the  bacteria;  the  presence  or  absence  of  blood,  fibrin,  body  secretions  or 
body  excretions  (bile,  tirine,  mucus,  feces,  etc.);  and  the  existence  or  non- 
existence of  putrefaction. 

Its  consistence  varies.  In  some  cases  it  is  scarcely  thicker  than  water,  in 
others  it  is  like  cream,  and  in  still  others  it  is  cheesy.  Thick  pus  is  opaque  and 
of  a  greenish-yellow  color,  and  thin  pus  has  a  distinct  reddish  or  yellowish  tinge. 
When  freshly  evacuated  many  varieties  are  almost  or  quite  odorless,  and  are 
alkaline  or  slightly  acid  in  reaction. 

Some  varieties  possess  a  very  offensive  odor.     Pus  contaminated  by  the 


Signs  and  Symptoms  of  Suppuration  135 

bacteria  of  putrefaction  is  certain  to  have  a  foul  odor.  Pus  which  forms  in  the 
tonsil,  in  the  brain,  about  the  vermiform  appendix,  or  around  the  rectum  usu- 
ally possesses  an  offensive  odor. 

Forms  of  Pus. — Laudable,  or  healthy  pus,  a  name  long  in  vogue,  is  a  con- 
tradiction, no  pus  being  healthy.  In  former  days  free  suppuration  after  an 
operation  was  regarded  as  a  favorable  indication,  and  when  it  occurred  the 
surgeon  congratulated  himself  that  surgical  fever  was  at  an  end.  At  the  present 
day  suppuration  after  an  operation  is  an  evidence  of  previous  infection,  of 
lack  of  care,  failure  in  our  precautions,  or  of  infection  by  the  blood.  The 
so-called  laudable  pus  is  seen  coming  from  a  healing  ulcer,  and  is  an  opaque, 
yellowish- white,  or  a  greenish  fluid  of  the  consistence  of  cream,  without  odor 
or  with  a  very  slight  odor  if  it  is  not  putrid,  and  having  a  specific  gravity  of 
about  1030. 

Malignant,  watery,  or  ichorous  pus  is  a  thin,  watery,  putrid  fluid.  It  is 
pus  filled  with  the  organisms  of  putrefaction. 

Stinking  pus  may  be  ichorous.  Its  odor  may  be  due  to  the  Bacterium  coli 
corrmume.  If  this  bacteriimi  is  the  cause  the  pus  is  very  foul,  but  not  thin. 
Pus  of  this  nature  is  met  with  in  ischiorectal  abscess  and  appendiceal  abscess. 
The  odor  of  stinking  pus  may  be  due  to  ordinary  bacteria  of  putrefaction,  in 
which  case  the  pus  is  usually  thin. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood  coloring-matter 
or  blood.  It  is  thin,  of  a  reddish  color,  and  very  acrid,  corroding  the  parts 
with  which  it  comes  in  contact.     It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrinous  pus,  which  contains  flakes  of  fibrin  or  coagulated 
fibropurulent  masses,  is  met  with  in  serous  cavities  (joints,  pleura,  etc.). 
These  masses  also  form  in  infective  endocarditis. 

Red  pus  signifies  the  presence  of  the  Bacillus  prodigiosus. 

Blue  Pus. — ^The  color  of  blue  pus  is  due  to  the  Bacillus  pyocyaneus. 

Orange  Pus. — The  color  of  orange  pus  is  due  either  to  the  action  of  Sarcina 
aurantiaca,  or  to  the  formation  of  crystals  of  hematoidin  from  the  coloring- 
matter  of  red  blood-cells  which  have  been  mingled  with  the  pus.  Pus  of  this 
color  appears  only  in  violent  inflammations. 

Serous  pus  is  a  thin,  serous  fluid,  containing  few  flakes. 

So-called  tuberculous,  scrofulous,  or  curdy  pus  is  not  pus  at  all,  unless  the 
tuberculous  area  has  undergone  pyogenic  infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a  gumma  which 
has  outgrown  its  own  blood-supply.     It  is  not  pus. 

Mucopus  is  found  in  purulent  catarrh — that  is,  in  suppurative  inflammation 
of  an  epithelial  structure.     It  contains  pus  elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus-corpuscles  or  in- 
flammatory exudations.  It  occurs  especially  in  tuberculous  processes.  A 
caseous  mass  may  calcify. 

Signs  and  Symptoms  of  Suppuration. — Suppiu-ation  is  announced  by 
the  intensification  of  all  local  inflammatory  signs.  The  heat  becomes  more 
marked,  the  discoloration  dusky,  the  swelling  augments,  the  pain  becomes 
throbbing  or  pulsatile,  and  the  sense  of  tension  is  greatly  increased.  The  skin 
at  the  focus  of  the  inflammation  after  a  time  becomes  adherent  to  the  parts 
beneath,  and  fluctuation  soon  appears.  This  adhesion  of  the  skin  is  a  prepara- 
tion for  a  natural  opening,  and  is  known  as  pointing.  An  important  sign  of  pus 
beneath  is  edema  of  the  skin.  This  is  always  observed  in  a  superficial  abscess, 
and  is  sometimes  noticeable  in  empyema  or  pyothorax,  in  appendiceal  abscess, 
and  in  perirenal  suppuration.  The  above  symptoms  can  be  reinforced  and  their 
significance  proved  by  the  introduction  of  an  aseptic  tubular  exploring  needle 
and  the  discovery  of  pus.  Irregular  chiUs,  high  fever,  drenching  sweats,  weak- 
ness, and  a  feeling  of  serious  sickness  are  very  significant  of  suppuration  in  an 


136  Suppuration  and  Abscess 

important  structure  or  of  a  large  area.  It  must  always  be  remembered  that  in 
some  virulent  pyogenic  infections  the  human  organism  is  so  overwhelmed  with 
toxins  that,  though  the  patient  is  desperately  ill,  the  temperatiire  is  normal  or 
even  subnormal.  This  means  that  body  resistance  has  abandoned  the  conflict. 
In  abscess  of  the  brain  the  temperature,  after  an  initial  rise,  often  becomes 
normal  or  subnormal. 

Diffuse  Cellulitis  or  Phlegmonous  Suppuration  (Purulent  Infiltration). — 
This  process  may  involve  a  small  area  or  an  entire  limb,  and  is  due  to  infection 
by  the  Streptococcus  pyogenes  (streptococcus  of  erysipelas),  usually  asso- 
ciated with  mLxed  infection  with  other  bacteria,  particular^  the  bacteria  of 
putrefaction.  The  streptococci  are  intensely  virulent.  Barriers  of  white 
corpuscles  do  not  form  early  enough  to  restrain  them,  and  tissues  break  down 
before  cellular  multipHcation  is  able  to  encompass  the  bacteria.  The  bacteria 
disseminate  through  the  lymph-spaces  and  lymph-vessels.  The  disease  in 
severe  cases  produces  enormous  swelling,  areas  which  feel  boggy,  a  dusky  red 
discoloration,  and  great  burning  pain.  Gangrene  of  superficial  areas  is  not 
unusual,  due  to  thrombosis  of  vessels  or  coagulation  necrosis  from  toxins. 
The  discharges  of  the  wound,  if  a  wound  exists,  are  apt  to  dry  up,  and  the 
wound  becomes  foul,  dry,  and  brown.  The  adjacent  lymphatic  glands  are 
much  enlarged.  The  disease  is  ushered  in  by  a  chill,  which  is  followed  by  high 
oscillating  temperature,  due  to  suppurative  fever,  sapremia,  or  even  septic 
infection  or  pyemia.  Sweats  are  noted  during  periods  of  falling  temperature. 
Diffuse  suppuration  tends  to  arise  in  an  infected  compound  fracture  after  ex- 
travasation of  urine  and  after  the  infliction  of  a  wound  upon  a  person  broken 
down  in  health.  It  is  not  unusual  after  typhoid  or  scarlet  fever,  and  is  t^q^ical 
of  phlegmonous  erysipelas.  The  pus  is  sanious  and  offensive,  and  burrows 
widely  in  the  subcutaneous  tissue  and  intermuscular  planes.  This  diffuse 
suppuration  may  widely  separate  muscles  and  even  lay  bare  the  bones.  It  is  a 
very  grave  condition,  and  may  cause  death  by  exhaustion,  septic  intoxication, 
septic  infection,  pyemia,  or  hemorrhage  from  a  large  vessel  which  has  been 
corroded.  Cellulitis  of  a  mild  degree  is  due  to  attenuated  streptococci  or  to 
staphylococci.  An  area  of  cellulitis  may  surround  an  infected  w^ound  or  a 
stitch-abscess.  Its  spread  is  manifested  by  red  lines  of  l^onphangitis  running 
up  to  the  adjacent  lymphatic  glands.  Light  cases  may  not  suppurate,  the 
lymphatics  carrying  off  the  poison.  Any  case  of  cellulitis  is,  however,  a  menace, 
and  any  severe  case  is  highly  dangerous.     (See  Erysipelas.) 

Wooden,  Woody,  or  Ligneous  Phlegmon. — This  condition  was  fully  de- 
scribed by  Reclus  in  1893.  It  is  chronic  inflammation  of  the  ceUular  tissue  and 
fascia,  and  is  characterized  by  the  production  of  quantities  of  fibrous  tissue. 
It  occurs  in  those  over  fifty  years  of  age.  The  neck  is  the  region  usuaUy 
involved.  It  begins  with  hard  sweUing  of  one  side  or  of  the  front  of  the  neck 
and  for  weeks  is  unaccompanied  by  any  other  sign.  The  sweUing  may  be  at 
first  localized,  but  it  spreads  slowly  and  widely  and  finally  comes  to  involve 
an  extensive  area,  even  perhaps  the  front  of  the  neck  and  both  sides  from  the 
jaw  to  the  collar-bone.  It  may  involve  the  cervical  muscles  and  thus  create 
rigidity,  and  it  may  compress  the  larynx  and  trachea  and  thus  interfere  with 
breathing.  In  most  cases  there  is  difficulty  in  swaUowing.  After  weeks,  or 
perhaps  a  month  or  two,  the  skin  becomes  edematous  and  red  or  rather  of  a 
violet  hue.  There  is  no  fever  and  rarely  pain.  The  significant  facts  are  the 
graduaUy  advancing  hard  swelling  long  unaccompanied  by  fever,  pahi,  dis- 
coloration, or  cutaneous  edema.  The  condition  is  due  to  the  deposition  and 
multiplication  of  bacteria,  which  reach  the  tissues  from  the  lymph-glands  and 
reach  the  glands  from  an  area  of  infection  in  the  pharynx,  a  salivary  gland,  or 
the  mouth.  Pus  does  not  form  at  all  or  only  minute  encapsulated  foci  form, 
probably  because  the  bacteria  are  of  greatly  attenuated  virulence  or  because 


Furuncle,  or  Boil  137 

the  local  vital  resistance  is  at  a  high  level  to  these  bacteria.  Inflammation 
occurs,  there  is  copious  exudation,  and  enormous  amounts  of  fibrous  tissue  form. 
If  pus  forms,  it  may  discharge  spontaneously  in  six  or  seven  weeks.  The  causa- 
tive bacteria  are  often  attenuated  pyogenic  microbes.  In  one  of  Reclus's  cases 
diphtheria  bacilli  were  found,  and  this  case  got  better  after  being  given  anti- 
toxin.   Cases  have  been  reported  which  were  caused  by  pneumococci. 

Wooden  phlegmon  is  occasionally  found  in  syphilitics,  but  it  is  not  a  syphil- 
itic condition.  Neither  B right's  disease  nor  diabetes  has  anything  to  do  with 
its  origin.  It  may  be  mistaken  for  actinomycosis  or  tuberculosis.  It  is  fre- 
quently mistaken  for  sarcoma  or  carcinoma,  in  fact,  Lange  believes  it  to  be 
cancer.  It  arises  in  those  who  are  in  ill  health  rather  than  in  the  vigorous  or 
robust.  Wooden  phlegmon  is  always  dangerous  and  is  sometimes  fatal.  One 
of  Reclus's  cases  died  of  edema  of  the  glottis.  We  have  spoken  of  woody 
phlegmon  as  though  it  only  could  involve  the  neck;  as  a  matter  of  fact  it  can 
involve  other  parts.  Reclus  maintains  that  it  can  occur  in  the  right  iliac  fossa, 
and  that  perinephric  sclerosis  is  in  reahty  due  to  it  (Powers,  in  ''Jour.  Amer.  Med. 
Assoc,"  July  20,  1911).  A  case  has  been  reported  by  Todd  in  which  the 
abdominal  wall  was  involved  ("Jour.  Missouri  State  Med.  Assoc,"  February  8, 
1912).  Duse  also  reported  such  a  case  ("Gazz.  d.  Osped.,"  1910,  xxxi).  W.  W. 
Grant,  of  Denver,  has  reported  ligneous  phlegmon  of  the  abdominal  wall  ("Jour. 
Amer.  Med.  Assoc,"  April  5,  1913).  A  similar  condition  may  arise  in  the  peri- 
neimi,  after  urinary  extravasation  or  fistula  formation.  Charles  A.  Powers,  of 
Denver,  has  reviewed  this  subject  and  presented  the  report  of  an  admirably 
studied  case  (Ibid.,  July  20,  191 1). 

Treatment. — Extirpation,  if  feasible,  is  the  best  plan.  It  is  seldom  feasible, 
and  the  surgeon  instead  makes  numerous  incisions  and  usually  dresses  with 
antiseptic  poultices.  In  these  cases  free  suppuration  occasionally  occurs 
after  a  long  delay,  and  when  it  does  occur  a  cure  may  promptly  follow  evacua- 
tion. An  autogenous  vaccine  should  be  made  and  injected  into  the  indu- 
rated area.  The  surgeon  must  be  prepared  to  do  tracheotomy  should  an 
emergency  arise. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflammation  of  the 
deep  layer  of  the  true  skin  and  the  subcutaneous  cellular  tissue  following 
bacterial  infection  of  a  hair-follicle  or  a  sebaceous  gland  and  resulting  in  local 
necrosis  of  the  dermis.  A  bofl  is  caused  by  infection  of  a  hair-folhcle  through  a 
slight  w^ound  (by  scratching,  shaving,  etc)  with  the  Staphylococcus  pyogenes 
aureus.  Boils  are  very  common  in  individuals  with  Bright's  disease,  diabetes, 
gout,  lithemia,  tuberculosis,  and  disorders  of  menstruation  and  digestion;  and 
crops  of  bofls  are  apt  to  appear  during  convalescence  from  typhoid  fever. 
Boils  are  commonest  in  the  spring,  and  sometimes  an  epidemic  of  furunculosis 
appears  in  a  hospital,  a  jafl,  or  an  asylum. 

The  symptoms  of  a  bofl  are  as  follows:  a  red  elevation  appears,  which 
stings  and  itches;  this  elevation  enlarges  and  becomes  dusky  in  color;  a  pus- 
tule forms  that  ruptures  and  gives  exit  to  a  very  little  discharge  which  forms 
a  crust.  Inflammatory  infiltration  of  adjacent  connective  tissue  advances 
rapidly,  and  the  boil  in  about  three  days  consists  of  a  large,  red,  tender,  and 
painful  base  capped  by  a  pustule  and  a  little  crusted  discharge.  _  In  rare  in- 
stances, at  this  stage,  absorption  occurs,  but  in  most  cases  the  swelling  increases, 
the  discoloration  becomes  darker,  the  skin  becomes  edematous,  the  pain 
becomes  severe  and  pulsatile,  and  the  center  of  the  bofl  becomes  raised.  About 
the  seventh  day  rupture  occurs,  pus  flows  out,  and  a  "core"  of  necrosed  tissue 
is  found  in  the  center  of  a  ragged  opening.  This  core  consists  of  the  sebaceous 
gland  and  hair-follicle,  which  have  undergone  coagulation  necrosis  (Warren). 
In  a  day  or  two  more  the  core  wfll  be  discharged,  and  healing  by  granulation 
will  begin.    A  blind  boil  lasts  only  three  or  four  days  and  has  no  core.     The 


138 


Suppuration  and  Abscess 


constitution  often  shows  reaction  during  the  progress  of  a  boil.  Boils  may  be 
either  single  or  multiple.  The  development  of  one  boil  after  another,  or  the 
formation  of  several  boils  at  once,  is  known  as  '^furunculosis."  Boils  are  com- 
monest upon  the  neck  and  the  back. 

The  treatment  consists  in  excision  or  in  crucial  incision,  removal  of  necrotic 
tissue,  irrigation  with  peroxid  of  hydrogen,  touching  with  pure  carbolic  acid, 
and  the  application  of  hot  antiseptic  fomentations. 

Aleppo  Boil  {Endemic  Boil  of  the  Tropics;  Delhi  Boil;  Oriental  Sore,  etc.). — 
It  is  not  a  pyogenic  process.  Papules  appear  upon  the  exposed  parts  of  the 
body.  These  papules,  which  ulcerate,  do  not  cicatrize  for  at  least  a  year,  and 
leave  ineradicable  scars.  This  condition  is  due  to  a  protozoon.  Man  is  infected 
by  means  of  flies,  lice,  or  other  insects.  The  Aleppo  boil  was  once  apparently 
confined  to  India,  Arabia,  Persia,  Egypt,  Algeria,  etc.  Of  late  it  is  said  to 
have  appeared  in  Panama,  Phihppine  Islands,  and  Hawaii. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious  inflammation 
of  the  deeper  layer  of  the  true  skin  and  of  the  subcutaneous  tissue,  with 
fibrinous  exudation,  multiple  foci  of  necrosis  arising,  and  the  tissue  adjacent 
to  each  necrotic  plug  becoming  gangrenous.       The  infection   takes  place 

through  a  hair-folHcle.  It  is  really  a 
boil  with  extensive  infiltration  of  ad- 
jacent tissues.  A  boil  may  become  a 
carbuncle,  and  pus  from  a  carbuncle 
inoculated  into  a  healthy  person  may 
cause  either  a  boil  or  a  carbuncle. 
The  causative  organism  seems  to  be 
the  Staphylococcus  pyogenes  aureus. 
Carbuncle  is  most  common  in  the 
upper  part  of  the  back  and  on  the 
back  of  the  neck.  In  this  region  the 
skin  is  very  thick;  each  hair-folUcle 
holds  only  a  downy  hair,  is  shaUow, 
and  projects  but  a  short  distance  into 
the  cutis  vera.  Columns  of  fatty  tis- 
sue run  from  the  subcutaneous  tissue 
in  an  oblique  direction  to  join  the 
point  and  sides  of  the  hair-follicle. 
These  columns  are  known  as  columna 
adiposcB,  and  each  one  contains  a 
sweat-gland  (Fig.  72).  When  pus 
runs  down  one  of  these  columns,  it 
seeks  an  outlet;  it  cannot  spread  easily 
to  the  sides,  so  it  slowly  works  its  way  to  deeper  tissue  and  from  one  to  another 
interspace  and  finds  its  way  to  the  surface  through  other  fatty  columns  (War- 
ren's "Surgical  Pathology")  (Fig.  73).  When  pus  finds  its  way  to  the  sur- 
face, an  opening  forms,  hence  the  numerous  foci  of  pointing;  finally  a  large 
opening  forms  (Fig.  74).  Carbuncles  are  most  common  in  the  spring  of  the 
year.  In  persons  with  diabetes  and  Bright's  disease  carbuncles  not  unusually 
occur. 

The  local  symptoms  in  the  beginning  resemble  those  of  a  boil,  but  the 
constitution  sympathizes  from  the  very  start  (perhaps  a  chill  and  always  a 
septic  fever)  and  the  pain  is  usually  severe.  The  inflammatory  area  begins 
as  a  papule  with  an  indurated  base,  it  enlarges  enormously,  is  boggy  to  the 
touch,  is  dusky  in  color,  is  edematous,  and  the  skin  is  not  freely  movable 
over  the  deeper  parts.  In  a  few  days  many  pustules  appear,  each  pustule 
marking  the  site  of  a  focus  of  necrosis.     Large  vesicles  filled  with  bloody 


Fig.  72. — Columna  adiposa  (Warren). 


Carbuncle 


139 


serum  ver>^  frequently  form.  In  some  cases  about  the  tenth  day  the  pustules 
rupture,  the  necrotic  plugs  are  discharged,  and  the  case  slowly  progresses 
toward  cure;  but  in  many  cases  the  carbuncle  spreads  at  the  peripher}-  while 
pustules  are  rupturing  near  the  center  of  inflammation,  and  pus  forms  in  the 
deeper  tissues,  reaching  the  surface  through  many  small  openings,  each  of 
which  is  partly  blocked  by  a  plug  of  dead  tissue.     A  carbuncle  in  this  stage 


Fig.  73. — Infiltration  of  columna  adiposa  and  subcutaneous  tissue  with  pus  in  carbuncle  (Warren). 

resembles  a  honeycomb  (Fig.  74),  discharges  bloody  pus,  and  large  masses  of 
skin  and  subcutaneous  tissue  are  destroyed.  The  entire  carbuncular  mass  may 
become  gangrenous,  and  a  sudden  and  almost  complete  cessation  of  pain  points 
to  this  complication.  An  ordinary'  carbuncle  remains  acute  for  about  three 
weeks,  but  healing  requires  a  month  or  more.  The  most  dangerous  situations 
in  which  to  have  a  carbuncle  are  the  face  and  neck  (tends  to  produce  septic 


Fig.  74. — Diagram  of  a  carbuncle  (Warrenl. 

phlebitis,  septic  clots  in  the  facial,  jugular,  or  ophthalmic  veins,  or  in  the 
cerebral  sinuses,  or  infective  emboH).  The  mortality  of  facial  carbuncle  is  at 
least  50  per  cent.  The  most  usual  positions  for  carbuncle  are  the  neck,  the 
back,  and  the  buttocks.  The  diagnosis  of  carbuncle  is  made  by  noting  the 
multiple  foci  of  necrosis  and  the  profound  constitutional  involvement.  A 
carbtmcle  may  produce  death  by  causing  septicemia,  pyemia,  or  profuse  hem- 
orrhage. 


I40 


Suppuration  and  Abscess 


Treatment. — Some  have  suggested  the  treatment  of  a  carbuncle  in  an 
early  stage  by  injecting  5  to  30  drops  of  carbolic  acid  (80  per  cent.)  into  and 
around  the  inflammatory  mass.  Such  a  method  does  not  promise  success  and 
necessitates  dangerous  delay.  The  best  treatment  if  the  case  is  seen  sufiiciently 
early  is  thorough  extirpation  while  the  patient  is  anesthetized.  The  entire 
area  of  the  infection  is  thus  removed,  and  the  large  wound  heals  by  granulation 
and  is  subsequently  skin-grafted.  When  the  condition  is  too  far  advanced  to 
admit  of  complete  extirpation,  the  following  useful  plan  should  be  employed: 

Give  ether,  make  free  crucial  incisions,  remove  dead  and  necrosing  tissue 
and  also  the  points  of  the  skin-flaps  with  the  scissors  and  forceps,  curet  pockets, 
arrest  hemorrhage  by  pressure  and  hot  water,  cauterize  with  pure  carbolic  acid, 
dust  with  iodoform,  pack  with  iodoform  gauze,  and  dress  with  hot  antiseptic 
fomentations.  Cover  the  gauze  with  a  piece  of  some  impermeable  material 
and  lay  a  hot-water  bag  upon  the  dressing.  Every  day,  or  several  times  a  day, 
remove  the  dressings,  wash  with  peroxid  of  hydrogen,  irrigate  with  corrosive 
sublimate  solution,  dust  with  iodoform,  and  reapply  the  iodoform  gauze  and 
antiseptic  fomentation.    Keep  up  this  treatment  until  sloughs  are  separated. 


Fig. 


75. — Infiltration  of  connective  tissue  of  cutis  (X  500)  with  beginning  suppuration  in  the  center 

(Senn) . 


then  dress  with  dry  antiseptic  gauze.  Secure  sleep  by  morphin,  give  quinin, 
milk-punch,  and  nourishing  diet,  and  maintain  the  action  of  the  bowels  and 
kidneys. 

Acute  Abscesses. — ^An  acute  abscess  is  a  circumscribed  cavity  of  new  for- 
mation containing  pus.  We  emphasize  the  fact  that  it  is  a  circumscrihed  cavity 
— circumscribed  by  a  mass  of  leukocytes  and  proliferating  fibroblasts.  A  puru- 
lent infiltration  is  not  circumscribed,  hence  it  does  not  constitute  an  abscess. 
An  essential  part  of  the  definition  is  the  assertion  that  the  pus  is  in  a  cavity 
of  new  formation,  in  an  abnormal  cavity;  hence  pus  in  a  natural  cavity 
(pleural,  pericardial,  synovial,  or  peritoneal)  constitutes  a  purulent  effusion, 
and  not  an  abscess,  imless  it  is  encysted  in  these  localities  by  waUs  formed  of 
inflammatory  tissue. 

An  acute  abscess  is  due  to  the  deposition  and  multiplication  of  pyogenic 
bacteria  in  the  tissues  or  in  inflammatory  exudates.  These  bacteria  attack 
exudates  or  tissues,  form  irritants  which  cause  inflammation  or  intensify 
existing  inflammation,  and  by  exerting  a  peptonizing  action  on  intercellular 
substance  and  the  fibrin  of  the  exudate,  liquefy  tissue  and  the  products  of 
inflammation,  and  form  pus.    As  a  rule,  within  twenty-four  hours  after  lodg- 


Forms  of  Abscesses 


141 


ment  of  the  bacteria  the  exudation  increases  in  amount,  the  migrated  leuko- 
cytes gather  in  enormous  numbers,  the  tibers  of  tissues  swell,  and  the  connective- 
tissue  spaces  distend  with  cells  and  fluid.  The  connective-tissue  cells,  acted 
on  by  pus  cocci,  mifltiply  by  karyokinesis,  develop  many  nuclei,  lose  their 
stellate  projections,  degenerate,  and  constitute  one  form  of  pus-corpuscle, 
leukocytes  forming  the  other.  All  the  small  vessels  are  choked  with  leukocytes, 
this  blocking  serving  to  cut  off  nourishment  and  tending  to  produce  anemic 
necrosis.  Liquefaction  occurs  at  many  foci  of  the  inflammation,  drops  of  pus 
being  formed,  the  amount  of  each  being  progressively  added  to  and  many  foci 
coalescing  (Fig.  75).  The  pus-cavity  is  circumscribed,  not  by  a  secreting  pyo- 
genic membrane,  but  by  a  mass  of  fibroblasts,  whose  cells  and  intercellular 
material  have  not  as  yet  broken  down ;  such  a  mass  of  fibroblasts  is  often  called 
embryonic  tissue,  and  it  is  circumscribed  by  a  zone  of  inflammation  in  which 
there  are  hordes  of  migrated  leukocytes  (Fig.  76).  As  an  abscess  increases  in 
size,  the  embrj^'onic  tissue  from  within  outward  liquefies  into  pus,  and  the 
zone  of  inflammation  beyond  continually  enlarges  and  forms  more  embryonic 
tissue.  After  a  time  the  inflammation  reaches  the  surface,  the  embryonic 
tissue  glues  the  superficial  to  the  deeper  parts,  the  superficial  parts  inflame 
and  become  embryonic  tissue,  and  the  in- 
tercellular substance  is  liquefied.  When 
pus  has  aU  but  reached  the  surface,  a  thin 
layer  of  tissue  only  being  undestroyed,  an 
elevation  or  tit  of  thin  tissue  is  formed,  due 
to  the  fluid  pressure.  This  process  is 
known  as  pointing.  The  elevation  or  point 
thins  from  tension  and  liquefaction,  and 
iinaUy  gives  way  and  spontaneous  evacuation 
occurs.  When  an  abscess  forms  in  an  internal 
organ  or  in  some  structure  "which  is  not  loose, 
like  connective  tissue — for  instance,  in  a 
hnnphatic  gland — a  mass  of  pyogenic  bac- 
teria, floating  in  the  blood  or  lymph,  lodges, 
and  these  bacteria  by  means  of  irritant  prod- 
ucts cause  coagulation  necrosis  of  the  adjacent 
tissue  and  inflammatory  exudation  around 
it.  The  area  of  coagulation  necrosis  be- 
comes filled  with  white  blood-ceUs,  and  the  dry  necrosed  part  is  liquefied  by 
the  cocci.  Suppuration  in  dense  structures  causes  considerable  masses  of  tissue 
to  die  and  to  be  cast  off,  and  these  masses  float  in  the  pus.  Death  of  a  mass  with 
dissolution  of  its  elements  is  necrosis,  or  inflammatory  gangrene.  Pus  travels 
in  the  line  of  least  resistance.  It  may  reach  a  free  surface,  or  may  break  into  a 
ca^ity  or  joint,  may  invade  bone  or  destroy  a  vessel.  When  an  abscess  ceases 
to  spread  or  is  evacuated,  the  fibroblastic  layer  forming  the  walls  becomes 
vascularized  and  is  converted  into  granulation  tissue.  An  abscess  heals  by  the 
collapse  of  its  walls  and  fusion  of  the  gramflations  (union  by  third  intention), 
or  by  granulation  (union  by  second  intention).  In  either  case  granulation 
tissue  is  ultimately  converted  into  fibrous  or  scar  tissue. 

Forms  of  Abscesses. — ^The  foUowing  are  the  various  forms  of  abscesses: 
Acute,  which  follows  an  acute  inflammation.  Strumous,  cold,  lymphatic,  tubercu- 
lous, or  chronic  abscess  is  due  to  the  baciUi  of  tuberciflosis,  and  does  not  contain 
true  pus  unless  there  is  secondary  pyogenic  infection.  It  presents  no  signs  of  in- 
flammation. Such  abscess  occasionally  forms  in  a  week  or  two,  and  hence  is  not 
necessarily  chronic.  Caseous  or  cheesy  abscess,  a  ca\ity  containing  thick  cheesy 
masses,  is  due  perhaps  to  the  fatty  degeneration  of  inflammatory  exudate 
and  pus-corpuscles,  but  most  commonly  results  from  the  caseation  of  a  tuber- 


Fig.  76. — ^Diagram  of  an  abscess:  A, 
Pus;  B,  layer  of  fibroblasts;  C,  tissue  in- 
filtrated with  leukocytes;  D,  zone  of  sta- 
sis; E,  zone  of  active  hyperemia;  F, 
healthj'  tissue. 


142  Suppuration  and  Abscess 

culous  focus.  Circumscribed  abscess  is  one  limited  by  a  layer  of  fibroblasts. 
Diffused  abscess  is  an  unlimited  collection  of  pus,  in  reality  not  an  abscess,  but 
either  a  purulent  effusion  or  a  purulent  infiltration.  Congestive,  gravitative, 
wandering,  or  hypostatic  abscess  is  a  collection  of  pus  or  tuberciilous  matter 
which  travels  from  its  formation  point  and  appears  at  some  distant  spot  (as 
a  psoas  abscess).  Critical  or  consecutive  abscess  is  one  which  arises  during  an 
acute  disease.  Diathetic  abscess  finds  its  predisposing  cause  in  a  diathesis. 
Embolic  abscess  is  due  to  an  infected  embolus.  Tympanitic  or  emphysematous 
abscess  is  one  which  contains  air  or  the  gases  of  putrefaction.  Encysted  ab- 
scess, in  which  pus  is  circimascribed  in  a  serous  cavity.  Fecal  or  stercoraceous 
abscess  is  one  containing  feces  in  consequence  of  a  communication  with  the 
bowel.  Follicular  abscess  is  one  arising  in  a  follicle;  hematic  abscess,  one  arising 
around  a  blood-clot,  as  a  suppurating  hematoma;  marginal  abscess,  which 
appears  upon  the  margin  of  the  anus.  Pyemic  or  metastatic  abscess  is  the  em- 
bolic abscess  of  pyemia.  Milk  abscess  is  an  abscess  in  the  breast  in  a  nursing 
woman.  Ossifluent  abscess  arises  from  diseased  bone.  Psoas  abscess  is  a  tuber- 
culous abscess  arising  from  vertebral  caries,  the  matter  following  the  psoas  mus- 
cle, and  usually  pointing  in  the  groin  (see  page  241).  A  sympathetic  abscess, 
arising  some  distance  from  the  exciting  cause,  such  as  a  suppurating  bubo 
from  chancroid,  is  not  in  reality  sympathetic,  because  infective  material  has 
been  carried  from  the  primary  focus.  Thecal  abscess  is  a  purulent  effusion  in  a 
tendon-sheath.  Tropical  abscess  is  an  abscess  of  the  liver,  so  named  because  it 
occurs  chiefly  in  those  dwelling  in  tropical  countries:  it  usually  follows  dysen- 
tery. Urinary  abscess,  caused  by  extravasated  urine.  A  verminous  abscess  is 
one  which  contains  intestinal  worms  and  communicates  with  the  bowel.  A 
syphilitic  abscess  occurs  in  the  bones  during  tertiary  syphilis,  and  is  gumma- 
tous and  not  primarily  pyogenic.  Brodie's  abscess  is  a  chronic  abscess  of  the 
head  of  a  long  bone,  most  common  in  the  head  of  the  tibia  (see  page  497).  A 
superficial  abscess  occurs  above  the  deep  fascia;  a  </ee^  abscess  occurs  below 
the  deep  fascia.  A  residual  or  Paget' s  abscess  is  a  recurrence  of  active  changes; 
it  may  be  after  years  around  the  residue  of  a  former  tuberculous  abscess  (see 
page  237). 

Symptoms  of  Acute  Abscesses. — In  an  acute  abscess,  as  before  stated,  a 
part  becomes  inflamed  and  a  quantity  of  fibroblasts  are  formed;  fibroblastic 
tissue  is  liquefied  (as  above  noted)  and  pus  is  produced.  An  acute  abscess  can 
occur  in  a  person  of  any  constitution. 

Local  Symptoms. — Locally,  there  is  intensification  of  inflammatory  signs 
and  enormous  increase  of  the  swelling.  At  first  the  area  is  hard,  but  after- 
ward becomes  soft,  and  it  finally  fluctuates.  The  discoloration  becomes  dusky. 
The  pain  becomes  throbbing  and  the  sense  of  tension  increases.  The  pain  is 
greater  the  denser  the  implicated  tissue  and  the  greater  the  number  of  nerves 
it  contains.  At  every  piilse-beat  the  tension  in  the  abscess  increases  tempo- 
rarily, and  hence  the  pain  momentarily  increases.  Pain  is  increased  by  a  de- 
pendent position  of  the  part.  There  is  great  tenderness.  The  pain  may  be  felt 
at  the  seat  of  suppuration  or  may  be  referred  to  some  distant  point.  Tender- 
ness is  located  at  the  focus  of  disease.  The  cutaneous  surface,  if  the  abscess  is 
adjacent,  is  seen  to  be  polished  and  edematous,  and  after  a  time  pointing  is 
observed  and  fluctuation  can  be  detected.  If  pus  is  deeply  situated  the  skin  may 
not  be  reddened,  and  perhaps  the  area  of  induration  cannot  be  palpated.  In 
such  a  case  there  is  often  rigidity  of  the  muscles  overlying  the  abscess  (as  in 
abdominal  suppurations),  the  skin  may  be  edematous  (as  in  deep  abscess  of 
the  neck),  and  besides  local  pain  there  maybe  pain  due  to  pressure  upon  a  nerve- 
trunk,  the  pain  perhaps  being  referred  to  a  distant  point. 

Constitutional  Symptoms. — If  there  is  a  small  collection  of  pus  in  an  un- 
important structure,  there  may  be  no  obvious  constitutional  disturbance. 


Acute  Abscesses  in  \'arious  Regions  143 

If  the  abscess  contains  much  pus  or  affects  an  important  part,  disturbances 
generally  appear,  from  sHght  rigors  or  moderate  fever  to  chills,  high  tempera- 
ture, and  drenching  sweats.  The  constitutional  condition  tA-pical  of  an  abscess 
is  due  to  the  absorption  of  retained  toxins,  and  is  known  as  "suppurative 
fever."  When  an  abscess  is  open  but  ill-drained,  or  when  it  is  imopened  and 
deep-seated,  long-continued  suppuration  causes  a  fever  which  is  markedlv 
periodic:  the  temperature  rises  in  the  evening,  attaining  its  highest  point 
usually  between  4  and  S  p.  m.,  and  sinks  to  normal  or  nearly  normal  in  the 
early  morning  U'rom  4  to  S  A.  M.L  \Mien  the  temperature  begins  to  fall, 
profuse  sweating  takes  place.  This  fever  is  known  as  hectic.  As  pre\'iouslv 
stated,  the  temperature  may  be  normal  or  subnormal  in  abscess  of  the  brain. 
Prolonged  suppuration  causes  albuminoid  changes  in  various  organs,  notably 
in  the  liver,  spleen,  and  kidneys.  Albuminoid  changes  are  especially  common 
when  there  has  been  mixed  infection  of  a  tuberculous  area  and  long-continued 
suppuration.    It  also  occurs  as  a  result  of  s^'philis. 

J.  C.  DaCosta,  Jr.  (/'Clinical  Hematolog}-"')  tells  us  that  "in  both  tri\-ial 
and  extensive  pus  foci  the  number  of  leukoc}"tes  may  be  normal  or  even  sub- 
normal: in  the  former  instance  because  systemic  reaction  is  not  provoked, 
and  in  the  latter  because  it  is  overpowered.  Leukoc\-t05is  may  also  be  absent 
in  case  toxic  absorption  is  impossible,  owing  to  the  complete  walling  off  of 
the  abscess.  In  all  other  instances  save  these  a  definite  and  usually  well- 
marked  leukoc\"tosis  occurs,  amounting  on  the  average  to  a  count  of  about 
twice  the  mean  normal  standard,  but  frequently  greatly  exceeding  this  figure 
in  the  indi\"idual  case.'' 

The  signs  and  s}"mptoms  of  an  abscess  are  somewhat  modified  by  location, 
and  it  is  wise  to  discuss  acute  abscesses  in  different  situations. 

Acute  Abscesses  in  \'arious  Regions. — Abscess  of  the  brain  may 
follow  cerebral  concussion  or  fracture  of  the  skull,  may  arise  during  a  general 
infection,  but  in  about  50  per  cent,  of  cases  results  from  chronic  suppurative 
disease  of  the  middle  ear.  In  abscess  of  a  silent  region  of  the  brain  s}Tnptoms 
may  long  be  entirely  absent.  The  usual  s^Tnptoms  are  a  temporary-  initial  rise 
of  temperature,  which  soon  gives  place  to  a  normal  and  in  one-half  of  the  cases 
to  a  subnormal  temperature,  headache,  vomiting,  delirium,  drowsiness,  and 
choked  disk.  Localizing  s}-mptoms,  spasmodic  or  parahiric.  may  be  present. 
There  is  usually  but  not  always  leukocAtosis.  In  but  few  uncompUcated  cases 
are  there  elevated  temperature  and  sweats.  Toward  the  end  of  the  case  there 
may  be  elevated  temperature  and  delirium.  In  extradural  abscess  there  is 
fever  from  beginning  to  end  (see  page  805). 

Appendiceal  ox  appendicular  abscess  results  from  inffammation.  usually 
but  not  always  with  perforation  of  the  vermiform  appendix,  plastic  peritonitis 
leading  to  agglutination  of  the  mesentery-  and  omentum,  adhesion  of  the  bowels 
and  mesenter}-,  and  the  formation  of  a  barrier  of  leukoc}i:es  and  a  mass  of  fibro- 
blasts. This  process  circumscribes  the  pus.  If  the  pus  in  suppurative  ap- 
pendicitis has  been  formed  by  colon  bacilli  or  staphylococci,  it  will  probably 
be  circumscribed  and  limited.  If  the  pus  has  been  formed  by  streptococci, 
it  wiU  probably  not  be  limited,  and  the  peritoneum  will  be  attacked  by  diffuse 
septic  peritonitis.  The  signs  of  appendicular  abscess  are  pain,  tenderness, 
muscular  rigidity,  and  the  existence  of  a  mass  in  the  right  iliac  fossa.  The  mass 
may  be  palpated  through  the  abdominal  wall  or  perhaps  the  rectum  and  is 
dull  on  percussion.  There  may  be  vomiting,  and  sometimes  constipation  and 
sometimes  diarrhea.  Ven.-  seldom  is  there  skin  edema  and  fluctuation.  The 
patient  Hes  upon  his  back,  usually  -^-ith  one  or  both  thighs  flexed.  In  appen- 
dicular abscess  there  is  fever,  usually  higher  at  night  than  in  the  morning,  pro- 
fuse sweating  occurring  during  the  fall.  In  some  cases  the  temperature  is  per- 
sistently high;  in  some  the  elevation  is  tri\-ial;  in  some  chills  occur.    A  sud- 


144  Suppuration  and  Abscess 

den  fall  of  temperature  with  shock  is  produced  by  rupture  of  the  abscess  wall. 
If  this  accident  happens,  general  peritonitis  quickly  arises.  In  appendicular 
abscess  there  is  marked  leukocytosis,  unless  the  walls  are  very  thick  or  unless 
the  process  has  diffused  and  general  peritonitis  has  taken  place,  in  which 
conditions  it  may  be  absent.  Appendiceal  abscess  may  be  assumed  to  exist 
when  the  symptoms  of  appendicitis  persist  after  the  fifth  or  sixth  day,  or 
when,  after  the  symptoms  have  subsided,  they  reappear  a  day  or  two  later 
(see  page  1006). 

Abscess  of  the  liver  may  not  be  announced  by  symptoms  until  rupture. 
It  may  follow  dysentery,  may  be  a  result  of  the  lodgment  of  infected  clots  from 
the  hemorrhoid  veins,  may  follow  upon  the  infective  phlebitis  of  appendicitis, 
may  result  from  septic  cholangitis  or  suppuration  of  a  hydatid  cyst.  Abscess 
from  dysentery  is 'apt  to  be  soHtary.  Portal  infection  induces  multiple  ab- 
scesses. We  speak  now  of  solitary  abscess.  The  bacterial  origin  of  this  is  in 
doubt.  Ameba  are  usually  present.  We  usually  find  fever  of  an  intermittent 
t5/pe,  profuse  sweats,  pain  in  the  back,  the  right  shoulder,  or  the  right  hypo- 
chondriac region,  enlargement  of  the  area  of  liver-dulness,  and  hepatic  tender- 
ness. Sometimes  there  are  fluctuation  and  skin  edema  over  the  liver,  and  the 
general  cutaneous  surface  may  be  a  little  jaundiced.  The  symptoms  vary  as 
the  pus  invades  adjacent  organs.  When  there  are  pain  on  respiration  and 
evidences  of  diaphragmatic  pleuritis,  the  pus  is  probably  breaking  into  the 
pleural  sac.    There  may  or  may  not  be  leukocytosis  (see  page  1035). 

Deep  Abscess  of  the  Neck. — The  majority  of  these  abscesses  are  due  to 
suppuration  of  lymph-glands,  bacteria  having  reached  the  glands  from  an  ad- 
jacent area  of  infection,  cutaneous,  mucous,  or  osseous.  Suppuration  beneath 
the  deep  fascia  induces  dusky  discoloration  of  the  surface,  great  pain,  extensive 
edematous  swelUng,  and  often  interference  with  respiration.  The  constitu- 
tional evidences  of  suppuration  are  noted.  Acute  suppuration  under  the  deep 
fascia  of  the  submaxillary  region  causes  extensive  inflammatory  edema,  inter- 
ference with  respiration  and  deglutition,  violent  constitutional  symptoms,  and 
often  sloughing  of  tissues  (see  Ludwig's  Angina).  A  deep  abscess  over  the 
carotid  artery  is  lifted  by  each  arterial  beat  and  may  be  mistaken  for  aneurysm, 
but  the  pulsation  is  not  expansfle.  The  pus  of  a  deep  cervical  abscess  may  track 
its  way  into  the  mediastinum  or  axiUa,  or  the  abscess  may  break  into  a  large 
blood-vessel,  the  pharynx,  the  wind-pipe,  or  the  guUet. 

Axillary  Abscess. — Superficial  abscesses  are  usuaUy  multiple,  are  in  reaHty 
furuncles,  and  resvilt  from  infection  of  the  sweat-glands  and  hair-follicles. 

Deep  abscesses  are  in  most  instances  due  to  suppuration  of  the  axillary 
lymph-glands.  The  most  common  cause  is  an  infected  wound  or  a  focus  of 
suppuration  about  the  hand,  forearm,  arm,  or  chest,  but  it  may  result  from 
caries  of  a  rib  or  may  follow  a  deep  cervical  abscess.  An  axillary  abscess  may 
be  hfted  at  each  beat  of  the  artery  and  to  this  extent  it  resembles  an  aneurysm, 
but  the  pulsation  is  not  expansile. 

Acute  retropharyngeal  abscess  is  due  to  pyogenic  infection  of  the  retro- 
pharyngeal tissues.  The  abscess  usually  forms  upon  one  of  the  lateral  halves 
of  the  pharynx.  It  may  be  due  to  traumatism,  to  acute  infectious  diseases, 
to  infective  processes  of  the  mucous  membrane  of  the  mouth,  ear,  and  naso- 
pharynx, or  to  pyogenic  infection  of  a  tuberculous  abscess.  In  the  great  major- 
ity of  cases  the  disease  is  due  to  suppuration  of  the  deep  cervical  glands. 
There  is  pain,  difficulty  in  swallowing,  dyspnea,  nasal  voice,  biflging  into  the 
pharynx,  which  is  detected  by  inspection  and  palpation,  enlargement  of  the 
deep  cervical  glands,  fever,  sweats,  and  great  weakness.  Tuberculous  Retro- 
pharyngeal Abscess  is  considered  on  page  241. 

Subphrenic  or  subdiaphragmatic  abscess  is  apt  to  begin  beneath  the  dia- 
phragm, though  in  some  few  instances  the  pus  forms  above  this  muscle,  and  sub- 


Acute  Abscesses  in  \'arious  Regions  145 

sequently  gains  access  to  the  region  beneath.  Such  an  abscess  may  contain 
not  only  pus,  but  gas.  and  in  some  cases  also  tiuid  from  the  stomach  or  intestine. 
The  gas  of  a  subphrenic  abscess  may  have  entered  from  a  perforation  of  a  hol- 
low \iscus  or  may  have  been  made  by  gas-forming  bacteria.  Subphrenic 
abscess  may  arise  after  perforation  of  the  bowel  or  stomach,  or  it  may  result 
from  Pott's  disease,  perinephric  abscess,  traumatism,  abscess  of  hver,  kidney, 
spleen  or  pancreas,  empyema,  or  pneumonia  (Greig  Smith) .  Inflammation  of 
the  gall-bladder  or  appendicitis  may  cause  it.  The  s\"mptoms  are  pain,  fever, 
sweats,  dyspnea,  cough,  and  the  physical  signs  of  a  collection  of  fluid  beneath 
the  diaphragm  and  often  of  gas  in  the  ca\dty  of  the  abscess.  There  is  usually 
leukocytosis  (see  page  143). 

Abscess  of  the  Jung  gives  the  physical  signs  of  a  ca\ity:  the  expectoration  is 
offensive  and  contains  fragments  of  lung-tissue.  An  abscess  may  often  be 
located  by  the  use  of  the  .v-rays.  Pyemic  abscesses  may  exist  and  yet  escape 
discover}-.     (See  Smger\-  of  Respirator}-  Organs.) 

Abscess  of  the  mediastinum  may  arise  secondarily  to  deep  abscess  of  the  neck 
or  vertebral  suppuration;  suppuration  of  the  mediastinal  glands,  lung,  or  pleura; 
caries  of  a  rib  or  of  the  sternum,  ulceration  of  the  esophagus  or  pericarditis.  It 
causes  throbbing  retrosternal  pain,  pain  in  the  back,  chills,  fever,  sweats, 
irregular  pulse,  and  often  dyspnea.  A  lump  may  appear  which  pulsates  and 
fluctuates,  but  the  pulsation  is  not  expansile. 

Perinephric  aiscess  usually  causes  tenderness  and  pain  in  the  Imnbar 
region  or  about  the  hip-joint,  which  pain  runs  down  the  thigh  and  is  accom- 
panied by  retraction  of  the  testicle.  Induration,  fluctuation,  or  edema  of  the 
skin  may  be  obser^-ed  in  the  lumbar  region.  The  constitutional  s}-mptoms  of 
suppuration  usually  exist  (see  page  143  K    There  is  a  high  leukoc}-tosis. 

Abscess  or  empyema  of  the  antrum  of  High  more  is  a  collection  of  pus  within 
the  maxillar}-  antrum.  It  results  from  inflammation  of  the  jaw.  the  teeth,  or 
the  mucous  membrane  of  the  nose.  It  causes  pain,  edematous  swelling  of  the 
overl}-ing  soft  parts,  and  crepitation  on  pressure  upon  the  superior  maxillar}- 
bone.  Piis  may  escape  from  the  nostril  of  the  diseased  side  when  the  head 
is  bent  in  the  direction  of  the  healthy  side.  A  rhinoscopic  examination  dis- 
closes the  fluid  passing  into  the  nares.  The  antrum  on  the  side  of  the  abscess 
cannot  be  transiUuminated  b}-  an  electric  light  in  the  mouth  (Garel's  sign). 
The  constitutional  s}-mptoms  of  suppuration  usuaUy  arise. 

Alveolar  abscess  is  suppurative  dental  periostitis  due  to  diseased  teeth. 
The  simplest  form  is  a  gum-boiL  a  coUection  of  pus  between  the  giun  and  the 
bone  external  to  the  inflamed  root  of  a  tooth.  In  more  severe  cases  the  suppu- 
ration begins  within  the  tooth  socket  and  the  pus  escapes  around  the  neck  of 
the  tooth;  a  distinct  and  local  abscess  may  be  situated  at  the  end  of  the  root, 
absorption  of  bone  ha\-ing  occurred,  or  a  considerable  ca^-ity  may  form  in  the 
bone,  the  external  maxfllar}-  plate  being  perforated.  In  the  xery  severe  cases 
the  cheek  is  involved.  An  alveolar  abscess  may  break  through  the  gmn  into 
the  mouth  or  it  may  break  externally  through  the  cheek.  Alveolar  abscess 
causes  intense  pulsatile  pain,  marked  swelling  of  the  gum  and  cheek,  and  some- 
times ver}-  great  edematous  and  dusky  swelling  of  the  face.  A  sinus  may  follow 
its  evacuation.    Dead  bone  may  form. 

Abscess  of  the  larynx  invariably  causes  lar}-ngeal  edema,  which  obstructs 
respiration  and  puts  hfe  in  jeopardy.  Such  an  abscess  is  most  apt  to  appear 
upon  the  oral  siirface  of  the  epiglottis,  but  may  arise  within  the  lar}-nx.  It  in- 
duces "s-iolent  cough,  pain,  interference  with  the  voice,  swaUowing,  and  breath- 
ing, and  the  swelling  can  often  be  felt  with  a  finger  and  can  always  be  seen  by 
the  aid  of  a  lar}-ngoscope. 

An  ischiorectal  abscess  is  situated  in  the  areolar  tissue  of  the  ischiorectal 
fossa.     The  pyogenic  organisms  usually  gain  entrance  to  the  l}-mphatics  by 


146  Suppuration  and  Abscess 

way  of  an  abrasion,  fissure,  or  ulceration  of  the  rectum  or  anus.  A  perfora- 
tion made  by  a  foreign  body  may  inaugurate  the  condition.  In  rare  cases 
bacteria  reach  the  fossa  in  the  blood-stream.  The  pain  is  severe  and  throbbing; 
there  are  great  tenderness,  redness  and  edema  of  skin,  induration,  and  usually 
the  constitutional  symptoms  of  pus  formation.  Fluctuation  is  a  very  late 
sign  because  of  the  density  of  the  fascia. 

Prostatic  abscess  may  result  from  catheter  infection,  from  infection  of  the 
bladder  or  urethra,  or  from  traumatism,  but  the  commonest  cause  is  gonorrhea. 
There  may  be  one  abscess,  several  abscesses,  or  many  abscesses.  Pus  may 
break  into  the  rectum,  the  bladder,  or  the  urethra,  or  may  break  externally. 
A  prostatic  abscess  is  manifested  by  chills,  fever,  sweats,  frequency  of  mic- 
turition, tenderness  of  the  perineum  and  rectum,  and  agonizing  pain,  develop- 
ing during  an  attack  of  acute  prostitis.  A  finger  in  the  rectum  can  palpate 
the  swollen  gland. 

Abscess  of  the  breast  follows  absorption  of  pyogenic  bacteria  from  a  fissure 
or  abrasion  of  the  nipple.  Some  surgeons  maintain  that  the  bacteria  enter 
along  the  milk-ducts,  while  others  assert  that  they  gain  entrance  by  the  lym- 
phatics. It  is  most  common  in  nursing  women.  Its  symptoms  are  swelling, 
tenderness,  pulsatile  pain,  dusky  discoloration,  skin  edema,  fluctuation,  and 
usually  constitutional  disorder.     (See  Mastitis.) 

Orbital  abscess  is  a  diffuse  suppuration,  due  to  cellulitis  or  a  collection  of 
pus  due  to  caries  or  necrosis  of  the  orbital  wall,  suppuration  of  the  accessory 
nasal  sinus,  facial  erysipelas,  or  dental  caries.  In  severe  orbital  cellulitis 
the  movements  of  the  eye  are  limited,  the  lids  are  very  red  and  edematous, 
the  conjunctiva  is  red  and  swollen  (chemosis),  and,  if  the  case  is  not  promptly 
relieved,  optic  neuritis  may  arise  and  sloughing  of  the  cornea  occur. 

Von  Bezold's  Abscess.— In  this  condition  the  pus  of  a  suppurating  mastoid 
process  breaks  through  the  mastoid  near  the  tip  and  enters  into  the  sheath  of 
the  digastric  muscle  or  the  sheath  of  the  sternocleidomastoid.  There  exist  ex- 
tensive inflammatory  swelling  of  the  neck,  a  history  of  mastoid  trouble,  usually 
a  lessened  amount  of  pus  from  the  ear,  pain  in  the  neck,  and  constitutional 
symptoms.  The  condition  suggests  thrombosis  of  the  lateral  sinus,  but  the 
symptoms  are  not  so  violent  and  are  not  pyemic  as  they  are  in  that  disease. 

Abscess  of  the  Groin  or  Pyogenic  Bubo. — Such  an  abscess  may  have  mounted 
up  from  the  pelvis,  tracked  forward  from  the  sacro-iliac  joint,  or  descended  in 
the  psoas  sheath  from  the  vertebrae,  but  in  a  very  great  majority  of  cases  it  is 
due  to  suppuration  of  the  lymphatic  glands.  A  bubo  may  be  tuberculous, 
venereal,  or  pyogenic.  A  pyogenic  bubo  results  from  an  area  of  infection  in 
the  trajectory  drained  by  the  lymph-vessels  of  the  inguinal  or  femoral  glands. 
The  glands  involved  may  be  superficial  or  deep.  The  symptoms  are  those 
ordinarily  linked  with  suppuration.  Occasionally,  the  pulsations  of  the  great 
vessels  may  lift  the  mass. 

Abscess  of  the  Popliteal  Space. — This  results  from  traumatism,  mixed  in- 
fection of  a  tuberculous  or  S3^hilitic  area,  suppuration  of  the  contained  lymph- 
glands,  of  one  of  the  adjacent  bursae,  or  of  the  neighboring  bone.  In  rare 
cases  it  arises  as  a  result  of  suppuration  of  the  sac  of  an  aneurysm.  The 
symptoms  are  severe  pain,  swelling,  flexion  of  the  knee,  and  edema  of  the  leg. 
The  pulsations  of  the  popliteal  artery  may  be  transmitted  to  the  abscess. 
These  pulsations  are  not  expansile,  as  in  aneurysm.  Pus  may  pass  under 
the  deep  fascia,  up  or  down  the  extremity,  or  may  break  into  the  knee-joint. 

Suppurative  thecitis  or  felon  is  a  form  of  diffuse  suppuration.     (See  Felon.) 

Palmar  abscess  is  a  purulent  effusion  (see  page  721). 

Furuncle  and  carbuncle  are  discussed  on  pages  137  and  138. 

Empyema  is  a  purulent  effusion  into  the  pleural  sac  (see  page  891).  It  is 
technically  an  abscess  if  it  becomes  encapsuled. 


Diagnosis  of  Abscess 


147 


Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — (i)  its  history;  (2) 
fluctuation;  (3)  pointing;  (4)  surface  edema;  (5)  the  use  of  the  tubular  ex- 
ploring needle;  (6)  leukocytosis. 

Fluctuation  is  the  sensation  imparted  to  a  finger  held  against  a  sac  con- 
taining fluid  when  a  wave  is  started  in  the  fluid  by  striking  the  mass  with  a 
finger  of  the  other  hand.  Fluctuation  cannot  be  obtained  if  the  amount  of 
fluid  is  small.  It  should  never  be  sought  for  across  a  limb,  but  rather  along  it, 
because  a  false  sense  of  fluctuation  can  always  be  obtained  across  the  muscles 
of  the  limb.    Pointing  and  surface  edema  have  been  discussed. 

A  suspected  abscess  in  a  part  containing  large  blood-vessels  under  no  cir- 
cumstance should  be  opened  by  a  bistoury  without  knowing  that  the  diagnosis 
is  certainly  correct.  This  knowledge  is  obtained  in  some  cases  by  inserting 
a  small  aspirating  needle  and  observing  the  nature  of  the  fluid  which  exudes. 
This  operation  must  be  performed  with  aseptic  care;  otherwise,  if  there  is  no 
abscess,  infection  may  be  inaugurated;  if  there  is  an  abscess,  mLxed  infection 
may  occur.  The  older  operators  used  a  grooved  exploring  needle,  but  many 
able  surgeons  object  to  its  use,  on  the  ground  that  when  plunged  into  an  in- 
fected area  pus  bathes  the  track  of  puncture  and  may  cause  infection  of 


Fig.  77. — Vischer's  case  for  caro'ing  culture-tubes  for  inoculation. 

other  tissues  and  diffusion  of  the  pyogenic  process.    The  tubular  exploring 
needle  is  the  proper  instrument. 

An  abscess  which  moves  with  the  pulse  because  it  rests  upon  an  artery 
may  be  confounded  with  an  aneurysm.  The  pulse  movements  of  such  an 
abscess  are  in  one  direction  only;  the  abscess  is  lifted  with  each  pulse-beat, 
but  does  not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of  it  the  fingers 
will  be  lifted,  but  not  separated.  The  pulse  movements  of  an  aneurysm  are 
in  all  directions;  they  are  expansile,  the  sac  grows  larger,  and  the  fingers 
will  not  only  be  lifted,  but  will  also  be  separated.  The  small  tubular  exploring 
needle  may  be  used  in  doubtful  cases;  if  aseptic,  it  will  do  no  harm  even  to  an 
aneurysm.  A  rapidly  gro'\;\ing,  small-cell  sarcoma  feels  not  imlike  an  abscess, 
but  the  exploring  needle  discovers  blood  and  not  pus.  A  cystic  timior  is 
separated  from  an  abscess  by  the  absence  of  inflammation,  or,  if  it  inflames, 
by  the  nature  of  the  contained  fluid.  Ordinary  caution  will  prevent  one  con- 
founding an  abscess  with  strangulated  hernia.  A  tuberculous  abscess  is  sepa- 
rated from  an  acute  abscess  by  the  absence  of  inflammatory  signs  in  the 
former.  The  contents  of  the  acute  abscess  differ  from  those  of  the  tuberculous 
abscess.  When  an  abscess  exists  in  an  important  region  (brain,  appendix, 
liver,  etc.)  cultures  of  the  pus  should  be  taken  after  incision.  Such  studies 
often  give  valuable  information  as  to  the  probable  course  of  the  condition, 


148  Suppuration  and  Abscess 

and  an  accumulation  of  many  accurate  observations  will  add  greatly  to  scien- 
tific information.  Figure  77  shows  a  convenient  case  for  carrying  culture- 
tubes. 

Prognosis, — The  prognosis  varies  according  to  the  number  of  abscesses, 
their  location  and  size,  the  strength  of  the  patient,  and  the  virulence  of  the 
causative  bacteria. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one  absolute  rule 
which  knows  no  exception,  namely,  that  whenever  and  wherever  pus  is  found 
the  abscess  should  be  evacuated  at  once,  and,  after  evacuating  it,  thorough 
drainage  must  be  provided  for.  It  should  be  opened  early,  if  possible,  even 
before  fluctuation  and  positively  before  pointing,  to  prevent  tissue  destruc- 
tion, subfascial  burrowing,  and  general  contamination.  Drainage  is  continued 
until  the  discharge  becomes  scanty,  thin,  and  seropurulent. 

Alveolar  abscess  requires  prompt  incision  through  the  gum,  extraction  of 
the  diseased  tooth  in  most  cases,  and  the  rinsing  of  the  mouth  at  frequent 
intervals  with  hot  fluid.  Heat  should  not  be  applied  to  the  cheek  or  jaw  exter- 
nally, as  it  would  favor  external  rupture.  If  spontaneous  rupture  externally 
is  inevitable,  then  an  incision  must  be  made  at  the  point  where  the  abscess 
is  nearest  the  surface.  The  cut  will  leave  less  scar  than  wiU  spontaneous 
evacuation.  It  is  sometimes  necessary  to  gouge  through  the  external  table 
of  the  bone,  pus  being  lodged  within  the  two  osseous  plates. 

Abscess  of  the  liver,  if  the  liver  is  adherent  to  the  parietal  peritoneum,  is 
opened  at  one  operation;  if  the  liver  is  not  adherent,  some  surgeons  operate 
in  two  stages.  In  the  two-stage  operation  an  incision  is  made  along  the  edge 
of  the  ribs  down  to  the  liver,  which  organ  is  then  stitched  to  the  edges  of  the 
wound.  In  a  day  or  two  after  the  first  operation  the  two  layers  of  peritoneum 
are  firmly  adherent,  and  the  abscess  can  be  opened  without  danger  of  the 
passage  of  pus  into  the  peritoneal  cavity.  The  abscess,  located  by  an  aspirat- 
ing needle,  is  opened  by  the  Paquelin  cautery,  is  washed  out  with  salt  solution, 
and  a  tube  is  inserted.  If  care  is  taken,  the  operation  can  be  safely  completed 
in  one  seance  even  if  the  liver  is  not  adherent  to  the  parietal  peritoneum. 
If  this  course  is  determined  on,  after  the  liver  is  exposed  by  incision,  the  ex- 
posed surface  of  the  organ  is  surrounded  with  iodoform  gauze,  the  abscess  is 
located  by  an  aspirating  needle,  is  opened  by  the  cautery,  is  irrigated  and 
drained  as  directed  above.  Some  physicians  try  to  locate  an  abscess  by  plung- 
ing an  aspirating  needle  into  the  Hver  before  making  an  abdominal  incision. 
This  procedure  seems  to  me  uncertain  and  dangerous. 

Abscess  of  the  dome  of  the  liver  may  be  reached  by  resecting  a  rib,  in- 
cising the  pleura,  and  opening  through  the  diaphragm  (transthoracic  hep- 
atotomy) . 

Abscess  of  the  mediastinum,  like  all  other  abscesses,  requires  incision  and 
drainage.  This  is  effected,  if  the  abscess  can  be  reached  from  in  front,  by 
cutting  between  the  rib  cartilages  or  by  trephining  the  stermmi.  Abscess  of  the 
posterior  mediastinimi  can  be  reached  only  by  resecting  portions  of  several  ribs 
near  their  vertebral  ends. 

In  abscess  of  the  lung  an  incision  is  made  and  the  pleura  is  exposed.  The 
incision  is  usually  through  an  intercostal  space;  but  if  the  spaces  are  narrow, 
it  will  be  necessary  to  resect  a  rib.  If  the  two  layers  of  pleura  are  found  ad- 
herent, the  operation  is  proceeded  with.  If  they  are  not  adherent,  they  are 
stitched  together  with  catgut  sutures,  and  the  surgeon  waits  forty-eight  hours 
before  continuing.  This  precaution  is  taken  in  order  to  prevent  collapse 
of  the  lung  from  acute  traumatic  pneumothorax,  and  to  save  the  pleura  from 
receiving  pus  during  operation.  The  operation  is  completed  by  locating  the 
pus  by  means  of  an  aspirating  needle,  evacuating  it  by  the  cautery  at  a  duU- 
red  heat,  and  inserting  a  drainage-tube  into  the  abscess-cavity. 


Treatment  of  Abscess  149 

A  subphrenic  abscess  requires  operation  at  once.  Immediately  before  oper- 
ating, if  in  doubt,  it  may  be  justitiable  to  endeavor  to  locate  pus  with  an  aspi- 
rating needle.  Incise  the  abscess  and  open  any  secondan.-  abscesses.  !Manv 
abscesses  point  below  the  diaphragm,  and  are  easily  reached  by  an  incision  in  the 
loin  or  in  the  epigastric  region.  Lannelonge  resects  the  eleventh  and  twehth 
ribs  and  raises  the  pleura  out  of  the  way.  Some  surgeons  prefer  to  practice 
rib  resection  and  indse  the  adherent  pleural  layers  and  the  (haphragm.  After 
drainage  has  been  continued  for  a  time  it  may  be  necessar\-  to  do  a  secondary 
operation  in  order  to  cure  the  lesion  causative  of  the  abscess,  for  instance,  it 
may  be  necessar\-  to  close  a  chronic  gastric  perforation. 

In  abscess  of  the  antrum  of  Highmore  bore  a  gimlet-hole  through  the  supe- 
rior maxiUar}-  bone,  above  the  canine  tooth,  or  perforate  the  bone  by  means  of 
a  trocar.  Irrigate  daily  with  boiled  water  or  normal  salt  solution.  Keep 
the  opening  from  contracting  by  inserting  a  smaU  tent  of  iodoform  gauze.  In 
persistent  cases  it  may  be  necessan.-  to  draw  a  tooth,  break  through  the  socket 
of  the  first  or  second  bicuspid  into  the  antrum,  and  insert  a  silver  or  hard- 
rubber  tube,  and  also  to  perforate  the  antrum  from  the  inferior  meatus  and 
keep  the  opening  patent.  In  ver\-  persistent  cases  osteoplastic  resection  of  a 
portion  of  the  upper  jaw  wiU  be  demanded. 

In  appendicular  abscess  incise,  support  the  abscess  walls  with  gauze. 
remove  the  appendix  in  most  cases,  but  not  in  aU.  and  insert  a  drainage-tube 
and  strands  of  gauze  (see  page  loiS'. 

An  ischiorectal  abscess  must  be  opened  earh".  The  surgeon  never  waits 
for  fluctuation.  Fluctuation  is  a  ven.-  late  symptom.  To  wait  for  it  entails 
great  destruction  of  tissue  and  ser\-es  no  useful  purpose.  Place  the  patient 
on  his  side,  with  the  legs  drawn  up.  Insert  a  finger  in  the  rectum,  lift  the 
abscess  toward  the  surt"ace.  and  incise  it  from  the  surface.  The  incision  runs 
from  the  anal  margin  like  a  spoke  from  the  hub  of  a  wheel.  Irrigate  with 
salt  solution,  inject  iodoform  emulsion,  insert  a  drainage-tube,  dress,  and  let 
the  patient  know  he  is  in  danger  of  developing  a  fistula. 

A  retropharyngeal  abscess  must  be  opened  early,  because  delay  may 
lead  to  fatal  obstruction  and  because  if  spontaneous  evacuation  occiks  the 
patient  mav  be  suffocated.  Some  siKgeons  open  it  from  within  the  mouth, 
but  this  exposes  the  patient  to  the  danger  of  septic  bronchopnetimonia  from 
inhalation  of  purulent  elements  and  to  serious  gastro-intestinal  disorder  from 
swallowing  quantities  of  pus.  Again,  if  opened  through  the  mouth,  the  ab- 
scess is  liable  to  become  putrid.  It  is  better  to  open  it  from  the  neck  by  Hilton's 
method,  the  incision  being  carried  through  the  sternocleidomastoid  muscle 
or  posterior  to  it.  Drainage  is  inserted  and  the  abscess  treated  in  the  usual 
way. 

In  abscess  of  the  breast  make  an  incision  radiating  from  the  nipple,  or.  what 
is  better,  indse  under  the  breast  by  means  of  a  cut  at  the  inferior  thoracic 
m^ammaj}"  jimction  and  enter  the  abscess  from  beneath. 

In  abscess  of  the  brain  the  skuU  should  be  trephined,  the  membranes  incised, 
and  the  abscess  sought  for.  opened,  and  drained  (^see  page  S04). 

In  suppuration  within  the  orbit  due  to  ceUuhtis.  incise  from  the  conjunctiva 
and  drain.  In  suppuration  due  to  caries  or  necrosis  of  the  upper  orbital  wall 
make  a  transverse  incision  through  the  upper  Ud.  reach  the  pus  by  Hilton's 
method  (see  page  150),  remove  carious  or  loose  necrotic  bone,  and  drain. 

A  perinephric  abscess  requires  an  incision  in  the  lumbar  region  and  free 
drainage. 

An  abscess  of  the  larynx  requires  immediate  scarification  and  inhalation 
of  steam  to  abate  swelling.  In  a  severe  case  the  surgeon  should  at  once  per- 
form tracheotomy. 

Bezold's  abscess  requires  one  or  more  incisions  in  the  neck  for  drainage. 


150  Suppuration  and  Abscess 

Then  the  mastoid  is  exposed,  its  tip,  including  the  osseous  fistula,  is  removed, 
and  its  interior  is  cleared  out  by  a  complete  operation. 

J^  prostatic  abscess  should  be  opened  promptly  by  a  perineal  incision. 

In  an  ordinary  superficial  abscess,  after  cleansing  the  parts,  make  the  skin 
tense,  locate  the  superficial  vessels  and  nerves,  and  plan  the  incision  to  avoid 
them.  Incise  with  a  sharp-pointed  curved  bistoury  at  the  most  dependent 
part  of  the  abscess  or  through  the  region  of  pointing.  If  the  abscess  is  upon 
the  face  or  neck,  make  the  incision  in  the  line  of  the  skin  creases  so  as  to  limit 
the  scar.  The  incision  must  not  be  made  suddenly  and  fiercely,  neither  should 
it  be  made  with  hesitation  and  uncertainty.  Thomas  Bryant  says:  "It 
should  be  done,  as  ought  every  other  act  of  surgery,  with  confidence  and  de- 
cision, boldness  and  rapidity  of  action  being  governed  by  caution  and  made  sub- 
servient to  safety'.'  ("Practice  of  Surgery").  Permit  the  pus  to  run  out  spon- 
taneously; pressure,  as  a  rule,  is  undesirable  because  it  may  damage  the  abscess 
wall  and  cause  dift^usion  of  the  infection.  If  tissue  shreds  block  the  opening, 
they  must  be  picked  out  with  forceps.  If  the  atmospheric  pressure  will  not 
cause  the  pus  to  flow  out,  make  light  pressure  with  warm,  moist,  aseptic 
gauze  pads.  After  the  pus  has  come  away  gently  wash  the  cavity  with  normal 
salt  solution  or  boiled  water,  and  drain  with  a  tube  for  two  or  three  days  when 
the  discharge  becomes  serous.  It  is  not  desirable  to  overdistend  the  abscess- 
cavity  with  fluid,  because  the  hydrostatic  pressure  might  break  down  the  wall 
of  young  ceUs  and  infection  be  diffused.  Do  not  irrigate  with  powerful  disin- 
fectants. They  cannot  be  used  strong  enough  to  reaUy  disinfect,  but  may 
easily  be  used  strong  enough  to  cause  necrosis  of  an  abscess  w^aU.  Peroxid 
of  hydrogen  is  not  to  be  used  unless  the  incision  is  large,  because  the  gas  it 
generates  may  tear  the  abscess  w^all  and  diffuse  the  infection.  Peroxid  of 
hydrogen  is  a  dangerous  agent  to  inject  into  the  cavity  of  a  deep  abscess  of  the 
neck,  as  the  liberated  gas  may  not  escape  from  the  opening,  but  may  pass 
■widely  into  the  tissues  and  cause  great  distention.  The  author  saw  a  child 
who  narrowly  escaped  death  after  such  an  injection.  In  this  patient  the  gas 
passed  beneath  the  pharyngeal  mucous  membrane  and  the  swelling  almost 
occluded  the  air-passages.  If  an  abscess  contains  putrid  pus  the  incision 
should  be  free,  and  after  evacuation  it  should  be  irrigated  with  hot  salt  solution 
or  peroxid  of  hydrogen  and  injected  with  iodoform  emulsion.  Pursue  rigid 
antisepsis  in  deahng  with  purulent  areas.  It  is  true  we  already  have  infection 
with  pyogenic  bacteria,  but  infection  can  also  take  place  with  organisms 
of  putrefaction,  causing  pus  to  become  putrid,  or  with  other  bacteria,  for 
instance,  those  of  tetanus.  If  a  tube  is  not  used  and  the  ca\aty  is  packed  ^dth 
iodoform  gauze,  remember  that  gauze  wiU  not  drain  pus  and  requires  to  be 
changed  once  a  day  or  oftener.  An  abscess  should  be  dressed  \^dth  hot,  moist, 
antiseptic  dressings  (antiseptic  fomentation)  and  the  part  must  be  put  at 
rest.  When  the  discharge  becomes  thin  and  scanty,  dry  aseptic  or  antiseptic 
dressings  are  used. 

In  a  deep  abscess  or  an  abscess  situated  near  important  vessels  do  not 
boldly  plmige  in  a  knife.  Hilton  says  to  "plunge  in  a  knife  is  not  courageous, 
as  it  is  without  danger  to  the  surgeon,  but  may  be  fatal  to  the  patient."  Re- 
member also  that  a  large  amount  of  pus  displaces  normal  anatomical  relations. 
Hilton's  method  of  opening  a  deep  abscess  (as  in  the  axilla  or  neck)  is  to  cut 
to  the  deep  fascia,  nick  the  fascia  with  a  knife,  and  then  push  into  the  abscess 
a  grooved  director  until  pus  shows  in  the  groove ;  along  the  groove  push  a  pair 
of  closed  dressing  forceps;  after  they  reach  the  depths  take  out  the  director, 
open  the  forceps,  and  withdraw  them  whfle  open,  and  so  dilate  the  opening; 
then  insert  a  tube  and  gently  irrigate  with  warm  salt  solution. 

Always  endeavor  to  open  an  abscess  at  its  most  dependent  part,  remem- 
bering that  the  situation  of  this  part  may  depend  upon  whether  the  patient  is  to 


Ulceration  and  Fistula 


be  erect  or  recumbent.  If  we  do  not  make  the  opening  at  the  lowest  point,  all 
the  pus  will  not  run  out  and  the  walls  will  not  completely  collapse.  A  deep 
abscess  must  be  drained  thoroughly  until  the  chscharge  becomes  seropurulent. 
When  the  tube  is  removed  it  is  ^^ise  to  insert  a  tent  of  iodoform  gauze  just 
through  the  outlet  of  the  abscess.  This  tent  prevents  the  skin  from  closing 
over  the  channel.  It  is  removed  and  a  new  one  inserted  ever\-  day  until  it  is 
clear  that  there  is  no  longer  danger  of  liuid  becoming  blocked  and  retained. 
\Mien  an  abscess  contains  diverticula  or  pouches  they  should  be  sHt  up  or  a 
counteropening  ought  to  be  made.  A  counteropening  is  made  by  entering 
the  dressing  forceps  at  the  first  incision,  pushing  them  through  the  abscess 
to  the  point  where  we  wish  to  make  our  counteropening.  opening  the  blades, 
and  cutting  between  them  from  "v\'ithout  inward.  The  blades  are  then  closed 
and  projected  through  the  incision:  they  are  opened  in  order  to  dilate  the 
new  door,  and  are  closed  again  upon  a  drainage-tube,  which  is  pulled  through 
from  opening  to  opening  as  the  instrument  is  ■^dthdra-uTi.  When  pus  burrows, 
insert  a  grooved  director  in  each  channel  and  sHt  the  sinus  with  a  knife.  An 
abscess  may  make  an  opening  through 
dense  fascia,  the  opening  being  small 
like  the  neck  of  an  hour-glass  (shirt- 
stud  abscess) .  Always  examine  to  see 
if  such  a  condition  exists,  and  if  it  is 
found,  incise  the  fascia. 

In  a  deep  abscess  containing 
putrid  pus  frequent  irrigation  is 
desirable.  In  such  a  case  two  tubes 
may  be  employed  (Fig.  78).  The 
tubes  are  prevented  from  shpping  in 
by  the  use  of  a  safet\"-pin  (a).    The 

irrigating  fluid  is  passed  into  the  ca^ity  (d^  through  the  tube  b.  which  is 
'^dthout  fenestra,  and  most  of  it  runs  out  through  the  tube  c.  which  possesses 
fenestra. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess,  and  we  tn.-  to 
obtain  it  by  bandages,  splints,  and  pressiure,  which  will  immobilize  adjacent 
muscles  and  approximate  the  abscess  walls.  If  an  abscess  is  slow  to  heal,  use 
as  a  daily  injection  a  solution  of  corrosive  subHmate  of  the  strength  of  i:  1000, 
or  3  drops  of  nitric  acid  to  i  oz.  of  water,  or  3  gr.  of  zinc  sulphate  to  i  oz. 
of  water,  or  a  5  per  cent,  solution  of  carbohc  acid,  or  a  2  per  cent,  aqueous 
solution  of  pyoktanin.  or  20  drops  of  tincture  of  iodin  to  i  oz.  of  water,  or  a 
2  per  cent,  solution  of  acetate  of  aluminum.  The  constitutional  treatment  of  an 
abscess  depends  upon  the  severity  of  the  morbid  process  and  the  importance 
of  the  structures  involved.  In  a  serious  case  the  patient  shoifid  be  put  to 
bed,  opiates  should  be  given  with  a  free  hand,  the  bowels  be  kept  active  by 
calomel  and  salines,  skin  acti^fity  be  maintained,  the  taking  of  nutritious  food 
insisted  on,  and  stimulants  liberally  employed. 

Purulent  Effusions. — (See  Suppurative  Thecitis.  Palmar  Abscess,  Sup- 
purative S}Tio\-itis,  Purulent  Peritonitis,  Empyema,  etc. ) 


Fig.  78. — Drainage-tubes  for  abscess  requiring  irri- 
gation. 


MI.  ULCERATION   AND    FISTULA 

An  ulcer  is  a  loss  of  substance  due  to  molecular  death  of  a  superficial 
structure.  The  molecular  death  is  brought  about  by  bacteria.  Ordinan,- 
ulcers  are  caused  by  pus  organisms.  The  action  of  the  pus  organisms  is  the 
same  as  in  an  abscess.  A  broken  abscess  becomes  an  ulcer,  and  an  ulcer  is 
in  structure  a  haK-section  of  an  abscess.    The  floor  of  an  ulcer  consists  of- 


152  Ulceration  and  Fistula 

granulation  tissue  and  corresponds  to  the  abscess  wall.  An  abscess  arises 
from  molecular  death  within  the  tissues;  an  ulcer,  from  molecular  death  of 
a  free  surface.  An  ulcer  may  increase  in  size  by  molecular  death  of  adja- 
cent structures  or  by  sloughing,  that  is  to  say,  by  death  of  visible  masses  of 
tissue.  A  wound  healing  by  granulation  is  often  wrongly  called  an  ulcer. 
An  ulcer  must  not  be  confounded  with  an  excoriation.  In  an  ulcer  the  corium 
is  always,  and  the  subcutaneous  tissue  is  generally,  destroyed,  and  a  scar  is 
left  after  healing.  In  an  excoriation  the  mucous  layer  of  epitheliiim  is  ex- 
posed, or  this  is  destroyed  and  the  corium  is  exposed.  In  an  excoriation  the 
coriiun  is  never  destroyed,  and  no  scar  remains  after  healing.  An  ulcer  heals 
by  granulation  (see  page  117).  Embryonic  tissue  by  vascularization  becomes 
granulation  tissue,  granulation  tissue  is  converted  into  fibrous  tissue,  the  fibrous 
tissue  contracts,  and  by  pulling  the  edges  of  the  ulcer  toward  each  other  lessens 
the  size  of  the  cavity.  When  the  granulations  reach  the  level  of  the  skin  the 
epitheliimi  at  the  edges  of  the  iilcer  proliferates  and  the  sore  is  soon  covered 
over  with  new  epitheliimi. 

Necrosis  of  a  superficial  part  may  arise  from — (i)  Inflammation.  The 
pressure  of  the  exudate  can  cut  off  the  circulation,  or  bacteria  may  directly 
destroy  tissue.  Suppuration  occurs.  (2)  The  action  of  pus  bacteria,  causing 
primary  cell-necrosis.  (3)  Bacteria  of  putrefaction  and  organisms  of  suppura- 
tion acting  upon  a  wound.  (4)  Traumatism  or  irritants,  producing  at  once 
stasis,  which  is  added  to  by  secondary  inflammation,  the  exudate  imdergoing 
purulent  Hquefaction.  (5)  Prolonged  pressure.  (6)  Deficient  blood-supply. 
(7)  Faulty  venous  return.  (8)  Degeneration  of  a  neoplastic  infiltration  (gum- 
matous, malignant,  or  tuberculous).  (9)  Trophic  disturbance.  (10)  Nutri- 
tional disturbances  (as  scurvy).  Most  ulcers  are  due  directly  to  pus  organ- 
isms, and  areas  of  necrosis  of  superficial  parts  that  arise  from  something  else 
(as  gummatous  degeneration)  suppurate. 

Classification. — Ulcers  are  classified  into  groups  according  to  the  con- 
dition of  the  ulcer  and  the  associated  constitutional  state.  In  the  first  group 
we  find  the  varicose,  hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc. 
In  the  second  group  are  placed  the  tuberculous,  syphilitic,  senile,  scorbutic, 
etc.  AU  ulcers,  whatever  their  origin,  are  either  acute  or  chronic,  and  such 
conditions  as  great  pain,  hemorrhage,  edema,  exuberant  granulations,  phage- 
dena, sloughing,  eczema,  gout,  syphilis,  scurvy,  etc.,  are  to  be  looked  upon 
as  compHcations.  The  leg  is  so  common  a  site  for  ulcers  as  to  warrant  a  special 
description  of  ulcers  of  this  part.  In  describing  an  ulcer  state  the  patient's 
previous  history;  the  supposed  cause;  the  situation;  the  outline;  the  dura- 
tion, and  the  mode  of  onset  of  the  ulcer.  State  if  the  ulcer  is  single  or  if  mul- 
tiple sores  exist,  and  if  there  is  or  is  not  pain;  whether  or  not  any  healing  has 
ever  occurred,  and  the  patient's  constitutional  condition.  Set  forth  the  com- 
pHcations; the  state  of  anatomicaUy  related  glands;  the  condition  of  the  edge, 
the  floor,  and  the  parts  about  the  ulcer,  and  the  nature  and  quantity  of  the 
discharge. 

Acute  or  inflamed  ulcer  of  the  leg  may  follow  an  acute  inflammation 
and  may  be  acute  from  the  start,  or  may  be  first  chronic  and  then  become  acute. 
It  is  especiaUy  common  in  drunkards,  and  among  those  of  dflapidated  con- 
stitutions. It  is  characterized  by  rapid  progress  and  intense  inflammation. 
There  is  rarely  more  than  one  ulcer.  In  outline  these  ulcers  are  usually  oval, 
but  may  be  irregular.  The  floor  of  an  acute  ulcer  contains  no  granulations, 
but  is  composed  of  the  raw  and  inflamed  tissues,  or  is  covered  by  a  mass  of 
gray  aplastic  lymph,  or  it  may  have  upon  it  large  greenish  sloughs.  The 
edges  are  thin  and  imdermined.  The  discharge  is  very  profuse  and  ichorous, 
excoriating  the  surrounding  parts.  The  adjacent  cutaneous  surface  is  in- 
flamed and  edematous,  and  there  is  much  burning  pain.    In  some  cases  the 


Chronic  Ulcer  of  the  Leg  153 

glands  in  the  groin  enlarge.  Constitutionally,  there  is  gastro-intestinal  de- 
rangement, but  rarely  fever.  When  the  ulcer  spreads  with  great  rapidity 
and  becomes  deeper  as  well  as  larger  in  surface  area,  it  is  called  "phagedenic." 
The  formation  of  sloughs  indicates  that  tissue  death  is  going  on  so  rapidly 
that  the  dead  portions  have  not  time  to  break  down  and  be  cast  off.  Limited 
stasis  produces  molecular  death;  more  extensive  stasis,  a  slough.  If  a  chronic 
ulcer  becomes  acute,  existing  granulations  are  destroyed. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a  dose  of  blue 
mass  or  calomel,  followed  in  eight  or  ten  hours  by  a  saline  (2  dr.  each  of  Rochelle 
and  Epsom  salts),  and  order  light  diet.  Deny  stimulants  except  in  a  case 
of  diphtheritic  ulcer.  Administer  opium  if  pain  is  severe.  Spray  the  ulcer 
with  hydrogen  peroxid,  use  the  scissors  and  forceps  to  get  rid  of  sloughs,  and 
after  sloughs  are  removed  wash  the  ulcer  with  corrosive  sublimate  solution 
(i:  1000)  or  paint  it  with  pure  carbolic  acid.  Paint  the  skin  adjacent  to  the 
ulcer  with  equal  parts  of  tincture  of  iodin  and  alcohol.  Dress  with  hot  anti- 
septic fomentations.  Apply  a  bandage  from  the  toes  to  well  above  the  ulcer. 
Insist  on  the  patient  remaining  in  bed  with  the  leg  slightly  elevated.  Change 
the  dressings  before  they  become  cool  and  always  as  soon  as  they  are  satu- 
rated with  discharge.  Every  day  or  two  paint  the  parts  about  the  ulcer  with 
equal  parts  of  iodin  and  alcohol. 

Many  cases  do  very  well  after  antiseptization  and  dusting  the  ulcer  with 
iodoform,  lead-water  and  laudammi  being  applied  to  the  inflamed  parts  around 
the  ulcer;  but  in  a  bad  case  hot  antiseptic  fomentations,  compression,  and 
elevation  are  more  useful  until  sloughs  separate.  If  the  discharge  is  offen- 
sive, apply  acetanilid,  aristol,  or  iodoform,  or  use  3  gr.  of  chloral  to  i  oz.  of 
water  before  applying  hot  fomentations  or  ordinary  antiseptic  dressings.  A 
25  per  cent,  ointment  of  ichthyol  is  very  useful  when  applied  to  parts  around 
the  ulcer.  If  sloughs  continue  to  form,  touch  the  sloughing  area  with  a  i :  8 
solution  of  acid  nitrate  of  mercury  or  with  a  solution  of  pure  carbolic  acid, 
and  reapply  antiseptic  fomentations.  If  an  ulcer  continues  to  spread,  cleanse 
with  peroxid  of  hydrogen,  dry  with  absorbent  cotton,  touch  with  nitrate  of 
mercury  solution  (1:8),  and  apply  antiseptic  fomentations.  Repeat  the  appli- 
cation of  nitrate  of  mercury  every  day  until  the  ulcer  ceases  to  extend  and 
granulations  begin  to  form.  When  granulations  begin  to  form  freely  moist 
hot  dressings  are  no  longer  desirable,  and  dry  aseptic  or  antiseptic  dressings 
can  be  used. 

If  an  ulcer  is  covered  with  a  great  mass  of  aplastic  lymph,  touch  daily  with  a 
solution  of  silver  nitrate  (40  gr.  to  i  oz.)  or  with  acid  nitrate  of  mercury  (1:15), 
and  dress  with  iodoform  and  antiseptic  fomentations.  Give  internally  tonics, 
stimulants,  and  nutritious  liquid  food.  In  any  case,  when  granulations  form, 
dress  antiseptically  with  dry  dressings,  or  employ  a  non-irritant  ointment,  such 
as  cosmolin.  If  granulations  form  slowly  touch  them  every  day  with  a  solution 
of  silver  nitrate  (10  gr.  to  the  oz.)  and  dress  antiseptically,  or  apply  a  stimulating 
ointment  (resin  cerate  or  i  dr.  of  ung.  hydrarg.  nitratis  to  7  dr.  of  ung.  petrolii, 
or  an  ointment  of  copper  sulphate,  3  gr.  to  the  oz.),  or  dress  with  gauze  soaked 
in  a  solution  of  3  drops  of  nitric  acid  to  i  oz.  of  gum  arable.  When  the  granu- 
lations are  healthy  cicatrization  can  be  greatly  hastened  by  an  application 
of  scarlet  red  ointment  (8  per  cent.).  This  is  kept  in  place  for  twenty-four 
hours  at  a  time.     It  is  used  intermittently. 

Chronic  ulcer  of  the  leg  is  characterized  by  low  action  and  slow  prog- 
ress. It  may  be  chronic  from  the  start,  or  it  may  result  from  acute  ulcer. 
Usually  it  is  found  as  a  solitary  ulcer  2  inches  above  the  internal  mal- 
leolus. Syphilitic  ulcers  often  occur  in  a  group,  are  usually  crescentic,  and 
are  frequent  upon  the  front  of  knee.  A  tuberculous  ulcer  may  have  no  granu- 
lations, but  is  usually  covered  with  pale  edematous  granulations,  which  signify 


154  Ulceration  and  Fistula 

the  existence  of  a  tendency  to  venous  stasis.  The  edges  of  the  tuberculous 
ulcer  are  undermined  and  irregular,  the  parts  about  it  are  livid  and  tender, 
and  the  discharge  is  thin  and  scanty  (see  page  246).  An  ordinary  chronic  ulcer 
is  circular  or  oval,  and  is  surrounded  by  congested,  discolored,  and  indurated 
skin,  this  induration  being  due  to  fibrous  tissue,  and  there  is  often  eczema  or  a 
brown  pigmentation  of  the  neighboring  skin.  The  floor  of  the  ulcer  is  uneven, 
and  usually  is  covered  with  granulations,  each  of  which  is  red  and  the  size  of 
a  pin-point,  but  which  may  be  exuberant  or  edematous.  If  granulations  are 
absent,  the  ulcer  has  the  appearance  of  a  piece  of  liver,  or  is  smooth  and 
glazed.  The  edges  are  thick,  turned  out,  and  not  sensitive  to  the  touch. 
Occasionally,  but  rarely,  they  are  thin  and  undermined.  Some  ulcers  are 
indurated  and  adherent;  this  adhesion  to  the  deeper  structures  prevents 
healing  by  antagonizing  contraction.  An  ulcer  may  fail  to  heal  because  of 
severe  infection;  because  of  want  of  rest;  because  of  absence  of  granulations 

resulting  from  deficient  blood-supply ;  because 
of  edematous  granulations;  because  of  exu- 
j^'CziwaV^  --7    ,  -  -^        berant  graniilations ;  because  of  adhesion  to 

_^  .f^^%  /  ''^^%X^.      deep    structures,   or   because   of   some  con- 

stitutional disease. 

Treatment. — In  treating  a  chronic  ulcer, 
give  a  saline   cathartic    every    day    or    so. 
Treat  any  existing  diathesis.     Insist  on  rest 
Fig-  79-  Fig.  80.  and,  if  possible,   elevation.     Asepticize  the 

Figs.  79  and  80.— Incisions  for  adherent      ulccr.      Draw  blood  by  shalloW  SCarificationS 

^cer.  q{  the  bottom  and  edges  of  the  ulcer  and 

the  skin  about  it.  If  the  ulcer  is  adherent  to 
deeper  structures,  make  incisions  like  those  shown  in  Figs.  79  and  80,  each  cut 
going  through  the  deep  fascia.  These  incisions,  besides  permitting  contrac- 
tion, allow  granulations  to  sprout  in  the  cuts  and  absorb  exudate.  Nussbaum 
advocated  encircling  the  ulcer  with  an  incision  about  i  or  §  inch  away  from 
the  edge  of  the  ulcer,  the  incision  passing  through  the  skin.  After  incision 
keep  the  part  elevated  and  dressed  antiseptically  for  two  days.  In  two 
days  after  scarification  or  incision  scrape  the  ulcer  with  a  curet  until  sound 
tissue  is  reached.  Use  hot  antiseptic  fomentations  for  two  days  more,  then 
paint  the  parts  adjacent  to  the  ulcer  with  tincture  of  iodin  and  alcohol 
(1:3),  dress  the  parts  about  the  ulcer  with  ichthyol  ointment,  and  dress  the 
ulcer  antiseptically  or  with  sterile  gauze.  In  a  day  or  so  the  use  of  ichthyol 
should  be  discontinued  and  the  ulcer  be  dressed  with  sterile  gauze,  normal  salt 
solution,  boric  acid,  solution  of  acetate  of  aluminum,  chlorin-water,  a  solution 
of  permanganate  of  potassium,  sulphur,  glutol,  protonuclein,  or  bovinin. 
Glutol  (formalin-gelatin)  is  very  useful  in  some  cases  and  so  is  protonuclein. 
When  healing  begins,  treat  as  outlined  for  healing  acute  ulcer  (see  page  153). 
Many  cases  can  be  cured  by  baking  in  the  hot-air  apparatus  from  half  an  hour 
to  an  hour  daily.  A  moderate  heat  is  indicated,  and  in  the  intervals  of  treat- 
ment an  elastic  bandage  should  be  used  and,  if  possible,  the  patient  should  be 
kept  in  bed. 

Unna's  dressing  is  satisfactory  in  many  cases.  It  is  applied  as  a  fluid, 
painted  on  when  hot.  It  solidifies  on  cooling  and  resembles  rubber.  The 
paint  is  made  as  follows:  Dissolve  4  parts  of  the  best  gelatin  in  10  parts  of 
water  by  means  of  a  hot- water  bath.  While  the  fluid  is  hot  add  10  parts  of 
glycerin,  and  then  4  parts  of  powdered  white  oxid  of  zinc  and  stir  energetically 
until  the  mixture  is  cold.  Melt  the  paint  before  using  by  placing  the  receptacle 
in  a  hot-water  bath.  The  extremity  must  be  clean  and  thoroughly  dry.  Apply 
the  paint  from  just  above  the  roots  of  the  toes  to  just  below  the  knee.  Cover 
the  layer  of  paint  with  a  gauze  bandage;  put  over  this  another  layer  of  paint, 


Varicose  \^eins  155 

then  another  bandage,  and  so  on  until  three,  four,  or  five  bandages  have 
been  applied.  To  prevent  wrinkling  apply  the  gauze  in  short  pieces.  The 
outer  layer  of  the  dressing  is  a  coat  of  the  paint.  This  dressing  is  worn  from 
four  to  eight  weeks  unless  it  loosens  sooner.  When  it  loosens,  it  is  changed. 
If  the  ulcer  discharges  freely  and  stains  the  dressing,  cut  a  trap-door  in  the 
dressing  and  through  this  cleanse  the  ulcer  and  apply  dressings  and  a  bandage 
as  often  as  necessar}^  (Michel,  in  ''Chicago  Clinic,"  Xo.  8,  1900). 

An  excellent  treatment  if  the  patient  must  walk  about  is  camphor,  first 
recommended  by  Schulze  (''Mlinchener  medicinische  Wochenschrift,"  March 
19,  1901).  It  is  most  conveniently  used,  as  Walbaum  shows,  in  the  form  of 
spirits  of  camphor  (Ibid.,  June  25,  1901).  He  applies  the  dressing  in  the 
follo^^ing  manner:  Clean  the  ulcer  with  green  soap  and  dress  it  daily  with 
dressings  wet  with  a  2  per  cent,  solution  of  the  acetate  of  aluminum.  In 
about  three  days  the  discharge  will  become  scanty  and  free  from  odor. 
It  is  at  this  period  that  camphor  should  be  used.  A  small  piece  of  gauze 
wet  with  spirits  of  camphor  is  apphed  directly  and  only  to  the  ulcer.  Over 
this  is  appUed  a  large  piece  of  dx}"  sterile  gauze,  a  rubber-dam,  a  large 
piece  of  absorbent  cotton,  and  a  bandage  from  the  toes  up.  Every  other  day 
the  dressings  are  removed,  the  ulcer  is  washed  with  a  2  per  cent,  solution  of 
carboUc  acid,  and  the  dressings  are  reappHed.  Usually  the  ulcer  is  healed  in 
three  weeks. 

Complications. — Remove  by  scissors  and  forceps  any  badly  damaged 
tissue.  Take  out  dead  bone;  slit  sinuses;  trim  overhanging  edges.  Treat 
eczema  locally  by  washing  -vNith  ethereal  soap  and  apphdng  powdered  oxid 
of  zinc  or  borated  talcum,  the  leg  then  being  wTapped  in  cotton.  Unna's 
paint  is  very  useful  in  chronic  eczema.  If  the  part  is  crusted,  the  crusts  should 
be  removed  by  applying  some  oily  materials  and  washing  with  ethereal  soap 
and  water.  Ordinary  soap  should  not  be  used.  In  an  acute  case  soap  and 
water  always  do  harm  and  the  part  is  to  be  cleaned  by  "gently  "^-iping  ^\-ith 
cold  cream  or  petrolatum'"  (Stelwagon,  on  "Diseases  of  the  Skin").  If  crusting 
is  very  marked  it  may  be  necessary  to  remove  it  by  means  of  an  ordinars^  poul- 
tice or,  better,  a  starch  poultice  made  with  a  2  per  cent,  solution  of  boric  acid. 
When  scales  or  crusts  are  sHght  or  absent  or  when  they  have  been  removed,  the 
remedial  agent  should  be  appHed.  The  remedies  for  eczema  are  legion.  Among 
them  are  a  solution  of  lead  acetate;  lead- water  and  laudanum;  a  powder  com- 
posed of  30  gr.  of  powdered  boric  acid  and  §  oz.  each  of  talc  and  zinc  oxid; 
ung.  picis  hquidae,  i  dr.,  "v\ith  sufficient  ung.  zinci  oxidi  to  make  i  oz.;  ^  oz.  of 
Hquor  carbonis  detergens  to  i  pint  of  water.  In  even,-  case  of  eczema  place 
the  patient  upon  a  plain  and  nutritious  diet;  order  him  to  avoid  -uines  and 
liquors;  give  an  occasional  saline  laxative;  keep  the  skin  and  kidneys  active, 
and  if  the  patient  is  gouty  or  rheumatic,  give  appropriate  remedies.  The  value 
of  arsenic  in  eczema  has  been  much  overrated. 

Varicose  veins  may  demand  either  Hgation  at  several  points,  excision, 
Trendelenburg's  operation  (see  page  462),  or  the  continued  use  of  a  flannel 
roller  or  a  Martin  rubber  bandage.  Xever  operate  on  varicose  veins  if  phlebitis 
exists  unless  a  clot  has  formed,  in  which  case  apply  a  ligature  above  the  clot. 
Never  operate  on  the  veins  for  varicose  ulcer  unless  the  ulcer  is  in  an  aseptic 
state.  Inflammation  of  the  ulcer  is  met  by  rest,  elevation,  painting  the  neigh- 
boring parts  with  dilute  tincture  of  iodin,  and  applying  about  the  ulcer  ichthyol 
ointment.  For  calloused  edges,  bhster,  employ  radiating  incisions,  or  cut  the 
edges  away.  Ordinary  thick  edges  should  be  strapped.  In  strapping  use  zinc 
oxid  adhesive  plaster  and  do  not  completely  encircle  the  limb  (Fig.  81).  WTien 
the  parts  are  adherent  the  ulcer  is  inmiovable,  being  firmly  anchored  to  struc- 
tures beneath  it.  In  such  a  condition  completely  or  partly  surround  the  sore 
with  a  cut  through  the  deep  fascia  (see  Figs.  79,  So) .    This  cut  sets  the  ulcer  free 


156 


Ulceration  and  Fistula 


from  its  anchorage  and  permits  it  to  contract.  Edematous  granulations  require 
dry  dressings  and  pressure  by  a  flannel  bandage,  a  rubber  bandage,  or  adhesive 
plaster.  If  the  bottom  of  the  ulcer  is  foul,  dry  it  and  touch  with  a  solution  of 
acid  nitrate  of  mercury  (i :  8)  or  with  crystals  of  pure  carbolic  acid.  Repeat  this 
every  third  day  and  dress  with  hot  antiseptic  fomentations  until  granulations 
appear.  Superfluous  granulations  (proud  flesh)  should  be  cut  away  with  scissors, 
scraped  away,  or  burned  down  with  a  strong  solution  of  silver  nitrate,  with 
the  solid  stick  of  lunar  caustic  or,  better,  with  pure  carbolic  acid,  which  causes 
much  less  pain  than  does  silver.  Absence  of  granulations  or  scantiness  of 
granulations  means  deficiency  of  blood-supply.  The  surgeon  endeavors  to 
bring  more  blood  to  the  part,  and  to  do  this  induces  inflammation.  The 
usual  method  of  procedure  is  to  apply  daily  to  the  sore  a  solution  of  nitrate 

of  silver  (lo  or  15  gr.  to  the 
ounce) .  Argyrol  of  a  strength 
of  25  per  cent,  is  not  painful 
and  is  as  efficient.  In  ob- 
stinate cases  blister  the  ulcer 
or  scrape  it,  or  paint  it  with 
tincture  of  iodin,  or  apply 
pure  carbolic  acid,  or  touch 
it  with  the  actual  cautery. 
In.  many  cases  granulation 
is  greatly  stimulated  by  a 
twenty-four-hour  application 
of  an  8  per  cent,  ointment  of 
scarlet  red.  If  it  causes  irri- 
tation its  use  is  suspended 
for  a  day  or  two,  and  then 
the  ointment  is  reapplied.  If 
an  ulcer  of  the  leg  becomes 
painful  at  one  point  (see  page 
157),  touch  with  pure  car- 
bolic acid  after  curetting,  or 
find  the  painful  spot  with 
a  probe  and  divide  the  ex- 
posed nerve  filament  with  a 
tenotome. 
Among  the  methods  of  skin-grafting 
(See  Plastic  Surgery.) 


Fig.  81. — Strapping  an  ulcer  of  leg  ("Keen's  Surgery"). 


If  healing  entirely  fails,  skin-graft 
are — (i)  Reverdin's,  (2)  Thiersch's,  and  (3)  Wolfe's 

When  a  man  having  an  ulcer  must  go  out  and  about,  the  camphor  treatment 
can  be  employed  (see  page  155),  Unna's  dressing  may  be  applied  (see  page  154), 
the  patient  can  use  a  firmly  applied  roller  or,  better  still,  a  Martin  bandage. 
Martin's  bandage,  which  is  made  of  red  rubber,  limits  the  amount  of  arterial 
blood  going  to  the  ulcer  and  favors  venous  flow  from  the  sore  and  its  neigh- 
borhood. The  bandage  should  be  used  as  follows:  Before  getting  out  of  bed 
spray  the  sore  with  hydrogen  peroxid  by  means  of  an  atomizer,  remove  the  froth 
with  absorbent  cotton,  wash  the  leg  with  soap  and  water,  dry  it  with  a  towel,  dust 
the  skin  with  borated  talcum  powder,  and  apply  the  bandage  from  the  toes  up. 
All  of  these  things  should  be  done  before  putting  the  foot  to  the  floor.  At 
night,  after  getting  on  the  bed,  remove  the  bandage,  wash  it  with  soap  and 
water,  dry  it  with  a  towel,  hang  it  unrolled  over  the  back  of  a  chair  to  air,  and 
again  cleanse  the  leg  and  ulcer.  If  these  rules  are  not  strictly  observed,  the 
Martin  bandage  will  produce  pain,  suppuration^  and  eczema  of  the  leg. 

Tuberculous  Ulcers. — (See  pages  246,  247.) 

Syphilitic  Ulcers. — (See  page  328.) 


Erethistic,  Irritable,  or  Painful  Ulcers  157 

A  healthy  ulcer  is  covered  with  small,  bright-red  granulations  which  do 
not  bleed  on  touching,  are  painless,  and  grow  rapidly.  The  edges  of  the  sore 
are  soft  and  show  the  opalescent  blue  line  of  proliferating  epithelium.  The 
sore  is  movable,  the  discharge  is  purulent  and  yellow,  and  the  parts  about 
are  not  inflamed. 

Various  Ulcers. — The  fungous  or  exuberant  ulcer  of  the  leg  is  produced 
by  interference  with  the  return  of  venous  blood  from  the  part,  and  it  is  specially 
common  after  burns  and  other  injuries  when  cicatricial  contraction  causes 
venous  obstruction.  The  granulations  are  large,  deep  red  in  color,  bleed 
when  touched,  form  rapidly,  and  mount  above  the  level  of  the  skin.  The 
discharge  from  a  fungous  ulcer  is  profuse,  thin,  and  bloody.  In  the  treatment 
of  such  an  ulcer  venous  return  must  be  favored  by  bandaging  and  by  elevation 
of  the  part.  If  the  edges  are  very  thick,  divide  them  in  a  mmiber  of  places. 
The  superfluous  granulations  should  be  burnt  down  with  lunar  caustic  or 
pure  carbolic  acid  or  should  be  cut  off.  Strapping  with  adhesive  plaster  or 
the  use  of  a  rubber  bandage  does  good.  The  sore  can  be  dressed  with  europhen, 
aristol,  or  dry  aseptic  gauze. 

A  varicose  ulcer  of  the  leg  is  an  ulcer  complicated  by  varicose  veins.  It  is 
usually  single,  is  oval,  round,  or  irregular  in  outline,  and  is  most  often  seen 
above  the  inner  malleolus.  Its  edges  are  thick,  everted,  and  swollen.  The 
swelling  is  largely  due  to  edema,  and  is  found  to  pit  on  pressure.  The  edges 
are  not  undermined,  but  slope  gently  to  the  floor  of  the  ulcer.  The  floor  is 
usuaUy  covered  with  rather  large  granulations  which  bleed  freely  on  touching. 
In  a  varicose  ulcer  the  destruction  of  tissue  often  begins  at  the  margin  of  a  con- 
gested area  and  advances  toward  the  center.  Such  an  ulcer  is  usually  sur- 
rounded by  eczema.  To  aid  the  healing  of  a  varicose  ulcer  it  is  first  of  all 
necessary  to  favor  the  return  of  venous  blood  from  the  part  by  position  and 
bandaging.  Martin's  bandage  is  very  useful  and  the  daily  use  of  the  hot-air 
apparatus  is  of  value.    It  may  be  necessary  to  operate  on  the  veins. 

Erethistic,  irritable,  or  painful  ulcers  are  very  sensitive,  a  condition  due 
to  the  exposure  of  nerve-filaments  and  destruction  of  nerve-sheaths.  Irritable 
ulcers  are  especially  found  near  the  ankle,  over  the  tibia,  in  the  anus  (fissure), 
or  in  the  matrix  of  the  nail  (ingrowing  nail) .  Fissure  of  the  anus  is  considered 
on  page  1177.  An  ingrowing  nail  is  sometimes  encountered  on  the  finger,  but 
far  more  commonly  affects  the  toe.  The  great  toe  is  especiaUy  apt  to  suffer. 
We  caU  it  ingrowing  nail,  but  the  condition  is  really  overgrowing  skin.  As  a 
result  of  wearing  ill-fitting  boots  or  stockings,  especially  shoes  which  are  too 
short  or  are  pointed,  the  toes  are  forced  together  and  the  skm  at  the  edge  of  the 
nail  is  squeezed.    After  a  time  an  ulcer  forms. 

When  a  nail  begins  to  ingrow  the  condition  can  usually  be  arrested  by 
w^earing  weU-fitting  shoes  and  stockings,  allowing  the  nail  to  grow  somewhat 
long  and  cutting  it  square  across  instead  of  cutting  away  the  troublesome 
corner.  Daily  a  Httle  absorbent  cotton  should  be  packed  under  the  ingrowing 
corner.  In  more  severe  cases,  under  local  anesthesia  cut  away  the  overlapping 
skin  and  a  portion  of  the  flesh  on  the  side  of  the  toe,  split  the  nail  longitudinally, 
remove  the  ingrown  portion  of  nail  and  a  corresponding  part  of  the  matrix. 

An  erethistic  ulcer  of  the  cutaneous  surface  is  treated  as  follows:  Curet 
and  touch  with  pure  carbolic  acid  or  with  the  solid  stick  of  silver  nitrate. 
Chloral,  20  gr.  to  the  ounce,  allays  the  pain;  so  do  cocain  and  eucain  for  a 
time.  In  some  cases  the  painful  area  can  be  located  by  a  probe  and  the 
nerve-filament  di\T[ded  by  a  tenotome. 

The  indolent  ulcer  of  the  leg  shows  no  tendency  to  heal.  In  such  an  ulcer 
there  is  usually  venous  congestion  from  varicose  veins  or  from  cardiac  weak- 
ness. A  great  mass  of  scar-tissue  forms  at  the  base  and  edges,  which  fastens 
the  ulcer  to  bone  or  fascia,  so  that  the  edges  cannot  contract.    Healthy  granula- 


^58 


Ulceration  and  Fistula 


tions  cease  to  form.  The  edges  of  such  an  ulcer  are  thick,  smooth,  immovable, 
and  free  from  tenderness.  Granulations  are  entirely  absent  or  there  are  seen 
here  and  there  a  few  unhealthy  granulations.     The  discharge  is  thin,  sero- 


Fig.  82. — Marjolin's  ulcer  (epithelioma)  in  a  man  twenty  years  of  age,  arising  in  the  cicatrix  of  a  burn. 

purulent,  and  offensive.     The  parts  about  the  ulcer  are  congested  and  pig- 
mented.   The  pigmentation  is  due  to  the  fact  that  in  the  area  of  chronic  con- 


Fig.  83. — Same  case  as  Fig.  82,  after  excision  and  skin-grafting  by  the  Thiersch  method. 

gestion  numbers  of  red  blood-cells  have  been  disintegrated.  Such  an  ulcer 
is  treated  by  making  incisions  to  loosen  the  base  and  edges,  so  that  contrac- 
tion can  take  place.    Venous  congestion  is  corrected  by  means  of  position,  the 


Marjolin's  Ulcer 


159 


use  of  compression,  and  in  some  cases  the  administration  of  cardiac  stimu- 
lants. In  all  cases  the  surgeon  employs  stimulating  applications  to  the  ulcer  in 
order  to  increase  the  supply  of  arterial  blood.  Scarlet  red  ointment  (8  per  cent.) 
strongly  stimulates  granulation. 

The  callous  ulcer  of  the  leg  is  the  most  chronic  form  of  indolent  ulcer  and  is 
sunken  deeply  below  the  level  of  the  skin.  Its  border  is  hard  and  knobby.  Its 
floor  shows  no  granulations,  and  is  either  smooth  and  glistening  or  foul  and 
liver  colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer  varies  Httle  in 
appearance  from  week  to  week  or  even  from  month  to  month.  The  treatment 
consists  in  scraping  and  cauterizing  the  \ilcer;  making  radiating  incisions 
through  the  margins  and  floor  or  elliptical  incisions  about  the  ulcer;  applying 
antiseptic  dressings  and  firm  bandages.  In  some  cases  the  ulcer  should  be 
strapped.  The  daily  baking  in  the  hot-air  oven  is  often  of  great  benefit. 
In  severe  cases  it  is  necessary  to  extirpate  the  ulcer  and  apply  skin-grafts. 

Hemorrhagic  ulcers  bleed  easily  and 
profusely.  Pressure  must  be  applied; 
it  is  sometimes  necessary  to  cut  or  burn 
away  the  granulations. 

Phagedenic  Ulcers. — ^The  phagedenic 
ulcer  results  from  the  profound  microbic 
infection  of  tissues  debilitated  by  local  or 
constitutional  disease,  and  is  commonly 
venereal.  This  ulcer  has  no  granula- 
tions and  is  covered  with  sloughs;  its 
edges  are  thin  and  undermined,  and  it 
spreads  rapidly  in  all  directions.  Such 
an  ulcer  should  be  touched  with  strong 
caustics  or  Paquelin's  cautery,  and 
dressed  with  iodoform  gauze  and  anti- 
septic fomentations.  Tonics  and  stimu- 
lants should  always  be  administered. 

The  edematous  ulcer  may  result  from 
inpediment  to  the  venous  return  or,  as 
De  Nancrede  points  out,  m^y  be  pro- 
duced by  the  persistent  use  of  poultices 
or  wet  dressings  upon  any  ulcer.^  It 
is  most  often  met  with  in  tuberculous 
processes  and  is  occasionally  seen  in 
the  leg  when  varicose  veins  exist.  The 
granulations  are  large  and  pale,  and  are 
apt  to  bend  over  like  unsupported  vines. 
The  discharge  is  profuse  and  seropurulent.  The  edges  are  softened  and  des- 
quamating. An  edematous  ulcer  requires  dry  dressings,  stimulation,  and 
compression. 

A  rodent  or  Jacob's  ulcer,  noli  me  tangere,  or  cancroid  ulcer,  is  a  super- 
ficial epithelioma  developing  usually  from  sebaceous  glands,  sweat-glands, 
or  hair-follicles.  It  requires  scraping  and  cauterization,  the  application  of  the 
a;-rays,  or,  what  is  better,  excision  (see  page  394). 

Marjolin's  ulcer  (Figs.  82-86)  is  an  epitheHoma  arising  from  a  chronic 
ulcer  or  an  old  cicatrix.  The  malignant  change  begins  at  some  point  of  the 
edge  of  the  ulcer,  and  its  first  evidence  is  induration.  The  induration  spreads 
slowly  and  comes  to  involve  a  considerable  part  of  or  even  the  entire  ulcer. 
MarjoHn's  ulcer  is  the  seat  of  scalding,  darting  pain;  the  discharge  is  profuse, 
ichorous,  and  foul,  and  the  floor  of  the  ulcer  is  uneven,  warty,  or  cauliflower- 

1  "Principles  of  Surgery." 


Fig.  84. — Marjolin's  ulcer  (epithelioma)  from 
the  scar  of  a  burn. 


i6o 


Ulceration  and  Fistula 


like.  The  anatomically  related  lymph-glands  eventually  become  involved. 
This  involvement  is  seldom  early  because  induration  has  blocked  lymph- 
channels.  In  order  to  confirm  the  diagnosis  a  bit  of  tissue  should  be  removed, 
and  the  removed  piece  must  include  a  portion  of  the  edge  of  the  ulcer  and 
of  some  apparently  sound  tissue  beyond  it.     If  a  microscopic  examination 


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^1 

^^^^H 

^ 

J^ 

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Fig.  85. — Epithelioma  arising  in  the  scar  of  a  burn  (Marjolin's  ulcer). 


shows  epithelial  infiltration  of  the  apparently  sound  tissue,  a  diagnosis  of 
malignant  disease  must  be  made.  In  an  early  stage  of  such  an  ulcer  free 
extirpation  and  removal  of  the  anatomically  related  glands  may  cure  the 
patient.  In  a  more  advanced  case,  if  an  extremity  is  involved,  amputate  and 
clear  out  the  related  lymphatic  area.     In  a  very  advanced  case  use  the  x-rays. 


Fig.  86.— ilarjolin's  ulcer  arising  from  a  chronic  ulcer  of  the  leg- 
Fig.  82  shows   a   MarjoHn  ulcer  in  a  man  twenty  years  of  age.     It   arose 
in  the  cicatrix  of  a  burn.     I  removed  it  and  applied  Thiersch  grafts  to  the 
raw  surface.     Figs.  84,  85,  and  86  show  Marjolin's  ulcers. 

Decubitus,  or  bed-sore,  is  due  to  pressure  upon  an  area  of  feeble  circu- 
lation (see  page  180).     It  is  in  most  instances  a  condition  of  gangrene. 


Scorbutic  Ulcer  i6i 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of  the  trophic  nerve- 
fibers  or  of  the  trophic  centers  in  the  cord. 

The  perforating  ulcer,  as  it  was  named  by  Vesigne,  is  believed  to  result 
from  peripheral  neuritis.  It  is  certain,  however,  that  in  some  of  these  cases 
there  is  arteriosclerosis,  and  it  has  been  held  that  the  vascular  sclerosis  is  the 
real  cause  and  that  the  nerve  changes  are  secondary  to  the  vascular  changes. 
My  own  belief  is  that  perforating  ulcer  is  a  condition  dependent  upon  both  ar- 
teriosclerosis and  peripheral  neuritis,  traimiatism  usually  being  the  exciting 
cause  of  the  ulcer.  It  is  met  with  most  frequently  in  diabetics,  but  may  be  en- 
countered in  the  victims  of  chronic  alcoholism,  injuries  and  diseases  of  the 
spinal  cord,  injuries  and  diseases  of  nerves,  Bright's  disease,  and  syphilis.  I 
have  seen  this  ulcer  in  an  individual  with  a  fractured  spine,  in  several  tabetics, 
and  in  not  a  few  diabetics.  The  perforating  ulcer  commonly  affects  the  plantar 
surface  of  the  metatarsophalangeal  joint  or  the  pulp  of  the  great  toe  or  little 
toe  about  a  callosity  or  corn.  It  may  arise  on  the  heel  or  the  sole  or  the  side 
of  the  foot.  It  is  usually  unilateral,  but  sometimes  both  feet  are  affected. 
In  very  rare  cases  more  than  one  ulcer  is  present  on  the  foot.  Very  rarely  it 
affects  the  palm  of  the  hand.  The  parts  about  the  corn  inflame,  and  pus  forms 
and  reaches  into  the  bone.  A  sinus  evacuates  the  pus  by  the  side  of  the  corn 
or  callosity  or  the  center  of  the  callosity  exhibits  a  blister  containing  seropus. 
A  portion  of  the  callous  mass  is  cast  off  and  a  shallow  ulcer  is  often  exposed. 
This  ulcer  is  small,  has  a  punched-out  appearance,  and  is  surrounded  by 
calloused  margins.  The  ulcer  penetrates  deeply  and  after  a  time  the  bone 
is  laid  bare  or  the  joint  opened.  The  margins  of  the  ulcer  or  sinus  exhibit 
sprouting  granulations  and  these  are  encircled  by  an  area  of  markedly  thick- 
ened epidermis.  The  discharge  from  a  perforating  ulcer  is  thin  and  scanty,  and 
the  ulcer,  which  slowly  advances,  is  very  chronic.  It  is  not  painful  and  is 
slightly,  if  at  all,  tender.  The  foot  is  cold  and  often  edematous  and  the  parts 
about  the  ulcer  may  be  anesthetic.  The  ulcer  may  heal  when  the  patient  is 
kept  in  bed  and  open  again  when  he  gets  out.  The  disease  is  far  more  common 
among  males  than  among  females  and  is  most  often  met  with  in  the  fifth  or 
sixth  decades  of  life.  As  this  ulcer  may  be  present  in  anesthetic  leprosy,  in 
diabetes,  peripheral  neuritis,  syphUis,  in  a  paralyzed  limb,  and  tabes  dorsalis, 
and  as  the  part  on  which  it  occurs  is  apt  to  be  sweaty,  cold,  and  more  or  less 
anesthetic,  and  as  the  sore  may  be  hereditary,  it  is  usually  set  down  as  trophic 
in  origin.  In  treatment  of  a  perforating  ulcer  I  follow  the  plan  suggested 
by  Treves.  This  consists  in  putting  the  patient  to  bed  and  appljdng  poultices 
to  the  sore.  Every  time  a  poultice  is  removed  the  raised  epitheliiun  around 
the  ulcer  is  cut  away  and  then  the  poultice  is  reapplied.  In  about  two  weeks 
an  ulcer  remains  surrounded  by  healthy  tissue.  Treves  treats  this  sore 
with  glycerin  made  to  a  creamy  consistency  with  salicylic  acid,  to  each  ounce 
of  which  mixture  lo  min.  of  carbolic  acid  have  been  added.  He  directs  the 
patient  to  wear  during  the  rest  of  his  life  some  form  of  bunion-plaster  to 
keep  off  pressure.  If  in  a  perforating  ulcer  the  bone  is  diseased,  it  must  be 
removed.  If  the  patient  is  diabetic  he  must  be  placed  on  antidiabetic  diet  and 
drugs.  Nerve-stretching  has  been  recommended  as  the  proper  treatment  for 
perforating  ulcer,  but  I  have  never  tried  it.  No  matter  what  treatment  is 
employed,  the  sore  is  apt  to  reappear  in  the  old  situation  or  an  adjacent 
region  when  the  part  is  subjected  to  pressure.  In  order  to  prevent  pressure 
upon  the  region  of  ulceration  some  advise  the  use  of  an  artificial  leg,  the  knee 
being  kept  bent.     It  may  be  necessary  to  amputate  the  toe  or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust,  beneath  which 
are  pale  and  bleeding  granulations.     The  parts  adjacent  are  of  a  violet  color. 

Epitheliomatous,  sarcomatous,  tuberculous,  and  syphilitic  ulcers  and  ulcers 
of  the  stomach  and  duodenum  are  considered  under  these  respective  diseases. 


i62  Ulceration  and  Fistula 

Curling's  Ulcer. — This  is  an  ulcer  of  the  first  portion  of  the  duodenum 
which  in  very  rare  cases  follows  an  extensive  burn  or  scald  of  the  cutaneous 
surface.  Curling  described  this  condition  in  1841,  but  Sir  Berkeley  Moynihan 
points  out  in  his  book  upon  "Duodenal  Ulcer"  that  Long,  of  Liverpool,  de- 
scribed it  in  1840.  It  is  small,  clean  cut,  and  deep.  It  may  be  due  to  toxic 
material  in  the  bile,  the  toxic  material  being  due  to  the  burn,  but  against  this 
is  the  occurrence  of  the  ulcer  well  above  the  opening  of  the  bile-duct.  Sir 
Berkeley  Moynihan  regards  it  as  a  toxic  ulcer  and  points  out  that  the  ulcer 
practically  never  occurs  unless  there  were  septic  changes  in  the  burnt  area. 
Septic  emboU  may  be  the  cause.  So  far  no  case  of  Curhng's  ulcer  seems  to 
have  been  treated  surgically.  As  Sir  Berkeley  Moynihan  says,  "there  is  no 
reason  why  it  should  not  prove  successful  if  the  condition  of  the  patient  were 
not  too  exhausted  by  the  extent  or  severity  of  the  original  injury."  If  per- 
foration occurs  the  treatment  is  as  for  any  other  perforating  duodenal  ulcer. 

A  fistula  is  an  abnormal  communication  between  the  surface  and  an 
internal  part  of  the  body,  or  between  two  natural  cavities  or  canals.  The 
first  form  is  seen  in  a  rectal  fistula,  a  urethral  fistula,  or  a  biliary  fistiila; 
and  the  second  form  is  seen  in  a  vesicovaginal  fistiila.  Fistulae  may  result 
from  congenital  defect,  as  when  there  is  failure  in  the  closure  of  the  branchial 
clefts,  and  can  arise  from  sloughing,  traumatism,  and  suppuration.  Fistulae 
are  named  from  their  situation  and  communications.  For  instance,  a  pleural 
fistula,  an  intestinal  or  fecal  fistula,  a  rectal  fistula,  an  anal  fistula,  a  gastric 
fistula,  a  bronchial  fistula,  a  vesical  fistula,  a  bihary  fistula,  etc.  Many  fis- 
tulae are  tuberculous  and  lead  to  some  deeply  placed  tuberculous  focus.  A 
fistiila  in  communication  with  a  viscus  (for  instance,  the  gall-bladder j  may  be 
maintained  by  an  obstruction  of  the  duct  of  that  viscus;  the  removal  of  such 
an  obstruction  cures  the  fistula. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free  surface  and  leading 
down  into  the  cavity  of  an  imperfectly  healed  abscess.  A  sinus  may  be  an 
imhealed  portion  of  a  wound.  Many  sinuses  are  due  to  pus  burromng  sub- 
cutaneously.  A  sinus  fails  to  heal  because  of  the  presence  of  some  irritant 
fluid,  as  sahva,  urine,  or  bile;  because  of  the  existence  of  a  foreign  body,  as 
dead  bone,  a  bit  of  wood,  a  bullet,  a  septic  ligature,  etc. ;  or  because  of  rigidity 
of  the  sinus  waUs,  which  rigidity  will  not  permit  collapse.  Sinuses  may  be 
maintained  by  want  of  rest  (muscular  movements)  and  general  iU  health. 
The  walls  of  a  tuberculous  sinus  are  fined  with  a  material  identical  T\ith  the 
Volkmann's  membrane  of  a  cold  abscess. 

Treatment. — In  treating  a  fistiila  or  a  sinus,  remove  any  causative  ob- 
struction and  any  foreign  body,  lay  the  channel  open,  curet,  brush  -^dth 
pure  carboHc  acid,  and  pack  with  iodoform  gauze.  Sometimes  cure  of  a 
tuberculous  sinus  may  be  secured  by  repeated  injections  of  iodoform  emul- 
sion or  by  injecting  a  paste  of  sub  nitrate  of  bismuth  and  vaselin  (see  page  894). 
The  mixture  remains  in  the  sinus  and  serves  as  a  framework  for  granulations. 
When  a  sinus  closes  after  injections  of  bismuth  paste,  bismuth  concretions 
sometimes  form  and  lead  to  reopening  after  weeks  or  months.  In  obstinate 
cases  of  fistula  or  sinus  entirely  extirpate  the  fibrous  walls,  sew  the  deeper 
parts  of  the  wound  \\dth  buried  catgut  sutures,  and  approximate  the  skin 
surfaces  with  interrupted  sutures  of  silkworm-gut.  To  stimulate  a  sinus  to 
granulation  it  is  sometimes  necessary  to  touch  it  throughout  with  the  actual 
cautery,  nitric  acid,  pure  carbolic  acid,  nitrate  of  silver  fused  on  a  metallic 
probe,  or  in  a  solution  of  a  strength  of  40  gr.  to  the  ounce,  or  argyrol  of  a 
strength  of  50  per  cent.  Fresh  air  is  a  necessity  to  the  patient,  and  nutritious 
food  and  tonics  must  be  ordered.  There  is  some  testimony,  although  scarcely 
as  yet  evidence,  that  the  use  of  bacterial  vaccines  may  at  times  be  of  value 
in  the  treatment  of  certain  sinuses  (see  page  47). 


Gangrene  163 


MIL  MORTIFICATION,   GANGRENE,   OR   SPHACELUS 

^Mortification,  or  gangrene,  is  death  in  mass  of  a  portion  of  tlie  living 
body — the  dead  portions  being  large  enough  to  be  ^'isible — ^in  contrast  to  ulcera- 
tion, or  molecular  death,  in  which  the  dead  particles  have  been  hquefied.  cannot 
be  seen,  and  are  cast  away.  When  all  the  tissues  of  a  part  are  dead,  the  proc- 
ess is  spoken  of  as  sphacelus.  Gangrene  is.  in  reahty,  a  form  of  necrosis,  but 
clinically  the  term  "necrosis''  is  restricted  to  molar  death  of  bone  or  to  death 
of  parts  below  the  surface  en  masse.  In  gangrene  a  portion  of  tissue  dies 
becatise  of  anemia,  and  the  dead  portions  may  either  desiccate  or  putref}'. 
Gangrene  may  be  due  to  tissue  injur}',  either  chemical  or  mechanical,  to  heat 
or  cold,  to  failure  of  the  general  health,  to  circulator}"  obstruction,  to  ner\-e 
disorder,  the  ner\'es  involved  being  the  vasomotor  or  possibly  the  trophic,  or 
to  microbic  infection.  A  microbic  poison  can  directly  destroy  tissues.  It 
can  indirectly  destroy  them  by  causing  such  inflammation  that  the  products 
obstruct  the  circulation,  but  gangrene  can  occur  when  no  bacteria  are  present. 
The  essential  cause  of  gangrene  is  that  the  tissues  are  cut  oft  from  a  due  supply 
of  nourishment,  and  cell-nutrition  is  no  longer  possible.  In  other  words, 
the  essential  cause  of  gangrene  is  the  cutting  off  of  arterial  blood.  De  Xancrede 
says:  "Indeed,  except  when  the  trainnatism  physically  disintegrates  tissues, 
as  a  stone  is  reduced  to  powder,  heat  or  strong  acids  physically  destroy  struc- 
ture, or  cold  suspends  cellular  nutrition  so  long  that  when  this  nutrition  be- 
comes a  physical  possibihty  \"ital  metaboHsm  cannot  be  resumed,  gangrene 
always  results  from  total  deprivation  of  pabulum  (■"Principles  of  Surger}-"). 
Classification. — Gangrene  is  divided  into  the  follo^^■ing  three  great  groups: 
(i)  Dry  gangrene,  which  is  due  to  circulator}-  interference,  the  arterial 
supply  bing  decreased  or  cut  off.     The  tissues  dr}-  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  intert"erence  not  only  with  arterial 
ingress,  but  also  A\"ith  venous  return  or  capillar}-  circulation,  the  dead  parts 
remaining  moist. 

(3)  Microbic  gangrene,  arising  from  ^-irulent  bacteria.  In  this  form 
the  bacterial  process  causes  the  gangrene,  and  is  not  merely  associated 
with  it. 

The  above  classification,  if  unqualified,  suggests  erroneous  ideas.  It  in- 
dicates that  there  is  an  essential  difference  between  dn,-  gangrene  and  moist 
gangrene,  which  is  not  the  case.  If,  when  gangrene  begins,  the  tissues  are 
free  from  fluid,  the  patient  develops  dr}-  gangrene :  if  they  are  fuU  of  fluid,  he 
develops  moist  gangrene.  If  the  arterial  supply  is  gradually  cut  off,  the  tissues 
are  sure  to  be  free  from  fluid,  and  the  gangrene  wiU  certainly  be  of  the  dr}^ 
form.  If  arterial  blood  is  suddenly  cut  off.  the  gangrene  may  be  dr}-  or  moist, 
according  as  to  whether  the  tissues  are  or  are  not  drained  of  fluid.  When 
gangrene  results  from  inflammation,  strangulation,  and  infection  it  is  certain 
to  be  of  the  moist  variety,  because  the  tissues  are  sure  to  be  fifled  with  fluid. 

De  Xancrede  says,  in  his  ver}-  valuable  work  on  the  ••Principles  of  Bur- 
ger}^": ''Yet,  let  accidental  inflammation  have  preceded  the  final  blocking  of  an 
arter}-,  or  let  Hgation  of  the  main  arter}-  cause  gangrene  because  the  collateral 
circulation  cannot  become  developed,  and  if  an  aneur}-smal  sac  is  so  situated 
as  to  interfere  with  a  free  return  of  venous  blood  and  h-mph,  this  anemic 
gangrene  wiU  in  both  instances  prove  moist  and  not  dr}-." 

There  are  many  gangrenous  processes  which  belong  under  one  or  other 
of  the  above  heads,  namely:  congenital  gangrene,  a  rare  form  existing  at  birth; 
constitutional  gangrene,  arising  from  a  constitutional  cause,  as  diabetes; 
cutaneous  gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue,  as  in 
phlegmonous  er}-sipelas;  gaseous  or  emphysematous  gangrene,  in  which  the 


164  Mortification,  Gangrene,  or  Sphacelus 

subcutaneous  tissues  are  filled  with  putrefactive  gases  and  crackle  on  pressure; 
hospital  gangrene,  which  is  defined  by  Foster  as  specific  serpiginous  necrosis, 
the  tissues  being  pulpefied:  some  consider  it  a  traumatic  diphtheria;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead  (sphacelus);  hot  gan- 
grene, which  is  associated  with  inflammation,  as  shown  by  heat;  dermatitis 
gangrenosa  infantum,  or  the  multiple  cachectic  gangrene  of  Simon;  idiopathic 
gangrene,  which  has  no  ascertainable  cause;  mixed,  which  is  partly  dry  and 
partly  moist;  primary,  in  which  the  death  of  the  part  is  direct,  as  from  a  burn; 
secondary,  which  follows  an  acute  inflammation;  multiple,  as  gangrenous 
herpes  zoster;  diabetic  or  glycemic  gangrene,  which  arises  during  the  existence 
of  diabetes;  gangrenous  ecthyma,  a  gangrenous  condition  of  ecthyma  ulcers; 
pressure,  which  is  due  to  long  compression;  purpuric  or  scorbutic,  which  is 
due  to  scurvy;  Raynaud's  or  idiopathic  symmetrical,  which  is  due  to  vascular 
blocking,  perhaps  from  nerve  disorder;  senile,  the  dry  gangrene  of  the  aged; 
veitous  or  static,  which  is  due  to  obstruction  of  circulation  as  in  a  strangulated 
hernia;  trophic,  which  is  due  to  nutritive  failure  by  reason  of  disorder  of  the 
trophic  nerves  or  centers;  thrombotic,  which  is  due  to  thrombus;  embolic, 
which  is  due  to  embolus;  and  decubitus,  decubital  gangrene,  or  bed-sores  due  to 
pressure. 

Dry  gangrene  arises  from  deficiency  of  arterial  blood.  For  this  reason 
De  Nancrede  calls  it  anemic  gangrene. 

This  form  of  gangrene  is  far  more  apt  to  result  from  the  gradual  than  from 
the  sudden  cutting  off  of  the  supply  of  arterial  blood,  and  is  more  common  if 
the  blood-vessels  are  atheromatous  than  if  they  are  healthy;  but  even  in  a 
person  with  healthy  arteries  gangrene  will  ensue  upon  blocking  of  the  main 
artery,  if  the  collaterals  fail  to  supply  the  part  with  blood.  This  form  of 
gangrene  can  occur  after  laceration,  ligation,  or  the  lodgment  of  an  embolus 
in  the  main  artery  of  a  limb;  but  in  such  accidents  considerable  fluid  usually 
remains  in  the  tissues  and  the  gangrene  is  apt  to  be  moist  rather  than  dry. 

Gangrene  Due  to  Embolism  or  Thrombosis. — An  embolus  may  cause 
gangrene  in  rare  instances,  hence  the  cause  of  embolism  is  responsible  for  the 
gangrene.  There  may  be  vascular  disease.  There  may  be  or  have  been  an 
infectious  process  (typhoid  fever,  pneumonia,  influenza,  diphtheria,  etc.).  If 
an  embolus  causes  gangrene,  it  is  probable  that  the  blocking  was  not  at  once 
complete.  Why  an  embolus  in  a  young  person  causes  gangrene  is  perplexing, 
because  in  such  a  person  we  can  tie  a  large  artery  with  comparatively  little 
fear  of  gangrene.  It  must  be  that  a  clot  forms  proximally  to  the  embolism, 
fills  a  considerable  extent  of  the  vessel,  and  cuts  off  the  collaterals.  When  an 
embolus  lodges  in  an  artery  and  causes  dry  gangrene,  the  case  runs  the  follow- 
ing course:  sudden  severe  pain  at  the  seat  of  impaction,  and  also  tenderness; 
pulsation  above,  but  not  below,  this  point,  after  obstruction  has  become  com- 
plete; the  limb  below  the  obstruction  is  blanched,  cold,  and  anesthetic;  within 
forty-eight  hours,  as  a  rule,  the  area  of  gangrene  is  widespread  and  clearly  evi- 
dent; the  limb  becomes  reddish,  greenish,  blue,  and  then  black;  the  skin 
becomes  shriveled  and  its  outer  layer  stony  or  like  horn  because  of  evaporation. 
The  entire  part  may  become  dry;  but  usually  there  are  spots  where  some  fluid 
remains,  and  these  spots  are  soft  and  moist,  and  the  dead  tissue,  where  it  joins 
the  living,  is  sure  to  be  moist.  The  moist  areas  become  foul  and  putrid,  but  the 
dry  spots  do  not.  In  dry  gangrene,  at  the  point  of  contact  of  the  dead  and 
living  tissues,  inflammation  arises  in  the  latter  structures,  a  bright-red  Hiie 
forms,  exudation  occurs,  and  ulceration  takes  place.  This  line  of  ulceration  in 
the  sound  tissues  is  called  the  line  of  demarcation.  It  is  Nature's  effort  at 
amputation,  and  in  time  may  get  rid  of  a  large  portion  of  a  limb,  and  then 
heal  as  any  other  ulcer.  A  line  of  demarcation  rarely  causes  hemorrhage, 
because  it  enters  a  vessel  only  after  inflammation  has  caused  occlusion  by  throm- 


Presenile  Spontaneous   Gangrene  165 

bosis.  In  drv  gangrene  from  arterial  obstruction  there  is  gastro-intestinal  de- 
rangement and  also  some  fever.  The  gangrene  does  not  extend  up  to  the  point 
of  obstruction,  but  only  to  a  region  in  which  the  anastomotic  circulation  is  suffi- 
ciently active  to  permit  of  the  formation  of  a  line  of  demarcation.  Below  this 
point  inflammator}-  stasis  arises,  but  before  this  can  go  on  to  ulceration  the  parts 
die.  In  cases  in  which  the  arterial  obstruction  is  sudden  and  complete  the  Umb 
swells  decidedly.  This  is  due  to  the  sudden  loss  of  vis  a  tergo  in  the  arterial 
system,  venous  reliux  occurring  and  fluids  transuding.  In  such  a  case  the 
tissues  contain  duid  and  putrefy;,  and  the  process,  though  due  to  the  cutting  off 
of  the  arterial  circulation,  is  moist  gangrene.  Embolic  gangrene  attacks  the 
leg  more  often  than  the  arm.  A  thrombus  in  an  artery  rarely  causes  gangrene 
except  in  the  aged,  as  the  collateral  circulation  has  time  to  adjust  itself:  but 
gangrene  may  foUow  thrombus  formation,  and  when  it  does  it  comes  on  more 
slowly  than  does  gangrene  from  embolus,  and  is  certain  to  be  of  the  dn,-  form. 
Treatment  of  Thrombotic  and  Eynholic  Gangrene. — \A'hen  injur}-  or  blocking 
of  a  healthy  artery  causes  us  to  fear  the  onset  of  gangrene,  the  patient  should 
be  placed  in  bed,  the  extremity  should  be  elevated  a  Httle.  kept  wrapped  in  cot- 
ton-wool, and  siurroimded  v^-ith  bottles  filled  v^-ith  warm  water.  It  is  useless  when 
an  arter\-  is  extensively  diseased  to  incise  it  and  remove  a  clot,  because  another 
clot  -nUl  form  at  once.  If  a  clot  forms  in  a  limited  area  of  disease,  it  may  be  possi- 
ble to  excise  a  small  section  of  the  arter\-  and  do  end-to-end  anastomosis,  and  in- 
sert by  implantation  a  section  taken  from  a  distant  vein.  In  cases  of  thrombosis, 
however,  the  best  operation  is  probably  arteriovenous  anastomosis  (see  page 
463).  In  embolism  it  is  a  logical  procedure  to  make  a  longitudinal  incision 
in  the  artery,  remove  the  embolus,  and  suture  the  vround  in  the  vessel.  So 
far  arteriotomy  for  embolism 
has  not  been  as  successful  as 
Carrel's  experiments  lead  us  to 
infer  it  should  be:  the  probable 
reason  is  that  most  reported 
operations  were  upon  elderly 
people,  in  whom,  because  of 
diseased  arteries,  extensive 
clots  existed.  Lejars  believes 
that  in  the  young  results  are 
sure  to  be  better.  ]Mosny  and 
Dtmiont  report  a  successful 
arteriotomy  for  embohsm  of 
the  femoral  arter\-  in  a  case 
of  mitral  stenosis  ('quoted  in 
''Lancet.''  ]\Iarch  g.  1912).  If 
in  spite  of  oiu*  efforts  gangrene 
begins  and  progresses,  vs-ait  for 

a  line  of  demarcation,  and  while  ^i^,^:—l;;,.::-r;;:v  ::_::;  :::r:-b;-..:;^::::^     _        -      - 

waiting  dress   the    dpng    and 

dead  parts  antiseptically.  wrap  the  extremit}-  in  cotton  and  keep  it  warm,  and 
see  to  it  that  the  patient  gets  plenty  of  sleep  and  nourishment.  It  is  also 
ad^•isable  to  give  tonics  and  stimulants.  \Alien  a  line  of  demarcation  forms, 
amputate  well  above  it. 

Presenile  Spontaneous  Gangrene. — I  have  adopted  Buerger's  suggested 
name  for  this  condition.  The  vascular  disease  responsible  for  the  gangrene 
is  in  dispute.  Winiwarter  and  others  beheve  it  is  obhterative  endarteritis  of 
aU  the  arteries  of  a  leg.  Buerger  regards  the  condition  as  thrombo-angiitis 
obliterans,  appearing  in  the  larger  arteries  and  also  in  the  veins  of  the  leg 
(■"Amer.  Jour.  Med.  Sciences,"  Oct.,  igcS). 


i66 


Mortification,  Gangrene,  or  Sphacelus 


It  occurs  among  young  adults  (from  twenty  to  forty)  and  is  especially  noticed 
among  the  PoHsh  Jews  in  our  large  cities.  It  usually,  but  not  always,  begins 
in  the  left  leg.  It  may  start  almost  simultaneously  in  both  legs.  If  it  begins  in 
one  leg,  the  other  tends  to  become  affected  sooner  or  later.  It  comes  on  with 
attacks  of  severe  pain  in  the  toes,  foot,  or  leg,  the  extremity  feels  cold  and  looks 
bloodless,  and  no  pulse  can  be  detected  in  the  dorsalis  pedis  and  posterior  tibial 
arteries.  Such  attacks  are  at  first  brought  on  by  cold,  later  they  appear  to  arise 
spontaneously. 

When  the  foot  is  warmed  some  color  returns  and  feeble  pulse  may  be  ap- 
preciated. Many  of  these  patients  get  so  that  any  attempt  at  walking  causes 
violent  pains  in  the  calf  muscles,  pain  so  violent  as  to  make  the  victim  limp  in 
torture  or  at  once  stop  walking  {intermittent  claudication). 

After  a  case  has  lasted  a  number  of  months  erythromelagia  may  develop.  In 
this  condition  when  the  foot  is  hung  down  the  toes  and  dorsum  of  foot  rather 
rapidly  grow  bright  red. 

After  a  case  has  lasted  for  many  months  it  will  be  impossible  at  any  time 
to  detect  a  pulse  in  the  dorsalis  pedis  or  posterior  tibial.  The  patient  is  wear- 
ing out  with  violent  pain  and  cannot  walk.  Whenever  the  foot  hangs  down  it 
becomes  red  or  cyanotic.  A  bleb  or  ulcer  may  form  upon  the  foot  or  great  toe; 
it  is  sure  to  be  intensely  painfiil,  and  finally  dry  gangrene  occurs. 

I  have  seen  5  such  cases  of  gangrene  and  in  3  of  them  I  performed  ampu- 
tation. The  examination  of  the  vessels  in  the  amputated  legs  accorded  with 
Buerger's  view  that  the  condition  is  one  of  thrombo-angiitis  obliterans,  the 
veins  often  suffering  as  well  as  the  arteries.  Perivascular  inflammation  exists 
and  in  cases  w^hich  have  lasted  for  years  there  is  arterial  sclerosis,  but  cases 
seldom  last  for  years  without  gangrene.  The  clot  often  fills  the  vessels  of  the 
toes,  the  dorsalis  pedis,  the  plantar,  and  may  extend  well  up  both  tibials 
toward  the  popliteal.  Before  gangrene  arises  various  diagnoses  are  apt  to  be 
made  (Raynaud's  disease,  intermittent  claudication,  erythromelagia). 

The  characteristic  com- 
bination is  violent  pain, 
with  absent  pulse  in  the 
dorsalis  pedis  and  posterior 
tibial  arteries. 

Treatment.  —  I  have 
never  seen  the  slightest 
lasting  benefit  result  from 
medication.  Sooner  or 
later  these  cases  come  to 
amputation.  In  some  cases 
violent  pain  compels  am- 
putation even  before  gan- 
grene begins.  Gangrene 
Not  imusually,  weeks  or  months  after  amputation 


Fig.  88. — Senile  gangrene  of  the  feet  (Gross). 


imperatively  calls  for  it 

of  one  leg,  the  other  leg  has  to  be  sacrificed. 

The  amputation  shoiild  always  be  above  the  knee  in  order  to  be  well  above 
the  thrombi  in  the  vessels.  Surgeons  have  used  Moskowicz's  test  to  deter- 
mine where  to  amputate.  (See  Senile  Gangrene,  page  169.)  Since  Carrel's 
studies  on  reversal  of  circulation  surgeons  have  attempted  to  prevent  this  and 
other  forms  of  gangrene  by  arteriovenous  anastomosis. 

Early  in  a  case,  when  we  may  assvime  that  the  veins  are  free  from  clot,  the 
operation  is  clearly  justifiable  and  may  perhaps  prove  successful.  Bloodgood 
has  had  success  in  a  case  which  seems  to  have  been  of  this  type  (Bernheim,  in 
"Amer.  Jour.  Med.  Sciences,"  Feb.,  191 2). 

Senile  gangrene,  chronic  gangrene,  Pott's  gangrene  (Fig.  88),  is  a  form 


Senile  Gangrene 


167 


of  gangrene  due  to  feeble  action  of  the  heart  plus  obliterating  endarteritis 
or  atheroma  of  peripheral  vessels.  The  vessels  do  not  carry  a  normal  amount 
of  blood,  and  may  at  any  time  be  occluded  by  thrombosis.  In  a  drunkard  or 
in  a  \ictim  of  s\-philis  or  tubercle  the  changes  supposed  to  characterize  old  age 
may  appear  while  a  man  is  young  in  years.  It  was  long  ago  said.  Tsith  truth, 
'"a  man  is  as  old  as  his  arteries."'  Senile  gangrene  most  often  occurs  in  a  toe 
or  the  foot. 

Symptoms. — ^A  man  whose  vessels  are  in  the  state  above  indicated  is  gener- 
ally in  feeble  health  and  has  a  fatty  heart  and  an  arcus  senilis  (a  red  or  white 
Hne  of  fatty  degeneration  around  the  cornea) .  His  toes  and  feet  are  cold  and 
feel  numb,  and  they  "go  to  sleep"  ver}-  easily,  and  he  suffers  from  cramp  of  the 
legs  and  feet.  He  is  dyspeptic  and  short  of  breath,  and  his  urine  is  frequentlv 
albuminous.  The  arteries  are  felt  as  rigid  tubes,  like  pipe-stems.  He  is  in 
danger  of  edema  of  the  lungs  and  of  dr\-  gangrene  of  the  toes.  A  slight  injur}' 
of  a  toe — for  instance,  cutting  a  corn  too  close — \^"ill  produce  extensive  in- 
flammatory- stasis  followed  by  thrombosis,  which  completely  cuts  off  the  blood- 
supply  and  causes  gangrene  of    _      

the  part.  Gangrene  is  usually 
annoimced  by  the  appearance 
of  a  purple  and  anesthetic  spot 
followed  by  a  vesicle  which 
ruptures  and  Hberates  a  small 
amount  of  bloody  serum  and 
exposes  a  dr\'  floor.  In  the 
parts  about  the  gangrenous  area 
there  is  often  burning  pain.  The 
circulation  in  the  tissues  im- 
mediately adjacent  to  the  dead 
spot  is  retarded  or  stagnated. 
the  parts  being  purple  and  the 
color  not  disappearing  or  dis- 
appearing slowly  under  pressure. 
If  the  color  fades  under  pressure 
it  retm^ns  slowly  when  pressure  is 
removed.  The  parts  a  little  fur- 
ther removed  are  h}-peremic.  the 
color  disappearing  rapidly  on 
pressure,  and  returning  rapidly 
when  pressure  is  removed.  The  dead  parts  do  not  putrefy  at  all  or  do  so  but 
slightly,  hence  the  odor  is  never  ven,-  offensive  and  is  usually  trivial.  They  are 
anesthetic,  hard,  leather}-  and  ■^-rinkled,  and  resemble  a  varnished  anatomical 
specimen  or  the  extremity  of  a  mummy  (hence  the  term  mummincation'' .  Before 
the  line  of  demarcation  forms  there  is  burning  pain;  after  it  forms  pain  is  rarely 
present.  If  an  embolus  or  thrombus  in  a  diseased  vessel  of  some  size  causes  gan- 
grene, the  pain  is  severe  at  the  point  of  impaction.  In  senile  gangrene  the  distal 
portion  of  the  dead  area  is  always  dr\-,  the  part  nearer  the  body  being  generally 
somewhat  moist.  The  process  may  be  ver}-  limited  or  it  may  spread  up  along 
the  dorsum  of  the  foot  and  the  leg,  even  to  the  knee.  As  it  spreads  the  area  of 
li}-peremia  advances  at  the  margin,  the  area  of  stasis  follows,  and  the  zone  of 
gangrene  becomes  more  extensive.  \Mien  tissues  are  reached,  the  blood-supply 
of  which  is  sufficiently  good  to  permit  of  inflammation  going  beyond  the  stage  of 
stasis  and  to  allow  of  stasis  without  extensive  thrombosis.  Nature  tries  to  limit  the 
gangrene  by  the  formation  of  a  line  of  demarcation.  A  line  of  demarcation  may 
begin,  but  prove  abortive,  the  tissue  mortif}-ing  above  it.  This  proves  that 
tissue  near  the  line  is  in  a  state  of  low  ^italitv.     The  line  of  demarcation  mav 


Fig.  Sg. — Dr.  Keller's  case  of  spontaneous  amputation  of 
a  foot  and  part  of  a  leg  in  a  condition  of  semle  gangrene. 


i68  Mortification,  Gangrene,  or  Sphacelus 

prove  durable  and  in  some  few  cases  spontaneous  amputation  takes  place  (Fig. 
89).  When  a  limited  area  is  gangrenous,  constitutional  symptoms  are  trivial  or 
absent;  but  when  a  large  area  is  involved,  the  fever  of  septic  absorption  exists. 
Death  may  ensue  from  exhaustion  caused  by  sleeplessness  and  pain,  from 
septic  absorption,  from  embolism  of  internal  organs,  or  from  some  compli- 
cation (renal,  pulmonary,  or  cardiac).  In  many  cases  of  senile  gangrene  clots 
are  formed  in  the  superficial  femoral  artery  or  its  branches,  an  observation  it  is 
important  to  bear  in  mind  when  amputating. 

Prevention  of  Senile  Gangrene  in  the  Predisposed. — Such  a  patient  must 
avoid  injuring  the  toes  and  feet.  Cutting  corns  carelessly  is  highly  dan- 
gerous, and  any  wound,  however  slight,  requires  rest  and  antiseptic  dressing. 
The  victim  of  general  atheroma  must  wear  woolen  stockings,  put  a  rubber 
bag  containing  warm  water  to  his  feet  on  cold  nights,  and  attend  to  his  general 
health.  He  must  avoid  overeating  and  is  to  be  particularly  moderate  in  the 
use  of  meats,  shoiild  have  a  daily  bowel  movement,  and  should  drink  water 
in  plenty  between  meals.  He  should  avoid  as  far  as  may  be  work  and  worry, 
and  enough  sleep  is  imperative.  A  Httle  whisky  after  each  meal  is  indicated, 
and  occasional  courses  of  nitroglycerin  are  desirable.  Courses  of  iodid  of  potas- 
sium, given  in  small  doses,  may  retard  the  progress  of  the  sclerosis. 

Treatment  of  Senile  Gangrene. — When  gangrene  occurs,  if  it  is  limited  to 
one  toe  or  a  portion  of  several  toes,  if  it  is  a  first  attack,  if  there  is  no  fever  or 
exhausting  diarrhea,  if  there  is  no  tendency  to  pulmonary  congestion,  if  the 
appetite  is  fair  and  sleep  refreshing,  it  is  best  to  avoid  radical  interference 
and  to  await  the  formation  of  a  line  of  demarcation.  While  awaiting  the  line 
of  demarcation  dress  the  part  antiseptically,  raise  the  foot  several  inches 
from  the  bed,  and  surround  the  part  with  bottles  of  moderately  warm  water. 
Very  warm  water  may  do  harm.  Give  the  patient  nourishing  diet,  stimulants, 
and  tonics;  see  to  it  that  he  sleeps,  and  during  the  spread  of  the  gangrene  watch 
for  fever,  diarrhea,  pulmonary  congestion,  and  kidney  failure.  When  a  line  of 
demarcation  forms,  dress  with  warm  antiseptic  fomentations  and  iodoform,  and 
every  day  pick  away  dead  bits  with  the  scissors  and  forceps.  A  tendon  or  liga- 
ment should  be  cut  through  and  a  protruding  phalanx  should  be  divided  with 
a  Gigli  saw.  If,  after  separation,  an  ulcer  forms,  skin-grafts  may  .be  applied. 
In  many  cases  healing  will  occur;  but  even  when  the  parts  heal  the  patient 
will  always  be  in  deadly  peril  of  another  attack.  If  the  gangrene  shows  a 
tendency  to  spread,  if  it  involves  more  than  a  portion  of  several  toes,  if  it  is 
not  a  first  attack,  if  there  is  sleeplessness,  fever,  exhausting  diarrhea,  anorexia, 
or  a  strong  tendency  to  pulmonary  congestion,  do  not  delay,  but  at  once  am- 
putate high  up.  If  the  gangrene  shows  no  tendency  to  limit  itself,  or  if  the 
patient  develops  sepsis  or  exhaustion,  at  once  amputate  high  up.  The  best 
point  at  which  to  amputate  is  above  the  knee,  so  that  the  deep  femoral  artery, 
which  rarely  becomes  atheromatous,  can  nourish  the  flap  and  gangrene  will 
not  occur.  It  has  been  pointed  out  that  the  superficial  femoral  artery  and  its 
branches  often  contain  a  clot.  Never  amputate  below  the  tubercle  of  the  tibia. 
Some  operators  disarticulate  at  the  knee-joint.  Heidenhain  affirms  that  so 
long  as  the  gangrene  is  limited  to  one  or  two  toes  we  should  merely  treat  it 
antiseptically,  elevate  the  limb,  and  wait  for  the  dead  part  to  be  cast  off  spon- 
taneously; if,  however,  it  extends  to  the  dorsum  or  sole  of  the  foot,  we  should 
amputate  at  once  above  the  knee.  He  further  states  that  gangrene  of  the 
flaps  almost  always  occurs  in  amputations  below  the  knee,  and  high  amputa- 
tion is  indicated  in  advancing  gangrene  with  or  without  fever.^  Personallv,  I 
still  follow  Heidenhain 's  rule.  Many  surgeons  dissent  from  it  and  believe  that 
in  certain  cases  we  can  amputate  lower  down.  Moskowicz  suggested  a 
method  of  determining  the  viable  area.  He  applies  an  elastic  bandage  from 
^  "Deutsche  medicinische  Wochenschrift,"  1891,  p.  1087. 


Moist  Gangrene  of  a  Limb  169 

the  toes  to  high  up  the  thigh,  puts  in  place  the  tourniquet  band,  and  removes 
the  bandage.  In  five  or  ten  minutes  he  removes  the  band  and  notes  the  color 
of  the  limb  as  it  is  invaded  by  reactionary  hyperemia.  This  wave  of  color 
travels  toward  the  periphery.  High  up  the  extremity  the  reactionary  blush 
appears  quickly.  The  nearer  the  area  of  vascular  obstruction,  the  slower  the 
manifestation  of  color.  In  doubtful  areas  the  blush  comes  slowly  and  imper- 
fectly, and  patches  of  white  show  here  and  there  in  the  color.  In  a  region  of 
total  ischemia  no  reactionary  blush  occurs. 

Operation  must  be  performed  in  the  region  where  there  was  a  complete  red 
reaction,  and  never  through  an  area  where  anemic  patches  were  noted.  This 
very  ingenious  test  of  Moskowicz  has  not  seemed  to  me  conclusive,  and  I  have 
fancied  in  cases  of  threatened  gangrene  that  it  helped  to  bring  about  the  very 
condition  we  feared.  It  is  only  just  to  say  that  in  other  hands  the  test  seems 
to  have  proved  successful.  When  amputation  has  been  performed  and  the 
Esmarch  band  has  been  removed  and  no  arterial  bleeding  takes  place  from 
the  superficial  femoral  artery,  a  clot  is  lodged  in  that  vessel.  If  such  a  condi- 
tion exists,  insert  into  the  artery  a  fine  rubber  catheter  or  a  filiform  bougie  and 
break  up  the  clot.  When  blood  flows  we  are  sure  that  the  clot  has  been  washed 
out.i 

Some  surgeons  have  practised  arteriovenous  anastomosis  between  the 
femoral  vein  and  common  femoral  artery  in  hope  of  establishing  sufficient 
circulation  to  prevent  im- 
pending or  to  cure  exist- 
ing gangrene.  The  results 
are  as  yet  inconclusive, 
but  some  successes  have 
been    reported    (see    page 

In  moist  or  acute  gan-  '^ 

grene    (Fig.     go)    the    dead  Fig.  90.— Acute  gangrene  (Gross). 

part    remains    moist    and 

putrefies.  As  De  Nancrede  points  out,  there  are  two  forms  of  moist  gangrene: 
"that  limited  to  the  areas  actually  killed  by  a  traumatism,  with  some  sur- 
rounding tissue  which  dies,"  and  "that  which  tends  to  spread  widely,  this 
latter  being  usually  caused  by  specific  micro-organisms,  an  intense,  wide- 
spread, pyogenic  inflammation  resulting,  involving  the  subcutaneous  and 
intermuscular  cellular  planes,  by  strangulation  of  the  vessels  by  which  all 
blood-supply  to  the  remaining  soft  parts  is  destroyed."^  In  a  case  of  moist 
gangrene  the  parts  remain  moist,  either  because  the  main  artery  has  become 
suddenly  blocked,  and  the  tissue  fluids  are  not  urged  by  sufficient  vis  a  tergo 
to  cause  them  to  flow  out  of  the  limb,  or  because  the  main  vein  is  blocked.  It 
may  arise  in  a  limb  after  ligation,  obstruction,  or  destruction  of  its  main  artery, 
main  vein,  or  both;  after  long  constriction,  as  by  a  tight  bandage;  after  crushes 
and  lacerated  wounds,  and  after  thrombosis  of  the  vein.  Moist  gangrene  may 
follow  severe  pyogenic  infection  or  may  be  due  to  local  constriction  (strangu- 
lated hernia),  crushing,  chemical  irritants,  heat,  and  cold. 

Moist  gangrene  of  a  limb  may  be  seen  typically  in  certain  cases  in  which 
the  main  vein  or  artery  or  both  vein  and  artery  are  constricted,  damaged, 
or  destroyed.  The  leg  swells  greatly  and  is  pulseless  below  the  obstruc- 
tion; the  skin,  at  first  pale,  cold,  and  anesthetic,  becomes  livid,  mottled,  purple, 
or  greenish.  A  greenish  color  signifies  putrefaction.  Blebs  are  formed  which 
contain  a  reddish  or  brown  fluid.  "These  blebs,  being  caused  by  the  accumu- 
lation of  serum  beneath  epithelium  which  has  lost  its  vital  connection  with  the 

1  Severeano.     See  Mancozet's  report  before  the  Second  Pan-American  Medical  Congress. 

2  De  Nancrede's  "Principles  of  Surgery." 


170  Mortification,  Gangrene,  or  Sphacelus 

derm,  can  be  slipped  around  upon  the  surrounding  true  skin,  the  epithelium 
readily  separating  for  long  distances  around,  as  in  a  cadaver"  (De  Xancredej. 
The  extremity  swells  enormously,  there  may  be  pain  at  the  seat  of  obstruction, 
but  there  is  no  pain  in  the  gangrenous  area,  and  sapremic  symptoms  quickly  de- 
velop. The  bullae  break  and  disclose  the  brown  derm  and  sometimes  the  deeper 
structures,  which  are  swollen  and  edematous.  The  fetor  is  horrible.  Shght 
or  moderate  fever  usually  exists.  In  mild  cases  a  line  of  demarcation  soon 
forms.  In  severe  cases  in  which  virulent  saprophytes  are  present  the  process 
spreads  with  great  rapidity,  neighboring  glands  enlarge,  the  temperature  is 
much  elevated,  no  line  of  demarcation  forms,  there  is  profound  exhaustion, 
and  gases  of  decomposition  accumulate  in  and  distend  the  tissues  and  cause 
crackling  when  the  parts  are  pressed  upon.  Such  severe  cases  are,  in  reality, 
examples  of  foudroyant  or  emphysematous  gangrene. 

Moist  gangrene  from  inflammation  is  due  to  pressure  of  the  exudate, 
cutting  of  the  blood-supply,  or  to  loss  of  blood-circulation  because  of  microbic 
involvement  of  vessels  and  clotting  of  blood.  It  occurs  typically  in  phleg- 
monous erysipelas.  When  an  inflammation  is  about  to  terminate  in  gangrene 
all  the  signs  of  inflammation,  local  and  constitutional,  increase;  sweUing 
becomes  very  great  and  may  be  due  partly  to  fluid  and  partly  to  gas.  If  gas 
is  present  pressure  will  cause  crackling.  The  color  becomes  li\dd  or  purple. 
The  anatomically  related  glands  are  enlarged  and  the  symptoms  of  sapremia 
or  suppurative  fever  exist.  When  gangrene  is  actually  present  the  signs  of 
inflammation  have  passed  away,  bullae  and  emphysema  are  noted,  with  great 
swelling  and  aU  the  other  s3anptoms  of  molar  death.  The  sudden  cessation 
of  pain  is  very  suggestive  of  gangrene.  The  constitutional  symptoms  are 
those  of  suppurative  fever  and  sapremia,  or  possibly  of  septic  infection. 

When  a  wound  becomes  gangrenous  the  surface  looks  like  yellow  or  gray 
tow,  the  discharge  becomes  profuse  and  very  fetid,  and  the  parts  about  swell 
enormously  and  gradually  become  gangrenous. 

Treatment  of  Moist  Gangrene. — In  extensive  moist  gangrene  of  a  limb,  if 
the  condition  is  of  the  form  described  as  mild,  in  which  there  are  not  severe 
symptoms  of  sepsis  and  in  which  the  gangrene  is  not  rapidly  progressive, 
wait  for  a  Line  of  demarcation,  and  amputate  clear  of  and  above  it.  While 
waiting  for  the  line  to  form,  dress  the  dead  parts  antiseptically,  wTap  the  ex- 
tremity in  cotton,  apply  warmth,  and  sHghtly  elevate  the  Umb.  Give  opium, 
tonics,  nourishing  food,  and  stimulants.  In  the  severe  form  of  moist  gangrene 
(reaUy  foudroyant  gangrene)  amputate  at  once  high  above  the  gangrenous 
process.  In  inflammatory  gangrene,  such  as  is  sometimes  associated  with 
phlegmonous  erysipelas,  relieve  tension  by  incisions,  cut  away  the  dead  parts, 
brush  the  raw  surface  with  pure  carbolic  acid,  dust  with  iodoform,  and  dress 
with  hot  antiseptic  fomentations.  Stimulate  freely,  administer  nourishment 
at  frequent  intervals,  and  treat  the  patient  in  general  as  we  would  a  case  of 
sapremia  or  suppurative  fever.  A  gangrenous  wound  is  treated  as  pointed 
out  in  the  section  on  Sloughing. 

Acute  microbic  gangrene,  fulminating  gangrene,  emphysematous  gan- 
grene, gaseous  phlegmon,  gangrenous  emphysema,  gangrene  foudroyante, 
or  traumatic  spreading  gangrene,  resiflts  from  a  virulent  infection  of  a  wound. 
It  was  first  described  in  1853  by  Masionneuve  under  the  name  of  gangrene 
foudroyante.  In  1864  Pirogoff  called  it  acute  gangrenous  edema.  The  condi- 
tion may  be  due  to  a  mixed  infection  with  virulent  streptococci  and  organisms 
of  putrefaction;  or  to  infection  with  the  bacilli  of  malignant  edema,  and 
putrefactive  organisms.  Some  cases  are  due  to  the  bacillus  of  malignant  edema 
alone;  some  are  due  to  the  Bacillus  aerogenes  capsulatus  oi  Welch  and  Flexner. 
These  gas  baciUi  are  found  in  soil,  in  animal  and  human  feces,  in  street  dirt,  and 
the  dust  of  floors.     The  injury  is  usually  severe — often  a  crush  which  destroys 


Hospital  Gangrene  171 

the  main  artery  and  renders  an  anastomotic  circulation  impossible,  sometimes 
a  compound  fracture  or  a  gunshot-wound.  In  such  severe  accidents  the  limb 
is  much  swollen  and  the  pulse  below  the  seat  of  injury  is  imperceptible,  and  the 
surgeon  is  often  at  this  time  uncertain  whether  to  amputate  at  once  or  to  wait. 
Emphysematous  gangrene  is  commonest  after  compound  fractures,  and  begins 
within  forty-eight  hours  of  the  accident.  The  extremity  becomes  enormously 
swollen  from  edema  and  gas.  The  gangrene  does  not  begin  at  the  periphery, 
as  does  ordinary  moist  gangrene,  but  at  the  wound  edges,  which  turn  red,  green, 
and  finally  black;  the  extremity  soon  undergoes  a  like  change  and  becomes  mor- 
tified. The  skin  peels  off,  emphysematous  crackling,  due  to  gas  formed  and 
retained  in  the  tissues,  can  be  detected  over  large  areas,  and  the  extremity 
becomes  anesthetic  and  pulpy.  The  gases  formed  in  the  tissues  are  sulphid 
of  hydrogen,  sulphid  of  ammonium,  volatile  fatty  acids,  and  ammonia.  Great 
fetor  is  soon  noted.  The  gangrene  spreads  up  and  down  from  the  wound,  and 
red  lines,  due  to  lymphangitis,  run  from  above  the  wound.  The  adjacent 
lymph-glands  swell.  I  have  seen  the  gangrene  involve  an  entire  limb  in  thirty- 
six  hours.  No  line  of  demarcation  forms.  The  system  is  soon  overwhelmed 
with  ptomains,  and  the  patient  suffers  from  putrid  intoxication,  with  deUrium, 
and  often  passes  into  profound  collapse  with  coma  and  subnormal  temperature. 
Traumatic  spreading  gangrene  must  not  be  confused  with  erysipelas.  In 
erysipelas  the  color  is  red,  pressure  instantly  drives  it  out,  and  on  the  release  of 
pressure  it  at  once  returns.  In  early  gangrene  the  color  is  purple,  pressure  fails 
to  drive  it  out  at  all  or  only  does  so  very  slowly,  and  if  the  surface  is  blanched  by 
pressure,  on  the  release  of  pressure  the  color  crawls  slowly  back.  Sometimes 
emphysematous  gangrene,  in  the  form  of  gangrenous  cellulitis,  follows  a 
trivial  injury  such  as  a  puncture,  the  entrance  of  a  splinter,  an  abrasion,  or 
a  slight  cut.  The  region  about  the  injury  becomes  red,  then  livid,  and  finally 
green  or  black.  Enormous  swelling  takes  place,  partly  due  to  edema,  partly 
to  gas,  and  the  swelling  and  discoloration  spread  rapidly.  Red  fines,  subse- 
quently becoming  greenish,  run  toward  enlarged  lymphatic  glands  above  the 
gangrenous  part.  The  tissues  are  rapidly  separated  and  destroyed  and  the 
bone  is  often  quickly  exposed  and  infected.  The  symptoms  point  to  over- 
whelming sepsis.  There  is  high  fever  and  delirium,  and  coma  and  death 
are  apt  to  ensue.  The  patient  may  die  in  from  twenty-four  to  forty-eight 
hours.  Welch  estimates  the  mortality  from  gaseous  phlegmon  at  almost  60 
per  cent. 

Treatment. — In  acute  spreading  gangrene  of  an  extremity  following  a 
severe  injury  no  delay  is  admissible.  To  wait  for  a  line  of  demarcation  is  to 
expect  the  impossible,  and  a  delay  dooms  the  patient  inevitably  to  death. 
Amputation  must  be  performed  at  once  high  up,  the  flaps  should  be  brushed 
with  pure  carbolic  acid,  and  then  every  effort  is  to  be  made  to  sustain  the 
patient's  strength  by  the  administration  of  food  and  stimulants.  Antistrep- 
tococcic serimi  may  possibly  be  useful.  In  cases  of  acute  spreading  gangrene 
following  trivial  injuries  it  may  be  possible  to  arrest  the  process  by  free  in- 
cisions, thorough  drainage,  hot  antiseptic  fomentations,  the  continuous  hot 
bath  or  continuous  antiseptic  irrigations,  stimulants,  etc.,  but  in  some  cases 
amputation  is  necessary.  Some  surgeons,  notably  Doerfler  ("Miinchener 
medicinische  Wochenschrift,"  April  23  and  30,  1901),  oppose  amputation  in 
cases  of  spreading  gangrene  following  trivial  or  moderately  severe  injury. 
Doerfler  maintains  that  cases  which  recover  after  amputation  would  have 
recovered  if  amputation  had  not  been  performed.  From  this  positive  state- 
ment I  am  obliged  to  dissent.  (See  article  on  this  form  of  gangrene  by  Blake 
and  Labey,  "Jour.  Amer.  Med.  Assoc,"  May  21,  1910.) 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease  that  has  prac- 
tically  disappeared   from   civifized   communities.     It   formerly   occurred   in 


172 


Mortification,  Gangrene,  or  Sphacelus 


crowded,  ill-ventilated  hospitals.  Some  consider  it  traumatic  diphtheria. 
Koch  thinks  it  is  due  to  streptococci.  Jonathan  Hutchinson  says:  "Hospital 
gangrene  is  set  up  by  admitting  to  the  wards  a  case  of  syphilitic  phagedena." 
It  may  show  itself  as  a  diphtheritic  condition  of  a  wound,  as  a  process  in  which 
sloughs  which  look  like  masses  of  tow  form,  or  as  a  phagedenic  ulceration. 
The  surrounding  parts  are  inflamed  and  painful,  and  buboes  form  in  adjacent 
lymphatic  glands.     The  system  passes  into  a  low  septic  state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be  given,  the  large 
sloughs  removed  with  scissors  and  forceps,  the  parts  dried  with  gauze  and 
cauterized  with  bromin.  The  surgeon  should  take  a  tumblerful  of  water 
and  into  it  pour  the  bromin,  which  will  fall  to  the  bottom  of  the  glass.  The 
drug  can  be  drawn  up  with  a  syringe  and  injected  into  the  depths  of  the  wound. 
The  wound  should  be  plentifully  sprinkled  with  iodoform  and  dressed  with 
hot  antiseptic  fomentations.  When  the  sloughs  separate  the  sore  can  be 
treated  as  an  ordinary  ulcer.  The  constitutional  treatment  is  that  employed 
for  sepsis. 

Special  Forms  of  Gangrene. — Raynaud's  disease  may  be  responsible 
for  symmetrical  gangrene.     Raynaud's  disease  (Fig.  91)  was  first  described 


Fig.  gi. — Raynaud's  disease  (Horwitz). 

as  a  distinct  malady  by  Maurice  Raynaud  in  1862.  It  is  usually  regarded 
as  a  vasomotor  neurosis,  is  seen  particularly  in  children  and  young  female 
adults,  but  is  sometimes  met  with  in  men.  Chlorotic  and  hysterical  women 
seem  more  apt  than  others  to  suffer  from  it.  The  condition  is  much  com- 
moner in  winter  than  in  simamer,  and  cold  seems  to  be  an  exciting  cause. 
The  well-known  chilblain  is  an  area  of  local  asphyxia.  The  essential  cause 
of  Raynaud's  disease  is  uncertain.  In  some  acute  cases  associated  with  fever, 
albuminuria,  and  splenic  enlargement  it  seems  to  be  a  part  of  an  acute  in- 
fectious disease.  It  can  occur  in  a  variety  of  toxic  conditions  and  in  a  number 
of  infectious  diseases  fti^hoid  fever,  for  instance).  It  may  develop  in  the 
course  of  gout  and  also  of  diabetes.  In  many  cases  neuritis  exists ;  in  some  there 
is  either  obKterative  endarteritis  or  angiothrombosis  of  the  larger  peripheral 
vessels.  Some  cases  seem  to  be  purely  hysterical.  The  fact  that  attacks  of 
Raynaud's  disease  are  sometimes  accompanied  by  hemoglobinuria  has  sug- 
gested malaria  as  a  possible  cause.  Raynaud's  disease  is  characterized  by 
attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a  result  of  exposure 
to  cold  or  of  emotional  excitement  {local  syncope).      In  the  more  severe  cases 


Raynaud's   Gangrene 


173 


there  are  capillarv'  congestion  and  mottled,  livid  swelling  {local  asphyxia). 
A  case  may  begin  with  attacks  of  local  syncope,  and  after  a  longer  or  shorter 
time  get  instead  attacks  of  local  asphyxia.  Attacks  may  be  occasional  and  far 
apart,  may  be  frequent,  or  the  condition  of  "dead"  bloodlessness  or  asphyxia 
may  be  almost  continuous.  In  some  cases  they  only  occur  in  winter;  in 
others  the  slightest  chill  develops  them.  The  patient  complains  of  pain,  ting- 
ling, mmibness,  coldness,  and  stiffness  in  the  affected  parts.  In  some  few  cases 
the  skin  of  the  face  or  trunk  is  attacked.  Local  syncope  is  thought  to  be  due 
to  vascular  spasm,  and  local  asphyxia  to  some  contraction  of  the  arterioles,  \\-ith 
dilatation  of  the  capillaries  and  venules.  It  is  after  local  asphyxia  that  san- 
grene  may  appear.  Attacks  of 
Raynaud's  disease  occur  again  and 
again,  and  may  never  eventuate  in 
gangrene. 

Ra\Tiaud's  disease  is  seldom 
fatal  and  is  often  recovered  from. 

Ever  since  Raynaud's  day  it  has 
been  generally  maintained  that  the 
attacks  are  always  s\Tnmetrical  and 
that  the  blood-vessels  are  not  dis- 
eased. We  now  know  that  man\" 
cases  are  successive  but  not  sym- 
metrical in  the  beginning,  and  that 
some  never  become  s^rmmetrical. 
This  is  especially  true  in  the  lower 
extremities.  It  has  been  shown  of 
recent  years  that  cases  of  throm- 
botic blocking  of  the  larger  arteries 
of  the  legs  exhibit  sATnptoms  of 
Ra\Tiaud's  disease  before  gangrene 
occurs,  and  that  cases  of  Ra^-naud's 
disease  of  the  feet  and  of  ery- 
thromelalgia  are  apt  to  suffer 
from  vascular  thrombosis  and  gan- 
grene from  this  cause. 

Raynaud's  gangrene  (Fig.  92)  is 
a  dr\-  gangrene  and  is  most  com- 
monly met  with  upon  the  ends  of  the 
fingers  or  the  toes,  but  it  may  attack 
the  lobes  of  the  ears,  the  tip  of  the 
nose,  or  the  skin  of  the  arms  or  the 
legs.  Sometimes  the  disease  is  seen 
upon  the  trunk.  The  gangrene  may  be  symmetrical  from  the  beginning,  may  be 
successive,  or  may  remain  as}Tnmetrical.  Certain  it  is  that  many  cases  which 
we  formerly  regarded  as  clear  cases  of  Ra^maud's  disease  of  the  lower  ex- 
tremities develop  gangrene,  due  either  to  obliterative  endarteritis  or  angio- 
thrombosis  (see  page  165).  In  such  cases  there  is  usually  ^dolent  pain  for  weeks 
or  months  before  gangrene  begins.  When  gangrene  is  about  to  occur  in  Ray- 
naud's disease  the  local  asph^^a  at  that  point  deepens,  anesthesia  becomes 
complete,  and  the  part  blackens  and  feels  cold  to  the  touch.  The  epidermis  may 
be  raised  into  blebs  at  the  margin  of  the  gangrene,  which  blebs  rupture  and 
expose  dry  surfaces.  A  line  of  demarcation  forms,  and  the  necrosed  area  is  re- 
moved as  a  slough.  Widespread  gangrene  from  pure  Raynaud's  disease  is  rare; 
there  is  not  often  an  extensive  area  involved — rather  a  small  superficial  spot. 
Small  areas  are  usually  recovered  from  if  not  upon  the  lower  extremity. 


Fig.  92, — RajTiaud's  gangrene.  Patient  has  lost 
most  of  the  terminal  phalanges  of  the  fingers  and  also 
the  left  leg.  Right  leg  was  amputated  soon  after  this 
picture  was  taken.  (Patient  of  Dr.  T.  E.  Wanna- 
maker,  Jr.,  of  Cheraw,  S.  C.) 


174  Mortification,  Gangrene,  or  Sphacelus 

Treatment  of  Raynaud's  Disease  and  of  Raynaud's  Gangrene. — If  an  indi- 
vidual suffers  from  attacks  of  Raynaud's  disease,  every  effort  should  be  made 
to  improve  the  general  health  and  to  avoid  chilling  the  surface  of  the  body. 
During  the  attack  employ  gentle  massage,  place  the  extremity  in  warm  water, 
and,  if  pain  is  severe,  give  morphin  hypodermatically.  Amyl  nitrite  is  without 
value  in  this  condition.  When  attacks  of  Raynaud's  disease  are  so  severe  as 
to  threaten  gangrene,  put  the  patient  to  bed;  if  the  feet  are  attacked,  elevate 
the  legs  sHghtly,  wrap  the  affected  extremities  in  cotton-wool,  and  apply 
warmth.  If  the  hands  are  affected,  wrap  them  in  cotton-wool,  elevate  them 
slightly,  and  apply  warmth.  Massage  is  useful.  Arteriovenous  anastomosis 
has  been  employed  for  threatened  gangrene,  and  several  apparent  successes 
have  been  reported  (see  page  i66).  When  gangrene  occurs,  dress  the  part 
antiseptically  until  a  line  of  demarcation  forms,  and  then  remove  the  dead 
parts  by  scissors,  forceps,  and  antiseptic  fomentations.  If  amputation  be- 
comes necessary,  wait  for  a  line  of  demarcation.  In  gangrene  of  a  toe,  toes,  or 
foot  due  to  angiothrombosis  or  obliterative  endarteritis,  amputation  is  always 
necessary.  The  terrible  pain  calls  for  it,  and  even  if  the  gangrenous  area  is 
very  small  it  is  certain  to  spread  or  new  areas  are  sure  to  arise.  This  form 
of  gangrene  has  been  treated  by  several  surgeons  by  anastomosing  the  femoral 
vein  to  the  femoral  artery.  Several  times  this  operation  seems  to  have  proved 
successful.  In  an  advanced  case  with  thrombosed  veins  it  cannot  succeed 
(see  page  i66). 

Diabetic  gangrene  often  resembles  strongly  senile  gangrene,  but  in  many 
cases  the  dead  portions  remain  somewhat  moist  and  putrefy.  Some  sur- 
geons attribute  it  directly  to  the  sugar  in  the  blood.  Some  think  diabetes 
causes  gangrene  indirectly  by  rendering  the  tissues  less  resistant  to  infection  and 
less  capable  than  normally  of  repair.  We  know  that  sugar  in  blood  removes 
fluid  of  the  tissues  and  causes  wound  fluids  to  contain  sugar.  Hence  wound  fluids 
become  excellent  culture-media  and  body  cells  lose  resisting  power  (see  Morris, 
page  1 1 6).  There  is  a  great  deficiency  of  oxygen  in  the  tissues,  which  probably 
predisposes  to  infection  (Lockwood,  in  "Lancet,"  February  lo,  191 2).  The 
frequency  in  diabetes  of  boils,  carbuncles,  and  spreading  suppuration  indicates 
lessened  resistance  to  infection,  and  any  infected  area  may  become  gangrenous. 
If  phthisis  exists  or  arises  in  a  diabetic  it  develops  with  fearful  speed  toward 
a  fatal  issue.  J.  C.  DaCosta,  Jr.,  and  Beardsley  demonstrated  that  diabetic 
blood-serum  shows  a  lowered  opsonic  index  for  tubercle  bacilli,  staphylococci, 
and  streptococci.  It  is  an  interesting  fact  in  this  connection  that  the  blood- 
serimi  of  a  pancreatectomized  dog  has  a  very  low  bactericidal  power.  Some  hold 
that  diabetic  gangrene  is  of  neurotic  origin,  being  the  result  of  nerve  degenera- 
tion. Heidenhain  believes  that  it  is  due  to  arterial  sclerosis.  That  most  of  the 
victims  of  diabetic  gangrene  suffer  from  arteriosclerosis  is  certain.  It  seems 
probable  that  the  gangrene  is  due  to  infection  of  tissue  predisposed  to  infection 
by  the  presence  of  sugar  and  lessened  amount  of  oxygen,  and  weakened  by 
changes  in  the  nerves  and  blood-vessels.  Diabetic  gangrene  is  most  usually  met 
with  upon  the  feet  and  legs  of  elderly  people,  but  it  may  arise  at  any  age  and 
may  attack  the  genital  organs,  thigh,  lung,  buttock,  eye,  back,  finger,  or  neck. 
It  may  affect  only  a  single  area,  may  attack  several  areas,  or  may  be  sym- 
metrical. It  may  arise  in  any  stage  of  diabetes,  from  the  earliest  to  the  latest. 
It  may  begin  as  a  perforating  ulcer.  It  is  much  more  common  in  men  than  in 
women.  There  are  clearly  two  forms  of  this  condition.  In  one  there  is  a  slowly 
progressive,  fairly  dry  gangrene,  probably  due  chiefly  to  arterial  sclerosis.  In 
such  a  case  a  small,  dry,  dead  patch  sometimes  lasts  months  before  spreading 
begins.  As  in  senile  gangrene,  a  trivial  injury  is  apt  to  be  the  exciting  cause. 
In  such  a  case  the  urine  contains  sugar  and  perhaps  albumin,  but  seldom  either 
acetone  or  diacetic  acid.    In  the  other  form  an  injury,  perhaps  a  trivial  one,  is 


Diabetic  Gangrene  and  Diabetic  Coma  175 

followed  by  a  rapidly  spreading  cellulitis,  which  seldom  forms  pus  and  which 
eventuates  in  moist  gangrene.  In  such  a  case  the  urine  is  apt  to  contain  acetone 
and  diacetic  acid  and  there  is  grave  danger  of  coma.  When  the  gangrene  fol- 
lows a  traumatism  there  are  no  prodromic  symptoms.  When  it  arises  spon- 
taneously in  the  skin,  it  is  often  preceded  by  pain  of  a  neuralgic  nature  and 
attacks  of  "n\dd  or  violaceous  discoloration  of  the  skin,  with  lowered  surface 
temperature  and  sometimes  loss  of  sensation"  (EUiot).  In  diabetic  gangrene 
of  an  extremity  the  pain  is  often  most  \'iolent,  due  probably  to  neuritis.  In 
fact,  neuritis  may  precede  the  gangrene.  Diabetic  gangrene  is  often  super- 
ficial, but  may  become  deep  if  it  follows  an  injury  or  ulceration.  Many  of 
these  patients  are  cyanosed  (Lockwood,  in  "Lancet,"  February  10,  191 2). 
A  sufferer  from  diabetic  gangrene  is  hable  to  cardiac  failure,  collapse,  and 
coma. 

Diabetic  coma  is  an  acid  intoxication  due  to  accumulation  in  the  blood  of 
acids  which  do  not  belong  there,  the  chief  of  which  is  beta-oxybutyric  acid. 
Acid  gathers  in  the  blood  because  of  lack  of  proper  oxidation.  Diacetic  acid 
is  formed  from  beta-oxybutyric  acid,  and  the  breaking  up  of  diacetic  acid  in 
the  urine  forms  acetone.  Hence,  acetonnria  means  acidosis.  Acetone  is  found 
in  the  urine  when  carbohydrates  are  not  taken  in  sufiicient  quantity  or  are  not 
assimilated  by  the  tissues.  Coma  in  acidosis  commonly  comes  on  rapidly, 
with  vomiting,  abdominal  pain,  weakness,  restlessness,  and  drowsiness,  which 
soon  passes  into  coma.  Sometimes  it  is  ushered  in  by  collapse,  at  other  times 
by  confusion  of  thought  and  speech.  In  coma  the  respiration  is  usually  slow 
and  deep,  but  may  be  sighing.  The  pulse  is  small,  of  low  tension,  and  usually 
rather  frequent.  The  temperatiure  becomes  subnormal,  although  during  the 
onset  it  may  be  elevated.  Cyanosis  arises,  the  breath  smells  of  acetone,  the 
patient  lies  quietly  in  bed,  and  the  pupils  are  dilated.  In  from  twenty-four  to 
forty-eight  hours,  as  a  rule,  the  patient  dies. 

Never  fail  to  carefully  examine  the  urine  in  every  surgical  case  and  espe- 
cially in  every  case  of  gangrene,  because  diabetes  may  exist  when  least  sus- 
pected. If  albumin  is  present  in  the  uiine  of  a  diabetic  it  means  increased 
peril;  if  casts  are  foimd  the  prognosis  is  still  worse.  In  such  a  case  uremic 
coma  mav  occur  and  be  mistaken  for  diabetic  coma. 

Treatment  of  Diabetic  Gangrene  of  Foot. — Most  surgeons  had  grown  very 
shy  of  amputating  for  diabetic  gangrene  until  Kiister,  of  Berlin,  warmly 
advocated  amputating  above  the  knee  without  waiting  for  a  line  of  demarca- 
tion. He  showed  that  if  amputation  is  performed  below,  the  flaps  will  become 
gangrenous,  and  that  after  high  amputation  sugar  may  disappear  from  the 
urine.  Of  11  amputations  by  Kiister,  6  recovered  and  5  died;  and  of  these  5,  3 
had  albumin  in  the  urine  as  well  as  sugar. 

Heidenhain  warmly  advocated  early  high  amputation,  with  the  making  of 
short  flaps,  and,  in  the  United  States,  Powers,  of  Denver,  defended  the  views  of 
Kiister  ("Amer.  Jour,  of  Med.  Sciences,"  Nov.  11,  1S92).  I  always  amputate 
through  the  lower  third  of  the  thigh.  Most  wTiters  now  advocate  high  opera- 
tion -nithout  waiting  for  line  of  demarcation  if  the  gangrene  is  moist  and  due  to 
bacteria  attacking  tissue  weakened  by  diabetes.  The  same  practitioners,  if 
dry  gangrene  due  to  arterial  changes  exists,  advocate  awaiting  the  formation 
of  a  line  of  demarcation  before  amputating.  I  agree  vnth  Klemperer  ("Therapie 
der  Gegenwart,"  Jan.,  1907)  that  we  should  reach  a  conclusion  as  to  the  proper 
course  to  pursue  more  from  the  character  of  the  diabetes  than  from  the  nature 
of  the  gangrene.  If  neither  diacetic  acid  nor  acetone  is  in  the  urine,  the  glyco- 
suria can  be  much  improved  and  the  general  health  vastly  benefited  by  re- 
stricting the  carbohydrates  and  administering  codein  or  opium.  In  many 
cases  sugar  rapidly  disappears.  In  such  a  case  during  the  improvement  of  the 
glycosuria  we  await  the  formation  of  a  line  of  demarcation,  and  while  waiting 


I76«  Mortification,  Gangrene,  or  Sphacelus 

the  gangrenous  area  and  the  parts  immediately  above  are  dressed  with  warm 
antiseptic  fomentations.  When  a  line  of  demarcation  forms,  spontaneous  heal- 
ing will  probably  occur.    If  it  does  not  occur,  amputate  high  up. 

If  acetone  and  diacetic  acid  persist  in  the  urine,  and  if  that  excretion  con- 
tains not  only  sugar,  but  also  quantities  of  albumin,  we  cannot  dare  to  wait  for 
a  line  of  demarcation  because  of  the  high  probability  that  during  the  wait  the 
patient  will  perish  of  septicemia  (Klemperer,  "Therapie  der  Gegenwart," 
Jan.,  1907).     In  such  a  case  perform  an  immediate  high  operation. 

If  the  urine  contains  acetone  and  diacetic  acid  a  line  of  demarcation  will 
almost  never  form,  and  high  amputation  must  be  performed  at  once.  _ 

To  put  such  a  patient  on  a  pure  meat  diet  increases  the  risk  of  diabetic  coma. 
In  order  to  lessen  the  risk  of  coma  give  bicarbonate  of  sodium  before  and  after 
operation.  Twenty  grains  of  this  drug  dissolved  in  Vichy  water  are  given 
every  two  or  three  hours.  If  coma  arises  give  intravenously  40  gr-  of  car- 
bonate of  sodium  in  i  quart  of  water. 

The  worst  cases  are  those  in  which  the  urine  contains  sugar,  albumin,  casts, 
acetone,  and  diacetic  acid.  In  any  case  if  over  i  gr.  of  ammonia  is  excreted 
in  twenty-four  hours,  postpone  operation  until  ammonia  is  reduced  by  diet. 

In  operating,  ether  and  chloroform  (especially  chloroform)  are  to  be  avoided, 
because  either  is  Hable  to  induce  acid  intoxication.  The  operation  may  be 
performed  under  spinal  anesthesia,  although  i  case  in  which  I  amputated  under 
spinal  anesthesia  died  of  coma.  In  a  recent  successful  case  I  infiltrated  all  the 
nerves  with  cocain  and  amputated.  There  was  no  pain  and  apparently  no 
shock. 

My  experience  in  diabetic  gangrene  of  the  leg  comprises  6  cases.  In  4  cases 
the  urine  contained  sugar,  acetone,  and  diacetic  acid,  and  in  2  of  these  cases 
albumin  was  also  present.  In  2  cases  sugar  was  in  the  urine,  but  no  albumin, 
acetone,  or  diacetic  acid.  In  each  case  a  high  amputation  was  performed — 
I  case  (one  of  those  with  albumin)  died  of  shock;  2  cases  died  in  coma;  i  case 
died  of  sepsis;  2  cases  recovered. 

Treatment  of  Diabetic  Gangrene  in  General. — In  gangrene  of  some  region 
other  than  an  extremity,  place  the  patient  on  antidiabetic  treatment,  treat 
locally  with  hot  antiseptic  fomentations,  remove  tissue  which  is  completely 
dead  with  scissors  and  forceps,  and  sustain  the  strength. 

Gangrene  from  Ergotism. — Ergotism  is  a  diseased  condition  resulting 
from  eating  bread  made  from  rye  which  has  been  attacked  by  a  fungus  (Clavi- 
ceps  purpura) .  In  former  days  it  was  not  unusual  to  have  epidemics  of  ergot- 
ism from  time  to  time,  but  at  present  the  disease  is  found  in  individuals  or, 
at  most,  in  a  few  of  a  community.  Ergotism  is  very  rare  in  the  United  States, 
but  it  is  not  uncommon  in  southern  Russia.  It  has  occurred  during  the  ad- 
ministration of  ergot  as  a  drug.  Billroth  reported  such  a  case.  It  is  never  seen 
in  unweaned  children.  The  eating  of  bread  made  of  diseased  rye  provokes 
gastro-enteritis,  the  evidences  of  which  are  abdominal  pain  of  a  crampy  char- 
acter, vomiting,  diarrhea,  and  exhaustion.  The  patient  complains  of  formi- 
cation and  itching  of  the  skin  of  the  extremities;  severe,  cramp-like,  and  ting- 
ling pains  in  the  limbs,  and  disorders  of  vision.  The  pulse  becomes  small  and 
slow.  In  some  cases  very  painful  spasms  attack  the  muscles  of  the  extremities 
and,  finally,  tonic  spasm  is  noted,  and  the  patient  probably  perishes  from  ex- 
haustion after  developing  general  convulsions  and  passing  into  coma.  In 
other  cases  certain  areas  exhibit  "gradual  blood-stasis"  (Osier),  anesthesia,  and, 
finally,  gangrene.  The  gangrene  is  dry  and  peripheral.  It  usually  affects^  the 
fingers  or  toes,  but  may  involve  an  entire  limb  and  may  be  symmetrical. 
Chronic  ergotism  is  usually  recovered  from,  but  acute  cases  die  in  from  seven 
to  ten  days.i  The  ingestion  of  ergot  in  quantity  sufficient  to  produce  chronic 
1  Pick,  in  Heath's  "Surgical  Dictionary." 


Gangrene  from  Frost-bite  177 

poisoning  causes  tonic  contraction  of  the  peripheral  blood-vessels,  degeneration 
of  the  inner  coats,  and  thrombosis  of  some  arterioles.  It  is  also  maintained  that 
degeneration  of  the  posterior  columns  of  the  spinal  cord  takes  place. 

Treatment. — Ergotism  is  treated  by  forbidding  the  eating  of  the  poison- 
ous bread,  allaying  gastro-enteric  inflammation,  favoring  elimination,  and 
administering  nourishment  and  stimulants.  If  gangrene  is  threatened,  en- 
deavor to  prevent  it  by  gentle  massage  and  the  application  of  warmth.  If 
superficial  gangrene  occurs,  dress  with  warm  antiseptic  fomentations  and  ele- 
vate the  part,  and  every  day  take  scissors  and  forceps  and  remove  the  loose 
crusts.  If  deeper  and  more  extensive  gangrene  arises  in  an  extremity  wait 
for  a  line  of  demarcation  and  amputate  above  it. 

Gangrene  from  Frost-bite. — Frost-bite  is  most  common  in  the  fingers, 
toes,  nose,  and  ears,  but  the  genital  organs,  the  cheeks,  the  chin,  the  feet  and 
legs,  and  the  hands  and  arms  may  be  attacked.  Cold  causes  a  primary  con- 
traction of  the  vessels  and  pallor  and  numbness  of  the  part.  After  reaction 
the  vessels  dilate,  the  part  reddens  and  swells,  and  a  burning  sensation  or 
actual  pain  is  experienced.  In  a  trivial  frost-bite  the  swelling  and  redness 
usually  disappear  after  a  few  days,  but  in  some  cases  the  redness  is  permanent, 
and  in  many  cases  the  redness,  in  the  form  of  local  asphyxia,  returns  under 
the  influence  of  slight  cold.     (See  Chilblains.) 

In  a  more  severe  frost-bite  the  affected  part  becomes  purple  and  covered 
with  vesicles,  and  gangrene  may  or  may  not  follow.  When  a  part  has  been 
badly  frozen  it  is  whiter  than  normal,  painless,  anesthetic,  and  the  peripheral 
portion  dries.  The  part  is  deprived  of  all  blood  because  of  contraction  of  the 
vessels  and  because  plasma  coagulates  at  a  few  degrees  above  freezing.  Cold 
disorganizes  the  blood,  breaking  up  white  corpuscles  with  the  liberation  of 
fibrin  ferment.  Coagulation  of  plasma  and  destruction  of  red  corpuscles  with 
the  liberation  of  hemoglobin  subsequently  takes  place.  The  thrombosis  which 
is  established  prevents  circulation,  and  the  tissue-cells  are  damaged  beyond 
repair.  The  part  is  bloodless  and  anesthetic,  and  a  line  of  demarcation  forms; 
hence  we  note  that  severe  frost-bite  causes  dry  gangrene.  Areas  of  superficial 
gangrene  are  not  uncommon.  If  a  part  which  is  not  so  badly  frozen  is  brought 
suddenly  into  a  warm  atmosphere,  hyperemia  takes  place  when  the  blood  runs 
into  the  frosted  tissues,  blebs  form,  and  moist  gangrene  may  result.  Baron 
Larrey  ("Surgical  Memoirs"),  in  speaking  of  the  retreat  from  Russia,  tells  a 
dreadful  story  of  the  suffering  from  cold.  He  says:  ''Persons  were  seen  to  fall 
dead  at  the  fires  of  the  bivouacs.  Those  who  approached  them  sufficiently  near 
to  warm  their  frozen  feet  and  hands  were  attacked  by  gangrene." 

Treatment  of  Frost-bite  and  of  Gangrene  from  Frost-bite. — ^A  frost-bite  in 
which  the  skin  is  livid  and  not  as  yet  gangrenous  should  be  treated  by  frictions 
with  snow  or  rubbing  with  towels  soaked  in  iced  water.  Larrey  says  that  if 
frictions  with  snow  or  ice  fail  the  part  should  "be  plunged  in  cold  water,  in 
which  it  should  be  bathed  until  bubbles  of  air  are  seen  to  disengage  themselves 
from  the  congealed  part.  This  is  the  process  adopted  by  the  Russians  for 
thawing  a  fish"  ("Surgical  Memoirs").  Whatever  method  is  used,  as  the  skin 
becomes  warmer  and  congestion  disappears  the  part  should  be  subjected  to 
dry  friction  and  wrapped  in  cotton- wool.  As  previously  stated,  a  sufferer  from 
frost-bite  should  not  suddenly  be  brought  into  a  warm  room.  When  gangrene 
follows  frost-bite,  if  only  small  areas  are  involved,  allow  the  dead  parts  to  come 
away  spontaneously,  applying  in  the  meanwhile  hot  antiseptic  fomentations. 
If  separation  be  delayed  by  cartilage,  ligament,  or  bone,  cut  through  the 
restraining  structure.  If  amputation  becomes  necessary,  await  a  line  of  demar- 
cation, as  it  is  not  possible  otherwise  to  be  certain  how  high  tissue  damage 
extends,  and  to  amputate  through  devitalized  parts  would  mean  renewed 
gangrene. 


lyS 


Mortification,  Gangrene,  or  Sphacelus 


Noma  is  a  rapidly  spreading  gangrenous  process  which  is  most  apt  to 
begin  upon  the  mucous  membrane  of  the  gums  or  cheeks.  Noma  of  this 
region  is  known  as  cancrum  oris.  Occasionally  it  begins  in  the  ears,  the  geni- 
tals, or  the  rectimi.  When  it  attacks  the  vulva  it  is  called  noma  pudendi. 
It  may  originate  in  the  mouth  and  subsequently  attack  other  regions.  Noma 
is  a  very  rare  disease,  is  chiefly  met  with  in  children  between  the  ages  of  three 
and  ten,  but  it  may  attack  older  persons.  O.  Zusch^  reports  a  case  in  a  man 
sixty-six  years  of  age.  King  reports  a  case  in  a  woman  of  fifty-nine."  It  occurs 
in  girls  oftener  than  in  boys.  The  disease  is  most  frequently  encountered  in 
children  recovering  from  an  acute  disease.  It  is  seen  after  scarlatina,  typhoid, 
pneumonia,  erysipelas,  nephritis,  dysentery,  and  especially  after  measles;  in 
fact.  Osier  says  that  over  one-half  the  cases  follow  measles.  Children  of  tuber- 
culous tendencies  seem  more  liable  than  others.  Young  children  who  live 
amidst  filth  and  squalor,  in  damp  and  ill-lighted  apartments  are  most  prone  to 


Fig.  93. — Noma.  Seven  days  after  first  appearance  of  measles  child  showed  gangrenous  condition 
of  mouth.  Now,  three  days  later,  it  involves  both  cheeks  and  under  surface  of  upper  and  lower  lips. 
Left  cheek  perforated.  Two  days  before  death  a  septic  diarrhea  developed  which  was  uncontrollable 
(Crandon,  Place,  and  Brown). 


suffer,  but  that  such  conditions  are  not  essential  to  the  genesis  of  the  disease  is 
shown  by  the  report  of  an  epidemic  of  noma  in  the  Albany  Orphan  Asylum. 
In  this  excellently  situated,  well-lighted,  and  well -ventilated  building  the 
children  are  carefully  fed  and  cared  for,  and  yet  i6  cases  of  noma  occurred 
after  an  epidemic  of  measles.  (See  "An  Epidemic  of  Noma,"  by  Geo.  Blumer 
and  Andrew  MacFarlane,  in  "Amer.  Jour,  of  Med.  Sciences,"  Nov.,  igoi.) 
The  disease  is  thought  by  many  to  be  due  to  pus  organisms.  Lingard  de- 
scribes a  bacillus  which  he  considers  causative.  Blumer  and  MacFarlane 
conclude  that  the  disease  begins  as  a  simple  infection  and  a  mixed  infection 
takes  place  later.  The  mixed  infection  is  not  always  due  to  the  same  organism, 
but  is  usually  due  to  a  long  organism  of  a  leptothrix  type  (Ibid.).    Some 

^  "  Miinchener  medicinische  Wochenschrift."  May  14,  1901. 
^  "Jour.  Amer.  Med.  Assoc,"  1911,  vol.  Ivi. 


Treatment  of  Sloughing 


179 


think  that  cases  of  noma  are  due  to  a  variety  of  spirochetes,  and  it  is  an 
interesting  observation  that  in  noma  the  Wassermann  serum  reaction  can  be 
obtained. 

In  190S  Crandon,  Place,  and  Brown  studied  an  outbreak  of  noma.  Measles 
had  been  through  the  ward,  46  children  had  had  gangrenous  stomatitis,  and  6  of 
them  developed  gangrene  of  the  lip  and  cheek.  A  seventh  case  of  gangrene 
appeared  from  another  source  (''Boston  ^led.  and  Surg.  Jour.,"  April  15,  1909). 
They  decided  that  the  lesion  was  necrosis  due  to  fusiform  bacilli  which  invade 
li\ing  tissue,  but  rapidly  die  in  necrotic  tissue.  Of  these  y^^cases,  2  recovered. 
The  writers  state  that  the  duration  of  the  disease  is  from  four  to  ten  days. 
They  do  not  regard  it  as  proved  that  noma  is  contagious  and  do  not  ad^^se 
isolation. 

Symptoms. — The  disease  begins  as  a  sloughing  ulcer;  thrombosis  and  gan- 
grene are  soon  observed.  The  edges  of  the  ulcer  are  dark  red  and  indurated.  The 
gangrene  usually  spreads  with  ver\^  great  rapidity,  but  in  some 
cases  it  remains  apparently  stationary  for  days  at  a  time. 
There  is  little  or  no  pain.  The  odor  is  horrible.  The  dis- 
ease is  frightfully  destructive,  and  if  the  mouth  is  involved 
is  apt  to  destroy  the  cheeks,  lips,  eyelids,  and  large  portions 
of  the  jaws.  There  is  usually  fever,  but  the  temperature 
may  be  normal  or  even  subnormal.  The  pulse  is  rapid,  and 
exhaustion  appears  early  and  deepens  rapidly.  The  mortality 
is  large:  Bruns  says  70  per  cent.;  RiUiet  and  Barthez  say  95 
per  cent.  ("Amer.  Jour,  of  Med.  Sciences,''  Nov.,  1901).  Out 
of  NicoU's  II  cases,  9  died  ("Progressive  Med.,"  March,  191 2). 
The  cause  of  death  is  exhaustion,  pyemia,  or  septic  broncho- 
pneumonia. 

Treatment. — ^Administer  an  anesthetic  and  destroy  the  gan- 
grenous area  \^-ith  the  PaqueHn  cautery.  In  noma  of  the 
mouth  chloroform  is  used  instead  of  ether  because  the  hot  iron 
is  to  be  applied  in  a  region  siurroimded  with  anesthetic  vapor, 
and  ether  vapor  is  inflammable.  In  noma  in  some  other  re- 
gions ether  can  be  given.  After  cauterization  directions  are 
given  to  wash  the  part  every  few  hours  "^"ith  peroxid  of  hydro- 
gen, irrigate  it  with  hot  salt  solution  or  boric  acid  solution, 
and  dress  it  "u-ith  compresses  soaked  in  Labarraque's  solution 
(Bliimer  and  ]MacFarlane,  in  ''Amer.  Jour,  of  Med.  Sciences," 
Nov.,  1901).  Nourishing  food  is  given  at  frequent  intervals, 
alcohol  is  administered,  and  strychnin  is  used  to  combat 
weakness.  Rumple  and  Nicoll  have  each  employed  salvarsan 
and  they  beheve  with  benefit.  In  one  of  NicoU's  successful 
cases  two  doses  of  3  gr.  each  were  given  intravenously  at  an 
interval  of  three  days.  Each  injection  produced  a  great  local 
reaction  in  the  cheeks.  If  the  surgeon  succeeds  in  arresting  the  gangrene 
it  will  probably  be  necessary  later  to  perform  a  plastic  operation  in  order  to 
replace  loss  of  substance. 

Sloughing  is  a  septic  process  by  which  \'isible  portions  of  dead  tissue  are 
separated.  These  \dsible  portions  are  called  "sloughs" ;  if  they  were  large  they 
would  be  called  "gangrenous  masses."  A  large  septic  slough  is  a  gangrenous 
mass;  a  small  gangrenous  mass  is  a  slough:  there  is  no  difference  in  the  process, 
which  corresponds  to  the  formation  of  a  Une  of  demarcation. 

Treatment. — Sloughing  requires  thorough  and  frequent  irrigation  by  an 
antiseptic  fluid,  removal  of  the  sloughs,  and  antiseptic  treatment.  An  irriga- 
tor can  be  impro\'ised  from  an  ordinarv^  bottle  (Fig.  94).  Warm  antiseptic 
fomentations  are  appUed  until  granulation  is  well  advanced.     In  some  cases 


Fig.  94. — Im- 
pro\ised  appara- 
tus for  the  irriga- 
tion of  a  wound. 


i8o  Mortification,  Gangrene,  or  Sphacelus 

continuous  irrigation  with  a  hot  antiseptic  fluid  is  useful;  in  other  cases  con- 
tinued immersion  in  a  hot  antiseptic  solution  is  employed. 

Phagedena  is  a  process  of  ulceration  and  gangrene  (most  common  in 
venereal  sores)  in  which  the  surrounding  tissues  are  rapidly  eaten  up,  the  sore 
becoming  jagged  and  irregular,  with  a  sloughy  floor  and  thin  edges.  The  dis- 
charge is  thin  and  reddish,  and  the  encircling  tissues  are  deeply  congested. 
This  tflcer  has  no  tendency  to  heal.  Phagedena  may  attack  wounds,  but  in 
this  age  is  almost  never  seen  except  in  venereal  sores.  When  it  does  so  the 
wound  discharge  is  arrested,  the  parts  about  the  wound  become  dark  red  and 
swollen,  a  black  slough  forms  upon  the  wound,  and  the  process  spreads  rapidly 
in  aU  directions.  The  process  when  it  attacks  a  wound  is  similar  to  or  identical 
with  a  mild  case  of  hospital  gangrene,  differing  from  the  gangrene  in  the  fact 
that  in  most  cases  a  line  of  demarcation  forms  and  the  depression  is  not  so 
great.     Phagedena  is  probably  due  to  mixed  infection  with  pus  organisms. 

The  treatment  of  phagedena  consists  in  repeated  touching  with  tincture 
of  chlorid  of  iron  and  the  local  use  of  iodoform,  the  employment  of  continued 
irrigation  or  immersion  in  hot  antiseptic  fluids,  or  the  application  of  the 
cautery,  chemical  or  actual.  After  using  the  cautery  the  part  is  dressed  with 
hot  antiseptic  fomentations.  Whatever  else  is  done,  tonics,  stimulants,  and 
nutritious  diet  must  be  given  and  opium  is  often  required. 

Decubitus,  Decubital  Gangrene,  or  Bed=sore. — A  bed-sore  is  the 
result  of  local  failure  of  nutrition  in  a  person  whose  tissues  are  in  a  state  of 
low  vitaHty  from  age,  disease,  or  injury.  The  arterial  condition  of  the  aged 
favors  the  development  of  bed-sores.  Such  sores  are  due  to  pressure,  aided 
it  may  be  by  some  slight  injury  or  by  the  irritation  produced  lay  urine,  feces, 
sweat,  crumbs  or  other  foreign  bodies  in  the  bed,  or  by  wrinkHng  of  the  sheets. 
The  pressure  destroys  vascular  tone,  stasis  results,  thrombosis  occurs,  and  gan- 
grene follows.  Sores  occur  over  the  heels,  elbows,  scapulae,  trochanters,  sacrimi, 
and  nucha.  In  some  cases  after  pressure  is  removed  there  are  stasis,  vesication, 
suppuration,  and  the  formation  of  an  ugly  ulcer,  surrounded  by  a  zone  of 
swelling  and  hyperemia.  These  ordinary  pressure-sores  arise  like  a  splint-sore 
due  to  the  pressure  of  a  spHnt  upon  the  tissues  over  a  bony  prominence.  The 
pressure  interferes  with  the  blood-supply,  the  weakened  tissues  inflame, 
vesication  occurs,  sloughs  form,  and  an  ugly  ulcer  is  exposed.  When  a  bed- 
sore is  about  to  form  the  skin  becomes  red  and  edematous.  Pressure  with 
the  finger  drives  the  color  out  rather  slowly.  The  color  becomes  purple  or 
black,  a  slough  forms  and  separates,  and  a  large,  irregular,  foul  cavity  is  ex- 
posed. The  discharge  is  profuse  and  offensive.  The  parts  about  are  swollen 
and  red.  If  the  sore  is  not  upon  an  anesthetic  part,  much  suffering  is  produced 
by  it.  Bed-sores  are  most  common  in  paralyzed  parts;  such  parts  are  anes- 
thetic, and  injurious  pressure  is  not  painful  and  does  not  attract  attention,  and 
in  such  parts  there  is  vasomotor  paresis. 

The  acute  bed-sores  of  Charcot  are  seen  during  certain  diseases  and  after 
some  injuries  of  the  nervous  system.  These  sores  are  usual  over  the  sacrum  in 
acute  myelitis,  and  may  appear  in  four  or  five  days  after  the  beginning  of  that 
disease  or  the  infliction  of  an  injury  upon  the  spinal  cord.  The  surgeon  sees 
acute  bed-sores  upon  the  buttock  of  the  paralyzed  side  after  brain-injuries, 
and  over  the  sacrum  and  other  bony  points  after  spinal  injuries.  Some  believe 
these  sores  are  due  to  vasomotor  disorder;  but  others,  notably  Charcot,  at- 
tribute them  to  disturbance  of  the  trophic  nerves  or  centers. 

Treatment  of  Bed-sores. — The  "ounce  of  prevention"  is  here  invaluable. 
From  time  to  time,  if  possible,  alter  the  position  of  the  patient,  keep  him 
clean,  maintain  the  blood-distribution  to  the  skin  by  frequent  rubbing  with 
alcohol  and  a  towel,  keep  the  sheet  clean  and  smooth,  and  in  some  situations 
use  a  ring-shaped  air-cushion  to  keep  pressure  from  the  part.    When  conges- 


Ludwig's  Angina  i8i 

tion  appears  {paratrimma,  or  beginning  sore),  at  once  use  an  air-cushion  or  a 
water-bed  and  redouble  the  care  to  frequently  change  the  position  of  the 
patient.  Xot  only  protect,  but  also  harden,  the  skin.  Wash  the  part  twice 
daily  and  apply  spirits  of  camphor  or  glycerol  of  tannin;  or  rub  with  salt  and 
whisky  {2  dx.  to  i  pint) ;  or  apply  a  mixture  of  h  oz.  of  powdered  alum,  2  ti.oz. 
of  tincture  of  camphor,  and  the  whites  of  four  eggs;  or  paint  with  corrosive 
sublimate  and  alcohol  (2  gr.  to  i  oz.) ;  or  apply  tannate  of  lead  or  equal  parts  of 
oil  of  copaiba  and  castor  oil;  or  paint  upon  the  part  a  protective  coat  of  flexible 
collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it  with  a  solution  of 
nitrate  of  silver  (20  gr.  to  i  oz.).  \^Tien  the  skin  breaks,  a  good  plan  of  treat- 
ment is  to  touch  once  a  day  with  a  solution  of  silver  nitrate  (10  gr.  to  i  oz.)  and 
cover  with  zinc-ichthyol  gelatin.  We  can  wash  the  sores  daily  with  i :  2000 
corrosive  sublimate  solution,  dust  with  iodoform,  and  cover  with  soap  plaster, 
with  lint  spread  with  zinc  ointment,  or  with  dry  aseptic  gauze.  WTien  sloughs 
form,  cut  most  of  them  off  with  scissors  after  cleansing  the  parts,  sUt  up  sinuses, 
and  use  antiseptic  fomentations.  In  sloughing  Dupuytren  employed  pieces  of 
Unt  wet  with  lime-juice  and  dusted  the  sore  with  cinchona  and  charcoal.  In 
obstinate  cases  use  the  continuous  hot  bath.  "VlTien  the  sloughs  separate, 
dress  antisepticaUy  or  with  equal  parts  of  resin  cerate  and  balsam  of  Peru. 
If  healing  is  slow,  touch  occasionally  with  a  solution  of  silver  nitrate  (10  gr.  to 
I  oz.).  Bed-sores,  being  expressive  of  lowered  vitality,  demand  that  the  patient 
shall  be  stimulated,  shall  be  well  nourished,  and  shall  obtain  soimd  sleep. 

Ludwig's  Angina  {Angina  Ludovici). — ^This  disease,  which  was  first  de- 
scribed by  LudT\-ig,  of  Stuttgart,  in  1836,  is  an  acute  septic  infection  about  the 
submaxQlarv-  salivary-  gland  and  in  the  cellular  tissue  beneath  the  mucous 
membrane  of  the  floor  of  the  mouth  and  of  the  upper  portion  of  the  neck. 
Ludwig  caUed  it  ■"gangrenous  induration  of  the  neck"  (D.  Ludwig,  "Med. 
Correspondez  Blatt,"  p.  21,  Feb.,  1S36,  Stuttgart).  The  disease  may  arise 
in  an  apparently  healthy  man  or  during  or  after  an  infectious  fever.  It  can 
arise  at  any  age.  The  bacteria  enter  from  the  mouth  by  way  of  abrasions, 
wounds,  ulcerations,  or  dental  caries.  It  may  be  caused  by  delayed  develop- 
ment of  the  third  molar,  necrosis  of  the  tooth  and  alveolar  process  taking  place 
and  an  abscess  forming  (G.  G.  Ross,  "Annals  of  Surgery,"  June,  1901).  In 
most  cases  the  condition  is  a  pure  streptococcic  infection  or  a  streptococcic 
infection  associated  with  infection  by  some  other  organism,  for  instance,  sta- 
phylococci, pneumococci,  or  bacilli.  In  one  of  Davis's  cases  it  was  due  to 
pneumococci  alone;  in  another,  to  staphylococci  alone  (Gwill^Tn  W.  Da\-is, 
"Annals  of  Surgen.-,'"  August,  1906).  In  a  case  reported  by  Lockwood  the 
bacillus  of  malignant  edema  was  found.  The  condition  is  essentially  an  acute 
spreading  cellulitis  about  the  submaxillarv"  gland.  It  usually  begins  about  that 
gland,  but  in  some  cases  seems  to  arise  about  the  sublingual  gland.  It  is 
visually  a  \dolent  process  from  the  start,  but  sometimes  it  is  first  an  indolent 
swelling  in  the  submaxillar}-  region  and  becomes  violent  and  begins  to  spread 
rapidly  after  a  few  days.  It  spreads  along  planes  of  connective  tissue  to  the 
sublingual  region  of  the  mouth  and  to  the  pharvaix. 

The  bacteria  reach  the  submaxillar}-  region  in  the  hinph.  A  l}-mph- 
gland  or  perhaps  several  glands  enlarge  and  are  rapidly  destroyed,  the  peri- 
glandular ceUiflar  tissue  becomes  involved,  and  after  this  spread  takes  place 
along  connective-tissue  planes  rather  than  by  hmph-paths,  and  other  hinph- 
glands  seldom  enlarge. 

The  localization  in  the  submaxfllarv-  region,  the  ^dolence  of  the  inflamma- 
tion, the  rapidity  of  the  spreading,  and  the  subsequent  involvement  of  the 
phar}-nx  and  floor  of  the  mouth  are  the  characteristic  features  of  Ludwig's 
angina    (T.  Tvumer   Thomas,   "Annals  of  Surger}-,"   Februar}^  and  ^larch, 


i82  Mortification,  Gangrene,  or  Sphacelus 

1908).  Thomas,  in  the  article  just  referred  to,  proves  by  anatomical  studies 
that  the  connective  tissue  in  the  submaxillary  fossa  is  directly  continuous  with 
that  in  the  floor  of  the  mouth.  The  disease  begins  as  a  painful  indurated 
swelling  beneath  the  body  of  the  jaw,  the  swelling  rapidly  increases  in  the  neck, 
and  may  even  pass  to  the  level  of  the  sternum.  A  board-Hke  feel  of  this  swell- 
ing is  distinctive.  The  skin  may  be  pale  or  dusky  red.  There  may  or  may 
not  be  marked  tenderness. 

After  a  few  hours  or  a  day  or  two  the  floor  of  the  mouth  becomes  involved; 
as  a  result  of  this  the  tongue  is  raised  and  pushed  back,  the  mouth  is  kept 
from  closing,  swaUo"v^ing  becomes  difficult,  speech  is  impaired,  the  saHva 
dribbles  constantly,  and  dyspnea  becomes  an  alarming  feature  of  the  case. 

In  some  cases  the  temperature  is  much  elevated,  but  in  most  it  is  moder- 
ately or  only  shghtly  elevated. 

If  a  spontaneous  opening  should  occur  it  will  be  within  the  mouth.  Free 
suppuration  may  occur  or  only  a  little  watery  pus  may  form  and  the  pus  may 
be  brown  and  putrid.  In  many  cases  the  cellular  tissue  becomes  gangrenous, 
the  gangrene  resembling  that  of  noma.  The  mortality  is  high.  In  Thomas's 
collection  of  106  cases  it  is  seen  that  43  died  (Ibid.),  though  with  the  prompt 
intervention  which  is  now  advised  the  mortality  should  be  much  below  this 
figure  at  the  present  time.    I  have  had  4  cases  and  2  of  them  died. 

Death  may  take  plac.e  suddenly.  Death  is  seldom  due  to  septic  intoxica- 
tion or  pyemia,  but  may  be.  It  is  usually  due  to  edema  of  the  glottis  or  to 
bronchopneumonia. 

Treatment. — Operate  promptly  and  incise  freely.  If  there  is  an  infective 
focus  within  the  mouth,  remove  it.  Make  an  incision  through  the  swelling  in 
the  submaxillary  region,  carry  the  incision  forward  to  the  median  line  and 
divide  the  mylohyoid  muscle.  "The  finger  should  be  passed  upward  in  the 
wound  until  only  mucous  membrane  interv^enes  between  it  and  the  mouth. 
Gangrenous  tissue  is  cut  away,  the  woimd  is  painted  with  pure  carbolic  acid, 
and  dusted  with  iodoform"  (T.  Turner  Thomas,  Ibid.).  Drainage-tubes  are 
inserted  and  the  part  is  dressed  by  antiseptic  fomentations.  If  edema  of 
the  glottis  exists,  tracheotomy  should  be  performed  promptly.  Stimulants 
are  given  with  a  free  hand  in  Ludwig's  angina. 

Carbolic  Acid  Gangrene. — Dressings  moistened  with  a  solution  of 
carbolic  acid  of  a  strength  of  from  3  to  5  per  cent,  if  wrapped  for  a  number 
of  hours  around  a  finger  or  toe,  a  hand  or  a  foot,  may  cause  dr}^  gangrene. 
There  is  but  little  danger  when  such  dressings  are  applied  to  the  tissues  of  the 
trimk,  because  these  thicker  tissues  are  better  nourished  and  cannot  be  com- 
pletely surrounded  by  the  wet  dressings.  When  a  dressing  wet  ^^dth  a  waters'- 
solution  of  carbolic  acid  is  wrapped  about  the  part  the  water  evaporates,  and 
as  it  does  so  the  carbolic  acid  becomes  more  and  more  concentrated.  A  well 
mixed  solution  seldom  causes  gangrene.  A  recent  aqueous  solution  often  con- 
tains free  globules  of  acid  and  is  particularly  apt  to  cause  gangrene  (Murphy). 
It  is  claimed  that  a  solution  of  carbolic  acid  in  glycerin  never  causes  gangrene 
(Pautrier,  in  "Presse  Medicale,"  March  2,  1907).  Gangrene  of  a  toe  has  oc- 
curred from  the  application  of  carbolized  vaselin  (Buckmaster's  case,  "Jour. 
Amer.  Med.  Assoc,"  January  13,  1912).  Two  cases  have  been  reported  in 
which  gangrene  of  a  finger  was  caused  by  carbolized  ointment  (Brown, 
"Jour.  Amer.  Med.  Assoc,"  November  11,  1911;  Schussler,  "Jour.  Amer. 
Med.  Assoc,"  August  19,  191 1).  In  one  case  reported  by  DeWitt  gangrene 
of  the  thiimb  resulted  from  injecting  a  ganglion  of  the  thumb  with  equal  parts 
of  camphor  and  pure  carbolic  acid  ("Southern  Med.  Jour.,"  June,  1909). 
The  appHcation  of  strong  acid  rarely  causes  gangrene,  but  Levan  fotmd  14 
reported  cases  in  which  it  did  (J.  Levan,  in  "Centralbl.  f.  Chir.,"  August  14, 
1897),  and  Wallace  has  reported  several  more  ("Brit.  Med.  Jour.,"  May  11, 


Rules  When  to  Amputate  for  Gangrene  183 

1907).  A  solution  as  mild  as  i  per  cent,  has  caused  gangrene.  The  con- 
tinuous application  of  a  solution  of  a  strength  of  3  per  cent,  or  over  is  very 
dangerous  and  ought  never  to  be  practised.  The  author  has  seen  7  cases. 
Harrington  saw  18  cases  of  gangrene  in  five  years  in  the  Massachusetts 
General  Hospital,  and  collected  132  cases  from  Hterature  ("Boston  Med.  and 
Surg.  Jour.,"  May  2,  1901).  Carbolic  acid  gangrene  is  due  to  great  exuda- 
tion into  the  cellular  tissue,  blocking  the  circulation  (Housell),  and  the  pro- 
duction of  arterial  thrombi,  a  condition  to  which  the  patient  is  predisposed 
by  the  injury  and  often  by  tight  bandaging.  The  dressing  is  frequently  ap- 
plied by  a  druggist;  it  produces  anesthesia  of  the  part,  and  the  dressing  may 
not  be  removed  for  days,  gangrene  perhaps  progressing  beneath.  In  the 
author's  7  cases  pain  was  absent  and  there  was  no  smokiness  of  the  urine  or 
any  other  evidence  of  absorption  of  the  drug.  Dressing  of  lysol  and  alcohol 
may  produce  gangrene,  but  the  necrosis  is  more  superficial  than  that  due  to 
carbolic  acid. 

Treatment. — If  the  gangrene  is  very  superficial,  recovery  may  be  obtained 
by  using  hot  fomentations  and  picking  the  dead  parts  gradually  away.  In 
most  cases  the  finger  or  toe  is  completely  destroyed,  a  line  of  demarcation 
forms,  and  amputation  is  required. 

Postfebrile  Gangrene. — Drv-  or  moist  gangrene  may  follow  any  fever, 
but  is  most  frequent  after  tj^hoid  (may  follow  t\^hus,  influenza,  measles, 
diphtheria,  scarlet  fever,  etc.).  Keen  tells  us  that  the  gangrene  resulting  from 
arterial  obstruction  is  apt  to  be  dry,  and  that  from  venous  obstruction  is 
usually  moist.  The  same  observer  has  collected  203  cases.^  It  is  most  usual  in 
the  lower  extremities,  but  may  appear  in  the  upper  extremities,  cheeks,  ears, 
nose,  genitals,  Imigs,  etc.  Some  writers  have  assigned  as  the  cause  weakness  of 
cardiac  action,  but  most  observers  believe  an  obstructing  clot  is  the  usual 
cause.  This  clot  may  come  from  the  heart,  but  is  in  most  cases  secondary  to 
endarteritis  due  to  the  action  of  the  toxins  of  the  baciUi  of  the  specific  fever. 
Keen  shows  that  in  some  cases  gangrene  is  due  to  obstruction  of  peripheral 
vessels  and  not  of  a  main  trunk.  In  rare  cases  gangrene  arises  after  throm- 
bophlebitis. Gangrene  may  begin  as  early  as  the  fourteenth  day  of  t^-phoid, 
but  usually  appears  late  in  the  disease  and  may  arise  far  into  convalescence. 
In  the  course  of  a  continued  fever  frequent  examinations  should  be  made  to 
see  that  gangrene  is  not  arising.  Particular  examination  from  time  to  time 
should  be  made  of  the  lower  extremities  and,  in  yoimg  girls,  of  the  genitals. 
If  gangrene  arises  in  an  extremity,  apply  antiseptic  dressings,  wait  for  a  fine 
of  demarcation,  and  then  amputate.  If  gangrene  occurs  in  other  regions, 
remove  the  dead  tissue  and  employ  hot  antiseptic  fomentations. 

Rules  When  to  Amputate  for  Gangrene. — In  dry  gangrene,  due  to 
obstruction  of  a  non-diseased  artery,  wait  for  a  line  of  demarcation.  In  senile 
gangrene,  if  it  affect  only  one  or  two  toes,  let  the  dead  parts  be  cast  off  spon- 
taneously. If  a  greater  area  is  involved  or  the  process  spreads,  amputate 
above  the  knee  -without  waiting  for  the  line.  In  ordinary  moist  gangrene,  if 
there  are  not  severe  s>Tnptoms  of  sepsis,  and  ff  the  gangrene  is  not  rapidly 
progressive,  wait  for  a  line  of  demarcation.  In  the  severer  cases  amputate 
at  once  high  up.  In  traumatic  spreading  gangrene  amputate  at  once  high 
up.  In  many  cases  of  diabetic  gangrene  amputate  at  once  high  up  (see  page 
175).  In  ergot  gangrene,  in  carbolic  acid  gangrene,  in  postfebrile  gangrene,  in 
Raynaud's  gangrene,  and  in  frost  gangrene  wait  for  a  line  of  demarcation. 

Arteriovenous  Anastomosis  for  the  Prevention  or  Treatment  of  Gan- 
grene of  an  Extremity. — This  operation  took  origin  from  Carrel's  famous 
demonstration  of  the  reversal  of  the  circiflation  in  a  dog's  leg.  The  axil- 
larv'  artery  has  been  anastomosed  to  the  axiUary  vein;  the  femoral  artery  has 
^  Keen  on  the  "Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


1 84  Thrombosis  and  Embolism 

been  anastomosed  to  the  femoral  vein.  We  know  that  by  an  anastomosis 
we  can  send  arterial  blood  into  a  vein,  but  usually  a  clot  soon  forms  at  the 
junction.  Those  who  advocate  the  operation  assert  that  the  force  of  the  arterial 
blood-current  overcomes  the  valves  of  the  vein,  and  that  arterial  blood  goes 
toward,  even  if  it  does  not  reach,  the  periphery.  Further,  that  even  if  a  clot 
does  form,  it  forms  slowly,  circulation  is  arrested  gradually,  and  collaterals 
distend  during  clotting. 

The  opponents  of  the  operation  assert  that  the  valves  cannot  be  overcome, 
that  the  blood  flows  off  into  venous  branches  and  returns  to  the  heart.  Though 
it  is  doubtful  how  far  toward  the  periphery  the  blood  goes,  we  believe  that  the 
repeated  impact  of  the  arterial  blood  must  finally  overcome  the  valves;  and  in 
spite  of  great  uncertainty  as  to  the  retiu-n  of  blood  to  the  heart,  we  know  that 
successful  reversal  seems  to  have  been  accompHshed. 

Bernheim  ("Annals  of  Surgery,"  February,  191 2)  has  collected  46  cases 
from  literature  and  has  added  6  operations,  2  of  which  were  performed  on 
the  same  indi\ddual  (Halsted's  case,  Finney's  case,  Bloodgood's  4  cases). 
In  the  52  operations  gathered  in  Bernheim's  table  the  ages  of  the  subjects 
varied  from  twenty  to  eighty  years.  There  were  13  deaths.  He  considers 
15  of  the  cases  successful,  that  is,  "cases  in  which  reversal,  as  far  as  one  can 
judge,  actually  saved  the  limb  from  real  or  threatened  gangrene."  H.  Mor- 
riston  Da\des  recently  reported  a  successful  operation  for  gangrene.  The 
artery  and  vein  were  completely  divided  and  anastomosed  in  Hunter's  canal 
("Annals  of  Surgery,"  191 2). 

The  best  plan  is  lateral  anastomosis  with  proximal  ligation  of  the  vein,  to 
prevent  the  deviated  blood  from  returning  at  once  to  the  heart.  Bernheim 
and  Stone  devised  this  method  (Ibid.)  and  Murphy  advocates  it.  Only  one- 
third  of  the  artery  is  used  for  the  anastomosis  and  some  blood  continues  to 
fiow^  in  the  artery  toward  the  periphery.  The  artery  carries  blood  to  where 
the  block  is;  the  vein  is  supposed  to  carry  blood  much  fiu-ther.  Bernheim 
points  out  that  if  a  thrombus  forms  it  will  do  so  on  the  side  of  the  artery  and 
the  limb  will  be  no  worse  off. 

In  suitable  cases  the  operation  is  justifiable  and  age  is  no  bar.  It  is  useless 
if  veins  are  occluded  as  weU  as  arteries,  hence  it  is  useless  in  advanced  cases  of 
gangrene  from  thrombo-angiitis  obliterans.  If  any  considerable  area  of  gan- 
grene exists  veins  are  involved  and  the  operation  is  useless. 


IX.  THROMBOSIS  AND    EMBOLISM 

Thrombosis  is  the  antemortem  coagulation  of  blood  in  the  heart  or  in  a 
vessel,  the  coagulimi  remaining  at  its  point  of  origin  and  plugging  up  the 
vessel  partially  or  completely.  The  process,  and  also  the  condition  significant 
of  the  process,  is  known  as  thrombosis;  the  clot  is  called  the  thrombus.  This 
process  is  an  essential  part  in  the  arrest  of  hemorrhage;  it  occurs  in  phlebitis 
and  arteritis,  and  affords  a  frequent  basis  for  embolism.  The  thrombus  is  com- 
posed of  red  corpuscles,  white  corpuscles,  fibrin,  and  platelets  in  varying  pro- 
portions. Thrombi  may  form  in  the  veins,  in  the  arteries,  in  the  capillaries, 
or  in  the  heart.  Clotting  is  due  to  destruction  of  white  blood-cells,  fibrin 
ferment  being  set  free,  causing  the  union  of  calcium  and  fibrinogen  and  thus 
forming  fibrin.  Thrombosis  is  more  common  in  the  veins  than  in  the  arteries, 
the  slow  blood-current  and  the  existence  of  valves  favoring  the  deposit,  though 
not  causing  it.  A  thrombus  forms  gradually,  being  deposited  layer  by  layer; 
hence  it  is  stratified  or  laminated.  Figure  95  shows  a  thrombus  in  a  vein.  All 
thrombi  are  either  infectious  or  simple,  the  latter  being  also  called  aseptic  or 
bland.    Thrombi  are  also  spoken  of  as  fibrinous,  red,  hemostatic,  leukocytic,  etc. 


Causes  of  Thrombosis 


l8: 


Fig.  95. — Thrombus 
in  the  saphenous  vein. 
(Green). 


Causes  of  Thrombosis. — In  the  formation  of  thrombi  four  conditions  are 
to  be  considered,  viz.,  chemical  alterations  in  the  blood,  a  bacterial  attack  on  the 
intima,  tissue  changes  in  the  inner  coat  of  the  vessel,  and  slowing  of  the  cir- 
culation. One,  several,  or  all  of  these  conditions  may  exist  in  a  case  of  thrombo- 
sis. In  arteries  the  chief  causes  are  disease  of  the  coats  and  emboHsm.  In 
veins  the  chief  causes  are  injury  and  infectious  phlebitis.  Capillar}'  thrombi 
may  be  due  to  propagation  from  veins  or  arteries  or  may  form  in  the  capillaries. 
The  latter  condition  is  seldom  seen.  The  essential  cause  of  all  intravascular 
thrombi  is  damage  to  the  endothelial  coat  and  in  most  instances  the  damage 
is  effected  b}-  bacteria,  hence  most  cases  of  thrombosis 
seen  by  the  surgeon  are  infectious.  Any  condition 
■u-hich  causes  the  blood  to  contain  an  excess  of  fibrin- 
forming  elements  favors  thrombosis,  in  the  sense  that  a 
shght  injur}-  of  the  vascular  endotheHum  "^-ill  be  fol- 
lowed by  clot  formation.  Among  conditions  favoring 
thrombosis  we  must  note  particularly  slowing  of  circu- 
lation, however  caused.  A  special  predisposing  condi- 
tion is  the  retarded  circulation  in  tuberculosis,  influenza, 
and  fevers,  the  blood-clotting  behind  the  vein-valves 
after  the  endotheHvma  has  been  damaged  by  toxins. 
Among  other  inciting  states  are  inflammations;  wounds; 
fractures ;  the  pressure  of  a  bandage  or  of  a  splint ;  vari- 
cose veins;  Hgation  of  a  vessel;  injmy-  of  a  vessel;  foreign 
bodies  in  a  vessel;  atheroma  in  arteries;  sutures  in  a 
vessel;  pregnancy;  certain  diseases,  such  as  gout,  t^-phoid 
fever,  and  septic  processes;  phlebitis  or  arteritis  arising 
in  the  vessel  or  from  extension  of  surroimding  inflammation,  and  the  entrance 
of  specific  organisms. 

It  has  been  asserted  that  so  long  as  the  endothehiun  of  a  vessel  is  unin- 
jured a  clot  does  not  form.  Slowing  of  the  blood-current  in  aseptic  conditions, 
it  is  now  taught,  will  not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thehal  coat  is  to  keep  the  blood  fluid  by  preventing  corpuscular  disintegration. 
A  thrombus  can  form  only  when  fibrin  ferment  is  set  free,  and  fibrin  ferment 
can  be  set  free  only  when  white  corpuscles  disintegrate.  \\Tien  mo\-ing  blood 
coagulates,  the  third  corpuscles  or  platelets  first  settle  out  and  form  a  nucleus 
and  then  the  leukocytes  gather  about  it.  This  is  knoT\"n  as  the  icliite  or  "ante- 
martem'-  thrombus — the  clot  of  moA-ing  blood.  Thrombi  from  mo^•ing  blood 
are  rarely  pure  white;  they  contain  some  red  corpuscles,  forming  mixed  thrombi. 
White  thrombi  and  mixed'  thrombi  are  stratified  and  are  at  first  soft,  but  harden 
as  they  age.  The  red  thrombus  plugs  vessels  which  are  cut  across  or  ligated;  it 
also  occins  in  septic  processes  and  is  the  thrombus  formed  after  death.  A 
primary  thrombus  remains  in  the  original  region  of  thrombosis.  A  secondary 
thrombus  forms  about  an  emboHsm.  A  propagating  or  spreading  thrombus  ex- 
tends a  considerable  distance  from  the  seat  of  initial  disturbance.  A  thrombus 
soon  undergoes  a  change.  An  aseptic  clot  usually  ''organizes'" — that  is,  the  clot 
is  absorbed  and  is  replaced  by  fibrous  tissue.  The  walls  of  the  injiu^ed  vessel 
become  tilled  with  leukocytes,  leukocytes  invade  the  clot,  the  vascular  endo- 
theKmn  proliferates,  and  the  yoiing  cells  foUow  the  colonies  of  leukocytes  into 
the  thrombus.  The  thrombus  is  gradually  removed  by  leukocytes  and  replaced 
by  fibroblasts,  the  new  tissue  is  vascularized  and  becomes  granulation  tissue, 
the  granulation  tissue  is  converted  into  fibrous  tissue,  and  the  fibrous  tissue 
contracts.  In  some  instances  a  thrombus  is  implanted  on  the  waU  of  the  vessel 
and  the  tube  is  not  permanently  occluded.  Such  a  condition  may  be  obtained 
by  the  appHcation  of  a  lateral  Hgature  about  a  small  tear  in  a  large  vein.  In 
most  instances,  after  the  formation  of  an  intravascular  thrombus,  the  vessel  is 


1 86  Thrombosis  and  Embolism 

converted  into  a  narrow  cord  of  fibrous  tissue.  A  thrombus  may  degenerate 
and  break  down  (fatty  degeneration),  giving  rise  to  emboH,  or  a  thrombus  may 
undergo  calcification.  A  calcified  thrombus  in  a  vein  is  known  as  phlebolith. 
An  infected  thrombus  may  undergo  liquefaction,  infective  emboli  being  set 
free  (Fig.  96). 

A  clot  may  propagate  in  both  directions,  that  is,  toward  the  periphery  and 
toward  the  heart.  It  was  taught  for  many  years  that  when  an  artery  is 
ligated  a  thrombus  quickly  forms  and  reaches  to  the  first  collateral  branch 
above.  This  view  was  formulated  in  pre-antiseptic  days.  It  is  now  known  that 
when  aseptic  ligation  is  performed  the  thrombus  is  small  and  rarely  reaches 
the  first  collateral  branch;  and  is  often  actually  absent,  vascular  obliteration 
being  obtained  by  proliferation  of  connective- tissue  cells  and  of  cells  from  the 
endothelial  coat.  If  an  infection  takes  place  the  clot  may 
reach  the  first  collateral  branch.  The  old  rule  of  surgery 
was  as  follows:  If  an  artery  is  cut  near  a  large  branch, 
tie  the  branch  as  well  as  the  artery,  in  order  to  permit  of 
the  formation  of  a  lengthy  clot.  This  rule  is  no  longer 
followed  unless  infection  exists  or  is  anticipated. 

A  clot  in  a  vein  often  extends  a  long  distance.  The 
author  has  seen  in  a  postmortem  examination  a  venous 
thrombus  reaching  from  the  ankle  to  the  vena  cava.  A 
common  example  of  thrombus  in  a  vein  is  the  clot  formed 
in  the  uterine  sinuses  in  a  condition  of  puerperal  sepsis,  a 
clot  which  tends  to  extend  into  the  iliac  and  femoral 
thrombus^  oF  a  ^veln  vcins.  In  infectious  thrombosis  of  the  lateral  sinus  there 
(schematic).  is  thrombophlebitis,  and  the  clot  tends  to  extend  up  to 

the  torcular  and  into  other  sinuses  and  down  into  the 
jugular.  Phlegmasia  alba  dolens  or  milk-leg  is  a  condition  in  which  the  leg 
or  the  leg  and  thigh  are  swollen  and  painful  because  of  venous  thrombosis 
or  sometimes  lymphatic  thrombosis  (see  page  187). 

Lymphatic  thrombosis  occasionally  occurs  in  the  thoracic  duct,  axillary  lym- 
phatics, or  inguinal  lymphatics.  It  is  most  common  in  the  uterine  lymphat- 
ics during  puerperal  fever.  Lymphatic  thrombosis  may  be  due  to  infection, 
to  cancer,  to  tuberculosis,  or  to  change  in  the  lymph  itself. 

General  Symptoms. — The  symptoms  are  dependent  on  the  seat  of  the 
obstruction  and  the  presence  or  absence  of  infection.  An  organ  or  a  part 
of  an  organ  may  exhibit  functional  aberration.  The  local  signs  in  a  vessel 
accessible  to  touch  or  sight  are  the  presence  of  a  clot;  if  it  be  in  an  artery, 
anemia  and  the  absence  of  pulse  below  the  clot;  if  it  be  a  vein,  sweUing  and 
edema  below  it.  There  is  usually  pain  at  the  seat  of  trouble,  and  anesthesia 
below  it.  Moist  gangrene  may  follow  venous  thrombosis,  and  dry  gangrene, 
arterial  thrombosis.  Thrombosis  of  the  mesenteric  vein  is  followed  by  gan- 
grene of  the  bowel.  Infective  thrombophlebitis  is  a  spreading  inflammation 
of  a  vein.  A  septic  thrombus  forms  and  the  condition  is  an  early  step  in 
pyemia.  We  see  this  condition  sometimes  in  the  lateral  sinus  of  the  brain  as  a 
result  of  suppuration  in  the  middle  ear ;  in  any  of  the  cerebral  sinuses  after  in- 
fected compound  fracture  of  the  skull ;  and  in  the  uterine  veins  during  puerperal 
sepsis.  Portal  pyemia  results  from  thrombophlebitis  of  branches  of  origin  of 
the  portal  system  (see  page  1036).  Thrombo-arteritis  is  a  spreading  inflamma- 
tion of  an  artery  in  which  a  septic  thrombus  forms  or  in  which  a  septic  embolus 
lodges.  It  occasionaUy  attacks  an  aneurysmal  sac.  In  infectious  thrombo- 
phlebitis and  in  arterial  pyemia  the  symptoms  are,  of  course,  those  of  pyemia. 
A  great  danger  of  thrombosis  is  embolism,  especially  pulmonary  embolism. 
Infective  Thrombosis  of  the  Lateral  Sinus. — (See  page  805.) 
Thrombosis  of  the  Jugular  Vein. — This  condition  is  usually  infectious  and 


General  Symptoms  of  Thrombosis  187 

secondary  to  infectious  thrombosis  of  the  lateral  sinus  or  sometimes  of  the 
petrosal  sinus.  It  is  occasionally  due  to  cancer,  tuberculosis,  acute  rheu- 
matism, or  pyemia,  taking  origin  from  a  distant  focus.  If  it  is  infectious,  the 
chills,  the  high  and  fluctuating  temperature,  and  the  great  exhaustion  pro- 
claim the  existence  of  pyemia.  Locally  the  vein  feels  hard,  the  adjacent  tissues 
are  edematous,  the  branches  of  the  jugular  are  visibly  distended,  there  may 
be  linear  discoloration  over  the  course  of  the  jugular,  and  the  head  is  held 
stiffly  with  an  inclination  to  the  diseased  side. 

thrombosis  of  the  Mesenteric  Vessels  (see  page  988). — The  arteries  are 
affected  much  more  commonly  than  the  veins,  and  the  superior  mesenteric 
artery  far  more  often  than  the  inferior.  Vascular  disease  is  the  cause  of  arte- 
rial thrombosis,  and  arterial  thrombosis  occurs  chiefly  in  those  beyond  middle 
life.  Venous  thrombosis  may  be  primary  and  has  been  observed  after  splen- 
ectomy, the  clot  having  propagated  to  the  mesenteric  veins.  It  may  occur 
as  a  result  of  any  gastro-intestinal  or  general  infection  (pyemia,  appendicitis, 
typhoid  fever).  Secondary  venous  thrombosis  is  due  to  portal  obstruction  or 
accompanies  arterial  mesenteric  thrombosis. 

Mesenteric  thrombosis  usually  produces  sooner  or  later  gangrene  of  the 
gut,  but  does  not  always  do  so. 

The  period  at  which  gangrene  develops  after  blocking  is  uncertain;  it 
mav  arise  in  thirty-six  hours,  it  may  not  arise  for  two  weeks  or  more.  The  gut 
becomes  distended,  bloody  serum  exudes  into  the  peritoneal  cavity,  and  in 
most  cases  into  the  lumen  of  the  bowel.  The  mucous  membrane  undergoes 
necrosis  and  perforation  occurs.  The  area  involved  varies  greatly  in  differ- 
ent cases.  In  some  cases  it  is  very  limited,  and  is  rather  apt  to  be  in  the  large 
intestine.  In  other  cases  it  is  very  extensive,  and  is  apt  to  be  in  the  small 
intestine.  In  a  case  of  the  author's  ui  the  Jefferson  College  Hospital  prac- 
tically the  entire  ileum  w^as  gangrenous  and  numerous  perforations  existed. 

In  mesenteric  thrombosis  pain  arises  rather  suddenly  and  rapidly  becomes 
severe.  It  is  a  persistent  pain  wdth  paroxysmal  exacerbations  and  is  usually 
generalized,  though  in  many  cases  it  has  an  area  of  peculiar  intensity.  The 
pain  is  accompanied  by  rapid  pulse,  growing  exhaustion,  distention,  subnormal 
temperature,  tenderness,  a  mass  appreciable  by  palpation  in  the  region  of  the 
mesentery,  free  fluid  in  the  peritoneal  cavity,  nausea,  and  vomiting.  The 
condition  suggests  intestinal  obstruction.  The  vomited  matter  consists  first 
of  the  contents  of  the  stomach,  then  of  bile,  finally  becomes  stercoraceous, 
and  sometimes  contains  blood. 

In  nearly  one-half  of  aU  cases  blood  in  considerable  quantity  passes  from 
the  rectum. 

BaUance  points  out  that  cardiac  disease  or  arterial  degeneration  suggests 
the  artery  as  the  seat  of  thrombosis. 

The  only  chance  for  recovery  without  operation  is  the  estabHshment  of 
the  coUateral  circulation,  and  as  the  superior  mesenteric  vessels  are  terminal 
vessels  this  seldom  occurs  (in  only  about  5  per  cent,  of  cases).  (See  Intestinal 
Obstruction  from  Mesenteric  Thrombosis.) 

Iliac  Thrombosis  After  Abdominal  Operations. — This  compKcation  is  occa- 
sionally encoimtered  and  is  most  often  met  with  in  the  left  side,  even  when 
the  operation  was  in  the  middle  line  or  the  right  side.  It  is  a  rare  complica- 
tion, occurring,  according  to  Professor  Clark,  35  times  in  a  series  of  3000 
operations. 

Many  explanations  have  been  given  of  it.  A  great  many  surgeons  regard  it 
as  infectious,  but  many  cases  certainly  are  not.  Clark  believes  it  is  due  to  injury 
of  the  deep  epigastric  vein,  forcible  and  prolonged  separation  of  the  woimd 
edges  by  retractors  being  a  common  cause.  The  free  anastomosis  between 
the  epigastric  veins  of  the  two  sides  accounts  for  the  appearance  of  thrombosis 


i88  Thrombosis  and  Embolism 

on  one  side  after  operation  on  the  other.  It  is  probable  that  in  many  slight 
cases  the  condition  is  not  recognized,  and  it  will  not  be  recognized  unless  the 
clot  reaches  the  femoral  vein,  and  it  requires  one  or  two  weeks  to  reach  this 
vein  if  it  does  reach  it  at  all.  When  a  clot  forms  in  the  femoral  vein  a  milk- 
leg  develops.  The  entire  extremity  swells  below  the  seat  of  thrombus,  the 
temperature  is  usually  normal,  but  may  be  distinctly  elevated. 

Thrombosis  in  General  Infections. — In  typhoid  fever  a  thrombus  may  form 
in  the  heart,  the  veins,  or  the  arteries.  Thrombosis  may  occur  in  pneumonia, 
in  influenza  and  in  gther  fevers,  and  in  tuberculosis.  The  vessels  of  a  limb,  a 
lung,  the  brain,  or  the  mesenteric  zone  may  suffer.  The  condition  follows  bac- 
terial infection,  the  veins  are  most  prone  to  suffer  and  gangrene  may  ensue. 

Thrombosis  in  Appendicitis. — In  about  2  per  cent,  of  cases,  according  to 
Sonnenberg,  this  complication  is  noted.  It  may  affect  the  femoral  or  saphenous 
vein  of  either  side  or  of  both  sides,  the  portal  vein  or  the  vena  cava,  and  may 
occur  diu"ing  an  acute  attack,  but  is  more  often  noted  in  an  interval. 

It  is  not  very  unusual  to  find  liver  abscess  follow  appendicitis,  the  in- 
fection being  carried  by  the  portal  vein  and  the  condition  being  known  as 
septic  pylephlebitis  (see  page  1036). 

Treatment. — If  an  aseptic  thrombus  forms  in  a  large  vessel  of  a  limb,  raise 
the  limb  a  few  inches  from  the  bed,  keep  it  perfectly  quiet  to  avoid  detachment 
of  fragments  (emboli),  apply  a  bandage  lightly  from  the  toes  up,  and  place  bags 
of  warm  water  about  the  extremity.  Maintain  rest  for  four  or  five  weeks.  The 
great  danger  is  the  formation  of  emboli,  hence  movements  and  rough  handling 
are  to  be  avoided.  Gangrene  is  another  danger,  hence  it  is  wise  to  favor  venous 
return  and  the  development  of  the  collateral  circulation  by  warmth,  elevation, 
and  bandaging.  In  infectious  thrombophlebitis,  if  the  vessel  is  accessible,  tie 
it  above  and  below  the  clot,  open  the  vessel,  remove  the  clot,  irrigate,  and  pack 
the  woimd  with  iodoform  gauze.  The  general  treatment  for  a  septic  condi- 
tion should  be  stimulating  and  supporting.  Massage  is  unsafe  in  any  con- 
dition of  thrombosis,  and  is  particularly  dangerous  in  septic  thrombosis.  In 
thrombo-arteritis  treat  as  in  the  thrombophlebitis.  If  gangrene  of  an  extremity 
follows  thrombosis,  treat  as  previously  directed  (see  page  164).  Gangrene 
of  the  intestine  in  mesenteric  thrombosis  if  not  too  extensive  is  treated  by 
resection. 

The  treatment  of  infective  thrombosis  of  the  lateral  sinus  is  set  forth  on 
page  806. 

Embolism  signifies  vascular  plugging  by  a  foreign  body  (usually  a  blood- 
clot)  which  has  been  brought  from  a  distance.  The  foreign  body  is  called  an 
embolus.  An  embolus  usually  consists  of  a  separated  or  ruptured  portion  of  a 
thrombus,  atheromatous  material  from  a  diseased  artery,  or  a  bit  of  fibrin 
from  a  diseased  heart-valve.  In  some  cases  an  embolus  consists  of  bacteria, 
of  air,  of  fat,  of  a  fragment  of  a  timior,  or  of  parasites.  In  severe  burns  the  blood 
undergoes  changes  and  jelly-like  matter  is  often  precipitated  and  may  cause 
embolism.  Emboli  vary  in  shape,  in  size,  and  in  consistency.  Emboli  are 
divided  into  simple,  bland  or  aseptic  and  infections,  toxic  or  septic.  Emboli  may 
arise  either  in  the  venous  or  in  the  arterial  system,  but  are  particularly  prone  to 
arise  in  the  veins;  they  lodge  in  an  artery,  in  capillaries,  or  in  the  veins  of  the 
liver.  An  embolus  taking  origin  in  one  of  the  systemic  veins  passes  through 
the  right  heart  and  lodges  in  a  terminal  branch  of  the  pulmonary  artery.  If 
at  this  point  it  disintegrates,  smaller  emboli  pass  to  the  left  heart  and  enter 
the  arterial  circulation  to  be  deposited,  as  are  emboli  originating  in  the  heart 
or  arteries,  in  the  arteries  of  an  extermity,  the  kidneys,  spleen,  or  brain.  Em- 
boli of  the  portal  circulation  lodge  in  the  liver  or  perhaps  pass  through  that 
organ  and  reach  the  Itmgs.  An  embolus  is  arrested  when  it  reaches  a  vessel  the 
diameter  of  which  is  less  than  its  own.    It  is  usually  caught  just  above  a  bifur- 


General  Symptoms  of  Embolism 


189 


cation.  WTien  an  embolus  lodges,  it  at  once  partially  or  entirely  obstructs  the 
circulation  and  increases  in  size  by  thrombosis.  Figure  97  shows  an  impacted 
embolus.  A  non-septic  embolus  when  lodged  usually  "organizes,"  as  does  a 
thrombus,  and,  as  described  on  page  185,  is  replaced  ultimately  by  fibrous 
tissue.  A  soft  embolus  may  disintegrate  and  permit  the  re-establishment  of 
the  circiilation.  An  embolus  may  cause  an  aneurysm.  A  septic  embolus  breaks 
down,  forms  a  metastatic  abscess,  and  sends  other  emboli  onward  in  the  blood- 
stream. 

An  embolus  is  more  serious  than  a  thrombus:  it  causes  sudden  plug- 
ging, which  makes  dangerous  anemia  inevitable,  and  it  will  produce  gan- 
grene if  the  collateral  circulation  fails.  Embolism  of  the  mesenteric  artery 
causes  necrosis  of  the  intestine.  In  organs  A\'ith  terminal  arteries  (spleen, 
kidney,  brain,  and  lung)  there  is  no  collateral  circulation  and  embolism  causes 
infarction.  For  instance,  if  an  embolus  lodges  in  the  lung  it  produces  an  area 
of  ischemia;  the  removal  of  all  propulsion  upon  the  venous  blood  causes  it  to 
flow  back  and  stagnate,  and  vascular  elements  exude  and  form  a  wedge-shaped 
area  of  red  tissue,  the  embolus  being  the  apex  of  the  wedge.  This  is  known  as 
hemorrhagic  or  red  infarction,  and  is  often  seen  in  the  lung  (Fig.  98).     The 


Fig.  gy. — Embolus  impacted  at  bifurcatioa  of  a 
branch  of  the  pulmonan-  arter\-  (Green). 


Fig.  gS. — Diagram  of  a  hemorrhagic  infarct:  a. 
Artery  obUterated  by  an  embolus  (e) ;  v,  vein  filled 
with  a  secondary  thrombus  (Jh);  i,  center  of  in- 
farct, which  is  becoming  disintegrated;  2,  area  of 
extravasation;  3,  area  of  collaterall  hyperemia 
(O.   Weber). 


white  infarction,  seen  in  the  brain  and  kidney,  is  not  due  to  retrogression  of 
venous  blood,  but  is  due  to  ischemia  and  resulting  coagulation-necrosis.  A 
septic  embolus  causes  septic  thrombosis  and  a  septic  infarction,  and  a  septic 
infarction  is  followed  by  suppuration  and  the  production  of  a  pyemic  abscess. 
That  emboli  of  the  systemic  venous  circulation  usually  lodge  in  the  lungs  ex- 
plains the  occurrence  of  pulmonarv'  embolism  after  certain  operations  upon 
and  during  certain  diseases  of  the  regions  drained  by  the  systemic  veins. 
Emboli  formed  in  vessels  of  the  systemic  circulation  lodge  most  often  in  the 
lungs,  brain,  kidney,  or  spleen.  It  is  because  emboli  which  pass  into  the  portal 
vein  lodge  in  the  liver  that  operations  upon  the  rectum  may  be  followed  by 
hepatic  embolism  and  abscess  of  the  liver. 

General  Symptoms.— The  s\Tnptoms  depend  upon  the  organ  involved 
and  the  presence  or  absence  of  infection.  They  are  sudden  in  onset,  and 
are  due  to  loss  of  fimction,  which  may  be  permanent  or  which  may  be  fol- 
lowed by  inflammation,  softening,  or  gangrene.  In  a  septic  embolus  there 
are  symptoms  of  infection  and  abscess  forms  at  the  seat  of  lodgment.  In 
the  course  of  pyemia  a  chill  usually  means  the  occurrence  of  embolism.  Em- 
bolism of  the  cerebral  arteries  may  cause  aphasia,  paralysis,  or  coma.  Embo- 
lism of  the  pulmonary  artery  may  cause  almost  instant  death.    Embolism  of 


igo  Thrombosis  and  Embolism 

a  large  artery  of  a  limb  produces  symptoms  similar  to  those  of  thrombus,  ex- 
cept more  sudden  and  decided.  Below  the  obstruction  the  pulse  is  absent  and 
the  limb  is  swollen  with  edema,  is  cold,  and  is  discolored.  There  is  pain  at 
the  seat  of  obstruction.  This  condition  is  frequently  followed  by  gangrene. 
Embolism  of  the  superior  mesenteric  artery  produces  symptoms  similar  to 
those  caused  by  acute  intestinal  obstruction,  and  results  in  gangrene  of  a 
portion  of  the  intestine. 

Pulmonary  Embolism. — This  condition  occasionally  follows  operations 
and  injuries  and  sometimes  develops  during  certain  diseases.  I  have  seen  a 
case  after  an  operation  for  appendicitis,  a  case  after  an  operation  for  varicocele, 
a  case  after  an  operation  for  hydrocele,  a  case  after  operation  for  perforated 
duodenal  ulcer,  a  case  after  gastrostomy,  and  a  case  in  a  man  with  a  large 
lumbar  contusion  to  which  massage  was  injudiciously  applied.  It  is  not  very 
common.  Albanus  ("Beitrage  klin.  Chir.,"  xl)  in  1140  abdominal  operations 
found  23  cases.  The  emboli  may  be  aseptic  or  septic.  The  condition  is  most 
common  as  a  result  of  thrombosis  of  the  veins  of  the  lower  extremities,  appendi- 
citis, and  strangulated  hernia.  Certain  postoperative  pneumonias  are  embolic. 
Very  small  aseptic  emboli  may  cause  no  symptoms  or  slight  symptoms.  When 
aseptic  hemorrhagic  infarction  occurs  there  are  symptoms.  These  symptoms 
are  a  chill  or  chilly  sensations,  moderate  fever  which  may  be  transitory, 
dyspnea,  rapid  pulse,  pain  in  the  chest,  sometimes  rapidly  advancing  signs  of 
consoHdation,  often  a  pleural  friction  sound,  and  bloody  expectoration.  Some- 
times immediate  death  occurs.  The  mortality  is  always  large  (80  per  cent.). 
I  am  satisfied  that  it  is  a  much  more  common  condition  than  we  formerly 
supposed,  and  that  some  cases  in  which  the  emboli  are  very  small  are  not 
diagnosticated  and  recover. 

A  septic  embolism  causes  metastatic  abscess  and  usually  suppurating 
pleuritis,  the  condition  being  known  as  septic  embolic  pneumonia.  Recovery 
is  rare,  but  occasionally  occurs.  The  symptoms  are  those  of  pyemia  with  the 
physical  signs  of  consolidation  and  of  pleuritis. 

Embolism  of  the  Mesenteric  Arteries. — The  superior  mesenteric  is  the 
vessel  usually  affected.  It  may  arise  in  pyemia,  septicemia,  arterial  or  cardiac 
disease.  The  symptoms  are  practically  identical  with  thrombosis  of  the 
mesenteric  vessels,  except  they  arise  suddenly.  There  is  usually  endo- 
cardial disease  (see  page  983). 

Treatment. — Murphy  removed  an  embolus  of  the  femoral  and  iliac  arte- 
ries through  an  incision  of  the  femoral,  and  then  sutured  the  incision 
("Jour.  Amer.  Med.  Assoc,"  May  22,  1909).  The  operation  was  too  late  to 
prevent  gangrene,  but  it  emphasizes  the  truth  that  an  aseptic  embolism  of  a 
large  artery  can  be  treated  by  incision  of  the  artery,  removal  of  the  clot, 
and  suture  of  the  vessel.  The  treatment  long  in  vogue  was  as  follows:  In  a 
limb,  keep  the  part  warm  in  order  to  stimulate  the  collateral  circulation,  ele- 
vate the  extremity  several  inches  from  the  bed,  apply  a  bandage  lightly  from 
the  periphery,  and  insist  on  perfect  quiet.  Massage  is  unsafe.  If  gangrene 
ensues,  await  a  line  of  demarcation  and,  when  it  forms,  amputate.  In  septic 
embolic  arteritis  in  an  accessible  region  it  would  be  good  surgery  to  act  as  in 
septic  thrombophlebitis.  After  an  operation  upon  veins  (as  the  operation  for 
varicocele,  for  varix  of  the  leg,  or  for  hemorrhoids),  after  any  cutting  operation, 
and  after  the  infliction  of  a  fracture,  avoid  as  much  as  possible  and  for  some 
time  movements  or  handling,  as  fragments  of  thrombus  may  be  detached. 

In  mesenteric  embolism  exploratory  laparotomy  may  disclose  a  perfora- 
tion which  can  be  closed  or  a  portion  of  gangrenous  gut  which  can  be  resected. 

In  aseptic  pulmonary  embolism  enforce  absolute  rest,  give  strychnin  and 
morphin  hypodermatically,  and  inhalations  of  oxygen.  Trendelenburg  has 
suggested  operation  for  occluding  pulmonary  embolism  (see  page  900). 


Fat-embolism 


191 


In  septic  embolic  pneumonia  pursue  the  conservative  plan  of  treatment 
unless  a  large  pulmonan,-  abscess  forms  or  an  empyema  arises.  In  either  case 
operate  to  remove  pus. 

Fat=emboIism  in  the  human  being  was  lirst  noted  by  ^lacGibbon.  of  Xew 
Orleans,  in  1S56.  and  was  hrst  thoroughly  described  by  von  Recklinghausen  in 
1SS4,  although  Magendie.  in  1827,  and  Virchow.  in  1856,  developed  it  experi- 
mentally in  animals.  It  is  a  process  which  leads  to  an  accumulation  in  the 
capillaries  of  Hquid  fat  after  injury-  to  adipose  tissue,  high  tension  ha^'ing 
forced  the  fat  into  the  open  mouths  of  veins.  Fat  may  be  forced  into  open 
veins  by  muscular  action,  by  efforts  at  repair,  or  by  concealed  bleeding.  Fat 
may  get  into  the  blood  by  means  of  the  hTnphatics  and  it  can  also  enter  by  way 
of  the  s>-no\dal  membrane.  Wilms  beUeves  that  fat  reaches  the  veins  by  way 
of  the  hmiphatics  and  the  thoracic  duct.  Fat  in  the  blood  is  quite  a  common 
condition,  but  seldom  produces  serious  trouble,  although  it  is  occasionally  fatal 
and  is  responsible  for  some  otherwise  inexplicable  sudden  deaths  after  fractures. 
Fat-embolism  may  arise  during  osteomyelitis,  after  extensive  bruises,  crushes, 
lacerations,  amputations,  fractures,  resections,  or  rupture  of  the  liver.-  In  a 
fatal  case  of  mine  it  developed  as  a 

result  of  manipulation  of  a  fracture  ^  _   _      _ 

of  the  neck  of  the  femur.      In  an-  ~^ 

other  fatal  case  it  followed  amputa- 
tion for  cancer  of  the  breast  of  a 
ver\-  fat  woman.  This  fluid  fat  ac- 
cumulates especially  in  the  capil- 
laries of  the  limgs  and  brain.  It 
may  plug  systemic  capiQaries.  If 
the  patient  recovers,  he  does  so  be- 
cause the  fat  has  been  forced  through 
the  vessels;  if  he  dies,  the  death 
results  from  mechanical  hindrance 
to  function  and  nutrition.  "VMien 
the  emboli  are  widely  scattered  and 
not  large,  and  when  they  do  not  lodge 
in  vital  parts  of  the  brain  or  cord 
they  may  produce  no  s^Tuptoms  and 

and  do  no  real  harm.  Xormal  blood  contains  a  small  amount  of  finely  emulsified 
fat  (from  i  to  3  parts  per  1000).  In  a  number  of  physiological  and  pathological 
conditions  the  circulating  blood  contains  considerable  free  fat.  It  may  be  found 
in  a  pregnant  woman,  a  nursing  baby,  a  fat  indi\-idual.  or  in  anyone  during 
digestion.  "It  has  been  noted  in  the  foUo^Adng  conditions:  chronic  alcoholism; 
chabetes  meUitus:  certain  diseases  of  the  liver,  heart,  and  pancreas:  chronic 
nephritis:  splenitis,  tuberculosis:  malarial  fever,  t^-phus  fever:  Asiatic  cholera, 
and  poisoning  by  phosphorus  and  by  carbon  monoxid.  Lipemia  commonly 
occurs  as  the  result  of  lacerated  wounds  of  the  blood-vessels  situated  in  fatt\' 
tissue,  and  after  fractures  of  long  bones  invohdng  injm^*  of  the  fatty  matter'' 
('■'CKnical  Hematology-,"  by  John  C.  DaCosta,  Jr.l.  In  many  cases  of  fracture 
in  adults  fat  is  foimd  in  the  urine.  I  have  had  this  demonstrated  by  repeated 
obsen.-ations.  \Mien  we  recall  how  rarely  simple  fracture  causes  death  it 
becomes  e^•ident  that  a  moderate  amoimt  of  fat  in  the  blood  is  not  dangerous 
or  only  becomes  dangerous  if  it  fails  to  flow  out.  In  Hpemia  fatt\-  embolism 
may  occur  if  the  amount  of  fat  becomes  excessive  or  if  vascular  damage  favors 
plugging.  At  my  suggestion,  Dr.  Wm.  Carrington  conducted  an  investigation 
to  determine  the  frequency  of  lipuria  after  fractures  (Essay  Awarded  the  Siu"- 
gical  Prize  in  Jefferson  ]\Iedical  College  in  igo8\  He  determined  that  fractiu-e 
^  G.  H.  Makins,  in  "  Heath's  Dictionary-.'' 


Fig.  gg. — Fat-embolism  of  the  lung  after  fractiire 
of  tlie  femur.  The  fat-globules  and  masses,  stained 
black  with  osmic  add,  lie  in  the  capillaries  of  the 
lung:  X  150  'Hektoen). 


ig2  Thrombosis  and  Embolism 

of  long  bones  invariably  causes  lipuria,  fracture  of  small  bones  seldom  does ;  that 
after  fracture  of  a  long  bone  fat  appears  in  the  urine  "on  different  days,  in  dif- 
ferent amounts,  and  in  different  forms"  (this  curious  periodicity  was  first 
observed  by  Scriba  in  1878) ;  that  when  fat  is  present  albumin  is  almost  always 
present  and  blood  is  occasionally  foimd;  that  the  urea  percentage  falls  as  the 
fat  content  rises  and  rises  as  the  fat  content  falls;  that  the  condition  is  rare 
in  young  children  and  that  fat-embohsm,  as  a  rule,  is  a  benign  process;  that 
about  the  fifteenth  day  after  a  fracture  fat  usually  disappears  from  the  urine. 
Carrington,  in  1908,  found  in  hterature  276  reported  cases  of  fat-embolism. 

Symptoms  arise  only  when  many  emboli  block  a  multitude  of  the  capillaries 
of  an  organ,  when  a  large  embolism  lodges,  or  when  the  capillaries  of  a  vital 
region  of  the  brain  are  blocked  (the  medullary  centers).  Emboli  are  most  apt  to 
form  after  or  during  handling  of  the  wound  or  seat  of  injury  or  exhausting 
movement  of  the  patient.  Hence  one  peril  of  transportation  after  an  accident, 
of  early  massage,  of  frequent  changes  of  dressings,  and  of  too  early  getting  up 
after  operation  (Groendahl,  "Deut.  Zeitsch.  f.  Chir.,"  1911,  cxi).  The  symp- 
toms are  those  of  edema  of  the  lungs  and  exhaustion,  often  with  coma  or  delir- 
ium, and  sometimes,  in  the  beginning,  are  wrongly  thought  to  be  due  to  shock. 
There  are  restlessness,  dyspnea,  rapid  and  weakening  pulse  and  rapid  respira- 
tion, contracted  pupils,  and  pallor  followed  by  cyanosis.  The  temperature 
may  be  elevated,  normal,  or  subnormal.  Many  coarse  rales  are  heard  in  the 
chest,  but  percussion  gives  a  clear  note.  If  pulmonary  edema  becomes  marked, 
the  patient  spits  up  a  bloody  froth.  If  hfe  is  prolonged  a  day  or  two,  oil  is 
found  in  the  urine.  Small  amounts  of  oil  may  be  found  in  the  urine  after 
serious  injuries  or  operations  when  no  symptoms  of  embolism  exist.  Never- 
theless, the  presence  of  the  oil  is  always  a  cause  of  anxiety  and  is  often  a  warn- 
ing. It  is  maintamed  by  Groube  that  the  amount  of  fat  in  the  urine  is  in  inverse 
ratio  to  the  amount  in  the  blood;  the  greater  the  amount  excreted  in  the  urine, 
the  less  the  amount  retained  in  the  blood.  Hence,  fat  in  the  urine  makes  the 
surgeon  anxious,  and  a  sudden  diminution  of  the  amount  in  the  urine  is  a  sign 
of  grave  danger  if  there  develops  increasing  difficulty  in  respiration  ("Rev.  de 
Chir.,"  July,  1895) .  The  inverse  ratio  said  to  be  maintained  between  fat  in  the 
blood  and  fat  in  the  urine,  if  it  really  exists,  is  similar  to  a  finding  of  Lepine  in 
diabetes,  that  is,  if  a  diabetic  is  given  diuretics,  the  sugar  in  the  urine  increases 
and  the  sugar  in  the  blood  decreases.  The  symptoms  of  fat-embolism  seldom 
occur  until  at  least  twelve  hours  after  an  accident,  and  rarely  before  the  third 
day,  but  may  occur  as  early  as  three  hours.  The  symptoms  occur  at  a  later 
period  than  those  of  shock  and  at  an  earlier  period  than  those  of  ordinary  embo- 
hsm  of  the  lung.  The  important  point  emphasized  by  Carrington  is  that  after 
the  reaction  from  shock,  if  there  were  shock,  and  for  hours  or  days  after  the 
injury  in  any  case,  there  is  a  period  of  freedom  from  all  alarming  symptoms, 
and  that  the  symptoms  of  f  at-emboUsm  come  on  suddenly  and  without  warning. 
If  some  of  the  oil  is  forced  through  the  vessels  of  the  lung,  it  will  lodge  in  other 
regions  and  produce  other  symptoms.  Oil  may  appear  in  the  urine  as  above 
stated.  Urinary  suppression  may  occur.  Dehrium  may  arise,  there  may  be 
twitching,  convulsions  or  paralysis,  or  the  patient  may  pass  into  coma.  The 
eye-ground  may  show  choked  disk,  hemorrhage,  and  fat  in  the  vessels  (Con- 
nel's  case  and  Czerny's  case).  Cases  of  fat-embohsm  with  severe  symptoms 
are  commonly  fatal;  milder  cases  are  often  recovered  from.  In  mild  cases  the 
symptoms  last  but  a  few  days,  in  severe  cases  the  condition  may  prove  fatal 
in  from  a  few  hours  to  seven  days  after  the  injury,  and  in  from  a  few  to 
forty-eight  hours  after  the  appearance  of  S3nnptoms.  A  patient  may  have  two 
or  three  attacks,  Connel's  patient  had  three  attacks,  there  being  an  interval 
of  a  week  between  the  first  and  second  and  between  the  second  and  third 
attacks. 


Treatment  of  Air-embolism  193 

Treatment. — Wilms,  acting  on  his  belief  that  fat  enters  the  lymphatic  duct 
and  from  there  gets  into  the  venous  circulation,  treated  one  case  of  fat-embol- 
ism successfully  by  making  a  fistula  in  the  thoracic  duct.  This  operation  might 
be  justifiable  when  dangerous  brain  S}Tnptoms  are  knowm  to  be  due  to  fat- 
emboli.  The  usual  treatment  consists  in  absolute  rest  of  the  diseased  or  injured 
part  and  the  administration  of  stimulants,  such  as  str^-chnin,  alcohol,  and 
carbonate  of  ammonium,  the  use  of  external  heat;  the  emplo^mient  of  oxy-gen 
by  inhalation,  and  the  administration  of  diuretics  and  of  nitroglycerin  h\-po- 
dermatically.  Artificial  respiration  may  tide  a  patient  over  a  crisis.  If  an  exter- 
nal wound  exists,  free  drainage  must  be  established,  and  the  diseased  or  damaged 
part  should  be  thoroughly  immobilized  if  possible.  In  order  to  prevent  fat- 
embolism  after  a  severe  injury-  insist  on  rest.  ^Massage  used  early  after  some 
injuries  is  dangerous,  as  it  may  force  fluid  fat  into  the  vessels.  Ver\-  early 
getting  up  after  operation  is  not  safe.  Frequent  changes  of  dressings  are  im.- 
desirable.  \\Tien  severe  contusion  causes  the  formation  of  a  large  ca^ity  filled 
vrith  blood.  Groube  wisely  ad^•ise3  incision  to  lessen  the  danger  of  fat-embohsm.^ 

Air=embolism. — ^Air  may  enter  a  vein  during  a  surgical  operation  or  it 
may  be  injected  accidentally  while  gi\"ing  a  hypodermatic  injection,  h}po- 
dermoclysis,  or  a  saline  infusion  into  a  vein.  It  may  follow  irrigation  of  the 
pleura  v^-ith  hydrogen  peroxid.  In  caisson  disease  it  is  taught  by  some  that 
nitrogen  is  set  free  in  the  blood.  It  may  occur  when  a  cerebral  sinus  is  opened, 
or  in  the  uterine  veins,  if  the  uterus  does  not  remain  contracted  after  deliver}". 
It  is  ver\^  seldom  that  any  s^Tnptoms  follow.  It  was  long  thought  that  such 
an  accident  must  be  always  extremely  dangerous.  The  experiments  of  my  col- 
league, Professor  Hare,  indicate  that  quantities  of  air  may  be  injected  into  the 
veins  of  a  dog  "without  apparent  harm.  The  entr\'  of  a  small  amount  of  air  into 
the  veins  of  a  human  being  "^"ill  not  be  apt  to  induce  dangerous  5}"mptoms. 
but  it  may  be  fatal.  The  more  rapidly  it  is  introduced  and  the  greater  the 
amount,  the  greater  is  the  danger.  The  manner  m  which  it  can  uiduce  death 
is  doubtful.  Some  maintain  that  it  causes  blood  in  the  right  side  of  the  heart 
to  froth,  and  thus  prevents  normal  action  of  the  valves,  the  heart  becoming 
imable  to  propel  blood  through  the  lungs.  Others  maintain  that  air  reaches 
the  cerebral  capillaries  and  so  causes  cerebral  anemia.  Some  believe  cardiac 
failure  results  from  the  presence  of  air  in  the  pulmonary-  capillaries.  The 
fi.rst  \-iew  is  the  most  probable.  If  a  surgeon  di\-ides  a  large  vein,  air  may  be 
sucked  in,  and  there  is  particular  danger  in  such  an  accident  if  a  vein  at  the 
root  of  the  neck  or  a  cerebral  sinus  is  torn  or  incised,  or  if  the  damaged  vessel 
lies  in  scar  tissue  and  cannot  coUapse. 

Symptoms. — \Mien  during  an  operation  air  enters  a  large  vein  there  is 
a  sucking  soimd,  air-bubbles  may  be  noted  in  the  woimd,  and  serious  s\Tiip- 
toms  may  or  may  not  follow.  Twice  I  have  wounded  the  subcla\'ian  vein  and 
have  heard  this  sound,  but  no  alarming  s^inptoms  developed.  If  serious 
s\TQptoms  are  produced,  they  arise  suddenly,  and  consist  of  extreme  failure 
of  circulation,  a  curious  whirring  or  churning  sound  on  cardiac  systole  audible 
even  without  a  stethoscope,  deadly  pallor  or  cyanosis,  gasping  for  air,  con-vul- 
sions,  and  possibly  death. 

Treatment. — Compress  the  vein  with  the  finger  and  clamp  it  quickly. 
Suspend  the  anesthetic,  lower  the  head,  employ  artificial  respiration,  give 
inhalations  of  oxygen,  h\-podermatic  injections  of  str\xhnin,  and  intravenous 
infusion  of  normal  salt  and  adrenalin. 

1  "Rev.  de  Chir./'  July,  1S95. 


13 


194  Septicemia  and  Pyemia 


X.  SEPTICEMIA   AND    PYEMIA 

Septicemia,  or  sepsis,  is  a  febrile  malady  due  to  the  introduction  into 
the  blood  of  pyogenic  organisms  or  the  products  of  saprophytic  bacteria. 
There  is  no  one  special  causative  organism,  and  any  microbe  which  pro- 
duces inflammatory  and  febrile  products  may  cause  it.  Either  streptococci 
or  staphylococci  may  be  present.  Pneumococci  are  a  not  very  unusual  cause. 
Septicemia  arises  by  absorption  of  septic  matter  by  the  lymphatics.  Clin- 
ically, we  distinguish  two  forms  of  septicemia:  (i)  sapremia,  septic  or  putrid 
intoxication,  and  (2)  septic  infection,  true  or  progressive  septicemia.  In 
these  conditions  the  area  of  infection  is  usually  discovered  by  the  surgeon; 
but  when  it  cannot  be  located,  the  disease  is  called  by  the  Germans  crypto- 
genetic  septicemia. 

Sapremia,  Septic  or  Putrid  Intoxication. — This  condition  is  due  to  the 
absorption  of  poisonous  ptomains  from  a  putrefying  area.  The  bacteria 
do  not  enter  the  blood,  but  their  toxins  do,  and  as  these  toxins  are  active 
poisons  the  condition  is  comparable  to  poisoning  by  successive  alkaloidal 
injections,  the  symptoms  and  prognosis  depending  upon  the  dose.  Not 
unusually  there  is  absorption  not  only  of  the  toxins  of  saprophytic  bacteria, 
but  also  of  the  toxins  of  pyogenic  micro-organisms.  Even  if  some  of  the  bacte- 
ria enter  the  blood,  they  do  not  multiply  in  this  fluid.  Slight  symptoms 
and  recovery  follow  a  small  dose;  grave  symptoms  and  death  follow  a  large 
one.  The  poison  does  not  multiply  in  the  blood,  and  a  drop  of  the  blood  of 
a  person  laboring  under  putrid  intoxication  will  not  produce  the  disease  when 
introduced  into  the  blood  of  a  well  person;  in  other  words,  the  disease  is  not 
infective.  Considerable  putrid  material  must  be  absorbed  to  cause  sapremia. 
What  is  known  as  surgical  fever  is  due  to  the  absorption  of  a  small  amount 
of  putrid  or  fermented  wound  fluid,  and  is,  in  reality,  a  mild  form  of  sapremia. 
If  sapremia  arises,  it  does  so  soon  after  the  infliction  of  a  wound,  and  after  a 
large  rather  than  small  wound  when  a  considerable  amount  of  wound  fluid  is 
pent  up  under  pressure.  It  may  follow  labor  where  putrid  fluid  is  retained  in 
the  womb,  may  follow  an  injury  of  or  an  operation  upon  a  joint,  may  follow 
amputation  where  decomposing  blood-clot  or  wound  fluid  is  pent  up  within 
the  flaps,  or  may  ensue  upon  an  abdominal  operation  or  injury.  In  sapremia 
there  always  exist  a  considerable  absorbing  surface  and  a  large  amount  of 
dead  matter  which  has  become  putrid.  Roswell  Park^  points  out  that  sapre- 
mia arises  from  putrefaction  of  a  blood-clot  or  wound  fluids  which  are  retained 
like  foreign  bodies  in  the  tissues,  and  does  not  arise  from  putrefaction  of  the 
tissues  themselves.  He  speaks  of  the  condition  as  due  to  the  absorption  of 
poison  from  a  "putrid  suppository."  Sapremia  will  not  occur  after  granu- 
lations form.  The  term  "putrefaction"  is  used  because  this  is  the  usual 
change,  but  any  fermentative  organism  may  cause  the  disorder.  Sapremia 
is  a  malignant  form  of  surgical  fever,  and  its  existence  means  an  ill-drained 
wound,  and  a  fermenting  and  probably  putrid  collection  of  blood-clot  or  wound 
fluid. 

In  sapremia  there  is  congestion  of  the  stomach,  intestines,  and  other 
abdominal  viscera,  particularly  the  kidneys,  and  also  of  the  brain,  and  numbers 
of  red  blood-cells  disintegrate.  o 

Symptoms. — The  patient  often  seems  to  react  incompletely  from  the 
injury;  he  feels  miserable,  complains  of  headache,  nausea,  and  pain  in  the 
back  and  limbs;  or,  he  may  react  and  in  a  day  or  two  develop  this  condition 
of  malaise.  In  some  cases  an  aseptic  fever  is  directly  succeeded  by  sapremia. 
In  most  cases  of  sapremia,  between  twenty-four  hours  and  two  or  three  days 
^  "Treatise  on  Surgery  by  American  Authors." 


Septic  Infection,  or  True  Septicemia  195 

after  labor,  after  an  injury,  or  after  an  operation,  there  is  usually  a  chill  or  a 
chilly  sensation,  though  in  some  cases  this  is  wanting.  The  temperature 
rapidly  rises  to  103°  F.  or  even  more.  There  are  severe  headache,  dry  and 
coated  tongue,  rapid  and  weak  pulse,  nausea  and  often  vomiting,  diarrhea, 
great  prostration,  restlessness,  muscular  twitching,  and  active  delirium.  The 
woimd  is  found  to  be  foul,  and  sometimes  there  is  dr^-ing  up  of  wound  discharge. 
There  is  diminution  or  suppression  of  urine,  and  a  strong  tendency  to  conges- 
tion of  various  organs.  Jaundice  is  not  unusual.  Petechial  spots  are  frequently 
noticed  upon  the  skin.  They  occur  also  upon  mucous  membranes  and  serous 
surfaces,  and  result  from  the  plugging  of  small  vessels  with  detritus  of  broken- 
do^Ti  red  corpuscles  and  consequent  vascular  rupture.  Great  elevation  of 
temperature  often  precedes  death.  In  some  cases  the  dose  of  poison  is  so 
large  that  the  patient  passes  into  rapid  collapse  without  preliminary-  fever. 
Some  cases  recover  if  the  initial  dose  is  not  overvv^helming  and  if  additional 
doses  are  not  absorbed.  ^Slany  cases  die  of  exhaustion.  Some  become 
linked  with  fatal  pyemia  or  septicemia.  Hemoglobin  and  red  blood-corpus- 
cles are  rapidly  and  notably  diminished.  Distinct  leukocytosis  exists,  except 
in  those  cases  in  which  the  organism  is  ovem'helmed  with  the  poison  and 
is  unable  to  react.  Cover-glass  preparations  do  not  show  organisms  in  the 
blood,  and  cultures  from  the  blood  are  sterile. 

Treatment  consists  in  at  once  draining  and  asepticizing  the  putrid  area 
and  administering  ver\-  large  doses  of  alcohol  and  large  medicinal  doses  of 
str\'rhnin  and  digitalis.  The  patient  should  be  plugged  and  diaphoresis  favored. 
The  hot  bath  is  valuable  to  cause  sweating.  The  action  of  the  kidneys  must 
be  maintained  if  possible.  Purgatives,  diuretics,  and  diaphoretics  are  given 
to  aid  in  remo\'ing  the  toxin,  and  stimulants  are  used  to  sustain  the  strength 
of  the  patient  during  the  elimination  of  the  poison.  \"omiting  is  allayed  by 
champagne,  cracked  ice,  calomel,  cocain,  or  carbolic  acid  with  bismuth.  Food 
should  be  administered  ever}-  three  hours.  The  patient  is  fed  on  milk,  milk  and 
lime-water,  liquid  beef-peptonoids,  beef-juice,  and  other  concentrated  foods. 
Quinin  in  stimulant  doses  is  of  value.  Antip}T:etics  are  useless.  The  use  of 
saline  fluid  by  h}-podermoclysis  or  intravenous  infusion  dilutes  the  poison  and 
stimiilates  the  heart,  skin,  and  kidneys  to  acti\-ity.  Msceral  complications 
must  be  watched  for  and  should  be  promptly  treated  if  discovered.  Among 
the  possible  \-isceral  complications  are  nephritis,  cholecystitis,  enteritis,  hepa- 
titis, peritonitis,  pleuritis,  empyema,  bronchopneimionia,  pericarditis,  and 
endocarditis.     Antistreptococcic  serum  is  useless  in  sapremia. 

Septic  Infection,  or  True  Septicemia. — This  condition  is  a  true  infective 
process.  In  sapremia  the  blood  contains  toxins  of  putrefactive  bacteria, 
but  not  the  bacteria  themselves.  In  septic  infection  the  blood  contains 
both  pyogenic  toxins  and  multiph-ing  pyogenic  bacteria,  the  bacteria  per- 
haps being  free  in  the  blood  or  in  white  cells.  In  sapremia  the  causative 
condition  is  putrid  material  lodged  like  a  foreign  body  in  the  tissues.  In 
septic  infection  the  tissues  themselves  are  suppurating,  and  both  bacteria 
and  toxins  are  being  absorbed  by  the  h-mphatics.  Of  course,  septic  infection 
may  be  associated  with  septic  intoxication  or  may  follow  it.  In  suppurative 
fever  the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  absorbed,  and 
not  the  pyogenic  bacteria.  In  septic  infection  both  the  pyogenic  bacteria 
and  toxins  enter  the  blood,  and  the  bacteria  multiply  in  the  blood  and  pro- 
duce continually  increasing  amounts  of  poison.  The  s\-mptoms  of  sapremia 
depend  on  the  dose.  In  septic  infection  only  a  small  number  of  organisms 
may  get  into  the  blood,  but  they  multiply  enormously.  The  pus  microbes 
cause  true  septicemia,  and  reach  the  blood  chiefly  through  the  h-mphatics, 
but  to  some  degree  by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from 
a  man  with  septic  infection  wiU  reproduce  the  disease  when  injected  into  the 


196  Septicemia  and  Pyemia 

blood  of  an  animal;  hence  the  disease  is  truly  infective.  The  wound  in  such 
cases  is  often  small,  but  may  be  large,  and  is  commonly  punctured  or  lacerated, 
and  the  disease  begins  later  after  the  infliction  of  a  wound  than  does  sapre- 
mia.  No  wound  may  be  discoverable,  the  infection  having  arisen  from 
an  unrecognized  focus  of  suppuration — for  instance,  gonorrhea,  middle-ear 
disease,  dental  caries,  tonsillar  suppuration,  appendicitis,  etc.  The  initial 
atrium  of  infection  may  or  may  not  be  discovered. 

The  bacteria  which  exist  in  the  blood  and  organs  in  septicemia  are  usually 
staphylococci  or  streptococci,  often  both.  Pneumococci  or  colon  bacilli  in  some 
cases  are  causative.  The  blood  is  found  to  have  lost  much  of  its  coagulating 
power;  it  remains  fluid  for  some  time  after  death,  quantities  of  red  corpuscles 
are  destroyed,  and  minute  hemorrhages  take  place  in  the  brain,  mucous  mem- 
branes, skin,  serous  membranes,  muscles,  and  various  viscera.  There  may 
be  inflammation  of  synovial  and  serous  membranes.  There  is  congestion  of 
the  gastro-intestinal  tube  and  of  the  abdominal  viscera.  The  lymph-glands 
are  larger  than  normal  and  the  spleen  is  notably  enlarged.  The  wound  con- 
tains numbers  of  bacteria. 

Symptoms. — The  type  of  this  condition  is  met  with  in  puerperal  septicemia 
or  in  septicemia  from  an  infected  wound.  When  septicemia  arises  from  an 
infected  wound,  red  lines  due  to  lymphangitis  are  usually  seen  about  the 
wound,  and  there  is  enlargement  of  related  lymphatic  glands.  In  some  cases, 
however,  the  wound  and  the  parts  about  it  look  normal.  A  supposed  aseptic 
fever  after  an  injury  may  continue  for  an  undue  time  and  the  surgeon  may 
find  that  septicemia  has  developed.  Septicemia  may  arise  during  the  exist- 
ence or  after  the  abatement  of  sapremia,  or  may  arise  when  the  aseptic  fever 
has  passed  away  and  when  there  has  been  no  putrid  intoxication.  It  begins 
in  from  four  to  seven  days  after  labor  or  an  injury,  usually  with  a  chill,  which 
is  followed  by  fever,  at  first  moderate,  but  soon  becoming  high.  In  some 
cases  there  is  a  chilly  sensation,  but  no  distinct  chill.  There  is  always  great 
prostration  even  before  the  chill.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  intermission.  When 
the  remission  begins  there  is  a  copious  sweat.  As  the  case  progresses  the 
temperature  may  fluctuate,  and  it  often  rises  very  high  before  death.  The 
pulse  is  small,  weak,  very  frequent,  and  compressible.  The  tongue  is  dry 
and  brown,  with  a  red  tip.  Sordes  gather  on  the  teeth  and  gums.  Vomiting 
is  frequent,  and,  as  a  rule,  there  is  diarrhea.  Low  delirium  alternates  with 
stupor,  and  coma  is  usual  before  death.  The  great  prostration  is  a  noticeable 
and  characteristic  feature  of  the  sufferer  from  septicemia.  There  are  sub- 
sultiis  tendinmn  (twitching  of  the  muscles  of  the  hands  and  feet)  and  carpho- 
logia  (picking  at  the  bedclo thing) .  Toward  the  end  the  face  often  becomes 
Hippocratic  (hollow  temples,  pinched  nose,  sunken  eyes,  livid  skin,  lead-colored 
and  cold  ears,  and  relaxed  lips).  Visceral  congestions  occur.  The  spleen  is 
enlarged,  ecchymoses  and  petechise  are  noted,  urinary  secretion  becomes  scanty 
or  is  suppressed,  and  the  wound  becomes  dry  and  brown.  Blood  examination 
detects  a  rapid  and  great  diminution  in  red  corpuscles  and  hemoglobin.  The 
anemia  is  in  many  cases  profound.  There  is  marked  leukocytosis  except  when 
the  system  is  overwhelmed  by  the  poison.  Cover-glass  preparations  made  from 
blood  may  show  bacteria,  but  often  fail  to  do  so.  Cultures  from  the  blood 
are  sterile  in  most  cases,  but  not  in  all.  A  negative  finding  does  not  disprove 
the  existence  of  septic  infection;  a  positive  finding  is  of  conclusive  diagnostic 
value.  Pneumococcic  septicemia  is  extremely  violent  in  manifestation.  In 
some  cases  death  ensues  before  the  lung  has  consolidated.  If  it  is  not  so 
rapid,  endocarditis,  arthritis,  peritonitis,  meningitis,  or  osteomyelitis  may  de- 
velop. 

The  prognosis  of  true  septicemia  is  very  unfavorable,  and  in  some  malig- 


Pvemia 


197 


nant  cases  death  occurs  within  twenty-four  hours,  but  mild  cases  often  recover. 
Welch  points  out  that  finding  the  Staphylococcus  pyogenes  albus  in  the  blood 
is  not  particularly  ominous,  but  the  presence  of  other  pyogenic  cocci  is  exceed- 
ingly threatening.  Endocarditis,  pericarditis,  peritonitis,  pleuritis,  broncho- 
pneumonia, empyema,  nephritis,  arthritis,  cholecystitis,  hepatitis,  meningitis, 
and  pyehtis  are  among  the  complications  which  may  arise. 

Treatment  in  general  is  the  same  as  for  septic  intoxication.  Antistrepto- 
coccic serum  is  employed  by  some  surgeons,  but  the  value  of  this  method  is 
as  yet  doubtful.  It  does  not  do  any  harm.  It  may  do  good.  It  is  proper  to 
use  it.  but  not  to  the  exclusion  of  other  remedies.  The  usual  dose  is  10  c.c. 
injected  into  the  abdominal  wall.  The  injection  may  be  repeated  two,  three, 
or  even  six  times  a  day,  and  may  be  used  for  a  number  of  days.  Because 
of  uncertainty  as  to  the  causative  organisms  poh'^'alent  serum  is  used  by  some. 
Some  use  bacterial  vaccines.  Petre  has  injected  fresh  warm  horse-serum  to 
stimulate  leukocytosis.  Jayle  ('"La  Presse  medicale,"  1905,  p.  722)  and 
Federman  have  also  used  it.  All  sera  and  vaccines  are  as  yet  of  undetermined 
value  in  septic  infection.  Washing  the  blood  by  the  intravenous  infusion  of 
salt  solution  often  produces  distinct  improvement,  which,  unfortunately, 
is  usually  temporan.-.  Dr.  C.  C.  Barrows  commends  formalin  used  intra- 
venously. The  strength  of  the  solution  is  i  part  of  formalin  to  5000  parts  of 
salt  solution.  The  dose  is  500  c.c.  I  have  had  no  experience  with  formalin 
in  septicemia,  but  do  not  believe  that  any  reagent  can  be  safely  introduced 
which  would  rapidly  and  directly  kill  the  bacteria.  Even  if  such  an  agent  could 
be  found,  the  attempt  to  use  it  would  be  dangerous,  as  dead  bacteria  liberate 
a  poison,  and  the  rapid  death  of  immense  numbers  of  bacteria  would  mean  the 
entrance  into  the  blood  of  an  enormous  amount  of  toxic  matter. 

Pyemia  is  a  condition  in  which  metastatic  abscesses  arise  as  a  result 
of  the  existence  of  septic  thrombophlebitis,  the  disease  being  characterized 
by  fever  of  an  intermittent  t^-pe  and  by  recurring  chills.  It  is  not  actually 
due  to  free  pus  in  the  blood,  but  to  the  passage  into  the  blood  of  the  clots 
filled  -ndth  toxins  or,  far  oftener,  of  clots  infected  by  streptococci,  staphylo- 
cocci, or  both.  After  a  woimd  is  inflicted  blood  clots  in  the  divided  veins. 
If  suppuration  occurs,  the  clots  may  become  filled  with  the  toxins  of  pyo- 
genic bacteria  or  be  invaded  by  the  bacteria  themselves.  Thus  it  becomes 
e\'ident  that  pyemia  may  develop  with  septicemia.  It  may  also  develop  when 
there  is  suppuration  in  a  wound,  but  not  septicemia,  no  hinphatic  absorption 
of  bacteria  or  toxins  ha\'ing  occurred.  A  suppurating  focus  about  a  vein  may 
cause  thrombophlebitis  and  clot-formation  even  when  no  wound  exists.  This 
is  seen  in  thrombophlebitis  of  the  lateral  sinus  secondary  to  suppuration  of  the 
middle  ear. 

A  vessel  thrombus  runs  up  in  the  lumen  of  a  vein,  and  the  apex  of  the 
clot  softens,  a  portion  of  it  is  broken  off  by  the  blood-stream  and  carried  as 
an  embolus  into  the  circulation.  Many  of  these  poisonous  emboli  enter  into 
the  blood  and  lodge  in  some  vessels  which  are  too  small  to  transmit  them,  and 
at  their  points  of  lodgment  form  embolic,  secondary,  or  metastatic  abscesses. 
If  the  embolus  contains  only  pyogenic  toxins  the  danger  is  infinitely  less  than 
if  it  contains  bacteria.  The  secondar\-  abscess  if  caused  by  a  clot  containing 
only  toxins  may  not  lead  to  further  dissemination  of  disease.  If  the  embolus 
contains  bacteria,  thrombophlebitis  occurs  about  it,  and  new  infected  emboli 
form  and  are  sent  throughout  the  system.  Wounds  of  the  superficial  parts 
and  bones  produce  pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
\Mien  these  infarctions  break  into  fragments  particles  may  return  to  the  heart 
and  lodge,  or  may  be  sent  out  through  the  arterial  system  to  form  other  foci 
in  distant  organs.  Infected  areas  connected  with  the  portal  circulation 
(intestinal  injuries,  appendicitis,  or   suppurating  piles')  may  produce   portal 


198  Septicemia  and  Pyemia 

pyemia  and  multiple  abscesses  of  the  liver  (see  page  1036).  Wounds  of  bones 
which  open  the  medullary  cavity  or  diploic  structure  are  particularly  apt  to  be 
followed  by  pyemia,  and  the  disease  may  follow  labor,  phlegmonous  erysipelas, 
and  other  conditions.  Malignant  endocarditis  is  called  '^arterial  pyemia,''^  and 
is  due  to  endocardial  embolic  infection.  In  this  disorder  infected  emboli  lodge 
in  the  kidneys,  the  spleen,  the  alimentary  tract,  the  brain,  and  the  skin  (Osier). 
Idiopathic  pyemia  is  a  misnomer.  Some  primary  focus  of  infection  must  exist, 
as  was  pointed  out  when  discussing  septicemia. 

Symptoms. — ^The  wound  often  becomes  dry  and  brown,  and  sometimes 
also  offensive.  A  severe  and  prolonged  chill  or  a  succession  of  chills  ushers 
in  the  disease;  high  fever  follows,  and  drenching  sweats  occur.  The  chills 
recur  every  other  day,  every  day,  or  oftener.  A  chill  arises  from  the  libera- 
tion and  lodgment  of  emboli.  During  the  sweat  the  temperature  falls  and 
may  become  nearly  normal,  normal,  or  actually  subnormal.  The  tempera- 
ture often  oscillates  violently.  The  general  symptoms  of  vomiting,  wasting, 
etc.,  resemble  those  of  septicemia.  In  some  cases  the  mind  remains  clear,  in 
many  the  delirium  is  purely  nocturnal.  The  skin  frequently  becomes  jaun- 
diced and  a  profound  adynamic  state  is  rapidly  established.  The  blood 
changes  are  like  those  of  septicemia.  The  spleen  is  enlarged.  The  lodgment 
of  emboli  produces  symptoms  whose  nature  depends  upon  the  organ  involved. 
Lodgment  in  the  lungs  causes  shortness  of  breath  and  cough,  with  slight  physi- 
cal signs.  Lodgment  in  the  pleura  or  pericardium  gives  pronounced  physical 
evidence.  Lodgment  in  the  spleen  produces  severe  pain  and  great  enlarge- 
ment.    The  parotid  gland  not  unusually  suppurates. 

In  a  suspected  case  of  pyemia  always  examine  an  existing  wound,  and  if 
there  is  no  wound,  remember  that  the  infection  may  arise  from  gonorrhea, 
osteomyelitis,  suppuration  in  the  middle  ear,  appendicitis,  dental  caries,  ton- 
sillar suppuration,  abscess  of  the  prostate,  etc.  Chronic  pyemia  may  last 
for  months;  acute  pyemia  may  prove  fatal  in  three  days.  The  chief  com- 
plications are  joint-suppuration,  bronchopneumonia,  pleuritis,  empyema, 
endocarditis,  pericarditis,  peritonitis,  nephritis,  cholecystitis,  pyeHtis,  venous 
thrombosis,  and  abscesses. 

Treatment  is  the  same  as  for  septicemia.  Open,  drain,  and  asepticize 
any  wound  and  any  accessible  secondary  abscess.  The  remarks  made  as  to 
the  use  of  sera  and  bacterial  vaccines  in  septicemia  apply  also  to  pyemia. 

Erysipeloid  {reticular  lymphangitis,  crab  cellulitis)  was  described  by  Rosen- 
bach  in  1887,  although  like  cases  were  reported  nearly  fifteen  years  before 
by  Morrant  Baker  under  the  name  of  erythema  serpens.  Gilchrist,  in  1904, 
reported  329  Baltimore  cases.  I  have  seen  a  number  of  cases  in  the  Jefferson 
Hospital.  The  condition  is  due  to  infection  from  handling  putrid  animal 
matter,  especially  fish;  bites  of  crabs,  and  sticks  of  fish  fins.  Rosenbach 
claimed  to  find  a  special  organism  resembHng  but  larger  than  a  staphylococcus, 
but  other  observers  fail  to  find  it.  The  period  of  incubation  is  from  a  few 
hours  to  two  days.  Jopson  describes  the  disease  as  follows  ("Amer.  Jour. 
Med.  Sciences,"  May,  1908):  "It  appears  as  a  swelling  with  elevated,,  sharply 
defined  edges,  which  soon  affects  the  entire  circvunference  of  the  finger;  and  is 
commonly  described  as  of  a  dark-red  color,  with  purplish  or  even  livid  edges. 
The  finger  is  tense  and  only  moderately  painful,  but  itching  and  burning  are 
prominent  symptoms.  Sections  of  tissue  excised  show  an  inflammation  of  the 
entire  corium  and,  to  a  slight  extent,  of  the  subcutaneous  tissue,  with  infiltra- 
tion of  polynuclear  leukocytes  and  small  lymph-cells;  edema  of  the  epithelial 
cells  of  the  epiderm,  and  inflammatory  changes,  especially  marked  around  the 
sweat-glands  and  blood-vessels  (Gilchrist).  It  has  a  characteristic  tendency 
to  spread  from  its  usual  point  of  origin,  near  the  end  of  the  finger,  toward  the 
palm,  the  primarily  affected  area  fading  from  red  to  yellow,  and  thence  to 


Erysipelas  199 

normal.  Reaching  the  palm,  it  may  spread  over  it;  but  commonly,  it  soon 
affects  the  neighboring  finger;  and,  when  untreated,  it  may  gradually  spread 
to  all  the  fingers  and  to  the  back  of  the  hand.  There  is  no  fever  or  other 
constitutional  disturbance,  and  the  lymph-glands  are  almost  never  involved. 
It  is  more  or  less  self-limited,  commonly  lasting  from  ten  days  to  three  weeks; 
and  during  this  time  there  is  a  well-marked  tendency  to  relapse.  There  is  no 
suppuration,  pustulation  or  vesiculation,  and  no  scaling  follows." 

It  is  treated  by  applications  of  lead-water  and  laudanum,  ichthyol  or  com- 
presses soaked  in  a  saturated  solution  of  Epsom  salt.  Jopson  applies  tincture 
of  iodin,  and  Gilchrist,  25  per  cent,  salicylic  acid  plaster. 


XI.  ERYSIPELAS   (ST.   ANTHONY'S   FIRE) 

Er\'sipelas  is  an  acute,  contagious,  spreading  capillar}-  lymphangitis 
due  to  the  streptococci  of  er\'sipelas,  which  grow  and  multiply  in  the  smaUer 
lymph-channels  of  the  skin  and  the  subcutaneous  cellular  layers  and  also  in 
the  l_\Tnph-channels  of  serous  and  mucous  membranes.  Erv'sipelas,  though 
contagious,  is,  as  a  matter  of  fact,  seldom  conveyed  as  such  from  one  patient  to 
another.  Pantou  and  Adams  ("Lancet,"  Oct.  9,  1909)  present  this  truth  con- 
vincingly. In  St.  Thomas's  Hospital  from  1896  to  1905  er\'sipelas  cases  were 
kept  with  other  cases  in  the  septic  wards.  In  1906  isolation  was  begun.  The 
records  of  1907  show  that  isolation  had  no  effect  in  diminishing  the  number 
of  cases  of  er}-sipelas  arising  in  the  septic  wards.  Cutaneous  erysipelas  is 
characterized  by  a  rapidly  spreading,  acutely  beginning  dermatitis,  by  a  remit- 
tent fever  due  to  absorption  of  toxins,  and  by  a  tendency  to  recurrence.  It 
is  always  preceded  by  a  wound,  a  scratch,  or  an  abrasion,  which  may  have  been 
tri\aal  and  may  never  have  been  noticed.  The  so-called  idiopathic  er\-sipelas 
is  preceded  by  a  breach  of  surface  continuity  so  small  as  to  escape  notice.  The 
initial  point  of  infection  may  be  in  the  mouth,  the  nostril,  the  phar\-nx,  the 
auditors'  meatus,  between  the  fingers  or  toes,  at  the  margin  of  a  nail,  or  in  a 
cutaneous  furrow.  The  involved  area  in  cutaneous  er}-sipelas  seldom  sup- 
purates, but  sometimes  does,  ver\'  thin,  water}'  pus  being  formed.  If  thick 
pus  forms  it  means  mixed  infection  vnth.  staphylococci,  but  the  formation  of 
thin  pus  does  not  require  a  mixed  infection,  as  the  streptococcus  is  identical 
with  the  Streptococcus  pyogenes.  In  some  cases  of  er^'sipelas,  staphylococcus 
infection  follows  and  even  actually  replaces  streptococcus  infection.  The 
rapid  spread  of  erysipelas  is  due  to  the  fact  that  the  streptococci  prevent  coagu- 
lation of  exudate  and  are  not  actively  attacked  by  leukocytes.  Erysipelas 
is  most  common  in  the  spring  and  fall,  and  is  most  usually  met  'U'ith  among 
those  who  are  crowded  into  dark,  dirty,  and  ill- ventilated  quarters;  it  attacks 
by  preference  the  debiHtated  and  broken-down  (as  alcohoKcs  and  sufferers 
from  Bright's  disease).  The  disease  may  become  endemic  in  special  places 
or  locahties.  The  poison  of  er^^sipelas  will  produce  puerperal  fever  in  a  hing- 
in  woman.  The  streptococcus  was  first  obtained  in  pure  cultures  by  Feh- 
leisen.  This  organism  is  -n-idely  diffused.  The  question  of  identity  with  the 
Streptococcus  pyogenes  is  discussed  on  page  50. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory,  or  wandering  er\-sipe- 
las  is  a  form  which  tends  to  spread  widely  over  the  body,  lea\'ing  one  part  and 
going  to  another.  Bullous  erysipelas  is  attended  by  the  formation  of  buUce. 
In  diffused  erysipelas  the  borders  of  the  inflammation  gradually  merge  into 
healthy  skin.  Erythematous  er\^sipelas  involves  the  skin  superficially.  Meta- 
static erysipelas  appears  successively  in  various  parts  of  the  bod}^  Puer- 
peral er^'sipelas  begins  in  the  genitals  of  Mng-in  women,  producing  puerperal 
fever.     Erysipelas  simplex  is  the  ordinar}-  cutaneous  form.     Erysipelas  neo- 


200  Erysipelas 

natoriim  begins  in  the  unhealed  navel  of  a  newborn  child  and  spreads  from 
this  point.  Typhoid  erysipelas  occurs  with  profound  adynamia.  Univer- 
sal erysipelas  involves  the  entire  body.  Cellulitis  is  often  erysipelas  of  the 
subcutaneous  layers.  Phlegmonous  erysipelas  involves  the  skin  and  the 
cellular  tissues,  and  causes  suppuration,  and  often  gangrene.  Edematous 
erysipelas  is  a  variety  of  phlegmonous  erysipelas  with  enormous  subcutaneous 
edema.  Lymphatic  erysipelas  is  characterized  by  rose-red  lines  due  to  lym- 
phangitis. Venous  erysipelas  is  marked  by  the  dark  color  of  venous  congestion. 
Mucous  erysipelas  involves  a  mucous  membrane.  Erysipelas  may  attack 
the  fauces,  producing  the  very  grave  condition  known  as  faucial  erysipelas. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  erysipelas,  cellulo- 
cutaneous  or  phlegmonous  erysipelas;  cellulitis,  and  mucous  erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face.  A  fever  sud- 
denly appears,  rises  rapidly,  reaches  a  considerable  height,  is  remittent  in 
type  and  sometimes  distinctly  fluctuating,  and  usually  terminates  in  four  or  five 
days  by  crisis.  At  the  time  of  febrile  onset  spots  of  redness  appear  on  the 
skin.  These  spots  run  together,  and  soon  a  large  extent  of  surface  is  found 
to  be  red  and  a  little  elevated.  Any  wound,  ulcer,  or  abrasion  which  exists 
becomes  dry  and  unhealthy,  and  its  edges  redden  and  swell.  The  erysipe- 
latous area  of  redness  and  swelling  extends  either  in  spots  with  intervening 
healthy  skin  or  in  an  uninterrupted  hne.  The  margin  is  usually  sharply 
defined  from  the  healthy  skin,  and  the  color  fades  at  the  original  focus  as  the 
disease  advances  at  the  periphery  of  the  red  area.  The  border  shows  the  most 
intense  redness,  the  most  marked  inflammatory  swelling  (if  there  is  swelling), 
and  the  greatest  pain.  The  point  of  origin  shows  the  least  redness,  the  least 
swelling,  and  the  least  pain.  Thus  erysipelas  reverses  the  rule  of  an  ordinary 
inflammatory  process.  Milian  calls  this  tendency  of  erysipelas  "the  law^  of 
centrifugal  maximimi"  ("La  Presse  medicale,"  Nov.  5,  1910).  The  color  fades 
at  once  on  pressure  and  returns  at  once  when  pressure  is  removed.  There  is 
burning  pain,  which  is  most  intense  at  the  border  and  which  is  increased  by 
pressure.  In  the  hyperemic  area  vesicles  or  bullae  form,  containing  first  serum, 
and  later  it  may  be  seropus,  but  there  is  rarely  genuine  suppuration  in  cuta- 
neous erysipelas.  Edema  affects  the  subcutaneous  tissues,  producing  great 
swelling  in  regions  where  there  is  much  loose  ceUular  tissue  (as  in  the  eyelids) . 
Anatomically  related  lymphatic  glands  may  become  large  and  tender.  In 
an  ordinarily  strong  person  the  color  of  an  erysipelatous  area  is  bright  red  or, 
more  rarely,  dark  red.  A  dusky  color  precedes  suppuration.  A  blue  color 
precedes  gangrene  or  indicates  profound  cardiac  or  pulmonary  involvement. 
Erysipelas  spreads  now  in  one  direction,  now  in  another,  influenced,  according 
to  Pfleger,  by  the  furrows  of  the  'skin.  As  facial  erysipelas  spreads  it  involves 
the  ear.  All  subcutaneous  inflammations  stop  short  at  the  ear  and  cannot 
invade  it  because  of  the  close  adhesion  of  the  skin  to  the  cartilage.  Milian 
caUs  this  the  "ear  sign."  When  the  disease  ceases  to  spread,  the  sweUing  and 
redness  gradually  abate,  and  after  they  disappear  desquamation  takes  place, 
and  the  blebs  become  dry  and  crusted. 

In  strong  subjects  the  constitutional  symptoms  of  cutaneous  erysipelas  are 
often  slight.  In  the  old  and  debilitated  the  symptoms  are  typhoidal,  there 
is  a  dry  tongue,  dyspnea  and  hebetude,  delirium  comes  on,  and  death  is 
usual.  Possible  complications  are  meningitis,  pneumonia,  septicemia,  pleuri- 
tis,  pyemia,  myocarditis,  endocarditis,  arthritis,  and  albuminuria.  Erj^sipelas 
neonatorum  is  very  fatal.  The  mortality  in  infants  is  certainly  50  per  cent. 
(Sir  Watson  Cheyne's  "Weightman  Lecture  for  1908").  In  some  instances 
an  attack  of  erysipelas  will  cure  an  old  skin  eruption,  a  new  growth,  an 
ulcer,  or  an  area  of  lupus.  This  is  the  erysipele  salutaire  of  our  French 
confreres. 


Cutaneous  En'sipelas  201 

Treatment. — Isolate  the  patient.  Asepticize  the  wound,  if  there  be  a  wound. 
Examine  to  determine  if  there  is  diabetes  or  Bright's  disease.  Administer  a 
purge.  Cases  of  cutaneous  erysipelas  occurring  in  a  fairly  healthy,  young 
or  middle-aged  subject,  tend  to  get  well  without  treatment.  The  late  J.  j\I. 
DaCosta  advocated  the  administration  of  i  to  ^  gr.  of  pilocarpin.  Debility 
absolutely  contra-indicates  this  drug.  If  a  person  is  debilitated,  free  stimula- 
tion is  necessary.  Tincture  of  chlorid  of  iron  is  usually  administered  in  doses 
of  from  20  to  40  min.  well  diluted,  and  given  three  or  four  times  a  day.  Tonic 
doses  of  quinin  are  also  given.  Nutritious  food  is  given  at  intervals  of  three 
or  four  hours.  For  sleeplessness  or  dehrium  use  chloral  or  the  bromids;  for 
ver\-  high  temperature  cold  sponging  is  required.  Early  in  an  attack,  when  the 
area  is  limited,  the  appKcation  of  Bier's  cup  may  do  good.  To  prevent  spread- 
ing some  have  ad\*ised  injection  of  the  healthy  skin  near  the  blush  with  a  2 
per  cent.  carboHc  solution  or  Tvith  fluid  containing  -yq  gr.  of  corrosive  sub- 
limate. A  band  of  iodin  painted  on  the  skin  may  arrest  the  progress  of  the 
disease,  and  so  may  a  ring  streaked  aroimd  a  lunb  or  about  an  er\^sipela- 
tous  area  by  lunar  caustic.  Kraske  has  suggested  a  method  of  preventing  the 
spread  of  cutaneous  er\-sipelas  which  is  often  effective.  The  patient  is  anes- 
thetized. At  about  2  inches  from  the  margin  of  the  redness  a  series  of  cuts 
are  made  into  the  skin,  to  a  sufficient  depth  to  cause  free  oozing.  Each 
cut  is  crossed  by  another  cut  and  a  ring  of  scarifications  is  made  to  surround 
the  region  of  the  er\-sipelas.  After  the  oozing  ceases  the  scarified  area  is 
soaked  for  one  hour  with  a  solution  of  carbolic  acid  (i  :  20)  or  corrosive  sub- 
limate (i  :  2000) .  The  part  is  dressed  ^-ith  pads  wet  \vdth  carbolic  acid  (i  :  40) 
or  corrosive  sublimate  (i  :  2000).  This  operation  causes  the  formation  of  a 
protective  barrier  of  leukocytes.  For  a  number  of  years  I  have  used  with  satis- 
faction a  treatment  taught  me  by  my  old  master,  Prof.  S.  W.  Gross.  It  is  as 
follows:  Paint  the  part  and  well  around  the  part  several  times  a  day  with  a 
mixture  of  equal  parts  of  tincture  of  iodin  and  alcohol.  If  a  woimd  exists, 
keep  it  open  and  disinfect  it  wdth  the  iodin  once  a  day.  Cover  the  part  with 
lint  wet  with  lead-water  and  laudanum,  and,  if  it  be  an  extremity,  bandage  it 
from  the  toes  or  fingers  to  well  above  the  er\-sipelatous  area.  The  iodin  is 
germicidal  and  quickly  enters  the  h-mph-spaces.  The  lead-water  and  lauda- 
num  aUays  the  burning  pain.  Saturated  solution  of  Epsom  salt  is  a  useful 
preparation.  It  is  applied  on  gauze  which  is  kept  constantly  moist.  It 
quickly  allays  the  burning  pain  and  seems  to  limit  the  spread  of  the  infection. 
Some  advocate  a  daily  inunction  of  Crede's  soluble  silver.  A  good  appHcation 
is  a  50  per  cent,  ichthyol  ointment  with  lanolin.  A  very  useful  method  is  von 
Nussbaum's.  The  author  appHes  it  somewhat  modified,  as  follows:  wash  the 
part  with  ethereal  soap,  irrigate  vdth.  a  solution  of  corrosive  sublimate  (i  :  1000), 
dr\-  with  a  sterile  towel,  apply  an  ointment  of  ichthyol  and  lanolin  (50  per  cent.), 
and  dress  with  antiseptic  gauze.  Some  use  iced-water  cloths.  Hot  fomenta- 
tions are  distinctly  harmful.  Some  apply  borated  talc  or  saUcylated  starch. 
Ringer  adxised  painting  ever}^  three  hours  with  a  mixture  composed  of  30  gr. 
of  tannic  acid,  30  gr.  of  camphor,  and  4  dr.  of  ether.  Antistreptococcic  senun 
has  been  used  in  er>-sipelas,  and  most  iDeneficial  results  have  been  claimed  for 
it.  It  is  asserted  that  under  its  influence  the  temperature  soon  becomes 
normal.  jMy  personal  experience  vnXh  the  serum  treatment  has  not  cominced 
me  of  its  value,  although  some  cases  seem  to  be  benefited.  Schorer  studied 
100  cases  of  er\-sipelas  in  BeUe\'ne  Hospital  and  determined  the  opsonic  index 
and  its  relation  to  treatment  by  inoculation  of  dead  streptococci.  He  concluded 
that  a  vaccine  does  not  prevent  migration  or  recurrence,  but  seems  to  shorten 
the  duration  of  the  disease  (''Amer.  Joiir.  Med.  Sciences,"  Nov.,  1907).  Ross 
and  Johnson  regard  treatment  by  a  specific  vaccine  as  verv'  efficient  C'Jour. 
Amer.  Med.  Assoc,"  March  6,  1909). 


202  Erysipelas 

Cellulocutaneous  or  phlegmonous  erysipelas  is  characterized  by  high 
temperature  (io4°-io6°  F.),  the  rapid  onset  of  grave  prostration,  irregular 
chills,  sweat,  and  a  strong  tendency  to  delirium.  The  constitutional  condition 
may  be  one  of  suppurative  fever,  sapremia,  septicemia,  or  pyemia.  The  parts 
are  red,  as  in  cutaneous  erysipelas,  and  the  tumefaction  is  vastly  greater.  The 
swelling  is  brawny,  comes  on  early,  increases  with  exceeding  rapidity,  induces 
a  high  degree  of  tension,  and  frequently  becomes  associated  with  sloughing 
or  even  cutaneous  gangrene.  The  lymphatic  glands  are  swollen,  but  the  in- 
flamed lymphatic  vessels  are  hidden  by  the  tumefaction.  In  most  cases 
suppuration  occurs,  and  when  this  happens  the  parts  become  boggy  and  the 
pus  is  widely  disseminated  in  the  subcutaneous  and  intramuscular  tissues, 
and  even  into  muscle-sheaths  and  tendon-sheaths  {purulent  infiltration). 
When  the  disease  abates  sloughs  form,  which  leave  ulcers  upon  being  cast  off. 
In  bad  cases  muscles,  vessels,  tendons,  and  fascia  may  slough  away.  The 
commonest  complications  are  suppression  of  urine,  bronchopneumonia,  con- 
gestion and  edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys,  and 
acute  pleurisy.  Septicemia  or  pyemia  may  occur.  We  sometimes  meet  with 
this  form  of  erysipelas  after  extravasation  of  urine.  It  is  not  a  pure  strepto- 
coccic infection.  There  is  a  mixed  infection  with  other  pyogenic  cocci,  and 
often  with  organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  any  existing  wound,  and  dress 
such  a  wound  with  hot  antiseptic  fomentations.  If  there  are  inflamed  lymph- 
vessels  or  glands  above  the  area  of  cellulocutaneous  infection,  paint  the  skin 
above  them  with  iodin  and  smear  it  with  blue  ointment  or  rub  in  Crede's 
ointment  of  soluble  silver.  Make  numerous  incisions  into  the  inflamed 
tissues.  These  incisions  should  be  near  together,  and  each  cut  should  be 
2  or  3  inches  long.  Spray  the  wounds  with  hydrogen  peroxid  by  means  of  a 
atomizer,  wash  with  a  solution  of  acetate  of  aluminum  (2  per  cent.),  and  pack 
each  wound  with  iodoform  gauze.  Dress  with  many  layers  of  gauze  wet  with 
a  hot  solution  of  acetate  of  aluminum  (2  per  cent.).  The  gauze  is  covered 
with  a  rubber-dam  and  a  hot-water  bag  is  laid  upon  the  dressing.  If  sloughs 
form,  cut  them  away  and  employ  hot  antiseptic  fomentations.  Change  the 
dressings  often.  In  some  cases  it  may  be  necessary  to  employ  continuous  irriga- 
tion with  warm  antiseptic  fluid,  or  continuous  immersion  in  a  hot  aseptic  or 
antiseptic  bath.  It  is  not  unusually  necessary  to  operate  for  the  removal  of 
enlarged  lymphatic  glands.  The  Bier  treatment  is  a  valuable  addition  to  our 
resources.  In  rare  cases  amputation  is  demanded.  When  granulations  begin 
to  form,  treat  as  a  healing  wound.  The  constitutional  treatment  is  that 
previously  set  forth  as  applicable  to  septicemia,  viz.,  purgation,  the  use  of 
diuretics  and  diaphoretics,  the  administration  of  strychnin,  quinin,  digitaHs, 
alcoholic  stimulants,  and  nourishing  food.  In  severe  cases  employ  hypodermo- 
clysis  or  saline  infusion  into  a  vein.  Antistreptococcic  serum  may  be  em- 
ployed. 

Cellulitis  (Fig.  100)  is  a  microbic  inflammation  of  the  cellular  tissue. 
It  may  be  due  to  staphylococci,  to  streptococci,  to  other  pyogenic  bacteria, 
or  to  mixed  infection  with  two  varieties  of  pyogenic  organisms.  The  com- 
monest form  is  streptococcic  infection,  and  this  is  a  variety  of  erysipelas. 
A  streptococcic  infection  may  be  followed  and  replaced  by  a  staphylococcic 
infection.  Infection  with  the  Bacillus  aero  genes  capsulatus  causes  gangrenous 
cellulitis.  Cellulitis  is  prone  to  arise  in  damaged  tissues,  for  instance,  in 
a  crushed  part,  a  limb  the  seat  of  a  compound  fracture,  or  tissue  containing 
extravasated  urine.  In  tissue  the  resistance  of  which  has  been  lessened  by 
diabetes,  Bright's  disease,  irritating  discharges,  or  trophic  lesions,  ceUulitis 
is  rather  apt  to  develop.  In  cellulitis  of  the  subcutaneous  tissue  the  micro- 
organisms find  entrance  by  means  of  a  wound.     SweUing  precedes  redness. 


Treatment  of  Cellulitis 


203 


The  swelling  is  not  so  marked  as  in  phlegmonous  erysipelas,  and  the  redness  is 
darker  and  is  less  distinct  than  in  cutaneous  erysipelas.  The  redness  of 
cellulitis  is  about  the  wound;  it  spreads,  but  does  not  fade  at  the  center  as  does 
ordinary  erj^sipelas;  red  lines  due  to  lymphangitis  ascend  the  limb  from  the 
infected  wound,  and  the  anatomically  associated  lymphatic  glands  enlarge. 
In  the  wound  and  its  neighborhood  there  is  severe  throbbing  pain.  The 
constitutional  symptoms  of  infection  develop  rapidly.  In  trivial  cases  the 
lymphatics  dispose  of  the  poison  and  suppuration  does  not  occur.  In 
severe  cases  pus  forms  about  the  wound  and  IjTnphatic  glands"  may  sup- 
purate. In  staphylococcic  infection  pus  is  thick,  in  pure  streptococcic  in- 
fection it  is  thin.  Phlegmonous  erysipelas  may  develop,  and  septicemia  or 
pyemia  may  arise. 

Treatment. — Open,  disinfect,  and  drain  the  wound.  Paint  iodin  upon 
the  skin  over  inflamed  lymphatic  vessels  and  glands  and  cover  with  ichthyol 
ointment,  or  rub  Crede's  soluble  silver  ointment  into  the  skin  over  the  inflamed 
lymph-glands  and  vessels.     Dress  the  wound  and  the  adjacent  inflamed  area 


Fig.  100. — Acute  cellulitis  of  palm  and  forearm  following  a  slight  wound. 

with  hot  antiseptic  fomentations.  Secure  rest  of  the  part.  It  may  be  neces- 
sar\^  to  make  incisions  as  in  phlegmonous  er^'sipelas.  In  some  cases  it  is 
necessary-  to  remove  breaking-down  glands.  The  constitutional  treatment  is 
that  employed  for  septicemia. 


XII.  TETANUS,   OR    LOCKJAW 

Tetanus  is  a  microbic  disease  invariably  preceded  by  some  injury  and 
characterized  by  spasm  of  the  voluntarv^  muscles.  The  wound  may  have  been 
severe,  it  may  have  been  so  slight  as  to  have  attracted  no  attention,  it  may 
have  been  inflicted  upon  the  alimentary  canal  by  a  iish-bone  or  other  foreign 
hody,  or  may  have  been  situated  in  the  nose,  urethra,  rectum,  vagina,  or  ear. 
It  is  possible  that  infection  can  occur  through  a  mere  abrasion  of  a  mucous 
membrane.  Sir  David  Semple  has  recently  sought  to  demonstrate  that 
tetanus  does  not  of  necessity  depend  on  spores  or  bacilh  introduced  at  the 
time  of  the  injury.  He  believes  that  spores  may  be  taken  up  from  the  intes- 
tine and  deposited  from  the  blood  in  the  anaerobic  area  created  by  a  woimd 
or  contusion  ("Lancet,"  May  20,  1911,  ISIarch  g,  1912).  As  yet  this  view  lacks 
general  acceptance.    It  has  long  been  taught  that  so-called  idiopathic  tetanus  is 


204  Tetanus,  or  Lockjaw 

either  not  tetanus  at  all,  or  the  term  expresses  the  fact  that  we  have  not  found 
the  traces  of  an  injury  which  did  exist.  Sir  David  Semple  maintains  that 
spores  may  enter  into  trivial  wounds  and  remain  in  the  healed  area  for  months, 
to  possibly  become  active  as  a  result  of  exposure  to  great  heat  or  cold,  to  fatigue, 
or  to  bruising  of  the  part.  Semple's  view  would  explain  so-called  idiopathic 
tetanus  (see  "Lancet,"  May  20,  1911).  Tetanus  arises  most  frequently  after 
punctured  and  particularly  after  lacerated  wounds  of  the  hands  or  feet;  In  a 
surgical  experience  of  over  twenty-five  years  in  connection  with  the  Philadel- 
phia Fire  Department  I  have  known  himdreds  of  firemen  to  injure  their  feet 
by  stepping  on  nails  and  not  one  developed  tetanus.  In  fact,  the  only  case  of 
tetanus  among  them  since  1871  arose  in  a  man  who  lacerated  his  hand  with 
glass.  Before  tetanus  appears  a  wound  is  apt  to  suppurate  or  slough;  but  in 
some  instances  the  wound  is  found  soundly  healed  when  the  tetanus  begins. 
The  toy  pistol  produces  a  peculiarly  dangerous  wound.  In  the  United  States 
many  cases  of  tetanus  follow  the  celebration  of  the  Fourth  of  July,  a  large  per- 
centage of  the  causative  wounds  being  from  the  toy  pistol.  The  Fourth  of  July, 
1903,  was  responsible  for  466  reported  and  no  one  knows  for  how  many  unre- 
ported cases  in  the  United  States.  Since  that  date  the  prophylactic  use  of 
antitetanic  serum  has  become  the  rule  of  practice  in  suspected  injuries  and  there 
has  been  a  notable  diminution  in  the  number  of  cases.  In  1909  there  were  150 
cases;  in  19 10  there  were  72  cases;  in  191 1  there  were  18  cases;  in  191 2 
there  were  only  7  cases  (''Jour.  Amer.  Med.  Assoc,"  Sept.  7,  1912).  Of  the 
7  cases,  6  died  (86  per  cent.).  The  fact  that  the  bacillus  of  tetanus  is  anaerobic 
explains  the  comparative  frequency  with  which  punctured  and  lacerated 
wounds  are  attacked,  for  in  such  woimds  the  bacilli  are  deeply  lodged  in  recesses 
or  cavities  into  which  air  does  not  penetrate  or  are  covered  with  discharges 
which  exclude  air.  Suppuration  favors  the  growth  of  tetanus  bacilli  because 
the  pyogenic  organisms  consume  oxygen.  Occasionally,  though  fortunately 
very  rarely,  tetanus  follows  vaccination.  It  is  essential  that  vaccine  virus 
should  be  carefully  selected  and  prepared.  When  care  is  taken,  the  operation 
is  absolutely  safe.  When  tetanus  follows  vaccination,  it  arises  from  infection 
of  the  wound  either  at  the  time  of  vaccination  or,  as  is  far  more  common,  at  a 
later  period  from  scratching  or  some  other  fouling.  The  tetanus  organism  is 
not  introduced  in  the  vaccine,  but  obtains  entrance  during  or  subsequent  to  the 
operation  of  vaccination,  because  of  utter  neglect  of  the  vaccine  lesion  and  in 
consequence  of  the  accumulation  of  filth  upon  and  about  it.  In  no  reported 
case  have  the  symptoms  of  tetanus  appeared  earlier  than  two  weeks  after 
vaccination  (Wm  N.  Welch,  "N.  Y.  Med.  Jour.,"  Jan.  16, 1909).  The  organisms 
or  its  spores  have  never  been  discovered  in  tubes  or  in  points,  and,  as  Rosenau 
points  out,  the  organism  cannot  grow  and  cannot  form  toxins  on  dry  points  or  in 
glycerinated  virus.  The  most  scrupulous  care  is  taken  to  prevent  contamina- 
tion of  vaccine  virus,  and  it  is  examined  for  tetanus  toxin  and  tetanus  bacilli 
before  it  is  placed  on  the  market.  Tetanus  has  followed  the  injection  of  gela- 
tin. Commercial  gelatin  often  contains  the  bacilli  and  should  never  be  used 
without  careful  fractional  sterilization  (see  page  422).  Roberts  reports  a  case 
of  fatal  tetanus  in  a  patient  with  chronic  ulcer  of  the  leg  ("Lancet,"  vol.  i,  191 2). 
Evler  infected  himself  while  operating  on  a  case  of  tetanus  ("Berliner  klin. 
Wochenschr.,"  Sept.,  12,  19 10).  Tetanus  has  followed  a  burn,  a  frost-bite, 
a  hypodermatic  injection  of  quinin,  child-birth,  abortion,  and  the  use  in  a 
wound  of  contaminated  catgut.  Most  cases  of  postoperative  tetanus  depend 
upon  infected  catgut.  The  disease  sometimes  arises  when  no  catgut  is  used 
(J.  B.  Smith's  case,  "Brit.  Med.  Jour.,"  May  6,  191 1).  Cases  have  arisen 
from  such  trivial  operations  as  ligation  of  piles  and  hypodermatic  injection  of 
quinin.  Peterson  ("Jour.  Am.  Med.  Assoc,"  Jan.  8,  1910)  collected  49  cases 
of  postoperative  tetanus  reported  since  1890.      In  40  the  peritoneal  cavity  had 


Tetanus,  or  Lockjaw  205 

been  opened.  In  only  18  cases  suture  material  was  named  (catgut,  3;  catgut 
and  kangaroo-tendon,  2;  catgut  with  other  material,  7;  silk,  4;  silk  and  silk- 
worm-gut, I ;  silk  and  silver  wire,  i).  No  case  appeared  before  the  fourth  day, 
most  on  the  ninth  day.  Drainage  should  tend  to  prevent  it.  Tetanus  may 
appear  within  twenty-four  hours  after  an  accident,  but  it  may  not  arise  until 
many  days  or  even  several  weeks  have  elapsed.  Rose  reported  a  case  which 
began  within  twenty-four  hours.  Kuhn  (''Berliner  klinische  Wochensch.," 
1901)  reports  a  fatal  case  of  tetanus  beginning  twelve  hours  after  an  injection  of 
gelatin.  Such  a  rapid  case  could  only  be  due  to  the  gelatin  having  contained 
a  large  quantity  of  tetanus  toxin  (Schuckmann).  Samuel  D.  Gross,  in  his 
"System  of  Surgery,"  speaks  of  i  case  occvu"ring  in  a  man  live  weeks  after  in- 
jury, and  another  in  a  girl  four  weeks  after  injury.  Jacobson  and  Pease  are 
of  the  opinion  that  ''such  cases  as  have  been  recorded  with  periods  of  incubation 
under  three  days  must  be  accepted  with  considerable  reserve''  (''Annals  of 
Surgery,''  Sept.,  1906).  Tetanus  prevails  more  in  certain  localities  than  in 
others,  but  it  is  met  with  all  over  the  world  from  the  Arctic  Zone  to  the  Tropics, 
and  may  arise  in  either  sex,  in  any  race,  and  at  any  age.  Colored  people  are 
very  susceptible,  and  the  disease  may  exist  endemically,  and  does  so  in  certain 
portions  of  New  Jersey  and  of  Cuba.  In  our  country-  the  greatest  prevalence, 
according  to  Anders,  is  in  Pennsylvania,  northern  New  York,  Long  Island, 
Virginia,  Georgia,  and  Louisiana.  Anders  collected  1201  cases  and  Pennsyl- 
vania stands  first  on  his  list  with  224  cases  ("Jour.  Am.  ]\Ied.  Assoc,"  July  29, 
1905).  It  is  stated  that  in  certain  districts  of  Nigeria  the  soil  contains  so  many 
tetanus  spores  that  the  natives  poison  their  arrows  by  sticking  them  into  the 
ground  (Allan  C.  Parsons,  in  "Brit.  ]\Ied.  Jour.,"  Jan.  23, 1909).  Tetanus  is  due 
to  the  growth  in  a  wound  of  a  bacillus  which  was  first  described  by  Nicolaier  and 
was  first  cultivated  by  Kitasato.  It  is  the  most  widely  distributed  of  all  the 
pathogenic  bacteria.  It  is  very  difficult  to  cultivate  and  cannot  be  cultivated 
at  all  unless  air  is  absolutely  excluded.  Tetanus  bacilli  or  their  spores  are  found 
particularly  in  garden  soil,  in  the  dust  of  walls,  walks  and  cellars,  in  street  dirt, 
and  in  the  refuse  of  stables.  There  is  much  suggestive  evidence  that  ^drulent 
tetanus  bacilli  come  from  the  intestinal  canal  of  animals;  that  the  bacteria 
lose  their  \'irulence  when  they  have  been  long  outside  of  the  intestinal  canal; 
and  that  the  highest  degree  of  \drulence  is  obtained  by  those  which  have 
passed  frequently  through  intestinal  canals.  The  above  view  is  kno\^^l  as  the 
fecal  theors'  and  is  strongly  advocated  by  Somani.^ 

It  is  taught  that  in  tetanus  the  bacilli  do  not  enter  into'the  blood,  and  toxic 
products  produced  by  them  are  not  directly  absorbed  by  the  blood  or  h-mph. 
Porter  and  Richardson  ("Boston  'Med.  and  Surg.  Jour.,"  Dec.  2;^,  1909)  in  2 
cases  obtained  cultures  of  the  baciUi  from  lymph-glands  which  received  drain- 
age from  the  wound  region.  This  is  a  highly  important  obser^'ation.  The 
toxic  products  alone  without  any  bacteria  enter  the  muscular  end  organs  of 
motor  ner^-es,  ascend  ■oithin  the  nerv'es,  and  reach  the  spinal  cord  and  medulla 
(Brunner,  ]\Iarie),  become  fixed  in  the  ner\'e-ceUs  of  the  spinal  cord  and  medulla, 
and  produce  the  sAinptoms  of  the  disease.  Metschnikofi"  found  tetanus  toxin 
in  the  cord.  Emulsion  made  from  the  region  of  the  masticators-  nuclei  of  the 
floor  of  the  fourth  ventricle  is  peculiarly  rich  in  highly  potent  toxin  (Trosier 
and  Georges  Roux,  quoted  in  "Lancet,"  Jan.  15,  1910).  Tetanus  is  an  intoxi- 
cation and  not  an  infection,  and  a  drop  of  blood  of  an  animal  ^\ith  tetanus,  if 
injected  into  another  animal,  wiH  not  produce  the  disease.  Tetanus  toxin 
poisons  the  ner\'ous  system  as  would  strs^chnin  or  some  other  vegetable  alkaloid. 
It  is  probably  the  most  powerful  of  known  poisons.  It  has  been  estimated 
that  2+8  gr.  is  sufficient  to  kill  an  adult  weighing  165  lbs.  ("American  ]\Iedi- 

^  "Verhandl.  d.  X  intemat.  med.  Cong.."  Berlin,  1S90,  Bd.  v,  Abth  15,  p.  152. 


2o6  Tetanus,  or  Lockjaw 

cine,"  Nov.  30,  1901).  The  great  power  of  the  poison  is  shown  by  the  report  of 
Dr.  Nicholas's  case  ("Comptes  rendu  de  la  Societe  de  Biologie,"  1893).  Dr. 
Nicholas  had  been  using  a  syringe  to  inject  filtered  cultures  of  the  bacilli  of 
tetanus  and  he  accidentally  pricked  his  finger  with  the  needle.  In  four  days 
tetanus  began,  and  he  barely  escaped  with  his  life  in  spite  of  the  fact  that 
the  fluid  was  free  of  bacteria  and  the  dose  of  toxin  was  extremely  minute. 
The  nature  of  the  virulent  poison  which  is  produced  at  the  seat  of  inoculation 
is  uncertain.  Some  believe  it  to  be  alkaloidal,  like  the  vegetable  alkaloids; 
some,  that  it  is  a  toxalbumin;  others  maintain  that  it  is  an  enzyme  or  ferment 
(Nocard,  Courmont,  and  others).  In  a  very  few  instances  the  injection  of 
perfectly  sterile  antidiphtheritic  serum  into  himian  beings  has  caused  death 
with  all  the  symptoms  of  tetanus.  The  serum  must  have  been  obtained  from 
horses  in  whom  tetanus  was  incubating,  and  the  blood-serum  injected  must  have 
contained  a  fatal  dose  of  tetanus  toxin.  In  tetanus  an  ascending  neuritis 
occasionally,  though  seldom,  exists  in  the  peripheral  nerve  near  the  lesion. 
The  toxin  is  carried  to  the  cord  by  the  motor  nerves  only,  and  it  is  not  only 
absorbed  by  the  l3rmph-channels  of  the  nerve,  but  ascends  along  the  axis-cylin- 
ders of  the  nerve  itself  and  reaches  the  motor  cells  of  the  spinal  cord  (Meyer 
and  Ransom,  in  "Arch,  exper.  Path.  u.  PharmakoL,"  1903).  On  reaching 
the  cord  it  attacks  the  motor  nerve-cells,  producing  changes  similar  to  those 
produced  by  certain  infections,  and  ascends  in  the  motor  tracts  of  the  cord 
to  the  medullary  nerve-centers.  WhUe  toxin  is  ascending  the  axis-cylinders 
a  certain  amount  is  taken  up  by  the  lymphatics,  enters  the  blood,  and  reaches 
the  spinal  cord  by  other  nerve-fibers  (Jacobson  and  Pease,  in  "Annals  of  Sur- 
gery," Sept.,  1906).  The  essential  basis  of  tetanus  is  spreading  irritation  of 
the  motor  portion  of  the  spinal  cord  accompanied  by  extreme  reflex  excitability 
which  is  due  to  poisoning  of  sensory  neurones  (Meyer  and  Ransom).  The 
irritation  of  the  motor  cord  produces  tonic  contraction  of  the  muscles;  the 
excitation  of  the  sensory  neurones  is  responsible  for  clonic  convulsions.  There 
are  no  instances  on  record  of  second  attacks  of  lockjaw,  but  it  is  not  believed 
that  one  attack  confers  any  prolonged  immimity. 

Local  Tetanus. — In  some  cases  local  symptoms  precede  widespread  evi- 
dences of  tetanus.  Experimental  tetanus  in  animals  "exhibits  almost  without 
exception  as  its  earliest  manifestations  those  of  a  purely  local  character  and 
which  are  at  first  restricted  to  the  neighborhood  of  the  inoculation.  This 
is  now  understood  to  be  due  to  the  absorption  of  the  toxin  by  the  motor  nerve 
of  the  part.  The  conditions  favoring  the  local  appearance  of  tetanus  are  a 
short  motor  nerve,  as  in  head  injuries;  an  injury  to  a  nerve-trunk  permitting 
the  rapid  absorption  of  a  large  amount  of  toxin;  the  production  of  a  meager 
amount  of  toxin  or  the  presence  of  something  which  prevents  the  admission 
of  a  large  amount  of  toxin  into  the  circulation  (Nathan  Jacobson  and  Herbert 
D.  Pease,  Ibid.).  Cases  with  local  symptoms  in  the  beginning  are  apt  to 
have  had  long  periods  of  incubation,  are  apt  to  be  cured,  and  usually  endure 
a  considerable  time. 

Mortality. — It  is  a  very  fatal  disease.  Acute  tetanus  has  a  mortality  of 
from  75  to  90  per  cent.;  chronic  tetanus,  from  40  to  50  per  cent.;  postoperative 
tetanus,  of  over  85  per  cent.  (Peterson's  estimate  in  "Jour.  Am.  Med.  Assoc," 
Jan.  8,  1910). 

Local  tetanus  is  apt  to  terminate  in  recovery.  Tetanus  produces  death 
by  overwhelming  the  patient  with  toxin  by  exhaustion  resulting  from 
repeated  convulsions,  by  spasm  of  the  glottis,  or  fixation  of  the  respiratory 
muscles. 

Symptoms. — ^Acute  tetanus  begins  within  ten  days  of  an  accident.  The 
usual  period  of  incubation  is  from  three  to  five  days.  Evler  had  the  rare  and 
dreadful  experience  of  contracting  the  disease  from  a  victim  of  tetanus  on  whom 


Symptoms  of  Tetanus  207 

he  was  operating,  and  the  extreme  good  fortune  to  recover.  He  reports  his  own 
case  and  says  that  various  short  and  transient  early  symptoms  occur  which  the 
patient  is  apt  to  attribute  to  the  healing  wound.  Among  these  he  mentions 
restlessness,  sleeplessness,  bad  dreams,  oppression  of  breathing,  frequent  and 
difficult  micturition,  headache,  fatigue,  vertigo,  chilliness,  darting  pains  in 
various  regions,  and  perhaps  pains  about  the  injured  part.  If  an  extremity 
is  the  seat  of  wound,  it  may  swell  and  remain  swollen  even  when  elevated, 
and  it  feels  hot,  but  is  not  discolored.  Before  long  the  wound  becomes 
tender  and  glands  often  swell.  There  may  be  painless  contractions  and 
tremors  of  injured  extremity.  Single  groups  of  muscles  may  undergo  tonic 
contraction  ("Berliner  klin.  Wochensch.,"  Sept.  12,  1910).  In  most  cases  of 
tetanus  the  first  symptom  noted  by  the  patient  is  stiffness  of  the  jaw  on 
opening  the  mouth.  In  some  cases  the  first  symptom  is  stiffness  of  the  neck, 
and  the  patient  beheves  he  has  "caught  cold."  In  any  case  the  neck  soon 
becomes  stiff,  and  finally  both  the  neck  and  jaw  become  as  rigid  almost  as  iron. 
The  fixation  of  the  jaw  is  called  trismus.  The  muscles  of  deglutition  become 
rigid  on  attempts  at  swallowing.  The  muscles  of  the  back,  legs,  and  abdomen 
are  thrown  into  tonic  spasm,  but  the  arms  rarely  suffer.  If  the  infected  injury 
is  on  the  hand  or  foot,  that  extremity  usually  is  found  to  be  rigid.  Spasm  of  the 
face  muscles  causes  the  risus  sardonicus,  or  sardonic  smile  (contraction  particu- 
larly of  the  musculus  sardonicus  of  Santorini).  The  contraction  of  the  muscles 
of  the  back  is  often  so  powerful  as  to  bend  the  patient  into  a  curve  like  a  bow 
and  allow  him  to  rest  only  on  his  occiput  and  heels.  This  condition  is  known  as 
opisthotonos.  If  he  is  bent  forward,  so  that  the  face  is  drawn  to  the  legs,  it  is 
called  emprosthotonos.  If  his  body  is  curved  sideways,  it  is  designated  pleuros- 
thotonos.  An  upright  position  is  orthotonos.  The  spasm  may  be  so  violent  as 
to  cause  muscular  rupture. 

The  characteristic  condition  in  tetanus  is  one  of  widely  diffused  tonic 
spasm,  aggravated  frequently  by  clonic  spasms  arising  from  peripheral  irri- 
tations. These  irritations  may  be  drafts,  sounds,  lights,  shaking  of  the 
bed,  attempts  at  swallowing,  contact  of  the  bed-clothing,  the  presence  of  urine 
in  the  bladder  or  of  feces  in  the  rectum,  or  various  visceral  actions.  The  clonic 
spasms  begin  early  in  the  case  and  become  more  frequent  and  more  violent 
as  the  disease  progresses.  The  muscles  become  more  rigid  and  the  attitude 
produced  by  the  tonic  contraction  of  the  muscles  is  temporarily  exaggerated. 
The  forcible  contraction  of  the  jaw  may  loosen  or  break  teeth.  The  spasms 
of  the  diaphragm,  of  the  glottis,  and  of  the  muscles  of  respiration  may  produce 
death  and  always  produce  great  dyspnea.  The  man  laboring  under  a  tetanic 
convulsion  presents  a  dreadful  picture;  he  is  bent  into  some  unnatural  atti- 
tude, the  face  is  cyanotic  and  wet  with  drops  of  sweat,  the  lips  are  covered 
with  froth  which  is  often  bloody,  the  eyes  bulge  and  are  suffused,  and  the 
countenance  expresses  deadly  terror  and  stiff ering.  The  agonizing  "girdle 
pain"  so  often  met  with  is  due  to  spasm  of  the  diaphragm.  Each  clonic  spasm 
causes  a  hideous  scream  by  the  constriction  of  the  chest  forcing  air  through 
a  contracted  glottis.  During  the  progress  of  the  disease  constipation  is 
persistent,  and  retention  of  urine  is  the  rule  (because  of  sphincter  spasm). 
The  mind  is  almost  invariably  entirely  clear  until  near  the  end — one  of  the 
worst  elements  of  the  disease.  There  is  obstinate  insomnia.  Headache  is 
common.  Hearing,  at  first  hyperacute,  is  later  impaired.  Deafness  may  arise. 
Pulse  is  slow  and  full,  with  high  tension.  In  very  rare  cases  delirium  arises.  I 
have  seen  it  twice,  due,  I  fancy,  in  each  case  to  the  drugs  employed.  It  might, 
of  course,  be  due  to  previous  alcoholism.  Swallowing  in  many  cases  is  impos- 
sible. Talking  is  very  difficult  and  it  is  impossible  to  project  the  tongue.  The 
muscles  throughout  the  body  feel  very  sore.  The  temperature  may  be  normal, 
but  it  is  usually  a  little  elevated,  and  always  arises  just  before  death.     Hyper- 


2o8  Tetanus,  or  Lockjaw 

pyrexia  sometimes  occurs  (io8°-iio°  F.),  and  the  temperature  may  even 
ascend  for  a  time  after  death.  An  injection  of  serum  raises  the  temperature 
several  degrees.  In  about  80  or  85  per  cent,  of  cases  of  acute  tetanus  death 
occurs  within  five  days,  and  many  of  these  patients  die  within  two  or  three  days. 
Very  few  puerperal  cases  recover  and  practically  no  cases  which  follow  abortion 
recover.  Of  late  years  the  mortaUty  in  acute  tetanus  has  sKghtly  diminished. 
If  a  patient  Hves  a  week,  his  chance  of  recovery  is  good.  Death  may  be  due  to 
exhaustion  or  to  carbonic-acid  narcosis  from  spasm  of  the  glottis  or  fixation  of 
the  respiratory  muscles. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten  days  to  several 
weeks) .  The  symptoms  are  not  so  severe  as  in  acute  tetanus.  The  muscular 
spasm  is  widespread,  but  it  may  not  be  persistent,  intervals  of  relaxation 
permitting  sleep  and  the  taking  of  food.  Chronic  tetanus  long  had  a  mor- 
tality of  40  or  50  per  cent.,  but  modern  methods  of  treatment,  it  has  been 
claimed,  have  considerably  reduced  it.  According  to  the  report  of  Jacobson 
and  Pease  it  is  still  from  35  to  50  per  cent.  ("Annals  of  Surgery,"  Sept.,  1906). 
The  disease  may  last  for  some  weeks. 

Trismus  neonatorum,  or  trismus  nascentium,  the  lockjaw  of  the  newborn,  is 
due  to  infection  of  the  stimip  of  the  umbiUcal  cord,  and  is  practically  invariably 
fatal.  Hydrophobic  tetanus,  head  tetanus,  or  cephalic  tetanus  is  a  condition  in 
which  the  spasms  are  confined  chiefly  to  the  face,  phary^nx,  and  neck,  although 
the  abdominal  muscles  are  usually  also  rigid,  and  in  which  there  is  palsy  of  the 
seventh  nerve.  It  follows  head  injuries,  and  gives  a  better  prognosis  than  does 
general  tetanus. 

Two  other  forms  of  tetanus  have  been  produced  in  animals  by  experi- 
menters. One  is  cerebral  tetanus,  produced  by  injecting  tetanus  toxin  into 
the  brain  and  characterized  by  mental  SA^mptoms  (Roux  and  Borrell,  in  "An- 
nals Inst.  Pasteur,"  July,  1897).  Another  is  tetanus  dolorosa,  produced  by 
injecting  toxin  into  the  posterior  roots  of  the  spinal  nerves,  and  characterized 
by  violent  spasms  of  pain  without  motor  sjonptoms. 

Diagnosis. — Tetanus  may  be  confoimded  with  strychnin-poisoning,  with 
hysteria,  with  tetany,  or  with  hydrophobia.  Wood's  table  (see  page  209)  makes 
the  diagnosis  clear  between  tetanus,  strj^chnin-poisoning,  and  hysteria.^ 

Tetany  is  distinguished  from  tetanus  by  the  milder  nature  of  the  spasms, 
by  the  greater  limitation  of  the  rigidity,  by  the  fact  that  spasms  begin  in  the 
hands  or  feet,  not  in  the  jaw  and  neck,  and  in  most  cases  by  periods  of  dis- 
tinct intermittence. 

In  hydrophobia  tonic  spasm  does  not  exist,  and  if  clonic  spasms  occur  they 
are  secondary  to  suffocative  attacks. 

Treatment. — Far  better  even  than  to  treat  tetanus  well  is  to  prevent  it. 
Careful  antisepsis  v^ill  banish  it  as  a  sequence  of  surgical  operations  as  thor- 
oughly as  it  has  banished  septicemia.  'Every  infected  woimd  must  be  dis- 
infected with  the  most  scrupulous  care.  Every  pimctured  wound  is  to  be 
incised  to  its  depths  and  thoroughly  cleaned  and  drained.  In  a  very  sus- 
picious wound,  such  as  a  Fourth  of  July  injury  or  a  wound  from  a  dung  fork, 
or  the  entrance  into  the  tissues  of  a  splinter  from  a  stable  floor,  after  the 
removal  of  foreign  bodies  and  thorough  antiseptic  cleansing,  dust  the  wound 
with  antitoxin  powder  or,  better,  give  hy-podermatically  2000  or  3000  units  of 
antitetanus  serum.  It  seems  reasonably  certain  that  tetanus  antitoxin  has 
prophylactic  power;  in  fact,  Jacobson  and  Pease  say  that  "as  a  prophylactive 
measure  it  merits  our  fullest  confidence"  (Loc.  cit.).  Obviously,  this  cannot  be 
done  for  every  wound.  The  procedure  is  not  a  certain  preventive.  Reynier 
injected  antitoxin  into  a  patient  on  whom  he  was  about  to  operate  because 

1  "Nen'ous  Diseases,"  by  Prof.  H.  C.  Wood. 


Diagnosis  of  Tetanus 


209 


Tetanus. 


Hysteric  TET.wnjs. 


Strychnin-poisoning  . 


^luscular  symptoms 
usually  commence  with 
pain  and  stiffness  in  the 
back  of  the  neck,  some- 
times with  slight  muscu- 
lar twitching;  comes 
on  gradually.  Jaw  one 
of  the  earliest  parts 
affected;  rigidly  and  per- 
sistently set. 

Persistent  muscular 
rigidity  ver>'  general!}-, 
with  a  greater  or  less 
degree  of  permanent 
opisthotonos,  empros- 
thotonos,  pleurosthoto- 
nos,  or  orthotonos. 

Consciousness  p  r  e  - 
ser\-ed  until  near  death, 
as   in   strychnin-poison- 


Drafts,  loud  noises, 
€tc.,  produce  convul- 
sions, as  in  strychnin- 
poisoning;  may  com- 
plain bitterly  of  pain. 

Eyes  open  and  rigidly 
fixed  during  the  convul- 
sion. 


Commences   with   blind- 
ness and  weakness. 


Muscular  symptoms 
commence  with  rigidity  of 
the  neck,  which  creeps 
over  the  body,  affecting  the 
extremities  last.  Jaws 
rigidly  set  before  a  con\Til- 
sion,  and  remain  so  be- 
tween the  paroxj'sms. 


Persistent  opisthotonos 
and  intense  rigidit}^  be- 
tween the  convulsions  and 
after  the  con\'ulsions  have 
ceased,  the  opisthotonos 
and  intense  rigidity  last- 
ing for  hours. 

Consciousness  lost  as 
the  second  convulsion 
comes  on,  and  lost  with 
every  other  convulsion,  the 
disturbance  of  conscious- 
ness and  motility  being 
simultaneous. 


Crvdng  spells  altematinc 
with  convulsions. 


Ej'es  closed. 


Begins  with  exhilaration  and  rest- 
lessness, the  special  senses  being 
usually  much  sharpened.  Dimness 
of  vision  may  in  some  cases  be 
manifested  later,  after  the  develop- 
ment of  other  symptoms,  but  even 
then  it  is  rare. 

Muscular  sj-mptoms  develop  very 
rapidly,  commencing  in  the  extremi- 
ties, or  the  con\-ulsion  when  the  dose 
is  large  seizes  the  whole  body  simul- 
taneously. Jaw  the  last  part  of  the 
body  to  be  affected;  its  muscles  re- 
lax first,  and  even  when,  during  a 
severe  convulsion,  it  is  set,  it  drops 
as  soon  as  the  latter  ceases. 

MusAilar  relaxation  (rarely  a 
slight  rigidity)  between  the  convul- 
sions, the  patient  being  exhausted 
and  sweating.  If  recovery  occurs, 
the  convulsions  gradually  cease, 
lea\'ing  merely  muscular  soreness, 
and  sometimes  stiffness  like  that 
felt  after  \-iolent  exercise. 

Consciousness  always  preserved 
diiring  convulsions,  except  when  the 
latter  become  so  intense  that  death 
is  imminent  from  suffocation,  in 
which  case  sometimes  the  patient 
becomes  insensible  from  asphjrxia, 
which  comes  on  during  the  latter 
part  of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  "slightest  breath  of  air" 
produces  con\'Tilsion.  Patient  ma}- 
scream  with  pain  or  may  express 
great  apprehension,  but  "crj-ing 
spells"  would  appear  to  be  impos- 
sible. 

Eyes  stretched  wide  open. 


Partial  spasm  in  the  leg,  Legs  stiffly  extended  with  feet 
producing  in  Wood's  cases  everted,  as  the  spasms  affect  all  the 
crossing  of  the  feet  and  muscles  of  the  leg. 
inversion  of  the  toes.  If  j 
all  the  muscles  were  in- 
volved, eversion  would  oc-  | 
cur,  as  the  muscles  of  ever- 
sion are  the  stronger. 


there  was  a  case  of  tetanus  in  the  wards,  and  yet  this  man  developed  tetanus 
("Gaz.  des  Hopiteaux,"  July  16,  1901).  Thirty  Ught  cases  have  been  reported 
in  which  prophylactic  injections  failed  to  prevent  the  disease.  WTien  in  spite 
of  such  injections  the  disease  does  arise,  it  is  apt  to  be  mitigated  in  \iolence. 
Nevertheless  it  is  siure  that  animals  can  be  rendered  immune  to  tetanus,  and 
the  prophylactic  power  of  antitoxin  is  warmly  advocated  by  many  eminent 
men.  It  is  extensively  and  most  successfully  used  by  veterinarians  to  pre- 
vent tetanus  after  castration  of  horses,  and  this  success  is  a  guide-post  to  us. 
The  following  table  is  most  suggestive  (quoted  by  Heineck  in  "Surgery, 
Gynecolog}',  and  Obstetrics,"  Jan.,  1909,  from  Scherck's  article  in  "Jour.  Am. 


2IO  Tetanus,  or  Lockjaw 

Med.  Assoc,"  1906,  vol.  xlvii,  p.  500).     It  sets  forth  the  Fourth  of  July 
injuries  treated  in  St.  Louis  dispensaries: 

■^r„„„  xT^   „( „„  Antitetanic  serum  as        t\     ^u  c         ..  .. 

Years.  No.  of  cases.  ^  preventive.  Death  from  tetanus. 

1903  56  no  16 

1904  37  yes  none 

1905  84  yes  none 

1906  170  yes  none 

Puerperal  tetanus  is  prevented  by  antiseptic  midwifery,  and  tetanus  neo- 
natorum by  the  antiseptic  treatment  of  the  stump  of  the  cord.  In  order 
to  obviate  all  danger  of  the  development  of  tetanus  after  vaccination  per- 
form the  Httle  operation  mth  cleanhness  and  care  properly  for  the  wound 
and  for  the  pustule.  The  skin  should  be  cleansed  with  soap  and  water,  rubbed 
with  alcohol,  and  washed  \^dth  boiled  water.  It  should  be  gently  scraped  with 
a  knife  (which  has  been  boiled)  until  serum  exudes.  The  virus,  taken  from 
a  hermetically  sealed  tube,  is  apph'ed  to  the  raw  surface  and  allowed  to  remain 
exposed  to  the  air  until  dry.  A  piece  of  sterile  gauze  is  laid  over  the  part  and 
is  held  in  place  by  a  bandage.  This  dressing  is  changed  as  may  be  necessary, 
and  is  used  until  granulation  begins,  at  which  time  the  use  of  any  simple 
ointment  is  admissible.  Do  not  apply  a  shield.  The  evil  of  shields  is  pointed 
out  by  Robert  N.  WUlson  ("American  Medicine,"  Dec.  7,  1901). 

When  tetanus  exists,  always  look  for  a  wound,  and  if  one  is  found,  open 
it;  if  there  are  sloughs,  cut  them  away,  wash  the  wound  with  peroxid  of  hydro- 
gen and  then  with  hot  normal  salt  solution,  dry  the  wound  with  gauze,  paint 
the  surfaces  of  the  wound  with  bromin,  and  secure  drainage  by  packing  %\-ith 
iodoform  gauze.  Dennis  disinfects  the  wound  with  a  solution  of  trichlorid 
of  iodin  (0.5  per  cent.). 

Surgeons  of  a  former  day  were  accustomed  to  amputate  for  tetanus  if  the 
wound  was  upon  an  extremity.  When  we  reflect  that  the  poison-producers 
are  in  the  wound  and  not  in  the  circulation,  it  seems  a  reasonable  treatment. 
As  a  matter  of  fact,  it  never  does  any  good,  because,  when  the  symptoms 
begin,  the  toxin  has  already  entered  into  the  nerve-cells  and  become  fLxed. 
Kitasato  has  shown  that  if  a  mouse  is  inoculated  with  tetanus  near  the  root  of 
the  tail,  excision  of  the  tail  and  cauterization  of  the  stump  wall  not  prevent 
tetanus  unless  it  is  performed  within  one  hour  of  the  inoculation.  Nocard 
inoculated  sheep  near  the  root  of  the  tail  with  tetanus  spores,  and  although 
the  moment  symptoms  appeared  he  amputated  well  above  the  point  of  inocu- 
lation, the  animals  died  of  the  disease.  We  must  regard  amputation  as  a 
useless  method  of  treatment.  The  cases  of  Porter  and  Richardson  in  which 
bacilli  were  found  in  adjacent  glands  suggest  the  wisdom  of  removing  any  en- 
larged glands  which  chould  have  received  lymph  from  the  wound. 

Keep  the  sufferer  from  tetanus  in  a  darkened,  well-ventUated,  and  quiet 
apartment,  so  as  to  exclude  as  far  as  possible  peripheral  irritation.  Watch  for 
the  occurrence  of  retention  of  urine,  and  use  the  catheter  if  necessary.  Secure 
movements  of  the  bowels  by  administering  salines,  castor  oil,  croton  oil,  or 
enemas.  Stimulate  freely  wdth  alcohol,  and  give  fluids  by  h}T3odermoclysis. 
Give  plenty  of  concentrated  Hquid  food  imless  swallowing  causes  convulsions, 
then  feed  by  the  rectum.  If  swallowing  causes  convulsions  some  surgeons 
give  an  inhalation  of  nitrite  of  amyl  before  an  attempt  is  made  to  swallow. 
If  this  treatment  does  not  make  swallowing  possible,  then  partially  anesthetize 
the  patient  and  feed  him  by  means  of  a  pharyngeal  tube  passed  through  the 
nose.  It  may  become  necessary  to  abandon  mouth  feeding.  Large  doses 
of  the  bromid  of  potassium,  or  of  this  drug  with  chloral,  give  the  best 
results,  as  far  as  drug  treatment  is  capable  of  giving  results.  If  bromid  is 
used,  give  about  i  dr.  every  four  to  six  hours.     Chloretone  has  warm  advocates. 


Treatment  of  Tetanus  211 

It  is  given  in  large  doses.  It  abates  rigidity  and  diminishes  the  number  and 
severity  of  clonic  con\iilsions.  Other  drugs  that  have  been  used  with  some 
success  are  gelsemium.  morphin.  curare,  infections  and  fomentations  of 
tobacco,  physostigmin,  anesthetics,  cocain,  and  cannabis  indica.  An  ice- 
bag  to  the  spine  somewhat  relieves  the  girdle  pain.  Hot  baths  have  been 
ad^•ised.  It  is  said  that  venesection  followed  by  the  intravenous  infusion 
of  saline  fluid  does  good.  This  procedure  is  followed  by  a  free  flow  of  luine 
and  by  lessening  of  the  number  of  the  parox}.-sms.  It  may  be  repeated  several 
times  during  a  few  days  (E.  J.  McOscar,  in  '"American  ]SIedicine."'  Sept. 
14,  1901;  A.  V.  Moschcowitz,  in  "^led.  News,"  Oct.  13,  igoo). 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus:^  "Recoveries 
from  traumatic  tetanus  have  been  usually  in  cases  in  which  the  disease  occurs 
subsequent  to  nine  days  after  the  injur\-.  \Mien  the  symptoms  last  fourteen 
days  recover}-  is  the  rule,  apparently  independent  of  treatment.  The  true 
test  of  a  remedy  is  its  influence  on  the  history-  of  the  disease.  Does  it  cure 
cases  in  which  the  disease  has  set  in  pre\-ious  to  the  ninth  day?  Does  it  fail 
in  cases  whose  duration  exceeds  fourteen  days?  Xo  agent  tried  by  these 
tests  has  yet  estabUshed  its  claim  as  a  true  remedy  for  tetanus. '"- 

It  is  now  claimed  by  some  observ'ers  that  we  have  a  remedy  which  fulfils 
the  requirements  of  Yandell  in  the  tetanus  antitoxin  serum.  Behring's 
senmi  is  said  to  be  six  times  as  strong  as  Tizzoni's,  but  it  is  difficult  or  impos- 
sible to  estimate  the  exact  power  of  either.  Behring  and  Kitasato  succeeded 
in  immunizing  animals,  and  Tizzoni  and  Cattani  assert  that  the  antitoxin 
is  an  enzATiie.  The  antitoxin  destroys  the  acti\-ity  of  the  toxin  and  is  obtained 
from  an  immunized  horse. 

If  injected  subcutaneously  it  is  absorbed  ver\-  slowly,  and  even  twenty- 
foiu:  hours  or  more  after  such  an  injection  a  considerable  amount  remains 
unabsorbed  in  the  tissues.  It  is  not  absorbed  at  all  by  the  ners'ous  structures. 
It  is  eliminated  rapidly  and  unaltered  in  the  urine,  feces,  and  sweat.  It  seems 
to  be  harmless  and  its  immunizing  powers  are  certain.  Its  curative  power  is 
ver\-  much  less  certain.  H^-podermatic  injections  are  practically  useless.  In- 
travenous injections  are  of  more  service,  but  even  then  the  antitoxin  oifly 
grasps  the  toxin  in  the  blood  and  fails  to  reach  that  in  the  nerv"es,  ner\-e-ceUs, 
and  ner\-e-tracts.  Some  practise  intramuscular  injections,  but  7  acute  cases 
so  treated  died,  a  mortality  of  100  per  cent.  (Jacobson  and  Pease,  ■'Annals 
of  Surger}-/'  Sept.,  1906).  Injection  into  the  theca  of  the  cord  (intraspinal 
injection"^  by  means  of  lumbar  puncture  is  an  attractive  method,  but  the 
inability  of  ner\-e-elements  to  absorb  antitoxins  when  the  pia  inter\"enes  is 
an  argument  against  it,  though  in  i  ^-iolent  acute  case  of  my  own,  occur- 
ring in  a  boy,  recovery-  followed  this  method.  In  7  acute  cases  treated  by 
this  method  the  mortahty  was  57.1  per  cent.  (Jacobson  and  Pease,  Ibid.). 
John  Rodgers  injected  antitoxin  into  the  cauda  equina  and  ner\-es  and 
apparently  hopeless  cases  recovered  ('']Med.  Record,""  July  2.  1904^  In- 
jection into  a  nen.-e  (intraneural  injection)  is  a  more  rational  method,  but 
even  this  plan  is  only  of  service  in  localized  tetanus,  the  main  ner\-e  about 
the  part  tetanized  being  injected  (Kiister,  in  German  Surgical  Congress  of 
1905).  However  antitoxin  is  given,  the  dose  must  be  large  if  any  good 
is  to  be  done.  Serum  is  usually  prepared  as  follows:  A  horse  is  injected  re- 
peatedly with  the  toxins  obtained  from  cultures  of  tetanus  bacilli,  the  strength 
of  the  injections  being  gradually  increased.  Eventually  the  animal  becomes 
imTTmne  to  tetanus.  Some  days  after  the  final  injection  a  cannula  is  placed 
in  the  jugular  vein  of  the  immunized  animal,  blood  is  drawn  into  a  sterile 
vessel  and  is  permitted  to  coagulate  during  twenty-four  hours,  and  at  the  end 

^  "-\inerican  Practitioner,"  Sept..  1S70. 

-  Quoted  by  Hammond,  in  his  "'Diseases  of  the  Xer\-ous  S>-stem." 


212  Tetanus,  or  Lockjaw 

of  this  period  the  serum  is  separated  from  the  clot,  is  evaporated  to  dryness  in 
a  vacuum  over  sulphuric  acid,  and  the  powder  is  placed  in  hermetically  sealed 
glass  tubes.  In  order  to  use  the  serum,  dissolve  the  powder  in  sterile  water,  in 
the  proportion  of  i  gm.  to  lo  c.c.  The  fluid  serum  sold  in  the  shops  bears 
this  proportion  to  the  powder.  The  serum  can  be  given  subcutaneously  or 
intravenously,  or  can  be  injected  into  the  brain  or  under  the  cerebral  dura  or 
the  spinal  arachnoid,  or  into  a  nerve.  If  used  subcutaneously,  from  20  to  30  c.c. 
of  the  fluid  serum  should  be  injected  into  the  abdominal  wall,  and  this  dose 
should  be  given  every  six  or  eight  hours  until  there  is  improvement.  Then 
from  5  to  10  c.c.  should  be  given  every  six  or  eight  hours.  As  the  symptoms 
abate  the  dose  is  lessened  and  the  intervals  between  the  doses  are  increased. 
In  a  violent  cases  of  tetanus  the  first  dose  should  consist  of  40  to  50  c.c,  and 
this  can  be  repeated  in  four  or  five  hours.  In  a  case  of  tetanus  which  recovered, 
reported  by  Mixter,  enormous  doses  were  given.  This  patient  received  in  the 
aggregate  3400  c.c.  of  serum,  or  285  c.c.  a  day.^  In  47  acute  cases  treated  by 
subcutaneous  injection  the  mortality  was  82.6  per  cent.  In  30  acute  cases 
treated  by  a  combination  of  either  subcutaneous,  intraspinal,  intravenous,  or 
intracranial  injections  the  mortality  was  93.1  per  cent.  (Jacobson  and  Pease, 
in  "Annals  of  Surgery,"  Sept.,  1906).  Roux  and  Borrel  maintain  that  the 
toxins  of  tetanus  pass  from  the  blood  into  nervous  tissue  and  are  ILxed  in  the 
nerve-cells.  As  the  antitoxin  when  given  hypodermatically  or  intravenously 
remains  in  the  blood,  it  can  only  antidote  the  poison  in  the  blood  and  not  that 
in  the  nerve-cells.  These  observers  advise  that  the  antitoxin  be  placed  where 
the  toxins  are  active — that  is,  that  it  be  thrown  into  the  cerebrum  (intracere- 
bral injections).  The  skull  is  trephined  or  opened  with  a  small  drill,  a  blunt 
needle  is  passed  to  the  depth  of  15  inches  into  the  frontal  lobe,  and  the  serum 
is  slowly  injected.  Abbe  follows  Kocher;  uses  a  local  anesthetic  and  bores  a 
very  small  hole  through  the  skull  midway  between  the  outer  angle  of  the  orbit 
and  the  middle  of  a  line  running  across  the  head  from  one  external  auditory 
meatus  to  the  other.  The  serum  should  be  concentrated.  One  gram  of  dry 
antitoxin  is  dissolved  in  5  c.c.  of  water,  and  this  amount  is  the  proper  dose. 
The  opposite  frontal  lobe  should  also  be  injected  either  at  once  or  the  next 
day.  Even  when  serum  has  been  injected  into  the  cerebrum  it  should  also 
be  given  subcutaneously.  Abbe  employed  intracerebral  injection  in  5  severe 
cases  and  3  of  them  recovered.  He  is  a  strong  believer  in  the  method  (Ibid.). 
Moschcowitz  has  collected  38  cases  so  treated  and  claims  that  one-half  of 
them  recovered.  Cerebral  abscess  followed  in  i  case  ("Med.  News,"  Oct.  13, 
1900).  Tuffier  has  reported  a  successful  case  in  which  he  injected  10  c.c. 
of  serum  into  each  frontal  lobe  ("Gaz.  heb.  de  Med.  et  Chir.,"  July  4,  1901). 
The  method  has  of  late  been  practically  abandoned  in  spite  of  the  early 
favorable  reports. 

The  value  of  the  tetanus  antitoxin  in  acute  tetanus  is  more  than  doubtful. 
In  the  Russo-Japanese  War  its  use  was  abandoned,  and  d'Autma  found  it  of  no 
value  in  the  tetanus  cases  which  followed  the  Italian  earthquakes  of  1908.  A 
serum  injection  in  tetanus  raises  the  temperature  and  may  cause  depression 
of  the  circulation,  severe  headache,  vomiting,  diarrhea,  perhaps,  in  very  rare 
cases,  death.  Under  its  use  the  mortality  from  acute  tetanus  is  said  to  fall  from 
nearly  90  to  75  per  cent.,  but  the  figures  above  given  do  not  sustain  this  con- 
tention. Neither  do  the  figures  indicate  that  the  mortality  in  chronic  tetanus 
ha'^  been  greatly  influenced  by  it. 

Kitasato  has  shown  that  injections  of  iodoform  render  animals  immune, 
and  Sonnani  has  maintained  that  this  drug  placed  in  a  wound  prevents  the 
disease.  If  antitoxin  is  not  obtainable,  give  hypodermatic  injections  of  iodo- 
form, 3  to  5  gr.  t.  i.  d. 

1  "Boston  Med.  and  Surg.  Jour.,"  Oct.  6,  1898. 


Bacelli's  Treatment  of  Tetanus  213 

Bacelli's  treatment  was  introduced  by  Bacelli,  of  Rome,  in  1892.  It  consists 
in  the  hypodermatic  injection  of  carbolic  acid,  which  is  thought  to  grasp  tetanus 
toxin  and  mitigate  its  \"irulence  or  even  make  it  inert.  The  drug  is  also 
thought  to  be  sedative  and  to  lower  temperattu^e.  Tetanus  toxin  is  destroyed 
by  carbolic  acid  (shown  by  TLzzoni  and  Cattani  in  1890).  Kitasato  pointed 
out  in  1 89 1  that  cultures  of  tetanus  bacilU  can  be  rendered  sterile  in  thirt\' 
minutes  by  a  5  percent,  solution  of  carboKcacid.  The  usual  dose  is  15  minims  of 
a  3  per  cent,  solution  ever\-  two  hours.  Three  times  this  amount  can  be  given  in 
a  day.  To  avoid  irritation  Maragliano  uses  a  5  per  cent,  solution  in  sterile 
olive  oil.  Favorable  results  are  claimed  for  the  plan.  Bacelli  has  collected 
190  cases  (all  severe  or  ver^-  severe).  There  were  94  severe  cases  and  92 
recovered  (2^  per  cent,  mortaht}-).  There  were  38  ven.-  severe  cases  and  22 
recovered  (see  Bacelli.  in  ''Berliner  klinische  Wochenschrift.'"  Jime  5,  1911). 
Even  the  occurrence  of  carboluria  does  not  cause  the  surgeon  to  suspend  the 
treatment.  These  results  are  the  best  ever  given  in  tetanus  and  will  cause  us 
to  tr\-  the  treatment. 

The  h}-podermatic  injection  of  an  emulsion  of  fresh  brain-matter  has  been 
advocated  on  the  ground  that  brain-matter  and  tetanus  toxin  have  a  mutual 
affinit}'  (Krokiewicz ) .     The  results  are  not  conclusive 

Mathews  reports  cure  in  2  cases  following  the  ver}*  gradual  introduction 
into  a  vein  of  a  solution  containing  sodium  chlorid.  sodium  citrate,  sodium  sul- 
phate, and  chlorid  of  calciimi  ("Jour.  Am.  ]Med.  Assoc..'"  August  29,  1903). 
Cure  of  acute  tetanus  has  followed  the  intraspinal  injection  of  a  solution  of 
magnesiimi  sulphate,  which  drug,  ^leltzer  has  shown,  strongly  stimulates  in- 
hibition. Blake  has  reported  such  a  case  ('■"Jour,  of  Surgen.-.  G^Tiecolog}-, 
and  Obstetrics.""  May,  1906).  If  magnesium  sulphate  is  used,  2  c.c.  of  a 
25  per  cent,  solution  are  injected  into  the  subarachnoid  space  of  the  cord, 
after  first  remo\"ing  an  equal  quantity  of  cerebrospinal  fluid.  Some  hours 
after  such  an  injection  there  is  marked  muscular  relaxation  lasting  a  number 
of  hours.  Not  imusuaUy  there  is  lowering  of  respirator}'  rate.  When  the 
improvement  ceases  another  dose  is  given.  Heinecke  (Ibid.)  reports  a  suc- 
cessful case  and  collects  12  other  cases  so  treated.  7  of  which  died.  Smithson 
used  this  drug  and,  although  the  patient  died,  there  was  not  a  con^nilsion 
after  the  injection. 

]Murphy  reports  the  recoverA"  of  a  case  after  spinal  puncture  and  injection 
of  morphin  and  eucain  into  the  theca  of  the  cord  '"•Jour.  Am.  Med.  Assoc," 
August  13,  1904 1.  The  only  case  of  acute  tetanus  I  have  ever  had  recover  was 
treated  by  intraspinal  injection  of  antitoxin.  I  have  known  3  cases  of  chronic 
tetanus  to  recover:  i  was  treated  by  chloral  and  bromid  only,  2  were  treated 
bv  chloral  and  bromid  and  antitoxin  subcutaneouslv. 


XIII.  SURGICAL   TUBERCULOSIS 

Tuberculosis  is  an  infective  disease  due  to  the  deposition  and  multipli- 
cation of  tubercle  bacilli  in  the  tissues  of  the  body.  The  term  surgical  tuber- 
culosis is  applied  to  aU  of  those  mmierous  tuberculous  lesions  that  may  demand 
surgical  treatment.  Such  lesions  may  exist  in  different  structures,  often  seem 
clinically  to  be  strictly  localized  processes,  and  in  many  instances  may  be  ex- 
tirpated, drained,  or  sterilized.  Among  the  conditions  placed  under  the 
heading  of  surgical  tuberculosis  are:  Tuberculosis  of  glands,  of  bones,  of 
joints,  and  of  the  skin.  These  lesions  are  most  common  in  children,  the 
majority  of  cases  are  curable,  and  they  are  not  so  often  associated  with  or 
followed  bv  pulmonan."  phthisis  as  are  some  other  tuberculous  lesions.  They 
tend  in  manv  cases  to  remain  local  and.  bevond  doubt,  a  considerable  mmiber 


214  Surgical  Tuberculosis 

of  them  are  due  to  infection  with  bovine  bacilli.  Tuberculosis  is  characterized 
either  by  the  formation  of  tubercles  or  by  widespread  cellular  proliferation  (dif- 
fuse tubercle)  or  by  fibrinous  exudation,  which  is  very  rich  in  cells.  Tuber- 
culous conditions  tend  to  caseation,  sclerosis,  or  ulceration. 

A  tubercle  is  a  non-vascular  infective  focus,  appearing  to  the  unaided  vision 
as  a  semitransparent  gray  or  yellowish  mass  the  size  of  a  mustard-seed.  The 
microscopic  tubercle  is  the  most  characteristic  evidence  of  the  disease.  The 
microscope  shows  that  a  gray  tubercle  consists  of  a  number  of  cell-clusters, 
each  cluster  constituting  a  primitive  tubercle.  A  topical  primitive  tubercle 
shows  a  center  consisting  of  one  or  of  several  polynucleated  giant-cells  sur- 
roimded  by  a  zone  of  epithelioid  cells  which  are  surrounded  by  an  area  of  leuko- 
cytes. When  the  baciUus  obtains  a  lodgment  the  ILxed  connective-tissue  cells 
multiply  by  kar^^okinesis,  forming  a  mass  of  nucleated  polygonal  or  round  cells. 
These  cells  are  connective-tissue  cells  and  are  derived  particularly  from  endothe- 
lium and  are  called  epithelioid  cells  from  their  resemblance  to  epithelial  cells. 
Early  in  the  development  of  a  tubercle  blood  channels  lined  with  epithelioid 
cells  exist,  but  continued  cell  proliferation  blocks  the  channels  and  at  the  same 
time  the  blood-supply  of  the  growth  is  further  limited  by  the  pressure  of 
proliferating  perivascular  cells  and  the  proUferation  of  the  endothelial  cells 
of  adjacent  vessels.  Some  of  the  epitheHoid  cells  proliferate,  and  others 
attempt  to,  but  faU  for  want  of  blood-supply.  Those  which  fail  to  multiply 
succeed  only  in  dividing  their  nuclei  and  enormously  increasing  their  bulk 
(giant-cells).  Giant-ceUs,  which  may  also  form  by  a  coalescence  of  epithe- 
Hoid cells,  are  not  always  present.     Giant-cells  are  not  certain  e\ddence  of 

tuberculosis,  for  they  occur  in   s}'philitic   lesions, 
^^^^^^^^^^^j^     The    presence    of    irritant  bacterial   products   in- 
^°^^^^^5^^ftl§^^     duces   surrounding  inflammation   and  numbers  of 


,*ss>^  iaP-i 


^'"^^^^^^^^i^*     leukocytes  gather  about  the  epithelioid  cells  (Fig. 

'^'^J'<Ss%-i^^V^(livi'^'*<  The  bacUli,  when  found,  exist  in  and  about  the 

epitheHoid  ceHs,  and  sometimes  in  the  giant-ceUs. 
When  baciUi  enter  the  tissues  they  are  often  killed. 
If  they  enter  in  large  numbers  or  are  pecuHarly 
virulent  they  induce  chronic  inflammation,  granu- 
lation tissue  forms,  and  the  cells  of  the  focus  often 
have  the  characteristic  arrangement  described 
above.  The  baciUi  are  not  pyogenic  and  suppura- 
tion means  secondary  infection.  If  rmxed  infec- 
tion of  any  considerable  area  occurs,  the  patient  is 
apt  to  develop  fever  and  to  perish  from  exhaus- 
tion, amyloid  disease,  dissemination,  or  a  terminal 
showhig'giiat°ceUs  (BOT'lby)?'     infection.     In   rare  cases  the  tuberculous  area  is 

destroyed  and  cure  is  brought  about.  A  tubercu- 
lous focus  tends  strongly  to  degenerative  changes  because  of  the  local  anemia 
and  the  presence  of  baciUi.  If  numerous  active  bacilli  are  present  caseation 
takes  place.  This  is  coagulation  necrosis  due  to  the  action  of  bacteria  upon  a 
non-vascular  area.  It  starts  at  the  center  of  a  tuberculous  focus  and  spreads 
toward  the  periphery  and  finaUy  forms  masses  Hke  cheese.  WTien  caseated 
material  is  mixed  with  serum  tuberculous  pus  is  formed. 

A  caseated  focus  may  be  surrounded  or  encapsulated  by  fibrous  tissue. 
When  this  happens  the  tuberculous  process  may  remain  latent  for  months 
or  years,  perhaps  awakening  into  acti\-ity  as  the  result  of  a  traumatism  or 
lowered  general  resistance.  A  caseated  focus  may  be  cured  by  growth  of  fibrous 
tissue  which  replaces  the  tuberculous  focus.  This  is  cure  by  sclerosis.  A 
caseated  area  may  calcify.     Even  when  tuberculous  pus  forms  encapsulation 


The  Incidence  of  Tuberculosis  215 

may  occur,  the  fluid  being  absorbed,  and  the  remains  being  surrounded  hv 
fibrous  tissue.  Whenever  tubercle  bacilli  consume  all  available  food  thev  die  or 
remain  latent.  If  they  die  the  granulations  are  converted  into  librous  tissue  and 
the  part  is  healed.  If  they  remain  latent  they  may  at  any  time  become  again 
active.  Infiltrated  tubercle  is  due  to  the  running  together  of  manv  minute 
infective  foci,  or  to  ^\idespread  inliltration  -n-ithout  any  formation  of  foci. 
Infiltrated  tubercle  tends  strongly  to  caseate.  The  description  of  a  tubercle 
pre\-iously  given  relates  to  the  common  reticulated  tubercle.  Two  other 
varieties  exist. 

The  jibrous  tubercle  is  much  richer  in  dense  connective  tissue  than  is  the 
ordinary  tubercle.  It  forms  when  baciUi  are  greatly  weakened  or  killed. 
When  this  happens  embr}-onal  cells  cease  to  degenerate,  and  ordinar\-  inflam- 
mation results  in  fibrous  tissue  formation.  Fibrous  tubercle  is  e\'idence  of 
an  effort  at  cure. 

Hyaline  tubercle  results  from  hyaline  degeneration  of  the  reticulum  of  an 
ordinary-  tubercle  and  is  the  early  stage  of  coagulation  necrosis. 

Knowledge  of  recent  years  proves  that  the  baciUus  of  tubercle  may  fail  to 
cause  the  supposed  essential  lesions  outlined  above,  but  may  induce  instead 
tissue  changes  identical  vrith.  those  due  to  various  other  organisms.  Some 
of  these  changes  are  acute,  some  are  chronic.  In  some  there  is  h}-peremia. 
in  some  serous  exudation,  in  some  fibrous  exudation,  in  some  ceUular  h\"per- 
plasia,  perhaps  vrith.  parenchimatous  degeneration,  or  perhaps  with  sclerosis 
causmg  cirrhosis  (Rudolph  Matas.  in  ■"Southern  Med.  Join-..'"  Oct.,  1911). 
^latas  says  that  this  group  is  non-tuberculomatous,  at}-pical,  and  non-specific. 

The  Incidence  of  Tuberculosis. — Tuberculosis  is  the  most  wide- 
spread of  diseases,  being  particularly  common  in  northern  countries,  in  civil- 
ized regions,  and  in  great  cities.  Both  men  and  domestic  animals  suffer 
from  it,  and  it  is  occasionaUy  met  with  in  captive  wild  animals.  It  may 
even  occur  in  cold-blooded  animals.  It  is  rare  in  savage  races  and  extremely 
rare  in  ^"ild  animals  dwelling  imder  natural  conditions. 

^lanv  people  possess  lesions  of  tuberciflosis  who  present  no  clinical  e^"idence 
of  it.  C'arefifl  necropsies,  with  microscopical  studies  and  obser^-ations  with  the 
aid  of  tuberculin,  prove  this.  The  greatest  death-rate  of  those  infected  is  in 
childhood  and  early  adult  life  (Burkhardt.  in  1903,  quoted  by  Hamman  and 
Wolman  in  their  book  on  '' Tuberculin" "). 

How  manv  persons  die  of  tuberculosis  is  a  much  debated  point.  Some 
writers  clain  that  consumption  of  the  lungs  alone  kflls  one- third  of  aU  that 
die;  and  if  the  deaths  from  various  other  tuberculous  lesions  are  added  to 
this,  it  will  be  seen  what  an  enormous  part  the  disease  plays  in  the  mortahty 
tables.  ]Many  obser\-ers  hold  that  one-third  of  the  human  race  suffer  from 
tuberculosis,  and  that  in  ever\'  country"  the  remaining  two-thirds  free  from 
the  disease  are  even,-  moment  in  danger  of  acquiring  it.  E\-ans  has  main- 
tained that  of  the  35.000.000  deaths  that  occur  yearly  in  the  world.  5,000.000 
are  the  result  of  tuberculosis.  Pfliigge  thinks  that  one-seventh  of  the  race  die  of 
tuberculosis.  Sherman  G.  Bonney.  in  his  work  on  "Pulmonarx-  Tuberculosis." 
asserts  that  "from  85  to  95  per  cent,  of  the  human  race  have  been  at  some 
period  of  life  the  subject  of  tuberculous  infection"  and  that  i  person  in  7  dies 
of  the  disease. 

This  enormous  incidence  of  the  disease,  however,  is  disputed  by  some 
authorities;  notably,  by  G.  Cornet  (Xothnagei's  "Encyclopedia  of  Practical 
Medicine")-  This  obser\'er  states  that  apparently  one-seventh  of  aU  deaths 
result  from  tuberculosis,  and  that  some  pathologists  have  reported  that  in 
one- third  of  aU  necropsies  tuberciflous  lesions  are  found:  but  that  these  sta- 
tistics are  obtained  from  institutions  where  only  the  ver\-  poor  are  cared  for. 
and  that  the  percentage  of  tuberculosis  is  vastly  lower  in  the  better  classes  of 


2i6  Surgical  Tuberculosis 

the  community.  The  exact  figures,  however,  are  difficult  to  determine.  It  is 
certain  that  enormous  numbers  of  people  are  affected  with  tuberculosis. 
I  believe  many  affected  ones  recover,  for  Naegeli  points  out  that  almost  aU  who 
perish  after  thirty  from  non-tuberculous  conditions  show  healed  lesions  of 
tubercle.  Of  420  adults,  391  (93  per  cent.)  showed  signs  of  tuberculosis. 
Spengler  claims  that  every  human  adult  was  at  some  period  of  life  a  host 
for  tubercle  bacilH.  Bollinger  stated  that  in  one-fourth  of  all  postmortems 
upon  adults  evidences  of  tuberculous  disease  are  found  at  the  pulmonary  apices. 
Batmigarten  asserts  that  one  corpse  out  of  every  three  showed  a  tuberculous 
focus,  latent  or  healed.  Tuberculin  tests  confirm  the  views  of  Burkhardt  and 
NaegeH  and  contradict  the  opinions  of  Cornet.  Franz  injected  400  recruits 
who  had  passed  their  physical  examination  for  the  army  and  61  per  cent, 
reacted.  Von  Behring  maintains  that  all  of  us  are  "a  little  tuberculous" 
(Jonathan  Wright,  in  "New  York  Med.  Jour.,"  April  2,  1904).  Pfliigge 
maintains  that  from  50  to  70  per  cent,  of  the  human  race  are  predisposed 
to  tuberculous  infection,  and  if  infected  will  die  of  it  unless  an  intercurrent 
malady  destroys  them. 

The  Bacillus  of  Tuberculosis. — The  tubercle  bacillus  was  discovered  by 
Robert  Koch  in  1882.  It  is  a  little  rod  with  a  length  about  equal  to  one-half  the 
diameter  of  a  red  corpuscle.  It  is  non-motile,  does  not  form  spores,  and  requires 
oxygen  in  order  to  grow,  but  it  may  obtain  oxygen  from  body-cells  or  fluids. 
Tubercle  bacilli  exist  in  all  active  tuberculous  lesions,  and  the  more  active  the 
process  the  greater  their  numbers.  They  may  not  be  found  in  a  tuberculous 
area,  having  once  existed,  but  having  died  for  want  of  nourishment.  For  in- 
stance, in  a  cold  abscess  they  are  frequently  absent.  Bacilli  may  be  destroyed 
by  a  secondary  infection,  for  example,  by  a  pyogenic  infection.  Even  when 
present,  tubercle  bacilli  may  be  overlooked.  Differential  staining  may  exhibit 
the  bacilli.  In  the  material  from  an  active  tuberculous  lesion,  even  if  bacilli  are 
not  found,  injection  of  the  tuberculous  matter  into  a  guinea-pig  will  be  followed 
by  the  production  of  the  disease,  and  in  these  lesions  bacilli  can  be  demonstrated. 
Bacilli  may  be  widely  distributed  throughout  the  body.  It  has  long  been 
taught  that  they  may  occasionally  though  seldom  be  demonstrated  in  the  blood 
in  cases  of  acute  miliary  tuberculosis.  We  have  discussed  the  tubercle  bacillus 
on  page  52.  The  bacillus  of  leprosy,  the  smegma  bacillus,  and  the  tubercle 
bacillus  are  similar,  but  not  identical.  Each  is  an  acid-fast  bacillus;  that  is, 
if  stained  with  an  anilin  color,  mineral  acids  will  not  wash  out  the  stain. 
AU  acid-fast  bacilli  are  capable  of  producing  lesions  that,  to  some  extent  at 
least,  resemble  tuberculous  lesions;  but  the  lesions  produced  by  all,  except 
the  tubercle  bacillus  and  the  leprosy  bacillus,  tend  to  recovery.  It  is  possible 
that  all  acid-fast  bacilli  are  branches  from  a  common  stem. 

The  tubercle  bacilli  obtained  from  different  animals  differ  considerably^ 
both  in  morphology  and  in  virulence.  Koch  asserted,  in  1901,  that  the  bacilli 
of  hmnan  tuberculosis  differ  radically  from  those  of  bovine  tuberculosis, 
that  himian  tuberculosis  cannot  be  given  to  cattle  at  all,  and  that  it  is  so 
difficult  to  transfer  bovine  tuberculosis  to  the  human  being  that  the  danger 
from  infected  cattle  is  utterly  trivial  and  may  be  disregarded.  Ravenal 
and  others  have  positively  opposed  this  view  of  Koch's,  and  there  have  been 
reported  what  appear  to  be  imdoubted  cases  of  the  transference  of  tuberculosis 
from  animals  to  man.  There  is  still  dispute  upon  this  point,  but  most  writers 
believe  that  bovine  tuberculosis  and  human  tuberculosis  are  essentially  the 
same,  although  the  bacilli  present  temporary  differences  due  to  altered  en- 
vironment. The  bacilli  of  bovine  tuberculosis  are  certainly  far  less  danger- 
ous to  man  than  are  the  bacilli  of  human  tuberculosis,  and  the  bacilli  of  human 
tuberculosis  are  vastly  less  dangerous  to  cattle  than  are  the  bacilli  of  bovine 
tuberculosis.     Human  bacilli  introduced  into   cattle  may  produce   chronic 


Routes  of  Infection  217 

lesions,  but  they  are  always  non-progressive.  The  histologic  lesions  seen  in 
man  and  cattle  are  identical  and  so  are  the  degenerative  changes,  and,  as  Baum- 
garten  showed,  cattle  react  to  tuberculin  obtained  from  human  bacilli. 

Nocard  reports  2  cases  of  individuals  who  wounded  themselves  while 
cutting  the  flesh  of  tuberculous  cattle.  Both  developed  generalized  lesions 
and  died.  Ravenal  strongly  opposes  the  view  of  Koch  and  maintains  that 
the  bacillus  of  bovine  tuberculosis  is  highly  pathogenic  for  man  ("University 
of  Penna.  Med.  Bull.,"  xiv,  238,  1901).  The  same  author  has  reported  4  cases 
of  undoubted  inoculation  tuberculosis  in  the  hands  of  veterinarians.  Similar 
cases  have  been  placed  on  record  by  other  observers.  The  entire  question  is 
one  of  immense  importance.  If  Koch  is  right,  there  is  practically  no  danger 
to  man  in  eating  tuberculous  meat  or  in  drinking  tuberculous  milk.  Most 
observers  endorse  the  words  of  the  report  of  the  British  Commission  of  1904. 
This  commission  positively  maintained  that  bovine  tuberculoiss  can  be  com- 
municated to  man. 

The  baciin  of  bovine  tuberculosis,  when  they  find  lodgment  in  human  tissues, 
are  apt  to  produce  local  lesions  and  seldom  disseminate,  and  vice  versa.  It 
has  been  proved  that  many  cases  of  tuberculous  cer\ical  adenitis  in  children, 
but  only  3  per  cent,  of  cases  in  adults,  are  due  to  bovine  baciUi.  Fifty  per  cent, 
of  cases  of  abdominal  tuberculosis  in  children  and  20  per  cent,  in  adults  are  due 
to  bovine  bacilH.  Some  bone  cases  and  a  considerable  number  of  joint  cases  in 
children  depend  on  bovine  bacilli,  but  very  few  in  adults  are  so  caused.  Pul- 
monary tuberculosis  very  seldom  depends  upon  bovine  organisms.  It  is  thus 
clear  that  himian  infection  with  bovine  bacilli  is  most  common  in  the  young, 
and  that  surgical  tuberculosis  is  far  more  apt  to  have  such  origin  than  other 
forms.     Such  infections  frequently  tend  to  spontaneous  cure. 

Distribution  of  the  Bacilli. — These  bacilli  are  parasites,  and  not  sapro- 
phytes; and  the  real  source  of  infection  is  a  tuberculous  person  or  animal. 
Wherever  there  are  tuberculous  men  or  animals  the  bacilli  get  into  the  air. 
The  number  that  get  into  the  air  depends  upon  the  number  of  animals  affected, 
the  seat  of  the  tuberculous  lesion  in  each,  the  care  taken  by  the  victims,  and 
the  control  exercised  by  the  community. 

Tubercle  baciUi  from  an  infected  individual  may  get  into  the  atmosphere 
from  the  urine,  the  sputum,  the  feces,  the  sweat,  the  milk,  or  caseous  or  puru- 
lent material.  The  bacilli  from  dried  sputum  enter  the  dust,  in  which,  for- 
tunately, they  are  usually  destroyed  quickly  by  the  complete  dryness,  the 
oxygen  of  the  air,  and  the  sunlight;  but  under  some  circumstances  they  may 
retain  their  \drulence  for  weeks  or  even  for  months.  The  infected  area  itself 
is  usually  the  direct  soiu-ce  of  the  bacteria  from  a  given  case  of  tuberculosis, 
but  this  is  not  invariably  so;  for  a  tuberculous  woman  with  a  healthy  mammary 
gland  may  secrete  milk  containing  tubercle  baciUi, -a  consumptive  free  from 
genito-urinary  tuberculosis  may  occasionally  pass  urine  containing  bacteria,  a 
cow  may  give  tuberculous  milk  when  the  udder  is  not  diseased,  and  tubercle 
bacilli  may  enter  the  bUe  of  a  tuberculous  patient.  The  Third  Interim  Report 
of  the  Royal  Commission  on  Tuberculosis  states  positively  that  the  mUk  of 
tuberculous  cows  may  contain  baciUi  even  when  the  udder  is  not  diseased. 
It  is  probable  that  fUes  and  insects  may  transmit  infection  (Lord,  in  "Boston 
Med.  and  Surg.  Jour.,"  1904,  cU);  and  it  is  certain  that  putrefaction  does 
not  surely  destroy  tubercle  baciUi.  This  is  proved  by  the  fact  that  U\Tng 
baciUi  may  be  passed  in  the  feces  of  an  animal  that  has  been  fed  on  tuberculous 
meat,  and  that  they  may  be  found  in  the  feces  of  an  individual  suffering  from 
intestinal  tuberculosis.  We  are  thus  justified  in  concluding  that  slaughter- 
house waste,  if  improperly  disposed  of,  is  a  danger  to  the  community. 

Routes  of  Infection. — An  individual  may  acquire  tuberculosis  by  inhaling 
tuberculous   material    {inhalation   tuberculosis),    by    swaUow^ing    tuberculous 


2i8  Surgical  Tuberculosis 

material  {ingestion  tuberculosis),  and  by  inoculation  with  tuberculous  material 
(inoculation  tuberculosis).  Infection  of  the  lungs  may  be  brought  about 
by  the  inhalation  of  dried  tuberculous  sputum  or  dust  carrying  tubercle  bacilli. 
Ingestion  tuberculosis  may  follow  the  eating  of  tuberculous  meat,  the  drinking 
of  tuberculous  milk,  or  the  consumption  of  uncooked  articles  on  which  tubercle 
bacilli  have  gathered.  It  has  been  shown  that  the  lacteals  may  take  up  tubercle 
bacilli  from  the  intestine,  even  if  there  is  no  intestinal  lesion;  and  that  bacilU  can 
pass  through  the  thoracic  duct  and  into  the  blood,  and  lodge  in  some  tissue, 
particularly  the  pulmonary  tissue,  so  inducing  tuberculosis.  They  are  apt  to 
lodge  at  any  point  of  least  resistance;  and  if  not  caught  up  in  the  lungs,  wiU 
tend  to  be  arrested  in  an  irritated  gland  or  in  some  region  that  has  been  the 
seat  of  a  trifling  injury — for  instance,  in  an  epiphysis  that  has  been  strained. 
It  is  a  peculiar  fact  that  a  trivial  injury  constitutes  a  point  of  least  resistance; 
but  a  severe  injury,  such  as  a  fracture  of  a  bone,  does  not  do  so.  Baumgarten 
was  a  strong  beUever  in  the  idea  that  bacilli  enter  the  organism  with  the  food 
and  von  Behring  now  warmly  advocates  the  same  view,  teaching  that  bacilli 
enter  the  organism  of  every  person  in  early  life.  They  may  be  destroyed  by 
tissue  resistance,  but  if  not  destroyed  have  a  period  of  latency  and,  finally, 
perhaps  after  years,  become  active  and  cause  the  disease  ("Deutsche  Med. 
Woch.,"  Sept.  24,  1903).  Cahnette  and  Vanstenberg  ("Annales  de  ITnstitut 
Pasteur,"  1906)  have  long  insisted  that  infection  is  chiefly  by  the  alimentary 
canal  and  that  inhalation  infection  is  rare. 

It  is  certain  that  inoculation  may  be  followed  by  tuberculosis.  The  inocu- 
lation of  tubercle  bacilli  in  the  intestine  may  produce  intestinal  ulceration.  It 
has  been  shown  experimentally  that  rubbing  the  bacilli  into  the  nasal  mucous 
membrane  may  produce  a  local  area  of  disease.  Inoculation  of  the  skin  may 
result  from  a  wound,  the  bacilli  being  carried  into  the  wound  itself.  The  vic- 
tims of  cutaneous  inoculation  are  usually  butchers,  veterinary  surgeons,  phys- 
icians who  have  made  postmortem  examinations,  and  workmen  who  handle 
hides.  In  these  cases,  as  a  rule,  an  ulcer  promptly  forms  at  the  point  of  inocula- 
tion; but  in  some  few  cases  the  woimd  heals  soundly  and  tuberculous  lesions 
develop  in  several  or  many  weeks  later  in  the  wound  area  or  in  the  neighbor- 
hood. In  still  rarer  instances  no  apparent  inflammation  or  iflceration  occurs  in 
or  around  the  seat  of  inoculation,  but  the  anatomically  related  lymph-glands 
become  tuberculous.  In  other  cases  adjacent  bone  or  an  adjacent  joint  be- 
comes tuberculous.     Disease  of  the  limgs  may  follow  cutaneous  inoculation. 

A  number  of  cases  of  inoculation  tuberculosis  have  been  reported.  Not 
a  few  pathologists  have  developed  anatomic  tubercle  (see  page  247).  Schmidt 
records  a  case  of  tuberculous  ulcer  on  a  woman's  hp  due  to  a  bite  from  her 
tuberculous  husband.  It  is  recorded  that  a  tuberculous  person  inoculated 
others  while  tattooing  them,  the  needle  having  been  moistened  with  saliva. 
Letulle's  case  of  inoculation  tuberculosis  was  a  woman,  who,  while  scrubbing 
the  floor  of  the  room  in  which  her  tuberculous  husband  had  died,  ran  a 
splinter  into  her  hand.  The  wound  became  tuberculous.  Bosanquet  ("Lan- 
cet," Jan.  13,  191 2)  refers  to  a  laundress  who  infected  a  whitlow  with  tu- 
berculosis while  washing  infected  linen.  I  have  treated  a  physician  who  inocu- 
lated his  finger  while  making  culture  studies  with  tuberciilous  material.  In 
this  case  the  axillary  glands  became  tuberculous  and  were  removed.  I  have 
also  seen  a  tuberciilous  ulcer  of  the  forearm  in  an  attendant  of  a  lunatic 
asylum  who  had  been  bitten  by  a  tuberculous  patient.  Inoculation  tubercu- 
losis occasionally  follows  circumcision,  as  practised  by  an  orthodox  rabbi, 
the  operator  being  tuberculous.  A  ritual  operator  (as  Bosanquet  calls  him) 
stops  bleeding  either  by  applying  his  mouth  to  the  wound,  or  by  squirting 
wine  from  his  mouth  upon  the  wound.  There  have  been  reported  apparent 
cases  of  direct  inoculation  of  the  genito-urinary  tract  during  sexual  intercourse. 


Latent  Lesions  of  Tuberculosis  219 

If  there  has  been  some  definite  injury  of  the  tissues,  inoculation  may  follow  a 
simple  rubbing  of  tubercle  bacilli  into  a  part. 

When  the  mother's  ovum  is  tuberculous,  the  disease  may  be  directly  trans- 
mitted to  the  fetus,  producing  the  condition  known  as  congenital  tuberculosis. 
Rosenberger  found  bacilli  in  the  blood  from  the  umbilical  cord  of  the  placenta 
of  a  tuberculous  mother.  This  proves  that  congenital  tuberculosis  may  exist 
even  when  the  ovum  is  not  known  to  be  tuberculous,  and  also  that  a  child 
born  of  a  tuberculous  mother  is,  if  not  unmune  to  the  bacteria,  tuberculous 
from  the  moment  circulation  is  established  between  embryo  and  mother. 
Baumgarten  believes  that  bacilli  may  pass  the  placenta,  enter  the  fetus,  and 
remain  latent  for  years.  Latent  bacilli  have  been  found  in  normal  lymph- 
nodes  (Harbitz,  in  "Jour.  Infect.  Diseases,"  vol.  ii,  1904);  this  proves  that 
latency  is  possible.  However  common  the  direct  transmission  of  bacilK  may 
be,  the  direct  transmission  of  the  disease  is  unusual,  but  the  transmission  of  an 
hereditary  predisposition  to  infection  is  not  unusual.  In  spite  of  recent  asser- 
tions to  the  contrary,  I  believe  that  there  is  such  a  thing  as  hereditary  predis- 
position to  tuberculosis.  The  experience  of  the  human  race  uniformly  con- 
firms the  beUef  in  predisposition.  In  some  cases  of  tuberculosis  we  can  satisfy 
ourselves  cHnically  as  to  the  cause  of  the  infection.  For  instance,  when  an  in- 
dividual is  injured  with  an  object  known  to  carry  tubercle  bacilli,  if  an  ulcer 
of  the  skin  forms,  and  the  adjacent  lymphatic  glands  enlarge,  the  deduction  is 
obvious.  In  other  cases  it  is  impossible  to  make  up  our  minds  as  to  the  cause 
of  a  tuberculous  lesion.  For  instance,  we  can  only  guess  that  a  person  has 
inhaled  tuberculous  material  or  has  eaten  tuberculous  food.  If  in  inoculation 
tuberculosis  no  lesion  arises  at  the  point  of  entry,  the  opinion  as  to  the  causa- 
tion will  be  founded  merely  upon  guesswork. 

It  seems  certain  that  when  the  bacilli  of  tuberculosis  enter  into  the  body, 
if  they  are  not  destroyed  by  the  body-resistance,  they  may  produce  a  local 
lesion  at  the  site  of  inoculation,  or  pass  to  the  nearest  lymphatic  glands  or  to 
some  point  of  least  resistance,  and  there  establish  disease.  The  first  lesion  is 
known  as  the  primary  focus,  and  from  this  focus  disease  may  be  dissemi- 
nated to  the  most  distant  parts.  The  bacilli  enter  readily  if  there  is  a  wound 
or  an  abrasion;  but  in  exceptional  circumstances  they  may  enter  through  un- 
broken skin  and  undamaged  mucous  membrane.  Any  structure  may  become 
tuberculous,  but  some  structures  are  much  more  liable  to  do  so  than  others. 
The  lungs  are  very  liable;  the  conjunctiva  is  very  resistant. 

The  bacilli  are  generally  distributed  by  the  lymph,  but  may  enter  the  blood. 
Those  which  do  enter  the  blood  may  pass  out  in  the  urine  or  feces,  may  produce 
local  lesions,  or  may  induce  advancing  and  widespread  tuberculosis.  Dissemi- 
nation by  the  lymph-stream  is  known  clinically  to  occur,  and  it  means  slowly 
advancing  tuberculosis  with  localization  of  lesions.  In  dissemination  by  the 
lymph-stream,  the  dissemination  is  usually  in  the  normal  direction  of  the 
lymph-current ;  but  if  the  lymph- vessels  become  blocked,  lymph-regurgitation 
may  occur,  and  then  the  dissemination  takes  place  in  a  direction  opposite  to 
the  normal  flow  of  the  lymph-current. 

Latent  Lesions. — By  a  latent  lesion  we  mean  a  non-progressive  or  a  healing 
lesion  which  gives  no  clinical  evidence  of  its  progress.  Such  a  lesion  is  most 
apt  to  be  in  a  lung  or  in  a  gland.  It  may  serve  to  furnish  bacilli  to  distant  parts 
and  hence  be  responsible  for  secondary  lesions.  It  may  give  toxin  to  the  blood 
and  thus  induce  distant  trouble.  The  frequency  of  latent  lesions  becomes  evi- 
dent when  we  test  apparently  healthy  adults  with  tuberculin.  Although  we 
state  that  a  latent  lesion  causes  no  symptoms,  we  had  better  say  presents  no 
S5Tnptoms  to  suggest  tuberculous  involvement  of  the  part.  Hollos,  of  Hungary, 
insists  that  such  an  area  contains  toxin-forming  bacilli,  and  that  the  poisons 
taken  up  from  it  by  the  circulation  cause  a  chronic  toxemia  productive  of 


220  Surgical  Tuberculosis 

numerous  symptoms.  Such  symptoms  are  usually  thought  to  be  due  to  anemia 
or  neurasthenia.  This  subject  has  been  brilliantly  discussed  by  Matas  in  the 
"Southern  Med.  Jour.,"  Oct.,  1911. 

Products  of  the  Tubercle  Bacilli. — A  great  variety  of  products  are  formed 
by  the  tubercle  bacilli,  and  among  them  we  may  mention  alkaloids,  toxal- 
bumins,  fatty  acids,  and  ferments.  Experimental  injection  of  the  toxalbu- 
mins  produces  inflammation;  and  of  the  alkaloids,  fever.  It  has  been  shown 
by  Maragliano  that  injection  of  the  toxalbumins  actuaUy  lowers  the  tempera- 
ture. Beyond  any  doubt,  the  cultiu^e  material  in  which  tubercle  bacilli  are 
growing  contains  poison;  and  the  bodies  of  the  bacilli  themselves  contain  poison. 
The  poisons  in  the  culture-medium  are  called  extracellular  poisons,  and  those 
within  the  bacilli  are  called  intracellular  poisons.  It  is  quite  probable  that  the 
former  poisons  are  identical  with  the  latter,  and  have  merely  passed  from  the 
bacilli  into  the  culture-medium. 

Tuberculin. — It  was  proved  some  time  ago  that  dead  bacilli  are  toxic 
and,  if  experimentally  injected,  induce  a  toxic  condition  in  the  animal,  cause 
inflammation  of  the  kidneys,  and  sometimes  produce  subsequently  cold  abscess 
at  the  seat  of  injection.  In  1890  Koch  collected  the  poison  from  dead  bacteria 
in  the  form  of  a  liquid,  which  he  called  tuberculin.^  A  number  of  different 
methods  of  extracting  such  poison  have  been  suggested;  hence,  there  are  a  num- 
ber of  different  tuberculins,  not  one  of  which  contains  living  baciUi.  Koch  has 
made  several  himself.  His  early  tuberculin  was  made  by  making  a  glycerin- 
bouillon  culture  of  tubercle  bacilli,  evaporating  on  a  water-bath  to  one-tenth 
of  its  volume,  and  filtering  out  the  dead  baciUi.  The  filtrate  contained  tuber- 
culin mixed  with  glycerin.  It  is  now  known  as  original  or  old  tuberculin  or 
OT.  Later  Koch  prepared  tuberculin  from  virulent  cultures  of  bacilli,  dried, 
ground  up,  and  mixed  with  water,  the  fluid  being  centrifuged  for  forty-five 
minutes.  When  centrffuged,  two  layers  separate.  The  upper  layer,  which  is 
white  and  opalescent,  contains  the  elements  soluble  in  glycerin,  is  like  the  old 
tuberculin,  and  is  called  TO.  The  lower  layer  contains  an  emulsion  of  insoluble 
elements  of  high  immunizing  power,  and  is  called  TR.  In  190 1  Koch  presented 
another  tuberculin  of  dried  bacilli  in  equal  amounts  of  glycerin  and  water. 
It  is  caUed  bacillary  emulsion  or  BE.     This  is  reaUy  a  vaccine. 

It  was  discovered  by  Koch  that  tuberculous  animals  are  much  more  strongly 
affected  by  an  injection  of  tuberculin  than  are  healthy  animals.  The  most 
positive  reaction  is  noted  in  the  tuberculous  area;  but,  as  a  rule,  there  is  also 
a  reaction  in  the  area  where  the  injection  is  made.  We  get  no  reaction  from 
the  administration  of  tuberculin  by  the  stomach,"  but  occasionally  can  obtain 
it  by  the  inhalation  of  the  dried  material.  If  a  moderate  dose  of  tuberciilin  is 
injected  into  a  non-tuberculous  animal,  there  may  be  a  trivial  redness  at  the 
point  of  injection  and  a  slight  and  temporary  rise  of  temperature;  or  there 
may  be  no  evidence  of  reaction  whatever.  An  injection  in  a  tuberculous  ani- 
mal, however,  is  foUowed  by  distinct  inflammation  at  the  seat  of  injection,  and 
a  positive  reaction  in  the  tuberculous  area.  This  area  undergoes  congestion 
or  inflammation,  leukocytes  collect  around  it,  and  the  part  tends  to  necrosis 
and  is  liable  to  break  down.  It  is  not  that  the  bacilli  are  killed,  but,  rather,  the 
tissues  containing  the  bacilli  die. 

In  addition  to  the  changes  already  mentioned  there  is  elevation  of  tempera- 
ture. If  the  dose  has  been  smaU,  there  may  be  only  a  slight  feeling  of  coldness 
to  usher  in  the  rise  of  temperature;  but  if  the  dose  has  been  large,  there  is 
usually  a  distinct  chiU.     This  chiU  comes  on  eight  to  twelve  hours  after  the 

^  "Deutsch.  med.  Wochenschr.,"  1891,  xvii. 

2  Latham  and  S.  Solis-Cohen  claim  results  from  oral  administration.  MoUer  and 
Heinemann  seem  to  demonstrate  that  those  clinicians  are  mistaken  (''  Deutsche  med. 
Woch.,"  Oct.  5,  1911. 


Immunity  221 

injection  and  is  accompanied  and  followed  by  elevated  temperature.  The 
fever  lasts  from  four  to  twenty-four  hours,  and  the  temperature  may  be  ele- 
vated from  2°  to  5°  F.  The  febrile  condition  is  accompanied  by  pain  in  the 
head,  limbs,  and  back,  with  increased  rapidity  of  the  circulation,  restlessness, 
weakness,  and  usually  nausea.  xA-s  the  temperature  passes  to  normal  all  the 
symptoms  disappear.  The  slight  elevation  of  temperature  which  may  be  noted 
after  tuberculin  has  been  injected  into  a  non-tuberculous  animal  is  not  ushered 
in  by  a  chill,  and  does  not  exceed  1°  F.  unless  a  very  large  dose  has  been  given. 
We  thus  note  that  the  injection  of  tuberculin  may  be  of  the  greatest  possible 
value  in  diagnosis. 

A  person  with  a  thoroughly  healed  lesion  does  not,  and  a  far-advanced  case 
may  not,  react  to  tuberculin. 

Much  has  been  written  on  the  reaction  of  non-tuberculous  human  beings  to 
tuberculin.  Such  reaction  is  said  to  occur  in  leprosy,  in  convalescents  from 
acute  illnesses,  in  S}q3hilis,  and  in  actinomycosis.  Many  supposedly  healthy 
people  react  to  tuberculin.  Some  react  to  a  moderate  dose,  some  only  to  a 
large  one.  We  are  now  convinced  that  the  tuberculin  reaction  is  specific  and 
that  any  one  who  exhibits  it  possesses  a  tuberculous  focus,  active,  latent,  or 
healing.  Reaction  means  infection,  but  not  of  necessity  disease  with  clinical 
evidences.  Young  children,  especially  infants,  are  very  refractory  to  tuberculin 
because  young  children  are  seldom  tuberculous. 

A  real,  complete  reaction  to  tuberculin  has  three  elements : 

1.  A  constitutional  reaction  manifested  by  fever. 

2.  A  local  reaction  manifested  by  the  indication  of  swelling  and  redness,  a 
nodule,  or  an  infiltrating  area  in  the  region  of  puncture  (stick  reaction).  Some- 
times adjacent  glands  swell. 

3.  A  focal  reaction,  that  is,  inflammation  about  the  lesion.  ("Tuberculin," 
by  Hamman  and  Wolman.) 

A  good  many  observers  have  grown  fearful  of  injecting  tuberculin,  believ- 
ing that  it  is  hable  to  cause  the  tuberculous  focus  to  spread,  or  actually  to 
lead  to  the  development  of  disseminated  tuberculosis.  Virchow  was  of  this 
opinion.  That  such  a  condition  may  follow  the  use  of  large  doses  seems  cer- 
tain, but  moderate  or  small  doses  appear  to  be  entirely  safe.  Flick  has  pointed 
out  that  if  a  blister  is  applied  to  a  tuberculous  person  a  distinct  febrile  reaction 
appears  a  number  of  hours  after  the  application.  This  is  due  to  the  absorption 
of  toxic  material,  probably  tuberculin,  from  the  blister.  It  is  known  that  in  a 
tuberculous  animal  certain  excretions  (urine)  and  serous  exudates  contain  tu- 
berculin. Merieux  and  Baillon  show  that  if  a  tuberciilous  person  is  blistered 
the  fluid  of  the  blister,  injected  into  a  tuberculous  animal,  produces  a  definite 
reaction.  This  proceeding  is  of  diagnostic  value.  A  fluid  containing  tubercu- 
lin comes  from  the  blister  upon  the  tuberculous  person  and  he  is  proved  to 
be  tuberculous  by  injecting  the  blister  fluid  into  another  tuberculous  animal. 

Resistance  of  Bacilli. — ^Among  the  antagonistic  elements  we  have  men- 
tioned ox}^gen,  dryness,  and  sunHght.  Moist  heat,  at  the  temperature  of  boil- 
ing water,  is  rapidly  fatal.  A  5  per  cent,  solution  of  carbolic  acid  is  one  of  the 
most  powerful  of  germicides.  Full-strength  alcohol  is  next  in  point  of  power. 
Corrosive  sublimate  is  not  a  satisfactory  germicide.  Formaldehyd  is  fatal  only 
after  long  exposure.     Iodoform  and  ether  is  a  reasonably  powerful  mixture. 

That  the  virulence  of  tubercle  bacilli  varies  under  different  circumstances 
is  sure.  Under  some  circumstances  they  may  be  extremely  powerful;  under 
others,  nearly  innocuous.  The  liability  to  infection  depends,  probably,  in 
part,  on  individual  predisposition,  and  certainly,  to  a  great  extent,  on  the 
number  and  the  virulence  of  the  bacteria. 

Immunity. — It  seems  likely  that  some  persons  are  immune  to  tuberculo- 
sis.    Such  persons  may  come  from  an  ancestral  fine  in  which  all  the  predis- 


222  Surgical  Tuberculosis 

posed  died  of  tuberculosis,  so  that  the  immediate  ancestors  of  the  line  were  non- 
susceptible.  The  tendency  to  immunity  may  be  strengthened  by  proper  mar- 
riages, and  may  be  weakened  by  improper  marriages;  or  immunity  in  a  line 
may  be  destroyed  by  the  continuance  of  unfavorable  conditions.  Spengler 
claims  to  find  in  red  blood-corpuscles  of  healthy  men  an  immunizing  body.  It 
is  sometimes  noticed  that  during  the  progress  of  a  localized  tuberculous  infec- 
tion a  deep-seated  tuberculosis  (for  instance,  phthisis)  improves.  This  exhibits 
a  progressive  development  in  the  powers  of  the  organism  to  resist  infection  by 
stimulation  of  the  apparatus  for  opposing  infection.  That  numbers  of  people 
get  entirely  well  of  tuberculosis  is  certain  and  that  many  such  people  have 
secured  prolonged  immunity  is  probable.  Paretic  dements  seem  to  possess  a 
high  degree  of  immunity  to  tuberculosis  (Rosanoff,  in  "Jour.  Amer.  Med. 
Assoc,"  February  13,  1909).  Of  course,  the  term  "immunity"  is  only  relative. 
No  one  can  be  absolutely  immune;  for  when  subjected  to  extremely  unfavorable 
circumstances,  or  when  a  number  of  virulent  bacilli  are  introduced,  any  one 
may  become  tuberculous. 

Predisposition. — Personally,  I  believe  that  there  is  such  a  thing  as  a 
predisposition  toward  tuberculosis,  just  as  there  is  toward  many  other  diseases. 
Such  a  predisposed  individual  possesses  temporarily  or  permanently  a  condi- 
tion of  the  body-cells,  body-fluids,  or  both,  that  either  makes  easy  the  entrance 
of  the  bacilli  or  prevents  strong  opposition  to  their  multipHcation  when  they 
have  entered.  A  person  is  predisposed  to  an  infectious  disease  when  the 
opsonic  index  is  low,  for  this  indicates  lack  of  phagocytic  power  in  the  leuko- 
cytes. Predisposition  may  be  increased  by  some  extraneous  circimistance, 
such  as  occupation,  residence,  etc.,  that  brings  the  individual  into  frequent 
or  prolonged  contact  with  virulent  bacteria. 

There  is  certainly  such  a  thing  as  congenital  tuberculosis,  and  any  tissue 
may  be  involved  in  the  congenital  trouble.  Rosenberger  showed  that  blood  in 
umbihcal  veins  from  the  placenta  of  a  tuberculous  mother  contained  bacilli 
("Amer.  Jour.  Med.  Sciences,"  1909).  Young  children  are  very  liable  to 
tuberculosis  of  the  acquired  form.  According  to  Professor  Behring,  many 
children  become  infected  with  tuberculosis  in  their  early  years  by  eating  tuber- 
culous food;  but  such  a  tulperculosis  often  remains  latent  for  a  considerable 
length  of  time,  and  then  develops.  This  liability  depends  probably  upon  the 
fact  that  the  digestive  organs  of  the  child  are  not  so  strongly  protective  against 
bacteria  as  are  those  of  the  adult. 

Do  certain  individuals  possess  a  special  predisposition  to  develop  tuber- 
culosis, and  is  this  hereditary?  Hereditary  predisposition  was  once  regarded 
as  practically  the  only  cause  of  the  disease,  but  many  thinkers  now  regard  it 
as  of  slight  importance,  although  I  do  not  see  how  we  can  deny  its  existence. 
To  do  so  is  to  run  counter  to  the  experience  of  the  human  race  in  all  countries 
and  at  all  times.  We  all  see  how  common  tuberculosis  is  in  the  descendants  of 
tuberculous  persons.  Hutley  studied  432  cases  of  tuberculosis.  In  23.8  per 
cent,  one  or  both  parents  had  the  disease  (the  father  alone  in  11. 5  per  cent., 
the  mother  alone  in  9.9  per  cent.,  and  both  in  2.4  per  cent.).  Some  maintain 
that  in  30  per  cent,  of  consumptives,  one  parent  or  both  parents  have  been  con- 
sumptives, and  in  60  per  cent,  a  parent  or  a  grandparent  has  suffered  from 
tuberculosis.  Of  course,  the  above  statements  do  not  prove  that  the  cases  in. 
a  family  are  due  to  heredity;  but  that  there  must  be  such  a  thing  as  heredi- 
tary predisposition  is  indicated  by  the  fact  that  there  are  many  families  living 
under  similar  conditions  to  the  tuberculous  families,  without  there  having 
occurred,  through  several  generations,  a  single  case  of  tuberculosis  among  their 
members.  A  feature  that  makes  us  imable  to  reach  a  certain  conclusion  is 
that  tuberculosis  is  contagious  and  several  members  of  a  family  may  be  in- 
fected from  one  member,  even  when  there  is  no  predisposition  to  the  trouble 


Relation  of  Trauma  to  Tuberculosis  223 

by  heredity.  The  mere  living  in  one  house  may  account  for  the  infection. 
A  fact  strongly  in  favor  of  the  hereditary  intluence  is  that  in  a  family  whose 
ancestors  have  been  tuberculous  and  whose  members  have  not  lived  together, 
but  have  been  scattered  widely  over  the  earth,  member  after  member  may 
die  of  the  disease. 

Unhealthy  environment  particularly  predisposes  to  tuberculosis;  and 
the  element  of  poverty — leading  as  it  does  to  taking  improper  or  insufficient 
food,  dwelling  in  an  unhygienic  room  or  in  an  overcrowded  building,  pursuing 
an  exhausting  occupation,  working  for  long  hours,  and  obtaining  insufficient 
amusement  and  outdoor  exercise — also  has  a  most  powerfully  unfavorable 
effect.  As  a  class  the  poor  dislike  ventilation,  take  insufficient  exercise  in 
the  open  air,  do  not  get  enough  sunlight,  work  in  a  dusty  atmosphere,  take 
insufficient  nourishment  and  eat  improper  food,  live  in  damp  and  dirty  rooms, 
are  subjected  to  grinding  competition  and  cruel  anxieties,  and  many  of  them 
drink  quantities  of  whisky.  City  life  is  a  predisposing  cause  of  tuberculosis 
for  many  of  the  foregoing  reasons,  and  particularly  because  many  city  workers 
follow  an  indoor  occupation.  The  enemies  of  tuberculosis  are  sunlight,  fresh 
air,  nourishing  food,  and  outdoor  exercise,  and  the  limiting  of  any  of  these 
factors  favors  the  development  of  the  disease. 

Tuberculosis  may  occur  in  any  region  that  man  inhabits ;  although  in  some 
regions  it  is  rare,  and  in  others  it  is  excessively  common.  Its  great  frequency 
in  some  regions  is  probably  due  less  to  climate  than  to  en^'ironment,  occupation, 
and  heredity;  and  the  greatest  predisposition  is  found  in  the  town  dweller. 
There  is  much  more  tuberculosis  among  males  than  among  females. 

]Many  diseases  and  conditions  predispose  to  tuberculosis.  It  is  very  com- 
mon in  chronic  drunkards,  in  the  insane,  in  the  occupants  of  prisons,  alms- 
houses, and  reformatories;  among  negroes  in  the  North,  particularly  those 
engaged  in  indoor  occupations;  among  American  Indians  subjected  to  the 
blighting  influences  of  ci^-ilization  by  formula  and  routine ;  and  in  the  sufl"erers 
from  tertiars'  s^.'philis,  diabetes,  and  Bright's  disease.  Any  exhausting  malady 
may  be  foUowed  by  tuberculosis. 

Relation  of  Traiima  to  Tuberculosis. — (Inoculation  Tuberculosis  is  dis- 
cussed on  page  218.)  This  question  is  often  in  dispute  and  has  become  of  much 
medicolegal  importance.  Several  times  of  late,  in  the  courts  of  Philadelphia, 
it  has  been  the  subject  of  acrimonious  controversy.  Suitors  affirm  the  rela- 
tionship, corporations  deny  it,  and  experts  wrangle  till  judge  and  jurymen  do 
not  know  what  to  believe. 

There  can  be  no  doubt  that  tuberculosis  often  becomes  manifest  in  a  part 
after  that  part  has  been  subjected  to  traumatism.  Xo  one  denies  this.  In 
fact,  in  over  one-sixth  of  aU  cases  of  bone  and  joint  tuberculosis  traimiatism 
is  set  down  as  causal. 

I  do  not  mean  that  trauma  causes  the  tissue  changes  characteristic  of  tuber- 
culosis. Such  changes  are  always  and  only  produced  by  the  action  of  tubercle 
bacilli.  I  do  mean  that  the  injur}"  puts  the  part  in  such  a  condition  that 
the  bacilli  of  tubercle  attack  the  injured  tissue,  having  been  unable  to  attack  it 
when  it  was  in  a  state  of  health.  The  injur}-  creates  an  area  of  least  resistance. 
In  such  an  area  the  cellular  acti\-ities  are  no  longer  able  to  ^^•ithstand  the  action 
of  bacteria.  Without  an  injury  it  is  highly  improbable  that  tuberculosis  would 
ever  have  arisen  in  the  part.  At  least  the  injun,^  determined  the  localization 
and  multiplication  of  bacilli  and  the  origin  of  an  active  tuberculous  focus,  and 
to  this  extent  the  injur}'  was  causal. 

Osteomyelitis  is  due  to  pyogenic  cocci.  It  may  arise  in  a  bone  subjected  to 
traumatism.  Traiunatism  is  stated  to  be  a  cause.  \Miy  should  a  tuberculous 
process  be  placed  in  a  different  categor}-?  \Miere  do  the  tubercle  bacilli  come 
from?     Some  maintain  that  if  tuberculosis  follows  traumatism  of  a  part,  there 


224  Surgical  Tuberculosis 

was  a  latent  and  undiscovered  tuberculous  process  in  the  part  before  the  acci- 
dent, and  that  all  the  accident  did  was  to  light  up  a  latent  focus  into  activity; 
in  other  words,  to  precipitate  an  inevitable  event.  This  contention  is  true  in 
some  few  cases;  we  believe  it  to  be  untrue  in  a  large  majority  of  cases. 

Some  beheve  that  though  there  may  have  been  no  local  latent  focus,  there  is, 
at  least,  somewhere  in  the  body  an  area  of  tuberculosis  to  furnish  the  baciUi. 
This  view  is  true  of  many,  but  we  do  not  believe  of  all,  cases.  It  gains  in  proba- 
bihty  from  the  estabhshed  fact  that  tuberculous  bone  or  joint  disease  is  most 
apt  to  arise  in  those  known  to  have  tuberculous  infection  somewhere  about 
them.  It  is  certain  that  in  many  cases  there  is  no  demonstrable  focus  of 
tubercle  anywhere  to  be  found  except  in  the  injured  part.  It  is  hard  to  prove 
a  negative,  and  it  is  impossible  in  any  case  to  deny  arbitrarily  that  an  un- 
recognizable distant  latent  focus  may  exist. 

We  know,  however,  that  many  cases  never  give  any  sign  of  distant  tuber- 
culosis before  the  accident,  and  never  give  any  sign  of  it  afterward.  We  do 
know  that  bacilli  can  exist  for  a  considerable  time  in  blood  or  lymph  when  there 
is  no  demonstrable  lesion  of  tuberculosis.  From  such  blood  or  lymph  bacilli 
may  be  deposited  in  the  injured  part  and  become  active  for  harm. 

W^e  do  know  that  bacilli  may  live  for  a  long  time  in  glands  or  bone-marrow 
without  producing  any  evidence  of  a  lesion  of  bone  or  of  gland  (Petrow,  Lan- 
nelongue).  If  bone-marrow  or  gland  containing  bacilli  is  injured,  these  bacilU 
become  active  and  estabhsh  an  area  of  disease.  Without  the  injury  it  is  im- 
probable that  there  would  have  been  disease. 

Local  tuberculosis  follows  slight  rather  than  severe  injury.  I  have  seen  it 
after  a  strain  of  an  epiphysis,  never  after  a  fracture.  I  have  seen  it  after  a  sprain 
of  a  joint,  never  after  a  dislocation.  After  a  severe  injury  tissue  reaction  is  so 
marked  that  bacilh  are  destroyed.  It  is  particularly  in  bone  and  joint  tubercu- 
losis that  traumatism  is  held  to  be  causal.  Whitman  tells  us  that  out  of  nearly 
3400  cases  occurring  in  the  clinics  of  Bruns,  Koenig,  Mikulicz,  and  Hildebrand 
over  500  were  attributed  to  trauma.  I  have  seen  a  number  of  such  cases,  most 
of  them  involving  the  knee,  foot,  or  wrist.  I  have  seen  tuberculosis  of  the  glands 
of  the  groin  arise  after  a  bruise,  tuberculous  pleuritis  and  tuberculosis  of  the 
chest-wall  follow  a  chest  contusion,  and  sacro-Uiac  tuberculosis  follow  a  sprain. 
Tuberculous  meningitis  has  followed  head  injury.  I  have  seen  several  cases  of 
tuberculosis  of  the  testicle  after  contusion.  When  injury  is  followed  by  a  tuber- 
culous lesion,  the  definite  signs  and  symptoms  of  that  lesion  do  not  appear  for 
from  three  to  six  weeks  after  the  accident.  We  may  conclude  that  tuberculosis 
may  arise  at  the  seat  of  an  injury;  that  in  some  cases  there  may  have  been  an 
antecedent  lesion  at  that  point;  in  some  cases  there  is  a  distant  active  lesion; 
in  some  cases  a  distant  latent  lesion ;  in  some  the  bacilh  must  have  been  lying 
inactive  in  the  part  or  must  have  lodged  there  from  blood  or  lymph,  after  the 
accident  and  because  of  it.  R.  L.  Dixon  reported  a  number  of  such  cases 
("Physician  and  Surgeon,"  Jan.,  1909).  Hueter  and  Schiiller  insist  on  the 
tendency  of  trauma  to  localize  tuberculosis.  Ribera  Y  Sans  (quoted  in 
"Practical  Medicine  Series,"  vol.  in  Surgery,  1912,  edited  by  John  B.  Murphy) 
states  that  in  45  per  cent,  of  cases  of  tuberculosis  of  the  larger  joints  the  condi- 
tion is  preceded  by  trauma.  In  an  appended  note  by  Murphy  we  learn  that 
that  surgeon  believes  that  tubercle  baciUi  tend  to  escape  from  the  circulation  at 
the  site  of  a  slight  trauma  and  to  light  up  disease.  Bosanquet  ("Lancet,"  Jan. 
13,  191 2)  says  that  in  expressing  an  opinion  "as  to  the  probabihty  of  a  tuber- 
cular lesion  being  due  to  a  preceding  accident,  I  think  we  must  put  disease  of 
joints  in  a  class  by  itself.  There  is  a  considerable  mass  of  evidence,  that  in 
some  way  or  other  injury  does  lead  to  tubercular  arthritis,  and  if  the  occurrence 
of  the  accident  is  clearly  estabhshed  and  it  is  followed  at  a  reasonable  interval 
by  the  tuberculosis,  we  may  accept  the  causal  connection  as  probable."     He 


Lymphatism,  or  the  Lymphatic  Constitution   (Status  Lymphaticus)     225 

regards  "a.  reasonable  period  of  time"  as  not  over  three  months.  During  the 
interval  there  should  have  been  some  pain  in  or  stiffness  of  the  joint. 

The  Term  "Scrofula." — Many  surgeons  positively  oppose  the  use  of  the 
term  scrofula,  but  I  believe  that  there  is  clinical  value  in  retaining  it.  The  sur- 
geons that  have  entirely  abandoned  it  think  that,  after  all,  it  is  exactly  synony- 
mous with  tuberculosis.  I  use  it  to  designate  the  persons  that  are  predisposed 
to  tuberculosis  through  possessing  a  type  of  tissue  of  low  resisting  power. 
These  tissues  fall  a  ready  prey  to  the  bacteria  of  tuberculosis.  Such  tissue  vul- 
nerability is  usually  hereditary;  and,  as  a  rule,  one,  or  even  both  parents  are 
tuberculous,  are  in  ill  health,  or  are  themselves  predisposed.  Occasionally 
this  type  of  tissue  is  acquired,  a  child  having  at  first  been  apparently  entirely 
healthy,  and  later,  owing  to  poor  food,  insufficient  air,  and  bad  hygienic  sur- 
roundings, developing  scrofula. 

That  scrofula  is  not  simply  osseous,  articular,  or  glandular  tuberculosis  is 
proved  by  the  fact  that  a  person  that  we  recognize  as  scrofulous  may  never 
throughout  his  life  develop  a  recognizable  tuberculous  lesion.  Some  surgeons 
think  that  scrofula  is  latent  tuberculosis,  and  will,  under  the  influence  of  an 
exciting  cause,  burst  into  activity.  This  is  possible,  but  unproved.  We  do 
know  that  some  so-called  scrofulous  lesions  are  not  tuberculous ;  for  instance, 
facial  eczema,  corneal  ulceration,  granular  lids,  and  mucous  catarrh.  These 
lesions  are  rather  expressive  of  poor  health,  improper  food,  and  deprivation 
of  fresh  air. 

The  subjects  of  scrofula,  besides  being  prone  to  the  non-tuberculous  lesions 
above  mentioned,  are  particularly  prone  to  develop  tuberculous  lesions;  and 
such  a  lesion  may  arise  in  any  part  that  has  been  the  seat  of  a  slight  injury  or 
of  a  non-tuberculous  inflammation.  The  parts  most  apt  to  become  tubercu- 
lous are  the  bones,  the  joints,  and  the  glands. 

There  are  two  types  of  the  so-called  scrofulous,  that  is,  two  types  of  those 
that  are  predisposed.  The  common  type  is  known  as  the  phlegmatic,  or 
lymphatic;  and  it  is  this  type  that  is  particularly  described  by  our  surgical 
forefathers.  In  the  phlegmatic  type  the  individual  is  stolid  of  expression, 
and  has  thick,  coarse  skin,  a  muddy  complexion,  dark,  coarse  hair,  a  thick 
neck,  thick  lips,  a  thick  nose,  and  a  heavy  lumbering  gait.  He  is  dull  of 
apprehension,  with  feeble  emotional  reaction,  and  but  little  capacity  for  con- 
centratioir  or  interest.  The  other  type  is  much  more  seldom  met  with.  It  is 
what  is  called  the  sanguine  type,  or  what  the  elder  Gross  spoke  of  as  the  an- 
gelic type.  Such  a  child  is  frequently  beautiful  and  graceful  in  its  movements. 
Its  skin  is  transparent  and  clear,  and  the  color  comes  and  goes.  The  eyes 
are  blue,  the  lashes  long,  and  the  hair  silky.  The  tendency  is  to  thinness, 
rather  than  fat;  the  mind  is  not  dull,  but  precocious,  and  the  temperament 
is  nervous.     In  both  these  types  of  scrofula  the  condition  of  lymphatism  exists. 

Lymphatism,  or  the  Lymphatic  Constitution  (Status  Lymphati= 
cus). — The  term  was  introduced  by  Potain  to  designate  a  condition  in  child- 
hood in  which  there  is  a  very  strong  disposition  to  the  development  of  disease 
of  the  lymphatic  structures,  or  in  which  at  birth  there  was  excessive  develop- 
ment of  these  structures.  As  a  matter  of  fact,  the  condition,  though  most 
common  in  infancy  and  childhood,  can  exist  in  adults.  The  enlarged  glands 
may  be  tuberculous  from  the  beginning;  but,  as  a  rule,  they  are  not  so  in  the 
beginning,  but  tend  to  become  so.  Inflammation  of  a  mucous  membrane  is 
followed  by  enlargement  of  the  anatomically  related  lymphatic  glands.  These 
enlarged  glands  are  frequently  met  with  in  the  neck.  We  find  them  associated 
with  enlarged  tonsils  and  pharyngeal  adenoids. 

Usually  lymphatism  is  congenital,  but  it  may  be  acquired  when  children 
are  placed  under  unfavorable  conditions.  Lymphatic  children  frequently 
have  rickets  and  are  invariably  anemic,  yet  there  is  considerable  or  much  sub- 
15 


226  Surgical  Tuberculosis 

cutaneous  fat  (Escherich).  In  infancy  it  is  the  bronchial  and  mesenteric  glands 
that  are  particularly  apt  to  enlarge;  in  childhood,  it  is  the  glands  of  the  neck. 
Usually  the  tonsils  are  enlarged  and  the  nasopharynx  contains  adenoids.  The 
spleen  is  usually  palpable.  In  lymphatic  children  it  is  not  uncommon  to  have  a 
persistent  and  h^pertrophied  thymus  gland.  The  gland,  however,  is  not 
obvious,  but  rather  hides  at  the  root  of  the  neck  (Humphrey,  in  "Lancet," 
Dec.  26,  1908),  and  may  be  missed  at  necropsy.  During  life  the  thymus  is 
sometimes  observed  as  a  pulsating  mass  at  the  root  of  the  neck.  Even  if  it 
cannot  be  seen  its  presence  can  usually  be  determined  by  percussion  and  by 
the  x-Ta.ys  (Hochsinger)  (see  page  1247).  In  about  half  the  cases  a  goiter  is 
obvious,  and,  as  pointed  out  by  Berg,  many  of  those  with  goiter  have  symptoms 
of  Graves's  disease.  As  the  child  increases  in  age,  the  lymphatic  enlargements 
are  likely  to  disappear  unless  tuberculous  infection  has  occurred.  After  a 
child  has  reached  the  age  of  seven  or  eight  years  non-tuberculous  glands  of  the 
neck  cease  to  enlarge,  and  by  the  time  of  puberty  they  have  usually  disappeared. 
Buxton  ("Lancet,"  Aug.  6,  1910)  states  that  young  persons  suffering  from  this 
condition  are  tall  and  thin;  possess  clear,  fair,  and  pale  skins;  the  temperament  is 
blended,  there  is  mental  slowness  yet  intelligence,  there  is  shyness  and  strong 
self-feeling.  They  cannot  withstand  cold,  are  very  emotional,  and  yet  may 
be  able  to  appear  calm.  The  pulse  is  normally  50  to  60,  but  is  made  rapid 
and  irregular  by  trifling  excitement.  I  do  not  beheve  that  the  condition  can 
be  certainly  diagnosticated  during  life.  McCardie  regards  hypertrophied  lin- 
gual follicles,  and  the  existence  of  lymphoid  masses  in  the  wall  of  the  pharynx, 
the  pyriform  sinus,  and  in  the  anterior  surface  of  the  epiglottis  as  significant 
of  the  existence  of  lymphatism. 

If  an  operation  is  performed  on  the  victim  of  lymphatism  the  wound  is 
very  liable  to  become  infected,  and  the  bleeding  from  the  wound  is  very  trivial. 
The  victims  of  lymphatism  are  more  apt  than  other  persons  to  die  under  a 
general  anesthetic,  and  occasionally  one  of  them  dies  during  natural  sleep. 
(See  Dr.  Geo.  Blimier,  in  the  "Bulletin  of  the  Johns  Hopkins  Hospital," 
Oct.,  1903.)  Cases  have  died  from  injection  of  diphtheria  antitoxin  (see  page 
46).  This  disease  accounts  for  most  otherwise  inexplicable  cases  of  sudden 
death  in  children  and  young  persons,  and  such  deaths  are  respiratory  and  not 
cardiac  (Humphrey,  in  "Lancet,"  Dec.  26,  1908). 

The  Diagnosis  of  Tuberculosis. — Whenever  he  sees  a  persistent  area 
of  chronic  inflammation  in  any  structure  of  the  body  the  surgeon  must 
think  of  the  possibility  of  its  being  tuberculous.  A  thorough  investigation 
must  be  made  into  the  local  disease  and  the  body  generally;  and  it  is  of  par- 
ticular importance  to  determine  whether  there  is  any  other  diseased  locality, 
and  whether  there  is  any  evidence  of  tuberculous  disease  anywhere  in  the  body. 
The  patient's  history  must  be  investigated,  and  any  possible  tendencies  or 
predispositions  inquired  into.  Tuberculosis  does  not  cause  leukocj^tosis 
except,  perhaps,  occasionally  and  moderately  in  tuberculosis  of  serous  mem- 
brane, and  even  in  this  condition  there  is  no  increase  in  polymorphonuclear 
cells.   A  mixed  infection  causes  only  a  trivial  increase  in  polynuclear  leukocytes. 

In  many  cases  of  tuberculosis  the  diagnosis  can  be  made  from  purely 
clinical  investigation.  This  is  the  case,  for  instance,  in  many  tuberculous 
ulcers,  abscesses,  and  glands.  In  some  cases  the  diagnosis  can  be  made  only 
by  making  differential  stains  of  material  obtained  from  the  suspected  focus, 
or  by  removing  a  section  of  the  inflammatory  area  by  Mixter's  cannula,  and 
studying  it  carefully  under  the  microscope.  Cultures  may  be  taken  from  any 
material  obtained  from  the  suspected  focus. 

In  doubtful  cases  animal  inoculation  is  necessary  to  make  a  diagnosis. 
The  material  is  injected  into  a  guinea-pig;  and  if  it  be  tuberculous,  theanirnal 
will  develop  miliary  tuberculosis  within  a  few  weeks.     With  apparently  sterile 


The  Tuberculin  Test  227 

fluid  obtained  from  a  tuberculous  focus  the  disease  can  be  induced  in  guinea- 
pigs  by  inoculation.  Blistering  a  tuberculous  person  causes  elevated  tempera- 
ture (see  page  221).  If  the  fluid  of  the  bhster  be  injected  into  a  tuberculous 
animal  a  distinct  reaction  occurs  (see  page  221). 

In  a  suspected  case  of  tuberculous  meningitis  of  the  brain  or  of  tuberculous 
disease  of  the  membranes  of  the  cord,  the  theca  of  the  cord  should  be  tapped 
(lumbar  puncture),  and  the  fluid  obtained  should  be  carefully  examined.  Of 
course,  if,  in  a  case  of  tuberculous  cerebral  meningitis,  the  foramina  in  the  floor 
of  the  fourth  ventricle  have  been  blocked  by  exudate,  no  characteristic  fluid 
wiU  be  obtained  by  tapping.  It  is  usually  found,  however,  that  even  in  tuber- 
culous cerebral  meningitis  there  is  increased  tension  of  the  fluid  in  the  sub- 
arachnoid space  of  the  cord,  that  this  fluid  is  present  in  unnaturally  large 
quantity,  and  that  it  is  turbid  through  the  presence  of  pus  and  lymphocytes. 
Sometimes  it  contains  bits  of  fibrin  and  sometimes  blood;  and  in  many  cases 
the  bacflli  of  tuberculosis.  Exploratory  abdominal  incision  is  sometimes  nec- 
essary to  determine  the  existence  of  tuberculous  peritonitis. 

The  x-rays  are  of  great  aid  in  making  a  diagnosis  of  osseous,  articular, 
and,  perhaps,  certain  forms  of  pulmonary  tuberculosis.  The  area  of  tuber- 
culosis is  lighter  than  the  surroimding  healthy  structures  when  seen  in  a 
skiagraph. 

The  Tuberculin  Test. — This  test  may  sometimes  be  used  to  advantage 
in  making  an  early  diagnosis  of  recent  lesions.  Some  physicians  \^dll  not 
use  it,  believing  that  it  is  very  dangerous.  However  tuberculin  is  used,  it  is 
much  more  reliable  diagnostically  in  chfldren  than  in  adiflts.  Apparently 
healthy  infants  never  react.  Apparently  healthy  children  under  sLx  or  seven 
years  of  age  seldom  react.  In  many  adults  free  from  demonstrable  signs  of 
tuberculosis,  tuberculin  gives  a  distinct  reaction  because  many  adults  have 
encapsuled,  quiescent,  or  retrogressive  lesions  of  tuberculosis.  I  have  already 
expressed  the  belief  that  if  given  in  moderate  doses  it  is  safe;  that  is,  it  is  safe 
if  the  disease  is  not  too  far  advanced.  Very  large  doses,  or  the  giving  of  the 
remedy  at  all  in  greatly  advanced  tuberciflosis,  would  not  be  safe.  Some  con- 
ditions contra-indicate  its  use,  among  them  are  the  following:  Addison's  disease, 
recent  pulmonary  hemorrhage,  and  suspected  bilateral  renal  tuberculosis 
(Howes  and  Floyd,  in  "Publications  of  Mass.  Gen.  Hospital,"  1908).  A  contra- 
indication is  the  finding  of  cocci  in  the  sputum.  It  should  only  be  given  when 
other  diagnostic  methods  fail  to  give  certain  information,  and  is  only  to  be 
used  by  a  man  trained  in  its  use.  Too  large  a  dose  may  cause  a  severe  chill, 
high  fever,  and  great  exhaustion,  may  arouse  a  latent  focus  to  activity,  and 
may  actuafly  cause  dissemination  of  the  disease. 

The  elements  of  the  reaction  following  a  tuberculin  injection  are: 

1.  Constitutional  (fever,  etc.). 

2.  Local  (redness  or  nodule  at  the  point  of  puncture). 

3.  Focal  (inflammation  at  the  seat  of  lesion). 

If  fever  exists  we  never  seek  to  obtain  the  constitutional  reaction  by  an 
injection  of  tuberculin.  The  result  would  be  misleading.  We  never  inject 
tuberculin  when  there  is  mixed  infection. 

A  temperature  of  99.5°  F.  or  over,  when  the  patient  is  quiet  in  bed,  contra- 
indicates  the  emplo}Tnent  of  the  test.  The  test  should  be  used  as  directed  by 
John  B.  Howes  and  Cleveland  Floyd  (Ibid.).  These  rules  are  as  follows: 
Koch's  old  tuberculin  is  used  and  the  preparation  must  not  be  over  two 
months  old.  One  c.c.  (100  mg.)  of  the  material  is  drawn  up  in  a  pipet  and 
is  dropped  into  10  c.c.  of  a  ^  per  cent,  solution  of  carbolic  acid.  Each  cubic 
centimeter  of  this  solution  contains  10  mg.  of  tuberculin;  i  c.c.  of  solution 
No.  I  is  mixed  with  9  c.c.  of  a  ^  per  cent,  solution  of  carbolic  acid.  Each 
cubic  centimeter  of  solution  No.  2  contains  i  mg.  of  tuberculin. 


228  Surgical  Tuberculosis 

One  c.c.  of  solution  No.  2  is  mixed  with  9  c.c.  of  the  very  dilute  carbolic  solu- 
tion.   Each  cubic  centimeter  of  solution  No.  3  contains  .1  mg.  of  tuberculin. 

The  patient  is  kept  in  bed  for  three  days  before  beginning  the  test,  and  also 
during  the  test,  and  during  all  of  this  time  the  temperature  is  taken  every  two 
hours.  The  injection  is  to  be  made  at  an  indifferent  point.  The  first  dose  is 
.1  mg.  of  tuberculin  (i  c.c.  of  solution  No.  3).  If  there  is  no  reaction,  wait  for 
three  days  and  then  give  i  mg.  (i  c.c.  of  solution  No.  2).  If  No.  2  gives  no 
reaction,  wait  three  days  and  give  10  mg.  (i  c.c.  of  No.  i  solution) ;  if  No.  2 
gives  a  slight  reaction,  inject  5  mg.  {h  c.c.  of  No.  i  solution). 

We  have  previously  described  the  tuberculin  reaction;  that  is,  the  temporary 
local  congestion  or  inflammation  in  the  tuberculous  area,  and  the  chilly  sensa- 
tion or  chill,  followed  by  marked  elevation  of  temperature  (see  page  221). 
The  constitutional  signs  of  reaction  are  chilly  sensations  or  chills,  sweats,  skin 
eruptions,  headache,  pain  in  the  back  and  joints,  diarrhea,  nausea,  malaise, 
cardiac  palpitation,  and  dyspnea.  Howes  and  Floyd  regard  even  i°  F.  of 
fever  as  significant  of  reaction  if  there  are  also  constitutional  symptoms  and 
local  signs.  The  focal  reaction  is  the  most  important.  In  certain  tuberculous 
lesions  we  can  see  the  focal  reaction;  for  instance,  in  lupus.  In  lupus  the  dis- 
eased skin  begins  to  swell  and  redden  a  few  hours  after  the  injection.  The 
reddened  tissue  may  actually  necrose.  The  ulcerated  area  becomes  crusted. 
The  swelling  and  redness  disappear  in  a  few  days.  In  joint  tuberculosis  the 
skin  over  the  joint  becomes  red.  In  a  tuberculous  ulcer  of  the  mouth  we  can 
see  the  changes;  and  in  a  lesion  of  the  larynx  the  laryngologist  can  observe  them 
with  the  laryngoscope.  By  means  of  a  cystoscope  the  local  reaction  can  be 
seen  in  a  tuberculous  ulcer  of  the  bladder. 

Epstein  in  1891  pointed  out  that  redness  and  swelling  at  the  seat  of  injec- 
tion constitute  a  specific  reaction. 

The  tuberculin  test  should  not  be  used  in  advanced  pulmonary  tuberculosis 
because  it  is  unsafe.  In  advanced  cases  it  fails  to  cause  any  reaction  because 
the  tissues  are  unable  to  produce  antibodies  when  acted  on  by  toxin  (Howes 
and  Floyd,  in  "Publications  of  the  Mass.  General  Hosp.,"  1908).  As  a  matter 
of  fact,  there  is  never  any  need  of  using  the  test  in  an  advanced  case,  because  the 
diagnosis  is  perfectly  clear  without  it.  We  should  never  give  extremely  large 
doses  in  making  the  tuberculin  test.  If,  after  the  careful  use  of  tuberculin, 
there  is  no  reaction,  it  is  usually  a  safe  conclusion  that  there  is  no  tuberculosis. 
The  tendency  is  more  and  more  to  use  as  a  diagnostic  test  the  local  rather  than 
the  constitutional  reaction. 

Various  methods  have  been  devised  for  obtaining  a  local  reaction  (oph- 
thalmo-tuberculin  reaction,  von  Pirquet's  reaction,  Moro's  reaction).  The  local 
reaction  is  obtained  without  danger  of  dissemination  of  infection  and  can  be 
used  even  if  fever  exists. 

Calmette's  Ophthalmo-tuberculin  Reaction. — It  was  pointed  out  that  when 
tuberculin  is  injected  into  a  tuberculous  individual  a  reaction  arises  at  the  seat 
of  injection.  It  has  been  shown  that  if  tuberculin  is  placed  in  the  conjimctival 
sac  of  a  tuberculous  individual  a  reaction  occurs,  and  this  method  is  valuable 
because  even  a  trivial  reaction  is  easily  observed.  The  introduction  of  tuber- 
culin into  the  conjunctival  sac  is  usually  spoken  of  as  Calmette's  method. 
This  test  can  be  used  even  if  fever  exists  and  even  if  a  skin  eruption  exists. 
It  is  not  as  satisfactory  in  surgical  as  in  medical  cases.  The  old  tuberculin  of 
Koch  is  used.  It  is  carefully  freed  from  irritant  materials,  a  i  per  cent,  solu- 
tion is  made  in  normal  salt  solution,  and  i  drop  of  this  is  placed  in  the  eye. 
Baldwin  regards  i  per  cent,  as  dangerously  strong  and  uses  h  per  cent.  No 
constitutional  symptoms  develop,  but  in  four  or  five  hours,  if  the  subject  be 
tuberculous,  the  conjunctiva  of  the  Hds  becomes  injected,  the  corneal  vessels 
distend,  lacrimation  arises,  and  the  lids  may  swell  (Howes  and  Floyd,  Ibid.). 


Prognosis  of  Tuberculosis  229 

The  reaction  attains  its  height  in  from  twelve  to  twenty-four  hours  and  dis- 
appears in  from  forty-eight  to  seventy-two  hours  after  its  first  appearance. 
In  a  non-tuberculous  person  no  redness,  or  only  a  trivial  and  temporary  red- 
ness, is  noted.  There  is  never  a  constitutional  reaction  even  in  a  case  of 
advanced  tuberculosis.  Of  course,  this  test  is  contra-indicated  if  there  is  a 
tuberculous  lesion  of  the  lids  or  eye,  if  there  is  ulceration  of  the  cornea,  or  if 
conjunctivitis  exists.  I  have  never  become  convinced  that  the  method  is 
entirely  free  from  danger  to  the  eye,  and  I  own  that  I  rather  fear  to  use  it. 
Cases  of  permanent  ocular  injury  are  on  record.  Baldwin  ("Jour.  Am.  Med. 
Assoc,"  February  20,  1909)  made  over  1000  tests.  He  says  that  the  test  has 
some  value  in  diagnosis,  no  value  in  prognosis,  and  as  yet  cannot  distinguish 
"active  latent"  from  healed  tuberculosis.    He  says  danger  to  the  eye  is  slight. 

Von  Pirquet's  Cutaneous  Tuberculin  Reaction. — After  the  skin  has  been 
cleansed  with  alcohol  2  drops  of  old  tuberculin  are  applied  a  short  distance 
apart.  The  skin  is  then  abraded  or  scarified  between  the  drops  and  through 
each  drop.  The  abrasion  between  the  drop  is  a  control  experiment.  The  tuber- 
culin is  permitted  to  remain  for  ten  minutes  and  is  then  wiped  off.  In  a  tuber- 
culous individual  local  redness  will  appear  in  ten  or  twelve  hours,  and  in  twelve 
hours  more  the  area  will  be  swollen  and  perhaps  edematous.  This  condition 
disappears  in  a  few  days,  leaving,  perhaps,  as  a  legacy  a  trivial  induration. 
There  is  very  seldom  a  febrile  reaction. 

Moro's  Cutaneous  Tuberculin  Reaction. — The  material  used  is  5  c.c. 
of  old  tuberculin  and  5  gm.  of  lanolin.  It  is  rubbed  into  the  abdominal  skin- 
and  if  the  individual  is  tuberculous  red  papules  or  nodules  or  numerous  vesicles 
appear  in  the  area  where  the  inunction  was  made.  A  severe  reaction  or  a 
moderate  reaction  will  be  noted  within  twenty-four  hours.  A  slight  reaction 
appears  in  from  twenty-four  to  forty-eight  hours.  The  eruption  of  a  slight 
or  a  moderate  reaction  disappears  in  a  few  days.  After  a  severe  reaction  the 
skin  may  remain  red  for  several  weeks.  In  suspected  surgical  tuberculosis 
Moro's  reaction  is  generally  used.     There  is  no  febrile  reaction. 

Blistering  a  Tuberculous  Person. — (See  page  221.) 

Injecting  a  Tuberculous  Animal  with  Blister  Fluid  from  a  Person  Suspected 
to  be  Tuberculous. — (See  page  221.) 

Massage  of  a  Tuberculous  Focus. — Wright  has  shown  that  gentle  mas- 
sage of  a  tuberculous  focus  may  be  followed  by  a  reaction  like  that  which  fol- 
lows the  diagnostic  use  of  tuberculin.  In  such  a  case  the  massage  drives 
tuberculous  products  into  the  blood  and,  perhaps,  if  the  massage  is  frequently 
repeated,  auto-immunizes  the  individual. 

Animal  Inoculations. — This  method  of  diagnosis  is  seldom  employed 
and  only  in  unusually  obscure  cases. 

The  Agglutination  Test. — This  test,  as  applied  to  the  blood-serum  of  a 
tuberculous  individual,  is  decidedly  uncertain. 

Prognosis. — Many  cases  of  tuberculosis  are  cured.  This  is  indicated 
by  the  frequency  with  which  we  find  healed  tuberculous  lesions  in  necropsies 
on  individuals  dead  of  other  diseases.  We  reach  the  same  conclusion  from 
the  clinical  study  of  many  cases.  The  prognosis  of  a  single  tuberculous  focus, 
especially  if  it  can  be  extirpated  or  sterilized,  is  very  good;  provided  that  the 
general  health  is  good,  that  there  is  not  much  anemia,  that  the  digestive 
processes  are  well  performed,  that  mixed  infection  is  absent,  that  there  are  no 
albuminoid  changes  in  the  viscera,  and  that  the  patient  is  able  and  willing  to 
live  the  life  that  is  necessary  for  his  welfare.  Unfavorable  prognostic  indications 
are  inability  to  eat,  disturbance  of  digestion,  deepening  anemia,  progressive 
loss  of  weight,  high  fever,  and  sweats.  Of  course,  the  prognosis  is  influenced 
by  the  patient's  temperament,  his  willingness  to  brook  control,  his  monetary 
status,  and  his  habits.     The  danger  is  greatly  increased  by  multiple  lesions. 


230  Surgical  Tuberculosis 

The  dangers  of  mixed  infection  and  of  albuminoid  disease  have  been  previously 
discussed. 

In  very  young  children  the  prognosis  is  most  unfavorable;  but  in  older 
children  it  is  very  much  better ;  in  fact,  it  is  better  in  them  than  in  adults. 

Tuberculosis  of  the  skin  gives  a  very  fair  prognosis;  and  glandular,  bony, 
and  articular  tuberculosis  are  frequently  recovered  from;  but,  of  course,  any 
tuberculous  lesion,  however  Umited  in  area,  is  a  profound  menace. 

Another  fact  to  be  borne  in  mind  is  that  many  cases  apparently  cured  are 
not  reaUy  cured;  and  that  the  disease  strongly  tends  to  reappear  in  the  same 
region  or  in  a  nearby  region,  or  to  reappear  later  in  another  part  of  the  body. 
We  should,  further,  remember  that  in  many  cases  in  which  there  is  apparently 
one  lesion  only,  there  are,  in  reahty,  distant  lesions  undiscoverable  by  cHnical 
methods.  In  any  case  of  tuberculosis  the  higher  the  opsonic  index  the  better 
the  prognosis,  the  lower  the  opsonic  index  the  worse  the  prognosis. 

Another  important  fact  is  that  when  an  individual  has  a  latent  focus  of 
tuberculosis,  especially  if  this  latent  focus  is  in  the  lungs,  should  a  surgical 
operation  be  performed  for  some  other  purpose,  and  the  patient  be  kept  in 
bed  for  a  considerable  length  of  time,  the  latent  focus  may  become  active.  I 
have  always  beheved  that  in  latent  pulmonary  tuberculosis  the  administration 
of  ether  or  chloroform  might  awaken  the  disease  into  activity.  It  therefore 
becomes  evident  that  in  such  persons  operations  of  necessity  are  the  only 
ones  that  should  be  undertaken.  Such  an  operation,  if  possible,  should  be 
done  under  nitrous  oxid  or  a  local  anesthetic;  and  the  patient  should  be  got 
about  again  at  the  earhest  possible  moment. 

Tubercvilin  in  Prognosis. — Wolff-Eisner  maintains  that  advanced  and 
rapidly  advancing  cases  fail  to  show  an  ophthalmo-tuberculin  reaction,  hence, 
when  the  existence  of  tuberculosis  is  proved  cHnically,  a  negative  ophthalmo- 
tuberculin  reaction  indicates  a  bad  prognosis.  Most  observers  reject  this  con- 
tention. "Of  two  individuals  with  moderately  advanced  disease  and  in  equally 
good  general  condition,  tubercuhn  cannot  predict  with  more  assurance  than 
other  cHnical  methods  the  state  of  affairs  a  year  hence"  ("Tubercuhn,"  by 
Hamman  and  Wolman). 

Treatment. — One  of  the  first  thoughts  of  the  surgeon  is  to  provide  against 
the  contamination  of  healthy  individuals  by  the  infected.  Any  infected  ex- 
cretion or  suspicious  discharge  from  the  patient  must  be  disinfected  at  once  and 
dressings  that  are  removed  from  the  patient  should  be  burned. 

We  are  not  in  this  section  discussing  the  treatment  of  tuberculosis  of  the 
lungs,  which  belongs  to  the  medical  man,  and  in  which  climate  is  of  great 
importance.  In  cases  of  surgical  tuberculosis,  however,  the  patient  may  do 
better  in  some  climates  than  in  others;  and  the  change,  by  stimulating  the 
appetite  and  causing  sleep  and  giving  renewed  hope,  will  be  beneficial.  In 
surgical  tuberculosis  climate  is  not  the  factor  that  it  is  in  tuberculosis  of  the 
lungs;  but  if  there  is  pure  atmosphere,  an  equable  temperatiu-e,  and  plenty  of 
sunlight,  the  climate  wiU  lure  the  patient  out-of-doors,  and  will  thus  be  greatly 
to  his  advantage. 

A  life  in  the  open  air  is  the  most  essential  thing  in  the  treatment  of  surgical 
tuberculosis;  but,  as  Professor  Halsted  points  out,  it  is  not  of  much  use  to  tell  a 
great  many  persons  to  live  in  the  fresh  air.  They  will  not  do  it  unless  they  are 
made  to;  and  it  is  hard  to  make  them  unless  they  five  in  quarters  especially 
built  with  this  object  in  view.  Therefore,  other  things  being  equal,  if  patients 
with  surgical  tuberculosis  have  the  means,  it  is  a  good  plan  to  send  them  to 
a  sanatorium  in  the  mountains  or  at  the  seashore,  where  they  can  obtain  the 
persistent,  imbroken  hfe  in  the  open  air  that  is  the  cure  of  the  disease.  The 
patient  should  spend  his  days  in  the  fresh  air,  and  he  should  sleep  at  night 
directly  exposed  to  the  air;  and  if  the  atmosphere  is  free  from  dust  and  foul 


Treatment  of  Tuberculosis 


231 


odors,  so  much  the  better.  The  poorer  patients  must  get  the  fresh  air  at  home, 
if  they  cannot  be  sent  to  some  camp  or  colony.  In  large  cities  adjacent  to  the 
seaside  resorts  poor  people  can  usually  be  sent  for  a  short  time,  at  least,  to 
the  seaside:  and  I  am  a  ver\-  great  believer  in  the  beneficial  efi'ects  of  Atlantic 
City  and  other  seashore  resorts. 

It  is  frequently  necessary"  to  do  an  operation  in  a  great  city,  although  we 
operate  much  less  than  formerly  for  these  conditions.  If  an  operation  is  done 
in  a  great  city,  the  patient  is  kept  in  the  fresh  air  as  much  as  possible  during 
his  convalescence.  If  it  is  feasible,  he  is  sent  away  to  a  colony  or  sanatorium 
to  recuperate.  It  would  be  an  excellent  thing  if,  in  many  of  those  cases  in 
which  operation  is  necessary-,  the  operation  could  be  performed  at  the  camp  or 
the  sanatorium.  One  advantage  of  the  camp  or  sanatorium  is  that  the  patient  is 
watched  and  regulated  daily,  and  is  led  to  do  things  that  otherodse  he  would  ne- 
glect. ]\Iany  patients  endeavor  to  avoid  going  out  when  they  should  go  out 
because  they  are  afraid  of  taking  cold:  and  many  of  them  are  simply  neglectful 
and  do  not  want  to  take  the  trouble  to  do  it. 

It  cannot  be  soo  strongly  insisted  on  that  in  surgical  tuberculosis  fresh  air 
is  of  as  much  importance  as  in  tuberculosis  of  the  lungs.  It  increases  the  xital 
resistance,  it  stimulates  opsonic  power,  and  it  causes  the  patient  to  eat  more 
nourishing  food  and  to  sleep  better  at  night.  Frequently  we  see  children 
that  have  had  sinuses  for  months  get  rapidly  well  when  they  adopt  an  open-air 
Life:  and.  although  albuminoid  changes,  when  they  once  exist,  will  never  pass 
away,  further  albuminoid  changes  ma}'  not  take  place  if  the  patient  lives 
properly. 

A  patient  ^ith  surgical  tuberculosis  can  have  no  more  mjurious  en\"iron- 
ment  than  a  dark,  damp  room,  especially  if  it  is  in  a  crowded  tenement  and  up 
a  narrow  court.  The  value  of  sunshine  is  also  beginning  to  be  appreciated 
{heliotherapy  K  We  know  that  it  limits  the  growth  of  tubercle  bacilli.  It  is 
not  the  heat  that  benefits  the  person,  but  the  chemical  rays  of  sunlight.  These 
rays  have  some  germicidal  uifiuence.  have  considerable  penetrating  power,  and 
seem  to  infiuence  decidedly  the  nutritive  processes.  Tuberculous  joints,  even 
when  sinuses  exist,  are  often  much  benefited  by  exposure  to  the  direct  rays  of 
the  sun.  It  is  often  ad^-isable  to  expose  the  entire  body  except  the  head. 
Leysin  begins  with  a  three-minute  exposure  and  gradually  increases  it  up  to 
two  or  three  hours.  During  exposure  traction  is  usually  maintained  on  the 
joint.  Excessive  simlight  is,  however,  not  beneficial.  In  summer  it  exhausts 
the  patient  and  even  in  winter  it  produces  eye-strain  and  headache.  ]Major 
Woodruff.  U.  S.  A.,  insists  that  excessive  sunhght  is  actually  harmful,  particu- 
larly to  blondes  ("The  Effects  of  Tropical  Light  on  WTiite  ]Men"\  Tubercu- 
losis is  dreadfully  fatal  in  certain  tropical  countries  and  is  more  fatal  to  blondes 
than  brimettes.  Open-air  treatment  is  more  valuable  in  ^^inter  than  in  summer, 
perhaps  because  cold  stimulates  respiration  and  because  the  winter  smiHght 
is  not  debilitating. 

The  tuberculous  structures  require  rest.  We  haA-e  long  known  how  disas- 
trous it  is  to  confine  a  person  to  bed  in  a  dark,  ill-Hghted.  and  improperly 
ventilated  room.  We  can.  however,  confine  a  person  to  bed  -viith  perfect  safety 
if  there  is  a  free  flow  of  fresh  air.  We  must  conflne  certain  cases  to  bed:  for 
instance,  cases  of  tuberculous  peritonitis,  and  some  cases  of  bone  tuberculosis 
and  of  joint  tuberculosis.  A  patient  T^ith  tuberculosis  who  has  fever  ought  to 
be  in  bed.  We  can  put  such  patients  to  bed  v^dthout  any  fear  of  the  disease 
becoming  worse  or  spreading  if  the  supply  of  fresh  air  is  plentiful  and  if  the 
paUent  is  kept  warmly  covered  and  wears  a  skuH-cap.  Of  course,  a  draft  is  to 
be  avoided.  Patients  that  are  confined  to  bed  do  excellently  in  a  tent,  in  a 
cottage  sanatorium,  or  on  a  porch  that  has  been  altered  for  the  purpose. 

At  the  ver}-  first  possible  moment  the  patient  should  be  sent  out-of-doors; 


232  Surgical  Tuberculosis 

and  in  many  cases  of  tuberculous  disease  (for  instance,  vertebral  disease) 
the  tuberculous  part  is  supported  by  means  of  a  brace  or  a  splint. 

We  thus  see  the  twofold  nature  of  the  modern  treatment  of  surgical  tuber- 
culosis: rest  for  the  tuberculous  part  and  a  life  in  the  open  air.  Exercise  is 
of  importance  also,  although  it  should  never  be  taken  in  excess.  If  the  patient 
is  confined  to  bed,  he  should  be  massaged  and  rubbed  with  alcohol,  the  tuber- 
culous part  being  usually  avoided.  Forcible  manipulation  must  never  be 
applied  to  a  focus  of  tuberculosis  because  it  may  lead  to  dissemination.  Gentle 
massage  of  a  tuberculous  part  may  do  good.  Wright  has  shown  that  it  is  fol- 
lowed by  a  reaction  like  that  produced  by  tuberculin — a  reaction  due  to  the 
absorption  of  tuberculin  from  the  seat  of  disease.  If  a  person  has  fever  he 
must  not  attempt  active  exercise,  but  must  be  confined  to  bed. 

One  should  overfeed  tuberculous  patients  if  the  stomach  tolerates  it, 
but  not  on  any  single  article,  or  even  on  any  particular  one.  The  diet  should 
contain  a  sufficiency  of  fats,  proteins,  and  carbohydrates;  and  the  food  should 
be  agreeable  to  the  taste  and  readily  assimilable.  Otherwise,  disgust  will  be 
engendered;  and  with  disgust  come  indigestion  and  loss  of  appetite.  The 
very  life  of  the  patient  may  depend  on  his  remaining  able  to  take  a  sufficiency 
of  nourishing  food. 

There  is  no  specific  diet  for  tuberculosis,  although  many  have  been  sug- 
gested. One  of  the  most  valuable  foods  is  milk,  taken  raw  or  mixed  with 
other  articles,  such  as  lime-water  or  sodiimi  bicarbonate,  and  frequently  with 
brandy.  The  use  of  an  exclusive  diet  of  boiled  milk  is  to  be  deprecated,  and  in 
children  it  sometimes  leads  to  the  development  of  scurvy.  Practically  anyone 
can  take  milk  if  proper  efforts  are  made. 

Soft-boiled  eggs  are  useful ;  and  bread  or  toast  should  be  eaten  with  plenty 
of  butter,  which  is  an  agreeable  form  of  fat.     Vegetables  and  fruits  are  desirable. 

If  the  patient  can  take  cod-liver  oil  without  impairing  his  appetite  or  di- 
gestion, it  should  be  given,  provided  the  weather  is  not  too  hot.  Cod-liver 
oil  produces  diarrhea  in  very  hot  weather.  Children  learn  to  take  it  very  well. 
To  many  adults,  however,  it  is,  and  remains,  absolutely  abhorrent.  The 
chief  value  of  cod-liver  oil  is  that  it  is  a  fat,  and  it  seems  improbable  that  it 
contains  any  elements  specifically  antagonistic  to  tubercle.  If  used,  large 
doses  should  not  be  given,  as  they  will  not  be  digested.  The  common  dose 
for  an  adult  is  a  teaspoonfiil  two  or  thee  hours  after  meals.  Thirty  drops  three 
times  a  day  is  usually  given  a  child,  and  an  infant  should  receive  15  drops 
three  times  a  day. 

We  know  of  no  drug  or  medicine  that  can  with  safety  be  used  at  the  present 
time  with  any  real  hope  that  it  will  specially  destroy  tubercle.  Drugs  are, 
of  course,  given,  but  they  are  of  secondary  importance. 

Tonics  are  used,  and  in  children  the  syrup  of  the  iodid  of  iron  has  con- 
siderable reputation.  Remedies  may  be  needed  to  improve  digestion  or  con- 
trol night-sweats,  etc.  I  do  not  believe  that  beechwood  creosote  or  carbonate 
of  guaiacol  internally,  or  iodoform  inunctions,  or  painting  the  surface  with 
guaiacol  confer  any  real  benefit  in  tuberculosis. 

Alcohol  is  often  required.  It  is  not  needed  in  all  cases,  but  is  in  many. 
We  should  avoid  it  in  children,  however,  imless  there  is  a  particular  indication 
for  its  use.  When  a  tuberculous  patient  is  weak,  milk-punch  or  egg-nog  is 
of  service;  and  in  any  case  of  mixed  infection  alcohol  is  required  in  full  doses. 
If  fever  exists,  and  the  administration  of  alcohol  makes  the  pulse  more  rapid 
and  the  delirium  worse,  and  causes  flushing  of  the  face,  the  dose  is  too  large 
and  should  be  diminished.  Any  patient  that  smells  strongly  of  alcohol  is  get- 
ting an  overdose. 

Tuberculin  in  Treatment. — Many  able  investigators  in  many  lands  are 
striving  to  work  out  a  safe  and  satisfactory  specific  treatment  for  tuberculosis. 


Tuberculin  in  Treatment  233 

Landerer  proved  that  immunity  to  tuberculosis  can  be  produced  in  the  lower 
animals  by  injection  of  living  bacilli.  We  dare  not  practice  this  on  human 
beings.  Injections  of  tuberculin  finally  produce  immunity  to  that  product. 
The  original  plan  of  using  tuberculin  therapeutically  was  to  obtain  definite 
reactions  again  and  again.  This  plan  was  founded  on  the  belief  that  the  reac- 
tion did  the  good  and  that  cure  might  be  obtained  in  this  way  in  a  few  weeks. 
This  utterly  reckless  plan  was  most  disastrous,  produced  many  deaths,  and 
caused  widespread  distrust  and  final  abandonment  of  tuberculin.  Tuberculin 
treatment  was  not  an  error,  the  plan  adopted  was,  as  the  material  was  given  in 
large  doses  to  any  and  all  tuberculous  patients.  Just  at  present  we  are  "^^'itness- 
ing  a  revival  of  faith  in  tuberculin.  The  object  now  is  to  stop  short  of  ob\-ious 
reaction,  beHe\Tng  that  reaction  is  misafe,  as  it  may  at  any  time  get  beyond 
control  and  do  harm.  Treatment  is  begun  vdih  ver\'  small  doses  which  pro- 
duce no  reaction.  Larger  and  larger  doses  are  ver\-  gradually  attained  until 
immunity  to  tuberculin  is  established. 

When  an  animal  becomes  immune  to  tuberculin  the  body  cells  resist  and 
finally  destroy  the  tubercle  bacilli  (Braun,  in  "Boston  JMed.  and  Surg.  Jour.," 
July  23,  1908).  From  six  months  to  a  year  is  required  for  the  treatment. 
The  essence  of  treatment  is  the  ver\'  small  dose  and  the  ver\-  gradual  increase, 
reaction  being  scrupulously  avoided. 

Many  different  tuberculins  have  been  recommended.  The  best  known 
ones  are  Koch's  old  tuberculin  (0.  T.),  Koch's  new  tuberculin  (T.  R.),  Koch's 
bacillary  emulsion  (B.  E.),  the  bouillon  filtrate  of  Denys  (B.  F.),  von  Ruck's 
water}-  extract,  and  bo\Tne  tuberculins.  There  seems  to  be  no  sound  clin- 
ical reason  for  insisting  on  the  use  of  any  particular  form  of  tuberculin. 
Bo^dne  tuberculin  does  not  seem  more  useful  than  hiunan  tuberculin  in 
tuberculosis  of  the  abdomen,  glands,  and  liver,  structures  so  often  the  seat 
of  infection  with  bovine  bacilli.  \\Tiatever  form  is  chosen  is  given  subcu- 
taneously  in  the  back  and  near  to  the  skin,  so  that  a  local  reaction  may  be 
quickly  recognized.  If  after  any  dose  there  is  even  a  slight  elevation  of  tem- 
perature or  even  a  tri\-ial  local  reaction  the  dose  must  not  be  advanced  untU  that 
dose  can  be  given  without  reaction.  Loss  of  weight  means  that  doses  are  too 
large.  Judiciously  small  doses  are  entirely  safe  even  when  tuberculosis  is  com- 
plicated. One  or  two  injections  are  given  each  week  imtH  the  maximum  dose 
■v\'ithout  reaction  is  attained.  The  maximum  dose  when  attained  may  be  given 
at  weekly  intervals  for  months.  Another  plan  is  to  reach  the  maximiun  dose, 
stop  the  treatment  for  months,  and  then  start  it  again,  beginning  ^^'ith  the 
smallest  dose. 

The  initial  dose  and  the  maximum  dose  of  certain  tuberculins  are  given  in 
the  following  table  taken  from  the  valuable  work  of  Hamman  and  Wolman  on 
"Tuberculin."     The  dose  is  expressed  in  cubic  centimeters  instead  of  grams: 


Tuberculin. 

IxTTLiL  Dose. 

Maximum  Dose. 

O.T. 
T.R. 
B.  E. 
B.  F. 

Beraneck's 

0.000,000,1  to  0.000,001  C.C. 
0.000,001  to  0.000,1  C.C. 
0.000,001  to  0.000,1  C.C. 
0.000,000,01  to  0.000,000,1  C.C. 
Of  A  32,  0.05  C.C. 

1  C.C. 

2  C.C. 
2  C.C. 
I   C.C. 

Of  H  I  C.C. 

Wright  gives  very  small  doses  of  emulsion  of  powdered  bacilli,  not  with  the 
idea  of  causing  directly  body  immtmity  to  tuberculin,  but  to  produce  immunity 
by  strengthening  the  phagocytic  power  of  the  leukocytes. 

WTien  this  plan  is  followed  the  dose  is  determined  by  the  opsonic  index, 
and  the  dose  is  only  raised  to  a  sufificient  degree  to  estabUsh  the  positive  phase 


234  Surgical  Tuberculosis 

without  producing  even  the  most  trivial  subjective  symptoms.  One  dose 
causes  an  increase  of  immunizing  power  in  the  body  for  about  a  fortnight  and 
then  another  dose  is  given.  Many  clinicians  deny  positively  the  need  of  giving 
the  dose  by  the  opsonic  index.  When  tuberculin  is  given  by  either  of  the  above 
plans  it  is  entirely  safe,  and  I  believe,  beyond  doubt,  is  of  value  in  suitable  cases. 
It  is  not  to  be  used  in  advanced  cases  or  in  febrile  conditions.  For  lupus, 
tuberculous  glands,  tuberculous  bones,  or  tuberculous  joints  one  dose  a  week  is 
given.  It  is  of  real  service  in  these  conditions,  but  general  treatment  must  not 
be  discontinued  because  tuberculin  treatment  is  employed.  It  may  be  used 
after  operation  to  prevent  recurrence.  When  given  in  this  way  it  is  safe,  never 
produces  trouble  at  the  site  of  injection,  seems  to  arrest  some  cases  of  tuber- 
culosis, improves  the  local  trouble  in  many,  and  benefits  the  general  conditions 
of  most.  According  to  Trudeau  tuberculin  strengthens  the  individual's 
immunity  to  tuberculosis.  According  to  Wright  it  causes  an  increase  in  defi- 
cient opsonins.     Tuberculin  is  of  unquestionable  value  in  some  cases  of  lupus. 

Ringer  has  recently  strongly  advocated  the  use  of  tuberculin  ("Jour.  Am. 
Med.  Assoc,"  May  2,  1908).  Maragliano  treats  tuberculosis  with  the  serum 
of  animals  which  have  been  injected  with  dead  bacilli  and  toxins,  and  he  be- 
lieves that  this  serum  contains  quantities  of  antibodies  and  antitoxins.  The 
animal  is  injected  many  times  until  its  serum  becomes  highly  agglutinative. 
Maragliano  believes  that  this  highly  agglutinative  serum  when  introduced  into 
the  human  body  causes  the  protective  mechanism  of  the  body  to  produce 
quantities  of  antibodies  and  antitoxins.  Most  clinicians  do  not  favor  the  use  of 
Maragliano's  serum. 

The  Local  Treatment  of  Tuberculosis. — When  certain  drugs  are  directly 
inserted  into  a  tuberculous  focus  they  possess  an  antagonistic  influence. 
Iodoform  is  the  most  powerful  of  these  drugs;  guaiacol,  balsam  of  Peru  (Lan- 
derer),  bismuth,  and  chlorid  of  zinc  (Lannelongue)  have  a  similar  action.  Iodo- 
form has  little  or  no  influence  when  placed  on  a  free  surface  exposed  to  the 
air,  but  when  in  the  form  of  an  emulsion  it  is  injected  into  a  tuberculous  area, 
the  air  being  excluded  (see  page  30),  this  drug  is  powerfully  antituberculous. 
Chlorid  of  zinc  seems  to  act  by  causing  the  development  of  quantities  of 
fibrous  tissue,  which  encapsulates  or,  perhaps,  replaces  the  tuberculous  focus. 
Some  surgeons  inject  tuberculous  nodules  with  camphorated  naphtol.  Every 
region  of  tuberculosis  requires  local  rest,  perhaps  by  the  use  of  a  splint  or  a 
brace. 

Special  Methods  of  Surgical  Treatment.— The  surgeon  may  endeavor 
to  extirpate  a  tuberculous  focus,  or  to  drain  it  thoroughly  and  to  sterilize  the 
area.  Extirpation  is  sometimes,  although  not  very  frequently,  possible.  Com- 
plete extirpation  is  a  valuable  method,  but  partial  extirpation  is  dangerous. 
If  a  part  only  of  a  tuberculous  focus  is  extirpated,  many  lymph-tracts  and  blood- 
vessels are  opened;  and  the  incomplete  operation  may  lead  to  the  dissemination 
of  the  disease.  The  methods  of  surgical  treatment  suited  to  different  forms 
of  tuberculous  disease  will  be  discussed  in  different  sections  of  this  book. 

Bier's  Method  by  Congestive  Hyperemia  (see  page  112). — Bier  believes  that 
passive  hyperemia  is  of  the  greatest  possible  benefit.  Active  hyperemia  is 
obtained  by  heat,  and  is  especially  valuable  to  induce  the  absorption  of  the  prod- 
ucts of  a  non-tuberculous  chronic  inflammation.  Passive  hyperemia  is  par- 
ticularly useful  in  tuberculosis  of  joints,  tuberculous  ulcers,  cold  abscesses, 
and  tuberculous  disease  of  the  tarsus,  carpus,  and  phalanges.  If  a  limb  is 
affected,  passive  hyperemia  is  obtained  by  placing  a  rubber  band  around  the 
limb  above  the  part,  the  band  being  applied  with  sufficient  firmness  to  inter- 
fere with  venous  return,  but  not  so  tightly  as  to  block  arterial  entry.  This 
band  should  be  applied  daily,  and  should  be  kept  in  place  for  an  hour  or  so 
at  each  application,  but  pain  should  not  be  produced.   In  the  intervals  between 


The  Tuberculous  Abscess  235 

the  treatments  the  limb  should  be  at  rest.  Bier  uses  special  apparatuses  for 
obtaining  congestive  hyperemia  in  various  parts  of  the  body. 

I  have  seen  cure  or  ven>-  great  improvement  follow  this  treatment  in  a  num- 
ber of  cases.  It  is  founded  on  the  old  idea  of  Laennec  that  cyanosis  and 
tubercle  are  antagonistic.  Why  this  method  is  beneficial  is  much  debated. 
Some  think  that  the  imprisoned  blood  takes  on  increased  bactericidal  power; 
some,  that  the  number  of  leukocytes  is  greatly  increased;  some,  that  quantities 
of  leukocytes  migrate;  and  some,  that  the  amount  of  bactericidal  blood-serum 
is  increased.  Bier  believes  that  it  depends  upon  phagocytosis.  It  would  seem 
possible  that  the  cells  in  this  locality,  under  the  influence  of  the  congestive 
hyperemia,  may  form  powerful  antitoxins. 

Heliotherapy. — i^See  page  231.') 

The  Finsen  Light. — Finsen  pointed  out  that  the  chemical  rays  in  sunlight 
are  powerfully  germicidal,  and  that  this  germicidal  power  can  be  notably  in- 
creased if  the  rays  are  concentrated  on  a  part  by  the  use  of  particular  apparatus. 
He  also  showed  that  enormous  numbers  of  chemical  rays  can  be  obtained  from 
electric  light.  The  Finsen  treatment  to-day  consists  in  apphing  the  actinic 
rays  obtained  from  electric  light.  They  act  most  powerfully  on  lupus,  but  re- 
quire a  ver\-  long  time  to  effect  a  cure. 

The  .x-rays  are  of  value  in  treating  certain  tuberculous  conditions.  They 
are  of  most  use  in  lupus,  their  effects  in  this  disease  being  nearly  as  power- 
fully curative  as  those  of  the  Finsen  light,  and  much  more  rapid. 

The  tuberculous  abscess  is  called  also  the  cold,  the  lymphatic,  the  con- 
gestive, the  scrofulous,  the  strumous,  the  wandering,  or  the  migrating  abscess: 
and  it  is  ver\-  commonly  called  the  chronic  abscess.  The  Germans  call  it 
Senkungsabscess.  Tuberculous  abscess  is  the  best  designation,  as  this  indicates 
the  cause  of  the  trouble. 

The  term  "cold  abscess"  is  often  used  because  the  cutaneous  surface  over  the 
disease  is  not  warmer  to  the  touch  than  is  the  skin  of  the  corresponding  part  of 
the  opposite  side  of  the  body.  The  term  "hTnphatic  abscess"  was  employed 
because  it  was  once  thought  that  such  abscesses  arose  only  from  hTnphatic 
structures.  Scrofulous  abscess  was  the  name  given  it  when  scrofula  was  sup- 
posed to  be  a  definite  disease,  the  common  phase  of  which  was  this  form  of 
abscess.  The  term  "chronic  abscess"  is  employed  because  the  condition  usually 
develops  slowly,  and  does  not  present  the  e^•idences  of  acute  inflammation ;  an 
acute  pyogenic  abscess  developmg,  as  a  rifle,  rapidly,  and  presenting  positive 
signs  of  inflammation.  I  agree  vriih.  the  late  Professor  Ashhurst  that  the  term 
''chronic."  in  this  connection,  is  improper,  as  it  tends  to  give  a  wTong  idea.  It 
refers  merely  to  time;  and  we  know  that  a  genuine  pyogenic  abscess  that  is 
deep  seated  may  be  rather  slow  in  developing,  and  that  a  tuberculous  abscess 
that  is  superficial  may  develop  with  considerable  rapidity.  \Mien  used  prop- 
erly, the  term  ''chronic  abscess"  means  that  real  pus  exists,  this  pus  ha^•ing 
arisen  from  the  pyogenic  infection  of  the  granulation  tissue  of  a  lesion  of  s^-ph- 
ihs.  tuberciflosis,  or  actinomycosis.  In  other  words,  a  genuine  chronic  abscess 
is  secondan,-  pyogenic  infection  of  an  infective  granifloma.  The  terms  "wan- 
dering," "migrating,"  "gra\"itating."  and  "congestive"  have  been  used  because 
the  fluid  products  of  a  tuberculous  inflammation  are  liable  to  wander  a  consid- 
erable distance  away  from  the  primars"  focus  of  disease.  For  instance,  a  tuber- 
culous abscess  that  is  discovered  in  the  groin  may  have  arisen  from  tuberculous 
caries  of  the  vertebrae.  This  tendency  to  wander  is  not  due  to  gravity,  as  one 
of  the  names  of  the  condition  would  suggest;  but  the  wandering  always  takes 
place  in  the  line  of  least  resistance. 

It  will  be  seen  from  the  foregoing  that  a  true  tuberciflous  abscess  is  not  an 
abscess  at  all,  because  it  does  not  contain  genuine  pus.  It  is  a  collection  of  the 
degenerated  products  of  tuberciflous  inflammation;  and  a  tuberculous  abscess 


236  Surgical  Tuberculosis 

may  be  defined  as  a  circumscribed  cavity  of  new  formation,  containing  the  de- 
generated products  of  a  tuberculous  inflammation.  These  products  may  have 
been  formed  in  that  region  or  may  have  passed  to  that  point  from  some  adja- 
cent or  distant  focus  of  tuberculous  disease.  If  a  supposed  tuberculous  abscess 
is  found  to  contain  genuine  pus,  there  must  have  been  mixed  infection  with 
pyogenic  bacteria;  and  such  mixed  infection  either  causes  violent  and  danger- 
ous inflammation  or  leads  to  the  formation  of  a  true  chronic  abscess,  in  which 
there  is  no  sign  of  acute  inflammation.  The  tubercle  bacillus  is  not  pyogenic. 
It  can  produce  inflammation,  but  not  pus,  and  pus  can  be  formed  in  a  tuber- 
culous focus  only  by  secondary  infection  with  pus  bacteria. 

Situations  of  Tuberculous  Abscesses. — ^These  abscesses  are  particularly 
apt  to  form  as  the  result  of  tuberculous  disease  of  bones,  joints,  lymph-glands^ 
and  subcutaneous  connective  tissue,  but  the  brain,  any  viscus,  or  any  tissue  in 
the  body  may  present  the  condition. 

Age. — No  age  is  exempt,  but  children  are  most  prone  to  the  trouble;  and 
the  period  of  greatest  liability  is  before  the  age  of  twenty  years. 

Contents. — The  usual  terms  for  the  contents  are  scrofulous,  curdy,  or  case- 
ous pus.  As  previously  stated,  it  is  not  true  pus,  but  it  resembles  pus  when 
viewed  by  the  naked  eye.  Examination  of  this  fluid  by  staining  methods,  by 
cultures,  and  by  inoculations  shows  that  it  contains  no  pyogenic  bacteria.  It 
consists  of  liquefied  and  caseated  tubercle,  masses  of  coagulated  fibrin,  and 
bits  of  necrotic  tissue.  The  tuberculous  material  is  whitish,  yeUowish,  or 
yellowish  green,  thick,  and  without  odor.  Floating  in  this  pus  are  portions 
of  caseous  matter,  which,  as  the  elder  Gross  said,  resemble  bits  of  soft-boiled 
rice.  Occasionally  the  tuberculous  material,  especially  if  it  comes  from  disease 
of  a  lymph-gland  or  of  a  bone,  is  almost  watery  and  nearly  colorless,  and  con- 
tains curd-like  masses,  consisting  of  tuberculous  granulations,  coagiilated  fibrin, 
and  necrotic  tissue.  It  was  previously  stated  that  tuberculous  pus  is  free  from 
odor.  This  is  not  true  of  tuberculous  pus  from  the  ischiorectal  fossa,  which 
is  highly  putrid;  but  in  an  ischiorectal  abscess,  as  a  matter  of  fact,  there  is 
usually  mixed  infection  with  pyogenic  organisms,  as  well  as  with  the  organisms 
of  putrefaction.  If  tuberculous  pus  is  permitted  to  stand,  the  curdy  mass 
settles  to  the  bottom,  and  a  thin  serous  fluid  remains  above. 

Formation  of  Tuberculous  Abscess. — The  growth  of  tubercle  bacilli  in 
the  tissues  causes  chronic  inflammation.  The  cells  of  the  tissues,  especially 
the  fixed  cells,  proliferate  and  form  granulation  tissue.  This  granulation 
tissue  consists  of  multitudes  of  cell  clusters,  and  each  cluster  is  called  a 
primitive  tubercle  (see  page  214).  Each  individual  tubercle  enlarges;  myriads 
of  new  ones  form,  and  many  of  the  old  ones  fuse.  These  new  cells,  how- 
ever, do  not  become  vascularized.  In  the  earliest  stage  of  their  formation 
there  are  blood-channels,  but  these  become  closed  through  endothelial  prolifer- 
ation and  through  the  pressure  of  cells  external  to  them.  The  tuberculous  area 
then  becomes  absolutely  avascular.  This  avascular  mass  of  cells  is  composed  of 
what  are  known  as  epithelioid  cells,  and  the  cells  obtain  nourishment  by  imbibi- 
tion. The  nourishment  is  very  incomplete.  As  the  nodule  enlarges  the  nour- 
ishment grows  more  and  more  insufficient.  Finally,  the  adjacent  blood-vessels 
that  fiu-nished  the  fluid  for  imbibition  become  occluded,  and  nourishment  is 
no  longer  possible.  The  toxins  of  the  tubercle  bacilli,  acting  upon  this  area 
of  greatly  lowered  nutritional  activity,  produce  coagulation  necrosis,  and 
caseation  follows  this.  The  caseation  begins  at  many  points  near  the  middle 
of  the  tuberculous  nodule.  Each  area  of  caseation  enlarges.  Several  of  them 
fuse,  and  eventually  many  caseated  areas  coalesce.  The  tuberculous  lesion  may 
be  spreading  at  the  periphery  at  the  same  time  that  it  is  undergoing  caseation 
at  the  center.  The  bacilli  in  the  caseated  material  soon  die  for  want  of  nourish- 
ment.    When  an  area  of  caseated  tubercle  is  liquefied  by  the  addition  of  serum, 


Secondary  Infection  of  Tuberculous  Area  by  Bacteria  of  Suppuration     237 

what  we  call  caseous  or  curdy  pus  is  produced,  and  the  lesion  is  then  known  as 
a  tuberculous  abscess. 

The  wall  of  the  abscess  is  formed  by  compressed  or  solidified  tissues.  In 
a  very  recent  case  the  wall  is  soft  and  will  readily  collapse.  In  an  old  case  it  is 
dense  or  actually  fibrous  and  will  not  collapse.  This  wall  of  compressed  tissue 
is  not,  as  used  to  be  thought,  a  pyogenic  membrane  which  secretes  the  tuber- 
culous material,  but  it  actually  surrounds  the  tuberculous  material  and  hinders 
its  diffusion.  i\.s  Roswell  Park  says,  it  is  not  a  pyogenic  membrane,  but  it  is  a 
prophylactic  membrane.  The  inner  surface  of  the  wall  of  the  compressed  tis- 
sue is  lined  with  tuberculous  granulations,  which  at  different  points  show 
different  stages  of  the  tuberculous  lesion.  This  layer  of  tuberculous  granula- 
tions is  known  as  Volkmann's  memhrane.  The  fluid  in  the  abscess  may  con- 
tain a  few  living  bacteria,  but  often  none  can  be  found;  and  certainly  the  bac- 
teria are  not  multiphdng  in  this  fluid,  but  they  exist  in  numbers  and  multiply 
in  Volkmann's  membrane.  WTien  tuberculous  matter  has  been  long  retained 
and  is  thoroughly  encapsuled  the  bacilli  soon  die  for  want  of  nourishment,  and 
because  a  culture  from  a  supposed  tuberciflous  area  fails  to  show  the  baciUi  of 
tuberculosis  we  have  not  obtained  conclusive  e\ddence  that  the  area  is  not 
tuberculous.  We  know  this  same  fact  to  be  true  of  the  fluid  of  tuberculous 
empyema. 

From  the  abscess  wall  there  may  be  one,  two,  several,  or  many  sinuses 
tracking  out.  These  sinuses  are  lined  with  granulation  tissue  exactly  like 
the  Volkmann's  membrane  in  the  main  abscess;  and  they  may  spread  b}^  a 
sort  of  crawling  progression  for  long  distances,  perhaps  passing  through  dense 
fascia,  and  at  their  terminations  may  form  secondary  tuberculous  abscesses. 
The  waU  of  an  abscess  may  contain  expansions  or  locuH.  If  an  abscess  spreads 
to  some  distant  place,  the  tuberculous  infection,  of  course,  goes  with  it,  and  it 
is  the  tuberculous  infection  that  causes  the  spread.  The  wandering  of  a 
tuberculous  abscess  is  in  the  line  of  least  resistance,  and  is  not  the  result  of 
gravity.  Injur}',  breaking,  or  contusion  of  this  granulation  tissue,  if  unac- 
companied with  the  removal  of  aU  the  tissue  or  the  kiUing  of  all  the  germs 
it  contains,  may  diffuse  the  infective  matter  and  actually  cause  disseminated 
tuberculosis.  We  sometimes  see  such  dissemination  after  spontaneous  opening, 
non-aseptic  operation,  or  forcible  squeezing;  and  particularly  after  an  imperfect 
operation  that  removes  only  a  part  of  the  tuberculous  area. 

Terminations  of  Tuberculous  Abscess. — The  abscess  may  slowly  and 
graduaUy  enlarge,  and  finafly  open  of  itself,  either  on  the  skin  or  on  the  mucous 
surface,  or  into  some  ^dscus  or  joint.  It  may  become  encapsuled  by  fibrous 
tissue,  there  being  absorption  of  the  fluid  and  shrinking  of  the  entire  focus, 
the  caseous  part  perhaps  remaining  or  becoming  calcified.  The  tuberculous 
abscess  may  actually  be  replaced  by  fibrous  tissue,  and  this  constitutes  a  per- 
manent cure.  When  the  tuberculous  area  is  merely  encapsuled  by  fibrous 
tissue,  some  living  bacilli  may  remain  latent  in  the  wall;  and  long  afterT\'ard, 
as  the  result  of  injury  or  of  some  other  damage,  an  abscess  may  re-form  at  the 
old  site  of  disease.  Sir  James  Paget  called  this  condition  residual  abscess. 
As  a  rule,  the  abscess,  as  it  shrinks,  tends  toward  cure.  The  bacilli  usually 
die  for  want  of  material  to  nourish  them,  but  occasionally  they  remain  latent 
for  a  long  period  of  time.  When  they  do  die,  the  tuberculous  granulation 
tissue  may  become  healthy  tissue,  be  vasciflarized  through  the  entrance  of 
blood-vessels,  and  be  converted  into  scar-tissue.  Tuberculous  abscess  may 
also  be  cured  by  a  surgical  operation. 

Secondary  Infection  of  a  Tuberculous  Area  by  the  Bacteria  of  Suppuration. 
— This  is  liable  to  occur  when  the  abscess  imdergoes  spontaneous  evacuation, 
and  may  occur  when  it  has  been  opened  by  the  surgeon.  It  occasional!}-  occurs 
when  the  abscess  has  neither  imdergone  spontaneous  evacuation  nor  has 


238  Surgical  Tuberculosis 

been  opened  by  the  surgeon,  having  been  infected  apparently  as  a  point  of 
least  resistance.  When  such  infection  does  occur,  there  is,  in  all  probability, 
some  area  of  ordinary  suppuration  elsewhere  in  the  person's  body,  and  the 
bacteria  of  suppuration  have  entered  the  body  fluids.  Pyogenic  infection  is 
apt  to  produce  violent  inflammation  and  profuse  suppuration — a  condition  that 
is  extremely  dangerous,  because  septicemia  is  very  liable  to  develop.  In  some 
very  rare  cases  suppuration  destroys  the  tuberculous  area  and  cures  the 
tuberculous  disease.  More  commonly,  however,  it  produces  illness,  and  in 
large  abscesses  it  may  cause  death.  Because  of  this  liability  to  secondary 
infection  surgeons  were  long  opposed  to  operating  on  tuberculous  abscess 
unless  it  was  evidently  going  to  evacuate  itself.  In  some  cases  secondary  in- 
fection produces  a  true  chronic  abscess  (see  page  235).  Infection  by  strep- 
tococci is  much  more  dangerous  than  is  infection  by  staphylococci.  Acute 
inflammation  with  dangerous  constitutional  symptoms  is  particularly  apt 
to  arise  if  the  walls  of  the  abscess  contain  very  little  tuberculous  tissue,  if 
they  have  been  bruised  or  damaged  by  powerful  chemicals,  if  there  is  poor 
drainage  (and  there  is  certain  to  be  poor  drainage  if  loculi  exist,  or  if  the 
incision  is  small  and  blocked  with  plugs  of  fibrin  or  necrotic  tissue),  if  a  par- 
tial or  imperfect  operation  has  been  performed,  if  a  number  of  virulent  bacteria 
have  been  introduced,  or  if  the  vital  resistance  is  at  a  low  ebb. 

Secondary  Infection  by  the  Bacteria  of  Putrefaction. — This  complica- 
tion is  extremely  grave  and  may  produce  death.  It  is  commonly  associated 
with  pyogenic  infection.  The  wound  fluid  becomes  intensely  putrid,  violent 
acute  inflammation  arises,  and  the  absorption  of  materials  from  the  wound 
induces  the  systemic  condition  known  as  sapremia  or  putrid  intoxication. 

Signs  and  Symptoms  of  Tuberculous  Abscess. — A  purely  tuberculous 
abscess  presents  no  evidence  of  inflammation  except  swelling;  and,  owing 
to  the  absence  of  heat,  it  has  received  its  name  of  cold  abscess.  The  cutane- 
ous surface  looks  and  feels  normal  or  is  paler  than  normal  until  the  struc- 
tures just  beneath  the  skin  or  the  skin  itself  become  involved.  When  this 
happens,  livid  discoloration  appears,  but  the  lividity  presents  a  very  different 
appearance  from  the  dusky  discoloration  of  an  acute  abscess.  Neither  is  the 
skin  edematous  or  glossy  as  it  is  in  acute  abscess. 

There  is  rarely  tenderness  in  the  region  of  the  abscess,  and  still  more  rarely 
spontaneous  pain.  Pain  and  tenderness,  although  frequently  absent  in  the 
area  of  a  tuberculous  abscess,  may  be  complained  of  at  the  primary  focus  of 
disease.  Tenderness  is  especially  likely  to  be  noted  at  the  primary  focus; 
and  in  cases  of  joint  tuberculosis  and  of  bone  tuberculosis  it  is  nearly  always 
present.  There  may  or  may  not  be  pain  at  the  primary  focus,  but  referred 
pain  is  frequently  complained  of.  For  instance,  in  tuberculous  disease  of  the 
hip-joint  the  pain  may  be  referred  to  the  inner  side  of  the  knee;  and  severe 
bellyache  is  frequently  observed  in  Pott's  disease  of  the  spine.  At  the  point  to 
which  pain  is  referred,  however,  there  is  seldom  tenderness.  For  instance,  in  the 
bellyache,  particularly  of  Pott's  disease  of  the  spine,  the  belly  is  not  tender,  al- 
though the  spine  may  be.  In  sacro-iliac  tuberculosis  the  pain  is  often  referred  to 
the  distribution  of  the  sciatic  nerve,  but  the  nerve  is  seldom  tender  on  pressure. 
In  a  psoas  abscess  we  find  that  pain  in  the  spine  can  be  induced  by  pressing 
on  the  spinous  process  of  the  diseased  vertebra,  by  concussion  to  the  heels  or 
the  head  when  the  spine  is  held  stiff,  and  especially  by  flexion  of  the  spine ;  but 
the  spinal  pain  is  lessened  or  completely  abolished  by  extension,  fixation,  and 
rest.  The  primary  focus  of  disease,  if  spinal  or  articular,  produces  rigidity 
in  the  adjacent  muscles,  and  rigidity  secures  rest  by  inhibiting  movement, 
but  it  also  impairs  the  function  of  the  part.  In  an  intra-abdominal  tubercu- 
lous abscess  there  is  rigidity  of  the  abdominal  muscles. 

In  a  tuberculous  abscess  fluctuation  is  usually  obtained  readily,  because 


Amyloid  Disease  239 

the  fluid  is  not  surrounded  by  a  thick  mass  of  granulation  tissue  and  also  be- 
cause a  considerable  amount  of  fluid  is  usually  present.  A  notable  character- 
istic of  a  tuberculous  abscess  is  the  tendency  to  wander,  and  it  may  appear 
with  suddenness  at  some  distant  point.  Abscesses  of  the  spine  wander  long 
distances,  but  the  wandering  is  not  the  effect  of  gravity,  and  is  due  to  the 
disposition  of  the  tuberculous  matter  to  travel  in  the  line  of  least  resistance. 
The  temperature  of  the  body  may  be  entirely  normal  if  the  infection  is  purely 
tuberculous.  As  a  rule,  however,  there  is  a  slight  evening  elevation;  and  the 
patient  is  weak  and  pale,  grows  tired  readily,  sleeps  poorly,  and  has  a  wretched 
appetite  and  impaired  digestion.  The  blood  examination  sometimes  shows  a 
notable  diminution  in  the  number  of  red  blood-cells,  and  the  hemoglobin  is 
usually  lowered  to  60  or  70  per  cent.  There  is  no  leukocytosis.  In  mul- 
tiple tuberculous  foci,  and  particularly  in  tuberculosis  in  children,  there  is  a 
marked  decrease  in  the  red  blood-cells.  If  secondary  infection  occurs,  there 
is  a  rapid  and  progressive  diminution  in  the  number  of  red  cells  and  usually 
a  trivial  increase  in  polynuclear  leukocytes. 

A  tuberculous  abscess  underneath  the  deeper  fascia  may  break  through 
the  fascia  by  making  a  small  opening,  and  a  large  secondary  abscess  may  arise 
in  the  subcutaneous  tissue.  The  entire  abscess  is  thus  shaped  like  an  hour- 
glass, the  opening  through  the  fascia  being  the  narrowest  point.  Such  an 
abscess  is  called  a  shirt-stud  abscess.  A  tuberculous  abscess  is  liable  to  form 
one,  several,  or  many  sinuses,  and  the  end  of  each  sinus  may  expand  into  a 
secondary  abscess.  The  surgeon  must  always  make  a  careful  examination 
to  try  to  determine  whether  the  abscess  is  the  primary  disease  focus  or  whether 
the  tuberculous  matter  has  wandered  from  a  distant  point.  He  must  also  make 
a  thorough  examination  to  see  whether  anywhere  in  the  body  there  are  other 
regions  of  disease.  He  will  often  find  such  a  region  of  disease;  for  instance, 
in  the  lungs.  In  many  cases,  however,  there  is  no  clinical  evidence  that  other 
areas  of  tuberculous  disease  exist. 

A  deeply  arising  tuberculous  abscess  usually  reqmres  weeks  or  months  to 
reach  the  overlying  skin  or  mucous  membrane  and  undergo  spontaneous  evacua- 
tion. That  spontaneous  evacuation  is  imminent  is  shown  by  livid  discoloration 
and  thinning  of  the  skin.  Finally,  at  the  area  in  which  the  skin  is  thinnest  a  little 
tit  is  elevated.  This  condition  is  known. as  pointing  and  a  rupture  occurs  at 
this  point,  tuberculous  pus  running  out.  Spontaneous  evacuation  is  a  peril, 
because  it  is  liable  to  be  followed  by  secondary  pyogenic  or  putrefactive  infec- 
tion. After  spontaneous  evacuation  has  occurred,  a  true  chronic  abscess  may 
form;  but  there  may  instead  be  violent  acute  inflammation,  manifested  locally 
by  pain,  heat,  and  dusky  discoloration.  If  acute  inflammation  does  arise  there 
develops  a  fever,  which  presents  evening  exacerbations  and  morning  remissions, 
and  is  accompanied  by  an  exhausting  sweat  during  the  night  or  early  morning. 
Fatal  septicemia  or  sapremia  may  follow  spontaneous  evacuation. 

Results  of  a  Tuberculous  Abscess. — It  may  undergo  spontaneous  cure, 
and  the  cure  may  be  lasting,  but  long  after  an  apparent  cure  a  new  abscess 
may  form  (the  residual  abscess  of  Sir  James  Paget).  A  tuberculous  abscess 
may  remain  stationary  for  a  very  long  time,  and  then  perhaps  diminish  in 
size  and  be  cured,  or  extend  in  size  and  rupture.  After  spontaneous  rupture, 
suppuration  may  cure  the  tuberculous  area  by  annihilating  the  tuberculous 
tissue ;  but,  as  a  rule,  after  spontaneous  rupture  there  is  either  an  acute  septic 
process  or  a  chronic  suppuration,  constituting  a  genuine  chronic  abscess. 

Amyloid  Disease.— The  pyogenic  infection  of  an  area  of  chronic  tuberculous, 
especially  a  bony  area,  if  it  induces  long-lasting  suppuration,  may  lead  to  the 
development  of  albuminoid,  amyloid,  waxy  or  lardaceous  disease.  Pyogenic 
infection  of  a  tuberculous  area,  though  by  far  the  commonest,  is  not  the  only 
cause  of  amyloid  disease.    It  may  arise  when  there  has  been  no  pyogenic  infec- 


240  Surgical  Tuberculosis 

tion  of  the  tuberculous  area.  It  may  arise  after  prolonged  ordinary  suppuration. 
It  may  follow  bone  syphilis,  and  may  be  due  to  cancer,  Bright's  disease,  malaria, 
chronic  dysentery,  or  prolonged  lactation.  In  this  condition  a  peculiar  mate- 
rial is  deposited  in  the  middle  coat  of  the  smaller  arteries  and  later  the  inner 
coat  is  involved.  The  albuminoid  substance  resembles  fibrin  and  there  has 
been  much  dispute  as  to  its  natiure.  One  theory  is  that  this  deposit  takes 
place  from  blood-serum  which  has  been  dealkahnized  because  the  flow  of  pus 
has  removed  potash  salts  from  the  blood.  Krakow  seems  to  have  demon- 
strated that  the  albuminoid  material  is  a  combination  of  chondroitin-sulphuric 
acid  and  histon.  This  acid,  carried  by  the  blood  or  lymph,  "combines  with  a 
protein  of  the  fixed  tissues"  (W.  Taylor  Cummins,  "Proceedings  of  Patholog. 
Soc.  of  Philadelphia,"  Dec,  1910). 

In  rare  cases  this  deposit  is  only  a  local  mass.  The  corpora  amylacea  of  the 
prostate  and  nervous  structure  are  due  to  albuminoid  deposit.  Such  a  deposit 
may  take  place  directly  in  a  tuberculous  focus  or  a  syphilitic  lesion. 

In  the  vast  majority  of  instances  the  disease  is  general,  involving  blood- 
vessels, the  membrana  propria  of  mucous  membranes,  the  liver,  the  kidneys, 
and  especially  the  spleen.  The  lymph-glands,  tonsils,  stomach,  intestines,  heart, 
and  connective  tissues  are  less  often  involved.  The  amyloid  material  is  de- 
posited between  the  cells  and  not  in  them.  The  tissues  of  a  subject  of  amyloid 
disease  are  very  prone  to  suppurate  from  even  slight  infection. 

In  all  or  nearly  all  cases  the  spleen  is  involved.  The  victim  of  general  al- 
buminoid disease  is  pale,  greatly  exhausted,  emaciated,  and  very  anemic; 
suffers  from  diarrhea  and  usually  develops  capillary  hemorrhages  beneath  the 
skin  and  mucous  membranes.  The  albuminoid  material  can  be  detected 
chemically  in  the  urine  if  the  kidneys  are  involved.  Albuminoid  degeneration 
is  incurable  and  is  usually  fatal;  but  if  the  patient  is  subjected  to  proper  treat- 
ment soon  after  it  begins  it  may  be  arrested  and  never  progress. 

Diagnosis  of  Tuberculous  Abscess. — The  fluctuation,  the  absence  of  evi- 
dences of  acute  inflammation,  the  tendency  to  wander,  and,  in  some  cases,  the 
sudden  appearance,  mark  the  diagnosis.  The  surgeon  always  examines  with  care 
to  see  whether  there  is  some  distant  tuberculous  focus  from  which  the  abscess 
may  have  wandered,  or  whether  the  abscess  itself  is  at  the  primary  seat  of 
disease.  The  advancing  impairment  of  the  general  health,  the  lessened  amount 
of  hemoglobin,  the  normal  or  almost  normal  temperature,  and  the  absence  of 
leukocytosis  are  points  in  the  diagnosis  of  the  condition.  In  a  doubtful  case 
the  aseptic  use  of  the  tubular  exploring  needle  is  important,  the  fluid  that 
emerges  being  studied  by  the  microscope  after  staining,  by  cultures,  and 
perhaps  by  inoculating  it  into  guinea-pigs.  The  fluid  that  is  withdrawn  may 
contain  no  bacteria  that  can  be  demonstrated;  but  if  it  is  sterile,  one  should 
strongly  suspect  tuberculosis.  Various  diagnostic  tests  for  tuberculosis  will 
be  found  on  pages  226,  227,  228,  229,  and  230. 

Prognosis. — Advanced  albuminoid  degeneration  makes  the  prognosis  of 
tuberculous  abscess  hopeless  and  any  extent  of  albuminoid  degeneration  is 
unfavorable.  Secondary  pyogenic  infection,  as  already  stated,  may  produce 
death  or  a  lingering  suppuration.  The  prognosis  is  worse  in  very  young  chil- 
dren than  in  adults ;  and  in  any  case  it  is  unfavorable  if  the  exhaustion  deepens, 
if  the  anemia  is  marked,  if  there  are  tuberculous  lesions  in  distant  parts  or  in 
important  organs  or  structures,  if  the  patient  is  unable  to  take  enough  food  or 
if  he  cannot  digest  what  he  does  take,  and  if  the  regions  of  tuberculosis  cannot 
be  extirpated  or  steriHzed.  Under  other  circumstances  the  prognosis  is  favor- 
able. 

Tuberculous  Abscesses  in  Various  Regions. — Tuberculous  abscess 
of  the  head  of  a  bone  (see  Brodie's  Abscess,  page  497)  arises  in  the  cancel- 
lous structure  of  a  long  bone,  most  often  in  the  head  of  the  tibia,  and  is  fre- 


Psoas  Abscess 


241 


quently  noted  as  having  been  preceded  by  a  trivial  traumatism.  The  focus 
of  tuberculosis  seldom  induces  severe  symptoms  unless  secondary  pyogenic  in- 
fection occurs.  A  tuberculous  nodule  forms  as  a  result  of  tuberculous  osteo- 
myelitis. The  bone  about  the  nodule  is  hyperemic,  the  bony  trabeculae  are 
thickened,  and  the  cancellous  spaces  "are  devoid  of  fat  cells,  and  they  contain 
a  swollen  semifibrous  material"  (Warren's  "Surg.  Pathol.").  The  center  of 
the  nodule  becomes  cheesy,  the  bone  trabeculae  are  absorbed,  and  the  bone 
becomes  cheesy  and  broken  up,  the  cheesy  mass  containing  bone  fragments. 
Finally  the  area  becomes  filled  with  tuberculous  pus,  the  cavity  which  contains 
it  being  lined  with  tuberculous  granulations.  Distinct  sequestra  may  form 
and  the  bone  about  the  diseased  focus  undergoes  sclerosis.  In  tuberculous 
abscess  of  bone  pain  is  continued,  but  is  not  usually  very  severe,  is  of  a  boring 
character,  and  is  worse  when  the  patient  is  in  bed.  Attacks  of  synovitis  arise 
from  time  to  time  in  the  adjacent  joint.  The  bacteria  of  tuberculosis  obtain 
access  to  the  bone  by  means  of  the  blood,  and 
iind  in  the  bone  a  point  of  least  resistance. 
There  is  no  such  thing  as  an  acute  abscess  of 
bone.  A  pyogenic  inflammation,  of  such 
severity  that  it  would  cause  an  acute  abscess 
in  soft  parts,  in  bone  causes  acute  necrosis. 
A  less  violent  pyogenic  infection  causes  a 
very"  chronic  suppuration. 

Retropharyngeal  or  postpharyngeal  ab- 
scess is  often  tuberculous.  Such  an  abscess 
is  usually  due  to  caries  of  the  cer\dcal  verte- 
brae, but  can  arise  in  the  connective  tissue  of 
the  parts  or  as  tuberculous  adenitis.  An 
abrasion  of  the  mucous  membrane  may  ad- 
mit the  bacilli  to  the  connective  tissue  or  the 
glands.  A  swelling  projects  from  the  pos- 
terior pharyngeal  wall,  and  there  is  great 
interference  with  respiration  and  deglutition. 
Caseous  matter  from  caries  of  the  cervical 
vertebrae  may  reach  the  posterior  medias- 
tinum by  following  the  esophagus,  or  may 
appear  in  front  of  or  behind  the  sternomastoid 
muscle  in  the  neck  (Edmund  Owen).  A 
tuberculous  abscess  back  of  the  pharynx  is  apt  to  undergo  pyogenic  infection, 
in  which  case  the  patient  develops  fever,  sweats,  pain,  and  prostration. 

Dorsal  Abscess. — ^The  tuberculous  matter  in  dorsal  abscess  arises  from 
dorsal  caries,  flows  into  the  posterior  mediastimmi,  and  reaches  the  surface 
by  passing  between  the  transverse  processes.  The  tuberculous  matter  from 
dorsal  caries  may  run  forward  between  the  intercostal  muscles  or  between 
these  muscles  and  the  pleura,  pointing  in  an  intercostal  space,  at  the  side  of  the 
sternum,  or  by  the  rectus  muscle.  It  may  burst  into  the  gullet,  windpipe, 
bronchus,  pleural  sac,  or  pericardium.  It  may  descend  to  the  diaphragm  and 
travel  under  the  inner  arcuate  ligament  to  form  a  psoas  abscess,  or  under  the 
outer  arcuate  Hgament  to  form  a  liunbar  abscess.  A  psoas  abscess  may  point 
above  Poupart's  ligament  or  in  the  lumbar  region.  If  it  extends  below  Pou- 
part's  ligament  it  usually  points  external  to  the  femoral  vessels  (a  characteristic 
w^hich  is  said  to  distinguish  it  at  once  from  an  ordinary  femoral  hernia),  but 
may  burrow  in  any  direction. 

Iliac  abscess  arises  from  lumbar  caries,  the  swelling  lying  in  the  iliac  fossa 
and  pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  but  may  arise  from  dorsal 
16 


Fig.  102. — Psoas  abscess  (Albert). 


242 


Surgical  Tuberculosis 


caries.  The  fluid  usually  points  in  Scarpa's  triangle  external  to  the  femoral 
vessels,  but  may  descend  much  lower  (Fig.  102).  A  psoas  or  iliac  abscess,  by 
following  the  lumbosacral  cord  and  great  sciatic  nerve,  forms  a  gluteal  abscess. 
These  abscesses  may  open  into  the  bowel,  bladder,  ureter,  or  peritoneal  cavity. 
A  hernia  is  almost  never  mistaken  for  a  psoas  abscess,  but  a  psoas  abscess 
is  sometimes  mistaken  for  a  hernia  (Fig.  103).  J.  Torrance  Rugh  points  out 
that  without  a  search  for  spinal  kyphosis  or  muscular  rigidity  the  mistake 
may  be  made,  but  that  the  presence  of  a  mass  in  the  iliac  fossa  continuous  with 
the  external  lump  eliminates  the  possibility  of  the  condition  being  hernia. 

Lumbar  Abscess. — In  a  lumbar  abscess  the  fluid  produced  by  dorsal 
caries  descends  beneath  the  outer  arcuate  ligament,  or  the  fluid  from  lum- 
bar caries  which  collected  anterior  to  or  in  the  quadratus  lumborum  muscle 
passes  between  the  last  rib  and  iliac  crest  in  the  triangle  of  Petit,  the  small 
space  bounded  by  the  crest  of  the  ilium,  the  posterior  edge  of  the  external 
oblique  muscle,  and  the  anterior  edge  of  the  latissimus  dorsi  muscle.^ 


Fig.  103. — Case  of  cold  abscess  of  the  abdominal  wall  which  had  been  treated  as  a  hernia. 

Tuberculous  abscess  of  the  neck  results  from  tuberculosis  of  the  cervical 
glands.  It  is  not  often  that  such  an  abscess  attains  any  considerable  size. 
It  tends  strongly  to  spontaneous  rupture,  and,  if  this  is  permitted  to  occur, 
a  livid,  corrugated  scar  results. 

Tuberculous  Abscesses  of  Joints. — (See  Section  XIX.) 

Tuberculous  Abscess  of  Rib. — It  is  not  imcommon  to  find  a  tubercu- 
lous abscess  of  moderate  size  about  a  tuberculous  rib.  The  pleura  may 
become  involved  secondarily. 

Tuberculous  mediastinal  abscess  may  result  from  the  dow^nward  passage 
of  a  cervical  abscess;  from  tuberculosis  of  the  sternum,  ribs,  vertebrae  or  pleura, 
or  from  tuberculous  mediastinal  glands. 

Tuberculous  abscess  of  the  breast  is  a  caseated  and  liquefied  a  ea  of 
tuberculosis  of  the  breast.  A  lump  is  detected,  which  slowly  enlarges  and  finally 
ruptures,  sinuses  being  formed.  The  axillary  glands  are  apt  to  be  implicated. 
The  patient  may  belong  to  a  tuberculous  stock,  as  a  rule  gives  a  history  of 


1  For  a  lucid  description  of  these  abscesses  see  Owen's 
which  much  of  the  above  is  condensed. 


Manual  of  Anatomy,"  from 


Treatment  of  Tuberculous  Abscesses  of  Considerable  Size 


243 


previous  tuberculous  troubles  of  \arious  sorts,  and  has  usually  borne  children. 
Tuberculous  abscess  of  the  breast  causes  little  or  no  pain. 

Treatment  of  Tuberculous  Abscess. — For  many  years  the  majority  of 
surgeons  would  not  open  a  tuberculous  abscess  unless  it  was  on  the  point  of 
rupturing.  With  the  advent  of  antiseptic  surgen,-  it  was  assumed  that 
aseptic  incision  and  drainage  would  be  the  proper  treatment  for  these  cases; 
but  the  results,  except  in  small  superficial  tuberculous  abscesses,  have  been  ex- 
tremely disappointing.  If  a  large  abscess  is  so  treated,  pyogenic  infection  will, 
in  all  probability,  sooner  or  later  occur,  with  all  its  possibilities  of  disaster. 
Incision  and  drainage  is.  therefore,  restricted  to  small  and  superficial  abscesses. 

Treatment  of  Small  Superficial  Tuberculous  Abscesses. — The  surgeon 
must  remember  that  after  one  has  opened  an  apparently  superficial  abscess 
it  is  his  duty  to  make  an  examination  to  see  that  there  is  no  channel  connecting 
the  abscess  with  a  deep  or  a  distant  focus.  If  he  finds  such  a  channel,  he  may  be 
disposed  to  follow  one  of  the  plans  of  treatment  outlined  below  and  on  page  244. 
It  is  also  his  duty  to  see  whether  there 
are  sinuses  tracking  off  from  the  abscess; 
and  if  these  exist,  he  must  sHt  them  up. 
If  there  are  locuh  in  the  wall  of  the 
abscess,  he  must  stretch  their  mouths. 
He  must  be  particularly  careful  to  see 
that  he  is  not  dealing  with  a  shirt-stud 
abscess,  in  which  there  is  a  little  opening 
through  the  deep  fascia  connecting  the 
abscess  above  -^-ith  the  abscess  below. 
In  a  shirt-stud  abscess  the  deep  fascia 
must  be  freely  incised.  After  the  ab- 
scess has  emptied  itself,  its  walls  must 
be  thoroughly  scraped  ^ith  a  curet,  and 
the  ca\'ity  must  be  drained  vvith  a  tube 
or,  preferably,  with  iodoform  gauze.  If 
the  skin  above  a  superficial  abscess  is 
diseased  and  discolored,  and  the  abscess 
is  on  the  eve  of  spontaneous  rupture 
or  has  ruptured,  the  discolored  skin 
must  be  cut  away  with  scissors.  If  the 
discolored  skin  is  allowed  to  remain,  a 
li\'id.  and  jagged  scar  vnR  inevitably  result. 
scar,  not  ven.-  deforming,  t\t11  result. 

Treatment  of  Tuberculous  Abscesses  of  Considerable  Size. — Method 
I.  Aspiration,  Irrigation,  and  the  Introduction  of  Iodoform. — The  operation  is 
carried  out  -^^ith  the  most  scrupulous  aseptic  care.  The  trocar  is  passed  through 
the  sound  skin;  is  carried  beneath  the  skin  for  an  inch,  as  Senn  suggests;  and 
is  then  made  to  enter  into  the  ca\nty  of  the  abscess.  The  stylet  is  pulled 
out,  and  the  flow  of  fluid  is  aided  by  ven.-  dehcate  pressure.  Occasionally  the 
tube  -^-ill  become  blocked  by  necrosed  tissue  or  plugs  of  fibrin.  It  is  opened 
up  again  by  pushing  in  a  "^"ire  or  forcing  through  it  a  stream  of  sterile  fluid. 
WTien  tuberculous  matter  ceases  to  rim  out  of  the  trocar,  a  ver\'  warm  solution 
of  boric  acid  is  thro'^m  in  in  order  to  wash  the  abscess  walls.  This  can  be  in- 
jected with  a  fountain  s}Tinge  or  with  the  special  apparatus  of  Senn  (Fig.  104). 
Enough  of  it  is  aUowed  to  enter  to  overdistend  the  abscess-cavity,  as  ]Mr.  Cal- 
lender  long  ago  advised.  The  fluid  is  then  allowed  to  pass  out;  fresh  fluid  is 
passed  in;  and  this  procedure  is  repeated,  perhaps  again  and  again,  until  entirely 
clear  fluid  flows  out.  When  this  takes  place,  an  emulsion  of  iodoform  is  thrown 
in  by  Senn's  svTinge.     A  10  per  cent,  emulsion  in  glycerin  is  as  satisfactory 


Fig.  104. — Senn's  injection  sjiinge. 

If   it   is   cut   awav  a  healthv 


244  Surgical  Tuberculosis 

as  the  more  elaborate  formulas.  Verneuil  used  to  employ  iodoform  and  ether; 
but  this  is  painful,  is  more  liable  to  cause  iodoform-poisoning,  and  sometimes 
induces  gaseous  distention  and  ruptures  the  wall  of  the  abscess.  In  order  to 
prevent  the  danger  of  iodoform-poisoning  the  surgeon  should  not  introduce  at 
one  time  more  than  8  dr.  of  the  emulsion,  if  dealing  with  an  adult;  or  more 
than  4  dr.,  if  dealing  with  a  child.  After  the  emulsion  has  been  inserted  into 
the  abscess-cavity  the  wound  in  the  skin  is  sealed  with  a  bit  of  gauze  and  iodo- 
form collodion.  Gauze  is  fluffed  up  and  laid  on  the  skin  above  the  abscess, 
and  the  walls  of  the  cavity  are  then  forced  toward  each  other  by  applying  a 
roller  bandage.  The  part  is  put  at  complete  rest,  and  it  is  usually  necessary  to 
put  the  patient  in  bed.  Sometimes,  although  very  seldom,  one  injection  will 
produce  a  cure;  but  usually,  after  one  or  two  weeks,  it  will  be  observed  that  the 
cavity  has  to  some  extent  filled  again.  A  second  operation  is  then  performed; 
and,  if  improvement  is  really  taking  place,  it  will  be  found  that  the  fluid  is  not 
nearly  so  thin  as  it  was  at  the  first  operation.  It  is  needless  to  persist  in  this 
method  after  six  or  seven  attempts  have  failed  to  cure.  If  the  abscess  has  thick 
and  uncollapsed  walls  it  is  not  fitted  for  treatment  by  aspiration  and  injection. 
Method  2.  Incision,  Cleansing,  and  Suture. — If,  owing  to  the  considerable 
size  or  the  rather  rigid  waUs  of  the  abscess,  one  believes  that  the  aspiration 
method  would  be  useless;  or  if  the  aspiration  method  has  been  tried  and  has 
failed,  one  may  adopt  the  following  plan.  It  should  not,  however,  be  em- 
ployed if  the  walls  are  very  thick  and  rigid.      An  incision  is  made  at  the  most 


Fig.   los. — Barker's  sharp-edged  irrigating  curet  ("Keen's  Surgery"). 

dependent  part  of  the  abscess.  The  walls  are  scraped  carefully  with  Barker's 
sharp-edged  irrigating  curet  (Fig.  105),  and  are  rubbed  smooth  with  bits  of 
gauze.  The  part  is  freely  irrigated  with  hot  boric  acid  solution,  and  pressure 
is  applied  to  arrest  bleeding.  Iodoform  emulsion  is  introduced;  the  skin  is 
sutured;  dressings,  compresses,  and  bandages  are  applied,  and  complete  rest 
is  secured.  This  operation  may  cure  an  abscess,  or  it  may  be  necessary  to 
repeat  the  procedure  two  or  three  or  many  weeks  afterward. 

Method  3.  Incision  and  Removal  of  the  Primary  Focus  of  Tuberculosis. — If 
the  surgeon  does  not  wish  to  use  the  iodoform  treatment,  or  if  it  has  failed, 
and  if  he  finds  that  the  primary  seat  of  disease  may  be  attacked  and  removed, 
an  operation  should  be  undertaken  to  get  rid  of  Volkmann's  membrane  in  the 
last-formed  abscess  and  also  to  remove  the  primary  tuberculous  focus.  An 
incision  is  made,  when  possible,  that  will  lay  open  not  only  the  last-formed 
abscess,  but  the  primary  lesion.  Tuberculous  tissue  is  thoroughly  removed 
by  Barker's  spoon  and  by  rubbing  with  gauze  or,  perhaps,  by  scissors  and 
forceps.  Any  focus  of  bone  disease  is  curetted  and  touched  with  pure  carbolic 
acid,  and  loose  fragments  of  bone  are  removed.  The  part  is  irrigated  with  a 
hot  solution  of  boric  acid;  bleeding  is  arrested  by  pressure,  and  the  wound  is 
nearly,  but  not  quite,  closed,  drainage  being  inserted  at  the  most  appropriate 
spot.  Dressings,  compresses,  and  bandages  are  then  applied.  In  this  opera- 
tion the  entire  tuberculous  area  has  been  removed  and  the  raw  surfaces  have 
been  forced  into  contact,  and  there  is  scarcely  more  danger  of  secondary 
pyogenic  infection  than  there  is  in  any  ordinary  wound. 

General  Treatment. — It  is  never  to  be  lost  sight  of  that  in  every  case  of 


Large  Tuberculous  Abscesses  245 

tuberculous  abscess  the  general  treatment  of  tuberculosis  must  be  rigorously 
pursued  (see  page  230).  In  the  treatment  of  a  cold  abscess  give  nutritious 
food,  cod-liver  oil,  quinin,  iron,  and  the  mineral  acids.  Removal  to  the 
mountains  or  the  seaside  is  often  indicated,  life  in  the  open  air  is  imperative, 
and  mechanical  appliances  may  be  needed  for  diseases  of  the  bones  and  joints. 

Tuberculous  Abscess  of  Bone. — Make  an  incision  to  bare  the  bone.  Open 
the  abscess  with  the  trephine,  the  gouge,  or  the  chisel ;  curet  the  interior  of  the 
wall  of  the  cavity  with  a  sharp  spoon  and  rub  it  with  bits  of  gauze;  cut  away 
the  edges  of  the  bone  with  rongeur  forceps ;  irrigate  the  cavity  with  hot  normal 
salt  solution,  dry  its  walls  with  gauze,  and  paint  the  cavity  with  pure  car- 
bohc  acid;  pack  with  iodoform  gauze  and  apply  antiseptic  dressings.  It  is 
better  not  to  employ  an  Esmarch  apparatus.  Bleeding  will  not  be  severe, 
and  when  no  apparatus  is  used  to  prevent  bleeding  it  is  possible  to  see  and  thus 
be  sure  that  all  the  diseased  bone  has  been  removed. 

Tuberculous  Abscess  of  Ljrmphatic  Glands. — In  non-exposed  portions  of  the 
body  the  capsule  of  the  gland  should  be  incised  and  dissected  or  scraped  away 
and  the  cavity  swabbed  out  with  pure  carbolic  acid  or  iodin  and  packed  with 
iodoform  gauze,  but  drainage  should  not  be  prolonged.  If  the  abscess  is 
allowed  to  burst,  it  will  cause  an  ugly  scar;  therefore,  in  exposed  portions  of 
the  body,  as  the  neck,  special  effort  should  be  made  to  prevent  a  scar  by  incising 
early  before  the  skin  is  involved.  When  only  a  little  caseated  matter  exists 
and  the  skin  is  not  discolored,  prepare  the  parts  antiseptically,  incise,  rub  the 
interior  with  gauze,  inject  iodoform  emulsion,  and  suture  the  wound.  It  used 
to  be  a  custom  in  such  cases  to  carry  a  silk  thread  by  means  of  a  needle  through 
the  skin,  through  the  gland,  and  out  at  its  lowest  point,  the  part  being  then 
dressed  with  gauze.  In  three  days  the  thread  was  removed  and  a  firm  com- 
press was  applied.  The  plan  is  not  satisfactory  and  incision  is  to  be  preferred. 
When  the  gland  is  almost  entirely  broken  down  and  the  skin  above  it  is  becom- 
ing purple  and  thin,  insert  a  hypodermatic  needle  through  soimd  skin  into  the 
abscess,  draw  off  the  fluid  tuberculous  matter,  and  inject  iodoform  emulsion. 
This  procedure  is  to  be  repeated  when  the  fluid  again  accumulates.  By  this 
means  we  can  sometimes  effect  a  cure  in  a  week  or  so.  When  an  abscess 
breaks  or  is  on  the  point  of  breaking,  cut  away  all  purple  skin,  curet  the  abscess 
walls  (the  abscess  having  become  a  tuberculous  ulcer),  remove  the  remains 
of  gland  and  capsule,  swab  the  cavity  with  pure  carbolic  acid,  and  dress  with 
iodoform  and  antiseptic  gaiize. 

Tuberculous  glands,  if  not  cured  by  general  treatment,  ought  to  be  extir- 
pated. They  should  certainly  be  extirpated  before  they  caseate  and  form 
an  abscess.  If  an  abscess  does  form  it  is  treated  as  directed  above,  and  after 
healing  takes  place  the  diseased  glands  may  be  extirpated.  If  sinuses  exist 
they  are  curetted  and  touched  with  iodin  or  carboHc  acid.  After  healing,  the 
glands  are  extirpated.     When  sinuses  exist  there  is  always  mixed  infection. 

Tuberculous  Abscess  of  a  Rib. — ^This  lesion  requires  incision  of  the  soft 
parts  and  resection  of  the  diseased  bone.  The  tuberculous  area  is  thoroughly 
curetted,  rubbed  with  pure  carbolic  acid,  and  packed  with  iodoform  gauze. 

Tuberculous  Mediastinal  Abscess. — In  tuberculous  abscess  of  the  me- 
diastinum aspiration  and  injection  of  iodoform  may  prove  efi&cient.  In  some 
cases  it  will  be  necessary  to  open  and  drain. 

Tuberculous  Abscess  of  the  Mammary  Gland. — Many  operators  simply  in- 
cise, curet,  pack  with  iodoform  gauze,  and  dress  antiseptically.  It  is  wiser  to 
remove  the  entire  gland  and  to  clear  out  the  axilla,  as  in  an  operation  for 
cancer,  in  order  to  prevent  both  recurrence  and  dissemination. 

Large  Tuberculous  Abscesses. — In  view  of  the  facts  that  these  abscesses 
may  cause  no  trouble  for  years  and  that  an  operation  may  be  fatal,  some  emi- 
nent surgeons  are  opposed  to  an  operation  unless  the  abscess  is  moving  toward 


246  Surgical  Tuberculosis 

inevitable  rupture  or  is  disturbing  the  function  of  organs  by  pressure.  Most 
practitioners  believe,  however,  and  I  agree  with  them,  that  this  mass  of 
tuberculous  matter  is  a  source  of  danger  through  being  a  depot  of  infective 
organisms  which  may  overwhelm  the  system,  and  that  death  will  seldom 
result  from  an  operation  performed  by  one  who  employs  with  intelligence 
strict  antisepsis.  In  no  other  cases  is  attention  to  every  detail  more  impor- 
tant, as  a  mixed  infection  may  easily  take  place,  and  will  probably  mean 
death.  As  W.  Watson  Cheyne  points  out,  over  70  per  cent,  of  cases  of  spinal 
abscess  treated  by  aseptic  methods  recover  completely  and  without  any 
real  illness  after  such  an  operation.  The  recoveries  from  the  old  let-alone 
method  will  be  infinitely  less  than  this,  and  cases  cured  by  operation  usually 
remain  well.  The  surgeon  must  always  remember  that  the  wall  of  the  abscess 
and  not  the  fluid  in  the  cavity  is  the  real  seat  of  disease,  and  this  wall  must  be 
actually  removed  or  completely  sterilized  if  operation  is  to  be  safe.  To  simply 
open,  drain,  and  leave  the  wall  to  Nature  to  get  rid  of  as  she  can  is  fraught 
with  the  gravest  peril. 

Psoas  Abscess. — Some  of  these  cases  can  be  treated  by  aspiration  and 
injection  (see  page  243),  others  by  incision  and  subsequent  suture  (see  page  244), 
others  by  the  radical  operation  set  forth  on  page  244. 

Treves's  operation  for  psoas  abscess  is  described  on  page  695. 

An  operation  occasionally  performed  for  psoas  abscess  consists  in  an 
incision  in  the  groin,  an  incision  in  the  back,  removal  of  carious  vertebrae, 
thorough  cleansing  of  the  abscess  wall,  and  through-and-through  tubular 
drainage.  It  has  been  found,  however,  that  this  operation  is  uncertain  and 
dangerous.  It  is  not  advisable  to  remove  carious  vertebrae  unless  the  carious 
parts  are  loose,  and  through-and-through  tubular  drainage  is  rarely  used  unless 
mixed  infection  already  exists.  When  a  large  abscess  breaks  spontaneously  it 
should  be  widely  opened  at  once,  scraped  and  irrigated,  rubbed  with  gauze, 
and  packed  with  iodoform  gauze.  If  secondary  pyogenic  infection  of  a  large 
tuberculous  abscess  does  occur  the  patient  will  develop  septic  fever  and  wiU 
probably  die  (q.  v.). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the  same  plan  as 
psoas  abscess.  One  incision  only  is  usually  necessary  unless  the  fluid  has 
traveled  to  a  distant  point. 

A  postpharyngeal  abscess  must  not  be  opened  through  the  mouth.  To 
open  it  in  this  manner  puts  the  patient  in  danger  of  suffocation  by  fluid  running 
into  the  larynx  during  or  after  the  operation.  Further,  mixed  infection  of  the 
abscess  area  will  be  certain  to  ensue.  Septic  pneumonia  wiU  be  apt  to  arise 
from  inhaled  infected  particles,  and  profound  gastro-intestinal  disturbance 
will  be  liable  to  develop  because  of  the  inevitable  swallowing  of  purulent, 
putrid,  and  tuberculous  masses.  Incise  the  neck  and  open  into  the  abscess 
by  Hilton's  method,  going  through  the  sternocleidomastoid  muscle  or  behind 
it.  Rub  the  wall  of  the  abscess  with  bits  of  gauze,  remove  any  loose  bone, 
irrigate  with  hot  normal  salt  solution,  inject  iodoform  emulsion,  insert  a  tube 
or  pack  with  iodoform  gauze. 

Tuberculosis  of  the  skin  may  arise  from  inoculation  with  material  de- 
rived from  a  bovine  or  human  source.  It  is  frequently  found  that  some 
other  member  of  the  family  labors  under  tuberculous  disease  or  that  some 
family  predecessor,  direct  or  collateral,  suffered  from  it.  Stelwagon  ("Dis- 
eases of  the  Skin")  includes  all  cases  under  five  heads:  (i)  tuberculosis  iil- 
cerosa;  (2)  tuberculosis  disseminata;  (3)  tuberculosis  verrucosa;  (4)  scrofulo- 
derma; (5)  lupus  vulgaris. 

Tuberculosis  Ulcerosa. — The  disease  arises  at  a  mucous  outlet  and  is 
usually  secondary  to  internal  tuberculous  disease.  Small  miliary  tubercles 
form  which  caseate   and  are  converted  into  ulcers.     An  ulcer  is  shallow, 


Tuberculosis  of  Subcutaneous  Connective  Tissue  247 

round  or  oval  in  outline,  with  soft  edges,  the  floor  being  composed  of  sluggish  or 
edematous  granulations  covered  with  a  crust.  The  discharge  is  scanty  and 
sercpurulent.  In  some  cases  there  is  but  one  ulcer;  in  others  there  are  two 
or  several,  and  the  fusion  of  ulcers  produces  a  serpiginous  outline.  The  ulcers 
do  not  tend  to  heal,  but  gradually  and  steadily  advance.  Such  ulcers  are  met 
with  about  the  mouth,  the  genital  organs,  and  the  anus. 

Tuberculosis  Disseminata. — This  occurs  only  in  children;  it  is  acute  in 
onset  and  widespread.  One  type  is  polymorphic:  spots,  papules,  pustules, 
and  crusted  ulcers  existing,  and  lymphatic  glands  being  enlarged.  Another 
t^pe  arises  after  an  attack  of  an  exanthematous  fever  and  presents  "a  rough 
resemblance  to  flat  lupus  tubercles,  to  sluggish  acne  papules,  and  to  lichen 
scrofulosum"  (Stelwagon,  "Diseases  of  the  Skin"). 

Tuberculosis  Verrucosa. — Anatomical  tubercle,  the  verruca  necrogenica  of 
W'ilks,  is  due  to  local  inoculation  with  tuberculous  matter.  It  may  be  met 
with  in  surgeons,  the  makers  of  postmortems,  leather  workers,  and  butchers, 
usually  upon  the  backs  of  the  hand  and  fingers.  It  consists  of  a  red  mass  of 
granulation  tissue  having  the  appearance  of  a  group  of  inflamed  warts.  Pus- 
tules often  form. 

Scrofulodermata  or  Tuberculous  Gummata. — By  "scrofulodermata"  we 
mean  chronic  inflammations  of  the  skin,  the  granulation-tissue  product  of 
which  caseates,  mLxed  infection  occurs,  and  small  abscesses,  sinuses,  or  ulcers 
form.  A  tuberculous  ulcer  has  a  floor  of  a  pale  color,  and  has  no  granulations 
at  all,  or  is  covered  with  large,  pale,  edematous  granulations.  The  discharge 
is  thin  and  scanty.  The  ulcer  is  surrounded  by  a  considerable  zone  of  purple, 
tender,  and  undermined  skin,  which  is  apt  to  slough.  When  healing  occurs, 
the  skin  puckers  and  usually  inverts. 

Lupus  begins  usually  before  the  age  of  twenty-five,  but  is  met  wdth  often 
in  individuals  in  middle  life.  It  is  most  common  upon  the  face,  especially  the 
nose.  It  is  a  very  chronic  and  extremely  destructive  disease.  Three  forms  are 
recognized:  (i)  lupus  vulgaris,  in  which  pink  nodules  appear  that  after  a  time 
ulcerate  and  then  cicatrize  partly  or  completely.  These  nodiiles  resemble 
jelly  in  appearance;  (2)  lupus  exedens,  in  which  ulceration  is  very  great,  and 
(3)  lupus  hypertrophicus,  in  which  large  nodules  or  tubercles  arise.  Lupus 
may  appear  as  a  pimple,  as  a  group  of  pimples,  or  as  nodules  of  a  larger  size. 
The  ulcer  arises  from  desquamation,  and  is  surrounded  by  inflammatory 
products  which,  by  progressively  breaking  down,  add  to  the  size  of  the  raw 
surface.  The  ulcer  is  usually  superficial,  is  irregular  in  outline,  the  edges 
are  soft  and  neither  sharp  nor  undermined,  the  sore  gives  origin  to  a  small 
amount  of  thin  discharge,  the  parts  about  are  of  a  yellowish-red  color,  the  edges 
are  solid  and  puckered  and  scar-like  and  there  is  no  pain.  The  sore  is  often 
crusted,  the  crusts  being  thin  and  of  a  brown  or  black  color;  it  may  be  pro- 
gressing at  one  point  and  healing  at  another;  it  is  slow  in  advancing,  but  often 
proves  hideously  destructive.  The  scars  left  by  healing  are  firm  and  corru- 
gated, but  are  apt  to  break  down.  ClinicaUy,  it  is  separated  from  a  rodent 
Tilcer  by  several  points.  The  rodent  iflcer  is  deep,  its  edges  are  everted,  and 
the  parts  about  filled  with  visible  vessels.  It  is  not  crusted,  has  not  a  puckered 
edge,  its  edges  and  base  are  hard,  and  it  rarely  shows  any  tendency  to  healing. 
Many  victims  of  lupus  live  twenty  or  thirty  years  and  die  without  the  devel- 
opment of  pulmonary  tuberculosis.  It  is  estimated  that  one-third  of  those 
who  die  show  signs  of  pulmonary  tuberculosis.  Lupus  patients  exhibit  a  strong 
focal  reaction  to  tuberculin  and  also  show  von  Pirquet's  reaction. 

Tuberculosis  of  Subcutaneous  Connective  Tissue. — In  this  form 
of  tuberculosis  tuberculous  nodules  form  and  break  down  (tuberculous  ab- 
scesses). In  the  deeper  tissues  these  abscesses  are  usuaUy  associated  with 
bone,  joint,  or  lymphatic  gland  disease  (see  Cold  Abscess,  page  236). 


248  Surgical  Tuberculosis 

Tuberculosis  of  the  Mammary  Gland. — (See  page  245.) 

Tuberculosis  of  Blood=vessels. — It  is  certain  that  bacilli  in  the  blood 
or  in  tuberculous  emboli  may  establish  intravascular  tuberculosis. 

Tuberculous  Meningitis. — (See  page  801.) 

Tuberculosis  of  nerves  is  excessively  rare.  Tuberculous  neuritis  may 
arise  in  the  course  of  general  tuberculosis.  A  nerve  lying  in  a  tuberculous 
area  may  itself  become  tuberculous.  It  rarely  does  so,  however.  In  fact, 
nerves  resist  infections  though  in  the  midst  of  them,  and  for  this  reason  have 
been  called  the  "aristocrats  of  the  body." 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are  more  commonly 
affected  than  any  other  structure.  The  lung  affection  may  be  primary  or 
may  be  secondary  to  some  distant  tuberculous  process.  Pulmonary  tubercu- 
losis belongs  to  the  province  of  the  physician  and  requires  no  description  here. 

Tuberculosis  of  the  pleura  is  not  uncommon.  Tuberciilous  pleurisy 
may  be  acute  or  chronic.  In  some  instances  mixed  infection  takes  place  and 
suppuration  occurs.  The  tuberculosis  may  be  primary,  but  is  usually  second- 
ary to  pulmonary  tuberculosis,  and  may  be  due  to  direct  extension  or  to 
rupture  of  an  area  of  pulmonary  softening.  A  primary  pleurisy  not  due  to 
traumatism  is  very  apt  to  be  tuberculous.  In  many  cases  of  tuberculous  pleu- 
risy there  are  tubercles  present  and  in  some  cases  there  are  none. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuberculous  ulcer  of  the 
lip  occasionally  arises,  and  may  be  mistaken  for  a  cancer  or  a  chancre.  A 
tuberculous  ulcer  of  the  tongue  is  commonly  associated  with  other  foci  of  dis- 
ease. Such  ulcers  are  separated  from  cancer  by  their  soft  bases  and  edges 
and  by  the  rarity  of  glandular  enlargements,  and  from  syphilitic  processes 
by  the  therapeutic  test.  Confirmation  of  the  diagnosis  is  obtained  by  culti- 
vations and  inociilations.  Tubercle  may  affect  the  pharynx,  palate,  tonsils, 
and,  very  rarely,  the  stomach. 

Gastric  Tuberculosis.— It  is  thought  that  the  acid  gastric  juice  must 
protect  the  stomach  from  tubercle,  because  tubercle  bacilli  are  frequently 
introduced  into  the  stomach,  but  the  organisms  very  rarely  lodge  and  multiply 
in  the  stomach  wall.  Furthermore,  bacilli  when  introduced  into  the  stomach 
are  retained  but  a  short  time  and  the  stomach  walls  contain  few  lymph-follicles 
(Barchasch,  in  "Beit.  Z.  klin.  d.  Tuberculose,"  vii.  Part  III,  1907).  It  may 
be  assumed  that  gastric  catarrh  and  motor  impairment  are  predisposing  causes. 
Gastric  tuberculosis  may  be  primary,  but  is  usually  secondary  to  pulmonary 
tuberculosis,  infected  sputum  having  been  repeatedly  swallowed  ("Jour.  Am. 
Med.  Assoc,"  Dec.  28,  1907).  Gastric  tuberculosis  may  cause  cicatricial 
stenosis  of  the  pylorus,  ulcer  (of  which  I  reported  an  instance),  a  tumor-like 
thickening,  solitary  tubercle,  and  miliary  tuberculosis  (Barchasch,  Loc.  cit.). 

Intestinal  tuberculosis  may  follow  pulmonary  tuberculosis,  but  it  may 
arise  primarily  in  the  mucous  membrane  of  the  bowel  or  result  from  tubercu- 
lous peritonitis.  Intestinal  tuberculosis  causes  diarrhea  and  fever,  may  re- 
semble appendicitis,  and  may  cause  abscess  and  perforation.  True  tubercu- 
lous disease  of  the  appendix  occasionally  occurs.  Tuberculosis  of  the  cecirai 
is  by  no  means  as  rare  as  we  used  to  believe  (see  page  1014).  Fistula  in  ano  is 
frequently  tuberculous,  and  when  it  is,  the  lungs  are  very  often  involved,  the 
pulmonary  lesion  being  usually  primary. 

Tuberculosis  of  the  Liver. — Tuberculous  disease  of  the  liver  causes 
cold  abscess  or  cirrhosis.  Typical  cirrhosis  without  tubercles  may  arise,  the 
bacilli  being  present  in  the  tissues.  Many  cases  of  supposed  alcoholic  cir- 
rhosis are  probably  tuberculous.  The  hepatic  cirrhosis  which  may  arise  during 
peritoneal  tuberculosis  is  tuberculous. 

Peritoneal  tuberculosis  (see  page  1027)  maybe  primary,  infection  having 
taken  place  by  way  of  the  blood,  may  be  part  of  a  diffused  process,  or  may  follow 


Tuberculous  Disease  of  Bone  249 

intestinal  tuberculosis,  the  serous  and  mucous  coats  of  the  bowel  having  been 
at  some  point  in  contact  or  a  follicular  ulcer  having  perforated  (Abbe).  The 
germ  may  have  entered  by  the  Fallopian  tube.  Tuberculous  peritonitis  may  be 
due  to  ovarian  or  Fallopian  tuberculosis,  or  to  ulceration  of  a  tuberculous  ap- 
pendix. In  some  cases  a  caseating  tuberculous  gland  furnishes  the  causative 
bacilli.  Peritoneal  tuberculosis  usually  causes  ascites,  tympany,  and  tumor- 
like formations  composed  of  adherent  bunches  of  bowel  or  omentum  or  dis- 
tended mesenteric  glands  (see  page  1027).    . 

Tuberculosis  of  the  Pancreas. — ^Tuberculous  sclerosis  of  this  organ  has 
been  induced  experimentally  by  Carnot. 

Tuberculosis  of  the  spleen  may  occur  with  tubercles  or  as  a  sclerosis. 

The  heart  muscle  is  rarely  attacked  by  tuberculosis.  In  fact,  valvular 
lesions  of  the  left  side  of  the  heart  actually  protect  the  individual  from  pul- 
monary tuberculosis.  Non-tuberculous  endocarditis  may  arise  in  the  course 
of  a  tuberculous  process  elsewhere.  Tuberculous  endocarditis  does  liery 
rarely  occur. 

The  endocardium  may  be  inflamed  and  covered  with  fibrous  exudate  as  a 
resvilt  of  the  toxins  from  some  distant  point  of  tuberculosis. 

The  pericardium  may  be  attacked  with  primary  tuberculosis,  or  the 
process  may  be  secondary  to  pleural  tuberculosis.  There  may  or  may  not  be 
tuberculosis. 

Tuberculosis  of  the  brain  induces  meningitis  and  hydrocephalus  (see 
page  801). 

Tuberculosis  of  the  membranes  of  the  spinal  cord  is  seen  alone 
or  in  association  with  tuberculous  inflammation  of  the  brain. 

Tuberculous  disease  of  fascia  is  common;  in  fact,  fascia  is  pecu- 
liarly prone  to  infection.  Fascia  may  be  attacked  primarily,  and  when  it  is, 
the  disease  is  apt  to  spread  rapidly  and  widely  and  to  produce  most  disastrous 
results.  The  elder  Senn  regards  tuberculosis  of  the  intermuscular  septa  of  the 
thigh  as  a  very  grave  condition,  which,  if  extensive,  demands  amputation  of 
the  limb.  Secondary  tuberculosis  of  fascia  is  far  more  common  than  the 
primary  form,  the  original  focus  of  disease  being  in  bone,  joint,  tendon-sheath, 
or  lymph-gland. 

Tuberculosis  of  muscle  is  rare.  Instances  of  primary  tuberculosis 
have  been  reported.  Secondary  tuberculosis  is  more  common,  but  even  this 
condition  is  rare,  muscle  seeming  to  have  a  high  degree  of  resistance. 

Tuberculous  disease  of  bone  (see  page  494)  is  very  common  in  youth, 
and  a  sprain  or  a  contusion,  which  is  oftener  slight  than  severe,  may  precede 
any  signs  of  the  disease.  The  injury  establishes  a  point  of  least  resistance,  and 
in  the  damaged  area  the  bacflli  are  depsoited  and  multiply,  or  a  latent  area 
of  tuberculosis  is  roused  into  activity  by  the  traimiatism.  The  organisms 
may  be  deposited  directly  from  the  lymph  or  blood,  or  may  arrive  in  an  embolus 
from  a  distant  tuberculous  focus  (limg  or  lymph-gland),  which  embolus  is 
caught  in  a  terminal  artery  in  the  end  of  a  long  bone  and  causes  a  wedge-shaped 
infarction. 

Tuberculous  osteomyelitis,  as  a  rule,  begins  just  beneath  the  articular 
cartilage  or  in  the  epiphysis.  There  may  be  one  focus,  several  foci,  or  many 
foci  in  the  same  bone.  The  products  of  the  tuberciilous  inflammation  con- 
stitute tuberculous  nodules  which  destroy  the  medullary  tissue  and  hence 
cut  off  the  nutrition  of  adjacent  bone.  Bone  trabeculae  are  destroyed,  and 
tuberculous  granulations  take  their  place,  and  here  and  there  small  dead 
portions  of  bone  trabeculae  lie  as  sequestra  among  the  granulations.  In  some 
bones,  for  instance,  the  vertebrae  and  the  bones  of  the  carpus  and  tarsus,  the 
tuberculous  process  spreads  widely;  in  some  it  tends  to  remain  localized. 
Tuberculous   granulations  may  be   absorbed,  may  be  encapsuled,  may  be 


250  Surgical  Tuberculosis 

replaced  by  fibrous  tissue,  or  may  caseate  (see  page  214).  When  an  osseous 
tuberculous  focus  spreads  the  bone  enlarges  and  becomes  spindle  shaped, 
as  is  seen  in  a  phalanx  the  seat  of  tuberculous  osteomyelitis,  the  condition 
known  as  spina  ventosa. 

Tuberculous  disease  of  the  joints  (see  page  618)  is  called  white 
swelling  and  also  pulpy  degeneration  of  the  synovial  membrane.  Joints  are 
especially  liable  to  tuberculosis  in  youth,  although  the  wrist  and  shoulder  not 
infrequently  suffer  in  adult  life.  Joint-tuberculosis  is  often  preceded  by  an 
injury.  The  tuberculous  process  in  rare  cases  begins  in  the  synovial  mem- 
brane. Primary  synovial  tuberculosis  is  most  often  met  with  in  the  knee-joint. 
Usually  the  disease  begins  in  the  end  of  a  bone,  dry  caries  resulting,  necrosis 
ensuing,  or  an  abscess  forming,  which  may  break  into  the  joint. 

Poncefs  rheumatism  or  tuberculous  articular  rheumatism  is  a  condition  in 
which  toxic  joint  inflammation  is  evidence  of  latent  tuberculous  infection 
perhaps  at  some  distant  point,  it  being  often  impossible  to  demonstrate  the 
bacillus  in  the  joint  fluid  or  tubercles  at  the  autopsy  (see  page  619). 

Tuberculosis  of  lymphatic  glands  is  known  as  tuberculous  adenitis. 
It  is  the  most  typical  lesion  of  scrofula.  Tuberculous  adenitis  is  most  fre- 
quent between  the  third  and  fifteenth  years.  A  person  not  of  the  tuberculous 
type  may  acquire  tuberculosis  of  the  glands,  but  the  disease  is  unquestionably 
of  much  greater  frequency  in  those  who  are  recognized  as  predisposed  to  tuber- 
culosis. Tuberculous  glands  may  get  well,  may  even  calcify,  but  usually 
caseate  if  let  alone.  Long  after  healing  they  may  break  down  and  soften 
{residual  abscess  of  Paget).  They  very  frequently  suppurate  because  of  mixed 
infection.  Though  at  first  a  local  disease,  tuberculous  glands  may  prove  to  be 
a  dangerous  focus  of  infection,  furnishing  bacteria  which  are  carried  by  blood  or 
lymph  to  distant  organs  or  throughout  the  entire  system.  Glandular  enlarge- 
ment is  in  rare  instances  widely  diffused,  but  it  is  far  more  commonly  localized. 
Enlargement  of  the  cervical  glands  is  most  common.  Tuberculous  disease  of 
the  mesenteric  gland  is  known  as  tabes  mesenterica.  Tuberculosis  of  lymph- 
glands  may  be  due  either  to  bovine  bacilli  or  to  human  bacilli. 

Tuberculosis  of  the  cervical  lymph=glands  is  a  very  common  condi- 
tion. It  is  most  common  in  children  over  two  years  of  age  and  is  often  seen  in 
young  adults.  It  is  rare  in  children  under  two  and  in  persons  of  mid-die  age. 
In  the  majority  of  cases  infection  takes  place  from  the  tonsils,  pharynx,  or  pos- 
terior part  of  the  oral  cavity,  and  in  these  cases  the  first  glands  to  enlarge  are 
those  just  below  the  parotid  salivary  gland.  In  a  number  of  cases  enlargement 
begins  in  the  submaxillary  or  submental  glands,  and  in  these  cases  infection 
originates  from  the  teeth,  mouth,  or  face  (Dowd,  in  "Surgery,  Gynecology,  and 
Obstetrics,"  March,  1909).  A  tuberculous  lesion  of  the  scalp  may  be  followed 
by  tuberculosis  of  the  parotid  lymph-glands.  Cervical  adenitis  may  be  uni- 
lateral or  bilateral  and  is  a  very  chronic  condition.  It  is  predisposed  to  by 
enlargement  of  the  tonsils,  adenoids,  and  nasopharyngeal  catarrh.  In  30  per 
cent,  of  cases  the  bacilli  of  bovine  tuberculosis  may  be  found  (Dowd,  Ibid.). 
The  enlargements  usually  arise  insidiously,  but  sometimes  (after  whooping- 
cough,  measles,  or  scarlet  fever)  they  come  on  more  rapidly.  When  first  ob- 
served the  enlargements  are  small,  round,  firm,  isolated,  painless,  and  somewhat 
movable.  As  they  enlarge  they  fuse  into  an  irregular  swelling  which  may  be 
quite  tender  and  is  always  anchored  to  surrounding  parts.  As  the  glands  case- 
ate the  mass  softens,  the  skin  over  it  becomes  adherent  and  red,  and  finally 
breaks  open.  Cold  abscess  may  form  or  mixed  infection  with  pus  cocci  may 
take  place. 

Cervical  lymphadenitis  may  be  confused  with  lymphadenoma.  The  former, 
as  a  rule,  first  appears  in  the  submaxillary  triangle ;  the  latter,  in  the  occipital 
or  sternomastoid  glands.     The  mass  in  the  former  is  more  tender,  softer,  and 


Tuberculosis  of  the  Cervical  Lymph-glands  251 

less  movable  than  in  the  latter.  Tuberculous  glands  weld  together,  they  are 
apt  to  remain  localized  for  a  considerable  time,  and  they  tend  to  soften.  The 
younger  the  patient,  the  greater  the  probability  of  softening.  In  adults  there 
is  comparatively  slight  tendency  to  softening.  Tuberculous  adenitis  may  be 
accompanied  by  other  tuberculous  manifestations.  Lymphadenoma  from 
the  start  affects  many  glands;  it  may  arise  simultaneously  in  several  regions, 
although  in  some  cases  there  is  a  distinct  beginning  in  one  region.  Lymph- 
adenoma  shows  very  little  tendency  to  suppurate,  and  does  not  break  down 
except  late  in  the  course  of  the  disease,  and  is  accompanied  by  great  debility 
and  anemia.  Tuberculin  tests  may  aid  in  the  diagnosis,  but  a  difficulty  is 
that  Hodgkin's  disease  and  tuberculosis  may  coexist.  Malignant  gland-tumors 
infiltrate  adjacent  glands  and  other  structures,  binding  skin,  muscles,  and 
glands  into  one  hard,  firm  mass. 

Tuberculous  cervical  adenitis  is  in  most  instances  a  reasonably  curable 
condition.  In  children  under  two  or  three  years  of  age,  however,  it  is  a  danger- 
ous condition  and  one  apt  to  be  associated  with  severe  pulmonary,  osseous,  or 
other  complications.  Some  cases  of  adenitis  can  be  cured  by  open-air  treatment, 
food,  medicine,  tuberculin,  and  hygienic  care.  In  many,  however,  operation  is 
indicated  in  addition  to  such  treatment,  and  these  operations  are  usually  suc- 
cessful if  thoroughly  performed  when  the  disease  is  localized  and  softening  has 
not  occurred.  When  possible  operation  should  be  performed  when  the  patient 
is  at  the  seaside,  or,  at  least,  the  patient  should  convalesce  there  if  circumstances 
permit.  Thorough  extirpation  is  the  proper  operative  treatment  and  any  dis- 
eased condition  of  scalp,  face,  mouth,  tonsil,  or  nasopharynx  is  to  be  corrected. 
My  belief  is  that  about  75  per  cent,  of  cases  are  permanently  cured  by  thorough 
operation.  If  a  patient  is  well  five  years  after  operation  the  cure  may  be  re- 
garded as  permanent.  Cured  cases  seldom  die  subsequently  of  any  tubercu- 
lous lesion. 

It  is  not  uncommon  after  removal  of  infected  glands  and  healing  of  the 
wound  to  have  several  or  nimierous  small,  hard  nodules  form  beneath  the  skin 
in  the  area  operated  upon.  Dowd  extirpated  some  of  these  nodules  and 
found  they  were  not  tuberculous,  but  were  fibrous.  I  have  been  able  to  con- 
firm Dowd's  statement  in  several  of  my  own  patients. 

Medical  treatment  is  not  nearly  so  valuable  as  surgical  treatment  in  this 
form  of  tuberculosis.  If  medical  treatment  alone  is  relied  on,  many  of  these 
cases  develop  pulmonary  tuberculosis.  Attridge,  quoting  Demme  and  Dowd 
("Surgery,  Gynecology,  and  Obstetrics,"  Dec,  1908),  sets  the  number  which 
develop  it  when  medical  treatment  is  relied  on  at  21  per  cent.,  and  the  number 
developing  other  distant  tuberculous  lesions  at  8.2  per  cent. — a  total  of  29.2 
per  cent.,  and  these  figures  do  not  include  bone  infections  and  late  infections 
of  the  lymph-nodes.  Even  in  cases  supposed  to  have  been  cured  by  medical 
means  it  will  be  found  that  most  of  them  react  to  tuberculin,  showing  that 
lesions  are  latent  rather  than  cured.  Wohlgemuth  shows  that  complete 
removal  cures  75  per  cent,  of  cases;  curetting  and  drainage  cures  63  per  cent.; 
general  treatment,  24  per  cent.  (Attridge,  Ibid.).  In  a  series  of  100  cases  oper- 
ated upon  by  Dowd,  pulmonary  tuberculosis  arose  in  but  i  case  and  bone 
tuberculosis  in  3  cases.  If  miliary  tuberculosis  exists,  if  the  patient  is  much 
exhausted,  if  the  infection  is  not  definitely  localized,  or  if  an  internal  organ  is 
the  seat  of  active  tuberculosis,  operation  is  not  indicated. 

Death  seldom  follows  operation.  The  mortality  without  operation  is 
probably  10  per  cent.  Complete  extirpation  of  the  involved  group  of  glands  is 
practised  when  the  disease  is  well  localized.  If  it  is  not  well  localized  I  follow 
Attridge's  plan  (Ibid.)  and  wait  until  it  becomes  so,  treating  the  patient  in  the 
interval  by  open-air  life,  nourishing  food,  medicine,  tuberculin,  and  the  if-rays. 
If  softening  occurs,  the  area  should  be  incised  and  curetted  and  the  exposed  sur- 


252  Rachitis,  or  Rickets 

face  should  be  treated  by  repeated  applications  of  tincture  of  iodin.  When 
healing  occurs,  extirpation  is  to  be  performed.  If  sinus  formation  exists, 
mixed  infection  has  occurred  or  will  occur  and  the  sinuses  must  be  curetted 
and  treated  with  iodin  until  they  heal,  when  the  glands  may  be  extirpated.  I 
do  not  beheve  in  a  bilateral  extirpation  at  one  seance.  The  operation  even 
on  one  side  is  prolonged  and  bloody  and  is  all  the  patient  is  fit  to  stand. 
If  both  sides  of  the  neck  are  involved,  an  interval  of  several  weeks  should  be 
insisted  on  before  the  other  side  is  attacked. 

In  chronic  cases  of  cervical  lymphadenitis  it  is  invariably  necessary  to 
search  for  intra-oral  and  nasopharyngeal  disease,  and  if  such  disease  exists  it 
must  be  treated  before  the  glands  are  removed.  After  operation  rigid  open-air 
life  is  insisted  on. 

Tuberculosis  of  tendon=sheaths  (tuberculous  tenosynovitis)  is  discussed 
on  page  722. 

Tuberculosis  of  the  Kidney. — (See  page  1290.) 

Tuberculosis  of  adrenals  may  cause  sclerosis. 

Tuberculosis  may  attack  the  Fallopian  tubes,  ovaries,  or  uterus. 

Tuberculosis  of  the  urethra,  prostate  gland,  seminal  vesicles,  and 
bladder  is  considered  in  a  section  on  Regional  Surgery. 

Tuberculosis  of  the  Testicle  (see  page  1393). — ^This  disease  is  not 
rare.  It  is  sometimes  primary,  but  is  usually  preceded  by  tuberculosis  of  the 
kidney,  bladder,  or  prostate.  But  one  testicle  is  affected  in  the  beginning,  but 
the  other  gland  is  apt  to  be  attacked  later.  The  tuberculous  mass  softens,  be- 
comes adherent  to  the  scrotimi,  and  breaks  or  bursts,  exposing  the  damaged 
testicle  (fungus  of  the  testicle).  The  cord  is  apt  to  be  involved  in  tuberculosis 
of  the  testicle. 

Typhobacillosis. — This  condition  was  described  by  Landouzy  in  1883. 
It  is  a  toxemia  in  which  the  localization  of  lesions  is  very  much  deferred 
and  is  preceded  by  a  prolonged  typhoid  or  septic  stage  (Matas,  ''Southern 
Med.  Joiir.,"  Oct.,  191 1).  Bacilli  of  tubercle  are  widely  distributed  through- 
out the  body,  but  for  a  long  time  there  are  no  tubercles  formed,  and  all  of 
the  symptoms  are  due  to  bacillary  poison.  Matas  describes  the  condition  as 
"a  continued  fever  with  remissions  and  enlargement  of  the  spleen,  without 
signs  of  visceral  localization"  (Ibid.).  It  strongly  resembles  typhoid,  but  the 
pulse  is  more  frequent,  the  temperature  is  less  regular,  there  are  no  spots, 
and  no  intestinal  or  bronchial  symptoms  pointing  to  typhoid.  Few  of  these 
cases  die  early.  Most  of  them  make  an  incomplete  recovery  after  several 
weeks,  and  in  periods  varying  from  weeks  to  months  develop  evident  localized 
tuberculosis. 

Acute  Miliary  Tuberculosis. — In  this  condition  an  organ,  several  or- 
gans, or  the  entire  body  is  infected  with  tubercle  bacilli  which  have  caused  the 
formation  of  multitudes  of  tubercles.  The  symptoms  for  a  time  resemble 
typhoid,  but  in  a  short  time  an  organ  or  organs  present  evidences  of  disease. 
Death  occurs  in  from  three  weeks  to  three  months. 


XIV.  RACHITIS,   OR   RICKETS 

Rickets  was  known  by  the  people  and  named  by  them  long  before  any  medi- 
cal man  had  written  of  it.  It  first  appeared  in  the  London  bills  of  mortahty  in 
1634.  GHsson,  in  1650,  wrote  the  first  description  of  it  and  renamed  it  rachitis, 
because  of  the  commonly  resulting  spinal  curvature.  Rickets  is  a  chronic  dis- 
order of  nutrition  arising  during  the  early  years  of  life  (the  first  two  or  three) 
as  a  result  of  insufficient  or  of  improper  diet,  aided  and  abetted  in  many  cases 
by  bad  hygienic  surroundings.     A  deficiency  of  fat  and  phosphate  in  the  food 


Evidences  of  Rickets  253 

or  the  use  of  a  diet  which,  by  inducing  gastro-intestinal  catarrh,  prevents  as- 
similation causes  rickets.  It  is  characterized  by  incomplete  osteogenesis  and 
other  nutritive  failures.  The  disease  is  not  common  in  nursing  children  unless 
breast-feeding  has  been  imduly  prolonged,  and  children  fed  upon  artificial 
food  are  particularly  apt  to  develop  it.  Holt  says  such  diet  is  ven,-  deficient  in 
fat  and  often  in  proteins,  and  contains  an  excess  of  carbohydrates  ("Diseases  of 
Infancy  and  Childhood").  Sir  J.  Bland-Sutton  made  some  valuable  experi- 
ments to  indicate  the  injury  done  animals  by  deming  them  nattu^al  diet.  He 
fed  lion  cubs  in  the  London  Zoological  Gardens  on  raw  horse  meat  onlv  and  the 
animals  developed  rickets.  The  rickety  animals  rapidly  recovered  on  feeding 
them  with  milk  and  powdered  bones  mixed  ^^dth  cod-liver  oil.  The  disease  is 
essentially  a  city  malady,  "being  principally  seen  in  children  li\-ing  in  crowded 
tenements  where  the  eitects  of  improper  food  are  most  strikingly  shown;  yet 
even  here  the  disease  is  rare  in  those  who  get  a  plentiful  supply  of  good  breast- 
milk"  (Holt,  Ibid.).  Rickets  must  not  be  regarded  as  a  bone  disease.  It  is  true 
the  bones  are  affected,  but  so  are  various  structures  and  organs,  all  of  the  dis- 
orders being  due  to  an  underhing  nutritive  defect.  Some  maintain  that  lactic 
acid  or  some  other  toxic  material  produced  in  the  intestinal  canal  causes  bone 
inflammation,  but  most  observ'ers  do  not  beheve  the  bone  changes  are  inflam- 
mator\-.  Children  are  very  seldom  born  \^-ith  rickets,  but  develop  it  later,  the 
period  of  greatest  liability  being  between  the  seventh  month  and  the  fifteenth 
month.  So-called  congenital  rickets  is  usually  sporadic  cretinism.  A  child 
with  rickets  may  become  scorbutic  (scurvy  rickets).  Some  regard  rickets  as 
the  result  of  an  infection.  GHsson,  in  the  seventeenth  centur\^,  thought  it  was 
infectious.  Some  obser\-ers  claim  to  have  found  bacteria  in  rickety  bone  and 
in  the  cerebrospinal  fluid  of  rickety  children  (]Mirculi,  Sorgente).  Others  think 
it  results  from  th^-mus  atrophy.  Some  blame  s}"philis,  some  malaria,  some  the 
th}Toid  gland,  some  the  nervous  system.  Some  beheve  that  disease  of  the 
parath^Toids  alters  calcimn  metabolism — ^perhaps  two  much  calcium  being  cast 
out,  perhaps  too  little  being  taken  in  or  assimilated. 

\\Tiatever  may  be  the  cause  of  rickets,  the  essential  condition  in  the  bones 
is  an  insufficient  deposit  of  mineral  matter  in  the  new  bone  cells.  The  new 
bone  is  soft  and  vascular  and  bone  lamellae  toward  the  medullar}-  canal  are 
actually  absorbed.  There  is  excessive  proliferation  of  cartilage  which  results 
in  enlargement.  The  proliferating  and  imperfectly  ossified  cells  cause  en- 
largements at  the  ends  of  long  bones  and  at  the  sternal  ends  of  the  ribs,  and 
various  bones  bend  and  are  distorted.  The  parietal  bones  bulge,  the  fonta- 
nels remain  long  open;  there  may  be  imossified  gaps  in  the  occipital  bone, 
membrane  only  filling  them  (craniotabes).  There  may  be  pigeon-breast,  bent 
long  bones,  curved  spine,  and  distorted  pehis.  The  bones  later  may  become 
firmly  ossified  in  deformity.  In  rickets  the  spleen  and  liver  are  enlarged  and 
the  thymus  is  atrophied. 

Evidences  of  Rickets. — Rickets  is  apt  to  arise  in  the  spring,  but  may  begin 
any  time  of  the  year.  In  some  few  cases  it  begins  with  fever.  The  condition 
is  one  of  general  Hi-health;  the  child  is  ill-nourished,  paUid,  flabby;  it  has  a 
tumid  beUy  and  suffers  from  attacks  of  diarrhea  and  sick  stomach ;  it  is  disin- 
clined for  exertion  and  has  a  capricious  appetite;  it  is  liable  to  night-sweats; 
enlarged  glands  are  often  noted,  the  teeth  appear  behind  time,  and  the  fontanels 
close  late.  In  health  the  posterior  fontanel  closes  in  the  second  month  and  the 
anterior  fontanel  in  the  eighteenth  month.  In  rickets  the  anterior  fontanel  is 
often  open  when  the  child  is  three  years  of  age.  The  sutures  are  often  open  at 
the  end  of  the  first  year.  The  head  is  square  in  shape,  the  cranial  bones  are 
thick,  and  areas  of  thickening  kno^\Ti  as  bosses  appear  over  the  parietal  bones. 
The  head  is  large  and  the  forehead  bulges.  The  long  bones  become  much 
ciir\'ed,  the  upper  part  of  the  chest  sinks  m,  curvature  of  the  spine  appears,  and 


254 


Rachitis,  or  Rickets 


the  pelvis  is  distorted.  The  ligaments  are  relaxed  and  lengthened  and  the 
joints  are  wobbly.  The  muscles  are  feeble  and  ill-developed.  Infantile  con- 
vulsions are  common.  Nocturnal  restlessness  and  night  terrors  are  the  rule. 
Laryngismus  stridulus  and  tetany  may  occur.  Swelling  appears  in  the  articu- 
lar heads  of  long  bones,  by  the  side  of  the  epiphyseal  cartilages,  and  in  the  ster- 
nal ends  of  the  ribs,  forming  in  the  latter  case  rachitic  beads.  The  lesions  of 
rickets  are  due  to  imperfect  ossification  of  the  animal  matter  which  is  prepared 
for  bone  formation,  and  the  soft  bones  gradually  bend.  The  swellings  at  the 
articular  heads  are  due  to  pressure  forcing  out  the  soft  bone  into  rings.  Ra- 
chitic children  rarely  grow  to  full  size,  and  the  disease  is  responsible  for  many 
dwarfs.  Most  cases  recover  without  distinct  deformity,  but  the  time  lost  dur- 
ing the  period  when  active  development  should  have  gone  on  cannot  be  made 
up,  and  some  slight  deficiency  is  sure  to  remain.  Bow-legs,  knock-knees,  and 
spinal  curvatures  are  usually  rachitic  in  origin.  The  disease  may  be  associated 
with  scurvy,  inherited  syphilis,  or  tuberculosis.  In  appearance  the  rickety  child 
is  pot-bellied,  pale  and  anemic,  and  usually  fat  and  flabby,  though  occasionally 
thin.  The  spleen  may  be  enlarged.  There  is  great  liability  to  enlargement  of 
the  tonsils,  gastro-intestinal  catarrh,  and  bronchial  catarrh.  The  blood  is 
deficient  in  red  corpuscles  and  hemoglobin,  and  sometimes  there  is  leukocytosis. 

The  disease  lasts  for  many 
months  and  is  usually  re- 
covered from.  It  does 
not  directly  produce  death, 
but  is  a  powerful  indirect 
cause  of  infant  mortality 
because  it  lessens  resist- 
ance and  predisposes  to 
many  diseases.  It  is  al- 
most always  afebrile, 
rarely  congenital,  and  in 
unusual  cases,  known  as 
late  rickets,  develops  be- 
tween the  fifth  and  tenth 
year.  The  so-called  acute 
rickets  is  practically  al- 
ways scurvy  (Holt).  The 
victims  of  rachitis  are  very 
liable  to  fracture  the  bones  from  slight  force  and  green-stick  fractures  are 
particularly  prone  to  occur  (Fig,  io6).  After  fracture  of  a  rickety  bone 
union  is  usually  delayed. 

The  treatment  consists  in  having  the  child  live  as  much  as  possible  in 
the  open  air  and  sunshine.  Salt-water  baths  are  useful.  Sea  air  is  very 
beneficial.  Fresh  food  (milk,  cream,  and  meat-juice)  should  be  ordered. 
Cod-liver  oil,  syrup  of  the  iodid  of  iron,  arsenic,  and  some  form  of  phosphorus 
are  to  be  administered.  It  is  absolutely  necessary  to  improve  the  primary  as- 
similation. Slight  deformities  of  the  extremities  require  no  special  treatment 
unless  they  increase.  If  the  deformity  is  marked  or  is  increasing,  use  braces; 
employ  massage,  manipulation,  and  faradism.  By  the  time  the  child  is  three 
years  of  age  the  bones  are  usually  so  firm  that  the  pressure  of  a  brace  cannot 
cure  the  deformity,  though  the  real  test  of  brace  efi&ciency  is  the  degree  of  elas- 
ticity present  in  the  bones,  as  determined  by  the  surgeon's  hands.  After  the 
age  of  three  braces  are  commonly  useless.  Pronounced  established  deformities 
of  the  extremities  are  usually  treated  surgically.  Kyphosis  is  treated  by  making 
the  patient  lie  upon  a  hard  bed  without  a  pillow.  The  child  sits  up  a  few  hours 
each  day,  the  shoulders  being  held  back  and  support  applied  to  the  body.     In 


Fig.  io6. — Fracture  of  femur  in  rickets. 


Scorbutus   (Scurvy)  255 

bad  cases,  during  the  time  the  child  is  erect  it  should  wear  a  brace  or  plaster- 
of-Paris  jacket.  Daily  manipulation,  the  child  lying  prone,  is  helpful.  Friction 
and  electricity  to  the  spinal  muscles  do  good. 

Scorbutus  (Scurvy). — Many  ancient  writers  described  symptoms  which 
must  have  been  due  to  scur\^^^  For  instance,  PUny,  speaking  of  the  army  of 
Germanicus  when  near  the  Rhine,  describes  a  condition  of  illness  characterized 
bv  sore  gums,  falling  out  of  teeth,  and  weakness  of  the  legs.  Voyagers  in  the 
fifteenth  centur\-  noted  symptoms  which  we  now  know  were  caused  by  scurvy. 
In  \'asco  de  Gama's  voyage  around  the  Cape  of  Good  Hope  more  than  half  of 
his  crew  perished  of  what  was  certainly  scur\y.  It  seems  to  have  been  first 
specifically  described  early  in  the  sixteenth  century-.  A  most  graphic  picture 
of  sciir\T  as  it  used  to  occur  at  sea  ^^-ill  be  found  in  '"A  \'oyage  Around  the 
World  in  1740  by  Lord  Anson,"  compiled  by  the  Rev.  R.  Walter,  chaplain 
of  the  "Centurion."  Scurvy  is  rare  to-day  in  adults,  but  was  at  one  time  ven,- 
common  among  those  who  took  long  voyages,  or  who  engaged  in  campaigns,  or 
were  the  ^•ictims  of  sieges,  and  was  quite  common  even  in  cities.  Poupart 
describes  it  as  he  saw  it  in  the  St.  Louis  Hospital  of  Paris  early  in  the  eighteenth 
century.  Of  recent  years  it  is  vers*  uncommon,  and  has  occurred  chiefly  among 
voyagers  in  the  Arctic  regions  or  those  who  were  beleaguered.  It  can  occur  in 
any  part  of  the  world,  on  land  or  sea.  Some  years  ago  I  saw  several  cases  in 
the  Philadelphia  almshouse.  It  is  important  to  remember  that  though  scurvy 
is  rare  in  adults,  it  is  by  no  means  imcommon  in  ill-nourished  infants. 

Scurvy  is  a  constitutional  malady  due  to  the  consumption  of  improper  diet, 
and  especially  to  the  emplo}-ment  of  a  diet  characterized  by  the  absence  of 
vegetables. 

The  use  of  salt  meat  as  a  staple  article  seems  to  favor  the  prpduction^of 
the  disease,  but  scurvy  can  occur  when  there  was  not  a  salty  diet,  and  in- 
crease of  sodium  chlorid  in  the  blood  is  not  characteristic  of  scuny,  but 
occiirs  in  various  forms  of  anemia.  Garrod  considered  absence  of  potassium 
salts  to  be  the  real  cause.  The  diminution  of  potassium  salts  is  supposed  to  be 
responsible  for  diminished  alkalinity  of  the  blood,  but  we  know  that  dimin- 
ished alkahnitv  is  conmaon  in  aU  forms  of  secondary-  anemia.  Absence  of 
varietv  in  diet,'  bad  water,  poorly  ventilated  quarters,  and  insvifficient  exercise 
favor  'the  development  of  the  disease.  Some  believe  that  an  organic  poison 
derived  from  tainted  food  is  responsible  (Torup).  A  bacterial  origin  has  been 
suggested  by  Berthenson.  Babes,  and  others.  Certain  studies  made  in  the 
Transvaal  suggest  the  bacterial  origin  of  scuny.  IMyer  Coplans  ("Lancet," 
June  18,  1904)  states  that  it  occurred  in  those  getting  excellent  rations  and 
began  as  inflammation  of  the  gimis,  the  constitutional  s>-mptoms  foUoTiing. 
If  the  gum  condition  is  early  recognized  and  cured  simply  by  cleanliness  and 
antiseptics,  that  is,  bv  pure'  local  treatment,  constitutional  trouble  does  not 
develop.  Goadlv  ("Brit.  Med.  Jour.,"  1910)  showed  that  the  mouth  of  a 
scur\y  patient  is 'acid  to  litmus,  and  even  though  there  is  no  dental  caries,  in 
most  'cases  there  is  early  inflammation  of  the  gums.  Hewetson  examined  400 
South  African  males,  var^-ing  in  age  from  fifteen  to  thirty-five.  He  found  134 
mth  scorbutic  gums,  although  they  seemed  in  good  health  ("Transvaal 
Medical  Journal,"  April,  1911). 

The  effect  of  great  depression  of  spirits  in  predisposing  to  _scur\y  and  in 
aggravating  cases  of  scurvy  has  often  been  commented  on.  During  the  siege  of 
Breda  in  1625  scur^y  was  rife.  Bad  news  rapidly  increased  the  number  of 
cases.     Good  news  checked  it.     Anson  made  a  similar  obser^'ation. 

Sc^n:^-^'  begins  with  sore  gums,  weakness,  drowsiness,  muscular  pains,  and 
great  susceptibilitv  to  cold.  The  skin  is  paflid  or  dirty  white,  and  is  occasionally 
mottled  and  often  peels  off.  The  patient  is  breathless  on  the  slightest  exer- 
tion.    The  pulse  is  excessively  weak  and  slow.     There  is  no  fever  unless  a  com- 


256 


Rachitis,  or  Rickets 


plication  arises.  The  gums  are  often  tender  and  inflamed  from  the  start,  but  in 
some  cases  they  are  not.  After  two  or  three  weeks  in  all  cases  usually  the  gums 
are  found  to  be  tender,  painful  and  swollen,  and  bleeding  at  frequent  intervals; 
the  breath  becomes  oft'ensive,  the  teeth  loosen  and  even  drop  out;  subcutaneous 
hemorrhages  take  place,  giving  rise  to  petechia;  or  extensive  extravasations ;  the 
vision  becomes  dim;  the  urine  becomes  scanty  and  of  low  specific  gravity; 
cutaneous  vesicles  form,  rupture,  and  give  rise  to  bleeding  ulcers,  and  ulcers 
likewise  arise  from  breaking  down  of  blood  extravasation;  hemorrhages  take 
place  into  and  between  the  muscles,' and  in  severe  cases  beneath  the  periosteum 
and  into  joints,  and  blood  may  flow  from  the  nose,  lungs,  kidneys,  stomach,  and 
intestines.  Deep  hemorrhages  are  palpable  as  hard  lumps.  Bleeding  at  an  epi- 
physeal line  may  separate  the  epiphysis  from  the  shaft.  If  an  inflammation 
or  ulceration  arises  at  any  point,  fever  is  observed.  In  many  cases  blood-clotting 
is  retarded.  Wright  maintains  that  there  is  diminished  alkalinity  of  blood  and 
that  scurvy  is  reaUy  acid  intoxication.  Other  observers  dispute  this.  The 
examination  of  corpuscles  and  hemoglobin  gives  a  picture  identical  with  second- 


Fig.  107. — The  gums  in  scurvy. 

ary  anemia.  As  a  rule  the  red  cells  mmiber  from  3,000,000  to  4,000,000  per 
c.mm.,  but  may  fall  to  1,000,000  or  even  less.  Hemoglobin  loss  is  more  marked 
than  corpuscular  diminution,  hence  the  color-index  is  low.  There  is  usually  an 
increase  in  leukocytes.  It  was  observed  by  DeHaven,  who  commanded  the 
Grinnell  expedition  in  search  of  Sir  John  Franklin,  that  scurvy  causes  old  and 
soimdiy  healed  wounds  to  ulcerate.  The  same  observation  was  made  years 
before  in  Lord  Anson's  voyage.  A  sailor  of  the  "Centurion"  had  been  wounded 
fifty  years  before  at  the  battle  of  the  Boyne.  He  developed  scurw  and  the 
old  wound  opened.  In  another  case  an  old  and  soimdly  united  fracture  gave 
way  and  felt  like  a  fresh  break.  Most  cases  of  scurvy  get  well  imder  proper 
treatment,  but  complete  recover}^  is  not  attained  for  a  long  time.  Sudden 
death  is  liable  to  occur  if  any  exertion  is  made.  The  lightest  exercise  may  be 
fatal.  Even  moving  a  man  while  he  is  lying  down  may  cause  death.  Many 
cases  while  quiet  and  recumbent  feel  well,  eat  well,  sleep,  make  no  complaint 
of  pain,  and  yet  even  slight  movement  may  cause  death.  Nansen  is  said  to 
attribute  the' loss  of  the  gallant  Scott  and  his  companions  in  the  Antarctic  to 


Infantile  Scur\y  or  Barlow's  Disease  257 

scuny,  the  effort  necessary  to  climb  a  glacier  being,  in  his  opinion,  the  cause 
of  death. 

Prevention  and  Treatment. — Captain  Cook  succeeded  in  preventing  scurw 
among  his  sailors  by  providing  plenty  of  fresh  water;  guarding  them  against 
fatigue,  wet,  and  extremes  of  heat  and  cold;  attending  to  cleanliness  and  ventila- 
tion, and  stimulating  cheerfulness.  This  great  navigator  lost  no  men  from 
scuny.  After  the  time  of  Captain  Cook,  the  British  Admiralty,  acting  on  the 
suggestions  of  Lind  and  Blane,  provided  ships  with  lime-juice  or  lemon-juice 
with  the  most  beneficial  results  in  preventing  the  disease.  As  a  matter  of  fact, 
lime-juice  was  suggested  by  John  Woodall  long  before  the  time  of  Lind  and 
Blane.  Woodall  died  in  1643.  Until  comparatively  recent  years  sailors  of 
the  United  States  Na\y  were  accustomed  to  refer  to  sailors  of  the  British 
Navy  as  ''lime-juicers."  Scur\y  is  prevented  at  the  present  time  by  employ- 
ing a  proper  diet  and  by  maintaining  cleanliness  and  hygienic  conditions. 

The  following  agents  are  believed  to  be  especially  useful  as  preventives: 
fresh  meat,  lemon-juice,  cider,  \dnegar,  milk,  eggs,  onions,  cranberries,  cab- 
bages, pickles,  potatoes,  and  lime-juice.  WTien  the  disease  develops,  give 
\dnegar,  lemon-juice,  onions,  scraped  apples,  cider,  nitrate  or  citrate  of  potas- 
sium, whisky  or  brandy,  and  plenty  of  nourishing  food.  Lind  used,  \\-ith  great 
success  in  many  cases,  4J  oz.  of  lemon-juice  or  lime-juice  and  2  oz.  of  sugar  in 
a  pint  of  ^Malaga  vrine.  This  was  taken  during  each  twenty-four  hours.  In 
twenty-fom*  hours  improvement  would  be  manifest.  Antiseptic  mouth-washes 
are  necessar\'  and  str\xhnm  is  a  valuable  stimulant  to  the  circulation.  Sleep 
must  be  secured  and  ulcers  are  treated  by  antiseptic  dressings  and  compression. 

Infantile  scurvy  or  Barlow's  disease  may  exist  alone  or  -^-ith  rickets  (scurvy 
rickets).  It  occurs  most  often  in  the  children  of  the  well-to-do,  those  who  have 
been  brought  up  on  artificial  foods,  in  fact,  only  children  who  are  fed  on  arti- 
ficial foods  get  it.  Sterilized  milk,  condensed  milk,  or  other  artificial  food  may 
be  responsible.  It  occurs  most  frequently  between  the  eighth  and  eighteenth 
months  of  life.  It  is  noted  that  the  child  has  lost  its  appetite,  is  losing  weight, 
has  lost  the  use  of  its  legs,  lies  quiet  with  the  thighs  flexed  and  abducted,  cries 
when  touched  and  when  it  fears  it  is  going  to  be  touched  (Grasty,  in  "Amer. 
Jour.  Obstet.,"  1910).  The  child  is  anemic,  sufifers  from  gastro-intestinal 
disorders,  spong\^  and  bleeding  gums  if  teeth  have  erupted,  weakness  of  the  legs, 
general  musciilar  tenderness,  night-sweats,  and  often  febrile  attacks  (Rotch), 
bleeding  from  the  nose,  bleeding  beneath  the  skin  (blue  spots),  blood}"  urine 
and  stools,  bleeding  beneath  the  periosteum,  into  joints,  viscera,  or  muscles. 
In  some  cases  hematuria  is  the  first  and  perhaps  the  only  s}'mptom  (J.  Lovett 
Morse,  "Jour.  Am,  Med,  Assoc.,''  Dec.  17,  1904).  A  subperiosteal  hemorrhage 
is  very  dense  to  palpation,  is  tender,  is  fusiform  in  outline,  and  does  not  fluc- 
tuate. It  is  sometimes  mistaken  for  sarcoma.  In  i  case  seen  by  the  author  a 
hemorrhage  beneath  the  periosteum  of  the  femur  was  mistaken  for  a  sarcoma. 
The  limb  attacked  is  flexed  and  the  child  wUl  not  move  it.  In  another  case 
hemorrhage  into  the  knee-joint  was  thought  to  be  inflammator}"  effusion  from 
traumatism.  Separation  of  an  epiphysis  may  result  from  hemorrhage  between 
it  and  the  bone.  Infantile  scurfy  is  often  unrecognized.  If  promptly  treated, 
recover}"  is  the  rule,  otherwise  death  may  occur  from  exhaustion. 

Treatment. — Keep  the  child  quiet  in  bed  and  give  liberal  amounts  of  fresh 
and  raw  cows'  milk  and  beef-juice  from  raw  meat.  Administer  orange-juice, 
grape-jmce,  scraped  apples,  and  tonics.  To  children  over  one  year  of  age  give 
potatoes.     Antiseptic  mouth-washes  are  necessary. 


17 


258  Contusions  and  Wounds 


XV.  CONTUSIONS   AND   WOUNDS 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous  laceration  due  to 
the  application  of  blunt  force,  the  skin  above  it  being  uninjured  or  damaged 
without  a  surface-breach  and  blood  being  effused.  Punches,  kicks,  blows 
from  a  blackjack,  etc.,  cause  contusions.  In  intra-abdominal  contusions 
the  skin  of  the  abdomen  is  frequently  not  damaged.  In  contusions  of  struc- 
tures overlying  a  bone  the  skin  suffers  with  the  deeper  structures.  If  a  large 
vessel  is  ruptured  hemorrhage  is  profuse  and  much  blood  gathers  in  the 
tissue.  If  only  small  vessels  suffer  hemorrhage  is  moderate.  An  ecchymosis 
is  diffuse  hemorrhage  over  a  large  area,  the  blood  lying  in  the  spaces  of  the 
subcutaneous  or  submucous  areolar  tissue.  A  ver}'  small  ecchymosis  is  known 
as  a  petechia;  a  very  large  ecchjonosis  is  called  a  suffusion  or  extravasation.  A 
hematoma  is  a  blood-tumor  or  a  circumscribed  hemorrhage,  the  blood  lying  in  a 
distinct  cavity  in  the  tissue.  In  extremely  severe  contusions  tissue  vitality 
may  be  destroyed  or  so  seriously  impaired  that  gangrene  follows.  Suppuration 
rarely  occurs,  but  occasionally  does  so,  and  is  most  apt  to  in  a  drunkard  or 
a  person  of  debiHtated  constitution.  When  hemorrhage  arises  in  the  tissues 
after  a  contusing  force  it  soon  ceases  unless  a  very  considerable  vessel  is  rup- 
tiired.  The  arrest  of  hemorrhage  is  brought  about  by  the  resistance  of  the 
tissues,  the  contraction  and  retraction  of  the  vessels,  coagulation  of  blood,  and 
in  some  cases  of  severe  injury  coagulation  is  favored  by  syncope.  Blood  in  the 
tissues,  as  a  rule,  soon  coagulates,  the  fluid  elements  being  absorbed  and  the 
red  corpuscles  breaking  up  and  setting  free  pigment,  which  pigment  may  be 
carried  away  from  the  seat  of  injun/'  or  may  crystallize  and  remain  there  as 
hematoidin.  In  some  cases  inflammation  occurs  about  the  extravasated  blood, 
a  capsule  of  fibrous  tissue  being  formed,  and  the  blood  being  slowly  absorbed  or 
the  fluid  elements  remaining  unabsorbed  (blood-cyst) ,  or  the  blood  becoming 
thicker  and  thicker,  finally  calcifying.  Blood  in  serous  sacs  (joints,  pleura,  peri- 
cardium) coagulates  very  slowly.  As  blood  is  being  absorbed  it  undergoes 
chemical  changes  and  color  changes  ensue,  the  part  being  at  first  red  and  then 
becoming  purple,  black,  green,  lemon,  and  citron.  The  stain  follc^dng  a  con- 
tusion is  most  marked  in  the  most  dependent  area.  After  a  bruise  of  the  perios- 
teum a  blood-clot  forms,  much  tissue-induration  occurs,  and  a  hard  edge  can 
be  detected  by  palpation  at  the  margin  of  the  clot. 

Symptoms. — ^The  symptoms  are  tenderness,  swelling,  and  numbness, 
followed  by  some  aching  pain  or  a  feeling  of  soreness.  The  pain  rarely  per- 
sists beyond  the  first  twenty-four  hoiirs.  Cutaneous  discoloration  appears 
quickly  in  superficial  contusions,  but  only  after  days  in  deep  ones.  In  some 
regions — the  scalp,  for  instance — it  can  scarcely  be  detected;  in  others,  as  in 
the  eyelid  and  vulA^a,  discoloration  is  early,  -^ddespread,  and  marked.  Dis- 
coloration and  swelling  are  ven.^  marked  in  regions  where  loose  cellular  tissue 
abounds  (eyelids,  prepuce,  scrotum).  The  discoloration  is  at  first  red,  and 
becomes  successively  purple,  black,  green,  lemon,  and  citron.  The  swelling  is 
primarily  due  to  blood,  and  is  added  to  by  inflammatory^  exudation.  In  a  more 
severe  contusion  a  hematoma  may  form.  A  recent  hematoma  fluctuates,  but 
gradually,  because  of  cell-proliferation,  the  edge  becomes  hard,  but  the  center 
continues  to  fluctuate.  The  mass  gradually  grows  smaller  and  finally  dis- 
appears. A  subperiosteal  hematoma  of  the  scalp  may  be  mistaken  for  depressed 
fracture  of  the  skiill.  Any  form  of  hematoma  of  the  scalp  may  be  mistaken 
for  an  abscess,  but  differs  from  it  in  the  absence  of  inflammatory^  signs.  It 
occasionally,  though  rarely,  suppurates.  In  a  case  in  which  suppuration  occurs 
an  abrasion,  which  may  be  very  minute,  often  exists  on  the  skin.  In  any 
severe  contusion  there  is  considerable  and  possibly  grave,  or  even  fatal,  shock. 


Shock  259 

Treatment. — In  a  severe  injury  bring  about  reaction  from  the  shock. 
Local  treatment  consists  in  rest,  elevation,  and  compression  to  arrest  bleeding, 
antagonize  inflammation,  and  control  swelling.  Cold  is  useful  earlv  in  most 
cases,  but  it  is  not  suited  to  verj-  severe  contusions  nor  to  contusions  in  the 
debilitated  or  aged,  as  in  such  cases  it  may  cause  gangrene.  In  ver\-  severe 
contusions  employ  heat  and  stimulation.  When  mflammation  is  subsiding 
after  a  contusion,  compression  and  inunctions  of  ichthyol  should  be  emploved. 
If  the  amount  of  blood  is  ven.-  large,  massage  must  not  be  used  because  it  may 
cause  embolism  or  fat-emboHsm.  ]Massage  and  passive  motion  are  impera- 
tively needed  after  contusion  of  a  joint.  If  a  distinct  ca\-ity  exists,  aspiration 
or  incision  lessens  the  danger  of  fat-embolism.  A  contusion  should  never 
be  incised  unless  the  amount  of  blood  is  large  and  a  distinct  cavity  exists, 
or  hemorrhage  continues,  or  infection  takes  place,  or  a  lump  remains  for 
some  weeks,  or  gangrene  is  threatened.  For  persistent  bleeding  freely  lay 
open  the  contused  area,  turn  out  clots,  ligate  vessels,  insert  drainage-strands 
or  a  tube,  and  close  the  wound.  If  gangrene  is  feared,  make  incisions  and 
apply  heat  to  the  part.  If  a  slough  forms,  employ  antiseptic  fomentations. 
The  constitutional  treatment  for  contusion,  after  the  patient  has  reacted  from 
shock,  is  the  same  as  that  for  inflammation.     (See  Abdomen,  etc.) 

Wounds. — A  woimd  is  a  breach  of  surface  continuity  eft'ected  by  a  sudden 
mechanical  force.  Wounds  are  divided  into  open  and  subcutaneous,  septic 
and  aseptic,  incised,  contused,  lacerated,  punctured,  gunshot,  stab,  and 
poisoned  wounds. 

The  local  phenomena  of  wounds  are  pain,  hemorrhage,  loss  of  func- 
tion, and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injiu^^  of  ner\xs,  and  it  varies  according  to  the  situation 
and  the  nature  of  the  injur}\  It  is  influenced  by  temperament,  excitement, 
and  preoccupation.  It  may  not  be  felt  at  all  at  the  time  of  injur^^  At 
first  it  is  usually  acute,  becoming  later  dull  and  aching.  In  an  aseptic  wound 
the  pain  usuaUy  remains  slight,  but  in  an  infected  wound  it  always  becomes 
severe. 

The  nature  and  amount  of  hemorrhage  vary  vdth  the  state  of  the  system, 
the  vascularity  of  the  part,  and  the  variety  of  injury'. 

Loss  of  function  depends  on  the  situation  and  extent  of  the  injury-. 

Gaping  or  retraction  of  edges  is  due  to  tissue  elasticity,  and  varies  according 
to  the  tissues  injured  and  the  direction,  nature,  and  extent  of  the  woimd. 

The  constitutional  condition  after  a  severe  injiir}^  is  a  state  kno-^Ti  as 
shock. 

Shock. — The  name  ''shock"  was  introduced  in  1795  by  James  Latta  to 
designate  the  condition  ensuing  upon  severe  injur}'.  (See  G.  C.  Kinnaman, 
in  '"'Annals  of  Surg.,"  Dec,  1903.)  Shock  is  a  depression  of  the  ^-ital  powers 
arising  from  an  injury  or  a  profound  emotion  acting  on  the  ner\'e-centers. 
Xo  theor\'  of  shock  is  entirely  satisfactory'.  Most  obser\^ers  state  that  there  is 
exhaustion  or  inhibition  of  the  vasomotor  mechanism.  Exhaustion  is  gradu- 
ally induced;  inhibition  is  suddenly  produced.  It  is  supposed  that  by  over- 
stimulation of  sensor}^  ner^^es  ^'iolent  impressions  are  conveyed  to  the  nerve- 
centers,  the  vasomotor  center  is  exhausted  or  inhibited,  vasoconstrictor 
power  is  lost,  the  peripheral  arteries  and  capillaries  are  palsied  and  are  depleted 
or  nearly  emptied  of  blood,  and  the  blood  is  largely  transferred  to  the  veins. 
The  blood-pressure  is  lowered,  the  cardiac  action  is  impaired,  the  respirator^' 
action  is  impeded,  and  quantities  of  dark-colored  blood  gather  in  the  somatic 
veins,  but  especially  in  the  veins  of  the  splanchnic  area.  (See  the  masterly 
study  of  "Surgical  Shock,"  by  Crile.)  Although  this  theory-  finds  -^-ide  accept- 
ance, some  able  investigators  do  not  accept  it.  In  shock  the  abdominal  veins 
are  greatly  distended  and  the  other  veins  of  the  body  may  also  be  overfull,  the 


26o  Contusions  and  Wounds 

arteries  contain  less  blood  than  normal,  and  an  insufficient  amount  of  blood  is 
sent  to  the  heart  and  to  the  vital  centers  in  the  brain.  In  other  words,  in  shock 
there  is  a  deficiency  in  the  circulating  blood.  The  term  collapse  is  used  by  some 
to  designate  a  severe  condition  of  shock,  and  is  employed  by  others  as  a  name 
for  a  condition  produced  by  functional  depression  of  the  vasomotor  center  the 
result  of  mental  disturbance,  cardiac  failure,  respiratory  failure,  or  vasomotor 
insufficiency,  rather  than  of  physical  injury.  Crile  regards  collapse  as  inhibi- 
tion of  the  vasomotor  center,  in  contrast  to  shock,  which  is  exhaustion  of  the 
center.  As  a  matter  of  fact,  shock  and  collapse  are  often  both  present.  That 
the  bombardment  of  the  nerve-centers  by  a  tumult  of  peripheral  impressions 
causes  shock  is  shown  by  the  fact  that  if  the  nerves  from  a  part  are  thoroughly 
cocainized  so  that  they  will  not  transmit  sensation,  operation  upon  the  part 
produces  practically  no  shock.  Crile  calls  such  cocainization  the  introduction 
of  a  physiological  block.  Again,  Crile  insists  that  in  shock  there  are  demon- 
strable changes  in  the  brain  cells.  The  changes  consist  in  shrinking  of  nuclei 
and  dissipation  of  the  granular  matter  of  the  protoplasm.  Such  changes 
mean  that  the  cells  involuntarily  discharged  nerve  force  many  times,  were 
caused  to  discharge  by  impressions  brought  to  them,  and  by  the  discharges  were 
exhausted  of  certain  necessary  chemical  materials.  Shock  may  be  slight  and 
transient,  it  may  be  severe  and  prolonged,  it  is  usually  sudden  in  onset,  but  may 
come  on  gradually,  and  it  may  even  produce  almost  instant  death.  I  agree  with 
Bloodgood  that  even  a  violent  injury  does  not  of  necessity  at  once  produce  it. 
Every  now  and  then  we  see  a  man  with  a  crushed  limb  who  does  not  exhibit 
shock,  the  condition  gradually  coming  on  from  pain,  terror,  etc.,  and  being  aggra- 
vated perhaps  by  hemorrhage.  During  an  operation  if  shock  arises  it  is  apt 
to  do  so  gradually,  but  this  is  not  always  the  case,  for  som_etimes  it  comes  on 
with  great  suddenness,  for  instance,  when  traction  is  made  upon  the  pedicle  of 
the  spleen,  when  the  bone  of  the  thigh  is  sawed  through,  or  when  there  is  a  burst 
of  blood  from  a  large  vessel.  Sudden  death  from  shock  is  probably  due  to 
reflex  stimulation  of  the  pneumogastric  nuclei  and  arrest  of  cardiac  action. 
It  is  known  as  death  by  inhibition.  Shock  is  more  severe  in  women  than  in 
men,  in  the  nervous  and  sanguine  than  in  the  lymphatic,  in  those  weakened  by 
suffering  than  in  those  who  are  strangers  to  illness.  It  is  predisposed  in  dis- 
ease of  the  kidneys,  diabetes,  chronic  cardiac  disease,  and  alcoholism.  Fear 
is  probably  a  great  factor  in  shock.  Injuries  of  nerves,  of  brain,  of  the  intra- 
thoracic viscera,  of  the  intra-abdominal  viscera,  of  the  urethra,  or  of  the  testicle 
produce  extreme  shock.  Anything  which  extracts  the  body-heat  favors  the  de- 
velopment of  shock  (exposure  to  cold  air,  insufficient  covering,  chilling  the  body 
by  solutions  or  wet  towels) .  In  cerebral  concussion  there  is  shock  plus  other 
conditions.  Sudden  and  profuse  hemorrhage  greatly  aggravates  shock.  Pro- 
longed anesthetization  causes  shock.  Great  shock  may  occur  after  the  removal 
of  a  large  tumor  or  a  quantity  of  fluid  from  the  abdomen.  In  such  a  case  shock 
is  brought  about  by  the  sudden  removal  of  pressure  and  the  consequent  rapid 
distention  of  intra-abdominal  veins.  Exposure  of  tissue  and  vital  parts  to  air 
aggravates  shock.  Crile  lays  down  as  the  most  important  causes  of  shock:  fear, 
pain,  and  traction. 

The  influences  which  cause  cells  to  exhaust  themselves  by  discharge  are 
recognized  by  the  nerve-cells  as  meaning  or  suggesting  harm  to  the  organism. 
Such  influences  cause  impiflses  to  escape.  Such  influences  are  called  by  Crile 
nocuous  or  noci  influences.  Fear  itself  can  cause  shock,  and  fear  is  a  factor 
even  when  shock  is  apparently  due  to  pain  or  traction.  Fear,  then,  is  the 
ever-existing  factor  in  shock  causation.  It  is  often  a  conscious  fear.  It  may 
be  subconscious  fear. 

Crile  maintains  that  an  individual  may  be  anesthetized  by  ether  or  chloro- 
form and  feel  no  pain,  and  yet  noci  influences  may  cause  shock.    The  influences 


The  Prevention  of  Shock  in  Operations  261 

then  act  by  suggesting  painful  or  harmful  things  to  the  nerve-cells,  that  is,  by 
causing  subconscious  fear.  Crile  calls  such  automatic  association  philogenetic 
association. 

The  symptoms  of  ordinary  shock  {torpid  or  apathetic  sJwck)  are  subnor- 
mal temperature;  weakness  of  heart  action:  irregular,  small,  weak,  rapid,  and 
compressible  pulse;  cold,  palhd,  bloodless,  and  often  clammy  or  profusely 
perspiring  skin;  shallow,  irregular,  and  often  gasping  respiration.  A  sphyg- 
momanometer will  indicate  a  notable  fall  in  blood-pressure.  Consciousness 
is  usually  maintained,  but  there  is  an  absence  of  mental  originating  power, 
the  injiu-ed  person  answering  when  spoken  to,  but  volimteering  no  state- 
ments and  King  i^ith  partly  closed  lids  and  expressionless  countenance  in  any 
position  in  which  he  may  be  placed.  The  answers  to  questions  though  ap- 
parently intelligent  are  utterly  unreHable.  There  is  great  motor  weakness. 
The  pupils  are  dilated  and  react  but  slowly  to  light.  The  sphincters  are  relaxed. 
Pain  is  slightly  or  not  at  all  appreciated.  Xausea  is  absent  and  vomiting  may, 
as  in  concussion,  presage  reaction.  Gastric  regurgitation,  after  a  considerable 
duration  of  shock,  is  not  imusual,  and  is  a  bad  omen.  It  must  impress  students 
of  physiolog}'  that  certain  of  the  well-known  signs  of  shock  do  not  seem  to  indi- 
cate that  there  are  paralysis  and  dilatation  of  the  peripheral  vessels,  as  the  pop- 
ular theor}^  of  shock  supposes.  The  signs  which  do  not  co-ordinate  vdth  the 
theor}-  are  anemia  of  the  surface,  lowered  temperatiure  of  the  stirface,  and  small 
pulse  (Seelig  and  Lyon,  in  "Surger};.  G}Tiecolog}'.  and  Obstetrics,"'  Aug.,  1910). 
Shock  is  not  rarely  followed  by  suppression  of  lu-ine.  ^^^lereas  the  ^-ictim  of 
shock  is  usually  stupid  and  indifferent,  he  may  become  delirious.  If  delirium 
arises,  the  condition  is  ver\"  grave.  Travers  called  shock  vriih  deliriima  erethistic 
or  delirious  shock.  As  a  matter  of  fact,  such  a  state  is  not  genuine  shock,  but  is 
either  a  traumatic  or  a  toxic  delirium  added  to  or  following  upon  shock.  It  is 
usuallv  due  to  uremia  or  sepsis.  Delirious  shock  may  arise  after  a  person  has  been 
bitten  bA'  a  poisonous  snake.  ]SIany  years  ago  Travers  described  a  secondary  or 
delayed  form  of  shock,  which  comes  on  several  hoius  after  an  injun,-  or  violent 
emotional  disturbance.  This  form  of  shock  is  seen  not  imusually  in  those  who 
have  passed  through  a  railroad  accident.  It  may  be  a  sign  of  hemorrhage,  and 
is  sometimes  met  vdxh  after  the  administration  of  ether  or  chloroform.  The 
statements  made  by  a  person  who  has  recovered  from  a  severe  shock  are  always 
imreHable  as  to  events  which  occurred  while  shock  existed,  and  are  often 
doubtful  as  to  the  details  of  the  accident.  Xot  unusually  the  memor\-  of 
the  accident  is  perverted  or  even  destroyed. 

Diagnosis. — Concealed  hemorrhage  is  difficult  to  differentiate  from  shock. 
The  former  produces  impairment  of  \ision  (retinal  anemia^,  irregular  tossing, 
frequent  vawning,  great  thirst,  nausea,  and  sometimes  com-ulsions.  In  shock 
the  hemoglobin  Is  unaltered;  in  hemorrhage  it  is  enormously  reduced  (Hare 
and  Martin).  In  hemorrhage  recurrent  attacks  of  syncope  are  met  with.  In 
pure  shock  such  attacks  do  not  occiu.  In  concealed  hemorrhage  the  abdomen 
may  exhibit  physical  signs  of  a  rapidly  increasing  collection  of  fluid.  _  Shock 
and  hemorrhage  are  often  associated.  A  usual  characteristic  of  shock  is  rapid 
onset,  which  separates  it  distinctly  from  exhaustion.  It  arises  at  a  much  earher 
period  after  an  injur}-  than  does  fat-embolism. 

The  Prevention '  of  Shock  in  Operations. — Examine  the  patient  \dth. 
care  before  operating,  giA"ing  special  attention  to  the  condition  of  the  kidneys. 
The  amount  of  mine  passed  and  the  amoimt  of  urea  it  contains  should  always 
de  determined  when  possible.  The  amoimt  of  urea  should  be  estimated  from 
the  twenty-foinr-hour  urine.  The  normal  amoimt  of  urine  in  the  twenty- 
four  hours  is  about  50  ounces  and  the  normal  amount  of  urea  2  per  cent. 
Less  urea  is  significant  of  danger  from  shock  and  subsequent  kidney  complica- 
tions.    If  the  condition  of  the  patient  leads  us  to  fear  that  there  will  be  dan- 


262  Contusions  and  Wounds 

gerous  shock,  do  not  purge  him  severely  before  operation,  and  just  previous 
to  operation  give  a  rectal  injection  of  hot  saline  fluid  and  a  h3qDodermatic  in- 
jection of  y-g^o  gr.  of  atropin.  It  is  also  a  good  plan  in  some  cases  to  give  a 
hypodermatic  injection  of  g-  gr.  of  morphin  twenty  minutes  before  operation. 
It  tranquillizes  the  patient  and  less  ether  will  be  needed  to  anesthetize  him. 
Examine  the  patient  thoroughly  and  prepare  him  carefully  beforehand  and 
decide  if  he  should  take  a  general  anesthetic  at  all,  and  if  so,  which  one.  Nitrous 
oxid  diminishes  operative  shock,  Crile  says,  because  cell  activity  is  lessened  by 
deficiency  of  oxygen. 

Many  operators  believe  that  ether  and  chloroform  lessen  shock.  Crile 
disputes  this.  He  holds  that  they  merely  inhibit  conscious  fear  and  muscular 
response  to  peripheral  impressions,  but  do  not  save  the  brain-cells  from  noci 
impressions,  and  hence  do  not  keep  cells  from  exhausting  discharges. 

It  would  seem  that  a  drugged  brain-cell  could  not  receive  influences  as 
acutely  and  strongly  as  one  untouched  by  ether  or  chloroform.  I  believe  that 
a  general  anesthetic,  given  properly  and  in  proper  amount,  does,  to  some  extent 
at  least,  lessen  the  shock  of  an  operation. 

In  some  cases  a  local  anesthetic  should  be  used,  for  instance,  some  cases  of 
typhoid  perforation  and  strangulated  hernia.  The  nerves  well  above  the  area 
of  operation  should  be  infiltrated  with  cocain.  This  prevents  the  ascent  of 
peripheral  impressions,  makes  what  Crile  calls  a  "physiological  block,"  and  so 
prevents  shock.  After  this  infiltration  a  limb  can  be  amputated  below  the  infil- 
trated area  without  pain  and  without  great  depression  of  the  vital  powers.  I 
have  performed  a  mmiber  of  amputations  most  satisfactorily  relying  for  anes- 
thesia purely  upon  cocainization  of  the  nerves.  In  these  cases  there  has  been 
very  little  shock.  This  is  a  valuable  procedure  even  when  ether  is  given.  I 
employ  it  frequently  and  am  satisfied  of  its  great  value  in  preventing  shock. 
The  ether  prevents  conscious  fear  during  the  operation,  the  cocainization  of  the 
nerve  intercepts  harmful  impressions  in  their  ascent.  Thus  is  shock  prevented. 
In  some  few  cases  in  which  we  fear  shock  spinal  anesthesia  is  used;  in  others, 
scopolamin  and  morphin.  If  a  general  anesthetic  is  used  it  must  be  skilfully 
given  and  not  a  drop  is  given  beyond  the  amount  necessary  to  maintain  thorough 
anesthesia.  Cover  every  part  but  the  field  of  operation  with  hot  blankets  and 
put  cans  of  hot  water  about  the  patient,  or  put  him  on  a  bed  composed  of  hot- 
"water  pipes  covered  with  blankets.  Prevent  bleeding  with  the  greatest  possible 
care.  Operate  as  rapidly  as  is  consistent  with  safety  and  thoroughness. 
The  blood-pressure  is  of  great  importance  in  estimating  the  degree  of  shock,  and 
any  sudden  fall  of  blood-pressure  is  ominous.  It  is  a  custom  with  many  opera- 
tors to  fix  a  sphygmomanometer  to  the  arm  and  have  an  assistant  watch  the 
scale  constantly  during  an  operation.  If  shock  develops  during  an  operation 
hasten  on  the  work,  lessen  the  amount  of  ether,  and  apply  active  treatment. 
Retiurn  the  patient  to  bed  as  soon  as  possible  and  without  exposure  in  cold  halls 
or  a  windy  elevator.  Occasionally  it  becomes  necessary  to  suspend  an  opera- 
tion in  order  to  prevent  death  on  the  table. 

Crile's  anoci  association  operation  is  founded  on  the  prevention  of  shock  by 
the  exclusion  as  far  as  possible  of  all  painful,  terrifying,  and  depressing  influ- 
ences from  a  patient  before,  during,  and  after  operation.  The  patient  is  not 
kept  for  days  or  even  for  hours  waiting  in  fear.  He  is  to  be  reassured,  made 
confident,  dominated  by  his  surgeon.  He  is  anesthetized  by  means  of  nitrous 
oxid  and  nitrogen,  ether  being  added  only  if  necessary.  The  tissues  are  infil- 
trated with  a  local  anesthetic.  During  the  operation  all  noci  impressions 
are  carefully  excluded.  This  method,  in  the  hands  of  Crile,  Bloodgood,  and 
others,  has  given  highly  satisfactory  resiilts. 

Treatment. — In  treating  ordinary  apathetic  shock  raise  the  feet  and  lower 
the  head,  unless  this  position  causes  cyanosis.    At  least  place  the  head  flat  and 


Treatment  of  Shock  •  263 

the  body  recumbent.  Wrap  the  patient  in  hot  blankets  and  surround  him  with 
hot  bottles,  hot  bricks,  hot-water  bags,  or  cans  of  hot  water.  Always  wrap  a  can, 
a  bottle,  or  a  bag  in  flannel  or  some  other  material  to  avoid  burning  the  patient. 
Ordinars-  stimulants  seem  of  httle  or  no  value  and  drugs  given  by  the  stomach  are 
not  absorbed.  Salt  solution  maybe  thrown  into  a  vein  {intravenous  infusion), 
may  be  given  by  the  rectum  {proctoclysis) ,  or  subcutaneously  {hy podermoclysis) . 
Intravenous  infusion  does  good,  but,  unfortunately,  the  benefit  is  ver}^  tem- 
porary except  in  cases  associated  with  hemorrhage.  In  hemorrhage  it  should 
always  be  given,  and  it  should  be  given  mLxed  with  adrenalin  chlorid  (i  tea- 
spoonful  of  the  I  :  1000  solution  of  adrenalin  chlorid  is  added  to  i  liter  of  salt 
solution).  The  operation  of  intravenous  infusion  is  described  on  page  465. 
The  custom  of  gi\ing  salt  solution  in  a  vein  has  become  so  common  that 
resident  physicians  are  apt  to  resort  to  it  as  a  routine.  It  is  to  be  remembered 
that  if  given  rapidly  or  in  too  great  quantity  it  may  gather  in  the  chambers  of  a 
dilated  right  heart  and  arrest  a  heart  so  weakened  that  it  has  almost  reached 
its  limit  of  fmiction.  I  am  satisfied  that  the  rapid  administration  of  salt  solu- 
tion intravenously  is  responsible  for  some  deaths.  Crile  maintains  that  the 
only  way  "to  increase  and  sustain  the  blood-pressure  when  the  vasomotor 
center  is  exhausted"  is  to  "create  a  peripheral  resistance  either  by  a  drug 
acting  on  the  blood-vessels  themselves  or  by  mechanical  pressure."^  In  order 
to  accomplish  this  he  uses  adrenalin  chlorid.  Because  of  the  rapidity  with 
which  this  drug  is  oxidized  he  gives  it  intravenously,  slowly  and  continuously 
from  a  buret,  using  a  solution  of  a  strength  of  from  i  :  50,000  to  i  :  100,000 
in  salt  solution.  The  rate  of  flow  should  be  "controlled  by  a  screw-cock 
attached  to  the  rubber  tube."  Crile  also  places  the  patient  in  a  rubber  suit 
and  distends  the  suit  by  means  of  an  air  pump  and  thus  obtains  equable  pres- 
sure upon  the  cutaneous  surface  and  an  increase  of  peripheral  vascular  resist- 
ance. The  difficulty  with  giving  the  solution  in  a  vein  is,  the  drug  first  comes 
in  contact  with  "the  vessels  ha^ing  the  least  power  of  influencing  blood-pres- 
sure," and  before  a  notable  rise  can  be  aft'ected  by  arterial  action  "it  is  necessary 
that  the  solution  should  pass  through  the  right  heart,  the  lungs  on  its  way  to 
the  aorta,  then  finally  affecting  the  coronar\^  arteries"  (Crile,  in  "Am.  Jour. 
Med.  Sciences,"  Jan.,  1909).  The  best  way  to  use  adrenalin  solution  in  severe 
shock  is  to  introduce  it  as  Crile  now  ad^dses,  that  is,  into  the  arterial  system  and 
toward  the  heart.  Occasionally,  by  this  means,  resuscitation  from  apparent 
death  may  be  accomplished.  Crile  calls  this  method  centripetal  arterial  trans- 
fusion.    It  is  applied  as  follows  ("Am,  Jour.  Med.  Sciences,"  April,  1909): 

"In  human  resuscitation  the  technic  is  as  follows:  The  patient  in  the 
prone  posture  is  subjected  at  once  to  rapid  rhythmic  pressure  upon  the  chest, 
with  one  hand  on  each  side  of  the  sternum.  This  pressure  produces  artificial 
respiration  and  a  moderate  artificial  circulation.  A  cannula  is  inserted  toward 
the  heart  into  an  artery.  Normal  saline.  Ringer's,  or  Locke's  solution,  or,  in 
their  absence,  sterile  water,  or,  in  extremity,  even  tap  water,  is  infused  by  means 
of  a  funnel  and  rubber  tubing.  But  as  soon  as  the  flow  has  begun  the  rubber 
tubing  near  the  cannula  is  pierced  with  the  needle  of  a  h}-podermatic  s}Tinge 
loaded  with  i  :  1000  adrenalin  chlorid  and  15  to  30  min.  are  at  once  in- 
jected. Repeat  the  injection  in  a  minute  if  needed.  Synchronous^  i;\-ith  the 
injection  of  the  adrenalin  the  rhythmic  pressure  upon  the  thorax  is  brought  to 
a  maximum.  The  resulting  artificial  circulation  distributes  the  adrenalin  that 
spreads  its  stimulating  contact  with  the  arteries,  bringing  a  wave  of  powerful 
contractions  and  producing  a  rising  arterial,  hence  coronar\-,  pressiue.  WTien 
the  coronar}'  pressure  rises  to,  say,  40  mm.  or  more,  the  heart  is  likely  to  spring 
into  action.  The  first  resiflt  of  such  action  is  to  spread  stiU  further  the  blood- 
pressure-raising  adrenalin,  causing  a  further  and  \-igorous  rise  in  blood-pres- 
1  George  Crile,  in  "Boston  Med.  and  Surg.  Jour.,"  March  5,  1903. 


264 


Contusions  and  Wounds 


sure,  possibly  even  doubling  the  normal.  The  excessively  high  pressure  is 
most  favorable  to  the  resuscitation  of  tissue,  especially  of  the  central  nervous 
system  (Stewart).  Just  as  soon  as  the  heart-beat  is  established  the  cannula 
should  be  withdrawn,  first,  because  it  is  no  longer  needed,  and  second,  because 
the  rising  blood-pressure  will  drive  a  torrent  of  blood  into  the  tube  and  fun- 
nel. Unless  there  has  been  hemorrhage,  the  only  object  in  the  use  of  saline 
infusion  is  to  serve  as  a  means  of  introducing  the  adrenalin  into  the  arterial 
circulation  toward  the  heart.  Bandaging  the  extremities  and  abdomen  tightly 
over  masses  of  cotton  is  very  useful." 

In  prolonged  shock  direct  transfusion  of  blood  should  be  employed  (see  page 
463).     The  use  of  hot  and  stimulating  rectal  enemata  is  important.     The 


Fig.  108. — Subcutaneous  saline  infusion  (Senn). 

rectum  may  absorb  fluids  when  the  stomach  refuses  to  do  so.  Enemata  of  hot 
normal  salt  solution  are  beneficial  {proctoclysis).  The  tube  is  carried  as  high 
as  possible  and  the  injection  is  introduced  so  as  to  distend  the  colon.  Hypo- 
dermoclysis  is  given  as  follows:  Insert  an  aspirator  tube  into  the  cellular  tissue 
of  the  loin,  scapular  region,  or  under  the  mamma,  cleansing  the  part  first.  The 
tube  is  attached  to  a  fountain  syringe,  which  is  filled  with  warm  normal  salt 
solution,  and  is  hung  at  a  height  of  2  or  3  feet  above  the  bed  (Fig.  108).  In 
an  hour's  time  a  pint  or  more  of  fluid  will  enter  the  tissue  and  be  absorbed. 
It  is  the  custom  to  give  hypodermatic  injections  of  ether,  brandy,  strychnin, 
digitalis  or  atropin,  or  inhalations  of  amyl  nitrite.  Crile  has  demonstrated 
experimentally  that  strychnin  is  perfectly  futile  in  pure  shock  and  may  actually 
aggravate  the  condition.     In  collapse  it  is  of  some  value.      We  believe  this 


Treatment  of  Shock  265 

statement  is  true  clinically.  Strychnin  goads  a  heart  to  increased  action 
when  that  organ  has  not  suf&cient  blood  passing  into  it  to  enable  it  to  firmly 
and  strongly  contract.  The  use  of  strychnin  in  shock  has  been  compared  by 
Hare  to  beating  a  dying  horse  to  make  it  pull.  I  believe  that  atropin  is  of 
great  benefit  in  shock,  especially  if  the  skin  is  very  moist.  This  drug,  according 
to  my  colleague.  Prof.  Hobart  A  Hare,  is  a  sedative  to  the  vagus;  but  what 
makes  it  particularly  valuable  is  that  it  acts  upon  the  vasomotor  system, 
combats  the  dilatation  of  the  blood-vessels,  maintains  vascular  tone,  opposes 
stagnation  of  blood  in  any  vessels,  and  increases  the  amount  of  moving  blood. 
If  the  skin  is  very  moist,  atropin  is  particularly  indicated.  Senn  recommends 
the  h^-podermatic  injection  of  sterile  camphorated  oil,  a  syringeful  every 
fifteen  minutes,  until  reaction  begins.  Inhalation  of  ox^'gen  is  often  of  much 
service,  and  artificial  respiration  may  be  necessary.  Opiates  are  contra-indi- 
cated in  shock.  IMustard  plasters  should  be  placed  over  the  heart,  spine, 
and  shins.  A  turpentine  enema  is  useful.  An  enema  of  hot  coffee  and 
whisky  is  valuable.  In  severe  cases  of  shock,  bandage  the  extremities. 
Bandaging  for  the  relief  of  shock  is  called  autotransfusion.  This  procedure 
increases  peripheral  resistance  and  enables  the  body  to  utilize  to  the  best 
advantage  the  small  amount  of  circulating  blood,  and  sends  most  of  it  to  the 
brain,  where  it  will  maintain  the  acti\ity  of  the  vital  centers  and  keep  up  cir- 
culation and  respiration.  For  this  purpose  ordinary  muslin  bandages  may 
be  used,  or  gauze  bandages,  or  the  bandages  of  Esmarch.  Crile's  rubber 
suit  accompHshes  the  object  more  satisfactorily  than  does  bandaging  the 
extremities.  Abdominal  massage  helps  drive  out  the  imprisoned  blood, 
and  after  massage  sets  free  the  abdominal  blood  apply  a  compress  and  binder. 
In  serious  cases  artificial  respiration  and  stimulation  of  the  diaphragm  with 
a  galvanic  current  may  be  used.  If  shock  comes  on  diiring  an  operation, 
the  operation  must  be  hurried  or  even  abandoned,  and  proper  treatment  must 
be  instituted  at  once.  The  anesthetist  should  give  very  little  ether  when 
shock  becomes  at  all  evident.  Shoiild  we  operate  during  shock?  We  should 
only  do  so  when  death  without  instant  operation  is  ine\'itable.  We  must 
operate,  if  it  is  necessary  to  do  so,  to  arrest  hemorrhage,  to  reheve  strangu- 
lated hernia,  intestinal  obstruction,  obstruction  of  the  air-passages,  compoimd 
fractures  of  the  skull,  extravasated  urine,  or  intraperitoneal  extravasations 
from  ruptured  viscera.  If  hemorrhage  can  be  temporarily  controlled  by 
pressure  or  a  clamp,  so  much  the  better,  and  the  permanent  arrest  can  be 
effected  after  the  reaction  from  shock.  It  is  not  wise,  in  the  author's  opin- 
ion, to  amputate  during  shock.  A  tourniquet  or  Esmarch  bandage  should  be 
applied,  and  attempts  be  made  to  bring  about  reaction,  and  when  reaction 
is  obtained  the  amputation  should  be  performed.  It  is  only  just  to  say  that 
some  eminent  surgeons  oppose  this  rule.  Roswell  Park  says  that  ''shock  is 
often  aUe^-iated  by  the  prompt  removal  of  mutilated  limbs  which,  when  still 
adherent  to  the  trunk,  seem  to  perpetuate  the  condition."  The  same  teacher 
beHeves  in  operating  at  once  upon  severe  compoimd  fracttu-es.^  After 
ever^'  operation  keep  careful  watch  upon  the  amount  of  urine  passed,  see 
to  it  that  the  patient  takes  sufficient  fluid,  and  if  the  urine  becomes  scanty 
put  a  hot-water  bag  to  each  loin,  give  diuretics  by  the  mouth,  secure  cu- 
taneous acti\dty,  give  saline  purgatives,  and  administer  hot  saline  enemata. 
If  the  condition  is  not  soon  benefited,  the  custom  is  to  infuse  hot  saline  fluid 
into  a  vein.  I  am  doubtful  if  intravenous  infusion  of  saline  fluid  is  benefi- 
cial in  suppression,  and  I  even  fear  it  may  do  harm  (see  the  studies  of  Widal, 
Marie  and  Crouzon,  Merklen,  and  others)!  Rossle  C'Centralbl.  f.  Chir.,"  1907, 
xxxiv)  savs  that  in  certain,  cardiac  and  renal  conditions  salt  solution  damages 
the  capiliaries  and  does  actual  harm.  In  urinary  suppression  following  acci- 
1  Park's  "Surgery  by  American  Authors." 


266  Contusions  and  Wounds 

dent  or  surgical  operation  {postoperative  suppression  or  anuria)  the  condition 
is  so  dreadfully  grave  that  it  is  justifiable  to  expose  each  kidney  and  split  the 
capsule  in  order  to  relieve  tension  and  in  the  hope  of  thus  abating  congestion. 
In  fact,  I  believe  this  should  always  be  done.  In  a  case  in  which  there  had  been 
total  suppression  for  three  days  I  did  this  operation.  During  the  next  thirty- 
six  hours  the  patient  passed  1 2  oz.  of  urine,  but  died  of  complications.  Post- 
operative suppression  of  urine  is  almost  invariably  fatal.  Delayed  shock  is 
treated  in  the  same  manner  as  apathetic  shock  if  hemorrhage  can  be  excluded. 
If  hemorrhage  is  the  cause,  the  bleeding  must  be  arrested,  and  blood  be  trans- 
fused, or  saline  fluid  be  infused  into  a  vein.  If  delirious  shock  is  due  to  sepsis, 
the  treatment  is  that  of  sepsis.  If  it  is  a  nervous  delirium,  give  morphin  and 
other  sedatives.     If  due  to  uremia,  the  treatment  is  obvious. 

Fat=embolism. — (See  page  191.) 

Fever.^(See  Fevers,  page  128.) 

Treatment  of  Wounds. — All  wounds,  other  than  those  made  by  the 
surgeon,  are  regarded  as  infected.  The  rules  for  treating  such  woimds  are: 
(i)  arrest  hemorrhage;  (2)  bring  about  reaction;  (3)  remove  foreign  bodies; 
(4)  asepticize;  (5)  drain,  coaptate  the  edges,  and  dress;  and  (6)  secure  rest 
to  the  part  and  combat  overaction  of  the  tissues.  Constitutionally,  allay 
pain,  secure  sleep,  maintain  the  nutrition,  and  treat  inflammatory  conditions. 

Arrest  of  Hemorrhage. — To  arrest  hemorrhage  the  bleeding  point  must  be 
controlled  by  an  Esmarch  band  or  digital  pressure  until  ready  to  be  grasped 
with  forceps;  it  is  then  caught  up  and  tied  with  catgut  or  aseptic  silk.  Slight 
hemorrhage  ceases  spontaneously  on  exposure  of  the  bleeding  point  to  air, 
and  moderate  hemorrhage  ceases  permanently  after  the  temporary  applica- 
tion of  a  clamp.  An  injured  vessel  when  not  of  the  smallest  size  must  be 
Kgated,  even  if  it  has  ceased  to  bleed.  Capillary  oozing  is  checked  by  hot 
water  and  compression.  If  a  large  artery  is  divided  in  a  limb,  apply  a  tourni- 
quet before  ligating.     (See  Wounds  of  Vessels.) 

Bringing  About  of  Reaction. — (See  Shock.) 

Removal  of  Foreign  Bodies. — Remove  all  foreign  bodies  visible  to  the  eye 
(splinters,  bits  of  glass,  portions  of  clothing,  gun-wadding,  grains  of  dirt,  etc.)  by 
forceps  and  a  stream  of  corrosive  sublimate  solution,  sterile  water,  or  normal 
salt  solution.  In  a  lacerated  or  contused  wound  portions  of  tissue  injured  be- 
yond repair  should  be  regarded  as  foreign  bodies  and  be  removed  with  scissors. 

Cleaning  the  Wound.^ — To  clean  the  wound  shave  the  surrounding  area, 
if  it  is  hairy;  scrub  the  surface  about  the  wound  with  ethereal  soap,  green 
soap,  or  castile  soap;  wash  with  water,  scrub  with  alcohol,  and  then  with 
corrosive  sublimate  solution  (i  :  1000).  An  accidental  wound  is  infected, 
and  must  be  well  washed  out  with  an  antiseptic  solution.  In  every  wound  in 
which  we  have  reason  to  suspect  tetanus  infection  a  preventive  dose  of  anti- 
toxin should  be  given.  We  have  particular  occasion  to  apprehend  tetanus  if 
the  wound  is  contaminated  with  feces,  street  dirt,  stable  dust,  or  stable  refuse, 
or  if  it  was  infected  with  a  toy  pistol  such  as  boys  use  to  celebrate  the  Fourth  of 
July.  A  clean  wound  made  by  the  surgeon  need  not  be  irrigated;  in  fact, 
irrigation  with  an  antiseptic  fluid  leads  to  necrosis  of  tissue,  causes  a  profuse 
flow  of  serum,  and  necessitates  drainage.  If  clots  have  gathered  in  a  wound 
they  must  be  removed,  as  their  presence  will  prevent  accurate  coaptation  of  the 
edges.  In  an  infected  w^ound  they  are  washed  out  by  a  stream  of  corrosive 
sublimate  solution.  In  a  clean  wound  they  are  washed  out  by  hot  salt  solu- 
tion. If  dirt  is  ground  into  a  wound,  as  is  often  seen  in  crushes,  pour  sweet  oil 
into  the  wound,  rub  it  into  the  tissues,  and  scrub  the  wound  with  ethereal  soap. 
The  oil  entangles  the  dirt,  and  the  soap  and  water  remove  both  oil  and  dirt. 
After  the  rough  cleansing  irrigate  with  corrosive  sublimate  solution.  In 
^  The  use  of  iodin  as  a  germicide  is  discussed  on  page  68. 


Treatment  of  Wounds  267 

some  cases,  especially  in  bone  injuries,  it  is  necessary  to  scrape  the  wound 
with  a  curet.  If  a  fissure  of  the  skull  is  infected,  enlarge  the  fissure  with 
a  chisel  in  order  to  clean  it.  In  a  badly  infected  wound  one  of  the  most  valu- 
able agents  for  use  in  producing  disinfection  is  pure  carbolic  acid.  After 
cleaning  the  wound,  it  is  necessary  in  certain  regions  to  examine  in  order 
to  determine  if  tendons  or  considerable  nerves  have  been  cut.  If  such  struc- 
tures have  been  divided,  they  must  be  sutured  with  fine  silk,  chromic  gut, 
or  kangaroo-tendon. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  require  no  special 
drainage,  as  some  wound-fluid  will  find  exit  between  the  stitches  and  the  rest 
will  be  absorbed.  A  large  or  deep  wound  requires  free  drainage  for  at  least 
twenty-four  hours  by  means  of  a  tube,  strands  of  horsehair,  silk  or  catgut, 
or  bits  of  iodoform  gauze.  An  infected  wound  must  be  drained  invariably. 
Good  drainage  may,  to  a  considerable  extent,  compensate  for  imperfect  anti- 
sepsis. If  capillary  drains  are  employed,  apply  a  moist  dressing.  Other- 
wise the  strands  dry  and  fail  to  act  as  drains.  Approximate  the  edges 
with  interrupted  sutures  of  silk  or  silkworm-gut  if  the  wound  is  deep  and 
considerable  tension  is  inevitable.  Catgut  is  used  for  superficial  wounds 
and  for  those  where  tension  is  slight.  If  there  is  decided  tension,  silver  wire 
may  be  used.  In  very  deep  wounds  buried  sutures  must  be  used.  These 
sutures  may  consist  of  absorbable  material  (kangaroo-tendon  or  catgut)  or 
unabsorbable  material  (silver  wire)  or  very  fine  silk.  Of  late  I  have  been 
following  the  Johns  Hopkins  custom  and  have  closed  all  clean  wounds  with 
sutures  of  very  fine  iron  dyed  silk  passed  by  small  and  very  sharp  sewing 
needles.  By  the  use  of  these  fine  sutures  a  minimum  amount  of  tissue  necrosis 
occurs,  the  risk  of  infection  is  greatly  lessened,  and  the  resulting  scar  is  the 
smallest  that  can  be  obtained.  As  is  well  known,  tight  sutures  cause  tissue 
necrosis  and  hence  predispose  to  infection.  It  is  impossible  to  tie  the  fine 
black  silk  very  tight,  because  if  we  do  so  it  breaks.  It  requires  considerable 
practice  to  learn  to  tie  the  sutures  without  breaking.  This  fine  silk  can  be 
buried  without  fear,  as  it  never  causes  a  sinus,  and  it  is  used  for  layer  sutures 
with  perfect  confidence.  I  learned  this  plan  from  Dr.  Harvey  Gushing,  and 
am  much  pleased  with  it.  If  the  wound  is  infected,  dress  with  warm,  moist 
antiseptic  gauze.  If  it  is  not  infected,  dress  with  dry  sterile  gauze.  The 
custom  once  was  to  cover  even  dry  gauze  with  a  rubber-dam  to  diffuse  the  fluids, 
but  we  now  prefer  to  omit  the  rubber- dam  and  use  plentiful  dressings.  A  dry 
dressing  absorbs  wound-fluids  quickly  and  is  less  likely  to  become  infected. 
Ghange  the  dressings  in  twenty-foiir  hours  or  sooner  if  they  become  soaked 
with  discharge.  Dressings  are  changed  for  cause,  but  not  according  to 
scheduled  time.  They  must,  of  course,  be  changed  when  they  become  soaked 
with  wound-fluid,  and  soaking  may  occur  in  a  few  hours,  but  may  not  occur 
for  days.  As  long  as  the  temperature  remains  normal  and  the  wound  free 
from  pain,  if  the  dressing  is  not  wet  with  discharge,  it  can  be  left  in  place  unless 
removal  is  necessary  to  take  out  a  drainage-tube.  If  pus  forms,  open  the  wound 
at  once.  Many  surgeons  sprinkle  wounds  before  approximation  and  wound 
surfaces  after  approximation  with  a  drying  powder.  These  powders  are  of 
great  use  in  infected  wounds,  but  are  not  necessary  in  clean  wounds.  Among 
the  substances  employed  are  salicylic  acid,  boric  acid,  calomel,  acetanilid,  aris- 
tol,  iodoform,  subiodid  of  bismuth,  and  glutol.  In  large  wounds  which  can- 
not be  approximated  it  is  occasionally  advisable  to  skin-graft  by  Thiersch's 
method.  A  small  wound  which  cannot  be  sutured  is  dusted  with  an  anti- 
septic powder  and  dressed.  A  granulating  wound  is  dressed  as  is  a  healing 
ulcer.  In  recent  infected  wounds  rest  associated  with  Bier's  treatment  com- 
prise the  means  of  local  treatment.  Incision  is  usuaUy  required.  In  later  in- 
fections or  severe  infections  the  wound  must  be  opened  widely  and  drained. 


268  Contusions  and  Wounds 

A  sloughing  wound  is  opened,  is  dusted  with  iodoform  or  acetanilid,  and  is 
dressed  with  hot  antiseptic  fomentations. 

Rest. — Severe  wounds  require  the  confinement  of  the  patient  to  bed. 
Bandages,  spHnts,  etc.,  are  used  to  secure  rest.  In  a  closed  wound  rest  need 
not  be  protracted,  in  fact,  our  former  custom  was  to  insist  upon  it  for  too  long 
a  period.  The  slight  irritation  of  moderate  motion  stimulates  repair.  We 
no  longer  feel  it  necessary  to  keep  laparotomy  cases  in  bed  for  three  full  weeks, 
but  we  get  them  up  in  from  seven  to  ten  days.  By  doing  this  we  secure  just  as 
firm  a  cicatrix,  greatly  lessen  the  annoyance  from  constipation  and  flatulence, 
and  diminish  notably  the  number  of  cases  of  postoperative  pneumonia  and 
phlebitis.     I  do  not,  however,  advocate  getting  such  patients  up  in  twenty- 


Fig.  109. — Muscle  suture:  A,  Transverse  wound  of  biceps  muscle,  showing  marked  retraction  of  muscle- 
ends  and  mattress  suture  in  place;  B,  muscle  suture  completed  (Senn). 

four  to  thirty-SLx  hours,  as  is  advised  by  some  surgeons.  A  patient  with  an 
infected  wound  or  an  open  drainage  wound  should  be  confined  to  bed.  The 
methods  of  combating  inflammation  have  previously  been  set  forth. 

Constitutional  Treatment. — Bring  about  reaction  from  depression,  but  pre- 
vent imdue  reaction.  Feed  the  patient  well,  stimulate  him  if  necessary, 
attend  to  the  bowels  and  bladder,  secure  sleep,  and  allay  pain.  Watch  for 
compHcations,  namely,  inflammation,  suppuration,  gangrene,  tetanus,  ery- 
sipelas, suppression  of  urine,  and  pneiunonia.  Observe  the  temperature 
closely;  it  may  be  a  danger-signal  of  urgent  importance. 

Incised  Wounds. — An  incised  wound  is  a  clean  cut  inflicted  by  an  edged 
instrument.  Only  a  thin  film  of  tissue  is  so  devitalized  that  it  must  die. 
These  wounds  have  the  best  possible  chance  of  union  by  first  intention. 


Incised  Wounds 


269 


The  pain  may  be  very  severe;  but  if  the  instrument  is  sharp  and  used  quickly 
it  may  be  tri\-ial.  The  pain  is  less  severe  than  that  caused  by  some  other 
varieties  of  wounds.  The  acute  pain  does  not  last  long,  and  is  followed 
by  smarting.  The  hemorrhage  is  profuse,  varying,  of  course,  with  the  region 
cut.  Bleeding  from  the  scalp  is  violent,  because  there  are  nvmierous  vessels 
which  he  in  fibrous  tissue  and  cannot  retract  nor  contract.  The  edges  of 
incised  woimds  retract  because  of  tissue  elasticity,  and  the  woimd  "gapes." 
If  the  skin  or  fasciae  are  di\ided  at  a  right  angle  to  the  muscle  beneath,  there 
is  wide  gaping.     If  the  cut  is  parallel  to  the  muscle-fibers,  the  gaping  is  sHght. 

WTien  the  skin  is  \'iolently  pulled  upon,  it  tends  to  spht  in  a  certain  fine. 
Langer  and  Kocher  speak  of  this  as  the  line  of  cleavage,  and  point  out  the 
direction  of  these  lines  in  various  situations.  A  cut  across  the  line  of  cleavage 
is  followed  by  -u-ide  gaping.  A  cut  in  the  direction  of  the  line  of  cleavage  pro- 
duces slight  gaping,  and  is  followed  by  a  trivial  scar. 


r 

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no. — Suturmg  of  tendons  and  nerves  in  incised  wounds:  a,  Primarv'  tendon  suture;  h,  primary 

nerve  suture  (Senn). 


"WTien  a  muscle  is  cut  across  the  wound  edges  widely  separate.  When  a 
tendon  is  completely  cut  across  extensive  separation  occurs. 

An  incised  woimd  can  be  thoroughly  inspected,  aU  di\-ided  structiu-es  can 
be  identified,  foreign  bodies  can  be  easily  removed,  and  disinfection  can  be 
satisfactorily  carried  out. 

Treatment. — ^According  to  general  principles.  Arrest  hemorrhage,  asep- 
ticize, etc. 

Examine  the  wound  carefully  to  see  if  a  nerve,  a  tendon,  or  a  muscle  is 
di\T.ded,  and  if  such  injury  is  discovered,  sutmre  at  once  (Figs.  109  and  no). 
If  the  woimd  is  extensive  or  deep,  it  may  be  necessary  to  use  buried  sutures 
in  order  to  keep  the  sides  of  the  wound  in  contact.  If  the  surface  of  a  wound 
is  approximated,  but  the  depths  are  not,  the  dead  space  or  ca\aty  becomes 
filled  with  fluid,  and  infection  almost  certainly  occurs.  If  buried  sutures  have 
not  been  used,  such  a  cavity  must  be  obliterated  by  the  judicious  application 
of  pressure  upon  the  surface.  This  is  seciired  by  the  adaptation  of  a  mass  of 
loose  or  fluffed-up  gauze,  and  the  firm  application  of  a  bandage  or  binder.    An 


270 


Contusions  and  Wounds 


incised  wound  is  usually  closed  with  interrupted  sutures  (Figs,  iii  and  112). 
In  adjusting  the  sutures,  see  that  the  edges  of  the  wound  are  not  inverted,  but 
are  neatly  approximated  with  raw  edge  to  raw  edge.  Tie  the  stitches  firmly 
but  not  tightly.     If  a  stitch  is  tied  too  tightly  it  will  make  a  ridge,  as  shown 


The  right  way. 


Fig.  III. — ^The  interrupted  suture  (after  Bryant). 


Fig.  112. — Tying  an  interrupted  suture. 
The  knot  is  placed  to  the  side  of  the  wound 
as  shown  in  Fig.  109. 


V» 


Fig.    113. — Continuous   suture. 


in  Fig.  Ill,  and  undue  tightness  is  sure  to  cause  necrosis,  and  is  often  produc- 
tive of  a  stitch-abscess.  As  previously  stated,  I  usually  close  wounds  with 
sutures  of  very  fine  black  silk.  This  will  break  if  we  try  to  tie  it  tightly,  and 
as  it  never  causes  a  sinus  when  retained  in  the  tissues  it  can  be  used  for  buried 


Fig.  114. — Ford's  suture:  A  square  knot,  a  Fig.     115.— Ford's     suture:     Showing     two 

single  knot,  a  double  or  friction  knot,  and  the  square  knots,   a  single  knot,   and  the  method 

first  method  of  passing  the  needle  to  tie  a  single  of  completing  a  square  knot, 
knot  immediately. 

sutures  as  well  as  for  the  skin.  A  silk  suture  and  catgut  suture  should  be  tied 
with  the  reef  knot;  a  suture  of  silkworm-gut  may  be  tied  with  either  a  sur- 
geon's knot  or  a  reef  knot.  If  a  wound  is  on  the  face,  particular  care  must 
be  employed  in  closing  it,  in  order  to  limit  the  amount  of  disfigurement.^  Fine 
silk  sutures  are  passed  with  a  small  sharp  needle  or  a  subcuticular  stitch  is  used. 


Wounds  of  Mucous  Membranes 


271 


In  a  clean  wound  stitches  may,  as  a  rule,  be  removed  in  from  sbj  to  eight  days. 
In  a  large  wound  one-half  the  stitches  are  removed  at  one  sitting,  and  in  a  day 
or  two  the  rest  are  removed.  Stitches  are  promptly  removed  if  they  begin  to 
cut  out  or  if  infection  occurs. 

The  old  continued  suture  is  rarely  used  for  skin-wounds  at  the  present 
time.  This  suture  is  employed  to  suture  the  dura  after  diWsion,  to  suture 
the  two  layers  of  pleura  together  before  an  abscess  of  the  lung  is  opened,  to 
suture  the  peritoneiun  after  laparotomy,  and  to  suture  the  mucous  membrane 
after  certain  operations  upon  the  stomach.  The  continuous  suture  is  shown  in 
Fig.  113.  A  continuous  suture  knotted  after  each  emergence  was  de\dsed  by 
Ford.     It  is  very  useful  in  suturing  the  parietal  peritoneum  (Figs.  1 14  and  115.) 

Halsted's  subcuticular  stitch  (Fig. 
116)  makes  a  most  perfect  closure 
of  the  skin-wound,  and  is  followed 
by  the  smallest  possible  scar.  In 
closing  a  deep  wound  the  muscles 
and  fasciae  are  sutured  in  layers  by 
buried  sutures  before  the  subcutic- 
ular stitch  is  inserted.  It  is  only 
used  in  wounds  which   are   almost 

certainly  clean  (as  those  made  by  the  surgeon),  and  in  wounds  which  do  not 
require  drainage.  The  suture  material  should  be  of  silver  wire  caught  upon 
a  cur\'ed  Hagedorn  needle  or  silkworm-gut  carried  by  a  long,  straight,  round 
needle.  The  suture  is  passed  through  the  corium  on  each  side  of  the  wound, 
as  shown  in  Fig.  116.  The  cur\*ed  needle  must  be  held  in  the  bite  of  a  needle- 
holder.  WTien  the  suture  has  been  passed  the  ends  are  pulled  upon,  and  the 
skin-wound  closes  neatly. 

Halsted's  suture  does  not  penetrate  the  cuticle;  hence,  in  passing  it  the 
white  staphylococcus  is  not  carried  through  stitch-holes  and  into  the  wound, 
an  accident  which  might  be  followed  by  infection  of  a  stitch  hole  or  even  of 
the  wound.     \Mien  it  is  desired  to  withdraw  this  suture,  take  one  end  in  the 


Fis. 


-Halsted's  subcuticular  suture: 
true  skin. 


the 


Fig.  117. — The  quilled  suture. 

bite  of  the  forceps,  cut  it  off  short  with  scissors,  catch  the  free  end  viith  forceps, 
and  puU  steadily  upon  it. 

In  vev}'  deep  wounds  or  woimds  m  which  there  is  much  tension  after 
approximation  the  quilled  suture  (Fig.  117)  or  the  button  suture  (Fig.  118) 
may  be  used.     The  twisted  suture  or  hare-lip  suture  is  shown  in  Fig.  119. 

Problems  of  drainage,  dressing,  etc.,  are  discussed  on  pages  76,  77,  and  78. 

If  infection  occurs,  the  wound  becomes  swollen,  tender,  painful  and  dis- 
colored, and  the  temperature  of  the  patient  soon  becomes  elevated.  In  such  a 
condition  cut  the  stitches,  disinfect,  and  drain. 

Woimds  of  Mucous  Membranes. — If  the  surgeon  intends  to  inflict  a 
wound  upon  a  mucous  surface,  he  should  see  to  it  that  the  patient's  general 
condition  is  good.     Thorough  asepsis  is  impossible,  and  a  good  result  depends 


272 


Contusions  and  Wounds 


largely  upon  the  vital  resistance  of  the  tissues.  Before  operating,  irrigate  the 
part  frequently  with  boric  acid,  peroxid  of  hydrogen,  or  normal  salt  solution. 
When  ready  to  sew  up  the  wound  be  sure  that  all  irritant  fluids  are  removed 
(saliva  in  the  mouth,  etc.).  Cleanse  the  wound  with  hot  normal  salt  solution. 
The  stitches  must  include  submucous  tissue  as  well  as  the  mucous  membrane, 
and  consist  of  silver  wire,  catgut,  silk,  chromic  catgut,  or  silkworm-gut.  After 
sewing  up  a  wound  in  the  mouth  wash  the  oral  cavity  at  frequent  intervals 
with  salt  solution,  and  follow  each  washing  with  an  insufflation  of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  with  iodoform,  and 
close  as  directed  above.  Corrosive  sublimate  is  so  irritant  that  it  does  harm 
when  applied  to  a  mucous  membrane. 

Contused  and  Lacerated  "Wounds. — ^A  contused  wound  results  from  a 
blow  or  a  squeeze  which  bruises  and  crushes  the  tissues  and  splits  or  ruptures 
the  skin.  It  is  a  common  injury  when  force  is  applied  to  tissues  over  a  bone. 
The  blow  of  a  blackjack  upon  the  scalp  may  cause  either  a  contusion  or  a  con- 
tused wound.  A  contused  wound  is  irregular  in  outline,  has  jagged  edges,  and 
is  surroimded  by  a  broad  zone  of  contusion.  The  worst  form  of  contused 
wound  is  a  crush  of  an  extremity  produced  by  being  run  over.  The  skin  is 
often  widely  separated  from  the  tissues  beneath. 

A  lacerated  wound  results  from  tearing  apart  of  the  tis- 
sues. It,  too,  is  irregular  and  jagged,  and  is  accompanied 
by  more  or  less  contusion.  A  brush-burn  is  a  contused- 
lacerated  wound  due  to  friction.  Both  lacerated  and  con- 
tused wounds  contain  masses  of  partly  detached  and  damaged 
tissue,  the  vitality  of  which  is  endangered.  Nerve-trunks, 
muscles,  and  great  vessels  may  be  torn  across.  Hence,  such 
wounds  are  apt  to  slough,  frequently  suppurate,  and  are 
occasionally  foUowed  by  ceUu- 
litis  or  even  by  gangrene. 
There  is  more  danger  of  tetanus 
than  in  incised  wounds.  A 
wound  especially  apt  to  be 
followed  by  tetanus  is  made 
by  the  toy  pistol.  In  con- 
tused and  lacerated  wounds 
the  edges  are  discolored  and 
cold  to  the  touch,  and  there 
is  little  primary  hemorrhage  unless  a  cerebral  sinus  is  opened  or  a  great  ves- 
sel is  torn.  There  is  considerable  danger  of  secondary  hemorrhage  if  large 
vessels  have  been  bruised.  In  wounds  of  this  nature  the  pain  is  often  slight, 
but  it  may  be  violent.     Shock  is  very  severe. 

Avulsion  of  a  limb  is  a  dreadful  form  of  lacerated  wound.  The  thumb 
or  a  finger  may  be  torn  off  or  the  arm  may  be  wrenched  from  the  body  with 
or  without  the  scapula.  In  such  cases  the  wound  is  large,  jagged,  and  irreg- 
ular, long  strings  of  muscle  or  tendon  hang  from  the  gap,  the  wound  edges 
are  cold,  but  the  bleeding  is  trivial.     The  shock  is,  of  course,  profound. 

Avulsion  of  the  scalp  may  be  produced  when  the  hair  is  caught  in  machin- 
ery. The  American  Indian  inflicts  this  injury  when  he  scalps  a  conquered 
foe.  In  some  cases  of  avulsion  of  the  scalp  the  periosteum  is  removed  with 
the  flap ;  in  most  it  is  not.  The  flap  usually  consists  of  skin  and  aponeurosis. 
In  this  form  of  laceration  there  is  severe  bleeding. 

Treatment. — The  surgeon  brings  about  reaction  and  endeavors  to  asepticize 
the  wound  and  skin  about  it  (see  page  266),  arrests  hemorrhage,  and  ligates  any 
visible  damaged  vessel  whether  it  bleeds  or  not.  Hopelessly  damaged  tissue 
should  be  cut  away,  doubtful  tissue  being  retained.     In  some  cases  amputation 


Fig 


118.— Button 

suture. 


Fig.  iig. — ^The  twisted  suture. 


Punctured  Wounds  273 

is  necessaty.  If  we  apprehend  tetanus,  give  an  injection  of  antitetanic  serum 
as  a  preventive.  Secure  thorough  drainage,  in  some  situations  making  counter- 
openings  if  necessary.  Tube-drainage  may  be  necessary  or  iodoform  gauze 
in  strands  may  be  used.  Contused  wounds  and  lacerated  wounds,  except 
when  on  the  face,  are  seldom  closed  by  sutures.  They  are  rarely  closed, 
because  the  damage  is  so  great  and  the  blood-supply  so  interfered  vrith  that 
primarv-  union  will  not  occur.  In  the  face  the  blood-supply  is  so  good  that 
primary  union  may  be  obtained  in  part  or  entirely,  and  it  is  worth  while  to  try 
to  obtain  it.  Cold  must  not  be  appHed  to  a  region  of  lowered  \-itahty  because 
it  might  cause  gangrene.  Heat  is  useful.  Hence,  it  is  ad\'isable,  even  from 
the  start,  to  dress  with  hot  antiseptic  fomentations,  and  this  mode  of  dressing 
becomes  imperative  if  sloughing  begins.  An  excellent  fomentation  is  made  by 
soaking  the  gauze  in  a  hot  solution  of  acetate  of  aluminum,  using  i  fluidram 
of  a  7^  per  cent,  solution  to  an  ounce  of  water  (Waterhouse,  "British  ]\Ied. 
Jour.,"  July  9,  igio).  Of  course,  the  part  must  be  kept  at  rest.  After  healing 
has  advanced  the  occasional  apphcation  of  an  S  per  cent,  ointment  of  scarlet 
red  greatly  stimulates  cicatrization. 

If  suppuration  occurs,  the  surgeon  sees  to  it  that  the  pus  has  free  exit,  and 
if  necessary-  secures  free  exit  by  making  incisions.  Bier's  treatment  and  rest 
are  useful  for  infections. 

After  a\Tilsion  of  a  limb  the  patient  is  reacted  from  shock,  large  vessels  are 
sought  for  and  tied,  damaged  tissue  is  cut  away,  the  wound  is  drained  by 
gauze  and  is  partly  approximated  by  sutures.  After  a\'ulsion  of  the  scalp 
bleedhig  vessels  are  carefully  ligated.  A  portion  of  the  scalp  may  be  torn 
away,  but  a  pedicle  may  connect  it  v^ith  the  balance  of  this  structure.  In  such 
a  case  cleanse  the  parts  thoroughly  and  suture  the  flap  in  place  (W.  T.  Bi\-ings, 
"Phila.  Med.  Jour.,'"  June  7,  1902).  If  the  portion  of  scalp  is  entirely  sepa- 
rated, adopt  Gussenbauer's  suggestion  when  possible  and  graft  pieces  of 
the  a\'ulsed  scalp.  In  any  case  the  ulcer  resulting  from  a\TLlsion  must  be 
repeatedly  grafted.  Abbe  obtained  healing  in  a  case  after  four  years  by  the 
use  of  12,000  grafts. 

Punctured  woimds  are  made  with  pointed  instruments,  as  needles,  splinters, 
etc.  The  depth  of  a  punctured  wound  greatly  exceeds  its  surface  area. 
After  the  -withdrawal  of  the  instrument  inflicting  the  injurv^  the  wound 
partly  closes  at  points,  blood  and  wound-tiuid  cannot  find  exit,  and  if,  as 
is  probably  the  case,  bacteria  were  deposited  in  the  tissues,  infection  by  pus 
organisms  is  ver\'  likely  to  occur,  and  if  it  does  occur  suppiu-ation  spreads 
widely.  There  is  also  danger  of  infection  by  tetanus  baciUi.  Such  a 
wound  may  involve  an  important  blood-vessel,  and  in  such  a  case  profound 
hemorrhage  may  occur;  otherwise  hemorrhage  is  slight.  A  great  canity  of 
the  body  may  be  penetrated  or  an  important  organ  may  be  wounded. 
Large-sized  foreign  bodies  may  be  driven  into  the  tissues  or  a  portion  of  the 
instrument  may  break  off  and  lodge.  Pain  is  rarely  severe  miless  a  consid- 
erable ner\-e  has  been  damaged.  If  both  a  large  vein  and  arter}^  are  punctured, 
varicose-aneurysm  or  aneur\-smal-varix  may  arise. 

Treatment. — WTien  possible,  inspect  the  instrument  which  did  the  dam- 
age to  see  if  a  piece  has  been  broken  off.  If  there  is  severe  hemorrhage, 
enlarge  the  wound  and  tie  the  bleeding  vessels.  In  a  puncture  not  made  by  the 
surgeon  the  wound  must  be  regarded  as  infected.  If  a  wound  is  made  by  a 
dirty  instrument  through  skin  known  to  be  unclean,  it  is  proper  that  the  skin 
about  the  pimcture  be  sterHized,  that  the  wound  be  enlarged,  that  foreign  bodies 
be  removed,  that  the  wound  be  irrigated  with  an  antiseptic  solution  or  be 
painted  with  pure  carboHc  acid,  and  be  drained  "with  a  tube,  a  strip  of  gauze,  or 
a  piece  of  rubber  tissue.  Such  treatment,  though  painful,  and  appearing  im- 
necessarily  severe  or  even  cruel  to  the  sufferer  from  a  tri\ial  puncture,  is  neces- 
18 


2  74  Contusions  and  Wounds 

sary,  and  may  save  the  patient  from  serious  illness  or  from  death.  Every  deep 
puncture  inflicted  by  an  instrument  not  surgically  clean,  and  every  puncture 
inflicted  by  a  nail,  a  splinter,  a  meat-hook,  a  rusty  pin,  a  tooth  of  a  cat  or 
dog,  etc.,  must  be  regarded  as  grossly  infected  and  must  be  treated  by  incision, 
sterilization,  drainage,  hot  antiseptic  fomentations,  and  rest.  If  the  puncture 
is  superficial  and  is  made  with  a  smooth-pointed  instrument  like  a  needle, 
when  the  instrument  was  not  grossly  infected  the  parts  may  be  dressed  with 
hot  antiseptic  fomentations,  but  they  should  be  inspected  daily  for  evidence 
of  infection,  and  at  the  first  sign  of  trouble  an  incision  must  be  made.  If  a 
foreign  body  is  retained  in  the  tissue  it  must  be  removed. 

Pure  carbolic  acid  is  a  most  efficient  agent  to  sterilize  a  punctured  wound. 

If  an  important  cavity  of  the  body  has  been  invaded  by  a  puncture  ex- 
ploratory incision  is  necessary  (see  Brain,  Thorax,  Abdomen).  In  punctures 
with  contaminated  instruments  the  antitetanic  serum  finds  a  valuable  place  as 
a  preventive  of  tetanus. 

Stab-wounds  were  formerly  considered  with  punctured  wounds,  but  Senn 
wisely  placed  them  in  a  class  by  themselves.  Stab-wounds  are  inflicted  by 
penetrating  the  tissues  with  a  pointed  or  narrow  instrument — for  instance,  a 
dagger,  a  knife,  the  blades  of  scissors,  a  bayonet,  or  a  sword.  Such  wounds 
are  narrow  and  very  deep.  A  stab-wound  may  cause  rapid  death  by  penetra- 
tion of  a  large  blood-vessel.  Some  great  cavity  of  the  body  may  be  penetrated 
and  internal  hemorrhage  will  then  occur.  The  body  may  be  transfixed  by  a 
sword  or  bayonet.  Bone  is  rarely  injured  unless  the  skull  is  penetrated  or  the 
chest  entered.     In  stab-wounds  there  is  usually  great  hemorrhage  and  shock. 

Treatment. — Whenever  possible,  look  at  the  instrument  which  did  the 
damage  and  see  if  a  piece  is  broken  off.  If  no  great  cavity  is  entered,  treat  by 
general  rules:  arrest  bleeding,  react  from  shock,  etc.  The  treatment  of  pene- 
trating wounds  of  the  abdomen,  thorax,  and  cranium  is  discussed  in  the  special 
sections. 

Arrow-wounds  might  be  considered  under  the  head  of  punctured  wounds  or 
stab-wounds.  When  hostilities  with  the  red  men  were  frequent  and  before 
mercenary  traders  had  fitted  out  the  savages  with  rifles,  arrow-wounds  were 
common  among  the  men  of  the  frontier.  They  are  now  very  rare.  Military 
surgeons  still  encounter  them,  especially  in  some  parts  of  Africa  and  in  the 
Philippine  Islands.  An  arrow-wound  may  be  a  trivial  puncture  of  the  skin, 
a  deep  wound  of  the  soft  parts  with  or  without  bone  injury,  a  penetration 
of  a  joint,  or  of  one  of  the  body  cavities.  The  skull  cavity  may  be  entered  by 
an  arrow.  In  some  of  these  cases  there  is  a  pimcture  of  the  bone  without 
the  formation  of  fissures,  but  usually  when  bone  is  punctured  there  is  fissure 
formation,  splintering,  or  depression.  A  large  blood-vessel  may  be  divided 
by  an  arrow  and  violent  bleeding  resiilt  or  fatal  concealed  hemorrhage  may 
take  place  from  a  wounded  viscus.  Some  tribes  poison  arrows.  It  is  said  that 
the  Piutes  were  the  only  tribe  of  North  American  Indians  which  did  this. 

Some  tribes  in  South  America  use  curare,  others  use  snake-poison,  others 
used  decomposed  meat.  In  Northern  Nigeria  some  form  of  strophanthus 
plays  a  part  in  nearly  all  the  poisons  used  (Allan  C.  Parsons,  in  "Brit.  Med. 
Jour.,"  Jan.  23,  1909).  The  same  author  points  out  that  the  poison  used  is 
generaUy  complex  and  contains  also  various  animal  and  vegetable  ingredients, 
particularly  decomposed  organic  matter,  plant  juice  containing  strychnin,  and 
soil  contaminated  with  tetanus  organisms. 

Treatment. — An  arrow  is  always  septic  and  should  be  extracted.  Some- 
times when  it  has  been  buried  deeply  in  a  part  it  should  be  pushed  across  and 
extracted  through  a  counteropening  after  the  protruding  shaft  has  been  cut 
off.  An  arrow-head  cannot  be  pulled  out  by  the  shaft.  The  barbs  on  the  head 
catch  and  prevent  extraction  and  the  neck  of  the  shaft  is  apt  to  break.     The 


Gunshot- wounds  275 

tissues  should  be  freely  divided  down  to  the  head  of  the  arrow  and  on  each  side 
of  it,  when  it  can  usually  be  withdra\\Ti  by  forceps.  If  imbedded  in  bone,  the 
head  must  be  gently  rocked  from  side  to  side  to  loosen  it,  ever\-  care  being  taken 
to  avoid  breaking  a  stone  or  bending  an  iron  arrow  head.  If  an  arrow  has 
penetrated  the  abdomen,  a  laparotomy  should  be  performed.  If  it  has  entered 
a  joint,  the  joint  should  be  freely  opened.  If  it  has  entered  the  chest,  one  or 
more  ribs  will  require  resection.  If  it  has  entered  the  skull,  trephining  is 
indicated.  -\ny  bleeding  vessels  axe  to  be  caught  and  tied.  The  track  of  the 
arrow  should  be  carefully  disinfected  and  drainage  should  be  secured.  It  is 
particularly  important  to  remove  a  poisoned  arrow  at  once.  After  remo\"ing  a 
poisoned  arrow,  if  the  nature  of  the  poison  is  known,  proper  treatment  should 
be  applied  to  antidote  the  poison.  The  French  Colonial  surgeons  fill  wounds 
inflicted  by  poisoned  arrows  with  tannic  acid.  The  same  custom  is  followed  bv 
Enghsh  surgeons  in  West  Africa  (^Allan  C.  Parsons,  in  "Brit.  ^led.  Jour.,"  Jan. 
23,  1909). 

Giinshot-wounds  are  contused  or  contused-lacerated  wounds  infhcted 
by  materials  projected  by  explosives.  A  bit  of  rock  or  a  crowbar  hurled  by 
d^Tiamite  inflicts  a  gimshot-wound,  as  does  a  shell-fragment,  a  pistol-ball, 
small  birdshot,  a  rifle  bullet,  pieces  of  a  hand  grenade,  a  flying  cap,  a  piece  of 
■wadding,  grains  of  powder,  a  buckshot,  a  fragment  of  metal  broken  off  a  shell, 
grapeshot  and  canister,  or  a  cannon-ball.  Injuries  by  shell-fragments,  portions 
of  a  bursted  boiler,  pieces  of  masonry-  or  wood,  are  either  lacerated  or  pimctured 
wounds,  and  need  no  special  consideration  here.  In  this  article  we  treat  of 
injuries  caused  by  bullets  and  shot,  that  is,  by  missiles  propelled  from  firearms. 

Firearms  are  instruments  by  means  of  which  missiles  are  projected  to  a 
distance  by  the  expanding  gases  of  burning  gunpowder.  There  are  many 
different  sorts  of  firearms.  Artillery-  includes  various  sizes  of  guns  upon  sup- 
ports, from  the  great  12-inch  guns  of  a  battleship,  which  fire  shells  weighing 
850  poimds.  to  machine-guns,  which  fire  ordinar}-  rifle  bullets.  Field  artiller\- 
uses  httle  but  shrapnel-shells.  Such  a  shell  is  a  case  of  steel,  cyhndroconoidal 
in  shape,  containing  a  number  of  bullets  and  a  charge  of  explosive,  the  shell 
exploding  by  means  of  a  time-fuse.  Canister  is  an  iron  casing  containing 
bullets  vmassociated  with  an  explosive  discharge  within  the  casing.  The 
canister  breaks  when  fired,  and  the  balls  separate  over  a  large  area.  It  is 
used  only  at  close  range — that  is,  300  or  400  yards. 

Among  small  arms  mav  be  mentioned  muskets,  revolvers,  shotguns,  and 
rifles.  Woimds  from  the  old-time  musket  ball  are  now  never  met  with  except 
in  warfare  against  barbarous  tribes.  The  musket  has  a  smooth  bore  and 
fires  roimd  bifllets  of  soft  lead.  This  round,  soft  bullet,  being  large,  mo\'ing 
with  comparative  slowness,  and  flattening  easily,  is  ver}'  liable  to  glance,  to 
deform,  and  to  lodge.  When  a  musket  is  fired  at  close  range  and  the  bullet 
strikes  the  tissue  at  a  right  angle,  it  produces  a  punched-out  entrance  woimd. 
If  the  velocity  is  low  or  the  impact  is  not  at  a  right  angle  to  the  tissues,  the  en- 
trance wound  may  'Tae  formed  of  triangular  flaps."  the  comers  of  which  are 
inverted.^  The  entrance  woimd  is  surroimded  by  a  bruised  area.  The  track 
of  the  bullet  is  larger  than  the  bullet,  and  is  so  badly  contused  and  lacerated 
that  some  tissue  is  de\-italized :  and  the  shaft  of  a  bone,  if  struck,  is  likely  to 
be  spKntered.  If  the  ball  emerges,  the  wound  of  exit  is  larger  than  the  bullet, 
and  forms  triangular  and  everted  flaps.  Healing  by  first  intention  seldom 
occurs  in  such  wounds.  The  old  smooth-bore  musket,  firing  a  roimd  bullet, 
has  been  displaced  by  the  rifle  propelling  a  conical  projectile. 

In  the  firearms  of  ciAiHans,  as  a  rule,  the  bullets  are  made  of  lead,  hardened 
and  shaped  by  compression  or  hardened  by  an  admixture  with  tin.  The 
conical  or  cylindroconoidal  rifle  bullet  has  much  greater  velocity  and  pene- 
^  "Wounds  in  War,'"  bv  Surseon  Col.  W.  F.  Stevenson. 


276 


Contusions  and  Wounds 


trating  power  than  the  round  bullet.  Hence,  it  is  more  liable  to  penetrate  and 
less  likely  to  deflect  and  to  lodge.  The  tissues  in  the  track  of  this  bullet  are  less 
devitalized  than  in  the  track  of  the  round  bullet.  The  cutaneous  surface  is  not 
so  much  contused.  The  wound  of  entrance  is  about  the  size  of  the  bullet,  and  is 
punched  out  or  inverted;  and  the  wound  of  exit  is  larger  than  that  of  entrance 
and  is  often  everted.  The  bones  are  more  seriously  comminuted  than  by  the 
roimd  bullet,  and  osseous  fragments  may  be  driven  widely  into  the  tissues.  In 
fact,  "an  explosive  effect"  may  occur  at  close  range.  Delorme  lays  it  down  as 
a  rule  that  comminution  of  bone  makes  the  wound  of  exit  larger;  and  he 
asserts  that  a  wound  of  exit  larger  in  diameter  than  the  thimib  means  com- 
minution of  bone. 

Gunshot-wounds  Seen  in  Civil  Life. — Wounds  are  occasionally  inflicted  by  the 
sporting  rifle  or  the  shotgun,  and  frequently  by  blank  cartridges;  but  the  vast 
majority  of  such  woimds  seen  by  the  civilian  surgeon  are  inflicted  by  the  revolver. 


Fig.  120. — Lodged  shot. 

Wounds  from  the  Sporting  Rifle. — In  the  sporting  rifle  a  large  charge  of 
powder  is  employed.  Some  sporting  rifle  bullets  have  no  hard  jackets.  Others 
have  an  incomplete  hard  jacket.  In  a  bullet  with  a  partial  hard  jacket  the 
"nose"  of  the  bullet  is  exposed  and  soft.  The  buUets  are  usually  larger  than 
those  used  in  the  military  rifle.  Such  bullets  deform  in  the  tissues,  and  inflict 
dreadful,  tearing  wounds.  If  a  bullet  of  a  sporting  rifle  strikes  a  Hmb,  ampu- 
tation may  be  reqmred.  If  it  strikes  the  head  or  trunk,  it  will  almost  certainly 
produce  a  fatal  wound. 

Wounds  from  the  Shotgun. — The  degree  of  injury  is  in  direct  relation  to  the 
adjacency  of  the  wounded  individual  to  the  gun,  when  the  discharge  takes 
place,  to  the  size  and  number  of  the  shot,  and  to  the  charge  of  powder.  Single 
shot  may  bruise  the  surface  and  fail  to  enter  the  tissues  or  may  enter  the  tissues. 


Gunshot- wounds  277 

When  many  shot  enter  together  they  strike  as  a  solid  body.  Single  shot  are 
usually  deflected  from  vessels  and  nerves,  and  seldom  lodge  in  bone,  but, 
rather,  flatten  on  the  bone  surface.  Even  a  single  shot  lodged  in  the  eyeball 
is  apt  to  produce  violent  inflammation  which  may  destroy  the  eye.  Numerous 
shot  entering  together  at  close  range  produce  extensive  contusions  of  the  surface 
and  fearful  lacerations  of  the  tissues,  and  often  inflict  irreparable  damage. 
Bone  may  be  fractured  and  bits  of  clothing  or  other  foreign  bodies  may  be 
carried  into  the  wound  with  the  shot.  At  close  range  toes  or  fingers  may  be 
blown  off,  an  eye  may  be  blown  out,  or  portions  of  tendon  or  muscle  may 
be  shot  away.  At  close  range  dreadful  subcutaneous  lacerations  are  caused  by 
the  gases.  Primary  hemorrhage  is  seldom  severe  because  the  wound  is  lacer- 
ated; but  secondary  hemorrhage  is  to  be  feared,  and  serious  infection  usually 
follows  such  injuries.  Buckshot  at  close  range  inflict  grave  or  dreadful 
woimds.  The  United  States  Army  is  supplied  with  a  cartridge  for  use  in  riots. 
This  cartridge  contains  two  shot,  each  about  the  size  of  a  buckshot. 

The  Treatment  of  Shotgun  Wounds. — If  the  shot  be  scattered  and  lodged 
it  is  seldom  necessary  to  remove  them.  As  a  rule,  such  cases  require  only 
cleansing  of  the  skin  and  aseptic  dressings.  If  shot  lodge  in  a  joint,  they 
impair  function;  if  in  the  face,  they  produce  deformity.  In  both  of  these 
cases  removal  is  necessary.  When  a  shot  lodges  in  the  eye  it  usually,  but  not 
always,  causes  blindness.  If  the  eye  is  gravely  damaged  it  must  be  enucleated. 
In  serious  lacerations  produced  by  shot  at  close  range  the  hopelessly  damaged 
tissue  must  be  cut  away,  hemorrhage  must  be  arrested,  foreign  bodies  must  be 
removed  (though  no  protracted  search  is  either  necessary  or  desirable  to  re- 
move grains  of  shot),  the  wound  must  be  disinfected  as  well  as  possible,  and 
free  drainage  must  be  employed.  It  is  wise  to  give  a  prophylactic  dose  of 
anti tetanic  serum. 

Blank-cartridge  Injuries. — These  injuries  can  occur  only  at  close  range. 
They  consist  of  burns  and  lacerations,  frequently  a  wad  or  a  bit  of  clothing 
lodge  in  the  tissues,  and  tetanus  is  a  not  unusual  sequence.  The  explosive 
used  in  the  toy  pistol  is  a  fulminate,  and  bits  of  the  envelope  of  the  explosive 
may  be  driven  quite  deep  into  the  tissues.  There  is  considerable  danger  of 
tetanus  after  injuries  inflicted  by  the  toy  pistol.  What  in  the  United  States 
is  called  "Fourth  of  July  tetanus"  is  tetanus  following  such  an  injury,  the  small 
boy  being  prone  to  employ  a  toy  pistol  to  contribute  noise  to  the  celebration 
of  the  nation's  birthday  (see  page  203). 

Blank-cartridge  wounds  and  toy-pistol  wounds  are  treated  by  cleansing 
the  skin,  enlarging  the  wound,  removing  foreign  bodies,  disinfecting,  and 
draining.     A  prophylactic  dose  of  antitetanus  serum  should  always  be  given. 

Wounds  Inflicted  by  the  Revolver  Bullet. — The  revolver  varies  in  caliber 
from  .22  to  .45.  Whereas  it  is  true  that  certain  military  revolvers  of  the  auto- 
matic type  fire  a  hard-jacketed  rifle  bullet,  the  revolvers  of  civil  life  propel 
cylindroconoidal  unjacketed  bullets  at  a  velocity  of  about  700  feet  a  second. 
A  revolver  bullet  of  the  civilian's  weapon  never  produces  an  explosive  effect. 
It  is  liable  to  deform  in  the  tissues,  is  often  deflected  from  bone  or  tendon,  and 
is  very  apt  to  lodge.  The  shape  of  the  bullet,  the  velocity  with  which  it  is  pro- 
pelled and  with  which  it  rotates,  and  its  hardness  make  it  unlikely  that  at  any 
near  range  the  bullet  will  merely  contuse,  and  not  enter,  the  skin.  Unless  strik- 
ing at  an  angle  to  the  perpendicular,  it  will  almost  always  enter.  In  some 
cases,  however,  a  pistol  bullet,  like  a  spent  rifle  biillet,  may  fail  to  enter  the 
tissues.  It  then  grazes  the  surface  and  inflicts  a  brush  burn  or  simply  contuses 
the  part.  Sometimes  it  perforates,  more  often  it  lodges.  Whereas  it  may  be 
deflected,  it  comparatively  seldom  is;  and  it  often  deforms,  though  it  does 
not  do  so  to  anything  like  the  degree  that  the  soft,  round  bullet  does.  If  a 
buUet  enters  the  tissues,  a  cavity,  or  an  organ,  and  lodges  there,  it  causes  a 


278  Contusions  and  Wounds 

penetrating  wound.  If  it  enters  and  emerges  it  causes  a  perforating  wound. 
The  bullet  may  not  enter  alone,  but  may  carry  with  it  bits  of  clothing  or  other 
foreign  bodies,  though  this  complication  is  much  rarer  in  injury  with  the  conical 
bullet  than  with  the  round  ball.  On  one  occasion  I  removed  a  piece  of  coat 
from  the  interior  of  the  lung,  to  which  it  had  been  carried  by  a  pistol  bullet.  In 
another  instance  I  removed  a  piece  of  shirt  from  the  interior  of  the  abdomen,  to 
which  it  had  been  carried  by  a  similar  bullet.  A  revolver  bullet  may  break 
bone,  though  it  is  not  nearly  so  liable  to  do  so  as  a  rifle  bullet. 

In  studying  a  gunshot-wound  one  must  consider  the  womtd  of  entrance, 
the  tissue  track,  and,  if  the  bullet  has  emerged,  the  wound  of  exit.  It  is  usually 
stated  that  if  a  revolver  biillet  fired  from  a  distance  of  10  feet  or  more  from 
the  person  struck  hits  the  skin  at  a  right  angle,  it  makes  a  wound  of  entrance 
that  is  smaller  than  the  bullet  because  the  skin  is  elastic.  It  is  a  certain  fact 
that  one  cannot  assert  from  a  mere  inspection  of  the  wound  of  entrance  what 
size  bullet  a  man  was  struck  with.  A  .22  often  leaves  a  most  trivial  opening. 
Careful  separation  of  the  margins  enables  us  to  measure  a  wound  of  entrance, 
and  if  this  is  done  it  will  be  found  that  a  wound  of  entrance  is  never  smaller 
than  the  bullet.  (See  Wm.  S.  Wadsworth,  in  "International  CHnics,"  Vol.  IV, 
Twentieth  Series.)  The  shape  of  the  wound  is  somewhat,  but  not  regularly, 
circular,  because  a  certain  amount  of  tissue  is  destroyed.  The  margins 
are  also  somewhat  depressed.  It  has  a  punched-out  look,  and  the  edges, 
as  Draper  tells  us,  are  frayed  in  appearance  ("Text-book  of  Legal  Medicine"). 
The  edges  of  the  woimd  look  thickened  and  are  contused,  this  discoloration 
being  noted  for  a  distance  of  i  inch  or  even  2  inches  from  the  margin  of  the 
wound.  The  skin  surface  is  distinctly  blackened;  but  unless  the  weapon  were 
fired  at  very  close  range  this  is  not  due  to  burning,  but  rather  to  staining  with 
a  mixture  of  burnt  gunpowder  and  the  grease  of  the  outer  surface  of  the  bullet. 
The  appearance  of  the  wound  of  entrance  will  be  very  different  if  the  bullet 
strikes  the  surface  at  an  acute  instead  of  a  right  angle.  Then  the  wound  will 
not  be  round,  but  oval  or,  perhaps,  linear.  When  a  bullet  is  fired  very  near  to 
the  surface  of  the  body  the  hair  of  the  skin  will  be  burned,  there  will  be  some 
staining  with  gunpowder  around  the  wound,  and  powder-grains  will  be  found 
lodged  in  the  skin.  The  burning  is  due  to  hot  gases  and  with  the  gases  come 
powder-grains.  Whether  the  weapon  inflicting  the  wound  was  close  or  dis- 
tant there  is  bruising  of  the  skin,  but  when  the  powder  is  found  in  the  tissues 
or  on  the  surface  and  when  the  surface  is  scorched  the  weapon  must  have  been 
close  at  the  time  of  discharge.  Hot  gases  singe  hairs,  clothing,  or  the  skin 
itself.  The  nearer  the  skin  the  weapon  was  held  the  more  severe  the  burning. 
Wordsworth  says,  "all  gas  phenomena  require  very  close  range,  usually  within  18 
inches."  What  is  called  the  smudge  is  due  to  "the  debris  and  smoke  from  the 
powder"  and  takes  place  at  a  range  of  less  than  18  inches  (Wadsworth,  in  "Inter- 
national Climes,"  Vol.  IV,  Thirtieth  Series) .  The  absence  of  embedded  powder, 
however,  does  not  prove  that  the  shot  was  not  close,  because  the  weapon  em- 
ployed might  have  been  one  using  smokeless  powder.  When  smokeless  powder 
was  used  the  burn  is  the  same  as  from  black  powder,  the  smudge  is  apt  to  be  of 
an  orange  color,  tattooing  is  rarer,  and  when  it  does  occur  shows  fewer  grains. 
If  the  smokeless  powder  contains  graphite  it  produces  a  smudge.  If  the 
weapon  were  fired  at  close  range  the  skin  may  have  been  burnt  by  burning  gases 
or  the  clothing  may  have  been  burnt  and  the  skin  scorched  by  the  burning  cloth- 
ing. Staining  of  the  skin  with  powder  can  be  washed  off,  but  when  the  skin 
has  been  burnt  it  is  dry  like  parchment.  When  unexploded  powder-grains  are 
lodged  in  the  skin  the  resulting  condition  is  spoken  of  as  tattooing,  and  this 
always  means  a  very  close  shot.  Powder-grains  may  cause  severe  wounds.  It 
has  been  held  by  some  that  powder-grains  are  never  found  in  the  skin  unless  the 
bullet  has  been  fired  from  a  distance  of  less  than  3  feet,  but  this  is  too  arbitrary 


Gunshot-wounds  279 

a  statement  to  make  in  a  court  of  law.  In  any  medicolegal  case  experiments 
should  be  made  with  a  weapon  and  ammunition  similar  to  those  used  in 
inflicting  the  wound  in  order  to  determine  the  real  facts  of  the  case.  Draper 
("Text-book  of  Legal  Medicine")  makes  the  following  important  statement 
relating  to  burns  of  the  skin:  "If  the  weapon  is  held  in  the  hand  in  the  ordinary 
way,  hammer  and  sight  on  the  barrel  directed  upward,  the  wound  in  the  skin 
will  show,  immediately  above  its  orifice,  a  brand  or  scorching  caused  by  a  slight 
recoil  in  the  act  of  firing.  The  location  of  this  brand  will  change  as  the  posi- 
tion of  the  hammer  is  changed.  If  the  weapon  is  held  in  a  vise  and  fired 
this  relation  of  the  brand  to  the  wound  is  obliterated.  This  observation,  first 
made  and  published  by  Dr.  D.  B.  N.  Fish  in  1883,  supplies  an  accurate  index 
of  the  position  in  which  the  pistol  is  held  in  firing."  Wadsworth  is  of  the 
opinion  that  the  "flip"  is  usually  but  not  always  toward  the  hammer  side. 
It  is  modified  "by  the  grip  on  the  handle  at  the  instant  of  discharge."  If 
the  muzzle  of  a  pistol  is  pressed  lightly  against  the  skin  gases  enter  with 
the  bullet  and  "burst  the  skin  outward,  giving  a  large  ragged  wound,  which 
is  not  a  wound  of  entrance,  though  always  called  so,  but  a  wound  of  exit 
of  the  gas"  (Wadsworth,  in  "International  Clinics,"  Vol.  IV,  Thirtieth 
Series).  If  the  muzzle  is  held  firmly  against  the  surface  the  gases  cause 
a  horrible  wound  under  the  skin.  This  condition  is  not  the  same  thing  as 
the  explosive  effect  of  a  bullet.  In  passing  through  the  tissues  the  revolver 
bullet  makes  a  contused-lacerated  wound,  and  we  may  find  along  this  wound 
powder-grains  (if  the  bullet  has  been  fired  at  close  range)  and  portions  of 
clothing,  pieces  of  the  buhet  itself,  or  perhaps  of  bone.  A  bullet  may  pass 
directly  through  both  walls  of  the  skull,  traversing  the  brain  in  its  passage. 
It  may  pass  through  a  wall  of  the  skull  and  lodge  within  the  cavity  of 
the  cranium.  In  some  cases  it  makes  an  opening  of  entrance  that  is  smallest 
on  the  external  surface  of  the  bone  and  largest  on  the  inner  table.  In  other 
cases  it  makes  extensive  comminuted  fractures.  When  a  bullet  tracks  its 
way  through  a  muscle  it  makes  a  jagged,  contused,  lacerated  wound.  It 
does  the  same  in  the  brain.  In  both  cases  the  track  of  the  bullet  is  larger 
than  the  biillet,  and  the  tissue  for  a  considerable  distance  wide  of  the  track 
is  contused  or  actually  destroyed.  In  passing  through  an  aponeurosis  or  a 
serous  membrane  the  bullet  may  make  a  round  orifice  or  a  slit-like  tear.  Of 
course,  the  nature  of  the  wound  in  the  tissues  will  be  greatly  affected  if  the  bul- 
let is  deformed  by  having  struck  bone,  or  if  it  carries  bits  of  bone  along  with  it. 
The  deflection  of  a  bullet  from  an  aponeurosis,  fascia,  or  bone  so  alters  its 
course  that  the  missile  becomes  very  difficult  to  locate  and  remove.  In  some 
cases  a  bullet  has  entered  near  the  front  of  the  body  and  passed  around  the 
waU  of  the  chest  until  it  has  almost  reached  its  point  of  entrance,  or  else  has 
lodged  or  emerged  at  some  point  of  this  course — in  either  case  constituting  what 
is  known  as  a  contour  wound.  Contour  wounds  are  not  infrequently  seen  upon 
the  head.  For  instance,  a  bullet  may  strike  the  frontal  region,  pass  around  un- 
der the  scalp,  and  lodge  in  or  emerge  from  the  occipital  region. 

When  the  biillet  does  not  lodge,  but  emerges  from  the  body,  the  wound  of 
exit  must  be  studied.  If  an  undeformed  bullet  passes  straight  through  the 
body  it  makes  a  wound  of  exit  that  is  somewhat  larger  than  the  bullet.  It  has 
a  torn-out  appearance,  but  without  distinct  destruction  of  tissue,  and  exhibits 
an  irregular  outline  and  eversion  of  the  edges.  The  margins  of  such  a  wound 
are  bruised,  but  are  never  scorched  and  never  show  powder-grains.  If  a  bullet 
has  been  deformed  by  hitting  bone,  or  if  it  has  driven  bone  before  it,  a  very 
large  lacerated  wound  of  exit  may  be  formed.  It  is  unportant  to  remember 
that  the  presence  of  a  nimiber  of  wounds  on  the  surface  of  the  body  does  not 
in  itself  prove  that  a  number  of  different  bullets  have  been  fired,  for  in  certain 
circumstances  one  bullet  may  make  several  wounds.     A  few  years  ago  I  saw 


28o  Contusions  and  Wounds 

a  case  in  which  a  bullet  had  penetrated  the  right  hand  and  the  right  thigh, 
and  had  lodged  in  the  left  thigh.  There  were  three  wounds  of  entrance 
and  two  wounds  of  exit.  Many  very  extraordinary  cases  of  this  sort  have  been 
reported. 

Sjonptoms  of  a  Gunshot-wound. — Hemorrhage  is  often  considerable, 
but  ceases  spontaneously  imless  a  large  vessel  has  been  divided.  If  hemor- 
rhage is  profuse  the  constitutional  symptoms  of  hemorrhage  exist  (see  page 
436).  These  symptoms  are  of  great  importance  in  abdominal  wounds.  A  pistol 
baU  seldom  causes  severe  primary  hemorrhage,  because  it  will  not  often  pene- 
trate a  large  artery.  It  is  apt  to  push  aside  a  vessel  and  secondary  hemorrhage 
is  not  unusual.  Even  if  a  large  vessel  is  wounded  and  a  succession  of  violent 
hemorrhages  occur,  a  man  may  Hve  for  several  days.  Secondary  hemorrhage 
may  foUow  a  gunshot-wound  because  of  contusion  of  vessels  or  of  infection. 

Pain  is  often  not  noticed  at  first.  The  injured  individual,  if  greatly  pre- 
occupied or  excited,  may  not  know  that  he  has  been  struck  by  a  bullet. 
There  may  be  only  a  feeling  of  numbness,  but  usually  there  is  a  dull  or  stinging 
pain.  If  a  large  nerve  has  been  injured  there  may  be  violent  pain.  Even 
trivial  gunshot-wounds  frequently  produce  profound  shock,  and  yet  it  may 
happen  that  severe  wounds  may  be  accompanied  by  but  slight  shock.  In 
most  gunshot-wounds  of  the  brain,  abdomen,  and  spinal  cord  the  shock  is 
very  great. 

General  Considerations  as  to  Treatment. — The  dangers  are  shock,  hemor- 
rhage, and  infection.  Bullets  are  not  aseptic  when  they  enter  a  part,  but  a 
bullet  usually  carries  few  bacteria,  and  if  infection  is  not  inserted  in  the  track 
of  the  ball  the  wound  will  in  most  instances  heal  kindly.  A  stationary  bullet, 
when  there  is  no  infection,  is  usually  let  alone.  "The  fate  of  a  wounded  man 
is  in  the  hands  of  the  surgeon  who  first  attends  him"  (Nussbamn).  The 
danger  of  a  wound  depends  upon  the  size  and  velocity  of  the  bullet,  the 
part  struck,  "and  the  degree  of  asepsis  observed  during  the  first  examina- 
tion and  dressing"  (De  Nancrede).  The  rules  of  treatment  are:  bring  about 
reaction,  arrest  hemorrhage,  preserve  asepsis,  and,  in  some  cases,  remove 
the  ball.  Always  notice  if  a  wound  of  exit  exists.  It  is  a  good  plan, 
when  endeavoring  to  determine  the  extent  of  injury,  to  put  the  parts  in  the 
position  they  were  in  when  the  injury  was  inflicted.  We  should  try  to  ascer- 
tain the  size  and  nature  of  the  weapon,  and  the  range  at  which  it  was  fired. 
Examine  the  clothing  to  see  if  any  fragments  are  missing  and  could  have  been 
carried  in.  Such  fragments  render  sepsis  almost  inevitable.  The  surgeon  must 
not  feel  it  his  duty  to  probe  in  all  cases.  In  many  cases  it  is  better  not  to  probe 
at  aU.  Never  probe  when  there  is  a  wound  of  entrance  and  a  woimd  of  exit. 
Explore  for  and  remove  the  ball  when  there  is  infection  or  when  sm-e  that 
it  has  carried  with  it  foreign  bodies;  or  when  its  presence  at  the  point  of  lodg- 
ment interferes  with  repair;  or  when  it  is  in  or  near  a  vital  region  (as  the  brain). 
We  must  locate  the  ball  when  it  is  necessary  to  know  its  position  in  order  to 
determine  the  question  of  amputation  or  resection.  If  the  wound  is  large 
enough  the  finger  is  the  best  probe.  The  x-rays  render  the  use  of  the  probe 
seldom  necessary. 

Fluhrer's  aluminum  probe  is  a  valuable  instrimient  (Fig.  121).  It  is 
employed  especially  in  brain-woimds,  and  is  allowed  to  sink  into  the  track  of 
the  ball  by  the  influence  of  gravity  after  the  part  has  been  placed  in  a  proper 
position.  If  a  lead  bullet  is  deeply  embedded  it  is  possible  to  distinguish  the 
hard  projectile  from  a  bone  by  inserting  the  asepticized  stem  of  a  clay  pipe,  a 
bit  of  pine  wood,  or  Nelaton's  porcelain-headed  probe  (Fig.  122).  On  any 
one  of  these  appHances  lead  wiU  make  a  black  mark.  No  such  test  can 
be  appHed  to  a  military  buUet,  for  this  has  a  hard  metal  jacket,  and  will  not 
make  a  black  mark  on  a  white  substance. 


General  Considerations  as  to  Treatment 


281 


Though  Nekton's  probe  will  not  show  the  difference  between  a  hard-jacketed 
projectile  and  bone,  it  is  a  valuable  instrument  to  follow  the  track  of  any  bullet 
womid.  The  porcelain  head  ought  to  be  larger  than  it  is  usually  made;  in  fact, 
it  should  be  nearly  the  size  of  the  bullet  (Senn)  (Fig.  123). 

In  passing  a  probe  use  no  more  force  than  in  passing  a  catheter. 

The  induction  balance  of  Graham  Bell  has  been  employed  to  determine 
the  situation  of  a  bullet.  The  bullet  may  be  located  by  Girdner's  telephonic 
probe.  In  order  to  construct  this  instrument  take  a  telephone  receiver,  fasten 
one  of  the  wires  to  a  metal  plate  and  the  other  one  to  a  metaUic  probe.  Mois- 
ten a  portion  of  the  patient's  body  and  place  the  metal  plate  in  contact  -u-ith  it. 
The  surgeon  places  the  receiver  to  his  ear  and  inserts  the  probe  into  the  wound. 


Fluiirer's  aluminum  gra\'itation  probe  (natural  size,  except  the  length,  which  is  12  inches). 


Fig.  122. — Xela ton's  bullet-probe. 


Semi's  bullet-probe. 


If  the  probe  strikes  metal,  a  click  is  heard  with  distinctness.  A  bullet  may 
be  located  by  Lilienthars  probe.  This_  apparatus  consists  of  a  mouth-piece, 
two  insulated  copper  -^ires,  and  a  probe.  The  mouth-piece  is  composed  of 
two  plates,  one  of  copper  and  one  of  zinc,  which  are  applied  to  the  sides  of  the 
tongue.  xA.n  insulated  M"ire  runs  from  each  plate  and  into  the  metal  probe. 
The  tip  of  the  probe  is  composed  of  two  or  four  pieces  of  metal,  is  separated 
from  the  shank  by  a  washer  of  rubber,  and  is  attached  to  the  "wires.  The 
operator  closes  the  teeth  upon  the  mouth-piece  and  inserts  the  probe  into  the 
woimd.  If  the  probe  touches  the  bullet  a  distinct  and  continuous  metallic 
taste  is  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fl Horoscope  or  take  a 
skiagraph.     In  order  to  locate  it  accurately  ^dew  it  through  a  series  of  squares, 


124. — BuUet-forceps. 


insert  guide-pins,  or,  better  than  either  of  these  plans,  employ  Sweet's  appa- 
ratus. Bullets  are  readily  seen  by  the  fluoroscope  in  the  superficial  soft  parts, 
and  are  discovered  in  deeper  structures  (bone,  abdomen,  limg,  brain,  etc.) 
by  taking  skiagraphs. 

In  extracting  the  ball  use  ver\'  strong  forceps  (Fig.  124).  The  old  Amer- 
ican buUet-forceps  is  useless  for  the  extraction  of  the  hard-jacketed  ball,  as  the 
points  will  not  penetrate  and  the  instrimient  vnR  not  hold. 

If  hemorrhage  is  severe  in  a  gimshot-woimd,  enlarge  the  woimd,  find  the 


282  Contusions  and  Wounds 

bleeding  vessel,  and  tie  it.  Before  handling  a  gunshot-wound  asepticize  the 
parts  about  it  and  irrigate  the  wound  with  hot  sterile  salt  solution.  In  some 
situations  a  wound  should  be  drained  with  a  short  tube  or  a  bit  of  iodoform 
gauze;  in  other  regions  this  is  unnecessary.  The  dressing  should  be  anti- 
septic. Primary  union  rarely  takes  place  after  a  wound  inflicted  by  a  pistol- 
ball  or  an  ordinary  rifle-ball,  because  of  the  inevitable  necrosis  of  damaged 
tissue  in  the  track  of  the  ball,  but  in  some  cases  it  can  be  obtained.  Primary 
union  is  frequent  after  injury  by  the  small  hard-jacketed  modern  army  pro- 
jectile. Healing  begins  in  the  depths  of  the  wound  and  extends  toward 
the  wound  of  entrance,  or,  if  there  be  also  a  wound  of  exit,  toward  both. 
Radical  operations  may  be  demanded:  laparatomy,  trephining,  rib-resection, 
joint-resection,  or  amputation. 

Excision  may  be  required  when  there  is  great  comminution.  Amputation 
is  sometimes  demanded  because  of  severe  injury  to  the  soft  parts  (as  by  a  shell- 
fragment),  great  splintering  of  a  bone,  grievous  injury  of  a  joint,  damage 
to  the  chief  vessels  or  nerves,  or  the  destruction  of  a  considerable  part  of  a 
limb.  Perform  a  primary  amputation  if  possible,  and  make  the  flaps  through 
tissue  that  will  not  slough.  In  civil  practice,  with  careful  antisepsis,  more 
questionable  tissue  can  be  admitted  into  a  flap  than  in  military  practice, 
where  transportation  will  become  necessary  and  antisepsis  may  be  imperfect 
or  wanting.  It  has  been  shown  in  recent  years  that  even  when  a  large  joint 
has  been  perforated  by  a  small  hard-jacketed  projectile,  amputation  or  resec- 
tion is  rarely  required  if  the  wound  was  treated  aseptically  from  the  begin- 
ning, but  this  is  scarcely  true  of  the  revolver  bullet. 

Wounds  by  Grenades. — In  the  Russo-Japanese  War  grenades  were  largely 
used  at  close  range.  At  close  range  they  are  much  more  destructive  than 
rifle  bullets  because  they  explode  and  hurl  fragments  all  about.  The  grenade 
may  be  cast  by  the  hand,  but  it  can  be  projected  to  a  much  greater  distance 
"when  fixed  to  and  fired  from  the  muzzle  of  a  rifle  by  the  discharge  of  a  small 
blank  cartridge"  (Lt.-Col.  Borden,  in  "Keen's  Surgery,"  vol.  vi).  Grenade 
fragments  produce  nasty  lacerated  and  usually  infected  wounds. 

Wounds  by  Cannon-balls. — A  solid  shot  was  apt  to  kiU  a  man  instantly, 
tear  off  a  limb  or  lacerate  it  extensively.  Strange  cases  have  been  reported  in 
which  balls  weighing  5  and  6  pounds  were  embedded  in  the  tissues.  In  some 
cases  of  injury  by  spent  baUs  the  bone  is  destroyed  and  the  muscles  disor- 
ganized while  the  skin  is  intact.  At  the  present  time  the  projectiles  usuaUy  fired 
in  war  by  cannon  are  shells.  A  shell  is  a  metal  case  containing  an  explosive 
charge  and  perhaps  also  buUets. 

Wounds  by  Shells. — Sometimes  a  sheU  fails  to  explode  and  may  then  pro- 
duce fearful  mutilation  or  tear  off  a  limb.  Bursting  sheUs  may  cause  "injury 
by  their  concussion-blast,  their  flame  may  produce  extensive  burns,  and  their 
fumes  may  be  overpowering.  Actual  wounds  are  inflicted  by  the  fragments 
and  by  splinters,  to  which  has  been  communicated  the  natin-e  of  missiles" 
("Naval  Surgery,"  by  Surgeon-General  Stokes,  in  "American  Practice  of 
Surgery").  The  fragments  vary  in  size,  one  man  may  be  struck  by  many 
of  them,  wounds  may  be  deep  or  superficial,  may  be  horrible  pulpifications, 
grave  lacerations,  or  slight  tears.  Fragments  are  usually  embedded,  but  may 
not  be  deep.     Fractures  are  common.     AU  shell  wounds  suppurate. 

An  ordinary  shell  contains  only  an  exploding  charge  and  injury  is  inflicted 
by  the  fragments  of  the  exploded  sheU.  Some  shells  explode  by  a  time-fuse, 
others  by  percussion  when  the  shell  strikes  a  hard  substance.  The  shrapnel 
shell  is  filled  with  biillets. 

Wounds  in  War  Inflicted  by  Rifle-bullets. — During  the  last  few  years 
frequent  and  notable  improvements  have  been  made  in  the  military  rifle. 
The  range  and  rapidity  of  firing  have  been  vastly  increased,  the  velocity  of  the 


Wounds  in  War  Inflicted  by  Rifle-bullets  283 

projectile  and  its  penetrating  power  have  been  enormously  added  to,  and  the 
trajectory  has  been  decidedly  lowered.  Hence,  the  zone  dangerous  to  an 
enemy  has  been  lengthened.  In  order  to  accomplish  these  things  changes  have 
been  made  in  the  gun,  the  explosive,  and  the  projectile.  It  is  a  far  cry  from 
the  old  Brown  Bess,  of  song  and  story,  to  the  modern  Lee-Enfield  of  the  British 
Army,  or  the  Springfield  of  the  United  States  Army.  All  modern  military  rifles 
are  of  small  caliber,  that  is,  less  than  .35  inch.  The  Springfield  rifles  of  the 
days  of  the  war  between  the  States  had  a  caliber  of  .45  inch.  The  old  Spring- 
field projected  a  bullet  at  an  initial  or  muzzle  velocity  of  1300  feet  a  second; 
whereas  the  modern  rifle  sends  a  projectile  on  its  way  with  an  initial  velocity  of 
2700  feet  a  second,  the  bullet  rotating  on  its  long  axis  more  than  2500  times 
during  the  first  second  of  translation.  At  a  range  of  1000  yards  it  will  pene- 
trate nearly  13  inches  of  pine  wood.  At  a  range  of  100  yards  it  "will  penetrate 
a-vSteel  plate  .3843  inch  thick"  (Borden,  in  "Keen's  Surgery,"  vol.  vi).  Up 
to' 5000  yards  a  modern  rifle  can  inflict  a  fatal  wound,  and  it  can  be  used  point- 
blank  at  a  range  of  from  500  to  over  700  yards.  With  the  present  gun  of  the 
United  States  Army  the  point-blank  zone  of  danger  is  about  718  yards.  A 
bullet  from  a  modern  military  rifle,  even  after  having  struck  some  solid,  hard 
body,  may  grievously  injure  a  man  by  ricochet.  With  a  magazine  rifle,  at 
2500  yards,  from  5  to  10  per  cent,  of  the  balls  will  ricochet  from  turf.  At 
3000  yards  they  wiU  bury  in  turf,  but  may  ricochet  from  very  hard  ground. 
The  IJnited  States  Army  now  uses  a  magazine  Springfield  that  weighs  less 
than  9  pounds.  The  barrel  is  24  inches  in  length  and  the  diameter  of  the  bore 
is  .30  inch.  The  rifling  makes  one  complete  turn  in  every  10  inches.  With 
this  weapon,  by  magazine  fire,  25  aimed  shots  may  be  fired  in  a  minute;  and 
when  used  as  a  single-loader,  23  aimed  shots  (Surgeon-General  O'Reilly, 
U.  S.  A.,  in  "Keen's  Surgery,"  vol.  iv). 

Old-fashioned  Black  Gunpowder  as  Compared  with  Smokeless  Powder. — 
There  are  many  different  varieties  of  smokeless  powder,  but  each  is  essentially 
a  nitro-powder.  Among  these  smokeless  powders  are  melenite,  used  by  the 
French;  lyddite,  employed  by  the  British;  and  shimose,  adopted  by  the  Japan- 
ese. The  United  States  forces  use  cellulose  nitrate  in  perforated  cylindrical, 
amber-colored  grains.  Nitro-powder  is  very  nearly  smokeless  because  all 
the  products  of  its  combustion  are  gases.  Of  the  products  of  the  combustion 
of  black  gunpowder,  57  per  cent,  by  weight  settle  out  from  the  atmosphere 
in  solid  form  on  cooling. 

There  are  great  advantages  in  the  use  of  smokeless  powder.  It  is  much 
more  powerful  than  black  gunpowder;  hence,  a  smaller  charge  can  be  em- 
ployed. The  modern  Springfield  requires  a  charge  of  47  gr.;  and  at  the 
time  of  the  discharge  the  pressure  in  the  chamber  is  about  49,000  pounds  to 
the  square  inch.  Smokeless  powder  gives  the  bullet  a  greater  velocity,  causes 
less  recoil,  and  fouls  the  barrel  infinitely  less  than  black  powder;  and  the  ab- 
sence of  smoke  maintains  a  clearer  atmosphere  for  observation,  and  also  fur- 
nishes no  sign  of  location  which  might  prove  of  advantage  to  the  enemy. 

Projectiles. — The  bullet  of  a  modern  rifle  is  conical,  has  a  lead  core,  and  is 
hardened  by  being  covered  with  a  mantle  or  jacket  of  copper,  steel,  or  nickel, 
or  of  alloys  of  copper  and  nickel,  or  of  copper,  nickel,  and  zinc.  The  hard 
jacket  is  absolutely  essential,  because  the  speed  of  the  projectile  is  so  great  that 
no  soft  bullet  would  take  the  rifling.  Fragments  would  be  torn  off  from  the 
bullet  in  the  gun,  and  the  grooves  of  the  gun  would  soon  be  filled  with  metal, 
the  gun  becoming  useless.  The  projectile  of  a  modern  Springfield  rifle  is 
elongated  and  pointed.  The  air-resistance  is  least  in  a  bullet  of  this  shape. 
The  core  is  composed  of  lead  hardened  with  tin,  and  its  jacket  is  of  nickel 
and  copper. 

The  military  surgeon  deals  with  wounds  inflicted  by  these  small,  dense, 


284 


Contusions  and  Wounds 


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Wounds  in  War  Inflicted  by  Rifle-bullets 


285 


hard,  conical  projectiles,  impelled  with  great  velocity,  and  carried  long  dis- 
tances. The  old  bullet  was  liable  to  lodge,  was  often  deflected  in  the  tissues, 
was  flattened  out  on  meeting  with  resistant  structures,  such  as  bone  or  cartil- 
age, and,  after  flattening,  became  larger,  tearing  and  lacerating  the  soft  parts 
and  comminuting  the  bone.  The  modern  projectile  is  likely  to  penetrate,  is 
rarely  deflected,  and  is  so  hard  that  its  shape  is  often  but  little  altered  on 
meeting  with  resistant  structures.  Hence,  it  was  thought  that  the  new  bullet 
woidd  prove  more  humane  than  the  old  projectile  and  inflict  wounds  that  would 
be  more  easily  treated,  because  the  bullet  would  be  unapt  to  lodge  and  ex- 
tensive damage  would  seldom  be  inflicted.  This  view  has  proved,  to  a  great 
extent,  correct. 

With  the  modern  rifle  of  small  caliber  and  the  hard  projectile  propelled 
by  smokeless  powder  the  range  has  been  notably  increased,  the  trajectory 
of  the  bullet's  flight  has  been  greatly  lowered,  and  the  danger-zone  to  an  enemy 
has  been  correspondingly  lengthened. 


Fig.  125. — I,  Krag-Jorgensen;  2,  new  Springfield. 

Mechanics  of  Projectiles. — If  a  moving  bullet  were  acted  upon  by  no  force 
but  propulsion,  it  would  continue  to  move  in  the  direction  that  it  was  piirsuing 
when  it  left  the  muzzle  of  the  gun  and  its  course  would  be  a  straight  line, 
but  it  is  acted  upon  by  other  forces.  Even  in  a  vacuum  its  course  would  not 
be  a  straight,  but  a  curved  line,  because  gravitation  would  draw  it  toward  the 
earth.     Under  ordinary  circumstances  the  air  also  resists  its  forward  progress. 

A  moving  bullet  is  urged  onward  by  the  force  of  the  exploding  powder. 
This  onward  movement  is  called  the  motion  of  translation.  The  rate  of  for- 
ward movement  is  the  velocity,  and  this  is  expressed  in  feet  per  second.  Air- 
resistance  causes  the  velocity  to  lessen  rapidly,  and  the  farther  away  from  the 
gun  the  projectile  is,  the  greater  is  its  loss  of  velocity.  For  instance,  on  leaving 
the  muzzle  of  the  Lee-Enfield  rifle  a  buQet  has  a  velocity  of  2060  feet  a  second 
{muzzle  velocity  or  initial  velocity);  at  700  yards  it  has  a  velocity  of  1039  feet  a 
second;  at  2000  yards,  571  feet  a  second;  at  3000  yards,  369  feet  a  second 
("Gunshot-woimds,"  by  Major  C.  G.  Spencer).    The  muzzle  velocity  of  the 


286  Contusions  and  Wounds 

bullet  of  the  United  States  Army  Springfield  is  2700  feet  a  second.  The  veloc- 
ity of  a  bullet  at  any  particular  portion  of  its  flight  is  called  remaining  velocity. 

A  bullet  fired  from  a  rifle  rotates  on  its  long  axis.  This  rotation  is  called 
spin  or  the  movement  of  rotation,  and  is  in  the  direction  of  the  groove  of  the 
rifling.  It  is  this  motion  that  keeps  the  point  of  the  buUet  toward  the  front 
and  prevents  rotation  on  its  short  axis,  which  would  be  responsible  for  increased 
air-resistance,  diminished  striking  force,  and  lessened  range.  If  a  cylindro- 
conoidal  bullet  were  fired  from  a  smooth  bore,  it  would  rotate  on  its  short  axis 
at  even  as  short  a  range  as  9  yards,  and  would  strike  a  target  in  its  length 
(Stevenson's  "Wounds  in  War"). 

The  diminution  in  the  transverse  diameter  of  bullets  has  necessitated 
an  increase  in  length  in  order  to  maintain  their  weight  and  sectional  density. 
{Sectional  density  is  the  weight  divided  by  the  area  of  the  cross-section.)  The 
increase  in  length  makes  an  increased  rapidity  of  rotation  indispensable.  The 
higher  the  pitch  of  the  rifling,  the  more  rapid  the  rate  of  rotation  imparted 
to  the  bullet.  The  Minie  rifle  had  a  complete  turn  in  78  inches.  The  United 
States  Army  Springfield  has  a  complete  turn  in  10  inches.  The  velocity  of  spin 
as  the  bullet  leaves  the  barrel  of  a  Springfield  is  about  2500  times  a  second. 
The  velocity  of  rotation  changes  as  the  velocity  of  translation  changes;  and 
when  translation  ceases,  because  the  energy  of  propulsion  has  expended  itself, 
rotation  also  ceases.  "But  when  the  motion  of  translation  is  suddenly  and 
completely  arrested  by  contact  with  an  obstacle,  then,  if  the  bullet  is  not  broken 
up,  the  motion  of  rotation  continues  until  its  energy  is  expended"  ("Wounds 
in  War,"  by  Surgeon-General  W.  F.  Stevenson,  C.  B.,  A.  M.  S.).  A  rifle-bullet 
in  its  flight  deviates  a  little  laterally,  and  in  the  direction  of  the  groove  of  the 
rifling.  In  the  United  States  Army  rifle  the  groove  of  the  rifling  is  toward  the 
right  when  the  gun  is  held  with  the  butt  toward  the  shoulder;  hence,  the  devia- 
tion of  the  bullet  is  toward  the  right.     This  lateral  deviation  is  called  drift. 

Influence  of  Gravity  and  Air-resistance. — We  have  previously  stated  that, 
even  if  moving  in  a  vacuimi,  the  line  of  flight  of  a  bullet  (the  trajectory)  would 
be  a  curved  and  not  a  straight  line,  because  of  the  influence  of  gravity,  which 
pulls  the  bullet  toward  the  earth.  The  bullet  would  fall  16  feet  the  first  second, 
48  feet  the  second  second,  80  feet  the  third  second,  and  so  on.  A  bullet  moving 
forward  in  a  vacuum  would  advance  through  equal  distances  in  equal  periods 
of  time,  and,  as  gravity  would  draw  it  toward  the  earth  with  increasing  rapidity, 
the  trajectory  would  be  a  parabola  (Fig.  126,  line  A-E-F-G). 

Air-resistance  strongly  retards  the  advance  of  a  bullet  and  causes  it  to 
rapidly  lose  its  velocity,  and  a  bullet  fired  in  air  does  not  advance  through  equal 
distances  in  equal  periods  of  time.  Because  of  air-resistance  a  bullet  falls  to 
the  earth  sooner  than  it  would  under  the  influence  of  gravity  alone.  Hence, 
the  trajectory  of  a  bullet  in  air  is  not  a  true  parabola,  but  the  line  of  descent  is 
much  nearer  to  the  vertical  than  would  be  the  case  in  a  vacuum  (Fig.  126,  line 
A-e-f-g).  _ 

Air-resistance  depends  upon  the  velocity  of  the  bullet,  the  cross-section  area 
of  the  bullet,  the  shape  of  the  head  of  the  bullet,  the  atmospheric  density,  and 
the  steadiness  of  flight  ("Gunshot-wounds,"  by  Major  C.  G.  Spencer).  Air- 
resistance  is  least  in  the  bullet  that  tapers  rapidly.  A  bullet  begins  to  lose 
its  steadiness  of  flight  about  1000  yards  from  the  muzzle  of  the  rifle. 

The  Danger  Zone. — Owing  to  the  fact  that  the  trajectory  is  a  curved  line 
elevation  must  be  given  to  rifles  except  at  point-blank  range,  and  the  degree  of 
elevation  must  be  increased  according  to  the  range.  Point-blank  range  for  a 
Springfield  is  up  to  718  yards.  By  this  term  is  meant  that  when  a  gun  is  aimed 
horizontally  the  entire  course  of  the  bullet  up  to  718  yards  is  dangerous  for 
infantry.  For  longer  ranges  the  rifle  must  be  elevated  and  the  bullet  "shot  into 
the  air,"   Sighted  at  2000  yards  the  Snider  sent  a  bullet  866  feet  above  the  line 


Wounds  in  War  Inflicted  bv  Rifle-bullets 


287 


of  sight;  the  Martini-Henry  sighted  at  the  same  range,  357  feet;  the  Lee-Enfield 
at  the  same  range,  194  feet.  It  becomes  evident  that  when  a  rifle  is  elevated  the 
bullet  rises  far  above  a  man's  head,  and  continues  to  rise  to  what  is  known  as 
the  culminating  point,  w^hen  it  begins  to  descend.     It  does  not  become  dangerous 


S      B 


c    d 


Fig.  126. — Trajectories  in  vacuo  and  in  air  (Stevenson). 

to  men  until  it  gets  near  to  the  earth.  The  point  at  which  it  becomes  dangerous 
to  cavalr}'  is  called  ''the  point  of  first  catch  for  cavalry"  (Fig.  127).  The  point  at 
which  it  becomes  dangerous  for  infantrv-  is  called  ''the  point  of  first  catch  for 
infantry"  (Fig.  127).     The  dangerous  zone  (Fig.  127)  is  from  the  point  of  first 


A"  B'  D 

Fig.  127. — ^Trajectory,  showing  dangeroiis  zones:  A-B-D,  Trajector%-  of  bullet;  D,  point  of  termina- 
tion of  the  bullet's  flight;  A-B,  point  of  first  catch  for  cavahj';  B,  point  of  first  catch  for  iafantry; 
A'— D,  dangerous  zone  for  cavalry;  B'— D,  dangerous  zone  for  infantry  (Spencer). 

catch  to  the  termination  of  the  bullet's  flight,  because  am^'here  in  this  zone 
men  may  be  struck,  but  between  the  point  of  first  catch  and  the  man  firing  the 
gim  soldiers  are  perfectly  safe.  The  point  of  first  catch  for  cavalry  is  about 
8i  feet  and  for  infantr\-  about  6  feet  above  the  ground. 


Fig.  128. — ^Trajectories  of  bullets  from  certain  rifles:  i,  Trajector>^  of  Lee-Enfield  at  1500  yards> 
action-point,  81  feet;  2,  trajectoiy  of  Martini-Henrj-  at  1500  yards,  action-point,  17S  feet;  3,  trajectory 
of  Lee-Enfield  at  2000  yards,  action-point,  1Q4  feet:  4,  trajectorj-  of  iSIartini-Henrj-  at  2000  yards,  action- 
point,  357  feet;  5,  trajectory-  of  Snider  at  2000  yards,  action-point,  866  feet;  horizontal  scale,  ^^J^j,  (i 
inch  =  2000 feet);  vertical'scale  lacuu  (i  inch  =  1000  feet).  Vertical  measurements  are  represented 
on  twice  as  large  a  scale  as  horizontal  measurements  (Spencer") . 

The  more  nearly  vertical  the  line  of  the  bullet's  descent,  the  shorter  is  the 
danger  zone;  the  less  vertical  the  line  of  descent,  the  longer  is  the  danger 
zone.  The  higher  the  culminating  point  of  the  trajector}^,  the  more  vertical 
is  the  line  of  descent,  hence  the  shorter  is  the  danger  zone;  the  lower  the 


288 


Contusions  and  Wounds 


culminating  point,  the  flatter  is  the  trajectory,  and  the  less  vertical  the  line  of 
descent,  hence  the  longer  the  danger  zone.  The  chief  object  of  unprovements 
in  rifles  is  to  lower  the  trajectory  (that  is,  make  it  less  curved)  and  thus  lengthen 
the  danger  zone,  render  marksmanship  more  accurate,  and  insure  velocity. 

Power  of  the  Bullet  to  Wound. — According  to  Spencer  ("Gimshot- wounds"), 
this  depends  upon  its  energy  and  the  ease  with  which  its  energy  is  converted 
into  work  on  striking.  Energy  is  largely  a  matter  of  range.  At  short  range 
energy  is  enormous,  but  it  rapidly  diminishes  as  the  range  is  increased. 
At  3000  yards  energy  is  only  about  one-sixteenth  of  what  it  is  at  300  yards. 
The  ease  with  which  a  bullet  converts  energy  into  work  depends  upon  (see 
Spencer  (Ibid.):  (i)  The  area  of  the  cross-section  of  the  bullet.  The  larger 
the  bullet,  the  worse  the  wound.  (2)  The  deformation  of  the  buUet.  Such 
deformation  enlarges  the  area.  A  bullet  that  expands  on  striking  is  said 
to  ''mushroom.''  The  modern  bullet  seldom  deforms  much  unless  its  jacket 
has  been  more  or  less  torn  off;  and  it  inflicts,  as  a  rule,  a  much  less  grave  injury 
than  does  the  soft  bullet.     It  has  been  found  that  this  very  humanity  of  the 

buUet  is  at  times  regarded  as  an  objection. 
The  buUet  lacks  "stopping  power"  unless  it 
strikes  a  vital  part  or  a  large  bone,  and  a 
wounded  man  may  continue  to  fight  and 
charge.  Civilized  men  will  usually  stop  when 
hit,  but  savages  very  often  will  not.  Hence, 
in  warfare  with  barbarous  people,  it  was 
imtil  recently  the  custom  to  modify  the 
bullet.  A  portion  of  the  soft  bullet  at  the 
apex  of  the  projectile  was  left  exposed,  and 
such  a  bullet  was  said  to  be  uncovered  or  to 
have  a  "soft  nose.'"  It  was  called  a  Dumdum 
bullet,  because  such  missiles  were  first  made 
at  Dimidum,  the  ordnance  factory  near  Cal- 
cutta. When  a  Dumdum  bullet  strikes,  it 
spreads  and  expands,  or  "mushrooms,"  and 
inflicts  an  extensive  and  dreadful  woimd, 
which  stops  the  most  ferocious  savage  or  the 
most  fanatical  tribesman.  These  expanding 
or  deformable  bullets  are  often  wrongly 
called  "explosive  biillets."  They  have  been 
forbidden  by  The  Hague  Convention,  al- 
though Stevenson  and  some  other  surgeons 
maintain  that  they  are  more  humane  than 
were  the  buUets  of  the  Snider  or  the  Martini- 
Henry  rifle.  The  present  weapon  of  the 
United  States  Army  will  produce  wounds  "which  will  resemble  the  wounds 
made  by  the  'deformable'  bullets  whose  use  is  forbidden  in  civilized  warfare" 
(Borden,  in  "Keen's  Surgery,"  vol.  vi). 

The  Resistance  Encountered. — If  energy  is  great  (as  at  close  range)  and 
a  very  resistant  tissue  is  struck  (bone),  dreadful  injury  may  be  inflicted, 
but  if  a  tissue  with  little  resistance  is  struck  but  little  damage  may  be  done. 
At  a  long  range  the  energy  of  the  bullet  is  so  lessened  that  the  danger  to  re- 
sistant tissue  will  be  much  less;  whereas  injury  of  soft  parts  may  be  much  the 
same  as  at  closer  range. 

The  Nature  of  the  Wounds  Inflicted  by  the  Small  Projectile. — The  effect  of 
lessening  the  size  of  the  bullet  is  to  decrease  its  wounding  power,  because, 
other  things  being  equal,  the  larger  the  bullet,  the  greater  its  wounding  power. 
In  many  instances  the  modern  bullet  will  make  a  clear  track,  without  lacera- 


Fig.  129. — Mauser  bullet-wound  of 
chest:  a,  Wound  of  entrance;  b,  point 
where  bullet  was  extracted  (Major 
Charles  F.  Kieger,  U.  S.  A.). 


Wounds  in  War  Inflicted  bv  Rifle-bullets 


289 


tion  or  comminution.  It  was  thought,  as  has  been  stated,  that  this  projectile 
would  prove  himiane,  that  it  would  kiU  comparatively  few,  and  that  the 
wotmded  would  receive  injiuries  which  would  incapacitate  them,  but  from  which 
most  of  them  woifld  subsequently  recover.  Recent  wars  have  indicated 
that  at  a  range  of  over  1500  yards  the  bullet,  as  a  rule,  penetrates  cleanlv, 


130. — Deformation  of  leaden  bullets  (natural  size)   (Sej-del). 


making  a  woimd  that  heals  by  first  intention.    Sir  Frederick  Treves  expressed 
his  experience  by  sa}-ing,  "the  Mauser  buUet  is  a  very  merciftfl  one."' 

Very  many  studies  have  been  made  of  the  action  of  the  modern  bullet,  and 
ntmierous  experiments  have  been  carried  out — firing  through  boxes  fiUed  'oith 
wet  sand,  firing  into  thick  oak,  firing  at  cadavers  at  fixed  distances  with  re- 
duced charges,  and  firing  at  corpses  and  at  live  horses  with  service  charges. 


mm 

Fig.  131. — Deformation  of  small-caliber  jacketed  bullets   'after  Bruns\ 

DeXancrede.  some  years  ago,  wisely  cautioned  us  to  remember  that  experi- 
ments upon  the  cadaver,  employing  reduced  charges  and  standing  at  fixed  dis- 
tances, are  uncertain  in  their  pro^ings.  "The  difference,"  he  said,  "between  the 
velocity  of  rotation  and  the  angle  of  incidence  with  reduced  charges  at  fixed 
distances  and  sersdce  charges  at  actual  distances  is  marked.  The  tension  of 
li\ing  muscle  and  fascia,  as  compared  with  dead  tissues,  and  the  physical 


Fig.  132. — I,  Empti-  Krag  jacket  removed  from  thigh  after  penetrating  6  inches  at  340  yards;  2,  3, 
4,  5,  lodged  Krag  bullets  removed  from  woimds  after  deflection  from  frozen  ground.  Ranges  from 
50  to  300  yards. 

change  of  semiliquid  fat  of  adipose  tissue  and  medulla  to  a  more  soHd  condi- 
tion by  the  loss  of  animal  heat,  influence  the  results''  (Ibid.,  "Gtmshot- 
wounds,''  Roswell  Park's  "Surgers^  by  American  Authors''). 

AU  the  theoretical  conclusions  derived  from  experiment  and  the  obser^-a- 
tions  made  on  the  occasional  ^-ictims  of  suicide  or  homicide  have  been  put  to  the 
test  of  war  in  recent  vears;  and  we  now  draw  our  deductions  from  a  study  of  the 


ago  Contusions  and  Wounds 

wounds  in  the  Chitral  Expedition,  the  Greco-Turkish  War,  the  Spanish-Ameri- 
can War,  the  South  African  War,  the  taking  of  Pekin,  and  the  Russo-Japanese 
War.  (Reports  from  the  Balkan  War  are  not  as  yet  accurate  or  comprehen- 
sive.) Preconceived  opinions  have,  to  a  great  extent,  at  least  been  confirmed. 
It  has  been  found  that  the  wounds  are  usually  non-infected  and  are  apt  to  heal 
by  first  intention  unless  inflicted  by  ricochet,  which  deforms  the  bullet.  _  At  a 
range  of  1500  yards  or  more  the  wounds  are  commonly  clear  tracts,  without 
much  splintering  of  bone  or  laceration  of  tissues.  The  wound  of  entrance  is 
extremely  small  and  could  be  overlooked  by  a  careless  observer.  It  is  usually 
circular,  it  may  be  triangular.  The  bullet  is  far  less  liable  to  lodge  in  the  body 
than  was  the  older  bullet.  If  it  perforates,  the  wound  of  exit  is  usually  small, 
and  may  be  either  round  or  a  sht.  The  wound  of  exit  is  large  if  the  injury 
was  inflicted  at  close  range,  or  if  bone  was  spHntered  and  fragments  were  driven 
along  with  the  bullet. 

TheoreticaUy,  the  projectile  does  not  flatten,  but  it  has  been  found  that  in 
many  instances  it  does  flatten  a  Httle  (Fig.  131).  Its  coat  is  apt  to  be  torn  off 
when  it  strikes  hard  bone  at  a  distance  of  less  than  1800  yards.  Treves  has 
pointed  out  that  if  a  buflet  smashes  a  bone  and  lodges,  the  shell,  as  a  rule,  peels 
off  from  the  core.  Then  the  buUet  may  be  distorted  or  broken  into  fragments. 
When  a  hard-jacketed  bullet  is  "traveling  over  2000  feet  per  second"  it  "will 
hold  together"  and  penetrate  any  human  structure  "without  breaking  up,  but 
as  the  velocity  drops,  there  comes  a  point  when  the  resistance  is  too  great  for  the 
momentum  of  the  bifllet  to  overcome  quickly,  and  then  the  bullet  piles  up  on 
itself,  just  as  it  does  when  it  strikes  a  very  hard  object,  and  the  lead  crowds  to 
the  front  part  of  the  buflet  tfll  the  nose  of  the  jacket  bursts.  When  this  hap- 
pens the  wounds  are  very  serious  and  have  given  rise  to  rumors  of  the  use  of 
'dumdum'  or  soft-nose  bullets  or  of  explosive  bullets"  (Wadsworth,  in  "Inter- 
national Clinics,"  Vol.  IV,  Twentieth  Series).  At  long  range  the  buflet  may 
lodge,  or  it  may  also  do  so  if  it  hits  a  man  after  bounding  from  a  stone,  hard 
ground,  or  a  piece  of  metal.  It  may  lodge  in  compact  bone.  In  Cuba  10 
per  cent,  of  the  wounded  suffered  from  lodged  buflets.  In  the  Russo-Japanese 
War  less  than  10  per  cent,  of  the  wounded  suffered  from  lodged  bullets. 

It  is  seldom  that  bits  of  clothing  are  carried  in  with  the  buflet,  but  some- 
times they  are,  and  some  fabrics  are  more  liable  to  be  carried  in  than  others. 
Threads  are  not  unusually  carried  in  on  the  roughened  areas  cut  into  the  bifllet 
by  the  gooves  of  the  rifflng.  If  the  buflet  ricochets  from  stony  ground,  bits 
of  stone  may  enter  the  tissues. 

Blood-vessels  are  flkely  to  be  cut  and  not  pushed  aside,  as  was  often  the 
case  with  the  old-time  buflets.  Cases  of  arterial  contusion  and  subsequent 
secondary  hemorrhage  are,  however,  occasionally  met  with.  If  a  large  vessel 
is  struck  and  cut,  primary  hemorrhage  is  profuse  and  may  prove  rapidly  fatal. 
The  modern  buflet  is  seldom  deflected  in  the  tissues,  but,  as  a  rule,  it  passes 
straight  ahead.  The  skin  is  usually  split  by  it.  Fascia  and  muscle  are  Hkely 
to  be  much  damaged,  but  in  a  transverse  wound  of  muscle  the  fibers  may  be 
separated  rather  than  destroyed. 

Although  under  most  circumstances  this  bifllet  is  humane,  it  has  been 
found  that  in  some  instances  it  pulpifies  structure  for  a  considerable  distance 
around  the  track  of  the  ball,  producing  what  is  known  as  an  explosive  ejfed. 
The  cause  of  this  condition  has  been  much  debated,  though  it  never  means  that 
the  buflet  has  exploded.  Some  think  that  it  is  always  due  to  comminution  of 
bone  and  the  blowing  of  bone-fragments  ahead  of  and  around  the  ball.  Most 
befleve  that  the  sudden  impact  against  the  tissues  engenders  waves  of  force, 
which  cause  explosive  and  distant  damage.  Certain  it  is  that  an  explosive 
effect  causes  horrible  and  often  irreparable  injury. 

Explosive  effects  are  most  frequently  seen  at  close  range,  when  the  velocity 


Symptoms  of  Wounds  Inflicted  by  Rifle-bullets  291 

of  translation  and  the  frequency  of  rotation  are  most  marked.  Such  injuries 
were  seen  in  the  marines  killed  at  Guantanamo,  in  persons  killed  during  the 
jMilan  riots,  and  in  many  instances  in  South  Africa,  China,  and  Manchuria. 

A  pistol-bullet  has  no  explosive  action  at  all;  and  the  old-time  large,  soft 
bullet  possessed  it  only  at  a  very  close  range.  The  modern  projectile  is  apt  to 
produce  explosive  eft'ects  up  to  500  yards,  but  it  does  not  invariably  do  so.  Up 
to  1300  yards  it  is  liable  to  produce  them  in  the  skull  and  brain;  and  at  this 
distance  a  single  bullet  may  entirely  destroy  the  cranium.  Explosive  efl"ects 
may  at  times  occur  at  longer  distances  upon  the  liver,  spleen,  kidneys  and  lungs, 
and  upon  hollow  viscera  containing  fluid.  x\t  a  distance  of  500  yards  or  less 
a  bone  will  usually  be  shattered  into  many  fragments;  whereas,  at  a  range  of 
1500  or  2000  yards  the  bone  ^AiU,  as  a  rule,  be  cleanly  perforated,  usually  with- 
out comminution. 

It  is  often  extraordinary  how  httle  trouble  follows  a  wound  by  a  modern 
projectile  and  how  quickly  healing  occrnrs.  This  is  due  to  the  facts  that  the 
tissue  is  cleanly  perforated,  that  foreign  bodies  are  seldom  carried  in,  and  that 
the  wound  rarely  becomes  mfected.  This  freedom  from  infection  is  not  due  to 
the  bullet  being  sterile.  It  is  not  sterile,  and  when  the  gun  is  fired  the  bul- 
let does  not  heat  sufficiently  to  certainly  destroy  bacteria.  The  bullet  is 
carried  in  a  dirty  belt  or  pouch,  is  handled  by  dirty  hands,  and  is  not  clean 
when  put  into  the  rifle,  but  its  sides  may  be  scraped  cleaner  by  the  rifling 
and  the  burning  powder  may  disinfect  it  in  part.  The  point,  however,  contains 
bacteria  on  its  surface.  They  are  few  in  number;  are  readily  scattered  in  the 
tissues;  and,  in  most  instances,  are  overcome  by  tissue  resistance.  The 
clean  track  of  the  bullet  which  is  usual  in  wounds  inflicted  at  ordinary  fight- 
ing ranges  impairs  tissue  resistance  much  less  than  a  badly  contused  and  lacer- 
ated wound.  In  some  observed  cases  there  have  been  almost  no  symptoms 
after  perforation  of  the  limg.  In  others,  none  after  perforation  of  the  abdo- 
men, a  joint,  or  the  skuU.  The  buUet  when  it  has  become  stationary  seldom 
does  harm,  imless  lodged  in  the  brain.  It  is  obvious  that  in  most  conflicts  the 
modern  rifle  has  proved  to  be  humane  and  that  its  humanity  is  largely  a 
matter  of  range.  At  a  range  of  1500  yards  or  over  modern  rifles  (except  the 
Springfield)  are  humane  weapons. 

What  used  to  be  caUed  a  uind  contusion  is  a  severe  and  often  a  dreadful 
injury.  The  skin  being  unbroken,  bones  may  be  broken,  viscera  ruptured, 
tissues  torn  asunder.  The  older  surgeons  believed  that  such  an  injury  was 
produced  by  the  wind  pressure,  a  projectile  passing  close  to,  but  not  touching 
the  surface."^  We  know  now  that  they  result  from  a  projectile's  glancing  along 
the  surface,  the  elasticity  of  the  skin  sa\ing  it  from  immediate  destruction, 
although  in  many  instances  it  Roughs  later. 

A  bullet  in  striking,  never  gets  hot  enough  to  burn  a  part.  It  is  needless  to 
say  that  bullets  are  never  deliberately  poisoned. 

'  Symptoms. — Pain  is  seldom  severe  in  wounds  of  the  soft  parts,  but  \iolent, 
immediate  pain  is  felt  when  a  bone  or  a  nerve  is  injured;  the  pain  is  usually 
stinging  or  burning,  but  is  seldom  of  long  duration,  except  in  bone  injuries, 
spinal  cord  injuries,  and  nerv^e  injuries.  Sometimes  a  man  does  not  know 
he  has  been  struck.  It  is  common  to  have  anesthesia  or  mmabness  and  loss  of 
muscle-fimction  about  the  wound  for  several  hours  or  days. 

Shock  is  very  variable.  In  some  cases  it  is  scarcely  noticeable,  in  others 
it  is  ovem^hehning.  It  is  most  marked  in  wounds  of  bone,  the  spine,  the  ab- 
domen, and  the  brain.  It  is  greatly  aggravated  by  hemorrhage.  Hemorrhage 
is  great  if  a  large  vessel  is  struck.  If  the  vessel  is  in  a  limb  it  is  seldom  that 
much  blood  escapes  externaUy,  but  a  large  hemorrhage  occurs  in  the  tissues. 
Such  cases  reach  the  hospital  for  treatment,  and  are  spoken  of  as  "traumatic 
aneurysm."     They  were  quite  common  in  South  Africa.     Secondary  hemor- 


292  Contusions  and  Wounds 

rhage  is  uncommon.  When  it  does  occur  it  is  usually  a  result  of  infection,  but  it 
may  arise,  as  in  a  soft-bullet  injury,  from  contusion  of  a  vessel.  De  Nancrede 
reports  secondary  hemorrhage,  in  the  absence  of  infection,  from  contusion  of 
the  brachial  artery.  If  a  great  vessel  is  divided  in  the  chest  or  abdomen,  the 
patient  rapidly  bleeds  to  death  on  the  field,  and  seldom  reaches  the  hospital 
at  all.  A  mihtary  bullet  may  cause  arteriovenous  aneurysm.  Makins, 
De  Nancrede,  and  others  have  reported  cases.  De  Nancrede  saw  one  arterio- 
venous aneurysm  of  the  subclavian,  two  of  the  femoral,  and  one  of  the  external 
iliac  from  Mauser  bullet  wounds. 

Primary  infection  is  rare.  The  bullet  wound  tends  to  remain  uninfected 
unless  bits  of  clothing  or  other  foreign  bodies  have  been  carried  in,  unless  the 
bullet  was  deformed,  unless  the  wound  was  at  close  range,  or  unless  imnecessary 
and  uncleanly  probing  was  practised.  If  suppuration  occurs,  it  is  apt  to  remain 
localized.  Pyemia  and  true  septicemia  are  rare.  In  the  Russo-Japanese  War 
suppuration  seems  to  have  been  common.  In  the  Japanese  hospitals  at 
least  60  per  cent,  of  wounds  of  the  soft  parts  by  undeformed  bullets  suppu- 
rated. At  most  in  only  one  case  out  of  ten  does  the  bullet  lodge.  (Report 
on  Russo-Japanese  War,  by  Maj.  Chas.  Lynch,  Medical  Department,  General 
Staff,  U.  S.  A.)  It  is  stated  that  among  the  Russians  suppuration  occurred  in 
30  per  cent,  of  the  cases.  More  wounds  suppurated  in  winter  than  in  summer. 
The  Russians  used  a  larger  bullet  than  the  Japanese,  and  the  wound  inflicted 
by  the  Russian  bullet  was  far  more  hable  to  suppurate  than  was  that  produced 
by  the  Japanese  projectile.  Practically  all  wounds  of  bone  made  by  Russian 
bullets  suppurated.  (Lynch,  Ibid.)  The  above  remarks  upon  the  military 
projectile  do  not  apply  in  all  particulars  to  the  new  bullet  adopted  by  the 
United  States  (model  of  1906).  It  is  of  the  same  caliber  as  its  predecessor, 
but  it  is  .17  inch  shorter,  70  gr.  lighter,  and  its  point  is  decidedly  sharper.  The 
muzzle  velocity  is  400  yards  per  second  greater.  Point-blank  range  has  been 
extended  from  600  to  718.6  yards.  Because  the  new  bullet  is  short  and  be- 
cause the  center  of  gravity  is  toward  the  base  the  bullet  is  easily  deflected  and 
is  prone  to  enter  the  tissues  sideways,  inflicting  a  frightful  wound,  instead  of  the 
usual  small  puncture  of  the  ogival  headed  bullet  of  1903.  La  Garde  has 
pointed  out  that  even  the  skin  resistance  may  cause  the  bullet  to  turn.  Hence 
it  is  evident  that  the  bullet  of  the  Springfield  now  in  use  is  distinctly  not  a 
humane  weapon ;  it  will  inflict  horrible  injury  and  will  be  very  apt  to  kill  the  vic- 
tim outright  (Lt.-Col.  Borden,  U.  S.  A.,  in  "Keen's  Surgery,"  vol.  vi).  It  has 
not  yet  been  tested  in  war. 

Treatment. — The  military  surgeon  is  a  specialist,  and  he  must  know 
many  things  besides  the  treatment  of  the  sick  and  injured.  He  must  be  a 
master  of  hygiene;  he  must  possess  executive  capacity;  he  must  be  able  to 
discipline  others  and  to  subject  himself  to  discipline;  he  must  be  forceful, 
self-reliant,  and  resourceful;  he  must  be  acquainted  with  the  laws  and  regula- 
tions of  the  military  establishment;  and  he  must  have  a  special  knowledge  of 
gunshot-wounds  as  received  in  battle.  Even  the  best  qualified  civil  surgeon 
is  unfit  to  pass  into  mflitary  service  without  special  instruction.  It  is  for  this 
reason  that  the  United  States  insists  that  every  man  appointed  to  the  Medical 
Corps  of  the  Army  or  Navy  shall  receive  special  instruction  in  the  Army  Medical 
School  or  the  Naval  Medical  School  before  he  goes  to  a  regiment  or  a  ship. 
The  wounds  received  in  war  are  peciiliar,  and  treatment  appropriate  for  a 
wound  inflicted  by  a  revolver  bullet  is  often  inappropriate  or  impossible  for  a 
wound  inflicted  by  the  projectile  of  a  military  rifle. 

In  civil  life  the  patient  has  the  best  of  surroimdings.  Every  care  can  be 
given  him.  Numerous  skilled  assistants  are  at  hand  if  needed.  The  problems 
of  the  case  are  entirely  surgical,  and  the  case  can  be  dealt  with  purely  accord- 
ing to  its  surgical  necessities.     In  war  there  are  problems  of  transportation 


Treatment  of  Wounds  Inflicted  by  Rifle-bullets  293 

which  are  not  presented  in  civil  life,  for  strategic  necessity  may  compel  hurried 
movement.  Accommodations,  also,  may  be  bad.  Shelter  may  be  imperfect, 
climate  and  meteorologic  conditions  may  be  most  trv-ing.  Food  may  be 
scanty  and  inappropriate.  Medicines  may  be  scarce.  There  are  sure  to  be  too 
few  assistants.  After  some  engagements  in  South  Africa  the  British  sur- 
geons had  to  care  for  numbers  of  men  under  difficulties  that  were  appalling, 
among  which  were  fearful  clouds  of  dust  and  swarms  of  flies.  In  other  words, 
the  militar\-  surgeon,  after  a  battle,  is  seldom  able  to  treat  his  cases  purely  in 
accordance  with  surgical  necessities,  but  his  conduct  must  be  influenced'  by 
other,  often  imperative,  needs.  If  there  are  numerous  wounded,  he  does  not 
have  time  to  do  immediate  laparotomies.  He  will  lose  some  cases  because 
he  has  not  done  laparotomy,  but  he  would  lose  many  other  cases  from  delay 
in  treating  dangerous  but  remedial  conditions  were  he  to  make  manv  simpler 
cases  wait  until  his  laparotomies  had  been  performed.  He  is  forced'  to  make 
the  abdominal  woimds  wait,  and  after  long  delay  there  is  seldom  any  use  in 
opening  the  abdomen  at  all. 

Again,  the  wound  inflicted  by  the  bullet  of  a  military  rifle  is  ver\^  different 
in  nature  and  in  danger  from  the  woimd  inflicted  by  a  revolver  bullet.  In  the 
former,  if  a  large  vessel  is  struck,  it  is  usually  perforated  or  divided,  and  profuse 
bleeding  occurs,  either  into  a  ca\'ity  or  in  the  tissues.  If  the  bleeding  occurs  in  a 
ca\'ity  the  patient  usually  dies  on  the  field,  and  does  not  reach  the  first  dressing- 
station  at  all.  If  it  occiurs  in  the  tissues  a  '"traimiatic  aneurysm"  forms.  In 
revolver  buUet  woimds  primary  hemorrhage  is  seldom  severe.  Woimds  with 
revolver  bifllets  are  very  apt  to  suppurate.  Woimds  with  the  undeformed 
hard-jacketed  projectile  that  has  not  ricocheted  very  commonly  escape 
primary  infection. 

Wounds  that  in  civil  life  might  require  only  a  resection,  may  in  military 
practice  require  amputation.  The  promise  of  aseptic  healing  leads  the  mili- 
tary* surgeon  to  trust  many  wounds  without  operation  which  in  civil  life  would 
be  operated  upon  at  once,  and  both  surgeons  would  be  right  in  the  different 
coiirses  pursued  by  them. 

In  ci\il  life  the  rule  is  absolute  to  open  the  abdomen  for  every'  case  of 
gimshot-wound  entering  that  cavity.  The  experience  of  all  military  men  is 
that  more  cases  get  weU  imder  a  poHcy  of  non-interference  than  -with  laparot- 
omy. In  military  surgery  laparotomy  can  be  performed  only  when  there  is 
"'time  to  do  it" ;  and,  even  then,  is  performed  only  when  there  is  hemorrhage 
or  else  certain  e\'idence  or  a  very  strong  probability  that  an  organ  or  Aiscus  has 
been  struck  or  perforated.  On  accoimt  of  the  difficulties  in  the  treatment  of 
the  wounded  in  military  life,  as  compared  with  ci\"il  Iffe,  rrdlitary  surgery  is  a 
pmre  specialty;  and  the  details  of  the  treatment  of  woimds  in  war  must  be  sought 
for  in  treatises  by  military  surgeons.  The  watchwords  of  the  mflitary  surgeon 
are  to  preser\*e  asepsis  and  to  avoid  meddlesome  interference. 

In  handling  patients  in  the  field  the  clothing  is  cut  away  (if  the  wound  is 
under  the  clothing  1.  If  possible,  the  wound  and  skin  about  it  are  washed 
■udth  alcohol  and  painted  -ndth  iodin  (tincture,  diluted  one-half  with  alcohol) 
and  then  the  dressings  are  applied.  If  this  cannot  be  done  the  dressings  are 
applied  at  once.  The  dressing  shoifld  be  absorbent  and,  if  possible,  antiseptic 
rather  than  aseptic  gauze.  Absorbent  cotton  should  be  placed  over  the  gauze, 
and  a  bandage  of  linen  should  be  appHed  to  hold  the  dressing  in  place. 

In  warfare  at  the  present  day  an  attempt  is  made  to  limit  the  death-rate 
from  gunshot-wounds  b}'  protecting  them  from  infection  at  an  early  period 
after  the  accident.  Esmarch  offered  a  suggestion  which  has  been  adopted  in 
the  armies  of  aU  ci\ilized  countries.  Ever\"  officer  and  private  soldier  carries  a 
package  which  contains  antiseptic  dressings,  and  at  the  first  opportunity  after 
the  infliction  of  a  wound,  if  possible  on  the  field,  these  dressings  are  applied  by 


294  Contusions  and  Wounds 

the  soldier,  by  a  comrade  (for  even  the  privates  are  instructed  in  the  applica- 
tion), or  by  an  ambulance  man.  If  not  applied  on  the  field,  they  are  applied 
at  the  first  dressing-station  by  a  surgeon  or  a  hospital  steward.  The  dressing 
is  removed  only  when  there  are  indications  calling  for  surgical  interference. 
Many  wounds  heal  under  this  primary  dressing.  In  the  United  States  Army 
the  first-aid  package  is  carried  in  a  metal  case  to  prevent  contamination  and 
damage  by  moisture.  The  case  is  hermetically  sealed,  but  can  be  easily  opened. 
It  is  carried  hooked  to  the  cartridge  belt.  It  contains  two  bandages,  two  com- 
presses of  absorbent  corrosive  sublimate  gauze,  and  two  No.  3  safety-pins,  all 
wrapped  in  waxed  paper.  One  compress  is  stiched  to  the  center  of  each  band- 
age, and  the  bandage  is  so  folded  that  the  compress  can  be  opened  without 
touching  its  inner  surface.  Each  private  of  the  hospital  corps  and  the  orderly 
of  each  medical  ofi&cer  carries  the  hermetically  sealed  tubes — each  tube  con- 
tains I  gm.  of  iodin  and  i^  gr.  of  iodid  of  potassium.  By  adding  50  c.c. 
of  water  or  alcohol  a  proper  antiseptic  solution  is  obtained.  In  injury  of  limbs 
amputation  is  seldom  necessary.  It  is  done  when  the  great  vessels  are  injured, 
when  the  soft  parts  are  grievously  lacerated,  when  an  articular  surface  is  badly 
comminuted,  and  perhaps  when  there  is  menacing  secondary  infection.  Ex- 
cision is  occasionally  performed  when  there  is  comminution.  As  a  rule,  a 
wound  of  an  articulation  is  recovered  from  by  antiseptics  and  splinting. 

Most  lodged  balls  are  let  alone.  If  the  wound  is  infected,  or  is  known  to  con- 
tain foreign  material  other  than  the  bullet,  the  bullet  and  all  other  foreign  mate- 
rial must  be  removed.  A  bullet  in  the  brain  should  be  removed,  though  we  often 
wait  perhaps  for  days  to  let  the  tissues  regain  resisting  power  (DeNancrede). 
Serious  hemorrhage  always  calls  for  operation.  Tie  the  vessel  in  the  wound 
if  possible;  if  not,  tie  the  main  trunk  above,  and  if  this  fails,  amputate 
(De  Nancrede).  In  a  chest  woimd  delay  for  symptoms.  In  an  abdominal 
wound  do  not  operate  except  for  hemorrhage  or  for  evident  visceral  injury. 

In  the  foregoing  article  I  have  obtained  facts  from  numerous  sources.  The 
following  books  and  articles  I  found  particularly  serviceable:  "Wounds  in 
War,"  by  Surgeon-General  W.  F.  Stevenson,  of  the  British  Army;  "Gunshot- 
wounds,"  bv  Major  C.  G.  Spencer,  of  the  British  Army;  "Military  Surgery," 
by  Surgeon-General  Robert  M.  O'Reilly,  U.  S.  A.,  in  Vol.  IV  of  "Keen's  Sur- 
gery"; "Naval  Surgery,"  by  Surgeon-General  P.  M.  Rixey,  U.  S.  N.,  in  Vol. 
IV  of  "Keen's  Surgery";  Treves,  in  the  "British  Medical  Journal,"  1900;  Serm, 
in  "The  Hispano-American  War";  Makin,  "Surgical  Experiences  in  South 
Africa";  "Chirurgie  de  Guerre,"  Paris,  1897,  by  Constans;  "Surgical  Notes 
from  the  Military  Hospitals  in  South  Africa,"  by  Dent,  in  the  "British  Medical 
Journal,"  1900;  "Gunshot- wounds,"  by  Maj.  Wm.  C.  Borden,  U.  S.  A.,  in  the 
"American  Practice  of  Surgery,"  by  Bryant  and  Buck,  Vol.  II;  "Delorme's 
Traite  de  Chirurgie  de  Guerre";  "Recent  Reports  of  the  Surgeon-General  of 
the  U.  S.  A.  and  of  the  Surgeon-General  of  the  U.  S.  Navy";  the  Chitral 
Campaign,"  by  H.  C.  Thomson;  "Les  Projectiles  des  Armes  de  Guerre,"  by 
Nimier  and  Laval;  "Volumes  of  the  Proceedings  of  the  Associations  of  Military 
Surgeons,  U.  S.  A.";  FoUenfant,  in  "Archives  de  Medicine  et  de  Pharmacia 
Militaire,"  July,  1906;  "Reports  of  Military  Observers  in  Manchuria  during 
the  Russo-Japanese  War,"  by  Maj.  Charles  Lynch,  Medical  Department, 
General  Staff,  U.  S.  A.,  1907;  Neate,  "The  Military  Surgeon,"  1911;  "United 
States  Magazine  Rifle,"  Government  Printing  Office,  Washington,  1909;  Bor- 
den, in  "Keen's  Surgery,"  Vol.  VI;  Surgeon-General  Stokes,  U.  S.  N.,  in 
"American  Practice  of  Surgery,"  191 1;  Wadsw^orth,  in  "International  Clinics," 
Vol.  IV,  Twentieth  Series.  (For  gunshot-wounds  of  special  structures,  see 
Bones,  Joints,  Abdomen,  Brain,  etc.) 

Poisoned  wounds  are  those  into  which  some  injurious  substance,  chem- 
ical or  bacterial,  was  introduced.     This  poison  may  be  microbic  and  capable 


Malignant  Edema  or  Gangrenous  Emphysema  295 

of  self-multiplication,  or  it  may  be  chemical,  and  hence  incapable  of  multi- 
plication. There  are  three  classes  of  poisons:^  (i)  mixed  infection,  as  septic 
wounds,  dissection-wounds,  and  malignant  edema;  (2)  chemical  poison,  such 
as  snake-bites  and  insect-stings;  and  (3)  infection  with  such  diseases  as  rabies, 
glanders,  etc. 

Septic  or  infected  wounds  are  those  which  putrefy,  suppurate,  or 
slough.  Septic  wounds  should  be  opened  freely  to  secure  drainage,  and  hope- 
lessly damaged  tissue  should  be  curetted  or  cut  away.  The  wound  should  be 
washed  with  peroxid  of  hydrogen  and  then  with  corrosive  sublimate,  dusted 
with  iodoform  or  orthoform,  either  drained  by  a  tube  or  packed  with  iodo- 
form gauze,  and  dressed  by  hot  antiseptic  fomentations.  The  part  must  be 
kept  at  rest  and  internal  treatment  should  be  stimulating  and  supporting.  If 
lymphangitis  arises,  the  skin  over  the  inflamed  vessels  and  glands  is  to  be 
painted  with  iodin  and  smeared  with  ichthyol,  and  quinin,  iron,  and  whisky 
are  given  internally.  The  temperature  is  watched  for  evidence  of  general 
infection  or  intoxication.  The  patient  must  be  stimulated  freely,  nourishing 
food  is  given  at  frequent  intervals,  pain  is  allayed  by  anodynes  if  necessary, 
and  sleep  is  secured.  In  infected  wounds  of  the  extremities  Bier's  treatment 
is  very  useful. 

Dissection=wounds  are  simple  examples  of  infected  wounds,  and  they 
present  nothing  peculiar  except  virulence.  They  affect  butchers,  cooks, 
surgeons  who  cut  themselves  while  operating  on  infected  areas,  those  who 
make  postmortems,  and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  possesses  but  few  ele- 
ments of  danger  unless  the  health  of  the  student  is  much  broken  down.  If 
a  wound  is  simply  poisoned  by  putrefactive  organisms,  there  is  rarely  serious 
trouble.  Postmortems  are  peculiarly  dangerous  when  the  subject  has  died 
of  some  septic  process.  When  a  wound  is  inflicted  while  dissecting,  wash  it 
imder  a  strong  stream  of  water,  squeeze,  and  suck  it  to  make  the  blood  run, 
lay  it  open  if  it  be  a  puncture,  paint  it  with  pure  carbolic  acid,  and  dress  it 
with  iodoform  and  hot  antiseptic  fomentations.  Trouble,  of  course,  may 
follow,  but  often  it  is  only  local,  and  a  small  abscess  forms.  It  should  be 
treated  by  hot  antiseptic  fomentations  and  early  incision.  Occasionally 
lymphangitis  arises,  adjacent  glands  inflame,  and  constitutional  symptoms 
arise.  It  is  rarely  that  true  septicemia  or  pyemia  arises  unless  the  wound 
was  inflicted  while  making  a  postmortem  upon  a  person  dead  of  septicemia 
or  while  operating  on  a  septic  focus.  If  glands  enlarge  and  soften,  it  may  be 
necessary  to  remove  them  surgically. 

Malignant  edema  or  gangrenous  emphysema  arises  most  commonly 
after  a  puncture.  It  is  due  to  a  specific  bacillus  which  produces  great  edema. 
The  emphysema  which  soon  arises  is  due  to  mixed  infection  with  putrefactive 
organisms.  Pus  does  not  form,  but  gangrene  occurs.  The  disease  is  identical 
with  one  form  of  traumatic  spreading  gangrene  (see  page  170). 

Symptoms. — These  are  identical  with  those  of  traumatic  spreading  gan- 
grene wdth  emphysema. 

There  is  a  rapidly  spreading  edema,  followed  by  gaseous  distention  of  the 
tissues  and  by  gangrenous  cellulitis.  The  zone  of  edema  is  at  the  margin  of 
the  emphysema,  and  the  process  spreads  rapidly.  The  emphysematous  zone 
crackles  w^hen  pressed  upon.  The  area  of  edema  is  covered  with  blebs  which 
contain  thin,  putrid,  reddish  matter,  and  the  skin  becomes  mottled.  If  a 
wound  exists,  the  discharge  will  be  bloody  and  foul.  If  incisions  are  made, 
a  thin,  brown,  offensive  liquid  flows  out.  High  fever  rapidly  develops,  the 
patient  becomes  delirious,  and  often  coma  arises.  In  most  cases  death  ensues 
in  from  twenty-four  to  forty-eight  hours. 

^  "American  Text-Book  of  Surgery." 


296  Contusions  and  Wounds 

Treatment.— If  malignant  edema  affects  a  limb  after  a  severe  injury 
amputate  at  once,  high  up.  If  it  affects  some  other  part  or  begins  in  a  limb 
after  a  trivial  injury,  make  free  incisions,  employ  hot,  continuous  antiseptic 
irrigations  or  the  hot  antiseptic  bath,  and  stimulate  freely  (see  page  171). 

Stings  and  Bites  of  Insects  and  Reptiles:  Stings  of  Bees  and 
Wasps. — ^A  bee's  sting  consists  of  two  long  lances  within  a  sheath  with  which 
a  poison-bag  is  connected.  The  wound  is  made  first  by  the  sheath,  the  poison 
then  passes  in,  and  the  two  barbed  or  twisted  lances,  moving  up  and  down, 
deepen  the  cut.  The  barbs  on  the  lances  make  it  difficult  to  rapidly  with- 
draw the  sting,  which  may  be  broken  off  and  remain  in  the  flesh.  Edematous, 
discolored  swelling  quickly  arises.  The  pain  is  severe  and  burning.  Besides 
bees,  hornets,  yellow  jackets,  and  other  wasps  produce  painful  stings  Hke  bee- 
stings. The  sting  of  a  wasp  is  rarely  broken  off  in  the  tissues  because  the  beards 
on  the  darts  are  shorter;  hence  the  sting  is  not  so  firmly  fixed  in  the  flesh,  and 
also  because  these  insects  are  more  rapid  and  nimble  in  their  actions.  Stings  of 
bees  and  wasps  seldom  cause  any  trouble  except  pain  and  swelling.  In  rare 
cases  syncope  occurs.  Widespread  urticaria  may  develop.  Erysipelas  or 
phlebitis  may  arise.  In  some  unusual  cases  a  bee-sting  is  fatal;  persons  have 
been  stung  to  death  by  a  great  number  of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear  rapidly,  and  con- 
sist of  great  prostration,  vomiting,  purging,  and  delirium  or  unconsciousness. 
These  symptoms  may  disappear  in  a  short  time,  or  they  may  end  in  death 
from  heart-failure.     Stings  of  the  mouth  may  cause  edema  of  the  glottis. 

Treatment. — ^To  treat  a  bee-sting,  extract  the  sting  \vith  splinter  forceps 
if  it  has  been  broken  off  and  is  visible  in  the  wound.  If  it  is  not  visible, 
squeeze  the  part  lightly  in  order  to  expel  it,  or  at  least  expel  the  poison.  Pres- 
sure may  be  most  satisfactorily  made  by  means  of  the  barrel  of  a  key.  The 
poison  is  counteracted  by  touching  with  ammonia  or  washing  the  part  in  am- 
monia-water, touching  with  pure  carbolic  acid,  painting  with  tincture  of  iodin, 
or  soaking  in  a  strong  solution  of  common  salt  or  carbonate  of  sodium.  The 
part  may  be  dressed  with  lead-water  and  laudanum,  a  solution  of  washing-soda, 
or  a  solution  of  common  salt.     If  constitutional  symptoms  appear,  stimulate. 

Other  Insect=bites  and  Stings.- — If  a  tick  bites  a  person  it  clings  to  the 
victim.  If  an  attempt  is  made  to  pull  it  off  the  barb  remains  in  the  tissues 
and  an  abscess  follows.  If  a  little  ammonia  is  dropped  on  a  tick  the  insect 
will  at  once  withdraw  its  barb.  A  tick  bite  never  causes  constitutional  symp- 
toms. The  mandibles  of  a  poisonous  spider  are  terminated  by  a  movable  hook 
which  has  an  opening  for  the  emission  of  poison.  The  bite  of  large  spiders  is 
productive  of  inflammation,  swelling,  weakness,  and  even  death.  The  bite  of 
the  poisonous  spider  of  New  Zealand  produces  a  large  white  swelling  and  great 
prostration;  death  may  ensue,  or  the  victim  may  remain  in  a  depressed,  enfee- 
bled state  for  weeks  or  even  for  months.  The  tarantula  is  a  much-dreaded  spider. 
The  scorpion  has  in  its  tail  a  sting.  The  sting  of  the  scorpion  produces  great 
prostration,  delirium,  vomiting,  diaphoresis,  vertigo,  headache,  local  sweUing 
and  burning  pain,  followed  often  by  fever  and  suppuration,  and  occasionally 
even  by  gangrene,  but  it  is  rarely  fatal.  Centipedes  must  be  of  large  size  to  be 
formidable  to  man,  and  the  symptoms  arising  from  their  stings  are  usually  only 
local. 

Treatment. — To  treat  the  bite  of  a  poisonous  spider  or  sting  of  a  scorpion 
tie  a  fillet  above  the  bitten  point;  make  a  crucial  incision,  favor  bleeding,  and 
paint  the  wound  with  pure  carbolic  acid  or  some  caustic  or  antiseptic  (if  in 
the  wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically  if  possible,  and 
stimulate  as  constitutional  symptoms  appear.  Slowly  loosen  the  Hgature  after 
symptoms  disappear.  Chloroform  stupes  and  ipecac  poultices  are  recom- 
mended; also  puncture  by  a  needle  and  rubbing  in  a  mixture  of  3  parts  of 


Snake-bites 


297 


alcohol  and  i  part  of  camphor  (Bauerjie).     Antiscorpion  venene  is  recom- 
mended by  Todd  for  scorpion  stings. 

Myiasis. — When  the  larva?  of  dipterous  insects  are  deposited  in  the  tissues 
the  condition  is  called  myiasis.  Certain  varieties  of  flies  sting  with  the  ovi- 
positor and  lay  their  eggs  in  the  skin  or  in  the  mucous  membrane  of  the  nose. 
The  bot-fly  may  do  this,  and  the  larvae  or  maggots  of  bot-flies  are  caUed  bots. 
Inflammation  arises  in  the  area  containing  the  ova  and  suppuration  may  occur. 
Myiasis  is  most  common  in  tropical  and  subtropical  countries,  but  the  blue- 
bottle fly  may  be  responsible  for  the  condition  in  temperate  climates. 

Treatment. — Incision  and  application  of  pure  carbolic  acid  to  kill  the  larvae. 
If  in  the  nasal  passages  inhalation  of  chloroform  may  prove  fatal  to  larvae. 

Maggots  in  Wounds. — In  tropical  countries  especially  flies  may  lay  eggs  in 
wounds  and  maggots  form  in  immense  numbers.  Larrey  saw  many  such  cases. 
I  have  seen  maggots  several  times  in  foul  leg  ulcers.  Antiseptic  dressings  prevent 
such  an  occurrence  and  antiseptics  will  destroy  larvae.     lodin  is  very  successful. 

Chigger. — The  chigger  or  sand  flea  is  common  in  the  tropics  and  subtropics. 
The  female  when  impregnated  may  enter  an  abrasion  or  may  pass  through  "the 
soft  skin,  especiaUy  in  the  sole  between  the  toes"  or  "around  the  nails"  (Mad- 
den, in  a  "System  of  Sm-gery,"  edited  by  C.  C.  Choyce). 

Inflammation  occurs  and  the  body  of  the  flea  is  recognizable  as  a  small  black 
spot.  Suppuration  may  occur  and  the  flea  may  be  cast  out  with  the  pus. 
Sinuses  may  arise  and  persist.  There  is  some  danger  of  erysipelas,  tetanus,  and 
gangrene  (Ibid.). 

Treatment. — ^Apply  a  hot  solution  of  bicarbonate  of  soda  for  some  hours, 
enlarge  the  opening  with  a  knife,  remove  the  insect  without  breaking  it  up,  and 
dress  the  part  antiseptically  (Ibid.). 

Fish  Stings. — The  spines  of  certain  fish  inflict  a  poisoned  wound,  as  they  are 
covered  with  an  irritant  material  obtained  from  the  skin.  The  spines  of  the 
catfish  are  known  to  do  this.  Certain  fish  actually  inject  poison  along  a  spine, 
the  poison  coming  from  a  receptacle  or  bag.  These  wounds  are  very  painful,  are 
septic,  and  are  apt  to  be  foUowed  by  lymphangitis,  erysipelas,  erysipeloid, 
gangrene,  or  general  sepsis. 

Treatment. — Incise,  favor  bleeding,  swab  mth  pure  carbolic  acid  or  iodin, 
and  apply  hot  antiseptic  fomentations. 

Snake=bites. — The  poisonous  snakes  of  America  comprise  the  copper- 
heads (red  vipers  or  upland  moccasins) ,  water  moccasins  (rice  snakes  or  cotton- 
mouths),  harlequin  snakes  (coral  snakes),  and  rattlesnakes.  The  cobra  of 
India  is  the  most  deadly  of  reptiles.  In  some  countries  great  numbers  of 
people  and  the  lower  animals  are  killed  by  poisonous  serpents.  In  India  during 
1898,  21,921  persons  and  at  least  80,000  cattle  were  killed  by  snakes  ("Brit. 
Med,  Jour.,"  Nov.  25,  1899).  The  coral  snake  is  found  in  the  southeastern 
United  States,  and  is  common  in  South  Carolina,  Georgia,  and  Florida.  It  is 
often  discovered  in  sweet  potato  fields. 

The  w^ater  moccasin,  which  is  semi-aquatic,  infests  "the  lagoons  and  sluggish 
waterways  of  the  southeastern  portion  of  the  United  States"  ("Reptiles  of  the 
World,"  by  Raymond  L.  Ditmars). 

The  copperhead,  which  is  a  variety  of  mocassin,  is  found  east  of  the  Missis- 
sippi River  from  Florida  to  Massachusetts,  and  west  of  the  Mississippi  in 
Texas.  In  the  South  it  lives  on  plantations,  in  the  North  in  or  near  forests 
(Ibid.).  In  practically  every  part  of  the  United  States  there  dwells  some 
variety  of  rattlesnake.  Fifteen  species  are  catalogued  as  dwelling  within  our 
borders  (Ibid.).  Some  inhabit  prairie,  some  desert,  some  rocky  land,  some 
timber  regions,  some  dwell  adjacent  to  water.  The  diamond-back  rattlesnake 
is  the  most  poisonous  serpent  of  the  United  States.  A  small  rattler  is  not  nearly 
so  dangerous  to  life  as  a  big  rattler.     Next  to  a  big  rattlesnake  in  poisonous 


298  Contusions  and  Wounds 

power  comes  the  water  moccasin.  Mr.  Ditmars  characterizes  the  coral  snake 
as  "highly  formidable"  and  the  copperhead  as  "highly  venomous."  Statistics 
seem  to  contradict  the  belief  that  the  copperhead  is  very  dangerous.  Prentiss 
Willson  ("Jour.  Am.  Med.  Assoc,"  Aug.  27,  1910)  has  established  99  instances 
of  persons  bitten  by  copperheads.  There  were  only  5  deaths.  It  used  to  be 
taught  that  there  is  no  essential  difference  in  the  action  of  venoms  of  different 
varieties  of  snakes,  and  that  the  venom  of  an  Indian  cobra  is  practically  identi- 
cal with  the  venom  of  an  American  rattler,  any  apparent  difference  in  action 
depending  upon  difference  in  toxic  power  and  the  different  dose  of  poison  intro- 
duced. We  now  know  that  there  are  essential  differences  in  venoms  (Leonard 
Rogers,  in  "Lancet,"  Feb.  6,  1904).  The  natural  toxic  power  of  the  poison 
varies  in  different  species  and  also  in  different  members  of  the  same  species. 
Poison  injected  into  a  vein  may  prove  almost  instantly  fatal.  The  poison  is 
not  absorbed  by  the  sound  mucous  membranes.  Poison  is  harmless  when  given 
by  the  mouth  and  swallowed,  but  if  directly  introduced  into  the  intestines  of  an 
animal  it  is  certainly  fatal.  The  pancreatic  ferment  destroys  the  toxic  power 
of  the  venom  (R.  H."  Elliot,  in  "Brit.  Med.  Jour.,"  May  12, 1900).  The  venom 
is  discharged  through  the  channeled  fangs  of  the  reptile,  having  been  forced  out 
by  contractions  of  the  muscles  of  the  poison-bag.  The  coral  snake,  like  the 
cobra,  has  short  and  rigid  fangs.  Rattlesnakes,  cotton-mouths,  and  copper- 
heads have  long  and  movable  fangs.  A  coral  snake  bites  like  a  cobra.  It 
grasps  the  object,  sinks  in  its  fangs,  and  then  advances  its  fangs  by  chewing, 
thus  inflicting  several  wounds.  In  viperine  snakes  the  teeth  He  along  the 
back  of  the  mouth  and  are  only  erected  when  the  reptile  strikes.  The  maxillary 
bones  of  the  rattlesnake  are  verv^  short  and  move  with  great  freedom  at  the 
prefrontal  articulation.  The  fangs  are  canaliculated,  are  attached  to  the  maxil- 
lary bones,  and  move  with  the  bones.  The  poison  gland  drives  the  poison  into 
the  canals  of  the  fangs.  The  canal  emerges  from  the  front  of  each  fang  near  the 
tip.  The  fangs,  when  depressed,  are  carried  in  a  fold  of  mucous  membrane. 
When  the  animal  is  ready  to  strike  the  fangs  are  erected  into  a  vertical  position 
and  carried  to  the  front  of  the  mouth.  Cope  describes  the  movement  used  by 
the  rattlesnake  in  biting.  The  body  springs  forward,  but  never  more  than 
two-thirds  of  the  reptile's  length,  the  jaws  seize  the  tissues  and  then  the  fangs 
penetrate  and  move  to  and  fro  as  the  poison  emerges  from  them.  Snake- 
poison  is  a  thin,  greenish-yellow,  turbid,  sterile  fluid,  of  acid  reaction  and  of  a 
distinctive  odor.  The  two  chief  poisonous  principles  are  called  venom-peptone 
and  venom-globulin  (Gustave  Langmann,  "Medical  Record,"  Sept.  15,  1900). 
Symptoms. — Rogers  ("Lancet,"  Feb.  6,  1904)  divides  poisonous  snakes 
into  two  classes:  the  colubrines  (of  which  the  cobra  is  an  example)  and  the 
viperines,  which  are  not  so  poisonous  (this  class  includes  rattlesnakes  and  piiff 
adders).  Colubrine  venom,  according  to  this  observer,  causes  paralysis  of 
the  respiratory  center  and  of  the  motor  end  organs  of  the  phrenic  nerves, 
destruction  of  red  blood-corpuscles,  lessened  coagulabiHty  of  blood,  and  death 
by  respiratory  paralysis.  Viperine  venom  causes  paralysis  of  the  vasomotor 
center  and  great  destruction  of  red  corpuscles.  Some  viperine  venoms  may  cause 
thrombosis,  and  death  from  any  one  of  them  is  due  to  vasomotor  paralysis. 
The  venom  of  some  snakes,  Rogers  says,  contains  a  mixture  of  the  above- 
mentioned  venoms  (among  such  snakes  are  the  Austrahan  colubrines  and  the 
American  pit-adders) .  The  mortahty  from  snake-bites  varies.  The  mortahty 
in  India  from  cobra  bites  is  about  25  per  cent.  (Sir  Joseph  Fayrer).  The  mor- 
tahty in  America  from  rattlesnake  bites  is  about  the  same.  According  to 
Willson  the  mortahty  from  copperhead  bites  is  only  5  per  cent.  ("Jour.  Am. 
Med.  Assoc,"  Aug.  27,  1910).  The  local  symptoms  are:  pain,  soon  becoming 
intense;  mottled  swelling  of  the  bitten  part,  which  swelling  may  be  enormous, 
and  which  is  due  to  edema  and  extravasation  of  blood,  and  assumes  a  pur- 


Treatment  of  Snake-bites  299 

puric  discoloration.  The  bUe  of  a  cobra  produces  inflammation  and  marked 
spreading  edema.  It  may  be  recovered  from  without  symptoms  or  with 
trivial  symptoms;  it  may  induce  profound  systemic  involvement.  The  gen- 
eral symptoms  begin  in  a  comparatively  few  minutes.  The  coagulating  power 
of  the  blood  is  lost,  and  there  is  great  destruction  of  red  corpuscles.  The 
patient  is  terror-stricken  and  soon  becomes  unable  to  stand  because  of  weak- 
ness of  the  legs.  Glossopharyngeal  paralysis  arises,  and  talking  and  swallowing 
become  impossible.  There  is  a  profuse  flow  of  saliva,  perhaps  nausea  and 
vomiting.  The  patient  may  be  duU  mentally,  but  is  not  unconscious.  The 
paralysis  becomes  widespread,  and  finally  the  diaphragm  and  respiratory 
center  become  involved,  and  death  occurs  from  respiratory  paralysis.  Arti- 
ficial respiration  may  prolong  life  for  hours  (Sir  Joseph  Fayrer).  Bad  cases 
usually  die  in  three  or  four  hours,  but  life  may  last  for  many  hours.  A  rattle- 
snake bite  produces  severe  pain  and  mottled  swelling  from  blood  extravasation. 
In  some  cases  there  is  enormous  swelling  from  edema  and  blood;  the  discol- 
oration in  such  a  case  is  purpuric.  The  blood  of  the  victim  quickly  undergoes 
hemolysis  and  loses  the  power  of  coagulation.  It  was  previously  stated  that 
in  laboratory  experiments  it  has  been  shown  that  viperine  poison  may  produce 
thrombosis,  but  it  does  not  do  so  in  man,  as  it  contains  a  very  small  amount 
of  the  coagulating  element  (Rogers) .  Extravasations  of  blood  occur  in  serous 
and  mucous  membranes  and  in  the  skin,  petechial  spots  frequently  arising 
upon  the  cutaneous  surface.  There  may  be  free  bleeding  from  mucous  sur- 
faces and  great  extravasation  beneath  the  conjunctivae.  These  blood  extrav- 
asations are  due,  according  to  Flexner,  to  destruction  of  vascular  endothelium. 
General  symptoms  begin  in  from  a  few  minutes  to  several  hours.  The  symp- 
toms are  those  of  profound  shock,  possibly  with  delirium,  the  vasomotor  center 
being  exhausted  and  finally  paralyzed.  There  are  usually  muscular  twitching 
and  convulsions,  and  finally  paralyses  are  noted  in  most  cases  (pharyngeal  palsy, 
paraplegia,  and  ascending  paralysis).  There  may  be  complete  consciousness, 
or  there  may  be  lethargy,  stupor,  or  coma.  Death  may  occur  in  about  five 
hours,  but,  as  a  rule,  it  is  postponed  for  a  number  of  hours.  If  death  is  deferred 
for  a  day  or  more,  profound  sepsis  comes  upon  the  scene,  with  glandular 
enlargement,  suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be  treated  without 
proper  appliances.  The  elder  Gross  was  accustomed  to  relate  in  his  lectures 
how  he  had  seen  an  army  officer  blow  off  his  finger  by  a  pistol  the  moment 
after  it  was  bitten  by  a  rattlesnake,  and  thus  escape  poisoning.  If  the  bite 
is  upon  a  limb,  and  it  usually  is,  twist  several  fillets  at  diJfferent  levels  above  the 
bite  to  prevent  the  dissemination  of  the  poison  from  the  limb  throughout  the 
body.  If  possible  the  fillets  should  be  elastic,  but  in  an  emergency  any  available 
material  must  be  used.  As  soon  as  fillets  have  been  applied  above  the  bitten  area 
make  crucial  incisions  to  the  depth  of  each  bite.  A  rattlesnake  bite,  a  copper- 
head bite,  and  a  water  mocassin  bite  show  but  two  punctures.  A  coral  snake  bite 
shows  several.  After  incising  suck  or  cup  it  if  possible,  and  cauterize  it  with  pure 
nitric  acid  or  by  a  cautery.  There  is  no  danger  in  sucking  the  wound,  provided 
there  are  no  abrasions  upon  the  lips,  cheeks,  or  tongue.  Before  sucking,  fill 
the  mouth  with  a  dilute  solution  of  permanganate  of  potash,  to  oxidize  and  thus 
destroy  the  poison.  An  expedient  among  hunters  is  to  cauterize  by  pouring 
a  very  little  gunpowder  on  the  excised  area  and  applying  a  spark,  or  by  laying  a 
hot  ember  on  the  wound.  Some  surgeons  inject  in  many  places  about  the 
wound  a  10  per  cent,  watery  solution  of  chlorid  of  calcium  to  chemically  neutral- 
ize the  poison.  It  is  taught  by  others  that  if  a  man  is  bitten  by  a  large  and 
deadly  snake,  the  surgeon,  if  one  is  at  hand,  should  at  once  amputate  well  above 
the  bite.^  Wynter  Blyth  pointed  out  that  permanganate  of  potassium  mixed 
^  Charters  James  Symonds,  in  "Heath's  Dictionary  of  Practical  Surgery." 


300 


Contusions  and  Wounds 


with  an  equal  weight  of  cobra  venom  renders  the  venom  inert.  A  number  of 
surgeons  have  treated  snake-bites  by  injecting  in  and  about  the  wound  a  i  per 
cent,  solution  of  permanganate  of  potassiimi,  but  this  plan  is  inefficient.  Rogers 
("Lancet,"  Feb.  6,  1904)  says  we  should  tie  iillets  around  the  limb  above  the 
bitten  part,  take  a  knife  and  enlarge  the  wounds,  and  rub  in  crystals  of  perman- 
ganate. The  fiUets  are  not  to  be  removed  suddenly,  and  they  had  best  be  kept 
on  for  some  time.  Remove  the  highest  constricting  band  first;  if  no  symptoms 
come  on  after  a  time,  remove  the  next,  and  so  on ;  if  symptoms  appear,  reapply 
the  fillets.  Whatever  local  treatment  is  employed,  stimulants  are  given.  Some 
give  strychnin  hypodermatically;  others,  ether;  others,  digitahs.  Halford,  of 
Australia,  advocated  the  intravenous  injection  of  ammonia  (10  min.  of  strong 
ammonia  in  20  min.  of  water).  AdrenaKn  as  given  in  shock  is  indicated  if  there 
is  a  marked  fall  in  blood-pressure,  and  autotransfusion  and  external  heat  are 
also  indicated.  If  the  respiration  is  faihng,  artificial  respiration  and  oxygen  in- 
halation are  required.  Few  beliefs  are  more  tenaciously  held  than  that  large 
amoimts  of  whisky  or  brandy  should  be  given  to  the  victim  of  snake  venom. 
And  yet  this  belief  is  false.  In  a  person  badly  poisoned  by  snake  venom  the 
mediilary  centers  are  depressed  and  threatened  with  paralysis.  Large  doses 
of  alcohol  increase  this  tendency  and  may  hasten  death.  It  is  well  known  that 
if  a  drunken  man  is  bitten  by  a  large  poisonous  snake  he  is  practically  certain  to 
to  die,  because  the  depression  produced  by  alcohol  is  enormously  accentuated 
by  the  venom.  Moderate  doses  of  whisky  or  brandy  are  useful  (i  to  i^ 
ounces  every  half -hour) .  The  wounds  made  by  the  incisions  of  the  surgeon 
are  kept  open  for  a  number  of  days  by  the  insertion  of  bits  of  rubber  tissue,  and 
warm  and  moist  antiseptic  dressings  are  used.  Attempts  are  being  made 
to  obtain  a  curative  serum.  Animals  can  be  rendered  immune  by  giving 
them  at  first  small  doses  of  the  poison  and  gradually  increasing  the  amoimt 
administered.  It  is  asserted  that  the  serimi  of  immune  animals  will  cure  a 
person  bitten  by  a  venomous  snake.  Cures  have  been  reported  after  the  use 
of  Calmette's  antivenene  serum.  Antivenene  is  obtained  by  immunizing  a 
horse  by  injecting  attenuated  venom.  The  mixture  to  be  attenuated  consists 
of  80  parts  of  cobra  venom  and  20  parts  of  viperine  venom.  It  takes  a  number 
of  months  to  obtain  strong  antivenene.  The  dose  is  from  10  to  20  c.c.  hj^po- 
dermatically,  repeated  if  necessary  in  three  or  four  hours.  It  seems  cer- 
tain, however,  that  no  single  serimi  can  antidote  the  venom  of  all  varieties  of 
serpents  (A.  T.  F.  Macdonald,  of  Australia),  and  it  has  been  shown  that, 
though  Calmette's  antivenene  is  antagonistic  to  colubrine  venom,  it  is  inert 
against  viperine  venom.  Again,  as  Rogers  says,  it  deteriorates  quickly  in  hot 
climates  and  is  seldom  on  hand  when  wanted.  The  horse  can  be  immunized 
against  rattlesnake  venom,  and  antivenene  obtained  from  the  horse  may  be 
used  against  rattlesnake  poison. 

The  poisonous  lizard  {Gila  monster),  of  the  southwestern  United  States, 
can  certainly  kill  small  animals,  but  it  is  doubted  by  many  that  its  bite  is  ever 
fatal  to  man.  When  we  recall,  however,  that  small  animals  which  die  of  the 
poison  present  symptoms  identical  with  those  produced  by  serpent  venom,  we 
should  regard  the  Gila  monster  with  careful  respect. 

The  Hzard  bites  and  hangs  on.  Each  tooth  of  the  lower  jaw  has  a  conduct- 
ing channel  for  poison  and  there  is  a  poison  gland  for  each  tooth. 

The  treatment  of  a  bite  of  the  Gila  monster  is  practically  the  same  as  for  a 
snake-bite. 

Anthrax  (malignant  pustule,  charbon,  wool=sorters*  disease, 
milzbrand,  or  splenic  fever)  is  a  term  used  by  some  as  synonymous  with 
ordinary  carbuncle,  but  it  is  not  here  so  employed.  It  is  a  specific  contagious 
disease  resulting  from  infection  with  the  bacihus  of  anthrax.  Cattle  anthrax 
has  long  been  known.     Virgil  refers  to  it  (Ponder,  in  "Lancet,"  Nov.  4, 1911). 


Anthrax 


301 


PoUender  showed  more  than  fifty  years  ago  that  a  rod-shaped  organism  is 
present  in  the  blood  of  animals  dying  from  splenic  fever.  Duvaine  insisted 
that  the  organisms  caused  the  disease.  Koch  proved  it  in  1876.  Animal 
anthrax  is  particularly  common  in  the  East  and  in  Russia,  and  is  frequently 
met  with  in  Germany,  Italy,  and  South  America.  In  some  regions  so  many 
cases  arise  year  after  year  that  the  district  obtains  an  evil  notoriety.  It  is 
stated  that  in  Novgorod,  Russia,  in  four  years  "56,000  horses,  cattle  and  sheep, 
and  528  men  perished  from  anthrax"  (Frank  S.  Billings,  in  "Twentieth  Century 
Practice").  It  is  a  rare  disease  in  the  United  States.  In  Philadelphia  cases 
occasionally  occur  in  workers  in  the  woolen  mills.  The  author  has  seen  5  cases 
of  human  anthrax,  4  of  which  occurred  in  Philadelphia  and  i  in  New  Jersey. 
Herbivora  are  most  liable,  next  omnivora,  but  carnivora  seldom  suffer.  Anthrax, 
as  met  with  in  man,  is  a  disease  contracted  in  some  manner  from  an  animal 
with  splenic  fever.  It  may  be  contracted  by  inoculation  while  working  around 
diseased  animals,  while  handling  or  tanning  their  hides,  or  sorting  their  hair  or 
wool;  brush-makers,  spinners,  workers  in  horn  and  combers,  rag  sorters,  veter- 
inary surgeons,  clippers,  stockmen, 
farmers,  and  butchers  may  become 
moculated.  Infection  may  take  place 
through  the  hair-follicles  of  unbroken 
skin.  Menschig  reported  2  such  cases 
C'N.  Y.  Med.  Jour.,"  Nov.  18, 1905). 
Anthrax  may  be  conveyed  by  eating 
infected  meat  or  by  drinking  infected 
milk.  Flies  may  carry  the  poison. 
Inhalation  of  poisoned  dust  may  in- 
fect the  lungs.  Catgut  ligatures  may 
be  contaminated  and  carry  the  poison. 
Blood-stained  wools  and  hides  are  a 
particular  peril.  It  is  stated  that 
in  England  i  out  of  7000  leather 
makers  dies  of  anthrax  each  year 
(Ponder,  in  "Lancet,"  Nov.  4,  191 1). 
Ponder  points  out  that  40  per  cent, 
of  English  cases  (arising  among  those 
working  in  the  hide,  skin,  and  leather 
industries)  are  due  to  Chinese  or  East 
Indian  goods;  that  no  anthrax  has 
ever  been  traced  to  wet  salted  hides; 
that  infection  may  arise  at  wharf, 
dockyard,  or  tannery;  that  the  pul- 
monary   form     occurs    particularly 

among  wool  workers;  that  among  those  who  work  with  hides,  skin,  and 
leather  cutaneous  anthrax  is  the  common  form,  and  intestinal  anthrax  is  ex- 
tremely rare. 

In  all  probability  many  slight  cases  are  recovered  from  without  being  recog- 
nized. This  would  explain  the  fact  that  it  is  particularly  among  recent  em- 
ployees that  anthrax  seems  to  occur  (Mitchell,  "Brit.  Med.  Jour.,"  April 4, 1911). 
Many  older  employees  may  be  immune  because  they  have  had  the  disease. 
Many  attempts  have  been  made  to  render  animals  immune  (Pasteur,  Wool- 
bridge,  Hankin) .  Pasteur's  method  has  been  used  in  France  with  decided  suc- 
cess, but  with  less  success  in  other  countries.  Pasteur  devised  a  method  for 
vaccinating  animals  against  anthrax  by  injecting  attenuated  cultures  beneath 
the  skin.  First,  a  much-attenuated  culture  is  used  and  later  a  stronger  one. 
When  an  animal  has  been  actively  immunized,  its  blood-serum  contains  pro- 


Fig.  133. — Anthrax.  Case  in  author's  wards 
in  Philadelphia  Hospital,  recovered.  Treated  by 
ipecac  both  externally  and  internally. 


302  Contusions  and  Wounds 

tective  materials  of  a  specific  nature  and  may  be  used  therapeutically.  The 
immunity  is  regarded  by  some  authorities  as  "a  phagocytic  immunity"  (Jor- 
dan's "General  Bacteriology").  Certain  organisms  are  antagonistic  to  anthrax 
(the  streptococcus  of  erysipelas,  the  pneumococcus,  the  Micrococcus  prodigio- 
sus,  and  the  Bacillus  pyocyaneus). 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease — external  and 
internal.  Internal  anthrax  may  be  intestinal  from  eating  diseased  meat, 
laryngeal  or  pulmonary  from  inhalation  of  poisoned  dust.  Intestinal  anthrax 
arises  only  when  the  bacilli  in  the  meat  contain  spores.  Koch  and  others  have 
pointed  out  that  the  non-sporulating  bacteria  are  destroyed  by  the  gastric  juice. 
Internal  anthrax  is  quick  in  progress,  and  death  sometimes  takes  place  within 
twenty-four  hours  of  the  onset  of  symptoms.  It  cannot  be  diagnosticated  with 
certainty  unless  bacilli  are  found  in  the  blood. 

External  anthrax  may  be  anthrax  carbuncle  or  anthrax  edema.  Anthrax  car- 
buncle or  malignant  pustule  appears  on  an  exposed  portion  of  the  body,  espe- 
cially the  face,  neck,  hand,  or  finger,  in  90  per  cent,  of  cases  of  external  anthrax. 
I  have  seen  one  upon  the  temple  and  one  on  the  neck.  It  appears  in  from 
twenty-four  hours  to  six  days  after  inoculation,  and  presents  an  itching,  burn- 
ing papule  with  a  purple  center  and  a  red  base;  in  a  few  hours  the  papule 
becomes  a  vesicle  which  contains  bloody  serum,  and  the  tissues  about  the 
papule  become  swollen,  reddened,  and  indurated.  The  vesicle  bursts  and 
dries,  the  base  of  it  swells  and  enlarges,  other  vesicles  appear  in  circles  around 
it,  and  there  is  developed  an  "anthrax  carbuncle,"  which  shows  a  black  or 
purple  elevation  with  a  central  depression  surrounded  by  one  or  more  rings 
of  vesicles.  The  surrounding  tissues  become  purple,  and  great  edema  may 
spread  widely,  the  vesicles  grow  very  large,  new  vesicles  form,  and  gangrene 
may  occur.  Pain  is  trivial  or  absent.  Lymphatic  enlargements  occur,  but 
pus  does  not  form.  The  constitutional  symptoms  may  rapidly  follow  the  local 
lesion,  but  may  be  deferred  for  a  week  or  more.  The  patient  feels  depressed, 
has  obscure  aches  and  pains,  and  is  feverish,  but  usually  keeps  about  for  a  short 
period.  In  some  cases  with  constitutional  symptoms  there  is  no  elevated  tem- 
perature, and  such  cases  are  frequently  fatal.  After  a  time  he  is  apt  to  develop 
rigors,  high  irregular  fevers,  sweats,  acute  fugitive  pains,  diarrhea,  deliriiun, 
typhoid  exhaustion,  dyspnea,  cough,  and  cyanosis.  The  carbuncle  of  anthrax 
is  distinguished  from  ordinary  carbuncle  by  the  central  depression,  the  adher- 
ent eschar,  the  absence  of  pain,  tenderness,  and  suppuration  of  the  first,  as 
contrasted  with  the  elevated  center,  the  multiple  foci  of  suppuration  and 
sloughing,  and  the  more  severe  pain  usual  in  the  second.  If  anthrax  has  a 
visible  lesion  and  the  constitutional  symptoms  are  slight  or  absent,  the  chance 
of  cure  is  good.  In  cases  which  get  well  a  line  of  demarcation  forms  about 
the  pustule  and  the  gangrenous  area  is  rather  rapidly  cast  off,  a  granulating 
surface  remaining. 

•Anthrax  Edema. — An  area  of  edema  surrounds  a  malignant  pustule  and 
often  spreads  widely,  but  in  cases  of  external  anthrax  without  a  pustule  there 
is  edema  alone.  This  lesion  occurs  in  connective  tissue,  especially  loose 
tissue.  It  is  a  spreading,  livid  edema,  with  an  ill-defined  margin.  There 
is  no  pain  and  usually  no  vesication  and  no  fever.  In  severe  cases,  however, 
there  is  fever,  vesicles  form,  and  gangrene  may  arise.  Anthrax  edema  differs 
from  cellulitis  in  the  absence  of  pus  formation,  and  from  malignant  edema 
by  the  less  disposition  to  result  in  gangrene.  Two  of  the  cases  I  have  seen 
were  anthrax  edema.  In  Horwitz's  case  in  the  Philadelphia  Hospital  the 
forearm,  arm,  and  shoulder  were  enormously  edematous.  In  Keen's  case 
in  the  Jefferson  College  Hospital  the  forearm  and  arm  were  edematous. 

Bacilli  in  the  Blood  in  All  Forms  of  Anthrax. — In  some  cases  they  are  found, 
in  others  they  are  not.     To  find  them  is  extremely  ominous,  as  most  cases  with 


Treatment  of  External  Anthrax  303 

bacilli-laden  blood  die.  Bacilli  are  seldom  found  until  thirty-six  hours  before 
death  (Mitchell,  in  "Brit.  Med.  Jour.,"  April  i,  1911).  In  fatal  cases  the  blood 
always  contains  bacilli. 

Prognosis. — When  bacUli  are  found  in  the  blood  the  prognosis  is  very 
bad.  Becker  knows  only  of  3  such  cases  which  survived  ("Mlinchener  medi- 
cinische  Wochen.,"  Jan.  23,  1912).  Of  Becker's  44  cases  which  had  no  bacilli 
in  the  blood,  43  recovered.  There  were  11  with  bacilli  in  the  blood  and  all  died. 
A  case  which  is  going  to  be  fatal  always  shows  bacilli  in  the  blood,  at  least 
within  thirty-six  hours  of  death.  Even  apparently  bad  cases  with  negative 
blood  findings  are  apt  to  recover  (Becker,  Ibid.).  During  six  years  the  Board  of 
the  Bradford  woolen  industry  reported  that  in  71  cases  of  anthrax  24  died  (15 
internal  and  9  external).  The  former  estimate  of  the  death-rate  from  external 
anthrax  was  from  25  to  30  per  cent.  If  a  lesion  is  upon  the  face  the  prognosis 
is  much  worse  than  if  it  is  upon  an  extremity,  and  if  upon  the  upper  extremity 
it  is  worse  than  if  it  is  upon  the  lower.  It  is  claimed  that  death-rate  has  been 
notably  reduced  by  modern  treatment,  and  under  serum  treatment  is  said  to 
be  but  little  over  6  per  cent.  In  a  series  of  1 5  cases  of  external  anthrax  re- 
ported by  Royer  and  Holmes  there  were  3  deaths  ("Therapeutic  Gazette," 
Jan.,  1908).     Eleven  of  these  cases  received  serum,  and  of  the  11,  2  died. 

Pulmonary  anthrax  and  intestinal  anthrax  have  been  regarded  as  in- 
variably fatal,  but  vastly  better  results  may  be  looked  for  hereafter. 

Prevention  of  Human  Anthrax. — Spores  are  the  great  danger.  Unfortu- 
nately, there  is  no  known  disinfectant  for  wool  which  will  kill  spores  and  not 
injiure  fabric  (London  letter  in  "Jour.  Am.  Med.  Assoc,"  Feb  17, 1912).  Blood- 
stained wools  are  the  great  peril.  The  blood  contains  the  spores  and  formalin 
will  not  penetrate  dried  blood.  Wet  salted  hides  are  entirely  safe,  and  govern- 
mental regulation  to  prevent  the  importation  of  any  other  kind  would  prevent 
anthrax  among  those  who  work  in  hide,  skin,  and  leather  industries  (Ponder,  in 
"Lancet,"  Nov.  4  191 1). 

Treatment  of  External  Anthrax. — If  a  person  is  wounded  by  an  object 
suspected  of  carrying  the  infection,  cauterize  the  woimd  by  the  hot  iron  or 
fuming  nitric  acid.  A  sufferer  from  anthrax  must  be  isolated  in  a  well-venti- 
lated room.  All  dressings  are  to  be  burned,  all  discharges  asepticized,  and 
after  the  removal  of  the  patient  the  bed-clothes  are  burned  and  the  room  dis- 
infected. If  there  are  no  bacilli  in  the  blood  a  malignant  pustule  should  be 
entirely  excised,  and  the  wound  mopped  out  with  pure  carbolic  acid  or  burned 
with  the  hot  iron.  If  there  is  an  extensive  area  of  edema,  it  should  be  freely 
incised  down  to  the  deep  fascia  at  several  points.  The  area  about  an  anthrax 
edema  or  an  excised  pustule  should  be  injected  every  sixth  hour  with  a  5  per 
cent,  solution  of  carbolic  acid.  The  wound  and  the  edematous  area  should  be 
dressed  with  hot  antiseptic  fomentations,  and,  if  dealing  with  an  extremity,  a 
splint  is  applied.  Excision  should  be  practised  for  pustule  even  when  glands  are 
enlarged.  When  excision  cannot  be  performed  make  crucial  incisions  through 
the  lesion,  mop  the  wounds  with  pure  carbolic  acid,  and  inject  about  and  in  the 
pustule  carbolic  acid  (i :  20)  every  six  hours  until  the  disease  abates  or  toxic 
symptoms  appear.  Dress  the  part  as  directed  above.  In  a  successful  case 
the  adherent  eschar  is  finally  separated  by  the  influence  of  the  fomentations. 
Davaine  advised  the  following  plan:  Inject  the  pustule  and  the  tissues  about 
it  at  many  points  every  eight  or  ten  hours  with  i  part  of  tincture  of  iodin 
diluted  with  2  parts  of  water  or  with  a  10  per  cent,  solution  of  carbolic  acid, 
or  with  a  0.1  per  cent,  solution  of  corrosive  sublimate.  Dress  with  wet  anti- 
septic gauze  and  apply  an  ice-bag.  Personally  I  would  not  use  an  ice-bag  on 
an  area  of  infection,  but  would  prefer  heat.  In  Keen's  very  severe  case  of  an- 
thrax edema  multiple  incisions  were  made,  carbolic  acid  was  injected  into 
sound  tissues  above  the  edema,  and  the  part  was  dressed  with  hot  antiseptic 


304  Contusions  and  Wounds 

fomentations.  Recovery  followed.  Constitutional  treatment  in  anthrax  ede- 
ma, malignant  pustule,  or  internal  anthrax  must  be  sustaining  and  stimulat- 
ing. Maffucci  gives  carbolic  acid  internally,  and  also  uses  it  externally. 
Davies-Colley  uses  ipecac  locally  and  gives  5  gr.  by  the  mouth  every  four  hours. 
Statistics  indicate  that  the  serum  treatment  is  of  the  greatest  value.  The 
material  is  known  as  Sclavo's  serum;  it  is  obtained  from  the  immunized  ass, 
and  it  was  introduced  into  practice  in  1897.  It  is  perfectly  harmless  and  may 
be  given  in  a  vein  or  subcutaneously.  Sclavo  injects  40  c.c.  in  different  regions 
of  the  wall  of  the  abdomen.  Usually  the  temperature  begins  to  fall  in  an 
hour;  if  improvement  is  not  obvious  in  twenty-four  hours,  the  dose  is  repeated. 
Intravenous  injection  is  reserved  for  severe  cases,  the  dose  being  10  c.c.  into  a 
subcutaneous  vein  of  the  dorsal  surface  of  the  hand.  The  serum  can  do  no 
harm  and  should  always  be  given.  If  given  early,  all  cases  but  very  severe 
ones  will  recover  (Legge's  Nilray  Lectures,  "Brit.  Med.  Jour.,"  March  18, 
1905).  Becker  ("Miinch.  med.  Woch.,"  Jan.  23,  1912)  has  given  salvarsan, 
and  he  believes  it  saved  the  life  of  a  very  ill  man.  The  persistence  of  anthrax 
infection  in  a  room  was  well  shown  in  the  record  of  Keen's  case.  The  infection 
lingered  on  the  floor  of  the  room  in  which  the  patient  had  been  operated  upon 
for  a  long  time.  Three  disinfections  were  necessary  before  it  became  impossible 
to  obtain  anthrax  bacilh  from  the  contaminated  floor.  This  indicates  that  such 
a  case  should  be  operated  upon  in  a  room  not  regularly  used  for  operations. 

Hydrophobia,  Rabies,  or  Lyssa. — Hydrophobia  is  a  spasmodic  and 
paralytic  disease  due  to  inoculation  with  virus  from  a  rabid  animal.  In- 
oculation is  nearly  always  through  a  wound,  but  cases  occur  after  the  licking 
of  the  hand  by  a  diseased  dog.  The  disease  does  not  appear  to  arise  except 
as  the  result  of  inoculation.  It  is  most  common  in  dogs  and  wolves,  but  it 
may  develop  in  cats,  horses,  goats,  foxes,  cattle,  sheep,  and  pigs.  Cats  are 
said  to  cause  6  per  cent,  of  the  cases  (Cumming,  in  "Jour.  Am.  Med.  Assoc," 
May  18,  191 2).  Lack  of  water  is  never  a  cause.  It  is  far  more  common  in 
the  carnivora  than  the  herbivora.  In  Russia  wolves  are  responsible  for  many 
cases.  It  is  said  that  poultry  may  suffer  from  it.  Human  hydrophobia  in 
most  instances  follows  dog  bites.  Roux  estimates  that  about  14  per  cent,  of 
the  people  bitten  by  mad  animals  develop  the  disease.  If  the  bite  is  on  an 
exposed  part,  it  is  far  more  apt  to  cause  rabies  than  if  the  rabid  animal's  teeth 
passed  through  clothing.  The  saliva  is  the  usual  vehicle  of  contagion,  but  other 
fluids  and  tissues  contain  the  virus,  especially  the  brain  and  cord.  The  blood 
and  urine  do  not  contain  it.  Hydrophobia  has  been  known  for  centuries.  It 
is  not  spoken  of  by  Hippocrates,  but  is  described  in  animals  by  Aristotle, 
Pliny,  and  Celsus,  and  is  alluded  to  by  Ovid,  Horace,  Virgil,  and  Plutarch. 
Celsus  first  described  the  disease  in  man  and  first  used  the  term  "hydrophobia." 
At  the  present  day  some  ardent  antivivisectionists  dispute  its  existence.  The 
fact  that  an  infant  bitten  by  a  rabid  animal  may  develop  rabies  proves  that 
the  disease  is  not  due  to  the  imagination.  Hydrophobia  is  almost  invariably 
fatal.  No  causative  micro-organism  has  been  demonstrated.  One  must 
exist,  but  it  probably  escapes  detection  because  of  its  very  small  size.^  Negri 
has  discovered  in  the  central  nervous  system  bodies  which  are  probably 
protozoa  and  are  perhaps  the  cause  of  the  disease.  They  are  called  Negri 
bodies.  The  poison  cannot  gain  entrance  through  sound  mucous  membrane. 
It  used  to  be  thought  that  the  disease  was  particularly  apt  to  arise  in  hot 
weather,  but  it  is  now  known  that  it  may  occur  any  time  of  the  year.  There 
was  a  veritable  epidemic  of  it  among  the  animals  in  Greenland  in  i860,  and  at 
this  time  the  temperature  averaged  25  degrees  below  zero  (F.  W.  Dudley,  in 
"Jour.  Am.  Med.  Assoc,"  Dec.  19,  1908).     It  is  common  in  Russia.      No 

1  Since  the  above  was  written  Noguchi  has  announced  the  discovery  of  the  causative 
protozoon. 


Symptoms  of  Hydrophobia  305 

portion  of  the  world  is  completely  exempt.  No  constant  postmortem  lesions 
have  been  certainly  demonstrated  in  those  dead  of  rabies.  Gowers  believes 
that  in  the  spinal  cord  there  is  hyperemia,  but  no  inliltration  with  cells,  whereas 
in  the  medulla,  especially  about  the  respiratory  center,  there  are  hyperemia 
and  cellular  infiltration  of  the  perivascular  spaces;  but  such  perivascular 
infiltration  can  occur  in  some  other  acute  conditions  and  hence  is  not  charac- 
teristic. What  is  known  as  the  rabic  tubercle  is  found  in  the  medulla  and  about 
the  motor  cells  of  the  upper  part  of  the  spinal  cord.  Each  tubercle  consists 
of  an  aggregation  of  embryonal  cells,  which  destroy  and  finally  replace  the  nerve- 
cells  which  they  surround.  Babes  thinks  the  tubercle  characteristic.  In- 
filtration of  the  ganglia  with  epithelioid  cells  and  round  cells  has  been  held  by 
some  to  be  characteristic,  but  both  the  rabic  tubercle  and  ganglion  infiltration 
occur  in  other  conditions.  The  disease  is  extremely  rare  in  the  United  States 
and  the  author  has  not  seen  a  single  case. 

If  a  dog  is  poisoned  with  barium  carbonate  the  symptoms  are  similar  to 
those  of  rabies  ("Penna.  Health  Bulletin,"  Aug.,  1909). 

Symptoms. — The  period  of  incubation  of  himian  hydrophobia  is  from  a  few 
weeks  to  several  months,  and  it  has  been  alleged  that  it  may  even  be  two 
years,  but  it  is  very  doubtful  if  there  is  ever  a  period  of  incubation  of  over 
six  or  seven  months.  The  average  incubation  period  in  man  is  forty  days 
(Ravenel).  The  initial  symptoms  are  mental  depression,  anxiety,  sleepless- 
ness, restlessness,  headache,  malaise,  and  often  pain  or  even  congestion  in 
the  cicatrix.  The  anxiety  which  is  usually  present  may  be  deepened  into 
actual  fear.  In  dogs  the  condition  of  fear  is  so  evident  that  Caelius  Aure- 
lianus  centuries  ago  called  the  disease  pantophobia  (fear  of  everything).  The 
previously  mentioned  symptoms  are  qmckly  followed  by  dysphagia.  It 
is  not  only  water  that  is  difficult  to  swallow,  but  everything  the  patient  tries 
to  drink  or  eat.  The  difficulty  in  swallowing  results  apparently  from  apnea 
produced  instantly  when  an  attempt  is  made  to  swallow.  Curtis  points 
out  that  the  difficulty  is  not  spasm  of  the  pharynx  and  larynx,  but  a  sense  of 
immediate  suffocation  due  to  reflex  stimulation  of  respiratory  inhibition. 
If  spasms  occur — and  they  may  occur — they  are  secondary  to  this  suffocative 
state,  a  state  in  which  the  action  of  the  diaphragm  ceases  for  a  time.  The 
air-passages  become  congested  and  the  sufferer  makes  frequent  and  painful 
efforts  to  expel  thick  mucus,  and  the  efforts  produce  paroxysms  of  suffocation. 
Between  the  paroxysms  the  patient  is  evidently  somewhat  breathless,  and 
Warren  tells  us  that  his  speech  is  not  unlike  that  "of  a  child  who  has  recently 
been  crying  and  is  endeavoring  to  control  itself"  ("Surgical  Pathology  and 
Therapeutics").  As  the  condition  grows  worse,  suffocative  attacks,  which 
were  at  first  induced  by  attempts  at  swallowing,  come  to  be  caused  also  by 
bright  lights,  sudden  or  loud  noises,  irritations  of  the  skin,  or  even  thinking  of 
swallowing.  At  length  suffocative  paroxysms  occur  spontaneously  and  the 
patient  jumps,  or  hurls  himself  about,  or  the  muscles  of  the  entire  body  are 
thrown  into  clonic  spasm.  Tonic  spasm  does  not  occur.  A  condition  of  general 
hyperesthesia  exists.  The  mind  is  usually  clear,  although  during  the  periods 
of  excitement  there  may  be  maniacal  furor  with  hallucinations  which  pass 
away  in  the  stage  of  relaxation.  The  temperature  is  moderately  elevated 
(101°  to  103°  F.  or  higher).  The  spasmodic  stage  lasts  from  one  to  three 
days,  and  the  patient  may  die  during  this  stage  from  exhaustion  or  from 
asphyxia.  If  he  lives  through  this  period,  the  convulsions  gradually 
cease,  the  power  of  swallowing  returns,  and  the  patient  succimibs  to  ex- 
haustion in  less  than  twenty-four  hours,  or  he  develops  ascending  paralysis 
which  soon  causes  cardiac  and  respiratory  failure.  In  what  is  known  as 
paralytic  rabies,  a  very  rare  form  of  the  disease  in  human  beings,  the  attack 
comes  on  with  the  same  early  symptoms  met  with  in  the  commoner  form. 


3o6  Contusions  and  Wounds 

but  paralysis  soon  begins  about  the  bitten  part  and  spreads  to  all  the  limbs 
and  to  the  trunk. 

In  hydrophobia  death  is  almost  inevitable.  Practically  all  cases  in  which 
it  is  alleged  that  recovery  ensued  were  not  true  hydrophobia,  but  hysteria. 
An  exception  must  be  made  of  Murri's  case.  Wood  says  that  in  hysteria, 
especially  among  boys,  "beast-mimicry"  is  common,  the  sufferer  snarling  like 
a  dog;  and  in  the  form  known  as  ^'spurious  hydrophobia,"  in  which  there  may 
or  may  not  be  convulsions,  there  are  a  dread  of  water,  emotional  excitement, 
snarling,  and  attempts  to  bite  the  bystanders  (in  genuine  hydrophobia  no  at- 
tempts are  made  to  bite,  and  no  sounds  are  uttered  like  those  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  paroyxsms  of  suffocation  and  the 
absence  of  tonic  spasms  in  the  former,  as  contrasted  with  the  fixation  of  the  jaws 
and  the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid  animal  and  is 
seen  soon  after  the  injury,  constriction  should  be  applied  if  possible  above  the 
wound,  the  wounded  area  should  be  incised,  allowed  to  bleed  freely,  and  should 
then  be  washed  with  a  5  per  cent,  solution  of  formaldehyd  and  dressed  for 
twelve  hours  with  a  like  solution.  It  is  held  that  formaldehyd  is  a  specific 
disinfectant  of  the  virus  (Gumming,  in  "Jour.  Am.  Med.  Assoc,"  May,  8, 191 2). 
If  not  seen  for  a  day  or  two,  open  the  wound  and  scrub  with  a  5  per  cent, 
solution  of  formaldehyd.  Many  physicians  advocate  excising  the  wounded 
area  and  cauterizing  with  pure  nitric  acid,  a  hot  iron,  or  the  Paquelin  cau- 
tery. Fimiing  nitric  acid  is  warmly  commended  by  Paul  Bartholow  and 
others.  Ravenel  believes  it  may  save  a  man  even  after  twenty-four  hours  have 
elapsed  since  the  bite.  After  the  wound  has  been  treated  with  formaldehyd 
or  cauterized  it  is  to  be  dressed  antiseptically.  If  the  patient  is  not  seen  for 
a  day  or  two  after  the  injury,  cauterization  is  useless;  it  is  not  only  useless, 
but  it  may  delude  the  patient  and  his  friends  into  a  feeling  of  security.  In 
any  case,  early  or  late,  send  the  patient  at  once  to  a  Pasteur  institute.  If 
the  animal  which  inflicted  the  injury  was  not  hydrophobic,  no  harm  will  result 
from  inoculations;  if  it  was  hydrophobic,  preventive  treatment  may  save  the 
patient.  The  method  known  as  the  preventive  treatment  was  devised  by  Pas- 
teur, who  discovered  the  following  remarkable  facts :  If  the  virus  of  a  rabid  dog 
(street  rabies)  be  placed  beneath  the  dura  of  another  dog,  it  always  causes  hy- 
drophobia in  from  sixteen  to  twenty  days,  and  invariably  causes  death.  If  the 
virus  is  passed  through  a  series  of  rabbits  it  gets  stronger  (laboratory  virus), 
and  if  inserted  beneath  the  dura  of  a  dog  it  causes  the  disease  in  from  five  to  six 
days,  and  kills  in  four  or  five  days.  The  virus  can  be  attenuated  by  passing 
it  through  a  series  of  monkeys  or  by  keeping  it  for  a  definite  time.  To  obtain 
attenuated  preparations  in  a  convenient  form  Pasteur  made  emulsions  from 
the  spinal  cords  of  hydrophobic  rabbits,  the  animals  having  been  dead  two  or 
three  weeks.  He  found  that  the  emulsion  obtained  from  the  rabbit  longest 
dead  is  the  weakest.  He  injected  a  dog  with  emulsions  of  progressively  in- 
creasing strength  and  made  it  immune  to  hydrophobia.  The  patient  is  injected 
with  an  emulsion  made  from  the  dried  spinal  cords  of  hydrophobic  rabbits.  In 
this  emulsion  the  virus  is  attenuated,  and  day  by  day  the  strength  of  the  in- 
jected virus  is  increased.  These  emulsions  cause  the  body-cells  to  form  anti- 
toxin, and  either  the  virus  of  street  rabies  does  not  develop  at  all  or  by  the  time 
it  begins  to  develop  a  quantity  of  antitoxin  is  present  to  antagonize  it.  In  the 
New  York  Pasteur  Institute  patients  remain  under  treatment  for  fifteen  da^^s, 
two  inoculations  being  given  daily.  In  cases  in  which  treatment  is  begun  late, 
or  in  which  the  head  or  face  was  bitten,  from  four  to  six  inoculations  are  given 
each  day.  The  report  of  the  Parisian  Pasteur  Institute  shows  that  since  its 
foundation  there  has  been  a  mortality  of  0.5  per  cent.  The  lowest  estimated 
number  of  those  attacked  by  hydrophobia  before  this  method  was  used  was  5 


Glanders,   Malleus,   Farcy,  or  Equinia  307 

per  cent,  of  those  bitten,  and  all  attacked  died;  hence,  the  Pasteur  treatment  as 
applied  in  the  Parisian  Institute  shows  one-tvventy-fifth  of  the  mortalit\-  which 
attends  other  preventive  methods.  In  the  Paris  Pasteur  Institute  during  1910 
401  patients  were  treated  without  a  death.  Ravenel,  in  1901,  estimated  that 
55,000  persons  have  been  treated  by  the  Pasteur  method  and  that  less  than  i 
per  cent,  have  died.  The  value  of  this  plan  seems  definitely  established.  The 
general  public  believes  that  the  dog  which  did  the  biting  should  be  killed.  The 
dog  should,  if  possible,  be  locked  up  and  watched  rather  than  killed.  It  may 
be  proved  in  this  way  that  it  did  not  have  hydrophobia.  If  it  were  necessary 
to  kill  the  dog,  or  if  the  dog  was  killed  at  once  or  soon  after,  the  physicians  of 
the  New  York  Pasteur  Institute  advise  that  the  dog's  head  be  cut  from  the 
body  with  an  aseptic  knife  and  a  piece  of  the  medulla  oblongata  be  abstracted. 
The  bit  of  medulla  should  be  placed  in  a  mLxture  of  equal  parts  of  glycerin  and 
water  which  was  previously  sterilized  by  boiling.  The  bottle  should  be  sealed 
and  sent  to  the  institute,  in  order  that  inoculations  may  be  made  upon  animals 
to  prove  the  existence  or  absence  of  hydrophobia.  Babes  tubercles  and  Negri's 
bodies  are  at  once  sought  for  in  the  specimen,  and  if  they  are  found,  treatment 
should  be  started  at  once.  In  the  paroxysm  of  hydrophobia  the  treatment 
in  the  past  was  purely  palliative.  If  we  employ  only  palliative  methods,  keep 
the  patient  in  a  dark,  quiet  room,  relieve  thirst  by  enemata,  saturate  him  with 
morphin,  empty  the  bowels  by  enemata,  attend  to  the  bladder  by  regular 
catheterization,  and  during  the  paroxysms  anesthetize.  Murri,  of  Bologna, 
cured  a  case  of  hydrophobia  by  injecting  emulsions  of  cords  of  rabbits  dead 
six,  five,  four,  and  three  days  respectively.  It  would  be  proper  to  try  this 
remedy  if  hydrophobia  develops.  A  serum  has  been  prepared  by  Tizzoni  and 
Centani  which  they  claim  is  successful  in  treating  the  disease  as  experimentally 
induced  in  the  laboratory.  The  remarkable  suggestion  has  come  from  Tizzoni 
that  rabies  be  treated  with  rays  of  radium,  it  having  been  shown  that  rabic 
virus  can  be  destroyed  by  radium. 

Glanders,  Malleus,  Farcy,  or  Equinia. — Glanders  is  an  infectious 
eruptive  fever  occurring  in  horses,  mules,  and  asses,  sometimes  noted  in 
goats,  hogs,  dogs,  cats,  and  some  other  animals,  and  communicable  to  man. 
Cattle,  house  mice,  house  rats,  white  mice,  and  white  rats  are  immune.  The 
disease  is  most  common  in  the  horse  and  is  due  to  the  Bacillus  mallei  (see 
page  52).  These  baciUi  are  found  chiefly  in  the  nasal  discharge  and  the  recent 
nodules.  There  are  few  in  older  ulcerations.  They  are  not  found  in  the  blood. 
Human  glanders  is  by  no  means  as  imcommon  as  was  once  thought.  Not  a 
few  cases  die  undiagnosticated.  In  a  recent  study  156  cases  of  chronic  glanders 
were  discussed  (Robin,  "Studies  from  the  Royal  Victoria  Hospital  of  Montreal," 
1906).  If  the  nodules  occm:  in  the  nares,  the  disease  is  called  "glanders";  if 
beneath  the  skin,  it  is  termed  "farcy."  The  Bacillus  mallei  is  communicated 
to  man  through  an  abraded  surface  or  a  mucous  membrane.  Bernstein  and 
Carling  reported  6  cases  of  human  glanders.  They  say:  "In  none  of  our  cases 
was  there  definite  evidence  of  the  point  of  inoculation  or  path  of  infection,  and 
the  general  evidence,  clinical  and  experimental,  on  both  of  these  questions  is  so 
conflicting  that  the  time  is  hardly  ripe  for  the  expression  of  decided  opinions. 
The  hypothetic  paths  are  by  direct  inoculation  through  a  wound  or  by  the 
hair-foUicles,  by  inhalation  or  by  ingestion  ("Brit.  Med.  Jour.,"  Feb.  6,  1909). 
The  characteristic  lesions  are  infective  granulomata  in  the  nares,  skin,  lungs, 
and  subcutaneous  tissue.  In  the  nares  granulomata  result  in  ulcers  and  under 
the  skin  break  down  into  abscesses.  In  some  cases  there  is  no  nasal  discharge. 
Multiple  abscesses  anywhere  should  excite  suspicion  of  the  existence  of  glan- 
ders. From  the  site  of  inoculation  the  bacilli  are  disseminated  and  the  cutaneous 
and  muscular  structures  and  lungs  become  involved.  There  is  usually  a 
remittent  fever.     There  is  no  known  method  of  immimizing  animals  and  mallein 


3o8  Contusions  and  Wounds 

has  no  immunizing  power.  One  attack  does  not  prevent  another.  Man  may 
be  infected  from  a  diseased  animal,  and  as  the  common  source  of  infection  is 
the  horse,  the  usual  victims  are  those  who  use  or  work  about  horses,  and  yet 
people  who  have  never  been  about  horses  may  develop  the  disease.  The  period 
of  incubation  after  infection  is  four  or  five  days. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is  septic  inflam- 
mation at  the  point  of  inoculation;  nodules  may  form  in  the  nose  and  ulcerate; 
there  is  profuse  nasal  discharge ;  the  glands  of  the  neck  enlarge ;  there  is  weak- 
ness, frontal  headache,  chilliness,  pain  in  the  back  and  limbs;  often  diar- 
rhea ;  after  a  time  the  muscles  become  painful ;  there  is  fever,  the  evening  tem- 
perature being  ioo°  F.  or  higher  and  the  morning  temperature  being  lower. 
Chills  may  occur.  There  may  be  chest  pains,  severe  muscular  pain,  bron- 
chitis, and  signs  of  pulmonary  congestion.  The  lungs  may  be  infected  by 
inspiration  of  the  bacilli  in  the  discharge  of  the  ulcers.  It  may  not  be  sus- 
pected that  the  patient  has  glanders  and  the  diagnosis  of  typhoid  may  per- 
haps be  made.  Twelve  to  fourteen  days  after  the  beginning  of  the  trouble  little 
hard  lumps  arise  in  the  muscles  and  just  beneath  the  skin.  In  a  few  days 
the  lumps  soften,  break  down,  and  discharge  a  bloody  fluid  which  contains 
the  bacilli  of  glanders.  In  a  number  of  cases  an  eruption  resembling  small- 
pox appears  on  the  face  and  about  the  joints,  and  this  exanthem  is  usually 
prophetic  of  approaching  death.  It  differs  from  small-pox  in  not  being  um- 
bilicated.  Leukocytosis  may  or  may  not  exist.  In  chronic  glanders  there  are 
like  symptoms  which  last  six  weeks  or  more.  Acute  glanders  is  nearly  always 
fatal.  Chronic  glanders  lasts  for  months,  is  rarely  diagnosticated,  being  mis- 
taken for  catarrh,  may  be  recovered  from,  but  if  not  soon  eradicated  "^vill  sooner 
or  later  eventuate  in  a  fatal  acute  condition.  The  mortality  is  about  90  per 
cent. 

Acute  and  Chronic  Farcy. — Acute  farcy  arises  at  the  site  of  a  skin  inocu- 
lation; it  begins  as  an  intense  inflammation,  from  which  emerge  inflamed 
lymphatics  that  present  nodules  or  "farcy-hids.'"  Abscesses  form,  but  the  pus 
differs  in  appearance  from  ordinary  pus,  is  often  gelatinous,  and  may  be  red  in 
color.  There  are  joint-pains  and  the  constitutional  symptoms  of  sepsis,  but  no 
involvement  of  the  nares.  In  it  nodules  occur  upon  the  extremities,  which 
nodules  break  down  into  abscesses  and  eventuate  in  ulcers  resembling  those  of 
tuberculosis  or,  perhaps,  of  syphilis.     The  ulcers  form  rapidly  and  often  heal. 

Diagnosis  of  Glanders  and  Farcy. — Mallein  is  a  concentration  of  the  glycerin 
broth  in  which  the  bacilli  of  glanders  w^ere  grown.  Injection  of  mallein  into  an 
infected  animal  produces  a  significant  reaction  (fever,  malaise,  restlessness, 
perhaps  a  distinct  rigor,  sometimes  vomiting,  marked  swelling  at  the  point  of 
inoculation).  The  dose  used  is  10  to  15  min.  (Bernstein  and  Carling,  in  "Brit. 
Med.  Jour.,"  Feb.  6,  1909). 

Mallein  has  proved  highly  valuable  in  the  hands  of  veterinarians.  The 
reaction  when  it  is  injected  into  an  animal  with  glanders  is  like  the  reaction 
produced  by  tuberculin  on  a  tuberculous  animal. 

Animal  injection  is  very  valuable  in  diagnosis.  The  highly  susceptible 
guinea-pig  is  used  for  this  purpose.  The  doubtful  material  (nasal  mucus  or  pus 
or  a  tissue  fragment)  is  injected  into  the  peritoneal  sac  of  a  male  guinea-pig. 
Usually  in  three  or  four  days  the  testicles  enlarge  and  later  suppurate. 

The  pig  is  killed  and  the  pus  examined  for  the  bacillus  of  glanders.  Testic- 
ular enlargement  does  not  always  occur  even  when  the  inoculated  material 
was  from  a  lesion  of  glanders.  In  some  cases  it  does  not  occur  for  weeks.  As 
a  rule,  it  does  occur. 

In  the  lesions  of  glanders  the  bacilli  of  the  disease  are  scanty  and  in  many 
lesions  are  mingled  with  other  bacteria,  hence  the  bacteriologic  diagnosis  is 
always  difficult  and  is  often  impossible  mthout  animal  inoculation.     The 


Actinomycosis  309 

value  of  an  agglutination  test  is  as  yet  undetermined,  but  it  is  regarded  with 
confidence  by  some. 

Treatment. — In  treating  this  disease  the  point  of  infection  is  at  once  to 
be  incised  and  cauterized,  dusted  with  iodoform,  and  dressed  antiseptically. 
The  skin  over  enlarged  glands  and  swollen  lymphatics  is  to  be  painted  with 
iodin  and  smeared  with  ichthyol.  Bandages  are  applied  to  edematous  extrem- 
ities. Ulcers  are  curetted,  touched  with  pure  carbolic  acid,  dusted  with  iodo- 
form, and  dressed  antiseptically.  In  glanders  the  nostrils  should  be  sprayed  at 
frequent  intervals  with  peroxid  of  hydrogen  and  syringed  with  a  solution  of 
sulphurous  acid.  The  mouth  must  be  rinsed  repeatedly  with  solutions  of 
chlorate  of  potassium.  Abscesses  are  to  be  opened,  mopped  with  pure  car- 
bolic acid,  and  dressed  antiseptically,  Stimiilants  and  nourishing  diet  are 
imperatively  demanded.  Morphin  is  necessary  for  the  muscular  pain,  restless- 
ness, and  insomnia.  Digitalis  is  given  to  stimulate  the  circulation  and  kid- 
ney secretion.  Sulphur  iodid  and  arsenite  of  strychnin  have  been  used. 
Diseased  horses  ought  at  once  to  be  kUled  and  their  stalls  should  be  torn  to 
pieces,  purified,  and  entirely  rebuilt.  A  man  with  chronic  glanders  should 
be  removed  to  the  seaside.  The  nasal  passages  must  be  kept  clean  and  the 
ulcers  must  be  cauterized  and  dressed  with  iodoform  gauze.  Nutritious  foods, 
tonics,  and  stimulants  are  necessary. 

Treatment  of  recent  cases  by  frequent  small  doses  of  mallein  finds  advocates. 
It  has  been  suggested  that  injection  of  the  serum  of  the  blood  of  an  immune  ani- 
mal (the  ox,  for  instance)  might  be  serviceable.  Most  observers  assert  that 
serum  of  naturally  immune  animals  and  the  serum  of  animals  which  have  been 
repeatedly  injected  with  mallein  are  equally  worthless. 

Actinomycosis  {streptotrichosis)  is  a  specific  infectious  disorder  character- 
ized by  chronic  infiltrating,  granulomatous  inflammation,  and  is  due  to  the 
presence  in  the  tissues  of  some  variety  of  streptothrix.  It  was  long  believed 
that  the  actinomyces  bovis  or  ray-fungus  was  the  only  cause  of  the  disease. 
We  now  believe  that  other  members  of  the  streptothrix  group  may  be  respon- 
sible. As  stated  on  page  19  the  streptothrices  are  usually  regarded  as  molds, 
but  they  possibly  constitute  a  transition  stage  between  filamentous  fungi  and 
bacteria.  At  present  many  pathologists  use  the  term  "actinomyces"  as  the 
generic  name  for  the  various  forms  of  these  parasites.  Other  pathologists 
designate  them  as  streptothrix  forms,  of  which  the  actinomyces  bovis  is  one. 
In  1877  Bollinger  recognized  and  described  these  parasites  as  causative  of  dis- 
ease in  cattle.  In  1878  Israel  described  human  actinomycosis.  Acland,  in  1884, 
reported  the  first  English  case  of  human  actinomycosis.  Some  of  the  varieties  of 
the  organism  are  pathogenic,  others  do  not  seem  to  be.  Some  forms  are  anae- 
robic, others  are  aerobic.  When  dried  they  are  not  killed  at  once,  but  months 
after  may  develop  if  placed  under  favorable  conditions.  When  growing  in 
the  tissues  they  usually  form  numerous  distinct  yellow,  reddish,  black,  or  gray 
aggregations,  each  about  the  size  of  a  sand  grain,  and  called  from  their  color 
sulphur  grains  or  red  pepper  grains.  They  grow  from  mycelia.  Usually  the 
growths  lie  in  thick  and  sticky  purulent  matter.  If  purulent  matter  containing 
growths  is  rubbed  between  the  fingers,  it  will  give  a  gritty  sensation  like  sand 
if  the  growth  is  not  very  recent.  The  grit  is  due  to  lime-salts.  The  growth  of 
the  fungi  causes  the  formation  of  an  infective  granuloma,  and  great  masses 
of  granulation  tissue  may  form  with  collections  of  necrotic  or  purulent  matter 
here  and  there,  and  zones  of  fibrous  tissue.  Thejungi  are  easily  discovered 
in  the  sulphur  grains  by  the  microscope,  but  if  the  fungi  are  mycelial  and  are 
scattered  instead  of  being  gathered  into  granules  it  is  difficult  to  discover 
them.  This  disease  occurs  in  cattle  (lumpy  jaw)  and  in  pigs,  and  can  be  trans- 
mitted to  man.  It  is  believed  by  many  that  the  fungi  exist  normally  inside 
the  husks  of  barley  and  other  grasses  and  that  animals  are  inoculated  by  eating 


3IO  Contusions  and  Wounds 

•the  contaminated  grasses,  scratches  on  the  mucous  membrane  of  the  tongue, 
mouth,  or  pharynx  being  inoculated.  In  man  the  fungus  may  be  taken  in  with 
food,  by  chewing  the  mold-bearing  grass  or  straw,  or  by  inhalation  of  contami- 
nated dust.  Its  development  seems  dependent  upon  processes  of  decay.  It 
may  lodge  and  develop  in  a  breach  of  mucous  continuity,  a  crypt  of  the  tonsil, 
or  a  hollow  tooth. 

Lord,  of  Boston,  has  found  the  parasite  in  carious  teeth  of  those  free  from 
actinomycosis,  and  has  produced  actinomycosis  in  guinea-pigs  by  inoculating 
them  wdth  the  contents  of  carious  teeth  ("Publications  of  the  Massachusetts 
General  Hospital,"  Oct.,  1911).  Lord  reaches  the  conclusion  that  true  actino- 
mycosis (the  disease  due  to  ray-fungi)  arises  from  within  the  mdividual,  carious 
teeth  being  the  cause. 

The  disease  is  at  first  local;  later  there  may  be  general  blood  infection 
and  abscesses  may  form  in  the  lung,  liver,  kidney,  etc. 

The  fungi  ma}^  pass  into  the  lungs,  causing  pulmonary  actinomycosis;  into 
the  intestines,  causing  intestinal  actinomycosis;  into  the  skin,  the  bones,  the 
subcutaneous  tissues,  the  heart,  the  brain,  the  liver,  the  urinary  organs,  etc. 
Abdominal  anthrax  is  the  commonest  form  and  comprises  nearly  50  per  cent, 
of  cases.  Cases  of  human  actinomycosis  until  recently  were  looked  upon  as 
sarcomata.    Many  sinuses  form,  ulcers  develop,  but  large  abscesses  do  not  arise. 

Cutaneous  actinomycosis  may  be  secondary  to  visceral  infection  with  the 
disease,  may  be  a  purely  local  condition  due  to  inoculation  of  a  wound,  or  may 
be  associated  with  some  adjacent  area  of  bone  infection.  The  gummatous  form 
of  actinomycosis  resembles  a  gummatous  syphilitic  area,  and  in  it  many  small 
purulent  pockets  open  by  fistulae. 

In  actinomycosis  there  is  no  spread  by  lymphatics  until  very  late  in  the 
case.  In  fact,  the  adjacent  lymph-glands  are  very  seldom  involved  unless  there 
is  secondary  pyogenic  infection,  and  if  metastasis  occurs  it  takes  place  by  the 
veins.  The  condition  causes  but  slight  pain.  A  diagnosis  must  be  made  from 
syphilis,  sarcoma,  carcinoma,  and  tuberculosis.  The  formation  of  a  tumor, 
foUow^ed  by  sinuses  and  ulceration,  the  ulcer  having  thin,  non-indurated,  under- 
mined edges  and  edematous  granulations,  and  adjacent  pus  ca\dties  joining  by 
sinuses,  the  appearance  of  the  pus  and  the  microscopic  study  of  the  discharge 
are  significant.  An  actinomycotic  ulcer  may  partially  heal  here  and  there. 
It  has  been  stated  that  an  individual  wdth  actinomycosis  may  react  to  tuberculin 
like  a  person  with  tuberculosis  (see  page  227).  The  muscular  and  connective 
tissues  become  infiltrated  and  hard,  as  though  a  coagulating  material  had  been 
injected  into  them  (Poncet  and  Berard,  in  "Lyon  Medicale,"  March  27,  1904). 
Edema  and  induration  extend  wide  of  the  active  focus  of  disease  (Plate  2) . 
Actinomycosis  may  last  for  years  or  it  may  prove  fatal. 

In  the  anthracoid  form  there  are  no  distinct  purulent  collections,  but  many 
fistulce  discharge  pus  at  various  points  (Monestie). 

An  area  of  cutaneous  actinomycosis  is  characterized  by  the  existence  of 
violet,  blue,  gray,  or  black  maculee,  var}ang  in  size  from  that  of  a  pin's  head 
to  that  of  a  bean,  the  center  of  each  macule  being  white  and  containing  a 
minute  quantity  of  pus  (Der\dlle). 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes  painful,  the  parts 
adjacent  swell  from  infiltration  and  soften,  pus  forms  and  reaches  the  surface 
through  fistulae,  and  the  skin  becomes  involved  secondarily. 

Abdominal  actinomycosis  takes  origin  from  the  gastro-intestinal  tract, 
an  actinomycotic  nodule  of  the  intestine  having  ulcerated,  adhesions  having 
formed,  and  an  actinomycotic  abscess  havuig  arisen,  or  actinomycotic  disease 
of  the  intestine  having  spread.  In  over  50  per  cent,  of  cases  of  abdominal 
actinomycosis  the  cecum  is  the  part  attacked.  A  fecal  fistula  may  form  and 
the  liver  may  be  mvolved.    At  least  150  cases  of  actinomycosis  of  the  appendix 


ACTIXO-MYCOSIS. 


Plate  2. 


Author's  case  of  facial  actinomycosis. 


Blastomycosis  311 

have  been  reported.  A  mass  containing  putrid  pus  develops.  If  not  evacuated 
listulae  form.  It  is  a  verv'  chronic  condition,  and  although  fistulae  ma}-  heal, 
they  break  open  again  and  again  (Short,  in  "Lancet,"  Sept.  14,  1907).  The 
fmigi  may  be  found  in  the  stools. 

The  mortaUty  of  actinomycosis  depends  upon  the  site  of  infection,  the 
question  of  secondary  infection,  and  the  plan  of  treatment.  If  pyogenic  in- 
fection occurs,  fatal  pyemia  may  arise.  The  prognosis  is  reasonably  good  in 
many  cases.  The  majority  of  cutaneous  cases  (nearly  90  per  cent.)  and  many 
osseous  cases  can  be  cured.  The  mortality  m  the  abdominal  cases  is  large. 
Grill  says  that  of  77  abdominal  cases  treated  surgically  45  died,  22  recovered, 
and  10  were  improved.  Frazier  ("Keen's  System  of  Surgen,-'')  teUs  us  that 
the  mortality  of  the  reported  cases  of  actinomycosis  in  the  United  States  was 
47  per  cent.,  and  quotes  Jiron  as  follows  regarding  the  mortality  of  the  various 
forms:  Face  and  neck,  11  per  cent.;  thorax,  83  per  cent.;  abdomen,  71  per 
cent.;  brain,  100  per  cent.  Actinomycosis  has  a  strong  tendency  to  redevelop 
even  after  apparently  thorough  excision.  A  case  of  cutaneous  actmomycosis 
of  the  arm,  seen  by  the  author,  was  operated  on  twenty  times.  Ulceration 
took  place  into  the  axiUan.-  arter\-  and  death  was  narrow!}-  averted.  Recover}- 
hnally  ensued.  I  have  seen  4  cases  of  human  actinomycosis:  one  was  the 
patient  just  referred  to;  another  was  a  mattress  stuffer  (straw  being  used), 
his  lesions  were  on  the  chest  and  jaw  and  recover}'  followed  operation;  the 
third  was  a  stable  hand,  who  died  from  lesions  of  the  face,  jaw,  and  neck;  the 
fourth  was  a  railroad  watchman  who  had  nothing  to  do"v\'ith  horses  (Plate  2). 

Treatment. — Free  excision  if  possible;  otherwise  incision,  scraping,  cau- 
terization with  pure  carbolic  acid  or  silver  nitrate,  and  packing  with  iodoform 
gauze.  If  possible,  remove  the  entire  area ;  if  not  possible,  remo^■e  aU  that  can 
be  safely  taken  away.  Sinuses  must  be  widely  opened,  each  collection  of  pus 
must  be  drained,  and  granulation  tissue  if  not  extirpated  must  be  scraped 
away  vrith.  a  sharp  spoon.  Give  internally  large  doses  of  iodid  of  potassium. 
This  drug  alone  has  cured  many  cases.  It  is  given  for  a  week  or  two  and  is 
then  discontinued  for  one  week.  It  is  curious  that  though  iodid  of  potash 
seems  to  influence  actinomycosis  favorably,  the  fungus  will  live  imharmed  in  a 
2  per  cent,  solution  of  that  drug  (Harbitz  and  Grandahl.  in  "Amer.  Jour.  Med. 
Sci.,"  Sept.,  1911).  In  a  fistula  from  intestinal  or  appendical  actinomycosis 
give  potassiiun  iodid  and  sulphate  of  copper  (Bevan")  and  irrigate  the  sinuses 
with  diluted  tincture  of  iodin.  Cases  of  actinomycosis  should  be  placed  under 
the  best  hygienic  conditions,  should  Hve  as  much  as  possible  in  the  sunlight 
and  open  air,  and  should  be  given  nutritious  diet,  tonics,  and  often  stimulants. 

Blastomycosis. — ^lay,  in  1894,  called  attention  to  the  disease.  In  1894 
Busse  described  a  fatal  infection  due  to  a  pathogenic  yeast.  The  very  exist- 
ence of  this  disease  has  been  denied,  but  nimierous  cases  have  been  reported 
and  most  obser\-ers  regard  it  as  an  entity.  ]\Iany  cases  have  been  reported 
from  Chicago  and  its  neighborhood  by  Bevan,  Hektoen,  Hyde,  and  others.  It 
maybe  a  local  infection  (cutaneous  blastom}xosis\,  but  in  some  cases  the  dis- 
ease is  generalized  (systemic  blastomycosis').  The  disease  is  fotmd  in  North 
America,  South  America,  Europe,  and  the  East.  In  generalized  blastomycosis 
the  lungs  are  usually  primarily  infected.  Generalized  blastomycosis  is  usuaUy 
fatal.     The  yeasts  when  found  in  the  tissues  are  in  the  budding  stage. 

Cutaneous  blastomycosis  (blastomycetic  dermatitis  or  oidiomycosis)  was 
first  described  by  Gilchrist  in  1S94.  It  is  due  to  infection  ^^•ith  a  variety  of  yeast 
fungus.  In  the  skin  it  begins  as  a  papule  or  an  indurated  pustule,  which 
becomes  crusted  and  finally  warty,  enlarges  at  the  peripher}-,  and  becomes 
surrounded  by  more  recently  developed  lesions.  The  area  becomes  studded 
with  minute  abscesses,  crusted  foci,  and  areas  of  bleeding  granulations.  Here 
and  there  heahna:  mav  occur. 


312  Burns  and  Scalds;  Effects  of  Cold 

The  disease  may  arise  on  any  portion  of  the  body,  but  the  hands  and  face 
are  most  liable  to  it.  It  is  slow  in  progress  and  lasts  for  many  months. 
If  it  progresses,  it  will  finally  produce  systemic  blastomycosis  or  secondary 
infection  wiU  produce  fatal  septicemia.  Bevan  (Lexer's  "General  Surgery," 
edited  by  Arthur  Dean  Bevan)  says  the  evidences  of  general  infection  are: 
"irregular  temperature,  loss  of  appetite,  general  weakness,  emaciation,  cough, 
rapid,  feeble  pulse,  acceleration  of  the  respiration,  at  times  albumin  in  the 
urine,  multiple  subcutaneous  nodules  and  abscesses  resulting  in  superficial,  ir- 
regular ulcers,  abnormal  physical  findings  in  the  lungs,  edema  of  the  extremi- 
ties, and  various  grades  of  anemia."  Coccidial  disease  is  caused  by  an  organism 
strongly  resembling  the  yeast  of  blastomycosis.  Bevan  places  the  two  diseases 
in  the  same  group.  Some  observers  regard  them  as  identical.  The  symptoms 
are  indistinguishable.  Montgomery  regards  iodid  of  potassium  as  a  test 
agent — it  is  without  effect  on  coccidial  disease,  but  acts  strongly  and  favorably 
upon  blastomycosis. 

Treatment. — In  some  cases  excision,  in  others  the  x-rays.  Potassiiun 
iodid  in  very  large  doses  is  given.  It  greatly  benefits  most  cases  and  cures 
many.  Its  employment  in  this  disease  is  due  to  Bevan.  He  also  gives  copper 
sulphate  internally  (l  gr.  three  times  a  day),  and  appUes  a  i  per  cent,  solution 
of  that  chemical  to  local  lesions. 


XVI.  BURNS  AND  SCALDS;  EFFECTS  OF  COLD 

Bums  and  scalds  are  injuries  due  to  the  action  of  caloric.  Scalds  are 
due  to  heated  fluids  or  vapors.  There  is  no  true  pathological  difference 
between  burns  and  scalds.  Dupuytren  classified  burns  into  six  degrees,  as 
follows:  (i)  Characterized  by  er}^thema;  (2)  characterized  by  dermatitis  with 
the  formation  of  vesicles;  (3)  characterized  by  partial  destruction  of  the  skin, 
which  structure  is  not,  however,  entirely  burned  through;  (4)  characterized 
by  destruction  of  the  skin  to  the  subcutaneous  tissue;  (5)  characterized 
by  destruction  of  all  superficial  structures  and  of  part  of  the  muscular 
layer;  (6)  characterized  by  "carbonization"  of  the  whole  thickness  of  the 
muscles. 

The  symptoms  of  a  severe  burn  are  local  and  constitutional.  Local  symp- 
toms are  pain  and  inflammation,  which  vary  in  nature,  in  intensity,  or  in  degree 
according  to  the  extent  of  tissue  damage.  Constitutional  symptoms  are  very 
weak  pulse,  shallow  respiration,  and  subnormal  temperature — in  other  words, 
the  condition  of  shock  exists.  The  patient  may  die  without  reacting  from 
shock,  but  in  most  cases  there  is  reaction,  followed  by  a  severe  reactionary 
fever,  with  a  strong  tendency  to  congestion  of  internal  parts.  During  the 
existence  of  fever  there  may  be  vomiting,  diarrhea,  hemoglobinuria,  albuminu- 
ria and  enlargement  of  the  liver,  spleen,  l}Tnph-glands,  and  tonsils.  Marked 
blood  changes  follow  burns  (see  "Clinical  Hematolog>^,"  by  J.  C.  DaCosta,  Jr.). 
There  is  a  marked  and  rapid  increase  in  red  blood-ceUs  (polycythemia).  This 
is  due  in  part  to  venous  stasis  and  in  part  to  loss  of  blood-plasma.  Leu- 
kocytosis is  rapid  and  pronoimced  and  there  is  a  notable  increase  in  blood- 
plaques. 

The  blood  has  a  marked  disposition  to  clot,  and  clots  may  damage  various 
structures  or  organs.  Further,  the  altered  blood  damages  the  organs  of 
excretion,  and  the  liver  and  kidneys  may  cease  to  perform  their  functions 
properly.  After  a  severe  burn  there  are  imperfect  ox^'genation  and  a  tend- 
ency to  universal  fatty  degeneration.  The  symptomatic  stages  are  often 
designated  as  prostration,  reaction,  and  suppuration.  During  the  first  forty- 
eight  hours  after  a  burn  there  are  congestion  in  and  about  the  burned  area, 


Treatment  of  Burns  313 

severe  pain,  and  possibly  internal  congestions.  There  may  be  shock  and 
possibly  toxic  delirium  or  convulsions.  From  the  end  of  the  second  to  the 
end  of  the  eighth  or  ninth  day  there  are  severe  inflammation  of  the  burned  area, 
formation  of  sloughs,  and  a  strong  tendency  to  inflammation  of  the  brain  in 
head  burns,  of  the  Imigs  in  chest  burns,  of  the  abdominal  organs  in  abdominal 
burns.  Duodenal  inflammation  may  arise  after  any  burn.  Septic  emboli  in  ver\- 
imusual  cases  cause  Curling's  ulcer  of  the  duodenum  (see  page  162  1.  Duodeni- 
tis and  Curling's  ulcer  are  possibly  due,  as  Wm.  Hmiter  suggested,  to  the  bile 
ha\'ing  become  irritant  by  the  excretion  in  it  of  toxic  matter.  After  the  eighth 
or  ninth  day  the  sloughs  separate  from  the  burned  area  and  healing  begins. 
The  raw  surface  is  slow  to  heal,  hemorrhages  may  occur,  the  granulations  are 
apt  to  be  exuberant  and  edematous,  and  the  scars  are  very  contractile  and 
often  produce  hideous  or  disabling  deformity.  If  over  one-half  of  the  body 
surface  is  badly  burned,  death  vnll  almost  certainly  occur,  and  probably  within 
two  days.  The  danger  of  a  burn  depends  upon  its  extent,  its  depth,  and  its 
situation.  Burning  of  a  large  area  superflcially  is  much  more  dangerous 
than  burning  a  small  area  deeply.  Bums  of  the  extremities  are  not  so  danger- 
ous as  are  burns  of  the  head,  chest,  or  abdomen.  Death  after  severe  burns  is 
positively  not  due  to  loss  of  body-heat  in  the  burned  area.  Some  think  it  is 
produced  by  auto-intoxication  with  retained  body  secretions.  High  tempera- 
ture produces  blood  changes — ^Iz.,  disintegration  of  red  corpuscles.  Throm- 
bosis may  occur,  and  irritation  of  the  kidneys  and  other  organs  is  produced  by 
"products  of  corpuscular  degeneration.""^ 

The  blood  of  burned  animals  contains  toxins  (Klianitzen\.  and  so  does 
the  urine  (Reis\  It  seems  probable  that  the  constitutional  s\"mptoms  and 
death,  if  it  occurs,  are  due  partly  to  corpuscular  disorganization  and  partly 
to  the  absorption  of  toxic  matter  from  the  seat  of  injurs-,  this  matter  having 
been  formed  by  the  action  of  heat  on  the  body-cells  and  fluids.  Sepsis  is  not 
infrequent.  Death  may  be  directly  due  to  shock,  to  sepsis,  to  exhaustion,  to 
tetanus,  to  embolism  or  thrombosis,  to  congestion  of  the  brain,  lungs  or  kid- 
neys, or  to  Curling "s  ulcer  of  the  duodenum. 

Treatment. — The  local  treatment  of  slight  burns  is  to  moisten  the  parts 
frequently  ^dth  a  saturated  solution  of  bicarbonate  of  sodium  or  with  normal 
salt  solution.  In  bums  of  moderate  degree  a  mixture  of  zinc  ointment  with 
iodoform,  though  not  antiseptic,  is  a  comfortable  dressing. 

If  a  large  surface  is  burned,  remove  the  clothing  with  great  care,  and  before 
apph-ing  dressings  give  a  h^-podermatic  mjection  of  morphin,  administer 
stimulants,  and  if  the  patient  has  a  dull,  place  him  in  a  warm  bath.  Use  aH 
ordinary-  means  to  secure  reaction  from  shock.  Waterhouse  makes  a  recom- 
mendation which  I  have  frequently  used  with  advantage,  \iz..  dress  the  burn 
with  a  I  per  cent,  solution' of  acetate  of  aluminum,  wrap  the  patient  in  blankets, 
hold  up  the  other  bedclothes  with  a  cradle,  and  put  imder  the  bedclothes  an 
electric  light  of  ;^2  candlepower.  This  will  make  the  temperature  imder  the 
clothes  from  100''  to  105°  F.  ("Brit.  Med.  Jour.,"  July  9,  1910).  If  we  desire 
to  dress  a  large  bum  aseptically,  anesthetize  the  patient,  spray  the  burnt  area 
with  peroxid  of  hydrogen,  irrigate  it  with  a  solution  of  boric  acid,  dn.-  with 
sterile  cotton,  dust  with  Senn's  poivder  (3  parts  of  boric  acid  and  i  part  of 
salicyUc  acid\  and  dress  with  salicylated  cotton.  Senn's  powder  is  better 
than  iodoform.  Iodoform  may  allay  pain,  but  is  apt  to  produce  dermatitis. 
Change  the  dressing  no  oftener  than  is  required,  and  at  each  change  proceed 
as  above  described,  although  it  will  not  be  necessar\-  to  anesthetize.  Per- 
oxid of  hydrogen  softens  and  loosens  the  dressings,  and  they  can  be  readily 
removed.  The  custom  in  the  Jefferson  ^Medical  CoUege  Hospital  is  to  give 
morphin  and  stimulants,  to  cut  away  the  clothing,  to  wrap  the  unbumed  parts 
1  Bardeen,  in  "Jo^^  Hopkins  Hospital  Bulletin,"  April.  1897. 


314  Burns  and  Scalds;  Effects  of  Cold 

with  blankets,  and  place  about  them  cans  or  bags  of  hot  water.  The  burned 
region  is  sprayed  with  diluted  peroxid  of  hydrogen  contained  in  an  atomizer,  and 
is  irrigated  with  salt  solution.  Portions  of  epidermis  which  remain  are  re- 
tained. Any  blisters  are  opened  with  a  sterile  needle,  and  the  part  is  dressed 
with  several  layers  of  sterile  lint  or  tarlatan  soaked  in  normal  salt  solution, 
and  the  dressing  is  kept  moist.  During  the  second  or  inflammatory  stage 
use  stimulants  and  concentrated  food,  allay  pain  by  opium  or  morphin,  favor 
elimination  by  the  skin,  bowels  and  kidneys,  and  combat  any  tendency  to 
internal  congestion  or  .inflammation.  In  very  extensive  burns  complete  and 
continuous  immersion  of  the  part  in  warm  salt  solution  is  an  excellent  treat- 
ment. 

The  picric  acid  treatment,  first  suggested  by  Thiery,  has  many  advocates. 
It  greatly  mitigates  the  pain.  It  is  used  early  only  in  limited  burns  of  the 
first  and  second  degrees,  but  it  can  be  employed  in  late  stages  of  deep  burns 
to  stimulate  the  formation  of  epidermis.  If  used  early  in  a  large  or  a  deep 
burn,  it  may  poison  the  patient.  It  may  poison  a  child  when  used  upon  a 
burn  of  the  second  degree.  A  case  was  reported  by  Dr.  J.  Stuart  Rose  ("Scot- 
tish Med.  and  Surg.  Jour.,"  Dec,  1903),  occurring  in  a  boy  of  nine,  who 
was  treated  with  picric  acid  for  a  scald  of  the  first  degree,  there  being  only 
one  or  two  small  blisters  in  addition  to  the  redness.  Ointment  of  picric 
acid  was  used  (i  dr.  to  i  oz.  of  vaselin).  Symptoms  were  noted  three  days 
after  beginning  the  treatment.  The  symptoms  of  poisoning  are  dark-col- 
ored urine  (carboluria) ,  albuminuria,  marked  yellowness  of  the  skin,  yellow- 
ness perhaps  of  hair  at  the  scalp  margins,  diarrhea,  and  elevated  tempera- 
ture. Rose  considers  a  i  per  cent,  solution  safe.  It  is  applied  as  follows: 
The  part  should  be  disinfected,  gauze  saturated  with  a  i  per  cent,  watery 
solution  of  picric  acid  shoiild  be  laid  upon  the  burned  area,  and  be  covered 
with  absorbent  cotton  and  a  bandage.  This  dressing  is  not  changed  for 
three  to  five  days,  and  the  next  dressing  can  be  left  in  place  until  the  burn 
is  healed.  D'Arcy  Power  has  carefully  studied  the  real  status  of  picric 
acid  as  a  remedy  for  burns,  and  some  of  his  conclusions  have  been  set 
forth  above. 

Perier  dresses  a  burn  with  a  tarlatan  compress,  folded  six  times  and  soaked 
in  the  following  solution:  boric  acid,  2^  dr.;  antipyrin,  ij  dr.;  sterile  water, 
8  oz.  The  following  ointment  is  used  by  Reclus:  iodoform,  15  gr. ;  antipyrin, 
75  gr. ;  boric  acid,  75  gr. ;  vaselin,  ih  oz. 

Carron  oil  consists  of  equal  parts  of  linseed  oil  and  lime-water.  It  allays 
the  pain  of  a  burn,  but  it  is  a  filthy  preparation,  and  its  use  is  followed  by 
much  pus  formation.  Cosmolin  gives  comfort  as  a  dressing,  but  should 
not  be  used  on  the  face,  lest  it  cause  pigmentation.  The  elder  Gross  used 
lead  paint.  A  solution  of  nitrate  of  potassium  allays  the  pain.  Bismuth 
paste  is  a  very  satisfactory  dressing.  In  every  burn  of  the  fingers  and  toes 
keep  the  burnt  digits  separated  by  gauze,  lint,  or  rubber  tissue  during  healing, 
otherwise  adjacent  fingers  will  adhere  and  ''webbing'^  will  result.  When  ex- 
tensive destruction  of  tissue  has  taken  place  and  healing  has  begun,  use  splints 
and  extension  to  limit  contractures,  and  skin-graft  as  soon  as  possible.  If 
granulation  is  slow,  stimulate  with  copper  sulphate  or  mild  silver  nitrate  solu- 
tions. Exuberant  granulations  require  burning  down.  Flabby  granulations 
require  pressure.  If  healing  is  slow,  or  if  the  burn  is  extensive,  skin-graft. 
Skin-grafting  should  be  done  early  in  an  extensive  burn.  If  performed  before 
much  cicatricial  tissue  has  formed,  the  graft  will  be  more  apt  to  adhere,  and  if 
the  graft  does  adhere,  further  formation  of  scar  tissue  will  be  greatly  limited. 
When  an  extremity  has  been  carbonized,  amputation  must  be  performed. 
The  constitutional  treatment  of  a  severe  burn  is  to  bring  about  reaction ;  combat 
pain  with  opium,  and  keep  the  bowels  and  kidneys  active.     If  suppuration 


Chilblain  or  Pernio  315 

occurs,  give  tonics,  stimulants,  and  concentrated  foods.     Complications  are 
treated  according  to  general  rules. 

Burns  and  Scalds  of  the  Tongue,  Pharynx,  Glottis,  and  Epi= 
glottis. — A  child  or  lunatic  may  drink  boiling  fluid  or  inhale  steam  from 
a  tea-kettle.  Firemen  occasionally  suffer  from  scalds  of  the  tongue  and  phar- 
ynx after  being  suddenly  enveloped  in  a  cloud  of  hot  steam,  and  from  burns 
by  the  inhalation  of  hot  vapor  or  flame.  Caustic  may  be  taken  into  the  mouth 
or  swallowed.  The  tongue  and  pharyngeal  mucous  membrane  swell  greatly, 
large  vesicles  form,  there  are  shock,  severe  pain,  dysphagia,  and  dyspnea. 
Edema  of  the  glottis  may  arise. 

Treatment. — Combat  shock;  give  morphin  for  pain;  puncture  vesicles, 
and  have  the  patient  almost  constantly  suck  bits  of  ice.  If  great  swelling 
occurs,  make  multiple  longitudinal  incisions  through  the  mucous  membrane 
of  the  dorsum  of  the  tongue.  If  edema  of  the  glottis  begins,  scarify  it.  If 
this  fails,  perform  intubation  or  tracheotomy. 

Burns  of  the  Esophagus. — The  esophagus  is  seldom  scalded,  as  a 
boiling  fluid  rarely  gets  below  the  pharynx.  The  swaUowing  of  an  acid  or 
alkali  produces  severe  burns  at  the  constricted  portions  of  the  guflet  (see  page 
933)-  Such  an  accident  produces  shock,  dyspnea,  violent  pain,  vomiting 
of  blood,  and  thirst.  Death  may  occur  from  shock  or  perforation  of  the 
stomach.  In  many  cases  severe  gastritis  foUows  a  burn  of  the  esophagus. 
As  the  acute  symptoms  of  a  burn  of  the  gullet  gradually  abate,  sloughs  are 
cast  off,  iflcers  form,  cicatrization  begins,  and  the  signs  of  stricture  develop 
(see  page  933). 

Treatment.— Give  a  remedy  to  neutralize  the  caustic.  Administer  several 
large  drafts  of  water  and  wash  out  the  stomach.  Combat  shock.  Give 
morphin  for  pain.  Feed  by  the  rectum  as  long  as  the  patient's  strength  does 
not  begin  to  fail.  On  beginning  mouth-feeding,  use  at  first  milk  and  then 
beef-juice,  jefly,  and  ice-cream.  In  from  two  to  four  weeks  after  the  infliction 
of  the  burn  begin  the  use  of  bougies  to  limit  contraction. 

Effects  of  Cold. — Local  Effects. — Cold  produces  numbness,  pricking, 
a  feeling  of  weight,  redness  of  the  surface  foUowed  by  stiffness,  local  insensi- 
bility, and  mottling  or  pallor.  Sudden  intense  cold  causes  the  formation 
of  blebs,  the  coagulation  of  blood  in  the  superficial  veins,  and  violent  pain 
in  the  part.     Cold  locally  produces  frost-bite  (see  page  177). 

The  constitutional  effects  of  cold  are  at  first  stimulating,  then  depressing, 
and  are  exhibited  by  uneasiness,  pain,  and  an  intense  drowsiness  which,  if 
yielded  to,  is  the  road  to  death  by  way  of  internal  congestion.  Death  from 
prolonged  cold  resembles  in  appearance  death  from  apoplexy.  ^  Death  from 
sudden  and  overwhelming  cold  is  caused  by  anemia  of  the  brain  from  weak 
circulation  and  capiUary  embohsm.  To  bring  a  partly  frozen  person  into 
a  warm  room  may  cause  death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  177.  When  a 
person  is  nearly  frozen  to  death  place  him  in  a  cool  room,  but  under  no  cir- 
cimistance  in  a  cold  bath;  make  artificial  respiration,  rub  him  briskly  with 
flannel  soaked  in  alcohol  or  in  whisky,  and  follow  this  by  rubbing  by  dry 
hands.  After  a  time  wrap  the  patient  in  warm  blankets  and  give  an  enema 
of  brandy.  Mustard-plasters  are  to  be  applied  over  the  heart  and  spine. 
As  soon  as  swallowing  is  possible,  brandy  is  administered  by  the  mouth. 
As  the  condition  improves  graduaUy  raise  the  temperature  of  the  room  and 
give  hot  drinks. 

Chilblain  or  pernio  is  a  secondary  effect  of  cold.  It  is  reaUy  an  area 
of  local  asphyxia  (see  page  173).  It  usually  appears  as  a  local  congestion  upon 
the  toes,  the  ears,  the  fingers,  or  the  nose,  and  now  and  then  inflames  and  ulcer- 
ates.    A  chilblain  is  apt  to  become  congested  on  the  victim  approaching  a  fire 


3i6  Syphilis,  or  Pox 

or  on  taking  exercise,  and  when  congested  it  itches,  tingles,  and  stings.  Fre- 
quent attacks  of  congestion  produce  crops  of  vesicles;  these  vesicles  rupture 
and  expose  ulcers,  which  in  rare  instances  slough. 

Treatment. — If  chilblain  affects  the  toes,  prevent  congestion  of  the  legs 
and  feet.  Order  large  shoes  and  woolen  stockings  and  forbid  tight  garters. 
The  patient  with  pernio  must  take  regular  outdoor  exercise  and  must  not 
loiter  around  a  hot  fire.  Every  morning  and  evening  he  should  take  a  gen- 
eral cold  sponge-bath,  followed  by  rubbing  with  alcohol  and  friction  by  a 
coarse  towel,  and  in  winter  he  should  sleep  wearing  warm  stockings  or  with 
his  feet  upon  a  warm-water  bag.  When  a  chilblain  is  only  a  congested  spot, 
it  should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry  with  flannel, 
and  subjected  to  applications  of  tincture  of  iodin  and  soap  liniment  (i  :  2), 
tincture  of  cantharides  and  soap  linunent  (i  :  6),  or  equal  parts  of  turpentine 
and  oHve  oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  reheved  by 
painting  belladonna  liniment  upon  the  part  and  allowing  it  to  dry.  Tincture 
of  iodin  may  relieve  it,  and  so  may  a  mustard  foot-bath.  A  valuable  prepara- 
tion for  itching  is  composed  of  i  dr.  of  powdered  camphor  and  4  oz.  of  cosmohn. 
A  little  of  this  ointment  is  rubbed  in  twice  a  day.  The  following  prescription, 
the  source  of  which  I  do  not  remember,  is  very  valuable  for  itching:  i  dr.  of 
powdered  camphor,  i  J  dr.  of  ichthyol,  J  dr.  of  lanolin,  and  4  oz.  of  cosmolin^ 
rubbed  into  the  part  and  covered  with  cotton-wool.  If  vesicles  form,  paint 
with  contractile  collodion;  if  ulcers  form,  dress  antiseptically.  If  ulcers  are 
sluggish,  use  equal  parts  of  resin  cerate  and  spirits  of  tiupentine.  A  good 
antiseptic  and  protective  is  the  following:  oxid  of  zinc,  6  gr.;  chlorid  of  zinc, 
20  gr. ;  gelatin,  2  oz. ;  distilled  water,  i  oz. 


XVII.  SYPHILIS,   OR   POX 

The  name  comes  from  the  title  of  a  poem  which  was  published  in  Italy  in 
1530,  "Syphilis  sive  Morbus  Gallicus,"  by  Hieronymus  Fracastorius.  For 
centuries  there  has  been  fierce  dispute  as  to  the  origin  of  syphilis.  Many  assert 
that  Europe  was  free  of  it  until  the  discovery  of  America  and  that  the  sailors  of 
Columbus  brought  it  from  Hayti.  Others  claim  that  the  disease  has  always 
existed  in  Europe  and  the  East.  We  know  there  was  a  violent  outbreak  of  it  in 
1494  among  the  French  soldiers  besieging  Naples. 

Definition.— Syphilis  is  a  chronic  contagious,  and  sometimes  hereditary, 
constitutional  disease.  It  is  one  of  the  most  common  of  diseases  and  were 
facts  known  would  rank  high  as  a  cause  of  death.  Lesser  states  that  in  Ber- 
lin, of  men  over  twenty-five  years  of  age  who  come  to  autopsy,  9  per  cent,  are 
syphilitic.  In  the  United  States  it  is  twice  as  frequent  among  negroes  as  com- 
pared with  whites,  although  in  them  the  disease  is  apt  to  be  more  curable  and 
less  disastrous.  It  was  long  believed  that  only  members  of  the  human  family 
could  take  syphilis,  but  Metchnikoff  and  Roux  have  succeeded  in  inoculating 
chimpanzees  ("Annals  of  Pasteur  Institute,"  Dec,  1903).  These  two  observers 
have  inoculated  many  animals  and  have  shown  that  the  nearer  the  animal  is  to 
man,  the  more  nearly  the  disease  resembles  human  syphilis.  Anthropoid  apes 
can  be  successfully  inoculated,  but  only  in  the  chimpanzee  are  human  symptoms 
accurately  produced.  At  first  the  causitive  protozoons  are  localized.  Metch- 
nikoff in  1906  inoculated  a  student  and  a  monkey  with  syphilitic  virus.  An 
hour  after  inoculating  the  man  the  seat  of  inoculation  was  rubbed  for  five  min- 
utes with  mercurial  ointment  and  the  man  escaped  syphilis.  The  ointment  was 
not  used  on  the  monkey  and  a  chancre  developed.  Its  first  lesion  is  an  infect- 
ing area  or  chancre,  which  is  followed  by  lymphatic  enlargements,  eruptions 
upon  the  skin  and  mucous  membranes,  affections  of  the  appendages  of  the  skin 


Transmission  of  Syphilis  317 

(hair  and  nails),  "chronic  inflammation  and  infiltration  of  the  cellulovascular 
tissue,  bones,  and  periosteum"  (White),  and,  later,  often  by  gummata.  The 
disease  is  due  to  a  protozoon,  the  Spirochasta  pallida.  This  fact  was  demon- 
strated by  Schaudinn  in  1905  (see  page  55).  The  Spirochaeta  pallida  is 
demonstrated  in  recent  scrapings  from  specific  lesions.  The  more  contagious 
the  lesion,  the  more  of  the  organisms  are  found.  The  later  the  lesion,  the  fewer 
the  organisms  found.  Spirochetes  are  always  discoverable  in  the  chancre. 
They  can  usually  be  found  in  the  secondary  lesions  and  sometimes  in  the  blood 
during  the  secondary  stage.  Spirochetes  are  present  in  tertiary  lesions,  al- 
though in  less  number  than  in  secondary  lesions.  The  presence  of  a  great 
number  of  spirochetes  means  a  malignant  case.  They  tend  to  disappear  under 
mercurial  treatment  (see  pp.  336  and  340).  S>'philitic  fever  is  due  to  absorp- 
tion of  toxins.  Skin  eruptions  and  eruptions  on  the  mucous  membranes  in  the 
secondary  stage  arise  from  local  deposit  and  multiplication  of  the  spirochetes. 
The  spirochetes  continue  to  exist  in  the  body  after  the  cessation  of  second- 
ary^ S}Tnptoms,  and  may  die  out  or  may  awaken  into  activity,  producing 
reminders. 

Up  to  about  twelve  days  after  the  appearance  of  a  chancre  a  person  can  still 
be  infected  by  a  fresh  exposure  to  inociilation.  After  twelve  days  he  cannot  be 
unless  inoculated  with  a  very  large  amount  of  virus  (Pinard).  In  other  words, 
after  twelve  days  there  is  immunit}'  to  fresh  inoculation,  but  the  immunity  is 
not  powerful  enough  to  kill  the  spirochetes  already  in  the  body.  During  the  pri- 
mary stage,  from  the  twelfth  day  after  the  appearance  of  the  chancre,  and  during 
the  secondary  stage  fresh  poison  cannot  infect,  and  this  is  true  for  a  long  time 
after  the  disappearance  of  secondary  s^Tnptoms.  As  a  matter  of  fact,  the  im- 
munity generally  lasts  for  life  and  reinfection  is  one  of  the  rarest  of  occurrences. 
Most  supposed  cases  of  reinfection  were  really  instances  of  a  fresh  outbreak  of  an 
old  disease,  but  a  few  undoubted  cases  of  reinfection  have  been  reported. 
Immunity  in  the  primary  stage  is  due  to  products  absorbed  from  the  infected 
area.  CoUes's  immunity  is  that  acquired  by  mothers  who  have  borne  s}'philitic 
children,  but  who  themselves  show  no  sign  of  the  disease.  Profeta's  immunity 
is  the  immunity  against  infection  possessed  by  children  born  of  syphilitic 
parents.  Some  of  these  children  have  never  shown  signs  of  disease,  but  never- 
theless they  are  immune.  It  is  claimed  that  a  person  long  free  from  active 
syphilis,  but  still  immune,  can  transmit  immimity  to  his  children.  Tertiarv* 
s^philis  is  not  nearty  as  readily  transmissible  as  secondar}'  syphilis,  but  it 
secures  immunity. 

Transmission  of  Syphilis. — This  disease  can  be  transmitted:  (i)  by 
contact  with  the  virus — acquired  s}philis,  and  (2)  by  hereditary  transmis- 
sion— hereditary  syphilis.  The  poison  cannot  enter  through  an  intact  epi- 
dermis or  epithehal  layer,  and  abrasion  or  solution  of  continuity  is  requisite 
for  infection.  S^phiHs  is  usually,  but  not  always,  a  venereal  disease.  It 
may  be  caught  hy  infection  of  the  genitals  during  coition,  by  infection  of 
the  tongue  or  Hps  in  kissing,  by  smoking  poisoned  pipes,  by  drinking  out 
of  infected  vessels,  or  by  beastly  practices.  S}philis  not  due  to  sexual  rela- 
tions is  called  syphilis  of  the  innocent.  The  barber  is  a  danger,  and  cases 
are  reported  as  foUomng  razor  cuts  and  particiilarly  the  application  of  the 
alum  stick  to  arrest  bleeding.  This  stick  is  used  over  and  over  again  and 
dried  blood  is  often  to  be  found  upon  it.  I  was  consulted  by  a  man  who 
had  been  thus  infected.  I  have  treated  two  young  girls  infected  by  den- 
tists' instrtmients,  a  policeman  infected  by  a  pipe,  a  glassblower  infected 
from  the  blo-^pipe,  a  street  car  driver  who  got  the  disease  from  a  borrowed 
whistle,  a  poHce  officer  who  got  it  striking  a  prisoner  on  the  mouth  and  cutting 
his  owTi  knuckle  on  the  teeth,  a  hospital  orderly  who  infected  his  nose  pick- 
ing it  by  a  contaminated  finger,  and  three  physicians  who  caught  it  from 


3i8  Syphilis,  or  Pox 

patients.  Schamberg  makes  a  valuable  contribution  to  the  accumulation  of 
facts  which  demonstrates  the  danger  of  promiscuous  osculations  ("Jour.  Am. 
Med.  Assoc,"  Sept.  2,  191 1).  A  party  of  young  men  and  women  indulged  in 
a  kissing  game.  One  of  the  young  men  had  a  sore  lip.  As  a  result  of  the  party 
6  men  and  i  woman  developed  labial  chancres.  A  girl  kissed  at  another 
party  by  the  contaminator  of  the  first  party  got  a  chancre.  The  solitary 
male  victim  of  the  first  party  evidently  got  the  disease  by  kissing  a  girl  re- 
cently kissed  by  the  syphilitic  man.  Bulkley  (Ibid.,  March  4,  1905)  collected 
1863  cases  following  vaccination;  179  following  circumcision;  82  following 
tattooing,  and  745  following  cupping  or  venesection.  The  initial  lesion  of  s^q^h- 
ilis  may  be  found  on  the  finger,  penis,  eyelid,  lip,  tongue,  cheek,  palate,  tonsil, 
labiimi,  vagina,  anus,  nipple,  etc.  A  person  may  be  a  host  for  syphilis,  carry  it, 
give  it  to  another,  and  yet  escape  it  himself  (a  surgeon  may  carry  it  under 
his  nails  and  a  woman  may  have  it  lodged  in  her  vagina).  Syphilis  can  be 
transmitted  by  vaccination  with  human  lymph  which  contains  the  pus  of  a 
syphilitic  eruption  or  the  blood  of  a  syphilitic  person.  Vaccine  lymph,  even 
after  passage  through  a  person  with  pox,  will  not  convey  syphilis  if  it  is  free 
from  blood  and  the  pus  of  specific  lesions;  it  is  not  the  lymph  that  poisons, 
but  some  other  substance  which  the  lymph  may  carry.  When  syphilis  is 
caught  from  one  of  a  different  race  the  disease  is  apt  to  run  a  peculiarly  severe 
course.  The  apprehensions  of  the  sailor  regarding  "Chinese  pox"  are  probably 
well  founded.  John  Knott  says  ("New  York  Med.  Jour.,"  Oct.  31,  1908): 
"The  Swan  Alley  sore  of  the  days  of  Benjamin  Travers  was  immeasurably  more 
severe  and  more  rapidly  destructive  in  its  progress  than  any  average  London 
chancre;  for  it  was  the  fruit  of  the  continuous  patronizing  culture  of  the  for- 
eign sailors  and  refugees  who  were  derived  from  the  veriest  social  and  moral 
dregs  of  the  population  of  all  foreign  countries." 

Effect  of  Syphilis  Upon  Longevity.— This  is  a  difficult  matter  to 
determine.  Many  deaths  result  from  diseases  caused  by  syphilis  and  yet  they 
are  not  certified  as  due  to  syphilis.  My  own  behef  is  that  the  mortality  directly 
due  to  syphiHs  is  very  small  indeed  (except  in  cases  of  congenital  syphilis), 
but  that  the  mortality  indirectly  due  to  it  is  very  large.  I  think  that  the  life 
insurance  companies  are  justified  in  requiring  those  who  have  had  syphilis  to 
pay  higher  premiums  than  those  who  have  never  had  the  disease. 

Syphilis  and  Tuberculosis. — Syphilis  and  tuberculosis  may  coexist. 
The  syphilis  may  be  severe  and  the  tuberculosis  mild,  or  vice  versa.  In  some 
cases  neither  is  severe  and  in  some  cases  both  are.  As  a  rule,  they  have  an 
unfavorable  influence  on  each  other.  Tuberculosis  is  not  very  unusual  in  the 
course  of  secondary  syphilis.  It  is  apt  to  run  a  rapid  course  because  of  the 
patient's  debility  and  worry  and  because  of  the  treatment  employed  for  the 
syphilis.  Old  syphilitics  may  develop  tuberculosis,  but  do  not  seem  particularly 
prone  to  do  so.  A  child  born  syphilitic  is  very  apt  to  become  tuberculous, 
more  apt  even  than  is  a  child  born  of  tuberculous  parents.  If  a  patient  who  is 
thought  to  be  well  of  syphilis  becomes  tuberculous  the  syphilis  may  crop  out 
again.  If  a  tuberculous  patient  becomes  syphilitic  the  tuberculosis  usually 
gets  worse.  It  is  well  known  that  syphihtic  ulcers  may  become  tuberculous. 
This  sometimes  occurs  in  the  larynx.  (See  chapter  on  Syphilis  in  Bonney's 
treatise  on  "Pulmonary  Tuberculosis"). 

Syphilitic  Stages. — Syphilis  was  divided  by  Ricord  into  three  stages: 
(i)  The  primary  stage — chancre  and  indolent  bubo;  (2)  the  secondary  stage 
— disease  of  the  upper  layer  of  the  skin  and  mucous  membranes;  and  (3)  the 
tertiary  stage — affections  of  connective  tissues,  bones,  fibrous  and  serous 
membranes,  and  parenchymatous  organs.  This  division,  which  is  useful 
clinically,  is  still  largely  employed,  but  it  is  not  so  sharp  and  distinct  as 
was  beHeved  by  Ricord;   it  is  only   artificial.       For  instance,   ozena  may 


Initial  Lesions  319 

develop  during  a   secondary  eruption,  and  bone   disease  may  appear  early 
in  the  case. 

Syphilitic  Periods. — White  divides  the  pox  into  the  following  periods: 
(i)  Period  of  primary  incuhation — the  time  between  exposure  and  the  appear- 
ance of  the  chancre,  from  ten  to  ninety  days,  the  average  being  twenty-five 
days;  (2)  period  of  primary  symptoms — chancre  and  bubo  of  adjacent  lymph- 
glands;  (3)  period  of  secondary  incuhation — the  time  between  the  appear- 
ance of  the  chancre  and  the  advent  of  secondary-  s}-mptoms,  about  sLx  weeks 
as  a  rule;  (4)  period  of  secondary  symptoms — lasting  from  one  to  three  years; 
(5)  intermediate  period — there  may  be  no  s>Tnptoms  or  there  may  be  Ught 
symptoms  which  are  less  symmetrical  and  more  general  than  those  of  the 
secondary-  period:  it  lasts  from  two  to  four  years,  and  ends  in  recovery-  or 
tertiar^•  s\-philis;  (6)  period  of  tertiary  symptoms — indefinite  in  duration. 
The  fifth  and  sLxth  periods  may  never  occiu".  the  disease  ha^•ing  been  cured. 

Primary  Syphilis. — The  primar\-  stage  comprises  the  chancre  or  infect- 
ing sore  and  bubo.  A  chancre  or  initial  lesion  is  an  infective  granuloma 
resulting  from  the  poison  of  syphilis  and  is  most  usually  met  with  upon  the 
genital  organs.  A  chancre  may  be  derived  from  the  discharges  of  another 
chancre,  from  the  secretion  of  mucous  patches  and  moist  papules,  from  s}^!!!- 
litic  blood,  or  from  the  pus  or  secretion  of  any  secondary-  lesion.  Tertiary- 
lesions  seldom  cause  chancre.  It  appears  at  the  point  of  inoculation  (see  page 
316),  and  is  the  first  lesion  of  the  disease.  During  the  three  weeks  or  more  requi- 
site to  develop  a  chancre  the  poison  is  continuously  entering  the  system,  and 
when  the  chancre  develops  the  system  already  contains  a  large  amount  of  poi- 
son. A  chancre  is  not  a  local  lesion  from  which  s}-philis  springs,  but  is  a  local 
manifestation  of  an  existing  constitutional  disease,  hence  excision  is  entirely 
useless.  If  twelve  days  or  more  after  the  appearance  of  a  chancre  we  take 
some  of  the  discharge  and  insert  it  at  some  indifi'erent  point,  into  the  per- 
son from  whom  we  took  it,  a  new  indurated  chancre  ^^ill  not  be  formed. 
This  means  that  the  subject  has  become  immune  to  inoculation,  but  the  im- 
munitv  is  not  sufficiently  powerful  a  factor  to  kill  the  spirochetes  already  in 
the  body.  \Mien  inoculation  fails  it  means  that  the  indi^idual  already  has 
constitutional  s}'philis.  If  a  sj^hilitic  is  inoculated  with  the  discharge  of 
a  chancre  twelve  days  or  more  after  the  chancre  began,  no  indurated  sore 
develops,  but  if  the  chancre  furnishing  the  virus  was  irritated,  a  non-indurated 
sore  mav  arise  at  the  point  of  inoculation.  If  we  take  the  discharge  of  a 
chancre  and  insert  it  into  a  healthy  person,  an  indurated  chancre  follows. 
Hence  we  say  that  primary-  s}-philis  is  not  auto-inoculable,  but  is  hetero-inocu- 
lable.  A  soft  sore  can  be  produced  in  the  lower  animals  by  inoculation  v^-ith  the 
\Trus  of  a  chancre,  but  a  hard  sore  cannot  except  in  monkeys.  Some  obsen.-ers, 
notably  Kaposi,  of  Menna,  advocate  the  unity  theory.  This  theor\-  maintains 
that  both  hard  and  soft  sores  are  due  to  the  same  ^■irus,  the  infective  power  of 
the  soft  chancre  simply  being  less  than  that  of  the  hard  sore,  the  possibility 
of  constitutional  infection  depending,  not  upon  dift'erences  in  the  poison,  but 
rather  upon  differences  in  the  soil  and  in  the  local  processes.  The  unicists 
advocate  excision  of  chancres,  soft  or  hard,  to  prevent,  if  possible,  constitutional 
involvement.  ^lost  s}-philographers  believe  in  the  duality  theory,  which  we 
have  pre^-iously  set  forth.  This  theor\-  took  origin  from  the  classical  investiga- 
tions of  Basse'reau  and  RoUet.  The  duality  theory-  maintains  that  the  soft 
sore  is  caused  by  a  poison  different  from  the  one  which  originates  the  hard 
sore,  and  that  a  true  soft  sore  never  infects  the  system.  The  discovery  of  the 
micro-organism  causing  s\'philis  proves  the  dualists  to  be  correct. 

Initial  Lesions. — ^An  initial  lesion,  hard  chancre,  or  infecting  sore 
never  appears  xmtil  at  least  ten  days  after  exposure;  it  may  not  appear  for 
many  weeks,  but  it  usually  arises  in  about  twenty-five  da^-s.     There  are  three 


320  Syphilis,  or  Pox 

chief  forms  of  initial  lesion:  (i)  A  purple  patch  exposed  by  peeling  epidermis, 
without  induration  and  ulceration— a  rare  form;  (2)  an  indurated  area  under 
the  epidermis,  without  ulceration — a  very  common  form;  and  (3)  a  round, 
indurated,  cartilaginous  area  with  an  elevated  edge,  which  ulcerates,  exposing 
a  velvety  surface  looking  Hke  raw  ham;  it  bleeds  easily,  rarely  suppurates, 
does  not  spread,  and  the  discharge  is  thin  and  watery.  This  is  the  Hunterian 
chancre,  which  is  rarer  than  the  second  variety,  but  commoner  than  the  first, 
and  which  ulcerates  because  of  dirt,  caustic  applications,  or  friction. 

A  chancre  is  rarely  multiple,  but  if  it  is  so,  all  the  sores  usually  appear  to- 
gether as  a  result  of  the  primary  inoculation;  they  seldom  follow  one  another 
because  of  auto-infection,  although  during  the  first  twelve  days  such  a  result 
is  possible.  A  hard  sore  does  not  suppurate  unless  irritated  by  caustics, 
friction,  or  dirt,  or  unless  there  be  mixed  infection  with  chancroid;  its  nature 
is  not  to  suppurate.  The  hardness  may  affect  only  the  base  and  margins  of 
an  ulcer  or  it  may  affect  considerable  areas,  but  it  has  well-defined  margins 
and  feels  like  cartilage  encapsuled,  so  that  it  can  be  picked  up  between  the 
fingers.  This  hardness  or  sclerosis  is  due  to  gradual  inflammatory  exudation 
into  "the  tissue  at  the  base  of  the  ulcer  and  to  growth  of  the  nodule"  (von 
Zeissl).  It  feels  distinct  from  the  surrounding  tissues,  Hke  a  foreign  body 
lying  in  the  part.  A  chancre  untreated  may  last  many  months.  The  indu- 
ration usually  disappears  soon  after  the  appearance  of  secondary  symptoms. 
A  copper-colored  spot  remains,  and  does  not  disappear  until  the  disease  is 
cured.  Induration  may  again  appear  before  the  outbreak  of  some  distant 
lesion. 

Mixed  Infection  of  Chancre  and  Chancroid. — Von  Zeissl  says: 
'Tf  syphilitic  contagion  is  mixed  with  pus,  a  chancre  begins  as  a  circimascribed 
area  of  hyperemia  and  swelling,  which  undergoes  ulceration,  and  does  not 
develop  hardness  for  a  period  of  from  ten  days  to  several  weeks,  and  may 
develop  a  nodule  after  the  first  ulcer  has  entirely  healed."  This  condition  is 
seen  when  mixed  infection  occurs,  the  chancroid  poison  being  quick,  and  the 
syphilitic  poison  being  slow,  to  act.  If  chancroid  poison  is  deposited  some 
time  after  the  syphiHtic  poison  has  been  absorbed,  the  induration  may  appear 
in  a  few  days  after  the  chancroid  begins.  A  soft  chancre  may  arise  upon  an 
existing  syphilitic  nodule  and  may  eat  out  the  induration. 

Diagnosis  of  Chancre. — It  is  necessary  to  distinguish  a  chancre  from  a 
chancroid  and  from  ulcerated  herpes.  A  chancroid  appears  in  from  two  to 
five  days  after  contagion  (always  less  than  ten  days) ;  it  may  be  multiple  from 
the  start,  but,  even  if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation; it  begins  as  a  pustule,  which  bursts  and  exposes  an  ulcer;  the  ulcer 
is  circular,  has  thin,  sharp-cut,  or  undermined  edges,  a  sloughy,  non-granu- 
lating base,  and  gives  origin  to  a  thin,  purulent,  offensive  discharge  which  is 
both  auto-  and  hetero-inoculable.  These  soft  sores  have  no  true  sclerotic  area, 
do  not  bleed,  produce  no  constitutional  symptoms,  and  are  apt  to  be  followed 
by  acute  inflammatory  buboes  which  tend  to  suppurate.  A  chancroid  causes 
pain,  and  the  original  ulcer  enlarges  greatly.  A  chancre  appears  in  about 
twenty-five  days  after  inoculation  (never  before  ten  days) ;  it  is  generally  sin- 
gle, but  if  multiple  sores  exist  they  usually  aU  appear  together,  for  their  dis- 
charge is  not  auto-inoculable  after  the  twelfth  day  if  the  sore  is  not  irritated; 
an  auto-inoculation  of  the  products  of  an  irritated  chancre  may  produce  a  soft 
purulent  ulcer.  A  chancre  begins  as  a  desquamating  area,  an  excoriation,  or  a 
nodule;  if  an  ulcer  forms,  its  floor  is  covered  with  granulations  and  it  is  red  and 
smooth;  the  discharge  is  thin  and  scanty  and  not  offensive;  the  edges  are  thick 
and  sloping;  it  is  surrounded  by  an  area  of  induration,  and  bleeds  when  touched; 
there  appear  about  the  same  time  wdth  the  induration  or  very  soon  after  it 
indolent  multiple,  unfused  enlargements  of  the  adjacent  glands,  which  rarely 


S}'philitic  Bubo  321 

suppurate,  and  it  is  followed  by  secondan-  symptoms.  A  chancre  causes  little 
pain,  and  after  it  has  existed  for  a  few  days  rarely  shows  any  tendency  to  spread. 
For  the  first  few  days  after  the  appearance  of  a  chancre  the  Wassermann  reac- 
tion is  negative,  then,  in  nearly  three-fourths  of  the  cases,  it  becomes  positive. 
There  is,  however,  dispute  as  to  the  value  of  the  reaction  in  the  diagnosis  of 
primary-  s\phihs.  Finding  the  Spirocha^ta  pallida  in  scrapings  from  or  the 
discharge  of  the  sore  is  proof  that  the  lesion  is  a  chancre.  A  urethral  chancre 
appears  after  the  usual  period  of  incubation;  it  is  situated  near  the  meatus,  one 
Up  of  which  is  usually  indurated;  the  discharge  is  sKght,  often  bloody,  seldom 
purulent;  indurated  multiple  buboes'  arise;  the  sore  can  be  seen,  and  constitu- 
tional s}'mptoms  foUow. 

Herpetic  ulceration  has  no  period  of  incubation;  it  may  foUow  fever,  but 
usually  arises  from  friction  or  irritation  due  to  dirt  or  acrid  discharges.  It 
appears  as  a  group  of  vesicles,  all  of  which  may  dr\-  up,  or  some  may  dn.-  up 
and  others  ulcerate,  or  they  may  nm  together  and  ulcerate.  The  edges  of  a 
herpetic  ulcer  are  in  segments  of  circles;  the  ulcer  is  superficial,  has  but  Httle 
discharge,  and  does  not  have  much  tendency  to  spread;  it  has  no  induration; 
it  is  painful:  it  is  not  accompanied  by  bubo  imless  suppuration  is  marked. 
Herpes  is  not  followed  by  constitutional  involvement. 

A  chancre  may  be  mistaken  for  cancer  of  the  tongue.  '"A  chancre  of  this 
region  is  brownish  red,  a  cancer  being  bright  red.  A  chancre  is  soft  in  the 
center;  a  cancer  presents  uniformity  of  induration.  A  chancre  gives  origin 
to  a  thin,  purulent  discharge,  free  from  blood;  a  cancer  furnishes  a  non- 
purulent, bloody  discharge.  A  chancre  is  soon  followed  by  indolent  h-mphatic 
enlargements  under  the  jaw;  a  cancer  is  followed  by  painful  enlargements."' 
A  cancer  is  slower  in  evolution,  is  not  followed  by  constitutional  s^-mptoms, 
and  the  h-mphatic  enlargements  are  much  later  in  appearing  than  in  chancre.' 

Phagedena. — A  chancre  or  a  chancroid  may  be  attacked  by  phagedena,  a 
destructive  form  of  ulceration  which  was  once  common,  but  at  present  is  rare. 
The  ulceration  often  spreads  on  aU  sides  and  also  deeply  into  the  tissues.  In 
some  cases  it  spreads  at  the  edge  in  one  direction  {serpiginaus  ulceration),  in 
some  cases  sloughing  occurs.  Phagedena  occurs  only  in  the  debilitated  (^anemics, 
drunkards,  strimious  subjects,  sufferers  from  diabetes,  Bright's  disease,  etc.; 
saHvation  can  cause  it).  The  phagedenic  ulcer  is  irregular,  with  congested 
and  edematous  edges,  and  a  foul,  sloughy  floor. 

Chancre  Redux. — Some  obser\-ers  believe  that  reinfection  v.ith  s}-philis 
is  not  ver}-  imusual.  ]SIost  authorities  maintain  that  it  is  ver}-  rare.  The  latter 
school  maintains  that  the  region  once  occupied  b}-  a  chancre  may,  after  months 
or  several  or  even  many  years,  become  indurated  anew.  Occasionally  such  a 
relapse  occurs  during  full  treatment.  Foinrnier  pointed  out  this  fact  thirty 
years  ago.     Such  a  reinduration  is  called  chancre  redux,  or  relapsing  chancre. 

If  5\-philitic  manifestations  follow  such  an  induration,  we  must  conclude 
that  reinfection  has  truly  occurred.  If  they  do  not  follow,  and  this  is  the  rule, 
the  lesion  is  not  really  a  chancre,  but  is  probably  a  gumma  in  an  early  stage  of 
development.     ^Mauriac  pointed  out  this  last  fact.^ 

In  sj'philitic  bubo  anatomically  related  h-mphatic  glands  enlarge  about 
the  same  time  as  or  at  least  ver\'  soon  after  induration  of  the  initial  lesion 
begins.  In  the  ven,'  beginning  these  glands  may  be  a  httle  painful,  but  the 
pain  is  sHght  and  of  temporar}-  duration.  These  enlargements  are  called 
"'indolent  buboes"";  they  may  be  as  small  as  peas  or  as  large  as  walnuts,  are 
freely  movable,  and  ver}-  rarely  suppurate.  The  lesion  of  the  glands  is  hy- 
perplasia of  aU  the  gland-elements  and  of  their  capsules,  due  to  absorption  of 
the  \-irus.     If  the  patient  is  tuberculoiis,  the  bubo  is  apt  to  become  enormous, 

i^klracek,  in  ''Wien.  klin.  Rundscliau,"  1S96;  H.  G.  .\ntony.  in  "Chicago  Medical  Re- 
corder," April,  1S99. 


322  Syphilis,  or  Pox 

lobulated,  and  persistent.  If  the  chancre  appears  on  the  penis,  the  superficial 
inguinal  and  femoral  glands  enlarge,  usually  on  the  same  side  of  the  body  as  the 
sore.  If  the  sore  is  on  the  frenum,  both  groins  are  involved.  If  a  chancre  ap- 
pears on  the  lip  or  tongue,  the  bubo  is  beneath  the  jaw.  These  buboes  may 
remain  for  many  months;  they  do  not  break  down  unless  the  sore  suppurates 
or  unless  the  patient  is  of  the  tuberculous  type;  and  they  finally  disappear  by 
absorption  or  fatty  degeneration.  About  six  weeks  after  buboes  have  formed  in 
the  glands  related  to  the  lesion  all  the  lymphatics  of  the  body  enlarge.  General 
lymphatic  involvement  arises  about  the  time  the  secondary  eruption  appears. 
The  enlargement  of  the  postcervical  and  epitrochlear  glands  is  diagnostically 
important.  Glandular  enlargements  persist  until  after  the  eruptions  have 
disappeared. 

Glandular  enlargement  always  occurs  in  syphilis,  but  the  bubo  exists  in 
only  one-third  of  the  chancroid  cases.  The  bubo  of  syphilis  is  multiple,  con- 
sisting of  a  chain  of  movable  glands  (the  glandular  Pleiades  of  Ricord);  the 
bubo  of  chancroid  is  one  inflamed  and  immovable  mass.  The  bubo  of  syph- 
ilis is  indurated,  painless,  small,  and  slow  in  growth;  the  bubo  of  chancroid 
shows  inflammatory  hardness,  is  painful,  large,  and  rapid  in  growth;  the  first 
rarely  suppurates,  the  second  often  does.  The  skin  over  a  syphihtic  bubo  is 
normal;  that  over  a  chancroidal  bubo  may  become  red  and  adherent.  A  syph- 
ilitic bubo  is  not  cured  by  local  treatment,  but  is  cured  by  the  internal  use  of 
mercury  and  is  followed  by  secondary  symptoms.  A  chancroidal  bubo  re- 
quires local  treatment,  is  not  cured  by  mercury,  and  is  not  followed  by  secon- 
daries. Herpes,  balanitis,  and  gonorrhea  rarely  cause  bubo,  but  when  they  do 
the  bubo  in  each  case  is  similar  to  that  caused  by  chancroid.  A  positive 
diagnosis  of  syphiHs  can  be  made  when  an  indurated  sore  on  the  penis  is 
'foUowed  by  multiple  indolent  buboes  in  the  groin  and  by  enlargement  of 
distant  glands. 

General  Syphilis. — As  the  general  lymphatic  enlargement  becomes 
manifest  a  group  of  symptoms  known  as  syphilitic  fever  may  appear.  In 
many  mild. cases,  however,  fever  is  absent  and  the  eruption  is  the  first  sign 
of  constitutional  involvement.  The  patient  usually  thinks  he  has  a  severe 
cold,  is  feverish  and  restless;  complains  of  headache,  lassitude,  sleeplessness, 
and  anorexia;  his  face  is  pale;  he  has  intermitting  rheumatoid  pains  in  the 
joints  and  muscles,  especially  of  the  shoulders,  arms,  chest,  and  back,  which 
pains  change  their  location  constantly  and  prevent  sleep;  night-sweats  occur, 
and  the  pulse  is  quite  frequent.  The  fever  usually  reaches  its  height  in  forty- 
eight  hours,  and  falls  as  the  eruption  develops.  The  eruption  develops 
usually  in  from  forty-eight  to  seventy-two  hours  after  the  onset  of  the  fever, 
but  may  not  do  so  for  one  week  or  even  more.  The  fever  and  the  discomfort 
are  worse  at  night.  In  type  the  fever  may  be  intermittent,  remittent,  or  con- 
tinued. It  is  usually  intermittent.  There  may  or  may  not  be  chills,  and  chills 
may  occur  every  day  or  irregularly.  Prolonged  syphilitic  fever  with  delay  m 
the  appearance  of  the  eruption  gives  rise  sometimes  to  great  errors  in  diagnosis. 
Prolonged  and  irregular  fever  is  apt  to  arise  in  visceral  syphilis,  especially 
syphilis  of  the  liver.  In  syphihtic  fever  there  are  anemia,  trivial  leukocytosis, 
and  a  marked  fall  in  hemoglobin.  Syphilitic  fever  may  reappear  during  the 
progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary  syphilis  are  due 
to  poisoned  blood.  They  are  "local  reactions  against  the  spirochetes  which 
have  now  become  disseminated  by  the  blood-stream"  (H.  G.  Adamson,  in  the 
"Lancet,"  April  6,  1912).  During  untreated  active  secondary  syphilis  the 
Wassermann  reaction  is  practically  always  positive.  Scrapings  from  a  lesion 
may  show  the  causal  organisms.  Secondary  syphilis  is  characterized  by  plastic 
inflammation,  by  the  formation  of  fibrous  tissue,  and  by  thickening  of  tissue. 


En'thema  323 

Superficial  ulcerations  may  occur.  Structural  overgrowths  appear  (for  instance, 
warts'). 

Syphilitic  Skin  Diseases. — Syphilodermata  {syphilids)  are  due  to  cir- 
cumscribed inflammation,  and  may  be  dry  or  purulent.  There  is  no  one  erup- 
tion characteristic  of  s>-philis.  This  disease  may  counterfeit  any  skin  dis- 
ease, but  it  is  an  imitation  which  is  not  perfect  and  is  never  a  counterpart. 
Syphilitic  eruptions  are  often  circumscribed;  they  terminate  suddenly  at  their 
edges,  and  do  not  gradually  shade  into  the  sound  skin.  In  color  they  are  apt 
to  be  brownish  red,  like  tarnished  copper;  especially  is  this  the  case  in  late 
sxphilids.  Hutchinson  cautions  us  to  remember  that  an  ordinary-  non- 
specific eruption  may  be  copper  colored,  especially  in  people  with  dark  com- 
plexions and  when  it  occurs  on  the  legs.  Eruptions  are  apt  to  leave  a  brownish 
stain.  Early  s^-philitic  eruptions  are  s^Tnmetrical.  S>-philitic  eruptions  have 
an  affection  for  particular  regions,  such  as  the  forehead,  the  abdomen  and 
chest,  the  neck  and  scalp,  about  the  lips  and  the  alae  of  the  nose,  the  navel,  anus, 
groins,  between  the  toes,  and  upon  the  palms  and  soles.  Early  secondary 
eruptions  rarely  appear  on  the  face  or  hands.  Specific  eruptions  are  poly- 
morphous, various  forms  of  eruption  being  often  present  at  the  same  time,  so 
that  roseola  is  seen  here,  papules  there,  etc.  These  s}-philids  do  not  cause  as 
much  itching  as  do  non-specific  eruptions,  except  when  they  occur  upon  the 
scalp,  about  the  anus,  or  between  the  toes.  The  late  secondary-  eruptions 
tend  to  an  arrangement  in  cur\-ed  lines. 

Forms  of  Eruption. — The  chief  forms  of  eruption  are:  (i)  en,-thema, 
(2)  papular  s}-philids,  (3)  pustular  s^-plulids,  and  (4)  tubercular  s>-philids. 
Besides  these  eruptions  pigmentation  may  occur  (pigmentar\-  s\-philid), 
and  blood  may  extravasate  (purpuric  s}phiLid'> . 

Prince  A.  ^lorrow  does  not  believe  in  erecting  the  vesicular  syphilids  into 
a  special  group.  He  tells  us  that  vesicles  sometimes  form  on  er\"themato- 
papular  lesions,  but  their  presence  is  an  accident  and  not  a  regular  phenom- 
enon. So,  too,  the  bullous  s}'philid  is  a  rare  accident  in  a  case,  and  even 
when  it  occurs  soon  becomes  pustular.  The  pemphigoid  sA'phUid  is  found 
almost  exclusively  in  hereditar\'  disease.^ 

I.  Erythema  {Macula,  Roseola,  or  Spots). — This  eruption  usually  comes  on 
gradually,  crop  after  crop  of  spots  appearing,  and  many  days  passing  before 
an  extensive  area  is  covered.  Occasionally,  however,  it  arises  suddenly 
(after  a  hot  bath,  after  taking  ^'iolent  exercise,  or  after  eating  an  indigestible 
meal).  This  eruption  consists  of  circimiscribed,  irregularly  round,  h}'pereniic 
spots,  about  h  inch  in  diameter,  whose  color  does  not  entirely  disappear  on  pres- 
sure in  an  old  eruption,  but  does  in  a  recent  one.  The  color  is  at  first  light 
pink,  but  it  becomes  red,  purple,  or  even  brown.  In  the  papular  form  of 
er^^thema  the  spots  are  sHghtly  elevated.  Er}-thema  is  rare  upon  the  face  and 
the  dorsum  of  the  hands  and  feet.  It  attacks  especially  the  chest  and  belly, 
but  appears  often  on  the  forehead,  the  bend  of  the  elbow,  and  the  inner  por- 
tion of  the  thigh,  the  neck,  and  the  flexor  surface  of  the  forearms  and  arms. 
It  appears  first  on  the  abdomen  and  last  on  the  legs.  UsuaUy  er\-thema  fol- 
lows s}-philitic  fever,  about  six  weeks  after  the  chancre  appears,  and  the 
number  and  distinctness  of  the  spots  are  in  proportion  to  the  violence  of 
the  fever.  No  fever  or  sHght  fever  means  there  will  be  but  few  spots  and  they 
wHl  soon  disappear.  In  rare  cases  the  eruption  is  y&ix  transitory-,  lasting 
but  a  few  hours,  but  it  usually  continues  for  several  weeks  if  untreated.  It 
may  pass  away  or  may  be  converted  into  a  papular  eruption.  ^Merciuy-  will 
cause  it  to  disappear  in  a  couple  of  weeks.  In  examining  for  this  form  of 
eruption  in  a  doubtful  case,  let  cold  air  blow  upon  the  chest  and  belly;  this 
blanches  the  sound  skin  and  makes  clear  any  discoloration.  No  desquam- 
1  ]\Iorrow's  "System  of  Geni to-urinary  Diseases,  Sjphilolog}^,  and  De^matolog3^" 


324 


S}^hilis,  or  Pox 


ation  attends  the  macular  eruption,  but  a  brownish  stain  remains  for  a  vari- 
able time  after  the  eruption  fades.  Erythema  means,  as  a  rule,  a  mild  and 
curable  attack.  Maculae  may  be  combined  with  the  next  form,  constituting 
a  maculopapular  eruption. 

The  maculopapular  s}-philids  are  evolved  from  the  macular  syphilids. 
They  are  slightly  ele\-ated,  are  situated  upon  h\^eremic  bases,  and  the  sum- 
mits of  some  of  them  may  undergo  slight  desquamation.  A  roseolar  area 
may  show  one  or  several  of  these  macular  papules.  They  are  apt  to  arrange 
themselves  in  segments  of  circles  and  are  symmetrically  distributed.  This 
eruption  usually  appears  early,  but  may  appear  late.  It  may  fade  and  reap- 
pear several  times  in  the  same  patient.     The  eruption  lasts  a  few  weeks. 

2.  Papular  syphilids,  which  are 
papules  or  elevations  covered  with 
dry  skin,  may  or  may  not  des- 
quamate. If  they  do  desquamate, 
the  process  begins  over  the  center. 
They  usually  appear  from  the  third 
to  the  sixth  month  of  the  disease. 
They  may  be  preceded  by  fever,  and 
often  reappear  again  and  again. 
They  are  at  first  small  and  red,  but 
become  larger  and  brownish.  They 
are  firm  in  feel  and  vary  in  size 
from  the  head  of  a  pin  to  a  five- 
cent  piece  or  larger.  Very  large 
papules  constitute  nummular  syphi- 
lids. They  all  tend  to  scale.  The 
epiderm  becomes  thin,  red,  and  glis- 
tening, splits  in  the  center  and  des- 
quamates, and  a  fringe  of  epidermis 
surrounds  the  desquamated  area. 
This  process  may  be  repeated  once 
or  oftener.  When  lenticular  papules 
recur  in  the  late  secondar}^  stage  they 
are  apt  to  group  themselves  in  circles 
limited  to  particular  regions  (annular 
or  circinate  s>'philoderm).  They 
may  be  present  as  miliary  papules, 
lenticular  papules,  moist  papules, 
and  papules  with  marked  epidermic 
proliferation  resembling  psoriasis 
(papulosquamous  eruption).  Papules  on  fading  leave  very  persistent  cop- 
pery-looking stains.  Papules  upon  the  palms  and  soles  constitute  the  so-called 
"palmar  and  plantar  psoriasis,"  which  appears  from  three  months  to  one 
year  after  the  appearance  of  the  chancre.  Papules  just  below  the  line  of 
the  hair  on  the  forehead  constitute  the  corona  veneris.  Papular  S}^hilids 
appear  especially  upon  the  forehead,  the  neck,  the  abdomen,  and  the  extremi- 
ties. The  papular  or  squamous  s>T3hilid  of  the  palms  and  soles  begins  as  a 
red  spot,  which  becomes  elevated  and  brownish ;  the  epidermis  thickens  and  is 
cast  off,  and  there  then  remains  a  central  red  spot  surrounded  by  undermined 
skin.  If  papules  are  in  regions  where  they  are  kept  moist  (as  about  the  anus), 
they  become  covered  with  a  sodden  gray  film,  which  after  a  time  is  cast  off  and 
leaves  the  papule  without  epidermis.  The  sodden  papules  are  called  flat 
condylomata,  moist  or  humid  papules  or  plates  (Fig.  134).  Papules  which  are  at 
first  small  may  become  large.     The  small  or  miliary  papules  constitute  syphil- 


134. — Condylomata  THorwitz). 


Affections  of  the  Mucous  Membranes  325 

itic  lichen.  The  lenticular  papules  are  most  common,  and  strongly  tend  to 
scale  off.  The  papular  s\philids  give  a  worse  prognosis  for  the  constitutional 
disease  than  do  spots.  The  s}'philitic  negro  is  particularly  apt  to  develop  the 
annular  s\-philoderm. 

3.  Pustular  ss^philids  arise  from  papules.  The  condition  is  known  as 
acne  when  the  apex  of  the  papule  softens,  impetigo  when  the  whole  papule 
suppurates,  and  ecthyma  or  nipia  when  the  corium  is  also  deeply  involved. 
\'esicles  occasionally  precede  pustules.  The  pustular  eruption  appears  a 
number  of  months  after  infection  and  later  than  the  papular.  The  pustular 
eruption  gives  a  very  bad  prognosis  for  the  constitutional  disease.  Rupia  is 
formed  by  a  pustule  rupturing  or  a  papule  ulcerating,  the  secretion  drying 
and  forming  a  conical  crust  which  continually  increases  in  height  and  diam- 
eter, while  the  ulceration  extends  at  the  edges.  When  the  crust  is  pulled  off 
there  is  seen  a  foul  ulcer  vnth  congested,  jagged,  and  undermined  edges. 
Rupia  may  be  secondar}^  or  tertiary,  and  it  invariably  leaves  scars.  It  appears 
only  after  at  least  six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  s}-mmetrical.     Tertiary  rupia  is  as}-mmetrical. 

4.  Tubercular  syphilids  are  greatly  enlarged  papules  intermediate  between 
ordinary  papules  and  gummata. 

Diagnosis  Between  Secondary  and  Tertiary  Syphilids. — A  secondar\^  eruption 
is  distinguished  from  a  tertiary  eruption  by  the  following:  the  first  tends 
to  disappear,  the  second  tends  to  persist  and  to  spread;  the  first  is  general 
and  s\Tnmetrical,  the  second  is  local  and  as\Tnmetrical;  the  first  does  not 
spread  at  its  edge,  the  second  tends  to  spread  at  its  edge,  and  this  tendency, 
which  is  designated  serpiginous,  produces  an  ulcer  shaped  like  a  horseshoe 
(Jonathan  Hutchinson).  Secondar\'  lesions  appear  within  certain  limits  of 
time,  develop  regularly,  and  are  dispersed  by  merciurial  treatment.  Tertiary 
lesions  appear  at  no  fixed  time,  develop  irregularly,  and  are  not  cleared  up  by 
mercmy. 

Affections  of  the  Mucous  Membranes.— The  chief  lesions  in  sj^ph- 
ilitic  affections  of  the  mucous  membranes  are  mucous  patches,  warts,  and 
condylomata.  The  first  phenomena  of  secondary  s\-philis  are,  as  a  rule, 
s>Tnmetrical  ulcers  of  the  tonsils,  painless,  of  temporary  duration,  and  super- 
ficial (Hutchinson).  The  borders  of  the  ulcers  are  gray  and  the  areas  are 
reniform  in  shape.  Catarrhal  inflammations  often  occur.  Eruptions  appear 
on  the  mucous  membranes  as  upon  the  skin.  Mucous  patches  are  papules 
deprived  of  epithelium ;  they  are  gray  in  color,  are  moist,  and  give  off  an  offen- 
sive and  \'irulent  discharge.  They  usually  appear  as  areas  of  congestion,  swell- 
ing, and  abrasion  of  the  epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks, 
vagina,  labia,  \'ulva,  scrotima,  anus,  and  under  the  prepuce.  A  moist  papule 
of  the  skin  is  really  a  mucous  patch.  These  patches,  which  are  always  circular 
or  oval,  are  among  the  most  constant  lesions  of  the  secondary  stage,  appearing 
from  time  to  time  during  many  months.  If  a  patch  has  the  papillce  destroyed, 
it  is  called  a  hald  patch.  If  the  papules  present  h}'pertrophied  papillae  fused 
together,  there  appear  enlargements  with  flat  tops,  termed  condylomata  (Fig. 
134);  if  the  papillae  of  the  papules  hypertrophy  and  do  not  fuse,  the  growths 
are  called  warts.  Mucous  lesions  of  the  mouth  are  commonest  in  smokers 
and  in  those  with  bad  or  neglected  teeth.  Hutchinson  says  that  persistence 
in  smoking  during  s>"pliilis  may  cause  leukomata,  or  persistent  white  patches. 
The  vagina  and  Hps  of  the  \aLlva  during  the  secondary'  stage  are  often  covered 
with  mucous  patches.  The  uterus  may  contain  mucous  lesions  which  poison 
the  uterine  discharge.  The  larv-nx  may  suffer  from  inflammation,  eruptions, 
and  ulceration  (hence  the  hoarse  voice  which  is  so  usual).  The  nasal  mucous 
membrane  may  also  suffer.  The  rectal  mucous  membrane  may  be  attacked 
by  patches,  and  so  may  the  glans  penis,  the  inner  surface  of  the  prepuce. 


326  Syphilis,  or  Pox 

and  the  urethra.  Early  in  the  secondary  stage  in  some  cases  there  is  a  slight 
mucopurulent  urethral  discharge,  and  examination  with  an  endoscope  shows 
redness  of  the  mucous  membrane  of  the  anterior  urethra.  The  discharge  is 
contagious.  The  condition  may  be  followed  by  constriction  of  the  urethral 
caliber.     Distinct  ulceration  may  take  place. 

Affections  of  the  Hair. — In  syphilis  the  hair  is  usually  shed  to  a  great 
extent.  This  loss  may  be  widespread  (beard,  mustache,  hair  of  head,  eyebrows, 
pubic  hair,  etc.)  or  it  may  be  limited.  Complete  baldness  sometimes  ensues, 
but  it  is  rarely  permanent.  The  hairs  of  the  head  are  first  noticed  to  come  out 
on  the  comb;  on  pulling  them  they  are  found  loose  in  their  sheaths — so  loose 
that  Ricord  has  said  "a  man  would  drown  if  a  rescuer  could  pull  only  upon 
the  hair  of  the  head."  The  falling  out  of  the  hair,  which  is  known  as  alopecia, 
usually  begins  soon  after  the  fever  or  about  the  time  of  the  eruption,  but 
it  may  be  postponed  until  much  later.  The  skin  of  a  syphilitic  bald  spot  is 
never  smooth,  but  is  scaly.  The  hair  may  thin  generally,  baldness  may  appear 
in  twisting  lines,  or  it  may  be  complete  only  in  limited  areas.  Alopecia  results 
from  shrinking  of  the  hair-pulp,  death  of  the  hair,  and  casting  off  of  the  sheath. 

Affections  of  the  Nails. — Paronychia  is  inflammation  and  ulceration  of 
the  skin  in  contact  with  a  nail  and  extending  to  the  matrix.  The  nail  is  cast 
off  partially  or  entirely.  Onychia  is  inflammation  of  the  matrix,  and  is  mani- 
fested by  white  spots,  brittleness  or  extended  opa^city,  twisting,  and  breaking 
off  of  the  nail.  The  parts  around  are  not  affected.  The  damaged  nail  drops 
off  and  another  diseased  nail  appears. 

Affections  of  the  Ear. — Temporary  impairment  of  hearing  in  one  or 
both  ears  is  not  uncommon  in  syphilitic  affections  of  the  ear.  Rarely,  per- 
manent symmetrical  deafness  is  produced.  Meniere's  disease  is  sometimes 
caused  by  syphilis. 

Affections  of  the  Bones  and  Joints. — In  syphilis  there  may  be  slight 
and  temporary  periostitis.  Pain  and  tenderness  arise  in  various  bones,  the 
pain  being  worse  at  night  {osteocopic  pains).  Osteoperiostitis  usually  arises 
with  or  after  the  onset  of  the  secondary  eruption,  but  in  rare  instances  pre- 
cedes the  syphilids.  The  bones  usually  involved  are  the  tibiae,  clavicles,  and 
skull.  Intense  headache  may  be  due  to  periostitis  of  the  inner  surface  of  a 
cranial  bone.  Local  periostitis  may  form  a  soft  node,  which  by  ossification 
becomes  a  hard  node.  Pain  like  that  of  rheumatism  may  affect  the  joints.  It 
is  not  increased  by  motion  and  is  worse  at  night.  Such  pains  are  by  no  means 
uncommon  and  in  some  cases  are  very  severe.  The  joints  are  not  stiff  except 
perhaps  on  rising.  Paton  reminds  us  that  such  arthralgia  is  an  early  symp- 
tom and  may  actually  antedate  the  secondary  eruption  ("Brit.  Med.  Jour.," 
Nov.  28,  1903).  More  common  than  the  above  condition  is  synovitis,  acute  or 
chronic.  It  often  comes  on  rapidly  without  other  symptoms  and  is  announced 
by  swelling,  tenderness,  and  pain.  In  some  cases  the  pain  is  severe,  and  the 
patient  is  feverish  or  actually  ill.  Such  cases  constitute  what  is  called  syphilitic 
rheumatism,  but  the  profuse  sweats  of  acute  rheumatism  are  absent,  the  heart 
is  never  attacked,  the  skin  is  not  red,  the  fever  is  not  high,  and  the  condition  is 
not  migrating  (Ibid.).  Hydrarthrosis  may  arise  in  the  knee  as  a  sequence  of 
either  of  the  above  conditions,  or,  late  in  the  secondary  stage,  it  may  arise 
without  such  an  antecedent  trouble  (Paton).  Symmetrical  synovitis  has  been 
noted.  Secondary  syphilitic  disease  of  bone,  periosteum,  and  joints  lasts  only 
a  short  time  and  is  never  destructive. 

Affections  of  the  Eye. — Iritis  is  the  commonest  eye  trouble  which  may 
arise  during  secondary  syphilis.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming  affected.  The 
symptoms  are  a  pink  zone  in  the  sclerotic,  a  congested,  red  or  muddy  iris,  irreg- 
ularity of  the  pupil  accentuated  by  atropin,  the  existence  of  pain  and  photo- 


Intermediate  Period 


327 


phobia,  and  sometimes  hazy  or  even  clouded  pupil.  Rheumatic  iritis  causes 
much  pain  and  photophobia,  syphilitic  iritis  comparatively  little;  there  is  less 
swelling  in  the  first  than  in  the  second;  the  former  tends  to  recur,  the  latter 
does  not.  Iritis  is  usually  recovered  from,  good  vision  being  retained.  Diffuse 
retinitis  and  disseminated  choroiditis  never  occur  until  a  number  of  months 
have  passed  since  the  infection.  The  symptoms  are  failure  of  sight,  muscae 
volitantes,  and  very  little  photophobia.  The  diagnosis  of  retinitis  and  cho- 
roiditis is  made  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele. — The  testicle  enlarges 
because  of  plastic  inflammation.  Both  glands  usually  suffer,  but  not  always. 
Fluid  distends  the  tunica  vaginalis.  The  epididymis  escapes.  The  testicle 
is  not  the  seat  of  pain,  is  troublesome  because  of  its  weight,  and  has  very 
little  of  the  proper  sensation  on  squeezing.  The  plastic  exudate  is  generally 
largely  absorbed,  but  it  may  organize  into  fibrous  tissue,  the  organ  passing 
into  atrophic  cirrhosis. 

Nervous  System. — S3q3hilis  of  the  nervous  system  may  arise  as  early  as 
the  sixth  month  after  infection,  although  the  nervous  system  is  far  more  apt 
to  suffer  in  the  intermediate  period  or  in  the  tertiary  stage.  Actual  deposits 
in  the  brain  or  cord  do  at  times  take  place  in  the  secondary  stage.  These 
deposits  call  for  prompt  and  active  treatment  or  they  will  cause  permanent 
damage.  Such  lesions  are  particularly  common  in  untreated  cases  and  in  cases 
in  which  secondary  manifestations  were  slight  or  perhaps  even  unobserved. 

The  Albuminuria  of  Secondary  Syphilis. — It  is  not  very  unusual 
for  nephritis  with  albuminuria  to  develop  early  in  the  secondary  stage.  There 
may  be  the  ordinary  symptoms  of 
nephritis,  but  in  many  cases  there 
is  albuminuria  and  nothing  more. 
Large  amounts  of  albumin  run  away 
from  the  kidneys  and  the  high  per- 
centage of  albumin  in  the  urine  is  a 
notable  feature.  Many  of  these  casei 
recover  completely,  some  become 
chronic,  and  in  some  death  occurs. 
It  seems  probable  that  mercurial 
treatment  is,  in  part  at  least,  respon- 
sible for  some  of  these  cases.  The 
syphilitic  poison  causes  the  others. 
Those  in  which  there  is  albuminuria 
and  nothing  more  are  due  to  syphilis 
rather  than  to  mercury.  Those  in 
which  there  is  dropsy  are  aggra- 
vated and  perhaps  caused  by  mer- 
cury (Fleissinger,  in  "Journal  des 
Practicens,"  August  3,  1907). 

Intermediate  Period. — Secondary  lesions  cease  to  appear  in  from 
eighteen  months  to  three  years.  In  the  intermediate  period  no  symptoms 
may  appear,  yet  the  disease  may  be  still  for  some  time  latent  and  not  cured. 
The  Wassermann  reaction  may  be  negative.  Symptoms  may  arise  from  time 
to  time.  These  symptoms,  which  are  called  reminders,  are  not  so  severe 
as  tertiary  symptoms,  are  apt  to  be  symmetrical,  and  do  not  closely  resem- 
ble secondary  lesions.  Among  the  reminders  we  may  name  palmar  psoria- 
sis and  sarcocele.  Sarcocele  in  this  stage  is  bilateral  and  rarely  painful. 
Bilateral  indolent  epididymitis  occasionally  occurs.  Sores  on  the  tongue,  a 
papular  skin  eruption,  and  choroiditis  may  arise.  Gimimata  occasionalty  occiir 
in  this  stage,  but  they  are  apt  to  be  symmetrical  and  non-persistent.     Sym- 


Fig.  135. — Serpiginous  ulcers. 


328  S3^hilis,  or  Pox 

metrical  superficial  dactylitis  may  occur.  Arteritis  may  develop,  beginning  in 
the  intima  or  adventitia,  and  causing,  it  may  be,  aneurysm,  thrombosis,  or  em- 
bohsm.  Obliterative  endarteritis  may  cause  gangrene.  Vascular  changes  are 
notably  common  in  the  vessels  of  the  brain,  and  thrombosis  may  occur,  in  which 
case  paralysis  usually  comes  on  gradually,  preceded  by  numbness,  although 
sudden  paralysis  may  take  place.  The  paralysis  may  be  limited,  extensive, 
transitory,  or  permanent.  The  nervous  system  often  suffers  in  this  stage 
(anesthetic  areas  and  retinitis) .  The  viscera  are  often  congested  and  infiltrated 
(liver,  spleen,  kidneys,  and  lungs). 

Tertiary  Syphilis. — This  stage  is  not  often  reached,  the  disease  being 
cured  before  it  has  been  attained.  About  85  per  cent,  of  syphilitics  escape  it 
entirely.  In  this  stage  there  is  greatly  impaired  nutrition  the  resiilt  of  the 
prolonged  disease.  Until  recently  it  was  generally  thought  that  tertiary  lesions 
are  not  contagious.  This  statement  is  now  known  to  be  untrue.  They  are 
not  nearly  as  contagious  as  the  primary  lesions,  as  secondary  lesions,  or  as  blood 
of  the  secondary  stage,  but  they  are  contagious,  though  feebly  so.  A  tertiary 
lesion  contains  spirochetes,  but  not  nearly  so  many  as  a  secondary  lesion. 
The  primary  stage  disappears  without  treatment,  the  secondary  stage  tends 
ultimately  to  spontaneous  disappearance,  but  tertiary  lesions  tend  to  persist 
and  to  recur.  Tertiary  lesions  may  be  single  or  may  be  widely  scattered; 
when  multiple  they  are  not  symmetrical  except  by  accident.  These  lesions 
may  attack  any  tissue,  even  after  many  years  of  apparent  cure;  they  all  tend 
to  spread  locally,  they  all  leave  permanent  atrophy  or  thickening,  they  all 
tend  to  relapse,  and  a  local  influence  is  often  an  exciting  cause.  Tertiary  syph- 
ilis may  cause  marked  anemia  and  it  is  sometimes  the  cause  of  pernicious  anemia 
(Dumas  and  Pirrot,  in  "La  Presse  Medicale,"  xv,  Nos,  39  and  40). 

Tertiary  skin  eruptions  are  liable  to  ulcerate.  Various  eruptions  may 
occur:  papular  syphilids,  pustular  syphilids,  gummatous  syphilids,  ser- 
piginous syphilids,  and  pigmentary  syphilids.  The  characteristic  syphilid 
is  rupia,  which  is  formed  by  a  pustule  rupturing  or  a  papule  ulcerating.  A 
brown  or  black  crust  forms  because  of  the  drying  of  the  discharge,  ulceration 
continues  under  the  crust,  new  crusts  form,  and,  as  the  ulcer  is  constantly 
increasing  peripherally,  the  new  crusts  are  larger  in  diameter  than  the  old 
ones  and  the  mass  assumes  the  form  of  a  cone.  An  ulcer  which  has  destroyed 
the  deeper  layers  of  the  skin  is  exposed  by  tearing  off  the  crust.  On  healing, 
a  rupial  ulcer  always  leaves  a  permanent  scar. 

Serpiginous  ulcers  (Fig.  135)  are  common  in  tertiary  syphilis,  and  are 
especially  common  about  the  knees,  nostrils,  forehead,  and  lips.  Serpiginous 
ulceration  is  spoken  of  as  syphilitic  lupus.  It  is  preceded  by  a  widespread 
brown-colored  nodular  cutaneous  infiltration.  The  nodules  suppurate,  run 
together,  crust,  and  produce  an  ulcer  which  spreads  rapidly  and  assumes  the 
shape  of  a  horseshoe. 

The  gumma  (Fig.  136)  is  the  typical  tertiary  lesion.  In  some  cases  there 
is  a  solitary  gumma;  in  others,  two  or  three  or  even  many  gummata.  A 
gumma  is  a  mass  of  granulation  tissue,  grayish-yellow  in  color,  containing 
many  cells  and  few  fibers.  Organization  of  the  gumma  fails  to  take  place  be- 
cause of  a  want  of  sufficient  blood-supply,  the  cellular  mass  is  apt  to  undergo 
caseation,  and  when  this  occurs  an  ulcer  forms.  One  portion  of  the  mass 
may  caseate,  another  portion  may  become  fibrous.  In  some  cases  the 
entire  gumma  becomes  fibrous.  A  gumma  varies  in  diameter  from  ^ 
inch  to  2  or  3  inches,  presents  a  center  of  gummy  degeneration,  a  sur- 
rounding area  of  immature  fibrous  tissue,  and  an  outer  zone  of  embryonic  tis- 
sue and  leukocytes.  A  gumma,  when  it  is  spontaneously  evacuated,  exhibits 
a  small  opening  or  many  openings  with  very  thin  red  and  undermined  edges; 
the  ulcer  is  slow  to  heal,  and  forms  a  thin  scar,  white  in  the  center,  but  pig- 


Various  Lesions 


32g 


mented  at  the  margins  and  usually  depressed  (Jonathan  Hutchinson,  Jr.). 
The  gummatous  ulcer  is  deep,  circular  in  outline,  with  undermined  edges  and 
an  uneven  floor,  which  is  usually  covered  with  a  thick,  white,  adherent  slough. 
Sometimes  there  is  no  slough,  but  an  extensive  area  is  infiltrated.    A  gummatous 


Fig.  136. — Gumma  of  the  clavicle. 


ulcer  may  coalesce  with  one  or  more  adjacent  ulcers.  The  discharge  is  scantv 
and  tenacious.  These  ulcers  are  often  seen  upon  the  legs,  and  when  once  healed 
rarely  recur.  A  gumma  in  the  internal  organs  may  become  a  fibrous  mass. 
Gummata  form  in  the  skin,  subcutaneous  tissues,  submucous  structures,  mus- 
cles, tongue,  joints,  bones,  bursce,  testes,  _^  ^^ 
spinal  cord,  brain,  and  internal  organs. 
In  tertiar\-  s^'philis  an  inflammation 
may  not  form  a  circumscribed  gumma. 
but,  mstead,  may  produce  a  diftuse  de- 
generating mass.  This  t}"pe  of  inflam- 
mation, which  is  seen  in  bones,  is  called 
"gummatous."'  In  the  nasal  ca\-ity  a 
gumma  is  rapidly  followed  by  an  ulcer 
and  there  is  a  strong  tendency  to  ne- 
crosis of  the  vomer  and  sometimes  of 
the  turbinated  bones.  This  condition 
produces  a  foul  discharge  and  is  known 
as  s}-philitic  ozena.  Advanced  necrosis 
of  the  nasal  bones  causes  the  nose  to 
''fall  in,"  which  is  a  hideous  deformity 
(Fig.  137).  The  commonest  lar}-ngeal 
lesion  is  multiple  ulceration  following 
minute  gimamata.  A  healing  gumma 
in  a  mucous  canal  such  as  the  rectum 
or  lar^Tix  causes  thickening  and  stricture. 
Tertiar\^  s}-philis  is  a  common  cause  of 
amyloid  degeneration  and  the  most  fre- 
quent cause  of  arterial  and  ner\-ous 
sclerosis. 

Various  Lesions. — Hutchinson  enumerates  the  lesions  of  tertian.-  s^-phihs 
as  follows:  Periostitis,  forming  nodes  or  causing  sclerotic  h}-pertrophy.  suppu- 
ration, or  necrosis;  gummata  in  various  parts;  disease  of  the  skin  of  the  t\-pe 
of  rupia  or  lupus;  gumma  or  inflammation  of  the  tongue,  causmg  sclerosis; 


/ 

Fig.  137. 


Destruction  of  the  nose  in  tertian* 

syphilis. 


330  Syphilis,  or  Pox 

structural  changes  in  the  nervous  system,  causing  ataxia,  ophthalmoplegia 
externa  and  interna,  general  paresis,  optic  atrophy,  and  paralyses  of  cerebral 
nerves;  amyloid  degenerations;  and  chronic  inflammation  of  certain  mucous 
membranes  (of  the  mouth,  pharynx,  vagina,  rectum,  etc.),  with  thickening 
and  ulceration.  Gummatous  infiltration  of  the  eyehd  is  sometimes  observed. 
Gummatous  osteoperiostitis  of  the  vertebrae  may  arise,  and  this  may  be  asso- 
ciated with  disease  of  the  membranes  or  cord.  Syphilitic  inflammation  of 
vertebrae  is  called  syphilitic  spondylitis.  Unilateral  enlargement  of  the  epi- 
didymis is  sometimes  noted,  the  mass  feeling  heavy,  aching  a  Httle,  but  not 
being  very  tender.  Unilateral  sarcocele  may  be  met  with.  Gummata  may  arise 
in  the  iris,  the  larynx,  the  rectum,  and  the  nose. 

Tertiary  Syphilis  of  Bones. — The  bones  particularly  liable  to  disease 
are  the  skull,  sternum,  clavicle,  nasal  septum,  and  tibia.  There  may  be  pro- 
ductive periostitis.  This  arises  in  the  deeper  layer  of  the  periosteum.  It 
may  be  one  limited  area,  several,  or  many  areas;  may  be  circumferential,  or 
may  involve  the  length  of  the  shaft  of  a  long  bone.  In  most  cases  the  bone 
is  also  involved  (osteoperiostitis).  The  bone  thickens  under  the  periosteum 
or  toward  the  medullary  cavity,  or  in  both  directions.  The  cuticular  spongy 
substance  may  be  the  seat  of  disease.  The  lesion  may  be  small  and  circimi- 
scribed  or  extensive.  The  thick  bone  becomes  dense  (sclerosis).  In  protracted 
cases  of  bone  overgrowth  in  a  long  bone,  if  growth  occurs  in  the  direction  of 
the  long  axis,  the  bone  will  become  bent.  As  a  matter  of  fact,  each  of  the 
above  lesions  is  a  gumma  which  undergoes  resolution  or  organization.  Syph- 
ilitic periostitis  is  a  superficial  gumma.  Syphihtic  osteitis  is  a  deep  gumma. 
Syphihtic  osteomyehtis  is  a  deep  gimima  which  has  not  undergone  resolu- 
tion or  organization.  The  bone  about  a  deep  gumma  is  thickened.  There 
is  usually  but  one  gumma  in  a  bone,  but  there  may  be  two  or  several.  A 
large  gumma  weakens  bone  so  that  fracture  may  take  place  from  slight  force. 
Caries  or  necrosis  may  arise.  A  sequestrum  seldom  forms  unless  there  is 
mixed  infection.  Periostitis  affects  particularly  the  superficial  bones  (tibia, 
clavicle,  sternum,  ulna,  etc.).  It  begins  in  the  deeper  layer  of  the  periosteum, 
swelling  arises,  gummy  changes  occur,  and  the  bone  beneath  is  more  or  less 
destroyed.  In  the  skxfll  the  bone  may  be  completely  penetrated.  Not  un- 
usually syphilitic  periostitis  arises  at  the  seat  of  a  trivial  injury.  Syphilitic 
osteomyehtis  occurs  particularly  in  the  phalanges  and  skull.  An  area  of 
syphilitic  bone  disease  may  undergo  repair,  osteosclerosis  usually  and  osteo- 
porosis sometimes  resulting.  After  perforation  of  the  skull  there  is  no  bony 
repair.  Syphilis  of  the  bones  of  the  nose  is  necrosis  resulting  from  gummatous 
ulceration.  The  x-ray  picture  is  usually  most  valuable  in  reaching  a  diagnosis 
of  tertiary  syphilis  of  bone.  A  syphilitic  lesion,  if  visible,  usually  has  a  dis- 
tinct outline.  A  piire  periosteal  mass  may  not  show  at  all.  The  bone  lesion 
shows  the  deep  shadow  of  thickening  throughout  or,  as  in  the  gumma,  thick- 
ening around  a  much  hghter  region.  Tuberculosis  produces  absorption  of 
bone  and  hght  areas  in  the  plate.  Sarcoma  of  the  periosteum  always  shows. 
Sarcoma  has  not  a  distinct  margin  like  syphilis. 

Tertiary  Dactylitis  (Fig.  138). — This  condition  is  a  gummatous  formation  in 
a  finger  or  toe.  There  is  a  superficial  form  in  which  the  deposit  begins  in  the 
subcutaneous  tissue  and  subsequently  involves  the  joint  ligaments.  In  a  toe 
the  entire  digit  is  usually  involved,  in  a  finger  the  condition  is  usually  limited  to 
the  proximal  phalanx.  Superficial  dactylitis  is  a  very  early  tertiary  phenome- 
non. A  painless  sweUing  gradually  forms  and  it  is  most  distinct  on  the  dorsal 
surface.  The  sweUing  becomes  purplish  or  reddish-blue  in  color  and  the  joint 
becomes  preternaturally  mobile.     The  swelling  may  ulcerate. 

Deep  dactylitis  is  a  very  late  tertiary  manifestation  and  is  osteomyehtis  or 
periostitis  of  the  fingers  or  perhaps  of  the  toes.     One  or  more  proximal  pha- 


Nervous  S^-philis  331 

langes  are  apt  to  suffer.  The  skin  seldom  suiters.  Caries  and  necrosis  may 
occur  and  the  joint  may  be  destroyed,  or  the  bone  may  be  partially  absorbed 
and  shortened  from  dry  caries.     Ulceration  of  the  skin  is  rare. 

Tertiary  Syphilis  of  Joints. — (See  the  careful  study  of  E.  Percy  Paton, 
in  "Brit.  Med.  Jour.,"  Nov.  28,  1903.)  The  knee-joint  is  most  commonly 
-affected.  Chronic  synovitis  may  arise  with  considerable  or  even  great  swell- 
ing (hydrarthrosis),  trivial  pain,  slight  fimctional  impairment,  some  thicken- 
ing of  s\Tiovial  membrane,  and  some  harshness  or  grating  on  movement. 
Gimimatous  synoA"itis  may  arise,  a  condition  which  sometimes  follows  the 
-ordinar}-  synovitis,  but  more  often  exhibits  xer\-  little  swelling.  The  synovial 
membrane  exhibits  irregular  areas  of  thickening  and  the  s}Tnptoms  resemble 
those  of  a  tuberculous  joint  (Paton). 

In  some  s\philitic  joints  the  disease  begins  in  the  bone  and  cartilage. 
In  such  a  condition  there  is  rigidity,  marked  limitation  of  movement,  pains, 
not  often  severe,  and  some  deformity  (Ibid.).  Again,  as  Paton  points  out,  a 
joint  may  be  involved  by  an  adjacent  s}'philitic  area,  s}Tio^-itis  arising,  or,  if 
a  gumma  breaks  into  a  joint,  secondar}-  pyogenic  infection  may  follow.  Anky- 
losis may  follow  joint  s^-philis. 

Visceral  Syphilis. — Amyloid  changes  may  occur  in  any  of  the  \"iscera  of 
an  individual  with  tertiar\-  s}-philis,  and  such  changes  may  be  found  in  people 
in  whom  suppuration  never  occurred.  The  lungs  may  imdergo  fibroid 
induration  (syphilitic  phthisis).  S}"philitic  phthisis  is  often  a  non-febrile 
malady.  The  sputum  does  not  contain  the  bacihi  of  tuberculosis,  night- 
sweats  and  diarrhea  are  unusual,  and  emaciation  and  exhaustion  are  less 
decided  than  in  tuberculosis.  Gtunmata  may  form  in  the  heart,  liver,  spleen, 
or  kidneys.  The  capsule  and  fibrous  septa  of  the  liver  may  thicken,  the  organ 
being  puckered  by  contraction.  Albuminuria  may  occur  in  tertian,'  s^-philis. 
It  may  be  caused  by  fibroid  changes  in  the  kidneys,  by  the  formation  of  gum- 
mata,  or  by  amyloid  degeneration.  Its  occurrence  should  be  watched  for. 
Mercur\-  and  iodid  of  potassium  have  been  regarded  as  causative  of  albimiin- 
iiria  in  some  cases.  WTien  albuminuria  is  associated  with  arterial  disease  and 
elevated  tension,  the  condition  is  to  be  regarded  as  paras}-philitic  rather  than 
S}'philitic.  \Mien  albuminuria  results  from  a  true  s}-phiUtic  lesion  of  the  kid- 
ney, there  is  enlargement  of  the  liver,  that  organ  is  often  painful,  there  is 
ascites,  and  sometimes  jaundice  (Fiessinger"). 

S>-philis  may  cause  disease  of  the  stomach,  and  probably  does  so  more 
frequently  than  was  formerly  supposed,  because  it  is  difficult  to  distinguish 
from  more  common  diseases.  The  condition  may  be  gummatous  infiltration 
of  the  walls  of  the  stomach,  multiple  and  minute  gummata,  ulcerations  result- 
ing from  breaking  down  of  gummata,  or  s}-philitic  endarteritis  of  the  gas- 
tric vessels.  When  ulcers  heal,  cicatricial  contraction  results.  Sometimes  a 
large  mass  can  be  palpated.  The  s}-mptoms  last  for  years.  There  is  pain 
after  eating,  but  hemorrhage  does  not  occur  unless  ulcer  forms.  Sj^^hilitic 
ulcers  and  gummata  of  the  stomach  may  be  cm-ed  by  efficient  antis\-philitic 
treatment.  Like  lesions  may  form  in  the  intestines.  Flexner,  Frankel, 
Foiirnier,  and  others  have  discussed  this  subject.^ 

Nervous  syphilis  may  be  manifested  by  disorders  of  the  brain,  cord,  or 
nerves.  It  is  rare  after  severe  secondaries,  and  is  most  common  when  sec- 
ondaries were  light  or  so  tri\-ial  as  to  have  escaped  obser^'ation.  Severe 
secondaries  seem  to  cast  off,  mitigate,  or  exhaust  the  poison.  Nervous  syph- 
IHs  may  result  directly  from  the  specific  disease,  and  such  lesions  are  truly 
syphilitic.  Paresis,  locomotor  ataxia,  myelitis,  meningitis,  neiuritis,  arteritis  may 
be  direct^  due  to  the  presence  of  spirochetes  causing  the  formation  of  s}-philitic 

1  See  editorial  in  "Jour.  .\mer.  iMed.  Assoc,"  :March  24.  1900,  and  Roudnitzkj-,  quoted 
in  'Progressive  Medicine,"  June,  1908,  from  'Trakt.  Vratch,"  August  and  September,  1907. 


332  Syphilis,  or  Pox 

tissue.  Nerv^ous  s>'philis  may  result  indirectly  from  the  specific  disease,  but  not 
be  directly  caused  by  spirochetes  having  formed  syphilitic  tissue.  Such  lesions 
are  called  parasyphilitic.  For  instance,  a  gumma  of  the  brain  is  a  true  syph- 
ilitic lesion,  but  locomotor  ataxia  following  syphilis  is  often  a  parasyphilitic 
lesion.  As  a  matter  of  fact,  the  spirochetes  may  act  directly  on  nerve  matter 
"vvithout  forming  syphilitic  tissue.  Such  a  condition,  though  degenerative,  is 
syphilitic,  not  paras^-philitic.  SyphiUtic  lesions  are  improved  or  cured  by  anti- 
syphiHtic  treatment,  parasyphilitic  conditions  are  not.  The  diagnosis  between 
syphilitic  and  paras}philitic  lesions  is  often  impossible  without  the  therapeutic 
test  (mercury,  salvarsan).  The  former  are  far  more  apt  to  show  positive 
Wassermann  reactions  than  the  latter.  We  must  remember  that  brain  syphilis 
is  usually  a  late  phenomenon  (from  one  to  thirty  years  after  infection).  The 
lesion  may  be  gumma,  of  the  membranes  (tumor),  gimimatous  meningitis,  ar- 
terial atheroma,  or  obHterative  endarteritis.  A  gumma  may  eventuate  in  a 
scar,  a  cyst,  or  a  calcareous  mass.  The  s\Tnptoms  of  brain  syphilis  depend  on 
the  nature,  seat,  and  rate  of  development  of  the  lesions.  It  is  to  be  noted  that 
syphilitic  palsy  is  apt  to  be  limited,  progressive,  and  incomplete.  Epilepsy 
appearing  after  the  thirtieth  year  is  very  probably  specific  if  alcohol  as  a  cause 
can  be  ruled  out.  Persistent  headache,  tremor,  insomnia  or  somnolence,  transi- 
tory^, limited,  and  erratic  palsies,  unnatural  slowness  of  utterance,  amnesia, 
vertigo,  and  epilepsy  are  very  suggestive  of  syphilis.  Sudden  ptosis  is  very 
significant;  so  is  sudden  palsy  of  one  or  more  of  the  extrinsic  eye-muscles.  In 
syphilitic  insomnia  the  patient  cannot  get  to  sleep  at  night  for  a  long  while,  but 
when  he  once  gets  to  sleep  he  reposes  well.  The  type  of  insanity  which  is  most 
apt  to  arise  is  a  likeness  or  counterpart  of  general  paralysis,  and,  like  ordinary 
paresis,  it  is  not  curable.  Most  paretics  have  a  syphilitic  histor}-.  Spinal 
syphilis  may  cause  sclerosis,  a  condition  like  Landr^^'s  paralysis,  softening,  and 
tumor.     Neuritis  is  not  uncommon  in  s}philis. 

Justus's  Test  for  Syphilis. — The  test  described  by  Justus,  in  1894, 
consists  in  first  estimating  the  amoimt  of  hemoglobin  present,  then  making  a 
single  merciirial  inimction,  and  again  estimating  the  hemoglobin.  It  is 
claimed  that  the  corpuscles  of  an  imtreated  syphilitic  are  imduly  sensitive,  and 
if  the  disease  is  present  a  mercurial  inunction  will  cause  a  loss  of  10  to  20  per 
cent,  of  hemoglobin  within  twenty-four  hours,  which  fall  persists  a  few  hours 
and  is  then  followed  by  a  rise  to  a  level  above  that  which  existed  when  the  test 
was  applied.  It  is  often  demonstrable  in  secondan,^,  tertiary,  or  congenital 
syphilis.  It  usually  fails  in  latent  cases,  when  an  initial  lesion  is  recent,  and 
in  early  secondar\"  s}philis,  and  in  some  diseases  other  than  syphilis  the  reac- 
tion can  be  obtained. 

The  Serum  Diagnosis  of  Syphilis  (Wassermann 's  Test). — This 
test  can  only  be  employed  in  institutions  possessed  of  the  best  laboratory 
facilities.  It  is  technical  in  the  extreme.  In  order  to  understand  it  certain 
facts  must  be  known. 

Every  normal  serum  contains  an  activating  material  known  as  complement, 
and  complement  is  destroyed  by  heat.  When  bacteria  or  alien  corpuscles  are 
injected  into  a  living  animal,  the  tissues  of  that  animal  react  and  amboceptor 
is  formed.  Amboceptor  includes  all  antibodies.  Amboceptor  brings  together 
complement  and  the  bacterial  cell  and  it  is  not  destroyed  by  heat.  If  we 
inject  the  corpuscles  of  sheep's  blood  into  a  rabbit,  amboceptor  forms  and  ap- 
pears in  the  rabbit's  serum.  Amboceptor  unites  with  complement  and  with 
alien  corpuscles  and  the  sheep's  corpuscles  are  dissolved,  and  the  blood  of  the 
rabbit  now  contains  a  distinct  excess  of  amboceptor.  If  some  of  this  blood  is 
drawn  and  the  serum  is  placed  in  a  test-tube,  it  will  dissolve  in  the  tube  cor- 
puscles of  sheep's  blood  if  they  are  added  to  it.  If,  however,  the  rabbit  serum 
is  heated  for  one-half  hour  to  50°  C.  before  being  placed  in  a  test-tube,  the  heat 


Noguchi's  Cutaneous  Reaction  333 

destroys  the  complement,  and  then  the  rabbit  serum  will  be  unable  to  dis- 
solve the  corpuscles  of  sheep's  blood,  if  they  are  added,  because  amboceptor 
without  complement  is  incapable  of  effecting  the  solution. 

If,  however,  after  destroying  the  complement  by  heat,  any  other  serum 
is  added,  the  added  serum  furnishes  the  necessary  complement  and  the  mixture 
is  now  able  to  dissolve  sheep's  corpuscles. 

On  these  facts  the  serum  diagnosis  of  syphilis  depends. 

Wassermann  proved  that  if  an  extract  made  of  a  syphilitic  organ  is  placed 
in  the  serum  of  a  syphilitic  individual,  the  amboceptor  or  antibody  will  unite 
vdih  the  complement  and  the  organ  extract,  although  the  union  cannot  be 
recognized  by  inspection.  In  order  to  be  able  to  identify  the  occurrence  of 
such  a  union  a  process  must  be  gone  through. 

The  serum  of  the  patient  thought  to  be  syphilitic  is  heated  and  comple- 
ment is  thus  destroyed.  It  is  then  mixed  with  the  organ  extract,  which  unites 
with  the  amboceptor  of  the  serum,  one  arm  of  the  amboceptor  being  still 
unsaturated  and  open  for  union.  Guinea-pig  serum  is  now  added  to  furnish 
complement.  If  the  patient  is  syphilitic,  the  serum  complement  just  added 
will  unite  with  the  unsaturated  arm  of  the  antibody  or  amboceptor.  To  find 
out  if  this  has  taken  place  we  add  the  heated  serum  of  a  rabbit,  which  will 
destroy  sheep's  corpuscles  if  fresh  serum  is  added  to  it. 

"Sheep's  corpuscles  are  also  added.  If  the  complement  contained  in  the 
guinea-pig  serum  that  was  added  was  taken  up  or  united  with  by  the  syphilitic 
antibody,  there  will  be  none  left  over,  and  consequently  the  added  sheep's 
corpuscles  will  not  be  dissolved.  If,  however,  the  serum  was  not  syphilitic, 
the  complement  will  not  have  been  taken  up,  but  will  be  left  over  for  union 
with  the  hemolytic  amboceptor  of  the  inactivated  rabbit  serum,  which  latter 
imites  with  the  blood-corpuscles,  and  the  combination  causes  the  solution  of  the 
latter"  (Wm.  J.  Butler,  "N.  Y.  Med.  Journal,"  Jan.  30,  1909). 

The  test  is  usually  made  with  blood  of  the  suspected  individual,  but  may  be 
made  with  cerebrospinal  fluid.  The  test  can  be  made  with  milk  taken  from 
the  breast  of  a  lactating  syphilitic. 

Major  Harrison  (quoted  by  D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7, 
191 2)  applied  the  test  in  489  cases.  It  was  positive  in  71.8  per  cent,  of  cases  of 
primary  syphilis,  in  90  per  cent,  of  cases  of  secondary  syphiHs,  and  in  83.5 
per  cent,  of  cases  of  tertiary  sj^hilis.  It  was  present  in  50  per  cent,  of  those 
in  a  stage  of  latency.  In  paretics  it  was  found  in  over  80  per  cent,  of  cases;  in 
tabetics  in  over  50  per  cent,  of  cases. 

A  positive  Wassermann  reaction  may  be  obtained  in  noma,  leprosy,  scarlet 
fever,  sleeping  sickness,  and  some  cases  of  malaria.  Practically,  a  positive  reac- 
tion obtained  from  a  patient  in  the  United  States  nearly  always  means  syphilis. 
A  negative  Wassermann  does  not  prove  that  syphilis  is  absent,  unless  it  is  con- 
stantly negative  and  the  patient  is  not  taking  mercury.  In  latent  stages  of 
syphilis  the  reaction  often  becomes  negative  for  a  considerable  time.  Active 
mercurial  treatment  or  an  injection  of  salvarsan  should  cause  a  positive  reac- 
tion to  become  negative.  The  earlier  mercury  is  given  in  a  case  of  syphilis, 
the  sooner  is  a  negative  reaction  obtained. 

It  seems  certain  that  the  serum  test  has  high  diagnostic  value.  It  may  en- 
able us  to  be  sure  of  the  diagnosis  long  before  the  appearance  of  secondaries. 
A  positive  reaction  indicates  that  the  poison  is  active  and  calls  upon  the  physi- 
cian to  apply  active  treatment.  This  should  be  the  rule,  no  matter  how  long 
it  has  been  since  there  were  any  external  manifestations  of  the  disease.  Wet 
nurses  should  be  tested  by  this  method  before  being  allowed  to  assume  charge 
of  an  infant. 

Noguchi's  Cutaneous  Reaction  ("Jour,  of  Exper.  Med.,"  191 1). — 
Noguchi  gives  the  name  luetin  to  an  emulsion  of  dead  cells  of  pure  culture  of 


334  Syphilis,  or  Pox 

Spirochaeta  pallida.  Rubbed  into  the  skin  it  produces  a  marked  reaction  in  ter- 
tiary and  hereditary  syphilis,  but  seldom  gives  a  reaction  in  primary  or  secondary 
syphilis  (Noguchi,  in  "Jour.  Am.  Med.  Assoc,"  1912,  vol.  Iviii). 

Diagnosis  by  Finding  the  Spirochaeta  Pallida. — This  method  is 
of  the  greatest  value.  The  organism,  if  carefully  searched  for,  is  found  in 
chancre,  in  all  the  lesions  of  early  secondary  syphilis,  and  in  congenital  syphilis. 
Spirochetes,  though  comparatively  few,  are  found  in  tertiary  lesions.  Hence, 
the  old  idea  that  tertiary  lesions  are  not  contagious  must  be  cast  aside.  It 
is  not  found  in  lesions  other  than  syphilis.  Spirochetes  can  be  found  in  a  few- 
minutes  in  material  from  a  syphilitic  papule  or  sore.  Williams  ("Archives  of 
Diagnosis,"  Jan.,  1910)  scrapes  the  papule  or  sore  lightly  with  a  scalpel,  drops 
a  little  warm  salt  solution  on  it,  and  examines  the  salt  solution  at  once. 

Prevention  of  Syphilis. — I  shall  not  discuss  the  various  plans  at  present 
imder  consideration  for  the  diminution  or  extinction  of  syphilis  in  conmiunities. 
It  is  sufficient  to  say  that  no  method  has  yet  been  decided  upon.  Desirable  as 
it  would  be  to  entirely  prevent  syphilis,  it  is  at  present  impossible,  as  promis- 
cuous sexual  intercourse  and  prostitution  are  still  with  us,  and  destined,  for 
some  time  at  least,  to  remain. 

The  individual  in  endeavoring  to  avoid  syphilis  should  avoid,  as  far  as  pos- 
sible, all  the  acts  spoken  of  on  pages  317  and  318,  which  may  be  responsible  for 
infection.  Metchnikoff  discovered  that  if  within  twenty-four  hours  of  inocula- 
tion calomel  ointment  is  rubbed  in  the  area  syphilis  can  be  prevented.  He  used 
I  part  of  calomel  and  2  of  lanolin.  This  fact  is  widely  utilized.  In  the  United 
States  Navy  when  a  sailor  returns  from  shore  leave  and  admits  to  a  suspicious 
connection,  the  penis  and  foreskin  are  rubbed  with  a  mixture  containing  33 
parts  of  calomel,  10  parts  of  vaselin,  and  67  parts  of  lanolin. 

If  before  connection  the  glans  and  prepuce  are  smeared  with  soap  or  calomel 
ointment,  the  liability  to  tearing  and  abrasion  is  lessened  and  crypts  and  fol- 
licles are  blocked  up.  If  this  plan  is  followed,  and  if  after  connection  the 
parts  are  washed  and  bathed  with  a  solution  of  corrosive  sublimate  (i :  2000) 
or  permanganate  of  potash  (i :  3000),  the  danger  of  infection  is  greatly  lessened. 
To  apply  the  calomel  ointment  gives  additional  assurances  of  safety. 

Abortive  Treatment. — I  do  not  believe  that  syphilis  can  be  aborted  by 
cauterization,  by  excision,  or  by  the  administration  of  mercury,  luetin,  or  sal- 
varsan.  Several  observers,  even  during  recent  years,  have  claimed  that  abla- 
tion of  the  chancre  will  sometimes  prevent  the  disease.  In  the  reported  cases 
there  is  some  doubt  as  to  the  diagnosis.  Neisser's  experiments  upon  apes  de- 
monstrate the  futility  of  excision.  He  found  spirochetes  in  adjacent  glands 
before  the  sore  had  indurated.  Injection  of  another  ape  with  material  from 
these  glands  was  followed  by  the  development  of  syphilis.  Excision  causes 
pain  and  diagnostic  uncertainty  and  is  invariably  useless. 

Treatment  of  the  Primary  Stage. — It  has  long  been  taught  that  a 
chancre  should  not  be  excised  because  the  disease  is  constitutional  when  the 
chancre  appears,  and  excision  and  cauterization  inflict  needless  pain  and  do  no 
good.  The  initial  lesion  should  never  be  cauterized  unless  it  is  phagedenic  or 
becoming  so.  Order  the  patient  to  soak  the  penis  for  five  minutes  twice 
daily  in  warm  salt  water  (a  teaspoonful  of  salt  to  a  cupful  of  water),  and  then 
to  spray  the  sore  with  peroxid  of  hydrogen  diluted  with  an  equal  bulk  of  water. 
The  ulcer  is  then  dried  with  absorbent  cotton  and  on  it  is  dusted  a  powder  com- 
posed of  equal  parts  of  bismuth  and  calomel  or,  better,  is  dressed  with  calomel 
ointment.  The  buboes  in  the  groin  require  no  local  treatment  unless  they 
tend  to  suppurate.  If  they  persist  or  become  large,  paint  them  with  iodin  or 
rub  ichthyol  ointment  or  mercurial  ointment  into  them,  and  apply  a  spica 
bandage  to  the  groin.  Some  authorities  give  mercury  in  this  stage  in  order  to 
prevent  secondaries.     The  younger  Gross  opposed  this  strongly,  and  affirmed 


Treatment  of  the  Secondary  Stage  335 

a  wish  to  see  the  secondary  eruption — first,  because  it  proves  the  diagnosis;  and, 
second,  because  it  affords  valuable  prognostic  indications  (an  env-thematous 
eruption  means  a  light  case,  an  early  pustular  eruption  means  a  grave  case  with 
serious  complications) ;  I  long  followed  the  plan  of  my  old  master,  and  did  not 
order  mercury  until  constitutional  symptoms  developed.  We  now  know  that 
the  development  of  a  positive  Wassermann  reaction  may  be  regarded  as  con- 
firmatory of  the  diagnosis,  the  finding  of  spirochetes  proves  it,  and  early  treat- 
ment may  prevent  disastrous  lesions.  We  make  the  diagnosis  early  and  at  once 
begin  constitutional  treatment  (see  page  336).  If  phagedena  arises,  place  the 
patient  promptly  upon  stimulants  and  nutritious  diet,  secure  sleep,  and  destroy 
the  ulcer  by  the  use  of  nitric  acid  or  the  cautery  while  the  patient  is  anesthetized. 
After  cauterization  dust  the  sore  with  iodoform  and  dress  with  wet  antiseptic 
gauze.  Several  times  a  day  change  the  dressings,  and  at  each  change  spray 
the  sore  with  peroxid  of  hydrogen,  irrigate  with  bichlorid  of  mercmy-  solution, 
and  dust  with  iodoform.  It  may  be  necessary  to  cauterize  several  times.  In 
some  cases  it  will  be  necessary  to  employ  continuous  irrigation  by  an  anti- 
septic fluid.  These  cases  are  sometimes  fatal  and  usually  produce  great 
destruction  of  tissue.  In  chancre  redux  watch  carefully  for  the  s^-mptoms  in 
order  to  determine  if  the  condition  is  really  one  of  reinfection  or  if  we  are 
dealing  with  a  gumma  which  resembles  a  chancre  in  appearance. 

A  chancre  usually  heals  promptly  after  the  administration  of  salvarsan,  and 
quite  rapidly  when  the  patient  is  placed  on  mercurs'.  It  is  not  "^dse  to  give 
iodid  of  potash  during  the  primary  stage  and  it  is  not  probable  that  it  is  helpful 
at  all.  Some  teach  that  iodid  of  potash  helps  the  absorption  of  granulation 
tissue  and  so  lessens  induration  and  promotes  healing.  It  certainly  is  not  as 
efficient  as  mercur\'  for  this  purpose;  it  does  not  kill  spirochetes,  the  tissues  of 
the  patient  soon  become  "habituated  to  its  presence  and  excrete  it  as  rapidly  as 
it  is  ingested"  (D'Arcy  Power,  in  "Brit.  ]Med.  Jour.,"'  Dec.  7,  1912). 

Treatment  of  the  Secondan'  Stage. — The  chance  of  cure  in  most  cases 
is  excellent  if  the  patient  follows  ad^-ice.  The  prognosis  is  much  worse  if  the 
patient  is  a  hard  drinker  or  is  the  "\-ictim  of  Bright's  disease,  diabetes,  tuber- 
culosis, or  other  chronic  exhausting  malady.  In  the  secondary'  stage  the  aim  is 
to  ciire  the  disease.  That  it  can  be  cured  is  kno"RTi  because  reinfection  occurs 
in  some  persons.     The  old  axiom,  "S}'philis  once,  s^.'philis  ever,''  is  not  true. 

Diet  and  General  Care. — In  the  beginnmg  of  treatment  the  patient  must 
see  his  ph}-sician  every  day  or  two  until  the  proper  dose  of  mercur\-  has  been 
ascertained.  For  the  follo'U'ing  six  months  he  should  see  his  physician  once 
a  week,  and  during  the  next  sLx  months  once  ever^^  other  week.  During  the 
second  year  he  needs  to  see  him  once  even,'  month.  Of  course,  if  comphca- 
tions  arise  at  any  period  the  \dsits  must  be  more  frequent.  At  the  beginning 
of  the  attack  he  must  have  his  teeth  put  in  perfect  order.  Tobacco  is  abso- 
lutely forbidden  because  its  use  favors  the  development  of  mucous  patches  in 
the  mouth.  Alcohol  as  a  beverage  is  prohibited.  It  is  used  only  as  a  medi- 
cine. The  teeth  should  be  gently  scrubbed  with  a  soft  brush  in  the  morning, 
in  the  evening,  and  after  each  meal,  and  a  mild  astrmgent  or  antiseptic  mouth- 
wash and  gargle  is  to  be  used  several  times  a  day.  If  the  giuns  become  red 
and  tender,  chlorate  of  potash  is  used  as  a  gargle  and  mouth-wash  (i  oz.  of 
the  drug  to  i  pint  of  water).  The  patient  should  wear  flannel  in  winter. 
The  author  beheves  Guiteras's  rules  are  sound,  and  in  accordance  with  them 
directs  the  patient  to  refrain  from  kissing  any  one  on  the  Hps  and  from  using 
a  common  towel,  wash-rag,  cup,  glass,  pipe,  or  razor.  He  is  told  to  sleep 
alone  in  bed,  to  wash  his  hands  often,  to  wear  gloves,  and  to  keep  his  fingers 
out  of  his  mouth.  Every  morning  he  should  take  a  warm  bath,  being  espe- 
ciaUy  careful  to  cleanse  the  anus,  permeum,  axillce,  groins,  and  between  the 
toes;  and  after  the  bath  these  parts  should  be  dusted  with  borated  talc  powder. 


336  Syphilis,  or  Pox 

A  Turkish  bath  once  a  week  is  ordered  by  Guiteras  when  no  skin  eruption 
exists.  The  patient  must  avoid  drafts,  cold,  and  wet;  must  take  a  moderate 
amount  of  gentle  outdoor  exercise,  and  must  sleep  eight  hours  out  of  the  twenty- 
four.  The  diet  is  of  importance,  and  in  this,  too,  the  author  follows  Guiteras 
and  orders  the  patient  to  avoid  eating  anything  fried,  or  any  meat  or  fish  which 
has  been  canned,  salted,  or  preserved.  Fruits,  pickles,  tea,  condiments,  alco- 
holic beverages,  clams,  pork,  veal,  and  pastry  are  not  to  be  taken.  (See 
article  by  Luke  Beggs,  in  "Phila.  Med.  Jour.,"  June  7,  1901.) 

Medical  Treatment. — Mercury  cures  syphilis.  We  no  longer  give  it  only 
to  remove  symptoms,  we  give  it  to  produce  cure.  It  is  given  in  small  doses 
for  a  long  period.  We  were  taught  this  by  Fournier,  Lang,  and  Sir  Jonathan 
Hutchinson  (D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7,  191 2).  Mercury 
kills  the  spirochetes.  This  is  proved  by  the  experiments  upon  apes  made  by 
Metchnikoff  and  Roux.  lodid  of  potash  is  seldom  used  in  the  secondary  stage 
for  the  same  reasons  that  it  is  avoided  in  the  primary  stage.  Mercury  must  be 
used,  the  form  being  a  matter  of  choice.  Fournier  advocated  intermittent 
treatment.  In  this  plan  give  J  gr.  of  protiodid  of  mercury  daily  for  sLx  months, 
then  stop  for  a  month;  then  give  mercury  for  three  months,  then  stop  two 
months.  During  the  first  year  the  patient  is  under  treatment  nine  months,  and 
during  the  second  year  eight  months.  Some  prefer  the  intermittent  and  others 
the  continuous  plan  of  treatment.  The  author  prefers  the  continuous  plan. 
In  following  the  continuous  plan  find  the  patient's  tolerance  to  mercury,  and 
keep  him  for  two  years  on  daily  doses  below  the  amount  he  will  tolerate.  Gross's 
rule  for  continuous  treatment  is  to  order  pills  of  green  iodid  of  mercury,  each 
pill  containing  i  gr.  The  patient  is  ordered  one  pill  after  each  meal  to  begin 
with;  the  next  day  the  after-breakfast  dose  is  increased  to  two  pills;  the  follow- 
ing day  the  after-dinner  dose  is  two  piUs,  and  so  on,  one  pill  being  added 
every  day.  This  advance  is  continued  until  there  is  sHght  diarrhea,  griping, 
a  metallic  taste,  or  tenderness  on  snapping  the  teeth  together,  whereupon  one 
pill  is  taken  off  each  day  until  all  unfavorable  symptoms  disappear.  Then 
the  dose  is  reduced  one-half  and  this  amount  is  called  the  tonic  dose.  This 
experimentation  finds  a  dose  on  which  the  patient  can  be  kept  with  entire 
safety  for  a  long  tune;  but  if  it  is  found  that  colic  or  diarrhea  is  apt  to  recur, 
there  must  be  added  to  each  pill  yV  gr-  o^  opium.  The  patient  is  given  mer- 
cury in  this  way  for  two  years.  Every  time  new  symptoms  appear  the  dose 
is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to  the  standard.  If  the 
protiodid  is  not  tolerated,  give  the  bichlorid: 

I^.     Hydrarg.  chlor.  corros.,  gr.  J; 

Syr.  sarsaparillae  comp.,  f5iij- — M. 

Sig. — One  fluidram,  in  water,  after  meals. 

Mercury  with  chalk  in  i-  or  2-gr.  doses  four  times  a  day,  with  or  without 
Dover's  powder  in  i-gr.  doses,  may  be  used.  Mercurial  inunctions  pro- 
duce a  rapid  effect,  but  irritate  the  skin.  The  drug  should  be  rubbed  in  with 
a  gloved  hand.  There  can  be  used  once  a  day  ^  dr.  of  oleate  of  mercury 
(10  per  cent.)  or  i  dr.  of  mercurial  ointment,  rubbed  into  the  skin.  The 
first  day  it  is  rubbed  into  the  inside  of  one  thigh;  the  second  day  into  the  inside 
of  the  other  thigh;  the  third  day  into  the  inside  of  one  arm;  the  fourth  day 
into  the  other  arm;  next,  into  one  groin  and  then  into  the  other  groin,  and  then 
inunction  is  again  made  at  the  point  of  original  application,  and  so  on.  After 
the  rubbing  the  patient  puts  on  underclothes  and  goes  to  bed,  and  in  the 
morning  takes  a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is  then 
worn  between  the  stocking  and  sole  of  the  foot  during  the  day. 

Fumigation  is  performed  by  volatilizing  each  night  i  dr.  of  calomel.  The 
patient  sits  naked  on  a  cane-seat  chair,  and  is  wrapped  up  to  the  neck  in  a 


Medical  Treatment  337 

blanket  which  drops  tent-like  to  the  floor;  the  calomel  is  put  upon  an  iron 
plate  under  the  chair,  and  is  heated  by  an  alcohol  lamp  beneath  the  plate. 
The  skin  becomes  coated  with  calomel,  and  the  subject,  after  putting  on 
woolen  drawers  and  an  undershirt,  gets  into  bed.  H^-podermatic  injections 
of  mercur}-  are  used  by  some  physicians.  They,  cause  an  eruption  to  dis- 
appear rapidly,  but  may  produce  abscesses,  and  relapses  are  prone  to  occur. 
The  injection  method  vriR  not  abort  the  disease;  should  never  be  a  routine 
treatment;  in  suitable  cases  it  is  very  valuable  for  symptomatic  use,  as 
when  lesions  on  the  face  or  in  important  structures  make  a  rapid  impres- 
sion desirable  or  necessar}^;  in  cases  which  obstinately  relapse  under  other 
treatment,  and  in  SA.-plulis  of  the  ner^-ous  system.  J.  William  White,  after 
a  large  experience  \sith  this  method,  says  that  h}-podermatic  injections  of 
corrosive  sublimate  are  painful  and  are  strongly  objected  to  by  many 
patients;  that  this  method  of  treatment  is  occasionally  dangerous  and  even 
fatal;  that  it  is  Uable  to  be  foUowed  by  local  compHcations  (er}-thema, 
nodosities,  cellulitis,  abscess,  sloughing)-;  that  it  cannot  be  carried  out  by  the 
patient,  but  requires  the  surgeon's  constant  inter\'ention.  This  s^-philographer 
concludes  that  h}-podermatic  medication  does  not  oft"er  advantages  justifying 
its  use  as  a  systematic  method  of  treatment,  and  that  it  encourages  insufficient 
treatment — those  "short  heroic  courses"  which  Hutchinson  shows  are  fol- 
lowed by  the  gravest  tertiar}^  lesions.  "The  claim  that  by  a  few  injections  the 
time  of  treatment  can  be  measured  by  months  or  even  by  weeks,  instead 
of  by  years,  would  seem,  as  ]Mauriac  has  said,  to  involve  the  idea  that  mercurs' 
given  h^-podermically  acquires  some  new  and  powerful  curative  property 
which,  given  in  other  ways,  it  does  not  possess."^  The  usual  plan  is  to  give 
daily  a  hypodermatic  injection  of  corrosive  sublimate  deep  into  the  back  or 
buttock,  the  dose  being  I  gr.  of  the  drug.  Thirty  such  injections  are  used 
unless  some  contra-indication  demands  their  discontinuance  sooner.  The 
treatment  is  then  stopped.  If  the  s}Tnptoms  recur,  however,  the  patient  is 
given  another  course,  the  daily  dosage  being  |  gr.,  the  treatment  being  again 
stopped  after  thirts"  injections,  but  being  continued  anew  in  i-gr.  doses  if 
the  s_\Tnptoms  recur.  The  follo'uing  preparation  is  used  by  some  s^'philog- 
raphers:  0.5  part  of  corrosive  sublimate,  3  parts  of  guaiacol,  and  97  parts  of 
sterile  oHve  oil.  Thirty  minims  contain  ^  gr.  of  corrosive  sublimate.  This 
mixture  should  be  thrown  deeply  into  the  buttock  and  it  causes  no  pain.  The 
use  of  gray  oil  h^-podermatically  has  warm  advocates.  It  is  claimed  that  it 
provokes  Uttle  pain  and  irritation,  and  that  it  is  a  ver}^  efficient  remedy. 
The  oil  should  not  be  thick  like  an  ointment,  because  such  a  preparation  could 
not  be  used  without  warming,  and  heat  causes  the  merciu*}'  to  aggregate  in 
lumps.  OHve  oil  should  not  be  used,  as  it  becomes  rancid.  Dimiesnil's 
formula  is  the  best  ("'Brit.  Med.  Jour.,"  Jan.  18,  1908): 

"The  ingredients  must  be  sterilized  before  they  are  incorporated,  as  it  is 
impossible  to  sterilize  the  product.  If  the  directions  given  below  are  carefully 
followed  no  risk  of  septic  poisoning  is  to  be  apprehended.  The  formula  pro- 
posed by  IM.  Dumesnil  has  been  accepted  by  a  committee  especially  appointed 
by  the  Societe  de  Pharmacie  of  Paris,  to  investigate  the  methods  of  preparing 
gray  oU.  Twenty-six  gm.  of  anhydrous  wool-fat  and  60  gm.  of  pure  liquid 
paraffin  {huile  de  vaseJin  medicinale)  are  sterilized  separately  in  glass  flasks 
at  120°  C.  for  twentv'  minutes.  A  pestle  and  mortar  are  sterilized  by  means  of 
burning  alcohol  and  placed  therein  are  40  gm.  of  mercur\'  and  then  the  wool- 
fat.  The  metallic  particles  are  triturated  until  they  are  sufficiently  minute 
when  examined  under  a  magnffication  of  4S0  diameters,  and  then  the  Hquid 
paraffin  is  added  in  small  portions.     The  product  should  weigh  126  gm.  and 

^  J.  William  "\Miite.  in  Alorrow's  "System  of  Genito-urinan-  Diseases,  Sj-philologj". 
and  Dermatology." 


338  Syphilis,  or  Pox 

measure  100  c.c.  and  should  be  transferred  immediately  to  phials  of  2-,  5-,  and 
lo-c.c.  capacity,  previously  sterilized  at  180°  C." 

An  injection  is  given  twice  during  the  first  week,  once  during  the  second 
week,  and  after  this  once  a  week  or  once  every  other  week  for  an  indefinite 
period  of  time.     It  may  be  given  oftener  if  symptoms  arise  or  persist. 

Taylor  believes  that  gray  oil  may  give  rise  to  unpleasant  and  sometimes 
even  dangerous  symptoms,  and  that  it  should  be  used  with  extreme  care  and 
only  in  selected  cases  in  which  other  remedies  are  contra-indicated.  He  says 
that  in  reading  about  the  hypodermatic  method  he  has  been  struck  with  the 
fact  that  "the  most  serious  results  have  almost  invariably  followed  injections 
in  which  fatty  matters  have  been  the  vehicle  of  suspension.""^ 

Some  surgeons  employ  intravenous  injections  of  mercury.  Lane  injects, 
at  first  every  other  day  and  later  daily,  20  min.  of  a  i  per  cent,  solution  of  cyanid 
of  mercury.  The  skin  in  front  of  the  elbow  is  rendered  aseptic,  a  fillet  is  tied 
around  the  arm,  the  needle  is  inserted  into  a  vein,  the  fillet  is  loosened,  the 
fluid  is  injected,  and  the  needle  is  withdrawn.  This  method  of  using  mercury 
is  painless  and  produces  a  rapid  effect.  It  may  be  used  in  nervous  syphilis, 
but  should  not  be  used  as  a  routine.  In  whatever  way  mercury  is  given,  do 
not  allow  it  to  produce  salivation  (hydrargyrism  or  ptyalism).  Always  re- 
member that  mercury  may  cause  albimainuria  and  examine  the  urine  at  regular 
intervals  during  a  course  of  the  drug.  If  albumin  appears  in  the  urine,  cut 
down  the  dose  of  mercury  or  stop  the  drug  for  a  time.  In  the  beginning  of  a 
case  of  S3^hilis,  if  the  kidneys  are  found  to  be  diseased,  give  the  mercury 
cautiously,  and  never  fail  to  examine  the  urine  at  regular  intervals.  An 
individual  can  take  more  mercury  in  summer  than  in  winter  because  during 
the  warm  weather  perspiration  favors  elimination. 

Sometimes,  when  a  patient  has  a  secondary  eruption,  the  eruption  grows 
temporarily  worse  when  mercury  is  administered.  This  is  called  Herxheimer's 
reaction.  It  is  due,  according  to  Adamson,  to  having  killed  some  spirochetes 
and  thus  caused  the  liberation  of  more  endotoxins,  the  endotoxins  causing  "a 
further  local  defensive  reaction"  ("Lancet,"  AprU  6,  191 2). 

In  order  to  cure  syphilis  mercury  should  be  given  for  two  years,  and  the 
mercurial  course  must  be  followed  by  at  least  a  six  months'  course  of  iodid  of 
potash.  Reminders  require  both  iodid  of  potash  and  mercury  (mixed  treat- 
ment) .  Throughout  the  mercurial  course  the  patient  should  be  weighed  once  a 
week,  and  if  it  is  at  any  time  found  that  the  weight  is  decreasing,  tonics,  con- 
centrated food,  and  cod-liver  oil  are  ordered.  If  the  weight  continues  to 
grow  less  and  the  health  begins  obviously  to  fail,  stop  the  mercury  for  a  time, 
continue  the  cod-liver  oil,  tonics  and  nourishing  food,  and  order  hot  baths, 
fresh  air,  iron,  and  chlorid  of  gold  and  sodium.  If  during  the  mercurial  course 
albumin  appears  in  the  urine  and  some  edema  is  noted,  the  mercury  should  be 
stopped  for  several  or  a  number  of  weeks  and  the  patient  should  be  given  a 
milk  diet.  If  marked  albuminuria  is  noted,  but  no  other  symptoms  exist, 
mercury  need  not  be  discontinued,  but  the  patient  is  watched  most  carefully 
for  the  advent  of  any  other  symptom  (Fiessinger,  in  "Journal  des  Practiciens," 
August  3,  1907). 

Acute  Ptyalism,  or  Salivation. — In  acute  ptyalism  the  saliva  be- 
comes thick  and  excessive  in  amount;  the  gums  become  spongy  and  tender  and 
liable  to  bleed.  Tenderness  can  be  detected  early  by  snapping  the  teeth.  A 
metallic  taste  is  complained  of;  the  breath  becomes  fetid;  the  oral  structures 
swell;  the  teeth  loosen;  the  saliva  is  produced  in  great  quantity;  and  there  are 
purging,  colic,  and  exhaustion.  Sometimes  there  are  fever  and  a  diffuse 
scarlatiniform  eruption  upon  the  skin.  A  chronic  hydrargyrism  may  be 
shown  by  salivation,  gastro-intestinal  disorder,  emaciation,  mental  depression, 
1  "Venereal  Diseases,"  by  Robert  W.  Taylor. 


Treatment  of  Complications  in  the  Secondary  Stage  339 

weakness,  albuminuria,  and  tremor.  To  avoid  salivation,  advance  the  dose 
with  great  caution  and  instruct  the  patient  as  to  the  iirst  sign  of  the  trouble. 
He  should  use  a  soft  tooth-brush  and  an  astringent  mouth-wash  (48  gr.  of 
boric  acid  to  4  oz.  each  of  listerine  and  water) .  When  ptyalism  is  noted,  dis- 
continue the  administration  of  the  drug.  Employ  the  above  mouth-wash  or 
one  composed  of  a  saturated  solution  of  chlorate  of  potassium.  Order  y^o  gr. 
of  atropin  twice  a  day,  and  in  bad  cases  spray  the  mouth  with  peroxid  of 
hydrogen  and  use  silver  nitrate  locally  (20  gr.  to  i  oz.).  Give  stimulants  (iron, 
quinin,  and  str\'chnin)  and  nutritious  food.  A  weekly  Turkish  bath  is  of 
great  service.  In  chronic  hydrargyrism  stop  the  administration  of  the  drug, 
use  tonics,  stimulants,  open-air  exercise,  Turkish  baths,  and  nutritious  food. 
The  chlorid  of  gold  and  sodiimi  forms  a  substitute  for  mercury.  The  use  of 
iodid  of  potassium  is  of  questionable  value  in  ptyalism. 

Treatment  of  Complications  in  the  Secondary  Stage. — The  complica- 
tions of  the  secondars^  stage  usually  require  local  applications  in  addition 
to  general  remedies.  jMucous  patches  in  the  mouth  should  be  touched  vdth. 
bluestone  every  day,  an  astringent  mouth-wash  being  employed  several  times 
daily.  If  the  patches  ulcerate,  they  should  be  touched  once  a  day  with  lunar 
caustic;  if  these  areas  proliferate,  they  should  be  excised  and  cauterized. 
Vegetations  or  growing  papules  on  the  skin  must,  if  calomel  powder  fails 
to  remove  them,  be  cut  aw^ay  with  scissors  and  be  cauterized  with  chromic 
acid  or  with  the  Paquelin  cauterv^  Condylomata  demand  washing  with 
ethereal  soap  several  times  daily,  thorough  drying,  dusting  with  equal  parts 
of  calomel  and  subnitrate  of  bismuth  or  with  borated  talcum,  and  covering 
with  dry  bichlorid  gauze.  If  these  simple  procedures  fail,  excise  and 
cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment,  mercurial  plaster, 
or  painting  with  tincture  of  iodin  should  be  employed.  Ulcers  of  paronychia 
are  dressed  with  iodoform  and  corrosive  sublimate  gauze.  Deep  cutaneous 
ulcers  are  cleaned  once  a  day  with  ethereal  soap,  sprayed  with  peroxid  of  hy- 
drogen, dressed  with  iodoform  and  corrosive  sublimate  gauze,  and  bandaged. 
When  the  process  of  granulation  is  weU  established  dress  with  i  part  of  un- 
guent, hydrarg.  nitratis  to  7  parts  of  cosmoKn.  In  sarcocele  mercurial  oint- 
ment should  be  rubbed  into  the  skin  of  the  scrotum  or  the  testicle  be  strapped. 
In  alopecia  the  hair  should  be  kept  short,  and  every  night  the  scalp  should  be 
cleaned  with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a  lather  with 
water.  After  the  soap  has  been  w^ashed  out  some  hair  tonic  should  be  rubbed 
into  the  scalp  with  a  sponge.  A  favorite  preparation  of  Erasmus  Wilson's 
consisted  of  the  following  ingredients: 

I^.     01.  amj'gd.  dil., 

Liq.  ammonice,  aa  foj; 

Sp.  rosemarini, 

AquEe  mellis,  aa  f  3  ii j  • — ^I- 

Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil  may  be  rubbed  into 
the  scalp.  Solutions  of  quinin  are  esteemed  by  some.  A  useful  wash  for  the 
scalp  is  the  following:  i  dr.  of  borate  of  sodiima,  i  dr.  of  spirits  of  camphor,  2  dr. 
of  glycerin,  and  sufficient  orange-flow^er  w^ater  to  make  4  fl.oz. 

In  treating  persistent  skin-lesions,  inunctions,  injections,  fumigations,  or 
mercurial  baths  may  be  used.  Baths  are  suited  to  patients  with  delicate  skins, 
to  those  whose  digestion  fails  when  mercury  is  given  by  the  mouth,  and  to 
those  w^hose  lungs  will  not  tolerate  fumigations.  Corrosive  sublimate,  h  oz., 
and  4  scruples  of  sal  ammoniac  are  mixed  in  about  4  oz.  of  water;  this  is 
added  to  a  bath  at  a  temperature  of  95°  F.      The  patient  gets  into  this  bath, 


340  Syphilis,  or  Pox 

covers  the  tub  with  a  blanket,  leaving  only  his  head  exposed,  and  remains  in 
the  bath  an  hour  or  so.     Mercurial  baths  may  rapidly  cause  salivation. 

Tertiary  Stage. — If  at  any  time  during  the  case  there  appear  tertiary 
symptoms,  the  patient  should  be  put  on  mixed  treatment,  that  is,  mercury 
and  an  iodid.  In  any  case,  after  two  years  of  mercury  add  iodid  of  potas- 
siimi  to  the  treatment.  If  any  tertiary  symptoms  appear,  the  rule  is  to 
use  mixed  treatment  and  to  continue  it  for  at  least  six  months  after  all 
symptoms  disappear,  the  six  months'  coiurse  dating  from  their  disappear- 
ance. This  emphasizes  the  fact  that  the  iodids  alone  will  not  cure  tertiary 
syphilis.  Iodid  of  potash  does  not  cure,  but  is  very  valuable  in  removing 
symptoms.  In  late  syphilis  both  iodid  and  mercury  are  given.  It  is  the  mer- 
cury that  cures.  The  mercury  is  given  in  small  or  tonic  doses.  Since  the 
days  of  Ricord  iodid  of  potash  has  been  held  in  high  esteem.  In  obstinate 
tertiary  lesions  and  in  nervous  syphilis  the  iodids  should  be  run  up  to  an 
enormous  amount  (from  30  to  250  gr.  per  day).  Sometimes  people  can  take 
large  doses  of  iodid  when  small  doses  produce  iodism.  Cyon  explains  this 
ciu-ious  fact  as  follows:  small  doses  combine  with  some  products  of  the  thyroid 
gland  and  form  toxic  iodoth^nrin.  Large  doses  are  diuretic,  form  soluble 
salts,  and  are  rapidly  eliminated.  An  easy  way  to  give  iodid  is  to  order  a 
saturated  solution  each  drop  of  which  equals  about  i  gr.  of  the  drug.  Each 
dose  of  the  iodid  is  given  one  hour  after  meals  and  in  at  least  half  a  glass 
of  water.  If  the  iodid  disagrees,  it  may  be  given  in  water  containing  i  dr. 
of  aromatic  spirit  of  ammonia,  or  5  drops  of  iluidextract  of  ergot,  or  it  may  be 
given  in  milk.  The  iodid  of  sodiiun  may  be  tolerated  better  than  the  potas- 
sium salt,  as  it  is  less  depressing  to  the  circulation,  or  the  iodids  of  sodiimi, 
potassium,  and  ammonium  may  be  combined.  Gotheil  sometimes  gives  tinct- 
ure of  iodin  in  lo-drop  doses,  well  diluted.  Iodid  may  be  given  as  an  enema 
in  milk.  In  giving  the  iodids,  begin  with  a  small  dose.  During  a  course  of 
the  iodids  always  give  tonics  and  insist  on  plenty  of  fresh  air.  Arsenic  given 
daily  tends  to  prevent  skin  eruptions.  The  iodids  may  disagree  for  a  time, 
but  tolerance  may  be  established  as  the  administration  is  continued.  The 
value  of  the  newer  organic  iodin  preparations  is  as  yet  uncertain.  Some  of 
them  are  given  hypodermatically.  An  iodized  oil,  known  as  iodipin,  can  be 
given  by  the  mouth  or  by  intramuscular  injection.  If  given  by  the  stomach  it 
may  be  taken  in  capsules,  in  tablets,  or  in  milk  (Coates,  in  "Brit.  Med.  Jour.," 
May  7,  1 9 10).  The  iodids  when  they  radically  disagree  produce  iodism — 
a  condition  which  is  made  manifest  by  a  flow  of  mucus  from  the  nose,  con- 
junctival irritation,  a  bad  taste  in  the  mouth,  exhaustion,  anorexia,  nausea, 
and  tremor.  In  some  subjects  there  are  outbreaks  of  acne,  vesicular  eruptions, 
or  even  buUee  or  hemorrhages.  Iodism  calls  for  the  abandonment  of  the  drug, 
and  the  administration  of  increasing  doses  of  Fowler's  solution  of  arsenic,  of 
laxatives,  of  diuretic  waters,  or,  if  there  is  great  exhaustion,  of  stimulants.  In 
some  cases  belladonna  is  of  service.  Some  patients  who  cannot  take  the  al- 
kaline iodids  may  take  syrup  of  hydriodic  acid.  After  the  patient  has  been 
for  six  months  under  mixed  treatment  without  a  S3anptom,  stop  all  treatment 
and  await  developments.  If  during  one  year  no  symptoms  recur,  the  patient  is 
probably  cured ;  if  symptoms  do  recur,  there  must  be  six  months  more  of  mixed 
treatment  and  another  year  of  watching.  It  would  be  wise  were  every  person 
who  has  had  s\'philis  to  take  a  sLx  weeks'  course  of  mercury  and  iodid  twice  a 
year  for  the  balance  of  life.  It  is  probable  that  such  a  plan  would  save  many 
from  visceral  S}q3hilis  and  late  nervous  s}q3hilis.  S>T3hilitic  ulcers  are  treated 
locally  by  cleanliness,  antiseptic  applications,  and,  if  the  situation  admits  of  it, 
by  the  daily  use  of  the  hot-air  apparatus  or  by  the  induction  of  hyperemia  by 
means  of  the  rubber  bandage  or  the  cupping-glass.  If  albuminuria  arises 
during  the  tertiary  stage  and  there  is  arterial  disease  with  high  tension,  mercury 


Tertiary  Stage  341 

will  do  harm.  In  albuminuria  without  high  tension  it  may  be  given  (see  pages 
327  and  33S). 

The  Question  of  Marriage. — Fournier  has  insisted  that  it  is  a  great  wrong 
to  tell  a  s^-phiHtic  that  he  can  never  marr}-.  He  must  not  marr>-  until  he  is 
cured,  and  he  is  not  cured  until,  after  the  cessation  of  the  use  of  mercury-  and 
iodid,  he  goes  one  year  without  treatment  and  ■^'ithout  s}Tnptoms. 

Treatment  of  SypJiilis  by  Salvarsan  or  "606"  [Hydrochlorid  of  Dioxydiamido- 
arsenohenzol). — Various  arsenic  compounds  have  been  tried  in  s}"philis  (atoxyl, 
cacodylate  of  sodium,  arsacetin,  5oamin\,  but  salvarsan  and  neosalvarsan 
are  the  most  important.  Ehrlich  introduced  "606"  (salvarsan)  in  1909  and 
"914''  (neosalvarsan^  early  in  1912.  It  was  hoped  that  a  single  intravenous  in- 
jection would  kiU  all  the  spirochetes  and  immediately  cure  the  disease.  This 
hope  has  not  been  realized,  though  the  remedy  has  great  power  for  good.  It 
kills  multitudes  of  spirochetes  by  directly  poisoning  them,  not  by  causing  the 
tissues  to  form  antibodies.  It  causes  s\Tnptoms  to  rapidly  pass  away,  but  if 
the  administration  is  not  continued  at  inter^'als  or  if  mercur\-  is  not  given, 
relapse,  and  probably  disastrous  relapse,  is  almost  certain  to  occur.  In  many 
cases,  but  not  in  all,  the  Wassermann  reaction  becomes  negative  after  the 
injection.  The  test  is  rendered  negative  more  quickly  than  by  mercury", 
but  it  may  soon  become  positive  again.  The  beneficial  effects  of  these 
arsenic  preparations  are  particularly  manifest  in  early  S}"philis.  and  are  very 
e\-ident  in  tertian.-  s^-philis.  The  drugs  are  of  little  or  no  use  in  parasyph- 
ilitic  lesions. 

In  some  cases  "a  spirochete  infection  which  has  been  in  abeyance"  can  be 
roused  by  salvarsan  "into  suflicient  acti\-ity  to  cause  the  Wassermann  reaction 
to  become  positive.""  when  it  was  before  negative.  Hence,  salvarsan  and  neo- 
salvarsan may  be  used  as  tests  for  s}"philis  and  as  tests  to  determine  if  s^-philis 
has  been  cured  (D"Arcy  Power,  in  "Brit.  Med.  Jour.,""  Dec.  7,  1912). 

Salvarsan  is  not  to  be  given  as  routine  treatment  of  s^-philis  because  it  does 
not  cure;  and  mercur\'  does.  It  is  not  a  substitute  for  mercur\-,  but  is  used  in 
particular  cases  for  particular  reasons.  Even  when  salvarsan  is  given,  mercury 
and  iodid  should  be  given  in  the  same  doses  and  for  the  same  time  as  they  would 
have  been  given  had  salvarsan  not  been  administered.  Salvarsan  should  be 
given  when  the  patient  is  intolerant  to  mercur\-  or  when  mercury-  fails  to  control 
the  disease ;  when  an  important  structure  is  threatened  \\-ith  damage  or  destruc- 
tion; when  the  sore  becomes  phagedenic;  for  malignant  S}philis;  for  persist- 
ent or  spreading  ulcerations;  for  larsiigeal  s}"philis;  for  tertiar\-  s}-philis; 
for  glossitis  and  ulceration  of  the  tongue  ^ith  leukoplakia,  and  for  periostitis 
and  osteitis  in  congenital  or  acquired  s^-plulis.  It  does  no  good  to  s}-philitic 
necrosis,  probably  because  pyogenic  organisms  are  active  ia  such  cases,  and  it 
is  useless  for  s}-mmetrical  s^TLO^'itis  of  the  knees,  possibly  because  the  child  ^-ic- 
tims  have  also  tuberculosis  (Ibid.V 

A  man  with  persistent  mucous  patches  in  the  mouth  and  ever}-  prostitute 
with  s\-philis  should  be  given  salvarsan  because  of  the  danger  to  the  commu- 
nity of  such  s}-philitics.  A  characteristic  and  disfiguring  eruption  calls  for  it. 
A  married  man  with  a  chancre  should  recei\-e  it  promptly.  Salvarsan  is 
contra-indicated  when  there  is  advanced  disease  of  the  heart  and  arteries; 
in  degenerative  conditions  of  the  brain  and  cord,  when  there  is  optic  atrophy; 
in  diabetes;  in  diseases  of  the  Hver  or  kidneys  (even  if  s^-philitic) ;  in  pulmonary 
tuberculosis,  and  in  children  before  the  age  of  three. 

It  is  estimated  by  some  that  salvarsan  is  responsible  for  i  death  in  ever\- 
1000  cases  treated.  Others  set  the  rate  at  a  much  higher  figm-e.  Major 
French  ("Lancet,"  Nov.  18, 1911'!  refers  to  41  deaths  as  having  occurred  in  less 
than  one  year.  Le\-}'-Bing,  of  Paris,  says  that  the  deaths  niunber  70  or  80 
and  that  death  may  occvu:  in  a  healthy  person.     HaUopeau,  Gaucher  and  Ra- 


342  Syphilis,  or  Pox 

vant  reported  3  deaths  ("Bull,  de  I'Acad.  de  Med.,"  Oct.  and  Nov.,  1911).  A 
man  of  nineteen  developed  arsenical  poisoning  and  died  of  uremia  on  the  sixth 
day  after  the  injection.  A  girl  of  eighteen  died  in  a  similar  manner.  Geronne, 
Finger,  and  others  seem  to  prove  that  the  symptoms  which  may  follow  the  ad- 
ministration of  salvarsan  are  manifestations  of  acute  intoxication  by  arsenic, 
and  are  not,  as  Neisser  claims,  produced  by  endotoxins  from  destroyed  spiro- 
chetes. Finger  had  a  fatal  case  due  to  arsenical  poisoning  ("Brit.  Med.  Jour.," 
Jan.  27,  191 2).  Auditory  and  ocular  complications  may  occur.  In  9  per  cent, 
of  patients  to  whom  Finger  gave  salvarsan  nerve  complications  developed. 
Most  of  the  deaths  followed  a  second  injection,  hence  the  claim  that  anaphy- 
laxis was  the  cause. 

The  drug  may  be  given  by  intramuscular  injection.  It  causes  pain  which 
is  often  severe  and  prolonged  inflammation.  This  method  is  employed  in 
children  from  three  to  seven  years  of  age,  because  the  veins  are  small  and  hard 
to  find.  In  adults  the  intravenous  method  is  always  to  be  preferred.  It  is 
given  in  a  vein  in  front  of  the  elbow.  One  capsule  containing  .6  gm.  of 
salvarsan  is  opened,  and  the  drug,  which  is  an  acid  salt,  is  dissolved  in  a  hot 
alkaline  solution.  A  pint  of  recently  sterilized  salt  solution  is  used  and 
ten  minutes  are  occupied  in  running  the  fluid  into  the  vein.  The  fluid  is 
given  at  a  temperature  a  little  above  blood  heat.  Neosalvarsan  to  the 
amoimt  of  .9  gm.  is  dissolved  in  6  oz.  of  freshly  distilled  water.  It  gives  a 
neutral  solution  and  is  very  soluble.  The  fluid  is  injected  at  a  temperature 
of  60  to  70° F. 

Several  hours  after  the  injection  of  salvarsan  symptoms  may  arise  (chills, 
elevation  of  temperature,  diarrhea,  vomiting,  headache).  In  a  few  hours,  as 
a  rule,  the  symptoms  pass  away.  One  must  be  on  the  watch  for  dangerous 
symptoms  (cardiac  depression,  dyspnea,  great  restlessness,  excitement,  edema 
of  the  face,  cyanosis  of  the  face,  persistent  vomiting,  diarrhea,  albuminuria, 
spasm  of  the  Hmb  muscles,  and  collapse). 

The  effect  of  salvarsan  on  the  Wassermann  reaction  has  been  much  discussed. 
TheoreticaUy,  it  should  always  make  a  positive  reaction  negative.  PracticaUy, 
it  often  does  not.  It  may  require  a  second  injection  to  do  it.  After  the  admin- 
istration of  salvarsan  the  reaction  may  become  negative,  remain  so  for  several 
months,  and  again  become  positive.  Neisser  claims  that  in  only  10  per  cent, 
of  latent  cases  is  a  negative  reaction  converted  into  a  positive  one.  It  was 
stated  above  that  in  latent  syphilis  with  a  negative  reaction  salvarsan  may 
actually  cause  a  positive  reaction.  Evidently,  a  negative  Wassermann  is  not 
to  be  regarded  as  absolute  and  unassailable  proof  that  a  patient  is  cured. 

Hereditary  Syphilis. — Transmitted  congenital  syphilis  is  heredi- 
tary syphilis  manifest  at  birth.  Acquired  S}q3hilis  (except  in  the  case  of  a 
woman  who  obtains  the  disease  from  a  fetus)  always  presents  the  chancre  as 
an  initial  lesion;  hereditary  s}^hilis  never  does.  Hereditary  s}TDhilis  may 
present  itself  at  birth,  and  usually  shows  itself  within,  at  most,  the  first  six 
months  of  extra-uterine  life.  In  rare  cases  (tardy  hereditary  syphilis)  the 
disease  does  not  become  manifest  until  puberty. 

Rules  of  Inheritance. — According  to  von  Zeissl,^  the  rules  of  inheritance  are 
as  follows: 

1.  If  one  parent  is  syphflitic  at  the  time  of  procreation,  the  child  may  be 
syphihtic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  chfld  syphilitic  from  the 
father,  the  mother  must  have  latent  pox,  having  become  infected  through  the 
placental  circulation,  or  must  be  immune.  She  often  shows  no  symptoms, 
having  received  the  poison  gradually  in  the  blood,  and  having  thus  received, 

1  "Pathology  and  Treatment  of  Sj^hilis." 


Hereditary  Syphilis  343 

it  may  be  said,  preventive  inoculations.     Certain  it  is  that  mothers  are  almost 
never  infected  by  suckling  their  s},-philitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation,  and  the  mother 
afterward  contracts  sj^philis,  the  child  may  become  s^-philitic,  and  the  earlier 
in  the  pregnancy  the  mother  is  diseased,  the  more  certain  is  the  child  to  be 
tainted.     This  is  known  as  "infection  in  utero.'" 

5.  The  more  recent  the  parental  syphilis,  the  more  certain  is  infection  of 
the  offspring.     The  children  are  often  stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be  tardy  in  the 
children. 

7.  The  longer  the  time  which  has  passed  since  the  disappearance  of  paren- 
tal symptoms,  the  more  improbable  is  infection  of  the  children. 

8.  In  most  instances  parental  S}q3hilis  grows  weaker,  and  after  the  parents 
beget  some  tainted  children  they  bring  forth  healthy  ones. 

S}-philis  in  the  mother  is  more  dangerous  to  the  offspring  than  s^^hilis  in 
the  father.  The  frequent  immunity  of  the  mother  is  due  to  the  fact  that  her 
tissues  produce  antitoxins  under  the  influence  of  the  slowly  absorbed  \drus. 
The  milk  of  a  SA-philitic  mother  contains  quantities  of  antibodies  (Bab,  "Zeit- 
schrift  f.  Geb.  und  Gynakologie,"  vol.  x.  No.  2). 

Many  women  affected  with  hereditar}'  s}^hilis  are  sterile.  Many  s^^h- 
ilitic  women  abort  before  the  eighth  month,  most  commonly  in  the  fifth  month. 
The  fetus  very  often  dies  at  an  early  period  of  gestation.  This  may  be  due 
to  a  gummatous  placenta  or  to  a  degeneration  of  placental  follicles.  Bab 
(Ibid.)  reports  that  out  of  7,t,  infants,  victims  of  congenital  s}^hilis,  16  were 
born  alive  and  7  of  these  died  within  a  few  days.  Hyde  says  that  about  90 
per  cent,  of  those  born  li\dng  subsequently  die  of  the  disease. 

Evidences  of  Hereditary  Syphilis  Manifest  At  or,  Oftener,  Soon  After  Birth. 
— Hutchinson  says  that  at  birth  the  skin  is  almost  invariably  clear.  In  from 
six  to  eight  weeks  "snuffles"  begin,  which  are  soon  followed  by  a  skin  eruption, 
by  body  wasting,  and  by  a  chain  of  secondar}^  sjTuptoms  (iritis,  mucous 
patches,  pains,  condylomata,  etc.).  The  child  looks  like  a  withered-up  old 
man.  Eruptions  are  met  with  on  the  palms  and  soles.  Intertrigo  is  usual. 
Cracks  occur  at  the  angles  of  the  mouth  and  leave  permanent  radiating  scars. 
The  abdomen  is  tumid  and  there  is  apt  to  be  exhausting  diarrhea.  The 
secreting  and  absorbing  glands  of  the  intestinal  tract  atrophy.^  It  is  seldom 
that  distinct  gummatous  tumors  form  in  hereditary  s^'philis.  The  t}^e  of  dis- 
ease induced  is  a  diffuse  interstitial  cellular  change  in  the  viscera,  and  the  viscera 
are  much  more  apt  to  suffer  than  in  acquired  s^-philis.  The  liver,  spleen, 
and  pancreas  often  enlarge  from  interstitial  changes,  and  the  lungs  some- 
times are  attacked  in  the  same  manner.  S^Tiovitis  or  arthritis  may  arise, 
the  condition  being  similar  to  that  met  -^ith  in  acquired  s}-philis.  A  form 
encountered  between  the  third  month  and  end  of  the  second  year,  according 
to  Paton,  is  characterized  by  growth  into  the  joint  of  fungating  granulation 
tissue,  the  joint  is  useless,  and  the  parts  about  are  swollen  and  edematous. 
Atrophic  lesions  may  appear  in  the  bones.  In  the  skull  the  bone  may  be 
softened  by  removal  of  its  lime  salts  or  be  thinned  by  the  pressure  of  the 
brain.  In  the  long  bones  the  epiphyseal  fines  suffer,  tfie  attachment  of  the 
epiphysis  to  the  shaft  is  weak,  and  separation  is  easfiy  induced.  Epiphysi- 
tis is  common,  seldom  causes  pain,  and  rarely  leads  to  suppuration,  except  in 
children  who  are  old  enough  to  walk  (Coutts).  Osteophytic  lesions  of  the 
skull  are  showTi  by  s}Tnmetrical  spots  of  thickening  upon  the  parietal  and 
frontal  bones  (nati'form  skulls).  In  the  long  bones  osteophytes  are  frequently 
formed.  In  some  cases  osteophytes  grow  from  the  epiphysis,  and  in  con- 
sequence deformity  and  impaired  function  are  noted  and  a  certain  amount 
1  Coutts,  in  "Brit.  Med.  Jour.,"  1894,  p.  1643. 


344 


Syphilis,  or  Pox 


Fig.  138. — Dactylitis. 


of  ankylosis  may  occur.  This  condition  of  osteophytic  growth  from  an  ep- 
iphysis was  called  by  Fournier  arthropathie  deformant.  A  child  with  preco- 
cious hereditary  syphilis  is  apt  to  die,  but  if  it  lives  from  six  months  to  one  year 
the  symptoms  for  a  time  disappear,  and  for  years  the  disease  may  be  latent. 
Diagnosis  is  difficult  after  the  third  or  fourth  year,  especially  if  the  disease  be 
associated  with  rickets  or  tuberculosis.  When  later  symptoms  arise  they  may 
be  various,  namely:  noises  in  the  ears,  often  followed  by  deafness;  interstitial 
keratitis;  synovitis  in  any  joint,  particularly  painless  but  marked  symmetrical 
effusion  in  the  knee-joints,  with  trivial  functional  disturbance;  ossifying  nodes; 
developmental  osseous  defects;  suppurative  periostitis;  ulcerations;  death  of 

bone;  falling  in  of  the  nose;  ner- 
vous maladies ;  occasionally  sar- 
cocele,  dactylitis,  etc. 

Dactylitis  (Fig.  138)  is 
common  in  hereditary  syphilis. 
There  is  a  superficial  and  a  deep 
form  (see  p.  330).  Commonly,  a 
swelling  gradually  forms.  It  is 
fusiform  in  shape  and  becomes 
purple  in  color.  It  lasts  for 
months.  One  or  more  fingers 
may  be  involved  and  the  fingers 
are  more  apt  to  suffer  than  the 
toes.  The  proximal  phalanx  is 
most  liable  to  the  lesion.  The  su- 
perficial form  is  apt  to  soften  and 
ulcerate.  Sinuses  seldom  form. 
The  deep  form  not  infrequently 
causes  tissue  destruction  and  shortening  of  the  digit  from  rarefying  osteitis 
or  dry  caries.  Some  cases  of  superficial  dactylitis  are  symmetrical  and  of 
short  duration  and  are  to  be  regarded  as  late  secondary  lesions. 

In  hereditary  syphilis  the  eye  symptoms  are  of  great  diagnostic  import- 
ance. In  212  cases  of  congenital  syphilis  Fournier  found  eye  trouble  in  loi. 
Keratitis  and  choroiditis  are  the  most  usual  forms.  Bone  trouble  occurs 
in  almost  half  of  the  cases,  but  is  not  often  severe  enough  to  cause  symptoms. 
The  tongue  often  shows  a  smooth  base  (Virchow's  sign).  It  is  due  to  lymphoid 
atrophy  and  fibrosis  (Symmers,  in  "Amer.  Jour.  Med.  Sci.,  Dec,  1910).  Hirsch- 
berg  believed  choroiditis  to  be  pathognomonic.  The  descendants  of  syphilitic 
parents  may  exhibit  certain  pathological  con- 
ditions which  are  not  directly  syphilitic. 
Fournier  calls  such  phenomena  parasyphilitic. 
Among  these  phenomena  are  arrest  of  develop- 
ment of  the  body  at  large  or  of  special  struct- 
ures, weakness  of  constitution,  and  other  stig- 
njata  of  degeneration. 
■•  In  the  diagnosis  of  hereditary  sjqahilis  the  condition  of  the  teeth  is  of  con- 
siderable importance :  the  temporary  teeth  decay  soon,  but  present  no  charac- 
teristic defect.  If  the  upper  permanent  central  incisors  are  examined,  they 
are  often,  but  by  no  means  always,  found  defective.  Other  teeth  may  show 
defects,  but  in  these  alone  are  characteristic  defects  likely  to  appear.  In  heredi- 
tary syphilis  they  may  present  an  appearance  of  marked  deviation  from  health, 
and  are  then  called  Hutchinson  teeth  (Fig.  139).  Hutchinson  stated  that  if 
they  are  dwarfed,  too  short  and  too  narrow,  and  if  they  display  a  single  central 
cleft  in  their  free  edge,  then  the  diagnosis  of  syphilis  is  probable.  If  the  cleft 
is  present  and  the  dwarfing  absent,  or  if  the  peculiar  form  of  dwarfing  be 


Fig.  139. — Hutchinson  teeth. 


Neoplasms  345 

present  ^Yithout  any  conspicuous  cleft,  the  diagnosis  may  still  be  made.  The 
view  that  teeth  of  this  nature  prove  the  existence  of  hereditary  s^-phihs  and  that 
they  occur  only  in  s}phihs  has  been  abandoned  by  Hutchinson  himself.  In 
fact,  only  one-fifth  of  congenital  syphiUtics  have  "these  teeth,  and  one-third 
of  the  cases  of  Hutchinson  teeth  are  in  indi\dduals  free  from  s^-philis.  In 
earl}-  infancy  the  diagnosis  of  s\phiHs  is  made  by  the  snuffles,  the  broad  nose, 
the  skin  eruptions,  the  wasted  appearance,  the  sores  at  the  mouth-angles, 
the  tenderness  over  bones,  condylomata,  and  the  history  of  the  parents.  The 
diagnosis  at  a  later  period  is  made  by  the  existence  of  symmetrical  inter- 
stitial keratitis,  choroiditis,  the  smooth  base  of  the  tongue,  deafness,  which 
comes  on  without  pain  or  running  from  the  ear,  ossifying  nodes,  white  radiat- 
ing scars  about  the  mouth-angles,  sunken  nose,  natiform  skull,  deformity  of 
long  bones,  painless  inflammation  of  epiphyses,  and  Hutchinson  teeth.  It 
must  be  remembered  that  a  cliild  born  apparently  healthy  and  presenting 
no  secondan,-  symptoms  may  show  bone  disease,  keratitis,  or  s\'philitic  deaf- 
ness at  puberty.  Fmding  the  spirochetes  is  of  immense  importance  in  arri\-ing 
at  a  diagnosis.  They  can  always  be  found  imless  the  organ  examined  is 
decomposed  or  the  fetus  is  macerated.  (See  article  by  Wm.  S.  Gottheil, 
"Progressive  Medicine,"  Sept.,  1908.) 

Treatment. — In  infants  mercurial  inunctions  are  to  be  used  until  the 
symptoms  disappear,  but  mercurv'  must  not  be  forced  or  be  continued  too  long 
after  the  s}Tnptoms  are  gone.  There  must  be  rubbed  into  the  sole  of  each 
foot  or  the  palm  of  each  hand  5  gr.  of  mercurial  ointment  every  morning 
and  night.  Brodie  advised  spreading  the  ointment  (in  the  strength  of  i  dr. 
to  the  ounce)  upon  flannel  and  fastening  it  around  the  child's  belly.  If  the 
skin  is  so  tender  that  mercury  must  be  administered  by  the  mouth,  order  that 
j^  to  I  gr.  of  mercury  with  chalk,  -^-ith  i  gr.  of  sugar,  be  taken  three  times 
a  day  after  nursing.  If  tertiarj-  symptoms  appear,  and  in  any  case  when  the 
secondaries  have  passed  away,  give  ^  to  i  gr.  or  more  of  iodid  of  potassium 
several  times  a  day  in  s\T"up.  The  mixed  treatment  should  be  continued 
intermittently  until  puberty.  Local  lesions  require  local  treatment,  as  in 
the  adult.  A  s\'philitic  child  should,  if  possible,  be  nursed  by  its  mother,  as 
it  will  poison  a  health}'  nurse,  and  also  because  the  mother's  milk  contains 
antibodies.  In  some  cases  the  mother  is  given  salvarsan.  If  the  baby  has  a 
sore  mouth,  it  must  be  fed  from  a  bottle,  and  if  the  mother  cannot  nurse  the 
child,  it  must  be  brought  up  on  the  bottle.  For  the  cachexia  use  cod-liver  oil, 
iodid  of  iron,  arsenic,  and  the  phosphates.  Salvarsan  is  not  given  to  a  s^'philitic 
child  under  three  years  of  age.  It  may  be  given  to  children  over  three  and 
under  seven  and  only  by  intramuscular  injection.  To  a  child  over  seven  it 
may  be  given  intravenously.     The  dose  for  a  child  of  seven  is  0.2  gm. 


XVIII.  TUMORS   OR   MORBID   GROWTHS 

Division. — jSIorbid  growths  are  divided  into  (i)  neoplasms  and  (2) 
cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth  which  tends  to 
persist  independently  of  the  structures  in  which  it  lies,  and  which  performs  no 
physiological  function.  We  say  that  a  tumor  performs  no  physiological  func- 
tion in  order  to  make  clear  that  it  is  never  a  useful  addition  to  the  economy, 
but  we  must  not  imagine  that  the  ceUs  of  even,-  tumor  are  devoid  of  physiolog- 
ical acti\'ity.  As  Fiitterer  ("Medicine,"  Alarch,  1902)  has  shown,  the  cells  of  a 
carcinoma  of  the  liver  ma}'  secrete  bile,  and  even  the  cells  of  a  secondary  focus 
developing  in  the  course  of  hepatic  carcinoma  may  also  secrete  bile.  The 
cells  of  a  tumor  may  be  active,  but  this  acti\aty  is  not  useful  and  does  not  con- 


346  Tumors  or  Morbid  Growths 

stitute  physiological  function.  A  hypertrophy  is  differentiated  from  a  tumor 
by  the  facts  that  it  is  a  result  of  increased  physiological  demands  or  of  local 
nutritive  changes,  and  that  it  tends  to  subside  after  the  withdrawal  of  the 
exciting  stimulus.  Further,  a  hypertrophy  does  not  destroy  the  natural  con- 
tour of  a  part,  while  a  tumor  does.  Inflammation  has  marked  symptoms:  its 
swelling  does  not  tend  to  persist,  it  terminates  in  resolution,  organization,  or 
suppuration,  and  examination  of  a  section  of  tissue  under  the  microscope  dif- 
ferentiates it  from  tumor.  Inflammation,  too,  has  an  assignable  exciting 
cause.  A  new  growth  is  a  mass  of  newly  formed  tissue;  hence  it  is  improper 
to  designate  as  tumors  those  swellings  due  to  extravasation  of  blood  (as  in 
hematocele),  or  of  urine  (as  in  ruptured  urethra),  to  displacement  of  parts 
(as  in  hernia,  floating  kidney,  or  dislocation  of  the  liver),  or  to  fluid  disten- 
tion of  a  natural  cavity  (as  in  hydrocele  or  bursitis) . 

Classes  of  Tumors. — There  are  two  classes  of  tumorsi  the  first  class 
includes  those  derived  from  or  composed  of  ordinary  connective  tissue  or  of 
higher  structures.  These  all  originate  from  cells  which  are  developed  from 
the  mesoblast.  There  are  two  groups  of  connective-tissue  tumors:  {a)  the 
typical,  innocent,  or  benign,  which  mimic  or  imitate  some  connective  tissue 
of  the  healthy  adult  human  body;  and  (6)  the  atypical  or  malignant,  which 
find  no  counterpart  in  the  healthy  adult  human  body,  but  rather  in  the  im- 
mature connective  tissues  of  the  embryo. 

The  second  class  of  tumors  includes  those  which  are  derived  from  or  com- 
posed of  epithelium:  (o)  the  typical,  or  innocent,  composed  of  adult  epithe- 
lium; and  (6)  the  atj^ical,  or  malignant,  composed  of  embryonic  epithelium. 

Miiller's  law  is  that  the  constituent  elements  of  neoplasms  always  have 
their  types,  counterparts,  or  close  imitations  in  the  tissues,  either  embryonic  or 
mature,  of  the  himian  body. 

Virchow's  law  is  that  the  cells  of  a  tumor  spring  from  pre-existing  cells. 
There  is  no  special  tumor-cell  or  cancer-cell. 

The  starting-point  of  a  tumor  is  a  focus  of  embryonal  cells,  which  focus 
may  have  originated  before  the  person  was  born  or  may  have  resulted  after 
birth  from  some  disease  or  injury.  The  nature  of  the  tumor  depends,  first, 
upon  the  embryonal  layer  from  which  it  took  origin.  Connective-tissue  tumors 
spring  from  the  mesoblast;  epithelial  tumors  spring  from  the  epiblast  or  the 
hypoblast.  The  nature  of  the  tumor  depends  also  upon  the  stage  in  which  the 
growth  of  its  cells  is  arrested.  If  the  cells  remain  embryonal,  the  growth  is  re- 
garded as  malignant;  if  they  become  fully  developed,  it  is  regarded  as  innocent. 

The  term  "heterologous"  is  no  longer  used  to  signify  that  the  cellular 
elements  of  a  tumor  have  no  counterpart  in  the  healthy  organism,  but  is 
employed  to  signify  that  a  tumor  deviates  from  the  type  of  the  structure  from 
which  it  takes  its  origin  (as  a  chondroma  arising  from  the  parotid  gland). 
Tumors  when  once  formed  almost  invariably  increase  and  persist,  though 
occasionally  warts,  exostoses,  and  fatty  tumors  disappear  spontaneously. 
Tumors  may  ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  undergo 
mucoid,  calcareous,  or  fatty  degeneration. 

The  causes  of  tumors  are  not  positively  recognized,  those  alleged  being 
but  theories  varying  in  probability  and  ingenuity. 

The  inclusion  theory  of  Cohnheim  supposes  that  more  embryonic  cells  exist 
than  are  needful  to  construct  the  fetal  tissues,  that  masses  of  them  remain  in 
the  tissues,  and  that  these  embryonic  cells  may,  later  in  life,  be  stimulated 
into  active  growth  perhaps  by  injury  or  irritations  or  hereditary  tendency. 
In  other  words,  Cohnheim  believes  that  all  tumors  arise  from  embryonal 
cells  which  were  included  or  imprisoned  by  adult  cells  during  fetal  life  and 
were  not  used  during  development;  or  from  cells  which  were  "displaced  from 
their  proper  relations  during  the  process  of  cell  differentiation  in  the  embryo" 


Causes  of  Tumors  347 

(Henr>'  Morris,  "Lancet,"  Dec.  12,  1903).  The  embryonic  h\'pothesis  seems 
to  receive  a  certain  force  from  the  facts  that  exostoses'  do  sornetimes  develop 
from  portions  of  unossiiied  epiphyseal  cartilage,  and  that  tumors  often  arise 
in  regions  where  there  was  a  suppression  of  a  fetal  part,  closure  of  a  cleft,  or 
an  involution  of  epithelium  (epithelioma  is  usual  at  mucocutaneous  junctions). 
This  theor}-  does  not  explain  the  origin  of  malignant  tumors  in  scars  or  recent 
callus  in  parts  subjected  to  injury  or  operation,  etc.  (Ibid.). 

Durante's  addition  to  Cohnheim's  theorv'  does  explain  them.  Cohn- 
heim  taught  that  the  matrix  from  which  a  tumor  springs  is  always  an  ante- 
natal embryonic  area.  Durante  says  a  tumor  may  also  spring  from  a  post- 
natal embryonic  area  resultmg  from  injury  of  the  mature  tissues,  lessening 
their  chemical  and  physiological  acti\dties  (]\Iorris)  and  causing  them  to  revert 
to  an  embryonic  condition. 

Objection  has  been  made  to  the  Cohnheim  theor\'  on  the  ground  that 
an  embrv-onal  matrix  could  not  remain  quiescent,  but,  as  Henr\-  jNIorris  savs, 
certain  teeth,  the  female  mammary  gland,  the  larynx,  and  certain  appendages 
of  the  skin  may  not  develop  until  puberty  ("Bradshaw  Lecture,"  in  ''Lancet," 
Dec.  12,  1903).  Branchial  cysts  which  are  known  to  have  such  an  origin  are 
seldom  seen  until  after  puberty,  and  the  same  is  true  of  many  dermoids. 

Morris  shows  that  congenital  matrices  have  been  shown  to  exist  in  the  brain, 
tongue,  eye,  testicle,  ovar\;,  broad  ligament,  line  of  coalescence  in  the  trunk, 
and  other  places,  and  such  matrices  constitute  fetal  rests  or  vestiges.  The 
same  author  shows  that  postnatal  matrices  may  arise  in  the  healing  of  a 
woimd  or  ulcer,  fistula,  biurns,  etc.  Portions  of  epitheHum  are  separated, 
get  placed  deeply  in  the  newly  forming  tissue,  become  surrounded  by  connect- 
ive tissue,  and  may  later  take  on  active  growth.  As  Ribbert  points  out,  any 
fragment  of  isolated  and  imprisoned  tissue  may  become  a  tumor. 

Heredity  is  an  extremely  imcertain  influence,  though  not  an  influence  to 
be  denied.  I  beheve  that  there  is  such  a  thing  as  a  more  or  less  complete 
immimity  to  cancer  and  that  there  is  such  a  thing  as  a  predisposition  to  cancer, 
and  the  predisposition  as  well  as  the  immimity  may  be  hereditary  or  acquired. 
Youth  constitutes  an  almost  though  not  quite  certain  immunity.  Cancer  is 
ver\'  rare  in  youth,  and  when  it  does  occur  in  a  young  person  it  is  always 
ver\"  mahgnant.  Its  occurrence  means  unnatural  lack  of  tissue  resistance  or 
unusual  \'igor  of  cancer-cell.  The  retrogressive  changes  of  age  are  predisposing 
causes.  S.  W.  Gross  foimd  direct  hereditary  influence  by  no  means  frequent  in 
cancer  of  the  breast.  From  25  to  37  per  cent,  of  cases  of  cancer  of  the  breast 
have  or  had  cancerous  relatives  (see  page  387).  Heredity  in  cancer  is  affirmed 
by  some,  denied  by  others,  and  doubted  by  a  number.  At  most,  hereditary'  in- 
fluence may  only  predispose.  Nevertheless,  cases  have  occurred  which  cannot 
be  explained  by  the  term  "coincidence."  In  the  celebrated  "Middlesex  Hospital 
case,"  a  woman  and  five  daughters  had  cancer  of  the  left  breast.  A.  Pearce 
Gould  had  charge  of  a  woman  for  cancer  of  the  left  breast.  The  mother  of  this 
patient,  the  mother's  two  sisters,  and  two  of  the  mother's  cousins  had  died  of 
cancer.  Power  reports  a  remarkable  instance  of  family  predisposition  to  cancer. 
A  patient  had  his  right  breast  removed  for  cancer  in  1896.  In  1897  cancerous 
glands  were  removed  from  the  axilla.  In  1898  he  was  seen  again  with  an 
irremovable  recurrent  growth.  His  father  died  of  cancer  of  the  breast.  He 
had  two  brothers,  one  of  whom  died  of  cancer  of  the  throat  when  sixty-five 
years  of  age,  the  other  ha\-ing  died  of  cancer  of  the  axilla  when  he  was  only 
twenty-four  years  old.  Of  his  eight  sisters,  four  died  of  cancer  of  the  breast, 
and  the  two  who  are  h\-ing  both  suffer  from  cancer  of  the  breast.  One  sister 
died  when  an  infant  and  one  died  after  gi\ing  birth  to  a  child.^  The  Emperor 
Napoleon,  his  father,  his  brother  Lucien,  and  his  sisters  Pauline  and  CaroHne 
1  "Brit.  Med.  Jour.,"  July  16,  189S. 


348  Tumors  or  Morbid  Growths 

died  of  gastric  cancer.  That  there  is  such  a  thing  as  predisposition  is  rendered 
probable  by  the  fact  that  out  of  many  exposed  under  Hke  conditions  a  single 
one  may  develop  cancer.  I  believe,  with  Murphy,  that  there  may  be  such  a 
thing  as  absence  of  resistance  to  the  cause  of  cancer  on  the  part  of  certain 
tissues  and  that  such  impairment  of  resistance  may  be  hereditary. 

Injury  and  inflammation  may  undoubtedly  prove  exciting  causes.  A 
blow  is  not  infrequently  followed  by  sarcoma;  the  irritation  of  a  hot  pipe-stem 
may  excite  cancer  of  the  lip;  the  scratching  of  a  jagged  tooth  may  cause  cancer 
of  the  tongue;  chimney-sweeps'  cancer  (which  used  to  be  seen  in  the  old  days 
when  "the  sweep"  was  an  institution)  arose  from  the  irritation  o'f  dirt  in 
the  scrotal  creases;  and  warts  often  arise  from  constant  contact  with  acrid 
materials. 

Physiological  activity  favors  the  development  of  sarcoma,  and  physiological 
decline  favors  the  development  of  carcinoma. 

Parasitic  Influences. — Many  believe  that  parasites  cause  cancer.  This 
theory  does  not  maintain  that  the  tumor  is  the  parasite,  but  that  it  contains 
the  parasite,  although  Pfeiffer  and  Adamciewicz  did  at  one  time  assert  that 
a  cancer-cell  is  not  a  body-cell,  but  a  parasite  resembling  an  epithelial  cell. 
Butlin  in  1905  asserted  his  belief  that  the  cancer-cells  are  parasites  and  act 
independently  like  protozoa.  Most  observers  deny  this  contention  because, 
were  it  true,  there  would  be  only  one  variety  of  cancer,  because  cases  could  only 
arise  by  direct  contact,  and  because  it  would  leave  unanswered  how  the  original 
growth  arose,  as  it  could  not  have  come  from  a  pre-existing  cancer-cell  (Brand, 
in  "Lancet,"  Jan.  11,  1908).  Some  facts  render  a  parasitic  origin  of  malig- 
nant growths  not  improbable;  as,  for  instance,  the  likeness  of  some  tumors  to 
infective  granulomata,  the  tendency  to  secondary  development  in 'distant  parts 
of  the  body,  the  resemblance  of  the  secondary  to  the  primary  growths,  and  the 
tenacity  of  their  persistence.  A  parasitic  origin  of  cancer  is  possibly  suggested 
by  its  geographical  distribution,  the  disease  being  very  common  in  low  and 
marshy  districts,  and  Haviland  ("Lancet,"  April  27,  1894)  and  others  main- 
tain that  certain  houses  become  infected,  the  disease  appearing  in  these  houses 
among  successive  families  inhabiting  them.  They  speak  of  such  abodes  as 
cancer-houses. 

Some  surgeons  believe  that  cancer  is  contagious,  but  most  observers  deny 
it.  Hanau  found  a  rat  with  a  cancer  and  inoculated  other  rats  from  it. 
Moreau  in  1894  inoculated  mice  from  a  mouse  with  cancer.  Guelliott,  of 
Rheims,  believes  that  cancer  is  primarily  a  local  infection.  He  believes  this 
because  Moreau  and  Hanau  have  inoculated  it  from  one  animal  to  another 
of  the  same  species,  and  if  this  can  be  brought  about  experimentally  he  sees 
no  reason  why  it  cannot  happen  accidentally.  This  surgeon  says  that  can- 
cer is  very  unequally  distributed,  that  genuine  cancer-centers  and  "cancer- 
houses"  exist,  and  that  niunerous  cases  of  accidental  infection  have  occurred.^ 
Hahn  apparently  succeeded  in  grafting  cancer  from  one  part  to  another  on 
the  same  individual.  Jensen  and  Borrell  have  inoculated  the  disease  in  white 
mice.  Mayet,  of  Lyons,  holds  that  cancer  can  be  reproduced  by  grafting  or 
by  injection  of  cancer-fluid.  Graf  could  not  find  "cancer-houses"  after  a 
careful  search."  Because  several  people,  in  the  course  of  years,  have  died  in 
the  same  house  of  cancer  is  not  proof  that  the  house  was  infected.  If  such  a 
thing  proves  contagion  there  must  be  contagion  in  many  things  now  thought 
free  from  it,  and  there  must  be  broken-leg  houses,  and  delirium-tremens  houses, 
and  heart-disease  houses.  Geissler  claims  to  have  produced  the  disease  in 
a  dog  by  planting  fragments  of  cancer  in  the  subcutaneous  tissue  and  vaginal 
tissue,  but  Czerny,  Rosenbach,  and  others  dispute  the  claim.     Plimmer  tells 

1  "Amer.  Jour,  of  Med.  Sciences,"  June,  1895. 

2  "Archiv.  f.  klin.  Chir.,"  1895,  1,  p.  144. 


Causes  of  Tumors  349 

us  that  an  epidemic  of  cancer  arose  among  the  captive  white  rats  in  the  Frei- 
burg Pathological  Institute,  and  in  each  case  the  growth  was  on  the  rear  part 
of  the  body.  Roswell  Park  believes  that  Gaylord  has  really  produced  adeno- 
carcinoma in  the  lower  animals.  Hauser  disputes  the  assertion  that  cancer 
must  be  an  infectious  disease  because  it  is  followed  by  secondary  growths. 
Secondary  growths  in  an  infectous  disease  are  caused  by  the  bacterium; 
secondar\^  growths  in  cancer  are  caused  by  the  transference  of  cells  of  pri- 
mary growth.^  Hauser  says  with  truth  that  the  close  connection  between 
innocent  and  malignant  growths  renders  the  parasite  view  untenable,  because 
to  hold  it  we  woiild  be  forced  to  believe  that  every  tumor  has  a  special  para- 
site or  that  one  parasite  may  cause  many  kinds  of  tumors. 

There  seems  to  be  no  doubt  that  autotransference  of  cancer  can  occur, 
although  it  rarely  does  so.  Sippel  has  reported  a  case  in  which  vaginal  car- 
cinoma developed  at  the  point  where  the  vagina  was  in  contact  with  a  pre- 
existmg  cancer  of  the  portio."  Cornil  has  seen  cancer  transferred  from  one 
of  the  labia  majora  to  the  other,  and  from  one  lip  to  the  other.  Geissler  was 
unable  to  transplant  cancer,  and  Gratia  also  failed  in  his  attempts.  Duplay 
and  Bazin  say  that  transmissibility  is  possible,  but  only  under  conditions  which 
are  not  practically  realized.  The  facts  that  transplantation  can  be  sometimes 
carried  out,  and  that  contagion  is  a  possible  occurrence  under  exceptional 
circumstances,  do  not  prove  that  cancer  is  a  parasitic  disease,  but  simply 
prove  that  it  can  be  transplanted.  It  is  not  that  the  cancer  carries  a  parasite 
which  will  cause  the  disease  in  sound  tissues,  but  rather  that  the  cells  of  the 
cancer  may  themselves  take  root  and  grow  in  sound  tissues.  The  parasitic 
theor}^  arose  from  observation  of  the  metastasis  which  occurs  during  the 
progress  of  the  disease,  and  received  support  from  the  fact  that  inoculation 
of  another  part  of  an  individual  suffering  from  cancer  may  be  followed  by 
the  development  of  a  tumor  like  the  original  growth.  For  instance,  if  a  can- 
cer is  growing  upon  the  lower  lip,  the  upper  lip  may  be  inoculated  {contact 
cancer).  The  same  is  true  of  the  labia.  Mr.  Harrison  Cripps  reported  the 
occurrence  of  cancer  of  the  skin  of  the  arm  from  contact  with  an  ulcerating 
scirrhus  of  the  breast.  It  has  also  been  pointed  out  that  carcinoma  is  especially 
common  in  regions  predisposed  by  their  situation  to  injury  and  infection,  and 
that,  ''among  the  lower  animals  at  least,  tiunors  resembling  carcinomata  have 
been  transplanted  from  one  to  another"  ("Recent  Studies  upon  the  Etiology 
of  Carcinoma,"  by  Joseph  SaUer,  "PhUa.  Med.  Jour.,"  Jime  7,  1902).  But 
there  is  great  doubt  as  to  the  cancerous  nature  of  some  of  the  tiunors  which 
have  been  successfully  transplanted  from  one  animal  to  another. 

A  transplanted  mouse  cancer  may  grow  for  a  time  and  then  completely 
disappear,  and  some  observers  (among  them  Gaylord)  hold  that  when  this 
occurs  the  mouse  has  become  immune. 

In  1908  the  German  Pathological  Society  met  in  Kiel  and  discussed  various 
problems  of  cancer.  In  this  meeting  Sticker  maintained  that  there  is  such  a 
thing  as  natm^al  immimity  to  tumors.  He  showed  that  a  timior  arising 
spontaneously  in  an  animal  can  never  be  transplanted  into  an  animal  of  another 
species,  and  very  seldom  can  a  malignant  tumor  be  transplanted  into  an  animal 
of  the  same  species.  He  quotes  Metchnikoff's  utter  failure  to  transplant 
hirnaan  tumors  into  anthropoid  apes  and  reports  his  own  failure  to  transplant 
human  tumors  into  various  domestic  animals.  He  made  over  400  trials  and 
failed  every  time  ("Jour.  Am.  Med.  Assoc,"  from  Sticker,  "Zeitschr.  f.  Krebs- 
forschung,"  1908,  vii). 

In  successful  transplantations  there  has  been  but  sHght  effort  to  prove  that 
epithelial  cells  were  not  transferred  with  the  supposed  parasites,  and  if  they 

1  Hauser,  in  "Biolog.  CentralbL,"  Oct.  2,  1895. 

2  "Centralbl.  f.  Gynak.,"  No.  4,  1894. 


350 


Tumors  or  Morbid  Growths 


were  transferred  the  success  of  the  experiment  does  not  prove  that  cancer  is  due 
to  parasites,  but  simply  proves  again  what  we  knew  before— that  epithelial 
cells  can  be  transplanted.  Many  parasites  have  been  regarded  as  causative  by 
different  observers.  Bacteria,  yeast-cells,  and  protozoa  have  been  found  by  dif- 
ferent experimenters.  It  is  not  thought  that  bacteria  are  causative.  Yeasts  are 
regarded  as  causative  by  some.  It  is  certain  that  they  may  exist  in  cancer, 
but  it  is  by  no  means  certain  that  they  cause  the  disease.  They  may  be 
only  a  contamination.  Gaylord  and  others  regard  protozoa  as  causative,  but 
this  statement  does  not  seem  to  be  proved.  Many  of  the  supposed  parasites 
of  cancer  have  been  shown  to  be  cell  degenerations  or  contaminations.  We 
are  justified  in  concluding  that  the  parasitic  origin  is  not  as  yet  proved,  and  we 
agree  with  the  elder  Senn  that  it  is  improbable. 

Tihrnanns  elaborately  discussed  the  subject  of  cancer  in  the  Congress  of 
1895.  His  conclusions  are  still  most  sound  and  scientific.  He  says  there  is 
no  evidence  of  a  bacterial  origin  of  cancer.  The  parasitic  origin  has  not  been 
proved,  and  protozoa  have  not  certainly  been  found.  Cancer  can  be  trans- 
ferred from  one  part  to  another  of  the  same  individual,  or  from  one  indi- 
vidual to  another  of  the  same  species,  but  never  to  one  of  a  different  species. 
It  is  possible  that  cancer  can  spread  by  contagion;  this  is  very  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cervix  cancer  in  a  wife).  Be- 
cause it  is  sometimes  possible  to  transfer  cancer,  this  does  not  prove  that  the 
disease  is  parasitic  or  infectious;  it  simply  shows  that  tissue  has  been  success- 
fully transplanted. 

Cancer  d  deux  is  cancer  developing  in  people  who  live  together.  Such 
cases  suggest,  but  do  not  prove,  contagion.  Behla  collected  19  cases  and 
Guelliot  103  cases.  Conjugal  cancer  is  classified  as  cancer  a  deux.  A  wife, 
for  instance,  may  have  cancer  of  the  womb  and  a  husband  may  develop  can- 
cer of  the  penis,  supposedly  from  contact.  Conjugal  cancer  is  probably  due 
to  irritation  or  implantation  and  not  to  microbic  inoculation. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now  known  to  arise 
from  the  ray-fungus.  Some  think  that  psorosperms  cause  cancer.  There 
can  be  no  doubt  that  changes  in  the  liver  which  practically  constitute  a  new 
growth  can  arise  from  the  growth  of  a  cell  called  by  Darier  the  "psorosperm." 
A  disease  due  to  psorosperms  is  called  a  "psorospermosis."  It  is  affirmed 
by  some  that  molluscimi  contagiosum,  follicular  keratosis,  cancer,  and  Paget's 
disease  are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in  aU  cases 
of  cancer,  while  others  can  find  it  in  only  4  or  5  per  cent,  of  the  cases. 

Heneage  Gibbes  affirms^  that  dilatation  of  the  bile-ducts  of  a  rabbit's 
Hver  is  caused  by  the  chronic  irritation  arising  from  multiplication  of  the  Coc- 
cidium  oviforme  in  them,  and  not  in  the  columnar  cells  of  the  bile-ducts,  as  has 
been  stated;  and,  further,  that  the  large  majority  of  glandular  cancers  show 
nothing  that  can  be  considered  parasitic,  the  suspicious  appearances  noted 
in  some  few  cases  being  due  to  endogenous  cell  formation.  The  Coccidiimi 
oviforme  is  a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division  of  the 
animal  kingdom.  To  this  case  belong  the  monera  and  unfusoria.  (For  a 
further  discussion  of  this  subject  see  page  55.) 

Malignant  and  Innocent  Tumors. — MaHgnant  growths  infiltrate 
the  tissues  as  they  grow;  benign  tumors  only  push  the  tissues  away;  hence 
malignant  tumors  are  not  thoroughly  encapsuled,  while  innocent  tumors  are 
encapsiiled.  Malignant  ttunors  grow  rapidly;  innocent  tumors  grow  slowly. 
Malignant  tumors  become  adherent  to  the  skin  and  cause  ulceration;  innocent 
tumors  rarely  adhere  and  seldom  cause  ulceration.  Many  mahgnant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands  (cancer,  except 
in  the  esophagus  and  antrum  of  Highmore,  always  does  so;  sarcoma  rarely 
1  "Amer.  Jour,  of  Med.  Sciences,"  Jvily,  1893. 


Classification  of  Innocent  and  Malignant  Tumors  351 

causes  them,  unless  the  growth  be  melanotic  or  lymphosarcoma,  or  unless  it 
arises  in  the  testicle  or  tonsil).  Innocent  tumors  never  cause  secondary 
lymphatic  involvement;  although  the  glands  near  the  tumor  may  enlarge  from 
accidental  inflammatory  complications.  The  malignant  tumors,  especially  cer- 
tain sarcomata  and  soft  cancers,  may  be  followed  by  secondary  growths 
(metastases)  in  distant  parts  and  various  structures  (bones,  viscera,  brain, 
muscles,  etc.);  innocent  tumors  are  not  followed  by  these  secondary  repro- 
ductions, although  multiple  fatty  tumors  or  multiple  lymphomata  may  exist. 
Malignant  tumors  destroy  the  general  health,  inducing  anemia  and  cachexia; 
innocent  tumors  do  not,  unless  by  the  accident  of  position.  Malignant  tumors 
tend  to  recur  after  removal ;  innocent  tumors  do  not  if  operation  was  thorough. 
The  special  histological  feature  of  a  malignant  growth  is  the  possession  by  its 
cells  of  a  power  of  reproduction  which  knows  no  limit,  the  cells  of  the  tumor 
living  among  the  body-cells  like  a  parasite  and  invading  and  destroying  the 
body-cells. 

The  Cachexia  of  Malignant  Disease. — This  condition  arises  sooner  or 
later  in  every  uncured  case  of  sarcoma  and  carcinoma. 

In  sarcoma  there  is  advancing  anemia  and  there  are  often  episodes  of  ele- 
vated temperature  due  to  the  absorption  of  toxic  materials  from  the  tiunor. 
The  blood  examination  gives  results  similar  to  those  found  in  cancer,  but  leu- 
kocytosis is  more  frequent.  Pain  is  far  less  prominent  than  in  cancer  unless  a 
nerve  is  involved  or  squeezed.  Ulceration  occurs  much  later  in  sarcoma  than 
in  carcinoma. 

In  carcinoma  (see  page  382)  the  emaciation  is  rapid  and  decided,  the  loss  of 
strength  is  significant  and  notable,  and  the  anemia  is  marked  and  progressive. 
It  is  due  to  pain,  sleeplessness,  ulceration,  impaired  appetite  and  digestion, 
repeated  hemorrhages,  and  the  absorption  from  the  tumor  of  toxic  products, 
which  are  probably  enzymes  (especially  isohemoly sins) .  Loss  of  hemoglobin 
is  early  and  is  followed  by  decrease  in  the  number  of  red  cells.  In  many  cases 
considerable  amounts  of  sugar  exist  in  the  blood.  Irregular  fever  may  occur. 
In  both  sarcoma  and  carcinoma  the  development  of  secondary  growths  aggra- 
vates the  anemia. 

Classification. — Tumors  may  be  classified  as  follows: 

I.  Connective- tissue  tumors  (those  derived  from  the  mesoblast). 

1.  Innocent  tumors,  or  those  composed  of  mature  connective  tissue: 
Lipomata,  or  fatty   tumors;  fibromata,  or  fibrous  tumors;  chondro- 

mata,  or  cartilaginous  tumors;  osteomata,  or  bony  timiors;  odonto- 
mata,  or  tooth- tumors;  myxomata,  or  mucous  tumors;  myomata,  or 
muscle-tumors;  neuromata,  or  tumors  upon  nerves;  gliomata,  or  tu- 
mors composed  of  neuroglia;  angiomata,  or  timiors  formed  of  blood- 
vessels; lymphangiomata,  or  tumors  formed  of  lymphatic  vessels. 
The  term  lymphoma,  meaning  a  tumor  of  a  lymphatic  gland,  was 
formerly  applied  to  hypertrophy  and  hyperplasia  of  a  lymphatic 
gland,  no  matter  whether  caused  by  syphilis,  tubercle,  Hodgkin's 
disease,  or  any  other  morbid  impression.  The  term  has  been 
largely  abandoned  except  as  expressing  enlargement  of  a  gland, 
and  does  not  convey  any  suggestion  as  to  the  cause.  It  is  doubtful 
if  there  is  such  a  thing  as  a  true  lymphoma,  understanding  by  the 
term  a  neoplasm  arising  from  and  composed  of  lymphoid  cells  and 
resembling  lymphatic  structure.  In  the  described  cases  the  possi- 
bility of  infection  as  a  cause  has  not  been  eliminated. 

2.  Malignant  timiors,  or  those  composed  of  embryonic  connective  tissue: 
Sarcomata  and  adrenal  tumors. 

Endotheliomata  are  regarded  by  some  as  constituting  an  independent 
group  and  by  others  as  a  variety  of  sarcomata. 


352 


Tumors  or  Morbid  Growths 


II.  Epithelial  tumors  (those  derived  from  the  epiblast  or  hypoblast). 

1.  Innocent  tumors,  or  those  composed  of  mature  epithehal  tissue: 
Adenomata,  or  tim^.ors  whose  type  is  a  secreting  gland;  and  papillo- 

mata,  or  tumors  whose  type  is  found  in  the  papillae  of  skin  and 
miucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic  epithelial  tissue: 
Carcinomata,  or  cancers. 

Cystomata  are  cystic  tumors,  the  cyst-walls  of  which  are  new  growths 
and  the  contents  of  which  are  produced  by  the  cells  of  the  newly 
formed  cyst  walls. 

Teratomata  (tumors  containing  epiblastic,  hypoblastic,  and  meso- 
blastic  elements). 

Innocent  Connective=tissue  Tumors. — These  growths  mimic  or  imi- 
tate some  connective  tissue  or  higher  tissue  of  the  mature  and  healthy  organism. 
Lipomata  are  congenital  or  acquired  txmiors  composed  of  fat  contained 
in  the  cells  of  connective  tissue,  which  cells  are  bound  together  by  fibers.     If 


III. 


IV. 


Fig.  140. — Lipoma,  wandered  from  axilla. 


Fig.  141. — DiflFuse  lipoma. 


the  fibers  are  excessively  abundant,  the  growth  is  spoken  of  as  a  fibrofatty 
tumor.  A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  surrounding 
parts,  but  loosely  attached  to  the  tumor;  hence  enucleation  is  easy.  Fibrous 
trabecule  run  from  the  capsule  of  a  subcutaneous  lipoma  to  the  skin;  hence 
movement  of  the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimpling  of  the  skin.  An  ordinary  circumscribed  lipoma  is  of  doughy  soft- 
ness, is  lobulated,  of  uniform  consistence,  and  on  being  tapped  imparts  to  the 
finger  a  tremor  known  as  pseudofluctuation.  A  fatty  tumor  is  mobile,  although 
it  may  be  attached  to  the  skin  at  points  by  trabeculse.  Sometimes  a  fatty 
timior  gradually  shifts  its  position  or  wanders  (Fig.  140).  This  is  due  to  grav- 
ity. Lipomata  are  most  frequent  in  middle  life,  and  their  commonest  situa- 
tions are  in  the  subcutaneous  tissues,  especially  of  the  back  or  of  the  dorsal 
surfaces  of  the  limbs;  they  usually  occur  singly,  but  may  be  multiple  and  some- 
times symmetrical.  Senn  described  the  case  of  a  woman  who  had  a  fatty 
tumor  in  each  axilla.  A  lipoma  may  grow  to  an  enormous  size  (in  Rhodius's 
case  the  tumor  weighed  60  pounds) ,  and  the  growth  may  be  progressive  or  may 
be  at  times  stationary  and  at  other  times  active.     The  skin  over  a  fatty  tumor 


Lipomata 


353 


sometimes  atrophies  or  even  ulcerates;  the  tumor  itself  may  inflame  or  partly 
calcify.  When  a  lipoma  has  once  inflamed,  it  becomes  immovable.  Subcu- 
taneous lipoma  of  the  palm  of  the  hand  or  sole  of  the  foot  bears  some  resem- 
blance clinically  to  a  compound  ganglion;  it  is  apt  to  be  congenital.  Lipomata 
of  the  head  and  face  are  rare.  In  the  subcutaneous  tissues  of  the  groins,  neck, 
pubes,  axillae,  or  scrotum  a  mass  of  fat  may  form,  unlimited  by  a  capsule  and 
known  as  a  diffuse  lipoma  (Figs.  141  and  143).  A  diffuse  lipoma  may  dip 
down  among  the  muscles.  Such  masses  attain  large  size.  The  t^-pical  diffuse 
lipoma  is  occasionally  seen  on  the  neck.  It  begins  back  of  the  mastoid  process 
on  one  side  or  on  both  sides.  When  large,  it  completely  surrounds  the  neck, 
a  huge  double  chin  forming  in  front,  a  great  mass  hanging  on  each  side,  and  the 
posterior  portion  being  divided  into 
two  halves  by  a  median  depression.  A 
nevolipoma  is  a  ne\TJS  with  much  fibro- 
fatty  tissue.  A  very  vascular  fatty  tu- 
mor is  called  lipoma  telangiectodes.  If 
the  tumor  stroma  contains  large  veins 


Fig.  142. — Lipoma  of  submaxillary  region. 


Fig.  143 . — Congenital  diffuse  lipoma  of  foot 
and  leg.  Child  seven  years  of  age,  second  and 
third  toes  amputated  at  thirteen  months  and 
large  mass  moved  from  sole  of  foot.  Later  a 
large  fatty  mass  moved  from  calf  of  leg,  sur- 
rounding gastrocnemius  and  soleus  muscles  and 
between  them  (Rugh). 


the  growth  is  called  a  cavernous  lipoma.  A  timior  containing  much  blood  can 
be  diminished  in  size  by  pressure.  Fatty  tumors  may  arise  in  the  subserous 
tissue,  and  when  such  a  growth  arises  in  either  the  femoral  or  inguinal  canal 
or  the  linea  alba  it  resembles  an  omental  hernia  and  is  spoken  of  as  &  fat-hernia. 
In  the  retroperitoneal  tissues  enormous  fibrofatty  tumors  occasionally  grow, 
and  these  neoplasms  tend  to  become  sarcomatous.  Lipomata  which  arise 
from  beneath  synovial  membranes  project  into  the  joints,  being  stiU  covered 
by  synovial  membrane.  Fatty  tumors  occasionaUy  arise  in  submucous  tissues, 
between  or  in  muscles,  from  periosteum,  and  from  the  meninges  of  the  spinal 
cord  (Sir  J.  Bland-Sutton) .  A  fatty  tumor  may  undergo  metamorphosis.  The 
stroma  may  be  attacked  by  a  myxomatous  process  or  a  calcareous  degenera- 
tion. The  fat-cells  themselves  may  become  calcareous.  Oil-cysts  sometimes 
form.  A  xanthoma  is  a  growth  composed  of  fatty  tissue  in  and  about  which 
23 


354 


Tumors  or  Morbid  Growths 


there  is  marked  infiltration  with  small  cells.  Such  a  tumor  is  flattened  and 
slightly  elevated.  Several  or  many  of  these  growths  occur  in  the  same  person. 
The  eyelids  are  the  most  common  seat  of  xanthoma.  The  tumor  may  undergo 
involution  or  may  become  sarcomatous. 

Diabetics  are  liable  to  develop  xanthomata. 

Treatment. — A  single  subcutaneous  lipoma  should  be  extirpated.  The 
capsule  must  be  incised,  when  the  timior  is  torn  out  forcibly  or,  better,  is 
enucleated  by  dissection;  drainage  is  always  employed  for  twenty-four  hours, 
as  butyric  fermentation  will  be  apt  to  occur,  and  necrosis  of  small  particles 
of  fat  predisposes  to  infection.  Multiple  subcutaneous  lipomata,  if  very 
numerous,  should  not  be  interfered  wdth  unless  troublesome  because  of  their 
size  or  situation,  when  the  growth  or  growths  causing  trouble  should  be  re- 
moved. It  is  difficult  to  extirpate  entire  a  diffuse  lipoma,  and  several  opera- 
tions may  be  needed  to  effect  complete  removal.  Liquor  potassae,  once  recom- 
mended as  possessing  power,  when  taken  internally,  to  limit  the  growth  of 
multiple   lipomata   or   diffuse   lipoma,   seems   to  be   useless.     Subperitoneal 


Fig.  144. — Fatty  tumor. 

lipomata  are  rarely  diagnosticated  until  the  belly  has  been  opened,  sometimes 
not  until  the  growth  has  been  removed. 

Fibromata  are  tumors  composed  of  bundles  of  fibrous  tissue.  There 
are  two  forms,  the  hard  and  the  soft.  A  hard  fibroma  consists  of  wavy  fibrous 
bundles  lying  in  close  contact.  Here  and  there  connective-tissue  corpuscles 
exist  between  the  fibers.  A  fibroma  has  no  distinct  capsule,  though  surround- 
ing tissues  are  so  compressed  as  to  simulate  a  capsule.  Fibromata  are  occa- 
sionally congenital,  are  most  usual  in  young  adults,  but  they  may  occur  at  any 
period  of  life,  and  in  any  part  of  the  body  containing  connective  tissue.  Pure 
fibromata,  which  are  rare,  are  generally  solitar\%  grow  slowly,  are  of  uniform 
consistence,  have  not  much  circulation,  and  are  hard  and  movable.  Fibro- 
mata may  form  upon  nerve-sheaths,  may  arise  in  the  mammar}'  gland,  may 
develop  in  the  lobe  of  the  ear,  and  may  spring  from  various  fibrous  mem- 
branes, from  the  periosteum  of  the  base  of  the  skull  (nasopharyngeal  fibro- 
mata), and  from  the  gums  (fibroiis  epulides).  A  soft  fibroma  contains  much 
areolar  tissue,  the  spaces  of  which  are  filled  with  fluid,  so  that  the  tissue  seems 


Fibromata  355 

edematous.  Soft  fibromata  grow  from  the  skin,  mucous  membrane,  subcu- 
taneous tissue,  intermuscular  planes,  and  periosteum.  Soft  fibromata  possess 
distinct  pedicles  and  are  especially  apt  to  arise  from  the  skin  of  the  scrotima, 
labia,  inner  surface  of  arm  and  thigh,  and  from  the  beUy  wall  of  a  pregnant 
woman.  They  are  not  imusually  multiple,  grow  slowly,  but  more  rapidly  than 
the  hard  fibromata,  and  may  become  quite  large.  Fibromata  may  become 
c\'stic,  calcareous,  osseous,  colloidal,  or  sarcomatous,  and  may  inflame,  ulcerate, 
or  even  become  gangrenous. 

A  painful  subcutaneous  tubercle,  which  is  a  form  of  fibroma  commonest  in 
females,  arises  in  the  subcutaneous  cellular  tissue,  usually  of  the  extremities. 
It  is  firm,  ver\-  tender,  movable,  rarely  larger  than  a  pea.  and  the  skin  over  it 
seems  healthy.  Molent  pain  occurs  in  parox}-sms  and  radiates  over  a  con- 
siderable area,  of  which  the  tubercle  is  the  center.  These  paroxA'sms  may 
occur  onlv  once  in  many  days  or  many  times  in  one  day.  Pain  is  always  de- 
veloped by  pressure,  and  may  be  linked  with  spasm.  Nerv^e-fibrillE  are  now 
known  to  exist  in  these  tubercles,  a  fact  which  was  long  denied. 

A  mole  is  a  fibroma  of  the  skin  which  is  congenital  or  appears  in  the  early 
weeks  of  life.  It  is  rounded  or  flat,  is  usually  pigmented  and  of  a  brown  color, 
is  sHghtly  elevated  above  the  cutaneous  level,  and  has  a  few  hairs  or  an  abun- 
dant crop  of  hair  growing  from  it,  and  varies  in  size  from  a  pin's  head  to 
several  inches  in  diameter,  or  may  even  occupy  an  extensive  area  of  a  limb  or 
of  the  trunk.  The  tumor  rarely  grows  after  the  thirteenth  or  fourteenth  year. 
A  mole  may  become  malignant,  melanotic  carcinoma  may  arise  from  its 
epithelial  structures,  or  melanotic  sarcoma  from  its  connective-tissue  ele- 
ments. A  mole  is  an  extremely  vascular  structure:  it  bleeds  freely  when  cut 
or  scratched,  and  it  sometimes  ulcerates.  Occasionally  several  or  many  moles 
exist  in  the  same  indi\ddual.  If  a  mole  begins  to  increase  rapily  in  size, 
operation  is  imperative,  as  rapid  growth  probably  indicates  malignant  change. 

Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  periodontal  membrane 
(Sir  J.  Bland-Sutton)  in  connection  with  a  carious  tooth  or  retained  snag;  it 
is  covered  by  mucous  membrane,  grows  slowly,  may  attain  a  large  size,  and 
sometimes  has  a  stem,  but  is  more  often  sessile.  It  may  undergo  m}.-xomatous 
change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovar\-,  the  intestine,  the  lar^Tix.  and 
the  submucous  tissues  of  the  gastro-intestinal  tract.  Pure  fibromata  of  the 
uterus  are  ver\-  rare,  but  fibromyomata  are  xexy  common  (see  ]\I}-omata.  page 
361);  hence  the  term  ''uterine  fibroid"'  should  be  abandoned. 

Desmoid  tumors  of  the  abdominal  wall  are  ceUular  fibromata.  A  desmoid 
tumor  has  a  strong  disposition  to  become  sarcoma.  It  has  no  real  capsule. 
It  takes  origin  from  one  of  the  abdominal  muscles  or  muscular  insertions 
or  from  fascia,  particularly  from  the  rectus  muscle  or  its  sheath.  In  most 
cases  the  growth  is  slow:  in  some  it  is  rapid  and  the  tmnor  may  attain  a  great 
size.  It  may  project  either  anteriorly  or  toward  the  abdomen.  This  form  of 
tumor  is  vastlv  more  common  in  women  than  in  men  and  is  especially  com- 
mon in  women  who  have  borne  children.  It  may  occur  at  any  age,  but  is  most 
frequent  in  those  between  twent\"-five  and  thirty-five.  It  is  a  ver}'  rare  tmnor. 
(See  Har\-ey  B.  Stone,  ''Annals  of  Surgery-,"  August,  1908.) 

Molluscum  fibrosum  is  an  overgrowth  of  the  fibrous  tissue  of  both  the  skin 
and  subcutaneous  structure.  Senn  excludes  this  form  of  growth  from  considera- 
tion with  fibromata  because  of  its  supposed  infective  origin.  It  may  be  limited 
or  widely  extended:  it  may  appear  as  an  infinite  number  of  nodules  scattered 
over  the  entire  body  or  as  hanging  folds  of  fibrous  tissue  in  certain  areas. 

Keloid  (Figs.  145,  1461  is  a  fibroma  of  the  true  skin.  It  is  a  hard  and 
fibrous  vascular  growth,  with  a  broad  base,  arising  in  scar-tissue;  it  is  crossed 
by  pink,  white,  or  discolored  ridges,  and  is  named  from  a  fancied  likeness  to 


356 


Tumors  or  Morbid  Growths 


the  crab.  It  has  rarely  attacked  mucous  membrane.  It  is  more  common  in 
negroes  than  in  whites,  and  is  most  frequent  in  the  cicatrices  of  burns,  though 
it  may  arise  in  the  scar  of  any  injury,  as  the  scar  from  piercing  the  ears,  and 
in  the  scars  of  syphilitic  lesions,  tuberculous  processes,  smallpox,  or  vaccina- 
tion. I  believe  that  the  scars  of  tuberculous  lesions  and  the  scars  even  of 
ordinary  wounds  in  tuberculous  individuals  are  particularly  apt  to  become 
keloidal.  It  is  very  common  in  a  person  with  keloid  to  be  able  to  find  some 
near  or  distant  tuberculous  lesion,  or  a  history  of  former  tuberculosis,  or  the 
record  of  the  individual  having  tuberculous  tendencies.  The  victim  of  keloid 
usually  reacts  to  tuberculin.  The  growth  seldom  begins  in  early  childhood  or 
in  old  age.  It  grows  slowly,  lasts  for  many  years,  and  may  eventually  undergo 
involution  and  disappear.  The  fact  that  keloid  is  especially  common  in  the 
negro  race  (a  race  predisposed  to  tuberculosis)  and  that  it  is  so  frequently  met 
with  in  the  scars  of  known  tuberculous  processes,  suggests  the  possibility  of 
a  tuberculous  cause  for  the  condition.  The  rapid  return  of  keloid  after 
operation  suggests  a  near  or  dis- 
tant infection  which  furnishes 
material  to  a  point  of  least  re- 
sistance which  causes  keloid  to 
redevelop.     Some  cases  of  keloid 


Keloid  following  a  burn. 


-Keloid  (case  of  Dr.  L.  L.  Hill,  Montgomery, 

Alabama). 


have  active  tuberculous  lesions,  others  have  had  them,  in  still  others  latent  or 
distant  lesions  may  be  found  by  careful  search.  In  many  cases  there  is  a  family 
history  of  tuberculosis.  I  am  at  present  investigating  this  important  matter. 
It  is  certain  that  the  keloid  itself  does  not  contain  bacteria.  Repeated  exami- 
nations have  failed  to  find  them.  It  is  quite  possible  that  the  growth  con- 
tains toxins  of  tubercle  bacilli,  the  toxins  being  the  irritant  cause.  I  am  now 
seeking  to  determine  if  material  from  keloid  introduced  into  tuberculous 
animals  will  cause  a  reaction.  It  is  usually  believed  that  it  is  almost  useless  to 
remove  keloid  by  operation,  as  it  will  almost  certainly  return,  yet  a  study  of 
the  growth  removed  shows  no  reason  for  the  inevitable  return.  Charles  A. 
Porter  has  reported  a  case  of  massive  keloid  of  the  face  and  hands  notably 
benefited  by  many  operations  and  skin-grafting.  In  this  case,  Porter  says, 
"there  has  been  a  gradual  but  distinct  abatement  of  the  tendency  to  form 
keloid  tissue"  ("Annals  of  Surgery,"  July,  1909).     The  fibrous  tissue  of  keloid 


Chondromata  '357 

springs  from  the  outer  walls  of  the  blood-vessels.  The  papillae  of  the  skin 
above  the  tumor  are  destroyed  or  replaced  by  fibrous  tissue. 

Morphea,  spontaneous  or  true  keloid,  is  a  name  used  to  designate  a  growth 
of  this  description  which  does  not  arise  from  a  scar;  but  it  seems  certain  that 
scar-tissue  was  present,  though  possibly  in  small  amount  from  trivial  injury. 

Fibrous  and  papillomatous  growths  co\-ered  with  endothelium  may  spring 
from  any  serous  membrane.  Such  a  growth  of  the  choroid  plexus  calcifies 
early  and  constitutes  a  psammoma  or  brain-sand  tumor.  Such  tumors  are 
met  with  not  only  in  the  choroid  plexus,  but  also  in  the  conarium  and  the  dura. 
All  psammomata  are  not  fibrous;  some  are  glioma tous  and  some  are  endo- 
theliomatous.  A  cholesteatoma  is  a  fibrous  growth  covered  with  endothelium 
and  containing  layers  of  crystalline  fat.  It  occurs  especially  in  the  pia  mater, 
but  may  arise  in  either  of  the  other  membranes  or  even  in  the  brain  substance, 
and  is  called  a  pearl  tumor. 

Treatment. — Fibromata  should  not  be  let  alone,  because  any  fibrous  tumor 
may  become  a  sarcoma.  WTien  in  accessible  regions  they  should  be  enu- 
cleated. If  a  hard  fibroma  of  the  skin  exists  the  skin  is  incised  and  the  tumor 
is  "shelled  out.  "A  soft  fibroma  is  removed  by  an  incision  carried  around  the 
base  of  its  pedicle.  A  painful  subcutaneous  tubercle  should  be  excised.  If 
a  mole  shows  the  sKghtest  disposition  to  enlarge,  or  if  it  is  subjected  to  pressure 
or  irritation,  it  should  be  removed,  because  if  allowed  to  remain  it  might 
develop  into  a  maHgnant  growth.  It  is  often  desirable  to  remove  a  hairy  or 
pigmented  mole,  not  only  because  it  may  become  malignant,  but  also  because 
it  is  unsightly.  A  mole,  if  not  too  large,  may  be  removed  by  a  30-second  appli- 
cation of  solid  carbonic  acid.  This  destroys  hair  and  often  causes  pigment 
to  disappear.  Many  moles  are  best  treated  by  excision.  Fibrous  epulis  re- 
quires the  cutting  away  of  the  entire  mass,  the  removal  of  the  related  snag  or 
carious  tooth,  and  sometimes  the  biting  away  of  a  portion  of  the  alveolus  ^dth 
rongeur  forceps.  A  nasophar\-ngeal  fibrous  poh-p  often  contains  sarcomatous 
elements  or  develops  into  a  spindle-celled  sarcoma.  If  the  polyp  is  recent  and 
has  a  pedicle  it  may  be  removed  by  the  cauter}^  loop.  Most  cases  require 
extirpation,  the  surgeon  cutting  wide  of  the  groT\1;h.  In  a  severe  case  a  part 
of  the  superior  maxillar\^  bone  is  removed  by  osteoplastic  resection  to  permit 
of  extirpation.  Keloid  should  rarely  be  operated  upon:  it  will  almost  certainly 
•  return,  and  will  also  develop  in  the  stitch  holes.  Trust  to  time  for  involution, 
or  use  pressure  with  flexible  collodion,  by  which  method  J.  M.  DaCosta  cured 
a  case  following  small-pox.  It  may  be  necessary  to  operate  because  of  ulcera- 
tion. If  it  is  necessary  to  operate,  remove  the  keloid  and  considerable  ad- 
jacent tissue  and  fill  the  gap  with  Thiersch  grafts.  The  administration  of 
thyroid  extract  may  be  of  benefit  (a  5-gr.  tablet  three  or  four  times  a  day). 
This  drug  must  be  given  cautiously,  as  it  may  cause  attacks  characterized  by 
fever,  dyspnea,  and  rapid  pulse.  Thiosinamin  h^-podermatically  has  been  used, 
it  is  claimed,  with  benefit.  A  10  per  cent,  solution  is  made,  and  from  10  to 
15  min.  can  be  injected  into  the  gluteal  muscles  ever\'  third  day.  I  have  seen 
two  keloids  cured  by  the  use  of  the  x-rays. 

Chondromata  (enchondromata)  are  tumors  formed  either  of  hyaline 
cartilage,  of  fibrocartHage,  or  of  both.  Chondromata  are  apt  to  arise  from 
certain  glands,  the  long  bones,  the  pelvis,  the  rib  cartilages,  and  the  bones  of 
the  hands  or  feet,  and  often  spring  from  imossified  portions  of  epiphyseal 
cartilage.  They  may  be  single  or  multiple,  and  are  most  commonly  met  with 
in  the  young.  They  have  distinct  adherent  capsules;  they  grow  slowly,  and 
if  of  osseous  origin  progressively  hollow  out  the  bones  by  pressure;  they  cause 
no  pain;  they  impart  a  sensation  of  firmness  to  the  touch,  unless  mucoid 
degeneration  forms  zones  of  softness  or  fluctuation ;  they  are  inelastic,  smooth 
or  nodular,  immovable,  and  often  ossify.     A  chondroma  may  grow  to  an  enor- 


358 


Tumors  or  Morbid  Growths 


mous  size.  A  chondroma  of  the  parotid  gland  or  testicle  practically  always 
contains  sarcomatous  elements,  and  any  chondroma  may  become  a  sarcoma. 
Chondromata  are  notably  frequent  in  persons  who  had  rickets  in  early  life. 
Ecchondroses,  which  are  "small  local  overgrowths  of  cartilage"  (Sir  J.  Bland- 
Sutton),  arise  from  articular  cartilages,  especially  of  the  knee-joint,  and  from 
the  cartilages  of  the  larynx  and  nose.  Loose  or  floating  cartilages  in  the  joints 
may  be  broken-off  ecchondroses  or  portions  of  hyaline  cartilage  which  are 
entirely  loose  or  are  held  by  a  narrow  stalk,  and  which  arise  by  chondrification 
of  villous  processes  of  the  synovial  membrane;  only  one  or  vast  numbers  may 
exist;  one  joint  may  be  involved  or  several;  they  may  produce  no  symptoms, 
but  usually  produce  from  time  to  time  violent  pain  and  immobility  by  acting 
as  a  joint-wedge.  An  ecchondroma  may  arise  within  the  medullary  canal  of  a 
long  bone,  from  foci  of  dormant  cartilage,  and  may  lead  to  the  development  of 
a  solitary  cyst  of  large  size  by  softening  of  the  tumor.  The  femur  is  the  most 
usual  site  of  solitary  cyst.  It  begins  very  insidiously  and  progresses  gradually. 
There  are  slight  lameness,  trivial  pain,  tenderness  below  the  level  of  the  tro- 
chanter, apparent  shortening,  and  some  bulging  of  bone.  The  bone  may  bend 
or  at  some  spot  may  thin  so  that  the  cyst  can  be  felt.  Such  a  bone  fractures 
from  slight  force,  and  after  a  fracture,  when  the  effused  blood  and  inflammatory 
exudate  have  been  absorbed,  a  tumor  can  be  distinctly  detected.     A  solitary 

cyst  of  a  long  bone  is  apt  to  be  re- 
garded clinically  as  a  sarcoma  (Berg- 
mann- Virchow) . 

Treatment.  —  Remove  chondromata 
whenever  possible,  for,  if  allowed  to  re- 
main undisturbed,  they  are  apt  to  resent 
this  hospitality  by  becoming  sarcoma- 
tous. A  chondroma  of  the  testicle  and 
of  a  salivary  gland  is  sure  to  be  sarcoma- 
tous. In  an  ordinary  chrondroma  incise 
the  capsule  and  take  away  the  growth, 
using  chisels  and  gouges  if  necessary. 
Incomplete  removal  means  inevitable  re- 
currence. Amputation  is  very  rarely 
demanded.  In  chondrosarcoma  incision  ' 
must  be  outside  of  the  capsule.  Loose 
bodies  in  the  joints,  if  productive  of 
much  annoyance,  are  to  be  removed,  the 
joint  being  opened  with  the  strictest 
antiseptic  care.  Amputation  is  some- 
times performed  for  a  solitary  cyst  of  a 
long  bone,  the  surgeon  having  looked 
upon  the  growth  as  sarcomatous.  If  a 
correct  diagnosis  is  arrived  at,  an  attempt 
should  be  made  to  remove  the  cyst  without  amputation.  Bergmarm  suc- 
ceeded in  extirpating  such  a  mass  from  the  femur. 

Osteomata  are  tumors  which  are  composed  of  osseous  tissue.  Sir  J. 
Bland-Sutton  says  that  osteomata  are  ossifying  chondromata.  Osteomata 
take  origin  from  bone,  cartilage,  connective  tissue,  especially  tissue  near  the 
bone,  serous  membrane,  and  certain  glands  and  organs.  Compact  osteomata, 
which  are  identical  in  structure  with  the  compact  tissue  of  bone,  arise  from 
the  frontul  sinus,  mastoid  process,  external  auditory  meatus,  and  other 
regions  in  those  beyond  middle  life;  they  are  small,  smooth,  round,  densely 
hard,  with  small  and  occasionally  cartilaginous  bases. 

Cancellous  osteomata,  which  comprise  the  great  majority  of  bone-tumors, 


Fig.  147. — Osteoma  of  femur. 


Osteomata 


359 


are  similar  in  structure  to  cancellous  bone.     They  spring  from,  and  are  crusted 
with,  cartilage;  they  may  have  fibrous  capsules,  and  are  often  movable  when 


,  i'^.'^^riS-iV- 


Fig.  148. — Osteoma  of  humerus. 

recent,  but  soon  become  fixed;  they  have  broad  bases,  are  angled,  nodular, 
fiirm  (but  not  so  hard  as  are  the  compact  osteomata),  painless  except  when 
pressed,  occur  particularly  at  the  ends 
of  long  bones  (Figs.  147  and  14S),  may 
grow  to  large  size,  and  are  commonest  in 
youth.  Osteomata  near  joints  become 
overlaid  by  bursse,  which  in  rare  instances 
communicate  with  an  adjacent  joint. 

Osteomata  do  not  tend  to  become  ma- 
lignant and  do  not  recmr  after  removal. 
The  term  exostosis  or  osteophyte  has  been 
used  as  being  s\Tion\-mous  with  osteoma, 
but  T\Tongly  so,  as  an  exostosis  is  an 
irregular,  local,  bony  growth  which  does 
not  tend  to  progress  without  limit,  and 
which  is,  hence,  not  a  tumor.  A  true 
exostosis  is  seen  in  the  ossification  of  a 
tendon  insertion  (Fig.  149),  in  a  limited 
growth  from  one  of  the  maxillary  bones, 
and  in  a  local  growth  from  the  last  pha- 
lanx of  the  big  toe,  which  latter  form  of 
gro\\i:h  is  kno-mi  as  a  subungual  exostosis.  Osteophytes  of  the  retrocakaneal  bursa 
occasionally  form  when  this  bursa  is  inflamed.     Inflammation  of  this  bursa  is 


Fig.  149. — Osteophyte  of  os  calcis. 


36o 


Tumors  or  Morbid  Growths 


known  as  Achillodynia,  or  Albert's  disease.  The  bony  masses  sometunes 
found  m  the  brain,  limgs,  testicles,  various  glands,  and  tumors  are  not  true 
osteomata.     Osteophytes  may  arise  in  a  joint  in  various  forms  of  arthritis. 

Multiple  exostoses  (Figs.  150, 151)  are  rare  and  depend  upon  some  anomaly 
in  and  ossification  of  temporary  cartilage.  They  arise  during  the  period  of  act- 
ive growth  of  bone.  Volkmann  and  others  assigned  rickets  as  the  cause.  Vir- 
chow  looked  upon  the  condition  as  hereditary. 
Lippert  traced  the  condition  through  four  genera- 
tions, but  hereditary  influence  is  not  always  evi- 
dent. Tuberculosis  has  nothing  to  do  with  their 
development.  One,  several,  or  many  of  the  growths 
may  diminish  in  size  or  even  disappear  (Bruns, 
"Beitrage,"  xxxiv,  1902).  In  Oberndorf's  case 
many  tumors  disappeared,  but  none  after  maturit\' 
("New  York  Med.  Jour.,"  March  5,  1910).  This 
patient  had  syringomyelia  and  acromegalic  symp- 
toms, causing  one  to  think  of  Charcot's  statement 
that  the  gray  matter  of  the  cord  contains  the 
center  for  the  nutrition  of  the  bone.  Exostoses 
within  the  cranium  or  spinal  canal  may  cause 
symptoms  from  irritation  or  from  pressure. 

Treatment.- — Osteomata  which  are  non-produc- 
tive of  pain  or  trouble  do  not  demand  removal. 
If  they  produce  pain  by  pressure,  if  they  press  upon 
important  structures,  if  they  cause  annoying  de- 
formities, or  if  they  grow  rapidly,  then  remove  them 
by  means  of  chisels,  gouges,  or  the  surgical  engine. 


Fig.  150. — Multiple  exostoses. 


Fig.  151. — Multiple  e.xostoses. 
Hundreds  of  them  throughout 
the  body. 


Subungual  exostosis  should  always  be  removed.  The  nail  should  be  split 
and  part  of  it  taken  away,  and  the  bony  mass  be  gouged  away  or  be  cut  off 
with  forceps. 

Odontomata^  are  tumors  composed  of  tooth-tissue.  They  spring  from 
the  germs  of  teeth  or  from  developing  teeth.  Sir  J.  Bland-Sutton  divides  them 
into  (i)  those  springing  from  the  follicle;  (2)  those  springing  from  the  papilla, 
and  (3)  those  springing  from  the  whole  germ. 

1  This  section  is  abridged  from  Sir.  J.  Bland-Sutton's  striking  chapter  upon  Odon tomes  in 
his  work  on  "Tumors." 


Myxomata  361 

Epithelial  odontomes,  or  multilocular  cystic  tiimors,  arise  from  the  follicle, 
occur  oftenest  iii  the  lower  jaw,  dilate  the  bone,  have  capsules,  and  are  made 
up  of  masses  of  C}-sts  which  are  tilled  with  brown  fluid.  These  cysts  are  met 
with  most  frequently  before  the  age  of  twenty.  Follicular  odontomes,  or  den- 
tigerous  cysts  [Yig.  152),  oftenest  spring  from  the  follicles  of  the  permanent 
molars.  In  a  dentigerous  cyst  there  exists  an  expanded  follicle  which  distends 
the  bone,  the  follicle  being  iiUed  with  thick  fluid  and  containing  a  portion  of  a 
permanent  tooth.  When  a  follicular  odontome  is  discovered  after  the  time  of 
second  dentition  the  patient  is  short  one  or  more  permanent  teeth.  The  corre- 
sponding milk  teeth  may  be  retamed.  The  position  of  the  portion  of  the  tooth 
is  variable.  It  is  usually  just  beneath  the  orbit.  In  a  case  operated  on  in  the 
Jefl'erson  Clinic  the  tooth  was  in  this  situation.  A  fibrous  odontome  is  due  to 
thickening  of  the  tooth-sac,  which  prevents  eruption  of  the  tooth;  fibrous  odon- 
tomes are  usually  multiple,  and  are  apt  to  occur  in  rickety  children.  A  cementome 
is  due  to  enlargement,  thickening,  and  ossification  of  the  capsule,  the  developing 
tooth  being  encased  in  cement.     A  compound  follicular  odontome  is  due  to  ossi- 


fU 


Fig.  152. — Dentigerous  cj-sts  removed  from  upper  jaw  of  a  negro.     Both  in  the  right  side.     Con- 
tained portions  of  undeveloped  teeth. 

fication  of  portions  only  of  an  enlarged  and  thickened  capsule,  and  the  tumor 
contains  bits  of  cementimi,  portions  of  dentin,  or  small  misshaped  teeth.  A 
radicular  odontome  springs  from  the  papilla  and  arises  after  the  crown  of  the 
tooth  is  formed  and  while  the  roots  are  forming;  hence  it  contains  dentin  and 
cement,  but  no  enamel.  Composite  odontomes  are  formed  of  irregular,  shapeless 
masses  of  dentin,  cement,  and  enamel.  All  the  above  forms  occur  m  man. 
They  present  themseh'es  as  hard  tumors  associated  with  teeth  or  in  an  area 
where  teeth  have  not  erupted.  Occasionally  an  odontome  simulates  necrosis; 
it  is  surrounded  by  pus,  and  a  sinus  forms. 

Treatment. — The  diagnosis  is  now  usuaUy  possible  b}-  the  aid  of  the  .v-rays. 
Be  in  no  haste  to  excise  large  portions  of  bone  for  a  doubtful  growth;  incise 
first  and  see  if  it  be  an  odontome,  which  usually  requires  only  the  removal  of 
an  implicated  tooth,  curetting  with  a  sharp  spoon,  and  packing  with  iodoform 
gauze. 

Myxomata  are  tumors  composed  of  mucous  tissue.  They  are  rare  as 
independent  growths,  although  myxomatous  change  is  frequent  in  the  stroma 
of  other  tmnors.     The  tissue  tj-pe  of  these  ttunors  is  found  in  the  ^dtreous 


362  Tumors  or  Morbid  Growths 

humor  of  the  eye  and  in  the  perivascular  tissues  of  the  umbilical  cord  (Whar- 
ton's jelly).  Bowlby  states  that  myxomata  are,  in  reality,  soft  fibromata  whose 
intercellular  substance  has  been  replaced  by  mucin.  The  myxomatous  state 
may  be  a  stage  in  the  formation  of  a  fibroma,  a  stroma  not  having  developed, 
Myxomata  may  result  from  myxomatous  degeneration  of  cartilage,  of  muscle, 
or  of  fibrous  tissue.  These  tumors  are  soft,  elastic,  usually  pedunculated, 
tremulous,  and  vibratory.  The  stroma  is  very  delicate  and  carries  minute 
blood-vessels.  Cutting  into  a  myxoma  causes  a  straw-colored,  clear  jelly 
to  exude.  Myxomata  grow  slowly,  are  encapsuled,  have  but  little  circulation, 
and  the  diagnosis  may  be  impossible  before  removal  of  the  growth.  Some 
pathologists  place  myxomata  among  the  malignant  tumors,  but  most  consider 
them  as  benign  tumors,  though  they  tend  strongly  to  become  sarcomatous 
(myxosarcomata) .     A  sarcoma  may  undergo  myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin;  from  the  mucous  membrane  of  the 
nose,  the  frontal  sinus,  the  antrum,  the  womb,  the  auditory  meatus,  and  the 
t3aiipanum  {gelatinous  polypi);  from  the  parotid  and  mammary  glands;  from 
the  subcutaneous  tissue,  the  nerve-sheaths,  the  intermuscular  septa,  the 
rectum,  and  the  bladder  (polyps).  They  may  be  congenital,  but  occur  most 
often  in  young  adults,  as  a  result  of  inflammation.  A  sudden  increase  of 
growth  indicates  beginning  malignancy  (sarcomatous  change).  When  a 
tumor  begins  to  undergo  myxomatous  transformation  we  give  to  it  a  com- 
pound name;  for  instance,  a  chondroma  undergoing  myxomatous  change  is 
a  chondromyxoma,  a  fibroma  undergoing  a  like  change  is  a  fibromyxoma,  etc. 
Mucous  polypi  grow  from  the  mucous  membrane  of  the  nose,  particularly 
from  the  outer  wall  near  the  middle  turbinated  bone,  and  often  from  the  roof 
of  the  nares.  Mucous  polypi  are  soft  and  jelly-like,  of  a  grayish  color,  and 
have  stems  or  peidcles;  they  may  be  seen  through  the  anterior  nares,  may 
project  behind  the  veil  of  the  palate,  and  may  bulge  out  from  the  passages  of 
the  nose;  they  may  be,  and  usually  are,  multiple;  they  may  be  present  in  one 
nasal  fossa  or  in  both;  and  they  occur  most  commonly  in  youths  and  adults 
between  the  ages  of  fifteen  and  thirty-five  years. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous  changes  in  the  chorion. 

Treatment. — In  treating  myxomata,  remove  them  promptly  and  thor- 
oughly, because  of  the  danger  of  sarcomatous  change.  Polypi  of  the  bladder 
are  removed  by  means  of  cutting  forceps  after  suprapubic  cystotomy  has  been 
performed.  Nasal  polypi  may  usually  be  twisted  off  or  be  removed  by  the 
wire  snare  or  galvanocautery.  Occasionally  when  the  growths  are  numerous 
and  recur  rapidly  after  removal,  the  inferior  turbinated  bones  should  be  re- 
moved with  a  saw  (Rouge's  operation).  This  operation  secures  ready  access 
to  the  area  of  disease,  which  can  be  attacked  radically.  A  very  soft  myxoma 
breaks  up  when  removal  is  attempted,  and  the  base  must  be  cauterized. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber  mixed  often 
with  fibrous  tissue.  They  are  called  leiomyomata.  Tumors  composed  of 
striated  muscle-fiber  and  spindle-cells  are  known  as  rhahdomyomata.  They 
are  very  rare  and  are  always  sarcomatous.  Leiomyomata  are  found  in  the 
womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet,  vagina,  stomach, 
bladder  and  bowel,  in  the  broad  ligament,  ovary  and  round  ligament,  in  the 
scrotum,  and  in  the  skin.  Myomata  usually  begin  during  or  after  middle 
age;  they  are  encapsuled,  they  grow  slowly,  they  are  firm  and  hard,  and 
produce  annoyance  by  their  size  and  weight  or  by  obstructing  a  viscus  or 
channel.  A  leiomyoma  of  the  posterior  portion  of  the  middle  of  the  prostate 
gland  is  known  as  a  ''middle  lobe." 

The  so-called  uterine  fibroid  is  a  myoma  or  fibromyoma.  Uterine  myo- 
mata may  originate  within  the  walls  of  the  womb  (intramural  myomata), 
from  the  muscular  structure  of  the  mucous  lining  (submucous  myomata),  or 


Treatment  of  Myomata  363 

from  the  muscular  tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  multiple  and  may  grow  to  an  enor- 
mous size.  Submucous  myomata  project  into  the  cavity  of  the  womb  (fleshy 
pol}-pi),  and  may  project  into  the  vagina.  They  distend  the  uterus  and  are 
often  accompanied  by  menorrhagia  or  metrorrhagia.  In  some  rare  cases  the 
projecting  tumor  is  detached  by  nature  and  the  patient  is  cured;  in  some  cases 
the  myoma  becomes  gangrenous.  A  fleshy  polj^D  may  produce  inversion  of 
the  fmidus  of  the  womb.  Subserous  uterine  myomata  cause  trouble  only  by 
the  inconvenience  of  weight  or  the  discomfort  of  pressure.  Uterine  myomata 
are  commonest  in  single  women,  and  arise  most  frequently  between  the  ages 
of  twenty-five  and  forty-five.  Negro  women  are  especially  prone  to  develop 
such  tumors.  They  may  never  produce  any  symptoms.  Some  of  these 
growths,  by  enlarging  until  they  ascend  above  the  pelvic  brim,  produce  ab- 
dominal distention;  some  become  jammed  or  impacted  in  the  pelvis,  and 
produce  by  pressure  retention  of  urine,  obstruction  to  the  passage  of  feces, 
or  hydronephrosis.  Impaction  may  occur  temporarily  at  each  menstrual 
period.  Many  myomata  produce  uterine  hemorrhage;  some  cause  retrover- 
sion of  the  womb;  some  protrude  from  the  cervical  canal;  some  are  so  large 
that  they  cause  disastrous  pressure  upon  the  colon  (obstruction),  upon  the 
iliac  veins  (great  edema),  or  upon  the  ureters  (hydronephrosis).  Uterine 
myomata  usually  shrink  after  the  menopause.  Pregnancy  in  a  myomatous 
^^-Dmb  usually  ends  in  abortion.  Uterine  myomata  may  undergo  fatty, 
calcareous,  or  myxomatous  change,  and  may  be  infected  by  septic  organisms 
as  a  result  of  the  use  of  a  uterine  sound  or  of  infection  of  the  pedicle  after 
oophorectomy.  Infection  of  a  uterine  myoma  causes  great  enlargement, 
elevated  temperature,  sweats,  and  exhaustion.  Sarcomatous  change  may 
take  place.  Virchow  pointed  out  this  fact  in  1863.  Cullen  found  sarcomatous 
change  in  17  cases  out  of  1400.  If  there  be  a  carcinoma  in  some  other  part  of 
the  body  metastatic  deposit  may  occur  in  a  uterine  growth. 

Uterine  fibromyoma,  if  unoperated  upon,  often  cause  death.  Noble 
claims  that  of  cases  denied  operation  or  who  refuse  operation,  33  per  cent, 
die  and  28  per  cent,  become  chronic  invalids. 

The  symptoms  of  myomata  of  the  alimentary  canal  are  similar  to  or  iden- 
tical with  the  symptoms  of  malignant  growths.  Myomata  of  the  skin  are  rare 
growths;  they  are  encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same  manner  as  fibrous 
tumors.  A  uterine  tumor  which  causes  symptoms  should  be  operated  upon. 
A  tumor  w^hich  causes  no  s^onptoms  need  not  be  operated  upon  if  the  patient 
can  lead  an  easy  life  and  can  rest  during  the  menstrual  periods.  Rest  is  an 
essential  of  the  treatment.  Ergot,  thyroid  extract,  barium  chlorid,  and  dilute 
sulphuric  acid  are  recommended.  In  some  cases  the  tumor  shrinks,  in  some 
it  disappears.  If  operation  is  required  the  form  of  operation  chosen  depends 
upon  the  case.  In  some  cases  the  operation  should  be  vaginal,  and  may  be 
dilatation  and  curetment,  torsion  or  incision  of  the  pedicle,  enucleation  or  hys- 
terectomy. In  other  cases  the  operation  should  be  by  the  abdominal  route, 
and  may  be  castration,  ligation  of  vessels,  myomectomy  (cutting  through  the 
pedicle  and  closing  with  deep  sutures),  enucleation,  shelling  out  growths  from 
the  wall,  partial  hysterectomy,  or  complete  hysterectomy.  Castration  aims  to 
create  an  artificial  menopause,  and  so  arrest  hemorrhage  and  cause  the  shrmk- 
ing  of  the  growth.  Sometimes  it  acts  admirably,  sometimes  it  fails,  and  it 
brings  with  it  its  own  perils,  for  the  sudden  creation  of  the  menopause  is  a  great 
danger  to  the  nervous  system.  For  subserous  myomata  myomectomy  is 
often  the  operation  of  choice.  A  very  large  tumor,  a  tiunor  which  continues  to 
enlarge  after  the  menopause,  and  an  infected  tmnor  require  partial  or  complete 
hysterectomy.     If  a  myoma  of  the  prostate  causes  severe  obstruction,  perform 


364 


Tumors  or  Morbid  Growths 


a  suprapubic  cystotomy  and  remove  the  enlarged  gland ;  or  make  both  a  supra- 
pubic and  a  perineal  opening,  push  the  gland  into  the  perineum  and  shell  it 
out  with  the  finger,  or,  if  the  condition  is  desperate,  make  permanent  supra- 
pubic drainage. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue  (brain,  cord,  or 
nerve-trunks);  it  is  composed  of  medullated  or  non-medullated  nerve-fibers 
which  form  a  plexus  or  network,  and  which  are  not  continuous  with  the  fibers 
of  the  nerve-trunk  or  other  area  from  which  the  tumor  grows.  True  neu- 
romata are  rare  growths.  They  arise  during  middle  life;  are  small  in  size, 
are  due  to  injury  or  hereditary  tendency,  and  may  be  single  or  multiple. 
There  is  usually  around  the  tumor,  rather  than  in  it,  severe  neuralgic  pain, 
which  is  greatly  intensified  by  dampness,  by  blows,  or  by  rough  handling. 
The  parts  below  a  neuroma  are  cold,  swollen,  often  anesthetic,  and  frequently 
present  motor  paralysis  or  trophic  disorder.  A  false  neuroma  or  neurofibroma 
is  a  fibrous  tumor  growing  from  a  nerve-sheath,  and  is  identical  in  structure 
with  the  sheath.  False  neuromata  may  be  single,  but  they  are  often  multiple; 
they  may  be  as  small  as  peas  or  as  large  as  oranges;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  be  painful  only  when  pressed  or 
struck;  they  may  spring  from  roots,  trimks,  or  branches,  and  they  may  be 
linked  with  the  disease  known  as  molluscum  fibrosum.  In  plexiform  neuroma 
some  brances  of  a  nerve  enlarge  and  lengthen  like  an  artery  in  a  cirsoid  aneu- 
rysm; the  mass  feels  like  beads  or  like  a  bag  of  worms;  it  is  mobile,  and  no  pain  is 
felt  on  moving  it;  and  it  is  generally  congenital.  In  plexiform  neuroma  the 
nerve-sheath  iindergoes  myxomatous  change.  Malignant  neuroma  is  usually  a 
primary  sarcoma  of  a  nerve-sheath,  though  any  neuroma  containing  fibrous 
tissue  may  become  sarcomatous. 

Traumatic  neuromata  are  false  neuromata,  and  are  occasionally  well  ex- 
hibited after  nerve-section  or  amputation.  After  nerve-section  the  distal  end 
shrinks  and  atrophies,  the  proximal  end  enlarges,  and  becomes  bulbous.  A 
traumatic  neuroma  is  composed  of  fibrous  tissue  which  contains  nerve-fibers. 
Such  a  growth  is  usually,  but  not  always,  painful  on  pressure  or  during  damp- 
ness, and  is  most  commonly  seen  in  a  stump  which  did  not  heal  by  first  inten- 
tion. In  performing  an  amputation  cut  the  nerves  high  up,  and  thus  keep 
them  out  of  the  scar,  permit  them  to  remaui  mobile  in  their  sheaths,  and  so 
prevent  a  tender  stimip.  A  tender  stump  may  be  due  to  anchoring  of  a  nerve 
in  a  scar,  the  nerve  ceasing  to  ghde  when  the  individual  moves  the  extremity. 
The  condition  known  as  painful  subcutaneous  tubercle  was  discussed  on  page 

355. 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possible,  without  de- 
stroying the  nerve-trunk.  If,  in  removing  a  neuroma,  it  is  necessary  to  exsect 
a  portion  of  a  nerve-trunk,  always  proceed  to  suture  the  ends  of  the  divided 
nerve  so  as  to  facihtate  restoration  of  function.  For  multiple  neuromata — at 
least  should  the  number  be  large  or  should  molluscum  fibrosum  exist— surgery 
can  do  nothing.  Plexiform  neuromata  may  often  be  removed,  but  amputation 
may  be  required.    Painful  neuromata  in  stumps  should  be  excised. 

Gliomata. — These  timiors  develop  from  neuroglia  and  more  often  from 
the  white  substance  than  from  the  gray.  They  are  usually  single,  and  arise 
not  unusually  in  the  brain,  rarely  in  the  cord,  and  very  rarely  in  the  cranial 
nerves.  They  may  take  origin  in  one  of  the  cerebral  hemispheres,  in  the  cere- 
bellum, in  the  pons,  or  in  the  medulla.  Some  gliomata  are  soft  and  bear  a 
close  relationship  to  sarcoma;  others  are  hard  and  resemble  fibroma.  _ 

A  glioma  is  a  circumscribed  growth  in  contrast  to  a  ghosis,  which  is  a 
widespread  and  unlimited  hyperplasia  of  the  neuroglia.  Syringomyelia  is 
due  to  gliosis  of  the  spinal  cord. 

"A  gHoma  consists  of  cells  containing  rounded  or  oval  nuclei  with  very 


Angiomata  or  Hemangiomata 


365 


little  protoplasm  and  fine  protoplasmic  extensions  which  interlace  and  form 
an  intercellular  reticulum"  (Stengel). 

A  glioma  passes  almost  insensibly  into  surrounding  tissue,  and  there  is  no 
distinct  edge;  hence,  because  of  the  slight  differentiation  from  brain  sub- 
stance, it  may  be  overlooked  during  exploration.  It  is  harder  than  the  sur- 
rounding tissue,  is  vascular  and  of  a  pink  or  red  color,  and  the  normal  shape 
of  the  part  is  often  very  little  altered,  although  the  tumor  may  reach  the  size 
of  a  lemon. 

Hemorrhage  may  take  place  into  a  glioma,  softening  may  occur,  cavities 
may  form,  or  the  growth  may  become  sarcomatous  or  psammomatous.  The 
symptoms  of  a  glioma  of  the  brain  depend  on  the  situation. 

Treatment. — When  a  glioma  of  the  brain  can  be  localized  and  is  hard, 
removal  should  be  attempted.  No  attempt  should  be  made  to  remove  a  soft 
glioma. 

Angiomata  or  Hemangiomata. — An  angioma  is  a  tumor  composed 
largely  of  dilated  blood-vessels.     The  older  surgeons  called  such  growths 


Fig.  153. — Dr.  Hansen's  case  of  cavernous  angioma 
of  the  eyelids. 


Fig.  154. — -Cavernous  angioma  of  face. 


erectile  tumors.    Some  of  the  so-called  angiomata  are  not  genuine  new  growths, 
but  are  due  to  dilatation  and  elongation  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  or  "mother's  marks,"  which  affect 
the  skin  or  subcutaneous  tissue,  are  composed  of  enlarged  and  twisted  capil- 
laries and  of  anastomosing  vessels  surroimded  by  fat.  These  growths  are 
congenital  or  appear  in  the  first  few  weeks  of  life;  they  are  flat  and  slightly 
raised,  and  are  of  a  bright-pink  color  if  composed  chiefly  of  arterioles,  and 
are  bluish  if  composed  mainly  of  venules;  they  are  but  little  elevated;  they  can 
be  almost  completely  emptied  by  pressure;  they  occasionally  pass  away  spon- 
taneously, but  usually  grow  constantly  and  may  become  cavernous;  they  may 
ulcerate  and  occasion  violent  or  fatal  hemorrhage.  One  or  several  large  ves- 
sels connect  a  nevus  to  adjacent  blood-vessels.  Port-wine  or  claret  stains 
are  pink  or  blue  discolorations  due  to  superficial  nevi  of  the  skin;  they  may 
be  small  in  extent  or  they  may  involve  a  very  large  area,  are  not  elevated,  and 
do  not  usually  spread.  Telangiectasis  is  a  form  of  nevus  involving  the  skin 
and  subcutaneous  tissue  in  which  many  arterioles  and  venules  exist.  Simple 
angiomata  are  common  on  the  forehead,  the  scalp,  the  face,  the  neck,  the  back, 
and  the  extremities.    They  may  appear  on  the  labia,  the  tongue,  or  the  lips. 


366 


Tumors  or  Morbid  Growths 


Cavernous  angiomata,  or  venous  nevi  (Figs.  153  and  154),  resemble  in 
structure  the  corpora  cavernosa  of  the  penis;  there  are  large  endothehal  lined 
spaces  with  thin  walls  carrying  blood,  and  there  may  be  distinct  vessels  as  well. 
Arteries  send  blood  into  the  spaces,  and  veins  receive  it  from  the  spaces.  These 
channels  and  sinuses  are  enormously  distended  capillaries.  Cavernous  angio- 
mata arise  in  the  skin  and  subcutaneous  tissues;  they  are  usually  congenital, 
but  may  develop  from  simple  angiomata;  they  are  purple  or  blue  in  color;  are 
more  distinctly  elevated  than  the  capillary  nevi;  may  be  either  cutaneous  or 
subcutaneous;  swell  when  the  child  cries,  and  are  apt  to  pulsate;  they  may  be 
emptied  by  pressure,  and  often  look  hke  cysts  with  very  thin  wails.  Cavern- 
ous angiomata  may  arise  in  the  breast, 
the  tongue,  the  lip,  the  cheek,  the 
gums,  the  subcutaneous  tissues,  or  the 
muscles.  If  an  angioma  contains  an 
excess  of  fat,  the  growth  is  called  a 
"nevoid  lipoma." 

Plexiform  angiomata  are  known  as 
"cirsoid  aneurysms"  or  aneurysms  by 
anastomosis  (see  page  434). 

Angiomata  noticed  soon  after  birth 
may  disappear  completely  or  may  en- 
large progressively. 

Treatment. — A  capillary  nevus  can 
often  be  quickly  cured  by  touching  it 
with  fuming  nitric  acid.  A  second  ap- 
plication of  acid  may  be  required.   The 


Fig.    155. — Cavernous    angioma:    Subcutaneous 
tissue  of  leg. 


Fig.  156. — Method  of  applying  Erichsen's 
suture. 


growth  may  be  destroyed  by  heat — "a  knitting-needle  at  a  dull-red  heat  or  the 
galvanocautery"  (Wharton).  The  application  of  ethylate  of  sodium  or  the 
employment  of  electrolysis  will  destroy  the  growth.  Solid  carbon  dioxid  is 
valuable  to  destroy  capillary  nevi.  Often  but  one  application  is  necessary, 
but  in  some  cases  two  or  more  are  required.  Astringent  injections  are  danger- 
ous unless  the  base  of  the  nevus  is  ligated,  because  they  may  lead  to  the  forma- 
tion of  emboli. 

Small  port- wine  stains  may  be  removed  by  electrolysis  or  multiple  incisions, 
but  extensive  stains  are  ineffaceable.  Solid  CO2  may  be  used.  Two  or  three 
applications  are  made  in  the  same  place  and  then  another  spot  is  selected.    It 


Treatment  of  Angiomata  or  Hemangiomata 


367 


usually  fails  to  cure.  Small  nevi  may  be  ligated  under  harelip  pins,  larger  nevi 
may  be  strangulated  in  sections  by  the  Erichsen  suture  (Fig.  156),  or  may  be 
completely  excised.  Excision  is  usually  the  best  plan  for  the  cure  of  angiomata. 
It  is  rapid,  thorough,  and  leaves  but  a  trivial  scar.  Excision  should  always  be 
employed  if  we  feel  sure  that  the  edges  of  the  wound  can  be  subsequently 
approximated  and  that  there  will  not  be  a  dangerous  loss  of  blood.  It  is  some- 
times justifiable  to  excise  an  angioma  even  when  approximation  of  the  wound 
will  obviously  be  impossible.  In  such  a  case  the  raw  surface  should  be  covered 
with  Thiersch  grafts. 

Most  superficial  nevi  and  some  cavernous  angiomata  can  be  treated  by 
solid  CO2,  and,  if  this  fails,  by  excision.     The  incisions  must  be  beyond  the 

dilated  vessels.  In  large  angiomata 
involving  the  skin  and  also  deeper 
parts,  or  involving  a  structure  like 
the  lip,  which  it  is  undesirable  to  re- 
move, electrolysis  should  be  employed. 
The  operation  should  be  carried  out 
with  aseptic  care,  and  if  the  tumor  is 
large  an  anesthetic  should  be  given. 

^The  positive  pole  produces  a  firm 
and  hard  clot.     One  or  more  needles 


Fig.    157. — Cavernous   angioma   and    lymph- 
angioma. 


Fig.   158. — Cavernous    angioma,    lymphangioma, 
and  lymphangiectasis,  also  beginning  cancer. 


connected  with  the  positive  pole  are  inserted  into  the  tumor,  the  needles 
being  insulated  to  within  about  I  inch  of  their  points.  A  flat  moist  pad  is 
placed  upon  the  skin  near  the  tumor  and  is  attached  to  the  negative  pole,  and 
the  pad  is  moved  from  time  to  time  during  the  operation. 

From  25  to  75  milliamperes  is  the  proper  strength,  and  the  current  is 
passed  for  ten  minutes.  The  current  is  increased  for  a  moment  before  with- 
drawing the  needles,  otherwise  they  will  stick  to  the  tissue  and  cause  bleed- 
ing when  torn  loose.  After  the  withdrawal  of  the  needles  the  nevus  will  be 
found  to  be  hard,  but  the  hardness  will  gradually  disappear.  It  may  be  neces- 
sary to  repeat  the  operation  a  number  of  times  at  intervals  of  ten  days.^ 
^  Cheyne  and  Burghard's  "Manual  of  Surgical  Treatment.'" 


368  Tumors  or  Morbid  Growths 

When  solid  CO2  is  applied  it  subjects  the  tissue  to  a  temperature  of  79°  F. 
below  zero.  It  is  called  carbonic-acid  snow.  It  is  applied  to  nevi  wdth  pressure. 
This  drives  out  the  blood.  It  is  held  against  the  part  for  thirty  or  forty  seconds. 
It  drives  the  color  out  of  the  part,  but  a  few  minutes  after  the  cessation  of  the 
action  color  returns,  reaction  occurs,  the  surface  becomes  moist,  and  fibrinous 
inflammation  takes  place  (E.  R.  Morton,  "Lancet,"  May  7,  1910). 

Necrosis  seldom  arises.  Within  an  hour  a  vesicle  forms,  which  should  be 
opened  aseptically.  A  crust  forms,  which  drops  off  in  about  two  weeks,  leaving 
"a  soft  and  elastic  scar,"  the  color  of  the  normal  skin  (Morton,  Ibid.). 

Lymphangiomata  are  tumors  composed  of  dilated  Ijnuph-vessels  and 
are  often,  though  not  invariably,  congenital  (Fig.  158).  A  lymphatic  nevus 
is  a  colorless  or  faintly  pink  elevation;  if  it  is  punctured  with  a  needle,  lymph 
flows  from  the  puncture.  One  or  several  nevi  may  be  present  in  the  same 
individual.  The  dilatation  is  due  to  blocking  of  the  lymph-channels.  Local 
lymphangioma  of  the  tongue  is  manifested  by  a  cluster  of  papillary  projec- 
tions containing  lymph.  Macroglossia  is  a  congenital  enlargement  of  the  an- 
terior portion  of  the  tongue,  which  enlargement  grows  more  and  more  marked, 
imtil  finally  the  tongue  is  forced  far  out  of  the  mouth.  This  condition  of  tongue 
enlargement  is  due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these  warty-looking  dila- 
tations is  called  lymphangiectasis .  Just  as  cavernous  angiomata  constitute 
a  variety  of  blood-vessel  timiors,  so  cavernous  lymphangiomata  constitute  a 
variety  of  Ijonph-vessel  tumors,  and  the  spaces  of  the  latter  are  filled  with 
lymph  instead  of  with  blood  (Figs.  157  and  158).  Areas  affected  with  lymph- 
angiectasis are  liable  to  repeated  attacks  of  erysipelas-like  inflammation. 
Whether  this  inflammation  is  causative  or  secondary  is  not  known.  In  trop- 
ical countries  blocking  of  lymph-channels  may  be  brought  about  by  the  Filaria 
sanguinis  hominis,  a  parasite  which  lurks  in  the  lymph-vessels  during  the  day 
and  is  found  in  the  blood  only  at  night.  Lymphangiectasis  is  often  the  first 
stage  of  elephantiasis. 

Treatment. — ^A  lymphatic  nevus  requires  excision.  In  macroglossia  the 
biflk  of  the  mass  should  be  removed  by  a  V-shaped  cut,  the  mucous  mem- 
brane being  sutured  so  as  to  cover  the  stump.  In  conditions  due  to  the  filaria, 
anilin-blue  has  been  given  internally. 

Malignant  Connective=tissue  Tumors,  or  Sarcomata. — The  sarco- 
mata are  composed  of  embryonic  tissue-ceUs,  the  intercellular  substance 
being  very  scanty,  and  they  resemble  a  process  of  chronic  inflammation.  They 
develop  from  connective  tissue,  rarely  have  a  definite  stroma,  and  the  con- 
stituent cells,  as  a  rule,  proliferate  with  great  rapidity.  If  a  sarcoma  has  a 
stroma  of  connective  tissue,  this  stroma  contains  lymphatics  and  such  a  sar- 
coma infects  adjacent  glands.  In  most  cases  there  is  no  connective-tissue 
stromia  and  no  lymphatics.  In  a  sarcoma  without  a  definite  stroma  the  blood- 
vessels are  not  surrounded  by  lymph-spaces  and  are  quickly  invaded  by 
ceUs  (B.  H.  Buxton).  The  rapidly  growing  forms  are  very  vascular,  the  blood 
flowing  in  vessels  whose  walls  are  very  thin  or  running  in  canals  lined  by  endo- 
thelium and  bounded  by  sarcomatous  cells.  Such  a  tumor  may  pulsate  and 
have  a  bruit,  and  hemorrhage  often  takes  place  into  its  substance.  A  rapidly 
growing  soft  sarcoma  with  dusky  skin  above  it  (Fig.  161)  may  be  mistaken  for 
an  abscess.  A  slow-growing  sarcoma  has  but  few  vessels.  Sarcoma  tends 
strongly  to  infiltrate  adjacent  parts.  The  growth  disseminates  by  means  of 
the  blood  and  the  vessel  waUs,  particles  of  the  tumor  being  carried  by  the 
venous  blood  to  the  heart,  and  from  this  organ  to  the  lungs,  where  they  lodge 
and  form  secondary  growths.  EmboH  from  these  secondary  foci  are  sent  out 
by  the  arterial  blood  to  various  portions  of  the  body,  as  the  bones,  kidneys, 
brain,  liver,  etc.    This  process  is  known  as  metastasis.    In  some  cases  sarcoma 


Malignant  Connective-tissue  Tumors,   or  Sarcomata 


369 


is  disseminated  widely  throughout  the  body,  almost  all  the  tissues  showing 
minute  white  spots  of  secondary  sarcoma  which  resemble  tubercles.  Such 
widespread  dissemination  is  called  sarcomatosis.     Sarcoma  follows  the  vein 

walls  for  considerable  distances 
and  builds  elongated  masses  of 
tumor  substance  inside  the  veins. 
The  primary  tumor  may  possess 
a  capsule  when  it  is  in  an  early 


Fig.  159. — Sarcoma  of  antrum. 


Fig.  160. — Sarcoma  of  antrum. 


stage,  but  soon  loses  this  except  in  very  slovv -growing  varieties  or  in  mLxed  forms 
growing  by  central  proliferation,  but  secondary  sarcomata  are  often  encap- 
suled.     Sarcomata  may  arise  at  any  age  from  birth  to  extreme  senility,  but 


Fig.  161. — Small  round-ceUed  fungating  sarcoma  of  neck. 

they  are  commonest  during  youth  and  early  middle  age.  They  are  not  heredi- 
tary. They  often  follow  traumatism  and  inflammation.  A  number  of  observers 
maintain  that  they  are  due  to  parasites  (the  question  of  the  parasitic  origin  of 
maHgnant  disease  is  discussed  on  page  348).    A  sarcoma  may  be  primary  or 


37° 


Tumors  or  Morbid  Growths 


may  arise  from  malignant  change  in  an  innocent  connective-tissue  growth 
(chondrosarcoma,  fibrosarcoma,  etc.)-  A  sarcoma  rarely  affects  adjacent 
lymphatic  glands  unless  it  contains  lymphatics,  and  the  great  majority  of 
sarcomata  do  not  contain  them.  Occasionally  sarcoma  cells  are  carried  to 
adjacent  glands  by  the  vein  walls  rather  than  by  the  lymph-stream.  Sarcoma 
of  the  tonsil,  sarcoma  of  the  testicle,  melanotic  sarcoma,  and  lymphosarcoma 
do  affect  the  glands.  The  skin  over  the  tumor  may  give  way,  a  bleeding 
fungous  mass  protruding  (fungus  haematodes)  (Figs.  i6i,  162,  and  163),  and 
suppuration  may  cause  septic  enlargement  of  adjacent  glands.  In  the  course 
of  growth  of  a  sarcoma  there  may  be  irregular  episodes  of  elevated  temperature 
(see  page  351).  After  removal  of  a  sarcoma  the  growth  tends  to  recur,  and  the 
recurrent  tumor  may  be  either  more  or  less  malignant  than  its  predecessor,  the 
degree  of  malignancy  being  in  direct  ratio  to  the  number  and  smallness  of  the 
cells.    A  sarcoma  is  malignant  by  local  tissue  infection  and  by  dissemination. 

—      Sarcomata  rarely  cause  pain  when  they 

are  not  ulcerated.  They  are  common- 
I  .J^^^^^^^^^  est  in  the  skin  and  connective  tissue 

of  the  extremities,  but  they  arise  also 


Fig.  162. — Small  round-celled  sarcoma  of 
neck.  Skin  has  given  way  and  a  bleeding  mass 
is  exposed. 


Fig.  163. — Sarcoma  of  neck  (Horwitz). 


from  bone,  neuroglia,  periosteum,  the  lymphatic  glands,  the  breast,  the  testicle, 
the  eyeball,  the  parotid,  and  other  parts.  A  pigmented  mole  may  become 
sarcomatous.  Hemorrhages  into  a  sarcoma  often  occur,  with  the  result  of 
suddenly  increasing  the  size  of  the  mass  and  formation  of  blood-cysts.  Sarco- 
mata are  subject  to  partial  fatty  degeneration,  to  myomatous  changes  which 
produce  cavities  filled  with  fluid,  to  calcification,  and  occasionally  to  necrosis 
of  large  masses. 

Varieties  of  Sarcomata. — The  following  species  of  sarcomata  are  recog- 
nized: 

I.  Round-celled  sarcoma  is  a  tumor  composed  of  round  or  spherical  cells 
and  resembling  a  chronic  inflammatory  area.  The  intercellular  substance 
is  scanty,  the  mass  is  soft  and  vascular,  and  grows  with  great  rapidity.  It 
often  softens,  and  may  become  cystic.  The  cells  may  be  smaH  or  large.  The 
smaller  the  cells,  the  more  malignant  the  growth.  A  growth  composed  of 
small  round  cells  is  the  most  malignant  form  of  sarcoma  (Fig.  166).  Lym- 
phosarcoma is  a  form  of  round-celled  sarcoma  which  arises  from  lymphatic 


Varieties  of  Sarcomata 


371 


glands,  lymphoid  tissues,  the  th>-mus  gland,  the  spleen,  and  some  other  struc- 
tures.   The  structure  of  a  lymphosarcoma  resembles  the  structure  of  a  lymph- 


Fis 


104. — Dr.  AV.  R.  Bishop's  case  of  small-celled  sar- 
coma of  the  antrum. 


Fig.  165. — Osteosarcoma  of  eighteen 
months'  standing  of  right  side  of  superior 
maxilla.  Note  bony  lump  on  left  side  of 
lower  jaw. 

gland  in  the  fact  that  it  has  a  reticulum  which  looks  like  lymph-adenoid 
structure.  Chloroma  is  a  form  of  l>Tnphosarcoma  arising  particularly  from 
the  periosteum  of  the  bones  of  the  cranium  and  face.  The  cells  contain  green- 
ish pigment,  hence  the  name.  What  is 
known  as  glioma  of  the  eyeball  is  not  a  true 
glioma,  but  is  really  a  sarcoma  composed  of 
small  round  cells. 


Fig.  166. — Small  round-celled  sarcoma  of 
the  neck. 


Fis 


167. — Spindle-celled    sarcoma    of    sheath   of    flexor 
tendon  of  finger. 


2.  Spindle-celled  sarcoma  is  a  tumor  composed  of  large  or  small  spindle- 
shaped  cells  l>ang  in  a  matrix,  which  may  be  homogeneous,  but  which  may 


372  Tumors  or  Morbid  Growths 

show  some  attempt  at  fiber  formation.  Angular  cells  and  stellate  cells  are 
often  present.  The  cells  may  be  placed  in  columns,  which  are  at  some  places 
nearly  parallel  and  which  at  others  diverge  or  interlace.  Often  there  is  no 
orderly  arrangement.  Spindle-celled  sarcomata  are  usually  harder  than  round- 
celled  growths,  but  are  sometimes  quite  soft.  Cystic  changes  may  occur.  If 
there  is  a  large  amount  of  intercellular  substance  the  growth  is  known  as  a 
fibrosarcoma.  A  rhabdomyoma  is  really  a  spindle-cell  sarcoma  containing 
striated  muscle-cells.  The  spindle-cell  sarcomata  often  contain  cartilage. 
Spindle-cell  growths  are  by  no  means  as  malignant  as  round-cell  tumors.  Often 
they  do  not  show  any  tendency  to  metastasis.  The  greater  the  amount  of 
intercellular  substance  and  the  fewer  the  cells,  the  less  the  malignancy.  Blood- 
good  points  out  that  in  one  group  of  cases  (the  least  malignant)  the  spindle 
cells  exhibit  a  disposition  to  form  fibroblasts  ifibro spindle- cell  sarcoma).  In 
another  group  (the  most  malignant)  there  are  no  fibroblasts  and  round  cells 
are  distributed  among  the  spindle  cells  {mixed  spindle-cell  and  round-cell  sar- 


Fig.  i68. — Melanotic  sarcoma.     Observe  the  pigmentation  ot  ihe  I'dce. 

coma).     Spindle-cell  growths  constitute  the  majority  of  sarcomata  met  with 
in  practice. 

3.  Giant-cell,  myeloid,  or  medullary  sarcoma  is  characterized  by  the  pres- 
ence of  numerous  very  large  cells  with  many  nuclei,  looking  exactly  like  the 
myeloplaques  of  bone-marrow.  Such  a  growth  is  maroon  colored  on  section. 
It  arises  usually  from  bone,  especially  from  the  interior  of  a  long  bone,  hence 
is  often  called  osteosarcoma.  It  is  almost  invariably  single,  but  Rehn  reported 
a  case  of  multiple  giant-cell  sarcoma  of  bone,  and  Crile  and  Hill  reported 
another.  It  may,  however,  arise  from  other  structures  than  bone.  It  is  the 
least  malignant  form  of  sarcoma.  Metastases  do  not  occur  and  the  growth 
often  admits  of  complete  extirpation  and  cure.  Some  surgeons  do  not  class 
these  growths  with  sarcomata.  Bloodgood  regards  their  malignancy  as  very 
slight.  Friedlander  looks  upon  them  as  benign  angeiomata  in  which  giant  cells 
have  been  formed  by  endothelial  cells  budding  into  spaces  lined  with  endo- 
thelium. 

4.  Alveolar  sarcoma  is  a  tumor  containing  both  round  cells  and  spindle 
cells,  and  characterized  b}-  the  formation  of  acini,  filled  with  round  cells  of 


Varieties  of  Sarcomata 


373 


large  size  resembling  epithelioid  cells.  The  walls  of  the  acini  are  formed  of 
spindle  cells  and  fibrous  tissue,  and  in  these  trabeculae  are  the  blood-vessels. 
The  collection  of  the  cdls  in  the  alveoli  makes  the  structure  resemble  that  of 
a  cancer.  Such  growths  are  often  pigmented.  Alveolar  sarcomata  arise  par- 
ticularly from  moles  of  the  skin,  but  may  arise  from  lymphatic  glands,  serous 
membranes,  the  testicle,  and  other  parts.     Such  growths  are  very  malignant. 

5.  Melanotic  or  Black  Sarcoma  (Fig.  168). — The  color  of  such  a  tumor  is 
due  to  pigment  in  the  cells  or  matrix.  These  growths  are  usually  composed  of 
round  cells,  but  may  consist  of  spindle  cells,  and  they  are  sometimes  alveolar. 
Melanotic  sarcomata  spring  from  parts  which  contain  pigment  (for  instance, 
the  skin  and  the  choroid  coat  of  the  eye),  pigmented  moles,  and  pigmented 
nevi;  they  are  very  malignant;  they  implicate  related  lymphatic  glands,  undergo 
early  metastasis,  and  during  their  existence  the  urine  contains  pigment. 

Malignant  growth  from  a  .- 
congenital  pigmented  mole  used 
to  be  regarded  by  most  observers 
as  melanotic  sarcoma,  but  Blood- 
good  would  place  these  growths 
in  a  group  by  themselves.  He 
says  that  the  weight  of  opinion 
is  on  the  side  of  those  who  main- 
tain that  the  cells  are  of  epi- 
thelial origin  misplaced  early  in 
embryonic  life,  and  that  the 
tumor  is  a  cancer.  Many  sur- 
geons still  regard  such  a  tumor 
as  sarcoma. 

6.  Hemorrhagic  sarcoma  is  a 
sarcoma  containing  blood-cysts 
which  result  from  parenchyma- 
tous hemorrhages. 

7.  Angeiosarcoma  or  heman- 
geiosarcoma  takes  origin  from 
the  outer  coat  of  a  blood-vessel. 
The  growth  is  often  very  vas- 
cular, and  when  the  blood-ves- 
sels are  notably  dilated  the 
tumor  is  called  a  telangiectatic 
sarcoma.    The  ordinary  forms  of 

angeiosarcoma  are  only  moderately  malignant,  but  alveolar  and  melanotic 
forms  occur  which  are  highly  malignant.  Angeiosarcoma  may  arise  in  the 
skin,  in  a  serous  membrane,  in  intermuscular  structure,  in  bone,  or  in  a 
salivary  gland.    It  most  frequently  takes  origin  from  a  nevus. 

8.  Cylindroma,  or  Plexiform  Sarcoma. — In  this  variety  the  sarcoma  cells 
adjacent  to  vessels  have  undergone  hyaline  or  myxomatous  degeneration;  the 
cells  distant  from  vessels  are  unchanged.  Section  shows  the  sarcoma  cells 
apparently  contained  in  spaces  with  hyaline  walls.  These  degenerative  changes 
occur  most  often  in  the  angiosarcomata.  Cylindromata  arise  from  the  brain, 
salivary  glands,  lacrimal  glands,  and  rarely  from  the  subcutaneous  tissue. 
The  growths  are  only  moderately  malignant.^ 

9.  Mixed  tumors  consist  partly  of  mature  and  partly  of  embryonic  tissue, 
the  cellular  elements  exceeding  the  adult  elements  in  amount.  Among  these 
mixed  tumors  are  fibrosarcoma  or  the  recurrent  fibroid  tumor,  myxosarcoma 
(Fig.  169),  chondrosarcoma,  gliosarcoma,  and  osteosarcoma. 

^  Stengel,  "Text-Book  of  Pathology." 


Fig.  169.- 


Hansen's  case  of  cystic  myxosarcoma  of  the 
orbit. 


374 


Tumors  or  Morbid  Growths 


lo.  Endotheliomata  are  tumors  springing  from  endothelium,  and  the  name 
is  retained  no  matter  what  changes  the  growths  ultimately  undergo.  Many 
writers  include  under  the  term  "endothelioma"  psammoma,  myxosarcoma, 
angiosarcoma,  and  plexiform  sarcoma.  Others  consider  endothelioma  a 
special  and  characteristic  form  of  sarcoma.  Some  would  not  consider  it  with 
the  sarcomata  at  all.  The  growth  may  take  origin  from  the  "endothelium 
of  the  blood-vessels  and  of  the  perivascular  lymph-spaces,  of  the  lymph- 
vessels,  and  of  the  great  serous  cavities  (peritoneum,  pleura,  meninges). ""^ 
The  characteristic  cell  is  the  endothelial  cell,  usually  known  as  the  epithe- 
lioid cell.  The  structure  of  these  tumors  is  very  variable  and  depends  upon 
the  origin;  some  tumors  "recalling  the  original  vascular  network"  ("Ameri- 
can Text-Book  of  Pathology"),  others  being  distinctly  alveolar.  Many 
pathologists  consider  a  psammoma  of 
the  dura  to  be  an  endothelioma  with  a 
fibrous  stroma.  A  psammoma  contains 
calcareous  particles.  In  appearance  an 
endothelioma  strongly  resembles  cancer, 
and    such   a  growth  is  often  spoken  of 


Fig.  170. — Recurrent  sarcoma  of  the  sternum. 


Fig.  171.— Periosteal  sarcoma  of  the  femur. 


as  endothelial  cancer.  Such  growths  can  arise  in  many  different  situations, 
but  are  particularly  common  in  the  peritoneum,  pleural  membrane,  mem- 
branes of  the  brain,  ovary,  and  testicle.  I  have  removed  an  endothelioma  of  the 
tonsil,  one  of  the  mammary  gland,  two  of  the  nasopharynx,  one  of  the  supe- 
rior maxillary  bone,  and  two  of  the  carotid  gland.  The  proliferating  endo- 
thelial cells  lie  in  lymph-spaces.  Many  endotheliomata  grow  rapidly,  second- 
ary growths  form,  and  metastases  are  apt  to  pass  to  the  serous  membranes. 
Certain  endotheliomata  grow  slowly,  do  not  infiltrate  adjacent  structure,  and 
do  not  produce  secondary  growths.  In  the  brain  and  cord  endothelioma  may 
produce  no  symptoms  for  a  long  time.  It  is  not  as  yet  possible,  clinically,  to 
distinctly  recognize  endotheliomata  from  ordinary  sarcomata. 

II.  Mycosis  or  granuloma  fungoides  is  a  disease  which  resembles  sarcoma 
in  many  particulars  and  may  perhaps  be  a  form  of  sarcoma.  It  attacks  the 
skin  and  subcutaneous  tissues.  It  is  preceded  for  months  or  years  by  an 
eczematous  or  urticarial  condition.  The  skin  becomes  red  and  swollen;  nu- 
merous pinkish  or  reddish  nodules  or  flat  areas  of  induration  form;  the  nodules 
become  distinct  tumors,  soften  at  their  centers,  usually  ulcerate,  and  fungation 
1  "An  American  Text-book  of  Pathology,"  edited  by  Hektoen  and  Riesman. 


Treatment  of  Sarcomata 


375 


occurs.  When  ulceration  occurs  the  mushroom-like  growths  form.  Micro- 
scopically, the  tumor  resembles  a  lymphadenoma.  Mycosis  fungoides  is  con- 
sidered by  some  pathologists  to  be  multiple  cutaneous  sarcoma.  It  is  very 
chronic  and  lasts  for  months  or  even  years.  It  was  first  described  and  was 
named  by  Alibert. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if  it  is  in  an  accessible 
spot.  Never  delay  removal,  and  alwa}-s  cut  well  clear  of  it.  If  affecting  a  part 
where  amputation  is  impossible,  the  rapidly  growing  sarcomata  will  almost  in- 
evitably return,  and  the  \-ery  malignant  variety,  if  uninterfered  with,  may  ter- 


Fig.  172. — Central  sarcoma  of  humerus. 


minate  life  in  six  months;  but  even  in  such  case  operation  postpones  the  e\'il 
day  and  renders  it  possible  that  death  will  occur  from  metastatic  growth  in  an 
organ,  and  that  the  patient  will  escape  the  horrors  of  ulceration  and  hemor- 
rhage from  the  original  tumor.  Slowly  growing  and  hard  tumors  offer  better 
prospects  of  cure.  The  mixed  tumor  (as  a  recurrent  fibroid)  may  repeatedly 
recur,  and  yet  the  patient  may  be  cured  at  last  by  a  sLxth,  an  eighth,  or  a 
tenth  operation.  In  a  case  of  spindle-cell  sarcoma  of  the  breast  the  younger 
Gross  performed  22  operations  in  the  course  of  four  years,  and  eleven  years 
later  the  woman  was  well.  In  a  case  of  recurrent  fibroid  of  the  neck  the 
yoimger  Gross  operated  five  times.    Three  years  after  Prof.  Gross's  death  I 


376 


Tumors  or  Morbid  Growths 


operated  upon  the  same  patient,  and  again  two  years  later.  Nine  years  after 
the  last  operation  she  was  alive  and  well.  In  sarcoma  of  a  long  bone  (though 
not  in  giant-cell  sarcoma)  amputation  should,  as  a  rule,  be  performed.  Blood- 
good  proves  that  in  some  of  these  cases  extensive  excision  is  just  as  useful. 
In  giant-cell  sarcoma  incision  and  curetting  may  be  employed,  or,  if  this  is 
insufj&cient,  subperiosteal  excision.  Bloodgood  has  reported  the  cases  of  giant- 
cell  sarcoma  from  Halsted's  clinic.  The  reports  show  that  excellent  results 
follow  this  plan  of  treatment.  If  the  soft  parts  are  involved,  they  must  be 
removed  wide  of  the  growth.  Amputation  is  necessary  only  when  the  removal 
of  soft  parts  must  be  so  extensive  as  to  hopelessly  mutilate  the  limb.  In  sar- 
coma of  either  jaw-bone,  excision;  of  the  eye,  enucleation;  of  the  testicle,  cas- 


Fig.  173. — Central  sarcoma  of  the  fibula. 


tration  is  demanded.  Sarcoma  of  the  ovary  in  adults  demands  removal,  but 
in  children  the  operation  is  generally  useless.  Sarcoma  of  the  kidney  in  adults 
calls  for  nephrectomy,  but  in  children  the  operation  is  usually  of  little  avail. 
In  my  experience,  in  the  cases  of  sarcoma  of  the  kidney  which  survived  opera- 
tion the  growth  always  appeared  in  the  other  kidney.  In  melanotic  sarcoma 
extirpate  the  growth  widely  and  remove  anatomically  related  lymph-nodes,  or 
in  some  cases  amputate  far  away  from  the  tumor  and  remove  lymph-nodes. 
In  very  malignant  sarcoma  even  amputation  does  not  often  cure.  Removal 
of  a  sarcoma  when  there  is  no  hope  of  a  cure  is  often  justifiable  to  prolong  life, 
to  relieve  the  patient  of  a  foul,  offensive,  bleeding  mass,  and  to  permit  of  an 
easier  road  to  death  by  means  of  metastasis  to  an  internal  organ.  In  an  in- 
operable case  the  ligation  of  the  vessel  of  supply  may  do  good.    In  sarcoma  of 


Treatment  of  Sarcomata 


377 


the  tonsil  Dawbarn  advises  the  extirpation  of  the  external  carotid  artery  and  the 
Hgation  of  its  branches.  The  operation  is  performed  first  on  the  side  occupied  by 
the  tumor  and  in  a  week  or  so  on  the  other  side.  I  employed  it  in  7  cases  with 
distinct  but  temporary  benefit.  Occasionally,  though  very  rarely,  suppuration 
cures  a  sarcoma.  Wyeth,  of  New  York,  reported  a  case  of  sarcoma  of  the  ab- 
dominal wall.  It  was  found  possible  to  remove  only  part  of  the  growth;  sup- 
puration followed  and  the  tumor  disappeared,  and  ten  years  later  had  not 
returned.  A  study  of  statistics  seems  to  indicate  that  more  cases  of  sarcoma 
are  cured  after  operation  if  the  wound  suppurates  than  if  it  remains  aseptic, 
and  it  has  been  proposed  to  deliberately  infect  the  wound  with  pus  germs  to 
lessen  the  danger  of  recurrence.  If  the  wound  is  large,  it  should  not  be  infected 
untn  it  is  nearly  healed.  If  it  is  small,  it  may  be  infected  at  the  time  of  opera- 
tion or  soon  after.  After  amputating  for  sarcoma,  Wyeth  waits  untU  the  wound 
is  nearly  healed  and  then  infects  it  by  inserting  a  gauze  drain  saturated  vnth 
cultures  of  pure  Streptococcus  pyogenes  (Wyeth's  "Surgery").  After  remov- 
ing a  sarcoma  from  any  region  the  patient 
should  be  given  courses  of  injections  of 
Coley's  fluid  (see  below). 

It  has  been  observed  that  an  attack 
of  erysipelas  occasionally  greatly  bene- 
fits a  sarcoma,  causing  large  masses  of 
the  growth  to  soften  or  to  slough  and 
exposing  a  granulating  surface.  Busch 
noticed  this  in  1866,  but  the  fact  had 
been  obser\-ed  in  the  seventeenth  cen- 
tury. Interest  was  decidedly  awakened 
by  BiUroth's  case  of  sarcoma  of  the 
phar}Trs:  which  was  cured  by  an  attack 
of  facial  er\-sipelas.  It  was  suggested 
that  in  inoperable  cases  of  sarcoma 
er\-sipelas  might  be  established  artifi- 
cially. Fehleisen  inoculated  tumors  with 
cultures  of  er}'sipelas.  Lassar  in  1S91 
employed  the  toxins  (cultures  rendered 
sterile  by  heat  and  filtration).  In  1S92 
Coley  began  his  obsers-ations.  The  first 
plan  was  as  follows:  a  bouillon  culture 
was  made  of  the  streptococci;  this  cul- 
ture was  filtered  through  porcelain  and 
an  injection  was  given  once  a  day  into 

and  about  the  sarcoma.  The  first  dose  was  10  min.  and  it  was  progres- 
sively increased.  The  effect  was  to  cause  a  febrile  reaction,  and  some- 
times the  injections  were  followed  by  softening  or  suppuration.  Coley's 
present  method  is  as  foUows:  ]Make  cultures  of  er\'sipelas  cocci  in  cacao  broth; 
after  three  weeks  inoculate  them  with  the  Bacillus  prodigiosus.  and  cultivate 
the  mixed  growth  for  ioui  weeks.  The  mixed  cultures  are  maintained  at  a 
temperature  of  136°  F.  until  they  become  sterile.  This  sterile  fluid  contains  the 
toxins.  The  usual  dose  for  an  adult  is  from  i  to  8  min.  Coley  has  given  as  high 
as  24  min.  I  have  never  given  over  iS  min.  i\Iost  cases  vnR  show  reaction 
at  4  to  6  min.  The  fiirst  dose  for  an  infant  is  yV  min.  If  in  an  adult  the  fluid 
is  injected  remote  from  the  tumor  the  initial  dose  should  be  i  min.  If  the 
fluid  is  injected  into  the  tumor  the  initial  dose  is  ^  to  J  min.  (Coley,  in  ''Amer. 
Jour.  Med.  ScL,"  March,  1906).  Some  cases  are  treated  purely  by  dis- 
tant injections  (gluteal  or  pectoral  regions),  others  by  alternately  injecting 
the  tumor  and  some  distant  point.     The  latter  plan  combines  local  action 


Fig.  174. — Inoperable  sarcoma  uf  the  back. 


378 


Tumors  or  Morbid  Growths 


and  systemic  effect.  The  dose  should  be  gradually  increased  until  a  chill 
occurs  in  from  one-half  an  hour  to  two  hours  after  the  injection,  followed  by 
a  temperature  of  ioi°  to  104°  F.  In  some  cases  there  is  so  much  depression  after 
reaction  that  injections  are  given  every  other  day,  but  if  safely  possible  they 
should  be  given  every  day.  The  object  is  to  obtain  a  reaction  with  each 
injection.  The  more  vascular  the  tumor,  the  more  severe  the  reaction  (Coley) . 
If  an  area  softens  during  treatment  Coley  advises  us  to  open  and  drain  the 
softened  area.  If  improvement  is  going  to  occur  it  usually  begins  in  from  one 
to  four  weeks.  If  there  is  no  improvement  within  four  weeks  there  will  not 
probably  be  any.  In  most  cases  as  injection  is  continued  susceptibility 
diminishes,  in  some  few  it  increases.  It  seems  definitely  proved  that  cases 
are  occasionally  cured  by  Coley's  fluid.  Spindle-celled  sarcomata  are  influ- 
enced most  favorably.  Round-celled  sarcomata  are  very  refractory  and  so  are 
cancers.  The  method  is  not  entirely  free  from  danger,  but  the  danger  is  very 
slight  if  treatment  is  begun  with  the  minimum  dose.  The  toxins  seem  of  value 
in  postoperative  cases  to  prevent  recurrence.  For  this  purpose  the  fluid  is  used 
twice  a  week  for  several  months  and  at  greater  intervals  for  a  long  period  of 
time.  During  the  autiimn  of  1910  I  brought  before  my  class  in  the  Jefferson 
Hospital  a  colored  woman  (Fig.  175)  with  an  inoperable  spindle-cell  sarcoma  of 


Fig.  175. — Huge  sarcoma  of  buttock  cured  by  partial  extirpation  and  Coley's  fluid. 

the  thigh  and  groin.  A  portion  of  the  growth  was  removed  and  the  remainder 
completely  disappeared  from  injections  of  Coley's  fluid.  She  remains  well  over 
three  years  after  treatment  was  suspended.  This  patient  had  a  violent  reac- 
tion every  day  for  weeks.     She  was  given  as  much  as  7  min.  at  a  dose. 

How  the  toxins  act  is  uncertain.  They  produce  some  change  in  the 
blood-serimi,  and  the  valuable  effect  is  systemic.  Nearly  always  they  cause 
leukocytosis.  Probably  they  cause  the  formation  of  antibodies,  which  are 
antagonistic  to  the  sarcoma  cells.  The  treatment,  as  Coley  insists,  is  not  a 
substitute  for  operation.  The  fluid  is  used  in  inoperable  cases,  a  trial  of  it  is 
made  in  sarcoma  of  long  bones  before  advising  operation,  it  is  given  after  all 
operations  for  cancer  or  sarcoma  to  combat  recurrence,  and  it  may  be  tried 
in  inoperable  cancer.  Coley  ("Surg.,  Gynec,  and  Obstet.,"  August,  191 1)  has 
had  65  cases  of  inoperable  sarcoma  in  which  the  tumor  disappeared  from 
the  treatment :  7  are  alive  and  well  at  the  end  of  fifteen  to  eighteen  years ; 
7  alive  and  well  at  the  end  of  ten  to  fifteen  years;  17  alive  and  well  at  the  end 
of  five  to  ten  years;  10  alive  and  well  at  the  end  of  three  to  five  years.  The 
others  could  not  be  traced. 

Emmerich  and  SchoU  claim  good  results  in  inoperable  sarcoma  from  the 
injection  of  erysipelas  serum.  A  sheep  is  injected  with  cultures  of  erysipelas, 
the  blood  is  drawn,  the  serum  separated,  filtered  to  remove  cocci,  and  injected 


Papillomata,  or  Warts 


379 


about  the  sarcoma.  Results  are  not  definite.  Among  other  agents  which 
have  been  used  to  inject  inoperable  sarcomata  we  may  mention  alcohol, 
chlorid  of  zinc,  arsenic,  corrosive  sublimate,  thiosinamin,  pepsin,  alkalis,  etc. 
The  injection  of  anilin  products  into  the  sarcoma,  which  once  received  qualified 
commendation  from  some  observers,  has  been  abandoned  by  most  surgeons. 
The  .v-rays  are  sometimes  of  benefit,  but  are  not  so  serviceable  as  in  carcinoma, 
and  possess  a  certain  danger,  for  occasionally  after  using  them  dissemination 
rapidly  occurs.  Abbe  and  others  have  obtained  some  remarkable  results  by 
radium,  but  such  results  are  exceptional  and  not  the  rule. 

Hypernephromata,  or  Adrenal  Tumors. — Some  of  the  tumors  bear 
a  strong  resemblance  to  adenomata  and  carcinomata.  Some  adrenal  tumors 
are  benign,  and  among  such  tumors  we  note  fatty  and  fibrous  growths  and 
growths  resembling  ghoma.  Another  benign  growth  imitates  the  structure  of 
the  cortex  of  the  adrenal.  Malignant  tumors  occur,  and  many  of  them  are 
identical  or  almost  identical 
with  sarcoma.  One  form  is 
composed  of  epithelioid  cells 
and  *  resembles  endothelioma. 
An  adrenal  tumor  may  arise 
from  the  adrenal  body  proper 
or  from  "rests"  in  ectopic  por- 
tions of  adrenal  within  the 
kidney,  ovary,  testicle,  solar 
plexus,  renal  plexus,  liver,  mes- 
entery, or  some  other  part. 
Some  of  these  tumors  attain 
a  large  size.  Metastases  are 
late,  but  tend  to  occur  eventu- 
ally even  in  hypernephromata 
which  seem  benign,  and  may 
occur  even  when  the  primary 
growth  has  given  rise  to  no 
symptoms.  The  metastases 
are  lodged  particularly  in  the 
bones,  the  limgs,  and  the  liver. 
In  a  case  from  which  I  re- 
moved a  goiter  and  death  resulted  from  reactionary  hemorrhage  the  tumor 
(which  I  had  considered  to  be  adenoma)  was  found  to  be  composed  of  adrenal 
tissue.     Unfortunately,  an  autopsy  was  not  permitted. 

Accessory  adrenals  are  common.  They  are  known  as  adrenal  rests. 
"They  are  found  oftenest  in  the  connective  tissue  about  the  main  adrenals, 
but  also  in  the  kidneys,  the  right  lobe  of  the  liver,  along  the  renal  vessels  and 
spermatic  veins,  in  the  inguinal  canals,  and  in  the  broad  ligaments"  ("Amer- 
ican Text-Book  of  Pathology"). 

Innocent  Epithelial  Tumors. — These  growths  imitate  an  epithelial 
tissue  of  the  mature  and  healthy  organism. 

Papillomata,  or  Warts  (Fig.  176). — Papillomata  are  formed  upon  the 
t3^e  of  cutaneous  and  mucous  papillae.  A  papilloma  consists  of  a  fibrous 
stroma,  which  contains  blood-vessels  and  lymphatics  and  is  covered  by  epithe- 
lium of  the  variety  appertaining  to  the  diseased  part.  Papillomata  grow  from 
the  skin  and  from  mucous  membranes;  they  may  be  single  or  multiple;  many 
may  form  in  one  region  or  various  distant  parts  may  be  affected;  they  may  be 
painless  or  may  be  ulcerated  or  bleeding;  they  vary  in  color  from  light  pink 
to  deep  brown  or  black.  Papillomata  of  the  skin  are  usually  hard;  papillo- 
mata of  mucous  membranes  are  soft.     A  skin- wart  may  be  smooth  and  rounded, 


Fig.  176. — Keen's  case  of  papilloma  with  angioma. 


380  Tumors  or  Morbid  Growths 

or  may  look  like  a  small  cauliflower,  the  epidermis  upon  it  being  very  rough. 
A  papilloma  of  a  mucous  membrane  looks  like  a  small  cauliflower.  Papilloma- 
tous masses  may  gather  around  the  anus,  the  vagina,  or  the  penis  during  the 
existence  of  a  filthy  discharge  {venereal  warts,  Fig.  177),  and  crops  of  warts 
may  appear  on  the  hands  of  those  who  work  in  irritant  material  (as  petroleum) . 
Papillomata  are  apt  to  arise  in  mucous  membrances  about  carcinomata  or 
chronic  ulcerations.  A  large  crop  of  warts  may  disappear  in  a  single  night; 
hence  the  popular  belief  in  the  efficacy  of  charms.  Warts  are  particularly 
common  on  the  skin  of  the  back  of  the  hands  and  fingers,  the  skin  of  the  back, 
and  the  skin  of  the  neck  and  scalp.  A  single  skin- wart  may  reach  the  size 
of  a  walnut  and  become  pigmented.  The  squamous  epithelium  covering 
a  skin- wart  may  become  horny  (a  wart-horn).  Other  cutaneous  horns  arise 
from  the  nails,  from  the  scars  of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder,  but  they  may  also  grow 
from  the  stomach  and  intestine.  A  papilloma  of  mucous  membrane  covered 
with  squamous  epitheUum  looks  like  a  wart  of  the  skin.     Papillomata  of  the 


Venereal  warts. 


larynx  are  formed  of  squamous  epithelium.  Villous  papillomata  form  tufts 
like  the  villous  processes  of  the  chorion;  they  may  be  single  or  multiple,  and 
may  be  sessile  or  pedunculated;  they  are  very  vascular,  and  are  apt  to  bleed 
freely.  Papillomata  may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the 
mammary  gland,  from  the  choroid  plexuses  of  the  ventricles  of  the  brain, 
and  from  the  spinal  membranes.  Papillomata  may  give  rise  to  hemorrhage 
or  may  impair  the  function  of  a  part.     Any  papilloma  may  become  a  cancer. 

Treatment. — Venereal  warts  are  treated  by  repeatedly  washing  with 
peroxid  of  hydrogen,  drying  with  cotton,  and  dusting  with  a  powder  composed 
of  borated  talcimi  or  of  equal  parts  of  calomel  and  subnitrate  of  bismuth,  or 
of  oxid  of  zinc  and  iodoform.  If  they  do  not  soon  dry  up,  cut  them  off  with 
scissors  and  burn  with  the  Paquelin  cautery.  Ordinary  warts  may  usually 
be  destroyed  in  a  short  time  by  daily  applications  of  lactic  or  chromic  acid. 
Most  warts  are  easily  destroyed  by  solid  CO2.  It  is  held  in  contact  with  the 
wart  for  thirty  or  forty  seconds.  In  a  few  days  the  warts  drop  off  or  can  be 
easily  picked  off.  In  multiple  warts  of  the  face  Kaposi  applies  daily  for  several 
days  a  portion  of  the  following  combination:  sublimed  sulphur,  5  dr.;  glycerin, 


Malignant  Epithelial  Tumors,   Carcinomata,  or  Cancers  381 

I  i  dr. ;  acetic  acid,  2  h  oz.  Keeping  a  wart  constantly  moist  with  castor  oil  will 
usually  cause  it  to  drop  off.  Warts,  and  even  extensive  callosities,  may  be  re- 
mo\-ed  by  painting  once  a  day  for  five  days  with  pure  carbolic  acid  and  covering 
with  lint  kept  wet  with  boric  acid.  A  convenient  plan  is  to  paint  a  wart  daily 
with  a  solution  containing  i  part  of  corrosive  sublimate  to  30  parts  of  collodion 
(hydrarg.  chlor.  corros.,  h  dr. ;  collodion,  15  dr.).  Large  warts  should  be  excised. 
\''illous  papillomata  of  the  bladder,  if  not  cured  by  fulguration,  demand  the 
performance  of  a  suprapubic  cystotomy  in  order  to  remove  them.  A  papilloma 
of  the  larynx  may  be  removed  by  the  cauterv^  or  may  be  destroyed  by  sparking. 

Adenomata  are  tumors  corresponding  in  structure  to  normal  epithelial 
glands.  They  have  a  framework  of  vascular  connective  tissue,  and  they 
may  contain  acini  and  ducts  like  racemose  glands  or  tubes  like  tubular 
glands.  The  acini  or  tubules  contain  epitheliimi  of  either  the  cylindrical  or 
polyhedral  variety.  Adenomata  grow  from  secreting  glands;  either  they 
cannot  produce  the  secretion  of  the  glands  from  which  they  spring,  or  thev 
do  secrete,  but  the  fluid  is  retained  and  not  discharged  by  the  gland-ducts. 
Adenomata  occur  in  the  mammary  gland,  the  parotid,  the  ovary,  the  thyroid 
gland,  the  liver,  the  sweat-glands,  the  sebaceous  glands,  the  kidnev,  the  pv- 
lorus,  and  the  prostate;  and  they  may  spring  as  pedunculate  growths  from 
the  mucous  lining  of  the  intestine  and  uterus.  They  are  encapsuled,  are  usually 
single,  but  may  be  multiple,  are  of  slow  growth,  but  may  attain  a  great  size; 
the\-  do  not  tend  to  recur  after  thorough  removal,  do  not  involve  lymph- 
glands,  and  do  not  disseminate;  they  are  firm  to  the  touch;  they  tend  to  become 
cystic  (especially  in  the  thyroid  gland),  the  fluid  which  distends  the  ducts  being 
formed  by  mucoid  liquefaction  of  the  proliferating  epithelium.  If  cysts  form, 
the  growth  is  spoken  of  as  a  cystic  adenoma.  If  the  framework  of  an  adenoma 
contains  considerable  fibrous  tissue,  the  tumor  is  named  a  jihro-adenoma. 
Adenomata  are  particularly  liable  to  become  carcinomatous. 
,  In  the  breast  a  fibro-adenoma  has  a  distinct  capsifle;  it  is  elastic  and 
movable,  is  usuaUy  superficial,  and  one  occasionaUy  exists  in  each  gland. 
They  are  most  common  before  the  age  of  thirty,  and  are  often  painful,  espe- 
cially during  menstruation.  Cystic  adenomata  of  the  breast  attain  a  large 
size;  they  are  encapsuled  and  grow  slowly,  are  most  common  after  the  thirtieth 
year,  and  are  rarely  painful.  Both  fibro-adenoma  and  cystic  adenoma  may 
arise  in  the  male  breast.  Young  lumiarried  women  not  unusuaUy  develop 
in  the  breast  smaU,  very  tender,  and  painful  bodies,  most  usuaUy  around 
the  edge  of  the  areola,  which  bodies  increase  in  size  and  become  more  tender 
during  menstruation;  they  are  only  cysts  of  the  mammary  tissue. 

Adenomata  of  the  thyroid  gland  usually  begin  before  the  fifteenth  year. 
They  may  arise  in  the  prostate  if  that  gland  be  already  the  seat  of  senile 
hypertrophy.  Adenomata  of  mucous  glands  may  arise  in  the  young  or  middle 
aged.  Adenomata  of  mucous  membranes  often  cause  hemorrhage  and  interfere 
with  fimction. 

Treatment. — /Vdenomata  should  be  extirpated.  To  let  them  alone  ex- 
poses the  patient  to  the  danger  of  cancerous  change.  By  confusing  adeno- 
mata of  the  mammary  gland  with  small  areas  of  chronic  mastitis  an  erroneous 
belief  has  arisen  that  the  former  as  well  as  the  latter  may  sometimes  be 
cured  by  the  local  use  of  iodin,  mercury,  ichthyol,  and  the  internal  use  of  iodid 
of  potassium.     The  treatment  in  the  breast,  as  elsewhere,  is  excision. 

Malignant  Epithelial  Tumors,  Carcinomata,  or  Cancers. — Can- 
cers are  tumors  taking  origin  from  epithelial  structures  and  composed  of 
embr\'onic  epithelial  ceUs  which  are  clustered  in  spaces,  nests,  or  alveoH  of 
fibrous  tissue,  and  which  proliferate  enormously,  extending  beyond  normal 
anatomical  boundaries  and  as  an  invading  host  entering  into  connective  tissue 
by  way  of  the  lymph-spaces.     Certain  cells  "pass  out  of  somatic  coordination" 


382 


Tumors  or  ^Morbid   Growths 


with  the  other  body  cells  and  become  as  parasites  (Walker,  in  "Lancet,"  May  13, 
191 1).  Such  cells  constitute  cancer.  The  unrestrained  and  unlimited  repro- 
duction of  epithelial  cells  and  the  assumption  by  them  of  parasitic  properties 
are  the  characteristics  of  cancer.  The  healthy  epithelium  has  a  strictly  limited 
power  of  reproduction,  as  is  illustrated  by  a  skin-graft.  Cancerous  epitheUum 
has  an  unlimited  power  of  reproduction.  The  alveoli  of  cancer  are  distended 
Ijonph-spaces  filled  with  proliferating  cells.  The  cells  of  a  cluster  are  not  sepa- 
rated by  any  stroma,  and  the  walls  of  the  alveoli  carry  blood-vessels  and  lym- 
phatics. The  growth  may  have  been  cancerous  from  the  start,  or  may  have 
begun  as  an  innocent  epithelial  tumor  which  became  cancerous.  Cancers  are 
always  derived  from  epithelium  (of  glands,  of  skin,  of  mucous  membrane,  etc.), 
and  if  found  in  a  non-epithelial  tissue  must  be  secondary,  or  must  have  arisen 
from  a  depot  of  embryonal  epithelial  cells  of  prenatal  origin  or  from  a  dermoid 
cyst  lying  in  the  midst  of  a  non-epithelial  tissue,  or  epithelial  cells  must  have 
been  displaced  by  inflammation  or  injury  so  as  to  be  among  mesoblastic  elements. 
For  instance,  the  bone  does  not  normally  contain  epithelial  cells.  If  osteomye- 
litis arises  operation  is  performed,  and  a  lot 
of  skin  may  be  buried  in  the  bone  ca\dty 
or  an  epithelial  graft  may  adhere.  Such 
an  epithelial  area  may  become  cancerous. 
Carcinomata  have  no  capsules,  rapidly  in- 
filtrate surrounding  tissues,  and  are  firmly 
anchored  and  immovable.  In  the  begin- 
ning a  cancer  is  a  local  lesion,  but  it  soon 
attacks  adjacent  tissue  and  related  honph- 
glands,  and  by  means  of  the  lymph-cells 
are  carried  to  other  structures,  producing 
secondary  tumors  and  diseases  and  en- 
largement of  more  distant  lymph-glands. 
Finally,  lymph  containing  cancer-cells 
reaches  the  blood  by  the  lymph-vessels 
and  passes  to  distant  parts,  and  second- 
ary tumors  or  metastatic  deposits  form. 
Wlien  lymphatic  vessels  are  obstructed, 
lymph  filled  with  cancer-cells  may  flow  in 
a  direction  the  reverse  of  that  pursued 
in  health.  Widespread  or  general  dis- 
semination may  be  due  to  carcinomatous 
thrombosis  of  a  vein,  or  perforation  of  the  wall  of  a  vein,  multiple  emboli 
forming.  Strange  to  say,  emboli  composed  of  cancer-cells  may  be  surrounded 
with  blood-corpuscles  and  move  against  the  blood-current.  A  secondary 
growth  (Fig.  178)  consists  of  cells  identical  in  character  with  and  similar  in 
arrangement  to  those  of  the  parent  growth.  It  may  be  clinically  more  or  less 
maKgnant  than  the  parent  growth.  The  cells  of  the  secondar}^  growth  were 
transported  from  the  primary  growth  and  multiply  in  their  new  situation. 
For  instance,  the  cells  of  a  primary  carcinoma  of  the  liver  may  secrete  bile, 
and  the  cells  of  a  metatastic  area  may  do  the  same.  Fiitterer  has  reported  a 
case  of  carcinoma  of  the  thyroid  the  pulmonary  metastases  of  which  secreted 
colloid.  Stewart  reported  a  case  of  cancer  of  the  lungs  and  liver  secondary 
to  cancer  of  the  pancreas.  The  secondary  growths  were  of  a  structure  similar 
to  the  pancreas  and  contained  tn,q3sin.  Metastases  from  a  columnar-celled 
rectal  cancer  are  composed  of  columnar  cells.  Metastases  from  a  squamous- 
celled  epithelioma  are  composed  of  squamous  cells.  In  rare  cases  metastasis 
of  carcinoma  of  the  stomach  has  occurred  in  the  rectum.  Schnitzler  reported 
II  cases   ("Mitth.  a.  d.  Grenzgeb.   der  Med.  u.  Chir.,"  1908,  xix,  No.  2). 


Fig.  178. — Secondary  carcinoma  of  the 
submental  and  submajdllary  lymphatic 
glands  following  carcinoma  of  the  hp  (Senn) . 


Malignant  Epithelial  Tumors,   Carcinomata,  or  Cancers  383 

Such  a  condition  is  probably  due  to  implantation.  Contact  cancer  has  already 
been  referred  to  (see  page  349).  We  often  speak  of  lymph-nodes  enlarging 
when  affected  with  cancer.  The  enlargement  certainly  occurs,  but  is  not  due 
to  growth  of  the  cells  of  the  l\Tnph-node.  It  results  from  multiplication  of  the 
carcinoma  cells  deposited  in  the  gland.  As  Henry  Morris  says  ("The  Brad- 
shaw  Lecture,"  "Lancet,"  Dec.  12,  1903),  the  parenchyma  of  the  involved 
part  does  not  undergo  transition  into  cancer.  After  the  growth  of  epithelium 
has  lasted  for  a  length  of  time  the  patient  becomes  poisoned  by  materials 
absorbed  from  the  seat  of  disease,  and  finally  dies  from  cachexia  and  exhaustion 
or  some  complication.  These  materials  are  probably  enz3rmes.  During  the 
progress  of  cancer  irregular  fever  may  arise  from  time  to  time  (see  page  351). 
Cancer  is  rare  before  the  age  of  forty,  although  occasionally  it  is  met  with  in 
younger  persons.  Cancer  of  the  rectiim  is  sometimes  met  with  as  early  as  the 
twenty-fourth  year.  I  have  operated  on  a  woman  of  twenty-sLx  for  cancer  of 
the  breast,  on  a  man  of  twenty-four  for  cancer  of  the  stomach,  and  on  a  man 
of  twenty  for  epithelioma  arising  m  the  old  scar  of  a  burn  (see  Fig.  82).  Kars- 
ner  ("Proc.  Path.  Soc.  Phila.,"  Feb.,  1910)  reports  10  cases  of  carcinoma  occur- 
ring before  the  age  of  twenty-four:  i  was  seven;  i,  ten;  i,  eleven;  i,  four- 
teen; I,  nineteen,  i,  twenty-one;  i,  twenty-two,  and  3,  twenty- three.  In  De 
la  Camp's  collection  of  9906  cases  of  cancer  only  19  were  under  twenty 
years  of  age.  X-ray  cancer  usually  occurs  in  young  people.  When  xeroderma 
pigmentosimi  exists  in  children  cancer  may  arise  in  areas  of  the  disease.  If 
cancer  appears  in  a  young  person,  growth  is  apt  to  be  extremely  rapid  and  early 
recurrence  is  common.  A  carcinoma  is  often  the  seat  of  pricking  pain;  the 
growth  tends  strongly  to  recur  after  removal ;  is  prone  to  ulcerate,  causing  pain, 
hemorrhage,  and  cachexia ;  makes  rapid  progress,  and  is  often  fatal  in  from  one 
to  two  and  a  half  years.  It  is  more  common  in  women  than  in  men,  and  rarely 
exists  in  association  with  tubercle.  After  a  cancer  has  existed  for  a  time  in 
an  important  structure,  or  after  a  superficial  cancer  has  ulcerated  and  become 
hemorrhagic,  there  are  noted  in  the  individual  evidences  of  illness  and  exhaus- 
tion. We  speak  of  this  condition  as  the  cancerous  cachexia,  and  in  it  the  mus- 
cles are  wasted,  the  body-weight  is  constantly  diminishing,  the  complexion  is 
sallow,  the  face  is  sunken,  pearly  white  conjunctivas  contrast  strongly  with  the 
yellow  skin,  the  pulse  is  weak  and  rapid,  and  night-sweats  occur.  The  above 
condition  is  due  to  the  absorption  of  toxic  products  from  the  diseased  tissues, 
which  products  damage  the  blood-corpuscles,  and  also  to  pain,  loss  of  sleep, 
deprivation  of  exercise,  malassimilation  of  food,  and  perhaps  bleeding.  It  is 
held  that  cancer  cells  contain  an  enzyme  which  disintegrates  the  body  cells; 
hence  the  wasting.  From  the  disintegrating  body  cells  poisons  also  come, 
hence  some  of  the  toxemia.  Perhaps  the  materials  from  disintegrating  body 
cells  favor  the  proliferation  of  cancer  cells.  Mental  depression  is  not  believed 
by  many  surgeons  a  cause  of  recurrence.  As  J.  D.  Bryant  says,  it  is  simply- 
expressive  of  a  condition  of  nutritive  failure  which  may  favor  recurrence.  We 
must  remember,  however,  that  the  great  name  of  Paget  is  associated  wath  the 
belief  that  not  uncommon  antecedents  of  the  disease  are  "deep  anxiety,  de- 
ferred hope,  or  disappointment"  ("Lectures  on  Surgical  Pathology,"  1863). 
Victims  of  rheumatoid  arthritis  are  particularly  liable  to  cancer.  Recurrence 
after  operation  is  due  to  the  growth  of  cells  which  were  not  removed  at  the 
operation.  Cancer  may  kill  by  obstructing  a  canal,  by  destroying  the  functions 
of  a  \dscus  or  organ,  by  hemorrhage,  by  anemia,  by  sepsis,  or  by  exhaustion. 
The  duration  of  life  varies  in  different  forms  of  cancer  and  in  different  situations 
of  the  growth.  After  the  first  symptoms  appear,  cancer  of  the  gall-bladder,  as 
a  rule,  causes  death  in  about  four  months;  cancer  of  the  stomach,  in  less  than  a 
year;  cancer  of  the  face,  in  from  three  to  three  and  one-half  years.  Billroth's- 
case  of  carcinoma  mastitoides  killed  the  patient  in  six  weeks. 


384  Tumors  or  Morbid  Growths 

Serum  Reaction  in  Cancer. — Kelling  in  1906  pointed  out  that  the  blood- 
serum  of  a  cancer  patient  has  a  hemolytic  action  on  the  red  corpuscles  of  the 
lower  animals.  It  has  been  known  for  some  time  that  the  serum  of  persons 
affected  with  certain  diseases  is  able  to  destroy  the  red  blood-corpuscles  of 
normal  individuals;  in  other  words,  such  sera  are  hemolytic  to  the  red  blood- 
corpuscles  of  healthy  human  beings.  The  agents  in  a  serum  which  hemohze 
the  red  corpuscles  in  other  sera  are  called  isohemolysins.  Isohemolysins  are 
contained  in  the  sera  of  syphilis,  tuberculosis,  and  cancer.  Freimd  and 
Kaminer  pointed  out  that  normal  serimi  dissolves  carcinoma  cells,  but  the 
serum  of  a  victim  of  carcinoma  does  not,  and  suggested  that  this  fact  might 
be  employed  diagnostically.  In  about  two-thirds  of  cancer  cases  the  reaction 
is  positive,  but  in  one-third  it  is  negative.  The  test  is  not  conclusive  and  is  un- 
reliable. Cobra  poison  contains  hemolysins  and  has  been  used  as  a  test  for  car- 
cinoma (Weil's  reaction).  The  results  are  positive  in  about  80  per  cent,  of 
cancer  cases.  Weil  pointed  out  that  the  serum  of  a  dog  suffering  from  advanced 
lymphosarcoma  destroys  the  red  corpuscles  of  normal  dogs,  but  is  resisted  by 
the  red  corpuscles  of  animals  that  are  victims  of  the  same  disease.  Attempts 
are  being  made  to  utilize  the  serum  reaction  for  diagnostic  purposes.  Different 
observ^ers  employ  different  technic  and  differ  widely  in  their  conclusions.  Crile 
("Jour.  Am.  Med.  Assoc,"  Dec.  12,  1908)  is  disposed  to  think  highly  of  the 
diagnostic  value  of  the  serum  reaction.  Janeway  ("Annals  of  Surgery,"  May, 
1909)  obtained  positive  results  in  48.5  per  cent,  of  the  35  cancer  cases  examined. 
Janeway's  conclusions  are  wisely  cautious.  He  states  that  a  negative  reaction 
is  not  proof  positive  that  cancer  is  absent.  A  positive  reaction  makes  the 
existence  of  malignant  disease  probable,  especially  if  advanced  tuberculosis 
and  syphilis  are  absent. 

The  fact  that  the  serum  of  a  cancer  patient  contains  agents  destructive  to 
red  corpuscles  explains  the  anemia  and  cachexia  of  cancer.  Janew^ay  points 
out  that  the  serum  of  sufferers  from  benign  tumors  never  exhibits  the  reaction. 

Some  Theories  as  to  Cause  of  Carcinoma. — Heredity  is  discussed  on  page 

347-  ... 

I.  Contusion  and   Irritation. — As   Dennis   says,    clinical   evidence  pomts 

strongly  to  the  view  that  inflammatory^  changes  foUowing  irritation  are  re- 
sponsible for  cancer.  Individuals  with  phimosis  are  particularly  prone  to 
cancer  of  the  penis.  Those  who  smoke  a  short-stemmed  clay  pipe,  which 
grows  hot  when  in  use,  are  most  liable  to  cancer  of  the  lower  Hp.  In  the  old 
days  chimney-sweeps  often  developed  cancer  of  the  scrotum,  which  was  al- 
ways irritated  by  soot  in  the  cutaneous  folds.  Cancer  of  the  gall-bladder  may 
arise  if  gall-stones  exist.  Cancer  of  the  skin  of  the  hands  may  arise  in  x-ray 
workers.  Cancer  of  the  skin  may  be  induced  by  the  influence  of  light  fjames 
Nevins  Hyde,  in  "Amer.  Jour.  Med.  Sciences,"  Jan.,  1906).  Aniluie  workers 
are  rather  liable  to  cancer  of  the  urinary  bladder.  An  ulcer  may  be  the  irri- 
tating focus  which  leads  to  the  development  of  cancer  at  its  edge  (see  Mar- 
jolin's  Ulcer,  page  159).  So  may  a  scar.  As  is  weU  known,  certain  innocent 
tumors  may  become  cancerous.  The  believers  in  the  parasitic  theory  main- 
tain that  irritation  and  inflammation  simply  open  the  gates  to  the  real  cause, 
which  they  assert  is  a  parasite. 

In  certain  regions  of  the  body,  notably  the  tongue  and  lip,  we  regard  pro- 
longed chronic  inflammation  as  very  apt  to  eventuate  in  cancer,  and  ff  an 
iflcerated  area  is  not  soon  cured  by  ordinan,^  means  we  advise  operation.  A 
condition  persisting  in  spite  of  ordinary  treatment,  prone  to  eventuate  in 
cancer,  but  not  as  yet  demonstrably  cancerous,  is  called  the  precancerous  stage 
of  cancer.  It  probably  is  already  cancer,  although  so  early  as  to  lack  the 
positive  signs. 

A  wart  is  the  result  of  inflammation  and  a  wart  may  become  a  cancer. 


Some  Theories  as  to  Cause  of  Carcinoma 


385 


The  edge  of  a  gastric  ulcer  may  become  cancerous.  Cancer  may  arise  from  a 
scar  (see  Fig.  85)  or  the  edge  of  an  old  ulcer  of  the  skin,  the  lip,  the  cheek,  or 
the  tongue. 

Certain  benign  tumors  tend  to  become  cancerous,  especially  if  irritated 
by  injuries,  caustic  applications,  or  inefficient  attempts  to  remove  them  surgi- 
cally. Any  papilloma  and  any  adenoma  may  become  cancerous.  A  benign 
epithelial  tumor  is  always  a  menace  and  is  to  be  regarded  as  a  possible  or 
potential  carcinoma. 

Whereas  chronic  inflammation  or  irritation  of  epithelial  structures  is  not 
infrequently  followed  by  carcinoma,  a  single  traumatism,  as  a  blow,  seldom 
is.  Nevertheless  well-established  cases  are  on  record  of  cancer  due  to  a  single 
trauma  (Coley,  in  "Annals  of  Surgery,"  April  and  May,  191 1).  A  woman  with 
cancer  of  the  breast  is  apt  to  lay  the  blame  upon  a  blow,  but  very  seldom  can 
the  surgeon  regard  the  blow  as  causal.  In  many  cases  cancer  was  present  when 
the  injury  was  received,  and  the  injury  drew  attention  to  the  tumor. 

2.  The  Inclusion   Theory  oj 
Cohnheim. — This  theory  was  set    [ 
forth  on  page  346. 

3.  The  Thiersch  Hypothesis. 
— This  maintains   that  normal, 

healthy  connective  tissue  has  a  | 

restraining     influence     on     the  j 

growth  of  adjacent  epithelium; 
when  connective  tissue  degener- 
ates (as  in  advancing  years  or 
after  prolonged  irritation)  its 
control  over  epithelium  is  weak- 
ened, and  the  epithelium  grows 
more  rapidly  than  it  does  nor- 
mally, and  from  the  moment  it 
invades  the  connective  tissue 
cancer  exists.  This  theory  as- 
sumes that  the  connective  tissue 
is  a  police  force  and  the  epi- 
thelial cells  the  criminal  class. 
When  the  first  is  weakened  or 
corrupted,  the  second  becomes 
active  and  uncontrolled. 

4.  The  Parasitic  Theory. — 
Various  agents  have  been  de- 
scribed as  causes,  viz.,  bacteria, 
protozoa,  and  yeast  fungi. 

This  theory  was  discussed  on  page  348.  We  do  not  regard  it  as  proved, 
and  even  Plimmer,  warm  advocate  as  he  is  of  the  theory  of  contagion,  admits 
that  as  yet  there  is  no  clearly  demonstrated  case  of  contagion  of  cancer 
from  one  man  to  another.  I  can  find  no  authenticated  case  on  record  of  a 
surgeon  having  been  infected  by  cancer  during  an  operation.  Transplanta- 
tion has  been  carried  out  from  one  animal  to  another  of  the  same  species, 
although  attempts  to  do  so  usually  fail.  Tyzzer,  of  Harvard,  succeeded  m 
nearly  46  per  cent,  of  his  inoculation  experiments  with  the  Jensen  tumor  and 
he  has  kept  up  the  tumor  formation  for  ten  generations.  (See  "Fourth  Report 
from  the  Harvard  Medical  School  of  the  Caroline  Brewer  Croft  Fund  Cancer 
Commission.")  It  is  a  serious  question,  however,  if  mouse  cancer  is  really 
cancer  at  all.  Mouse  cancer  is  far  more  strongly  hereditary  than  human 
cancer;  spontaneous  cure  is  by  no  means  uncommon;  metastasis  is  rare; 

25 


Fig.  179.— Epithelioma  of  right  temporal  region. 
Paralysis  of  right  side  of  face.  Papule  noticed  by 
patient  two  years  prior  to  admission. 


^86  Tumors  or  Morbid  Growths 

the  disease  may  occur  as  an  epidemic  in  a  laboratory.  It  has  been  asserted 
that  mouse  cancer  may  revert  to  sarcoma  (Apolant,  in  "Miinch.  med.  Wochen- 
schr.,"  1907,  liv),  and  it  may  revert  to  adenoma  (Ibid.)-  These  tendencies 
separate  mouse  cancer  very  positively  from  human  cancer.  It  is  said  that 
epidemics  of  fish  cancer  may  occur  in  a  hatchery.  Cancer  has  not  been  trans- 
planted from  an  animal  of  one  species  to  an  animal  of  another  species.  If  a 
portion  of  human  cancer  is  implanted  in  the  tissues  of  an  animal,  the  cells  of 
the  growth  retain  their  vitality  for  a  very  few  days  and  then  perish.  If  a  piece 
of  mouse  cancer  is  transplanted  into  a  rat  the  same  thing  happens.  In  any 
case,  even  a  successful  transplantation  of  cells  is  a  very  different  thing  from 
contagion.  The  late  Prof.  Nicholas  Senn  deliberately  implanted  a  piece  of 
cancer  in  the  tissues  of  his  own  forearm  without  result  ("Jour.  Am.  Med. 
Assoc,"  April  28,  1906).  Recently  advocates  of  the  contagion  theory  claim 
that  mouse  cancer  can  be  reproduced  after  transplantation  even  when  the  cells 
in  the  inoculated  matter  have  been  first  killed  by  exposure  to  the  intense  cold 
induced  by  liquid  air  (Salim,  Moore,  and  Walker,  in  "Lancet,"  Jan.  25,  1908). 
If  these  observations  should  be  sustained,  they  would  indicate  that  the  element 

responsible  for  growth  of  a  graft  is 
not  cellular  and  might  be  microbic. 
Alibert  carried  out  similar  experi- 
ments and  claims  to  have  ob- 
tained like  results.  Most  observers 
believe  that  transplantation  cancer 
is  due  to  cell  transplantation. 

5.  The  Biological  Theory. — In  a 
unicellular  organism  the  function  of 
reproduction  is,  of  course,  possessed 
by  the  cell.  In  a  multicellular 
organism  certain  cells  are  set  apart 
for  the  performance  of  the  function 
of  reproduction,  but  all  the  cells 
possess  the  potentiality  for  repro- 
180.— Carcinomatous  horn.  duction,  but  fail  to  exercise  it.    If 

cells  undergo  atavistic  reversion 
they  may  again  assume  the  reproductive  function.  If  they  do,  unrestrained 
growth  will  result,  and  such  unrestrained  growth  is  cancer. 

N.  F.  MacHardy  ("Lancet,"  Oct.  24,  1903)  states  that  if  a  unicellular 
organism  has  not  sufficient  reproductive  energy  it  fuses  with  another  cell  and 
is  thus  stimulated  to  produce  numerous  daughter-cells.  In  multicellular 
organisms  cells  may  also  fuse,  take  on  active  reproductive  power,  and  produce 
hosts  of  new  cells.  When  cells  are  persistently  irritated,  MacHardy  affirms 
that  they  become  worn  out  by  making  repeated  attempts  at  repair,  undergo 
atavistic  reversion,  and  actively  assume  the  power  of  reproduction.  Accord- 
ing to  this  theory  cancer  is  expressive  of  atavistic  reversion  of  epithelial 
cells. 

The  Prevalence  and  the  Alleged  Increase  of  Carcinoma. — Crile  estimates 
that  at  the  present  time  there  are  probably  80,000  cases  of  cancer  in  the 
United  States,  and  states  that  in  hospital  autopsies  cancer  is  found  in  i  case 
out  of  12  ("Med.  Record,"  June  6,  1908).  In  the  United  States  cancer 
causes  5  per  cent,  of  the  annual  deaths.  Kellogg  ("N.  Y.  Med.  Jour.,"  Sept.  2, 
191 1)  claims  that  there  are  300,000  cancerous  people  in  the  United  States, 
that  75,000  die  of  it  each  year,  and  that  in  1909,  of  women  who  died  between 
the  ages  of  forty-five  and  fifty-five,  i  in  6  died  of  cancer.  In  England  in 
1909  there  were  over  34,000  deaths  from  cancer.  In  France  in  1908  there  were 
over  30,000  deaths  from  cancer.     It  has  been  stated  that  of  persons  living 


Sex  387 

above  the  age  of  thirty-five,  that  i  woman  in  8,  and  i  man  in  12,  will  die  of 
cancer  (Copeman,  quoted  by  Brand,  in  "Lancet,"  Jan.  11,  1908).  Is  cancer 
increasing?  Of  course,  the  number  of  cases  increases  with  the  increase  of 
population.  The  apparent  death-rate  from  cancer  increases  year  by  year. 
It  is  pointed  out  by  W.  Roger  Williams  that  in  England  and  Wales'  the 
mortality  from  cancer  has  increased  from  i  to  5646  in  1840  to  i  to  1306 
in  i8g6,  and  the  proportion  to  deaths  from  other  causes  has  risen  from  i  to 
129  in  1840  to  I  to  22  in  1896  ("Lancet,"  Aug.  20,  1898).  Roswell  Park  com- 
ments on  the  increasing  number  of  deaths  from  cancer  in  New  York  State, 
and  says  if  it  continues  for  the  next  ten  years  the  disease  will  kill  more 
persons  annually  than  phthisis,  small-pox,  and  t}q3hoid  combined.  Kellogg 
("N.  Y.  Med.  Jour.,"  Sept.  2,  191 1)  believes  that  the  increase  is  enormous, 
and  claims  that  in  the  United  States  the  disease  has  increased  500  per  cent, 
in  SLxty  years.  Bertillon,  of  the  Statistical  Department  of  Paris,  believes  that 
cancer  is  increasing  in  all  countries.  The  increase  is  greater  among  men  than 
women.  Such  statements  are  truly  alarming,  and  yet  the  reality  of  all  of  this 
apparent  increase  is  doubtful.  A  part  of  the  apparent  increase  is  due  to  the 
greater  frequency  of  exploratory  operations  for  diagnostic  purposes,  to  the 
greater  frequency  of  postmortem  examinations,  to  more  correct  diagnoses  of 
obscure  internal  conditions,  and  to  greater  accuracy  than  was  once  either 
usual  or  expected  in  fillmg  up  death  certificates.  Neushohne  says  that  just  as 
deaths  certified  as  due  to  old  age  grow  apparently  fewer  every  year,  so  other 
non-specific  certifications  grow  fewer,  and  cancer  gains  as  they  lose.  The 
diminution  in  infant  mortality  also  causes  a  relative  rise  in  the  apparent  cancer 
mortality.  Further,  more  people  than  formerly  live  to  reach  the  cancerous 
age,  and  people  in  general  live  longer  than  formerly,  and  in  the  later  years  of 
life  cancer  is  common.  The  above  facts  certainly  account  for  a  portion  of  the 
alleged  increase,  but  we  must  also  remember  that  we  are  curing  many  more 
cases  by  operation  than  we  used  to  be  able  to,  and  hence  that  the  death-rate 
from  cancer  is  not  the  real  and  final  measure  of  the  incidence  of  cancer.  The 
experience  of  most  practical  siu"geons  is  that  there  is  a  real  increase  in  cancer, 
but  the  extent  of  the  increase  cannot  be  ascertained  with  any  accurac}'. 

Hereditary  Influence. — This  was  referred  to  on  page  347.  It  can  be  at 
most  only  tissue  predisposition  or  a  diminution  of  tissue  resistance  to  the  real 
cause  of  cancer,  whatever  that  may  be.  Some  previously  quoted  cases  are  too 
impressive  to  be  regarded  as  coincidences.  Williams  ("Brit.  Med.  Jour.," 
May  9,  1908)  points  out  that  24.2  per  cent,  of  women  wdth  cancer  of  the  breast 
have  or  had  relatives  with  a  history  of  cancer.  Williams  states  that  Butlin's 
estimate  is  37  per  cent.;  Leaf's,  23  per  cent.;  and  Nunn's,  29.3  per  cent. 

Immunity. — This  was  referred  to  on  page  347. 

It  is  known  that  mouse  tmnors  which  follow  transplantation  in  some  cases 
retrogress  and  imdergo  spontaneous  cure,  and  that  animals  in  which  this  has 
occurred  are  found  to  have  become  immune  to  a  re-inoculation  of  a  like  tumor. 
Crile  and  Beebe  present  some  studies  on  this  interesting  subject  in  the  "Journal 
of  Medical  Research,"  June,  1908.  Gaylord  and  Clowes  found  that  the 
serum  of  an  animal  thus  rendered  immune  tends  to  destroy  tumor  cells,  and 
experimented  wdth  the  transfusion  of  the  blood  of  immune  animals  into  ani- 
mals with  active  tumors;  7  animals  out  of  10  were  cured.  The  blood  of  an 
animal  naturally  immune  to  tumor  inoculation  is  said  to  act  similarly  to  that 
of  an  animal  which  has  acquired  immunity,  as  shown  by  retrogression  of  a 
tumor. 

Sex. — Cancer  is  more  common  in  women  than  in  men.  If  we  leave  out 
of  consideration  cancer  of  the  uterus  and  breast,  men  suffer  from  cancer  more 
often  than  women.  Men  are  most  apt  to  get  cancer  of  the  lip,  tongue,  and 
digestive  canal. 


388  Tumors  or  Morbid  Growths 

Distribution  of  Cancer. — It  occurs  in  all  climates  and  probably  all  races, 
although  it  has  been  asserted  that  Eskimos  are  not  liable  to  it.  It  is  much  more 
common  among  civilized  than  barbarous  people.  It  is  rarer  among  the  black 
and  yellow  races  than  the  white  race.  The  American  Indians  seldom  suffer  from 
it.  It  occurs  in  the  lower  animals  far  less  often  than  in  man,  is  more  common 
in  domestic  than  in  wild  animals,  and  in  captive  wild  animals  than  in  those  free 
and  at  large.  It  can  even  occur  in  cold-blooded  animals.  Cancer  is  most 
common  in  the  temperate  zone.  It  is  usually  asserted  that  the  disease  is  rare 
in  the  tropics,  but  Dudley  denies  that  this  statement  is  true  of  the  Philippine 
Islands  ("Jour.  Am.  Med.  Assoc,"  May  23,  1908).  Cancer  is  certainly  less 
common  in  India  than  in  England,  and  it  is  very  rare  in  Greenland.  It  is  al- 
most unknown  among  the  natives  of  Algeria.  It  is  usually  believed  that  cancer 
is  most  prevalent  in  low  and  marshy  districts.  It  is  less  common  at  high  alti- 
tudes and  among  the  dwellers  on  soils  of  chalk  and  lime. 

Cancer  Regions  and  "Cancer  Houses." — Some  regions  show  a  remark- 
able frequency  of  cancer.  In  Bookfield,  New  York,  during  five  years  nearly 
10  per  cent,  of  the  deaths  were  due  to  cancer. 

Tynes  (Ibid.,  March  21,  1908)  reports  that  in  Fisherville,  Pennsylvania,  in 
265  families  there  were  105  deaths,  and  18  of  them  were  due  to  cancer.  It  is 
maintained  by  Haviiand  and  others  that  certain  houses  become  infected  and 
that  cancer  appears  in  such  houses  again  and  again  among  successive  families 
inhabiting  them.  Such  houses  are  called  "cancer  houses,"  and  many  remark- 
able facts  have  been  collected  relating  to  them,  facts  which  to  some  observers 
seem  to  prove  contagion,  but  which  to  others  merely  serve  as  interesting  ex- 
amples of  coincidence. 

Leeson  ("Practitioner,"  Feb.,  1909)  is  of  the  latter  opinion  and  shows  that 
there  was  not  a  cancer  house  in  his  district.  He  studied  248  cases  of  cancer  and 
all  but  4  of  them  were  in  different  houses.  As  this  author  says:  "If  we  are  to 
accept  such  evidence  as  that  on  which  the  belief  in  '  cancer  houses '  is  foimded, 
we  must  believe  in  'apoplexy  houses,'  'liver  houses,'  etc." 

Influence  of  Diet. — Some  blame  meat,  some  tomatoes,  etc.,  for  the  de- 
velopment of  cancer.  Vernueil  and  Reclus,  commenting  on  the  fact  that 
carnivora  are  much  more  prone  to  cancer  than  herbivora,  suggested  that  the 
increase  of  cancer  during  recent  years  might  be  due  to  the  increased  consump- 
tion of  meat  by  the  poorer  clasess.  There  is  no  proof  of  the  truth  of  this 
suggestion.  In  fact.  Prof.  Senn  points  out  that  the  Eskimos  seem  immune  to 
tumor  formation,  yet  they  live  on  an  exclusive  animal  diet  and,  furthermore, 
are  the  healthiest  people  in  the  world. 

Arsenic  Cancer. — Sir  Jonathan  Hutchinson  pointed  out  in  1887  that  the 
administration  of  arsenic  may  lead  to  cancer.  DubreuiUi,  of  Bordeaux,  has 
collected  19  cases  ("Annales  de  Dermatoses,"  Feb.,  1910).  It  will  be  highly 
important  to  find  out  if  salvarsan  can  ever  be  responsible  for  malignant  growth. 

X-ray  Cancer. — ^A  number  of  x-ray  operators  who  worked  with  the  rays 
soon  after  Rontgen's  discovery  developed  cancer.  An  x-ray  operator  in  Phila- 
delphia died  of  carcinoma  of  the  hand.  It  led  to  axillary  and  mediastinal 
growths.  I  operated  on  him  twice  in  vain.  Another  Philadelphia  operator 
submitted  to  amputation  of  the  arm  and  subsequently  died.  The  cells  are 
repeatedly  injured  by  the  rays  and,  finally,  normal  repair  becomes  impossible. 

Recurrence  After  Operative  Removal. — This  is  usually  due  to  the  fact  that 
all  of  the  cells  were  not  removed.  It  may  be  due  to  a  new  growth.  Recur- 
rence may  be  due  to  cutting  across  lymph-tracts  and  flooding  the  wound  with 
carcinoma  cells,  which  lodge  and  grow.  The  growth  of  cancerous  nodules  in 
the  abdominal  scar  resulting  from  an  exploratory  operation  for  cancer  of  the 
stomach  is  observed  every  now  and  then.  It  is  probably  due  to  contact  inva- 
sion of  the  scar  area,  which  area  has  lessened  vital  resistance  to  cancer  cells. 


Spontaneous  Disappearance  of  Cancer  389 

Alurphy  thinks  that  the  same  explanation  holds  when  the  stitch  cica- 
trices become  cancerous  ("General  Surgery,"  in  "Practical  Medicine  Series  for 
1909"). 

Extension  of  Cancer. — It  spreads  by  the  lymphatics  and  rapidly  involves 
the  anatomically  associated  lymph-nodes.  In  the  nodes  the  migrating  cancer 
cells  are  imprisoned  for  a  time,  and  in  this  incarceration  lies  the  hope  of  sur- 
gery. The  adjacent  glands  are  involved  much  more  rapidly  than  we  used  to 
think.  They  are  usually  involved  within  a  few  weeks  of  the  start  of  the  growth, 
except  in  superficial  epithelioma,  in  which  cases  they  are  not  involved  at  all. 

In  a  structure  devoid  of  capsule  (as  the  tongue,  the  mammary  gland,  etc.) 
Lockwood  points  out  that  involvement  of  related  lymph-nodes  is  practically 
immediate. 

Lymphatic  involvement  may  result  in  the  formation  of  a  mass  much  larger 
than  the  parent  growth.  The  ducts  between  the  primary  cancer  and  the  in- 
volved glands  are  filled  with  carcinoma  cells  and  their  walls  become  infiltrated. 
Hence  in  an  operation  the  ducts  should  not  be  cut  across  or  the  wound  would 
be  flooded  \\dth  fluid  rich  in  cancer  cells.  The  ducts  should  be  extirpated  as  well 
as  the  glands.  To  flood  the  wound  with  fluid  containing  embryonic  cells  is 
very  dangerous,  for  some  of  them  may  adhere,  multiply,  and  reproduce  the 
disease.  After  a  time  the  capsules  of  cancerous  nodes  rupture  and  periglandular 
tissue  becomes  involved.  The  ceUs  are  held  in  the  first  glandular  stopping- 
place  (the  anatomically  related  glands)  for  a  time,  but  sooner  or  later  other 
and  more  distant  glands  become  involved.  In  certain  abdominal  cancers 
(stomach,  rectiun,  and  uterus)  the  thoracic  duct  may  become  obstructed 
by  cancer  cells.  Large  glands  may  cause  much  trouble  by  pressure.  When 
they  soften  and  break  down  the  skin  becomes  involved  and  dreadful  sores 
form,  oozing  foul  matter  and  blood.  Death  may  be  due  to  hemorrhage  from 
a  large  vessel  which  has  become  infiltrated. 

Several  times  I  have  been  consulted  by  patients  on  account  of  glandular 
enlargements  of  the  neck,  the  patients  never  having  noticed  a  smaU  primary 
lesion  in  the  mouth,  and  yet  the  entire  glandular  disease  was  secondary  to  the 
limited  oral  trouble. 

Dissemination  or  Metastasis. — These  terms  mean  the  formation  of  second- 
ary growths.  These  growths  are  formed  by  small  fragments  of  cancer  being 
broken  off  and  carried  to  lodgment  in  distant  structures.  Such  smaU  frag- 
ments are  called  cancer  emboli.  Cancer  emboli  may  be  carried  by  lymph  or 
blood.  When  cancer  emboli  lodge  in  a  region  favorable  to  their  growth  their 
constituent  ceHs  multiply  and  produce  secondary  growths.  A  secondary 
growth  is  the  histologic  counterpart  of  the  parent  growth,  and  an  examination 
of  a  secondary  growth  gives  us  accurate  information  as  to  the  nature  of  the 
primary  growth.  In  cancer  of  the  rectiun  there  may  be  secondary  deposits 
in  the  liver  or  in  bone  containing  structure  like  rectal  glands.  In  cancer  of 
the  stomach  secondary  nodules  in  the  skin  may  contain  structure  resembling 
the  gastric  glands.  Secondar}^  deposits  are  by  no  means  as  common  in  cases 
of  squamous-celled  cancer  as  in  glandular  cancer. 

Another  method  of  dissemination  is  observed  in  the  abdomen.  When 
cancer  of  a  viscus  breaks  through  the  peritoneal  coat  the  cells  are  spread  widely 
by  peristaltic  movements  and  peritoneal  fluid,  and  the  peritoneiun  becomes 
extensively  involved.  This  involvement  is  a  form  of  contact  cancer.  Any 
structure  may  be  the  seat  of  a  secondary  growth.  The  lung  is  frequently 
affected,  so  is  the  liver,  so  are  the  bones.  Any  organ  or  tissue  may  become 
the  host  for  secondary  deposits  of  carcinoma. 

Spontaneous  Disappearance  of  Cancer. — This  is  an  excessively  rare  event 
in  human  beings,  but  it  does  occasionally  occur.  Gaylord  has  collected  11 
cases  which  he  considers  authentic,  viz.,  2  epitheliomata  (i  of  the  tongue  and 


390 


Tumors  or  Morbid  Growths 


I  of  the  Hp),  I  scirrhous  cancer  of  the  breast,  i  maUgnant  adenoma  of  the 
rectum,  and  7  cases  of  chorion  carcinoma  ("Seventh  Annual  Report  of  the 
Cancer  Laboratory  of  New  York  State  Department  of  Health").  The  same 
author  also  notes  the  spontaneous  disappearance  of  two  sarcomata.  Spon- 
taneous disappearance  of  Jensen  tumors  successfully  inoculated  in  mice  is 
quite  common.  It  occurred  in  23  per  cent,  of  Gaylord's  animals.  Whereas 
it  is  common  in  mouse  tumors  resulting  from  inoculation,  it  is  rare  in  spon- 
taneous mouse  tumors.  Bushford  finds  spontaneous  healing  in  less  than  i  per 
cent,  of  the  latter  group.  Spontaneous  disappearance  is  not  due  to  the  fatty 
degeneration  and  necrosis  so  often  found  about  the  center  of  a  carcinoma,  but 
to  deprivation  of  the  epithelial  cell  of  some  or  all  of  its  vitality  by  an  utterly 
unknown  process.  Some  observers  think  spontaneous  cure  is  brought  about 
by  the  stimulation  of  an  immunizing  force.     When  spontaneous  cure  occurs 

cancer  cells  are  gradually  replaced 
by  scar  tissue,  and  the  resulting 
scar  may  contain  cancer  cells 
immeshed  in  it.  Hence,  after 
apparent  retrogression,  growth 
may  begin  anew. 

Besides  the  apparently  posi- 
tively authenticated  cases  re- 
ported by  Gaylord,  there  are 
numerous  cases  on  record  in 
which  it  is  highly  probable  can- 
cer disappeared  spontaneously. 
These  cases  are  collected  in  the 
appendix  to  the  previously  cited 
report  of  Gaylord. 

Blood     Changes     in     Cancer 
Cases. — In  early  cases  there  is  no 
notable  change  in  either  erythro- 
cytes or  hemoglobin.     In  more 
advanced  cases  as  cachexia  begins  secondary  anemia  develops,  fall  of  hemo- 
globin antedating  diminution  in  erythrocytes. 

The  anemia  may  become  so  profound  that  it  resembles  pernicious  anemia; 
in  fact,  some  observers  have  asserted  that  pernicious  anemia  may  arise.  The 
anemia  of  cancer  is  not  benefited  by  medical  treatment. 

In  gastric  cancer,  because  of  vomiting  and  diarrhea,  blood  concentration 
may  occur,  the  red  corpuscles  being  6,000,000  or  even  7,000,000  per  cmm. 

The  leukocytes  may  be  normal,  but  are  often  increased.  It  has  been 
claimed  by  Macalister  and  Ross  ("Lancet,"  Jan.  16,  1909)  that  the  blood  of 
a  patient  with  cancer  contains  a  material  in  its  plasma  which  is  an  excitant 
for  the  leukocytes  of  healthy  persons.  As  previously  stated  (see  page  384)  the 
serum  of  the  blood  of  a  person  with  cancer  contains  agents  destructive  to  the 
red  corpuscles  of  healthy  blood. 

Classification  of  Carcinomata. — Carcinomata  are  classified  as  follows: 
(i)  Epithelioma;  (2)  rodent  ulcer,  or  Jacob's  ulcer;  (3)  spheroidal-celled 
cancer;  (a)  schirrous;  (b)  encephaloid;  (c)  colloid,  and  (4)  cylindrical-celled 
cancer.  Clinically,  we  speak  of  cuirass  cancer,  a  condition  sometimes  arising 
when  the  mammary  gland  is  cancerous  and  due  to  the  infiltration  of  the 
cutaneous  lymphatics  with  cancer  cells;  chimney-sweeps'  cancer  and  paraffin 
worker's  cancer,  if  either  of  these  occupations  seems  to  have  been  causative; 
cancer  a  deux,  a  phrase  used  in  France  to  signify  that  carcinoma  has  occurred 
in  two  persons  of  a  household  who  are  not  blood  relations,  but  have  been  in 
close  contact ;  contact  cancer,  when  cancer  appears  in  an  area  which  was  in  close 


Fig.  181. — Carcinoma  of  the  auricle. 


Classitication  of   Carcinomata  391 

contact  with  a  cancerous  area  in  the  same  or  in  another  individual — for  in- 
stance, when  a  cancer  of  the  upper  Up  follows  a  malignant  growth  of  the  lower 
lip;  when  a  carcinoma  of  the  face  follows  a  like  growth  of  the  hand;  when  a 
cancer  appears  on  the  penis  of  a  husband  whose  wife  has  cancer  of  cer\'Lx  uteri 
or  vagina.  A  melanotic  carcifwma  is  a  form  of  encephaloid  in  which  the  cells 
contain  melanin.  Scirrhous  cancer  contains  much  fibrous  tissue  and  is  densely 
hard.  An  encephaloid  is  ver\-  soft  or  brain-like.  MarjoUn's  ulcer  is  an  epi- 
thehoma  which  arises  from  the  epithelial  edge  of  a  chronic  ulcer,  a  scar,  or  a 
sinus  (see  page  159).  Figures  $>2,  S3.  84.  and  S5  show  a  ]\Iarjolin  ulcer  arising 
in  the  scar  of  a  burn. 

Epitheliomata. — ^An  epithehoma  arises  from  surface  epithelium,  and  may 
arise  from  squamous  cells  or  cylmdrical  cells,  accorduig  to  the  location. 

Squamous-celled  epithelioma  (see  Fig.  179)  takes  origin  from  the  skin  or  from 
a  mucous  membrane  covered  -ndth  pavement-epithehum.  It  is  especially  apt 
to  appear  at  the  junction  of  skin  and  mucous  membrane  (as  the  lips)  or  the 
point  of  juxtaposition  of  different  kinds  of  epitheHimi.  Such  a  growth  may 
arise  in  the  anus  or  vagina;  on  the  penis,  scrotima.  Hps,  or  tongue;  in  the  mouth 
or  nose;  on  the  skin,  and  other  situations.  There  is  an  ingrowth  of  surface 
epithehum  into  the  subepithehal  connective  tissue,  colonies  of  cells  growing 
inward  and  forming  epitheUal  nests.  It  may  arise  v,ithout  discoverable  cause, 
it  may  follow  prolonged  irritation,  or  it  may  arise  in  a  wart  or  fissure.  In  the 
nipple  it  is  not  ver\'  miusually,  and  in  the  scrotum  and  nose  it  is  occasionally, 
preceded  by  a  persistent  dermatitis  due  possibly  to  psorosperms,  and  known  as 
Paget's  disease.  Paget's  disease  is  not  true  eczema,  but  is  rather  maUgnant 
dermatitis.  A  crust  gathers  on  the  part,  and  beneath  this  crust  is  a  raw,  red, 
and  moist  surface,  the  edge  of  which  is  slightly  elevated  and  somewhat  indu- 
rated. In  the  beginning  there  is  a  strong  resemblance  to  eczema.  The  nipple 
is  apt  to  retract.  The  parts  are  the  seat  of  a  constant  itching  and  scalding 
sensation.  The  area  may  become  cancerous  in  a  few  weeks,  but  may  not 
for  years.  I  have  seen  two  cases  of  Paget's  disease  of  the  glans  penis.  Squa- 
mous epithelioma  generally  begins  as  a  warty  protuberance  which  soon  ul- 
cerates. A  mahgnant  or  true  cancerous  ulcer  (see  Fig.  179)  has  a  hard,  irregular 
base,  uneven  edges,  a  foul,  fungus-like  bottom,  and  gives  off  a  sanious  or  ichor- 
ous discharge.  This  ulcer  is  the  seat  of  sharp,  pricking  pain,  sometimes  bleeds, 
and  extends  over  a  considerable  area,  embracing  and  destroying  every  struc- 
ture. Epithelioma  usually  affects  hmphatic  glands  early,  but  such  infection 
mav  be  long  delaved.  Epithehomatous  glands  break  down  in  ulceration, 
making  frightful  gaps  and  often  causing  fatal  hemorrhage.  Dissemination  is 
not  nearlv  so  common  as  in  other  forms  of  cancer,  but  it  does  sometimes  occur. 

Cylindrical-celled  Epithelioma. — This  form  of  growth  takes  origin  from 
structures  covered  with  or  containing  cylindrical  epithehimi,  and  it  contains 
cvhndrical  or  colmnnar  cells.  It  is  composed  of  a  stroma  of  fibers  between 
which  He  tubular  glands  lined  ^"ith  coliminar  epitheliimi  and  containing 
masses  of  epithehal  cells.  Such  tiunors  are  foimd  in  the  uterus  and  gastro- 
intestinal tract,  and  may  begin  from  the  surface  epithehum  or  from  the  cells 
of  tubular  glands.  In  these  timiors  there  is  an  acinus-hke  structure  and  the 
spaces  are  filled  with  proliferating  epithelium.  Cyhndrical-celled  cancers  may 
also  arise  from  the  mammar\-  gland,  fiver,  and  kidney.  One  of  the  most  com- 
mon seats  of  cylindrical-celled  cancer  is  the  rectum.  Cancer  of  the  rectum  may 
occur  at  an  earfier  age  than  cancer  elsewhere,  being  not  imcommon  between 
the  ages  of  twenty-eight  and  forty.  Cyfindrical-ceUed  epithehomata  are  at 
first  covered  with  mucous  membrane,  but  they  soon  ulcerate  and  involve  the 
submucous  and  muscular  coats  in  the  growth.  They  may  grow  rather  slowly, 
usually  but  not  always  cause  h-mphatic  involvement,  and  finally  dissemi- 
nate -widely.     They  require  in  some  regions  from  five  to  sLx  years  to  cause 


392 


Tumors  or  Morbid  Growths 


death.  In  the  rectum,  however,  growth  is  much  more  rapid  and  few  victims 
of  cylindrical-celled  carcinoma  of  the  rectum,  if  unoperated  upon,  live  beyond 
two  years,  and  many  of  them  die  long  before  this  period. 

A  rodent  or  Jacob's  ulcer,  epithelioma  exedens  or  cancroid  (Fig.  182),  was 
called  by  the  older  surgeons  noli  me  tangere,  because  they  found  that  surgical 
interference  (incomplete  removal  as  we  now  know)  was  sometimes  followed  by 
very  active  growth.  A  rodent  ulcer  is  scarcely  ever  met  with  except  upon  the 
face,  though  Jonathan  Hutchinson  saw  one  upon  the  forearm,  and  James  Berry 
met  with  one  upon  the  arm.  It  is  especially  common  upon  the  nose  and  fore- 
head. It  begins  after  the  age  of  forty  as  a  Httle  warty  prominence  which  ul- 
cerates in  the  center,  the  ulceration  progressing  at  a  rate  equal  to  the  new 
growth.  The  ulcer  becomes  deep;  it  is  not  crusted;  its  edges  are  irregular,  hard, 
and  everted;  the  floor  is  smooth  and  of  a  grayish  color;  the  discharge  is  thin 
and  acrid;  and  the  parts  about  the  sore  contain  numbers  of  visible  vessels. 
Jacob's  ulcer  grows  slowly,  may  last  for  years,  does  not  involve  the  lymphatics, 

produces  no  constitutional  ca- 
chexia, and  is  rarely  fatal.  In 
some  cases,  although  growth  is 
very  slow,  destruction  eventually 
becomes  very  great  because  of 
ulceration,  there  is  great  loss  of 
tissue  and  horrible  deformity.  A 
rodent  ulcer  is  usually  considered 
to  be  a  malignant  epithelial 
growth  which  springs  from  a 
sweat-gland,  a  sebaceous  gland, 
or  a  hair-follicle,  but  Kanthack 
asserts  that  before  ulceration  the 
rete  and  the  sweat-glands  are 
normal,  but  the  sebaceous  glands 
are  destroyed.  The  base  and  edges 
of  the  ulcer  are  hard,  which  dif- 
ferentiates it  from  lupus;  and, 
further,  the  bacilli  of  tubercle 
may  perhaps  be  cultivated  from 
the  discharge  of  an  area  of  lupus 
(see  page  247).  Rodent  ulcer 
begins  below  the  skin,  ordinary 
epithelioma  begins  in  the  skin, 
and  a  rodent  ulcer  contains  no  cell-nests.  A  rodent  ulcer  very  rarely  under- 
goes cicatrization,  a  fact  which  differentiates  it  from  lupus.  Occasionally, 
but  very  rarely,  a  small  portion  of  the  growth  sloughs  out  and  a  temporary 
scar  forms  at  this  point. 

Adenocarcinoma  or  Glandular  Carcinoma. — Glandular  carcinomata  in 
structure  resemble  racemose  glands.  They  consist  of  a  stroma  of  connective 
tissue  and  alveoli  filled  with  proliferating  epithelial  cells.  If  the  proportion 
between  the  fibrous  stroma  and  the  cellular  elements  is  about  the  same  as  in  a 
normal  gland,  the  growth  is  called  simple.  When  the  cellular  element  is  in 
excess  the  growth  is  soft  (medullary),  and  when  the  fibrous  stroma  is  in  excess 
the  growth  is  hard  (scirrhous). 

I.  Scirrhous  carcinoma  is  a  white  and  fibrous  mass  which  has  no  capsule, 
which  infiltrates  tissues,  and  which,  by  the  contraction  of  its  outlying  fibrous 
processes,  draws  in  toward  it  adjacent  soft  parts,  thus  producing  dimpling, 
or,  as  in  the  breast,  retraction  of  the  nipple.  It  is  composed  of  spheroidal 
cells  in  alveoli  formed  of  connective-tissue  bands.     The  commonest  seat  of 


Fig.  182. — Rodent  ulcer.     Case  in  the  author's  wards 
in  Philadelphia  Hospital. 


Treatment  of  Carcinomata  393 

scirrhus  is  the  female  breast.  It  occurs  also  in  the  skin,  vagina,  rectum, 
prostate,  uterus,  stomach,  and  esophagus.  It  is  most  frequent  in  women 
after  forty.  It  begins  as  a  hard  lump  which  is  at  first  painless,  but  which 
after  a  time  becomes  the  seat  of  an  acute,  localized,  pricking  pain.  This 
lump  grows  and  becomes  irregular  and  adherent,  causing  puckering  of  the 
soft  parts.  After  the  skin  or  mucous  membrane  above  it  has  become  infil- 
trated ulceration  takes  place  and  a  fungous  mass  protrudes  which  bleeds  and 
suppurates.  The  adjacent  lymphatic  glands  usually  become  cancerous  in  from 
six  to  ten  weeks,  and  constitutional  involvement  is  rapid  and  certain. 

2.  Medullary  or  encephaloid  carcinoma  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule,  and  it  may  appear  in  the  kidney,  liver, 
ovary,  testicle,  mammary  gland,  stomach,  bladder,  and  maxillary  antrimi. 
An  encephaloid  cancer  often  contains  cavities  filled  with  blood,  and  this 
variety  is  known  as  a  "hematoid"  or  a  "telangiectatic"  carcinoma.  These 
growths  are  soft  and  semifluctuating,  they  infiltrate  rapidly  and  soon  fungate, 
and  they  terminate  life  in  from  a  year  to  a  year  and  a  half.  If  the  cells  of 
encephaloid  become  filled  with  melanin,  the  condition  is  called  "melanosis" 
or  "melanotic  cancer." 

3.  Colloid  cancer  is  extremely  rare.  It  arises  from  either  a  scirrhus  or  an 
encephaloid,  when  the  cells  or  the  stroma  of  such  a  growth  undergo  colloidal 
degeneration.  On  section  there  will  be  seen  in  the  center  of  the  growth  a 
series  of  cavities  filled  with  a  material  resembling  honey  or  jelly;  the  periphery 
is  frequently  an  ordinary  scirrhus  or  encephaloid  cancer.  Colloid  degenera- 
tion is  most  prone  to  attack  carcinomata  of  the  stomach,  mammary  gland, 
and  intestine.  The  name  colloid  cancer  is  often  given  to  glistening,  gelatinous, 
malignant  growths  springing  from  the  ovary,  testicle,  mammary  gland,  or 
gastro-intestinal  tract.  The  condition  is  due  to  mucous  degeneration  of  the 
connective  tissue  or  of  the  epithelial  tissue  of  a  carcinoma.  Only  a  portion 
of  the  tumor  may  degenerate  or  the  entire  mass  may  become  gelatinous. 

Syncytioma  M  alignum. — By  this  name  is  meant  a  malignant  epithelial 
growth  arising  from  the  site  of  the  placenta  during  pregnancy  or  the  puerperal 
state.  It  resembles  placenta  in  appearance  and  rapidly  causes  metastases 
by  way  of  the  blood-vessels.      It  is  quickly  fatal. 

Treatment. — Cancer  is  so  prevalent,  is  so  dreadful  in  its  nature  and  in- 
exorable in  its  progress,  tends  so  strongly  to  cause  death  in  from  two  to  five 
years,  people  are  so  afraid  of  it,  and  so  many  physicians  are  hopeless  of  curing 
it  that  multitudes  seek  relief  from  the  obsessed  Christian  scientists  or  from  the 
vulgar  criminal  quacks.  It  cannot  be  too  strongly  insisted  that  in  the  begin- 
ning cancer  is  a  local  disease  curable  by  early  and  radical  operation,  that  early 
diagnosis  should  be  made,  and  that  prompt  operation  is  imperative.  Delay  is 
not  only  disastrous,  it  is  usually  fatal.  Certainly  at  least  50  per  cent,  of  the 
cases  of  cancer  I  see  are  beyond  operation  when  they  are  first  brought  to  the 
hospital,  they  having  sacrificed  the  golden  moments  during  which  cure  was 
possible.  Carcinomata  demand  early  and  wide  excision,  with  removal  of 
impHcated  glands.  Anatomically  related  lymph-nodes  must  be  removed  even 
if  they  show  no  evidence  of  involvement.  If  operation  is  early  and  thorough, 
and  if  certain  regions  are  involved,  a  considerable  proportion  of  cases  can  be 
cured.  Carcinomata  of  the  lip,  the  skin,  and  the  mammary  gland  can  often  be 
cured.  The  operation  must  be  radical.  That  the  tumor  is  small  and  recent  is 
no  justification  for  minimizing  the  extent  of  operation.  That  is  the  sort  of  case 
which  may  be  cured  by  radical  removal.  Anything  short  of  radical  removal 
is  bound  to  fail.  Recurrence  almost  certainly  means  that  cancer  cells  have 
been  left  behind.  Unless  a  wide  area  is  removed  cancer  cells  are  sure  to  be  left. 
During  removal  the  parts  should  be  handled  as  little  as  possible  so  as  not  to 
squeeze  malignant  cells  into  the  wound.    Cancer  cells  in  a  wound  soon  become 


394  Tumors  or  Morbid  Growths 

fixed  and  multiply.  Far  the  same  reason  tumor  and  glands  are  removed  in  one 
piece.  The  surgeon  avoid&cutting  across  lymph- vessels  and  planting  cancer  ceUs 
in  the  wound.  After  operation  the  a;-rays  should  be  used  in  hope  of  destroying 
cancer  cells  which  may  have  remained  in  the  tissues.  To  use  the  rays  lessens 
the  danger  of  recurrence.  Czerny  ("Deutsche  Med.  Wochen.,"  Nov.  2,  191 2) 
is  so  impressed  with  the  necessity  of  special  effort  to  prevent  recurrence  that 
he  leaves  the  operation  wound  open  for  two  or  three  months,  uses  radium,  the 
x-TSiys,  or  fulguration  in  the  wound,  and  then,  if  everything  seems  to  be  going 
on  well,  he  closes  the  wound  by  a  plastic  operation.  A  recurrent  growth  may 
be  removed  as  a  palliative  measure  to  lessen  pain  and  to  reheve  the  patient 
from  ulceration  and  hemorrhage,  but  such  an  operation  is  rarely  curative.  If  a 
growth  does  not  recur  within  five  years  after  removal,  a  cure  has  very  probably 
been  attained;  in  fact,  if  there  is  no  recurrence  within  three  years,  the  case  is 
probably  cured.  The  three-year  limit  has  been  usually  accepted  since  Volk- 
mann's  paper  on  the  subject.  A  rodent  ulcer  should  be  excised  or  else  be  cu- 
retted and  cauterized  with  the  hot  iron  or  the  Paquelin  cautery.  In  cancer  of 
the  lower  lip,  remove  the  growth  by  Grant's  operation  {q.  v.),  or,  if  necessary, 
cut  away  the  entire  lip.  In  every  case  remove  the  glands  beneath  the  jaw. 
In  cancer  of  the  tongue,  excise  this  organ  and  also  the  lymph-nodes  from 
beneath  the  jaw  and  in  the  anterior  carotid  triangles.  In  cancer  of  the  breast, 
remove  the  breast,  the  pectoral  fascia  and  the  pectoral  muscles,  and  take  away 
the  fat  and  glands  of  the  axilla.  In  cancer  of  the  rectum,  if  near  the  surface, 
excise  the  rectum  from  below;  if  above  5  inches  from  the  anus,  do  the  sacral 
resection  of  Kraske  and  then  remove  the  growth.  In  cancer  of  the  esophagus, 
perform  gastrostomy;  in  cancer  of  the  pylorus,  perform  pylorectomy  or  gastro- 
enterostomy; in  cancer  of  the  bowel,  do  resection,  side-track  the  diseased  area 
by  an  anastomosis,  or  make  an  artificial  anus;  in  cancer  of  the  penis,  amputate 
the  organ  and  remove  the  glands  of  the  groin. 

Treatment  of  Inoperable  Cancer. — Erysipelas  toxins  are  seldom  of  any 
service  in  carcinoma.  In  very  rare  cases  they  do  good.  It  is  justifiable  to  try 
them.  Claims  have  been  made  that  cancer  can  be  benefited  by  the  injection 
of  material  expressed  from  carcinomatous  tumors.  There  are  suggestions  of 
the  value  of  such  treatment.  The  late  Dr.  Hodenpyl  had  charge  of  a  case  in 
which  a  cancer  of  the  liver  was  undergoing  spontaneous  retrogression.  When 
a  cancerous  individual  was  injected  with  ascitic  fluid  from  this  case  a  local 
reaction  was  observed  in  the  tumor  (swelling,  redness,  diminution  in  size, 
necrosis).  It  was  assumed  that  the  fluid  contained  a  specific  material  which 
might  cure  cancer.  The  results  of  the  study  of  such  fluid  have  been  negative 
(Richard  Weil,  "Jour.  Med.  Research,"  August,  1910).  Serum  from  animals 
suffering  from  cancer  is  without  therapeutic  value.  Pyoktanin,  thiosinamin, 
trypsin,  and  many  other  materials  have  come  upon  the  scene  as  remedies. 
They  were  like  plausible  confidence  men,  but  each  was  soon  exposed.  There  is 
no  drug  and  no  serum  at  present  known  to  be  capable  of  curing  cancer.  Honest 
investigators  have  at  times  been  lead  into  error  by  forgetting  that  at  times  the 
rate  of  growth  of  a  cancer  may  temporarily  lessen  or  that  growth  may  for  a 
time  actually  cease.  (See  Lewis  S.  Pilcher's  address  before  the  Surgical  Society 
of  Brooklyn  in  Feb.,  1909.) 

Fulguration  has  of  late  excited  much  interest.  By  this  term  we  mean  bom- 
barding a  part  from  a  metal  electrode  with  sparks  flashed  from  a  high-tension 
current.  It  was  introduced  as  a  treatment  for  cancer  by  De  Keating-Hart  in 
1907.  The  sparks  have  no  specific  action  on  cancer  cells.  All  the  surface  cells 
of  an  ulcerated  growth  are  converted  into  an  eschar  and  the  connective  tissue 
under  and  around  the  sore  is  stimulated  to  cicatrize.  Sometimes  after  ful- 
guration healing  occurs  over  cancerous  nodules.  Fulguration  cannot  act 
through  the  imbroken  skin.     It  is  not  a  real  cure,  though  it  may  retard  the 


Malignant  Growth  from  Congenital  Pigmented  Mole  395 

progress  of  a  case  or  aid  in  preventing  recurrence  after  extirpation  of  a  growth. 
Application  of  sparks  may  be  followed  by  grave  or  fatal  sepsis.  The  early 
enthusiasm  for  fulguration  in  cancer  has  largely  waned.  No  operable  growth 
should  be  treated  by  it,  as,  at  best,  it  has  only  a  local  effect  and  cannot  act 
upon  the  involved  lymph-nodes.  The  .x-rays  are  of  distinct  value  in  certain 
cases  of  carcinoma.  Surface  growths  may  be  apparently  cured,  although, 
vmfortunately,  they  are  apt  to  return  even  after  total  disappearance.  Deeper 
growths  are  seldom  lessened  in  size  and  practically  never  cured,  but  the  rate 
of  growth  may  be  diminished  and  pain  be  abated  or  abolished.  The  knife  is 
to  be  preferred  to  the  .v-rays,  except  in  very  superficial  skin  cancer  about 
the  eyelid  or  nostril,  and  in  inoperable  cancer.  The  real  curative  power 
of  radium  is  as  yet  undetermined.  The  x-rays  and  radium  have  a  decided 
influence  in  lessening  the  horrible  pain  of  recurrent  or  inoperable  cancer.  In 
lymphatic  recurrence  after  operation  thyroid  extract  may  perhaps  be  of  some 
value.  In  some  cases  of  recurrent  cancer  Hgation  of  the  artery  of  supply  or 
extirpation  of  the  artery,  as  suggested  by  Dawbarn,  notably  retards  growth. 
I  have  been  able  to  confirm  this  statement.  In  cancer  of  the  breast,  oophorec- 
tomy occasionally  produces  great  benefit  (Beatson's  operation).  In  inop- 
erable cases  paUiative  operations  may  be  justifiable  to  relieve  some  urgent  dis- 
comfort or  get  rid  of  a  foul  or  bleeding  mass.  Gastro-enterostomy,  gastrostomy, 
and  colostomy  are  palliative  operations.  In  a  malignant  growth  of  the  naso- 
pharj^nx  tracheotomy  may  be  required,  and  in  a  malignant  growth  of  the  blad- 
der it  may  be  advisable  to  perform  suprapubic  cystostomy.  In  an  inoperable 
case  it  may  be  necessary  to  relie^-e  the  pain  by  opium,  gi^^ng  as  much  as  may 
be  required  to  secure  ease.  Opium  so  used  seems  not  onty  to  relieve  pain, 
but  to  retard  the  growth  of  the  tumor  and  to  favor  the  development  of  fibrous 
tissue  in  the  stroma. 

Chemotherapy  of  Cancer. — Wassermann  has  been  able  to  cause  mouse 
cancer  to  disappear  by  injecting  into  the  veins  of  the  animal  negrosin,  and  also 
by  injecting  eosin  and  selenium.  This  proves  that  a  chemical,  as  well  as 
a  parasite,  may  have  an  affinity  for  certain  cells.  The  chemicals  used  by 
Wassermann  attacked  the  cells  of  mouse  cancer,  and  did  not  attack  or  only 
slightly  influenced  the  other  ceUs  of  the  body.  The  world  is  seeking  for  a 
chemical  agent  to  destroy  cancer. 

Wassermann  desired  to  introduce  selenium  into  the  cancer  cells.  He  found 
eosin  (an  aniline  dye)  to  be  the  helping  hand  to  put  selenium  into  the  cells. 
When  the  pink  solution  of  eosin-selenium  is  thrown  into  the  blood  of  a  mouse 
the  skin  at  once  becomes  pink.  The  pink  color  of  the  skin  disappears  in  a 
few  hoiirs;  the  tumor  remains  deeply  stained.  Numerous  injections  wiU  kill 
the  mouse  or  cause  the  tumor  to  disappear,  and  the  action  is  just  as  positive 
in  spontaneous  as  in  transplanted  timior. 

This  material  is  too  dangerous  to  use  in  man,  but  the  investigation  suggests 
splendid  possibilities  for  the  future  (E.  F.  Bashford,  in  the  "Lancet,"  Jan.  13, 
1912). 

Malignant  Growth  from  Congenital  Pigmented  Mole  (Fig.  183). — 
As  pre\iously  stated,  the  embrs^onic  origin  of  the  pigment-producing  cells  is 
uncertain.  Some  regard  a  malignant  growth  of  a  congenital  pigmented  mole 
as  epithelioma,  others  as  alveolar  pigmented  sarcoma.  Bloodgood  thinks  it  is 
probably  carcinomatous. 

MaHgnant  change  seldom  occurs  before  the  flftieth  year,  the  growth  rarely 
attains  a  large  size,  metastasis  takes  place  very  rapidly  by  the  blood  and 
hTnphatics,  and  the  patient  seldom  lives  more  than  a  year  after  malignant 
change  begins.     (See  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1907.) 

Because  of  the  danger  of  subsequent  maHgnant  change  it  is  wise  to  remove 
large  pigmented  moles.     Every  pigmented  mole  which  is  irritated  or  begins  to 


396 


Tumors  or  Morbid  Growths 


enlarge  must  be  removed,  and  the  associated  lymph-nodes  should  also  be 
removed.  Bloodgood  knows  of  no  definite  cure  on  record  of  a  mahgnant 
tmnor  arising  in  a  pigmented  mole.  Prevention  is  easily  secured  by  extirpa- 
tion before  the  onset  of  malignancy. 

Cystomata. — A  cystoma  is  a  benign  cystic  tumor  in  which  the  cells 
of  the  cyst  wall  constitute  the  new  growth.  The  cyst  contents  are  derived 
from  the  cells  of  the  wall.  The  tumor  is  the  cyst  wall;  the  cells  of  thiswall 
are  derived  from  the  epiblast,  the  h\'poblast,  or  the  mesoblast,  and  are  either 
epithelial  or  endothelial.  The  cells  of  the  cyst  wall  adhere  to  connective 
tissue  which  seems  to  constitute  a  part  of  the  wall.  A  thick  wall  contains 
much  connective  tissue,  a  thin  wall  very  little.  The  nature  of  the  contents 
is  dependent  on  the  character  of  the  cells  which  constitute  the  tumor.  Cysts 
lined  by  endothelium  contain  serous  fluid;  a  cyst  of  the  th\Toid  gland  usually 

,:^^^^^^_     contains  colloid  material;  a  cyst  lined  by 

^^^^^^B     flat  epithelial  cells  contains  matter  re- 
^1^^^  JI^hI^^^^I     suiting  from  fatty  degeneration,  etc. 
^imfM|^^^||^H  Cystomata  may  be  congenital  or  ac- 

^8  quired,  and  an  acquired  cystoma  may 
arise  after  injiu"y  or  follow  inflammation. 
The  cyst  may  increase  in  size  progres- 
sively or  its  growth  may  be  halted.  The 
w^all  may  become  calcareous  or  even  bony. 
When  a  cyst  has  one  cavity,  w'e  caU  it 
monolocular;  when  there  are  several  or 
many  cavities  it  is  called  multilocular. 

Varieties  of  Cystomata.— The  chief 
varieties  are:  Traumatic  epithelial;  ath- 
eromatous; mucous;  mesoblastic. 

Traumatic  Epithelial  Cystomata. — 
These  growths  have  been  caUed  trau- 
matic dermoids.  Such  a  growth  may 
arise  after  an  injiuy  which  carries  and 
deposits  epithelial  ceUs  or  a  bit  of  skin 
deep  into  the  connective  tissue.  For 
instance,  a  punctured  wound  of  the  hand 
may  be  f  oUowed  by  an  epithelial  cystoma 
(Fig.  185).  It  may  arise  after  a  scalp 
wound  or  in  the  scar  of  a  biu'n.  The 
cyst  grows  only  to  a  certain  size  and  then  remains  stationary.  It  is  lined 
by  pavement-epitheliiun  and  it  contains  products  of  the  fatty  degeneration  of 
epithehal  cells. 

Treatment. — Extirpation  of  the  waU  of  the  cystoma. 

Atheromatous  Cystomata. — These  growths,  according  to  Senn,  are  met 
wdth  particularly  in  the  ovaries,  in  the  orbital  region,  and  at  the  base  of  the 
tongue,  but  they  can  arise  almost  anA'^^here.  They  may  remain  smaU  or  may 
attain  a  great  size.  Such  a  cystoma  contains  columnar  epithelial  cells  which 
have  imdergone  fatty  degeneration  and  sometimes  contains  oil.  An  athero- 
matous cystoma  is  deep  seated  and  is  not  connected  with  the  skin,  in  contrast 
to  a  sebaceous  cyst,  which  is  superficial  and  is  a  part  of  the  skin.  An  athero- 
matous cystoma  is  lined  with  epithelium,  but  not  with  skin.  A  dermoid  cyst  is 
lined  with  skin  or  other  definite  structure.  An  atheroma  is  due  to  the  dis- 
placement of  a  mass  of  epithelial  cells,  which  mass  was  the  matrLx  of  the  cys- 
toma. "The  displacement  of  the  matrLx  of  an  atheroma  occurred  at  a  time 
prior  to  the  differentiation  of  the  epiblastic  cells  into  the  organs  representing 
the  appendages   of   the  skin,  while  the  matrix  of  a  dermoid  cyst  points  to 


Fig.  183. — Melanotic  growth,   secondary   to 
pigmented  mole. 


Teratomata 


397 


a  later  displacement  of  the  matrix"  ("Pathology  and  Surgical  Treatment  of 
Tumors,"  by  Nicholas  Senn).  Atheromatous  cystomata  may  be  congenital, 
but  may  not  appear  until  puberty  or  even  much  later. 

Treatment. — Extirpation  of  the  wall  of  the  cystoma. 

Mucous  Cystomata. — A  mucous  cystoma,  like  an  atheromatous  cystoma, 
is  due  to  the  displacement  of  epithelium,  but  in  the  former  condition  it  is  pave- 
ment-epithelium and  in  the  latter  it  is  columnar  epithelium.  The  latter  is  filled 
with  a  mucoid  material  and  the  former  with  a  fatty  debris.  Such  a  mucous 
C3^stoma  must  not  be  confused  with  a  retention  cyst  of  a  mucous  membrane. 
Mucous  cystomata  are  found  particularly  about  the  lips,  mouth,  and  pharynx. 
They  rarely  attain  any  considerable  size.  Cystomata  lined  with  ciliated 
epithelium  may  arise  in  the  testicle,  the  liver,  and  the  brain. 

Treatment. — Incise,  cauterize,  and  drain.  The  wall  is  so  delicate  that 
excision  is  rarely  possible. 

Mesoblastic  Cystomata. — They  are  lined  with  endothelial  cells.  They 
contain  serous  fluid,  often  grow  to  a  large  size,  and  sometimes  disappear 
spontaneously.  ]\Iesoblastic  cystomata  are  probably  distended  lymph-spaces. 
They  are  congenital  and  are  most  common  in  the  neck,  axilla,  and  perineum. 


Fig.  184. — Hj'drocele  of  neck  in  boy  nine  weeks  of  age. 

In  one  case  seen  by  the  author  such  a  cystoma  of  the  neck  appeared  late  in 
life,  but  it  is  probable  that  it  had  existed  in  childhood,  and  after  disappearing 
for  a  long  time  had  reappeared.  The  most  common  form  of  mesoblastic 
cyst  is  known  as  hydrocele  of  the  neck  (Fig.  184). 

Treatment. — Excision  is  ver>^  difiicult.  In  i  case  in  which  I  assisted 
Professor  Keen  it  was  successfully  accomplished.  The  usual  treatment  is 
to  tap  frequently,  after  each  tapping  washing  out  with  carbolic  acid  (2  to  5 
per  cent.)  and  applying  pressure. 

Cystomata  of  bone,  of  the  thyroid  gland,  of  the  mammary  gland,  etc.,  are 
considered  in  the  sections  on  Regional  Surgery. 

Teratomata. — The  teratomata  contain  tissues  or  higher  structures  de- 
rived from  two  or  all  of  the  blastodermic  layers.  The  tumors  we  previously 
considered  are  derived  from  only  one  of  these  layers.  The  elder  Senn,  in  his 
work  on  "Tumors,"  thus  defines  a  teratoma:  "A  teratoma  is  a  tumor  com- 
posed of  various  tissues,  organs,  or  systems  of  organs  which  do  not  normally 
exist  at  the  place  where  the  tumor  grows.  The  highest  t^^e  of  a  teratoma 
is  a  fetus  in  fetu.  In  the  simpler  varieties  the  tumor  is  composed  of  hetero- 
topic tissue,  such  as  bone,  teeth,  skin,  mucous  membrane,  etc.  All  teratoid 
tumors  are  congenital;  that  is,  the  timior  either  exists  at  the  time  of  birth  or 


398  Tumors  or  Morbid  Growths 

the  patient  is  born  with  the  essential  tumor  matrix.  A  teratoma  never  springs 
from  a  matrix  of  postnatal  origin."  Any  human  structure  may  be  found  in 
a  teratoma.  Various  fetal  malformations  belong  to  this  group,  as  do  also 
double  monsters,  in  which  one  of  the  embryos  is  rudimentary.  Teratomata 
are  divided  into  external  and  internal.  To  the  external  teratomata  belong  the 
parasitic  fetus  and  the  suppressed  fetus.  A  parasitic  fetus  is  the  result  of 
fusion  of  two  embryos,  one  having  gone  on  to  complete  development,  and  the 
other  developing  partially,  and  obtaining  nutrition  from  the  fully  developed 
embrv'o  to  which  it  is  attached.  A  suppressed  fetus  is  an  irregular  mass  attached 
to  the  posterior  surface  of  the  sacrum,  to  the  chest,  or  to  the  abdomen.  It 
contains  a  conglomeration  of  tissues  and  fragments  of  organs,  for  instance, 
bone,  cartilage,  lung  tissue,  kidney  tissue,  a  piece  of  intestine,  or  a  portion  of 
liver.  In  a  case  pictured  by  Sir  J.  Bland-Sutton  a  leg  projects  from  the  sacral 
region. 

An  internal  teratoma  may  be  foimd  within  the  cranium,  chest,  abdomen,  or 
pelvis.  The  internal  teratoma  consists  of  a  conglomeration  of  the  tissues  and 
visceral  fragments  of  a  suppressed  fetus,  but,  unlike  the  external  teratoma,  it 
is  surrounded  by  a  cyst  wall.  The  members  of  this  group  most  often  seen  by 
the  surgeon  are  dermoid  cysts. 

Dermoid  Cysts. — These  cysts  were  first  studied  and  described  by  Lebert. 
The  name  "dermoid"  implies  that  the  cyst  contains  skin,  and  it  does  contain 
skin  or  mucous  membrane,  the  chief  mass  of  the  timior  being  derived  from 
proliferation  of  the  cells  of  a  portion  of  displaced  epiblast  or  hj'poblast,  but  it 
also  contains  mesoblastic  derivatives.  There  are  two  varieties  of  true  dermoid: 
sequestration  dermoid  and  the  tubidodermoid.  In  this  section  we  speak  of  the 
first  form.  The  second  form  is  considered  on  page  401.  A  superficial  der- 
moid is  formed  by  the  inclusion  in  mesoblastic  tissues  of  a  portion  of  the 
epidermis  or  mucous  membrane.  Superficial  non-traumatic  dermoids  are 
situated  in  regions  where  the  blastodermic  laA-ers  were  in  contact.  A 
deep  dermoid  is  formed  from  a  collection  of  epithelial  cells  completely  sepa- 
rated from  the  epiblastic  tissue  from  which  they  originated.  WTien  a  cyst 
originates  from  epiblastic  cells  so  immature  that  the  skin  appendages  have 
not  as  yet  been  formed,  it  will  contain  only  atheromatous  material  like  that 
found  in  a  sebaceous  cyst.  When  a  cyst  arises  from  epiblastic  cells  after 
they  have  so  matured  that  the  appendages  of  the  skin  have  been  formed,  it 
will  contain  atheromatous  matter,  sweat,  sebaceous  matter,  and  hair.  The 
first  form  is  known  as  an  atheromatous  cystoma;  the  second,  as  a  dermoid. 
h  deep-seated  dermoid  may  contain  also  such  structures  as  prove  it  must 
have  taken  origin  from  "a  displaced  matrix  representing  different  tissues 
and  organs"  (Senn).  Such  a  dermoid  may  contain  portions  of  organs,  bone, 
cartilage,  and  teeth.  A  dermoid  cyst  may  be  defined  as  a  heterotopic  cyst, 
the  wall  of  which  is  composed  of  connective  tissue  lined  with  epitheliimi 
and  containing  material  formed  by  the  proliferation  of  epithelium  and  often 
hair,  teeth,  or  even  bone.  An  injur}^  may  displace  a  bit  of  epithelium  and 
lodge  it  in  connective  tissue  and  from  this  a  traumatic  dermoid  may  arise 
(Fig.  185).  Traumatic  dermoids  are  not  true  dermoids.  Garre  called  them 
traumatic  epithelial  cysts.  They  are  most  often  encountered  in  the  palmar  sui- 
face  of  the  hand  or  fingers.  The  skin  above  such  a  cyst  is  not  adherent  to  it 
and  often  a  scar  is  visible.  The  cyst  wall  is  composed  from  without  inward 
of  connective  tissue  and  epithelial  cells,  the  stratum  cornemn  being  the  inner 
layer  (Leo  Buerger,  in  "Annals  of  Surgery,"  August,  1907).  The  cyst  contains 
desquamated  epithelium  and  often  cholesterin.  The  causal  injury  is  usually  a 
puncture,  but  may  be  a  laceration,  a  contused  wound,  or  a  bite.  Sometimes  a 
cyst  arises  in  the  track  of  a  healed  sinus.  Pietzner  collected  reports  of  73  cases 
("Ueber  Traumatische  Epithelcysten.  Dissert.  Rostock.,"  1905). 


Branchial  Cysts  and  Fistulas  399 

True  dermoid  cysts  are  most  commonly  found  in  the  ovary  and  in  regions 
where,  during  bodily  development,  the  blastodermic  layers  come  in  contact; 
for  instance,  in  the  neck,  the  eyelids,  the  orbital  angles,  the  lumbosacral  region, 
the  root  of  the  nose,  and  the  floor  of  the  mouth.  Such  cysts  are  also  found  in 
the  ovary,  testicle,  brain,  eye,  mediastinum,  lung,  omentum,  mesenter>%  and 
carotid  sheath. 

A  dermoid  of  the  lumbosacral  region  may  be  mistaken  for  a  spina  bifida. 
Sarcoma  may  form  from  the  connective-tissue  elements  of  the  wall  of  a  der- 
moid cyst.  A  dermoid  cyst  may  become  cancerous,  or  innocent  epithelial 
tumors  may  originate  from  the  cyst  lining.  The  epithelial  cells  may  become 
fatty  and  an  oil-cyst  may  actually  form.  If  the  cyst  epithelium  was  derived 
from  mucous  membrane,  mucus  may  gather  in  the  sac.  A  dermoid  cyst 
may  inflame  or  even  suppurate.  It  is  free  from  pain  unless  it  suppurates, 
inflames,  or  develops  into  a  malignant  tiunor;  it  grows  slowly  and  rarely 
attains  any  considerable  size  imless  it  arises  in  the  ovary.  A  subcutaneous 
dermoid  may  or  may  not  fluctuate.  It  is  not  in  the  skin  as  is  a  sebaceous 
cyst,  but  the  skin  can  be  moved  over  it.  A  sebaceous  cyst  moves  with 
the  skin.     Subcutaneous  dermoids  about  the  orbit  are  adherent  to  the  under- 


Fig.  185. — Traumatic  dermoid  cyst. 

King  periosteum.  The  matrLx  of  a  true  dermoid  is  congenital,  but  the  cyst 
often  does  not  appear  until  puberty  or  later.  Teratoids  and  dermoids  con- 
nected with  the  rectum  require  special  consideration  (see  page  1165). 

Treatment. — Complete  extirpation.  If  any  of  the  epitheliimi  of  the  cyst- 
waU  is  left,  the  cyst  will  re-form.  A  superficial  dermoid  should  be  removed 
in  the  same  manner  as  a  sebaceous  cyst,  and  if  it  is  adherent  to  imderlying 
periosteum  the  portion  of  this  membrane  to  which  it  adheres  should  also  be 
removed.  A  deep  dermoid  ought  to  be  removed  as  a  tiunor  would  be,  if 
operation  is  feasible. 

Branchial  Cysts  and  Fistulae. — When  a  branchial  cleft  fails  to  become 
completely  obliterated,  a  branchial  cyst  may  form.  The  branchial  clefts  are 
the  analogues  of  the  gill-slits  of  a  fish.  There  are  fomr  of  these  clefts  on  each 
side  of  the  neck.  They  are  called  clefts,  but  they  are  really  grooves,  and  each 
groove  on  the  skin  has  its  counterpart  in  the  mucous  membrane  of  the  pharynx. 
Each  pharvTigeal  groove  is  covered  with  h>^oblastic  epithelium;  each  cuta- 
neous groove  is  covered  with  epiblastic  epitheliimi,  and  the  two  grooves  are 
separated  by  mesoblastic  structures.  When  the  sides  of  a  cleft  do  not  imite 
and  an  opening  forms  in  the  mucous  membrane,  a  complete  branchial  fistula 


400  Tumors  or  Morbid  Growths 

{complete  congenital  cervical  fistula)  results.  When  the  sides  of  a  cleft  fail  to 
unite  and,  although  the  mucous  membrane  is  not  perforated,  the  skin  does  not 
cover  the  cleft,  a  branchial  sinus  or  an  incomplete  branchial  fistula  {incomplete 
congenital  lateral  cervical  fistula)  results.  When  the  sides  of  a  cleft  toward  the 
pharynx  fail  to  coalesce,  a  pharyngeal  diverticulum  is  produced.  When  the 
pharyngeal  surface  and  the  cutaneous  surface  both  close,  but  the  deeper  part 
of  a  cleft  remains  open  and  epithelial  cells  are  caught  in  mesoblastic  elements, 
a  branchial  cyst  is  formed.  Sinuses  are  more  common  than  complete  fistulae  or 
cysts. 

The  essential  cellular  element  of  a  branchial  cyst  is  epithelium,  derived  either 
from  the  skin  or  pharynx;  hence  the  branchial  cyst  is  not  a  true  dermoid, 
because  its  histologic  elements  are  derived  from  only  one  of  the  blastodermic 
layers.  Branchial  cysts  are  most  common  in  the  triangle  of  election  of  the 
left  side.  They  are  round,  smooth,  often  fluctuating,  and  are  very  deeply 
situated,  being  in  close  relation  with  the  great  vessels.  Some  cysts  contain 
mucus,  others  serous  fluid,  others  fatty  debris.  An  abscess  may  form.  The 
origin  of  a  cyst  or  fistula  is  usually  from  the  second  branchial  cleft,  but  I 
have  operated  on  two  cysts  of  the  first  branchial  cleft,  and  my  colleague.  Dr. 
Nassau,  also  operated  on  one  of  like  origin.  There  may  be  one,  two,  or  three 
openings  of  a  fistula.  Not  unusually  the  openings  are  bilateral.  Hereditary 
tendency  is  often  manifest.  The  cutaneous  openings  are  always  along  the 
anterior  margin  of  the  sternocleidomastoid  muscle.  At  the  external  orifice 
there  is  often  an  irregularly  shaped  bit  of  skin  and  cartilage,  which  is  called 
a  cervical  auricle. 

Treatment. — In  old  children  and  in  adults  it  may  be  possible  to  extirpate 
a  cyst  or  a  fistula,  although  this  is  very  difficult  and  often  impossible.  Other 
methods  employed  are  incision,  cauterization  with  the  Paquelin  cautery,  and 
packing  with  gauze;  frequent  tapping  and  injection  with  iodin;  incision  and 
drainage,  every  antiseptic  care  being  observed.  In  all  young  children  and  in 
some  older  persons  with  deep  cysts  the  latter  plan  is  the  only  one  advised,  and 
it  will  often  fail,  but  may  sometimes  produce  a  cure. 

Cysts. — A  cyst  is  a  cavity,  abnormal  or  pathological  in  character,  lined 
by  a  membrane  and  containing  material  usually  fluid  or  semifluid.  It  is 
necessary  to  bear  in  mind  the  distinction  between  a  cystoma  and  a  cyst.  Hek- 
toen  and  Riesman,  in  the  "American  Text-Book  of  Pathology,"  insist  on  this 
distinction.  They  say:  "A  cystoma  is  a  true  tumor,  arising  from  active  pro- 
liferation of  a  matrix  destined  to  form  cystic  spaces ;  whereas  a  cyst  is  a  second- 
ary formation  not  primarily  due  to  tissue  proliferation."  Cysts  are  divided 
into  the  following  classes:  Retention-cysts;  cysts  from  softening;  tubulo- 
cysts;  and  parasitic  cysts  (Ibid.). 

Retention=cysts. — A  retention-cyst  is  formed  by  blocking  of  the  duct  of 
a  gland  or  by  failure  in  the  absorption  of  the  proper  amount  of  the  secretion  of 
a  ductless  gland.    A  few  characteristic  forms  of  retention-cysts  will  be  described. 

Sebaceous  Cysts  (Wens). — A  sebaceous  cyst  arises  when  the  excretory 
duct  of  a  sebaceous  gland  is  blocked  by  dirt  or  occluded  by  inflammation. 
The  orifice  of  the  duct  is  often  visible  as  a  black  speck  over  the  center  of  the 
cyst.  They  are  very  common  in  the  scalp,  being  known  as  wens,  and  upon  the 
face,  neck,  shoulders,  and  back.  Arising  in  the  skin,  and  not  under  it,  the 
skin  cannot  be  freely  moved  over  a  sebaceous  cyst.  A  sebaceous  cyst  is  lined 
by  epithelium  and  is  filled  by  foul-smelling  sebaceous  material.  A  sebaceous 
cyst  may  suppurate.  When  a  cyst  ruptures  and  the  contents  become  hard, 
a  horn  is  formed.  Another  form  of  horn  has  been  previously  alluded  to  as 
due  to  horny  transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  incise  the  portion  of  skin  above  it 
and  dissect  the  sac  entirely  away  by  scissors  or  a  dissector,  trying  to  not 


Tubulocysts 


401 


rupture  the  delicate  wall.  If  even  a  small  particle  of  the  wall  is  left,  the 
cyst  will  re-form.  If  it  ruptures  during  removal  and  it  is  feared  that  some 
portion  may  remain,  cauterize  the  interior  of  the  wound  by  pure  carbolic 
acid.  If  acid  is  not  used,  close  without  drainage;  but  if  acid  is  used,  drain  for 
twenty-four  hours.  If  an  abscess  forms  in  a  sebaceous  cyst,  open  it,  grasp 
the  edges  of  the  cyst  lining  with  forceps,  dissect  out  this  lining  by  scissors 
curved  on  the  flat,  cauterize  by  pure  carbolic  acid,  and  drain  for  twenty-four 
hours. 

Mucous  Cysts. — ^A  mucous  cyst  is  due  to  the  blocking  of  a  mucous  gland 
or  a  mucous  crj-pt.  Mucous  cysts  occur  particularly  in  the  mucous  membrane 
of  the  mouth  and  genito-urinary  organs,  and  are  filled  by  thick,  adhesive 
mucus  containing  numerous  epithelial 
cells.  Such  a  cyst  is  of  spherical  out- 
line, and  the  epithelial  membrane 
which  Unes  it  is  strongly  adherent  to 
tissues  beyond. 

Treatment. — Incision,  curetment, 
cauterization  by  pure  carbolic  acid, 
and  packing  or  extirpation  of  a  con- 
siderable part  of  the  cyst,  and  curet- 
ment and  cauterization  of  the  part 
remaining. 

Oil  Cysts. — An  oil  cyst  is  due  to 
fatty  degeneration  of  the  epithelial 
lining  of  a  sebaceous  cyst,  or  a  milk 
cyst  of  the  breast.  As  previously 
noted,  a  dermoid  may  become  an  oil 
cyst. 

Treatment. — Extirpation,  as  for 
sebaceous  cysts. 

Salivary  Cysts. — A  retention-cyst 
of  a  salivary  gland  is  known  as  a 
ranula  {q.  v.).  These  cysts  are  most 
common  in  the  submaxillary  or  sub- 
lingual gland. 

Lacteal  or  Milk  Cysts  (Galactoceles) . — Such  a  cyst  occasionally  arises  in 
the  manomary  gland  during  lactation,  and  is  the  result  of  blocking  of  a  lac- 
tiferous duct  (see  Cysts  of  Mammary  Gland). 

Among  other  forms  of  retention-cysts,  most  of  which  are  discussed  in 
special  sections  of  this  book,  we  mention  hydrosalpinx,  a  cyst  due  to  blocking 
of  a  Fallopian  tube;  cysts  due  to  obstruction  of  the  bile-ducts  (the  most  com- 
mon form  is  known  as  hydrops,  which  is  a  dilated  gall-bladder  the  result 
of  obstruction);  cyst  of  the  thyroid  gland;  cyst  of  the  pancreas;  and  hydro- 
nephrosis, a  condition  produced  by  obstruction  of  the  lu-eter. 

Cysts  from  Softening. — These  cysts  are  formed  by  the  disintegration 
of  degenerated  tissues.  For  instance,  after  a  hemorrhage  into  the  brain, 
softening  may  follow  and  a  cyst  arise.  Cystic  changes  of  this  sort  are  fre- 
quently observed  in  sarcomata  and  carcinomata.  A  cyst  from  softening  has 
a  wall  of  connective  tissue,  but  there  is  no  endotheUal  or  epithelial  layer. 

Tubulocysts. — This  name  was  given  by  Sir  J.  Bland-Sutton  to  cysts 
formed  in  certain  remains  of  embryonal  ducts,  which  vestiges  ought  to  have 
been  destroyed  in  the  developed  body.  A  small  cavity  is  left  unobHterated,  and 
in  this  space  fluid  gathers.  The  source  of  the  fluid  is  usually  the  lining  cells 
of  the  ca\dty.  Branchial  cysts  are  frequently  considered  under  this  head- 
ing. Among  the  commoner  tubulocysts  are  cysts  of  the  \itello-intestinal 
26 


Fig.  186. — ^Dr.  Weatherby's  case  of  multiple  seba- 
ceous tumors  of  the  scrotum. 


402  Tumors  or  Morbid  Growths 

duct,  cysts  of  the  urachus,  and  thyroglossal  cysts.  Thyroglossal  cysts  and 
sinuses  are  considered  on  page  926. 

Mesenteric  cysts,  not  hydatid  and  not  due  to  carcinoma,  are  embryonic 
developments  from  remains  in  the  mesentery  of  the  vitelline  duct,  the  Wolffian 
ducts,  the  Wolfl&an  bodies,  and  the  Miillerian  ducts  (Moynihan). 

What  are  called  "chyle  cysts"  of  the  mesentery  are  embryonal  cysts  placed 
in  such  close  adjacency  to  lacteals  that  chyle  enters  into  them  (E.  P.  Baumann, 
in  "Lancet,"  May  7,  1904). 

Cysts  of  the  Vitello-intestinal  Duct. — Such  a  cyst  presents  itself  as  a  small, 
bright  red,  globular  mass,  which  appears  to  arise  from  the  umbilicus  of  a 
baby  or  a  young  child,  and  which  usually  has  a  distinct  pedicle,  but  may 
be  sessile.  A  cyst  of  this  character  forms  when  the  vitello-intestinal  duct 
atrophies  from  the  gut  toward  the  umbilicus,  but  a  remnant  at  the  umbUicus 
escapes  obliteration,  and  from  this  remnant  a  cyst  forms.  The  wall  of  such 
a  cyst  contains  unstriped  muscular  fiber  and  is  lined  by  mucous  membrane. 
Occasionally  the  duct  in  the  process  of  involution  is  not  destroyed — its  caliber 
is  simply  lessened — and  the  duct  remains  open  in  the  navel  and  feces  come 
from  it.  If  the  duct  fails  of  obliteration  at  the  intestinal  end,  a  diverticulum 
remains  at  this  point  {Meckel's  diverticulum). 

Treatment. — A  pedunculated  cyst  at  the  navel  is  treated  by  ligating  its  base 
and  dividing  the  stalk  beyond  the  ligature.  A  cyst  with  a  thick  base  is  dis- 
sected out.  The  surgeon  must  be  careful  to  avoid  confounding  an  umbilical 
hernia  with  a  cyst  of  the  navel. 

Urachal  Cysts.— The  urachus  is  the  obliterated  allantois,  and  is  a  cord 
running  from  the  summit  of  the  bladder  to  the  umbilicus.  This  structure 
is  in  the  middle  line  of  the  abdomen  and  in  front  of  the  peritoneum.  A  por- 
tion of  the  allantois  may  not  be  obliterated  at  birth,  and  in  consequence  of 
this  failure  a  cyst  forms.  It  grows  to  a  considerable  size,  may  push  the  peri- 
toneum away  and  reach  the  pelvis,  may  communicate  with  the  bladder,  may 
break  through  the  umbilicus,  or  grow  backward  toward  the  spine. 

Treatment. — Extirpation  of  the  lining  membrane,  partial  closure  of  the 
cavity  by  suture,  and  packing  the  unobliterated  part.  Complete  extirpation 
of  the  cyst  is  seldom  attempted.  W.  R.  Weiser  ("Annals  of  Surgery,"  Oct., 
1906)  collected  86  cases  of  cyst  of  the  urachus.  In  8  of  these  complete  extirpa- 
tion was  performed,  and  Macdonald  has  since  reported  a  successful  complete 
extirpation  (Ibid.,  August,  1907). 

Parasitic  cysts  are  due  to  the  development  of  certain  parasites  in  the 
tissues.    The  form  most  often  encountered  is  known  as  hydatid  cysts. 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are  frequent  in  Aus- 
tralia and  South  America,  but  are  very  rare  in  the  United  States.  In  the 
United  States  91  per  cent,  of  cases  occur  in  foreigners  (Lyon).  Hydatid  cysts 
are  due  to  echinococci.  The  adult  echinococcus  is  the  tapeworm  of  the  dog 
(Taenia  echinococcus),  and  its  ova  or  larvae  gain  access  to  man's  body  by 
accompanying  the  food  he  eats  and  passing  into  the  alimentary  canal,  from 
which  situation  they  are  transported  to  various  organs  by  the  blood.  Osier 
says  the  embryo  (which  has  six  booklets)  burrows  through  the  wall  of  the 
bowel  and  enters  the  peritoneal  cavity  or  muscles;  it  may  enter  the  portal 
vessels  and  reach  the  liver,  or  may  enter  the  systemic  circulation  and  pass 
to  distant  parts.  The  danger  depends  on  two  factors:  "the  situation  and 
the  liability  of  the  cyst  to  suppurate"  (Sidney  Coupland).  The  organs  most 
usually  attacked  are  the  liver  and  lung.  In  60  per  cent,  of  cases  the  liver 
suffers,  and  in  12  per  cent,  the  lung  (Thomas).  Lyon  estimates  that  the  liver 
is  the  seat  of  disease  in  73  per  cent,  of  cases.  Cysts  sometimes  arise  in  the 
intestine,  genito-urinary  passages,  brain,  or  spinal  canal.  When  the  embryo 
lodges,  the  booklets  disappear  and  a  cyst  is  formed.    This  cyst  is  composed 


Hydatid  Cysts  403 

of  two  layers,  an  outer  capsule  (cuticular  membrane)  and  an  inner  layer 
(endocyst).  The  cyst  contains  clear  saline  fluid.  As  the  cysts  grow,  daughter- 
cysts  bud  out  from  the  wall  of  the  mother-cysts,  the  structure  of  the  daughter- 
cysts  being  identical  with  that  of  the  mother-cysts.  From  the  lining  mem- 
brane of  all  the  cysts,  after  a  time,  growths  arise  known  as  scolices,  which 
represent  the  head  of  the  echinococcus  and  exhibit  four  sucking  disks  and  a 
row  of  booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is  thin  and  clear, 
and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate.  These 
cysts  are  very  firm,  but  usually  fluctuate.  Palpation  with  one  hand  while 
percussion  is  practised  with  the  other  gives  a  persistent  tremor  {hydatid  frem- 
itus). If  the  cyst  can  be  safely  reached,  some  fluid  should  be  drawn  and 
examined  for  diagnostic  purposes.  When  a  cyst  suppurates,  positive  con- 
stitutional and  local  symptoms  arise.  Hydatid  cysts  of  the  brain  and  cord 
tend  to  produce  death  in  the  same  manner  as  do  tumors.  A  cyst  of  the  liver 
may  rupture  into  the  pleural  sac,  into  the  belly  cavity,  into  the  stomach, 
or  into  the  bowel,  producing  shock,  hemorrhage,  and  probably  death.  In 
rare  cases  hydatid  cysts  rupture  into  the  pericardium  or  into  a  great  ab- 
dominal blood-vessel,  or  externally.  Rupture  into  the  bile-passages  is  usually 
followed  by  suppuration  of  the  cyst.  Suppuration  of  a  cyst  may  follow  un- 
cleanly tapping.  It  has  been  pointed  out  that  eosinophilia  is  noted  in  most 
persons  siiflering  from  hydatid  disease. 

Treatment. — An  unruptured  hydatid  cyst  of  a  superficial  structure  should 
be  incised  and  the  sac  wall  should  be  dissected  out.  Hydatids  of  the  brain 
have  been  successfully  removed  in  Australia.  A  cyst  of  the  kidney  is  re- 
moved through  a  lumbar  incision.  Omental  cysts  should  be  radically  re- 
moved if  possible;  if  this  is  not  possible,  open  the  abdomen,  surround  the 
cyst  with  gauze,  evacuate  through  a  trocar,  stitch  the  cyst  wall  to  the  wound, 
incise,  irrigate,  and  drain  by  gauze.  Bond  advocated  evacuating  the  cyst, 
closing  it  by  sutures,  and  dropping  it  back  in  the  abdomen.  Gardner  says 
tapping  is  dangerous,  as  it  may  cause  rupture  of  the  cyst.  In  a  hydatid  of 
the  liver  the  abdomen  should  be  opened,  the  cyst  should  be  surrounded  by 
gauze  pads,  and  tapped  by  a  trocar  and  cannula.  When  the  cyst  is  emptied 
of  fluid  it  is  grasped  by  forceps  and  pulled  to  the  incision  in  the  abdominal 
wafl;  it  is  sutured  to  this  incision,  the  trocar  opening  is  enlarged,  and  the  endo- 
cyst is  removed  by  irrigation.^  This  operation  is  called  marsupialization. 
If  the  cyst  is  on  the  summit  of  the  liver,  it  may  be  reached  by  a  transpleural 
hepatotomy.  If  aspiration  is  performed  to  settle  a  diagnosis,  operate  at  once 
after  doing  it,  because  of  fear  that  the  cyst  may  leak  and  disseminate  the 
disease  throughout  the  peritoneal  cavity.  If  hydatid  fluid  is  disseminated 
throughout  the  peritoneal  cavity,  it  may  or  may  not  lead  to  the  development  of 
new  cysts,  but  it  is  almost  certain  to  cause  a  febrile  condition  accompanied  by 
urticaria  and  known  as  hydatid  toxemia.  Brewer  ("Annals  of  Surgery,"  April, 
1908),  in  operating  on  a  case  of  hydatid  cyst  of  the  liver,  wounded  the  portal 
vein  and  was  obliged  to  tie  it.  The  patient  recovered.  That  there  was  no 
failure  of  nutrition  Brewer  attributes  to  the  fact  that  the  vein  had  been  long 
pressed  upon  and  the  collaterals  were  dilated  when  ligation  was  performed. 
1  John  O'Conor,  of  Buenos  Ayres,  in  "Annals  of  Surgery,"  May,  1897. 


404  Diseases  and  Injuries  of  the  Heart  and  Vessels 


XIX.  DISEASES  AND  INJURIES  OF  THE  HEART  AND  VESSELS 

Rupture,  Wounds,  and  Injuries. — Rupture. — The  heart  may  rupture 
and  cause  instant  death,  but  rupture  may  not  be  instantly  fatal.  Curtin 
reported  a  case  in  which  death  did  not  occur  for  over  twenty-four  hours. 
Eisner  reported  a  case  of  rupture  in  which  life  was  prolonged  for  ten  days. 
One  case  lived  eleven  days.  In  cases  in  which  death  does  not  occur  rapidly 
the  rupture  must  be  so  small  that  very  little  blood  escapes.  Rupture  occurs 
in  a  damaged  heart,  a  heart  in  which  the  muscular  fiber  is  fatty,  is  fibroid, 
or  is  necrotic  from  suppuration.  It  may  be  traumatic,  resulting  from  a  fall 
or  a  blow  upon  the  chest,  or  non-traumatic,  following  a  great  effort  or  strain. 
If  death  does  not  at  once  take  place  the  pulse  becomes  very  rapid,  there  is 
precordial  pain,  dyspnea,  cyanosis,  feeble  heart-sounds,  rapid  respiration,  great 
restlessness,  collapse  and  syncope,  and  the  development  of  a  triangular  area  of 
dulness  on  percussion.  Positive  diagnosis  is  impossible.  Meyer  collected  36 
cases  of  rupture  of  the  heart  reported  since  1870.  Death  occurs  from  accumu- 
lation of  blood  in  the  pericardium.  This  acute  compression  of  the  heart  due  to 
blood  escaping  from  the  heart  is  called  heart  tamponade.  It  is  held  by  Franke, 
of  Berhn,  and  others  that  in  heart  tamponade  the  pressure  within  the  peri- 
cardium comes  to  exceed  the  pressure  within  the  auricles,  that  the  pressure 
within  the  pericardium  causes  the  symptoms  of  the  injury,  and  finally  death. 
Some  would  treat  heart  tamponade  iDy  puncture  or  aspiration.  It  would  seem 
that  either  must  be  useless,  as  fresh  blood  is  bound  to  replace  what  is  with- 
drawn. Suturing  must  fail  in  non-traumatic  cases  because  of  the  badly  dis- 
eased myocardium.    In  traumatic  cases  it  may  possibly  succeed. 

Wounds  of  the  Pericardium  and  Heart. — Severe  wounds  usually, 
though  not  always,  produce  death,  but  slight  wounds  may  not  prove  fatal. 
It  is  a  popiilar  impression  that  the  expression  "stabbed  to  the  heart"  is  another 
way  of  saying  that  instant  death  has  occurred.  This  view  was  accepted  even 
by  surgeons  during  many  centuries.  During  the  sixteenth  century  sportsmen 
found  now  and  then  bullets  and  arrow-tips  healed  in  the  heart  walls  of  animals 
they  had  slain.  At  this  time  the  famous  case  of  a  duelist  was  published  by 
Pare:  a  man  received  a  sword  thrust  in  the  heart,  but  was  able  to  run 
after  his  opponent  many  hundred  feet  before  falling  down  in  death.  (See 
"An  Experimental  Investigation  of  the  Treatment  of  Wounds  of  the  Heart," 
by  Charles  A.  Elsberg,  in  "The  Journal  of  Experimental  Medicine,"  Sept. 
and  Nov.,  1899.)  From  Pare's  time  until  our  own  it  has  been  recognized 
by  surgeons  that  a  wound  of  the  heart  does  not  of  necessity  produce  immediate 
death,  and  may  even  be  recovered  from. 

In  1867  G.  Fisher  published  a  study  of  452  cases  of  wound  of  the  heart, 
and  pointed  out  the  surprising  fact  that  from  7  to  10  per  cent,  of  such  cases 
recover.  In  more  recent  years  Rosenthal,  Block,  Del  Vechio,  and  others 
proved  by  animal  experimentation  not  only  that  cardiac  wounds  are  not  of 
necessity  instantly  fatal,  and  that  in  some  cases  they  may  be  recovered  from, 
but  that  the  suturing  of  such  wounds  is  possible  and  greatly  enhances  the 
chance  of  recovery.  L.  L.  Hill  ("Med.  Record,"  Nov.  29,  1902)  shows  that 
although  90  per  cent,  of  heart- wounds  are  penetrating,  only  19  per  cent,  are 
immediately  fatal.  Sudden  death  occurs  when  Kronecker's  coordination 
center  is  damaged.  Several  times  during  postmortem  examinations  on  human 
beings  healed  scars  have  been  found  upon  the  heart.  The  heart  has  been 
punctured  a  number  of  times  accidentally  or  intentionally,  and  death  has  not 
ensued.  John  B.  Roberts,^  of  Philadelphia,  suggested  in  1881  that  it  would 
be  proper  to  try  to  suture  wounds  of  the  heart. 

1  The  author,  in  "Progressive  Medicine,"  vol.  i,  1899. 


Treatment  of  Wounds  of  the  Pericardium  and  Heart  405 

Symptoms. — A  wound  of  the  heart  causes  hemorrhage,  which  is  usually- 
copious,  but  owing  to  the  interlocking  of  muscular  libers  the  hemorrhage  may- 
be slight.  Bleeding  may  take  place  into  the  pericardial  sac  in  some  cases  where 
the  pericardium  has  been  injured  and  the  heart  has  escaped.  Such  an  injury- 
is  occasionally  inflicted  by  the  sharp  end  of  a  fractured  rib.  The  wound  is 
rarely  at  or  near  the  apex  of  the  sac.  In  most  heart  wounds  the  pleural  cavity 
is  also  opened  and  se\-ere  hemothorax  occurs.  The  lung  may  or  mav  not  be 
injured.  A  wound  of  the  pericardium  or  heart  causes  profoimd  shock,  irregular 
or  ver}-  weak  pulse,  sighing  respiration,  dyspnea,  and,  it  may  be,  the  signs 
of  hemopericardiimi,  pneimaopericardium,  or  hemothorax.  In  hemopericar- 
dium  splashing  soimds  are  heard  with  the  heart-beats  and  the  heart-sounds 
are  ver\-  feeble.  In  pneumopericardiiun  there  is  a  t\Tnpanitic  percussion- 
note  in  the  area  which  should  exhibit  the  cardiac  duJness.  There  may  or 
may  not  be  serious  external  bleeding.  Fatal  concealed  hemorrhage  may  occur. 
Pain  is  constant,  and  attacks  of  syncope  are  the  rule.  The  position  of  the 
wotmd  and  the  e\'idences  of  hemorrhage  may  aid  in  making  the  diagnosis. 
Death  is  apt  to  occur  suddenly  from  shock,  hemorrhage,  inability  of  the 
heart  to  contract  because  of  the  severed  libers,  or  inability  of  the  heart  to 
dilate  because  of  the  pressure  of  blood  in  the  pericardial  sac  (heart  tamponade). 
If  a  woimd  of  the  pericardium  or  heart  does  not  cause  death  during  the  first 
day  or  two,  inflammation  follows  (traumatic  pericarditis  or  carditis)  and  the 
patient  may  die  of  suppurative  pericarditis  or  of  empyema. 

Treatment. — Wounds  of  the  pericardiiun  and  heart  should  be  sutured. 
We  should  explore  if.  from  the  location  of  the  woimd  and  the  symptoms,  we 
suspect  a  cardiac  wound.  I  agree  with  Vaughan,  that  if  there  is  a  wound  in  the 
cardiac  region  and  if  the  symptoms  threaten  life,  exploration  should  be  per- 
formed at  once.  In  a  doubtful  case  exploration  should  be  made  by  enlarging 
the  wound,  and  this  may  be  done  imder  local  anesthesia.  In  operating  for  a 
heart-wound  the  cutaneous  surface  shoifld  be  rapidly  disinfected,  and  every 
effort  be  made  to  antagonize  shock  during  the  operation.  The  patient 
should  be  wrapped  in  hot  blankets  and  surrounded  with  hot  bottles  or  hot- 
water  bags,  or  should  be  placed  upon  a  table  composed  of  pipes  in  which  hot 
water  circulates.  The  foot  of  the  bed  should  be  raised.  Hot  saline  fluid  con- 
taining adrenalin  chlorid  should  be  infused  into  a  vein,  or,  in  desperate  cases, 
into  an  arten.-.  The  extremities,  except  the  one  selected  to  infuse  salt  solution 
in,  should  be  bandaged  (autotransfusion) ,  an  enema  of  hot  coffee  and  whisky 
should  be  given,  and  atropin  shoifld  be  injected  h}'podermaticaUy.  It  is  wiser, 
in  most  cases,  to  give  a  general  anesthetic  than  not  to  give  it.  Local  anesthesia 
is  slow  and  unsatisfactory-.  Without  an  anesthetic  the  patient  will  probably 
struggle,  and  struggling  is  ver}'  dangerous,  as  it  loosens  clots  and  permits  hemor- 
rhage to  begin  again  (L.  L.  Hill,  in  '"Med.  Record,'""  Sept.  19,  1908).  Chloro- 
form is  the  anesthetic  used.  If  the  patient  is  unconscious  and  the  corneal 
reflex  is  abolished,  no  anesthetic  shoifld  be  given.  The  heart  is  exposed  by 
resecting  several  ribs.  In  a  knife-wound  of  the  right  pleural  caidty  and  right 
side  of  the  pericardium.  Earth,  of  Danzig,  removed  i  inch  from  each  of  three 
right  costal  cartflages  (fifth,  sixth,  and  seventh),  close  to  the  side  of  the  ster- 
num, and  removed  also  the  ensiform  cartflage  and  i  inch  of  the  sternum. 
The  same  surgeon,  in  the  case  of  a  man  stabbed  in  the  fourth  left  intercostal 
space,  removed  the  fourth  and  fifth  left  costal  cartflages  and  part  of  the  sternum 
("Deutsche  Zeitschrift  fiir  Chiriurgie,'"  Bd.  box.  No.  i).  Schwerin,  of  Berlm, 
in  a  stab-woimd  of  the  chest  exposed  the  heart  by  resecting  the  fourth  and  a  por- 
tion of  the  fifth  left  ribs  ("Proceedings  of  German  Surgical  Congress,"  1903). 
Wilms  r"Centralblatt  f.  Chirurgie,'"  Leipzic,  vol.  xxxiu.  No.  22),  in  a  case  of 
gunshot-wound,  obtained  access  to  the  anterior  and  posterior  surfaces  of  the 
heart  by  a  simple  intercostal  incision.    Parrozzani  makes  a  trap-door  in  the 


4o6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

chest,  the  hinges  of  the  door  being  the  rib  cartilages.  In  exposing  the  heart 
Giordono  enters  along  the  wound,  removing  any  obstacles  that  intervene. 
It  is  needless  to  try  to  avoid  opening  the  pleura  if  a  flap  with  an  internal 
hinge  is  used;  it  has  usually  been  opened  by  the  accident,  and  in  any  case 
can  very  seldom  be  avoided.  Matas  advises  Spangaro's  intercostal  in- 
cision. The  mammary  vessels  are  tied  and  the  width  of  the  intercostal 
space  is  greatly  increased  by  strongly  retracting  the  ribs  and  cartilages.  If 
more  space  is  needed,  the  incision  is  carried  upward  at  the  junction  of  the  carti- 
lages and  sternum.  The  heart  is  exposed,  clots  are  removed  from  the  peri- 
cardial sac,  and  the  sac  is  irrigated  with  hot  saline  fluid.  The  bleeding  may 
be  furious.  A  non-penetrating  wound  of  the  ventricle  may  bleed  so  profusely 
during  systole  as  to  resemble  a  penetrating  wound  (Sherman).  A  penetrating 
wound  may  bleed  most  during  diastole.  The  motions  of  the  chest  make 
manipulation  difficult.  It  is  wise  to  insert  two  traction  sutures  in  order  to  lift 
the  heart  toward  the  operator.  A  wound  in  the  heart  is  sutured  with  inter- 
rupted sutures  of  catgut,  which  are  passed  by  means  of  a  round,  curved  needle, 
and  if  a  cavity  of  the  heart  is  open  each  suture  includes  the  whole  thickness  of 
the  heart  wall  except  the  endocardium.  It  has  been  said  that  the  sutures  should 
be  tied  during  diastole,  otherwise  they  are  apt  to  cut  out,  but  Profs.  Gibbon, 
Stewart,  and  Nassau  tell  me  that  in  their  cases  such  a  procedure  was  impossible 
because  of  the  very  rapid  action  of  the  heart.  As  few  stitches  are  used  as  wiU 
efficiently  close  the  wound.  Numerous  stitches  cause  extensive  degeneration  of 
muscular  fiber  and  stitch-holes  ma}^  permit  leaking.  The  pericardium  is  sutured 
with  silk  or,  as  was  done  in  i  successful  case  (Rehn),  the  sac  is  packed  with  iodo- 
form gauze.  It  is  not  absolutely  necessary  to  drain  the  pericardial  sac.  Clots 
are  removed  from  the  pleural  sac  by  irrigation  with  hot  saline  solution,  pul- 
monary bleeding  is  arrested  by  the  suture  or  by  packing,  and  a  wound  in  the 
lung,  especially  if  it  communicates  with  the  air-passages,  is  sutured  if  the 
patient's  condition  justifies  prolonging  the  operation.^ 

After  such  an  operation  the  patient  is  in  great  danger  and  every  effort 
should  be  made  to  save  him  from  shock.  In  performing  operations  upon  the 
heart  the  pleura  is  almost  always  opened,  and  if  it  is  open  there  is  always 
pneimiothorax  and  grave  danger  of  pulmonary  collapse  and  overwhelming 
shock.  It  is  a  great  advantage  in  such  cases  to  have  at  hand  an  apparatus 
w^hich  will  prevent  or  amend  pulmonary  collapse  (see  page  896). 

Frazier  ("Progressive  Medicine,"  March,  1913)  collects  218  cases  of 
operation  for  heart-wounds.  The  mortality  in  the  series  was  55.5  per  cent. 
This  estimated  mortality  is  probably  much  too  low.  Many  operators  have 
reported  a  single  successful  case  each.  It  is  reasonable  to  believe  that  many 
unsuccessful  cases  have  not  been  reported.  It  is  eminently  desirable  to  have 
the  reports  of  a  number  of  consecutive  cases.  We  have  here  such  a  record. 
Hesse  (Bruns's  "Beitrage,"  1911,  Ixxv)  reports  21  cases  with  a  mortality  of 
71  per  cent.  We  believe  this  represents  about  the  average  mortality  of  heart- 
wounds  subjected  to  operation.  In  188 1  Dr.  John  B.  Roberts,  of  Philadelphia, 
suggested  that  heart- wounds  should  be  sutured.  In  1887  Dr.  Harvey  Reed 
sutured  a  wounded  pericardium  and  the  patient  recovered.  In  1S91  Dalton, 
of  St.  Louis,  obtained  recovery  by  a  similar  operation.  The  first  operation  on  a 
wounded  human  heart  was  performed  in  1896  by  Farina,  of  Rome.  The 
patient  had  been  stabbed  in  the  right  ventricle.  The  wound  was  sutured,  but 
he  died  of  pneumonia  on  the  sixth  day.  Rehn,  of  Frankfort,  in  1896  sutured 
a  wound  of  the  heart  and  packed  the  pericardium  with  gauze,  and  the  patient 
recovered.  Among  others  reporting  cases  are  Cappelan,  Peyrot,  Williams,  Barth 
(in  this  case  the  internal  mammary  artery  was  also  injured),  Wilms,  Hill,  Sher- 
man, Harte,  Gibbon,  Stewart,  Guinard,  Sultan,  Gumming  and  Beattie,  Wolff, 
^The  author,  on  "Suture  of  the  Heart,"  in  "Progressive  Medicine,"  1899,  vol.  i. 


Pericarditis  407 

Picque,  Lenormand,  and  Parrozzani.  There  have  been  12  cases  of  heart  suture 
in  Philadelphia  and  7  recoveries.  Stewart  had  5  cases  and  3  recoveries;  Gibbon, 
2  cases  and  i  recovery;  Nassau,  i  case,  which  recovered.  I  have  never  operated 
for  a  wound  of  the  heart.  According  to  Hill,  the  right  ventricle  is  most  often, 
the  left  auricle  least  often,  injured;  wound  of  the  auricle  is  generally  considered 
to  be  more  dangerous  than  wound  of  the  ventricle ;  and  wound  of  the  apex  is 
less  dangerous  than  either.  Peck  points  out,  however,  that  there  are  11  reported 
cases  of  auricle  wounds  with  4  deaths,  a  mortality  of  36.3  per  cent.,  while  the 
general  mortality  of  heart- wounds  is  about  64  per  cent.  ("Annals  of  Surger\'," 
July,  1909).  Wounds  of  the  left  ventricle  give  a  better  prognosis  than  of  the 
right  ventricle;  wounds  of  the  right  auricle  a  better  prognosis  than  of  the  left 
auricle.  A  needle  puncture  rarely  causes  serious  bleeding  from  a  ventricle,  but 
is  very  apt  to  cause  severe  bleeding  from  an  auricle.  A  wound  received  during 
diastole  is  less  dangerous  than  one  received  during  systole.  Wounds  of  the 
right  heart  bleed  more  than  wounds  of  the  left  heart.  Wolff  points  out  that 
ligation  of  one  coronary  artery  can  be  done  and  recovery  follow ;  wounds  of 
the  left  ventricle  give  the  best  prognosis  because  the  wound  is  closed  by  thick 
edges  of  muscle.  In  37  operations  for  heart-wounds  the  left  pleura  was  opened, 
in  3  the  right  pleura,  and  in  2  the  pleura  was  uninjured.  In  bullet-wounds 
death  usually  occurs  before  operation  can  be  done  (Wolff,  "Deutsche  Zeit- 
schrift  flir  Chirurgie,"  Bd.  bdx,  Xo.  i).  Bircher  reports  a  case  of  gunshot- 
wound  of  the  heart  in  which  there  was  no  operation,  yet  the  patient  recovered. 
He  believes  that  a  gunshot-wound  by  a  small  bullet  should  not  be  operated 
upon,  but  he  would  operate  for  wounds  by  large  bullets  and  for  stab-wounds 
("Arch.  klin.  Chir.,"  1912,  xcvii).  Manteuffel  reported  7  cases,  occurring  during 
the  war  in  jManchuria,  in  which  recovery  followed  gunshot-wounds  of  the  heart 
which  were  treated  expectantly.  Without  operation  the  mortality  of  heart- 
wounds  will  be  at  least  90  per  cent. ;  with  operation  it  will  be  about  60  to  70 
per  cent. 

Matas  ("Southern  Med.  Jour.,"  August,  1908)  discussed  160  cases  of  heart- 
wounds  "s\ith  43.83  per  cent,  of  recoveries.  In  134  cases  the  woiind  was  sutured, 
wdth  49  recoveries.  In  11  cases  it  was  exposed,  but  was  not  sutured,  and  5 
recovered.    In  5  cases  foreign  bodies  were  removed  wdth  success. 

In  Peck's  table  ("Annals  of  Surger\',"  July,  1909)  there  are  69  wounds  of 
the  right  ventricle  with  48  deaths  (69.6  per  cent.);  74  of  the  left  ventricle 
'\\dth  45  deaths  (60. S  per  cent.);  5  of  the  left  auricle  with  2  deaths  (40  per 
cent.) ;  6  of  the  right  auricle  with  2  deaths  (33.3  per  cent.) ;  and  7  miscellaneous 
cases  -^dth  5  deaths  (71.5  per  cent.),  a  total  of  160  cases  with  58  recoveries  and 
102  deaths,  a  mortality  of  63.7  per  cent. 

The  immediate  dangers  of  the  operation  are  hemorrhage,  shock,  and  the 
entrance  of  air.  The  late  dangers  are  pericarditis,  empyema,  and  pneumonia 
(Vaughan).  Traumatic  carditis  or  pericarditis  is  treated  in  the  same  way  as 
idiopathic  cases.  Pus  in  the  pericardial  sac  should  be  evacuated  by  resection 
of  the  fourth  left  costal  cartilage  and  incision  of  the  pericardium  (von  Eisels- 
berg's  case).  Pool  reviewed  the  subject  of  heart-wounds  in  the  "Annals  of 
Surgery,"  April,  1912. 

Pericarditis  is  an  infectious  condition  that  may  be  traumatic  or  non- 
traimaatic.  If  pericarditis  follows  an  open  wound,  it  is  obvious  how  the  in- 
fection must  have  entered;  if  it  follows  a  bruise  or  a  contusion,  the  injury 
has  rendered  the  pericardium  a  point  of  least  resistance.  In  some  few  cases, 
which  are  known  as  primary  pericarditis,  it  is  impossible  to  determine  how 
the  micro-organisms  gained  entrance.  The  ordinary  form  appears  as  a  com- 
pHcation  of  certain  infectious  diseases,  such  as  septicemia,  pneimionia,  rheu- 
matism, and  tuberculosis.  It  may  be  secondary^  to  some  adjacent  infection, 
such  as  an  empyema.    A  tuberculous  abscess  may  break  into  the  pericardium, 


4o8  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  an  abscess,  even  from  a  considerable  distance,  may  burrow  into  it.  It  may- 
arise  secondary  to  a  distant  infection,  as  a  suppurating  wound,  osteomyelitis, 
middle-ear  suppuration,  abscess  of  the  mastoid,  tonsillitis,  abscesses  any- 
where, peritonitis,  and  gastric  ulcer.  It  sometimes  follows  gastro-enterostomy 
and  may  arise  in  an  individual  with  Bright's  disease.  In  a  recently  born  child 
infection  of  the  stump  of  the  umbilical  cord  may  cause  pericarditis.  A  peri- 
cardial effusion  in  a  newborn  child  is  invariably  purulent  and  in  a  young  child 
it  is  usually  purulent.  In  children  the  condition  is  usually  associated  with 
pulmonary  disease  (Poynton,  in  "Brit.  Med.  Jour.,"  August  15,  1908).  A 
great  variety  of  bacteria  may  be  responsible  for  pericarditis.  The  exudation 
may  be  serofibrinous;  this  is  an  evidence  of  its  being  a  mild  infection,  and  such 
an  exudate  may  undergo  absorption.  On  the  other  hand,  the  exudate  may 
become  purulent,  and  in  such  a  case  cure  will  never  be  obtained  by  absorption 
of  the  pus.  In  pericarditis  there  is  usually  some  pain  in  the  region  of  the  heart, 
and  this  pain  is  apt  to  extend  into  the  left  arm.  Epigastric  pain  is  a  common 
symptom.  The  heart  is  overacting,  the  heart-sounds  are  indistinct,  the  pulse 
is  strong  and  very  rapid,  there  is  an  increased  area  of  cardiac  dulness,  and  the 
patient  complains  of  dyspnea.  The  temperature  is  elevated  and  a  double 
friction-sound  may  be  made  out  upon  auscultation. 

Treatment. — Ordinary  pericarditis,  without  pus-formation  or  extensive 
effusion,  is  managed  by  the  physician;  but  when  there  is  extensive  effusion 
with  symptoms  of  dangerous  compression  it  is  advisable  to  open  the  pericar- 
dium, and  if  there  is  purulent  effusion  the  pericardium  must  be  opened.  The 
procedure  usually  practised  in  the  past  to  reheve  pericarditis  with  marked 
effusion  was  puncture  or  aspiration.  This,  however,  is  dangerous.  The  heart  is 
not,  as  was  formerly  taught,  pushed  back  and  up  by  the  pericardial  effusion,  but 
is  lifted  upward  and  forward,  and  may  be  pushed  to  the  right  or  left  if  there  are 
adhesions  between  the  pericardium  and  heart;  and  it  is  impossible  to  select 
any  place  for  aspiration  that  assures  us  that  there  will  be  no  danger  of  punc- 
turing the  heart.  A  coronary  vein  may  be  injured,  the  pleiiral  cavity  may  be 
entered,  and  a  dry  tap  is  usual  from  blocking  of  the  needle.  Brentano  has  shown 
that  tapping  cannot  completely  empty  the  sac.  Many  surgeons,  however,  do 
not  fear  puncture,  and  explore  by  inserting  a  fine  needle  in  the  fourth  or  fifth 
space  of  the  left  side  close  to  the  sternum.  In  cases  of  extensive  pericardial 
effusion,  and  also  in  cases  of  suppuration  within  the  pericardium,  I  believe 
that  pericardiotomy  should  be  performed.  An  inch  or  more  of  the  car- 
tilage of  the  fourth  rib  of  the  left  side  should  be  removed  or  2  inches  of  the 
fourth  rib  itself,  and  the  pericardial  sac  should  be  exposed  and,  after  ex- 
ploratory puncture,  formally  incised.  In  this  operation  it  may  be  necessary 
to  tie  the  internal  mammary  artery.  In  pyopericardiimi  the  pleural  cavity  is 
very  seldom  invaded,  because  the  pleural  space  in  front  of  the  pericardium  has 
usually  been  obliterated  by  the  spread  of  the  inflammation.  The  pericardial 
sac  is  opened  as  directed  above,  is  cleared  of  purulent  material  and  fibrinous 
masses  by  irrigation,  the  edges  of  the  pericardial  wound  are  sutured  to  the 
edges  of  the  superficial  woimd,  and  gauze  drainage  is  introduced.  Incision  is 
safer  and  more  certainly  curative  than  aspiration;  for  whereas  aspiration  might 
be  curative  in  pericardial  effusion,  it  cannot  be  so  if  the  effusion  is  purulent. 
In  41  cases  of  purulent  pericarditis  (Roberts's  table  of  35  cases  and  Ljung- 
gren's  6  cases)  operated  upon,  16  recovered.  Local  anesthesia  is  safer  than 
general  anesthesia. 

Phlebitis,  or  Inflammation  of  a  Vein. — Acute  Phlebitis. — Phlebi- 
tis may  be  plastic  or  it  may  be  infective.  Plastic  phlebitis,  while  occasion- 
ally due  to  rheumatism,  to  gout,  to  advanced  phthisis,  to  a  febrile  malady, 
or  to  some  other  constitutional  condition,  usually  takes  its  origin  from  a 
wovmd  or  other  injury,  from  the  extension  to  the  vein  of  a  perivascular  inflam- 


Phlebitis,  or  Inflammation  of  a  Vein  409 

mation,  or,  in  the  portal  region,  from  an  embolus.  Varicose  veins  are  particu- 
larly liable  to  phlebitis.  When  phlebitis  begins  a  thrombus  usually  forms 
(see  Thrombosis,  page  184)  because  of  the  destruction  of  the  endothelial  coat 
of  the  vessel,  and  this  clot  may  give  rise  to  emboH,  may  be  absorbed,  or  may  be 
organized.  An  aseptic  clot  organizes  and  the  vein  becomes  permanently 
narrowed  or  blocked.  A  septic  clot  is  apt  to  soften  and  break  up.  In  the  lower 
extremities  paraphlebitis  is  common  with  slight  involvement  of  coats,  and  a 
clot  may  not  form.  Clot-formation  causes  edema.  Infective  phlebitis  is  a 
suppurative  inflammation  of  a  vein  arising  by  infection,  perhaps  from  suppu- 
ratmg  perivascular  tissues  {infective  thrombophlebitis),  perhaps  from  the  blood- 
stream or  in  the  portal  system,  perhaps  from  infective  embolism.  It  is  not 
unusually  met  with  in  celluhtis  or  phlegmonous  erysipelas,  may  arise  in  the 
lateral  sinus  as  a  result  of  mastoid  suppuration,  or  in  the  liver  from  appendi- 
citis or  from  phlebitis  of  the  rectal  veins.  Sometimes  as  the  convalescence  from 
pneumonia  begins,  phlebitis  due  to  pneumococci  arises.  If  a  septic  thrombus 
forms,  the  vein  wall  suppurates,  is  softened  and  in  part  destroyed,  and  the 
infected  clot  softens  and  gives  rise  to  emboli.  No  bleeding  occurs  when  the 
vein  ruptures  or  is  opened,  as  a  barrier  of  clot  keeps  back  the  blood-stream. 
The  clot  of  suppurative  phlebitis  cannot  be  absorbed  and  cannot  organize. 
Septic  phlebitis  causes  pyemia,  and  the  infected  clots  are  disseminated. 

Postoperative  phlebitis  of  the  iliac,  femoral,  or  saphenous  veins  is  not 
uncommonly  the  result  of  a  mild  or  attenuated  infection,  toxins  in  the  blood 
probably  attacking  the  vein.  As  a  rule,  the  toxins  are  non-pyogenic.  It  may 
follow  an  abdominal  operation  when  there  is  no  evidence  of  infection.  Accord- 
ing to  Cordier,  it  occurs  in  2  per  cent,  of  abdominal  operations.  It  is  called, 
as  is  the  like  puerperal  condition,  milk-leg,  or  phlegmasia  alba  dolens.  Nearly 
always  the  femoral  vein  is  the  one  which  suffers.  Strange  to  say,  it  is  most 
apt  to  attack  the  left  iliac,  femoral,  or  saphenous  veins;  it  matters  not  upon 
which  side  the  operation  was  performed.  In  over  90  per  cent,  of  cases  the  left 
femoral  or  left  saphenous  veins  are  attacked  (Cordier,  in  "Jour.  Am.  Med. 
Assoc,"  Dec.  9,  1905).  One  theory  regards  the  pressure  of  the  right  common 
iliac  artery  upon  the  left  common  iliac  vein  as  a  predisposing  cause.  Another 
theory  attaches  importance  to  the  pressure  of  a  loaded  sigmoid.  It  is  most 
common  in  anemic  subjects,  especially  when  anemia  results  from  blood  loss. 
It  may  be  due  to  toxins  damaging  the  inner  coat  of  the  vein,  but  feeble  circula- 
tion is  a  powerful  factor  in  its  production.  I  believe,  with  Clark,  that  powerful 
traction  on  the  sides  of  an  abdominal  wound  may  be  responsible  for  it  (see 
Thrombosis  after  Abdominal  Operations,  page  187).  Vanderveer  reported  4 
cases  in  which  sepsis  was  positively  absent  ("American  Medicine,"  July  13, 
1 901).  It  occurred  in  the  left  iliac  vein  of  a  woman  on  whom  I  had  oper- 
ated for  carcinoma  of  the  left  breast  six  days  before.  There  was  no  obvious 
infection  of  the  wound.  I  have  seen  it  occur  in  the  left  iliac  vein  after  an  in- 
terval operation  for  appendicitis.  Phlebitis  may  arise  in  the  vein  of  one 
extremity,  a  clot  may  form,  and  this  may  be  absorbed  or  may  organize.  The 
other  extremity  may  be  involved  afterward  or  simultaneously  (horseshoe 
form).  It  may  come  on  seven  or  eight  days  after  operation,  many  days,  or 
several  weeks.  It  usually  is  ushered  in  by  chilly  sensations  or  slight  chills 
and  elevated  temperature.  There  is  always  pain  in  the  limb.  The  pain  may 
be  dull  or  acute;  it  is  made  worse  by  motion  and  by  pressure  over  the  in- 
volved vein.  The  entire  extremity  swells  from  edema.  It  is  probable  that 
marked  edema  signifies  associated  lymphangitis  or  an  extensive  clot  running  into 
many  venous  branches.  The  edema  is  seldom  characterized  by  very  distinct 
pitting  on  pressure.  The  skin  is  white  and  looks  stretched  and  shiny.  The 
inguinal  glands  are  usually  enlarged.  Sensation  is  impaired  except  over  the  vein. 
Paresthesia  is  common.    The  involved  veins  come  to  feel  Hke  cords  to  the  touch. 


4IO 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


In  mild  cases  the  symptoms  disappear  in  a  few  days.  Severe  cases  continue 
for  several  or  many  weeks  or  even  months.  Involvement  of  the  deep  veins 
causes  prolonged  swelling.    There  is  seldom  any  disposition  to  gangrene. 

In  some  cases  there  is  extensive  muscular  atrophy,  in  some  there  are 
trophic  disturbances,  in  some  muscular  contractures.  Postoperative  phle- 
bitis is  sometimes  responsible  for  embolic  pneumonia  and  cerebral  embolism. 
Many  postoperative  pneumonias  are  due  to  this  cause. 

The  symptoms  of  plastic  phlebitis  are  pain,  tenderness  in  and  around  a 
vein,  discoloration  over  it,  and  edema  below  the  seat  of  the  disease.  Sup- 
purative phlebitis,  besides  these  conditions,  causes  the  constitutional  symp- 
toms of  pyemia  (see  page  197).     Any  thrombus,  if  it  loosens,  forms  emboli. 

It  is  said  that  the  clot  resulting  from  pneu- 
mococcic  phlebitis  forms  so  rapidly  that  it 
adheres  slightly  and  is  peculiarly  apt  to 
loosen  and  give  rise  to  emboli  (Pierre,  in 
"Gazette  des  Hopitaux,"  Sept.  3,  1904). 
Septic  thrombi  are  apt  to  cause  septic 
pneumonia. 

The  treatment  of  plastic  phlebitis  of  an 
extremity  comprises  rest  in  bed  for  from 
four  to  six  weeks,  slight  elevation  of  the 
part,  the  use  of  cold  for  the  first  twenty-four 
hours,  and  then  the  application  of  external 
heat  and  a  flannel  bandage.  If  the  patient 
is  gouty  or  rheumatic,  appropriate  remedies 
should  be  given.  A  clot  does  not  always 
form  in  an  inflamed  vein,  but  if  one  forms 
there  is  danger  of  embolism;  hence  mas- 
sage and  both  active  and  passive  move- 
ment are  dangerous  until  the  clot  becomes 
firm.  When  a  vein  is  involved  in  a  sup- 
purative process  and  septic  thrombophlebitis 
exists,  we  should  operate  when  the  situation 
makes  operation  possible.  Ligate  the  vein 
(compress  a  sinus  by  packing)  above  and 
below  the  clot,  open  the  vessel,  and  wash 
out  the  infected  clot,  or,  if  dealing  with  an  accessible  vein,  extirpate  the 
involved  portion.  This  plan  of  treatment  is  always  to  be  applied  in  infective 
thrombophlebitis  of  the  lateral  sinus  and  of  the  internal  saphenous  vein. 
The  constitutional  treatment  is  that  of  pyemia. 

Chronic  Phlebitis. — This  rare  condition  is  known  as  phlebosderosis,  and 
it  is  a  chronic  inflammation  of  the  wall  of  a  vein,  producing  a  fibrous  change 
in  the  vascular  coats.  It  may  arise  in  a  part  the  seat  of  chronic  venous 
engorgement,  but  its  most  frequent  cause  is  syphilis.  It  is  often  associated 
with  arteriosclerosis. 

Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  Varix  (Figs.  187 
and  188). — Definition  and  Causes. — Varicose  veins  are  unnatural,  irregular, 
and  permanently  dilated  veins  which  are  elongated  and  pursue  a  tortuous 
course.  This  condition  is  very  common,  and  20  per  cent,  of  adults  ex- 
hibit it  in  some  degree  in  one  region  or  another.  Some  facts  indicate  hered- 
itary predisposition.  In  over  80  per  cent,  of  cases  the  trouble  begins  before 
the  age  of  twenty-five.  The  causes  of  varicose  veins  are  said  to  be  obstruc- 
tion to  venous  return  and  weakness  of  cardiac  action,  which  lessens  the  pro- 
pulsion of  the  blood-stream.  A.  Pearce  Gould  says  obstruction  is  not  a 
cause,  because  in  pregnancy  varicose  veins  may  be  seen  early,  before  the 


Fig.  1 87. — Varicose  veins. 


Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  Varix 


411 


womb  is  much  enlarged.  The  real  cause  is  probably  a  predisposition  to  the 
growth  of  vein-tissue,  which  leads  to  valve  failure  and  a  regurgitation  of 
blood  from  the  deep  veins  into  the  superficial  venous  channels  (A.  Pearce 
Gould,  in  "Lancet,"  March  i  and  15  and  June  7,  1902).  As  Billroth  said 
over  thirty  years  ago,  sudden  obstruction  causes  edema  and  gradual  ob- 
struction a  free  collateral  circulation.  Neither  sudden  nor  gradual  obstruc- 
tion causes  true  varicosity  unless  the  veins  are  predisposed  by  a  tendency 
hereditary  or  acquired. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but  are  chiefly  met 
with  on  the  inner  side  of  the  lower  extremity,  in  the  spermatic  cord,  and  in 
the  rectum.  Varix  in  the  leg  is  met  with  most  commonly  during  and  after 
pregnancy  and  in  persons  who  stand  upon  their  feet  for  long  periods.  It  is 
especially  common  in  the  long  saphenous  vein,  which,  being  subcutaneous, 
has  no  muscular  aid  in  sup- 
porting the  blood-column 
and  in  urging  it  on. .  The 
deep  as  well  as  the  super- 
ficial veins  may  become 
varicose.  Verneuil  main- 
tained that  varix  of  the 
superficial  veins  is  almost 
always  secondary  to  varix 
of  the  deep  veins,  a  radical 
view  which  seems  improb- 
able. It  is  certain,  how- 
ever, that  after  contusions 
of  the  leg  it  is  not  unusual 
for  the  deep  veins  to  be- 
come filled  with  clot  and 
for  the  superficial  veins  to 
dilate  notably.  By  the 
term  "caput  meduscB"  is 
meant  dilated  veins  radiat- 
ing from  the  umbilicus. 
The  veins  of  the  esopha- 
gus may  become  varicose, 
and  this  malady  is  com- 
monly unrecognized  clinic- 
ally. Varicose  veins  are 
in  rare  instances  congeni- 
tal, but  they  are  most  often  seen  in  the  aged,  and  usually  are  first  observed 
between  the  ages  of  twenty  and  forty.  They  are  more  common  in  women 
than  in  men,  owing,  it  is  believed,  to  the  influence  of  pregnancy. 

Varix  of  the  spermatic  cord  is  known  as  varicocele.  It  is  apt  to  appear 
about  the  time  of  puberty,  and  most  adult  men  have  at  least  a  slight  varico- 
cele. Varix  is  more  likely  to  appear  in  the  left  spermatic  vein  than  in  the 
vein  of  the  right  side,  because  the  left  spermatic  vein  has  no  valves  (see  page 
1400). 

Varicose  tumors  of  the  rectum  constitute  hemorrhoids  or  piles.  Piles 
are  caused  by  obstruction  to  the  upward  flow  in  the  hemorrhoidal  veins, 
either  by  obstructive  liver  disease,  enlargement  of  the  uterus  or  prostate,  or 
the  presence  in  the  rectum  of  fecal  masses  in  a  person  habitually  constipated 
(see  page  11 77). 

A  vein  under  pressure  may  dilate  more  at  one  spot  than  at  another,  the 
distention  being  greatest  back  of  a  valve  or  near  the  mouth  of  a  tributar>^ 


Varicose  veins. 


412  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  valves  become  incompetent  and  the  dilatation  becomes  still  greater. 
Callender  has  pointed  out  that  varix  of  the  lower  extremity  is  apt  to  begin 
where  the  deep  vessels  join  the  superficial  veins.  At  this  point  Treves  says 
three  forces  meet:  the  blood  column  above,  the  valve  below,  and  the  force  of  the 
blood-current.  At  the  spot  where  the  pressure  is  greatest  the  vein  wall  dilates, 
and  from  this  dilatation  the  blood-current  is  deflected  and  causes  another  dila- 
tation higher  up  and  on  the  opposite  side  of  the  vessel.  The  blood  is  again 
deflected  and  causes  another  dilatation,  and  so  on.  The  vein  wall  may 
become  fibrous,  but  usually  it  is  thin  and  sometimes  it  ruptures.  The  veins 
not  only  dilate,  but  they  also  become  longer,  and  hence  do  not  remain  straight, 
but  twist  and  assume  a  characteristic  form.  It  seems  probable  that  the 
first  step  in  the  process  is  a  growth  of  new  venous  tissue  (A.  Pearce  Gould), 
and  then  follow  lengthening,  tortuosity,  incompetence  of  the  valves,  and 
dilatation  of  the  vessel. 

Delbet^  points  out  that  varicose  veins  of  the  leg,  which  begin  in  the  thigh, 
result  from  valvular  incompetence;  varicose  ulcers  arise  from  variations  of 
venous  pressure  due  to  valvular  incompetence.  The  incompetence  of  the  valves 
does  harm  by  allowing  the  intravenous  pressure  to  equal  the  pressure  in  the 
arterioles,  a  condition  which  arrests  capillary  circulation,  causes  conges- 
tion, and  greatly  lowers  tissue  resistance.  Incompetent  valves  also  favor 
ulceration  by  developing  a  vicious  venous  circle,  first  described  by  Trendelen- 
burg. Blood  passing  through  this  circle  loses  nutritive  elements.  Tren- 
delenburg has  described  the  vicious  circle  as  follows:  Blood  in  the  saphenous 
vein  flows  toward  the  periphery  instead  of  toward  the  center,  because  of  in- 
competent valves — it  passes  into  the  veins  which  connect  the  superficial  veins 
with  the  deep  veins  and  then  enters  the  tibial  and  peroneal  veins.  It  passes 
from  the  tibial  and  peroneal  into  the  popliteal  and  femoral  veins,  and  some 
blood  leaves  the  femoral  vein  and  again  enters  the  saphenous. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored  by  pigmenta- 
tion due  to  red  blood-cells  having  escaped  from  the  vessel  and  broken  up. 
The  tissues  around  a  varicose  vein  become  atrophied  from  pressure,  and  it 
is  not  unusual  to  meet  with  a  very  large  vein  whose  thin  walls  are  in  close 
contact  with  skin.  In  this  condition  rupture  and  hemorrhage  are  probable. 
When  the  vein  wall  forms  a  pouch-like  dilatation  the  condition  is  spoken  of 
as  a  vein  cyst.  Varicose  veins  are  apt  to  inflame,  and  thrombosis  frequently 
occurs.  When  a  thrombus  forms,  emboli  may  be  broken  off  and  carried  into 
the  circulation,  especially  if  the  patient  walks  about.  The  formation  of  emboli 
is  not  nearly  so  common  as  a  result  of  thrombosis  in  a  varicose  vein  as  in 
thrombosis  in  an  undistended  and  unelongated  vessel.  In  varicose  veins 
of  the  thigh,  however,  the  chance  of  embolism  following  thrombosis  is  much 
greater  than  when  the  veins  of  the  leg  alone  are  involved.  In  some  elderly 
people  thrombus  actually  effects  spontaneous  cure.  When  a  thrombus 
organizes,  more  or  less  calcification  is  apt  to  ensue,  and  a  vein-stone  or  phleb- 
olith  is  formed.  After  middle  life  many  varicosities  remain  stationary  or 
cease  to  give  trouble.  The  chief  complications  of  varicose  veins  of  an  extrem- 
ity are  thrombosis,  edema,  violent  hemorrhage  from  rupture,  phlebitis,  ec- 
zema, and  chronic  ulceration. 

Treatment  of  Varix  of  the  Lower  Extremitiy. — The  treatment  of  varix 
of  the  leg  may  be  palliative  or  curative,  but  whichever  plan  is  followed,  the 
surgeon  should  endeavor  first  of  all  to  remove  the  exciting  cause.  An  essen- 
tial part  of  palHative  treatment  is  to  attend  to  the  general  health,  to  keep  up 
the  force  and  activity  of  the  circulation,  and  to  prevent  constipation.  Mas- 
sage is  useful,  especially  alcohol  frictions,  if  eczema  is  absent.  Cold  baths  are 
always  forbidden  (Bennett).  The  patient  should  exercise  regularly  in  the 
1  Delbet,  "Sem.  med.,"  Oct.  13,  1897. 


Acute  Arteritis  412 

open  air  and  should  lie  down  for  a  time,  if  possible,  every  afternoon.  Instead 
of  lying  down  for  a  time  during  each  day,  he  may  sit  down  and  elevate  the  legs, 
resting  them  on  a  table,  and  thus  assuming  a  position  supposed  to  be  peculiarly 
American.  If  there  is  no  pain,  distinct  discomfort,  or  edematous  swelling,  a 
support  is  unnecessary,  but  if  these  conditions  exist  it  is  needed.  If  a  support 
is  required  in  varix  of  the  leg,  use  a  flannel  roller  or  a  perforated  rubber  bandage 
applied  over  a  long  stocking.  Such  a  bandage  supports  the  veins  and  drives 
the  blood  into  the  deeper  vessels,  which  have  muscular  support.  The  use  of  a 
rubber  pad  filled  with  glycerin  and  applied  over  the  saphenous  vein,  so  as  to 
support  the  blood  column  and  act  as  a  valve,  has  been  recommended.  A 
purely  local  varix  should  be  excised,  because  there  is  always  danger  of  injury, 
and  consequently  of  hemorrhage  or  thrombosis.  If  the  superficial  veins  have 
dilated  because  of  thrombosis  of  the  deep  veins  and  edema  exists,  ligation  or 
excision  is  contra-indicated,  as  its  performance  might  lead  to  permanent  edema. 
In  such  a  case  it  would  perhaps  be  proper  to  incise  the  deep  fascia  the  length 
of  the  thigh,  place  the  vein  beneath  it,  and  suture  the  fascia.  The  vein  would 
then  be  supported,  but  not  blocked.  If  the  disease  involves  the  leg  only, 
operative  treatment  is  rarely  required  and  may  even  do  harm.  Such  cases 
are  operated  upon  if  there  are  cyst-like  dilatations,  if  thrombi  form,  and,  as 
Bennett  points  out,  if  a  thin-walled  vein  crosses  the  tibia,  and  is  thus  exposed 
to  the  danger  of  injury  and  thrombosis.^ 

If  the  leg  is  involved  in  the  process,  and  the  saphena  in  the  thigh  is  also 
varicose,  operation  should  be  performed. 

If  a  thrombus  forms  in  a  superficial  varicose  vein,  tie  the  vein  above  and 
below  the  clot,  divide  the  vessel  in  two  places,  and  remove  the  vein  and  the 
clot  within  it.  Thrombosis  of  a  varicose  vein  is  not  so  apt  to  lead  to  emboli 
as  thrombosis  in  a  non-varicose  vein,  but  it  may  do  so,  and  the  condition  has 
some  elements  of  danger. 

If  edema  is  marked,  and  increases  in  spite  of  properly  applied  bandages, 
etc.,  it  probably  signifies  clot-formation,  and  the  patient  should  remain  in 
bed  until  this  question  is  determined.  Hemorrhage  from  a  ruptured  varicose 
vein  of  an  extremity  is  usually  readily  arrested  by  compression  and  elevation. 

The  radical  treatment  of  varix  of  the  leg  often  does  good,  often  relieves 
some  annoying  condition,  but  rarely  absolutely  cures  (W.  H.  Bennett).  There 
are  several  methods  of  operation:  ligation  with  excision  of  part  of  the  vein, 
exposure  and  ligation  of  the  vein  below  the  saphenous  opening,  or  circular 
incision  around  the  leg.     (See  Operations  Upon  Vessels.) 

Nevus.— (See  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  is  acute  or  chronic. 

Acute  Arteritis. — Slight  inflammation  is  by  no  means  unusual,  but  severe 
arteritis  is  decidedly  rare.  It  may  follow^  direct  injury  or  arise  secondar- 
ily to  a  perivascular  inflammation.  An  artery  is  very  resistant  to  the  spread 
of  inflammation,  but  we  sometimes  encounter  suppurative  arteritis  in  a  suppu- 
rating area.  Arteritis  may  arise  in  the  course  of  an  infective  malady,  being  pro- 
duced by  bacteria,  but  it  is  also  found  in  intoxications,  and  is  then  due  purely 
to  toxins.  It  may  occur  in  the  eruptive  fevers,  in  influenza,  typhoid  fever, 
acute  rheumatism,  gout,  syphilis,  diphtheria,  septicemia,  and  septic  intoxica- 
tion. Ford  points  out  that  acute  arteritis  developing  during  acute  or  chronic 
infections  is  particularly  apt  to  arise  in  the  lower  extremities  (Ford,  "These 
de  Paris,"  1901).  Toxins  or  bacteria  usually  reach  the  artery  in  the  main 
blood-stream,  but  may  be  lodged  in  the  vessel  wall  by  the  lymph  or  the  flow 
in  the  vasa  vasorum.  The  inner  coat  of  a  portion  of  an  artery  becomes  lined 
with  inflammatory  exudate  and  the  coats  are  infiltrated  with  small  cells. 
Often  parietal  thrombi  form.  Sometimes,  though  rarely,  the  vessel  is  com- 
1  W.  H.  Bennett,  "Lancet,"  Oct.  15,  1898. 


414  Diseases  and  Injuries  of  the  Heart  and  Vessels 

pletely  blocked  by  thrombosis.  In  acute  suppurative  arteritis  pus  accumulates 
in  the  arterial  wall,  a  clot  forms  in  the  lumen,  and  the  coats  of  the  vessel  undergo 
necrosis  and  give  way.  Violent  hemorrhage  may  thus  arise,  but  often,  in 
thrombo-arteritis  as  in  thrombophlebitis,  rupture  does  not  cause  hemorrhage. 
Acute  arteritis,  if  non-bacterial  in  origin,  is  usually  recovered  from  with  slight 
structural  change.  Infective  arteritis  is  recovered  from  if  the  causative  germ 
is  not  very  virulent  or  if  the  toxin  is  not  present  in  excessive  quantity.  Acute 
arteritis  may  terminate  in  arterial  obstruction  with  or  without  gangrene, 
permanent  dilatation,  arterial  rupture,  or  chronic  arteritis. 

The  symptoms  may  be  merged  with  those  of  an  acute  or  chronic  in- 
toxication 'or  infection,  or  vnth  those  of  a  local  perivascular  inflammation. 
In  arteritis  arising  during  infections  the  symptoms  appear  abruptly  and  the 
onset  is  marked  by  grea;t  pain.  Ford  studied  i8  cases  in  influenza.  He 
says  it  attacks  particularly  persons  over  thirty  years  of  age,  occurs  in  one 
leg  or  both,  arises  most  commonly  during  convalescence,  but  may  not  begin 
imtil  the  individual  is  apparently  well.  There  is  pain  and  tenderness  over  the 
vessels,  low  surface  temperature,  paresthesia,  and  mottled  skin  (Ford,  "These 
de  Paris,"  1901).  The  artery  may  be  obstructed,  and  if  a  large  vessel  is 
blocked,  the  pulse  below  the  clot  is  lost.  The  block  may  be  temporary  or 
persistent.  Gangrene  may  follow.  Ford  points  out  that  if  the  artery  only 
is  blocked,  the  gangrene  is  dry;  but  if  the  vein  also  is  occluded  it  may  be 
moist.     I  have  seen  2  cases  of  dry  gangrene  following  influenza. 

Treatment. — Secure  rest  in  bed;  elevate  the  extremity  slightly,  relax  it, 
smear  the  skin  over  the  inflamed  vessel  with  ichthyol  ointment  or  mercurial 
ointment,  or  follow  Ford's  advice  and  use  methyl  salicylate  or  an  ointment 
of  salicylic  acid,  turpentine,  and  belladonna.  Wrap  the  part  in  cotton  and 
surround  it  with  bottles  or  bags  filled  with  warm  water.  If  a  patient  is  very 
restless,  a  splint  must  be  used.  It  may  be  necessary  to  give  morphin  for  pain, 
and  any  infection  or  toxemia  must  be  combated  with  appropriate  remedies. 

If  gout,  rheumatism,  or  syphilis  is  regarded  as  causative,  proper  remedies 
must  be  given.  It  is  most  important  to  maintain  the  secretion  of  the  kidneys. 
If  abscesses  form  in  a  septic  case,  they  must  be  opened  and  drained.  If  a 
large  artery  of  one  of  the  lower  extremities  becomes  occluded,  raise  the  foot 
about  2  inches  from  the  bed,  wrap  the  foot  and  leg  in  cotton-wool,  apply  a 
flannel  bandage  from  the  toes  up,  and  surround  the  limb  with  bags  of  warm 
— not  hot — water.  Hot  water  would  take  more  blood  to  the  region  of  the 
block  than  could  be  distributed.    If  gangrene  occurs,  amputation  is  necessary. 

Chronic  Endarteritis  (Arteriosclerosis,  Atheroma,  Arteriocapillary  Fibrosis, 
Cardiovascular  Degeneration). — By  these  terms  we  mean  thickening  of  the 
walls  of  the  arteries,  limited  in  area  or  widespread,  due  to  inflammation  or 
degeneration  of  the  middle  coat,  the  media  tmdergoing  hypertrophy  and  the 
intima  fibrous  hyperplasia  (Wm.  Russell,  "Brit.  Med.  Jour.,"  Jiine  4,  1904). 
Atheroma  is  used  to  designate  the  disease  when  it  attacks  the  large  vessels 
and  is  characterized  by  advanced  degeneration.  Chronic  endarteritis  is  due  to 
increase  of  blood-pressure.  Hypertension  precedes  sclerosis  and  causes  it. 
Hypertension  is  detected  and  measured  by  the  sphygmomanometer.  Increase 
of  blood-pressure  means  increase  of  arterial  tension,  because  the  lumen  of  the 
vessels  is  lessened  and  the  heart  works  more  strongly  to  urge  the  blood  along, 
and  finally  hypertrophy  of  the  middle  coat  occurs.  The  persistence  of  arterial 
contraction  which  causes  increase  of  blood-pressure  may  be  brought  about  by 
kidney  disease,  hard  work,  violent  strains,  heart  disease,  care  and  anxiety, 
worry  and  mental  strain,  alcoholic  or  venereal  excesses,  habitual  gluttony, 
s)rphilis,  gout,  rheumatism,  lead-poisoning,  diabetes,  and  acute  infections  like 
typhoid  fever  and  influenza.  It  may  arise  in  an  old  man  who  has  not  suffered 
particularly  from  any  of  the  above-named  causes,  or  may  occur  prematurely 


Chronic  Endarteritis  415 

from  toxemia  or  heredity.  It  is  a  true  saying  of  CazaHs  that  "A  man  is  as  old 
as  his  arteries,"  and  a  young  man  debihtated  by  syphiUtic  disease  or  alcohol 
may  have  diseased  arteries,  and  hence  be  really  older  than  a  healthy  man  of 
sixty.  Heredity  may  be  commonly  traced  in  heart  disease  due  to  diseased 
coronary  arteries,  and  cerebral  hemorrhage  due  to  disease  of  the  middle 
cerebral  arteries.  The  aorta,  of  all  vessels,  is  most  prone  to  suffer.  The  large 
vessels  are  more  apt  to  be  diseased  than  the  small,  but  even  the  arterioles  can 
be  involved.  The  arteries  of  the  stomach,  liver,  and  mesentery  are  rarely 
sclerotic.  In  arteriosclerosis  connective  tissue  is  substituted  for  the  normal 
elements  of  the  vascular  wall,  and  this  tissue  undergoes  hyperplasia  and  sub- 
sequent contraction  and  induration.  If  the  mass  of  proliferating  fibroblasts 
undergoes  fatty  degeneration,  atheroma  is  said  to  exist,  and  an  atheromatous 
vessel  may  be  calcified  by  deposition  of  lime-salts.  When  fatty  degeneration 
occurs  the  endothelium  is  destroyed,  the  vessel  wall  is  damaged,  and  the  blood 
may  obtain  access  to  the  deeper  coats.  Atheroma  is  a  frequent  cause  of 
thrombosis,  aneurysm,  senile  gangrene,  and  apoplexy. 

A  sclerosed  artery  is  rigid,  non-contractile,  and  inelastic,  and  the  parts  it 
suppHes  are  cold,  congested  and  ill  nourished,  and  often  edematous.  When 
the  caUber  of  arteries  remains  narrowed  because  of  persistent  contraction 
or  of  arteriosclerosis  there  is  marked  accentuation  of  the  second  aortic  sound. 
The  valve  or  door  which  opened  dmring  systole  is  slammed  shut  during  diastole 
by  the  peripheral  resistance.  The  heart  is  obliged  to  overwork  and  in  conse- 
quence undergoes  hypertrophy.  The  h}'pertrophied  heart  finally  dilates.  If  a 
h}pertrophied  heart  exists  with  diseased  arteries,  apoplexy  or  aneurysm  is 
apt  to  occur  (Nammack,  ''Med.  Record,"  Oct.  26,  1901).  Syphilitic  arteritis 
is  characterized  by  an  enormous  growth  of  granulation  tissue  from  the  inner 
coats  of  arteries  of  small  size  (obi iterative  endarteritis).  Calcification  of  an 
artery  may  be  secondary'  to  fatty  change,  or  may  occur  primarily  from  de- 
posit of  lime-salts  in  the  middle  coat.  Periarteritis  is  inflammation  of  the 
sheath  and  outer  coat.  An  acute  arteritis  is  always  local,  but  a  chronic  arteritis 
may  be  general.  If  obHterative  endarteritis  exists  in  a  limb,  the  veins  are 
almost  certain  to  be  involved  as  well  as  the  arteries.  For  this  condition  of 
veins  and  arteries,  Buerger  suggests  the  term  "thrombo-angiitis  obhterans" 
(seepage  165). 

Treatment. — In  treating  chronic  arteritis,  endeavor  to  antagonize  the  dan- 
gers to  which  the  patient  is  ob^aously  liable.  Forbid  alcohol  as  a  beverage, 
though  a  little  whisky  may  be  taken  at  meals.  Maintain  the  acti\-ity  of  the 
skin  by  daily  baths,  and  of  the  kidneys  by  dim-etic  waters.  A  daily  bowel 
movement  should  be  secured.  The  diet  is  to  be  plain  and  is  to  contain  a 
minimum  of  nitrogen.  If  syphilis  has  existed,  occasional  courses  of  iodid  of 
potassium  are  to  be  given.  If  the  arterial  tension  at  any  time  becomes  in- 
ordinately high,  administer  nitroglycerin.  One  danger  to  which  the  patient 
is  liable  is  apoplexy-,  hence  excitement  and  \'iolent  exercise  are  to  be  avoided. 
Another  danger  is  senile  gangrene;  hence  the  patient  should  wear  woolen 
stockings,  put  a  bottle  or  bag  of  warm  water  to  his  feet  at  night,  and  be 
careful  to  avoid  injuring  his  toes  or  feet,  especially  when  cutting  his  corns. 
A  bag  of  very  warm  water  is  dangerous  and  may  actually  excite  gangrene. 
When  a  patient  with  atheroma  has  dyspnea  and  is  of  a  Hvid  color,  or  w^hen 
the  arterial  tension  is  very  high,  a  moderate  blood-letting  (16  to  18  oz.)  does 
good,  and  may  prevent  or  arrest  edema  of  the  lungs.  Still  another  danger  is 
aneurysm,  which  may  appear  suddenl}'  from  rupture  or  gradually  from  pro- 
gressive distention. 

It  has  been  suggested  that  endarteritis  threatening  gangrene  of  the  foot 
should  be  treated  by  an  anastomosis  between  the  common  femoral  artery 
and  the  femoral  vein,  in  order  that  the  blood  may  be  directed  from  blocked 


4i6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

to  open  channels,  and  hence  may  still  nourish  the  extremity.  The  operation 
is  only  to  be  advised  when  pulsation  is  absent  in  the  tibials,  when  the  femoral 
high  up  seems  normal,  and  when  the  deep  veins  are  patent  (see  page  183). 

Buerger  suggests  the  following  test  of  the  patency  of  the  deep  veins  ("Jour. 
Am.  Med.  Assoc,"  April  24,  1909):  'T  allow  the  limb  to  hang,  watch  for 
the  advent  of  the  erythema,  and  wait  until  a  fair  degree  of  cyanosis  has  be- 
come established.  This  may  take  considerable  time — five  to  ten  minutes. 
The  veins  are  then  obliterated  above  the  knee  by  means  of  a  Martin  bandage 
properly  applied.  The  limb  is  then  raised  high  and  the  bandage  loosened 
just  enough  so  as  to  remove  pressure  from  the  deep,  but  not  from  the  super- 
ficial, veins.  If  the  cyanosis  is  slow  in  disappearing  or  fails  to  disappear,  it 
may  be  concluded  that  the  function  of  the  deep  veins  is  impaired." 

An  aneurysm  is  a  pulsating  sac  containing  blood  and  communicating 
with  the  cavity  of  an  artery,  and  formed  partly  or  entirely  by  the  arterial 
walls  or  is  a  fusiform  dilatation  of  an  artery.  Some  restrict  the  term  "true 
aneurysm"  to  a  condition  of  dilatation  involving  all  the  coats  of  the  vessel. 
We  shall  consider,  with  Heath,  a  true  aneurysm  to  be  one  in  which  the  blood 
is  included  in  one  or  more  of  the  arterial  coats,  and  a  false  aneurysm  to  be  a  con- 
dition in  which  the  vessel  has  been  wounded,  has  ruptured  or  has  atrophied  and 
the  aneurysmal  wall  is  formed  by  a  condensation  of  the  perivascular  tissues. 

Forms  of  Aneurysm. — The  following  forms  of  aneurysm  are  recognized: 

1.  True  aneurysm — one  whose  sac  is  formed  of  one  or  more  arterial  coats. 

2.  False  aneurysm— one  whose  sac  is  formed  of  condensed  perivascular 
tissues  and  contains  no  arterial  coat. 

3.  Traumatic  difftised  aneurysm — a  false  aneurysm  due  to  a  wound  or 
traumatic  rupture  of  a  blood-vessel.  At  first  the  blood  is  widely  diffused  and 
unlimited  by  any  sac  or  capsule,  later  a  limitation  or  encapsulation  may  occur 
by  the  condensation  of  tissue,  any  wound  being  healed.  A  traumatic  diffuse 
aneurysm  may  follow  a  puncture  or  an  incised  wound  of  an  artery,  the  injury 
causing  the  aneurysm  directly.  It  may  follow  an  effort  or  a  strain,  the  injury 
indirectly  causing  the  aneurysm  by  acting  on  a  diseased  vessel.  As  Barwell 
says,  the  term  "traumatic  diffused  aneurysm"  is  an  extremely  bad  one,  as  the 
term  "aneurysm"  conveys  the  idea  of  some  sort  of  a  sac.  In  this  condition 
there  is  no  true  sac  and  blood  is  either  unlimited  or  limited  only  by  condensed 
tissue. 

4.  Diffused  aneurysm — a  term  used  to  mean  a  ruptured  aneurysm,  the 
blood  being  diffused  in  the  tissues  and  either  unlimited  or  limited  only  by  con- 
densed tissues.  The  term  should  be  limited  to  conditions  in  which  the  effusion 
of  blood  is  slow  and  trivial.  If  the  effusion  is  large  and  rapid,  the  term  rup- 
tured aneurysm  is  preferable. 

5.  Consecutive  aneurysm  results  from  the  rapid  growth  of  a  sacculated 
aneurysm.  At  a  certain  portion  of  the  sac  of  a  true  aneurysm  the  arterial  coats 
give  way  completely,  and  at  this  point  blood  is  limited  only  by  clot  and  by 
condensed  perivascular  tissue.  The  blood  is  not  diffused,  but  is  encapsuled, 
partly  by  the  old  sac,  partly  by  condensed  tissues,  aided  it  may  be  by  bone 
and  fascia. 

6.  Fusiform  or  tubulated  aneurysm — a  variety  of  true  aneurysm,  the  sac 
being  spindle-shaped  and  formed,  as  Matas  states,  "at  the  expense  of  the 
artery,"  the  artery  dilates,  the  continuity  of  the  parent  artery  is  interrupted 
for  a  variable  length,  and  is  lost  in  the  sac,  to  be  restored  once  more  as  a  normal 
vessel  at  the  outlet  of  the  aneurysm  ("Transactions  of  Am.  Surg.  Assoc," 
1905).  Such  an  aneurysm  has,  of  course,  two  openings.  This  form,  accord- 
ing to  Matas,  comprises  66.6  per  cent,  of  all  aneurysms. 

7.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in  which  the 
dilatation  is  like  a  pouch,  arising  from  a  part  of  the  arterial  circumference 


Forms  of  Aneurysm  417 

and  adjoining  the  lumen  of  the  vessel  by  a  single  aperture;  As  Matas  points 
out,  the  parent  artery  is  involved  in  but  a  portion  of  its  circumference,  the  con- 
tinuity of  the  vessel  is  not  lost,  the  arterial  caliber  is  maintained  at  a  nearly 
normal  diameter,  and  "the  sac  is  simply  grafted  or  attached  to  the  artery  by  a 
narrow  neck,  forming  a  sort  of  diverticulum  of  variable  shape  and  dimensions" 
("Proceedings  of  Am.  Surg.  Assoc,"  1905).  Such  a  sac  has  but  one  orifice. 
The  opening  from  the  artery  into  the  sac  is  called  the  mouth;  around  and  just 
above  the  mouth  is  the  neck;  the  balance  of  the  sac  is  much  larger  than  the 
neck  and  is  called  the  body.  A  sacculated  aneurysm  may  arise  from  an  artery 
of  normal  size,  from  a  dilated  artery,  or  from  a  fusiform  aneurysm.  A  sac- 
culated aneurysm  of  unknown  cause  is  called  a  spontaneous  aneurysm;  one 
which  is  due  to  injury  is  called  a  traumatic  aneurysm.  The  first  step  in  the 
formation  of  a  sacculated  aneurysm  is  stretching  or  giving  way  of  an  area 
of  the  middle  coat  (media),  followed  by  a  gradually  advancing  stretching  and 
dilatation  of  corresponding  areas  of  the  outer  coat  (adventitia)  and  the  inner 
coat  (intima). 

8.  Dissecting  aneurysm  (Shekelton's  aneurysm) — a  pouch-like  dilatation  of 
an  artery  due  to  the  blood-stream,  which  has  gained  access  to  the  middle  coat 
through  an  atheromatous  ulcer  or  a  minute  rupture  of  the  inner  coat.  It  used  to 
be  taught  that  the  blood  flows  between  the  media  and  adventitia ;  we  now  know 
that  it  flows  between  the  layers  of  the  middle  coat.  The  outer  wall  of  the  aneu- 
rysm consists  of  adventitia  and  a  portion  of  the  middle  coat.  The  unnatural 
channel  may  or  may  not  join  the  lumen  of  the  artery  at  another  point  by  a 
fresh  aperture  in  the  intima.  Dissecting  aneurysm  is  practically  only  met  with 
in  the  aorta.  It  is  most  common  in  the  thoracic  aorta.  About  80  cases  have 
been  reported.^ 

9.  Arteriovenous  aneurysm,  which  is  divided  into  aneurysmal  varix,  or 
Pott's  aneurysm,  when  there  is  direct  communication  between  a  vein  and  an 
artery ;  and  varicose  aneurysm,  when  there  is  communication  between  an  artery 
and  a  vein  by  means  of  an  interposed  sac. 

10.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart,  which  cavity  com- 
municates with  the  interior  of  this  organ,  and  which  is  due  to  suppuration 
in  the  course  of  acute  endocarditis  or  myocarditis. 

11.  Aneurysm  by  Anastomosis. — (See  Angiomata.) 

12.  Aneurysm  of  bone — an  inaccurate  cHnical  term  used  to  designate  a 
pulsatile  tvimor  of  bone.. 

13.  Circumscribed  aneurysm — when  the  blood  is  circumscribed  by  distinct 
walls. 

14.  Cirsoid  aneurysm — a  mass  of  dilated  and  elongated  arteries  shaped 
like  varicose  veins  and  pulsating  with  each  heart-beat. 

15.  Cylindrical  aneurysm — a  dilatation  which  maintains  the  same  dimen- 
sions for  a  considerable  space. 

16.  Embolic  or  capillary  aneurysm — dilatation  of  terminal  arteries  due  to 
emboli. 

17.  Spontaneous  aneurysm — non-traumatic  in  origin. 

18.  Miliary  aneurysm— a.  minute  dilatation  of  an  arteriole. 

19.  Secondary  aneurysm — one  which,  after  apparent  cure,  again  pulsates, 
the  blood  entering  by  means  of  the  anastomotic  circulation. 

20.  Verminous  aneurysm — one  containing  a  parasite.  This  form  of  aneu- 
rysm is  met  with  in  the  mesenteric  artery  of  the  horse. 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of  at  least  two  of  the 

arterial  coats,  reinforced  by  the  sheath  and  perivascular  tissues.     After  a 

time  the  blood-pressure  distends  the  sac,  and  the  inner  and  middle  coats  either 

stretch  with  interstitial  growth  or — what  is  more  common — are  worn  away 

1  Coleman,  in  "Dublin  Jour.  Med.  Sciences,"  Aug.,  1898. 

27 


4i8  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  lost.  When  all  the  coats  are  lost  and  the  blood  is  sustained  only  by 
the  sheath  and  surrounding  tissue,  a  true  aneurysm  becomes  a  false  or  con- 
secutive aneurysm,  the  limiting  tissues  and  sheath  being  condensed,  thick- 
ened, and  glued  together.  This  limiting  process  is  deficient  in  the  brain, 
hence  cerebral  aneurysms  break  soon  after  their  formation.  When  all  the 
arterial  coats  are  lost,  the  blood-pressure,  acting  on  the  tissues,  finds  some 
spots  less  resistant  than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures  externally  or  into 
a  cavity. 

An  aneurysm  may  rupture  into  a  cavity  (pleural,  pericardial,  or  peritoneal), 
into  the  perivascular  tissues,  or  through  the  skin.  Rupture  into  the  tissues 
may  produce  pressure-gangrene.  When  rupture  occurs  through  the  skin  the 
hemorrhage  is  not  often  instantly  fatal,  but  during  several  days  recurs  again 
and  again  in  larger  and  larger  amounts.  The  pressure  of  an  aneurysm  causes 
atrophy  of  tissues,  hard  and  soft,  bones  and  cartilages  being  as  easily  destroyed 
as  muscles  and  fat.  Sometimes  the  perivascular  tissues  inflame  and  suppurate, 
and  the  sac  is  opened  rapidly  by  sloughing.  An  aneurysm  usually  progresses 
toward  rupture,  the  slowest  in  this  progression  being  the  fusiform  dilatation, 
which  may  exist  for  many  years,  but  which  finally  is  converted  into  the  sac- 
culated variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure,  which  may 
result  from  laminated  fibrin  being  deposited  upon  the  walls  of  the  sac  as  the 
blood  circulates  through  it.  The  laminated  fibrin  is  known  as  an  "active 
clot,"  and  eventually  fills  the  sac.  The  weaker  and  slower  the  blood-stream, 
the  greater  is  the  tendency  to  the  formation  of  an  active  clot,  hence  any  agent 
impeding,  but  not  abolishing,  the  circulation  aids  in  the  deposition.  The 
weakening  and  slowing  of  circulation  may  be  brought  about  by  great  activity 
of  the  collateral  circiilation  diverting  most  of  the  blood  from  the  area  of  dis- 
ease. Sometimes  a  clot  breaks  off  from  the  sac  wall  and  plugs  the  artery 
beyond  the  aneurysm,  and  the  anastomotic  vessels,  enlarging,  divert  the 
blood-stream.  A  large  aneurysm,  falling  over  by  its  own  weight  upon  the 
vessel  above  the  mouth  of  the  sac,  may,  in  very  unusual  cases,  diminish  the 
blood-stream.  The  development  of  another  aneurysm  upon  the  same  vessel 
nearer  to  the  heart  weakens  the  circulation  in  and  may  cure  the  older  one. 
Inflammation  occasionally  forms  a  clot.  The  tissues  about  an  aneurysm 
tend  to  contract  w^hen  arterial  force  is  lessened,  hence  tissue-pressure  may 
more  than  counteract  blood-pressure  when  the  circulation  is  feeble.  Clotting 
of  the  blood  contained  within  a  sac,  circulation  through  the  aneurysm  having 
ceased,  causes  a  "passive  clot."  A  passive  clot,  which  occasionally  induces 
cure,  may  arise  from  a  twist  of  the  neck  of  the  sac  preventing  the  passage  of 
blood,  from  the  lodgment  of  a  clot  in  the  mouth  of  the  sac,  and  from  inflam- 
mation.    Spontaneous  ciire  is,  unfortunately,  very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial  coats  which  are  in 
a  condition  of  arterial  sclerosis,  or  of  coats  whose  resisting  power  is  lowered 
because  of  atheroma,  may  cause  aneurysm.  Hence,  the  causes  of  sclerosis 
and  atheroma  are  also  causes  of  aneurysm.  The  principal  cause  of  aneury^sm 
is  increased  blood-pressure.  This  increase  may  be  brought  about  by  severe 
labor;  by  sudden  strains,  as  in  lifting;  by  violent  efforts,  as  in  rowing  in  a 
boat-race;  by  chronic  interstitial  nephritis;  by  hypertrophy  of  the  heart; 
by  alcoholic  excess,  and  by  syphilis.  Arterial  disease  is  commonest  in  the 
larger  vessels,  and  in  the  aged,  but  it  may  occur  in  youth.  When  an  aneurysm 
follows  a  strain,  it  may  be  due  to  laceration  of  the  media  and  loss  of  resistance 
at  a  narrow  point.  The  intima  may  lacerate,  permitting  the  blood  to  come  in 
contact  with  the  media  or  causing  blood  to  diffuse  between  the  coats  (dis- 
secting aneurysm).     When  an  embolus  lodges  in  an  artery  the  vessels  may 


Symptoms  of  Aneurysm  41Q 

become  aneurysmal  on  the  proximal  side  of  the  clot.  The  embolus,  if  infective, 
causes  softening,  and  if  calcareous  causes  laceration  (Osier).  Colonies  of 
micrococci  may  cause  aneurysm.^  The  parasite  Strongylus  armatus  causes 
aneurysm  of  the  mesenteric  arteries  in  horses.  Suppuration  around  a  vessel 
weakens  its  coats  and  tends  to  aneurysm  by  inducing  acute  arteritis  and  soft- 
ening. Sometimes  an  individual  develops  multiple  aneurysms  the  origins  of 
which  are  absolutely  unknown.  A  bruise  of  a  vessel  may  be  followed  by 
aneurysm.  A  cut  or  puncture  of  a  healthy  artery  may  lead,  after  the  surface 
wound  heals,  to  the  development  of  an  aneurysm.  Such  an  aneurysm  does 
not  differ  in  symptoms  or  treatment  from  the  other  form. 

The  constituent  parts  of  an  aneurysm  are:  (i)  the  wall  of  the  sac;  (2)  the 
cavity;  (3)  the  mouth,  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — The  formation  of  an  aneurysm,  when  sudden, 
is  occasionally,  though  rarely,  appreciated  by  the  patient,  and  is  described 
by  him  as  a  feeling  of  something  having  given  way.  In  most  instances  the 
feeling  of  beating  and  the  discovery  of  the  lump  are  the  first  intimations  that 
anything  is  wrong.  An  oval  or  globular,  soft,  elastic,  and  pulsatile  protrusion 
develops  in  the  line  of  an  artery.  It  is  usually  quite  evident  to  the  touch  that 
the  sac  contains  fluid,  but  sometimes  in  old  aneurysms  the  sac  feels  firm  or 
even  hard,  because  of  the  deposit  of  fibrin  upon  its  inner  surface.  In  a  par- 
tially consolidated  aneurysm  pulsation  may  be  slight  or  even  inappreciable. 
The  protrusion  instantly  ceases  to  pulsate  and  almost  disappears  on  making 
fijrm  pressure  on  the  artery  above.  On  relaxing  the  pressure  the  pulsatile 
enlargement  at  once  reappears.  Direct  pressure  upon  the  tumor  may  cause 
it  to  almost  disappear.  Pressure  upon  the  artery  below  causes  the  tumor 
to  enlarge.  The  pulsation  is  expansile — that  is,  the  sac  expands  in  all  direc- 
tions during  every  cardiac  contraction — and  if  an  index-finger  be  laid  on  each 
side  of  the  timior  so  that  the  points  nearly  touch,  each  piilsation  not  only  lifts 
the  fingers,  but  it  also  separates  them.  It  is  important  to  remember  that  a 
large  intrathoracic  aneurysm  which  is  in  contact  with  the  chest  may  not  exhibit 
expansile  pulsation,  but  simply  transmit  pulsation  from  the  blood-stream 
(Sidney  Lange,  in  "N.  Y.  Med.  Jour.,"  Nov.  21,  1908).  On  placing  a  stetho- 
scope over  the  aneurysm  or  over  the  vessel  below  the  aneurysm  there  is  im- 
parted to  the  ear  a  distinct  bruit,  which  travels  in  the  direction  of  the  blood- 
stream, is  systolic  in  time,  and  is  usually  blowing  in  character.  In  some  cases 
bruit  is  absent  (when  a  sacculated  aneurysm  has  a  very  small  mouth,  when  the 
circulation  is  tranquil,  or  when  the  sac  is  full  of  blood  and  clot).  When  bruit  is 
absent,  it  may  sometimes  be  developed  by  muscular  exercise  or  raising  the 
affected  limb  (Halloway).  In  rare  cases  there  may  be  a  double  bruit.  Occa- 
sionally, in  fusiform  aortic  aneurysm  linked  with  aortic  regurgitation,  a  diastoUc 
bruit  exists.  A  bruit  is  arrested  by  pressing  upon  the  artery  between  the 
aneurysm  and  the  heart.  A  patient  who  has  an  aneurysm  of  an  extremity 
complains  of  a  sensation  of  beating,  of  weakness  or  stiffness  of  the  limb,  fre- 
quently of  pain  in  a  nerve,  a  feeling  of  fatigue  in  the  muscles,  and  edema  and 
dilated  veins  are  apt  to  develop  because  of  pressure  upon  large  veins  and  loss  of 
vis  a  iergo  in  the  circulation.  The  skin  over  an  aneurysm  may  be  normal,  may 
be  discolored,  may  ulcerate,  or  even  slough.  The  pulse  below  an  aneurysm  is 
weaker  than  the  pulse  of  a  corresponding  part  of  the  opposite  limb.  This  is 
well  shown  by  sphygmographic  tracings  (Fig.  189).  The  tracings  taken  below 
an  aneurysm  are  rounded  without  a  sudden  rise  or  an  abrupt  fall.  In  inter- 
nal aneurysms  pressure  symptoms  are  marked.  Thoracic  aneurysm  causes  in- 
tercostal pain;  iliac  aneurysm  causes  pain  in  the  thigh.  Abdominal  aneurysm 
is  very  rare.  It  is  most  common  near  the  diaphragm.  It  is  more  apt  to  be 
sacculated  than  fusiform.  As  a  rule,  it  distends  forward;  if  it  distends  back- 
^  See  Osier  on  "Malignant  Endocarditis." 


420  Diseases  and  Injuries  of  the  Heart  and  Vessels 

ward  it  may  destroy  the  vertebrae  and  press  upon  the  cord.  Pain  practically 
always  occurs,  usually  in  the  back,  sometimes  in  the  abdomen.  Expansile 
pulsation  and  bruit  make  the  diagnosis  clear.  The  x-rays  may  be  valuable  in 
establishing  the  diagnosis.  Aneurysm  of  the  thoracic  aorta  pressing  upon 
the  pneumogastric  nerve  causes  spasmodic  dyspnea,  and  upon  the  recurrent 


Fig.  189. — Radial  pulse-tracings  in  aneurysm  of  right  brachial  artery:  i,  Left  radial  pulse;  2,  right 

radial  pulse  (after  Mahomed). 

laryngeal  causes  hoarseness,  which  may  be  associated  with  loss  of  voice,  cough, 
and  laryngeal  spasm,  and  is  due  to  unilateral  abductor  paralysis.  Pressure 
upon  a  bronchus  or  the  trachea  causes  dyspnea  from  obstruction,  dysphagia, 
and  cough  from  laryngeal  spasm.     Pressure  upon  the  cervical  sympathetic 


Fig.  190. — X-ray  of  aneurysm  of  thoracic  aorta. 

first  causes  dilatation  and  later  contraction  of  the  pupil  of  the  same  side.  A 
thoracic  aneurysm  may  erode  the  ribs,  sternum,  or  vertebrae.  The  x-rays  are 
of  great  value  in  diagnosticating  thoracic  aneurysm  (Fig.  190).  An  aneurysm  in 
the  neck  may  interfere  with  the  cerebral  circulation  and  produce  vertigo  and 
even  attacks  of  unconsciousness.    The  evidences  of  rupture  of  an  aneurysm  of 


Treatment  of  Aneurysm  421 

an  extremity  into  the  tissues  are  loss  of  distinctness  of  outline  and  increase  in 
area  of  the  swelling,  weakening  or  disappearance  of  both  bruit  and  pulsation, 
absence  of  pulse  below  the  aneurysm,  severe  pain,  edema  and  coldness  of  the 
surface,  shock,  and  possibly  syncope.  External  hemorrhage  may  arise;  the 
tissues  may  become  extensively  infiltrated  with  blood;  sloughing  or  gangrene 
may  ensue.  Death  is  frequent,  and  only  in  very  rare  cases  does  spontaneous 
cure  take  place.  Rupture  of  a  large  aneurysm  into  a  cavity  causes  intense 
pallor,  advancing  weakness,  syncope,  and  death. 

Diagnosis. — ^A  cyst  or  abscess  over  a  vessel  may  show  transmitted  pulsa- 
tion which  is  not  expansile,  and  the  swelling  does  not  disappear  when  pressure 
is  made  upon  the  vessel  above  it.  The  pulsation  ceases  when  the  growth  is 
lifted  off  the  vessel,  or  when  the  position  is  changed  so  as  to  permit  it  to  fall 
away  from  the  vessel.  There  is  no  true  bruit,  and  the  history  is  widely  differ- 
ent. A  growth  under  a  vessel  may  lift  the  vessel  and  simulate  an  aneurysm, 
but  the  pulsation  is  not  noted  in  the  entire  growth,  the  growth  does  not  dis- 
appear on  proximal  pressure,  and  there  is  only  a  false,  and  never  a  true,  bruit. 
The  larger  the  growth  under  a  vessel  the  less  is  the  pulsation,  because  of  pres- 
sure narrowing  the  caliber  of  the  vessel.  A  sarcoma,  especially  a  soft  sarcoma 
attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate  and  often  have  a  bruit; 
the  tumor  never  disappears  from  proximal  pressure,  though  it  may  slowly 
diminish  in  size,  to  gradually  enlarge  again  when  pressure  is  withdrawn. 
These  growths  do  not  feel  fluid,  and  are  rarely  circumscribed.  An  aneurysm 
may  cease  to  pulsate  from  consolidation  leading  to  cure  or  from  rupture. 
Rupture  of  a  large  aneurysm  into  a  cavity  induces  deadly  pallor,  syncope, 
and  rapid  death.  Rupture  of  an  aneurysm  of  an  extremity  into  the  tissues  is 
made  manifest  by  a  sensation  of  something  breaking,  by  pain,  by  sudden  in- 
crease in  size,  by  diminution  or  absence  of  bruit  and  pulsation,  by  absence  of 
pulse  below  the  aneurysm,  by  swelling  and  coldness  of  the  limb,  and  by  shock. 
The  ic-rays  are  valuable  in  diagnosticating  thoracic  aneurysm  and  abdominal 
aneurysm. 

Treatment. — (For  the  history  of  the  evolution  of  the  treatment  of  aneurysm, 
see  "Studies  in  Aneurysm,"  by  James  G.  Mumford,  "Cleveland  Med.  Jour.," 
Feb.,  1908.)  In  inoperable  aneurysms,  general,  medical,  and  dietetic  treat- 
ment must  be  tried.  A  chief  element  in  treatment  is  rest  in  bed  to  diminish 
the  rapidity  and  force  of  the  circulation  and  favor  fibrinous  deposit.  Valsalva 
long  ago  suggested  rest,  occasional  bleeding,  and  a  diet  just  above  the  point 
cA  starvation.  Tuffnell's  plan  is  to  reduce  the  heart-beats  by  rest  and  mental 
quiet,  and  to  rigidly  restrict  the  diet  so  as  to  diminish  the  total  amount  of 
blood  and  render  it  more  fibrinous.  Liquids  are  restricted  in  amount,  and  the 
patient  lives  through  each  twenty-four  hours  upon  4  oz.  of  bread,  a  very 
little  butter,  8  oz.  of  milk,  and  3  oz.  of  meat.  This  plan  is  pursued  for  several 
months  if  possible,  or  it  is  employed  for  several  weeks,  intermitted  for  a  short 
period,  the  rigid  diet  again  returned  to,  and  so  on,  over  and  over  again.  There 
can  be  no  doubt  that  Tuffnell's  treatment  sometimes  cures  aneurysm  by  de- 
cidedly lowering  the  blood-pressure.  Many  who  suffer  from  aneurysm  may 
be  permitted  to  go  about,  taking  their  time  about  everything  and  avoiding  work, 
worry,  and  excitement.  The  diet  should  be  low  and  non-stimulating,  and  the 
bowels  must  be  maintained  in  a  loose  condition. 

Even  in  an  operable  case  diet  and  rest  are  of  importance.  Often  a  patient 
is  kept  in  bed  for  a  number  of  days  before  operation,  the  daily  diet  consisting 
of  10  or  12  oz.  of  soHd  food  with  a  pint  of  milk.  If  the  circulation  is  very 
active,  use  aconite  and  allay  pain  by  morphin. 

lodid  of  potassium  in  doses  of  20  gr.  undoubtedly  does  good  in  aneurysm 
and  not  only  in  syphilitic  cases.  It  seems  to  lower  the  blood-pressure.  Bal- 
four taught  that  it  thickened  the  walls  of  the  sac.     Osier  says  it  reheves  the 


42  2  Diseases  and  Injuries  of  the  Heart  and  Vessels 

pain.  Iron,  acetate  of  lead,  and  ergotin  are  prescribed  by  some.  Digitalis 
is  contra-indicated,  as  it  raises  the  blood-pressure.  S.  Solis-Cohen  has  used 
with  some  success  the  hydrated  chlorid  of  calcium.  Morphin  and  bromid  of 
potassium  are  occasionally  useful  to  tranquilize  the  circulation,  allay  pain,  or 
secure  sleep.     Aconite  and  veratrum  viride  have  long  been  employed. 

Lancereaux  and  others  claim  that  hypodermatic  injections  of  gelatin  at 
some  indifferent  point  may  cure  aortic  and  subclavian  aneurysm.  In  1896 
Dastres  and  Floresco  proved  that  gelatin  injected  into  the  blood  increases 
coagulability.  Later,  Lancereaux  and  Paulesco  showed  that  injections  into 
the  subcutaneous  tissue  act  similarly.  Carnot  pointed  out  that  gelatin 
applied  to  a  wound  may  arrest  bleeding.  How  gelatin  acts  is  uncertain,  but 
that  it  does  increase  blood  coagulability  seems  proved.  The  value  of  injec- 
tions of  gelatin  for  aneurysm  is  in  dispute.  Lancereaux  warmly  advocates  its 
use  for  sacculated  aneurysm,  and  says  that  after  the  first  dose  the  aneurysm 
is  seen  to  shrink  and  the  pulsation  is  observed  to  lessen.  He  injects  it  slowly 
and  with  aseptic  care  into  the  subcutaneous  tissue  of  the  thigh,  using  normal 
salt  solution  containing  from  5  to  10  per  cent,  gelatin.  He  never  injects  less 
than  5  gm.  He  gives  an  injection  every  tenth  to  fifteenth  day  and  admin- 
isters from  ten  to  twenty  injections.  But  the  treatment  is  not  free  from 
danger;  several  deaths  have  taken  place,  and  several  persons  have  died  from 
tetanus.  Care  must  be  taken  not  to  inject  gelatin  into  a  vessel,  and  it  must 
never  be  thrown  about  the  aneurysmal  sac.  It  irritates  the  kidneys  and 
its  use  is  contra-indicated  in  renal  disease.  The  injections  cause  much  pain, 
and  it  is  very  doubtful  if  they  do  any  real  good  in  aneurysm.  If  used  it  should 
be  given  at  the  temperature  of  the  body,  and  not  over  3  gm.  should  be  ad- 
ministered at  one  dose.  A  10  per  cent,  solution  is  the  proper  strength  and 
from  10  to  20  c.c.  the  correct  dose.  Gelatin  can  be  given  by  the  mouth. 
When  thus  given  it  is  not  so  powerful,  but  its  coagulating  property  is  not 
destroyed  by  digestion.  Gelatin  in  normal  salt  solution  is  known  as  Car- 
not's  solution.  Carnofs  solution  is  best  prepared  by  Sailer's  formula,  as 
follows  (Joseph  Sailer,  in  "Therapeutic  Gazette,"  August,  1901):  Take  5 
gm.  of  common  salt,  i  liter  of  distilled  water,  and  100  gm.  of  gelatin.  Bring 
the  water  to  a  temperature  of  80°  C.  and  slowly  stir  in  the  gelatin  until  it 
is  all  in  solution.  Remove  the  solution  from  the  stove,  cool  it  to  40°  C.,  add 
to  it  the  white  of  one  egg,  and  stir  for  several  minutes,  and  then  put  the  flask 
on  the  stove  and  boil  the  fluid.  The  white  of  egg  coagulates  and  clears  the 
solution.  Filter  through  gauze  and  then  through  paper.  Place  the  fluid  in 
test-tubes,  each  of  which  will  contain  10  c.c,  and  insert  a  cotton  plug  in  the 
mouth  of  each  tube.  Sterilize  by  putting  the  tubes  in  a  steam  sterilizer  for 
fifteen  minutes  on  three  successive  days.  When  wishing  to  use  a  tube,  place 
it  in  a  cup  of  hot  water  until  the  gelatin  liquefies,  pour  the  gelatin  into  a  sterile 
glass,  and  draw  it  up  into  a  sterile  syringe.  When  kept  several  weeks  the  gel- 
atin dries  out. 

Other  expedients  sometimes  used  in  the  treatment  of  aneurysm  are:  the 
kneading  of  the  sac  to  release  a  clot,  in  the  hope  that  it  will  plug  the  mouth 
of  the  sac  or  the  artery  beyond  it — this  is  dangerous;  electricity;  electrolysis; 
the  injection  of  an  astringent  liquid;  the  insertion  of  a  fine  aspirating  needle 
and  the  pushing  through  it  into  the  sac  of  a  large  quantity  of  silver  wire,  in 
the  hope  that  it  will  aid  in  whipping  out  fibrin.  Some  physicians  have  inserted 
needles  and  others  horsehair. 

Treatment  by  Pressure. — Instrumental  pressure  is  made  by  applying  two 
Signorini  tourniquets  or  some  specially  devised  apparatus  to  limit  the  flow 
of  blood  through  an  aneurysm  without  entirely  stopping  it,  the  aneurysmal 
sac  being  felt  to  still  slightly  pulsate.  In  some  situations  Lister's  abdominal 
tourniquet  is  applied;  in  other  regions  we  may  use  Tuffnell's  compress,  which 


Treatment  of  Aneurysm  423 

is  like  a  spring  truss  and  is  strapped  in  place.  A  heavy  body  suspended  over 
the  aLvtevy  and  resting  part  of  its  weight  upon  the  vessel  has  occasionally 
brought  about  cure.  Compressing  instruments  can  be  worn  for  from  twelve 
to  sixteen  hours  at  a  time;  usually  they  are  removed  to  permit  sleep  and  are 
reapplied  the  next  day,  and  so  on  for  several  days.  Before  applying  the  com- 
press be  sure  the  sac  is  full  of  blood,  and  render  this  certain  by  applying  for 
a  few  minutes  distal  compression.  This  method  may  cure,  but  it  is  very 
painful.  It  cannot  be  used  successfully  in  treating  aneurysm  of  the  axillary, 
subclavian,  or  carotid  artery.     It  aids  in  the  formation  of  an  active  clot. 

Digital  pressure,  made  vdth.  the  thumb  aided  by  a  weight,  and  maintained 
for  many  hours  by  a  relay  of  assistants,  has  cured  many  cases.  This  method 
may  be  used  alone  or  may  be  used  as  an  accessory  to  instrumental  pressure. 
Its  chief  field  is  in  the  treatment  of  aneurysm  for  which  other  methods  are 
inapplicable  (orbit  and  some  aneurysms  at  the  root  of  neck).  It  entirely  cuts 
oflf  the  blood  and  promotes  the  formation  of  a  passive  clot.  If  cure  does  not 
take  place  in  three  days,  abandon  pressure.  It  must  often  be  abandoned  far 
earlier  because  of  pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm  of  the  popliteal 
arter}^,  the  pressure  being  obtained  by  flexing  the  leg;  and  in  aneurj^sm  of  the 
brachial  artery  pressure  has  been  applied  at  the  bend  of  the  elbow  by  flexing 
the  elbow.  The  pressure  of  a  hollow  rubber  baU  has  been  used  in  aneurysm 
of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood  through  the  sac 
for  a  limited  time,  and  is  appHed  while  the  patient  is  under  the  influence  of 
an  anesthetic.  Take,  for  example,  a  case  of  popliteal  aneurysm:  the  patient 
is  placed  under  the  influence  of  ether;  two  Esmarch  bandages  are  used,  one 
being  applied  to  the  limb  frorii  the  toes  up  to  the  lower  limit  of  the  aneur\-sm, 
and  the  other  from  the  groin  down  to  the  upper  limit  of  the  sac,  and  the  Es- 
march band  is  fastened  above  the  upper  bandage.  This  prodecure  stagnates 
the  blood  both  in  the  veins  and  in  the  arteries,  and  the  sac  remains  fuU  of 
blood.  Pressure  is  thus  maintained  for  three  or  four  hours,  and  on  removing 
the  Esmarch  apparatus  a  tourniquet  is  put  on  the  artery  above  the  aneur\'sm 
and  partly  tightened  in  order  to  limit  the  amount  of  blood  passing  through 
and  thus  prevent  the  washing  away  of  clot.  This  method  of  rapid  pressure 
sometimes  cures  by  forming  a  passive  clot,  but  it  sometimes  results  in  gan- 
grene.    It  was  de\dsed  by  John  Reid. 

Operative  Treatment:  By  the  Ligature  and  by  Sutures. — Ligation  of  the  main 
arter\^  was  the  operation  employed  by  most  surgeons  untfl  the  Matas  opera- 
tion was  introduced.  The  methods  of  ligation  are:  (i)  the  method  of  An- 
tyUus;  (2)  extirpation  of  the  sac;  (3)  the  method  of  An  el;  (4)  the  method  of 
Himter;  (5)  the  method  of  Wardrop,  and  (6)  the  method  of  Brasdor. 

Aneurysmotomy,  the  7nethod  of  Antyllus  (Fig.  191),  a  Roman  successor  to 
Galen,  who  lived  in  the  third  century,  a.  d.,  is  usuaUy  described  as  a  method 
invoh-ing  a  direct  attack  upon  the  sac  itself.  The  arter}"  is  ligated  immediately 
above  and  below  the  sac,  the  sac  is  opened  and  its  contents  turned  out,  or  the 
sac  is  extirpated.  As  a  matter  of  fact,  Antyllus  advocated  applying  a  ligature 
on  each  side  of  the  sac  and  opening  the  sac  in  order  to  evacuate  its  contents, 
but  he  distinctly  opposed  extirpation  because  of  its  danger.  All  we  know  of 
AntyUus  is  found  in  the  wTitings  of  Oribasius,  who  lived  in  the  fourth  cen- 
tury. S}Tne  maintained  many  years  ago  that  incision  of  the  sac  is  the  proper 
operation  for  aneurv'sm  of  the  gluteal,  fliac,  carotid,  and  axiUary  arteries,  but 
Syme's  method  is  productive  of  fearful  hemorrhage,  and  the  plan  of  iVntyllus  is 
vastly  better.  S>Tne  opened  the  sac,  inserted  his  finger,  and  plugged  the 
artery  toward  the  heart  until  a  ligature  was  applied  and  tied.  He  then  packed 
the  sac  with  lint. 


424  Diseases  apd  Injuries  of  the  Heart  and  Vessels 

Aneurysmectomy  {extirpation  of  the  sac),  if  practised,  should  be  carried  out 
after  applying  a  ligature  on  each  side  after  the  method  of  Antyllus.  It  was 
originally  practised  by  Philagrius  and  was  reintroduced  by  Purmann  in  1699 
(Moynihan,  in  "Annals  of  Surgery,"  July,  1898). 

Extirpation  finds  warm  advocates  in  Delbet,  Littlewood,  and  Moynihan. 
Moynihan  claims  that,  as  compared  with  distal  ligature,  there  is  a  greater 
chance  of  recovery,  no  chance  of  recurrence,  less  risk  of  gangrene,  and  com- 
plete recovery  from  troubles  due  to  nerve  interference  (Ibid.).  Extirpation 
is  regarded  by  some  surgeons  as  the  best  operation  for  traumatic  aneurysm, 
but  if  the  vessel  is  seriously  diseased  near  the  sac  some  other  method  should 
certainly  be  employed.  In  aneurysm  of  the  common  carotid  after  extirpation 
(as  after  ligation)  there  is  grave  risk  of  cerebral  embolism,  and  it  might  be 
wise  to  attempt  a  re-establishment  of  the  circulation  by  circular  suture  of  the 
two  ends,  or,  as  Lexer  did  in  the  axillary  artery,  autoplasty  with  a  piece  of 
the  internal  saphenous  vein.  In  the  extremities  there  is  less  danger  of  gan- 
grene after  Matas's  operation  than  after  extirpation.  Monod  and  Vanverts 
("Rev  de.  Chir.,"  1910,  xli  and  xlii)  collected  205  cases  of  excision.  Of  these, 
90  per  cent,  were  cured.  Relapse  occurred  in  i  J  per  cent.  Direct  operative 
mortality  was  3  per  cent.  Gangrene  occurred  in  4  per  cent.  Extirpation  shows 
a  higher  percentage  of  cures,  a  lower  rate  of  mortality,  fewer  cases  of  gangrene, 
and  fewer  relapses  than  any  operation  except  that  of  Matas.  Monod  and  Van- 
verts collected  138  cases  of  ligation  by  dilferent  methods.  The  mortality  was 
7  per  cent.  There  were  12  per  cent,  of  relapses  and  6  J  per  cent,  of  gangrene. 
The  cures  numbered  74  per  cent. 


Fig.  191. — Old  operation  of  Antyllus  for  aneu-       Fig.  192. — Anel's  operation  for  aneurysm  ("Am. 
rysm  ("Am.  Text-Book  of  Surgery").  Text-Book  of  Surgery"). 

The  Method  of  Anel. — Anel,  of  Turin,  devised  and  performed  this  operation 
in  1 7 10.  In  Anel's  method  the  artery  is  ligated  above  the  sac,  and  so  close 
to  it  that  there  are  no  anastomotic  branches  between  the  sac  and  the  ligature 
(Fig.  192).  It  is  used  only  for  traumatic  aneurysms,  and  is  never  employed 
when  the  vessel  is  diseased  beyond  the  aneurysm.  Either  extirpation  or 
Matas's  operation  is  preferable  to  Anel's  operation. 

The  Method  of  Hunter. — This  operation,  which  is  the  modern  method  of 
ligation,  was  devised  by  the  illustrious  John  Himter,  and  was  first  employed  by 
him  in  January,  1786.  He  is  said  by  Sir  Everard  Home  to  have  recognized  the 
fact  that  the  vessel  adjacent  to  an  aneurysm  was  apt  to  be  diseased,  and  he 
discovered  the  anastomotic  circulation.  Putting  together  these  two  facts, 
he  devised  the  operation  which  goes  by  his  name.  It  consists  in  applying  a 
ligature  between  the  heart  and  the  aneurysm,  but  so  far  above  the  sac  that 
collateral  branches  are  given  off  between  it  and  the  point  of  ligation  (Fig.  193). 
This  operation,  which  is  done  upon  a  healthy  portion  of  the  artery,  does  not 
permanently  cut  off  all  blood,  but  so  diminishes  the  force  and  frequency  of 
the  circulation  that  an  active  clot  forms  within  the  sac.  Thus  are  lessened  the 
dangers  of  secondary  hemorrhage  and  gangrene.  According  to  Stimson 
("New  York  Med.  Jour.,"  July,  1884),  Hunter  really  builded  better  than  he 
knew,  for  he  sought  only  to  tie  the  artery  without  opening  the  sac  and  at  a 
healthy  point,  but  said  not  a  word  about  the  necessity  of  having  branches 
between  the  sac  and  the  ligature  or  about  the  desirability  of  diminishing 
the  flow  of  blood  instead  of  cutting  it  off  completely  (Moynihan,  in  "Annals 


Treatment  of  Aneurysm  425 

of  Surger}-,"  July,  1898).  Hunter  tied  the  artery  in  the  region  now  known 
as  Hunter's  canal.  Scarpa  introduced  the  custom,  which  we  still  follow,  of 
tying  it  in  Scarpa's  triangle.  The  Hunterian  method  was  for  many  years 
regarded  by  most  surgeons  as  the  proper  operation  for  aneurysm  in  the  ma- 
jority of  cases.  In  some  cases  pulsation  does  not  return  in  the  aneur\-sm 
after  tightening  the  ligature;  in  most  cases,  however,  it  reappears  for  a  time 
after  about  thirty-sLx  hours,  but  is  weak  from  the  start,  constantly  diminishes 
and  finally  disappears  permanently.  Previous  prolonged  compression  by  en- 
larging the  collateral  branches  permits  strong  pulsation  to  recur  soon  after 
ligation,  and  thus  militates  against  cure;  hence,  it  is  a  bad  plan  to  use  pressure 
in  cases  admitting  of  ligation  and  in  which  the  success  of  pressure  is  very  doubt- 
ful. Occasionall}-  after  Hunter's  operation  the  sac  suppurates,  producincr 
S}Tnptoms  like  those  of  abscess.  Suppuration  may  occur  between  the  first 
and  the  thirty-second  week  after  ligation.^  "When  pus  forms,  open  freely,  as 
we  would  open  an  abscess,  and  if  no  blood  flows,  treat  as  an  abscess,  but  have 
a  tourniquet  loosely  applied  for  several  days  ready  to  screw  up  at  the  first 
sign  of  danger.  If  hemorrhage  occurs,  tie  the  vessel  above  and  below  the 
aneurysm,  open  the  sac,  and  pack  \\'ith  iodoform  gauze.  If  bleeding  recurs, 
there  is  no  use  reapphing  the  ligature  and  there  is  little  use  t\ing  higher  up. 


Fig.  193. — Hunter's  method  of  ligating  for  aneiin'sm:  a,  The  aneurj'sin;  b,  point  of  ligation; 
c,  the  branches  between  the  aneun'sm  and  the  Hgature.  The  arrow  shows  the  direction  of  the  blood- 
cxirrent. 

If  dealing  with  the  upper  extremit}-,  tv}-  the  application  of  a  ligature  higher 
up;  if  dealing  vrith.  the  lower  extremity,  amputate  at  once. 

Distal  Ligation. — \Mien  an  aneun-'sm  is  so  near  the  trimk  that  Hunter's 
operation  is  impracticable,  or  when  the  arter}'  on  the  cardiac  side  of  the  timior 
is  greatly  diseased,  distal  ligation  may  be  employed.  Distal  ligation  forms 
a  barrier  to  the  onflow  of  blood,  collateral  branches  above  the  aneur\-sm 
enlarge,  the  blood-current  is  graduaUy  diverted,  and  a  clot  may  form  within 
the  aneun-'sm.  Distal  ligation  is  used  in  some  aneur}-sms  of  the  aorta,  Uiac, 
innominate,  carotid,  and  subcla^-ian.  It  occasionally  causes  ruptiue  of  the 
sac  of  the  aneur}-sm.  I  have  obtained  two  notably  successful  results  in  aneu- 
r}-sms  of  the  innominate  artery  by  ligation  of  the  common  carotid  and  sub- 
cla\"ian  of  the  right  side.  In  each  of  these  cases  I  tied  both  vessels  at  one 
seance,  t\dng  the  carotid  first.  In  i  case  I  tied  the  third  part  of  the  sub- 
cla^-ian  and  in  the  other  the  first  part.  The  first  patient  returned  to  his  work 
as  a  blacksmith  and  died  over  a  year  and  a  half  later  from  rupture  of  a  sec- 
ondary- aneuJA-sm  of  the  carotid  at  the  point  where  the  ligature  had  been 
applied.  The  second  case  is  liAing  and  apparently  weU  over  five  years  after 
the  operation  (the  author,  in  "Surg.,  G}ti.,  and  Obst.,"'  June,  1910). 

The  operation  of  Brasdor  consists  in  tying  the  main  trunk  some  little  dis- 
tance below  the  aneurs'sm  (Fig.  194).  It  completely  arrests  circulation  in 
the  sac.  The  operation  was  introduced  in  1760  by  the  French  surgeon  Brasdor. 
1  See  the  case  described  by  Sir  Astley  Cooper. 


426  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  operation  of  War  drop  consists  in  tying  one  of  the  branches  of  the 
artery  beyond  the  aneurysm.  Wardrop  originally  advocated  ligation  at  a 
point  where  there  is  no  intervening  branch  between  the  sac  and  the  ligature. 
Later,  he  advocated  ligation  at  a  point  where  there  is  an  intervening  branch. 
Since  then  it  is  the  custom  to  consider  Wardrop's  operation  to  be  the  ligation 
of  one  branch  beyond  the  aneurysm,  as  shown  in  Fig.  195.  The  circulation  is 
but  partially  arrested  by  Wardrop's  operation.  The  operation  was  introduced 
in  1825.  An  x-ray  picture  should  be  taken  in  every  case  of  aortic  aneurysm. 
Such  a  picture  may  aid  us  in  coming  to  a  conclusion  as  to  which  vessel  or  ves- 
sels to  tie. 

Matas's  Operation  (Aneurysmorrhaphy). — This  procedure  is  the  greatest 
advance  in  the  surgery  of  the  arterial  system  since  the  observations  of  John 
Himter.  It  was  first  practised  by  Matas  in  1889  on  a  negro  suffering  from 
traimiatic  aneurysm  of  the  brachial  artery  in  the  middle  of  the  arm.  The 
operation  was  a  complete  success.  In  1900  he  began  again  to  use  this  method, 
and  in  1902  described  it  to  the  profession  ("Trans,  of  Am.  Surg.  Assoc," 
1902;  "Annals  of  Surg.,"  Feb.,  1903;  "Trans,  of  Am.  Surg.  Assoc,"  1905). 


Fig.  ig4. — Brasdor's  operation  (Holmes).  Fig.  105. — Wardrop's  operation  (Holmes). 

One  procedure,  applicable  to  ordinary  fusiform  aneurysms,  is  called  ob- 
Uterative  endo-aneurysmorrhaphy  without  arterioplasty  (Fig.  196).  "No  at- 
tempt is  made  to  reconstruct  the  parent  artery  (arterioplasty),  and  the  arterial 
orifices  are  simply  obliterated  by  suture."  By  sutures  applied  within  the 
incised  sac  the  sac  is  cut  off  from  the  circulation  without  disturbing  adjacent 
collaterals  and  without  interfering  with  the  nutrition  of  the  sac  walls.  After 
this  operation  there  is  very  seldom  secondary  hemorrhage,  gangrene,  or  relapse. 

A  modification  of  the  above  operation  applied  to  sacculated  aneurysms 
in  which  there  is  one  orifice  of  commimication  with  the  artery  is  called  endo- 
aneurysmorrhaphy  with  partial  arterioplasty  (Fig.  196).  The  sac  is  opened, 
clots  are  washed  away,  the  opening  of  the  aneurysm  into  the  artery  is  closed  by 
a  continuous  suture  passing  through  all  the  coats  of  the  sac  at  the  edge  of  the 
opening  into  the  artery.  Blood  is  thus  excluded  from  the  sac,  the  lumen  of  the 
artery  is  not,  however,  obliterated,  and  the  blood-supply  of  parts  beyond  is 
not  interfered  with.  After  closing  the  cut  in  the  arterial  wall  the  sac  is  ob- 
literated by  rows  of  sutures  inserted  in  its  walls.  Matas  reports  4  cases  oper- 
ated upon  successfully  by  this  plan.  In  a  fusiform  aneurysm  with  a  firm  and 
resisting  sac  wall,  and  in  which  there  are  two  openings  near  together  on  the 
floor  of  the  sac,  endo-aneurysmorrhaphy  with  complete  arterioplasty  may  be 
performed  (Fig.  196).  This  operation  restores  arterial  continuity,  a  new 
channel  being  made  out  of  the  sac  walls  "by  simply  holding  these  over  a  rub- 
ber guide  (tube  or  catheter)  and  suturing  them  firmly  together  so  as  to  restore 


Treatment  of  Aneurysm 
B 


427 


F 


Fig.  196. — ^The  radical  cure  of  aneurysm  based  upon  arteriorrhaphy  (Matas) :  A,  First  tier  of  sutures 
in  a  fusiform  aneurysm;  B,  second  tier  of  sutures,  some  of  which  are  tied;  C,  sutures  to  approximate  the 
walls  of  the  aneurysm;  D,  suturing  the  opening  in  a  sacculated  aneurysm — the  main  artery  is  not  oblit- 
erated; E,  opening  completely  closed:  F,  diagram  of  cross-section  of  parts  after  complete  obliteration 
of  sac,  but  with  restoration  of  blood-channel;  G,  diagram  of  cross-section  of  parts  after  complete  oblitera- 
tion of  sac  and  blood-vessel;  H,  operation  for  fusiform  aneurysm  when  we  wish  to  restore  the  blood- 
channel — sutures  applied  over  a  rubber  tube,  most  of  the  sutures  tied,  tube  withdrawn,  and  remaining 
sutures  tied. 


428  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  continuity  of  the  artery  lost  in  the  sac."  The  catheter  is  withdrawn  before 
the  final  sutures  are  tied.  This  operation  has  been  performed  successfully  by 
Morris  and  also  by  Craig.  Some  surgeons  are  fearful  that  such  an  operation 
will  be  followed  by  relapse,  and  one  of  the  reported  cases  did  relapse.  Matas 
says  that  preservation  of  the  arterial  lumen  is  "only  indicated  positively  in 
the  sacciform  aneurysms  with  a  single  opening  where  the  parent  artery  already 
exists  as  a  formed  vessel,  and  in  which  the  closure  of  the  fistulous  opening  can 
be  accomplished  with  the  greatest  facility  and  simplicity"  (address  delivered 
at  the  Medical  Assoc,  of  Alabama,  April  22,  igo6).  It  is  not  probable  that  the 
artery  remains  patent  long,  because  the  seat  of  aneurysm  is  a  diseased  vessel 
and  vascular  disease  will  probably  cause  clotting,  but  even  a  temporary  restora- 
tion of  circulation  if  followed  by  gradual  abolition  prevents  gangrene.  The 
Matas  operation  differs  notably  from  the  Antyllus  operation  in  the  fact  that  it 
saves  certain  collaterals  which  the  Antyllus  method  destroys,  and  the  reten- 
tion of  these  collaterals  may  prevent  gangrene  in  the  limb.  It  differs  from  it 
further  in  the  fact  that  it  occludes  certain  small  vessels  which  after  the  An- 
tyllus method  continue  to  convey  blood  into  the  sac.  It  is  superior  to  extir- 
pation because  it  does  not  destroy  the  vascular  walls  of  the  sac,  the  blood- 
vessels of  which,  if  unblocked,  aid  in  preventing  gangrene  of  the  limb. 

Matas  points  out  that  suture  of  an  aneurysm  is  indicated  only  when  cer- 
tain essentials  exist. 

1.  The  situation  of  the  aneurysm  must  admit  of  the  control  of  the  circu- 
lation temporarily  on  the  proximal  side  of  the  sac.  In  most  aneurysms  of 
the  extremities  this  is  done  by  the  elastic  band  of  Esmarch.  In  the  neck  and 
abdomen  both  the  cardiac  and  peripheral  sides  of  the  main  vessels  must  be 
secured  by  traction  loops  and  compression. 

2.  The  sac  must  be  freely  opened  in  a  longitudinal  direction.  Its  wall 
must  not  be  dissected  and  must  be  separated  as  Httle  as  possible  from  sur- 
rounding tissue. 

3.  Every  orifice  opening  into  the  sac  must  be  thoroughly  exposed  so  that 
they  can  be  closed  by  sutures.  The  suture  material  is  chromic  gut,  the  num- 
ber being  i,  2,  or  3,  according  to  the  size  of  the  aneurysm. 

Fig.  196,  A  to  H,  shows  Matas's  various  operations.  For  a  full  description 
of  them  see  the  previously  quoted  articles  of  the  author.  I  believe  that  the 
Matas  operation  is  a  very  notable  advance  in  surgery,  that  it  is  safer  than 
older  methods,  and  much  less  apt  to  be  followed  by  gangrene.  The  idea 
seems  to  be  general  that  Matas  always  seeks  to  restore  arterial  limien.  This 
is  not  the  case.  He  only  seeks  to  do  this  in  exceptional  cases.  The  essence 
of  his  method  is  to  cure  the  aneurysm  by  sutures  within  the  sac  and  by 
obliteration  of  the  sac.  I  have  performed  the  Matas  operation  (obliterative 
endo-aneurysmorrhaphy)  successfully  on  a  case  of  ruptured  fusiform  popliteal 
aneurysm  and  on  a  case  of  ruptured  sacculated  popliteal  aneurysm.  In  the 
latter  case  there  was  profuse  hemorrhage  during  the  operation  from  vessels 
opening  into  the  sac. 

Matas,  in  "Annals  of  Surgery,"  July,  1910,  collected  149  cases  with  133 
cures.  In  Monod  and  Vanvert's  103  cases  there  were  89  cures.  Relapse 
occurred  in  1.5  per  cent.  Gangrene  occurred  in  from  3  to  5  per  cent,  of  the 
cases.  Direct  operative  mortality  was  3  per  cent.  ("Rev.  de  Chir.,"  1910, 
xli  and  xlii). 

Less  than  2  per  cent,  of  cases  relapse.  The  direct  mortality  is  3  per  cent. 
Gangrene  occurs  in  3  per  cent,  of  cases.    Secondary  hemorrhage  is  very  rare. 

The  operation  has  been  performed  upon  the  abdominal  aorta,  the  external 
iHac,  and  the  subclavian,  as  well  as  upon  smaller  vessels.  Munro,  Martin  and 
Parham,  Lilienthal,  Pringle,  and  Lozano  performed  endo-aneurysmorrhaphy 
for  subclavian  aneurysm  (Eliot,  in  "Annals  of  Surgery,"  July,  1912). 


Treatment  After  Operation  for  Aneur}-sm 


429 


Halsted's  Method  by  Partial,  Progressive,  and.  Finally,  Complete  Occlusion 
by  Metal  Band. — This  method  is  appHed  only  to  the  aorta  and  other  very  large 
arteries.  A  number  of  surgeons  have  sought  a  method  to  gradually  and  safely 
occlude  the  abdominal  aorta  in  order  that  they  may  attempt  to  cure  aneurysm 
of  the  aorta  or  of  the  ihac  arteries.  The  usual  thought  was  to  leave  a  metal 
instrument  Hxed  to  the  aorta,  the  handle  projecting  from  the  abdominal  wound, 
and  a  metal  clamp  or  a  snare  of  silk  or  catgut  being  around  the  vessel,  so  that 
by  means  of  a  screw  arrangement  pressure  could  be  gradually  increased. 

Halsted  showed  that  by  this  plan  sepsis  almost  certainly  occurs  along  the 
track  of  the  instrument.  (See  W.  S.  Halsted,  in  "Joliiis  Hopkins  Bulletin,"  1905, 
xvi,  346;  "Jour.  Am.  Med.  Assoc,"  1906,  xlvii;  "Jour.  Experimental  ]\Iedi- 
cine,"  1909,  vol.  xi,  No.  2.)  Halsted  sought  for  a  method  "permitting,  in 
each  entre-act,  complete  closure  of  the  wound."  He  uses  a  band  of  alu- 
minum curled  in  cylinder  form  about  the  vessel.  This  material  admits  of 
easy  readjustment  at  a  future  operation,  and  it  is  tightened  by  the  lingers. 

Halsted's  band,  when  used  to  partially  occlude,  seldom  causes  macroscopic 
alteration  in  the  wall  of  the  vessel;  when  used  to  completely  occlude,  the  vessel 
may  undergo  atrophy.     Ideal  closure  is  when  the  limien  was  nearly  but  not 


Fig.  ig?- 


-Halsted's  improved  band  roller:  The  instrument  shown  in  full  length  is  unloaded;  in  the 
abbre\-iated  cut  the  band  is  about  to  be  espeUed  from  the  roUer  (Halsted). 


quite  occluded,  spontaneous  obUteration  having  arisen,  the  arterial  wall 
embraced  by  the  band  ha\'ing  undergone  conversion  into  "a  sohd  cylinder 
of  ^^■ing  tissue.''    Animals  tolerate  gradual  occlusion  very  well  indeed. 

Halsted  has  made  numerous  experiments  on  dogs  and  has  used  the  band 
Tv-ith  encouraging  results  on  the  human  being  (partial  occlusion  of  the  innom- 
inate, twice;  common  carotid,  four  times).  In  a  case  of  aneur^^sm  of  the  ab- 
dominal aorta  Halsted  partially  occluded  the  aorta  near  the  diaphragm. 
Seventeen  days  later  he  placed  another  band  on  the  aorta  below  the  aneurysm. 
The  patient  Hved  twenty-four  days  after  the  second  operation.  The  operation 
checked  growth  and  arrested  pain  ("Trans.  Am.  Surg.  Assoc,"  1909-10). 
In  another  case  of  abdominal  aneur\-sm  Halsted  put  a  band  above  the  renals. 
Seventeen  days  later  Finney  inserted  '^"ire  into  the  aneur\'sm.  The  patient 
Hved  f orty-tive  days  after  the  first  operation  (Ibid.) . 

In  preparing  for  application  it  is  roUed  by  means  of  the  instrument  shown 
in  Fig.  197.  It  is  well  to  fasten  the  band  vrith.  a  sUver  hgature  after  apphca- 
tion.    The  ligature  prevents  unroUing  (Ibid.). 

Treatment  After  Operation  for  Aneurysm. — ^After  operating  for  aneur^-sm 
■of  an  extremity  by  the  ligature  or  by  sutures,  elevate  the  Hmb  shghtly,  keep 


43°  Diseases  and  Injuries  of  the  Heart  and  Vessels 

it  warm  by  wrapping  in  cotton  and  surrounding  with  bags  of  warm  water,  and 
subdue  arterial  excitement.  When  gangrene  of  a  limb  follows  ligation,  await  a 
line  of  demarcation,  and  when  it  forms,  amputate.  Rupture  of  the  sac  after 
ligation  may  produce  gangrene  or  be  associated  with  suppuration,  the  first 
condition  demanding  amputation;  the  second,  incision  for  drainage. 

Injection  of  coagulating  agents  into  the  sac  (ergot,  perchlorid  of  iron,  etc.) 
is  very  dangerous  and  is  to  be  utterly  condemned.  It  may  lead  to  suppura- 
tion, gangrene,  rupture,  or  embolism. 

Manipulation  to  break  up  the  clot  was  suggested  by  Sir  Wm.  Fergusson 
and  has  been  practised  by  some.  The  object  aimed  at  is  to  have  a  fragment 
of  clot  block  up  the  vessel  upon  the  peripheral  side  of  the  artery  and  act  like 
a  distal  ligature.  The  method  is  dangerous,  especially  in  carotid  aneurysm, 
and  should  never  be  employed. 

Amputation,  instead  of  distal  Ugation,  is  performed  in  some  perilous  cases 
of  subclavian  aneurysm. 

Electrolysis. — ^An  attempt  may  be  made  to  at  once  coagulate  the  blood  in 
the  sac,  or  from  time  to  time  an  endeavor  may  be  made  to  produce  fibrinous 
deposits,  but  the  first  method  is  the  better.  It  is,  however,  seldom  possible  to  at 
once  occlude  a  sac,  and  pulsation,  which  is  for  a  time  abolished,  usually  recurs 
as  the  gas  present  is  absorbed.  Use  the  constant  current.  Take  from  three  to 
SLx  cells  which  stand  in  point  of  size  between  those  used  for  the  cautery  and 
those  used  for  ordinary  medical  purposes.  A  platinum  needle  is  attached 
to  the  positive  pole  and  a  steel  needle  to  the  negative  pole,  each  needle  being 
insulated  by  vulcanite  at  the  spot  where  the  tissues  would  touch  it.  The  asep- 
ticized needles  are  plunged  into  the  sac  where  it  is  thick,  and  they  are  kept  near 
together.  The  current  is  passed  for  a  variable  period  (from  half  an  hour  to 
an  hour  and  a  half).  This  operation  is  not  dangerous.  Pressure  stops  the 
bleeding.  Electrolysis  often  ameliorates  and  sometimes  greatly  improves 
aortic  aneurysms. 

Acupuncture  consists  of  the  partial  introduction  of  a  number  of  ordinary 
sewing  needles  into  an  aneurysmal  sac  and  leaving  them  in  it  for  five  or  six 
days  or  more.  Professor  Macewen  introduces  a  needle,  and  with  it  irritates 
the  interior  of  the  sac  of  an  aneurysm,  hoping  thus  to  cause  deposition  of 
leukocytes,  thickening  of  the  sac,  and  clot  formation. 

Introduction  of  Wire. — This  operation  is  performed  by  inserting  into  the  sac 
a  hypodermatic  or  small  aspirating  needle,  and  pushing  in  through  the  needle  or 
cannula  a  considerable  quantity  of  aseptic  gold  or  silver  wire,  which  is  allowed 
to  remain  permanently.  Wiring  is  used  for  aneiirysms  otherwise  inoperable. 
Electrolysis  should  be  combined  with  the  introduction  of  wire.  Wiring  was 
first  proposed  by  Moore,  of  London,  in  1864.  The  details  were  improved  by 
Corradi  in  1879.  Loreta  and  Barwell  both  inserted  wire  into  an  aneurysm 
before  Corradi,  but  Corradi  inserted  wire  and  also  used  electricity.  The  first 
American  wiring  operation  was  performed  by  Ransohoff  in  1886.  Corradi's 
operation  can  be  used  when  distal  ligation  cannot  be  carried  out,  and  can  be 
used  even  when  the  vessel  is  extremely  atheromatous.  It  finds  its  chief  use 
in  aneurysms  of  the  thoracic  aorta  and  innominate.  In  some  cases  of  ab- 
dominal aneurysm  the  belly  has  been  opened  and  the  operation  carried  out. 
It  is  used  for  sacculated,  never  for  fusiform,  aneurysms.  The  operation  has 
not  many  elements  of  danger.  Sepsis  would  inevitably  cause  death.  If  the 
wire  is  carried  on  into  the  aorta  and  heart  death  will  follow.  A  cause  of  death 
is  embolism.  In  one  of  Finney's  cases  gangrene  of  the  arm  resulted  from 
emboUsm.  Too  strong  a  current  may  cause  sloughing  of  the  aneiirysmal  wall. 
The  wall  of  the  aneurysm  may  rupture  because  of  deviation  of  the  strong  blood- 
current  in  another  direction.  Some  cases  have  been  notably  improved.  The 
operation  is  performed  with  aseptic  care.    If  the  thoracic  aorta  is  to  be  oper- 


Treatment  of  Diffuse  Traumatic  Aneur\-sm  431 

ated  upon,  an  anesthetic  is  not  required.  If  the  abdommal  aorta  is  to  be  wired, 
the  patient  must  be  anesthetized,  because  the  abdomen  needs  to  be  opened. 
The  wire  used  must  have  been  p^e^"iously  drawn,  so  that  it  will  easily  pass 
through  a  h\-podermatic  needle  and  will  coil  up  spirally  within  the  sac.  The 
best  wire  is  of  silver  or  gold.  A  special  reel  is  used  to  keep  the  wire  from 
getting  kinked.  It  is  a  great  mistake  to  mtroduce  a  large  quantity.  Stewart 
decided  that  a  globular  sac  3  inches  in  diameter  requires  from  3  to  5  feet,  and 
a  sac  5  inches  in  diameter  requires  from  S  to  10  feet.  A  hypodermatic  needle, 
insulated  up  to  j  inch  of  the  point,  is  carried  into  the  interior  of  the  aneur^-sm 
through  a  fairly  thick  portion  of  the  sac.  The  shoulder  of  the  needle  is  not 
insulated  and  must  not  be  permitted  to  touch  the  skin,  because  if  it  did  so  it 
would  cause  a  burn  by  electrolysis.  The  required  amoimt  of  t^ttc  is  introduced. 
The  v.'iie  is  attached  to  the  positive  pole  of  the  battery.  The  negative  pole  is 
fastened  to  a  large  flat  piece  of  clay  or  a  pad  of  moistened  absorbent  cotton, 
and  the  negative  electrode  is  placed  upon  the  back  or  abdomen.  The  current  is 
turned  on  gradually  imtil  the  necessan."  strength  is  obtained  (40  to  So  ma.). 
When  ready  to  terminate  the  operation  the  current  is  lowered  gradually  to 
zero,  the  needle  is  •withdrawn,  the  wire  is  cut  ofl"  close  to  the  skin,  the  end  is 
pushed  under  the  skin,  the  puncture  is  covered  with  iodoform  collodion, 
and  pressure  is  appUed  to  keep  blood  from  gathering  in  the  tissue.  Such  a 
hematoma  might  cause  the  formation  of  a  slough.  The  entire  operation 
requires  from  three-quarters  of  an  horn:  to  one  and  a  hah  hours.  A  clot  forms 
with  considerable  rapidity-  and  expansile  pulsation  may  lessen  or  cease.  It 
requires  from  a  number  of  days  to  several  weeks  for  the  clot  to  become  hard. 
The  operation  can  be  repeated  if  necessary-.  Injections  of  gelatin  after  wiring 
may  be  beneficial.    Rest  is  imperative  for  months  after  "firing. 

Notable  improvement  is  common,  but  genuine  cure  is  not  obtained.  As 
Hare  savs,  ''adjacent  tissues  of  the  vessel  sooner  or  later  give  way,  because 
the  effort  is  like  an  effort  to  mend  a  rotten  hose;  though  mended  at  one  spot  it 
breaks  at  another."  One  of  Jones's  cases  remained  well  for  sLv  years  and  then 
pain  recurred.  The  operation  causes  prompt  and  marked  diminution  of  pain, 
an  amelioration  usually  spoken  of  by  the  patient  before  he  leaves  the  operat- 
ing table.  In  2  of  my  cases  pain,  which  had  been  severe,  disappeared  com- 
pletely during  the  operation.  "Dyspnea  is  also  benefited  and  just  as  rapidly" 
(H.  A.  Hare^  in  "Therapeutic  Gazette,""  April,  190S).  Finney  C" -Annals  of 
Surger>^,"  JMay,  191 2)  reported  23  cases  (mostly  thoracic,  some  abdominal). 
Of  these  cases  only  2  were  known  to  be  liA-ing  at  the  time  of  the  report. 

Treatment  of  Aneurysm  Folio-wing  Woimd  of  a  Healthy  Artery. — The 
prognosis  in  such  a  case  is  usually  extremely  good.  The  treatment  is  as  for 
the  other  forms.  Extirpation  is  particularly  adapted  to  such  direct  traumatic 
aneur}-5ms  in  the  neck  and  ^latas's  operation  to  those  in  the  extremities. 

Diffuse  Traumatic  Aneurysm. — When  an  arter}-  ruptm-es  or  an  aneu- 
r\-sm  ruptures  and  a  large  mass  of  blood  is  extravasated  mto  the  tissues,  no 
complete  sac  exists,  and  the  condition  is  usually  called  diffuse  tratmaatic 
aneur\-sm.  In  diffuse  traimiatic  aneur\-sm  a  large  oblong,  fluctuating  swelling 
is  found.  If  the  rent  is  large  there  may  be  bruit  and  pulsation.  There  is 
no  pulsation  in  the  arter\-  below  the  aneur^'sm,  and  the  Umb  is  cold  and  swol- 
len.   The  skin  is  at  first  of  a  natural  color,  but  later  becomes  thin  and  purple. 

Treatment. — If  an  aneur\'sm  ruptures,  cut  down  upon  the  aneur\-sm,  in- 
cise the  sac  longitudinally,  and  perform  ]Matas's  operation.  Some  surgeons 
cut  down  to  the  aneiu^-sm,  tie  on  each  side  of  the  tear,  open  the  sac,  and  pack 
it  lythe  operation  of  Ant\-llus),  but  ^Matas's  operation  is  the  preferable  pro- 
cedure. If  an  arter\-  is  ruptured,  empty  the  limb  of  blood,  apply  an  Esmarch 
band  above,  and  expose  the  seat  of  rupture  by  incision.  If  possible,  suture  the 
opening;  if  this  is  not  possible,  tie  the  vessel  on  each  side  of  the  ruptm-e  and 


432 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


excise  the  intervening  portion.  If  the  main  vein  is  also  ruptured,  suture  the 
vessels  if  possible.  If  suture  is  impossible,  apply  ligatures.  The  attempt 
will  probably  not  succeed  in  saving  the  extremity,  and  in  most  cases  ampu- 
tation will  be  required. 

Arteriovenous  aneurysm  was  first  described  by  Wm.  Hunter  .in  1757. 
By  this  term  we  mean  an  unnatural  passageway  between  a  vein  and  an  artery, 
through  which  passage  blood  circulates.  There  are  two  forms:  (a)  aneurysmal 
varix,  or  Pott's  aneurysm,  a  vein  and  an  artery  directly  communicating  (Fig. 


Fig.  198. — Dilatation  of  veins  in  arteriovenous  aneurysm  of  the  femoral  vessels. 

199);  and  (b)  varicose  aneurysm,  a  vein  and  an  artery  communicating  through 
an  intervening  sac.  These  conditions  arise  usually  from  punctured  wounds,  the 
instrimient  passing .  through  one  vessel  and  into  the  other,  blood  flowing  into 
the  vein,  the  subsequent  inflammation  gluing  the  two  vessels  together,  and 
the  aperture  fafling  to  close  (aneurysmal  varix,  Fig.  199).  After  the  infliction 
of  the  wound  the  two  vessels  may  separate;  the  blood  continuing  to  flow 
from  artery  into  vein,  and  the  blood-pressure,  by  consolidating  tissue,  forming 


Fig.    199. — Plan  of  aneurysmal  varix. 


Fig.  200. — ^Varicose  aneurysm  (Spence). 


a  sac  of  junction  (varicose  aneurysm,  Fig.  200).  Wounds  produced  by  a  smaU 
biiUet  may  result  in  arteriovenous  aneurysm  (Matas,  in  "Transactions  of 
Amer.  Surg.  Assoc,"  vol.  xix).  Aneurysmal  varix  is  a  less  grave  disorder  than 
varicose  aneurysm.  Arteriovenous  aneurysm  used  to  be  most  frequent  at  the 
bend  of  the  elbow,  the  vessels  being  injured  during  venesection.  The  condi- 
tion may  occur  in  the  neck,  the  axilla,  the  extremities,  or  the  groin.  I  assisted 
Professor  Keen  in  an  operation  upon  an  aneurysmal  varix  of  the  common 
carotid  and  internal  jugular  vein,  and  assisted  Professor  Hearn  in  operating 
on  a  varicose  aneurysm  involving  the  external  iliac  vessels.  Sir  Frederick 
Treves  operated  on  a  case  involving  the  internal  maxillary  vessels.     Very 


Treatment  of  Arteriovenous  Aneurysm  433 

rarely  an  arteriovenous  aneurysm  forms  spontaneously.  Spontaneous  arterio- 
venous aneurysm  is  most  frequent  between  the  aorta  and  vena  cava.  There 
is  no  tendency  to  spontaneous  cure  in  arteriovenous  aneurysm.  Edema  is 
the  rule,  muscular  atrophy  is  common,  and  ulceration  or  even  gangrene  of  a 
limb  may  occur.  Matas  has  collected  17  cases  of  arteriovenous  aneurysm  of 
the  subclavian  vessels  ("Transactions  of  Amer.  Surg.  Assoc,"  vol.  xix).  In  this 
list  is  the  celebrated  case  of  his  own,  a  traumatic  (gunshot)  arteriovenous 
aneurysm,  in  which  cure  followed  operation ;  in  the  operation  it  was  necessary 
to  obliterate  the  artery  by  ligatures,  but  the  venous  orifice  was  closed  by 
sutures  without  obliterating  the  lumen  of  the  vein.  In  the  analysis  of  Matas's 
paper  15  cases  are  used,  2  having  been  noted  too  late  for  incorporation;  9 
of  the  cases  resulted  from  "stab  or  penetrating  cut  wounds,"  6  from  bullets — 
in  5  of  the  cases  the  brachial  plexus  was  injured.  In  8  out  of  the  1 1  unoperated 
cases  the  time  after  the  injury  when  symptoms  of  arteriovenous  aneurysm 
was  noted  is  stated;  in  i  signs  were  definite  within  four  hours,  in  3  they  were 
noted  on  the  second  day,  in  3  on  the  third  day,  in  i  on  the  sixth  day,  in  i  on 
the  eighth  day,  in  i  on  the  ninth  day,  and  in  i  a  few  days  later.  In  3  of  the 
15  cases  secondary  hemorrhage  followed  the  injury.  Eleven  of  the  15  cases 
were  treated  expectantly;  i  died  from  secondary  hemorrhage  and  sepsis  three 
weeks  after  the  injury  and  10  "survived  the  immediate  effects  of  the  injury, 
their  wounds  healing  after  the  cessation  of  the  primary  hemorrhage." 

In  4  of  the  15  cases  operation  was  performed.  In  3  the  operation  was 
done  soon  after  the  injury  because  of  violent  secondary  hemorrhage.  In 
I  (Matas's  own  case)  operation  was  done  deliberately  to  prevent  complica- 
tions. Three  of  these  cases  recovered  (including  Matas's) ;  i  died  of  renewed 
secondary  hemorrhage  on  the  twenty-fourth  day  after  operation.  Matas 
points  out  the  fact  that  in  stab-wounds  of  the  subclavian  vessels  the  largest 
proportion  of  cases  die  of  primary  hemorrhage  before  assistance  is  obtained, 
but  in  a  considerable  number  of  cases  temporary  hemostasis  occurs,  which  is 
followed  by  secondary  hemorrhages  or  arteriovenous  aneurysm. 

Symptoms  of  Aneurysmal  Varix. — The  arterial  blood  is  cast  forcibly 
into  the  vein,  and  as  a  consequence  the  vein  becomes  enlarged,  tortuous,  and 
thickened.  The  scar  of  a  wound  is  almost  invariably  apparent.  At  the  seat 
of  vascular  trouble  the  most  marked  dilatation  exists  and  it  is  of  bluish  color. 
The  swelling  pulsates  markedly,  imparts  a  sensation  to  the  finger  like  that  felt 
when  the  hand  is  laid  upon  the  back  of  a  purring  cat.  This  thrill  or  vibration 
is  very  characteristic.  A  sound  of  a  hissing  or  buzzing  nature  can  be  easily 
heard.  The  swelling  at  once  disappears  on  pressure  being  made  upon  it  or  on 
the  artery  between  it  and  the  heart.  It  is  diminished  in  size  by  raising  the 
limb,  is  increased  in  size  by  a  dependent  position  of  the  limb  and  by  com- 
pressing the  vein  between  the  heart  and  the  tumor.  The  adjacent  veins  are 
dilated  and  often  the  dilatation  is  manifested  over  a  wide  area  above  and 
below  (Fig.  198),  and  the  thrill  and  bruit  are  transmitted  a  considerable  dis- 
tance. If  an  extremity  is  involved  it  is  usually  edematous.  The  parts,  as 
a  rule,  are  painful.  The  condition  progresses,  but  very  slowly,  and  sometimes 
years  may  elapse  without  any  notable  aggravation. 

Symptoms  of  Varicose  Aneurysm. — In  this  condition  we  find  many  of 
the  symptoms  of  aneurysmal  varix,  but  in  varicose  aneurysm  pressure  over 
the  artery  of  supply  between  the  heart  and  the  lesion  does  not  cause  the  entire 
disappearance  of  the  swelling;  the  veins  collapse,  it  is  true,  but  a  distinct  sac 
remains,  which  may  be  emptied  by  direct  pressure. 

Treatment. — The  prognosis  after  operation  is  better  than  in  ordinary 
aneurysm,  but  nevertheless  it  is  wisest  to  refrain  from  operating  on  aneu- 
rysmal varix  so  long  as  the  condition  is  not  progressing  obviously,  is  borne 
without  inconvenience,  and  is  not  leading  to  complications.  Varicose  aneu- 
28 


434  Diseases  and  Injuries  of  the  Heart  and  Vessels 

rysm  should  be  operated  upon.  If  we  refrain  from  operating  upon  aneurys- 
mal varix  the  patient  should  wear  a  support;  but  if  the  part  becomes  painful 
or  if  there  seems  to  be  danger  of  rupture  of  the  vein,  operation  should  be  per- 
formed. Until  recently,  when  operation  was  indicated,  surgeons  advised  that 
each  vessel  should  be  tied  above  and  below  the  opening  and  a  portion  of  each 
vessel  should  be  excised,  the  excised  area  including  the  opening.  In  varicose 
aneurysm  it  was  the  custom  to  tie  each  vessel  above  and  below  the  sac,  and 
excise  the  sac  with  a  portion  of  vessel.  At  the  present  time  surgeons  prefer 
the  Matas  operation  for  both  varicose  aneurysm  and  aneurysmal  varix.  In 
some  cases  of  varicose  aneurysm,  however,  the  sac  is  extirpated  and  the 
openings  in  the  vessels  closed  by  suture,  and  in  some  cases  of  aneurysmal 
varix  the  adherent  vessels  are  separated  and  the  opening  in  each  is  sutured. 
In  a  case  of  aneurysmal  varLx  of  the  popliteal  due  to  a  gunshot- wound,  I  opened 
the  vein  and  closed  the  fistula  in  the  arterial  wall.  In  accomplishing  this  I 
gathered  so  much  of  the  vein  wall  in  the  sutures  as  to  render  it  impossible  to 
suture  the  vein  and  retain  its  lumen.  I  cut  the  vein  across,  a  little  above  and 
a  little  below  the  sutured  fistula,  used  the  trapdoor-like  piece  of  vein  to  rein- 
force the  arterial  suture  line,  and  did  end-to-end  anastomosis  of  the  vein  ends. 
The  result  was  a  complete  success  (''Annals  of  Surgery,"  April,  1912). 

I  attempted  a  similar  operation  on  a  varicose  aneurysm  of  the  brachial 
in  the  middle  of  the  arm.  I  found  that  the  superior  profunda  also  ran  into 
the  sac,  and  that  a  saccular  aneurysm  had  formed  on  the  brachial  a  little 
below  the  varicose  aneurysm.  I  was  obHged  to  ligate  the  profunda  and  tie  the 
artery  and  vein  above  and  below  before  extirpating  the  aneurysm.  I  feared 
gangrene,  but,  fortunately,  the  patient  escaped  it. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis,  consists  in  great 
dilatation  with  pouching  and  lengthening  of  one  or  several  arteries.  The 
disease  progresses  and  after  a  time  involves  the  veins  and  capillaries.  The 
walls  of  the  arteries  become  thin  and  the  vessels  tend  to  rupture.  Cirsoid 
aneurysm  is  most  commonly  met  with  upon  the  forehead  and  scalp  of  yoimg 
people,  where  it  sometimes  takes  origin  from  a  nevus.  It  is  sometimes  seen 
upon  the  back  or  upper  extremity.  The  cause  is  unknown.  Usually  there 
is  no  assignable  cause,  but  occasionally  the  condition  follows  an  injury.  Preg- 
nancy causes  a  cirsoid  aneurysm  to  grow  rapidly,  and  so  usually  does  the  onset 
of  puberty.  Occasionally  some  of  the  enlarged  vessels  fuse  and  form  a  great 
cavity.     If  rupture  occurs,  desperate  hemorrhage  inevitably  ensues. 

Symptoms. — There  is  a  pulsating  mass,  irregular  in  outline,  composed 
of  dilated,  elongated,  and  tortuous  vessels  that  empty  into  one  another.  The 
mass  is  soft,  can  be  much  reduced  by  direct  pressure,  and  is  diminished  by 
compression  of  the  main  artery  of  supply.     A  thrill  and  a  bruit  exist. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation  of  the  larger 
arteries  of  supply  is  a  wretched  failure.  Subcutaneous  ligation  at  many 
points  of  the  diseased  area  has  effected  cure  in  some  cases,  but  it  has  failed 
in  more.  Direct  pressure  is  also  entirely  useless.  Ligation  in  mass  has  been 
successful.  Destruction  by  caustic  has  its  advocates.  Electropuncture  with 
circular  compression  of  the  arteries  of  supply  has  once  or  twice  effected  a 
cure.  Injection  of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor,  and  sank  a  con- 
stricting ligature  into  the  cut.  The  proper  method  of  treatment  is  excision 
after  exposure  and  ligation  of  ever}^  accessible  tributary  of  supply.  In  a  very 
extensive  mass  extirpation  is  impossible;  hence  one  of  the  other  methods 
suggested  must  be  employed.  A  very  considerable  mass  can  be  excised,  and 
the  resulting  wound  should  be  covered  with  Thiersch  skin-grafts. 

Wounds  of  arteries  are  divided  into  contused  and  incised,  lacerated, 
pimctured  and  gunshot-wounds,  and  vascular  ruptures. 


Gunshot-wounds 


435 


Contused  and  Incised  Wounds. — A  contusion  may  destroy  vitality  and 
be  followed  by  sloughing  and  hemorrhage.  A  contusion  may  rupture  a  blood- 
vessel, and  is  especially  apt  to  do  so  if  the  vessel  is  diseased.  Blood  is  at 
once  effused  at  the  seat  of  rupture.  If  an  artery  is  ruptured,  there  may 
or  may  not  be  a  bruit  and  pulsation  over  the  seat  of  rupture,  pulse  is  absent 
below,  and  the  leg  below  the  injury  swells  and  becomes  cold.  If  a  large 
vein  ruptures,  a  blood  tumor  forms,  which  does  not  pulsate  and  has  no  bruit, 
and  the  limb  below  becomes  intensely  edematous.  Gangrene  is  apt  to  follow 
the  rupture  of  a  main  blood-vessel  of  an  extremity.  A  contusion  may  rupture 
the  internal  and  middle  coats  of  an  artery,  the  external  coat  remaining  intact. 
When  this  happens  the  internal  coat  curls  up  and  the  middle  coat  contracts 
and  retracts,  the  blood-stream  is  arrested,  and  a  large  clot  forms  within  the 
artery.  If  the  clot  blocks  up  many  collaterals,  gangrene  ma}^  follow,  and, 
as  has  been  pointed  out,  the  gangrene  will  not  be  preceded  by  swelling  at 
the  seat  of  injury,  which  always  occurs  if  a  vessel  is  ruptured.  A  contused 
woimd  may  do  little  damage,  may  produce  gangrene  from  thrombosis,  or 
may  cause  secondary'  hemorrhage.  In  an  incised  wound  of  an  artery  there  is 
profuse  hemorrhage.  The  arter\'  after  a  time  is  apt  to  contract  and  retract, 
bleeding  being  thus  arrested.  A  transverse  wound  causes  profuse  bleeding, 
but  there  is  a  better  chance  for  natural  arrest  than  in  an  oblique  or  in  a  longi- 
tudinal wound.     The  clot  which  forms  within  a  cut  arters'  is  kno\\Ti  as  the 


Fig.  201. — Clots  formed  after  di\'ision  of  an  arter>':  i,  2,  3,  Outer,  middle,  and  inner  coats;  c,  c,  branches; 
d,  d,  internal  clot;  e,  e,  external  clot. 

"internal  clot."  It  used  to  be  taught  that  the  internal  clot  always  reaches 
as  high  as  the  first  collateral  branch,  and  subsequently  is  replaced  by  fibrous 
tissue,  which  permanently  obliterates  the  vessel,  and  converts  it  into  a  shrunken 
fibrous  cord.  As  a  matter  of  fact,  when  the  parts  are  aseptic  after  a  ligation 
the  clot  is  rarely  bulky  and  is  often  ver\^  scanty,  repair  being  quickly  effected 
by  proliferation  of  endothelial  cells.  Between  the  vessel  and  its  sheath,  over 
the  end  of  the  vessel,  and  in  the  surrounding  perivascular  tissues  is  the  "ex- 
ternal clot"  (Fig.  201). 

A  lacerated  wound  of  an  arter\'  causes  little  primary  hemorrhage.  The 
internal  coat  curls  up,  the  circular  muscular  fibers  of  the  media  contract 
upon  it,  the  longitudinal  fibers  retract  and  draw  the  vessel  within  the  sheath, 
and  the  external  coat  becomes  a  cap  over  the  orifice  of  the  vessel.  All  of 
these  conditions  favor  clotting.  The  vessel  wall  is  so  damaged  that  secondary 
hemorrhage  is  usual. 

Punctured  Wounds. — In  punctured  wounds  primary'  hemorrhage  is  slight 
imless  a  large  vessel  is  punctured.  Secondary  hemorrhage  is  not  common. 
Traumatic  aneur}-sm  and  arteriovenous  aneur\-sm  are  not  unusual  results. 

Gunshot-wounds  of  arteries  by  pistol  balls  and  the  balls  of  large-caliber 
rifles  are  apt  to  be  contusions  which  may  eventuate  in  sloughing  and  sec- 
ondar}'  hemorrhage  or  thrombosis  and  gangrene.  A  shell-fragment  makes 
a  lacerated  wound.    A  militars^  rifle-bullet  usuallv  makes  a  clean-cut  division  of 


436  Diseases  and  Injuries  of  the  Heart  and  Vessels 

an  artery,  but  may  contuse  it.  Secondary  hemorrhage  after  gunshot-wounds 
is  most  likely  to  occur  during  the  third  week  after  the  injury.  Partial  rupture 
of  an  artery  may  cause  sloughing  and  secondary  hemorrhage,  thrombosis  and 
gangrene,  or  aneurysm.  A  complete  rupture  constitutes  a  lacerated  wound, 
and  is  a  condition  accompanied  by  diffuse  hemorrhage  into  the  tissues. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries.  The  symptom 
of  any  vascular  wound  is  hemorrhage. 

Hemorileage,  or  Loss  of  Blood 

Hemorrhage  may  arise  from  wounds  of  arteries,  veins,  or  capillaries,  or 
from  wounds  of  the  three  combined.  In  arterial  hemorrhage  the  blood  is 
scarlet  and  appears  in  jets  from  the  proximal  end  of  the  vessel,  which  jets 
are  synchronous  with  the  pulse-beats;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsatile.  Venous  hemor- 
rhage is  denoted  by  the  dark  hue  of  the  blood  and  by  the  continuous  stream. 
In  capillary  hemorrhage  red  blood  weUs  up  like  water  from  a  squeezed  sponge, 
and  the  color  is  between  the  bright  red  of  arterial  blood  and  the  dark  color  of 
venous  blood. 

In  subcutaneous  hemorrhage  from  rupture  of  a  large  blood-vessel  there 
are  great  swelling,  cutaneous  discoloration,  and  systemic  signs  of  hemorrhage. 
If  a  main  artery  ruptures  in  an  extremity,  there  is  no  pulse  below  the  ruptujre, 
and  the  limb  becomes  cold  and  swollen.  At  the  seat  of  rupture  a  large  fluc- 
tuating sweUing  forms,  and  sometimes  there  are  brmt  and  pulsation.  If  a 
vein  ruptures  in  an  extremity,  a  large,  soft,  non-pulsatUe  swelling  arises, 
there  is  no  bruit,  and  intense  edema  occurs  below  the  seat  of  rupture.  Profuse 
hemorrhage  induces  constitutional  s^onptoms,  and  death  may  occur  in  a  few 
seconds.  Loss  of  half  of  the  blood  (from  4  to  6  pounds)  "v\'ill  usually  cause 
death,  though  women  can  stand  the  loss  of  a  greater  relative  proportion  of 
blood  than  men.  Young  children,  old  people,  individuals  exhausted  by  dis- 
ease, drunkards,  sufferers  from  Bright's  disease,  diabetes,  and  sepsis  stand  loss 
of  blood  very  badly.  An  indi\ddual  with  obstructive  jaundice  is  apt  to  suffer 
from  persistent  oozing  of  blood  after  operation,  an  oozing  which  is  particularly 
persistent  and  dangerous  in  obstruction  of  the  bile-ducts  due  to  malignant 
disease.  It  not  unusually  causes  death.  After  profuse  bleeding  has  gone  on 
for  a  time,  S5mcope  usually  occurs.  Syncope  is  Nature's  effort  to  arrest 
hemorrhage,  for  during  this  state  the  feeble  circulation  and  the  increased 
coagulabihty  of  blood  give  time  for  the  formation  of  an  external  clot.  When 
reaction  occurs  the  clot  may  hold  and  be  reinforced  by  an  internal  clot,  or  it 
may  be  washed  away  with  a  renewal  of  bleeding  and  S3nicope.  These  episodes 
may  be  repeated  until  death  super\'enes.  Nausea  exists  and  there  may  be 
regurgitation  from  the  stomach.  Vertigo  is  present.  The  room  may  seem 
to  be  turning  around.  There  is  dimness  of  \dsion  or  everything  looks  black; 
black  specks  float  before  the  e3^es  (muscae  volitantes),  or  the  patient  sees 
flashes  of  light  or  colors.  There  is  a  roaring  sound  in  the  ears  (tinnitus 
auritun).  The  patient  yawns,  is  restless,  tosses  to  and  fro,  casts  off  the  bed- 
clothes, and  great  thirst  is  complained  of.  The  mind  may  be  clear,  but  delir- 
iimi  is  not  imusual,  and  convulsions  often  occur.  After  a  very  severe  hemor- 
rhage an  individual  is  intensely  pale  and  his  skin  has  a  greenish  tinge;  his 
lips  are  blanched,  the  tongue  is  cold  and  white;  the  brow  is  covered  with 
cold  moisture,  the  breath  is  cold;  the  eyes  are  fixed  in  a  glassy  stare  and  the 
pupils  are  widely  dilated,  and  react  slowly  to  light;  the  respirations  are  shallow 
and  sighing;  the  skin  is  covered  with  a  cold  sweat;  the  hands  are  clammy  and 
look  like  wax;  the  legs  and  arms  are  extremely  cold,  and  the  body  temperature 
is  below  normal.     The  pulse  is  very  frequent,  soft,  smaU,  compressible,  flut- 


Treatment  of  Hemorrhage  437 

tering,  or  often  cannot  be  detected:  the  heart  is  ven-  weak  and  fluttering,  and 
the  arterial  tension  is  ahnost  aboHshed.  There  is  muscular  tremor;  the  patient 
tosses  about,  and  asks  often  and  in  a  feeble  voice  for  water.  The  suffering 
from  thirst  is  terrible  and  no  amount  of  water  gives  rehef.  There  is  often 
dreadful  dyspnea;  at  each  inspiration  the  nostrils  open  widely  and  the  acces- 
sor}- muscles  of  respiration  are  ah  in  action.  A  man  who  is  bleeding  to  death 
grasps  at  his  chest,  makes  ettorts  to  rise,  and  then  falls  back  in  a  dead  faint. 
Usually  reaction  occurs  after  a  faint,  though  the  patient  is  ob^iouslv  weaker 
than  before;  again  a  faint  may  happen,  and  so  there  is  fainting  spell  after  faint- 
ing spell  until  death  ensues.  Con\-ulsions  frequently  precede  death.  In  hemor- 
rhage the  hemoglobin  is  greatly  diminished  in  amount.  In  an  intra-abdominal 
hemorrhage  the  above  s}-mptoms  are  noted,  and,  except  in  splenic  hemor- 
rhage, blood  gathers  in  both  loins,  and  dulness  on  percussion  exists  which 
gradually  rises  and  shifts  as  the  patient's  position  is  shifted.  The  blood  also 
gathers  in  the  rectovesical  pouch  in  the  male,  and  in  the  recto-uterine  pouch 
in  the  female,  and  may  be  detected  by  digital  examination.  If  the  spleen  is 
wounded  the  blood  usually  clots  quickly,  and  if  it  does,  an  area  of  dulness, 
which  does  not  shift  and  which  progressively  increases,  is  noted  in  the  splenic 
region. 

Treatment, — ^Mien  serious  hemorrhage  exists  the  surgeon  should,  when 
possible,  arrest  bleeding  temporarily,  and  should  then  bring  about  reaction 
and  arrest  bleeding  permanently.  Temporary-  arrest  is  not  possible  in  an 
intra-abdominal  hemorrhage.  In  any  case  of  severe  hemorrhage  lower  the 
head,  and  have  compression  made  upon  the  femorals  and  subclaAdans.  so  as 
to  divert  more  blood  to  the  brain,  or  bandage  the  extremities  i  autotransfusion). 
Apply  artihcial  heat.  The  A^alue  of  adrenalin  in  restoring  or  maintaining  arte- 
rial tension  has  been  demonstrated  by  Crile.  We  should  give  the  patient  by 
h}"podermoclysis  i  pint  of  hot  normal  salt  solution  containing  i  dr.  of  the 
1 :  1000  solution  of  adrenalin  chlorid.  The  fluid  is  allowed  to  nm  in  the  sub- 
cutaneous tissue  beneath  the  breast.  The  infusion  of  i  pint  or  more  of  hot 
salt  solution  into  a  ^-ein  is  a  very-  valuable  remedy;  it  gi^-es  the  heart  some- 
thing to  contract  upon  and  thus  maintains  cardiac  action.  If  the  depression 
is  ver\-  severe,  inject  ether  hA-podennatically.  then  brandy,  and  then  atropin. 
Str\-chnin  may  be  given  h}-podermaticaUy  in  doses  of  -^-^  gr.,  but  atropin  is 
of  more  service.  Digitalin  is  ad\ised  by  some,  but  it  is  not  sufficiently  rapid 
in  action.  Give  enemata  of  hot  cofl'ee  and  brandy.  Apply  mustard  o^"er  the 
heart  and  spine.    Lay  a  hot-water  bag  over  the  heart. 

In  hemorrhage  from  a  vessel  of  an  extremit},-  temporarily  arrest  bleeding 
while  bringing  about  reaction.  Do  so  by  digital  pressure  in  the  wound,  or, 
if  the  bleeding  is  arterial,  by  the  appKcation  of  an  Esmarch  band.  In  some 
cases  forced  flexion  is  used.  As  soon  as  reaction  is  estabHshed.  permanently 
arrest  bleeding  by  the  ligature.  In  intra-abdominal  or  concealed  hemorrhage 
it  is  not  possible  to  temporarily  arrest  it  and  wait  for  reaction,  but  the  abdomen 
mtist  be  opened  and  the  work  proceeded  with  in  spite  of  the  patient's  condi- 
tion.   Ever\-  moment  we  wait  he  is  growing  worse. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever,  due  to  the  absorption 
of  fibrin  ferment  from  extravasated  blood  and  its  action  upon  a  profoundly 
debilitated  system.  After  a  severe  hemorrhage  leukocytes  are  increased,  not 
only  relatively,  but  absolutely.  Red  corpuscles  are  diminished  both  relatively 
and  absolutelv.  Hemoglobin  diminishes:  many  of  the  corpuscles  become 
irregular  and  microcytes  are  noticed. 

In  treating  a  patient  who  has  thoroughly  reacted  after  a  severe  hemor- 
rhage, apply  cold  to  the  head.  Fluids  and  ice  are  grateful.  Frequently  sponge 
the  skin  with  alcohol  and  water.  ^lilk-punch.  kotuniss,  and  beef-peptonoids 
are  given  at  frequent  inter^-als. 


438  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Hemostatic  agents  comprise:  (i)  the  Hgature  and  suture;  (2)  torsion; 
(3)  acupressure;  (4)  elevation;  (5)  compression;  (6)  styptics;  (7)  the  actual 
cautery;  (8)  forced  flexion  of  a  limb. 


Fig.  202. — Halsted's  straight  artery  forceps. 

The  ligature  was  known  to  the  ancients,  but  was  rediscovered  by  Ambroise 
Pare.     The  ligature  may  be  made  of  silk,  floss-silk,  or  catgut.      Whatever 


Fig.  203. — Curved  hemostatic  forceps. 

material  is  used  must,  of  course,  be  rendered  aseptic.     A  ligature  should 
be  about  10  inches  long.    The  vessel  to  be  tied  must  be  dra'WTi  out  with  for- 


Fig.  204. — Straight  hemostatic  forceps. 

ceps  and  separated  for  a  short  distance  from  its  sheath,  but  must  not  be 
separated  to  any  considerable  extent;  to  do  so  may  lead  to  necrosis  of  the 


Hemostatic  Agents 


439 


vessel  and  secondary  hemorrhage.  The  hemostatic  forceps  (Figs.  202,  203, 
204)  is  in  most  cases  a  better  instrument  than  the  tenacuhim  (Fig.  205).  The 
tenacukim  makes  a  hole  in  the  vessel,  and  sometimes  a  slit-like  tear.  A  por- 
tion of  this  opening  may  remain  back  of  the  tied  ligature,  the  vessel  may 
retract  a  little,  or  the  ligature  may  slip  slightly,  and  bleeding  may  occur. 
When  the  artery  lies  in  dense  tissues  or  is  retracted  deeply  in  muscle  or  fascia, 


Fig.  205. — Tenaculum. 

the  tenaculum,  when  carefully  used,  is  the  better  instrument.  The  ligature 
is  tied  in  a  reef-knot  (Fig.  206),  not  in  a  granny-knot  (Fig.  207)  and  not  in  a 
surgeon's  knot  (Fig.  208).  It  is  often  the  purpose  of  the  surgeon  to  divide  the 
internal  and  middle  coats  of  the  vessel,  and  if  such  is  his  desire  the  first  knot 
is  firmly  tied.  The  second  knot  must  not  be  tied  too  tightly  or  it  will  cut  the 
ligature.    The  ligature  must  not  be  jerked  as  it  is  being  tied.    If  a  third  knot 


Fig.  206. — Method  of  tying  square  or  reef-knot. 


Fig.  207. — Method  of  tying  granny-knot. 


overlies  the  first  two,  the  ligature  can  be  cut  off  close  to  the  knot,  otherwise 
it  is  cut  off  so  that  short  ends  are  left.  Both  ends  of  a  divided  vessel  should  be 
ligated.  If  a  vessel  is  atheromatous,  it  is  not  desirable  to  divide  the  internal 
and  middle  coats.  In  this  case  a  ligature  should  be  applied  firmly  rather  than 
tightly,  and  another  ligature  should  be  put  on  above  it,  or  ligation  can  be 
effected  by  the  stay  knot.  If  an  artery  is  incompletely  divided,  a  ligature 
should  be  applied  on  each  side  of  the 
wound  and  the  vessel  divided  between 
the  ligatures. 

When  the  parts  about  an  artery  are 
so  thickened  that  the  vessel  cannot 
be  drawn  out,  arm  a  curved  Hagedorn 
needle  (Fig.  209)  with  catgut  and  pass 
the  latter  around  the  vessel  in  such  a 
manner  that  the  catgut  will  include  the 
vessel  with  some  of  the  surrounding  tissue.  Then  tie  the  ligature  (Fig.  211). 
This  method  is  known  as  the  application  of  a  suture-ligature,  and  is  pursued 
in  necrosis,  atheroma,  scar-tissue,  sloughing,  etc.  Never  include  a  nerve  of  any 
size  in  the  ligature.    If  this  mode  of  ligation  fails,  we  may  try  acupressure. 

Doyen,  when  about  to  tie  a  thick  pedicle,  crushes  it  by  means  of  a  very 
powerful  instrument  and  then  ties  a  ligature  about  the  crushed  and  attenuated 
area.  The  vessels  are  closed  by  laceration  wide  of  the  ligature  and  the  ligature 
does  not  tend  to  slip.  Some  trust  such  a  stump  without  a  ligature,  but  most 
surgeons  prefer  to  ligate.  This  instrimient  is  known  as  the  vasotribe  or  angio- 
tribe  and  is  used  particularly  in  hysterectomy.     Figure  212  shows  a  vasotribe. 


Fig.  208. — Method  of  tying  surgeon's  knot. 


440 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


Veins  are  ligated  as  are  arteries.    If  a  large  vein  is  torn,  we  wish,  if  possible, 
to  control  hemorrhage  without  obliterating  the  lumen  of  the  vein  by  ligation. 


Fig.  2og. — ^Hagedorn's  needles. 


Fig.  2IO. — Method  of  controlliDg  hemorrhage 
by  ligature  (after  Esmarch):  a,  Artery  ligated; 
b,  lateral  ligature  of  vein. 


If  the  wound  is  not  greater  in  length  than  the  measure  of  the  diameter  of  the 
lumen,  a  lateral  ligature  may  be  used.    It  is  practically  always  used  in  small 

transverse  wounds.  In  order  to  apply  a  lateral 
ligature  the  two  lips  of  the  vein  wound  are 
seized  by  forceps  and  drawn  out  into  a  tit  (Figs. 
2IO  and  227).  A  ligature  is  placed  around  the 
base  of  the  cone  and  tied.  The  pull  in  the  cone 
is  relaxed  while  the  first  knot  is  being  tied  in 
order  that  the  Hgature  may  constrict  tightly. 
In  a  large  vessel  the  thread  should  be  passed  by 
a  needle  through  the  outer  coats  of  the  vein 
before  it  is  used  to  encircle  the  cone.  This 
plan  prevents  slipping.  In  some  cases  when 
a  lateral  ligature  or  suture  cannot  be  applied,  forcipressure  will  succeed.  One 
or  more  clamp  forceps  are  applied  and  are  left  in  place  for  several  days. 


Fig 


211. — ^Arrest   of   hemorrhage   by 
passing  a  suture-ligature. 


Fig.  212. — ^Vasotribe  of  Doyen. 

Phleborrhaphy  is  suture  of  a  vein,  with  preservation  of  the  lumen  of  the 
vessel.  It  is  used  when  complete  ligation  is  undesirable  (as  in  a  large  vein), 
and  when  lateral  ligation  without  obHteration  of  lumen  is  impossible.    It  is 


Hemostatic  Agents 


441 


commonly  employed  for  longitudinal  wounds  and  for  wounds  in  any  direction 
when  the  length  of  the  wound  is  greater  than  the  diameter  of  the  vessel.  Fine 
catgut  or  silk  may  be  used.  An  intestinal  needle  threaded  with  silk  is  entirely 
satisfactory.  The  thread  is  passed  through  the  external  coat  and  part  of  the 
middle  coat  on  each  side  of  the  wound.  Interrupted  sutures  are  employed  and 
thus  the  two  lips  of  the  wound  are  approximated.  A  vein  completely  divided 
across  can  be  united  by  end-to-end  suturing.  Figure  213  shows  the  operation 
of  phleborrhaphy. 

By  suturing  I  successfully  closed  a  tear  in  the  innominate  vein  inflicted 
during  the  removal  of  a  retrosternal  goiter,  and  also  a  considerable  longitudinal 

tear  in  the  internal  jugular  vein    

inflicted  during  the  removal  of    I  ] 

lymph-nodes.  j 

Murphy  and  Damar  Harri- 
son each  succeeded  in  suturing 
a  wound  of  the  inferior  vena 
cava.  Bier  successfully  applied 
sutures  in  2  cases  of  wound  of 
the  inferior  vena  cava. 

Israel  points  out  how  diffi- 
cult it  is  to  suture  in  the  depths 
of  a  cavity  full  of  blood.  This 
complication  always  exists  in 
wounds  of  the  inferior  cava,  and 
in  them  it  may  be  necessary  to 
use  forcipressure.  He  did  this 
in  2  cases. 

In  a  case  of  Korte's  the  cava 
was  wounded  during  nephrec- 
tomy. Forcipressure  and  lateral 
sutures  were  found  imprac- 
ticable. The  cava  was  tied. 
Thrombophlebitis  arose  in  both 
legs,  but  the  patient  eventu- 
ally recovered  ("Zentralbl.  fiir 
Chir.,"  August  8,  191 1). 

Arteriorrhaphy.— The  studies  of  Carrel,  Murphy,  Matas,  Abbe,  and 
others  have  shown  that  wounded  arteries  can  be  repaired  by  suturing;  that  a 
portion  of  an  artery  can  be  removed  and  repair  be  obtained  by  end-to-end 
suturing,  implantation,  or  lateral  anastomosis;  that  an  artery  can  be  obHter- 
ated  by  suturing  the  intima  from  within;  that  an  artery  can  be  anastomosed 
into  a  vein,  and  that  after  resection  of  a  portion  of  an  artery  vascular  integ- 
rity may  be  restored  by  suturing  into  the  gap  a  portion  of  a  vein  or  artery 
recently  resected. 

We  now  suture  certain  wounds  in  large  vessels  which  until  very  recently 
would  have  caused  us  to  completely  ligate  the  artery.  In  extirpating  malig- 
nant tumors  it  is  sometimes  necessary  to  remove  large  arteries  or  veins.  This 
may  cause  grave  danger  of  gangrene,  and  we  now  may  attempt  to  prevent 
gangrene  by  the  restoration  of  vascular  continuity. 

The  wonderful  experiments  of  Carrel  on  the  transplantation  of  organs  and 
the  brilliant  studies  and  operations  of  Matas  and  Murphy  have  been  the  great 
influences  that  have  brought  vessel  suture  into  the  field  of  practical  surgery. 

There  is  yet  much  to  learn.  What  we  do  know  is  really  little,  but  w^e  are 
probably  at  the  threshold  of  great  events. 

We  know  that  we  can  close  by  suture  a  lateral  wound  or  a  transverse  wound 


Fig.  213. — Phleborrhaphy:  Forceps  are  seen  everting 
lip  of  wound  for  passage  of  needle  and  interrupted  sutures 
CBickham). 


442 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


of  less  than  half  the  circumference  of  the  vessel;  that  we  can  perform  end-to- 
end  suturing ;  that  we  can  insert  a  piece  of  resected  vein  to  re-establish  vascular 
continuity;  and  that  after  such  an  operation  the  blood-current  will  be  re- 
established. We  do  not  know  how  long  the  circulation  will  continue  after 
re-establishment.  A  sutured  artery  will  certainly  carry  blood  for  a  time,  but 
in  most  cases,  at  least,  only  for  a  time,  the  ultimate  fate  of  the  vessel  being  ob- 
literation by  endothelial  proliferation.  If  the  vessel  operated  upon  is  diseased, 
obliteration  by  clot  is  practically  certain  to  ensue.  But  even  temporary  re- 
establishment  of  circulation  is  of  the 
greatest  value.  Even  though  the  lumen 
is  finally  closed,  the  closure  is  gradual. 
While  the  vessel  is  closing  the  collaterals 
are  dilating.  By  the  time  one  source  of 
supply  for  the  tissues  is  cut  off,  another 


Fig.  214. — Repair  of  longitudinal  wound  of 
artery  by  combination  cobbler's  stitch  through 
all  coats,  and  interrupted  sutures  through  outer 
coats,  as  suggested  by  the  author:  A,  Beginning 
of  cobbler's  stitch  through  all  coats;  B,  B,  needles 
in  act  of  passing  through  same  opening  in  opposite 
directions,  in  characteristic  cobbler  fashion;  C,  C, 
C,  three  interrupted  sutures  through  outer  coats, 
ready  to  be  tied;  D,  D,  two  interrupted  sutures 
tied,  passing  through  outer  coats  (Bickham). 


Fig.  215. — Repair  of  complete  trans- 
verse division  of  artery  by  combination  cob- 
bler's stitch  through  all  coats,  followed  by 
interrupted  sutiures  through  outer  coats,  as 
suggested  by  the  author:  A,  A,  Needles  pass- 
ing in  opposite  directions  through  all  coats, 
in  act  of  placing  cobbler's  stitch;  B,  super- 
ficial tier  of  interrupted  stitches  through  outer 
coats,  showing  three  untied  and  two  tied  (Bick- 
ham). 


has  come  into  being.  Thus  gangrene  is  prevented.  There  appears  to  be  a 
certain  amount  of  danger  of  the  development  of  aneurysm  at  the  seat  of  sutur- 
ing. In  a  longitudinal  wound  of  an  artery  or  in  a  transverse  wound  of  not  over 
half  the  circumference  of  the  vessel,  the  wound  may  be  closed  by  interrupted 
sutures,  passing  the  threads  through  the  two  outer  coats  and  bringing  the  wound 
edges  together  without  inversion.  Floss  silk  is  used,  and  it  should  be  as  large 
as  the  eye  of  a  curved  conjunctival  needle  will  carry  in  order  to  lessen  the 
danger  of  leaking  of  blood  through  the  stitch  holes.  The  sheath  is  sutured 
over  the  stitch  line  ("Bickham's  Operative  Surgery"). 


Hemostatic  Agents 


443 


A  better  plan  in  such  wounds  is  that  of  Bickham,  viz.,  a  cobbler's  stitch 
through  all  the  coats  to  bring  the  intima  of  each  lip  together  and  interrupted 
sutures  through  the  outer  coats  (Fig.  215).     An  oblique  wound  may  be  repaired 


Fig.  216. — Arteriorrhaphy  in  complete  circular  division  of  an  artery  (Murphy's  method):  A, 
Intussusception,  with  sutures  passing  through  outer  and  middle  coats;  B,  intussuscipiens  (split  to  aid 
invagination),  with  sutures  passing  through  all  coats;  C,  showing  all  sutures  tied  (Bickham). 

in  the  same  manner.  If  a  vessel  is  divided  transversely  through  more  than  half 
of  its  circumference  Murphy  believes  that  the  division  should  be  made  com- 
plete as  a  preliminary  to  suturing. 


Fig.  217. — Circular  arteriorrhaphy  in  complete  division  of  an  artery:  A,  Method  of  Salomoni 
and  Tomaselli — interrupted  sutures  through  all  coats;  B,  method  of  Gluck — interrupted  sutures 
through  outer  coats,  protected  by  cyhnder  of  decalcified  bone,  ivory,  or  rubber  (Bickham). 

Complete  circular  division  may  be  treated  by  Murphy's  plan,  viz.,  invagina- 
tion of  one  end  of  the  cut  vessel  into  the  other  end  split  to  receive  it  (Figs.  215 
and  216),  by  Bickham's  plan  of  a  cobbler's  stitch  followed  by  interrupted 
sutures,  or  by  one  of  the  plans  shown  in  Fig.  217. 


444  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  author  successfully  sutured  a  small  wound  in  the  axillary^  artery.  Stew- 
art removed  a  clot  from  the  femoral  and  sutured  the  vessel.  Murphy  removed 
a  clot  from  the  external  iliac  artery  and  sutured  the  vessel.  Braun  ("Zentral- 
blatt  fiir  Chirurgie,"  August  29,  1908)  resected  a  portion  of  the  aorta  along  with 
a  tumor  and  performed  circular  suture.  Depage  successfully  sutured  the  com- 
mon carotid  artery.  Pringle  sutured  a  wound  of  the  external  iliac  artery. 
The  wound  was  I  inch  in  length.  Dejemil  Pasha  sutured  a  lacerated  woimd  of 
the  axillary  artery.  Torance  sutured  a  wounded  brachial  artery.  Martin 
sutured  a  lacerated  wound  of  the  femoral  artery  ("Annals  of  Surgery,"  Oct., 
1905).  Henderson  sutured  a  transverse  wound  extending  half  across  the 
femoral  artery  ("American  Medicine,"  Jan.  14,  1905).  A.  E.  Halstead  cut 
two-thirds  through  the  circumference  of  the  axillary  artery  and  sutured  the 
wound  directly  instead  of  making  the  wound  first  of  all  a  complete  di\'ision, 
as  advised  by  Murphy.     Two  months  later  the  radial  pulse  was  present. 

Faykiss  made  an  end-to-end  suture  of  a  divided  carotid  artery  ("Centralb. 
fiir  Chirurgie,"  1908,  xxxv). 

Lexer  ("Ajrchiv.  fiir  klinische  Chirurgie,"  1907,  No.  2)  resected  the  sac  of  a 
traumatic  arteriovenous  aneurj^sm  of  the  popliteal  vessels,  removing  at  the 
same  time  5  cm.  of  arters^  and  as  much  vein. 

He  performed  end-to-end  anastomosis  of  each  vessel  over  a  thin  magnesiimi 
tube  (Payr's  tube).  The  pulse  was  restored.  Nine  months  after  operation 
the  pulse  was  present  below  the  seat  of  operation,  but  was  weaker  than  it  had 
been  some  months  before.  In  this  paper  Lexer  speaks  of  a  case  of  diffuse 
aneury^sm  of  the  axillary  artery.  The  surgeon  resected  the  sac  and  a  portion  of 
the  artery.  The  gap  of  over  3  inches  was  filled  by  a  piece  of  internal  saphenous 
vein  sutured  in  place  (autoplasty).  The  circulation  was  re-established  in  the 
limb,  but  the  patient  died  of  complications.  Postmortem  demonstrated  that 
the  transplanted  vein  was  patent  and  the  sutures  firm.  There  was  a  clot  above 
the  piece  of  vein  due  to  the  action  of  the  clamp  upon  a  sclerotic  arter}^  Gan- 
grene began  on  the  fourth  day  after  operation. 

]\Ianteuffel  successfully  sutured  a  wound  of  the  femoral  artery.  This  was 
the  first  case  to  be  recorded  (Bloodgood,  in  "Progressive  ^Medicine,"  Dec. 
I,  1908J,  although  Hallowell,  in  1759,  successfully  closed  a  wound  in  the 
brachial  artery  by  means  of  a  harelip  pin  and  a  ligature  fMumfordj.  Blood- 
good  in  the  same  article  notes  that  Korte,  in  1904,  performed  lateral  suture 
of  the  popliteal  arter>^  and  vein,  and  that  Garre  closed  a  woimd  in  the  pop- 
liteal artery  by  suture,  and  in  the  vein  of  the  same  patient  by  lateral  ligature. 

Murphy  was  the  first  surgeon  to  succeed  in  resecting  a  portion  of  a  large 
artery  (the  femoralj  and  doing  end-to-end  suturing  ("Med.  Record,"  Jan.  16, 
1897). 

Limd  ("Annals  of  Surgen,^"  March,  1909)  sutured  a  double  stab-wound  of 
the  femoral  artery  and  vein,  and  six  months  later  there  was  a  pulse  in  the  dor- 
salis  pedis.  Routier  tore  the  aorta  in  remo\dng  a  h^-pernephroma  of  the  kidney. 
He  sutured  the  wound  with  catgut.  The  patient  died  on  the  fourteenth  day, 
but  not  from  hemorrhage  ("Gaz.  des  HopitaiLx,"  1911).  ManteUi  closed  a 
gap  in  the  femoral  arterv'  by  a  segment  of  a  vein  (autoplastic  graft).  Buchanan 
performed  circular  resection  and  suture  of  the  axillar\^  arter\',  the  vessel  ha\ing 
been  lacerated  by  the  bone  fragments  after  fracture-dislocation  of  the  anatom- 
ical neck  of  the  humerus.  Buchanan  has  collected  29  instances  of  end-to-end 
suture  of  di\'ided  arteries  ("Surgery,  G}Tiecolog}%  and  Obstetrics,"  Dec,  1912). 

Among  other  surgeons  reporting  successful  cases  of  arterial  suture  are 
Heidenhain,  Orlow,  Pean,  Baum,  Sherman,  Krause,  Payr,  Kummell,  Seggel, 
Lindner,  and  Brougham. 

Torsion  was  practised  by  the  ancients,  but  was  reintroduced  in  modern 
times,   particularly  by  Amussat,   Velpeau,   Syme,   and  Bryant,   of  London. 


Hemostatic  Asfents 


445 


■Method  of  controlling  hemorrhage 
bv  torsion. 


By  means  of  torsion  the  internal  and  middle  coats  are  ruptured  and  the  external 

coat  is  twisted.     The  middle  coat  retracts  and  contracts,  and  the  inner  coat 

inverts  into  the  liunen  of  the  arter>-.     It  is  a  safe  procedure,  and  is  practised 

upon  vessels  as  large  as  the  femoral  by  many  surgeons  of  high  standing.     Before 

the  days  of  asepsis  torsion  possessed  the  signal  merit  of  not  introducing  possible 

infection  in  Kgatiu^es.     At  the  present  time  it  offers  no  particular  advantage. 

It  is  no  quicker  than  the  hgature,  and  damages  the  vessel  so  much  that  necrosis 

may  occur.     It   cannot  be  used  if  the 

vessels  are  diseased.     In  what  is  known 

as    free    torsion   the  vessel  is  grasped, 

dra\Mi  out,  and  t-^isted  until  the  free  end 

of  the  vessel  is   twisted  off.      Limited 

torsion  is  more  often  used.     The  vessel  is 

dra-^^-n  out  of  its  sheath  by  a  pair  of 

forceps  held  horizontally,  and  is  grasped 

a  little  distance  above  its  extremity  by 

another  pair  of  forceps  held  vertically 

(Fig.  2iS).     The  first  instrument  is  used 

to  twist  the  arter\-  six  to  eight  times. 

Acupressure  is  pressure  appKed  by  means  of  a  long  pin.  The  method 
of  hemostasis  by  acupressure  was  de\ised  by  Sir  James  Y.  Simpson.  A  pin 
is  simply  passed  under  a  vessel  (transfixion),  lea^'ing  a  little  tissue  on  each 
side  between  the  pin  and  vessel.  A  pin  can  be  passed  under  a  vessel,  and 
a  ^ire  be  throvvn  over  the  pin  and  twisted  (circimi elusion) .  The  pin  can 
be  inserted  upon  one  side,  passed  through  ^  inch  of  tissues  up  to  the  vessel, 
be  given  a  quarter  tTidst,  and  be  driven  into  the  tissues  across  the  arter^^ 
(torsoclusionX  Some  tissue  may  be  picked  up  on  the  pin,  folded  over  the 
vessel,  and  pinned  to  the  other  side  i^retroclusion\  Acupressure  is  occa- 
sionally used  to  arrest  hemorrhage  if  vessels  are  inflamed  or  atheromatous,  in 
sloughing  wounds,  in  scar-tissue,  and  when  a  Hgature  will  not  hold  firmly. 

Elevation  is  used  as  a  temporary-  expedient  or 
in  association  with  some  other  method.  It  is  of 
use  in  a  wound  of  a  bursa,  in  bleeding  from  a 
ruptured  varicose  vein,  and  its  use  is  frequently 
associated  with  compression. 

Compression  is  either  direct  or  indirect — that 
is,  in  the  wound  or  upon  its  arter\-  of  supply. 
In  the  removal  of  the  upper  jaw  arrest  bleeding 
by  plugging.  In  injury-  of  a  cerebral  sinus  plug 
■v^-ith  gauze.  Compression  and  hot  water  (115°- 
120°  F.)  wiLl  stop  capillar}'  bleeding.  A  gradu- 
ated compress  was  f  onnerly  recommended  in  hem- 


Fig.  2ig. — Tamponade  of  inter- 
costal artery  (after  Von  Langen- 
beck). 


Fig.  220. — Conic?. 


aseptic  tampon  (graduated  compress^i  com- 
pressing an  arterj-  (Senn) . 


orrhage  from  the  palmar  arch  (Fig.  220).     A  compress  will  arrest  bleeding  from 

superficial  veins.     The  knotted  bandage  of  the  scalp  will  arrest  bleeding  from 

the  temporal  arter\-.     Long-continued  pressure  causes  pain  and  inflammation. 

Indirect  compression  is  used  to  prevent  hemorrhage  or  to  temporarily 


446 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


arrest  it.  It  may  be  effected  by  encircling  a  limb  above  a  bleeding  point 
with  an  Esmarch  band  or  by  applying  a  tourniquet  or  an  improvised  tourniquet 
(Fig.  221).  It  may  also  be  effected  by  a  clamp.  Crile  has  devised  a  clamp  to 
effect  temporary  closure  of  the  carotid  artery.  In  operations  about  the  head 
one  or  both  carotids  may  be  closed  for  a  considerable  time  and  bleeding  may 
thus  be  largely  prevented.  Ip  10  cases  Crile  temporarily  closed  both  carotids. 
A  hypodermatic  injection  of  atropin  is  given  to  prevent  inhibition,  the  vessels 
are  exposed,  and  the  clamps  are  applied 
with  just  sulScient  firmness  to  approximate 
the  vessel  walls.  No  clot  will  form  if  the 
walls  are  not  compressed.  The  patient  is 
in  the  Trendelenburg  position.  If  it  is 
found  that  respiratory  difficulty  occurs,  one 


Fig.    221. — Impromptu  tourniquet  for  compressing  an 
artery  with  a  handkerchief  and  a  stick. 


Fig.  222. — ^Handle  of  door-key,  padded. 


clamp  must  be  loosened.  After  the  completion  of  the  operation  the  patient 
must  be  brought  to  the  horizontal  before  the  clamps  are  removed  (Crile,  in 
"Annals  of  Surgery,"  April,  1902). 

Digital  compression  is  a  form  of  indirect  compression.  It  can  be  main- 
tained for  only  a  few  minutes  by  one  person,  but  a  relay  of  assistants  can 
carry  it  out  for  a  considerable  time.  In  compressing  the  subclavian  artery 
wrap  a  key  as  shown  in  Fig,  222,  and  compress  the  artery  against  the  outer 


Fig.  223. — ^Digital  compression  of  the  brachial  artery 


Fig.  224. — Digital  compression  of 
the  brachial  artery. 


surface  of  the  first  rib.  The  shoulder  must  be  depressed  and  pressure  applied 
in  the  angle  between  the  posterior  border  of  the  sternocleidomastoid  and  the 
upper  border  of  the  clavicle.  The  direction  of  the  pressure  should  be  down- 
ward, backward,  and  inward. 

The  brachial  artery  can  be  compressed  against  the  humerus.  In  the  upper 
part  of  the  course  of  the  artery  the  pressure  should  be  from  within  outward 
(Fig.  223),  in  the  lower  part  from  before  backward  (Fig.  224).     The  abdomi- 


Hemostatic  Agents 


447 


nal  aorta  can  be  compressed  by  Macewen's  method  (q.  v.).  The  common 
iliac  can  be  compressed  through  the  rectum  by  means  of  a  round  piece  of 
wood  known  as  Davy's  lever.  The  femoral  artery  can  be  compressed  just 
below  Poupart's  ligament  against  the  psoas  muscle  and  head  of  the  femur 
(Fig.  225).  The  pressure  should  be  directly  backward.  In  the  middle 
third  of  the  thigh  digital  compression  is  unsatisfactory,  and  a  tourniquet 
should  always  be  used  or  an  Esmarch  band  be  employed. 

Forced  flexion  is  a  variety  of  indirect  compression  introduced  by  Adelmann. 
It  will  arrest  bleeding  below  the  point  compressed,  but  soon  becomes  intensely 
painful.  Forced  flexion  can  be  maintained  by  bandages.  Brachial  hyper- 
flexion  is  maintained  by  tying  the  forearm  to 
the  arm.  It  is  often  associated  with  the  use  of 
a  pad  in  front  of  the  elbow.  Genuflexion  is 
maintained  by  tying  the  foot  to  the  thigh.  It  is 
increased  in  efficiency  by  placing  a  pad  in  the 
popliteal  space. 

Styptics. — Chemicals  are  now  rarely  used  to 
arrest  hemorrhage.  In  epistaxis  we  may  pack 
with  plugs  of  gauze  saturated  with  a  10  per 
cent,  solution  of  antipyrin.  In  bleeding  from 
a  tooth-socket  freeze  with  chlorid  of  ethyl 
spray,  and  then  pack  with  gauze  soaked  with  10 
per  cent,  solution  of  antipyrin  or  pack  with 
dry  sponge  or  styptic  cotton  (absorbent  cotton 
soaked  in  Monsel's  solution  and  dried).  A  bit 
of  cork  may  be  forced  into  the  socket.  In 
bleeding  from  an  incised  urinary  meatus  pack 
with  styptic  cotton  and  compress  the  lips  of 
the  meatus.  Cold  water,  chlorid  of  ethyl  spray, 
and  ice  act  as  styptics  by  producing  reflex  vas- 
cular contraction.  Hot  water  produces  contraction  and  coagulates  the  albu- 
min. The  temperature  should  be  from  115°  to  120°  F.  A  mixture  of  equal 
parts  of  alcohol  and  water  stops  capillary  oozing. 

The  Use  of  Gelatin  in  Controlling  Hemorrhage. — It  seems  very  positively 
proved  that  gelatin  increases  the  coagulability  of  the  blood  if  given  hypo- 
dermatically.  It  has  been  shown  by  Horatio  C.  Wood,  Jr.  ("American 
Medicine,"  May  3,  1902),  that,  even  when  administered  by  the  stomach,  di- 
gestion does  not  destroy  its  coagulating  effect  upon  the  blood.  Carnot,  of 
Paris,  used  it  locafly  and  with  success  to  control  epistaxis  in  a  sufferer  from 
hemophilia  He  then  employed  it  to  arrest  bleeding  from  hemorrhoids, 
tumors,  and  incised  wounds;  and  demonstrated  in  animals  that  it  will  arrest 
oozing  from  the  cut  surface  of  the  liver.  Carnot  used  a  5  or  10  per  cent, 
solution.  It  has  been  employed  with  success  to  control  hemorrhage  in  many 
situations,  is  of  value  when  applied  locally,  and  possibly  of  use  when  injected 
subcutaneously. 

Intravenous  injections  are  extremely  dangerous,  and  are  apt  to  be  fol- 
lowed by  embolism.  Subcutaneous  injections  are  decidedly  painful  and 
are  not  altogether  safe,  producing  albuminuria  and  occasional  embolism. 
Another  danger  that  may  foUow  the  subcutaneous  administration  of  gelatin 
is  the  development  of  tetanus,  and  several  cases  have  been  reported.  The 
existence  of  disease  of  the  kidneys  contra-indicates  the  hypodermatic  use  of 
gelatin. 

It  has  been  successfully  used  as  an  enema  in  intestinal  hemorrhage,  and 
as  an  injection  in  hemorrhage  from  the  bladder.  I  have  used  it  with  success 
in  arresting  bleeding  from  the  cut  surface  of  the  human  liver;  to  check  bleed- 


Fig.  225. — Digital    compression    of 
the  femoral  artery. 


448  Diseases  and  Injuries  of  the  Heart  and  Vessels 

ing  from  an  incised  wound  in  a  victim  of  leukemia;  to  arrest  postoper- 
ative oozing  in  sufferers  from  cholemia;  and  in  several  cases  of  severe 
epistaxis. 

When  employed  locally  in  solution,  it  should  be  of  a  strength  of  from  2  to 
10  per  cent,  in  normal  salt  solution.  For  hypodermatic  use  some  employ  a 
5  per  cent.,  some  a  2  per  cent.,  and  some  a  i  per  cent,  solution.  In  using 
a  I  or  2  per  cent,  solution  a  very  large  amount  of  fluid  must  be  injected. 
This  causes  pain;  and  Sailer  maintains  that  the  pain  is  slight  or  absept  if  the 
solution  is  not  turbid  and  if  but  10  c.c.  of  a  10  per  cent,  solution  are  injected. 
The  injection  may  be  repeated  until  from  i  to  3  gm.  of  gelatin  have  been 
administered.  It  should  be  injected  on  the  outer  side  of  the  thigh,  under 
the  breast,  or  between  the  shoulder-blades.  If  the  drug  is  given  by  mouth, 
100  c.c.  of  a  10  per  cent,  solution  is  the  dose,  and  this  may  be  repeated  every 
two  or  three  hours. 

On  account  of  the  possible  danger  of  the  development  of  lockjaw  after 
infection  great  care  in  sterilizing  must  always  be  exercised.  The  method  of 
preparation  suggested  by  Joseph  Sailer  will  be  found  of  the  greatest  value. 
(For  the  formula  for  this  see  page  422.) 

In  view  of  the  fact  that  gelatin  is  such  an  excellent  culture  material, 
whenever  it  is  used  in  the  rectum,  nose,  pharynx,  vagina,  or  bladder  it  should 
be  mixed  with  some  antiseptic  agent. 

The  exact  mode  in  which  gelatin  acts  in  producing  coagulation  is  not 
certain.  Floresco  maintains  that  it  acts  like  an  acid.  Laborde  states  that 
undissolved  particles  of  gelatin  serve  as  centers  for  coagulation.  Other 
experimenters  insist  that  gelatin  destroys  the  leukocytes,  and  thus  liberates 
fibrin  ferment. 

Suprarenal  extract  is  a  valuable  agent  to  control  capillary  oozing.  It 
constricts  capillaries,  and  if  applied  to  a  mucous  membrane  will  rapidly  blanch 
it.  It  is  extensively  used  to  check  bleeding  during  operations  on  the  nose, 
throat,  larynx,  and  ear,  and  to  arrest  epistaxis  and  bleeding  from  the  uterus. 
The  solution  to  employ  is  adrenalin  chlorid  of  a  strength  of  from  i :  10,000 
to  1 :  1000.  A  piece  of  cotton  soaked  in  this  solution  is  pressed  lightly  upon 
the  part  or  it  is  sprayed  upon  the  part  by  an  atomizer. 

Chlorid  of  calcium,  given  internally,  is  said  to  favor  coagulation  of  the 
blood  and  is  used  to  check  oozing  or  to  prevent  hemorrhage.  It  is  used 
particularly  in  jaundice  cases  when  operation  must  be  performed.  If  given 
several  times  a  day  for  two  or  three  days  it  increases  the  coagulability  of 
the  blood;  but  if  given  for  more  than  four  days,  actually  diminishes  it.  The 
initial  dose  is  from  15  to  30  gr.,  then  5  gr.  every  hour  are  given  until  five 
or  six  doses  have  been  taken.  It  is  apt  to  provoke  gastric  irritability,  and 
it  is  often  given  by  the  rectum.  I  have  never  been  convinced  of  the  value 
of  the  drug. 

Blood-serum. — In  hemophiliacs  and  in  the  postoperative  oozing  of  jaun- 
diced patients  blood-serum  is  of  great  value.  The  wound  may  be  tamponed 
with  fresh  animal  blood  or  blood-serum.  A  suitable  material  for  local  use 
can  be  made  by  grinding  up  the  fresh  liver  of  an  animal,  soaking  it  in  water, 
filtering  the  mixture  through  gauze,  soaking  gauze  in  the  filtrate,  and  tampon- 
ing the  wound  with  the  wet  gauze.  This  fluid  contains  the  thrombokinase 
necessary  in  coagulation  (Kottmann  and  Lidsky,  in  "Deutsch.  medizin. 
Wochen,"  1910,  vol.  i).  Human  serum  is  even  more  efficient  locally.  In 
ordinary  cases  of  hemorrhage  serum  may  be  given  subcutaneously  in  very 
severe  hemorrhage  intravenously.  In  jaundice  cases  a  serum  injection  should 
precede  operation.  As  a  prophylactic  or  for  therapeutic  effect  human  serum, 
horse  serum,  rabbit  serum,  antistreptococcus  serum,  or  diphtheria  antitoxic 
serum  may  be  used.     The  dose  is  10  to  40  c.c.  subcutaneously. 


Guthrie's  Rule 


449 


The  actual  cautery  is  a  very  ancient  hemostatic.  It  is  still  used  occasion- 
ally after  excising  the  upper  jaw,  in  bleeding  after  the  removal  of  some  maUg- 
nant  growths,  in  continued  hemorrhage  from  the  prostatic  plexus  of  veins 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision  of  venereal  warts. 
We  are  often  driven  to  its  use  in  "bleeders,"  that  is,  those  persons  who  have 
a  hemorrhagic  diathesis,  and  who  may  die  from  having  a  tooth  pulled  or  from 
receiving  a  scratch.  It  will  arrest  hemorrhage,  but  the  necrosed  tissue  sepa- 
rates, and  when  it  separates  secondary  hemorrhage  is  apt  to  set  in.  The  iron 
for  hemostatic  purposes  must  be  at  a  cherry  heat.  The  old-fashioned  iron, 
which  was  heated  in  a  charcoal  furnace,  is  rarely  used.  It  is  large,  clumsy, 
and  cools  quickly  if  the  bleeding  is  profuse.  In  an  emergency  we  may  heat 
a  poker  or  a  coil  of  telegraph  ^^ire.  The  best  instrument  is  the  Paquelin 
cauter^\  The  Paquelin  cautery  consists  of  an  alcohol  lamp,  a  metal  chamber 
containing  benzene,  a  tube  of  entrance  for  air  containing  two  bulbs,  an  exit 
tube,  and  a  wooden-handled 
cautery  instrument,  the  tip  of 
which  is  hollow  and  composed 
of  platinum  (Fig.  226).  The 
tip  can  be  kept  hot  even  w^hen 
bleeding  is  profuse.  If  the  iron 
is  very  hot,  it  will  not  stop 
bleeding  completely.  In  order 
to  use  the  Paquelin  cauter\-, 
light  the  lamp,  heat  the  cauten.'- 
tip  in  the  flame  until  it  becomes 
red,  remove  it  from  the  flame, 
and  squeeze  the  bulb  repeatedly 
until  the  tip  becomes  bright  red. 
Each  time  the  bulb  which  is  not 
covered  with  netting  is  squeezed 
air  is  driven  through  the  metal 
chamber  into  the  tube  and  cauter}^,  and  this  air  carries  with  it  the  vapor  of 
benzene,  which  passes  to  the  hot  tip  and  takes  fire.  The  degree  of  heat 
maintained  depends  upon  the  rapidity  with  which  the  bulb  is  squeezed. 

Skene  has  de\dsed  a  method  known  as  electrohemostasis.  He  grasps  the 
vessel  or  tissue  with  specially  constructed  forceps,  an  electric  current  generates 
heat,  the  tissue  is  cooked,  and  the  waUs  of  the  vessel  united.  For  the  small 
instrument  Skene  uses  a  current  of  2  ma.  and  for  the  larger  instrument  a 
current  of  8  ma.^ 

Downes  has  devised  an  instrument  to  apply  electrothermic  hemostasis  in 
abdominal  and  pelvic  operations.  He  asserts  that  by  this  method  an  intra- 
abdominal operation  can  be  rendered  bloodless ;  that  the  lymph-ducts  are  sealed 
and  the  stump  rendered  sterile;  that  adhesions  are  less  apt  to  form;  and  that 
there  is  less  postoperative  pain  than  if  the  ligature  were  used  ("Boston  Med. 
and  Surg.  Jour.,"  July  10,  1902). 

Rules  for  Arresting  Primary  Hemorrhage. — i.  In  arterial  hemorrhage 
tie  the  artery  in  the  wound,  enlarging  the  wound  if  necessary  {Guthrie's  rule). 
In  tying  the  main  artery^  of  the  limb  in  continuity  for  bleeding  from  a  point 
below  we  fail  to  cut  off  the  bleeding  from  the  distal  extremity,  and  hemor- 
rhage is  bound  to  recur.  If  the  surgeon  does  not  look  into  the  wound,  he 
cannot  know  what  is  cut:  it  may  be  only  a  branch  and  not  a  main  trunk. 
The  same  rule  obtains  in  secondary^  hemorrhage." 

2.  We  can  safely  ligate  veins  as  we  would  arteries. 

1  "New  York  Medical  Journal,"  Feb.  18,  1898. 

2  For  observ^ations  on  suture  of  vessels,  see  page  444. 

29 


Fig.  226. — Paquelin  cautery. 


45©  Diseases  and  Injuries  of  the  Heart  and  Vessels 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends  of  the  divided 
vessel. 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the  wound,  if  necessary, 
in  the  direction  of  the  flexor  tendons,  at  the  same  time  maintaining  pressure 
upon  the  brachial  artery.  Catch  the  ends  of  the  arch  by  hemostatic  forceps 
and  tie  both  ends.  If  the  artery  can  be  caught  by,  but  cannot  be  tied  over 
the  point  of  the  forceps,  leave  the  instrument  in  place  for  four  days.  If  the 
artery  cannot  be  caught  by  forceps,  use  a  tenaculum.  The  ends  of  the 
divided  vessel  can  be  caught  and  must  be  caught  even  if  large  incisions  are 
needed  to  effect  it.  An  incision  which  will  probably  always  expose  the  vessel 
is  as  follows :  Make  a  cut  on  a  line  with  the  injury  from  the  web  of  the  fingers 
to  above  the  carpus,  separating  the  metacarpal  and  carpal  bones,  until  the 
artery  is  reached.  (This  is  really  Mynter's  incision  for  excision  of  the  wrist.) 
In  former  days,  if  the  surgeon  found  trouble  in  grasping  the  ends  of  the  vessel,  he 
applied  a  graduated  compress  (see  Fig.  220).  This  is  appHed  as  follows:  Insert 
a  small  piece  of  gauze  in  the  depths  of  the  wound,  put  over  this  a  larger  piece, 
and  keep  on  adding  bit  after  bit,,  each  successive  piece  larger  than  its  prede- 
cessor, until  there  exists  a  conical  pad,  the  apex  of  which  is  at  the  point  of  hem- 
orrhage and  the  base  of  which  is  external  to  the  surface  of  the  palm.  Band- 
age each  finger  and  the  thumb,  put  a  piece  of  metal  over  the  pad,  wrap  the 
hand  in  gauze,  bandage  each  finger,  the  thumb,  palm,  and  wrist,  place  the 
arm  upon  a  straight  splint,  apply  firmly  an  ascending  spiral  reverse  bandage 
of  the  arm,  starting  as  a  figure-of-8  of  the  wrist,  and  hang  the  hand  in  a  sling. 
Instead  of  applying  a  splint,  we  may  place  a  pad  in  front  of  the  elbow  and  flex 
the  forearm  on  the  arm.  The  palmar  pad  is  left  in  place  for  six  or  seven  days 
unless  bleeding  continues  or  recurs.  The  graduated  compress  is  unreliable, 
hence  it  is  a  dangerous  method  of  treatment.  It  is  an  evasion.  It  should  be 
employed  at  the  present  time  only  as  a  temporary  expedient  until  ligatures 
can  be  applied.  The  old  rule  of  surgery  was  as  follows:  If  bleeding  is  main- 
tained or  begins  again  after  application  of  a  graduated  compress,  ligate  the 
radial  and  ulnar  arteries.  If  this  maneuver  fails,  we  know  that  the  interosseous 
artery  is  furnishing  the  blood  and  that  the  brachial  must  be  tied  at  the  bend 
of  the  elbow.  If  this  fails,  amputate  the  hand.  At  the  present  day  it  is  hard 
to  conceive  of  such  radical  procedures  being  necessary  for  hemorrhage  from 
a  palmar  vessel. 

5.  In  primary  hemorrhage,  if  the  bleeding  ceases,  do  not  disturb  the 
parts  to  look  for  the  vessel.  If  the  vessel  is  clearly  seen  in  the  wound,  tie  it; 
otherwise  do  not,  as  the  bleeding  may  not  recur.  This  rule  does  not  hold 
good  when  a  large  artery  is  probably  cut,  when  the  subject  will  require  trans- 
portation (as  on  the  battlefield),  when  a  man  has  delirium  tremens  or  mania, 
or  when  he  is  a  heavy  drinker.  In  these  cases  always  look  for  the  artery  and 
tie  it. 

6.  When  a  person  is  bleeding  to  death  from  a  wound  of  an  extremity, 
arrest  hemorrhage  temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring  about  reaction 
and  then  ligate,  but  do  not  operate  during  collapse  if  the  bleeding  can  be 
controlled  by  pressure. 

7.  If  a  transverse  cut  incompletely  divides  an  artery,  it  may  be  found 
possible  and  may  be  considered  desirable  to  suture  the  cut.  Longitudinal 
cuts  can  certainly  be  sutured  (see  page  441).  If  suturing  is  impossible,  or  if 
the  surgeon  prefers  not  to  attempt  it,  apply  a  ligature  on  each  side  of  the 
vessel  wound  and  then  sever  the  artery  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  off  just  below  the  ligature,  tie  the  branch  as  well  as 
the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main  trunk,  the  rule 


Rules  for  Arresting  Hemorrhage  451 

used  to  be,  tie  the  branch  and  also  the  main  trunk.  It  was  thought  that  if 
the  branch  alone  were  tied  the  internal  clot,  being  ver>-  short,  would  be 
washed  away  by  the  blood-current  of  the  larger  vessel.  We  now  know  that 
the  clot  is  not  required  in  repair,  and  under  aseptic  conditions  it  is  tri\-ial  in 
size  and  rarely  reaches  the  lirst  collateral  branch.  Repair  is  efiected  by  en- 
dothelial proliferation. 

10.  If  a  large  \-ein  is  slightly  torn,  put  a  lateral  ligature  upon  its  wall 
(Fig.  227).  Gather  the  rent  and  the  tissue  aroimd  it  in  a  forceps  and  tie  tie 
pursed-up  mass  of  vein  wall.  It  is  a  wise  plan  to  pass  the  hgature  through  the 
two  outer  coats  by  means  of  a  needle  and  tie  the  knot  subsequently.  This 
expedient  prevents  sHpping.  If  a  longitudinal  wound  exists  in  a  large  vein, 
take  an  intestinal  needle  and  fine  silk  and  sew  it  up  (^see  page  440) .  Trans- 
verse woimds  can  also  be  sutured. 

11.  WTien  a  branch  of  a  large  vein  is  torn  close  to  the  main  trunk,  tie  the 
branch  and  not  the  main  tnmk.     Apply  practically  a  lateral  ligature. 

12.  If,  after  t}.ing  the  cardial  extremity  of  a  cut  arter\-.  the  distal  extremity 
cannot  be  found,  even  after  enlarging  the  wound  and  making  a  careful  search, 
firmly  pack  the  woimd. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Horsley's  antiseptic 
wax,  or  break  in  bony  septa  with  a  chisel,  or  plug  with  threads  of  gauze  or 
scrapings  of  catgut.     If  the  bleeding  is  verA-  free,  wax  ^ill  not  stick  and  mash- 


Fig.  227. — ^Application  of  lateral  ligature  to  a  vein. 

ing  the  bone  edges  usually  fails.  The  expedient  suggested  by  Vaughan  should 
then  be  employed,  viz.,  a  piece  of  muscle  or  other  tissue  is  cut  off,  and,  by 
means  of  the  fingers  or  a  knife  handle,  forcibly  rubbed  against  the  bleeding 
bone  surface.  Minute  fragments  of  the  soft  tissue  plug  the  open  vessels  and 
arrest  the  bleeding  (^George  TuUy  A'aughan,  in  "Jour.  Am.  ]Med.  Assoc," 
Nov.  9,  1907^ 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the  canal  with  an  anti- 
septic stick  and  break  the  wood,  or  fill  up  the  orifice  of  the  canal  with  antiseptic 
wax  or  a  separated  bit  of  tissue.     If  this  fails,  ligate  the  arter}-  of  supply. 

15.  In  bleeding  from  the  internal  mammary-  art  en.'  the  old  rule  was  to 
pass  a  large  cur\-ed  needle  holding  a  piece  of  silk  into  the  chest,  imder  the 
vessel  and  out  again,  and  tie  the  thread  tightly:  but  it  is  better  to  make  an 
incision  and  Hgate  the  artery-. 

16.  In  bleeding  from  an  intercostal  arter}"  make  pressure  upward  and  out- 
ward by  a  tampon  (see  Fig.  219^.  or  throw  a  ligature  by  means  of  a  cun,-ed 
needle  entirely  over  a  rib,  t^-ing  it  externaUy;  or.  what  is  better,  resect  a  rib 
and  tie  the  arter}". 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleeding  ha%-ing  ceased, 
do  not  hurry  reaction  by  stimulants.  Give  the  clot  a  chance  to  hold.  Wrap 
the  sufferer  in  hot  blankets.  If  the  condition  is  dangerous,  however,  stimulate 
to  save  life. 

18.  In  punctured  woimds,  as  a  rule,  tr.-  pressure  before  using  ligation. 


452  Diseases  and  Injuries  of  the  Heart  and  Vessels 

19.  x\fter  a  severe  hemorrhage  always  put  the  patient  to  bed  and  elevate 
the  damaged  part  (if  it  be  an  extremity  or  the  headj. 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary  hemorrhage  will 
probably  hold  permanently;  but  even  after  twelve  hours  be  watchful  and 
insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared,  mark  with  anilin 
or  iodin  the  spot  on  the  main  artery  where  compression  is  to  be  appUed,  apply 
a  tourniquet  loosely,  and  order  the  nurse  to  screw  it  up  and  to  send  for  the 
physician  at  the  first  sign  of  renewed  bleeding.  This  must  be  done  in  many 
gunshot- wounds. 

22.  When  the  femoral  vein  is  divided  high  up,  the  ad\dce  commonly 
given  is  to  Ugate  the  vein  and  also  the  femoral  artery.  Braune,  taught  that 
because  of  the  venous  valves  there  is  no  collateral  circulation,  and  to  tie  the 
vein  alone  renders  gangrene  inevitable.  Niebergall  shows  that  the  valves 
may  be  overcome  by  moderate  arterial  pressure,  and  thus  collateral  circula- 
tion be  estabhshed.  Hence,  when  the  femoral  vein  is  di\ided  tie  the  vein, 
but  leave  the  artery  imtied,  so  as  to  furnish  the  necessary  pressure.^ 

23.  In  extradural  hemorrhage,  trephine.  The  side  to  be  trephined  is 
determined  by  the  symptoms,  and  not  by  the  situation  of  the  injury.  The 
opening  is  made  on  a  level  with  the  upper  orbital  border  and  i\  inches  be- 
hind the  external  angular  process.  This  opening  exposes  the  middle  menin- 
geal and  its  anterior  branch.  If  this  does  not  expose  a  clot,  trephine  over 
the  posterior  branch,  on  the  same  level  and  just  below^  the  parietal  eminence. 
When  the  clot  is  found,  enlarge  the  opening  ^Aith  the  rongeur,  scoop  out  the 
clot,  and  arrest  the  bleeding  by  passing  ligatures  on  each  side  of  the  in- 
jury in  the  vessel  through  the  dura,  under  the  artery  and  out  again,  and  then 
t)dng  them.  If  the  arter}^  lies  in  a  bony  canal,  plug  the  canal  with  Horsley's 
wax.  In  some  cases  packing  must  be  used  to  arrest  bleeding.  In  subdural 
hemorrhage  open  the  dura  and  endeavor  to  ligate.  If  this  procedure  is  impos- 
sible, pack  with  iodoform  gauze. 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges  of  the  opening 
^dth  forceps,  if  possible,  and  apply  a  lateral  ligature,  or  leave  the  forceps  in 
place  for  forty-eight  hours,  or  compress  firmly  wdth  iodoform  gauze. 

25.  In  extramedullary  spinal  hemorrhage  rapidly  advancing  and  threaten- 
ing Life  perform  laminectomy  and  arrest  the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid  of  ethyl  spray  or  ice. 
If  this  treatment  fails,  plug  \\4th  gauze  infiltrated  with  tannin  or  soaked  in 
antipyrin  solution  of  a  strength  of  10  per  cent.,  or  in  Carnot's  solution  of 
gelatin.  Close  the  jaw^s  upon  the  plug,  and  hold  them  wdth  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution,  or  plug  with  a  bit 
of  cork  or  dry  sponge,  and  if  this  is  futile,  use  the  cautery.  Pressure  on  the 
carotid  and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be  necessary  to 
tie  the  external  carotid  artery. 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In  intra-abdominal 
hemorrhage  it  is  necessary  to  operate  during  shock.  If  the  blood  accumulates 
so  rapidly  as  to  prevent  the  location  of  the  bleeding  point,  compress  the 
aorta  or  pack  the  abdominal  cavity  with  large  sponges.  In  seeking  for  the 
bleeding  point  remove  the  sponges  one  by  one,  or  have  the  pressure  momen- 
tarily relaxed  from  time  to  time.  In  parenchymatous  hemorrhage  from  the 
liver,  suture  the  torn  edge  or  use  the  cautery.  In  some  cases  the  liver  is  sutured 
to  the  abdominal  wall  and  the  woimd  is  packed.  Severe  w'ounds  of  the  spleen 
demand  splenectomy.  Wounds  of  the  kidney  may  be  sutured,  but  may  re- 
quire partial  or  complete  nephrectomy.  Wounded  mesenteric  vessels  are  Hgated 
en  masse  with  silk  (Senn).     If  a  portion  of  intestine  is  found  to  be  deprived 

1  Niebergall,  "Deut.  Zeit.  f.  Chir.,"  vol.  xxx\ai,  Nos.  3  and  4. 


Rules  for  Arresting  Hemorrhage 


453 


of  blood  it  must  be  resected.  Wounds  of  the  stomach  and  intestines  causing 
hemorrhage  require  stitching  of  their  edges.  When  there  are  a  great  many  points 
of  bleeding,  take  a  number  of  gauze  sponges,  tie  a  piece  of  tape  firmly  to  each 
one,  pack  many  places  in  the  belly  with  the  sponges,  bring  the  tapes  out  of 
the  wound,  and  remove  the  sponges  from  below  upward  one  at  a  time,  securing 
the  bleeding  points  as  they  come  into  view. 

28.  In  abdominal  section  for  disease  of  the  female  pelvic  organs  bleeding 
is  limited  by  the  clamp  or  by  pressure-forceps.  Ligation  en  masse  is  often 
practised.  A  large  mass  can  be  transfixed  and  tied  in  sections.  Bleeding  edges 
are  stitched.  Areas  of  oozing  are  treated  by  temporary  pressure  and  hot 
water  or,  if  this  fails,  by  the  cauter}'.  Packing  can  be  used  as  a  tamponade, 
which  is  a  gauze  pouch,  pieces  of  gauze  being  packed  into  this  pouch  after 
its  insertion  into  the  belly  (see  Fig.  42). 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  bandage  from  the 
periphery  up,  and  elevation. 

30.  Most  cases  of  capillary  bleeding  can  be  controlled  by  compression 
with  gauze  pads  soaked  in  water  at  a  temperature  of  115°  to  120°  F.  This 
contracts  the  vessels  and  seals  them  with  coagulated  albimiin.  Keetly  in 
1878  impressed  the  profes- 
sion wdth  the  value  of  hot 
water  as  a  st^-ptic.  Cen- 
turies ago  surgeons  used 
hot  oil  for  the  same  pur- 
pose. Capillar}^  bleeding 
can  often  be  controlled  by 
the  appUcation  of  gauze 
soaked  in  Carnot's  solu- 
tion of  gelatin.  A  solu- 
tion of  suprarenal  extract 
may  control  capillary  ooz- 
ing. If  other  means  fail 
to  control  capillar}^  hemor- 
rhage, the  cauter}^  must 
be  used.  Understand  that 
the  term  "capillary  bleed- 
ing" does  not  so  much 
mean  bleeding  from  genu- 
ine capillaries  as  it  does 
bleeding  from  arterioles  and 
venules. 

31.  Pressure  above  a  woimd  may  arrest  arterial  hemorrhage,  but  aggravate 
venous  bleeding.  Pressiire  below  a  wound  may  arrest  venous  hemorrhage,  but 
increase  arterial  bleeding. 

32.  A  moderate  epistaxis,  or  bleeding  from  the  nose,  may  be  arrested  by 
an  injection  of  peroxid  of  hydrogen,  an  injection  of  a  solution  of  antipyrin, 
or  an  injection  of  Carnot's  solution  of  gelatin.  Favorite  domestic  expe- 
dients are  keeping  the  arms  raised  above  the  head  and  appljdng  ice  to 
the  back  of  the  neck.  In  severe  epistaxis  examine  the  nose  by  means  of 
a  head-mirror  and  a  speculum.  If  a  Uttle  point  of  ulceration  is  found,  touch 
it  by  a  cauter\^  If  the  bleeding  is  a  general  ooze,  if  it  is  high  up,  or  if  the 
cautery  does  not  arrest  it,  pack  the  nares.  It  may  be  necessary  to  pack  one 
nostril  or  both.  Pass  a  Bellocq  cannula  (Fig.  228)  along  the  floor  of  one 
nostril  into  the  phar\-nx,  project  the  stem  into  the  mouth,  tie  a  plug  of  lint 
or  gauze  wet  with  Carnot's  solution  of  gelatin  to  the  stem,  and  withdraw  it. 
Hold  the  double  string  which  emerges  from  the  nostril  in  the  hand  and 


Fig.  228. — Plugging  the  nares  for  epistaxis  by  the  aid  of  Bel- 
locq's  cannula  (Guerin). 


454  Diseases  and  Injuries  of  the  Heart  and  Vessels 

pack  gauze  wet  with  gelatin  solution  from  before  backward.  Tie  the  strings 
together  over  the  plug;  if  both  nostrils  are  plugged,  the  strings  from  one 
nostril  are  fastened  to  the  strings  from  the  other.  Do  not  use  subsulphate 
of  iron,  as  it  forms  a  disgusting,  clotty,  adherent  mass.  If  Bellocq's  cannula 
is  not  obtainable,  push  a  soft  catheter  into  the  pharynx,  catch  it  by  a  finger, 
pull  it  forward,  and  tie  the  plug  to  it.  Remove  the  plug  in  two  or  three  days. 
Do  not  leave  it  longer.  It  blocks  up  decomposing  fluids  and  may  lead  to 
blood-poisoning.  Pick  out  the  front  plug  first,  hold  the  string  of  the  second 
plug  in  the  hand,  push  the  plug  back  into  the  pharynx,  catch  it  by  forceps, 
and  withdraw  plug  and  string  through  the  mouth. 

33.  In  gunshot- wounds  the  primary  hemorrhage  is  slight  unless  a  large 
vessel  is  cut.  The  bleeding  may  be  visible  or  may  be  internal  (concealed), 
the  blood  running  into  a  natural  cavity  or  among  the  muscles.  Capillary  ooz- 
ing is  arrested  by  very  hot  water  and  compression.  Venous  bleeding  is  usually 
arrested  by  compression.  If  a  large  vessel  is  the  source  of  bleeding,  enlarge 
the  wound  and  tie  the  vessel.  If  the  artery  cannot  be  found  in  the  wound, 
tie  the  main  trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  try  compression  over  a  plug 
saturated  with  alum  or  with  tannin.  If  this  fails,  pass  under  the  wound  a 
harelip  pin  and  encircle  it  with  a  piece  of  silk.  If  this  fails,  use  the  actual 
cautery  or  excise  the  bite  and  suture  the  incision. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put  an  ice-bag  over 
the  mastoid,  give  opium  and  acetate  of  lead,  and,  if  blood  runs  into  the  mouth, 
plug  the  Eustachian  tube  with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure  over  a  plug  con- 
taining tannin,  alum,  or  gelatin  solution.  If  compression  fails,  pass  harelip 
pins  under  the  navel  and  apply  a  twisted  suture.  If  this  fails,  use  the  actual 
cautery. 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks,  insertion  of  pieces 
of  ice,  ice  to  the  anus  and  perineum,  astringent  injections  (alum),  injections 
of  gelatin,  injections  of  adrenalin,  and  the  internal  use  of  opium  and  acetate 
of  lead.  If  these  means  fail,  plug  the  bowel  over  a  catheter,  or  insert  and 
inflate  a  Peterson  bag  or  a  colpeurynter,  or  tampon  and  use  a  T-bandage.  If 
the  bleeding  persists  or  if  a  considerable  vessel  is  bleeding,  stretch  the  sphinc- 
ter, catch  the  bowel  and  draw  it  down,  seize  the  vessel,  and  tie  it  if  possible; 
if  not,  leave  the  forceps  in  place.  Failing  in  this,  the  actual  cautery  must 
be  used. 

38.  Subcutaneous  hemorrhage,  if  severe  and  persistent,  demands  that  an 
incision  be  made  and  ligatures  be  applied. 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the  insertion  of  st)^tic 
cotton  and  the  application  of  pressure.  Moderate  bleeding  from  the  deeper 
urethra  can  usually  be  arrested  by  a  very  warm  bougie,  by  very  warm  in- 
jections, or  by  tying  a  condom  over  a  catheter,  and,  after  inserting  it,  inflat- 
ing the  condom  by  blowing  through  the  catheter  and  plugging  the  orifice  of 
the  instrument,  thus  using  pressure.  Sitting  with  the  perineum  on  a  thickly 
folded  towel  is  useful.  Ice  to  the  perineum  does  good.  The  patient  can 
He  down,  have  a  folded  towel  applied  to  the  perineum,  and  a  crutch-handle 
pushed  upon  the  towel,  the  lower  end  of  the  crutch  being  jammed  against 
the  foot  of  the  bed.  If  a  solid  bougie  has  been  first  introduced,  firm  pressure 
can  be  made  by  this  method.  If  these  means  are  futile,  perform  external 
urethrotomy  and  reach  the  bleeding  point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injections,  the  introduction 
of  a  large  bougie  first  dipped  in  very  warm  water,  and  the  retention  of  a  cathe- 
ter for  two  days.  Perineal  section  may  be  required,  or  suprapubic  cystotomy 
with  packing  which  does  not  occlude  the  ureteral  orifices. 


Rules  for  Arresting  Hemorrhage 


455 


41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in  which  case  the 
urine  must  be  drawn  off  and  the  \dscus  be  washed  out  frequently  with  a  solu- 
tion of  boric  acid,  to  prevent  septic  cystitis.  If  blood-clots  prevent  the  flow 
of  urine,  break  them  up  with  a  catheter  or  a  lithotrite  and  inject  \anegar  and 
water,  a  2  per  cent,  solution  of  carboUc  acid,  or  a  solution  of  bicarbonate  of 
sodium.  Perfect  quiet  is  to  be  maintained,  cold  acid  drinks  are  given,  ice-bags 
are  put  to  the  perineum  and  hypogastric  region,  and  opium  with  acetate  of 
lead,  or  gallic  acid  is  to  be  given  by  the  mouth.  If  the  hemorrhage  is  severe 
or  persistent,  perform  suprapubic  cystotomy,  wash 
out  the  bladder,  and,  if  necessary-,  plug  the  bladder 
with  gauze,  lea\ing  the  ureters  uncovered. 

42.  In  hemorrhage  after  lateral  Uthotomy,  ligate 
if  possible.  If  the  vessel  can  be  caught  but  cannot 
be  Hgated,  leave  the  forceps  in  place.  If  it  is  not 
possible  to  catch  the  vessel  with  forceps,  use  a  te- 
naculum. If  the  tenaculum  fails,  pass  a  threaded 
cur\'ed  needle  through  the  tissues  around  the  vessel 
and  tie  the  ligature  (suture  Hgature).  Plugs  of  ice 
and  injections  of  hot  water  may  be  tried.  These 
means  failing,  pressure  is  indicated.  Take  a  cannula, 
fasten  to  it  a  chemise  (Fig.  229),  empty  clots  from 
the  bladder,  insert  the  instrument  into  the  viscus, 
and  pack  gauze  between  the  sides  of  the  cannula 
and  the  chemise.  The  chemise  is  bulged  out  and 
pressure  is  made.  Tie  the  cannula  by  means  of  tapes 
to  a  T-bandage.  Pressure  is  thus  combined  with 
vesical  drainage.  Buckstone  Brown  makes  pressiu'e 
by  inflating  a  rubber  bag  with  air.  The  hot  iron 
may  occasionally  be  demanded. 

43.  Renal  bleeding  requires  ice  to  the  loin,  tannic  acid  and  opiima,  gallic 
acid  or  sulphuric  acid  internaUy,  and  perfect  quiet.  The  use  of  a  cystoscope 
wiU  show  from  which  ureter  blood  is  emerging.  If  the  bleeding  threatens  life 
and  the  diseased  organ  is  identified,  make  a  lumbar  incision  and  suture  or 
perform  nephrectomy. 

44.  A'aginal  hemorrhage  requires  the  ligature  or  the  tampon. 

45.  Severe  uterine  hemorrhage  (unconnected  with  pregnancy)  requires 
the  tampon.  Persistent  hemorrhage  due  to  morbid  growths  may  require 
removal  of  the  tubes  and  appendages,  ligation  of  the  uterine  and  ovarian 
arteries,  or  hysterectomy. 

46.  Hematemesis.  or  bleeding  from  the  stomach,  is  treated  by  the  swallow- 
ing of  ice,  gi\-ing  tannic  acid  (dose,  20  or  30 gr.) ,  or  Monsel's  solution  (3  drops). 
Gelatin  by  the  mouth  is  recommended.  Never  give  tannic  acid  and  MonseFs 
solution  at  the  same  time,  as  they  mix  and  form  ink.  Opium  is  usually  or- 
dered. Acetate  of  lead  and  opium  and  gallic  acid  are  favorite  remedies,  and 
ergot  is  used  by  many.  Give  no  food  by  the  stomach.  If  life  is  threatened 
by  bleeding  from  an  ulcer,  open  the  belly  and  excise  the  iflcer  and  suture  the 
wound.  If  severe  hemorrhage  foUows  injury,  perform  an  exploratory  laparot- 
omy. Always  remember  that  furious  and  even  fatal  gastro-iatestinal  hemor- 
rhage may  be  due  to  cirrhosis  of  the  hver,  and  a  sHght  iujurv'  may  be  the  excit- 
ing cause  of  such  a  hemorrhage.  In  this  condition,  of  course,  operation  is 
useless. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead  and  opium, 
sulphuric  acid,  or  Monsel's  salt  in  pill  form  (3  gr.),  allow  no  food  for  a  time, 
and  insist  on  Hquid  diet  for  a  considerable  period.  If  hemorrhage  threatens  Hf e, 
do  a  ceUotomv  and  find  the  cause.    If  ulcer  exists,  excise  it  and  suture,  or 


Fig.  229. — Cannula  a  chemise. 


4S6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

suture   a  perforation   without  previously   excising.     If  violent  hemorrhage 
follows  injury,  explore  to  discover  the  vessel. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections  (10  gr.  of  alum 
or  5  gr.  of  bluestone  to  i  oz.  of  water).  If  bleeding  is  low  down,  use  small 
amounts  of  the  solution;  if  high  up,  large  amounts.  Do  not  use  absorbable 
poisons.  In  dangerous  cases  perform  an  exploratory  operation  to  find  the 
vessel.     (For  rectal  bleeding,  see  page  454.) 

49.  Hemoptysis,  or  bleeding  from  the  lung,  is  treated  by  morphin  hypo- 
dermatically,  by  perfect  rest,  by  dry  cups  or  ice  over  the  affected  spot  if  it 
can  be  located,  and  by  the  administration  of  gallic  acid,  which  drug  aids 
coagulation.^    Nitrite  of  amyl  by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open  the  chest  unless 
life  is  threatened.  If  life  is  endangered,  resect  a  rib,  allow  the  lung  to  col- 
lapse, and  see  if  this  arrests  bleeding.  If  bleeding  still  continues,  remove 
several  ribs,  find  the  bleeding- point,  ligate  or  employ  forcipressure.  A  small 
cavity  may  be  packed  with  gauze.  If  a  large  surface  is  bleeding,  fill  the  pleural 
sac  with  gauze  and  pack  more  gauze  against  the  oozing  surface.^ 

Reactionary  or  Recurrent  Hemorrhage  (called  also  Consecutive,  Inter- 
mediate, or  Intercurrent) . — This  form  of  hemorrhage  comes  on  during  reaction 
from  an  accident  or  an  operation,  that  is,  during  the  first  forty-eight  hours, 
but  in  most  cases  within  twelve  hours.  It  is  usually  bleeding  from  a  vessel  or 
vessels  which  did  not  bleed  during  the  shock  which  accompanied  operation, 
and  which  vessels  were  overlooked  and  not  tied.  It  may  be  due  to  faultily 
applied  ligatures.  It  is  favored  by  vascular  excitement  or  hypertrophied 
heart.  The  bleeding  is  rarely  sudden  and  severe,  but  is  usually  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually  the  cause.  The 
constricting  band  paralyzes  the  smaller  arteries,  which  do  not  bleed  during 
shock  and  do  not  contract  as  shock  departs;  hence  bleeding  comes  on  with 
reaction.  To  lessen  the  danger  of  the  Esmarch  apparatus  use  a  broad  con- 
stricting band  rather  than  a  rubber  tube.  After  an  amputation,  when  the 
larger  vessels  have  been  tied,  gauze  pads  wet  with  hot  water  (115°  to  120°  F.) 
should  be  placed  between  the  flaps.  This  not  only  arrests  capillary  oozing, 
but  stimulates  vessels  and  shows  points  of  bleeding  which  were  not  previously 
visible,  and  these  points  are  ligated.  During  reaction  after  an  amputation, 
if  slight  hemorrhage  occurs,  elevate  the  stump  and  compress  the  flaps.  If 
the  hemorrhage  persists  or  at  any  time  becomes  severe,  make  pressure  on 
the  main  artery  of  the  limb,  open  the  flaps,  turn  out  the  clots,  find  the  bleeding 
point,  ligate,  asepticize,  drain,  close,  and  dress.  In  any  severe  reactionary 
hemorrhage  open  the  wound  at  once  and  ligate. 

Secondary  hemorrhage  may  occur  at  any  time  in  the  period  between 
forty-eight  hours  after  the  accident  or  operation  and  the  complete  cicatriza- 
tion of  the  woimd.  Secondary  hemorrhage  may  be  due  to  atheroma,  to  slip- 
ping of  a  ligature,  to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature,  to 
sloughing,  to  erysipelas,  to  septicemia,  to  pyemia,  to  gangrene,  and  to  over- 
action  of  the  heart.  The  great  majority  of  cases  of  secondary  hemorrhage 
are  due  to  infection,  and  the  application  of  modern  surgical  principles  has 
rendered  secondary  bleeding  a  rare  calamity.  If  during  an  operation  the 
vessels  are  found  atheromatous,  a  thread  should  be  passed,  by  means  of  a 
curved  needle,  around  the  vessel,  including  a  cushion  of  tissue  in  the  loop  of 
the  ligature  (this  prevents  cutting  through,  see  Fig.  211).    Acupressure  may 

1  The  use  of  ergot  is  a  general  but  questionable  practice.  •  Bartholow  and  others  hold 
that  this  drug  does  harm;  it  contracts  all  the  arterioles,  and  hence  more  blood  flows  from  an 
area  where  there  is  damage.  Purgatives  do  good  in  bleeding  from  the  lung  by  taking  blood 
to  the  abdomen  and  lowering  blood-pressure. 

2  See  author's  case,  "Annals  of  Surgery,"  Jan.,  1898. 


Hemophilia,  Hemorrhagic  Disease,  or  Hemorrhagic  Diathesis      457 

be  used  in  such  a  case.  If  the  surgeon  decides  to  employ  the  ligature,  he  must 
not  tie  tightly,  but  must  endeavor  to  approximate  the  coats  rather  than  to  cut 
them.  Two  ligatures  can  be  applied  or  the  stay-knot  may  be  used.  One  great 
trouble  with  atheromatous  arteries  is  that  their  coats  cannot  contract;  another 
trouble  is  that  the  ligature  is  apt  to  cut  entirely  through  them.  If  after  an 
operation  the  pulse  is  found  to  be  forcible,  rapid,  and  jerking,  give  aconite, 
opiimi,  and  low  diet.  The  bleeding  may  come  on  suddenly  and  furiously,  but 
is  usually  preceded  by  a  bloody  stain  in  wound-fluids  which  had  become  free 
from  blood. 

Treatment  of  Secondary  Hemorrhage. — Suppose  a  case  of  leg  amputation 
in  which,  several  days  after  the  operation,  a  little  oozing  is  detected:  the  treat- 
ment is  to  elevate  the  stump,  apply  two  compresses  over  the  flaps,  and  carry  a 
firm  bandage  up  the  leg.  If  the  bleeding  is  profuse  or  becomes  so,  make  press- 
ure on  the  main  arten,-,  open  and  tear  the  flaps  apart  with  the  fingers,  find 
the  bleeding  vessel  and  tie  it,  turn  out  the  clots,  asepticize,  drain,  close,  and 
dress.  If  the  bleeding  begins  at  a  period  when  the  stump  is  nearly  healed,  cut 
down  on  the  main  artery  just  above  the  stump  and  ligate.  In  secondary 
hemorrhage  from  a  blood-vessel  in  nodular  tissue  apply  a  suture-ligature  or 
tie  higher  up,  or,  if  this  fails,  amputate.  When  secondary  hemorrhage  arises 
in  a  sloughing  wound  apply  a  tourniquet  or  an  Esmarch  bandage,  tear  the 
wound  open  to  the  bottom  with  a  grooved  director,  look  for  the  orifice  of  the 
vessel,  dissect  the  artery  up  imtil  a  healthy  point  is  reached,  cut  it  across,  and 
tie  both  ends.  If  this  fails,  apply  a  suture-ligature  or  use  acupressure.  In 
secondary  hemorrhage  from  atheromatous  vessels  use  the  suture-ligature, 
double  ligature  with  a  stay-knot,  or  employ  acupressure. 

Secondary  hemorrhage  may  occur  after  ligation  in  continuity,  the  blood 
usuaUy  coming  from  the  distal  side.  If  the  dressings  are  slightly  stained 
with  blood,  put  on  a  graduated  compress.  If  the  bleeding  continues  or  is 
severe,  make  pressure  on  the  main  artery  of  the  limb,  open  the  wound  and 
ligate,  wrap  the  part  in  cotton,  elevate,  and  surround  with  hot  bottles.  If 
this  rehgation  is  done  on  the  femoral  and  fails,  do  not  ligate  higher  up,  as 
gangrene  -^oLl  certainly  occur,  but  amputate  at  once  above  the  point  of  hemor- 
rhage. If  dealing  with  the  brachial  arterv',  do  not  amputate,  but  ligate  higher 
up  and  make  compression  in  the  wound.  In  a  secondary  hemorrhage  from 
the  innominate,  tie  the  innominate  again  and  also  tie  the  vertebral. 

Hemorrhage  After  an  Abdominal  Operation. — ^Hemorrhage  may  occur 
after  an  abdominal  operation.  It  may  come  on  gradually  with  reaction. 
If  it  does  so,  it  causes  thirst,  restlessness,  an  increasing  pulse-rate,  paUor, 
increasing  rate  of  respiration,  and  coldness  of  extremities.  The  temperature 
is  normal  or  subnormal.  If  the  hemorrhage  is  small  in  amoimt  the  condition 
may  be  recovered  from.  If  it  continues  it  produces  the  grave  symptoms  set 
forth  on  page  436.  A  rapid  secondary'  or  reactionar}^  hemorrhage  produces 
those  grave  sjonptoms  almost  suddenly.  If  a  severe  hemorrhage  is  occurring 
in  the  abdomen  nothing  but  an  operation  can  save  life  (see  page  452). 

Hemophilia,  Hemorrhagic  Disease,  or  Hemorrhagic  Diathesis. 
— The  term  "hemophilia"  expresses  the  existence  in  an  individual  of  a  tend- 
ency to  profuse  or  even  uncontrollable  hemorrhage  spontaneously  or  as  a 
result  of  some  ver\^  tri\dal  injury. 

Hemorrhage  may  take  place  from  mucous  or  serous  membranes  or  from 
wounds  of  the  cutaneous  surface,  into  tissue,  into  organs,  into  a  joint,  vmder  the 
scalp,  or  into  the  external  genitals.  In  a  hemophiliac,  if  a  cut  is  made,  the  hem- 
orrhage from  the  larger  vessels  is  easily  arrested,  but  capillary  oozing  continues. 

The  condition  is  far  more  common  in  males  than  in  females,  and  if  it 
exists  in  a  female,  which  it  rarely  does,  it  is  not  usually  provocative  of  danger- 
ous hemorrhage.    The  disease  is  nearly  alw^ays  transmitted  by  heredity.    It 


458  Diseases  and  Injuries  of  the  Heart  and  Vessels 

is  usually  transmitted  to  a  son  by  a  mother  who  is  free  from  the  disease,  but 
whose  father  had  it,  and  the  son  bleeds  dangerously  from  slight  causes.  Some 
reported  cases  were  transmitted  in  the  male  line  (Goodall,  in  "Scottish  Med. 
and  Surg.  Jour.,"  Feb.,  1905).  There  is,  however,  an  acquired  form  of  hemo- 
philia. The  existence  of  the  tendency  is  rarely  suspected  until  the  first  denti- 
tion, and  possibly  not  till  puberty;  "70  per  cent,  of  cases  appear  before  the 
fifth  year."^  The  discovery  of  the  existence  of  such  a  condition  may  not  be 
made  until  a  tooth  is  pulled,  and  extraction  is  followed  by  persistent  bleeding. 
It  is  alleged  that  the  tendency  may  disappear  in  middle  life.  The  victims  of 
this  hemorrhagic  tendency  are  called  "bleeders." 

The  cause  of  hemophilia  is  unknown.  It  has  been  assumed  that  there  is  a 
■condition  of  the  blood  which  prevents  coagulation.  The  blood-changes  are  not 
characteristic.  The  blood  is  similar  to  that  found  in  secondary  anemia,  the  red 
corpuscles  are  diminished,  but  the  hemoglobin  is  diminished  more  distinctly, 
hence  there  is  a  low  color  index.  The  white  corpuscles  are  not  increased  as  in 
scurvy  and  purpura,  and  often  there  is  a  positive  leukopenia.  Blood  coagula- 
tion is  slow  and  often  imperfect.  In  some  cases  coagulation  occurs  in  nine  min- 
utes, but  in  one  of  Wright's  cases  it  required  over  an  hour.  It  is  important  to 
remember  as  against  failure  of  coagulating  elements  as  the  cause  that  Agnew 
had  a  case  in  which  hemophilia  was  limited  to  the  head  and  neck,  and  that 
there  have  been  cases  in  which  bleeding  occurred  into  one  joint  or  from  one 
kidney.  Some  maintain  that  there  is  structural  defect  in  the  capillaries.  In  a 
case  of  hemophilia  in  the  Jefferson  Medical  College  Hospital,  in  which  it  was 
absolutely  necessary  to  amputate  a  finger  because  of  a  crush,  a  careful  study 
of  the  vessels  of  the  finger  by  Dr.  Coplin  failed  to  show  any  disease  of  the 
blood-vessels.  Wright  believes  with  Morawitz  that  the  serum  of  circulating 
blood  contains  fibrinogen  and  a  ferment  called  thrombogen.  The  leukocytes 
and  other  cells  of  the  body  produce  thrombokinase.  Thrombokinase  is  only 
set  free  when  leukocytes  or  body-cells  break  down.  Thrombokinase  in  the 
presence  of  calcium  converts  thrombogen  into  thrombin,  and  thrombin  con- 
verts fibrinogen  into  fibrin  (Wood,  in  "Australian  Med.  Jour.,"  1910,  vol.  xv). 
Sahli  believes  that  hemophilia  depends  on  defects  in  certain  cells  which  entail 
a  deficiency  of  thrombokinase,  and  hence  impairment  of  coagulating  power  in 
the  blood  ("Deutsch.  Archiv.  fiir  klinische  Medizin,"  1910,  vol.  xcLx).  A 
surgeon  must  be  on  the  lookout  for  hemophilia,  and  should  inquire  for  it  before 
deciding  to  do  an  operation.  If  it  exists,  only  an  operation  of  imperative  neces- 
sity should  be  undertaken.  It  is  now  well  recognized  that  joint  lesions  may 
occur  in  hemophilia  {hemophilic  arthritis).  The  condition  is  most  common  in 
children.  As  a  rule,  more  than  one  joint  is  involved,  but  only  a  few  joints 
suffer.  In  Rugh's  case  only  one  knee-joint  suffered  ("Annals  of  Surg.,"  May, 
1907).  If  more  than  one  joint  is  attacked,  the  involvement  may  or  may  not 
be  symmetrical. 

The  acute  form  resembles  acute  rheumatism  and  lasts  about  ten  days. 
In  the  subacute  form  the  temperature  is  lower,  the  symptoms  less  intense,  and 
the  duration  shorter.  In  both  forms  joint  function  is  restored  (Frolich,  "Cen- 
tralb.  fiir  Chir.,"  1905,  vol.  xxxii).  The  chronic  form  resembles  tuberculous 
arthritis  or  osteomyelitis.  In  this  form  there  is  a  tendency  to  loss  of  function, 
but  there  is  no  reaction  to  tuberculin. 

A  child  who  is  a  "bleeder"  must  be  unceasingly  watched  and  guarded.  A 
tendency  to  profuse  oozing  exists  in  leukemia  because  of  the  condition  of  the 
blood,  but  this  is  not  hemophilia.  A  tendency  to  oozing  also  exists  during 
jaundice. 

Treatment. — ^The  oozing  is  difficult  and  often  impossible  to  control,  al- 
though most  of  these  cases,  in  the  long  run,  recover.  In  the  acquired  form 
^  R.  C.  Cabot,  in  "International  Text-Book  of  Surgery." 


Paracentesis  Pericardii  459 

the  prognosis  is  better  than  in  the  congenital  (Weil,  "Centralb.  fiir  Chir.," 
1907,  vol.  xxxiv).  Internal  administration  of  such  drugs  as  ergot,  gallic  acid, 
and  acetate  of  lead  is  useless.  It  is  claimed  that  chlorid  of  calcium  internally  is 
of  service.  Lactate  of  calcium,  15  to  20  gr.,  is  sometimes  given  three  times  a 
day  by  the  mouth.  It  may  also  be  given  by  the  rectum.  Milk  may  be  given 
by  rectum,  in  order  to  obtain  the  combination  of  salts  of  milk  unchanged 
by  gastric  juice  (Solt,  Ibid.).  The  local  use  of  astringents  is  of  no  avail. 
Prolonged  elevation  may  in  rare  cases  succeed.  In  the  case  in  the  Jefferson 
Medical  College  Hospital  the  bleeding  was  arrested,  after  numerous  expedients 
failed,  by  compression  and  hot  water.  Nurses  sat  by  the  bed  for  several  days, 
constantly  compressed  the  wound  with  gauze  pads  soaked  in  hot  water,  and 
changed  the  pads  as  soon  as  they  cooled.  The  local  use  of  Carnot's  solution 
of  gelatin  has  apparently  saved  several  cases  from  death.  A  valuable  plan 
is  to  tampon  the  wound  with  gauze  containing  fresh  animal  or  human  blood 
or  blood-serum. 

Serum  in  doses  of  from  5  to  10  c.c.  may  be  given  hypodermatically  or,  if 
bleeding  is  very  severe,  intravenously.  We  may  use  human  serum,  horse  serum, 
rabbit  serum,  diphtheria  serum,  or  antistreptococcus  serum  (see  page  448). 
After  each  injection  of  serum  there  is  leukocytosis,  and  leukocytosis  means 
increase  of  cells  containing  fibrin  ferment  or  thrombokinase.  (See  Tremburg, 
in  "Medizinische  Klinik,"  Berlin,  Nov.  7,  1910.)  A  rapid  method  of  obtain- 
ing thrombokinase  is  to  take  the  liver  from  a  rabbit  or  other  animal,  chop  it, 
grind  it,  soak  in  water,  and  filter  through  cloth.  Gauze  soaked  in  this  fluid  is 
used  to  tampon  a  wound  (Koltmann,  Ibid.,  June  2,  1910). 

Witte  applies  locally  an  extract  of  lymphoid  organs  (spleen,  lymph-glands, 
or  thymus)  and  injects  hypodermatically  a  5  per  cent,  solution  of  sterile  peptone 
in  .5  salt  solution.  The  dose  is  3  c.c.  every  other  day  until  three  or  four  doses 
have  been  taken.  Then  the  injections  are  intermitted  for  three  or  four  weeks 
(Nolf  and  Kerry,  "Reme  de  Medecine,"  Feb.,  1910,  and  "Gaz.  des  Hopitaux," 
191 1).  Thyroid  extract  should  be  tried,  as  in  some  cases  it  seems  to  have  been 
of  value.  The  dose  is  5  gr.  after  each  meal.  Eugene  Fuller's  case  of  hemophilia 
C'Med.  News,"  Feb.  28,  1903)  was  apparently  cured  by  the  administration  of 
5  gr.  of  thyroid  extract  three  times  a  day.  In  a  case  of  hemophilia  in  the 
Jefferson  Hospital  thyroid  extract  apparently  arrested  the  bleeding.  In 
Rugh's  case,  after  excision  of  a  knee-joint,  bleeding  was  profuse  and  continued, 
but  ceased  in  eight  days.  The  patient  was  given  5  gr.  of  thyroid  extract  three 
times  a  day.  The  cases  are  particularly  interesting  in  connection  with  W.  J. 
Taylor's  observation  that  thyroid  extract  increases  the  rapidity  of  blood 
coagulation  in  jaundice  cases  and  lessens  the  tendency  to  postoperative 
oozing  in  such  cases. 

Operations  On  the  Vascular  System 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has  been  suggested 
for  the  relief  of  an  overdistended  heart  from  pulmonary  congestion.  The 
right  auricle  can  be  tapped.  Push  the  aspirator  needle  directly  backward 
at  the  right  edge  of  the  sternum,  in  the  third  interspace.  This  operation  is 
not  recommended,  as  it  is  highly  dangerous  and  is  of  questionable  value. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac,  is  done  only 
when  life  is  endangered  by  effusion.  Introduce  the  needle  2  inches  to  the 
left  of  the  left  edge  of  the  sternum,  in  the  fifth  interspace,  and  push  it  directly 
backward  (thus  avoiding  the  internal  mammary  artery).  The  operation 
of  tapping  is  extremely  dangerous.  The  heart  is  lifted  up  and  pushed  for- 
ward by  an  effusion  and  the  needle  is  apt  to  enter  it.  The  puncture  of  a  ven- 
tricle may  do  no  harm,  although  it  is  very  apt  to,  but  the  puncture  of  an 


460  Diseases  and  Injuries  of  the  Heart  and  Vessels 

auricle  is  almost  certain  to  be  followed  by  fatal  hemorrhage.  It  is  wiser 
and  safer  to  expose  the  pericardium  and  incise  it,  as  is  done  for  pericardial 
suppuration. 

Operation  for  Pericardial  Effusion  or  Suppuration. — The  oper- 
ation of  tapping  should  be  abandoned  in  favor  of  a  safer  but  more  radical 
procedure.  There  is  no  spot  where  we  can  introduce  the  needle  with  perfect 
safety,  and  the  heart  or  pleura  may  be  wounded;  further,  as  Brentano  shows,^ 
tapping  will  not  completely  empty  the  sac.  In  a  purulent  case  tapping  gives 
practically  no  chance  of  cure.  No  general  anesthetic  should  be  used.  A 
portion  of  the  fourth  rib  or  the  cartilage  on  the  fourth  rib  on  the  left  side 
should  be  excised,  the  pericardium  exposed  and  punctured  in  order  to  determine 
the  nature  of  the  fluid  present.  If  the  fluid  is  serous,  it  can  be  drained  away 
through  a  small  incision  and  the  pericardium  may  be  sutured.  If  the  fluid  be 
purulent,  the  pericardium  should  be  stitched  to  the  chest  wall  and  opened. 
Clots  should  be  removed  by  hot  salt  solution  irrigation  and  a  drainage-tube 
should  be  introduced. 

Operation  for  Wound  of  the  Heart. — In  many  cases  it  is  obviously 
impossible  to  administer  an  anesthetic,  but  when  possible  it  should  be  given 
because  the  movements  of  the  patient  while  under  the  knife  make  operation 
difficult  and  increase  bleeding.  Ether  may  be  used  or  we  may  take  Hill's 
advice  and  give  chloroform.  Hill  would  give  an  anesthetic  unless  the  patient 
is  unconscious  and  the  corneal  reflex  is  abolished.  Personally,  I  would  be 
disposed  to  use  chloroform  unless  the  patient's  general  condition  forbade 
it  (see  page  405).  The  pericardium  can  be  exposed  freely  and  Rotter's  incis- 
ion gives  excellent  access,  although  it  always  opens  the  pleura.  This  expo- 
sure is  described  by  Hill  in  the  "Medical  Record,"  November  29,  1902,  and 
was  employed  in  his  successful  case.  Begin  an  incision  over  the  third  rib 
f  inch  from  the  left  edge  of  the  sternum  and  carry  it  outward  along  the  rib 
for  4  inches.  Begin  an  incision  over  a  corresponding  point  of  the  sixth  rib 
and  carry  it  out  for  a  like  distance.  Join  the  outer  extremities  of  these  cuts. 
Cut  through  the  ribs  and  pleura  by  bone  forceps  and  scissors.  Raise  the  flap 
upon  its  hinges  of  cartilages,  and  have  an  assistant  grasp  the  lung  to  prevent 
collapse.  The  pericardium  thus  exposed  is  opened  widely  if  necessary.  Hill 
advises  us  to  steady  the  heart  by  pressing  the  hand  under  it  and  lifting  it. 
Parrozzani  did  this  by  inserting  a  finger-  in  the  wound.  Other  surgeons 
have  used  traction  sutures  of  silk.  For  wound  closure  interrupted  sutures  are 
preferred  to  the  continuous  suture.  Either  silk  or  catgut  can  be  used.  They 
should  be  inserted  by  a  round-edged  needle.  "As  few  as  possible  should  be 
passed  commensurate  with  safety  against  leakage,  as  they  cause  a  degenera- 
tion of  the  muscular  fiber."  It  does  no  harm  apparently  if  they  enter  a  heart 
chamber,  but  it  is  wiser  not  to  have  them  do  so.  If  the  heart  fails,  use 
heart  massage  (L.  L.  Hill,  Ibid.).  The  pericardial  and  pleural  sacs  are  cleansed 
by  salt  solution.  The  question  of  drainage  is  still  subjudice.  The  pleural  sac 
is  treated  according  to  indications  in  each  case. 

George  TuUy  Vaughan,  in  reporting  his  second  case  of  heart  suture  and  a 
table  of  150  operations  ("Jour.  Am.  Med.  Assoc,"  Feb.  6,  1909),  mentions  five 
methods  for  exposing  the  heart,  and  states  that  no  single  method  has  yet  been 
agreed  on  as  the  best.  The  kind  of  operation  is  often  determined  by  the  exter- 
nal wound,  and,  begun  as  an  exploration,  the  subsequent  steps  depend  on  the 
necessities  which  arise  during  its  progress.  The  five  methods  mentioned  by 
Vaughan  are:  (a)  Through  an  intercostal  space,  with  or  without  the  division 
of  one  or  two  cartilages;  (b)  resection  of  one  or  more  cartilages,  with  or  with- 
out a  portion  of-  rib;  (c)  flap  method  across  the  sternum,  dividing  the  ster- 
num and  cartilages  (this  avoids  opening  the  pleura) ;  (d)  flap  of  cartilages  and 
1  "Deut.  Med.  Woch.,"  Feb.  11,  1890. 


Operation  for  Varix  of  Leg  461 

ribs  with  an  external  hinge;  (e)  flap  of  cartilages  and  ribs  with  an  internal 
hinge. 

Vaughan's  table  shows  that  in  46  patients  the  pericardium  was  drained,  •nith 
25  recoveries  and  21  deaths;  in  44  the  pericardium  was  not  drained,  with  25 
recoveries  and  19  deaths;  in  42  both  the  pericardivun  and  pleura  were  drained, 
wdth  21  recoveries  and  21  deaths;  in  19  both  pericardium  and  pleura  were  closed 
without  drainage,  with  1 2  recoveries  and  7  deaths ;  in  7  2  the  pleura  was  drained, 
with  30  recoveries  and  42  deaths;  in  21  the  pleura  was  not  drained,  with  13 
recoveries  and  8  deaths.  These  figures  would  indicate  that  drainage  should 
not  be  the  rule.  It  should  be  used  though  if  bleeding  continues  or  if  we  greatly 
fear  infection.  Of  course,  drainage  causes  irritation,  prevents  the  lung  expand- 
ing, and  makes  secondar}^  infection  more  probable  (Vaughan,  in  "Jour.  Am. 
Med.  Assoc,"  Feb.  6,  1909). 

In  Vaughan's  table  of  150  cases  we  find  that  98  died  and  52  recovered,  a 
mortality  of  65  per  cent.;  32  patients  died  in  less  than  twenty  hours  after 
the  operation  for  the  injur}-  and  15  died  on  the  table  or  just  after  the  opera- 
tion. In  all  but  I  of  these  cases  death  was  due  to  hemorrhage.  In  i  it  was  due 
to  pneimiothorax  on  opening  the  pleura.  The  remaining  66  deaths  occurred 
in  from  twenty-four  hours  to  five  months  after  the  operation:  6  died  of  pleurisy, 
5  of  pericarditis,  21  of  combined  pleurisy  and  pericarditis,  3  of  pneumonia, 
3  of  peritonitis,  2  of  pericarditis  and  nephritis,  i  of  pleurisy  and  cerebral  ab- 
scess, I  of  pleurisy  and  wound  of  the  tricuspid  A-alve,  i  of  pleurisy  and  double 
pneumonia,  i  of  gangrene  of  the  lung,  i  of  two  wounds,  one  of  which  was  not 
sutured,  3  of  bleeding  into  the  pleura,  2  of  bleeding  into  the  pericardium,  i  of 
clot  in  the  tricuspid  opening,  and  15  of  unassigned  causes. 

Cardiolysis. — ^As  a  result  of  pericarditis  the  heart  may  adhere  to  the 
pericardiima  and  the  pericardium  to  the  chest  wall.  This  condition  is  dan- 
gerous, and,  if  imreheved,  vnil  eventually  prove  fatal. 

Delorme  has  suggested  that  the  pericardial  sac  be  opened  and  the  adhe- 
sions be  broken  down  ^^ith  the  finger,  a  verj^  dangerous  procedure,  which  is 
almost  certain  to  inflict  serious  injury  upon  the  heart. 

Brauer's  method,  which  he  suggested  in  1902,  consists  in  removing  the 
several  ribs  and  portion  of  the  sternum  to  which  the  pericardium  adheres.  The 
periosteum  is  to  be  removed  with  the  bone  to  prevent  the  formation  of  new  bone. 
This  is  the  preferable  operation.  The  safest  plan  is  to  remove  the  anterior,  but 
not  the  posterior,  periosteum.  The  danger  of  fresh  ossification  is  sHght  and  we 
avoid  injuring  the  left  pleura  (Poynton  and  Trotter,  quoted  by  Simon,  in 
"Brit.  Med.  Jour.,"  Dec.  14,  1912). 

Decompression  for  Heart  Hypertrophy. — In  a  case  of  cardiac  h}'per- 
trophy  in  which  the  heart  knocked  violently  against  the  ribs,  ]\Iorrison  per- 
formed thoracotomy.  He  removed  several  inches  of  the  fifth  rib  and  an  equal 
length  of  the  sixth  rib.  The  patient  was  much  improved,  the  capacity  of  the 
chest  was  increased,  and  the  painful  attacks  were  practically  cured  ("Lancet," 
July  4,  1908). 

Operation  for  Varix  of  Leg. — Many  cases  do  not  require  operation. 
In  some,  operation  is  positively  harmful.  In  some  selected  cases  operation  is 
very  useful  to  remove  certain  complications  (ulcer,  eczema,  etc.),  and  to  reHeve 
the  patient  from  annoyance,  but  the  operation  rarely  absolutely  cures  the 
condition.  As  Blake  points  out,  a  cure  cannot  be  claimed  until  at  least  one 
year  has  passed  after  operation  ^^■ithout  reappearance  of  the  varix  ("Boston 
Med.  and  Surg.  Jour.,"  Sept.  25, 1902).  The  indications  and  contra-indications 
are  discussed  on  page  412.  Never  operate  if  phlebitis  exists. except  to  treat 
thrombosis.  After  any  operation  for  varicose  veins  of  the  leg  follow  Bennett's 
ad^-ice  and  keep  the  patient  in  bed  for  three  weeks  and  do  not  let  him  resume 
active  work  for  three  weeks  more  ("Lancet,"  Nov.  22,  1902). 


462  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Trendelenburg's  Operation. — I  have  employed  this  with  much  satis- 
faction in  cases  of  varLx  of  the  leg  following  involvement  of  the  saphenous 
in  the  thigh.  Trendelenburg  believes  that  in  varix  the  valves  in  the  saphenous 
become  incompetent  because  of  high  central  pressure.  The  veins  of  the  leg 
distend,  as  they  are  unable  to  support  such  a  long  column  of  blood,  and  finally 
the  blood  begins  to  flow  in  the  wrong  direction  in  the  saphenous,  a  "vicious 
circle"  being  established.  We  determine  whether  a  case  is  a  suitable  one 
for  Trendelenburg's  operation  as  follows:  While  the  patient  is  lying  down 
raise  the  extremity  as  though  we  intended  to  empty  it  of  blood  previous  to 
amputation.  After  three  minutes  compress  the  saphenous  vein  about  the 
lower  third  of  the  thigh  by  means  of  a  moist  gauze  bandage,  which  must  not 
be  so  tight  as  to  shut  off  the  deeper  vessels.  Lower  the  leg  and  have  the 
patient  stand  up.  If  blood  flows  into  the  saphenous  from  above  and  distends 
the  portion  of  the  vein  above  the  compress,  the  valves  are  incompetent  and 
Trendelenburg's  operation  may  be  performed.  The  operation  is  performed  as 
follows:  Make  an  incision  about  4  inches  in  length  over  the  internal  saphenous 
vein  at  the  junction  of  the  lower  and  middle  thirds  of  the  thigh.  Expose  the 
vein,  ligate  each  visible  branch,  ligate  the  saphenous  at  the  lower  end  of  the 
wound  and  also  at  the  upper  end,  and  remove  the  portion  of  vein  included 
between  the  ligatures.  By  this  operation  the  central  pressure  is  intercepted 
and  the  dilated  veins  in  consequence  shrink.  Some  surgeons  have  advised 
the  removal  of  the  entire  length  of  the  long  saphenous  vein.  If  Trendelen- 
burg's operation  fails  and  a  relapse  occurs,  extirpate  the  varicose  veins  of 
the  leg. 

Madelung  cuts  down  over  the  varices  and  ligates  at  various  points.  Scheie 
makes  a  circular  cut  (a  circumcision)  completely  around  the  leg  at  the  junc- 
tion of  the  upper  and  middle  thirds,  the  incision  reaching  to  the  deep  fascia. 
All  bleeding  points  are  ligated  and  the  edges  of  the  incision  are  stitched  to- 
gether. This  operation  is  so  often  followed  by  persistent  hard  edema  that  it 
is  now  seldom  performed.  A  recent  operation  is  to  place  the  internal  saphenous 
beneath  the  deep  fascia.  Delbet  implants  the  saphenous  into  the  femoral  10  cm. 
below  its  normal  point  of  junction.  The  valvular  arrangement  of  the  femoral 
restores  normal  tension  in  the  saphenous.  Fergusson  ties  the  saphenous  vein 
near  the  femoral  and  removes  a  section  from  it.  This  makes  the  varices  clearly 
evident.  A  semilunar  incision  is  made  to  surround  the  varices,  which  incision 
reaches  to  the  deep  fascia.  The  flap  is  raised  and  dissected  up,  the  vessels  are 
tied,  and  the  flap  is  sutured  in  place.  Phelps  advises  multiple  ligation.  Sir 
Wm.  H.  Bennett  thinks  that  in  ordinary  cases  the  best  operation  consists  in 
removing  a  portion  of  the  long  saphenous  in  the  thigh  and  also  in  removing 
3  inches  of  the  vein  from  below  the  knee.  If  there  are  cystic  dilatations  above 
the  knee  he  removes  the  saphenous  from  the  thigh.  Some  local  varices  he 
dissects  out  ("Lancet,"  Nov.  22,  1902).  As  a  matter  of  fact,  excision  of  a  short 
piece  of  vein  seems  to  do  as  much  good  as  excision  of  a  long  piece.  Excision 
of  a  piece  at  several  points  is  valuable.  The  object  of  excision  is  to  reduce 
pressure  on  the  vein  walls  by  breaking  up  the  column  of  blood  (Barker,  in 
"Practitioner,"  Oct.,  1910).  Any  of  the  suggested  operations  may  be  followed 
by  relapse. 

Phlebotomy,  or  Venesection. — Operation. — The  patient  sits  on  a  chair 
"with  the  arm  abducted,  extended,  and  incHned  outward"  (Barker).  The 
parts  are  ascepticized  and  a  tape  is  tied  around  the  arm  just  above  the  elbow. 
The  patient  grasps  a  stick  firmly  and  works  his  fingers  in  order  to  cause  the 
veins  to  distend.  The  surgeon  stands  to  the  right  of  the  arm,  holds  the  elbow 
with  his  left  hand,  and  puts  his  thumb  upon  the  vein  below  the  intended  point 
of  puncture.  Either  the  median  cephalic  or  the  median  basilic  may  be  opened 
(Figs.  230,  231).    The  median  basilic  is  the  more  distinct,  and  is  the  vein  usually 


Arteriovenous  Anastomosis  for  Transfusion  of  Blood 


463 


Fig.  230. — Incisions  for 
venesection  (Bernard  and 
Huette). 


Fig.  231. — Superficial 
veins  in  front  of  elbow 
(Bernard  and  Huette). 


selected.  In  opening  it  do  not  cut  too  deep,  as  nothing  but  the  bicipital  fascia, 
separates  it  from  the  brachial  artery.  The  median  cephalic  may  be  selected 
(we  thus  avoid  endangering  the  brachial  artery) ;  under  this  vein  lies  the  external 
cutaneous  nerve  (Fig.  231).  Steady  the  vein  with  the  thumb  and  open  it  by 
transfixion,  making  an  oblique  cut  which  divides  two-thirds  of  it.  Remove  the 
thmnb  and  allow  bleeding  to  go  on,  instructing  the  patient  to  work  his  fingers. 
When  faintness  begins,  remove  the  fillet,  put  an  antiseptic  pad  over  the  punc- 
ture, apply  a  spiral  reversed  bandage  of  the  hand  and  arm  and  a  figure-of-8 
bandage  of  the  elbow,  and  place  the  arm  in  a  sling  for  several  days. 

Transfusion  of  Blood. — This 
operation  has  been  a  recognized 
procedure  since  1824,  though  it  has 
been  known  since  1492,  when  trans- 
fusion was  employed  in  the  case  of 
Pope  Innocent  VIII.  Its  chief  use 
was  in  severe  hemorrhage,  especially 
postpartum,  in  which  it  served  to 
replace  the  blood  lost  and  suppHed 
something  for  the  heart  to  contract 
upon  untU  new  blood  formed.  Senn 
insisted  that  the  operation  had 
proved  an  absolute  failure,  that  it  did 
not  prevent  death  from  hemorrhage, 
and  that  the  transferred  blood- 
elements  did  not  retain  vitality.  Von  Bergmann  maintained  that  after  severe 
hemorrhage  we  do  not  need  to  inject  nutritive  elements,  but  do  need  to  re- 
store the  greatly  diminished  intracardiac  and  intravascular  pressure.  At  the 
present  day  a  sahne  fluid  is  usually  infused  in  preference  to  transfusing  blood. 
In  fact,  the  operation  of  transfusion  had  become  all  but  extinct  until  Crile 
revived  it.  The  old  operation,  as  it  used  to  be  performed,  exposed  the  patient 
to  the  danger  of  embolism  and  infection.  It  had  come  to  be  believed  that 
transfusion  had  no  single  element  of  value  beyond  that  secured  by  the  use  of 
salt  solution,  except. in  cases  overcome  by  illuminating  gas,  in  which  a  more 
prolonged  good  effect  was  known  to  be  produced  than  by  salt  solution. 

Arteriovenous  Anastomosis  for  Transfusion  of  Blood  (Crile's  Opera- 
tion).— ^This  is  a  method  of  the  very  greatest  value  in  the  treatment  of  the  con- 
dition resulting  from  violent  or  prolonged  hemorrhage.  It  is  incomparably 
the  best  treatment  for  severe  hemorrhage.  It  can  be  employed  during  the  per- 
formance of  an  exhausting  operation  and  its  use  will  bring  not  a  few  cases  tO' 
operation  which,  without  its  aid,  would  be  esteemed  inoperable.  It  should 
be  used  for  severe  typhoid  hemorrhage  and  in  jaundiced  cases  requiring  opera- 
tion, but  showing  very  slow  coagulation.  It  seems  devoid  of  value  in  blood 
diseases.  There  are  certain  dangers  in  it  unless  there  is  time  to  examine  the 
blood  of  both  donor  and  recipient.  It  is  known  that  admixtiue  of  certain 
bloods  results  in  thrombosis.  If  the  corpuscles  of  the  donor  are  not  aggluti- 
nated by  the  serum  of  the  recipient,  and  vice  versa,  the  operation  is  safe. 

In  Crile's  operation  the  vascular  system  of  the  donor  is  united  to  the  vas- 
cular system  of  the  recipient.  He  places  intima  in  contact  with  intima.  This 
is  accompHshed  by  means  of  a  modification  of  Payre's  magnesium  tube  or  by 
Crile's  tube,  which  is  of  German  silver.  The  vein  of  the  recipient  is  drawn 
through  the  tube,  is  everted,  and  is  tied  into  the  second  groove  on  the  tube. 

The  end  of  the  tube  with  the  everted  vessel  over  it  is  passed  into  the  vessel 
of  the  donor  and  fixed  temporarily  by  a  ligature.  The  left  arm  of  each 
subject  is  usually  employed  and  the  radial  artery  of  the  donor  is  anastomosed 
to  a  superficial  vein  of  the  recipient.    Each  patient  should  be  on  a  table  the 


464  Diseases  and  Injuries  of  the  Heart  and  Vessels 

head  of  which  can  be  raised  or  lowered  at  will.  The  region  over  the  radial 
artery  of  the  donor  is  exposed  under  local  anesthesia.  Every  small  branch 
over  the  artery  is  carefully  tied  in  order  to  prevent  obstruction  by  blood.  The 
artery  is  bared  for  a  distance  of  about  3  cm.,  tied  distally,  lightly  clamped  with 
a  screw  clamp  proximally,  and  divided.  The  vein  of  the  recipient  is  bared, 
clamped,  and  divided,  the  tube  (dipped  in  sterile  olive  oil)  is  inserted  into  the 
vein,  the  cuff  of  everted  vessel  is  formed  over  the  end,  and  the  artery  is  pulled 
over  the  tube  and  the  cuff  of  vein,  and  held  by  a  ligature  tied  into  the  first 
groove  (Bevan,  in  "General  Surgery,"  by  Lexer-Bevan). 

The  flow  is  at  first  slow,  but  after  eight  or  ten  minutes  becomes  more 
rapid,  especially  if  warm  salt  solution  is  run  into  the  wounds.  The  amount 
used  depends  on  the  strength  of  the  donor  and  the  needs  of  the  recipient. 

I  have  used  Brewer's  tube  in  this  operation  with  much  satisfaction.  It 
makes  the  procedure  vastly  easier  of  execution.  Fig.  232  shows  Brewer's 
tubes. 

I  am  indebted  to  Dr.  George  Emerson  Brewer  for  describing  in  a  note  to 
me  the  technic  of  his  operation.     The  description  follows: 

"After  thorough  sterilization,  the  tubes  are  prepared  by  dipping  them  in 
melted  parafhn,  shaking  them  out,  and  allowing  them  to  cool,  or  immersing 


Fig.  232. — Brewer's  tubes  for  direct  transfusion. 

them  in  a  solution  of  parafi&n  in  benzine.  The  radial  artery  of  the  donor  is 
exposed  in  the  usual  manner,  and  also  the  median  basilic  or  some  other  avail- 
able vein  of  the  donee.  The  proximal  end  of  the  artery  is  next  drawn  over 
one  extremity  of  the  glass  tube  and  secured  by  a  silk  ligature.  This  is  facili- 
tated by  expanding  the  lumen  of  the  artery  by  means  of  three  mosquito  forceps 
or  artery  clamps.  When  all  is  ready  to  insert  the  free  extremity  of  the  tube 
into  the  vein  of  the  donee,  the  arterial  clamp  is  temporarily  released  and  a 
few  jets  of  blood  allowed  to  pass  through  the  tube,  which  is  then  quickly  placed 
within  the  lumen  of  the  vein  and  secured  by  another  silk  Ugature.  If  the 
vein  of  the  donee  is  large,  the  distal  end  of  the  glass  tube  may  be  inserted 
through  a  longitudinal  slit  in  the  vein,  after  the  manner  usually  adopted  when 
introducing  the  cannula  for  salt  infusion.  When  sufficient  blood  has  been 
transfused  the  tube  is  removed,  the  vessels  ligated,  and  the  cutaneous  wounds 
closed.  In  certain  rare  instances  where  it  is  advisable  to  transfuse  from  an 
adult  into  an  infant,  the  popliteal  vein  of  the  infant  may  be  employed,  as  the 
subcutaneous  veins  are  generally  too  small  to  admit  of  the  introduction  of  the 
tube.  In  these  cases  a  tube  of  diminishing  caliber  should  be  used,  the  larger 
end  for  the  donor's  artery,  the  smaller  for  the  donee's  vein." 

Fauntleroy's  Vein-to-vein  Anastomosis. — This  is  a  much  simpler  operation 


Intravenous  Infusion  of  Saline  Fluid 


465 


than  arteriovenous  anastomosis.  I  have  used  it  with  great  satisfaction.  A 
glass  tube  is  fixed  in  a  vein  of  the  donor  and  a  vein  of  the  recipient.  I  use  the 
tubes  devised  by  Dr.  A.  M.  Fauntleroy  of  the  United  States  Navy  ("Med. 
Rec,"  Sept.  3,  1910).  The  tube  is  -J-  inch  in  diameter  and  each  end  is  flanged 
to  prevent  slipping.  The  veins  in  front  of  the  elbow  are  used.  The  tube  chosen 
may  be  full  curved  or  S  shaped  (Fig.  233).  The  full  curved  tube  is  called  the 
"hand-to-shoulder  tube,"  because  when  it  is  used  the  hand  of  the  donor  is  toward 

the  shoulder  of  the  recipient  and  the  hand  of  the 
recipient  is  toward  the  shoulder  of  the  donor. 
The  S-shaped  tube  is  called  the  "shoulder-to- 
shoulder  tube."  It  is  used  when  donor  and  re- 
cipient are  placed  side  by  side  in  the  same 
Hand  to  Shoulder  Tube  \\     direction,  with  the  shoulders  together  (Faun- 

.  ^  i^ 1 1     tleroy,  Ibid.) . 

i.jl/'    'i|         J)o)ior 

Fig.  233. — ^Tubes  for  transfusion,  Fig.  234. — ^Vein-to-vein  transfusion  with  the  shoulder-to-shoul- 
one-half  natural  size   (A.   M.   Faun-  der  tube  (A.  M.  Fauntleroy,  in  "Medical  Record"), 

tleroy,  in  "Medical  Record"). 

The  tubes  are  prepared  with  paraffin.  A  rubber  band  is  placed  around 
the  arm  of  the  recipient  in  order  to  make  the  veins  prominent.  The  median 
basilic  or  median  cephalic  vein  is  exposed  and  freed  for  at  least  ij  inches.  A 
ligature  is  passed  under  the  vein  at  the  lower  angle  of  the  wound,  another 
under  the  vein  at  the  upper  angle  of  the  wound.  The  lower  Ugature  is  tied 
and  the  rubber  band  removed. 

The  tourniquet  is  now  applied  to  the  donor  and  the  vein  exposed  as  just  de- 
scribed. The  ligatures  are  placed,  but  only  the  upper  one  is  tied.  The  vein 
below  the  ligature  is  gently  grasped  with  rubber-protected  forceps  and  is  cut 
completely  across.  The  intima  is  grasped  with  fine  forceps  and  one  end  of  the 
tube  is  inserted  \  inch  into  the  vein,  and  the  lower  ligature  is  tied  in  order  to 
fLx  the  tube  in  the  donor's  vein. 

The  elbows  are  now  brought  together,  a  nick  is  made  in  the  vein  of 
the  recipient,  the  rubber-protected  forceps  are  released  from  the  vein  of  the 
donor,  and,  while  blood  flows,  the  tube  is  inserted  in  the  vein  of  the  recipient, 
and  is  held  by  the  tying  of  the  upper  ligature.  During  the  operation  the  rub- 
ber band  is  kept  on  the  arm  of  the  donor,  sufficiently  tight  "to  secure  well- 
marked  venous  hyperemia  in  the  forearm  and  a  consequent  increased  venous 
pressure."    The  tourniquet  must  not  cause  stoppage  of  the  radial  pulse. 

It  is  well  to  have  a  blood-pressure  apparatus  on  the  free  arm  of  the  donor 
and  one  on  the  free  arm  of  the  recipient.  The  pulse  and  general  condition  of 
donor  and  recipient  are  carefully  watched. 

Angulation  of  the  veins  would  cause  clotting  and  must  not  be  permitted. 
We  can  tell  that  blood  is  passing  by  the  improvement  in  color,  in  pulse,  and 
in  blood-pressure  of  the  recipient  and  by  the  fulness  of  his  vein  near  the  tube. 
Fauntleroy  in  i  case  kept  up  the  flow  for  thirty  minutes.  At  the  termination 
of  the  operation  the  tubes  are  removed,  the  veins  tied,  the  tourniquet  taken 
from  the  arm  of  the  donor,  and  the  wounds  sutured  and  dressed. 

Intravenous  infusion  of  saline  fluid  is  used  after  severe  hemorrhage,  in 
shock,  in  diabetic  coma,  in  postoperative   suppression   of  urine,  and  occa- 

30 


466 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


sionally  in  sepsis.  After  a  hemorrhage  its  beneficial  effects  are  often  prompt 
and  obvious.  The  saline  fluid  increases  the  arterial  tension,  gives  the  heart 
enough  matter  to  contract  upon,  and  so  restores  the  activity  of  the  circula- 
tion, and  does  not  destroy  the  red  corpuscles  as  plain  water  would  do.     We 

may  use  a  simple  appara- 
tus consisting  of  a  rubber 
tube,  a  funnel,  and  an 
aspirating  needle.  Some 
employ  an  Aveling  syringe, 
and  others  Collin's  appar- 
atus (Fig.  236).  The  last- 
named  instrument  can  be 
used  without  any  danger  of 
air  entering  with  the  fluid, 
Spencer's  instrument  (Fig. 
237)  is  convenient  and  use- 
ful. Normal  salt  solution 
is  the  fluid  usually  em- 
ployed, of  a  strength  of  0.9 
per  cent,  (i  heaping  tea- 
spoonful  of  common  salt  to 
I  quart  of  warm  boiled 
water) .  Some  surgeons 
employ  an  artificial  serum 
which  contains  50  gr.  of 
chlorid  of  sodium,  3  gr.  of 
chlorid  of  potassium,  25  gr. 
of  sulphate  of  sodium,  25  gr.  of  carbonate  of  sodium,  and  2  gr.  of  phos- 
phate of  sodium  in  i  quart  of  boiled  water.  Szumann's  solution  consists 
of  6  parts  of  common  salt,  i  part  of  sodium  carbonate,  and  1000  parts  of 
water.    The  following  solution  is  used  by  Locke  and  Hare:  Calcium  chlorid, 


Fig.  235. — ^Intravenous  saline  infusion.    Manner  of  incising  vein 
and  inserting  glass  tube  (Senn). 


Fig.  236. — ^Intravenous  injection  of  saline 
fluid. 


Fig.  237. — Spencer's  apparatus  for  the  infusion  of 
saline  fluid  into  a  vein.  The  cannula  can  be  plunged 
directly  into  the  vessel  without  preliminary  incision. 


25  gm.;  potassium  chlorid,  i  gm.;  sodium  chlorid,  9  gm.;  sterile  water  suf- 
ficient to  make  i  liter.  One  bottle  of  the  commercial  fluid  when  diluted 
to  I  liter  gives  a  solution  of  the  above  composition.  The  results  from  arti- 
ficial serum  containing  many  elements  are  no  better  than  from  normal  salt 


Arterial  Transfusion  and  Infusion  of  Saline  Fluid  in  Arteries      467 

solution.  Adrenalin  may  be  added  to  the  normal  salt  solution  (i  dram  of 
the  1:1000  solution  of  adrenalin  to  i  pint  of  salt  solution).  The  results 
of  a  single  dose  of  adrenalin  are  very  transitory.  Whatever  fluid  is  used, 
it  should  be  at  a  temperature  of  105°  F.  or  over  as  it  enters  the  vein.  The 
stimulant  effect  of  the  heat  is  of  great  value.  The  fluid  must  not  be  al- 
lowed to  cool;  and  a  nurse  gives  constant  attention  to  the  temperature  of  the 
fluid  in  the  reservoir.  This  degree  of  heat  will  not  damage  the  corpuscles; 
in  fact,  Dawbarn  has  used  saline  fluid  at  a  tempertature  of  118°  F.  without 
doing  damage  to  corpuscles  and  with  great  benefit  to  the  patient.  From  h 
pint  to  2  pints  or  even  more  are  slowly  injected,  the  condition  of  the  patient 
determining  the  amount  given.  In  one  case  of  violent  hemorrhage  the  author 
used  over  2  quarts.  In  order  to  infuse  this  fluid  tie  a  fillet  well  above  the  elbow, 
and  expose  by  dissection  the  median  basilic  vein,  or  the  basilic  vein  in  the  por- 
tion of  its  course  where  it  is  superficial  to  the  deep  fascia.  Tie  the  vein.  Incise 
it  above  the  ligature,  insert  a  fine  cannula  toward  the  heart,  and  hold  the  cannula 
firmly  in  the  Ivrnien  by  tightening  a  second  ligature  (Figs.  235,  236).  Remove 
the  fillet.      Slowly  and  gradually  introduce  the  fluid,  carefully  watching  the 


Fig.  23S.^Injection  of  saline  solution  and  adrenalin  into  an  artery  by  the  method  of  Crile. 

pulse.  Occupy  at  least  ten  minutes  in  introducing  i  pint,  except  in  a  very  des- 
perate case  of  hemorrhage,  when  the  rapidity  of  the  flow  may  be  accelerated. 
WTien  the  tension  of  the  pulse  returns,  withdraw  the  cannula,  tie  the  second  liga- 
ture tightly,  sew  up  the  wound,  and  dress  it  aseptically.  In  very  severe  opera- 
tions an  assistant  should  conduct  the  infusion  while  the  surgeon  is  operating. 
It  may  be  necessar}^  to  repeat  the  injection  if  the  circulation  fails  again.  The 
infusion  of  a  ver\^  large  amount  of  saline  fluid  may  do  harm.  It  may  embarrass 
the  heart  and  cause  acute  dilatation,  may  lead  to  edema  of  the  lungs  or  brain, 
and  cause  marked  anemia  which  lasts  for  days.  The  giving  of  salt  solution 
intravenously  should  never  be  regarded  as  routine  treatment,  judgment  is 
required  in  determining  that  it  shotfld  be  used,  when  it  should  be  used,  and  how 
much  is  required,  and  there  is  a  distinct  element  of  danger  in  the  procedure. 

Arterial  Transfusion  and  Infusion  of  Saline  Fliud  in  Arteries. — Hueter 
preferred  the  arterial  method  of  transfusion,  in  order  to  send  the  blood  more 
gradually  to  the  heart,  and  thus  prevent  sudden  disturbance  of  the  circulation. 
A  little  air  in  an  arter}^  wiU  do  no  harm,  and  the  danger  of  venous  embolism 
is  avoided.     Saline  fluid  can  be  infused  into  an  artery.     The  radial  artery  is 


468  Diseases  and  Injuries  of  the  Heart  and  Vessels 

exposed  and  surrounded  by  three  ligatures,  and  the  thread  toward  the  heart 
is  at  once  tied.  The  distal  ligature  is  slightly  tightened  to  cut  off  anastomotic 
blood-supply.  The  artery  is  cut  transversely  half  through;  the  syringe  is 
inserted,  pointed  toward  the  periphery,  and  fastened  by  the  third  hgature; 
the  second  ligature  is  loosened  and  the  material  is  injected.  On  finishing,  the 
peripheral  thread  is  tied  tightly  and  that  portion  of  the  artery  which  held  the 
cannula  is  excised.  Dawbarn  puts  a  hypodermatic  needle  into  the  radial 
artery  and  injects  saUne  fluid. 

Crile  (Crile  and  Dolley,  in  "Joui.  of  Exper.  Med.,"  Dec,  1906)  has  shown 
that  when  a  patient  is  nearly  dead  or  apparently  dead  the  introduction  of 
saline  fluid  by  a  vein  may  overwhelm  the  heart.  He  gives  it  in  these  cases  by 
an  artery  and  has  succeeded  in  resuscitating  those  apparently  dead.  The  tube 
of  the  apparatus  is  quickly  inserted  into  the  carotid  artery  and  toward  the 
heart.  The  reserv^oir  is  raised,  and  as  the  sahne  fluid  begins  to  flow  the  tube  is 
ptmctured  with  a  hypodermatic  needle  and  adrenaHn  is  added  to  the  saUne 
stream.  If  the  heart  starts  to  beat,  blood  will  appear  in  the  tube  and  then  the 
administration  is  discontinued.  By  this  method  we  may  re-establish  blood- 
pressure  in  the  coronary  arteries  (Fig.  238). 

Ligation  of  Arteries  in  Continuity 

The  instruments  used  in  this  operation  are  two  scalpels  (one  small, 
one  medium),  two  dissecting  forceps,  several  hemostatic  forceps,  blunt  hooks 
or  broad  metal  retractors,  an  AlHs  dissector,  an  aneurysm  needle,  for  superfi- 
cial arteries  the  instrument  of  Saviard  (Fig.  239),  for  deep  vessels  the  needle 


Fig.  230. — Aneur>-sm  needle  of  Saviard. 


of  Dupuytren  (Fig.  240),  ligatures  of  catgut,  of  chromicized  gut,  or  of  silk, 
curved  needles  and  a  needle-holder,  sutures  of  silkworm-gut,  and  the  re- 
flector or  electric  forehead-lamp  for  deep  vessels. 

The  position  in  which  the  patient  is  placed  varies  according  to  the  vessel 
to  be  ligated,  though  the  body  is  supine  except  when  ligation  is  to  be  performed 
on  the  gluteal,  sciatic,  or  popliteal  SLVtery.  The  operator,  as  a  nile,  stands 
upon  the  affected  side,  cutting  from  above  dowTiward  on  the  right  side,  and 
from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery,  and  make  an  in- 
cision at  a  slight  angle  to  this  line,  avoiding  subcutaneous  veins,  and  holding  the 
scalpel  like  a  fiddle-bow  or  a  dinner-knife  while  cutting  the  superficial  parts,  and 
like  a  pen  while  incising  the  deeper  parts.  On  reaching  the  deep  fascia  make 
out  the  required  muscular  gap  by  the  eye  and  finger,  so  moving  the  extremity 
as  to  bring  individual  muscles  into  action.  Treves  ("Operative  Surgery")  cau- 
tions us  not  to  depend  upon  the  yellow  line  of  fat,  which  often  cannot  be  seen  in 
emaciated  people  or  when  an  Esmarch  bandage  is  employed;  nor  upon  the  white 
line  due  to  attachment  to  the  fascia  of  an  intermuscular  septum.  In  opening 
the  deep  portion  of  the  woimd  relax  the  bounding  muscles  by  altering  the  post- 
ure. Open  a  muscular  interspace  by  a  sharp  knife,  not  by  a  dissector.  Make  the 
depths  of  the  wound  as  long  as  the  superficial  incision.  Do  not  tear  structures 
apart  with  a  grooved  director;  cut  them.  Arrest  hemorrhage  as  it  occurs.  Try 
to  find  the  situation  of  the  arter}^  with  the  finger.  Pulsation  is  present,  but  it 
mav  be  very  feeble  and  hard  to  detect.  The  artery  feels  like  a  very  thin  rubber 
tube;  it  is  compressible,  though  not  so  easily  as  a  vein,  and  when  compressed 


LIGATIONS. 


Plate  3. 


7.  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).     2.  Sheath  of  Artery  Open  (Guerin), 

?.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation:  i,  Abemethy's  incision  (Guerin).  5,  6.  Ballance  and  Ed- 
munds' Stay-knots. 


Ligation  of  Arteries  in   Continuity 


469 


feels  like  a  flat  band  which  is  thinner  in  the  center  than  at  the  edges.  A  ner\-e 
feels  like  a  hard,  round  cord.  Veins  are  soft,  larger  than  their  related  arteries, 
and  so  ven,-  compressible  that  they  can  scarcely  be  felt  when  pressed  upon,  and 
compression  causes  distal  distention.  If  the  wound  can  be  seen  into  clearly,  it 
will  be  noted,  as  Treves  ("Operative  Surger}-")  asserts,  that  "the  ner\-es  stand 
out  as  clear,  rounded,  white  cords;  that  the  veins  are  of  a  piurple  color  and  of 
somewhat  uneven  and  w-a\y  contour;  that  the  arter>-  is  regular  in  outline  and 
of  a  pale-pink  or  pinkish-yellow  tint,  the  large  vessels  being  of  lighter  color  than 
the  small."  Each  arten,-  of  the  upper  extremity  and  each  arter\-  below  the  knee 
is  accompanied  by  two  veins,  known  as  "venae  comites.""  The  arteries  of  the 
head  and  neck,  except  the  lingual,  have  each  a  single  attending  vein;  the  lingual 
has  venae  comites.  Zvlost  of  the  smaller  arteries  of  the  trunk  (pudic,  internal 
mammar}-,  etc.)  have  vense  comites.  These  companion  veins  may  lie  on 
each  side'  of  the  art  en,'  or  in  front  and  back  of  it,  and  they  communicate  with 
one  another  by  transverse  branches  crossing  the  arter\-.  On  reaching  the 
sheath  pick  up' this  structure  with  toothed  forceps  so  as  'to  make  a  transverse 
fold,  and  thus  avoid  catcliing  the  arterv*  or  vein;  lift  the  fold  to  see  that  it  is 

free,  and'  open  the  sheath  by  cutting  toward 
the  edge  of  the  forceps  with  a  scalpel  held 
obliquely  with  its  back  toward  the  vessel,  thus 
making  a  small  longitudinal  incision  (PI.  3, 
Figs.  1,2).  Hold  the  edge  of  the  incised  sheath 
with  the  forceps;  pass  a  metal  dissector  under 
the  vessel  and  from  the  forceps;  this  clears  one- 
half  of  the  vessel.  Grasp  the  other  edge  of  the 
sheath  and  pass  the  blunt  dissector  aU  the  way 
around  the  vessel.     Pass  an  aneun-sm  needle 


Kg.  240. — ^Dupuj-tren's  aneurysm 
needles. 


Fig.  241. — Reef-knot. 


under  the  cleared  vessel,  away  from  the  forceps  holding  the  sheath  and  away 
from  the  vessel's  most  dangerous  neighbor.  Thread  the  needle  and  withdraw 
it.  If  venae  comites  are  in  the  way,  try  to  separate  them:  but  if  this  proves 
difficult,  include  them  in  the  ligature.  In  smaU  vessels  always  include  them 
if  they  are  in  the  way,  as  this  saves  trouble.  If,  in  passing  the  needle,  a  large 
vein  is  severely  wounded  (such  as  the  femoral\,  Jacobson  ad\-ises  the  em- 
ploATuent  of  digital  pressure  in  the  lower  portion  of  the  wound  while  the 
arter\-  is  being  tied  on  a  level  above  or  below  that  of  the  vein  injiin.-,  and 
after  Hgation  the  maintenance  of  pressure  on  the  wound  for  a  couple  of  .days. 
A  sKght  pimcture  in  a  vein  merely  requires  a  lateral  Hgature.  A  small  wound 
can  be  closed  with  Lembert  sutures  of  fine  silk.  -After  getting  a  Hgature 
imder  an  arter\-  press  for  a  moment  upon  the  arten.*  over  the  ligature,  which 
is  held  teut;  this  pressure  will  arrest  pulsation  below  if  the  Hgature_  is  around 
the  maia  artery-  and  there  is  not  a  double  vessel.  Tie  the  thread  at  right  angles 
to  the  vessel  with  a  reef-knot  (Fig.  241),  rupturing  the  internal  and  middle 
coats.  As  the  ligature  is  tightened  place  the  extended  index-fingers  along  the 
Hgature  up  to  the  arten.-  (PI.  3,  Fig.  3^  usmg  the  middle  joints  as  the  fulcrum 
of  a  lever  bv  placing  them  against  each  other. 

BaUance'  and  Edmunds  claim,  as  Scarpa  and  Sir  Philip  Crampton  claimed 
long  since,  that  it  is  not  necessar}'  to  di^•ide  the  internal  and  middle  coats  to 


47©  Diseases  and  Injuries  of  the  Heart  and  Vessels 

insure  obliteration.  If  this  claim  be  true,  the  danger  of  secondary  hemorrhage 
can  be  greatly  lessened.  Holmes,  however,  thinks  the  older  method  the  more 
certain  of  the  two.  Ballance  and  Edmunds  use  floss  silk  as  a  ligature  material, 
because  it  is  soft,  broad,  and  flat,  and  they  surround  the  artery  with  a  double 
ligature.  These  surgeons  thus  describe  the  application  of  the  stay-knot: 
"The  best  way  of  tying  two  ligatures  is  to  make  on  each  separately,  and  in 
the  same  way,  the  first  hitch  of  a  reef-knot,  and  to  tighten  each  separately  so 
that  the  loop  lies  in  contact  with  the  vessel  without  constricting  it.  Then 
taking  the  ends  on  one  side  together  in  one  hand  and  the  two  ends  on  the 
other  side  in  the  other  hand,  constrict  the  vessel  sufficiently  to  occlude  it,  and 
finaUy  complete  the  reef-knot.  The  simplest  way  of  completing  the  knot  is  to 
treat  the  two  ends  in  each  hand  as  a  single  thread  and  to  tie  as  if  completing 
a  single  reef-knot."  This  knot  is  shown  in  PI.  3,  Figs.  5,  6.  The  stay-knot 
applied  by  this  method  is  of  great  value  if  a  vessel  be  atheromatous. 

The  chief  dangers  after  ligation  are  secondary  hemorrhage  and  gangrene. 
Rigid  asepsis  usually  prevents  the  first;  rest,  elevation,  and  heat  antagonize 
the  second. 

Radial  Artery. — The  line  of  the  radial  artery  is  from  the  middle  of 
the  front  of  elbow-joint  to  the  ulnar  side  of  the  styloid  process  of  the  radius. 
The  line  in  the  tabatiere  is  from  the  apex  of  the  styloid  process  to  the  posterior 
angle  of  the  first  interosseous  space  (Fig.  242). 


Fig.  242. — Lines  of  incision  for  ligation  of  the  axillary  (third  portion),  brachial,  radial,  and  ulnar  arteries 

(MacCormac). 

Anatomy  (PL  4,  Fig.  5). — The  radial  artery,  though  smaUer  than  the 
ulnar,  is  the  direct  continuation  of  the  brachial.  It  arises  from  the  bifurcation 
of  the  brachial  h,  inch  below  the  bend  of  the  elbow,  runs  down  the  radial 
side  of  the  forearm  to  the  front  of  the  styloid  process  of  the  radius,  passes 
beneath  the  extensor  muscles  of  the  first  metacarpal  bone  and  of  the  first 
phalanx  of  the  thumb,  and  over  the  carpus  to  the  first  interosseous  space. 
It  is  crossed  by  the  tendon  of  the  extensor  secundi  internodii  pollicis,  enters 
into  the  palm  between  the  heads  of  the  first  dorsal  interosseous  muscle,  and 
forms  the  deep  palmar  arch.  The  artery  in  the  upper  two-thirds  of  its  course 
is  somewhat  overlaid  by  the  supinator  longus  muscle;  in  the  lower  one-third 
of  the  forearm  it  is  superficial.  In  the  upper  third  of  the  forearm  it  lies  be- 
tween the  supinator  longus  on  the  outside  and  the  pronator  radii  teres  on 
the  inside ;  in  the  lower  two-thirds  of  the  forearm  it  lies  between  the  supinator 
longus  on  the  outside  and  the  flexor  carpi  radialis  on  the  inside.  Two  venae 
comites  attend  the  vessel.  The  radial  nerve  is  to  the  outer,  or  radial,  side 
of  the  artery,  well  removed  from  the  artery  in  the  upper  third,  nearer  to  the 
artery  in  the  middle  third,  far  external  to  the  artery  in  the  lower  third,  the 
nerve  at  this  point  passing  beneath  the  supinator  longus  muscle.  The  radial 
artery  from  above  downward  rests  upon  the  biceps  tendon,  the  supinator 
brevis,  the  flexor  sublimis,  the  pronator  radii  teres,  the  flexor  longus  pollicis, 
the  pronator  quadratus  muscles,   and  the  radius.     The  best  guide  to  the 


Ulnar  Artery  471 

radial  artery  in  the  forearm  is  the  outer  edge  of  the  flexor  carpi  radialis  muscle 
or  the  inner  edge  of  the  supinator  longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical  snuff-box,  is  a  tri- 
angle whose  base  is  the  lower  edge  of  the  posterior  annular  ligament,  the 
ulnar  side  being  formed  by  the  extensor  secundi  internodii  pollicis  tendon, 
the  radial  side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi  internodii 
pollicis  tendons;  the  floor  consists  of  the  trapezium,  scaphoid,  their  dorsal 
ligaments,  and  the  base  of  the  first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room  operation  of 
but  little  practical  use.  The  patient  is  placed  in  a  recumbent  position,  the 
arm  is  abducted,  and  the  forearm  is  placed  midway  between  pronation  and 
supination  (Barker).  The  surgeon  stands  upon  the  side  operated  upon. 
An  incision  2  inches  in  length  is  made  along  the  radial  border  of  the  exten- 
sor secundi  internodii  pollicis  muscle.  The  skin  and  superficial  fascia  are 
cut  and  some  venous  branches  are  divided.  The  deep  fascia  is  incised,  and 
the  vessel  is  easily  found  and  tied  before  it  passes  between  the  heads  of  the 
first  dorsal  interosseous  muscle  (Barker). 

Ligation  of  the  Lower  Third. — In  this  operation  (PL  4,  Fig.  6,  and  Fig.  242) 
the  patient  is  placed  supine,  the  arm  is  abducted,  the  forearm  is  supinated,  is 
rested  upon  a  table,  and  is  held  by  an  assistant.  The  surgeon  stands  on  the 
side  operated  upon,  and  cuts  from  above  downward  on  the  right  forearm  and 
from  below  upward  on  the  left  forearm.  The  line  of  the  vessel  should  be 
determined,  and  may  be  indicated  with  iodin.  An  incision  i^  inches  in  length 
is  made  at  a  slight  angle  to  this  line  and  midway  between  the  supinator 
longus  and  the  flexor  carpi  radialis  muscles,  which  incision  must  not  extend 
below  the  level  of  the  tuberosity  of  the  scaphoid  bone.  In  the  superficial 
fascia  watch  for  the  superficial  radial  vein,  and  if  it  comes  into  view  push  it 
aside.  Incise  the  superficial  fascia  and  locate  each  guide-tendon.  Open  the 
deep  fascia  in  the  length  of  the  first  cut;  try  to  separate  the  veins,  but  if  they 
strongly  adhere  include  them  in  the  ligature.  There  is  no  special  fascial  sheath. 
The  radial  nerve  will  not  be  seen,  but  a  division  of  the  anterior  cutaneous  nerve 
is  frequently  found  in  relation  with  the  vessel.  The  needle  can  be  passed 
in  either  direction.  A  high  origin  of  the  superficialis  volae  artery  is  con- 
fusing. 

Ligation  of  the  Middle  Third. — In  this  operation  the  position  of  the  patient 
should  be  the  same  as  in  the  preceding.  A  2-inch  incision  is  made.  Veins 
of  the  subcutaneous  tissues  are  avoided.  Lying  upon  the  deep  fascia  is  the 
anterior  division  of  the  musculocutaneous  nerve.  Open  the  fascia;  find  the 
inner  edge  of  the  supinator  longus  muscle  and  draw  it  outward,  flexing  the 
elbow  partly  if  necessary.  Be  sure  not  to  cut  external  to  this  muscle.  Find 
the  vessel  where  it  is  bound  down  by  connective  tissue  to  the  pronator  radii 
teres  muscle,  separate  the  veins,  and  pass  the  ligature  from  without  inward. 
The  nerve  is  external. 

Ligation  of  the  Upper  Third  (PI.  4,  Fig.  6,  and  Fig.  242). — For  this  oper- 
ation the  incision  is  as  described  above,  only  higher  up.  The  artery  is  be- 
tween ^e  supinator  longus  and  the  pronator  radii  teres,  which  muscles  are 
at  once  differentiated  by  the  different  direction  of  their  fibers.  The  arterj- 
is  usually  covered  by  the  supinator  longus  muscle,  which  must  be  retracted 
externally.  The  nerve  is  not  seen.  The  ligature  may  be  passed  in  either 
direction. 

Ulnar  Artery. — No  one  line  will  overlie  the  entire  ulnar  artery.  The 
line  of  the  upper  third  runs  from  the  middle  of  the  front  of  the  elbow-joint 
to  the  point  of  junction  of  the  upper  and  middle  thirds  of  the  ulna.  The 
line  of  the  lower  two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PI.  4,  Figs.  5,  6;  Fig.  242). 


472  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Anatomy  (PI.  4,  Fig.  5). — The  ulnar  artery  arises  from  the  brachial  bifur- 
cation and  runs  obliquely  inward  under  the  median  nerve  and  a  group  of 
muscles  from  the  internal  condyle;  it  turns  down  the  arm,  being  covered  in 
the  middle  third  of  its  course  by  the  flexor  carpi  ulnaris  muscle.  In  the 
lower  third  it  is  superficial,  between  the  tendons  of  the  flexor  carpi  ulnaris 
on  the  inside  and  the  flexor  sublimis  digitorum  on  the  outside,  the  vessel 
being  a  little  overlapped  by  the  flexor  carpi  ulnaris.  This  vessel  rests  first 
upon  the  brachialis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which 
it  is  bound  by  a  distinct  process  of  fascia,  and  next  upon  the  annular  ligament, 
which  structure  it  crosses  to  become  the  superficial  palmar  arch.  Two  venae 
comites  attend  the  vessel.  In  the  upper  third  the  ulnar  nerve  is  well  internal, 
but  in  the  lower  two-thirds  the  nerve  lies  near  the  artery  and  to  its  ulnar 
side.     The  guide  is  the  outer  edge  of  the  flexor  carpi  ulnaris. 

Operations  (PL  4,  Fig.  6,  and  Fig.  242). — Ligation  of  the  Lower  Third. — 
The  position  in  this  operation  is  the  same  as  for  ligation  of  the  radial  artery. 
Make  a  2-inch  incision  to  the  radial  side  of  the  tendon  of  the  flexor  carpi 
ulnaris,  which  incision  should  not  be  taken  lower  than  a  point  i  inch  above 
the  pisiform  bone.  Avoid  the  superficial  ulnar  vein  in  the  subcutaneous  tissue. 
Open  the  deep  fascia,  find  the  tendon  of  the  flexor  carpi  iilnaris,  flex  the  wrist 
and  draw  the  tendon  inward,  open  a  second  layer  of  fascia,  clear  the  vessel, 
separate  the  veins,  and  pass  the  Hgature  from  within  outward  to  avoid  the 
nerve.  On  the  artery  is  the  palmar  cutaneous  branch  of  the  ulnar  nerve,  and 
this  branch  must  not  be  included  in  the  ligature. 

Ligation  of  the  Middle  Third  (PL  4,  Fig.  6). — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding  one,  the  incision  being  3  inches  long. 
Avoid  the  anterior  ulnar  vein  and  the  branches  of  the  internal  cutaneous 
nerve  in  the  superficial  fascia.  Open  the  deep  fascia  a  Httle  external  to  the 
superficial  cut  (Treves).  Find  the  space  betv/een  the  flexor  carpi  ulnaris 
and  the  superficial  flexor,  feeling  with  the  index-finger,  and  when  the  space 
is  discovered  flex  the  wrist,  retract  the  flexor  carpi  ulnaris  inward  and  the 
flexor  sublimis  digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look 
external  to  it  for  the  artery,  clear  the  vessel,  separate  the  venae  comites,  and 
pass  the  needle  from  within  outward.  The  ulnar  artery  should  not  be  Hgated 
in  continuity  in  the  upper  third  of  its  course. 

Brachial  Artery. — The  line  of  the  brachial  artery  is  from  the  junc- 
tion of  the  anterior  and  middle  thirds  of  the  outlet  of  the  axiUa,  the  arm  being 
abducted  and  the  forearm  supinated,  to  the  middle  of  the  front  of  the  elbow- 
joint  (Fig.  242). 

Anatomy  (PL  4,  Fig.  i). — The  brachial  artery  is  the  prolongation  of  the 
axiUary,  and  extends  from  the  lower  edge  of  the  teres  major  muscle  to  J 
inch  below  the  bend  of  the  elbow,  where  it  di\ddes  into  the  radial  and 
ulnar  arteries.  It  lies  first  to  the  inner  side  of  the  arm,  but  passes  to  the 
front  of  the  elbow.  It  is  crossed  by  no  muscle,  and  is,  in  fact,  superficial, 
barring  its  being  somewhat  overlaid  in  part  of  its  course  by  the  edge  of  the 
biceps  muscle.  The  median  nerve  is  external  above,  crosses  over  the  vessel 
about  the  middle  of  the  arm,  and  reaches  the  inner  side  of  the  artery.  The 
coracobrachialis  and  biceps  muscles  are  external,  and  both  often  overlap 
the  vessel.  The  ulnar  nerve  is  internal  above,  and  the  median  nerve  is  in- 
ternal below  the  middle.  The  basihc  vein  is  to  the  inner  side  of  the  artery, 
being  outside  the  deep  fascia  to  near  the  middle  of  the  arm,  at  which  point 
it  pierces  it.  The  artery  above  is  separated  from  the  long  head  of  the  triceps 
by  the  musculospiral  nerve  and  superior  profunda  artery  and  vein;  it  rests 
from  above  down  on  the  inner  head  of  the  triceps,  the  coracobrachialis,  and 
the  brachiahs  anticus  muscles.  The  artery  is  covered  by  skin,  by  superficial 
fascia,  and  by  deep  fascia.     The  internal  cutaneous  nerve  Ues  in  front  of 


LIGATIONS. 


Plate  4. 


Axillary  Artery  473 

the  artery,  upon  the  deep  fascia,  until  it  pierces  the  fascia  along  with  the 
basilic  vein.  The  artery  has  venae  comites,  and  in  its  upper  half  has  also 
the  basilic  vein  to  its  inner  side.  The  guide  to  the  brachial  is  the  inner  edge 
of  the  biceps  muscle.  Just  in  front  of  the  elbow-joint  the  artery  Hes  in  a 
triangle,  the  base  of  which  is  formed  by  an  imaginary  transverse  line  above 
the  condyles,  and  the  apex  by  the  junction  of  the  pronator  radii  teres  and 
the  supinator  longus  muscles.  The  outer  hne  is  the  supinator  longus,  the 
inner  line  is  the  pronator  radii  teres,  and  the  floor  is  formed  by  the  brachialis 
anticus  and  the  supinator  brevis  muscles.  From  within  outward  the  triangle 
contains  the  median  nerve,  brachial  artery,  tendon  of  the  biceps,  anastomosis  of 
the  superior  profunda  and  radial  recurrent  arteries,  and  the  musculospiral  nerve. 

Operations. — Ligation  at  the  Bend  of  the  Elbow. — In  this  operation  (PL  4, 
Fig.  2,  and  Fig.  242)  the  patient  is  placed  supine,  the  arm  is  moderately 
abducted  and  extended,  and  is  allowed  to  lie  upon  its  posterior  aspect.  The 
forearm  is  supinated.  The  surgeon  stands  upon  the  side  operated  upon,  and 
cuts  from  above  downward  on  the  right  side  and  from  below  upward  on  the  left 
side.  The  tendon  of  the  biceps  and  the  median  basilic  vein  must  be  accu- 
rately located.  An  incision  is  made  parallel  to  the  inner  edge  of  the  biceps 
tendon  and  2  inches  in  length,  the  center  of  this  cut  being  in  the  crease  of  the 
elbow.  On  exposing  the  median  basilic  vein,  retract  it  downward  and  in- 
ward, open  the  bicipital  fascia,  clear  the  artery  of  fat,  separate  the  venae  comites, 
and  pass  the  Hgature  from  within  outward  to  avoid  the  median  nerve.  The 
above  operation  is  not  frequently  performed. 

Ligation  in  the  Middle  of  the  Arm  (Fig.  242). — In  this  operation  the  patient 
is  placed  supine,  the  arm  is  abducted,  and  the  forearm  is  supinated.  An 
assistant  holds  the  forearm,  but  the  arm  should  not  rest  upon  the  table,  because, 
if  it  be  allowed  to  do  so,  the  inner  head  of  the  triceps  wiU  be  forced  forward 
and  may  overhe  the  artery,  and  thus  complicate  the  operation.  Locate  the 
inner  edge  of  the  biceps,  which  is  the  guide.  Make  an  incision  3  inches  in  length 
in  the  hne  of  the  artery.  Incise  the  skin  and  fascia,  flex  the  elbow  shghtly, 
retract  the  biceps  outward,  feel  for  the  artery,  open  the  sheath,  separate  its 
ven£e  comites,  and,  having  located  the  median  nerve,  pass  the  Hgature  from 
it.  In  the  middle  of  the  arm  the  nerve  is  in  front  of  the  vessel,  above  the 
middle  it  is  external  to  it,  and  below  the  middle  it  is  internal  to  it.  High  up 
the  arm  the  inner  edge  of  the  coracobrachialis  is  the  guide,  rather  than  the 
biceps.  Above  the  middle  of  the  arm  the  basilic  vein  is  beneath  the  deep 
fascia  and  passes  along  by  the  inner  side  of  the  artery;  hence,  high  up  the 
artery  has  three  companion  veins,  the  venae  comites  and  the  basihc  vein, 
and  there  is  seen  the  ulnar  nerve  to  the  inside  of  the  artery. 

Axillary  Artery. — ^To  determine  the  line  of  the  axillary  artery  place  the 
arm  at  a  right  angle  to  the  body,  with  the  patient  supine,  and  lay  down  a 
hne  from  the  middle  of  the  clavicle  to  the  humerus  near  the  inner  border 
of  the  coracobrachialis.  The  line  of  the  third  portion  can  be  approximated 
by  projecting  the  line  of  the  brachial  upward  (Fig.  242). 

Anatomy  (PI.  4,  Fig.  3;  PI.  5,  Fig.  i). — The  axillary  artery  is  the  con- 
tinuation of  the  subclavian,  and  runs  from  the  lower  margin  of  the  first  rib 
to  the  inferior  border  of  the  teres  major  muscle.  It  is  divided  into  three 
portions  by  the  pectoralis  minor  muscle.  The  first  portion  is  above,  the 
second  portion  is  behind,  and  the  third  portion  is  below,  the  pectoralis  minor. 
The  position  of  the  artery  varies  "vvith  the  position  of  the  limb.  When  the 
arm  is  parallel  with  the  body  the  artery  is  far  from  the  surface  and  forms 
a  curve  whose  convexity  is  upward  and  outward.  When  the  arm  is  at  a  right 
angle  to  the  body  the  vessel  is  nearer  the  surface  and  straight.  When  the 
arm  is  raised  above  a  right  angle  the  artery  comes  near  the  surface  and  forms 
a  curve  with  the  convexity  downward. 


474  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  first  portion  of  the  axillary-  artery  is  occasionally  ligated.  It  lies  upon 
the  first  intercostal  muscle  and  the  first  serration  of  the  great  serratus  muscle, 
and  has  behind  it  the  posterior  thoracic  nerve;  the  brachial  plexus  is  external 
and  posterior  to  the  vessel;  on  its  inner  side  is  the  axillary  vein;  in  front  of 
it  are  the  clavicle,  the  great  pectoral  muscle,  the  subclavius  muscle,  the  costo- 
coracoid  membrane,  the  cephalic  and  acromiothoracic  veins,  and  the  external 
anterior  thoracic  nerve.  The  branches  of  the  first  part  of  the  axillary  artery 
are  the  superior  thoracic  and  the  acromiothoracic.  The  second  part  of  the 
arter\'  is  not  Hgated.  The  brachial  plexus  surrounds  the  second  portion. 
The  third  part  is  covered  in  front,  above,  by  the  great  pectoral,  but  is  covered 
below  by  skin  and  fascia;  behind,  it  has  the  tendon  of  the  subscapularis, 
the  latissimus  dorsi,  and  the  teres  major  muscles;  the  coracobrachiaHs  is  on 
the  outer  side;  the  axillary  vein  is  on  the  inner  side.  It  is  important  to  re- 
member that  there  may  be  three  veins,  one  external  and  two  internal.  The 
axillary  vein  is  formed  by  the  venae  comites  of  the  brachial  artery  joining, 
and  this  new  vein  effecting  a  junction  with  the  basilic  vein.  The  median 
nerv'e  Hes  upon  the  axillary  artery  in  the  upper  part  of  the  third  portion  of 
the  vessel's  course,  and  passes  to  the  outer  side.  The  musculocutaneous 
nerve  is  external,  but  it  is  only  seen  high  up;  the  ulnar  nerve  is  internal;  the 
lesser  internal  and  the  internal  cutaneous  nerves  are  internal;  the  muscu- 
lospiral  and  the  circumflex  nerves  are  behind.  The  branches  of  the  third 
portion  of  the  axillary  artery  are  the  subscapular  and  the  anterior  and  pos- 
terior circumflex. 

Operations. — Ligation  of  the  Third  Fortiori  (PL  4,  Fig.  4,  and  Fig.  242). — 
The  position  of  the  patient  should  be  supine,  -^dth  the  shoulders  raised  and  the 
arm  abducted  to  a  right  angle.  The  surgeon  stands  between  the  patient's  arm 
and  side,  with  his  back  toward  the  subject's  feet.  Kn  incision  is  made  3  inches 
in  length.  It  begins  half-way  up  the  axilla  opposite  to  the  head  of  the  humerus, 
and  is  taken  downward  parallel  to  the  lower  edge  of  the  great  pectoral  muscle 
and  crosses  the  junction  of  the  anterior  and  middle  thirds  of  the  outlet  of  the 
axilla.  The  integiunents  and  fascia  are  incised.  The  vein  or  veins  will  be 
prominent  to  the  inner  side  and  may  ovelie  the  vessel.  To  the  inner  side 
Tvith  the  veins  are  the  ulnar  and  internal  cutaneous  nerves.  The  median 
nerve  is  upon,  and  the  external  cutaneous  is  to  the  outer  side  of,  the  artery. 
Feel  for  the  pulsations  of  the  artery,  find  the  median  nerve,  and  draw  it  out- 
ward, draw  the  nerves  and  veins  which  lie  to  the  inner  side  inward,  clear  the 
artery  from  the  vense  comites,  and  pass  the  ligature  from  within  outward. 
Apply  the  Hgature  well  below  the  circumflex  branches. 

Ligation  of  the  First  Fart. — This  operation  (PI.  5,  Fig.  2,  and  Fig.  244) 
was  fiist  performed  in  181 5  by  Chamberlaine,  of  Jamaica.  The  patient  is 
placed  supine,  the  upper  part  of  the  body  being  raised,  a  sand-piUow  being 
placed  between  the  scapulae  to  insure  carrying  back  of  the  point  of  the  shoulder, 
and  the  arm  being  brought  down  along  the  side.  In  operating  on  the  left  side 
the  surgeon  stands  on  the  outer  side  of  the  left  arm;  in  operating  on  the  right 
side  he  stands  to  the  right  of  the  subject's  head  and  leans  over  his  shoulder. 
The  incision,  which  is  slightly  curved  downward,  begins  external  to  the  sterno- 
clavicular joint  and  ends  internal  to  the  margin  of  the  deltoid,  thus  avoiding 
the  cephalic  vein.  The  incision  is  \  inch  below  the  cla\'icle  (Fig.  244). 
Incise  the  skin,  platysma  myoides  muscle,  and  deep  fascia.  In  the  outer  angle 
of  the  wound  watch  for  the  acromiothoracic  artery  and  the  cephalic  vein. 
Incise  the  pectoralis  major;  draw  the  pectoraHs  minor  downward;  retract  the 
lower  margin  of  the  wound,  cut  through  the  costocoracoid  membrane  close  to 
the  coracoid  process  and  the  upper  border  of  the  lesser  pectoral  muscle.  Bring 
the  arm  to  the  side  so  as  to  relax  the  structures.  Find  the  brachial  plexus, 
feel  for  the  artery  internal  to  it,  clear  the  vessel,  draw  the  vein  internally,  and 


LIGATIONS. 


Plate  5. 


Subclavian  Arterv 


475 


pass  the  needle  from  within  outward.  This  avoids  the  dangerous  neighbor, 
which  is  the  axillary  vein.  This  operation  is  difficult,  dangerous,  and  unusual, 
and  in  its  performance  the  axillary  vein,  which  has  a  close  attachment  to  the 
costocoracoid  membrane,  is  apt  to  be  torn. 

Subclavian  Artery. — The  subclavian  artery  was  first  successfully  tied 
by  Post,  of  New  York,  who  applied  a  ligature  about  the  third  portion  of 
the  vessel  in  1817.  In  1809  Sir  Astley  Cooper  attempted  to  tie  the  first  part 
of  the  left  subclavian,  but  abandoned  the  operation  because  he  feared  he  had 
wounded  the  thoracic  duct.  The  first  part  of  the  subclavian  was  first  tied  by 
Colles  in  1S18  (Treves's  "Manual  of  Surgery"),  but  the  patient  died.  At 
the  present  day  the  first  and  second  portions  are  rarely  ligated.  Professor 
Halsted  in  1S92  successfully  tied  the  first  portion  of  the  left  side  for  aneurysm. 
Schumpert  tied  it  successfully  for  aneurysm.  I  assisted  Dr.  Nassau,  of  St. 
Joseph's  Hospital,  Philadelphia,  in  a  ligation  of  the  first  part  of  the  right  sub- 
cla\'ian.  The  man  suffered  from  a  ruptured  traumatic  aneurv'sm  of  the  third 
portion  of  the  vessel.  The  operation  was  followed  by  recover>^  Chilton 
produced  a  cure  of  an  aneurysm  of  the  third  portion  of  the  subcla\dan  of  the 
right  side  by  t}dng  the  first  portion,  and  twenty-four  hours  later  tying  the 
first  portion  of  the  axillary.  Curtis,  in  1897,  and  Allingham,  in  1899,  ligated 
the  first  part  successfully.  Neff ,  of  Spokane,  successfully  ligated  the  first  part 
of  the  left  subcla\'ian  ("Annals  of  Surgery,"  Oct.,  1911).  I  tied  the  first 
part  of  the  right  subcla\aan  and  the  first  part  of  the  common  carotid  for 
innominate  aneurysm.  The  aneur^'sm  was  apparently  cured.  I  also  tied 
the  third  part  of  the  right  subcla\dan  and  the  first  part  of  the  carotid  for  an 
innominate  aneurysm.  The  patient  apparently 
recovered,  but  many  months  later  developed  an 
aneurysm  at  the  point  of  carotid  ligation.  There 
is  no  U}2e  for  this  vessel. 

Anatomy  (PL  5,  Fig.  i).  —  The  subclavian 
arterj'  of  the  right  side  arises  from  the  innomi- 
nate; that  of  the  left  side,  from  the  arch  of  the 
aorta.  The  subcla\'ian  is  di\dded  into  three  parts: 
the  first  part  runs  from  the  origin  of  the  vessel 
to  the  inner  border  of  the  scalenus  anticus  muscle; 
the  second  part  lies  behind  the  scalenus  anticus 
muscle,  and  the  third  part  runs  from  the  outer 
edge  of  the  muscle  to  the  lower  border  of  the 
first  rib.  The  third  portion  is  contained  in  the 
subcla\'ian  triangle  (Fig.  243),  and  is  superficial. 
It  rises,  as  a  rule,  to  h  inch  above  the  cla\dcle. 
The  subcla^ian  vein  is  below  the  arter\%  being 
separated  from  it  by  the  scalenus  anticus  muscles. 
The  brachial  plexus  is  above  and  external  to  the 
artery.  The  vessel  rests  upon  the  first  rib,  and 
behind  it  is  the  scalenus  medius  muscle.  The 
suprascapular  and  transversalis  colli  arteries  and 
veins  and  branches  of  the  cervical  plexus  of  nerA^es  lie  in  front  of  the  artery, 
and  the  external  jugular  vein  crosses  it  at  its  inner  side.  The  third  portion 
gives  off  no  branches. 

Ligation  of  the  Third  Part  (PL  5,  Fig.  2,  and  Fig.  244). — ^The  patient 
is  placed  upon  his  back,  the  shoulders  are  raised,  the  head  is  extended  and 
tiirned  toward  the  opposite  side,  the  arm  is  pulled  down  and  held  by  pushing  the 
forearm  imder  the  patient's  back  (Treves).  This  pulls  down  the  clavicle,  thus 
increasing  the  size  of  the  subcla\dan  triangle.  The  operator  stands  facing 
the  shoulder,  with  his  back  toward  the  patient's  feet.     The  skin  over  the  sub- 


Fig.  243. — The  triangles  of 
the  neck,  right-sided  view:  i, 
Submaxillary  triangle;  2,  "tri- 
angle of  election,"  or  superior 
carotid  triangle;  3,  submental 
triangle;  4,  "triangle  of  neces- 
sity," or  inferior  carotid  triangle; 
5,  occipital  triangle;  6,  subclavian 
triangle  (after  Keen). 


476 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


clavian  triangle,  at  a  point  ^  inch  above  the  clavicle,  is  drawn  down  until 
it  overlies  the  bone  and  is  incised.  This  maneuver  enables  the  surgeon  to 
avoid  the  external  jugular  vein  and  to  make  an  incision  in  the  skin  ^  inch 
above  the  collar-bone.  The  incision  reaches  from  the  anterior  edge  of  the 
trapezius  to  the  posterior  border  of  the  sternocleidomastoid  (PL  5,  Fig.  2, 
and  Fig.  244),  and  is  about  3  inches  long.  This  incision  divides  the  skin, 
superficial  fascia,  the  platysma  myoides,  the  vein  running  from  the  cephalic  to 
the  external  jugular,  and  some  superficial  nerves.  The  deep  fascia  is  opened. 
The  external  jugular  vein  is  drawn  into  the  inner  angle  of  the  wound,  and  is 
not  divided  unnecessarily;  if  forced  to  divide  the  vein,  tie  with  two  hgatures 

and  cut  between  them.  The 
surgeon  seeks  to  find  the  outer 
edge  of  the  anterior  scalene 
muscle,  and  runs  the  finger 
down  along  it  to  the  tubercle 
on  the  first  rib.  The  posterior 
belly  of  the  omohyoid  muscle  is 
drawn  upward  by  an  assistant. 
The  surgeon,  with  a  finger  on, 
the  tubercle,  recalls  the  facts 
that  the  vein  is  in  front  of  the 
finger  and  the  artery  is  behind 
it,  and  that  the  subclavian  vein 
is  on  a  lower  plane  than  the 
artery.  The  artery  is  felt  beat- 
ing as  it  lies  upon  the  rib.  The 
artery  is  cleared  and  the  lower 
cord  of  the  brachial  plexus  is 
exposed.  The  vein  must  be 
guarded  with  the  finger  and 
the  needle  is  passed  from  above 
downward,  as  the  plexus,  which 
is  in  more  danger  than  the 
vein,  is  to  be  avoided.  In  this 
operation  the  transversalis  colli 
and  suprascapular  arteries  must 
not  be  cut,  as  they  are  necessary  to  the  future  anastomotic  circulation.  If 
the  field  of  operation  is  too  small,  the  trapezius  or  sternocleidomastoid,  or 
both  should  be  partly  divided  transversely. 

Results. — Before  the  days  of  antisepsis  ligation  of  the  subclavian  was  a 
very  fatal  operation.  Poland  estimated  the  mortality  at  70  per  cent.  In 
most  cases  death  was  due  to  secondary  hemorrhage.  Koenig  collected  20 
cases  of  ligation  of  the  first  part  of  the  right  subclavian,  with  19  deaths.  LiUen- 
thal  believes  that  the  mortality  after  ligating  the  first  portion  on  the  right  side 
is  now  only  16  per  cent,  (quoted  by  Neff  in  "Annals  of  Surg.,"  Oct.,  191 1). 
According  to  Joseph  D.  Bryant,  there  have  been  134  deaths  in  250  Hgations 
at  various  points  of  the  subclavian  ("Operative  Surgery").  I  have  twice  tied 
this  vessel  with  success.  Gangrene  seldom  follows  ligation  of  the  subclavian. 
In  42  recoveries  after  ligation  of  various  points  there  was  i  case  of  gangrene 
of  the  arm  (Poiret's  statistics,  quoted  by  Neff  in  "Annals  of  Surg.,"  Oct.,  191 1). 
In  Von  Bergmann's  90  ligations  for  gunshot- wounds  there  was  not  a  case  of 
gangrene  of  the  arm  and  only  3  of  gangrene  of  the  fingers. 

The  vertebral  artery  was  first  successfully  ligated  by  Smythe,  of 
New  Orleans,  in  1864.  He  had  ligated  the  innominate  for  aneurysm  of  the 
subclavian  and  at  the  same  time  tied  the  common  carotid.     Secondary  hemor- 


Fig.  244. — Position  of  the  lines  of  incision  of  temporal, 
facial,  lingual,  common  carotid  (above  the  omohyoid),  sub- 
clavian, axillary  (first  portion),  and  internal  mammary 
arteries  (MacCormac). 


The  Inferior  Thyroid  Artery  477 

rhage  occurred,  the  blood  coming  from  the  brain.  He  arrested  it  bv  t^-ing 
the  vertebral. 

Anatomy. — This  vessel  is  the  largest  branch  of  the  subcla\-ian.  and  is 
the  first  branch  coming  from  the  first  portion  of  the  5ubcla^-ian.  The  verte- 
bral arter}-  ascends  and  enters  the  foramen  in  the  transverse  process  of  the 
sixth  cervical  vertebra  (in  rare  cases  the  fifth  or  the  seventh\.  and  ascends 
through  foramina  in  the  cenical  vertebrae,  passes  behind  the  articular  process 
of  the  atlas  and  over  the  posterior  arch  of  this  first  vertebra,  pierces  the  pos- 
terior occipito-atloid  ligament,  and  enters  the  skull  by  way  of  the  foramen 
magnum  ("Gray's  Anatomy").  It  joins  its  fellow  of  the  opposite  side  to 
form  the  basilar  arter\-.  At  its  point  of  origin  the  vertebral  arter\-  has  in  front 
of  it  the  internal  jugular  vein  and  inferior  th\Toid  arter\-.  Near  the  spine  it 
lies  between  the  longus  colli  and  scalenus  anticus  muscles,  and  on  the  left  side 
has  the  thoracic  duct  to  the  left  and  in  front. 

Ligation. — The  position  of  the  patient  is  the  same  as  for  Hgation  of  the 
carotid  arten.-.  .Alexander  thus  describes  the  operation:  ""An  incision  3  or  4 
inches  long  is  made  in  an  upward  and  outn^ard  direction  along  the  hollow 
which  exists  between  the  scalenus  anticus  and  the  sternomastoid  muscles. 
The  incision  should  begin  just  outside  and  on  a  level  with  the  point  where  the 
external  jugular  vein  dips  over  the  edge  of  the  sternomastoid  muscle,  or.  if 
the  vein  is  in^'isible.  about  ^  inch  above  the  cla^"icle.  The  external  jugular 
vein  is  drawn  inward  vnih  the  sternomastoid  muscle.  The  connective  tis- 
sue now  appearing,  the  wound  is  opened  by  a  blimt  dissector  until  the  sca- 
lenus anticus  muscle,  the  phrenic  nen,'e,  and  the  transverse  cervical  artery- 
are  seen.  It  cannot  be  too  well  remembered  that  the  pleura  is  at  the  inner 
side  of  the  wound,  while  below  lies  the  subcla\-ian  arter}-.  It  is  now  only 
necessar}-  to  separate  the  edges  of  the  scalenus  anticus  and  the  longus  colli 
muscles  to  see  the  vertebral  arter}-  h^ing  in  the  space  between  them.  The 
arter\-  is  general!}-  completely  covered  b}-  the  vein,  which  is  drawn  aside,  and 
the  arter}-  is  then  Hgatured"  (quoted  in  Br}-ant's  ""Operative  Surger}-''\ 
TVTien  the  vessel  is  cleared  and  tied,  branches  of  the  inferior  cer\-ical  ganglion 
are  damaged  and  possibly  included  in  the  Hgature.  and  as  a  consequence  the 
pupil  contracts.  Jacobson  tells  us  to  remember  that  the  phrenic  ner\-e  Hes 
on  the  scalene  muscle,  the  pleura  is  internal,  the  internal  jugular,  inferior 
th}Toid_,  and  vertebral  veins  are  over  the  vessel,  and  the  thoracic  duct  on  the 
left  side  crosses  it  from  within  outward. 

Results. — In  36  ligations  of  the  vertebral  arter}-  there  were  3  deaths 
(Joseph  D.  Br}-anti. 

The  Inferior  Thyroid  Artery. — Anatomy. — The  inferior  thyroid  artery- 
is  a  branch  of  the  th}Toid  axis.  It  ascends  the  neck,  passes  back  of  the 
carotid  sheath  and  the  s}-mpathetic  ner\-e.  and  reaches  the  th}-Toid  gland. 
The  recurrent  lar}-ngeal  ner\-e  hes  behind  the  arter}-.  The  phrenic  ner\-e 
is  external  to  the  arter}-  and  near  to  it  in  the  first  part  of  its  course  up  to 
the  point  of  origin  of  the  ascending  cer\-ical  branch).  The  ascending  cer- 
Adcal  branch  takes  origin  just  before  the  arter}-  begins  to  dip  behind  the  caro- 
tid. In  front  of  the  beginning  of  the  inferior  th}Toid  arter}-  of  the  left  side 
the  thoracic  duct  crosses.  The  arter}-  is  ligated  in  the  second  part  of  its  course 
(between  its  distribution  and  the  origin  of  the  above-named  branch*. 

Ligation. — The  position  of  patient  and  the  incision  are  the  same  as  for 
the  ligation  of  the  common  carotid  arten,-  in  the  triangle  of  necessity  (see  page 
480).  After  exposing  the  sternocleidomastoid  muscle  retract  it  outward. 
and  then  draw  outward  the  common  carotid  arten.-  and  also  the  internal 
jugular  vein.  The  inferior  th}Toid  arter}-  will  be  found  a  Httle  below  the 
carotid  tubercle.  It  is  cleared  and  Hgated.  Treves  adA-ises  hgation  close  to 
the  level  of  the  carotid,  so  as  to  avoid  the  recurrent  lan-nseal  nen-e. 


478  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Innominate  Artery. — First  successfully  ligated  by  Smythe,  of  New- 
Orleans,  in  1864. 

Anatomy. — The  innominate  artery  arises  from  the  beginning  of  the  trans- 
verse portion  of  the  arch  of  the  aorta,  passes  to  the  back  of  the  right  sterno- 
clavicular joint,  and  divides  into  the  common  carotid  and  subclavian  vessels. 
It  rests  upon  the  trachea.  It  has  upon  its  outer  side  the  pleura,  the  right 
innominate  vein,  and  the  pneumogastric  nerve.  Upon  its  inner  side  are  the 
remnant  of  the  thymus  gland  and  the  beginning  of  the  left  carotid  artery. 
In  front  of  it  are  the  inferior  thyroid  veins  of  the  right  side,  the  left  innomi- 
nate vein,  the  sternohyoid  and  sternothyroid  muscles,  the  remnant  of  the 
thymus  gland,  and  sometimes  a  branch  from  the  right  pneumogastric  nerve. 

Ligation. — Place  the  patient  supine,  with  the  shoulders  a  Httle  raised, 
and  the  head  thrown  back.  Carry  an  incision  from  the  upper  margin  of 
the  sternum  for  3  inches  along  the  anterior  margin  of  the  sternomastoid. 
Make  another  cut  of  the  same  length  along  the  upper  border  of  the  clavicle 
to  meet  the  first  cut.  Dissect  up  the  flap  of  skin  and  fascia.  Divide  the 
sternal  origin  and  a  part  of  the  claviciilar  portion  of  the  sternocleidomastoid 
muscle,  and  cut  the  sternohyoid  and  sternothyroid  muscles  just  above  their 
sternal  origins  (Joseph  Bell).  Retract  the  inferior  thyroid  veins.  Divide 
the  dense  leaflet  of  cervical  fascia.  Find  the  common  carotid  artery,  and 
trace  back  along  this  vessel  until  the  innominate  comes  into  view.  Retract 
the  left  innominate  vein  downward.  The  needle  is  passed  from  without 
inward  to  avoid  the  right  innominate  vein  and  right  pneumogastric  nerve. 
If  the  needle  is  kept  close  to  the  artery  the  pleura  and  trachea  wiU  not  be 
injured.^ 

Results. — Burns,  of  Memphis,  collected  45  cases  and  added  i  of  his  own, 
making  46  cases,  with  9  recoveries  ("Jour.  Am.  Med.  Assoc,"  1908).  To  these 
should  be  added  Percy  Sargent's  successful  case  ("Lancet,"  May  6,  1911), 
making  47  cases  and  10  recoveries.  Burrell's  case  in  1895  is  counted  as  a 
success,  although  death  occurred  on  the  one  hundred  and  fourth  day.  Smythe's 
case  lived  ten  years.  Sargent's  case  lived  seventeen  months  and  then  died  of 
pneumonia  and  pericarditis.  He  tied  the  common  carotid  as  well  as  the  in- 
nominate. The  case  of  Coppinger,  of  Dublin,  was  alive  and  well  two  years 
after  operation.     Mitchell  Banks's  case  lived  over  three  months. 

Region  of  the  Neck. — ^Anatomy. — The  side  of  the  neck  is  that  space 
between  the  median  line  in  front  and  the  anterior  edge  of  the  trapezius  muscle 
behind,  which  space  is  limited  below  by  the  clavicle  and  above  by  the  body 
of  the  jaw  and  an  imaginary  line  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides  this  space  into  an 
anterior  and  a  posterior  triangle,  and  each  of  the  triangles  is  subdivided  by 
other  structures,  the  anterior  into  four  spaces  and  the  posterior  into  two  (Fig. 

243)- 

The  anterior  triangle  is  bounded  in  front  by  the  median  line  of  the  neck,, 
behind  by  the  anterior  margin  of  the  sternocleidomastoid  muscle,  and  above 
by  the  body  of  the  lower  jaw  and  an  imaginary  line  drawn  from  the  angle  of 
the  jaw  to  the  mastoid  process.  This  space  is  subdivided  into  four  smaUer 
triangles — namely,  the  inferior  carotid,  the  superior  carotid,  the  submaxillary, 
and  the  submental. 

The  inferior  carotid  triangle  is  called  the  "triangle  of  necessity,"  because  the 
common  carotid  artery  in  this  region  is  ligated,  not  from  choice,  but  through 
force  of  necessity.  It  is  bounded  in  front  by  the  median  line,  above  by  the 
anterior  belly  of  the  omohyoid  muscle  and  the  hyoid  bone,  and  below  by  the 
anterior  edge  of  the  sternomastoid  muscle.     The  floor  of  this  triangle  is  com- 

1  See  the  exceedingly  clear  and  terse  account  in  that  excellent  book,  "A  Manual  of  Surgical 
Operations,"  by  Joseph  Bell. 


Common  Carotid  Artery  479 

posed  of  the  longus  colli,  the  scalenus  anticus,  the  rectus  capitis  anticus  major, 
the  sternohyoid,  and  sternothyroid  muscles. 

The  superior  carotid  triangle  is  known  as  the  "triangle  of  election,"  be- 
cause, if  the  carotid  artery  must  be  tied,  the  surgeon,  whenever  possible, 
elects  or  chooses  to  tie  it  in  this  triangle.  In  this  region  the  carotid  is  super- 
ficial, and  there  can  be  tied  either  the  external,  the  internal,  or  the  common 
carotid  arterv*,  as  the  surgeon  elects.  The  triangle  is  bounded  behind  by  the 
anterior  edge  of  the  sternocleidomastoid,  above  by  the  posterior  belly  of  the 
digastric,  and  below  by  the  anterior  belly  of  the  omohyoid  muscles.  Its 
floor  is  composed  of  the  inferior  and  middle  constrictors  of  the  pharynx,  the 
thyrohyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body  of  the  jaw  and 
an  imaginarv'  Une  drawn  from  the  angle  of  the  jaw  to  the  mastoid  process, 
behind  by  the  posterior  belly  of  the  digastric  muscle  and  the  stylohyoid  muscle, 
and  in  front  by  the  anterior  belly  of  the  digastric  muscle.  Its  floor  is  composed 
of  the  mylohyoid  and  hyoglossus  muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the  anterior  belly  of 
one  digastric  muscle;  its  base  is  the  hyoid  bone  and  its  floor  is  the  mylohyoid 
muscle. 

The  posterior  triangle  is  bounded  in  front  by  the  posterior  border  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  edge  of  the  trapezius 
muscle,  and  below  by  the  clavicle.  The  posterior  belly  of  the  omohyoid 
muscle  subdivides  it  into  two  smaller  spaces,  the  occipital  and  subclavian 
triangles. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior  edge  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  border  of  the  trapezius 
muscle,  and  below  by  the  posterior  belly  of  the  omohyoid  muscle. 

The  subclavian  triangle  is  bounded  above  by  the  posterior  belly  of  the 
omohyoid  muscle,  below  by  the  cla\dcle,  and  in  front  by  the  posterior  border 
of  the  sternocleidomastoid  muscle.  Its  floor  is  formed  by  the  first  rib  and 
the  first  serration  of  the  serratus  magnus  muscle. 

Common  Carotid  Artery. — The  common  carotid  was  tied  to  arrest 
bleeding  by  Abernethy  in  1798,  and  was  first  ligated  successfully  for  aneu- 
r\-sm  by  Sir  Astley  Cooper  in  1806.  The  line  of  the  common  carotid  artery 
is  from  the  sternocla\icular  articulation  to  midway  between  the  angle  of  the 
jaw  and  the  mastoid  process,  the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PI.  5,  Fig.  3). — The  right  common  carotid  arises  from  the 
innominate  opposite  the  sternocla\dcular  joint;  the  left  common  carotid  arises 
from  the  arch  of  the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outw^ard  from  behind 
the  sternocla\'icular  articulation  to  a  level  with  the  upper  border  of  the  thyroid 
cartilage,  at  which  point  it  di\ddes  into  the  external  and  internal  carotid. 
The  common  carotid  is  contained  in  a  sheath  derived  from  the  cervical  fascia. 
This  sheath  also  contains,  in  separate  compartments,  the  internal  jugular 
vein  on  the  outer  side  of  the  artery^  and  the  pneumogastric  nerve  between 
the  vein  and  arter>^,  but  more  deeply  placed.  The  anterior  edge  of  the  sterno- 
cleidomastoid muscle  Hes  over  the  artery  and  is  a  guide.  Low  in  the  neck 
the  common  carotid  is  deep,  being  covered  by  skin,  superficial  fascia,  platysma, 
deep  fascia,  and  the  sternocleidomastoid,  sternohyoid,  and  the  sternothyroid 
muscles.  Above  the  omohyoid  muscle  the  vessel  is  more  superficial,  being 
covered  by  the  skin,  superficial  fascia,  platymsa,  deep  fascia,  and  the  anterior 
edge  of  the  sternocleidomastoid  muscle.  Upon  the  sheath  (occasionally  within 
it),  above  the  crossing  of  the  omohyoid  muscle,  Hes  the  descendens  noni 
nerve — the  descending  branch  of  the  ninth  pair  of  Willis  (the  hypoglossal).. 
This  nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of  election. 


480  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  stemomastoid  branch  of  the  superior  thyroid  artery  crosses  the  carotid 
artery  a  little  below  its  bifurcation,  and  the  superior  thyroid  vein  also  crosses 
it  in  this  region;  the  middle  thyroid  vein  crosses  the  artery  near  its  middle, 
and  the  anterior  jugular  vein  crosses  low  down.  The  common  carotid  rests 
upon  the  longus  colli  and  rectus  capitis  anticus  major  muscles,  the  sympa- 
thetic nerve  lying  between  the  last-named  muscle  and  the  vessel,  outside  the 
carotid  sheath.  The  recurrent  laryngeal  nerve  passes  behind  the  carotid 
below  the  omohyoid  muscle,  and  the  inferior  thyroid  artery  passes  behind 
the  carotid  just  above  the  omohyoid  muscle.  The  common  carotid  is  in 
relation  internally  with  the  trachea,  thyroid  gland,  larynx,  and  pharynx. 
To  the  outer  side  are  the  pneumogastric  nerve  (which  is  on  a  posterior  plane) 
and  the  internal  jugular  vein.  On  the  left  side,  low  down  in  the  neck,  the 
jugular  vein  often  lies  in  front,  or  partly  in  front,  of  the  artery. 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the  patient  is 
placed  supine,  with  the  shoulders  raised,  a  sand-pillow  under  the  neck,  and 
the  head  turned  to  the  opposite  side,  with  the  chin  raised.  The  operator 
stands  upon  the  side  operated  upon.  The  incision,  3  inches  long,  at  a 
slight  angle  to  the  arterial  line,  runs  from  the  level  of  the  cricoid  cartilage 
downward  and  inward  toward  the  sternoclavicular  joint,  following  the  inner 
border  of  the  sternocleidomastoid  muscle.  The  surgeon  opens  the  deep 
fascia,  draws  the  sternocleidomastoid  outward,  retracts  the  sternohyoid  and 
sternothyroid  muscles  inward,  and  feels  for  the  carotid  tubercle  of  Chassaignac. 
This  tubercle  is  the  costal  process  of  the  sixth  cervical  vertebra,  and  lies  di- 
rectly under  the  artery.  The  tubercle  is  found  about  the  point  at  which  the 
omohyoid  crosses  the  carotid.  When  the  tubercle  is  found  we  know  the  situa- 
tion of  the  artery,  and  that  the  triangle  of  necessity  is  below,  and  the  triangle 
of  election  above,  the  tubercle.  The  operator  draws  the  omohyoid  muscle 
upward,  opens  the  sheath  of  the  artery  on  its  inner  side,  clears  the  vessel,  and 
passes  the  needle  from  without  inward  to  avoid  the  internal  jugiilar  vein, 
remembering  that  the  pneumogastric  nerve  is  in  the  same  sheath  as  the  artery 
and  vein,  posterior  and  external  to  the  artery.  In  this  operation  the  inferior 
thyroid  veins  are  much  in  the  way,  the  anterior  jugular  vein  crosses  low  down, 
and  on  the  left  side,  at  the  root  of  the  neck,  the  internal  jugular  vein  may  be 
in  front  of  the  carotid  artery.  If  the  incision  is  not  sufl&ciently  wide,  partially 
divide  the  sternocleidomastoid  or  the  sternohyoid  and  thyroid  muscles.  In 
the  triangle  of  necessity  the  descendens  noni  nerve  does  not  serve  as  a  guide  to 
the  sheath  of  the  vessels.     (See  PI.  5,  Fig.  4.) 

Ligation  in  the  Triangle  of  Election  (Fig.  244) . — ^The  position  of  the  patient 
for  this  operation  is  the  same  as  in  the  preceding  one.  An  incision,  3 
inches  in  length,  is  made  along  the  anterior  edge  of  the  sternocleidomastoid 
muscle  in  the  line  of  the  artery,  the  middle  of  this  incision  being  opposite  the 
cricoid  cartilage  (Fig.  244).  In  cutting  the  superficial  fascia  the  surgeon 
avoids  the  external  jugular  vein,  the  course  of  which  should  be  outlined  before 
making  the  incision.  The  line  of  the  external  jugular  is  from  the  angle  of  the 
jaw  to  the  middle  of  the  -clavicle.  The  operator  opens  the  deep  fascia,  retracts 
the  sternocleidomastoid  muscle  outward,  feels  for  the  carotid  tubercle,  draws 
the  omohyoid  muscle  downward,  finds  the  descendens  noni  nerve  upon  the 
sheath,  opens  the  sheath  at  its  inner  side,  and  passes  the  needle  from  without 
inward.  This  incision  permits  ligation  of  either  the  superior  thyroid  or  the 
external,  internal,  or  common  carotid,  and  if  it  be  extended  up  a  httle  there 
can  be  tied  through  it  the  lingual  and  even  the  facial  and  occipital  arteries. 
(See  PI.  5,  Fig.  4.) 

Results. — In  from  20  to  25  per  cent,  of  cases  after  hgation  of  the  common 
carotid  artery  there  is  cerebral  softening  or  some  other  intracranial  com- 
plication.    Crile  states  that  of  the  cases  that  develop  cerebral  trouble,  one- 


Internal  Carotid  Artery  481 

half  die.  The  direct  operative  mortality,  according  to  Crile,  is  only  3  per  cent. 
Some  modern  operators  regard  the  mortality  as  much  higher  than  this.  I  was 
obliged  to  tie  the  common  carotid  during  an  operation  for  tumor  of  the 
carotid  gland;  the  patient  developed  hemiplegia. 

External  Carotid  Artery. — Burke  ligated  the  external  carotid  in 
1827  (Treves,  from  Chelius).  The  line  of  the  external  carotid  artery  is  the 
upper  portion  of  the  common  carotid  line. 

Anatomy  (PL  5,  Fig.  3). — The  external  carotid  artery,  which  is  one  of 
the  terminal  branches  of  the  common  carotid,  arises  on  a  level  with  the  upper 
border  of  the  thyroid  cartilage  and  runs  to  the  level  of  the  neck  of  the  condyle 
of  the  lower  jaw.  At  its  point  of  origin  it  is  covered  only  by  skin,  platysma 
and  fascia,  and  the  edge  of  the  sternomastoid,  but  as  it  ascends  it  passes  be- 
neath the  digastric  and  stylohyoid  muscles  and  into  the  parotid  gland.  The 
glossopharyngeal  nerve,  styloid  process,  and  stylopharyngeus  muscle  lie  be- 
tween the  external  and  internal  carotid  arteries.  The  hypoglossal  nerve 
crosses  the  vessel  just  below  the  digastric  muscle,  and  the  facial  and  lingual 
veins  cross  it  a  little  below  the  nerve.  The  first  branch  is  the  superior  thyroid, 
which  arises  from  the  very  beginning  of  the  trunk.  The  lingual  arises  on  a 
level  with  the  greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital  take 
origin  above  the  lingual.  Each  of  them  can  be  ligated  through  the  incision 
made  for  ligation  of  the  external  carotid. 

Operation. — Place  the  patient  in  the  same  position  as  for  ligation  of  the 
common  carotid.  The  point  of  election  is  between  the  superior  thyroid  and 
the  lingual  arteries.  Make  an  incision  3  inches  in  length  at  a  slight  angle 
to  the  arterial  line,  from  near  the  angle  of  the  jaw  to  opposite  the  middle  of 
the  thyroid  cartilage.  Cut  through  the  skin,  superficial  fascia,  platysma 
and  deep  fascia,  and  retract  the  sternocleidomastoid  muscle  outward. 
Watch  for  the  digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for 
the  greater  cornu  of  the  hyoid  bone.  Open  the  sheath  a  little  below  the 
hyoid  cornu  and  pass  the  needle  from  without  inward.  Ligation  of  the 
external  carotid  has  been  neglected  because  ligation  of  the  common  carotid  is 
easier. 

Results. — Crile  believes  the  operative  mortality  to  be  2  per  cent. 

Internal  Carotid  Artery.- — The  internal  carotid  was  tied  by  Keith, 
of  Aberdeen,  in  1851  (Ashhurst's  "International  Encyclopedia  of  Surgery"). 
The  line  of  the  internal  carotid  is  parallel  with  and  J  inch  external  to  the 
line  of  the  external  carotid. 

Anatomy  (PI.  5,  Fig.  3). — The  internal  carotid  artery,  the  other  terminal 
branch  of  the  common  carotid,  arises  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage  and  enters  the  carotid  canal.  The  first  inch  of  the  artery  is 
the  only  point  where  a  ligature  is  ever  applied,  this  point  being  covered  only 
by  skin,  platysma,  fascia,  and  the  sternocleidomastoid  muscle;  higher  up  the 
artery  is  more  deeply  placed.  It  rests  upon  the  vertebrae  and  the  rectus  capitis 
anticus  major  muscle.  The  internal  jugular  vein  is  in  the  same  sheath  and 
external  to  the  artery;  the  pneumogastric  is  in  the  same  sheath,  between  the 
artery  and  the  vein,  but  posterior  to  both.  The  superior  cervical  ganghon 
of  the  sympathetic  lies  behind  the  origin  of  the  internal  carotid,  and  between 
the  ganghon  and  the  artery  is  the  superior  laryngeal  nerve. 

Operation.— In  this  operation  the  position  of  the  patient  is  the  same  as 
for  ligation  of  the  external  carotid.  The  incision  is  of  the  same  length  and 
direction  as  that  for  ligation  of  the  external  carotid,  and  is  J  inch  external. 
The  sternocleidomastoid  muscle  is  drawn  outward,  the  external  carotid  artery 
is  found  and  drawn  inward,  the  internal  carotid  is  found  and  cleared,  and  the 
needle  is  passed  from  without  inward.  The  internal  carotid  is  known  by  its 
more  external  position  and  by  the  fact  that  it  gives  off  no  branches. 
31 


482  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Results. — There  is  the  same  danger  of  cerebral  complications  after  this 
operation  as  after  ligation  of  the  common  carotid.  The  operative  mortality 
is  probably  as  great. 

Superior  Thyroid  Artery  (PI.  5,  Fig.  3). — ^This  branches  off  from 
the  external  carotid  below  the  level  of  the  greater  cornu  of  the  hyoid  bone,  in 
the  triangle  of  election.  It  is  primarily  superficial,  runs  first  upward  and 
inward,  next  downward  and  forward,  passes  underneath  the  omohyoid,  ster- 
nohyoid, and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — The  position  of  the  patient  and  of  the  surgeon  is  the  same  as 
for  ligation  of  the  carotid.  The  artery  may  be  reached  through  the  incision 
employed  for  ligation  of  the  external  carotid.  Gross  made  an  incision  be- 
ginning at  the  edge  of  the  hyoid  bone,  and  running  downward  and  outward 
to  the  sternomastoid  muscle.  The  skin  and  superficial  and  deep  fasciae  are 
divided,  and  the  artery  is  found  deeply  placed  in  the  triangle  of  election  be- 
tween the  carotid  sheath  and  the  thyroid  gland. 

Lingual  Artery. — Charles  Bell  ligated  the  first  part  of  the  lingual 
artery  in  1814.  The  operation  beneath  the  hyoglossus  muscle  was  devised 
by  Pirogoff  in  1836  (Treves's  "Manual  of  Operative  Surgery"). 

Anatomy  (PI.  5,  Fig.  3). — The  lingual  artery  arises  from  the  external 
carotid  opposite  the  greater  cornu  of  the  hyoid  bone,  passes  beneath  the  di- 
gastric and  stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus  muscle, 
passes  under  that  muscle,  and  emerges  from  beneath  it  to  run  along  the  under 
surface  of  the  tongue.  The  place  of  election  for  ligation  is  where  the  artery 
is  beneath  the  hyoglossus  muscle.  Its  guide  is  the  hypoglossal  nerve,  which 
lies  upon  the  muscle,  but  at  a  slightly  higher  level  than  the  artery. 

Operation. — In  this  operation  the  patient  is  placed  recumbent  with  the 
shoulders  raised  and  the  face  turned  away  from  the  side  to  be  operated  upon. 
The  surgeon  stands  upon  the  affected  side.  A  curved  incision  is  made  from 
a  little  external  to  the  symphysis  of  the  lower  jaw,  downward  and  outward, 
to  just  above  the  greater  cornu  of  the  hyoid  bone,  and  upward  and  outward 
to  just  in  front  of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  The 
skin,  the  superficial  fascia  and  platysma,  and  the  deep  fascia  are  incised. 
The  submaxillary  gland  is  cleared  and  retracted  well  upward.  The  fascia 
beneath  the  gland  is  divided  by  a  transverse  incision.  The  posterior  edge  of 
the  mylohyoid  muscle  and  the  bellies  of  the  digastric  muscle  are  sought  for 
and  identified.  One  of  the  digastric  tendons  is  retracted  down  and  out 
(Treves).  The  hyoglossus  muscle  is  cleared  with  a  dissector;  the  hypoglossal 
nerve  and  ranine  vein  are  found  and  drawn  a  little  upward.  The  hyoglossus 
muscle  is  divided  transversely  a  little  above  the  hyoid  bone  and  below  the  level 
of  the  hypoglossal  nerve.  The  artery  is  found  under  the  muscle  and  the  needle 
is  passed  from  above  downward. 

Facial  Artery. — ^Anatomy  (PI.  5,  Fig.  3). — It  arises  from  the  external 
carotid  a  little  above  the  lingual,  runs  upward  and  forward  beneath  the  body 
of  the  inferior  maxillary  bone,  passes  along  a  groove  in  the  posterior  and  upper 
surface  of  the  submaxillary  gland,  crosses  the  body  of  the  lower  jaw  at  the 
lower  anterior  edge  of  the  masseter  muscle,  and  passes  forward  and  upward 
to  the  angle  of  the  mouth  and  side  of  the  nose. 

Ligation  (PI.  5,  Fig.  4). — The  facial  artery  is  rarely  ligated  in  the  cervical 
portion,  but  may  be  reached  through  the  incision  employed  for  ligation  of 
the  external  carotid.  The  vessel  may  be  tied  before  it  crosses  the  submax- 
illary gland,  the  stylohyoid  and  digastric  muscles  being  drawn  aside.  The 
vessel  is  reached  in  the  facial  portion  of  its  course  by  a  i-inch  cut  at  the 
anterior  edge  of  the  masseter  muscle  (Fig.  244).  Branches  of  the  facial 
nerve  are  pushed  aside.  The  needle  is  passed  from  behind  forward  to  avoid 
the  vein  (Jacobson). 


Dorsalis  Pedis  Artery  483 

Temporal  Artery. — The  line  of  the  temporal  artery'  passes  "upward 
over  the  root  of  the  zygoma,  midway  between  the  condyle  of  the  jaw  and  the 

tragus"  (Jacobson). 

Anatomy. — The  temporal  artery  arises  from  the  external  carotid  behind 
the  condyle  of  the  jaw  and  in  the  parotid  gland,  passes  over  the  zygoma,  and 
divides  into  two  terminal  branches. 

Ligation. — The  patient  is  placed  recumbent  and  the  head  is  turned  to  the 
opposite  side.  An  incision  i  inch  in  length  is  made  (see  Fig.  244),  the  super- 
ficial structures  and  dense  fascia  are  divided,  the  vein  is  retracted  backward, 
and  the  needle  is  passed  from  behind  forward. 

The  occipital  artery  takes  origin  from  the  posterior  surface  of  the  ex- 
ternal carotid,  below  the  digastric  muscle  and  opposite  the  point  of  origin 
of  the  facial  arterv*.  It  ascends  beneath  the  digastric  and  stylohyoid  muscles 
and  parotid  gland;  the  hypoglossal  nerve  hooks  around  it  from  behind  for- 
ward. It  crosses  the  internal  carotid  artery,  the  internal  jugular  vein,  the 
pneimiogastric  and  spinal  accessory  nerves ;  passes  between  the  mastoid  process 
of  the  temporal  bone  and  the  atlas;  grooves  the  temporal  bone;  penetrates 
the  trapezius  muscle,  and  ascends  over  the  occiput. 

Ligation. — This  vessel  can  be  Hgated  near  its  origin  through  the  same 
incision  as  is  employed  to  reach  the  external  carotid.  The  hypoglossal  nerv^e 
is  avoided.  To  tie  back  of  the  mastoid  process,  place  the  patient  in  the  same 
position  as  for  ligation  of  the  carotid.  Carry  an  incision  from  the  tip  of  the 
mastoid  upward  and  backward,  reaching  a  point  midway  between  the  mastoid 
and  the  occipital  protuberance  (Jacobson).  Cut  the  skin,  the  fascia,  the 
sternocleidomastoid,  the  splenius  capitis,  and  possibly  a  portion  of  the  trachelo- 
mastoid  muscles.  Bring  the  head  toward  the  operator  in  order  to  relax  the 
structures,  retract  the  edges  of  the  wound,  and  clear  the  arterv^  where  it  lies 
between  the  mastoid  process  and  the  transverse  process  of  the  atlas  (Jacob- 
son).  x\n  electric  forehead  Hght  is  of  great  assistance  in  finding  the  vessel. 
Pass  the  needle  away  from  the  vein  or  veins  (there  are  often  several). 

Dorsalis  Pedis  Artery. — The  line  of  the  dorsaHs  pedis  artery  is  from 
the  middle  of  the  front  of  the  ankle-joint  to  the  middle  of  the  base  of  the  first 
interosseous  space. 

Anatomy  (PI.  6,  Fig.  i). — The  dorsalis  pedis  is  a  continuation  of  the  an- 
terior tibial  artery,  and  it  runs  from  the  bend  of  the  ankle  to  the  proximal 
extremity  of  the  first  interosseous  space,  where  it  di\'ides  into  the  dorsaHs 
hallucis  and  the  communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  cimeiform  bones,  and  at 
its  point  of  bifurcation  lies  between  the  heads  of  the  first  dorsal  interosseous 
muscle.  It  may  lie  in  some  persons  a  little  external  to  this  course.  It  is  held 
upon  the  bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This  artery 
is  covered  by  skin,  by  superficial  and  deep  fascia,  and  by  the  annular  ligament 
above,  and  is  sometimes  partly  overlaid  by  the  extensor  proprius  pollicis 
muscle,  and  is  crossed,  just  before  its  bifurcation,  by  the  innermost  tendon 
of  the  extensor  bre\ds  muscle.  The  inner  tendon  of  the  extensor  commimis 
digitor-um  is  to  the  outer  side  of  the  vessel;  the  tendon  of  the  extensor  proprius 
poUicis  is  to  the  inner  side,  and  is  a  guide.  The  artery  is  ligated  in  the  dorsal 
triangle  of  the  foot — a  space  which  is  bounded  above  by  the  lower  edge  of  the 
annular  ligament,  externally  by  the  inner  tendon  of  the  extensor  brevis,  and 
internally  by  the  tendon  of  the  extensor  proprius  pollicis.  The  arter>'  has 
venae  comites;  the  anterior  tibial  nerve  lies,  as  a  rule,  to  its  inner  side,  but  may 
be  found  upon  the  arter\^  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  ner^-e  is  external  to  the  vessel  in  the  superficial  parts. 

Operation  (PL  6,  Fig.  2). — In  this  operation  the  patient  is  placed  supine 
with  the  leg  and  foot  extended.    Heath  flexes  the  leg  partly  and  rests  the  sole 


484  Diseases  and  Injuries  of  the  Heart  and  Vessels 

of  the  foot  directly  upon  the  table.  The  surgeon  stands  below  the  extremity 
and  cuts  from  above  downward.  Make  an  incision  2  inches  in  length  along 
the  arterial  line,  beginning  opposite  the  lower  edge  of  the  annular  ligament 
and  running  along  by  the  tendon  of  the  extensor  proprius  poUicis;  cut  through 
the  skin  and  superficial  and  deep  fascia;  have  the  toes  extended;  retract  the 
tendon  of  the  extensor  proprius  poUicis  inward,  and  the  tendon  of  the  extensor 
communis  digitorum  outward;  clear  the  artery,  find  the  nerve,  try  to  separate 
the  venae  comites,  and  pass  the  needle  from  the  nerve. 

Anterior  Tibial  Artery. — To  locate  the  line  of  the  anterior  tibial 
mark  a  point  midway  between  the  head  of  the  fibula  and  the  tuberosity  of  the 
tibia,  drop  i  inch,  and  draw  a  line  from  the  second  point  to  the  middle  of  the 
front  of  the  ankle-joint. 

Anatomy. — ^The  anterior  tibial  artery  is  one  of  the  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  forward  between  the  two  heads  of  the  posterior  tibial  muscle,  comes 
to  the  front  of  the  leg  through  an  opening  in  the  interosseous  membrane,  and 
runs  down  to  the  middle  of  the  front  of  the  ankle-joint.  In  the  upper  two- 
thirds  of  its  course  it  rests  upon  the  interosseous  membrane,  to  which  it  is 
fastened  by  firm  fascia;  in  the  lower  third  it  lies  first  upon  the  front  of  the 
tibia  and  then  upon  the  anterior  Hgament  of  the  ankle-joint.  For  its  upper 
two-thirds  the  artery  has  the  tibialis  anticus  muscle  just  external  to  it;  at  the 
junction  of  the  middle  and  lower  thirds  the  extensor  proprius  pollicis  comes 
from  the  outside  and  lies  either  upon  the  artery  or  to  its  inner  side  for  the 
rest  of  its  course.  Externally  in  its  upper  third  is  the  extensor  communis 
digitorum;  in  the  middle  third  is  the  extensor  proprius  pollicis;  in  the  lower 
third,  the  proprius  pollicis  having  crossed  to  the  inner  side,  the  extensor 
communis  digitorum  again  becomes  the  outer  boundary.  The  artery  is  cov- 
ered by  skin  and  by  superficiall  and  deep  fascia.  In  its  upper  third  it  is  deeply 
placed  between  the  muscles;  in  its  middle  third  it  is  less  overlaid  by  muscle; 
in  its  lower  third  it  is  superficial  except  where  it  is  crossed  by  the  extensor 
proprius  and  where  it  is  covered  by  the  annular  ligament.  The  artery  has 
venae  comites.  In  the  lower  three-fourths  of  its  course  it  is  accompanied  by 
the  anterior  tibial  nerve,  which  in  its  course  in  the  upper  third  of  the  leg  is 
external  to  the  artery;  in  the  middle  third  it  is  external  and  a  little  in  front  of 
the  artery;  and  in  the  lower  third  it  is  external  to  or  upon  the  artery  (PI.  5, 

Fig.  5)- 

Operations. — The  ligations  of  the  anterior  tibial  (PI.  5,  Fig.  6)  are:  (i)  of 
the  lower  third;  (2)  of  the  middle  third;  (3)  of  the  upper  third.  In  all  these 
ligations  the  patient  is  placed  recumbent  with  the  leg  extended,  and  the  sur- 
geon stands  to  the  outer  side  of  the  extremity,  cutting  from  above  downward 
on  the  right  side  and  from  below  upward  on  the  left  side. 

Ligation  of  the  Lower  Third. — Make  an  incision  3  inches  long  in  the  line 
of  the  artery  and  over  the  annular  ligament.  This  incision  is  external  to 
the  tibialis  anticus  muscle  and  h  inch  from  the  outer  border  of  the  tibia 
(Barker).  Divide  the  skin  and  fascia,  retract  the  tendon  of  the  tibialis  anticus 
inward,  and  the  tendon  of  the  extensor  proprius  pollicis  outward,  along  with 
the  tendons  of  the  extensor  communis.  Flex  the  ankle-joint  to  relax  the 
tendons  and  clear  the  arter\^  Draw  the  nerve  external  and  pass  the  ligature 
from  without  inward.  In  order  to  recognize  the  muscles  in  this  as  in  other 
ligations,  rely  largely  upon  the  finger  while  the  muscles  are  being  moved. 

Ligation  of  the  Middle  Third. — In  this  operation  the  procedure  is  similar 
to  the  above.  Remember  that  the  nerve  lies  in  front  of  the  vessel  and  that 
the  extensor  proprius  pollicis  muscle  is  external.  The  nerve  is  retracted 
outward  and  the  needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this  locate  the  inter- 


LIGATIONS. 


Plate  6. 


<  < 


Posterior  Tibial  Artery 


485 


osseous  membrane,  and  then,  by  passing  out  along  this  membrane,  discover 
the  artery. 

Ligation  of  the  Upper  Third. — Make  an  incision  3  inches  long  in  the  arte- 
rial line.  On  opening  the  deep  fascia,  do  not  rely  on  the  eye  for  finding  the 
muscular  interspace,  as  often  the  latter  cannot  be  seen,  and  neither  a  white 
nor  a  yellow  line  is  reliable.  Place  the  index-finger  deep  in  the  wound  and  have 
the  tibialis  anticus  and  extensor  communis  digitorum  muscles  successively 
rendered  tense  by  an  assistant.  In  opening  the  interspace  use  the  handle 
of  the  knife.  Relax  the  muscles,  retract  the  tibialis  anticus  inward  and  draw 
the  extensor  communis  digitorum  outward.  Find  the  interosseous  membrane 
where  it  is  attached  to  the  edge  of  the  tibia,  and  the  artery  will  be  found  upon 
this  membrane,  between  the  tibia  and  the  nerve.  Clear  the  vessel  and  pass 
the  ligature  from  without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery. — The  line  of  the  posterior  tibial  is  from 
the  middle  of  the  popliteal  space  to  a  point  midway  between  the  tip  of  the 
inner  malleolus  and  the  point  of  the  heel  (PI.  6,  Figs.  5,  6). 


Fig.  245. — The  lines  indicate  the  incision  to  be  made  for  the  ligature  of  the  common  femoral,  of  the 
femoral  in  Scarpa's  triangle  and  in  Hunter's  canal,  and  of  the  posterior  tibial  in  the  calf  and  behind  the 
malleolus  (AlacCorrgac). 

Anatomy.— The  posterior  tibial  is  the  larger  of  the  two  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  down  between  the  deep  and  superficial  flexor  muscles  to  midway  be- 
tween the  tip  of  the  malleolus  and  the  point  of  the  heel,  and  divides  into_  the 
external  and  internal  plantar  vessels.  In  the  upper  third  of^  its  course  it  is 
very  deeply  placed  midway  between  the  tibia  and  fibula;  in  its  middle  third 
it  is  less  deep,  having  passed  inward;  and  in  its  lower  third  it  is  superficial. 
At  the  ankle  the  artery  is  beneath  the  annular  ligament.  From  above  down- 
ward the  posterior  tibial  artery  rests  upon  the  posterior  tibial  muscle,  the 
flexor  longus  digitorum  muscle,  the  posterior  surface  of  the  tibia,  and  the 
internal  lateral  ligament  of  the  ankle-joint.  For  the  first  inch  or  two  of  the 
course  of  the  artery  the  posterior  tibial  nerve  is  to  the  inner  side;  the  nerve 
then  crosses  to  the  outer  side,  and  remains  in  that  relative  position  throughout 
the  rest  of  the  course  of  the  artery.  When  the  knee  is  partly  flexed  and  the 
leg  is  laid  upon  its  outer  surface  the  artery  is  between  the  operator  and  the 
nerve,  and  the  nerve  is  between  the  artery  and  the  table.    Back  of  the  malleo- 


486 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


lus,  in  the  first  compartment,  lies  the  posterior  tibial  muscle;  in  the  next  com- 
partment is  the  ilexor  longus  digitorum  muscle;  in  the  next  compartment 
are  the  artery  and  nerve ;  and  in  the  most  posterior  is  the  flexor  longus  pollicis 
muscle. 

Operations. — Ligation  Back  of  the  Malleolus. — In  this  operation  the 
patient  is  placed  recumbent,  with  the  thigh  abducted  and  the  leg  flexed  and 
resting  upon  its  outer  surface.  The  surgeon  stands  to  the  outer  side.  Make 
a  2-inch  semilunar  incision  corresponding  in  its  curve  to  the  malleolus  and 
^  inch  posterior  to  its  margin  (Fig.  245).  Cut  down  to  the  annular  liga- 
ment, incise  the  ligament,  and  find  the  artery  and  venae  comites.  Clear  the 
vessel  and  pass  the  needle  from  behind  forward  (to  avoid  the  nerve,  which  is 
here  posterior  and  external).  Do  not  make  the  preliminary  incision  nearer 
the  malleolus  than  i  inch,  as  the  sheath  of  the  tibialis  posticus  muscle  will 
then  surely  be  opened.  In  closing  the  wound,  suture  the  ligament  by  buried 
sutures  of  catgut  before  closing  the  superficial  parts  (PL  6,  Fig.  6). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the  patient  is  placed 
in  the  same  position  as  for  the  ligation  back  of  the  malleolus.  Feel  for  the 
inner  border  of  the  tibia,  and  make  an  incision  4  inches  long  i  inch  behind 
the  osseous  border,  parallel  with  it,  and  extending  through  skin  and  super- 
ficial and  deep  fascia  (Fig.  245).  Draw  the  gastrocnemius  muscle  outward. 
Incise  the  soleus  muscle,  but  not  the  fascia  beneath  the  soleus;  cut  this  fascia, 


Fig.  246. — Anatomy  of  popliteal  artery  (Bernard 
andHuette). 


Fig.    247. — Ligation  of   popliteal   artery  in  its 
upper  third  (Bernard  and  Huette). 


after  dropping  the  handle  of  the  knife  so  that  the  blade  is  at  right  angles 
with  the  plane  of  the  tibia.  Clear  the  artery;  pass  the  needle  from  without 
inward  (PI.  6,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  continuity.  Jt  can  be 
tied  at  the  upper  portion  of  the  popliteal  space,  at  the  lower  portion  of  the 
popHteal  space,  or  at  the  inner  side  of  the  thigh. 

Anatomy  (Fig.  246). — The  popHteal  artery  is  the  continuation  of  the 
femoral,  and  runs  from  the  opening  in  the  adductor  magnus  muscle  to  the 
lower  margin  of  the  popliteus  muscle.  This  vessel  rims  downward  and  out- 
ward behind  the  knee-joint  and  in  the  popliteal  space.  The  ham,  or  popHteal 
space,  is  a  lozenge-shaped  space,  which  above  the  joint  is  bounded  on  the 


Femoral  Artery  487 

outer  side  by  the  biceps  muscle,  and  on  the  inner  side  by  the  semitendinosus, 
semimembranosus,  gracilis,  and  sartorius  muscles,  while  below  the  joint  it 
is  bounded  externally  by  the  plantaris  and  outer  head  of  the  gastrocnemius 
muscles,  and  internally  by  the  inner  head  of  the  gastrocnemius  muscle.  The 
floor  of  this  space  is  formed  by  the  surface  of  the  femur,  the  posterior  ligament 
of  the  knee-joint,  the  head  of  the  tibia,  and  the  popliteus  fascia.  The  internal 
popliteal  nerve  passes  down  the  middle  of  the  popliteal"  space ;  it  is  superficial 
to  the  vessels  in  the  upper  half  of  the  space,  and  is  external  to  them ;  it  is  inter- 
nal to  the  vessels  in  the  lower  half  of  the  space.  The  external  popliteal  nerve 
is  in  the  outer  side  of  the  space.  The  popliteal  vein  is  between  the  nerve  and 
the  artery.  Above  the  knee-joint  it  is  to  the  outer  side  of  the  artery,  but 
below  the  knee-joint  it  is  to  the  inner  side.  The  artery  lies  deeply  in  the 
space. 

Ligation  in  Upper  Third. — Place  the  patient  prone.  The  surgeon  stands 
to  the  outer  side  of  the  limb  and  makes  a  vertical  incision  3  inches  in  length 
along  the  outer  margin  of  the  semimembranosus  muscle,  exposes  the  popliteal 
nerve,  retracts  the  muscle  inward  and  the  nerve  outward,  exposes  the  artery, 
separates  it  from  the  other  structures,  and  passes  the  needle  from  without 
inward  (Fig.  247). 

Ligation  in  Lower  Third. — Make  a  3 -inch  vertical  incision  between  the 
heads  of  the  gastrocnemius  muscle.  Avoid  the  external  saphenous  vein 
and  nerve,  and  retract  them  with  the  popliteal  nerve.  Separate  the  artery 
from  the  vein  and  pass  the  needle  from  within  outward. 

Femoral  Artery. — ^The  line  of  the  femoral  artery  is  from  midway  be- 
tween the  anterior  superior  spine  of  the  iliiim  and  the  symphysis  pubis  to 
the  adductor  tubercle  on  the  inner  condyle  of  the  femur,  the  thigh  being 
abducted  and  resting  upon  its  outer  surface  (PL  6,  Fig.  3). 

Anatomy. — The  femoral  artery  is  the  continuation  of  the  external  iliac 
trimk;  it  extends  from  the  lower  border  of  Poupart's  ligament  to  the  opening 
in  the  adductor  magnus  muscle,  and  hence  occupies  the  upper  two-thirds  of 
the  thigh.  The  artery  for  its  first  5  inches  is  superficial,  lying  in  Scarpa's 
triangle,  a  space  which  is  bounded  externally  by  the  sartorius  muscle  and 
internally  by  the  adductor  longus,  its  base  being  Poupart's  ligament  and  its 
floor  being  composed  of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery  enters  the  triangle  as 
the  common  femoral,  but  after  a  2-inch  course  it  divides  into  the  profunda 
(which  passes  deeply)  and  the  superficial  femoral.  The  latter  vessel  is  the 
one  alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the  artery  is  between, 
and  the  nerve  is  external  (v.  a.  n.).  At  the  apex  of  the  triangle  the  vein  is 
internal  and  a  Httle  posterior.  At  the  apex  of  the  triangle  the  superficial 
femoral  passes  under  the  sartorius  muscle  and  enters  into  Himter's  canal, 
which  occupies  the  middle  third  of  the  thigh  and  which  terminates  at  an 
opening  in  the  adductor  magnus  muscle.  Himter's  canal  is  bounded  ex- 
ternally by  the  vastus  internus  muscle,  internally  by  the  adductors  longus 
and  magnus,  and  its  roof  is  fascia  which  stretches  from  the  adductor  longus 
to  the  vastus  mternus.  In  Himter's  canal  the  vein  is  behind  the  artery  in  the 
upper  part,  but  external  to  it  in  the  lower  part,  and  is  firmly  attached  to  the 
artery.  There  may  be  two  veins.  Inside  Hunter's  canal,  but  outside  the 
femoral  sheath,  is  the  long  saphenous  nerve,  which  crosses  the  artery  from 
without  inward. 

A  way  to  remember  the  relation  of  the  femoral  vein  to  the  femoral  artery 
is  to  recall  the  fact  that  the  relation  of  the  vein  to  the  artery  is  always  con- 
trary to  the  relation  of  the  sartorius  muscle  to  the  artery:  when  the  sartorius 
muscle  is  external  to  the  artery  the  vein  is  internal,  as  at  the  base  of  Scarpa's 


488  Diseases  and  Injurirs  of  the  Heart  and  Vessels 

triangle;  when  the  sartorius  muscle  is  crossing  in  front  toward  the  inside  of 
the  artery,  the  vein  is  passing  at  the  back  to  the  outside,  as  at  the  apex  of 
Scarpa's  triangle;  when  the  muscle  is  over  the  artery  the  vein  is  back  of  it, 
as  in  the  upper  third  of  Hunter's  canal;  and  when  the  muscle  is  to  the  inside 
of  the  artery  the  vein  is  to  the  outside,  as  in  the  lower  two-thirds  of  Hunter's 
canal.  In  a  ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of  the 
sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal  the  long  saphenous  nerve 
is  the  guide. 

Operations. — Ligation  of  the  Superficial  Femoral  at  the  Apex  of  Scarpa's 
Triangle. — In  this  operation  the  position  of  the  patient  is  supine,  with  the 
thigh  and  leg  partly  flexed,  and  the  thigh  abducted,  everted,  and  rested  upon 
its  outer  surface  on  a  pillow.  The  operator  stands  to  the  outer  side  of  the 
extremity.  From  a  point  corresponding  to  the  middle  of  Scarpa's  triangle, 
and  2^  inches  below  Poupart's  ligament,  make  a  3-inch  incision  in  the  arterial 
line  (Fig.  245).  Cut  the  skin  and  superficial  fascia.  The  saphenous  vein  will 
not  be  seen  unless  the  incision  is  internal  to  the  arterial  line;  if  this  vein  is 
seen,  draw  it  inward.  Open  the  fascia  lata,  find  the  inner  border  of  the  sar- 
torius muscle,  and  draw  it  outward.  The  fibers  of  this  muscle  run  downward 
and  inward,  thus  distinguishing  it  from  the  adductor  longus,  whose  fibers 
run  downward  and  outward.  Open  the  common  sheath  for  the  artery  and 
vein,  and  then  incise  the  individual  arterial  sheath.  Clear  the  artery  and 
pass  the  ligature  from  within  outward  (PI.  6,  Fig.  4). 

Ligation  of  the  Superficial  Femoral  in  Hunter^s  Canal. — This  operation 
was  first  performed  for  aneurysm  by  John  Hunter  in  1785.  In  this  operation 
the  position  of  the  patient  is  the  same  as  in  the  ligation  at  the  apex  of  Scarpa's 
triangle.  Make  a  3-inch  incision  in  the  middle  third  of  the  thigh,  parallel 
with  the  arterial  line  and  J  inch  internal  to  it  (Barker)  (Fig.  245).  Incise 
the  skin  and  superficial  fascia,  look  out  for  the  internal  saphenous  vein,  open 
the  fascia  lata,  find  the  sartorius  muscle,  and  retract  it  inward,  thus  exposing 
the  roof  of  Hunter's  canal,  which  is  to  be  opened  for  i  inch  or  more.  Within 
the  canal  is  seen  the  long  saphenous  nerve,  usually  upon  the  sheath.  Open 
the  sheath  of  the  artery,  clear  the  vessel,  and  pass  the  needle  from  without  in- 
ward. 

Results:  Ligation  at  the  apex  of  Scarpa's  triangle  is  a  method  for  treat- 
ing popliteal  aneurysm.  It  is  a  very  successful  procedure.  I  have  performed  it 
3  times  with  success  and  have  assisted  other  operators  in  3  successful  cases. 
Syme  successfully  ligated  the  femoral  about  its  middle  23  consecutive  times, 
and  in  Guy's  hospital  the  same  operation  was  done  24  times,  with  i  death 
("Practice  of  Surgery,"  by  Thomas  D.  Bryant). 

Iliac  Arteries. — ^The  line  of  the  common  and  external  iliac  arteries  is 
from  a  point  J  inch  below  and  ^  inch  to  the  left  of  the  umbilicus  to  midway 
between  the  anterior  superior  spine  of  the  ilium  and  the  pubic  symphysis. 
The  upper  third  of  this  line  represents  the  common  iliac,  and  the  lower  two- 
thirds  the  external  iliac  (PI.  3,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta  opposite  the 
left  side  and  lower  border  of  the  fourth  lumbar  vertebra,  and  extend  to  the 
upper  margin  of  the  right  and  left  sacro-iliac  joints,  where  they  each  bifurcate 
into  an  external  and  an  internal  iliac.  The  common  Uiac  arteries  lie  upon 
the  fifth  lumbar  vertebra,  are  covered  with  peritoneum,  and  are  crossed  by 
the  ureters.  In  women  the  ovarian  arteries  cross  the  common  iliacs.  Each 
common  iliac  vein  lies  to  the  right  side  of  its  associated  artery.  The  right 
common  iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and  ureter  (in 
women  also  the  ovarian  artery),  the  ileum,  branches  of  the  superior  mesenteric 
artery,  and  branches  of  the  sympathetic  nerve.  The  left  common  iliac  artery 
has  in  front  of  it,  in  addition  to  structures  common  to  both  sides  (ureter. 


Iliac  Arteries  489 

ovarian  artery,  sympathetic  branches),  branches  of  the  inferior  mesenteric 
artery,  and  the  sigmoid  flexure  with  its  mesocolon.  The  internal  iliac  artery 
runs  from  the  sacro-iliac  joint  to  the  upper  margin  of  the  great  sacrosciatic 
foramen.  It  is  ver\'  rarely  ligated  (only  for  gluteal  aneurysm,  for  uncontrol- 
lable hemorrhage  from  the  gluteal  or  sciatic  arteries,  or  to  produce  atrophy 
of  the  prostate  gland).  The  external  iliac  artery  runs  from  the  sacro-Uiac 
joint  along  the  pelvic  brim,  upon  the  inner  edge  of  the  psoas  muscle,  to  Pou- 
part's  Hgament.  The  external  iliac  vein  is  internal  to  the  artery.  On  the  right 
side,  high  up,  it  passes  behind  the  artery.  The  external  iliac  artery  has  in  front 
of  it  peritoneum  and  subserous  tissue  (Abernethy's  fascia).  The  ileum  crosses 
the  right,  and  the  sigmoid  flexure  crosses  the  left,  external  iliac  arter^^  The 
genital  branch  of  the  genitocrural  nerve  crosses  the  artery  low  down,  and  the 
circumflex  iliac  vein  crosses  it  just  before  it  terminates  in  the  femoral.  The 
spermatic  vessels  and  the  vas  deferens  in  the  male,  and  the  ovarian  vessels  in 
the  female,  lie  upon  the  artery  near  its  termination.  Sometimes  the  ureter 
crosses  the  vessel  near  its  point  of  origin. 

Ligation  of  the  Iliac  Arteries  After  Abdominal  Section. — The  best  method 
for  hgating  the  common,  the  internal,  and  sometimes  the  external  iliac  is  by 
abdominal  section.  The  patient  is  placed  in  the  Trendelenburg  position.  The 
abdomen  is  opened  in  the  midline  below  the  umbilicus  or  in  the  semilunar  line 
of  the  diseased  side.  The  intestines  are  lifted  toward  the  diaphragm,  and  are 
held  up  by  gauze  pads.  The  edges  of  the  incision  are  retracted.  The  vessel  to 
be  tied  is  located  and  the  point  for  ligation  is  selected.^  The  posterior  layer  of 
the  peritoneimi  is  opened  over  the  selected  point,  the  vessel  is  cleared,  and  the 
threaded  Dupuytren's  aneurysm  needle  is  passed  in  a  direction  away  from  the 
vein.  In  Hgating  either  common  ihac  pass  the  needle  from  right  to  left. 
In  Hgating  the  external  iliac  pass  the  ligature  from  "v\dthin  outward.  It  is  not 
necessan,^  to  suture  the  posterior  layer  of  peritoneum.  The  abdomen  is  closed 
^'^'ithout  a  drain.  In  these  operations  be  sure  to  push  the  ureter  out  of  the  way. 
This  operation  has  been  performed  by  Dennis,  Hearn,  ISIarmaduke  Shield, 
MitcheU  Banks,  the  author,  and  others. 

Results:  Br\*ant  ("Operative  Surgers'")  alludes  to  5  reported  cases  of 
transperitoneal  ligation  of  the  common  iHac  artery,  with  i  death. 

Ligation  of  the  Coynmon  Iliac  Artery  by  the  Extraperitoneal  Method. — The 
common  iHac  artery  was  tied  unsuccessfuUy  by  Dr.  Wm.  Gibson  in  181 2.  It 
was  first  successfuHy  Hgated  by  Valentine  Mott  in  1827.  The  patient  is  placed 
recumbent  or  in  the  Trendelenburg  position.  The  body  is  then  turned  a  little 
to  the  opposite  side  and  the  thighs  are  partly  flexed.  Bryant  says  there  are 
two  Hnear  guides  for  this  artery.  Crampton's  line  is  drawn  from  "the  apex  of 
the  cartilage  of  the  last  rib  downward  and  a  little  forward  nearly  to  the  crest 
of  the  ilium,  then  carried  forward  parallel  with  it  to  a  Httle  below  the  ante- 
rior superior  spine"  ("Operative  Surgen,',"  by  Joseph  D.  Br}"ant).  AIcKee's 
line  is  "drawn  from  the  tip  of  the  cartilage  of  the  eleventh  rib  to  a  point 
I J  inches  "v\dtliin  the  anterior  superior  spine,  then  cur\^ed  downward,  fom^ard, 
and-  inward,  and  terminating  abruptly  above  the  internal  abdominal  ring" 
(Ibid.). 

The  incision  can  be  begun  just  external  to  the  internal  abdominal  ring 
and  be  curv^ed  upward  and  outward  as  in  ligation  of  the  external  iliac,  but 
Crampton's  incision  gives  more  room.  The  superficial  tissues  are  di\nded 
down  to  the  transversaHs  fascia,  this  structure  is  nicked  and  di\ided,  and  the 
exposed  and  unopened  peritoneum  is  roUed  upward  and  inward.  The  mus- 
cular guide  is  the  inner  border  of  the  psoas  magnus  muscle.  By  its  side  an 
artery  is  felt.  If  the  sacrovertebral  prominence  is  above  the  vessel  touched, 
the  artery  is  the  external  iliac;  otherv\ise  it  is  the  common  iliac.  If  the  ex- 
ternal iliac  is  the  vessel  first  exposed,  follow  it  up  to  find  the  common  trunk. 


490 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


When  the  common  iliac  is  found,  separate  the  fatty  tissue  about  it  and  pass 
the  ligature  from  the  right  toward  the  left  in  order  to  avoid  the  associated 


vem. 


Results:  Jos.  D.  Bryant  tells  us  that  this  vessel  has  been  ligated  by  the 
extraperitoneal  method  69  times,  with  only  16  recoveries,  but  it  is  to  be  re- 
membered that  many  of  these  operations  were  in  pre-antiseptic  days.  The 
artery  has  been  tied  80  times,  with  56  deaths  (70  per  cent.). 

Twenty-one  of  these  operations  were  done  since  1880;  there  were  10  deaths 
(mortality  of  nearly  48  per  cent.).  In  these  21  cases  gangrene  occurred  7 
times.     (See  Wm.  J.  Gillette,  in  "Annals  of  Surgery,"  July,  1908.) 


Fig.  248. — A,  Nephrotomy:  a,  last  dorsal  n.;  b,  latissimus  dorsal  m.;  c,  serratus  post,  inferior  m.; 
d,  middle  layer  of  lumbar  fascia;  e,  outer  layer;/,  ext.  oblique  m.;  g,  int.  oblique  m.;  h,  perinephritic 
(extraperitoneal)  fat;  i,  quadratus  Imnborum  m.;j,  erector  spinae  m.  B,  Nephrotomy:  a,  first  lumbar 
n.;  b,  kidney;  c,  transversalis  fascia.  C,  Ligature  of  the  sciatic  and  internal  pudic  arteries,  and  exposure 
of  the  great  sciatic,  small  sciatic,  and]  internal  pudic  nerves:  a,  gluteus  maximus  m._;  b,  inf.  gluteal  n.; 
c,  sciatic  a.;  d.  int.  pudic  a.  and  n.;  e,  great  sciatic  n.;/,  small  sciatic  n.;  g,  pyriformis  m.  D,  Ligature 
of  the  gluteal  artery  and  exposure  of  the  superior  gluteal  nerve:  a,  gluteus  maximus  m.;  b,  gluteal  a.; 
c,  superior  gluteal  n.;  d,  pyriformis  m.;  e,  gluteus  medius  m.  (Kocher). 

Extraperitoneal  Ligation  of  the  Internal  Iliac  Artery. — This  operation  was 
first  performed  by  Stevens,  of  Vera  Cruz,  in  181 2  ("Practice  of  Surgery,"  by 
Thomas  Bryant).  The  incision  and  the  method  of  exposing  the  vessel  are 
identical  with  like  steps  in  the  ligation  of  the  common  iliac. 

Results:  Of  26  ligations  of  this  vessel  recorded,  18  were  fatal,  but  only 
a  few  of  the  cases  were  done  antiseptically  (Joseph  D.  Bryant's  "Operative 
Surgery"). 


The   Gluteal  Artery 


491 


Ligation  of  the  External  Iliac  by  Abernethy's  Extraperitoneal  Method  (Pi. 
3,  Fig.  4). — The  external  iliac  artery  was  first  ligated  by  Abernethy  in  1796. 
The  operation  failed,  but  he  did  the  first  successful  operation  in  1806.  The 
patient  is  placed  recumbent  with  the  thighs  extended  during  the  first  incisions; 
but  in  the  later  stages  of  the  operation  the  thighs  are  flexed  a  httle  to  relax 
the  abdominal  structures.  The  operator  stands  to  the  outer  side.  The 
surgeon  ^ill  find  the  arter>'  by 
the  side  of  the  psoas  muscle. 
Mark  a  point  i  inch  above 
and  I  inch  external  to  the 
middle  of  Poupart's  ligament, 
and  another  point  i  inch 
above  and  i  inch  internal  to 
the  anterior  superior  iliac 
spine  (Barker).  Join  these 
two  points  b>'  a  cun,'ed  in- 
cision 4  inches  long  and  con- 
vex downward.  Cut  the  skin, 
the  fat,  the  two  oblique  mus- 
cles, and  the  transversahs 
muscle;  open  the  transversahs 
fascia,  separate  the  perito- 
neum toward  the  vessels,  and 
draw  it  inward  by  a  broad 
retractor,  and  look  for  the 
arter\-  along  the  peh*ic  brim. 
The  anterior  crural  nen.'e  is 
seen  to  the  outer  side  of  the 
artery,  the  external  iliac  vein 
is  to  the  inner  side  of  the 
artery,  and  the  genitocrural 
nerve  is  upon  the  artery. 
Clear  the  arter\^  near  its 
middle  and  pass  the  Ugature 
from  -tt-ithin  outward.  In  Sir 
Astley  Cooper's  method  of 
ligation  the  inguinal  canal 
is  opened;  in  Abernethy's 
method  the  inguinal  canal  is 
not  opened. 

The  Gluteal  Artery. 
— This  vessel  is  a  continua- 
tion of  the  posterior  di\'ision 
of  the  internal  iliac.  It 
emerges  from  the  great  sacro- 
sciatic  foramen  at  the  upper 
border  of  the  p}Tiformis  muscle.  It  rests  upon  the  gluteus  minimus,  di^-ides 
into  three  branches,  and  is  covered  by  the  gluteus  maximus  muscle.  The 
superior  gluteal  nen.-e  Hes  inferior  to  the  arter\-  (Fig.  248). 

Ligation. — The  patient  should  be  prone.  The  surgeon  stands  to  the  outer 
side.  The  incision  corresponds  to  a  liine  drawn  from  the  posterior  superior 
iliac  spine  to  the  upper  border  of  the  great  trochanter  (Fig.  249) .  Di\'ide  the 
skin,  fascia,  gluteus  maximus  muscle,  and  the  fascia  over  the  gluteus  medius 
muscle,  and  retract  the  gluteus  medius  upward.  Feel  for  the  great  ^sacro- 
sciatic  foramen,  and  at  this  point  the  artery  is  found  above  the  p^Tiformis 


Fig.  249. — Position  and  direction  of  the  superficial  incis- 
ions wMch  must  be  made  Ln  order  to  secure  the  gluteal  artery 
and  the  sciatic  and  pudic  arteries:  A,  Posterior  superior  iliac 
spine;  B.  great  trochanter;  C,  tuberosity  of  the  ischium;  D, 
anterior  superior  ihac  spine;  A~B,  iliotrochanteric  line, divided 
into  thirds.  This  line  corresponds  in  direction  with  the  fibers 
of  the  gluteus  maximus  muscle.  The  incision  to  reach  the 
gluteal  arter\-  is  indicated  by  the  darker  portion  of  the  line. 
Its  center  is  at  the  junction  of  the  upper  and  middle  thirds  of 
the  iliotrochanteric  Une.  and  exactly  corresponds  with_  the 
point  of  emergence  of  the  gluteal  arterj-  from  the  great  sciatic 
notch.  A-C,  iho-ischiatic  Une.  The  incision  to  reach  the 
sciatic  arten,-  and  internal  pudic  is  indicated  by  the  lower  dark 
line.  It  is  also  to  be  made  in  the  direction  of  the  fibers  of  the 
gluteus  maximus  muscle.  The  center  of  the  wound  corre- 
sponds to  the  junction  of  the  lower  with  the  middle  third  of 
the  iho-ischiatic  line  (ilacCormac) . 


492  Diseases  and  Injuries  of  the  Heart  and  Vessels 

muscle.  Clear  the  vessel  and  pass  the  needle  from  below  upward  (Kocher's 
"Operative  Surgery").     There  is  practically  no  mortality  from  this  operation. 

The  Sciatic  Artery. — This  artery  is  the  larger  of  the  terminal  branches 
of  the  anterior  division  of  the  internal  iliac  artery.  It  passes  to  the  lower  por- 
tion of  the  great  sacrosciatic  foramen,  lying  back  of  the  internal  pudic  artery, 
and  resting  upon  the  sacral  plexus  of  nerves  and  pyriformis  muscle  (Gray).  It 
leaves  the  pelvis  between  the  pyriformis  and  coccygeus  muscles,  and  passes 
downward  between  the  ischial  tuberosity  and  great  trochanter.  It  is  covered 
by  the  glutaeus  maximus  muscle,  rests  upon  the  gemelli,  internal  obturator, 
and  quadratus  femoris  muscles,  has  the  great  sciatic  nerve  external  to  it,  and 
the  small  sciatic  nerve  external  and  posterior  (Fig.  248). 

Ligation. — The  patient  Hes  prone.  The  surgeon  stands  to  the  outer  side. 
The  incision  "corresponds  to  the  middle  two-thirds  of  a  line  extending  from  the 
posterior  inferior  ihac  spine  to  the  base  of  the  great  trochanter."^  MacCormac 
advises  the  incision  shown  in  Fig.  249.  Divide  the  skin,  fat,  fascia,  and  the 
glutaeus  maximus  muscle.  Find  the  artery  at  the  lower  border  of  the  pyriformis 
muscle  and  trace  it  to  its  point  of  emergence  from  the  pelvis.  Pass  the  ligature 
from  without  inward.     There  is  practically  no  mortahty  from  this  operation. 

Internal  Pudic  Artery. — This  artery  is  one  of  the  terminal  branches 
of  the  anterior  trunk  of  the  internal  iliac.  It  passes  to  the  lower  margin  of 
the  great  sacrosciatic  foramen,  and  leaves  the  pelvis  between  the  pyriformis 
and  coccygeus  muscles,  crosses  the  ischial  spine,  and  again  enters  the  pelvis 
by  the  lesser  sacrosciatic  foramen.  The  vessel  is  accompanied  by  the  internal 
pudic  nerve  (Fig.  248). 

Ligation. — The  position  of  the  patient  and  the  incision  are  the  same  as 
for  ligation  of  the  sciatic  artery  (Fig.  249).  The  artery  is  found  below  the 
ischial  spine.  Pass  the  needle  from  below .  upward  to  avoid  the  nerve.  There 
is  practically  no  mortality  from  this  operation. 

Ligation  of  the  Abdominal  Aorta. — This  operation  was  first  per- 
formed by  Sir  Astley  Cooper  in  181 7.  The  patient  Hved  but  a  few  hours. 
The  aorta  has  been  ligated  twenty  times  and  there  have  been  twenty  deaths. 
Nine  of  these  cases  were  aseptic  operations.  The  patient  of  Monteiro,  of 
Rio  Janeiro,  lived  for  ten  days.  The  circulation  was  entirely  restored  in 
the  limbs,  and  the  man  died  from  hemorrhage  resulting  from  the  ulceration 
produced  by  a  septic  hgature.  Keen's  case  lived  for  forty-eight  days  after 
ligation  just  below  the  diaphragm.  The  urinary  secretion  was  plentiful 
and  the  circulation  in  the  lower  extremities  was  restored,  death  resulting 
from  cutting  through  of  the  ligature.  Robert  T.  Morris  performed  distal  Uga- 
tion  below  an  aneurysm.  He  encircled  the  aorta  with  a  soft-rubber  catheter 
and  clamped  it  with  forceps.  Twenty-two  hours  after  operation  the  aneu- 
rysm began  to  shrink,  and  in  three  hours  more  had  apparently  disappeared. 
Twenty-seven  hours  after  operation  the  clamp  and  catheter  were  removed. 
The  patient  died  of  septicemia  fifty-three  hours  after  operation.  The  necropsy 
disclosed  gangrene  of  a  bit  of  intestine  which  had  been  in  contact  with  the 
forceps,  but  the  dissecting  aneurysm  was  filled  with  soHd  clot,  the  aorta  was 
patent,  and  the  circulation  in  the  extremities  was  re-established  ("Amer. 
Jour,  of  Med.  Sciences,"  Sept.,  1900).  These  cases  prove  that  under  certain 
circumstances  the  operation  is  feasible,  and  in  desperate  cases  it  must  be  con- 
sidered as  a  possible  means  of  treatment.  Halsted  and  Matas  prefer  a  metal 
band  to  the  ligature  (see  page  429).  Gradual  occlusion  and  partial  occlusion  of 
the  aorta  are  much  safer  than  sudden  closure. 

Murray  Operation. — This  procedure  aims  to  avoid  opening  the  peritoneimi. 
An  incision  is  made  from  just  below  the  tip  of  the  tenth  rib  to  a  point  i  inch 
internal  to  the  anterior  superior  iliac  spine.  The  peritoneum  is  separated 
1  Kocher's  "Operative  Surgery,"  by  Stiles. 


Tumors  of  Bone  493 

from  the  abdominal  wall  until  the  vessel  is  reached.  Cooper's  operation  by 
abdominal  section  is  the  preferable  procedure. 

Operation  by  Abdominal  Section  (Cooper's  Operation);  Instruments  Re- 
quired.— Those  used  in  any  ligation,  with  the  addition  of  an  aneur}-sm  needle 
with  a  large  curve  and  a  ver\-  long  handle.  With  an  ordinary-  instrument  it 
is  extremely  difficult  to  pass  the  ligature.  It  would  be  a  great  advantage  to 
use  an  instrument  which,  after  being  passed  under  the  vessel,  could  have  a 
central  eyed  shaft  projected,  as  is  the  center  shaft  of  a  Bellocq  cannula.  Floss 
silk  is  probably  the  best  ligature  material. 

If  the  patient  is  much  exhausted,  an  assistant  should  infuse  salt  solution 
in  a  vein  dviring  the  operation.  In  Keen's  case  there  was  profound  shock, 
but  the  moment  the  Hgature  was  tightened  it  passed  away. 

The  patient  should  be  placed  upon  his  back.  The  surgeon  stands  to 
the  right  of  the  patient  and  opens  the  abdomen  in  the  median  line,  a  little 
above  the  level  of  the  aneurysm.  The  intestines  are  packed  aside,  the 
posterior  layer  of  the  peritoneum  is  di\ided,  the  surface  of  the  aorta  over 
a  small  area  is  cleared  of  ner\-es,  the  plexuses  being  separated  with  a  blunt 
dissector. 

The  needle  is  passed  from  right  to  left.  A  double  ligature  of  tioss  silk 
should  be  passed  and  the  ends  should  be  tied  with  a  stay-knot.  The  wound  is 
closed  and  dressed. 

It  has  been  suggested — I  think  by  Wyeth — that  it  might  be  "uise  to  only 
partially  tighten  the  ligature  at  first,  completing  the  occlusion  of  the  artery- 
after  a  day  or  two.  Such  a  procedure  would  certainly  give  a  better  chance 
for  the  collaterals  to  dilate  and  restore  circulation  in  the  legs  (see  page  429). 

Unfortunately,  in  an  aneur\-sm.  the  vessel  -^"ill  usually  be  extensively 
diseased,  and  Hgation  -uill  be  out  of  the  question.  If.  however,  a  normal 
region  is  found,  the  chance  of  success  in  a  case  of  aneur\-sm  will  be  greater 
than  in  a  case  of  hemorrhage  from  a  branch  of  the  aorta,  because,  in  a  case 
of  aneur^-sm,  the  probabilities  are  that  the  collaterals  are  somewhat  distended 
before  a  Hgature  is  applied. 


XX.  DISEASES  AND    INJURIES   OF   BONES  AND   JOINTS 

Diseases  or  the  Boxes 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony  matter  without 
change  in  osseous  structure.  It  arises  from  want  of  use  (as  seen  in  the  wasting 
of  the  bone  of  a  stump)  or  from  pressture  (as  seen  in  the  destruction  of  the 
sternum  by  an  aneur\-sm  of  the  aorta) .  Eccentric  atrophy  is  the  thinning  of 
a  long  bone  from  within,  the  outer  surface  being  perhaps  unchanged.  It  is 
usually  a  senile  change.  Concentric  atrophy  means  a  thinning  of  the  outer 
surface  of  the  shaft,  causing  a  lessened  diameter.  It  is  usually  linked  ^ith 
eccentric  atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood-supply  (as  seen 
in  chronic  epiphyseal  inflammation),  the  bone  gro-ning  much  more  than  does 
its  fellow.  It  may  arise  from  excessive  use  or  from  strain  (as  seen  in  the 
increased  size  of  the  fibula  when  the  tibia  is  congenitally  absent). 

Tumors  of  Bone. — Bones  give  origin  to  both  innocent  and  mahgnant 
tumors.  Myeloid  sarcoma  takes  origin  in  the  endosteum  and  expands  the 
bone.  The  fasciculated  sarcoma  is  a  periosteal  growth.  Besides  these 
growths  there  may  develop  an  osteoma,  a  chondroma,  and  secondar}'  deposits 
of  cancer  and  sarcoma.  A  bone  may  become  0,'stic,  and  occasionally  the 
cysts  are  due  to  hydatids.     Gmnmata  are  frequently  met  with. 


494  Diseases  and  Injuries  of  the  Bones  and  Joints 

Cysts  and  Cystomata  of  Bone. — One  variety  of  cyst  is  found  in  the 
jaws  (dentigerous  cysts,  see  page  361).  The  other  variety  occurs  usually  in 
the  medullary  canal  of  long  bones  and  very  seldom  in  short  bones  and  flat 
bones.  "It  differs  from  the  dentigerous  cyst  in  the  absence  of  a  connect- 
ive-tissue capsule.  The  fluid  is  usually  hemorrhagic.  Islands  of  cartilage 
may  be  found  in  the  bone  capsule"  (Bloodgood,  in  "Progressive  Medicine," 
Dec.  I,  1907). 

A  bone-cyst  slowly  expands  and  thins  the  shaft  of  the  bone,  and  in  some 
cases  fracture  of  the  bone  is  the  first  evidence  of  the  trouble.  Union  takes 
place  after  fracture,  but  the  enlargement  remains.  The  x-ray  picture  does  not 
enable  us  to  make  the  diagnosis,  because  it  exactly  resembles  the  picture 
of  any  medullary  growth  possessed  of  a  bony  capsule  and  producing  osseous 
absorption. 

The  diagnosis  is  proved  by  exploratory  incision  and  the  condition  is  treated 
by  curettement  and  drainage. 

Many  bone-cysts  are  produced  b)^  softening  of  soUd  neoplasms  (sarcoma, 
myxoma,  medullary  fibroma,  chondroma).  Occasionally  cysts  form  in  osteo- 
malacia and  osteitis  deformans,  the  condition  arising  from  softening.  Hydatid 
cysts  and  dermoid  cysts  are  sometimes  encountered.  A  true  cystoma  of  bone, 
except  in  one  of  the  jaws,  is  a  surgical  rarity.  In  the  jaws  cystomata  are  not 
very  uncommon. 

Syphilis  of  Bone. — Secondary  syphilis  may  attack  the  bones  (see  page 
326).     Tertiary  syphilitic  lesions  are  considered  on  page  330. 

Actinomycosis  of  bone  is  most  usual  in  the  jaw,  but  may  attack  the 
orbit,  ribs,  sternum,  or  Hmbs  (see  page  309).  Actinomycosis  of  bone  may 
arise  secondarily  after  infection  of  superficial  parts  by  the  streptothrix.  In  the 
jaw  the  fungus  obtains  entrance  to  the  interior  of  the  bone  through  a  tooth 
socket.  In  some  cases  of  bone  actinomycosis  the  fungus  reaches  the  bone  by 
the  blood.  Actinomycosis  leads  to  the  production  of  granulation  tissue,  the 
bone  is  expanded  and  becomes  carious,  and  a  quantity  of  new  bone  is  some- 
times produced.  In  vertebral  actinomycosis,  although  the  condition  resembles 
tuberculosis,  angular  deformity  does  not  occur. 

Tuberculosis  of  bone  {tuberculous  osteomyelitis)  tends  especially  to  ap- 
pear in  the  cancellous  ends  of  long  bones.  In  about  one-fifth  of  the  cases  it 
is  primary,  that  is,  only  one  focus  can  be  found.  In  such  cases  the  point  of 
entry  shows  no  lesion,  or  the  lesion  at  that  point  may  have  healed.  In  some 
cases  the  bacilli  enter  through  the  tissue.  Trauma  may  be  an  exciting  cause. 
Long  after  apparent  healing  the  disease  process  may  awaken  into  activity 
and  trauma  is  often  the  cause  of  the  awakening.  In  one  of  Konig's  cases 
trouble  began  anew  after  sixty  years.  The  disease  is  especially  apt  to  attack 
the  epiphysis  and  spread  to  the  joint,  although  in  some  cases  it  spreads  to  the 
shaft.  Primary  tuberculosis  is  rare  in  the  shafts  of  long  bones,  but  is  not  un- 
common in  the  shafts  of  short  bones.  A  bone  focus  leads  to  the  formation  of  a 
bone  cavity  which  may  contain  tuberculous  granulations  or  bone  sequestra. 
The  sequestra  in  tuberculous  osteomyelitis  are  not  completely  loose,  but  are 
still  attached  at  some  point.  The  bone  may  sclerose  or  may  undergo  altera- 
tions of  an  osteoporotic  nature,  making  it  soft.  Sclerotic  bone  means  a  healing 
process.  Softened  bone  means  a  spreading  process.  A  sequestrum  in  tuber- 
culous osteomyelitis  is  usually  wedge  shaped,  the  base  being  toward  the  joint. 
A  sequestrum  is  due,  Konig  thinks,  to  the  obstruction  of  a  terminal  artery  by  a 
tuberculous  embolus  or  by  the  intra-arterial  growth  of  bacilli  ("Die  Tubercu- 
lose  der  Menschhchen  Gelenke,  swiel  der  Brustwand  und  des  Schaedels"). 
In  a  certain  nimiber  of  cases  tuberculosis  infiltrates  a  spongy  bone  with  great 
rapidity  because  of  rapid  caseation.  This  condition  is  known  as  infiltrating 
progressive  hone  tuberculosis. 


Symptoms  of  Osteitis  and  Osteoperiostitis  495 

Osteitis,  Periostitis,  and  Osteoperiostitis. — Osteitis,  or  inflammation 
of  bone,  may  be  due  to  traumatism,  to  a  constitutional  malady  or  diathesis, 
to  the  extension  of  inflammation  from  some  other  structure,  to  certain 
fevers,  to  cold,  to  phosphorus  or  mercury,  to  infection,  or  to  working  in 
pearl  button  factories.  In  inflammation  of  bone  the  exudate  and  leukocytes 
pass  into  the  Haversian  canals,  spaces,  and  canaliculi.  The  bone  corpuscles 
proliferate  and  the  bone  undergoes  thinning  (rarefaction),  not  because  of  pres- 
sure, but  because  of  absorption  by  voracious  leukocytes  and  osteoclasts.  This 
process  of  rarefaction  enlarges  all  the  bony  spaces,  and  by  destroying  septa 
throws  many  of  the  spaces  into  one.  If  the  surface  of  a  bone  inflames,  the 
periosteum  will  be  separated  more  or  less  by  exudation,  and  the  bone  will  be 
covered  with  little  pits  or  erosions  made  by  the  leukocytes.  Inflamed  bone 
is  so  soft  that  it  can  readily  be  cut  with  a  knife. 

Pearl  workers^  osteitis  occurs  particularly  in  youths  before  fusion  of  the 
epiphyses.  It  arises  in  the  diaphysis  by  the  epiphysis.  The  bones  of  the 
lunbs  are  most  apt  to  suffer,  but  the  bones  of  the  face  or  chest  may  be  attacked. 
The  attack  begins  with  pain  and  moderately  elevated  temperature  and  the 
fever  may  persist  for  several  weeks.  The  condition  may  apparently  get  well 
and  yet  begin  again  when  the  patient  returns  to  work.  The  lesions  are  often 
symmetrical  and  always  multiple  (Broca).  It  is  a  condensing  osteitis  and 
undergoes  spontaneous  cure  if  the  patient  gives  up  the  occupation  (Deturk,  in 
"Archives  Generales  de  Chirurgie,"  Nov.,  1908). 

Osteitis  may  terminate  in  resolution  or  it  may  terminate  in  sclerosis,  the 
mass  of  proliferating  cells  being  converted  first  into  fibrous  tissue  and  next 
into  dense  bone  which  contains  a  very  few  small  cancellous  spaces.  If  the 
exudation  is  under  the  periosteum,  the  bone  will  be  thickened  at  this  point, 
bone  stalactites  marking  the  points  of  passage  of  the  vessels.  Osteitis  may 
terminate  in  suppuration,  this  condition  being  often  called  caries.  In  tuber- 
culous osteitis  caseation  of  the  inflammatory  products  is  very  apt  to  arise  {tuber- 
culous caries,  the  strumous  caries  of  our  predecessors).  Acute  osteitis  may 
terminate  in  necrosis,  the  inflammatory  exudate  compressing  the  vessels  in 
their  bony  canals,  a  portion  of  the  bone  being,  in  consequence,  deprived  of 
nutritive  material.  The  portion  cut  off  from  nutritive  fluid  dies  ,en  masse 
(necrosis).  Osteitis  is  usually  associated  with  more  or  less  periostitis.  A 
simple  acute  periostitis  without  involvement  of  the  bone  may  arise  fromi 
traumatism  or  strain ;  but  in  all  severe  cases  of  periostitis,  in  all  chronic  cases, 
in  all  cases  due  to  syphilis,  rheimiatism,  measles,  scarlatina,  or  enteric  fever 
the  bone  is  involved  at  the  same  time  or  subsequently.  In  syphilitic  states 
gummatous  degeneration  frequently  ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis. — As  a  chronic  process,  osteitis 
is  most  commonly  found  in  the  femur.  The  history  may  exhibit  a  record 
of  an  antecedent  injury  or  chilling  of  the  body.  Pain  is  severe,  boring  or 
aching  in  character,  deep  seated,  worse  at  night,  and  aggravated  by  a  depend- 
ent position  of  the  part.  The  symptoms  closely  resemble  those  of  periostitis, 
with  which  disease  it  is  almost  sure  to  be  linked.  Tenderness  exists  on  per- 
cussion, and  sometimes  on  pressure.  Subperiosteal  swelling,  fusiform  in  shape, 
is  noted;  cutaneous  edema  and  discoloration  are  observed  if  a  superficial  bone 
is  inflamed.  In  syphilis  atrophic  osteitis  may  attack  the  cranial  bones  and 
produce  softening  or  even  perforation,  or  osteophytic  osteitis  may  arise, 
exostoses  being  formed.  Osteoperiostitis  may  be  acute  or  chronic,  circumscribed 
or  diffused,  and  may  terminate  in  resolution,  organization,  or  suppuration. 
It  arises  from  cold,  blows,  wounds,  strains,  the  spread  of  adjacent  inflammation, 
specific  febrile  maladies,  pyogenic  infection,  syphilis,  rheiunatism,  or  tubercu- 
losis. The  symptoms  are  pain  (which  is  worse  at  night  and  which  is  aggra- 
vated by  motion,  pressure,  or  a  dependent  position),  swelling,  edema,  and 


496  Diseases  and  Injuries  of  the  Bones  and  Joints 

discoloration  of  the  soft  parts.  Pain  in  the  syphiHtic  form  is  not  so  severe  as 
in  other  varieties.  Acute  necrosis  or  diffuse  osteoperiostitis,  a  pyogenic  inflam- 
mation of  bone  and  periosteum,  is  commonest  in  boys  about  the  age  of  puberty. 
It  is  usually  awakened  by  cold,  a  specific  fever,  or  injury,  and  most  often  affects 
the  tibia  or  femur;  the  symptoms  locally  are  redness,  swelling,  and  severe  pain; 
constitutionally  there  are  rigors,  fever,  and  sometimes  convulsions.  Necrosis  is 
apt  to  result.  Pyemia  is  common.  In  simple  acute  periostitis  a  swelling  is  felt 
upon  the  osseous  surface.  The  swelling  is  firmly  fixed  and  is  very  tender,  but 
the  bone  itself  is  not  enlarged.  There  is  some  local  heat,  discoloration,  often 
fever,  and  the  patient  complains  of  an  aching  pain,  which  is  worse  at  night. 

Periostitis  due  to  strain  demands  some  special  attention.  Sir  James  Paget, 
years  ago,  pointed  out  that  muscular  exertion  might  cause  periostitis.  C.  T. 
Dent  has  written  a  valuable  article  upon  this  subject.^ 

It  is  common  to  hear  football  players  complain  of  some  swelling  of  the 
knee-joint.  Examination  finds  tenderness  over  the  tubercle  of  the  tibia  with 
slight  swelling  of  the  joint.  Dent  points  out  that  pain  is  felt  on  straightening 
the  leg,  not  on  rotating  it.  The  same  observer  states  that  omnibus  drivers 
suffer  from  periostitis  of  the  fibula,  due  to  pressing  forcibly  against  the  foot- 
board; those  who  ride  may  develop  periostitis  of  the  adductor  insertion  (riders' 
bone) ;  the  victims  of  flat-foot  may  labor  under  periostitis  of  the  inner  tuberosity 
of  the  OS  calcis;  bar-keepers,  from  working  a  beer-pump,  may  get  periostitis 
of  the  scapula,  pain  being  marked  on  contracting  the  biceps ;  a  housemaid  may 
develop  periostitis  at  the  points  of  bony  origin  of  the  great  pectoral  from  the 
chest,  the  condition  being  due  to  sweeping  and  scrubbing.^ 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  syphilitic  forms  the  local 
treatment  consists  in  rest,  elevation  of  the  part,  the  application  of  iodin  and 
mercurial  ointment,  and  bandaging.  Specific  treatment  is  given  by  the  stom- 
ach or  hypodermatically.  Operation  is  rarely  justifiable.  In  other  forms,  if 
the  case  be  recent  and  severe,  put  the  patient  to  bed,  place  the  limb  in  a 
splint  and  elevate  it,  employ  cold,  apply  a  bandage,  and  give  salines  and 
iodid  of  potassium  internally.  Later  use  ichthyol  inunctions  locally  and  apply 
a  hot-water  bag.  Morphin  is  administered  for  pain.  If  these  means  fail, 
order  counterirritation  by  iodin  and  blue  ointment  or  blisters,  and  apply  heat 
locally.  In  severe  cases  take  a  tenotome  and  slit  the  periosteum  subcutane- 
ously  to  relieve  tension;  this  procedure  often  quickly  relieves  the  pain.  Some 
cases  demand  longitudinal  osteotomy,  which  is  performed  by  taking  Hey's 
saw  and  dividing  the  bone  longitudinally  into  the  medullary  canal.  If  pus 
forms,  drain  at  once. 

Diffuse  osteoperiostitis  requires  early  and  free  incisions  through  the  peri- 
osteum, antiseptic  irrigation,  drainage,  rest  and  elevation  of  the  limb,  and 
strong  supporting  and  stimulating  treatment.  Amputation  is  sometimes 
demanded,  as  when  the  patient  grows  weaker  and  weaker  even  after  incision, 
and  when  a  joint  is  seriously  involved.  If  the  necrosis  affects  the  entire  shaft, 
which  separates  from  its  epiphyses,  and  new  bone  has  not  yet  formed  from 
the  periosteum,  make  a  subperiosteal  resection  of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a  chronic  inflamma- 
tion of  the  deep  periosteal  layers.  Nodes  occurring  early  in  the  secondary 
stage  remain  soft  and  soon  pass  away  under  treatment,  but  those  occurring 
two  years  or  more  after  infection  are  apt  to  cause  a  bony  deposit.  A  node 
may  soften,  leaving  a  sinus,  at  the  bottom  of  which  is  a  piece  of  dead  bone. 
Gumma  of  the  periosteum  is  one  form  of  node  which  is  apt  to  produce  caries 
or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and  causes  the  de- 
posit of  new  bone,  which  undergoes  sclerosis.  The  chief  symptom  is  aching 
1  "Practitioner,"  Oct.,  1897.  ^  Ibid. 


Chronic  Abscess  of  Bone,   or  Brodie's  Abscess  497 

pain,  which  is  worse  when  the  patient  is  warm  in  bed,  and  is  aggravated  by 
damp  and  wet.  A  hard  swelling  is  found  at  the  seat  of  .pain  (often  over 
the  tibia,  ulna,  cla\'icle,  or  sternum).  The  soft  parts  are  iminflamed  and 
move  freely  unless  softening  or  suppuration  has  occurred.  Tenderness  is 
manifest. 

Treatment  of  Chronic  Periostitis  and  Osteoplastic  Periostitis. — For  the 
nodes  of  early  s\-philis  administer  mercury  by  the  plan  usually  followed  in 
secondary'  syphilis;  for  the  nodes  of  late  s}'philis  give  mercun.-  and  large  ad- 
vancing doses  of  iodid  of  potassium.  Bhsters,  blue  ointment,  and  iodin  are 
applied  to  the  skin  over  the  area  of  periostitis  in  both  forms,  and  subcutaneous 
di\'ision  of  the  periosteum  is  of  value.  If  suppuration  occurs,  incise  antisep- 
tically  and  drain. 

Chronic  Abscess  of  Bone,  or  Brodie's  Abscess. — This  condition  is 
sometimes  due  primarily  to  tuberculous  infection,  s}-mptoms  being  absent 
for  a  longer  or  shorter  time  and  arising  because  of  secondary  infection  with 
staphylococci.  It  is  always  chronic,  never  acute.  A  ver}-  acute  inflamma- 
tion, such  as  is  induced  by  \Trulent  pyogenic  organisms,  causes  acute  necrosis 
rather  than  an  acute  abscess.  After  t^^phoid  fever  an  area  of  suppuration  may 
slowly  form  in  the  head  of  a  long  bone,  due  to  action  of  t^-phoid  bacilli.  Xon- 
virulent  staphylococci  may  be  responsible,  and  the  condition  may  follow  long 
after  a  staphylococcus  osteomyelitis.  In  84 
per  cent,  of  cases  of  Brodie's  abscess  this 
is  the  histor\-  (Alexis  Thomson^  The 
same  author  says  the  latest  period  between 
the  osteomyelitis  and  the  abscess  varies 
from  one  to  fifty-seven  years.  Chronic 
abscess  of  bone  was  first  described  by  Sir 
Benjamin  Brodie,  and  is  often  called 
Brodie's  abscess.  It  occurs  in  the  cancel- 
lous structure  of  the  ends  of  bones — 
usually  in  the  head  of  the  tibia,  sometimes 
in  the  femur  (Fig.  250)  or  humerus.  It 
seldom  occurs  in  the  shaft  of  a  long  bone. 
A  tuberculous  abscess  of  bone  may  foUow 
a  sHght  injur}-,  which  constitutes  a  point 
of  least  resistance.  Bacteria  lodge  and 
multiply;  bone  rarefaction  leads  to  the 
formation   of   a    ca\atv,   the   mflammator\-  Fig.  250.— Chronic  abscess  in  the 

,       ,  ,  ■  .  .  •■,      great  trochanter  (".■Vmencan  Test-Book. 

products    caseate,    suppuration    arises,  and    of  Surgery-"). 

the  surrounding  bone  thickens  and  hardens 

because   of  gro'^'th  from  the  periosteum.     The  abscess  is  apt  to  break  and 

often  breaks  into  a  joint,  as  the  joint  surface  is  not  covered  by  periosteum 

and  no  barrier  of  bone  is  there  formed.     Brodie's  abscess  may  induce  necrosis. 

Alexis  Thomson  thus  describes  Brodie's  abscess  ('"'Edinburg  Med,  Jour.," 
April,  1906): 

In  the  first  or  quiescent  stage  there  is  a  ca\-ity  filled  with  serum  and  lined 
with  a  membrane  like  the  periosteum  of  young  bones.  The  outer  layer  of  the 
membrane  is  forming  new  bone  of  a  spong}'  nature,  "further  away  the  old  bone 
is  sclerosed  and  the  medullary-  canal  obHterated." 

WTien  the  mature  stage  or  abscess  stage  arises  the  lining  membrane  is 
converted  into  granulation  tissue,  and  the  ca\'ity  becomes  filled  \%-ith  staphy- 
lococcus pus.  The  outer  layer  of  granulations  erodes  the  bone  and  the  abscess 
progressively  enlarges.  As  the  bone  is  eroded  "vsithin,  new  bone  is  formed 
by  the  periosteum  and  the  bone  enlarges.  If  pus  formation  is  more  rapid 
than  bone  erosion  there  is  tension  and  pain,  but  if  bone  erosion  is  suffi- 


498  Diseases  and  Injuries  of  the  Bones  and  Joints 

ciently  rapid  to  prevent  tension  there  is  Httle  or  no  pain.  Finally,  the 
abscess  perforates  the  bony  shell  "on  the  periosteal  surface  or  into  an 
adjacent  joint." 

Symptoms. — There  are  attacks  of  boring  pain,  worse  at  night  and  aggra- 
vated by  motion  and  pressure  and  a  dependent  position.  The  pain  is  in- 
termittent, and  may  be  absent  for  many  days  at  a  time.  These  pains  are  fre- 
quently thought  to  be  rheumatic.  The  tenderness  is  marked,  even  when 
pain  is  absent,  and  is  not  in  the  joint,  as  the  patient  believed  the  pain  was,  but 
is  over  the  site  of  infection.  If  the  head  of  the  tibia  or  the  great  trochanter  is 
the  seat  of  disease,  percussion  over  that  region  develops  pain  most  certainly. 
At  times  pain  in  the  bone  becomes  excruciating  and  tenderness  acute.  There 
is  more  or  less  loss  of  function  in  the  limb  and  in  far  advanced  cases  the  bone  is 
enlarged.  There  may  be  thickening  of  the  bone  and  soft  parts,  edema  and 
discoloration  of  the  skin  over  the  seat  of  trouble,  and  attack  after  attack  of 
synovitis  in  the  nearest  joint.  Irregular  fever  and  sweats  are  usually  noted, 
but  there  may  be  no  fever.  The  harrassing  pain  causes  sleeplessness,  ex- 
haustion, and  emaciation.  When  the  pus  breaks  through  the  bone  abscess 
develops  in  the  soft  part,  and  if  this  bursts  or  is  opened  pain  ceases  (Thomson). 
The  x-rays  aid  greatly  in  making  the  diagnosis. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone  at  the  point  of 
greatest  tenderness,  and  if  the  abscess  is  missed,  follow  the  advice  of  Holmes 
and  perforate  the  wall  of  bone  with  the  trephine,  opening  in  several  directions, 
to  discover  the  pus.  It  is  often  easy  to  open  into  the  abscess  with  a  chisel  or 
gouge.  After  opening  the  cavity  scrape  its  walls,  remove  dead  bone,  thoroughly 
dry  with  gauze,  touch  with  pure  carbolic  acid,  and  pack  with  iodoform  gauze. 
If  the  abscess  opens  into  a  joint,  trephine  the  bone,  and  also  open,  irrigate,  and 
drain  the  joint. 

Caries  was  a  term  once  used  universally  to  signify  suppuration  or  molecular 
death  of  bone.  In  some  cases  caries  means  suppurative  osteitis;  in  others, 
tuberculous  osteitis;  in  still  others,  gummatous  osteitis.  Typhoid  fever  is 
occasionally  followed  by  a  carious  condition  of  bone.  Osteitis  is  apt  to  be- 
come purulent  when  the  bone  is  exposed  to  the  air,  when  rest  is  not  secured, 
when  the  health  of  the  individual  is  below  normal,  when  a  foreign  body  such 
as  a  bullet  is  in  the  bone,  or  when  tubercle  or  syphilis  exists.  The  term  is 
seldom  used  to-day  except  loosely,  and  then  usually  to  signify  tuberculous  dis- 
ease of  bone.  When  caries  arises  the  softened  and  granulating  bone  breaks 
down  and  is  eventually  discharged  through  a  sinus.  After  drainage  is  secured, 
organization,  sclerosis,  and  healing  may  result.  In  these  cases  new  bone  may 
form  and  a  cure  follow. 

Tuberculous  or  strumous  caries  {caseous  osteitis),  a  condition  produced  by 
the  caseation  of  the  products  of  a  tuberculous  osteitis,  seldom  shows  any  tend- 
ency to  self-cure,  neither  organization  nor  sclerosis  takes  place,  and  new  bone 
seldom  forms  unless  an  operation  is  performed.  The  interior  of  bones,  espec- 
ially of  the  carpus  and  tarsus,  is  entirely  softened  and  destroyed  and  thin  shells 
only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible  portions  of  soft 
and  dead  bone  are  cast  off;  caries  sicca  is  molecular  death  of  bone  without 
liquefaction  or  suppuration. 

The  caseating  masses  in  tuberculous  caries  contain  tubercle  bacilli.  If 
a  tuberculous  collection  is  evacuated  and  infection  with  pus  organisms  occurs, 
genuine  suppuration  takes  place,  and  constitutional  infection  causes  septic 
fever  and  may  cause  death.  Pyogenic  osteitis  may  affect  any  part  of  any 
bone;  but  caseous  osteitis  (tuberculous  caries)  tends  to  arise,  especially  in 
cancellous  structure  (heads  of  long  bones,  vertebral  bodies,  ribs  and  ster- 
num, and  bones  of  the  carpus  and  tarsus).    Tuberculous  osteitis  of  the  shaft 


Necrosis  499 

of  a  long  bone  occasionally,  but  rarely,  arises.    Tuberculous  osteitis  is  apt  to 
cause  tuberculous  disease  in  an  adjacent  joint.    Tuberculous  osteitis  may  be 

followed  by  the  formation  of  a  cold  abscess. 

Symptoms. — In  the  beginning  the  evidences  of  caries  are  usually  those 
of  osteitis,  but  the  first  sign  noted  may  be  a  fluctuating  swelling  due  to  pus 
or  to  caseated  tubercle.  After  a  time,  at  any  rate,  a  fluctuating  swelling  is 
discovered.  If  not  opened,  the  softened  mass  breaks  externally,  voids  its 
contents,  and  leaves  a  sinus  from  which  flows  caseated  matter  which  after  a 
time  becomes  thin,  reddish,  and  irritating  to  the  skin,  contains  small  portioa^ 
of  gritty  bone,  and  has  a  foul  smell.  The  opening  of  the  sinus  fiUs  up  with 
edematous  granulations.  A  probe  carried  to  the  bottom  of  the  sinus  finds  bone 
which  is  sieve-like  (worm-eaten),  and  which  on  being  struck  gives  a  mnffleo 
note  rather  than  the  clear,  sharp  note  of  necrosis;  the  bone  is  rough,  is  bared, 
and  is  so  soft  that  the  probe  can  usually  be  stuck  into  it.  In  old  cases  of 
caries  amyloid  disease  may  arise. 

Treatment. — If  s^-philis  exists,  give  iodid  of  potassiimi  in  advancing  doses 
and  a  mild  mercurial  course.  If  tuberculosis  exists,  give  iodid  of  iron,  arsenic, 
cod-Hver  oil,  and  nourishing  foods,  and  recommend  ocean  air  and  H^•ing  in  the 
open  air.  Locally,  in  all  cases,  insist  on  rest  and  at  once  secure  drainage, 
enlarging  the  opening,  if  necessarj',  and  inserting  a  tube,  and  even  making 
additional  openings ;  s}Tinge  often  -ndth  antiseptic  fluids  and  dress  antiseptic- 
aUy.  If  the  case  is  seen  before  spontaneous  evacuation  has  occurred,  open 
imder  strict  antiseptic  precautions.  \Mien  a  chronic  sinus  exists  there  arises 
the  question  of  operation.  Incomplete  operations  are  worse  than  useless,  for 
they  may  be  foUowed  by  diffuse  tuberculosis  or  pyemia.  If  the  gouge  is  used, 
tr}'  to  remova  all  carious  bone.  The  diseased  bone  is  white,  crumbles,  and 
does  not  bleed;  the  non-carious  bone  is  pink  and  vascular.  Scrape  away  aU 
granulations,  swab  the  cavity  "ndth  pure  carbolic  acid,  and  pack  it  with  iodo- 
form gauze.  Instead  of  gouging  away  bone,  there  may  be  used  the  actual 
cauter}',  sulphuric  acid,  or  hydrochloric  acid.  In  severe  cases  excision  is  re- 
quired, and  in  some  rare  cases  amputation  may  be  necessary-.  Caries  of  the 
spine  is  considered  under  Diseases  of  the  Spine. 

Necrosis  is  the  death  of  ^isible  portions  of  bone  from  circulator}-  im- 
pediment or  the  direct  action  of  bacterial  toxins.  It  is  analogous  to  gangrene. 
One  cause  of  necrosis  is  traumatism  (such  as  the  tearing  oS  of  periosteum) 
which  deprives  the  bone  of  blood.  Inflammation  of  the  periosteum  further 
lessens  the  nutrition.  Acute  inflammation  in  bone  causes  necrosis,  the  ex- 
cessive exudation  in  the  canals  and  spaces  occluding  the  blood-vessels  by 
pressure.  The  occlusion  of  vessels  by  bacterial  thrombi  or  emboK  may  lead 
to  necrosis,  or  the  direct  action  of  toxins  may  first  inflame  and  finally  destroy 
a  portion  of  the  bone.  A  thin  sheU  of  bone  only  may  necrose  from  periosteal 
separation,  or  an  entire  shaft  may  die  from  acute  pyogenic  osteomyelitis  or 
diffuse  infective  periostitis.  Osteomyelitis  is  the  most  usual  cause  of  necrosis. 
Necrosis  is  most  frequently  met  -n-ith  in  the  diaphyses  of  the  long  bones,  caries 
in  the  cancellous  tissue  of  bones.  The  ribs  may  become  carious,  but  ver\-  rarely 
become  necrotic.  A  sequestrum  may,  but  does  not  often,  form  in  a  vertebral 
body,  in  the  cancellous  head  of  a  long  bone,  in  the  carpus,  or  in  the  tarsus.  If  a 
sequestrum  arises  from  tuberculous  osteomyehtis  it  is  seldom  found  completely 
detached,  but  still  retains  some  vascular  connection.  In  tuberculous  osteo- 
myelitis of  a  long  bone  the  sequestrum  is  wedge  shaped  with  its  base  toward 
the  joint,  and  is  due  to  infarction  of  terminal  arteries.  A  fragment  of  dead 
bone  is  a  foreign  body;  the  healthy  bone  adjacent  to  it  inflames  and  softens; 
granulations  form,  and  this  line  of  granulation,  like  the  line  of  demarcation  of 
gangrene,  tends  to  separate  the  dead  part  from  the  living,  the  white  dead  bone 
being  surrounded  by  the  red  zone  of  granulation  tissue.    A  bit  of  dead  bone  is 


500 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  251. — Diagram  illustrating  the  formation  of  a  se- 
questrum: A,  A,  Sound  bone;  B,  B,  new  bone;  C,  C,  granu- 
lations lining  involucrum;  D,  cloaca;  E,  sequestrum. 


called  a  sequestrum,  and  Nature  tries  to  cast  it  off.     A  superficial  sequestrum  is 
known  as  an  exfoliation. 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows:  Suppuration 
takes  place  at  the  line  of  demarcation,  osteitis  extends  for  a  considerable 
distance  around  this  line,  the  periosteum  shares  in  the  inflammation,  and 
new  bone  forms.  A  cavity  is  made  within  by  suppuration,  and  a  box  or 
case  is  formed  without  by  ossification,  the  now  entirely  loosened  sequestrum 
being  so  encased  that  it  cannot  escape.  The  pus  finds  its  way  through  the 
new  bone,  and  there  is  pre- 
sented the  condition  so  often 
seen  by  the  surgeon — 
namely,  a  case  of  new  bone 
known  as  the  involucrum, 
a  cavity  containing  pus  and 
the  dead  fragment  or  se- 
questrum, and  a  discharg- 
ing sinus  or  cloaca  (Fig. 
251).  Nature  may  eventu- 
ally cast  off  the  fragment, 
but  the  surgeon  should  not 
wait  for  the  completion  of 
this  slow  process. 

When  a  portion  of  the  bone  surrounding  the  medullary  canal  dies,  the 
condition  is  called  central  necrosis.  In  some  rare  cases  necrosis  occurs  with- 
out apparent  suppuration,  a  painless  swelling  of  bone  simulating  sarcoma. 
This  condition  is  known  as  quiet  necrosis,  and  has  been  described  by  Sir  James 
Paget  and  Mr.  Morrant  Baker.  Mercury  is  an  occasional  cause  of  necrosis. 
The  fumes  of  phosphorus  may  cause  necrosis  of  the  lower  jaw  in  those  with 
decayed  teeth.  Necrosis  may  be  produced  also  by  frost-bites  and  burns. 
Many  fevers  (measles,  typhoid,  scarlet  fever,  etc.)  are  occasionally  followed 
by  necrosis.     Syphilis  and  tuberculosis  are  occasional  causes. 

The  symptoms  of  necrosis  are  at  first  those  of  osteitis  or  osteomyelitis.  The 
abscess,  when  formed,  opens  itself  or  is  opened  by  the  surgeon,  and  a  sinus 
or  sinuses  form  in  the  soft  parts,  as  happens  in  caries.  As  a  matter  of  fact, 
were  cases  of  acute  osteomyelitis  operated  on  early,  extensive  necrosis  would  be 
rare.  If  surgeons  followed  the  rule  of  removing  hopelessly  damaged  bone  at 
the  primary  operation  for  osteomyelitis  it  would  seldom  be  necessary  to  do' 
extensive  operations  for  dead  bone  at  a  later  period.  When  a  sequestrum 
exists  a  probe  introduced  into  the  sinus  strikes  upon  hard  bone  with  a  clear, 
ringing  note,  and  often  finds  a  sinus  or  sinuses  in  the  bone.  In  superficial 
necrosis  the  discharge  is  slight  and  the  probe  shows  the  limitations  of  the  dis- 
ease. In  extensive  necrosis  the  discharge  is  profuse,  much  new  bone  forms, 
several  sinuses  appear  far  apart,  and  the  probe  must  pass  through  a  consider- 
able thickness  of  new  bone  before  it  finds  the  bit  of  dead  bone.  In  a  chronic 
case  in  which  there  is  an  involucrum  the  surgeon  may  not  operate  until  the 
dead  bone  is  separated  from  the  living  by  a  line  of  demarcation  unless  there  is 
general  sepsis.  He  may  wait  until  the  sequestrum  is  loose  unless  the  patient 
is  being  poisoned  during  the  wait.  The  tendency  of  thought  is  against  such 
long  delay  as  was  formerly  the  custom.  In  youth  dead  bone  loosens  quickly, 
but  in  old  age  slowly.  An  exfoliation  becomes  loose  sooner  than  the  seques- 
trum of  central  necrosis.  In  diffuse  periostitis  the  necrosed  shaft  loosens 
quickly.  Necrosed  portions  of  the  upper  extremity  loosen  more  rapidly  than 
those  of  the  lower.  In  a  young  adult  two  or  three  months  will  he  required 
to  loosen  a  necrosed  fragment  in  the  lower  extremity  and  from  six  weeks  to 
two  months  in  the  upper.     A  loose  sequestrum  may  be  moved  by  the  probe, 


Treatment  of  Necrosis  501 

and  when  struck  gives  a  hollow  note.  In  protracted  cases  of  necrosis  there 
is  always  danger  that  amyloid  disease  may  arise. 

Quiet  necrosis  is  a  rare  condition  which  has  led  to  some  deplorable  but 
pardonable  mistakes,  because  it  resembles  ossifying  sarcoma.  It  follows 
injury,  particularly  fracture.  The  bone  enlarges  greatly.  There  is  little 
or  no  pain  and  no  fever.  The  diagnosis  can  only  be  made  by  exploratory 
incision,  and  it  may  even  be  necessary  to  remove  portions  for  microscopic 
study  before  a  conclusion  can  be  reached. 

Postfebrile  necrosis  is  most  usually  caused  by  typhoid  fever.  The  bacilli 
of  typhoid  cause  chronic  osteomyelitis,  and  this  may  be  followed  by  necrosis. 
Scarlet  fever,  measles,  and  other  febrile  processes  may  also  induce  necrosis.  It 
is  certain  that  bacilli  accumulate  in  the  bones  during  typhoid  fever.  They  may 
promptly  induce  disease;  they  may  remain  for  long  periods  apparently  inactive 
and  finally  pass  away;  or  after  a  slight  strain  or  injury  these  organisms  may 
induce  bone  disease  months  or  even  years  after  the  primary  infection.  Ty- 
phoid hone  disease  is  often  multiple,  many  bones  being  involved  successively.^ 
Not  unusually  after  typhoid  fever  muscle  strain  causes  periostitis  and  osteitis, 
and  at  such  a  point  necrosis  may  occur.  Either  exfoliation  or  central  necrosis 
may  follow  typhoid  fever.  The  tibia  is  involved  more  often  than  other 
bones. 

Treatment. — ^An  exfoliation  should  be  removed  as  soon  as  it  becomes 
loose,  the  seat  of  trouble  should  be  touched  with  pure  carbolic  acid,  and  pack- 
ing of  iodoform  gauze  should  be  inserted.  The  treatment  of  central  necrosis 
comprises  free  incisions  for  drainage,  removal  of  the  sequestrum  and  disinfection, 
antiseptic  dressing,  frequent  cleansing,  rest,  nourishing  food,  stimulants,  and 
tonics.  When  a  sequestrum  exists  the  operation  of  sequestrectomy  should  be 
performed.  The  extremity  is  drained  of  blood,  an  Esmarch  band  is  appHed, 
the  bone  is  exposed  by  a  longitudinal  incision,  the  periosteum  is  reflected  on 
each  side,  the  involucrum  is  broken  through,  and  the  opening  is  enlarged 
with  the  chisel,  gouge,  and  rongeur.  The  dead  bone  should  be  removed  by 
sequestrum  forceps,  the  cavity  scraped  by  a  sharp  spoon,  the  lateral  edges  of 
the  involucrum  cut  down  until  the  cavity  which  formerly  contained  the 
sequestrum  is  very  shallow,  the  wound  is  irrigated  with  hot  salt  solution,  dried, 
painted  with  pure  carbolic  acid  and  then  with  alcohol,  again  irrigated  with 
salt  solution,  and  firmly  packed  with  iodoform  gauze.  Remove  the  Esmarch 
band,  tie  the  vessels  in  the  soft  parts,  suture  the  wound,  and  apply  dressings. 
It  was  long  the  rule  of  surgery  to  remove  a  sequestrum  only  when  loose,  and 
wait  if  necessary  for  it  to  become  loose.  This  rule  has  been  largely  abandoned 
in  favor  of  early  operation.  The  simple  removal  of  a  sequestrum — i.  e.,  the 
operation  of  sequestrectomy — often  fails  to  effect  a  cure,  and  even  in  the  most 
satisfactory  cases  healing  requires  a  very  long  time.  "The  involucrum  always 
contains  pyogenic  germs  that  may  five  in  its  small  foramina  and  crevices 
almost  indefinitely.  For  this  reason,  and  on  account  of  the  denseness  of  bony 
structure,  it  is  well-nigh  impossible  to  disinfect  it"  (Dr.  J.  Shelton  Horsley,  in 
the  "Medical  Record,"  Oct.  20,  1900).  Because  of  the  difficulty  of  curing  a 
case  when  an  involucrum  has  formed.  Dr.  Gushing  has  warmly  advocated 
early  operation  in  osteomyehtis ;  that  is,  operation  before  an  involucrum  has 
formed,  and  when  the  osteoblasts  of  the  periosteum  are  extremely  active. 
He  points  out  that  if  an  involucrum  has  formed,  the  sequestrum  and  involu- 
crum should  be  removed  after  stripping  the  periosteum  from  this  region.  If 
the  periosteum  is  found  not  to  be  infected,  it  may  be  stitched  together  at  the 
gap  where  the  bone  has  been  removed,  so  that  a  periosteal  cord  exists  between 
the  two  ends  of  the  bone;  and  the  soft  parts  above  this  may  be  closed.  If  the 
periosteum  is  found  to  be  infected,  we  agree  with  Gushing  that  the  cavity  should 
1  Keen's  "Surgical  Complications  of  Typhoid  Fever." 


502  Diseases  and  Injuries  of  the  Bones  and  Joints 

be  packed  with  gauze.  The  cavity  that  is  left  by  the  removal  of  a  sequestrum 
and  the  chiseling  of  the  walls  of  the  involucrum,  if  large,  may  be  filled  by  vari- 
ous methods  more  or  less  satisfactory.  In  some  cases  of  widespread  necrosis 
due  to  diffuse  infective  osteoperiostitis  or  to  osteomyelitis,  extensive  resection, 
or  even  amputation,  may  be  necessary.  If  the  entire  shaft  of  the  tibia  requires 
removal  the  length  of  the  limb  may  be  maintained  by  implanting  the  head  of 
the  fibula  into  the  head  of  the  tibia.  Otherwise  extension  must  be  used  dur- 
ing repair. 

Treatment  of  Bone-cavities} — Before  filling  a  bone-cavity  try  to  disinfect 
it.  This  can  be  done  only  relatively.  It  may  be  swabbed  with  pure 
carbolic  acid,  followed  in  one  minute  by  alcohol,  or  can  be  mopped  with 
pieces  of  gauze  wet  with  boUing  water.  Schede  does  not  pack  the  bone- 
cavity,  but  allows  it  to  fill  up  with  blood-clot  after  the  wound  in  the  soft 
parts  has  been  closed  by  sutures.  The  blood-clot  obHterates  the  dead  space 
in  the  bone,  acts  as  a  support  for  granulations  from  the  margins,  and  is 
slowly  eaten  by  phagocytes.  Unfortunately,  it  is  an  excellent  culture-medium 
and  it  often  fails  of  its  purpose.  Sherman  arrests  hemorrhage,  fills  the  gap 
with  normal  salt  solution,  and  sutures  the  soft  parts  without  drainage.  The 
surgeon  may  try  to  fill  the  cavity  by  taking  flaps  of  skin  from  the  sides  of  the 
wound,  separating  them  freely  from  the  fascia  beneath,  and  holding  them  within 
the  bone-cavity  by  inversion  sutures  or  fastening  them  to  the  bottom  with 
tacks  {Neuber's  operation).  Another  operation  consists  in  breaking  the  edges 
.  of  the  involucrum  and  turning  them  in.  Some  surgeons  insert  decalcified  bone- 
chips.  The  cavity  in  the  bone  is  made  as  sterile  as  possible  and  is  well 
dusted  with  iodoform,  the  bone-chips  are  dried  and  inserted  into  the  cavity, 
a  capillary  drain  is  employed,  the  periosteum  is  stitched  over  the  opening,  and 
the  soft  parts  are  sutured;  but  if  this  cannot  be  done,  iodoform  packing  is 
used  to  keep  the  chips  in  place.  This  method  we  owe  to  the  genius  of  Senn. 
Senn's  method  often  fails  because  of  the  impossibility  of  completely  steriliz- 
ing the  walls  of  the  bone-cavity.  Attempts  have  been  made  to  fill  bone- 
cavities  as  a  dentist  fills  teeth— with  gutta-percha,  plaster-of-Paris,  copper 
amalgam,  etc.,  but  each  of  these  materials  acts  as  a  foreign  body  in  the  bone 
(James  E.  Moore,  on  "The  Treatment  of  Bone-cavities,"  "Jour.  Amer.  Med. 
Assoc,"  May  20,  1905).  Schleich  uses  formalin-gelatin  to  fill  bone-cavities. 
The  difficulty  in  every  case  is  the  impossibility  of  completely  sterihzing  the 
walls  of  the  cavity.  Dressman  has  advised  for  this  purpose  the  use  of  boiling 
oil,  but  it  is  apt  to  cause  superficial  necrosis.  In  some  cases  the  cavity  has  been 
healed  by  the  insertion  of  a  Thiersch  skin-graft.  This  method  has  been  ad- 
vocated by  J.  P.  Lord  ("Jour.  Amer.  Med.  Assoc,"  May  31,  1902).  Von 
Mosetig-Moorhof's  method  is  one  of  the  best  ("Zeitschrift  fiir  Chirurgie," 
Ixxi,  No.  5).  He  pours  into  the  cavity  a  melted  material  which  completely  fills 
the  cavity,  which  will  not  act  as  a  culture-medium  or  as  a  foreign  body,  which 
is  gradually  absorbed,  and  which  "possesses  the  inhibitory  and  medicinal 
properties  of  iodoform  without  causing  iodoform  intoxication"  (James  E. 
Moore,  Loc  cit.) .  Mosetig-Moorhof's  material  consists  of  60  parts  of  iodoform, 
40  parts  of  spermaceti,  and  40  parts  of  oil  of  sesame.  These  materials  are 
mixed  by  heating  gradually  up  to  100°  C.  On  cooHng,  a  soHd  mass  is  formed. 
When  the  surgeon  wishes  to  use  it  he  heats  it  up  to  50°  C.  and  stirs  it  while 
heating  (Moore),  and  pours  it  into  the  cavity  in  the  bone.  On  entering  the 
cavity  it  at  once  solidifies.  A  capillary  drain  is  introduced,  the  periosteum 
is  sutured  with  catgut,  and  the  other  soft  parts  are  sutured  with  silkworm-gut. 
Usually  union  by  first  intention  is  secured.  Even  if  the  wound  gaps  the  wax 
is  apt  to  hold.  Mosetig-Moorhof  has  used  this  material  in  4000  cases  without 
ill  effect.  Cases  of  poisoning  and  at  least  i  case  of  death  have  been  reported 
1  The  views  of  Macewen  and  Murphy  on  repair  of  bone  will  be  found  on  pages  126  and  127. 


Acute  Infective  or  Pyogenic  Osteomyelitis  503 

(Durvergey,  in  "Presse  Medicale,"  July  i,  1911).  Many  attempts  have  been 
made  to  fill  the  defect  by  hone-grafting.  The  first  case  of  satisfactory  trans- 
plantation from  one  of  the  lower  animals  with  the  retention  of  a  vascular 
attachment  was  reported  by  A.  W.  Morton,  in  "American  Medicine,"  July  12, 
1902.  The  patient  suffered  from  a  compound  comminuted  fracture  of  both 
bones  of  the  right  leg.  The  fracture  in  the  fibula  united,  but  the  tibia  under- 
went necrosis,  and  it  was  necessary  to  remove  5  inches  of  the  lower  end  of  the 
bone.  Some  days  later  the  periosteum  was  raised  from  the  ends  of  the  bone 
and  these  ends  were  freshened.  The  left  leg  of  a  dog  was  amputated  just 
above  the  tarsus,  the  bones  being  sawed  so  that  the  ulna  was  i  inch  longer 
than  the  radius.  The  lower  end  was  partly  bared  of  periosteum,  and  the  ulna 
of  the  dog  was  forced  into  the  cavity  of  the  tibia  of  the  man,  and  wired  to 
that  bone  with  silver  wire.  The  incision  in  the  man's  leg  was  then  sutured, 
and  powerful  tendons  in  each  leg  of  the  dog  were  divided.  Each  of  the  dog's 
other  legs  was  wrapped  separately  in  a  plaster-of-Paris  bandage,  and  the 
entire  animal  and  the  leg  of  the  man  were  then  put  up  in  a  plaster-of-Paris 
dressing.  Five  weeks  later  the  cast  was  removed,  and  the  bones  were  sawed 
and  placed  in  contact  with  the  astragalus.  Union  took  place,  and  the  man 
was  fortunate  enough  to  obtain  a  useful  leg.  In  some  cases  a  bone  defect 
may  be  supplied  by  transference  of  another  bone.  Nichols  reported  11  cases 
and  insisted  on  the  necessity  of  preserving  the  periosteum  ("Jour.  Amer.  Med. 
Assoc,"  Feb.  3,  1904).  Huntington  has  reported  a  case  similar  to  case  No.  2 
in  Nichols's  list.  The  patient  was  a  boy  of  seven.  A  large  piece  of  the  entire 
thickness  of  the  tibia  was  lost  as  a  result  of  acute  osteomyelitis.  There  was 
a  gap  of  5  inches  between  the  ends  of  the  bone,  and  the  leg  was  a  mere  flail. 
Eight  months  after  the  beginning  of  the  osteomyelitis  the  fibula  was  sawed 
opposite  the  lower  end  of  the  upper  fragment  of  the  tibia  and  the  upper  end 
of  the  lower  fragment  of  the  fibula  was  fixed  in  a  cup-shaped  depression  in 
the  lower  end  of  the  upper  fragment  of  the  tibia.  Six  months  later  union  was 
solid,  but  in  order  to  improve  the  weight-bearing  power  of  the  limb,  nine 
months  after  the  first  operation,  the  lower  end  of  the  upper  fragment  of  fibula 
was  fastened  to  the  upper  end  of  the  lower  fragment  of  tibia.  The  result 
was  excellent.    The  shortening  is  only  f  inch  ("Annals  of  Surgery,"  Feb.,  1905). 

Osteomyelitis. — By  this  term  we  mean  inflammation  arising  in  and  about 
the  blood-vessels  and  attacking  the  marrow  of  bone.  It  may  attack  the  soft 
tissues  and  cells  in  the  Haversian  canals,  in  the  cancellous  spaces,  or  in  the 
medullary  cavity.  It  may  be  acute  or  chronic,  localized  or  diffused.  Simple 
osteomyelitis  is  not  due  to  bacteria.  If  localized  it  usually  depends  upon  a 
traumatism  (fracture,  contusion,  wrench  of  an  epiphysis).  Simple  diffuse 
osteomyelitis  may  arise  in  a  victim  of  rickets  or  osteitis  deformans.  An  acute 
simple  inflammation  may  cause  softening  and  permit  bending.  A  chronic 
inflammation  causes  sclerosis. 

Acute  infective  or  pyogenic  osteomyelitis  is  an  acute  and  diffuse  in- 
flammation of  the  bone-marrow  due  to  pyogenic  organisms.  Infection  from 
staphylococci  may  be  limited  to  a  portion  of  one  bone.  Streptococcus  infection 
causes  widespread  involvement  of  a  bone  or  of  several  bones.  Acute  osteomye- 
litis may  be  due  to  mixed  infection  with  bacilli  of  typhoid  and  pyogenic 
organisms,  or  bacilli  of  tubercle  and  pyogenic  organisms,  a  typhoid  process  or 
a  tuberculous  process  serving  to  establish  a  point  of  least  resistance.  The 
gonococcus  and  the  pneumococcus  occasionaUy  produce  acute  osteomyelitis. 
In  a  case  of  gonorrheal  arthritis  in  which  I  resected  the  wrist-joint  cultures  of 
gonococci  were  obtained  from  the  interior  of  the  bone  removed. 

It  was  at  one  time  believed  that  osteomyelitis  was  due  to  a  specific  organism, 
but  Pasteur  proved  that  micrococci  are  the  cause,  and  Ogston  demonstrated 
pyogenic  bacteria  in  pus  obtained  from  cases  of  osteomyelitis.    In  some  cases 


504  Diseases  and  Injuries  of  the  Bones  and  Joints 

there  is  pure  staphylococcus  infection  (aureus  or  alb  us),  both  aureus  and  albus 
may  be  present,  there  may  be  mixed  infection  with  streptococci  and  staphylo- 
cocci, streptococci  and  several  sorts  of  bacilli,  or  staphylococci  and  bacilli. 
Mixed  infections  with  streptococci  are  more  malignant  than  staphylococcus 
infections.  Most  cases  of  osteomyelitis  are  due  to  staphylococci.  Trauma  is  a 
common  predisposing  cause.  It  creates  an  area  of  tissue  damage  which  cap- 
tures bacteria  from  the  blood.  UUman  was  unable  to  experimentally  induce 
osteomyelitis  without  first  creating  by  bone  injury  a  point  of  least  resistance. 
When  he  applied  a  ligature  to  a  rabbit's  leg  for  fourteen  hours  distinct  changes 
were  found  to  occur  in  the  marrow  of  the  bones.  These  changes  consisted 
chiefly  in  extravasation  and  localized  hemorrhages.  When  the  marrow  was  in 
this  condition,  if  virus  were  injected  into  the  animal,  osteomyelitis  resulted, 
because  the  bones  presented  points  of  least  resistance,  vulnerable  points  in 
which  pus  cocci  lodged  and  multiplied. 

The  pyogenic  organisms  may  gain  entrance  directly  by  way  of  a  wound 
(a  gunshot- wound,  a  compound  fracture,  an  amputation).  The  causative 
organisms  may  reach  the  bone  by  way  of  the  blood,  having  entered  the  blood 
originally  through  the  lymphatic  system  or  from  a  focus  of  suppuration  in 
the  skin,  the  subcutaneous  tissue,  or  a  deeper  part.  Staphylococcus  infection 
commonly  depends  on  cutaneous  suppuration. 

Pus  organisms  may  pass  into  the  blood  from  the  tonsils  or  respiratory 
organs  (Kraske);  the  intestinal  canal  (Kocher);  the  genito-urinary  tract;  or 
from  excoriations,  bruises,  small  wounds,  or  suppurations  in  the  skin.  Certain 
fevers  strongly  predispose  to  the  disease  by  preparing  the  soil,  as  it  were,  for 
the  growth  of  pyogenic  bacteria.  Typhus  fever,  small-pox,  malarial  fever, 
scarlet  fever,  measles,  and  diphtheria  lessen  the  vital  resistance  of  bone- 
marrow.  Typhoid  fever  is  not  unusually  followed  by  chronic  osteomyelitis, 
due  solely  to  typhoid  bacilli.  If  mixed  infection  with  pus  organisms  occurs, 
acute  osteomyelitis  arises.  Vital  resistance  of  marrow  is  lessened  by  exhausting 
diseases,  overexertion,  unhealthy  and,  especially,  putrid  food.  We  know  that 
various  infections  produce  various  reactions  in  marrow,  and  in  this  changed 
marrow  vital  resistance  is  probably  lessened  or  even  seriously  impaired. 
Longcope  made  a  study  of  the  marrow  in  26  fatal  cases  of  enteric  fever,  and 
he  invariably  found  numerous  lymphoid  cells,  phagocytes  of  large  size,  and 
multiple  foci  of  distinct  necrosis.  The  cells  whose  function  is  to  form  blood 
were  noted  to  be  undergoing  hyperplasia.  In  persons  dead  of  perforation  and 
general  peritonitis  there  were  numerous  foci  of  necrosis,  and  also  widespread 
degenerative  changes  in  the  blood-making  cells  and  pronounced  edema  and 
congestion  of  the 'marrow  ("A  Text-Book  of  Pathology,"  by  Alfred  Stengel). 
When  organisms  gain  entrance  directly  by  a  wound  (as  in  a  compound  frac- 
ture), the  endosteiim,  the  medulla,  and  the  cancellous  tissue  inflame  and 
suppurate,  and  the  entire  length  and  thickness  of  the  bone  may  be  involved. 
The  periosteum  becomes  infiltrated,  detached  from  the  bone,  and  retracted 
from  the  edges  of  the  wound  in  the  bone.  The  soft  tissues  around  the  bone 
may  inflame,  suppurate,  or  slough.    More  or  less  necrosis  inevitably  occurs. 

Acute  pyogenic  osteomyelitis  without  a  wound  is  often  called  acute  epiph- 
ysitis. This  condition  is  most  common  in  infants  or  children  of  one  or  two 
years  of  age,  but  is  not  uncommon  in  older  children  (from  ten  to  seven- 
teen years),  and  even  occurs  in  adults.  It  is  vastly  more  common  among 
males  than  females.  The  tibia  is  the  bone  most  prone  to  attack.  It  is  most 
common  during  the  period  of  active  growth  of  bone.  It  is  frequently  pre- 
ceded by  one  of  the  predisposing  causes  before  mentioned.  In  some  cases  a 
strain  or  bruise  is  followed  by  pyogenic  infection,  because  the  damaged  tissue 
extends  a  hospitable  welcome  to  micro-organisms  which  are  traveling  in  the 
body-fluids  and  pass  through  the  injured  area.    The  most  usual  antecedent 


Acute  Infective  or  Pyogenic  Osteomyelitis 


505 


injury  is  a  twist.  As  Oilier  showed,  a  twist  damages  the  weakest  structure, 
which  is  the  soft,  new  bone.  In  at  least  half  of  the  cases  a  history  of  trauma  can 
be  obtained.  In  some  cases  there  doubtless  was  trauma,  even  though  we  can 
obtain  no  history  of  it.  In  some  cases  chilling  of  the  surface  of  the  body 
is  a  predisposing  cause.    In  others  no  predisposing  cause  is  discoverable. 

The  compact  bone  suffers  secondarily,  but  is  never  attacked  primarily. 
New  tissue  is  more  susceptible  to  infection  than  old  tissue,  and  the  disease, 
as  a  rule,  begins  near  the  epiphyseal  Hne,  where  new  bone  is  being  formed. 
This  point  was  spoken  of  by  Oilier  as  "the  zone  of  election  of  pathological 
processes."  Warren  points  out  that  in  a  growing  bone  near  the  epiphyseal 
cartilage  there  exists  a  newly  formed  spong}-  tissue,  ver}-  vascular  and  con- 
nected with  the  cartilage  by  a  spong}-  layer  of  tissue,  which  is  not  yet  bone, 
but  which  does  not  possess  a  cartilaginous  structure.  It  is  in  this  portion 
of  the  skeleton  that  the  most  active 
changes  take  place  during  the  period  of 
growth.  The  medullar}^  substance  is 
very  vascular  at  this  point;  it  is  red  and 


Fig.  252. 


-Fracture  of  femur  after  acute  osteo- 
mvelitis. 


Fis 


;. — Osteomyelitis,    showing    sequestnmi 
formation. 


"^"ithout  fatty  tissue.  It  communicates  with  the  medullary  canal  and  with 
the  periosteum  by  a  mmiber  of  vascular  channels.  The  epiphyseal  cartilage 
itself  is  intimately  blended  "^dth  the  periosteum.  The  diaphyseal  side  of  the 
cartilage  produces  much  more  bone  than  is  found  in  the  epiphyseal  margin. 
There  is  also  an  active  growth  of  bone  in  the  periosteum,  and  it  is  in  these 
regions  and  in  the  medullar}-  canal  that  the  inflammatory  process  originates.^ 
The  end  of  the  diaphysis  is  ver\-  vascular,  but  the  blood-stream  is  sluggish  be- 
cause of  the  large  size  of  the  capillar}-  loops  ("Practice  of  Surger}-''  by  Spencer 
and  Gask).  The  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  are 
the  regions  most  commonly  attacked;  but  the  upper  end  of  the  femur  and  the 
lower  end  of  the  tibia  may  suffer,  and  other  bones  may  be  attacked,  especially 
^  Warren's  ''Surgical  Patholog}-." 


5o6  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  humerus,  radius,  ulna,  and  inferior  maxilla.  The  adjacent  joint  not  unusu- 
ally becomes  involved.  Though  the  inflammation  begins  in  the  spongy  tissue 
or  medulla,  it  passes  to  the  canals  and  spaces  of  the  compact  bone.  The 
inflammatory  exudate  in  the  canals  compresses  the  vessels  and  cuts  off  nutri- 
tion from  certain  areas.  Suppuration  begins,  clots  form  in  the  medulla  from 
thrombophlebitis,  and  the  clots  in  the  vessels  of  the  Haversian  canals  become 
septic.  A  small  sequestrum  forms  at  the  seat  of  origin  of  the  disease,  and  the 
pus  about  the  sequestrum  is  apt  to  empty  into  the  medullary  canal,  causing 
diffuse  osteomyelitis,  or  into  the  adjacent  joint,  causing  suppurative  inflam- 
mation of  the  articulation. 

Marked  constitutional  symptoms  arise  from  absorption  of  toxins  (sup- 
purative fever),  and  sometimes  true  septic  infection  or  even  pyemia  arises. 

Very  extensive  necrosis  may  follow  osteomyelitis  if  the  patient  recovers. 
Fracture  of  the  bone  may  occur  (Fig.  252).  An  acute  pyogenic  osteomyelitis 
may  involve  the  medulla,  may  break  into  the  adjacent  joint,  or  may  remain 
localized  in  the  head  of  a  bone  and  cause  an  abscess  containing  fragments  of 
bone  or  a  distinct  sequestrum  (Fig.  253).  The  walls  of  such  an  abscess  are 
composed  of  sclerosed  bone. 

When  the  medullary  canal  is  involved  in  a  pyogenic  inflammation,  a  part 
or  the  whole  of  the  medulla  may  suffer.  The  condition  may  result  in  central 
necrosis  or  in  suppurative  periostitis  and  death  of  the  shaft  of  the  bone. 
The  mortality  of  acute  osteomyelitis  is  high.  In  the  309  cases  collected  by 
Kennedy  the  mortality  was  34  per  cent.  ("Brit.  Med.  Jour.,"  July  20,  191 2). 
The  earlier  the  operation,  the  less  the  mortality.  Operation  within  forty-eight 
hours  of  the  initial  chill  has  a  mortality  of  less  than  10  per  cent. 

Symptoms. — Osteomyelitis  secondary  to  a  wound  of  the  bone  may  occur 
in  a  person  of  any  age.  If  a  wound  exists, — for  instance,  a  compound  fracture, 
— the  diagnosis  is  evident.  The  constitutional  symptoms  of  septic  absorption 
are  positive:  there  is  a  profuse,  offensive,  purulent  discharge  containing  bone- 
fragments  and  tissue-sloughs;  the  periosteum  is  red,  thick,  and  separated; 
there  are  swelling  over  the  bone,  great  tenderness,  and  violent  boring,  gnawing, 
or  aching  pain.  Osteomyelitis  occurring  without  a  wound,  the  condition 
often  known  as  acute  epiphysitis,  occurs  in  the  young,  and  particularly  in 
children  under  three  years  of  age. 

The  symptoms  of  acute  osteomyelitis  without  a  wound  of  the  bone  usuaUy 
come  on  suddenly  and  especially  at  night,  and  the  attack  may  be  so  acute 
as  to  cause  death  by  systemic  poisoning  before  a  diagnosis  is  arrived  at. 
The  disease  is  generally  ushered  in  by  a  chill,  which  is  followed  by  septic 
febrile  temperature.  The  history  wiU  sometimes  contain  the  statement  that 
a  blow  had  been  received,  that  a  febrile  process  had  existed,  or  that  the  patient 
had  been  suddenly  chilled  after  having  been  overheated  (sitting  in  a  draft  or 
in  a  cellar  on  a  hot  day,  possibly  swimming  when  very  warm,  etc.).  There  is 
violent  aching  pain  in  the  bone  and  acute  tenderness  near  the  joint.  Within 
seventy-two  hours  of  the  initial  chill  there  will  usually  be  pus  in  the  medullary 
cavity  and  a  quantity  of  hopelessly  damaged  bone  if  operation  has  not  been 
performed.  The  soft  parts,  which  at  first  are  healthy  in  appearance,  after  a 
time  discolor,  swell,  and  present  distended  veins,  and  may  become  glossy  and 
edematous  because  pus  is  gathered  below.  The  medullary  cavity  becomes 
filled  with  pus.  An  abscess  sometimes  reaches  the  surface  and  may  break 
spontaneously.  The  neighboring  joint  swells,  and  may  become  filled  with  pus; 
the  periosteum  and  the  shaft  are  involved  for  a  considerable  distance;  each 
epiphysis  may  become  affected,  the  shaft  between  being  comparatively  imin- 
volved,  and  the  epiphyses  may  separate,  displacement  and  shortening  taking 
place.  Extensive  necrosis  may  occur.  This  disease  is  often  mistaken  for  rheu- 
matism because  of  the  joint  swelling,  occasionally  for  typhoid  fever  because  of 


Chronic  Osteomyelitis 


507 


the  fever,  and  in  some  cases  for  erysipelas  because  of  the  redness  of  the  skin. 
It  gives  a  very  grave  prognosis.  Sometimes  an  epiphysitis  shows  milder  symp- 
toms and  is  slower  in  progress  (subacute).  These  cases  are  very  often  mis- 
taken for  rheumatism.  But  in  rheumatism  the  joint  is  the  part  involved  from 
the  beginning,  while  in  epiphysitis  the  joint  is  involved  secondarily  after 
obvious  evidence  of  inflammation  well  clear  of  the  articulation.  Further,  the 
symptoms  of  rheumatism  will  be  rapidly  improved  by  the  use  of  the  alkalis  or 
the  salicylates. 

Treatment. — If  osteomyelitis  arises  secondarily  to  a  wound,  apply  a  tourni- 
quet, sterilize  the  parts,  enlarge  the  wound,  expose  and  curet  the  medullary 
cavity,  remove  loose  fragments  of  bone,  irrigate  the  medullar)^  cavity  with  a  hot 
solution  of  corrosive  sublimate  or  hot  salt  solution,  scrape  it  with  bits  of  gauze 
held  in  the  bite  of  a  forceps,  paint  with  pure  carbolic  acid,  pack  lightly  with 
iodoform  gauze,  dress  with  hot  anti- 
septic fomentations,  and  secure  rest 
for  the  parts  by  splints  and  band- 
ages. The  constitutional  treatment 
is  the  same  as  that  for  septicemia. 
In  some  cases  amputation  is  neces- 
sarv\  Acute  osteomyelitis  wdthout 
a  wound  is  a  most  serious  condi- 
tion, rapidly  progressive,  apt  to  be 
quickly  fatal,  and  requiring  prompt 
and  radical  treatment.  Operation 
should  be  done  as  soon  as  possible 
after  the  initial  chill.  Murphy  has 
insisted  upon  this  for  years.  Gush- 
ing, Le  Conte,  and  others  warmly 
advocate  it.  I  alwa3"s  practice  it 
when  possible.  Within  seventy- two 
hours,  perhaps  within  forty-eight 
hoiirs  of  the  initial  chill,  there  will 
be  pus  in  the  medullary  cavity  and 
a  quantity  of  bone  will  be  hope- 
lessly damaged.  Operation  consists 
in  opening  the  medullary  cavity  by 
means  of  a  burr,  trephine,  or  chisel. 
At  such  an  early  stage  drainage  is 
all  that  is  necessary,  as  dead  bone 
has  not  as  yet  formed.  Vers'  early 
operation  anticipates  pus  formation. 
It  is  not  desirable  to  curet  the  cav- 
ity. A  delay  of  a  very  few  hours  will  be  responsible  for  pus  and  dead  bone. 
The  meduUarv^  ca\dty  must  then  be  freely  opened,  curetted,  and  disinfected 
with  piire  carbolic  acid.  The  former  custom  was  to  pack  with  iodoform  gauze 
and  wait  for  the  formation  and  loosening  of  a  sequestrum.  It  is  safer  and 
wiser  to  freely  remove  dead  bone  at  the  primary  operation  (Le  Conte,  "Boston 
Med.  and  Surg.  Jour.,"  June  i,  191 1).  In  any  case  if  the  joint  is  involved  it 
must  be  drained.  In  all  cases  employ  rest,  anodynes,  strong  supporting  treat- 
ment, and  other  remedies  advised  in  septicemia.  Amputation  may  be  required. 
In  a  neglected  or  prolonged  case  very  extensive  necrosis  occurs  and  a  formid- 
able operation  may  be  required.  Even  amputation  may  be  necessary.  The 
entire  shaft  may  have  to  be  removed,  a  bloody  and  dangerous  operation. 

Chronic   osteomyelitis   is  usually  Unked  with  osteitis.     Pus  may  or 
may  not  form.     There  may  be  only  thickening  of  and  pain  in  the  bone.     Such 


Fig.  254. — Chronic  osteomyelitis  of  the  tibia. 


5o8 


Diseases  and  Injuries  of  the  Bones  and  Joints 


a  condition  can  be  caused  by  attenuated  bacteria  or  by  bacteria  of  ordinary 
power  acting  on  tissue  possessed  of  a  very  high  vital  resistance.  It  may 
eventuate  in  osteosclerosis  with  filling  up  of  the  medullary  canal,  in  limited 
suppuration,  in  chronic  abscess  of  the  cancellous  tissue  (Brodie's  abscess), 
or  in  necrosis.  A  tuberculous  inflammation  is  one  form  of  chronic  osteomye- 
litis (see  page  249).  Syphilis,  typhoid  fever,  etc.,  may  cause  it,  and  it  can  be 
caused  by  glanders,  leprosy,  and  actinomycosis. 

The  typhoid  bacillus  under  certain  conditions  is  pyogenic.  Frankel 
taught  this  some  years  ago,  and  Keen  proves  it  in  his  work  on  "The  Surgery 
of  Typhoid  Fever."  Osteomyelitis  due  purely  to  typhoid  bacilli  is  chronic. 
When  the  medulla  contains  typhoid  bacilli  pus  infection  is  apt  to  take  place, 

and  if  such  a  mixed  infection 
arises  acute  osteomyelitis  de- 
velops. 

In  chronic  osteomyelitis  there 
are  pain,  tenderness,  and  swell- 
ing, but  no  marked  constitu- 
tional symptoms.  In  some  cases 
the  real  trouble  is  not  identified 
until  an  abscess  forms  (see  Ne- 
crosis). There  is  a  form  of 
chronic  osteomyelitis  which  is 
nearly  always  mistaken  for 
rheumatism.  J.  C.  Stewart  de- 
scribes it  fully  ("N.  Y.  Med. 
Jour.,"  March  25,  191 1).  It  is 
sometimes  preceded  by  a  fever, 
sometimes  by  a  trivial  trauma- 
tism, but  usually  comes  on  in- 
sidiously and  endures  indefinitely 
as  a  chronic  condition.  Stewart 
shows  that  the  bone  enlarges 
because  of  subperiosteal  produc- 
tion of  new  spongy  bone.  The 
marrow  cavity  fills  with  tissue 
resembling  red  marrow.  The 
thick  bone  is  tender  at  points, 
there  is  aching  pain,  and  a 
trivial  rise  of  temperature  to- 
ward night. 
Treatment. — If  an  abscess  exists,  at  once  evacuate  it  by  incising  the  soft 
parts  and  chiseling  the  bone.  Do  not  wait  for  an  involucrum  to  form,  but 
promptly  incise,  disinfect,  and  drain.  If  dead  bone  is  present  it  must  be 
removed.  In  the  insidious  form,  so  often  mistaken  for  rheumatism,  expose  and 
cut  through  the  new  bone  formation  and  open  the  marrow  cavity. 

Osteomalacia,  or  Mollities  Ossium. — In  this  disease  the  bones  are 
partly  decalcified,  and  consequently  soften  and  bend.  Masses  of  new  uncal- 
cified  bone-tissue  are  formed.  Many  bones  are  usually  involved,  but  the 
bones  of  the  head  are  not  obviously  affected.  It  is  commoner  beyond  than 
before  middle  age,  though  it  may  occur  in  infancy,  and  a  case  has  been  reported 
in  which  the  disease  arose  at  the  age  of  seventy.  It  is  more  frequently  met  with 
in  women  than  in  men,  and  pregnancy  seems  to  bear  more  than  a  casual  rela- 
tion to  its  production.  The  disease  is  particularly  apt  to  arise  when  preg- 
nancies are  rapidly  repeated  (Marquis,  "L'Obstetrique,"  June,  1910).  In 
osteomalacia  the  medulla  increases  in  bulk  and  becomes  more  fatty,  and  the 


Fig.  255.— Chronic  osteomyelitis  of  the  femur. 


Acromegaly  509 

osseous  matter  is  absorbed  gradually,  first  from  the  cancellous  tissue  and  then 
from  the  compact  tissue.  Some  observers  believe  that  this  curious  condition 
is  due  to  lactic  acid  in  the  blood,  an  abnormal  amount  of  acid  having  been  pro- 
duced and  absorbed  because  of  disorder  of  the  primary  assimilation.  Volk- 
mann  maintained  that  some  inflammatory  condition  disturbs  the  blood-supply 
of  the  medulla,  and  von  Recklinghausen  asserted  that  arterial  h^'peremia  is 
responsible.  Honnicke  suggests  that  the  disease  is  due  to  hypersecretion  of  the 
thyroid  gland. 

Fehling,  influenced  by  finding  that  improvement  may  follow  removal  of 
the  ovaries,  set  forth  the  \dew  that  the  disease  is  due  to  overaction  of  the 
ovaries,  causing  reflex  dilatation  of  the  blood-vessels  of  bone.  The  answer  to 
this  theory  is  the  fact  that  the  disease  can  occur  in  the  male.  Some  have 
thought  that  the  disease  is  of  bacterial  origin.  It  is  most  common  in  those 
who  dwell  in  damp  or  dark  habitations.  It  may  arise  after  a  soaking  and 
"taking  cold."  It  is  a  rare  disease  in  England  and  America,  but  is  much 
more  common  in  Germany. 

The  symptoms  of  osteomalacia  are  as  follows:  many  points  of  pain  which 
are  often  thought  to  be  due  to  rheumatism;  deformities  from  twisting  and 
bending  of  bone;  sometimes  lactic  acid  and  occasionally  an  excess  of  cal- 
cium salts  in  the  urine.  There  is  no  fever  early  in  the  case,  but  later  there 
may  be  a  hectic  fever.  When  the  disease  comes  on  after  childbirth  the  iliac 
bones  suffer  first.  Severe  pain  arises  in  the  pelvis  and  back  and  the  pain 
radiates  into  the  thighs,  the  pain  is  worse  at  night,  and  is  greatly  aggravated  by 
pressure  or  movements.  Finally,  standing  and  walking  become  unbearably 
painful.  The  earhest  pain  may  be  in  the  sacrum  and  be  felt  only  when 
supine.  Pains  eventually  become  generalized  throughout  the  skeleton.  Pain 
in  the  bony  w^alls  of  the  thorax  makes  respiration  difficult.  Great  deformity 
occurs  because  the  partly  decalcified  bones  bend.  Many  of  these  patients 
become  fat.  Fractures  occur  from  very  slight  force.  In  the  majority  of  cases 
the  disease  is  not  cured,  but  grows  progressively  worse  until  the  patient  dies, 
after  many  years,  from  exhaustion.  In  some  cases  the  process  is  arrested  and 
the  osteoid  tissue  is  calcified. 

Treatment. — In  treating  osteomalacia  in  women  insist  that  pregnancy 
must  not  occur.  In  all  cases  put  braces  and  supports  upon  distorted  limbs 
to  prevent  further  bending  and  fracture.  Ad\dse  hygienic  sinrroundings  and 
nourishing  food,  and  insist  on  the  value  of  fresh  air.  Among  the  medicines 
that  can  be  used  may  be  mentioned  cod-Kver  oil,  lime  salts,  extract  of  the 
pituitar}^  body,  preparations  of  phosphorus,  and  bone-marrow.  In  women  the 
removal  of  the  ovaries  sometimes  produces  great  improvement.  It  has  been 
asserted  that  the  production  of  anesthesia  by  means  of  chloroform  may  be  of 
benefit. 

Acromegaly. — In  1886  Marie  reported  2  cases  with  acquired  and  s\Tn- 
metrical  enlargement  of  the  face,  hands,  and  feet.  He  named  the  condition 
acromegaly.  This  curious  disease  is,  in  all  probability,  due  to  h}'persecretion 
or  perverted  secretion  of  the  anterior  portion  of  the  pituitary  body.  There  is 
a  hypertrophy  or  a  hyperplasia  of  this  body.  As  a  result  of  the  per\'erted 
secretion  or  accentuated  secretor\^  acti\dty  there  is  accelerated  growth  of  the 
skeleton.  It  was  once  thought  that  tumor  was  always  the  cause  of  acromegaly, 
but  it  is  now  known  that  whereas  tumor  may  be  a  cause,  many  cases  occur  with- 
out tumor.  Cases  of  adiposis  dolorosa  may  show  hypophyseal  symptoms. 
Gigantism  is  probably  acromegalic.  (For  a  masterly  discussion  of  this  subject 
see  "The  Pituitary'  Body  and  its  Disorders,"  by  Harvey  Gushing.)  Acromeg- 
aly is  a  disease  which  causes  progressive  and  often  great  enlargement  of  both 
the  bones  and  soft  parts  of  the  extremities,  which  enlargement  is  symmetrical. 
The  cranium  becomes  triangular  in  shape,  vdih  the  base  below,  at  the  lower  jaw. 


5IO 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  lower  jaw  projects  in  advance  of  the  upper  jaw,  the  nose  becomes  promi- 
nent and  thick,  the  supra-orbital  ridges  are  accentuated  (Fig.  256),  and  the 
costal  cartilages  and  inner  ends  of  the  clavicles  become  protuberant.  Later 
the  IsLTyjix,  ribs,  shoulder-blades,  and  vertebrae  become  involved,  and  the 
back  becomes  markedly  himaped  (cervicodorsal  hump).  The  hands  and  feet 
are  affected  in  advanced  cases.  As  a  rule,  the  thyroid  gland  is  enlarged,  and 
a  postmortem  examination  may  detect  a  diseased  pituitary  gland.  Severe  and 
uncontrollable  headache  is  sometimes  a  distressing  feature  of  the  disease.  In 
some  cases  there  is  marked  somnolence.  A  fireman  who  suffered  from  acro- 
megaly would  go  to  sleep  almost  the  moment  he  sat  down.  Early  there  is 
low  assimilation  of  carbohydrates,  often  with  glycosuria.  The  disease  is  not 
regularly  progressive,  but  exhibits  periods  of  rapid  increase,  a  stationary  con- 
dition, or  perhaps  retrogression.  In  a  prolonged  case  signs  of  pituitary  in- 
sufficiency are  noted,  viz. :  such  high  assimilation 
of  carbohydrates  that  it  is  difficult  or  impossible 
to  cause  alimentary'  glycosuria,  adiposity,  sub- 
normal temperature,  and  atrophy  of  the  sexual 
organs.  In  all  suspected  cases  an  a;-ray  picture 
should  be  taken.  If  a  tumor  is  present  or  if  the 
gland  is  h\^ertophied  the  plate  wall  show  an  en- 
larged sella  turcica.  A  tumor  causes  rapid  blind- 
ness. The  disease  slowly  but  surely  causes  death. 
Medical  treatment  is  of  no  avail  in  cases  of 
pituitary  overactivity  (hyperpituitarism) .  If  there 
is  evidence  of  h^-pophyseal  insufficiency  {hypo- 
pituitarism) administer  hypophyseal  extract. 

If  there  is  hyperpituitarism  it  is  justffiable  to 
partially  extirpate  the  gland,  on  the  same  principle 
as  we  partially  extirpate  the  thjToid  in  a  case  of 
exophthalmic  goiter.  In  Cushing's  case  the  opera- 
tion of  partial  extirpation  of  the  pituitary  body 
relieved  subjective  discomforts  and  modified  ac- 
romegalic conditions.  If  there  are  evidences  of 
tumor  of  the  h^-pophysis  it  is  justifiable  to  under- 
take its  removal  by  operation.  This  has  been 
accomplished  successfully  by  Hochenegg,  Von 
Eiselsberg,  Brochardt,  Gushing,  Sir  Victor  Horsley,  and  others.  In  the  cases 
of  Hochenegg  and  Gushing  not  only  were  pressure  symptoms  relieved,  but 
acromegalic  conditions  were  greatly  benefited. 

Leontiasis  Ossea  or  Hyperostosis  Cranii  (Virchow's  Disease). — This 
is  a  symmetrical  hypertrophy  limited  to  the  facial  and  cranial  bones,  and 
which  begins,  as  a  rule,  in  the  superior  maxillae.  The  hjqaertrophy  progress- 
ively increases,  causes  difficulty  of  mastication,  and  is  accompanied  by  head- 
ache. It  produces  distinct  deformity  of  the  jaw  like  a  tumor,  whereas  acro- 
megaly enlarges  all  of  the  proportions  of  a  bone  (Fig.  257).  It  may  produce 
blindness,  new  bone  pressing  upon  the  optic  nerves.  Treatment  is  very  unsat- 
isfactory. Horsley  has  obtained  some  degree  of  amelioration  by  operating  and 
removing  masses  of  bone. 

Osteitis  Deformans  {Pagefs  Disease)  (Fig.  258). — This  disease  was  first 
described  by  Paget  in  1877.  Higbee  and  Ellis  state  that  up  to  January,  191 1, 158 
cases  have  been  reported  ("Jour.  Med.  Research,"  vol.  xxiv,  No.  i).  Packard 
and  Steel  were  of  the  opinion  that  many  reported  cases  were  not  genuine  in- 
stances of  the  disease,  some  being  ordinary  osseous  tumors,  others  being  cases 
of  enlargement  after  fracture,  and  still  others  being  instances  of  mollities  ossium 
("Amer.  Jour.  Med.  Sciences,"  Nov.,  1901).     Many  of  the  reports  are  purely 


Fig.  256. — Face  in  acromeg- 
aly. Note  enlarged  superciliary 
ridge,  thickened  lips,  massive 
jaw,  and  general  grossness. 
(Church  and  Peterson). 


Osteitis  Deformans 


S" 


clinical.  The  disease  does  not  appear  to  be  hereditary.  It  is  usually  asso- 
ciated with  widespread  arterial  sclerosis.  There  is  no  evidence  that  gout, 
rheumatism,  or  disease  of  the  nervous  system  play  any  part  in  causation. 
Some  consider  the  condition  parasyphilitic,  but  there  is  no  real  evidence  of 
such  origin.  It  has  been  asserted  that  heat  or  cold  may  be  causal  and  that  the 
condition  has  begun  after  injury  of  a  long  bone.  A  possible  cause  is  disturb- 
ance of  some  internal  secretion.  The  enlarged  thyroid  in  Askanazy's  case 
led  him  to  suggest  the  theory.  No  parathyroids  were  found  at  autopsy  in 
the  patient  of  Higbee  and  Ellis.  These  two  observers  suggest  that  Paget's 
disease  may  be  due  to  absence  of  parathyroid  secretion  and  the  consequent 
formation  of  substances  which  abstract  calcium  from  the  bones.  In  this  dis- 
ease great  quantities  of  new  bone  are  formed,  but  calcification  does  not  occur. 
The  material  undergoes  absorption,  and  the 
medullary  substance  of  the  bone  becomes  ex- 
tremely vascular  and  filled  with  white  blood- 
cells,  and  also  with  giant-cells.  The  bones 
lengthen  and  thicken.     The  long  bones  bend 


Fig.  257. — Leontiasis  ossium. 


Fig.  258. — Paget's  disease. 


and  the  bones  of  the  skull  bulge.  The  bending  of  the  long  bones  has  been 
believed  to  depend  upon  the  weight  of  the  body  acting  on  uncalcified  new  bone, 
but  fracture  is  not  particularly  apt  to  occur.  It  is  now  maintained  that  the 
bending  and  bulging  are  active  processes,  "since  the  bending  is  always  well 
marked  in  those  bones  which  are  fixed  at  both  ends  by  muscles  and  ligamentous 
attachments,  e.  g.,  the  clavicle,  Tadius,  and  tibia,  the  accompanying  bone  (fibula 
or  ulna)  acting  as  the  string  to  the  bow"  (Gruner,  Scrimger,  and  Foster,  in  "Ar- 
chives of  Internal  Medicine,"  June,  191 2).  It  is  extremely  rare  before  the  age  of 
forty,  and  usually  begins  between  forty  and  fifty  or  later.  The  enlargement  of 
the  bones  is  usually  accompanied  by  pain  which  may  be  severe.  Enlarge- 
ment may  be  first  detected  in  the  cranium,  but  is  more  often  first  seen  in  some 
other  bone — for  instance,  the  clavicle,  the  tibia,  the  spine,  or  the  radius.  The 
tibia  in  most  cases  suffers  first,  and  other  bones  become  involved  later.     In 


512 


Diseases  and  Injuries  of  the  Bones  and  Joints 


fact,  in  some  cases  the  bones  of  the  head  do  not  enlarge  at  all;  but,  taking  all 
the  reported  cases,  the  skull  is  affected  more  frequently  than  any  of  the  other 
bones.  In  some  cases  the  enlargement  of  the  bones  seems  to  be  symmetrical; 
in  others  it  is  not.  In  the  disease  known  as  leontiasis  ossea  the  chief  enlarge- 
ment is  manifested  in  the  face;  in  Paget's  disease  there  is  no  enlargement  of  the 
bones  of  the  face,  or  else  these  bones  are  trivially  involved.  Packard  and 
Steele  point  out  that  the  diagnosis  is  extremely  difficult  when  but  a  single  bone 
is  involved;  but  that  if  two  or  more  bones  are  involved,  we  should  think  of 
Paget's  disease  as  the  condition,  especially  if  we  are  able  to  exclude  syphilis, 
cancer,  and  sarcoma.     In  moUities  ossium  the  head  is  not  involved  at  all, 

and  there  is  not  nearly  so  much  thick- 
ening of  the  bone.  The  two  authors 
before  quoted  show  that  in  acromegaly 
the  cranium  is  a  triangle  with,  its  base 
below  at  the  lower  jaw,  the  orbital 
arches  being  distinctly  involved,  but  that 
in  Paget's  disease  the  involvement  is 
chiefly  of  the  calvarium.  The  patient 
actually  diminishes  in  height.  The 
chest  becomes  deformed.  There  is  an- 
gular curvature  in  the  dorsocervical  re- 
gion. The  lower  extremities  are  usually 
bent,  and  the  pelvis,  as  a  general  thing, 
is  broadened.  Paget  says:  "The  most 
characteristic  features  are  the  loss  in 
height,  indicated  by  the  low  position  of 
the  hands,  the  stooping  with  round 
shoulders,  the  head  held  forward  with 
the  chin  raised  and  the  chest  sunken  to- 
ward the  pelvis,  the  abdomen  pendulous, 
the  curved  lower  limbs  held  apart  and 
usually  with  one  advanced  in  front  of 
the  other  and  both  with  knees  slightly 
bent,  the  ankles  overhung  by  the  legs, 
and  the  toes  turned  out.  The  enlarged 
cranium,  square  looking  and  bossed, 
may  add  distinctness  to  these  charac- 
teristics, and  they  are  completed  in  the 
slow  and  awkward  gait  of  the  patients." 
In  some  of  the  cases  there  is  a  tendency 
to  tumor  formation.  In  the  67  cases  col- 
lected by  Packard  and  Steele,  3  suffered 
from  cancer  and  5  from  sarcoma.  In 
the  158  cases  collected  by  Higbee  and 
Ellis  ("Jour.  Med.  Research,"  vol.  xxiv,  No.  i)  there  were  14  instances  of 
tumor  growth.  In  a  case  reported  by  Gruner,  Scrimger,  and  Foster  ("Archives 
of  Internal  Medicine,"  June,  191 2)  sarcoma  appeared  in  the  radius,  head  of 
the  humerus,  and  other  places.  Some  cases  are  associated  with  goiter.  It 
has  been  suggested  that  there  is  a  bacterial  cause  for  Paget's  disease.  An 
Italian  investigator  claimed  to  have  discovered  a  bacterium  and  made  a  serum 
for  use  in  treatment.  In  2  cases  I  exposed  areas  of  new  bone,  removed  por- 
tions, and  took  cultures.  One  set  of  cultures  remained  sterile.  A  tube  of  the 
other  was  found  contaminated  by  the  skin  staphylococcus. 

Treatment  is  practically  useless.     No  known  remedy  diminishes  the  size  of 
the  bones,  although  iodid  of  potassium  is  said  occasionally  to  mitigate  pain. 


Fig.  259. — Paget's  disease. 


Varieties  of  Fractures 


513 


Osteo=arthropathie  Hypertrophiante  Pneumique  (Marie's  Dis- 
ease).— (See  page  644.) 

Multiple  Myeloma. — By  this  term  we  mean  a  new  growth  in  the  bone- 
marrow  which  occurs  particularly  in  the  ribs,  sternum,  and  vertebrae.  It 
may  occur  also  in  the  bones  of  the  cranium  and  in  other  bones.  The  multi- 
plicity is  not  due  to  metastasis,  but  the  growths  start  as  separate  foci.  The 
nature  of  the  cells  in  the  growths  is  uncertain.  They  almost  certainly  spring 
from  marrow  cells.  Some  consider  them  myelocytes,  some  bone-marrow 
plasma  cells.  The  effect  of  the  growth  is  to  thin  the  bones  and  make  them  very 
brittle.  This  condition  was  first  described  by  Rustitzky  in  1873.  Stumm,  who 
reports  2  cases,  estimates  that  about  50  cases  have  been  reported. 

The  condition  begins  insidiously,  in  either  sex,  during  middle  age,  sometimes 
in  advanced  life.  It  begins  usually  with  attacks  of  aching  in  the  limbs  and 
weakness.  Such  attacks  may  come  and  go  over  a  considerable  period  of  time. 
Eventually  the  back,  chest,  and  ribs  become  the  seats  of  pain  and  tenderness. 
Finally,  the  pain  becomes  constant  and  the  patient  is  confined  to  bed.  In 
many  cases  a  sternal  tumor  can  be  palpated.  Spontaneous  fractures  are  apt 
to  occur.  Usually  the  Bence- Jones  body  is  found  in  the  urine.  Death  is  due 
usually  to  exhaustion.    Treatment  is  futile. 

Feactures 

Definition. — A  fracture  is  a  solution,  by  sudden  force,  of  the  continuity 
of  a  bone  or  of  a  cartilage.  Clinically,  under  this  head  are  placed  epiphyseal 
separations  and  the  tearing  apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are  as  follows: 
Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which  there  is  no 
wound  extending  from  the  surface  to  the  seat  of  bone  injury.     This  corre- 
sponds to  a  contusion  of  the  soft  parts. 


Fig.  260. — Compound  comminuted  fracture  of  the  tibia. 


Compound  fracture  (Figs.  260  and  270)  is  an  open  fracture,  or  one  in  which  an 
open  wound  extends  from  the  surface  to  the  seat  of  bone  injury  or  in  which  a 
wound  opens  up  a  passage  from  the  fracture  to  the  surface.  This  cocresponds 
to  a  contused  or  lacerated  wound  of  the  soft  parts.  The  opening  may  be 
through  the  skin;  through  a  mucous  membrane,  as  in  some  fractures  of  the 
base  of  the  skuU  and  pelvis ;  through  the  drum  of  the  ear,  as  in  some  fractures 
of  the  middle  fossa  of  the  base  of  the  skull ;  through  the  lung,  as  when  a  broken 
rib  penetrates  that  organ;  or  through  the  bowel  or  bladder,  as  in  some  fractures 
of  the  pelvis. 

A  primary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 
is  produced  at  the  time  of  the  accident,  either  by  the  direct  violence  of  the 
injury  or  by  the  forcing  of  a  bone  or  bones  through  the  tissues. 


33 


514 


Diseases  and  Injuries  of  the  Bones  and  Joints 


A  secondary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 
occurs  after  the  accident,  either  from  sloughing  of  damaged  tissues,  from 
ulceration  because  of  the  pressure  of  ill-adjusted  fragments,  or  from  the  forc- 
ing of  a  bone  or  bones  through  the  soft  parts  because  of  rough  handling,  neglect, 
or  the  tossing  of  delirium. 

Complicated  fracture  is  a  fracture  plus  the  complication  of  a  joint  injury, 
arterial  or  venous  damage,  or  injury  to  the  nerves  or  soft  parts.  When  a  frac- 
tured rib  injures  the  lung  or  when  a  broken  vertebra  damages  the  cord  a  com- 
plicated fracture  exists.  The  term  is  unfortunate,  as  it  conveys  no  definite 
meaning,  and  its  use  is  no  more  justifiable  than  it  would  be  to  speak  of  "com- 
plicated pneumonia"  or  "complicated  typhoid,"  for  the  complication  should 
be  named  in  any  case.  It  must  be  remembered  that  damage  to  the  soft  parts 
not  sufficiently  severe  to  produce  a  wound  reaching  from  the  surface  to  the 
seat  of  fracture  does  not  make  the  case  a  compound  fracture,  but  rather  com- 
plicates a  simple  fracture.  Remember  also  that  even  superficial  areas  of  tissue 
destruction  must  be  treated  antiseptically,  otherwise  absorption  of  pyogenic 
bacteria  and  their  deposition  at  the  seat  of  injury  may  cause  diffuse  osteo- 
myelitis. 

Complete  fracture  is  that  which  extends  through  the  whole  thickness  of 
a  bone  or  entirely  across  it  (Fig.  261). 


Fig.  261. — Complete  fractures:  a.  Transverse;  h,  spiral; 


c  d 

dentated;  d,  oblique  or  multiple. 


Incomplete  fracture  is  that  which  extends  only  partially  through  the  thick- 
ness of  a  bone  or  only  partially  across  it  (Fig.  262). 

A  linear,  hair,  capillary,  ox  fissured  fracture,  or  di.  fissure,  is  a  crack  in  a  bone 
with  very  little  separation  of  the  edges.  This  is  an  incomplete  fracture,  but 
may  be  associated  with  a  complete  break  (Fig.  261,  h). 

A  green- stick,  hickory-stick,  willow,  or  hent  fracture  is  a  true  incomplete  break 
(Fig.  262).  The  bones  most  frequently  so  broken  are  the  radius,  uJna,  clavicle, 
and  ribs.  It  arises  from  indirect  force,  and  it  is  very  rare  after  the  age  of 
sixteen.  In  rickets  green-stick  fractures  are  very  common.  It  is  called  "green- 
stick"  because  the  bone  breaks  like  a  green  stick  when  forced  across  the  knee, 
first  bending  and  then  breaking  on  its  convex  surface.  The  bone,  being  com- 
pressed between  two  forces,  bends,  and  the  fibers  on  the  outer  side  of  the  curve 
are  pulled  apart,  while  those  on  the  concavity  are  not  broken,  but  are  com- 
pressed. In  correcting  the  deformity  such  fractures  are  often  made  complete. 
The  permanent  bending  of  a  bone  without  a  break  may  possibly  occur  in 
youth.  In  children  a  portion  of  a  bone  of  the  skull  may  be  bent  inward,  caus- 
ing depression.  In  some  cases  such  a  depression  is  permanent;  in  others  it  is 
temporary,  the  bone  returning  to  its  proper  level. 

Depression-fracture  occurs  when  a  portion  of  the  thickness  of  a  bone  is 
driven  in  by  crushing.    Fracture  by  depression  is  a  result  of  the  bending  in 


Varieties  of  Fractures 


515 


of  a  bone  (as  the  parietal),  a  fragment  breaking  off  from  the  side  toward  which 
the  bone  is  bending.  A  depressed  fracture  is  complete,  not  incomplete,  and  by 
this  term  is  meant  an  injury  in  which  a  fragment  of  the  entire  thickness  of 
the  bone  is  driven  below  the  level  of  the  surrounding  surface. 

Splinter-  and  Strain- fracture. — The  breaking  off  of  a  splinter  of  bone 
(splinter-fracture)  or  of  an  apophysis  constitutes  a  form  of  incomplete  frac- 
ture. A  strain  upon  a  ligament  or  a  tendon  may  tear  off  a  shell  of  bone,  and 
this  injury  is  the  "strain-fracture"  or  "sprain-fracture"  of  Callender. 

Longitudinal  fracture  is  a  fracture  whose  line  is  for  a  considerable  distance 
parallel,  or  nearly  so,  with  the  long  axis  of  the  bone.  Such  fractures  are  com- 
mon in  gunshot  injuries  (Fig.  263). 

Oblique  fracture  is  a  fracture  the  direction  of  which  is  positively  oblique  to 
the  long  axis  of  the  bone.  Most  fractures  from  indirect  force  are  oblique  (Fig. 
261,  d). 

Transverse  fracture  is  a  fracture  the  direction  of  which  is  nearly  transverse 
to  the  long  axis  of  the  bone  (no  fracture  is  mathematically  transverse)  (Fig. 
261,  a).  The  cause  is  often,  but  not  invariably,  direct 
_  _^  force.    The  fracture  en  rave  (radish-fracture,  so  called 

H/W  because  the  bone  breaks  as  does  a  radish)  is  trans- 
verse at  the  surface,  but  not  within. 


^Vv>.^ 


§ 


Fig.  262. — Green-stick  frac- 
ture. 


Fig.  263. — ^Longitudinal  and 
oblique  fracture. 


Fig.  264. — Appearances  of  the 
ends  of  fragments. 


Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which  the  end  of  each 
fragment  is  irregularly  serrated  and  the  fragments  are  commonly  locked  to- 
gether; hence  it  is  difficult  to  correct  the  deformity  (Fig.  261,  c,  and  Fig. 
264).    Most  simple  fractures  from  direct  force  are  serrated. 

Wedge-shaped,  V-shaped,  cuneated,  or  cuneiform  fracture  ("fracture  oblique 
spiroide,"  "fracture  en  V"  of  Gosselin,  "fracture  en  coin")  is  one  the  lines  of 
which  take  the  shape  of  a  V,  which  may  be  entire  or  may  lack  the  point.  It 
occurs  at  the  articular  extremity  of  a  long  bone,  and  a  fissure  usually  arises  from 
its  point  and  enters  the  joint.    If  complete,  it  is  a  "comminuted  fracture." 

T-shaped  fracture  is  a  fracture  which  presents  a  transverse  or  obhque  line 
and  also  a  longitudinal  or  vertical  line.    It  occurs  at  the  lower  end  of  either  the 


Si6 


Diseases  and  Injuries  of  the  Bones  and  Joints 


humerus  or  femur,  the  transverse  line  being  above,  and  the  vertical  line  (inter- 
condyloid)  between,  the  condyles.  If  complete,  it  is,  in  reality,  a  form  of  com- 
minuted fracture. 

Multiple  or  composite  fracture  is  a  condition  in  which  a  bone  is  broken  into 
more  than  two  pieces,  the  lines  of  fracture  not  intercommunicating,  or  a  con- 
dition in  which  two  or  more  bones  are  broken.  Multiple  fractures  of  one  bone 
are  divided  into  double,  treble,  quadruple,  etc.  Multiple  fractures  involving 
more  than  one  bone  are  seldom  seen,  and  represent  less  than  2  per  cent,  of 
fracture  cases.  The  reason  of  their  rarity  in  hospitals  is  that  they  result  from 
severe  force  and  many  of  the  victims  die  before  they  can  be  brought  to  an 
institution.  The  mortality  in  cases  which  reach  the  hospital  is  large,  over  27 
per  cent.  (Astley  P.  C.  Ashhurst,  in  "Annals  of  Surgery,"  August,  1907). 

Comminuted  fracture  is  a  condition  in  which  a  bone  is  broken  into  more  than 
two  pieces,  the  Unes  of  fracture  intercommunicating  (Figs.  265  and  266). 

The  bone  may  be  broken  into  many  small 
fragments,  there  may  be  much  splintering,  or 
the  osseous  matter  may  actually  be  ground  up. 


Fig.  265. — Comminuted  fracture  of  the  lower  ex-       Fig.  266. — Comminuted  fracture  of  the  upper  part 
tremity  of  radius.  of  femur. 

Impacted  fracture  is  one  in  which  one  fragment  is  driven  into  the  other 
and  solidly  wedged  (Figs.  267,  268,  and  269). 


Fig.  267. — ^Impacted  fracture  of  the  neck  of  the 
femur. 


Fig.  268. — ^Impacted  fracture  of  the  neck  of  the 
femur. 


Fracture  with  crushing  or  penetration  is  a  fracture  in  which  one  bone  is 
driven  into  the  other,  the  encasing  bone  being  so  spUntered  that  the  impacting 
bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one  occurring  from  a 
very  insignificant  force  acting  on  a  bone  rendered  brittle  by  disease. 

Ununited  fracture  is  a  fracture  in  which  bony  union  is  absent  long  after  the 
passage  of  the  period  normally  necessary  for  its  occurrence. 


Varieties  of  Fractures 


517 


Direct  fracture  is  one  occurring  at  the  point  at  which  the  force  was  pri- 
marily applied. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from  the  area  of  pri- 
mary application  of  force. 

Stellate  or  starred  fracture  (fracture  par  irradiation)  is  one  in  which  several 
fissures  radiate  from  a  center.  If  the  fracture  be  complete,  the  condition  is, 
in  reality,  a  form  of  comminuted  fracture. 

Helicoid,  spiral,  or  torsion  fracture  is  a  fracture  resulting  in  a  long  bone 
from  t^\'isting. 

Fracture  by  contrecoup  is  a  fracture  of  the  skull  which  is  on  the  opposite 
side  of  the  head  to  that  which  was  the  recipient  of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injury  occurs  only  before  the 
age  of  twenty-five.  In  order  of  frequency,  the  bones  chiefly  subject  to  epiph- 
yseal separation  are:  the  upper  end  of  the  humerus,  the  lower  end  of  the  radius, 
the  lower  end  of  the  femur,  and  the  lower  end  of  the  tibia  (John  Poland,  in  the 
"Practitioner,"  Sept.,  1901).     This  injury  induces  deformity,  which  is  often 


Fig.  269. — Impacted  fracture  of  neck  of  femur  (Conner). 


difficult  to  reduce,  and  by  damaging  the  cartilage  may  retard  or  inhibit  a  fur- 
ther lengthening  of  the  limb  by  growth.  Occasionally  after  damage  to  an 
epiphysis  suppuration  will  occur,  sometimes  thickening  takes  place.  Non- 
union is  verv'  rare.  After  a  sprain  of  an  epiphysis  tuberculous  disease  some- 
times develops,  but  very  rarely  after  a  separation. 

Intra-nterine  fractures  are  usually  due  to  injuries  of  the  mother's  abdomen 
sustained  toward  the  end  of  pregnancy.  Some  hold  that  they  can  arise  as  a 
consequence  of  the  force  of  violent  uterine  contractions.  Many  so-called 
"intra-uterine"  fractures  are  wrongly  named,  as  they  result  from  injur\'  during 
dehverj^  In  sporadic  cretinism  the  bones  are  fragile  and  ill-ossified,  and  many 
fractiires  may  occur  in  utero. 

Designation  According  to  Seat  of  Fracture.— K  fracture  may  be  designated 
according  to  its  anatomical  seat;  for  instance,  fracture  of  the  upper  third  of  the 
shaft  of  the  femur,  fracture  of  the  olecranon  process  of  the  ulna,  fracture  of  the 
middle  third  of  the  cla\dcle,  and  fracture  of  the  body  of  the  lower  jaw.  Intra- 
articular fracture  is  one  within  or  extending  into  a  joint;  intracapsular  fracture 


5i8  Diseases  and  Injuries  of  the  Bones  and  Joints 

is  one  within  the  capsule  of  either  the  shoulder-  or  hip- joint;  and  extracapsular 
fracture  is  one  just  without  the  capsule  of  either  the  shoulder-  or  hip-joint. 

Causes  of  Fracture. — The  causes  of  fracture  are:  (i)  exciting,  imme- 
diate or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are:  (a)  external  violence  and  {h)  muscular  action. 

External  violence  is  the  most  usual  exciting  cause.  Two  forms  are  noted: 
(i)  direct  violence  and  (2)  indirect  force. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as  when  the  nasal 
bones  are  broken  with  the  fist.  In  such  fractures  the  soft  parts  are  injured; 
they  may  be  destroyed  at  once  in  part,  they  may  be  damaged  so  severely 
that  a  portion  sloughs,  or  they  may  be  damaged  so  slightly  that  they  do  not 
lose  vitality;  hence  fractures  by  direct  violence  may  be  compound  from  the 
start,  may  become  so,  or  may  remain  simple.  In  fractures  by  direct  force 
discoloration,  due  to  effused  blood,  usually  appears  at  the  point  struck  soon 
after  the  accident.  In  compound  fractures  by  direct  violence  the  soft-part 
injury  is  so  great  that  primary  tissue  union  cannot  occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of  application  of 
the  force,  but  at  a  distance  from  it,  the  force  being  transmitted  through  a 
bone  or  a  chain  of  bones,  as  when  the  clavicle  is  broken  by  a  fall  upon  the 
extended  hand.  Such  fractures  tend  to  occur  in  regions  of  special  predi- 
lection. If  they  are  not  compound,  there  is  no  injury  of  the  surface  over 
the  fracture.  If  they  become  compound  by  projection  of  fragments,  primary 
union  may  still  occur.  Discoloration  over  the  seat  of  fracture  is  usually  not 
present  soon  after  the  accident,  but  may  occur  later.  Discoloration  rapidly 
appears  in  soft  parts  at  the  point  where  the  force  was  first  applied. 

Muscular  action  is  rather  an  unusual  cause  except  in  the  patella.  Fractures 
thus  produced  result  from  sudden  or  violent  muscular  contraction.  Bones  so 
broken  are  usually  diseased.  Violent  coughing  may  fracture  the  ribs;  attempt- 
ing to  kick  may  fracture  the  femiu";  saving  one's  self  from  falling  backward 
may  fracture  the  patella;  throwing  a  stone  may  fracture  the  humerus;  and  sud- 
den extension  of  the  forearm  may  fracture  the  olecranon  process  of  the  ulna. 

Predisposing  Causes. — There  are  two  classes  of  predisposing  causes, 
namely:  (i)  physiological,  natural  or  normal,  and  (2)  pathological  or  abnormal. 

Natural  Predisposing  Causes. — Unde^  this  head  is  considered  the  liability 
to  fracture  possessed  by  individual  bones  because  of  their  shape,  structure, 
function,  or  position.  Those  predispositions  occasioned  by  special  ages  are 
also  considered.  In  youth  epiphyseal  separation  is  commoner  than  fracture 
and  a  fracture  is  apt  to  be  incomplete.  Fractures  are  commonest  between 
the  ages  of  twenty-five  and  sixty.  From  two  to  four  years  of  age  a  child 
is  more  liable  to  fracture  than  later,  because  he  is  then  learning  to  walk  (Mal- 
gaigne).  The  bones  of  the  old  are  easily  broken,  but  the  normal  lack  of  activ- 
ity of  the  aged  saves  them  from  more  frequent  injury.  Thus,  the  predisposi- 
tions of  age  are  in  part  due  to  habits  and  in  part  to  bony  structure.  The  bones 
of  the  young,  being  elastic,  bend  considerably  before  they  break;  the  bones 
of  the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not  bend.  In  old 
age  the  bones  become  lighter  and  more  porous,  though  they  do  not  diminish 
in  size.  Absorption  takes  place  from  the  interior  of  a  bone,  particularly  at  its 
articular  head,  the  medullary  canal  increases  in  size,  the  cancellous  spaces 
become  notably  larger,  and  portions  of  the  remaining  bone  of  the  interior  show 
a  fatty  change.  There  is  no  increase  in  the  amount  of  mineral  salts  present, 
as  was  long  taught.  These  alterations  occur  earlier  in  women  than  in  men.^ 
The  change  of  age  is  a  diminution  in  the  amount  of  bone  present,  and  some- 
times a  fatty  change  in  a  portion  of  what  remains.  If  the  atrophy  of  bone  is 
other  than  that  normal  to  senility,  it  constitutes  a  pathological  predisposing 

1  Humphrey  on  "Old  Age." 


Symptoms  of  Fractures  519 

cause  of  fracture.  Normal  predisposing  causes  include  the  person's  weight 
(which  determines  the  force  of  a  fall),  muscular  development,  habits,  sex, 
occupation,  and  the  season  of  the  year. 

Pathological  Predisposing  Causes. — Hereditary  fragility,  a  form  of  fragilitas 
ossium,  is  a  condition  commonest  among  women,  often  existing  in  genera- 
tion after  generation,  and  in  this  condition  fractures  occur  from  a  \er\  shght 
force.  There  exists  in  these  cases  bony  rarefaction — in  fact,  a  premature 
senilit}^  Fragilitas  ossii{>}!  (osteopsathyrosis)  may  be  congenital  or  may  come 
on  later  in  Hfe.  It  may  result  from  seniUty,  wasting  diseases,  scurvy,  scarla- 
tina, bone-cyst,  malignant  disease  of  the  bone,  certain  nervous  disorders, 
rickets,  osteomalacia,  and  atrophy  due  to  disuse. 

NervoHS  Diseases. — Bony  nutrition  is  dependent  on  the  spinal  cord,  and 
the  trophic  influence  is  probabh'  exerted  through  the  posterior  nerve-roots. 
In  diseases  of  the  anterior  cornua  bony  growth  is  much  interfered  Viith;  in 
diseases  of  the  posterior  columns,  as  in  locomotor  ataxia,  a  true  bony  atrophy 
bespeaks  trophic  disorder.  S)Tingomyelia  causes  brittleness  of  the  osseous 
structures,  and  in  paralysis  agitans  bones  are  thought  to  break  easily.  Trophic 
changes  may  occur  in  the  bones  of  the  insane,  most  commonly  when  insanity 
is  linked  to  organic  disease.  About  one-quarter  of  paretic  dements  show  xm- 
due  brittleness  or  unnatural  softness  of  bones. ^  The  bones  of  maniacs  are 
frequently  fragile.  Fractures  among  the  insane  are  not  necessarily  an  indica- 
tion of  abuse. 

Rickets  predisposes  to  fracture  because  of  altered  bone  structure  and  the 
great  hability  to  falls. 

Osteomalacia  predisposes  to  fracture  of  the  long  bones,  sternum,  and  ribs. 

Atrophy  of  Bone. — This  condition,  as  has  been  stated  (see  page  518),  is  nor- 
mal in  senility.  It  may  arise  from  want  of  use,  as  is  observ'ed  in  the  bedfast, 
in  the  wasted  femur  of  hip-joint  disease,  and  in  the  bones  of  a  stump.  It 
may  arise  from  presstu^e,  as  when  an  aneun,-sm  compresses  the  ribs,  sternum, 
or  vertebrse.  Among  other  of  the  pathological  predisposing  causes  are  to  be 
mentioned  cancer,  sarcoma,  hydatid  and  solitarv'  cysts  of  bone,  caries,  necrosis, 
gout,  scrofula,  s\-phili5,  mollities  ossiimi,  and  scurvy. 

Symptoms  of  Fractures. —  History  of  An  Injury. — In  spontaneous  frac- 
ture there  may  be  no  record  of  ^■iolence;  for  instance,  a  bone  may  break  while 
an  indi\'idual  is  turning  in  bed.  In  investigating  the  histor)',  not  only  seek 
for  a  record  or  for  e\'idences  of  \T.olence,  but  tr\'  to  determine  exactly  how  the 
accident  happened. 

A  sound  of  cracking  is  occasionally  audible  to  a  bystander  at  the  time  of  the 
injur}-.  The  patient  may  have  heard  it,  but  very  rarely  does.  A  rupture  of  a 
tendon  or  a  ligament  produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in  rickets).  In 
some  fractures  the  pain  is  sHght,  in  some  there  is  no  pain,  in  others  pain  is 
torturing,  and  in  most  it  is  severe  for  a  time  after  the  injux>',  but  gradually 
abates  imless  reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  s}-mptom  than  that  which  can  subsequently 
be  produced  by  movement.  In  indirect  fracture  there  is  an  area  of  pain  at  the 
point  of  application  of  the  force,  and  another  at  the  seat  of  fracture.  Pain  at 
the  seat  of  fracture  can  be  greatly  aggravated  b}'  pressure  or  movement  and  is 
rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part  to  swelling  and 
in  part  to  a  change  in  the  mutual  relation  of  the  fragments  (displacement). 
The  deformity  due  to  swelling  is  no  aid  to  diagnosis,  as  the  same  condition 
occurs  in  contusion,  and  often  hides  some  positive  symptomatic  distortion. 
The  swelling  is  due  first  to  blood  and  next  to  inflammator}-  products  and 
^  "Manual  of  Insanity,"  by  Spitzka. 


520  Diseases  and  Injuries  of  the  Bones  and  Joints 

pressure-edema,  and  is  very  great  in  joint  fractures.  Swelling  due  to  bleeding 
is  early  and  rapid.  Swelling  due  to  inflammatory  exudation  is  later  and  grad- 
ual. Swelling  due  to  pressure-edema  may  be  rapid.  The  greater  part  of  the 
swelling  is  due  to  hemorrhage  and  exudation  from  the  damaged  soft  parts,  a 
portion  of  it  is  due  to  hemorrhage  and  exudation  from  the  bone.  The  swell- 
ing is  usually  in  direct  ratio  to  the  mobihty,  the  greater  the  mobility,  the 
greater  the  swelling.  "The  swelhng  in  fractures  of  the  skull  is  inconsiderable, 
notwithstanding  that  the  total  area  of  bone  surface  involved  is  commonly 
more  than  ia  fractures  of  the  leg  or  arm,  and  the  vascularity  greater.  The 
reason  for  this  is  the  natural  immobUity  of  fractures  of  the  skull"  (James  P. 
Warbasse,  in  "Jour.  Amer.  Med.  Assoc,"  March  13,  1909).  The  deformity  of 
displacement  may  be  produced  by  the  violence  of  the  injury  (as  is  the  depres- 
sion in  a  skull  fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular  action  (as  is  the 
pulling  upward  of  the  fragment  of  a  fractured  olecranon  process). 

The  varieties  of  displacement  are:  (i)  transverse  or  lateral,  where 
one  fragment  goes  to  the  side,  front,  or  back,  but  does  not  overlap  the  other; 
(2)  angular,  the  bony  axis  at  the  point  of  fracture  being  altered  and  the  frag- 
ments forming  with  each  other  an  angle;  (3)  rotary,  one  fragment  rotating 
in  the  bony  circumference,  the  other  remaining  stationary.  As  a  rule,  it  is 
the  lower  fragment  w^hich  turns  on  its  long  axis,  the  limb  below  the  level 
of  the  break  rotating  with  it;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other  fragment.  It  is 
usually  the  lower  fragment  which  is  drawn  by  the  muscles  above  the  upper, 
but  in  a  fracture  of  the  lower  extremity  the  body-weight  and  sliding  down 
in  bed  may  push  the  upper  below  the  lower  fragment.  In  overriding  the 
ends  are  near  together  and  the  bones  are  usually  in  contact  at  their  periphery. 
It  is  obvious  that  overlapping  is  associated  with  transverse  displacement,  as 
one  fragment  must  go  front,  back,  or  to  the  side;  (5)  penetration  or  impaction 
when  one  fragment  is  driven  into  the  other,  thus  producing  shortening;  (6) 
separation  of  the  two  fragments  occurs  in  fracture  of  the  patella,  olecranon, 
OS  calcis,  certain  articulations,  and  in  some  breaks  of  the  humerus  when  the 
arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  as  well  as  a  fracture  may 
produce  displacement,  but  these  two  conditions  may  be  differentiated  by 
the  observation  that  the  displacement  of  fracture  tends  to  reappear  even 
after  complete  reduction,  while  the  displacement  of  dislocation  does  not 
reappear  after  correction.  A  displacement  is  difficult  of  detection  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  function  may  be  shown  by  inability  to  move  the  limb  because 
of  the  break,  but  it  is  not  always  markedly  present,  though  some  degree 
invariably  exists.  It  is  slight  in  "green-stick"  and  impacted  fractures  (unless 
the  loss  of  power  arises  from  pain  or  nerve  injury).  A  person  can  walk  when 
the  fibula  alone  is  broken,  and  Hkemse  in  some  cases  of  intracapsular  fracture 
of  the  femur,  and  can  often  put  the  hand  on  the  head  in  fractured  clavicle 
(Malgaigne).  The  pain  of  an  injury  or  the  loss  of  power  from  nerve  trauma- 
tism may  cause  loss  of  movement  in  the  limb.  This  s^onptom  is  of  slight  diag- 
nostic value  in  most  fractures. 

Extravasation  of  Blood. — A  contusion  of  the  surface  accompanied  by  skin 
abrasion  indicates  merely  the  point  of  appKcation  of  direct  external  \dolence. 
If  contusion  is  extensive  over  a  superficial  bone,  as  the  tibia  or  parietal,  after 
a  few  hours  it  often  stimulates  fracture  by  presenting  a  soft,  compressible 
center  surrounded  by  a  ring  of  hard,  condensed  tissues  and  coagulated  blood. 
Direct  external  violence  may  merely  occasion  ecch^onosis,  and  in  fracture 
from  indirect  force  ecchymosis  may  occur  throughout  a  considerable  area. 


Preternatural  Mobility  and  Crepitus  521 

In  regard  to  this  symptom,  note  that  even  great  external  violence  may  occasion 
no  evident  contusion  or  ecchymosis,  and  in  any  fracture  this  symptom  may  be 
present  or  absent.  In  old  people,  anemic  subjects,  fat  individuals,  alcoholics, 
and  opium-eaters  extravasation  of  blood  is  frequently  marked  and  persistent. 
By  suggillation  is  meant  an  extravasation  of  blood  which  slowly  invades  wide 
areas  of  tissue  and  which  appears  at  the  surface  only  after  some  time,  and 
then  usually  as  a  yellowish  discoloration,  red  hemoglobin  having  been  changed 
to  yellow  hematoidin.  Linear  ecchymosis  has  been  esteemed  by  some  as  a 
sign  of  fissure,  and  it  is  often  noted  after  fracture  of  the  fibula.  Linear 
ecchymosis  over  the  line  of  the  posterior  auricular  artery  was  shown  by 
Battle  to  be  a  valuable  sign  of  fractiire  of  the  posterior  fossa  of  the  base  of 
the  cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which  is  pathogno- 
monic when  surely  found.  The  unbroken  bone  is  nowhere  mobile  in  con- 
tinuity. By  preternatural  mobility  is  meant  that  a  bone  is  mobile  in  con- 
tinuity or  that  there  is  abnormality  in  the  direction  or  extent  of  joint  mobility. 
In  some  fractures  this  symptom  does  not  exist  (impacted,  green-stick,  and 
locked  serrated  fractures);  in  others  it  cannot  be  found  (fractures  of  tarsus, 
carpus,  vertebral  bodies);  in  others  it  is  difficult  to  obtain,  but  at  times  can 
be  developed  (fractures  near  or  into  many  joints).  To  develop  this  symptom 
try,  when  the  case  admits,  to  grasp  the  fragments  and  to  move  them  in  op- 
posite directions.  In  a  fracture  of  the  shaft  of  the  femur  or  humerus  fix  the 
upper  fragment  and  carry  the  knee  or  elbow  in  various  directions  to  develop 
bending  at  the  point  of  fracture.  In  fracture  of  the  clavicle  push  the  shoulder 
downward  and  inward.  In  fractures  of  either  bone  of  the  forearm  grasp  the 
parallel  bone  with  four  fingers  of  each  hand  and  make  pressure  on  the  sus- 
pected bone  alternately  with  either  thumb,  and  the  same  procedure  can  be 
used  in  fractures  of  the  leg.  In  fracture  of  the  neck  of  the  femur  the  altered 
rotation-arc  of  the  great  trochanter  demonstrates  preternatural  mobility 
(Desault).  In  fracture  of  the  lower  end  of  the  radius  bend  the  hand  back,  and 
in  a  break  of  the  lower  end  of  the  fibula  evert  the  foot  (Maisonneuve).  In 
seeking  preternatural  mobility  remember  that  the  elastic  ribs  when  forced 
in  give  a  sense  of  bending,  and  that  the  fibiila  at  its  middle  is  "normally  flexible" 
(Dupuytren).    Some  rachitic  bones  may  be  bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound,  which  indicates 
the  grating  together  of  the  two  rough  surfaces  of  a  broken  bone.  This  symp- 
tom is  of  great  value,  but  it  is  not  always  present.  It  is  absent  in  locked 
serrated  fractures,  in  impacted  fractures,  in  cases  where  the  broken  ends 
cannot  be  approximated  (as  in  overlapping),  is  rare  when  a  fractured  surface 
is  against  the  side,  and  not  the  broken  face,  of  the  other  fragment,  and  is 
unusual  in  incomplete  fractures.  Crepitus  is  often  absent  in  epiphyseal 
separation,  in  softened  bones,  and  in  fractures  in  or  near  joints,  and  it  raay 
be  prevented  from  occurring  by  blood-clot,  fascia,  synovial  membrane,  perios- 
teum, or  muscle  between  the  broken  surfaces.  The  grating  foimd  in  teno- 
synovitis must  not  be  mistaken  for  the  crepitus  of  fracture;  the  former  is 
diffuse,  large,  soft,  and  moist;  the  latter  is  limited,  small,  harsh,  and  dry. 
The  cHcking  of  an  inflamed  or  eroded  joint  and  the  crackling  of  emphysema 
must  also  be  separated  from  bony  crepitus.  Crepitus  of  fracture  may  be 
present  at  one  moment,  but  absent  the  next.  It  is  often  not  detected  during 
the  time  swelling  is  marked,  and  cannot  be  discovered  after  organization 
of  the  callus  begins.  In  but  few  fractures  is  it  needful  to  try  to  hear  crepitus 
with  the  unaided  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubtful 
cases  of  fractures  of  ribs  and  joints  this  e\ddence  should  be  sought  for. 

The  above-named  symptoms  are  known  as  "direct."  There  are  other 
symptoms  known  as  "circumstantial,"  such  as  the  flow  of  blood  and  cere- 


522  Diseases  and  Injuries  of  the  Bones  and  Joints 

brospinal  fluid  from  the  ear  after  some  fractures  of  the  middle  fossa  of  the  base 
of  the  skull;  emphysema  of  the  face  and  epistaxis  after  fracture  of  the  nasal 
bones;  hemoptysis  and  emphysema  after  crushes  of  the  chest;  discoloration 
following  the  line  of  the  posterior  auricular  artery  after  fracture  of  the  pos- 
terior fossa  of  the  skull,  and  subconjunctival  ecchymosis  after  fracture  of  the 
anterior  fossa  of  the  base  of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the  injury — before 
the  onset  of  swelling,  if  possible.  Expose  the  part  completely,  taking  oflf 
the  clothing,  if  necessary,  by  clipping  it  along  the  seams.  Attentively  scru- 
tinize the  part  and  compare  it  with  the  corresponding  part  on  the  opposite 
side.  If  any  deformity  be  present,  it  must  be  ascertained  that  it  did  not 
exist  before  the  accident.  If  the  nature  of  the  injury  be  uncertain,  if  the 
patient  be  very  nervous,  or  if  the  part  be  acutely  painful,  it  is  better  to  give 
ether  to  diagnosticate,  set,  and  dress.  In  injuries  of  the  elbow-joint  anes- 
thetize before  examination,  unless  an  x-ray  apparatus  is  accessible  to  settle 
the  diagnosis,  and  even  then  it  is  usually  well  to  anesthetize  in  order  to  facili- 
tate reduction  and  dressing.  In  every  case  of  suspected  fracture  get  an  x-ray 
picture  if  possible.  A  correct  diagnosis  is  of  the  first  importance  and  on  a  cor- 
rect diagnosis  proper  treatment  primarily  depends. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preternatural  mobility, 
its  easily  reduced  but  recurring  displacement,  and  its  crepitus,  as  contrasted 
with  the  preternatural  rigidity,  the  deformity,  difficulty  to  reduce  but  remaining 
reduced,  and  the  absence  of  crepitus  of  a  dislocation.  Further,  in  dislocation 
the  bone,  when  rotated,  moves  as  one  piece,  whereas  in  fracture  it  does  not 
so  move;  in  dislocation  the  bony  processes  are  felt  occupying  their  proper 
relations  to  the  rest  of  the  same  bone,  while  in  fracture  some  of  them  present 
altered  relations.  In  dislocation  the  head  of  the  bone  is  found  out  of  its 
socket,  but  in  fracture  it  is  felt  in  place.  It  is  important  to  remember,  more- 
over, that  a  fracture  and  a  dislocation  may  occur  together,  and  that  the  rubbing 
of  a  dislocated  bone  against  an  articular  edge,  when  the  joint  has  been  rough- 
ened by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may  mask  charac- 
teristic deformity  and  obscure  crepitus.  When  only  a  contusion  exists, 
pain  is  apt  to  be  widespread;  but  if  a  fracture  has  occurred,  the  pain  is  accen- 
tuated at  some  narrow  spot.  In  many  cases,  before  he  can  give  a  certain 
opinion,  the  surgeon  must  wait  some  days  until  the  swelling  has  largely  sub- 
sided. In  such  a  case  it  is  best  to  assume  in  our  treatment  that  a  fracture 
exists  until  the  contrary  is  known.  Combat  swelling  by  rest,  the  use  of  evapo- 
rating lotions,  and  moderate  compression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate  deformity  is  con- 
cealed by  swelling;  crepitus  and  preternatural  mobility  do  not  exist  unless 
the  fragments  are  pvilled  apart,  and  there  is  not  necessarily  much  loss  of 
function.  A  conclusion  is  reached  largely  by  considering  the  nature,  direction, 
and  extent  of  the  violence,  the  seat  of  the  pain,  and  by  a  careful  study  of  the 
most  minute  deformity.  It  is  difficult  to  recognize  fissures.  They  rarely 
present  any  evidence  of  their  existence  except  a  localized  pain,  and  possibly 
a  linear  ecchymosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possibly  crepitus 
during  reduction  help  in  the  diagnosis,  although  in  many  cases  no  crepitus  is 
obtained.  Epiphyseal  separations  are  diagnosticated  by  the  age,  the  pre- 
ternatural mobility,  the  pain,  the  swelling,  the  ecchymosis,  the  deformity, 
the  situation  of  the  injury,  and  the  absence  of  crepitus  or  the  presence  only 
of  a  soft  crepitus.  It  is  important,  however,  to  remember  that  an  epiphyseal 
separation  is  sometimes  incomplete,  and  even  when  it  is  complete  there  may 
be  no  displacement.     In  cases  without  displacement  the  x-rays  will  not  enable 


Repair  of  Fractures  523 

us  to  make  a  diagnosis.  In  many  cases  of  complete  separation  soft  crepitus  is 
obtainable,  but  in  not  a  few  cases  it  is  not  to  be  found.  In  incomplete  separation 
crepitus  is  absent.  If  absent  in  complete  separation,  probably  some  tissue  is 
caught  in  the  opened  area  between  the  fragments.  Fractures  are  often  difficult 
to  recognize  when  occurring  in  a  group  of  bones  (which  are  firmly  joined  by 
dense  ligaments)  like  those  of  the  carpus  and  tarsus,  or  in  one  of  two  parallel 
bones.  There  is  not  always  a  certainty  that  a  fracture  exists  (see  below),  and 
when,  after  a  careful  examination,  there  is  still  uncertainty,  do  not  prolong  the 
efforts  or  use  great  force,  but  treat  the  case  as  a  fracture  mitil  a  cure  ensues  or 
the  diagnosis  becomes  apparent. 

In  a  child  the  diagnosis  of  fracture  is  sometimes  difficult.  Pain  may  be 
trivial.  Children  are  Uable  to  a  form  of  fracture  in  which  the  periosteum  is 
but  slightly  torn  or  is  not  torn  at  all,  the  disability  and  pain  are  often  slight, 
and  the  fracture  may  be  easily  overlooked  (Cotton  and  Vose). 

We  have  recently  had  added  to  our  resources  a  method  of  incalculable 
value  in  diagnosticating  fracture;  that  is,  the  use  of  the  force  known  as  the 
.T-ray  or  the  Rontgen  ray.  We  can  look  through  a  part  ■o'ith  a  fiuoroscope- 
and  see  the  bones  as  shadows,  or  we  can  take  a  negative  of  the  shadows  and 
print  skiagraphs  from  it.  This  method  is  applicable  even  when  the  parts  are 
swollen,  and  even  when  a  limb  is  clothed  or  ^^Tapped  in  dressings.  It  is 
possible  to  obtain  a  picture  of  a  fractured  skull;  fractured  ribs  and  vertebrae 
can  be  detected;  and  the  process  is  of  the  greatest  use  in  detecting  fractures 
of  the  limbs.  It  is  not  infallible.  An  epiphyseal  separation  may  not  be  de- 
tected, and  a  slight  angling  of  the  plate  may  give  a  deceptive  apperance  of 
distortion.  An  .r-ray  picture,  to  be  useful,  must  be  taken  by  an  expert  and 
should  be  interpreted  by  a  surgeon  in  association  with  the  x-Ya.y  expert.  It  is 
imperative  to  employ  this  method  in  doubtful  cases  if  an  x-ray  apparatus  is 
accessible.  It  is  advisable  to  use  it  in  all  recognized  cases  and  in  all  suspected 
cases. 

Complications  and  Consequences. — Some  of  the  consequences  and 
complications  of  fractures  are — sloughing  of  the  soft  parts,  thus  making 
the  fracture  compound;  extravasation  of  blood,  causing  swelling  or  even  gan- 
grene; rupture  of  the  main  arters*  or  vein  of  the  limb;  dislocation;  edema 
from  pressure  of  extravasated  blood,  from  inflammaton,-  exudation,  from  tight 
bandaging,  from  thrombosis,  or,  later,  from  the  pressure  of  callus;  stiffness  of 
joints  from  s^^lo^'itis  vnih  adhesion,  from  displaced  fragments,  or  from  intra- 
articular callus ;  stiffness  of  tendons  from  adhesive  thecitis  or  from  the  pressure 
of  callus;  paralysis  from  traimiatic  neuritis,  the  pressure  of  callus  upon  ner\'e- 
tnmks,  or  from  division  of  a  nerve;  muscular  spasm;  painful  callus;  exuberant 
caUus;  embolism;  fat-embolism;  pulmonary  congestion;  pulmonan,-  embolism; 
gangrene;  shock;  septicemia;  pyemia;  tetanus;  delirium  tremens;  urinary  re- 
tention; extensive  laceration  of  the  soft  parts;  rupture  of  large  ner\-es,  and 
involvement  of  joints.  A  fracture  may  fail  to  unite,  fibrous  imion  or  carti- 
laginous union  only  being  obtained.  An  epiphyseal  separation  may  arrest  the 
futiu-e  growth  of  the  limb. 

Repair  of  Fractures. — Simple  Fracture. — In  a  simple  fracture  the 
bone  is  broken,  the  medullary  contents  are  lacerated,  the  periosteima  is  torn, 
and  the  overlying  soft  parts  are  damaged  to  a  considerable  degree.  The 
periosteum  is  stripped  more  or  less  from  each  fragment,  but  it  is  rarely  com- 
pletely torn  through,  an  untorn  portion  known  as  the  periosteal  bridge  re- 
maining. The  amount  of  blood  effused  is  usually  considerable,  and  it  forms 
a  decided  prominence  at  the  seat  of  fracture;  it  gradually  gathers  because 
of  oozing,  and  soon  clots.  This  clot  lies  in  the  medullary  canal,  between  the 
fragments,  under  the  periosteum  at  the  ends  of  the  fragments,  and  in  the 
tissues  outside  of  the  periosteum.     Ver\'  rapidly  after  the  accident  the  dam- 


524  Diseases  and  Injuries  of  the  Bones  and  Joints 

aged  parts  inflame  (bone,  endosteum,  periosteum,  and  the  torn  periosseous 
structures).  The  inflammatory  exudate  enters  into  the  blood-clot  and  the 
leukocytes  eat  up  and  destroy  the  clot.  The  clot  is  simply  dead  material 
and  in  no  way  contributes  to  repair.  The  cells  of  the  damaged  tissue  pro- 
liferate and  the  yoimg  proliferating  cells  ffibroblastsj  enter  into  the  spaces  in 
the  clot  which  were  eaten  out  by  the  leukocytes.  Finally,  the  entire  clot  is 
replaced  by  fibroblasts  and  much  of  this  cellular  mass  quickly  becomes  vas- 
cularized (granulation  tissue). 

The  osteoblasts  which  exist  in  the  deeper  layers  of  the  periosteum  and, 
in  the  tissue  of  the  medulla  itself,  begin  to  proliferate  actively  soon  after  the 
fracture  has  taken  place.  The  fibroblasts  have  been  formed  by  the  prolifera- 
tion of  the  ordinar\'  connective-tissue  cells,  and  the  proliferating  osteoblasts 
soon  enter  into  and  become  widely  distributed  through  this  mass  of  fibroblasts. 
Some  observers  mamtain  that  the  fibroblasts  themselves  are  directly  trans- 
formed into  bone;  others  deny  this,  and  think  that  all  bone  formation  comes  from 
the  osteoblasts.  Osteoblasts  may  form  bone  directly,  or  may  form  cartflage 
first  and  then  bone.  When  a  fracture  takes  place,  a  bridge  of  periosteum  is 
usually  left  untorn,  and  this  bridge  holds  the  fragments  in  contact  at  some  point, 
just  as  a  strap  nailed  to  a  trunk  and  also  to  its  lid  holds  these  two  objects 
in  contact  at  some  point.     The  new  tissue  about  the  periosteal  bridge  always 


Fig.  270. — Compound  fracture. 

becomes  cartilaginous  for  a  time,  but  the  rest  of  the  callus  rarely  shows  the  de- 
velopment of  cartilage,  and  passes  directly  into  bone.  If,  however,  osteoblasts 
fail  to  proliferate  with  sufficient  acti\ity,  the  mass  of  granulation  tissue  becomes 
fibrous  tissue;  bone  is  not  formed  at  all,  or  is  ver\'  scantily  formed,  and  fibrous 
imion  occurs.  If  the  osteoblasts  lack  actiAdty,  but  are  more  active  than  in  the 
case  just  cited,  they  form  cartilage  extensively— but  cartilage  only;_conse- 
quentlv,  cartilaginous  union  occurs.  During  the  process  of  the  repair  of  a 
fracture  the  ends  of  the  bony  fragments  are  always  softened,  and  some  of  the 
bone  is  absorbed  by  the  osteoclasts.  The  osteoclasts  are  really  large  osteoblasts 
that  have  lost  the'  power  of  producmg  bone  and  that  fiumish  a  secretion  to 
absorb  bone  (the  elder  Senn).  After  bony  imion  has  been  accomplished  the 
osteoclasts  absorb  the  superfluous  callus.  The  mass  of  new  tissue  around 
and  between  the  bone-ends  is  called  callus.  It  \M  be  obser\^ed  that  the 
name  is  applied  successively  to  fibroblastic  tissue,  granulation  tissue,  fibrous 
tissue,  and  bone.  Warren  tells  us  that  callus  has  no  well-defined  outline, 
and  "involves  not  only  the  bone  and  periosteum,  but  also  the  connective 
tissue  and  some  of  the  surroundmg  muscular  tissue."  Within  a  few  days 
after  the  injury  the  inflammatory^  mass  is  much  firmer  than  follows  inflam- 
mation invohong  other  structures,  and  the  bone  ends  have  become  deeply- 
embedded  in  a  dense  mass. 


Delayed  Union 


525 


During  the  second  week  the  callus  is  greatl\-  strengthened  by  the  forma- 
tion of  dense  fibrous  tissue  in  and  below  the  periosteum,  of  less  dense  fibrous 
tissue  outside  the  periosteum,  and  of  cartilage  from  the  periosteal  bridge. 
The  newly  formed  tissue  contracts  decidedly.  During  the  third  week  ossifi- 
cation begms  at  the  points  farthest  from  the  fracture,  and  in  the  course  of 
a  short  time  (from  three  to  sLx  weeks)  is  complete.  The  mass  of  ossified 
callus,  or  new  bone,  is  spindle  shaped  and 
spong}'. 

The  terms  intermediate,  definitive,  or 
permanent  callus  are  used  to  describe  the 
material  which  forms  between  the  ends 
of  the  broken  bone.  The  names  provis- 
ional or  temporary  callus  are  given  to  the 
material  within  the  canal  (central  callus) 
and  external  to  the  bone  (ensheathing 
callus).  The  amomit  of  pro^-isional'  cal- 
lus depends  directly  on  the  extent  of  sepa- 
ration and  the  amount  of  motion  between 
the  fragments.  It  is  Nature's  splint,  and 
when  the  break  is  not  well  immobilized 
a  large  amount  is  formed.  The  greater 
the  amount  of  motion,  short  of  a  degree 
sufficient  to  cause  non-union,  the  larger  the 
amomit  of  pro\"isional  callus. 

The  ensheathing  callus  is  after  a  time 
largely  absorbed,  and  the  central  callus  in 
the  course  of  a  long  time  may  also  be 
absorbed,  -^-ith  the  restoration  of  the  med- 
ullar}* canal,  although  this  latter  result  is 
rare.  An  excessive  amoimt  of  pro^-isional 
callus  may  ossif}*  nearby  tendons,  may  miite 
parallel  bones  (radius  to  ulna,  tibia  to 
fibula,  a  rib  to  its  neighbors),  may  block  a 
joint  just  as  a  stone  in  the  crack  of  a  door 
will  block  a  door,  or  may  absolutely  abolish 
a  joint.  Fragments,  even  if  entirely  de- 
tached, often  unite,  but  they  may  be  sur- 
TOimded  by  pro\isional  callus;  sometimes 
they  do  not  cause  trouble,  but  sometimes 

suppuration  takes  place.  It  takes  about  one  >-ear  for  Nature  to  remove 
the  temporar\-  callus.  The  definitive  or  permanent  callus  after  a  time  ceases 
to  be  porous  and  becomes  ver\'  dense  bone. 

Compoimd  fractures  (Fig.  270)  -uithout  much  destruction  or  bruising  of  soft 
parts,  if  treated  antiseptically,  soon  become  simple  fractures  and  miite  as  such. 
If  the  womid  is  not  drained  and  asepticized  and  septic  inflammation  occiu-s, 
pus  forms,  and  imion  by  granulation  is  the  best  that  can  be  obtained.  Com- 
poimd fractm-es  by  direct  \-iolence  will  not  heal  by  first  intention  because 
of  the  loss  of  \-itality  of  a  large  area  of  the  soft  parts. 

Delayed  union  is  usually  due  to  imperfect  approximation  or  imstable 
fixation  of  the  fragments.  Lnperfect  approximation  may  result  from  failure 
to  reduce  the  fracture  (muscle,  ligament,  or  s^•no^-ial  membrane  being  caught 
between  the  bone-fragments) ;  the  use  of  misuitable  splints :  too  tight  applica- 
tion of  bandages;  pregnancy;  and  general  causes  of  ill  health,  for  instance,  ane- 
mia, scurfy,  Bright's  disease,  rickets,  and  s\-philis.  In  delayed  union  there  is 
pain  on  passive  motion;  in  non-union  there  seldom  is.     In  delayed  miion  there 


Fig.  271.- 


-Unxinited  fracture  of  humerus: 
imsuccessful  wiring. 


;26 


Diseases  and  Injuries  of  the  Bones  and  Joints 


is  loss  of  voluntary  motion;  in  non-union  there  is  power  of  voluntary  motion 
(A.  H.  Tubby,  in  "Brit.  Med.  Jour.,"  Dec.  7,  1901).  In  delayed  union  there 
is  apt  to  be  tenderness  on  pressure  and  often  a  quantity  of  callus  can  be  pal- 
pated. Delayed  union  is  not  non-union,  but  may  eventuate  in  non-union. 
The  exact  time  requisite  for  the  solidification  of  a  particular  fracture  cannot 
be  predicted.  The  average,  taken  from  a  large  majority  of  patients,  is  not  true 
in  a  minority.  For  no  apparent  reason  consoHdation  may  require  two  or  three 
weeks  more  than  the  average,  but  be  accomplished  at  last.  Mr.  Jones,  of  Liver- 
pool, well  says  that  ununited  fracture  is  often  the  result  of  "surgical  impa- 
tience," the  surgeon  frequently  examining  a  part  in  which  union  is  slow,  and 
that  "non-union  would  rarely  occur  if  delayed  union  obtained  proper  atten- 
tion" ("Brit.  Med.  Jour.,"  Dec.  7,  1912). 


Fig.  272. — Vicious  union  of  fractured 
bones  of  the  leg.  View  from  inner  side  of 
limb. 


Ununited  fracture  of  the  femur. 


Bending  of  Callus. — Sometimes  apparently  sound  callus  will  bend.  This 
is  particularly  apt  to  occur  in  the  leg  if  the  bones  are  not  in  correct  alignment. 
Failure  of  correct  alignment  means  great  deflection  of  the  weight  of  the  body. 
I  have  seen  shortening  of  the  femur  increase  during  the  third  month  after  a 
fracture.  Mr.  Jones,  of  Liverpool  (Ibid),  points  out  that  the  surgeon  can  re- 
fracture  bones  by  manipulation  up  to  four  months  after  the  break.  It  is  obvi- 
ous that  fractures  are  not  soundly  united  as  early  as  we  used  to  believe,  and 
that  a  patient  must  not  be  allowed  to  walk  too  early. 

Vicious  or  faulty  union  is  union  with  great  deformity  (Fig.  272).  This 
occurs  when  no  treatment  has  been  employed,  or  when  immobilization  has  been 
imperfect,  or  when  deformity  has  not  been  reduced.  It  may  arise  because  re- 
tentive dressings  have  been  removed  by  the  patient  at  too  early  a  period,  the 


Treatment  of  Fractures  527 

callus  yielding.  In  many  cases  it  is  slight  and  produces  little  or  no  pain  or 
impairment  of  usfulness.  In  other  cases  it  is  pronounced  and  produces  func- 
tional impairment  or  disastrous  pressure  on  nerves  or  vessels.  Vicious  union 
near  a  joint  always  impairs  function.  If  there  is  pronoimced  vicious  union 
the  bone  should  be  rebroken  and  set  as  a  fresh  fracture.  In  some  recent  cases 
the  bone  is  broken  by  manual  force,  and  for  a  number  of  weeks  after  a  fracture 
this  can  be  easily  accomplished.  In  older  cases  osteotomy  should  be  performed. 
Non=union  of  Fractures. — An  ununited  fracture  is  a  fracture  in  which 
imion  is  not  efifected  at  all  or  in  which  it  is  not  brought  about  by  bone  (Figs. 
271  and  273).  Xon-union  is  especiall}-  common  in  fractures  of  the  upper  third 
of  the  femur  and  of  the  middle  third  of  the  humerus.  The  causes  are  local  and 
constitutional.  The  local  causes  are:  (i)  Want  of  approximation  of  fragments; 
a  frequent  cause  of  want  of  approximation  is  interposition  of  soft  tissues — viz., 
muscle,  fascia,  or  periosteum;  this  is  a  common  cause  of  non-union,  a  cause 
responsible  for  a  decided  majority  of  the  cases:  if  soft  tissues  are  interposed, 
between  bone-fragments  non-union  is  almost  ine\-itable:  (2)  want  of  rest.  As 
pointed  out  above,  delayed  union  may  result  in  non-union  because  of  frequent 
meddlesome  examinations.  As  Jones  says,  if  there  is  no  union  at  the  end  of  the 
fifth  week  do  not  examine  daily,  but  leave  the  parts  alone  for  a  fortnight  at  least; 

(3)  want  of  blood-supply  (as  seen  in  the  heads  of  the  humerus  and  femur,  or  when 
a  nutrient  arter}-  is  torn,  or  when  a  thrombus  forms  in  a  vein  near  the  fractiu-e) ; 

(4)  defective  innerv^ation;  (5)  bone  disease;  (6)  the  use  of  imsuitable  splints; 
(7)  tight  bandaging.  The  constitutional  causes  are  debility,  scur^-}-.  Bright's 
disease,  syphilis,  etc.  Sometimes  union  fails  "without  appreciable  reason.  In 
an  imunited  fracture  the  broken  ends  of  the  bone  round  oft"  and  the  medul- 
lar}- canal  of  each  fragment  becomes  closed  by  bone.  The  fragments  mav  not 
be  held  together  by  any  material,  or  they  may  be  held  by  ven,-  thin  and  much- 
stretched  fibrous  tissue  {membranous  luuon),  or  by  strong,  thick,  fibrous 
tissue  {ligamentous  or  fibrous  union).  \Mien  the  ends  of  the  bones  come  to- 
gether, are  held  by  a  fibrous  capsule,  and  move  on  each  other,  there  exists  a 
false  joint  or  pseudo-arthrosis.  Such  a  joint  may  after  a  time  secrete  serous 
fluid  for  lubrication.  In  ver}-  rare  cases  a  fracture  once  apparently  soundly 
imited  may  at  a  later  period  be  ob^-iously  ununited,  callus  ha^ing  been  ab- 
sorbed or  broken.  Pain  on  active  motion  in  the  region  of  a  fracture  a  num- 
ber of  weeks  old  suggests  non-union.  If  there  is  also  tenderness  non-union  is 
highly  probable.  If,  -u-ith  pain  and  tenderness,  there  is  marked  thickening  from 
callus,  non-imion  is  certain  ("Brit.  Med.  Jour.,"  Dec.  7,  1912). 

Treatment  of  Fractures. — If  a  man  is  found  in  the  street  -v\ith  a  frac- 
ture, further  injuiy  must  be  prevented  by  apphing,  after  cutting  oft"  the 
clothing  over  the  fracture,  some  temporary-  support.  If  an  ambulance  or 
patrol-wagon  cannot  be  obtained,  move  the  patient  by  hand.  If  the  lower 
extremity  be  involved,  an  improvised  stretcher  (a  board  or  a  shutter)  is  placed 
on  the  ground  beside  the  patient,  who  is  laid  on  the  stretcher,  the  surgeon 
lifting  the  injured  limb,  and  the  patient  is  then  carried  to  the  hospital  and 
carefully  transferred  to  a  fracture-bed.  or,  if  taken  home,  to  a  small  ordinar}^ 
bed,  several  boards  being  placed  transversely  beneath  a  rather  hard  but  even 
mattress.  The  temporary-  appliances  are  now  removed  and  a  diagnosis  is 
made  by  the  methods  before  given.  WTienever  possible  have  .v-ray  pictures 
taken  (see  page  523).  After  determining  the  nature  of  the  injury  the  fragments 
must  be  adjusted.  This  should,  if  possible,  be  done  at  once,  because  a  fracture 
remaining  unreduced  may  become  compound,  the  fragments  may  injure  im- 
portant structures,  and  they  are  apt  to  cause  intense  pain.  Reduction  is 
easily  eft'ected  during  shock,  as  the  muscles  are  in  a  state  of  relaxation.  Early 
reduction  and  fixation  largely  prevent  swelling.  If  there  is  ver\-  great  swelling, 
reduction  may  be  impossible,  and  the  part  must  then  be  supported,  moderate 


528  Diseases  and  Injuries  of  the  Bones  and  Joints 

cold,  sorbefacients,  and  gentle  pressure  being  used,  ice  and  tight  bandaging, 
which  predispose  to  gangrene,  not  being  employed.  In  most  cases  we  can 
reduce  displacement  in  spite  of  swelling  and  cure  swelling  by  the  reduction. 
Set  the  fracture  at  the  first  possible  moment.  Velpeau's  axiom  was  to  reduce 
fractures  at  once,  regardless  of  pain,  spasm,  or  inflammation,  as  reduction  is 
their  cure.  The  longer  we  wait  to  reduce  a  fracture,  the  greater  the  amount 
of  force  necessary  to  accompHsh  it  because  of  progressive  infiltration  of  the  soft 
parts  with  inflammatory  exudate  and  blood,  a  process  which  lessens  and  finally 
destroys  tissue  elasticity.  In  reduction  try  to  get  broken  ends  in  even  appo- 
sition. In  this  we  may  fail,  but  we  must  at  least  strive  to  obtain  a  correct 
alignment.  In  order  to  obtain  apposition  or  alignment  it  may  be  necessary 
to  make  traction  by  pulleys,  and  if  this  is  done  the  patient  must  be  anesthet- 
ized (Jones,  "Brit.  Med.  Jour.,"  Dec.  7,  1912).  He  says  that  "end-to-end 
apposition  with  an  angle  of  deflection  is  less  satisfactory  than  slight  overlap- 
ping in  the  presence  of  correct  alignment"  (Ibid.). 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if  rigid  muscles 
antagonize  the  efforts  of  the  surgeon,  reduce  the  fracture  under  anesthesia.  In 
some  fractures  (as  those  of  the  clavicle)  adjustment  is  effected  by  altering 
the  position,  and  in  others  (as  those  of  the  femur)  by  extension  and  counter- 
extension,  aided  perhaps  by  pulleys;  in  some  by  tenotomy,  and  in  some  by 
kneading,  bending,  and  coaptation.  When  extension  is  employed,  always  en- 
deavor to  get  a  point  of  counterextension.  The  extension  is  to  be  made  on  the 
broken  bone  (if  possible,  in  the  axis  of  the  bone),  is  to  be  steady,  and  neither 
jerky  nor  violent.  In  some  cases  complete  reduction  is  impossible.  This  may 
be  due  to  spasm,  to  swelling,  to  the  catching  of  soft  parts  between  the  frag- 
ments, to  the  existence  of  a  loose  fragment,  to  locking,  or  to  impaction.  An 
impaction  by  rotation  can  generally  be  released,  but  it  is  sometimes  undesir- 
able to  unlock  it.  If  the  fragments  cannot  be  adjusted  without  violence,  retain 
them  in  the  best  attainable  position,  combat  the  antagonistic  cause,  and  set 
them  properly  as  soon  as  possible  or  else  operate. 

After  adjusting  the  fragments  maintain  them  in  position  by  some  appa- 
ratus. Do  not  use  set  splints  for  each  variety  of  injury.  The  splints  we 
describe  as  commonly  used  are  suited  to  many  cases,  but  in  each  case  a  sur- 
geon uses  the  plan  of  treatment  which  in  his  opinion  is  suitable  to  that  case. 
In  a  given  case  the  routine  plan  may  prove  unsuitable.  The  treatment  is 
to  be  adjusted  to  the  individual  case.  The  case  is  never  to  be  forced  to  an 
unsuitable  routine  treatment.  All  sorts  of  materials  are  used  for  splints, 
among  them  may  be  mentioned  wood,  felt,  pasteboard,  plaster  of  Paris,  silicate 
of  sodium,  tin  (Levis),  and  aluminum  (Elsberg).  Avoid  pressure  over  joints 
or  bony  prominences  and  particularly  guard  against  tight  or  improper  bandag- 
ing. In  fracture  of  a  bone  of  a  limb  the  circulation  in  the  fingers  or  toes  must 
be  observed  as  an  index  of  circulation  in  the  limb;  hence  leave  those  digits 
exposed.  A  retentive  apparatus  should  prevent  the  redevelopment  of  deformity, 
and  not  be  itself  productive  of  pain  or  harm.  For  the  first  few  days  of  treat- 
ment of  a  simple  fracture  the  dressing  is  removed  every  day,  to  make  sure  that 
deformity  has  not  recurred,  and  if  it  does  recur  the  fragments  must  at  once  be 
reset.  The  spHnts  should  be  padded  thoroughly,  especially  when  over  joints 
or  bony  prominences,  and  they  should,  if  possible,  fix  the  joints  immediately 
above  and  below  the  break.  A  primary  roller  should  not  be  used  unless  plaster 
is  to  be  employed.  By  a  primary  roUer  is  meant  a  bandage  applied  to  the  ex- 
tremity before  splints  are  placed  upon  it. 

Some  surgeons  at  once  apply  an  immovable  dressing.  This  proceeding  is 
safe  in  simple  fractures  without  much  displacement  or  soft-part  injury.  This 
dressing  is  valuable  in  military  practice,  for  the  old  and  feeble  whom  we  fear 
to  put  to  bed,  for  the  young  who  are  very  restless,  and  for  the  insane  or  the 


Ambulatory  Treatment  of  Fractures  529 

delirious.  If,  however,  there  is  great  deformity,  much  soft-part  injury,  or 
marked  swelling,  immovable  dressings  may  induce  sloughing,  edema,  gangrene, 
or  faulty  union.  In  the  above-named  cases  use  ordinary  splints  for  the  first  few 
days;  then,  if  it  is  desirable,  the  immovable  dressing  can  be  applied.  Plaster-of- 
Paris  bandages  are  used  with  great  care  in  very  young  children,  as  gangrene  might 
result  from  careless  application.  It  is  dangerous  to  keep  old  or  feeble  persons 
long  in  bed,  as  they  are  prone  to  develop  bed-sores  and  hj-postatic  pulmonary 
congestion.  The  period  for  the  artificial  retention  of  the  fracture  varies  with 
the  seat  of  the  fracture  and  the  age  and  condition  of  the  patient.  Passive 
motion  is  to  be  made  in  most  fractures  in  from  two  to  three  weeks,  though  it  is 
sometimes  made  earlier  to  prevent  ankylosis,  and  sometimes  later  because  of 
risk  of  non-union.  Landerer  strongly  advocates  massage,  beheving  that  it 
hastens  union  and  prevents  wasting.  He  applies  it  as  soon  as  there  is  no 
danger  of  the  callus  bending  (in  from  eight  to  fourteen  days).  Massage 
should  not  be  used  when  great  edema  points  to  the  possibility  of  venous  throm- 
bosis. The  movements  might  break  up  a  clot  and  cause  fatal  embolism.^  Very 
early  massage  may  cause  fat-emboHsm.  In  fracture  of  the  patella  wiring  is 
frequently  performed,  and  wiring  or  plating  is  frequently  practised  in  fracture 
of  the  cla\dcle,  fracture  of  the  tibia,  fracture  of  the  upper  third  of  the  femiir, 
and  other  regions.  If  fragments  cannot  be  approximated  or  retained  by 
ordinary  methods,  an  incision  should  be  made,  approximation  effected,  and 
the  fragments  retained  by  wire,  a  clamp,  a  plate,  or  a  bone  ferrule. 

The  plan  known  as  the  ambulatory  treatment  of  fractures  of  the  lower 
extremities  has  had  warm  advocates.  The  ambulatory  spHnt  is  an  apparatus 
which  enables  a  man  to  walk  about  a  few  days  after  receiving  a  fracture  of  the 
leg  or  thigh.  It  was  devised  by  Hessing,  a  carpenter  dwelling  in  a  village  near 
Augsburg.  Its  aim  is  not  only  to  get  the  patient  about  on  crutches,  but  also 
to  cause  him  to  use  the  limb.  It  is  held  that  this  plan  of  treatment  greatly 
lessens  the  patient's  sufferings  and  actually  favors  union  by  the  stimulation  of 
walking.  Bardeleben,  in  his  report  to  the  German  Surgical  Congress,  gave  the 
records  of  in  fractures  of  the  lower  extremity  thus  treated  (77  simple  and 
12  compound  fractures  of  the  leg,  17  simple  and  5  compound  fractures  of 
the  thigh).  The  patients  were  gotten  about  a  few  days  after  the  accident, 
were  able  to  attend  to  business,  had  excellent  appetites,  digested  their  food 
perfectly,  slept  well,  and  were  saved  from  muscular  atrophy.  Pilcher  has 
warmly  advocated  the  method.  It  can  be  used  in  fractures  as  high  up  as  the 
middle  of  the  femur.  The  apparatus  which  we  should  employ  in  the  ambu- 
latory treatment  reaches  below  the  sole  of  the  foot,  and  is  supported  firmly 
above  the  seat  of  fracture,  the  weight  of  the  body  being  transferred  from 
above  the  fracture  to  the  firm  pad  below  the  sole  of  the  foot  on  which  the 
patient  walks  (Figs.  274  and  275) .  This  appHance  in  a  fractured  thigh  is  put  on 
about  one  week  after  the  infliction  of  the  injury.  While  the  patient  sits  on  the 
ischial  tuberosities  extension  is  made  upon  the  leg.  The  seat  of  fracture  is  en- 
circled by  a  thin  plaster  cast.  The  sole  of  the  other  foot  is  raised  by  a  cork 
sole.  Albers,  when  treating  a  fractured  thigh,  uses  plaster  of  Paris_  strength- 
ened by  bits  of  wood,  running  from  below  the  sole  of  the  foot  to  the  iliac  crept. 
Krause  says  in  fracture  of  the  ankle  carry  the  dressing  to  the  head  of  the  tibia; 
in  fracture  of  the  leg  carry  it  to  the  middle  of  the  thigh;  in  fracture  of  the  lower 
end  of  the  femur  carry  it  to  the  pelvis.-  Bradford  warmly  advocates  the  use  of 
Thomas's  splint  often  combined  with  plaster  of  Paris.  During  the  last  few- 
years  surgeons  have  come  to  recognize  that  ambulatory  treatment  must  not  be 
used  for  all  fractures  of  the  lower  extremity  and  is  only  suited  to  selected 
cases. 

1  Ceme's  case,  in  "Normandie  med.";  "Bull,  med.,"  1895,  No.  44. 
-  "Centralbl.  f.  Chir.,"  vol.  xxii,  1895. 

34 


530 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Prevention  and  Treatment  of  Complications. — In  every  case  of  frac- 
ture of  an  extremity  feel  for  the  pulse  between  the  periphery  and  the  seat  of 
injury  in  order  to  be  sure  the  artery  is  not  ruptured.  If  the  soft  parts  are  badly 
contused,  try  to  prevent  sloughing  by  employing  rest  and  relaxation  and  by 
applying  heat.  If  superficial  sloughing  occurs,  treat  antiseptically,  remember- 
ing that  even  a  superficial  excoriation  can  admit  bacteria  which,  carried  by  the 
blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads  down  to  the  fracture, 
treat  the  case  as  a  compound  fracture.  If  there  be  great  blood  extravasation 
the  danger  is  gangrene,  and  after  fracture  of  the  lower  extremity  the  foot  of  the 
bed  may  be  elevated,  or,  better,  after  fracture  of  the  upper  or  lower  limb  the 
extremity,  to  which  splints  and  bandages  are  to  be  loosely  apphed,  is  to  be 
raised  and  surroimded  with  hot  bottles.    If  a  bleb  forms,  it  is  to  be  opened 


Fig.  274. — ^Ambulatory  dressing  of  plaster  of  Fig.  275. — .\mbulatory  dressing  apparatus  for 
Paris  for  fracture  of  the  bones  of  the  leg  (PU-  fracture  of  thigh  (Harting). 

cher) . 

with  a  clean  needle  and  dressed  antiseptically.  If  gangrene  occurs,  treat  by 
the  usual  rules.  Frequently  after  fracture  of  a  bone  blebs  containing  reddish 
serum  form  on  the  skin.  The  appearance  of  blehs  when  the  circulation  is  good 
does  not  mean  gangrene,  and  is  not  of  any  particular  consequence.  If  blebs 
are  distinct  symptoms  of  circulatory  impairment,  gangrene  impends  or  already 
exists. 

Edema  may  be  due  to  tight  bandaging.  If  it  is  due  to  phlebitis,  there  is 
danger  of  pulmonary  or  cerebral  embolism.  In  phlebitis  elevate  the  limb, 
remove  all  constriction,  and  employ  locally  ichthyol  ointment ;  do  not  use  mas- 
sage, and  give  stimulants  by  the  mouth.  In  edema  due  to  weak  circulation  or 
venous  relaxation  use  daily  frictions  and  firm  bandaging.  If  the  fracture  in- 
volves a  joint,  carefully  adjust  the  fragments,  make  passive  motion  early,  and 
inform  the  patient  that  he  is  in  danger  of  a  permanently  stiff  joint. 


Treatment  of  Compound  Fractures 


531 


A  dislocation  occurring  with  a  fracture  is  reduced  at  once  if  possible.  To 
do  this,  splint  the  limb  and  give  ether,  and  try  to  reduce  while  the  limb  is  mass- 
aged, using  the  splint  as  a  handle.  Allis  is  often  able  to  reduce  a  dislocation 
accompanied  by  a  fracture.  He  uses  the  untorn  portion  of  periosteum  as  a 
hinge,  pulls  upon  the  lower  fragment,  and  thus  draws  down  the  upper  frag- 
ment and  pushes  it  in  place 
by  manipulation.  If  this  fails, 
it  is  best  to  incise  and  pull  the 
separated  end  in  place  by  the 
hook  of  McBurney  and  Dowd 
(Figs.  276-278) ;  but  some  sur- 
geons say,  get  the  bones  in 
the  best  possible  position,  set 
them,  await  union,  and  then 
treat  the  unreduced  disloca- 
tion. A  rupture  of  the  main 
artery  of  the  Hmb  presents  the 
symptoms  of  absent  pulse  below  the  rupture,  a  timior  which  may  pulsate, 
and  possibly  a  whirring  sound  or  an  aneurysmal  thrill  and  bruit.  This  con- 
dition demands  that  the  surgeon  should  apply  an  Esmarch  bandage,  cut  down 
upon  the  tumor,  turn  out  the  clot,  and  Hgate  each  end  of  the  vessel.  Rupture 
of  the  main  vein  of  a  hmb  causes  intense  edema  and  calls  for  sutures,  lateral 

ligature,  or  complete  ligation. 

0-' 


Fig.  276. — Fracture-hook  (McBurney  and  Dowd). 


course 

upper 

almost 

lower. 


277 


-Fracture-hook    appHed    at   base   of 
process  (McBurney  and  Dowd). 


If  these  measures  fail  after  in 
jury  of  vein  or  artery  it  is 
seldom  successful  to  ligate 
higher  up.  Such  a 
might  succeed  in  the 
extremity.  It  would 
certainly  fail  in  the 
Amputation  will  probably  be 
necessary.  If  gangrene  ap- 
pears, amputate  at  once  above 
the  seat  of  the  fracture. 

Inflammation  is  to  be  treated 
by  compression,  rest,  moderate 
cold,  and  later  by  50  per  cent,  ichthyol  ointment.  Muscular  spasm  requires 
morphin  internally,  firm  bandaging,  or  even  tenotomy.  Fat-embolism  is 
treated  by  stimulants  and  inhalation  of  oxygen,  and  possibl}^  artificial  respira- 
tion. Shock,  delirium  tremens,  urinary  retention,  etc.,  are  treated  according 
to  the  ordinary  rules  of  surgery. 
Functional  Result  of  Non- 
operative  Treatment. — Union 
with  a  good  anatomical  result 
means  a  good  fimctional  re- 
sult in  over  90  per  cent,  of  the 
cases.  We  used  to  suppose 
that  a  good  functional  result  is 
usual  even  with  a  poor  anatom- 
ical result,  but  Jones  ("Brit. 
Med.  Jour.,"  Dec.  7,  191 2)  shows  that  we  get  it  in  less  than  30  per  cent,  of 
cases  in  which  the  anatomical  result  is  bad. 

Treatment  of  Compound  Fractures. — It  must  first  be  decided,  in  a  case 
of  compound  fracture  of  a  limb,  if  amputation  is  necessary,  and  the  a;-rays  are 
of  great  value  in  determining  the  condition  of  the  bones  in  a  crushed  part. 


Fig.  278. — Fracture-hook   inserted   in  displaced   fragment 
(McBurney  and  Dowd). 


532  Diseases  and  Injuries  of  the  Bones  and  Joints 

Amputation  is  demanded  when  the  limb  is  completely  crushed  or  pulpified 
through  its  entire  thickness;  when  extensive  pieces  of  skin  are  torn  off;  when 
the  main  artery,  vein,  and  nerve  are  torn  through;  and  sometimes  when  there 
is  violent  hemorrhage  from  a  deep-seated  vessel  or  when  an  important  joint 
is  splintered.  What  is  to  be  done  is  to  some  extent  determined  by  the  patient's 
age  and  general  health.  In  a  healthy  young  person,  if  in  doubt,  give  the  limb 
the  benefit  of  the  doubt  and  try  to  save  it;  if  the  artery  alone  is  ruptured,  cut 
down  upon  it  and  tie  both  ends;  if  the  vein  alone  is  torn,  suture  it,  apply  a 
lateral  ligature,  or  tie  both  ends;  if  the  nerve  is  severed,  suture  it;  if  a  joint 
is  opened,  drain  and  asepticize.  If  an  attempt  is  made  to  save  the  limb,  be 
ready  at  any  time  to  amputate  for  gangrene,  secondary  hemorrhage  (if  re- 
ligation  at  original  point  and  compression  high  up  fail),  extensive  cellulitis, 
and  profuse  and  prolonged  suppuration.^  When  it  is  determined  to  try  to  save 
the  limb,  the  part  must  be  cleansed  thoroughly  by  the  antiseptic  method  (in 
no  injuries  is  this  more  important) .  If  a  small  portion  of  bone  protrudes,  cleanse 
the  skin  of  the  extremity  and  the  protruding  bone,  push  the  spicule  out  a  little 
more,  and  cut  it  off.     If  a  large  piece  of  bone  is  protruded  it  must  not  be  cut 


Fig.  279. — Fenestrated  plaster-of-Paris  dressing.     Drainage-tube  pulled  through  limb. 

away,  but  should  be  thoroughly  disinfected,  and  after  the  skin  wound  has 
been  enlarged  should  be  returned  into  place.  Hemorrhage  requires  a  free  in- 
cision to  permit  of  ligation  of  bleeding  points.  In  most  comminuted  fractures 
splinters  should  not  be  removed.  To  remove  them  favors  non-union.  In 
all  cases  a  drainage-tube  must  be  carried  down  to  the  seat  of  fracture,  and 
in  some  cases  a  counteropening  must  be  made  and  the  tube  be  pulled  through 
the  limb  (Fig.  279). 

After  inserting  the  tube  the  wound  is  sutured,  a  plentiful  antiseptic  dressing 
is  applied,  and  the  extremity  is  dressed  with  plaster.  The  plaster  can  be  ap- 
plied over  a  narrow  strip  of  wood,  trap-doors  or  fenestra  being  cut  in  the  plaster 
before  it  sets  (the  fenestrated  splint)  (Fig.  279).  The  wound  is  then  covered 
with  gauze  and  a  bandage. 

The  bracketed  splint  is  a  better  dressing  than  the  one  just  described.  After 
the  wound  has  been  dressed  with  gauze,  plaster  is  at  once  applied  over  the  ends 
of  brackets  (Fig.  280).  The  above  methods  not  only  immobilize  the  fractured 
bones,  but  keep  the  parts  aseptic  and  afford  easy  access  to  the  woimd.  The 
drainage-tubes  are  usually  removed,  if  suppuration  does  not  occur,  in  from 

1  See  Howard  Marsh,  on  "Fractures,"  in  Heath's  "Dictionary  of  Practical  Surgery." 


Treatment  of  Compound  Fractures 


533 


Fig.  280. — Bracketed  plaster-of-Paris  dressing. 


forty-eight  to  seventy-two  hours.    The  wound  is  treated  as  any  other  wound. 

In  some  compound  fractures  there  is  difficulty  in  retaining  the  fragments  in 

apposition  (lower  end  of  femur,  upper  third  of  femur).    In  such  cases  the  ends 

of  the  bone  should  be  resected  and  the  bones  should  be  fastened  together  as  in 

a  case  of  ununited  fracture,  with  silver  wire,  aluminum  wire,  chromicized  catgut, 

kangaroo-tendon,  or  the  bones  should  be  plated.     In  a  compound  fracture  of 

the  patella,  after  free  incision  and  disinfection,  investigate  to  determine  the 

gravity  of  the  injury.     In  an  ordinary  case  in  which  there  are  two  or  three 

fragments,  open  the  joint,  irrigate  with  saline  fluid,  drill  the  fragments,  and 

fasten  them  with  silver  wire. .  Very  small  fragments  should  be  removed.     A 

tube  is  carried  into  the  joint,  the  wound  is  sutured  and  dressed,  and  the  limb 

is  immobilized  in  extension.      In  a  case  of  severe  compound  comminuted 

fracture  of  the  patella, 

after    disinfection,    any 

completely    loose    piece 

should  be  removed  and 

"the  remaining  portions 

made  smooth  with  bone 

forceps    and    the   sharp 

spoon.  "^    The  wound  is 

only  partially  sutured,  is 

drained  and  dressed,  and 

the  limb  is  placed  on  a 

straight  posterior  splint. 

If  a  fracture  of  a  rib  is  compound  internally,  resect  the  rib;  if  it  is  compound 

externally,  dress  antiseptically. 

Compound  fractures  may  be  followed  by  gangrene,  sloughing,  periostitis, 
septicemia,  pyemia,  osteomyelitis,  necrosis,  etc. 

Operative  Treatment  of  Recent  Fractures. — Many  cases  are  now  operated 
upon  primarily.  Others  are  operated  upon  because  non-operative  methods 
fail  to  obtain  or  to  maintain  good  position.  In  some  fractures  reduction  and 
fixation  are  only  possible  by  operation. 

Skiagraphs  have  demonstrated  that  the  ordinary  non-operative  treatment 
is  often  follow^ed  by  permanent  displacement.  In  many  cases  this  does  not 
seriously  impair  function,  in  not  a  few  it  does.  There  is  much  impairment 
of  function  after  fracture  of  the  patella  with  wide  gaping  of  the  fragments, 
and  after  fracture  of  the  femur  with  repair  in  a  position  of  marked  angulation 
or  decided  overlapping. 

The  most  perfect  results  are  obtained  by  operation,  which  exposes  the 
fracture  and  enables  the  surgeon  to  correct  the  deformity  and  solidly  fix  the 
fragments.  Practically  all  surgeons  agree  that  for  fracture  of  the  patella, 
fracture  of  the  olecranon,  and  fracture  of  a  long  bone  with  incomplete  re- 
duction, or  in  which  deformity  recurs  in  spite  of  splintering,  operation  gives 
the  best  chance  for  a  good  functional  result.  In  most  fractures  of  long  bones 
treated  conservatively  perfect  apposition  of  the  fragments  is  not  obtained, 
although  we  may  think  it  has  been.  Bloodgood  points  out  that  in  fractures 
near  joints  there  is  great  difficulty  in  reduction  and  little  evidence  of  deformity. 

The  Special  Committee  of  Inquiry  of  the  British  Medical  Association  in  a 
recent  report  warmly  advocates  operation  in  many  cases,  Jones,  of  Liverpool, 
although  believing  as  a  general  rule  in  non-operative  treatment,  says  that  if 
in  any  case  there  is  sound  reason  to  doubt  the  successful  outcome  of  non- 
operative  treatment,  operation  should  be  performed.  He  opposes  waiting  to 
see  what  happens  because  the  delay  may  lose  the  chance  of  obtaining  a  good 
functional  result  ("Brit.  Med.  Jour.,"  Dec.  7,  1912). 
1  Lilienthal's  "Imperative  Surgery." 


534  Diseases  and  Injuries  of  the  Bones  and  Joints 

Personally,  I  follow  Mr.  Jones's  rule  and  operate  when  I  fear  that  con- 
servative treatment  may  fail.    I  operate  primarily  for: 

Fracture  of  the  patella. 

Fracture  of  both  bones  of  the  leg  in  the  lower  third. 

Most  fractures  of  the  os  calcis. 

Some  cases  of  Pott's  fracture. 

Most  cases  of  fracture  of  the  upper  third  of  the  femur. 

Some  fractures  of  the  neck  of  the  femur  in  the  young  and  middle  aged. 

Some  fractures  of  the  surgical  neck  of  the  humerus. 

Fractures  of  the  olecranon,  especially  those  in  which  the  upper  fragment 
has  rotated. 

Some  fractures  of  the  elbow-joint. 

Some  fractures  of  both  bones  of  the  forearm  (in  order  to  preserve  pronation 
and  supination). 

Some  fractures  of  the  metacarpus. 

Fractures  of  the  zygoma. 

Some  fractures  of  the  mandible. 

Fractures  of  the  clavicle  when  complete  reduction  is  impossible  or  when 
sharp-pointed  fragments  threaten  to  pierce  the  skin  or  damage  important 
structures. 

In  compound  fractures,  in  many  comminuted  fractures,  if  an  important 
nerve  or  blood-vessel  has  been  divided. 

Most  children  are  managable  by  conservative  methods  and  do  not  do  as 
well  as  adults  after  operation.  Hence  in  children  I  am  more  conservative  than 
in  adults. 

Again,  do  not  forget  that  operation  may  not  give  a  good  functional  result. 
It  often  fails  to  do  so.  If  this  is  not  well  understood  both  the  surgeon  and  pa- 
tient may  be  disappointed  after  operation.  There  is,  of  course,  some  risk  in  the 
treatment  by  incision,  and  it  is  only  justifiable  in  competent  hands  and  amid 
proper  surroundings.  The  occasional  operator  should  look  to  it  with  less  con- 
fidence than  the  daily  operator.  If  infection  occurs  it  will  be  a  catastrophe, 
and  may  cause  death,  hence  perfect  asepsis  is  imperatively  required.  It  can 
never  be  routine  treatment  and  will  never  be  extensively  employed  outside  of 
a  hospital. 

If  operation  is  determined  upon,  an  incision  is  made,  the  bone  is  inspected, 
tissue  intervening  between  the  fragments  is  removed,  and  the  fragments  are 
coaptated  and  fixed  by  screws  and  a  perforated  plate,  by  silver  wire  sutures, 
bone-ferrules,  chromic  catgut,  nails,  or  some  form  of  clamp. 

Plates  and  screws  give  the  best  results.  Wire  used  for  fracture  of  a  long 
bone  acts  as  a  hinge,  and  in  a  wired  fracture  the  alignment  is  apt  to  be  dis- 
turbed. Wire  was  first  used  for  this  purpose  in  1775  by  Lapeyode  and  Sicre,  of 
Toulouse  (Geo.  W.  Guthrie,  ''Amer.  Med.,"  March  7,  1903).  It  is  now  seldom 
used  except  for  the  patella,  the  olecranon,  the  clavicle,  the  zygoma,  and  the 
anatomical  neck  of  the  humerus.  I  prefer  the  steel  plates  of  Arbuthnot  Lane 
(Fig.  281)  or  the  silver  plates  of  Halsted.  These  plates  are  perforated  for 
screws.  The  plate  is  not  removed  unless  it  loosens  or  gives  trouble.  After 
operation  the  extremity  must  be  carefully  fixed  by  splints  or  plaster  of  Paris; 
the  circulation  must  be  watched,  guarded,  and  maintained;  massage  should  be 
used  and  passive  motion  be  employed  as  in  a  case  treated  by  the  non-operative 
method.  If  rigid  fixation  of  the  fragments  is  obtained  and  maintained  repair 
will  usually  occur  with  very  little  callous  formation. 

Treatment  of  Delayed  Union  and  Ununited  Fracture  (see  page  692). — When 
delayed  union  exists,  seek  for  a  cause  and  remove  it,  treating  constitutionally  if 
required,  and  thoroughly  immobilizing  the  parts  by  plaster.  Orthopedic  splints 
may  be  of  value.    Use  of  the  limb  while  splinted,  percussion  over  the  fracture,. 


Treatment  of  Fractures 


535 


and  rubbing  the  fragments  together,  thus  in  each  case  producing  irritation,  have 
all  been  recommended.  Blistering  the  skin  with  iodin  or  firing  it  has  been  em- 
ployed. If  the  union  be  very  long  delayed,  forcibly  separate  the  fragments  and 
put  up  the  limb  in  plaster 
as  we  would  a  fresh  break. 
If  these  means  fail,  irritate 
by  subcutaneous  drilling 
or  scraping,  or,  better,  by 
laying  open  the  parts  and 
then  drilling  and  scraping 
at  many  places.  Buechner 
advocates  the  induction 
of  h^-peremia  by  a  con- 
stricting band,  just  as 
Bier  induces  congestive 
hyperemia  in  treating  tu- 
berculous areas.  At  first 
the  constriction  is  per- 
mitted to  remain  but  a 
short  time,  but  the  period 
is  lengthened  every  day, 
imtil  in  a  few  days  it  re- 
mains almost  continuously 
day  and  night.  It  is  to 
cause  a  pinkish-blue  flush 
of  skin,  but  not  pain.  The 
limb  must  be  warm  to  the 
touch.  During  the  two  or 
three  hours  daily  that  the 
band  is  off  raise  the  limb  to 
relieve  edema.  Ten  days  of 
this  treatment  will  inaugu- 
rate imion  in  many  cases. 
Helferich  devised  this 
method  in  1 88  7 .  In  several 
cases  I  have  thought  that 
it  did  good.  I  also  administered  thyroid  extract  to  these  patients.  Lanne- 
longue  and  Menard  inject  a  i :  10  solution  of  zinc  chlorid  between  the  frag- 
ments.    I  have  had  several  successes  with  this  plan.     Leaving  acupuncture 


281. — Lane's  vanadium  steei  plates. 


Fig.  282. — Richter's  bone-drill  (pistol  grip). 

needles  in  for  days  is  approved  by  some,  and  electropuncture  is  advocated  by 
others.  Cases  of  ununited  fracture  must  be  treated  by  excision  of  the  bony 
ends  and  fibrous  tissue,  securing  the  fragments  together  by  periosteal  sutures, 
by  pins,  by  screws  and  plates,  by  ivory  pegs,  by  screws,  by  silver  or  alimiinum 


536 


Diseases  and  Injuries  of  the  Bones  and  Joints 


bronze  wire,  by  kangaroo-tendon,  by  Senn's  bone-rings  or  bone-ferrules,  or  by 
chromicized  catgut.  Personally,  I  use  Lane's  plates,  made  of  vanadium  steel. 
Delonne  makes  an  incision,  removes  bone-splinters  and  fibrous  tissue,  smooths 


Fig.  2 


^. — Lowman's  combination  bone 
and  plate  holder. 


Fig.  283. — Lowman-Lambotte  bone-holding  forceps 

off  one  end,  forces  this  into  the  bored-out  medtillary  canal  of  the  other  fragment, 
and  sutures  the  periosteum.  Gussenbauer's  clamp  will  often  give  a  good  result, 
and  was  used  for  years  by  Billroth.  This  is  a  metal  bar  with  two  nails  set  at 
right  angles  to  the  bar.  One  nail  is  driven  into  each  fragment.  Langenbeck 
fixed  a  screw  into  each  fragment 
and  connected  the  screws  by  a 
piece  of  iron.  Parkhill's  clamp, 
which  is  an  improvement  on 
Langenbeck's  instrument,  se- 
cures absolute  immobility  and 
is  a  very  useful  instrument. 

Sometimes  union  fails  in 
spite  of  a  formidable  operation. 
In  such  cases  there  is  no  tend- 
ency to  bone  production.  A 
bone-graft  may  be  partially  sepa- 
rated from  one  of  the  fragments  and  interposed  between  the  freshened  ends,  a 
bone-graft  may  be  taken  from  the  sound  tibia  and  be  interposed,  fresh  bone- 
splinters  may  be  interposed,  or  a  portion  of  a  rib  may  be  used  with  screws  or 
nails  as  a  clamp.  It  is  always  desirable  to  take  the  bone- 
graft  from  the  individual.  Such  a  graft  is  more  power- 
fully stimulating  to  bone  growth  than  a  graft  from 
another  individual  or  from  one  of  the  lower  animals. 
Transplantation  from  the  lower  animals  has,  however, 
been  successfully  practised  (see  page  503). 

Treatment  of  Vicious  Union. — If  angular  deformity 
results  from  faulty  union,  it  can  be  corrected  by  molding 
the  part   into  shape  while  the  callus  is  soft.     If   the 

callus  has  become 
hard,  the  bone  can 
be  refractured.  If 
faulty  union  occurs 
with  overriding,  an 
osteotomy  can  be 
performed. 


oni 


ODII 


4 


-zh 


Fig.  285. — Sherman's  bone  bolts  and  nut-driver. 


Special  Fractures. — Nasal  bones,  because  of  their  situation,  are  often 
broken.  The  commonest  seat  of  fracture  is  through  the  lower  third,  where 
the  bones  are  thin  and  lack  support.  The  fracture  is  usually  compound  exter- 
nally or  through  the  mucous  membrane  internally.  The  cause  is  direct  violence. 
Displacement  may  not  occur  at  all,  but  when  present  it  arises  purely  from 


Fractures  of  the  Nasal  Bones 


537 


force,  and  never  from  muscular  action,  no  muscle  being  attached  to  these  bones. 
If  the  force  is  from  the  front,  the  nose  is  flattened;  if  from  the  side,  it  is  deflected. 
Displacement  is  soon  masked  by  swelling.  Crepitus  can  sometimes  be  elicited 
by  lightly  grasping  the  upper  part  of  the  nose  with  the  fingers  of  one  hand  and 
moving  it  gently  below  from  side  to  side  with  the  fingers  of  the  other  hand. 
Preternatural  mobility  is  valueless  as  a  sign,  because  of  the  natural  mobility  of 
the  cartilages.  Nose-breathing  is  difiicult  because  of  blocking  of  the  nostrils 
by  blood-clot.    Diagnosis  may  be  almost  impossible  when  deformity  is  absent. 

The  complications  that  may  be  noted  are  cerebral  concussion,  brain  S}Tnp- 
toms  from  impHcation  of  the  frontal  bone  or  cribriform  plate  of  the  ethinoid 
bone,  and  extension  of  the  fracture  to  the  superior  maxillary-  or  lachrymal 
bones.  Emphysema  of  the  root  of  the  nose,  the  eyelids,  and  the  cheeks  is  com- 
mon, and  means  either  a  rent  in  the  mucous  membrane  of  Schneider  or  a  crack 
in  the  frontal  sinus.  There  may  be  much  discoloration  because  of  subcutaneous 
hemorrhage.  Epistaxis  is  usual,  and  is  recognized  from  the  epistaxis  produced 
by  fracture  of  the  base  of  the  skull  by  the  facts  that  the  bleeding  in  the  first 
condition,  although  profuse,  is,  as  a  nile,  soon  checked,  and  is  not  followed  by 
oozing  of  cerebrospinal  fluid,  whereas  in  the  second  condition  it  is  profuse,  con- 
tinued, and  is  perhaps  followed  by  a  flow  of  cerebrospinal  fluid.  Fracture  of 
the  bony  septum  occasionally  complicates  nasal  fractures,  and  de\dation  of  the 
cartilaginous  septum  often  takes  place.  Suppuration  may  occur  and  necrosis 
of  bone  or  cartilage  may  follow.    The  prognosis  is  usually  good. 

Treatment. — ^WTienever  possible  nasal  fractures  should  be  treated  by  a 
rhinologist.  After  cocainizing  the  nares  a  careful  inspection  should  be  made 
by  means  of  a  mirror  and  a  light  to  determine  if  there  is  any  injur\^  of  the 
septum.  This  point  must  be  determined  in  order  that  the  deformity  of  the 
septum  may  be  corrected  at  the  same  time  as  the  deformity  of  the  nasal  bones. 
WTien  there  is  no  displacement,  or  when  a  displacement  does  not  tend  to  be 
reproduced  after  reduction,  employ  no  retentive  apparatus  of  any  kind.  Order 
the  patient  not  to  blow  his  nose  for  ten  days  and  syringe  it  daily  "^ith  a  solu- 
tion of  bicarbonate  of  sodium.  If  deformity  be  noted,  correct  it  at  once,  as  the 
bones  soon  unite  in  deformity.  If  the  attempts  at  reduction  are  very-  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give  ether  to  obtain 
primar}-  anesthesia.  Reduction  is  effected  by  a  grooved  director  or  steel  knit- 
ting-needle T\Tapped  in  iodoform  gauze  and  passed 
into  the  nostril;  the  fragments  are  lifted -nith  this 
instrument,  and  the  fingers  externaUy  mold  them 
into  place.  A  rubber  dilator  can  be  used  in  re- 
duction. This  is  pushed  into  the  nose  and  inflated 
by  air  or  water.  If  the  septum  is  de\'iated  and  can- 
not be  pushed  in  place  by  a  metal  sound,  it  must 
be  twisted  into  place  by  means  of  septum  for- 
ceps. If  bleeding  is  moderate,  check  it  with 
cold;  if  severe,  by  plugging.  "For  fractures 
high  up  with  displacement,  gauze  packing  car- 
ried well  up  ■^•ill  be  required  to  retain  the  elevated 
bones.  For  lower  de\-iations  the  Asch  tube  -^-ill 
be  needed"  (Scudder,  on  "The  Treatment  of 
Fractiu-es") .  A  hollow  \nilcanite  plug  is  inserted 
in  each  nostril  and  the  nose  is  molded  into  cor- 
rect shape  over  the  plug.  The  patient  breathes  through  the  hoUow  plug. 
A  thread  rims  from  each  plug  and  is  fastened  to  the  cheek  by  adhesive 
plaster.  Once  or  twice  a  day  the  plugs  are  removed,  cleaned,  and 
greased  T\ith  iodoform  ointment.  The  nose  is  cleared  and  the  plugs  are 
reinserted.    If  flattening  tends  to  recur,  pass  a  Mason  pin  (Fig.  286)  just 


Fig.  286. — Mason's  pin. 


538  Diseases  and'  Injuries  of  the  Bones  and  Joints 

beneath  the  fragments,  through  the  line  of  fracture  and  out  the  opposite  side. 
Steady  the  fragments  by  a  piece  of  rubber  externally  caught  on  each  end  of 
the  pin,  or  with  figure-of-8  turns  around  the  ends  with  silk.  Leave  the 
pin  in  place  for  five  days.  The  instrument  of  Mason  is  a  sharp,  strong, 
nickel-plated  pin,  with  a  triangular  point. 

If  lateral  deformity  tends  to  recur,  hold  a  compress  over  the  fracture  or 
fix  a  molded-rubber  splint  over  the  nose  by  a  piece  of  rubber  plaster  i^ 
inches  broad  and  long  enough  to  reach  well  across  the  face,  and  use  com- 
pression for  ten  days.  In  neither  of  the  above 
cases  is  the  nose  to  be  blown,  and  in  both  cases 
it  is  to  be  syringed  once  or  twice  a  day.  In 
fractures  rendered  compound  by  tears  in  the 
mucous  membrane,  irrigate  "odth  normal  salt 
-Jones's  nasal  splint.  Solution  or  boric  acid  solution,  holding  the 
head  so  that  the  solution  will  not  nm  into 
the  mouth;  plug  with  iodoform  gauze  aroimd  a  small  rubber  catheter,  which 
instrument  permits  nose-breathing;  carefully  remove  the  gauze  daily  and 
syringe.  In  fractures  compound  externally  cleanse  antiseptically  externally, 
and  dress  with  a  film  of  cotton  soaked  in  iodoform  collodion  or  compound  tinct- 
ure of  benzoin,  or  apply  sterile  gauze.  Fractures  of  the  bony  septum,  if  show- 
ing a  tendency  to  reproduction  of  deformity,  require  packing  as  above  explained, 
or  the  use  of  a  special  splint  within  the  nostrils  (Fig.  287),  or  the  appHcation 
of  vulcanite  plugs,  so  made  that  the  patient  can  breathe  through  them  and 
threads  can  be  attached  to  them.  Fractures  of  the  nasal  cartilages  are  to  be 
pinned  in  place.  Fractures  of  the  nose  are  entirely  united  in  from  ten  to 
twelve  days. 

Fractures  of  the  Lachrymal  Bone. — The  lachrymal  bone  may  be  broken 
when  the  nasal  bones,  a  superior  maxillary  bone,  or  the  lateral  plate  of  the 
ethmoid  are  fractured,  and  union  is  solid  in  from  three  to  four  weeks.  The 
question  of  how  much  deformity  is  to  be  expected  is  always  uncertain,  and  in 
not  a  few  cases  obstruction  of  the  nose  follows  fracture  because  of  damage  to 
the  septima. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture  of  the  other  bone 
or  bones.  Maintain  the  patency  of  the  lachrjnnal  duct  by  frequently  pass- 
ing a  clean  probe. 

Fractures  of  the  Superior  Maxillary  Bone. — ^Although  a  fragile  bone, 
the  superior  maxillary  is  rarely  broken  except  through  the  alveolar  border. 
It  may  be  broken  by  transmitted  force  from  blows  on  the  chin,  or  on  the  head 
when  the  chin  is  fLxed;  but  direct  \iolence  is  the  usual  cause.  The  walls  of  the 
antrum  may  be  crushed  in.  Comminution  is  the  rule,  and  the  injury  is  often 
compound.  These  fractures  induce  great  swelling,  pain,  and  inability  to 
chew.  MobiUty  and  crepitus  may  be  detected.  Deformity  is  due  to  the  break- 
ing force,  and  not  to  the  action  of  any  muscle.  ^Vhen  a  portion  of  the  alveolar 
arch  is  fractured,  as  may  occur  in  piilling  teeth,  the  small  fragment  is  de- 
pressed backward,  and  there  exist  irregularity  of  the  teeth  (some  of  which 
may  be  loosened)  and  inability  to  chew  food.  Fracture  of  the  nasal  process 
is  apt  to  injure  the  lachrxTual  duct.  WTben  the  antrum  is  broken  in  there 
are  great  sinking  over  the  fracture,  depression  of  the  malar  bone,  and  emphy- 
sema. Transverse  fracture  of  the  upper  part  of  the  body  of  the  bone  may 
cause  no  deformity.  The  force  required  to  break  the  superior  maxillary 
bone  is  so  great  that  fractures  of  other  bones  almost  certainly  occur,  and  con- 
cussion of  the  brain  not  infrequently  exists.  Injury  of  the  infra-orbital  nerve 
is  not  miusual,  causing  pain,  mmibness,  or  an  area  of  anesthesia  involving 
one-half  of  the  upper  lip,  the  ala  of  the  nose,  and  a  triangle  whose  base  is 
one-half  the  upper  lip  and  whose  apex  is  the  infra-orbital  foramen.    There  is 


Fractures  of  the  Superior  Maxillary  Bone 


539 


also  loss  of  sensation  in  the  gums  and  upper  teeth  of  the  injured  side.  Frac- 
tures of  the  superior  maxillary  bone  occasionally  induce  fierce  hemorrhage 
from  branches  of  the  internal  maxillary  arter\-;  and  if  this  has  happened,  be 
on  the  watch  for  secqndary  hemorrhage  (these  vessels  being  in  firm  canals). 


Fig.  2S8. — Hard-rubber  splint:  \Mre  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 

Treatment. — If  the  fracture  does  not  implicate  the  alveolus,  or  if  no  deform- 
ity exists,  apply  no  apparatus,  but  feed  the  patient  on  liquid  food  for  four 
weeks.  Reduce  deformity,  if  it  exists,  by  inserting  a  finger  in  the  mouth. 
If  the  antrum  is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.     In  certam  cases  of  deformity  make  an  incision  at  the 

anterior  border  of  the  mas-     .- 

seter  muscle,  insert  a   ten-  , 

aculum  or  aneur^'sm  needle, 

and  pull  the  bone  into  place 

(Hamilton).     If  the  malar 

bone    or    malar    process  is 

driven    into    the    antrum, 

Weir  tells  us  to  incise  the 

mucous    membrane    above 

and  external  to  the  canine 

tooth    of    the    upper    jaw, 

break  into  the  antrimi  with 

a  bone-gouge,  insert  a  steel 

sound,  lift    out   the   malar 

bone,  and  pack  the  antrum 

with  gauze.   Loose  teeth  are 

not   to  be    removed;    they 

are  pushed  back  into  place 

and   held  by  -firing  them 

to   their   firmer    neighbors. 

Hemorrhage      is      arrested 

by  cold   and  pressure.     If 

hemorrhage  is  dangerously 

profuse    or    prolonged,    tie 

the  external  carotid  artery. 

If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not  regular,  mold  on 
an  interdental  splint.  The  usual  splint  for  the  upper  jaw  is  the  lower  jaw  held 
firmlv  against  it  bv  the  Gibson,  the  Barton,  or  the  four-tailed  bandage.  There 
is  a  great  amount'  of  dribbling  of  saliva  during  the  treatmicnt,  and  a  dressing 
must  be  used  to  catch  this  fluid.    Even*  day  remove  the  bandage  and  dressing, 


Fig.  2S9.- 


-Front  %-iew  of  splint  (Fig.  288), 
(Moriarty) . 


with  mouth  closed 


540 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  wash  the  face  with  ethereal  soap.  The  patient,  who  is  ordered  not  to  talk, 
is  to  Hve  on  Hquid  food  administered  by  a  nasal  tube  or  by  pouring  it  into 
the  mouth  back  of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding-cup. 
Never  pull  a  tooth  to  obtain  a  space;  but  if  a  tooth  is  lost,  utilize  the  vacant 
space  for  this  purpose.  After  every  meal  wash  out  the  mouth  with  peroxid 
of  hydrogen,  followed  by  chlorate  of  potassium,  boric  acid,  or  normal  salt  solu- 
tion, and  thus  prevent  foulness  and  the  digestive  disorders  it  may  induce. 
Dispense  with  the  dressings  in  six  weeks,  and  let  the  patient  gradually  return 
to  ordinary  diet. 

In  fractures  compound  externally  do  not  remove  fragments,  antisepticize, 
arrest  bleeding  as  far  as  possible  by  ligature,  by  pressure,  or  by  plugging,  wire 
the  fragments  if  feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 
frequency.  Fractures  compound  internally  are  treated  as  simple  fractures, 
except  that  the  mouth  is  washed  more  frequently. 

The  malar  bone  is  rarely  broken  alone.     Hamilton  says  no  uncompli- 
cated case  is  on  record.    The  malar  is  a  strong  bone  resting  on  a  fragile  sup- 
port, and  hence  it  may  become  a 
[:—:•  -     wedge  to  break  other  bones  and 

yet  itself  be  unfractured.  The 
cause  of  fracture  is  violent  direct 
force.  A  fracture  of  the  orbital 
surface  of  this  bone  causes  sub- 
conjunctival hemorrhage  like  that 
encountered  in  fracture  at  the 
base  of  the  skull,  and  may  pro- 
duce irritation  of  the  infra-orbital 
nerve.  Protrusion  of  the  eye  may 
result  either  from  hemorrhage  or 
from  crushing  in  of  the  malar 
bone.  There  is  a  hollow  below 
and  to  the  outer  side  of  the  orbit. 
Occasionally  the  line  of  fracture 
is  detectable,  but  mobility  and 
crepitus  are  very  rarely  discover- 
able. Chewing  is  apt  to  cause 
pain,  and  often  the  motions  of 
the  lower  jaw  are  limited,  the 
coronoid  process  being  pressed 
upon  by  a  depressed  malar  bone, 
an  associated  fracture  of  the 
zygoma,  a  blood-clot,  or  swollen  tissue  (see  Scudder,  on  "The  Treatment 
of  Fractures"). 

Treatment. — If  no  deformity  exists,  there  is  practically  nothing  to  be  done. 
If  deformity  exists,  try  to  correct  it  as  in  fractures  of  the  superior  maxillary 
bone.  If  correction  is  impossible  by  ordinary  methods  and  the  movements 
of  the  lower  jaw  are  impeded  by  the  displaced  bone,  make  a  small  incision 
and  through  this  insert  an  instrument  and  endeavor  to  lift  the  bone  into 
place.  As  these  cases  are  almost  invariably  complicated  by  fracture  of  the 
upper  jaw,  they  are  treated  in  the  same  manner  as  the  latter  injury.  The 
union  is  complete  in  three  weeks. 

Fractures  of  the  zygomatic  arch  are  very  rare.  The  causes  are:  (i)  direct 
violence;  (2)  indirect  force  (from  depression  of  the  malar)  and  (3)  forcing 
foreign  bodies  through  the  mouth.  Direct  violence  is  the  usual  cause.  Direct 
violence  causes  inward  displacement,  and  indirect  force  may  cause  outward 
displacement.     The  usual  seat  of  fracture  is  at  the  smallest  portion  of  the 


Fig.  290.- 


-Hard-rubber  splint  in  position,  upper  teeth 
resting  upon  it  (Moriarty). 


Fractures  of  the  Inferior  Maxillary  Bone 


541 


process — that  is,  on  the  temporal  side  of  the  temporomalar  suture  (Matas). 
The  symptoms  are  pain,  ecchymosis,  swelling,  displacement,  and  dif&culty  in 
moving  the  jaw  (because  of  injury  to  the  masseter  muscle). 

Treatment. — In  simple  fracture  give  ether  and  try  to  push  the  arch  in 
place.  Many  surgeons  do  not  make  an  incision,  as  depression  will  do  no 
harm  and  the  functions  of  the  jaw  will  be  restored.  Simply  dress  with  a  com- 
press, adhesive  strips,  and  the  crossed  bandage  of  the  angle  of  the  jaw.  Union 
will  take  place  in  three  weeks.  Matas^  advises  operation.  An  anesthetic  is 
administered  and  the  parts  are  antisepticized.  A  long  semicircular  Hagedorn 
needle  is  threaded  with  silk,  is  entered  i  inch  above  the  middle  of  the  dis- 
placed fragment,  is  passed  well  into  the  temporal  fossa,  and  is  made  to  emerge 
h  inch  below  the  arch.  The  silk  is  used  to  pull  a  silver  wire  around  the  frac- 
ture, and  this  wire  is  employed  to  pull  the  bone  into  position.  A  firm  pad  is 
appHed  externally  and  the  wire  is  twisted  over  the  pad.  Antiseptic  dressings 
are  applied,  and  on  the  ninth  or  tenth  day  the  wire,  splint,  and  dressings  are 
removed  permanently.  I  have  employed  this  plan  in  2  cases  with  perfect 
satisfaction. 

Fractures  of  the  inferior  maxillary  bone  may,  and  usually  do,  involve  the 
body,  although  they  occasionally  occur  in  the  rami.  Any  part  of  the  body 
may  be  fractured,  the  most  usual  seat  being  near  the  canine  tooth  or  a  little 
external  to  the  symphysis  (Pick).  A  portion  of  alveolus  may  be  broken  off. 
In  fractures  of  the  ramus  either  the  angle,  the  condyloid  neck,  or  the  coronoid 
process  may  be  broken.  In  fractures  of  the  body  the  posterior  fragment  gener- 
ally overrides  the  anterior.  Fractures  of  the  lower  jaw  are  often  multiple  and 
are  almost  always  compound,  because  the  oral  mucous  membrane  and  al- 
veolar periosteum  are  torn.  The  cause  is  usually  direct  violence.  Indirect 
violence  (lateral  pressure)  may  fracture  the  body  anteriorly.  Fractures  near 
the  angle  are  always  due  to  direct  violence.  Indirect  violence  may  fracture  the 
condyle  (falls  on  the  chin) ,  and  so  may  direct 
violence.  Fractures  of  the  coronoid  process 
are  very  rare,  and  they  arise  from  great 
direct  violence  (usually  a  gimshot- wound 
or  some  other  penetrating  force) . 

Symptoms. — In  fracture  of  the  body 
preternatural  mobility  and  crepitus  gener- 
ally exist.  The  gtmi  over  the  fracture 
swells  rapidly  and  decidedly.  There  is 
bleeding  because  of  laceration  of  the  gum; 
saKva  dribbles  constantly ;  the  patient  sup- 
ports the  jaw  with  the  hand;  great  pain 
exists  (possibly  from  injury  of  the  nerve), 
and  deformity  is  present,  shown  by  in- 
equality of  the  teeth  if  the  fracture  is  an- 
terior to  the  masseter,  the  anterior  frag- 
ment going  downward  and  backward  and 
the  posterior  fragment  going  upward  and 
forward.  The  downward  displacement  is 
due  to  muscular  action  (action  of  the  digastric,  geniohyoid,  and  geniohyo- 
glossus).  The  backward  displacement  is  due  to  the  violence.  The  temporal, 
internal  pterygoid,  and  masseter  muscles  draw  the  posterior  fragment  upward 
and  to  the  front.  Two  or  three  days  after  fracturing  the  jaw  some  of  the 
cer\'ical  lymph-glands  enlarge.  When  a  fracture  of  the  lower  jaw  is  com- 
pound internally,  suppuration  usually  takes  place  and  the  odor  of  decom- 
position becomes  marked.  In  fracture  of  the  neck  of  the  condyle  the  jaw 
^  "New  Orleans  Med.  and  Surg.  Jour.,"  Sept.,  1896. 


Fig.  2gi. — Hamilton's  bandage. 


542 


Diseases  and  Injuries  of  the  Bones  and  Joints 


is  drawn  toward  the  injured  side,  and  the  condyle  is  pulled  inward  and  for- 
ward by  the  action  of  the  external  pterygoid  muscle.  In  fracture  of  the 
coronoid  process  the  temporal  muscle  pulls  the  small  fragment  upward. 

The  complications  are:  digestive  disorders  and  dirrahea  from  swallowing 
foul  discharges;  loosening  of  the  teeth;  lodgment  of  loosened  teeth  between 
the  fragments;  bleeding  (usually  only  oozing  from  the  girai,  but  there  may 
be  hemorrhage  from  the  inferior  dental  artery),  and  suppuration.  Necrosis 
may  follow  these  fractures,  an  abscess  of  the  neck  may  develop,  or  a  sinus 
may  form. 

Treatment. — Correct  deformity  with  great  care  and  be  sure  to  bring  the 
teeth  into  normal  alignment.  As  a  rule,  push  loose  teeth  into  place  and  put 
back  detached  ones;   but   occasionally  a  tooth  obstinately  prevents  perfect 

approximation,  and  if  it  does  it  must  be 
removed.  Remove  a  tooth  if  it  Hes  be- 
tween the  fragments,  but  replace  it  in  its 
socket  after  reducing  the  fracture.  Wash  the 
mouth  with  hot  water  to  clean  it  and  to 
check  bleeding.  If  bleeding  is  very  severe, 
compress  the  carotid  artery  for  a  time. 
The  fracture  can  be  dressed  with  a  pad 
of  lint  over  the  chin  and  Hamilton's  four- 
tailed  bandage  (Fig.  291).  A  common 
plan  is  to  take  a  splint  of  pasteboard,  felt, 
or  gutta-percha;  pad  it  lightly  with  cotton, 
mold  it  to  the  part,  and  hold  it  in  place 
with  a  Barton  or  a  Gibson  bandage.  If 
apposition  of  the  fragments  cannot  be 
maintained  by  the  above  methods,  fasten 
the  teeth  together  with  wire,  wire  the 
fragments  together,  or  have  a  dentist  apply  an  interdental  splint  (Figs. 
292,  293).  Fracture  of  the  lower  jaw  can  often  be  satisfactorily  treated 
by  Angle's  bands.  These  bands  are  of  great  value  in  compHcated  cases, 
in  which  two  or  more  fractures  exist.  Each  band  consists  of  thin  metal  and 
a  screw  and  a  nut  to  fit  the  screw.  The  band  is  adjusted  around  a  firm  tooth 
and  a  nut  is  applied  so  as  to  hold  the  band  tightly.  Several  bands  are  placed 
upon  teeth  in  both  jaws.  Silver  wire  or  silk  is  thrown  around  the  pins  of  the 
bands  so  as  to  catch,  and  the  jaws  are  thus  held  firmly  together.  The  patient 
is  to  be  fed  on  liquid  food  (see  Fracture  of  the  Upper  Jaw),  the  mouth  is 
to  be  washed  frequently  with  peroxid  of 
hydrogen,  followed  by  boric  acid  solution 
or  normal  salt  solution,  and  if  bandages 
are  used  they  should  be  changed  every 
second  day.  The  union  should  be  complete 
in  five  weeks.  The  best  plan  of  treatment 
in  all  cases  not  operated  upon  is  to  send  the 
patient  to  a  skilfiil  dentist  and  have  him  apply 
an  interdental  splint  and  direct  the  treatment. 
Though  these  fractures  are  usually  compound, 
they  do  not  endanger  life. 

Fractures    of    the    Hyoid    Bone. — These 
fractures    are    uncommon    injuries,   and    are 

caused  by  hanging,  by  throttling,  and  by  falls  in  which  the  neck  strikes  some 
obstacle.  If  the  bone  breaks  by  throttling,  it  is  its  body  which  fractures  (in- 
direct force).     Fractures  by  muscular  action  are  most  unusual. 

Symptoms. — The    S3rmptoms    are:    A   sensation   of   something  breaking; 


Fig.  292. — Vulcanite  splint  with  boxes 
vulcanized  on  each  side.  If  the  jaw  is 
fractured  in  the  region  of  the  molars,  con- 
siderable pressure  is  required  to  get  the 
parts  in  position;  therefore  it  is  best  to 
vulcanize  on  to  the  sides  of  the  vulcanite 
spHnt  boxes  into  which  wire  arms  can  be 
inserted  (Pilcher). 


Fig.  293. — Interdental  splint. 


Fractures  of  the  Ribs  543 

bleeding  from  the  mouth  if  the  mucous  membrane  be  lacerated;  pain,  which 
is  worse  on  opening  the  jaws  or  on  moving  the  head  or  tongue;  difficulty  in 
swallowing;  muffled,  hoarse  voice  or  aphonia;  swelling,  and  frequently  ecchy- 
mosis,  of  the  neck.  There  are  observed  occasionally,  though  rarely,  harsh 
cough  and  dyspnea,  irregularity  of  bony  contour,  and  crepitus.  Always  look 
into  the  mouth  and  see  if  there  can  be  detected  ecch}Tnosis  or  laceration  of 
the  mucous  membrane  or  projection  of  a  bony  fragment.  The  displacement 
is  produced  by  contraction  of  the  middle  constrictor  of  the  phar>Tix.  A  frac- 
ture of  the  hyoid  bone  may  destroy  life. 

Treatment. — For  dyspnea,  be  ready  to  perform  intubation  or  tracheotomy 
at  a  moment's  notice.  Edema  of  the  glottis  is  a  great  danger.  Trj'  to  restore 
the  fragments  with  one  hand  externally  and  ■v^•ith  a  finger  in  the  mouth.  Put 
the  patient  to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that  his  shoulders 
are  elevated.  His  head  is  to  be  placed  between  extension  and  flexion,  a  paste- 
board splint  or  collar  is  molded  on  the  neck,  and  a  bandage  is  appHed  around 
the  forehead,  neck,  and  shoulders  to  keep  the  head  immobile.  The  patient 
must  not  utter  a  word  for  a  week;  he  must  at  first  be  fed  by  enemata,  and  then 
for  some  time  on  liquid  diet,  which  is  given  through  a  tube  earh*  in  the  case. 
Endeavor  to  control  the  cough  by  opiates.  A  fractured  hyoid  bone  requires 
about  four  weeks  to  unite. 

Fractures  of  laryngeal  cartilages  are  caused  by  direct  \iolence,  as  throt- 
tling, blows,  or  kicks.  They  are  rare  in  yoimg  persons,  and  are  commonest 
when  the  cartilages  have  begim  to  ossify.  They  are  verA'  grave  injuries,  death 
tending  to  occur  from  obstruction  to  the  entrance  of  air. 

The  symptoms,  which  are  severe,  are  pain,  aggravated  by  attempts  at  swal- 
lo"^-ing  or  speaking;  swelling,  ecch}inosis  it  may  be,  and  emphysema  of  the  neck; 
cough;  aphonia;  intense  dyspnea;  and  bloody  expectoration  if  the  mucous 
membrane  is  ruptured.  There  can  be  detected  inequality  of  outline  (flattening 
or  projection)  and  perhaps  moist  crepitus.  The  usual  seat  of  the  injur}*  is  the 
th}Toid  cartilage. 

Treatment. — Cases  \\*ithout  dyspnea  require  quiet,  avoidance  of  all  talking, 
feeding  with  a  stomach-tube,  the  application  of  compresses  and  adhesive 
strips  over  the  fracture,  and  the  use  of  remedies  to  quiet  cough.  The  surgeon 
must  be  readv  to  operate  at  any  moment.  In  most  cases  dyspnea  exists, 
due  to  projection  of  the  fragments  or  submucous  extravasation.  ^Mien  there 
is  dyspnea,  emphysema,  or  spitting  of  blood,  at  once  practise  intubation, 
or,  if  imable  to  do  this,  open  the  lar^oix  or  trachea  below  the  seat  of  fracture. 
If  lar}Tigotomy  or  tracheotomy  is  performed,  tr\^  to  restore  displaced  frag- 
ments to  proper  position.  If  the  fragments  ^dll  not  remain  reducep,  introduce 
a  Trendelenburg  cannula  or  a  tracheotomy  tube,  and  pack  gauze  around 
it.  Take  out  the  packing  in  four  days,  and  remove  the  tube  as  soon  as  the 
patient  breathes  well,  when  the  opening  may  be  aUowed  to  close.  In  these 
cases  feed  with  a  stomach-tube  and  keep  the  patient  absolutely  quiet.  Union 
takes  place  in  four  weeks. 

Fractures  of  the  Ribs. — The  ribs,  o-^ing  to  their  shape,  elasticity,  and 
mode  of  attachment,  readily  bend  and  as  readily  recover  shape,  and  thus 
withstand  considerable  force  without  breaking.  NotT^ilhstanding  these  facts, 
the  situation  of  the  ribs  so  exposes  them  that  in  16  per  cent,  of  all  cases  of 
fractures  noted  by  Gin-lt  these  bones  were  involved.  In  children  fracture 
of  a  rib  seldom  occurs  and  is  usually  incomplete;  it  is  common  in  adults  and 
the  aged,  and  in  them  is  generally  complete.  It  is  more  frequent  among 
men  than  among  women.  The  ribs  commonly  broken  are  from  the  fifth 
to  the  ninth,  the  seventh  being  the  one  that  most  frequently  sufi'ers.  Fracture 
of  the  first  rib  alone  is  an  excessively  rare  accident.  The  eleventh  and  twelfth 
ribs  are  seldom  broken.    A  rib  may  be  broken  in  several  places,  and  several 


544  Diseases  and  Injuries  of  the  Bones  and  Joints 

ribs  are  often  broken  at  the  same  time.  Fracture  of  a  single  rib  is  not  nearly 
so  common  as  fracture  of  several  ribs.  These  fractures  may  be  compound, 
either  through  the  skin  or  through  the  pleura,  a  damaged  lung  permitting 
pneumothorax.  Fractures  compounded  by  a  wound  of  the  skin  surface  are 
very  rare,  except  from  bullet-wounds. 

Causes. — Direct  force,  as  buffer  accidents,  kicks,  blows  with  heavy  instru- 
ments, or  being  jumped  on  while  recimibent,  may  produce  these  injuries. 
A  fracture  from  direct  violence  occurs  at  the  point  struck,  and  the  ends, 
projecting  inward,  may  damage  a  viscus.  Indirect  force,  as  great  pressure 
or  blows  which  exaggerate  the  natural  bony  curves,  tends  to  produce  fractures 
near  the  middle  of  the  ribs  or  in  front  of  their  angles  and  to  force  the  ends  out- 
ward. A  number  of  ribs  are  apt  to  be  broken.  Muscular  action,  as  in  cough- 
ing, sneezing,  lifting,  or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Symptoms. — In  connection  with  the  history  of  the  accident  the  symptoms 
are:  acute  localized  pain  (a  stitch)  on  breathing,  increased  by  pressure  over 
the  seat  of  pain,  pressure  backward  over  the  sternum,  cough,  and  forcible 
inspiration  or  expiration ;  respiration  is  largely  diaphragmatic,  the  patient  en- 
deavoring to  immobilize  the  injured  side;  cough  is  frequent  and  is  suppressed 
because  of  pain.  Crepitus  is  often,  but  not  invariably,  found.  The  surgeon 
seeks  for  it,  first,  by  resting  the  palm  of  his  hand  over  the  seat  of  pain  whUe 
the  patient  takes  long  breaths;  second,  by  placing  a  thumb  before  and  one 
behind  the  seat  of  pain  and  making  alternate  pressure;  third,  by  ausculta- 
tion.. It  should  be  remembered  that  incomplete  fractures  are  the  rule  in 
children;  hence  in  them  do  not  expect  crepitus.  Deformity  is  usually  trivial 
unless  several  ribs  are  broken,  because  shortening  cannot  occur  and  the  inter- 
costal attachments  prevent  vertical  displacement.  Preternatural  mobility 
may  occasionally  be  elicited,  when  the  region  is  not  deeply  covered  with  mus- 
cles, by  pressing  on  one  side  of  the  supposed  break  and  observing  that  a  part 
of,  and  not  the  entire,  rib  moves.  If  air  gathers  in  the  subcutaneous  tissue 
and  there  is  no  wound  of  the  surface,  it  is  proof  of  rib  fracture  with  lung  dam- 
age. In  such  a  case  the  lung  has  been  penetrated  by  a  fragment,  and  air  has 
been  forced  out  into  the  tissues.  This  condition  is  recognized  by  great  and 
growing  swelling,  which  crackles  when  touched.  Such  a  collection  of  air  is 
known  as  cellular  emphysema.  Bloody  expectoration  suggests  lung  injury; 
bloody  expectoration  and  cellular  emphysema,  without  an  external  wound, 
prove  injury  of  the  lung.  A  simple,  uncomplicated  case  of  fracture  of  a  rib 
or  ribs  in  a  young  person  gives  a  good  prognosis. 

The  complications  are:  additional  injury,  making  the  fracture  externally 
or  internally  compound;  laceration  of  the  pleura,  pericardiiim,  heart,  lung, 
diaphragm,  liver,  spleen,  or  colon;  rupture  of  an  intercostal  artery;  hemo- 
thorax; cellular  emphysema;  pulmonary  emphysema;  pneimio thorax;  pyo- 
thorax;  traumatic  pleurisy;  pneumonia;  bronchitis;  congestion  or  edema  of 
the  lungs. 

Treatment.— In  an  uncomplicated  case  the  patient  is  not  kept  in  bed,  as 
breathing  is  easier  when  erect  than  when  recumbent.  Angular  displacement 
outward  is  corrected  by  direct  pressure.  Displacement  inward  is  soon  cor- 
rected, as  a  rule,  by  the  expansion  of  ordinary  respiratory  action;  but  if  it 
is  not  thus  corrected,  etherize,  the  deep  breathing  of  the  anesthetic  state  almost 
always  succeeding.  If  ether  fails,  and  dangerous  symptoms  ensue,  incise  under 
strict  antiseptic  precautions,  elevate,  or  sometimes  resect  a  portion  of  the  rib. 

After  correcting  any  existing  deformity  immobilize  the  injured  side.  If  a 
man,  shave  the  chest.  Direct  the  patient  to  raise  his  arms  above  his  head,  to 
empty  his  chest  of  air  by  a  forced  expiration,  and  to  keep  it  empty  until  a 
piece  of  rubber  plaster  (2  inches  wide)  is  forcibly  applied  a  number  of  inches 
below  the  fracture  and  from  the  spine  to  the  sternum.    The  patient  is  now 


Fractures  of  the  Costal   Cartilages  545 

allowed  to  take  a  breath  and  is  directed  to  empty  the  chest  again,  another 
piece  of  plaster  being  applied,  covering  the  upper  two-thirds  of  the  width  of 
the  first  strip.  This  process  is  continued  until  the  side  is  strapped  well 
above  and  well  below  the  fracture  (PL  7,  Fig.  13).  Over  the  plaster  light 
turns  of  a  spiral  bandage  of  muslin  are  carried,  or  a  ligure-of-8  bandage  of  the 
chest  is  applied,  the  turns  crossing  over  the  seat  of  injury.  About  once  a 
week  the  plaster  is  removed  and  fresh  pieces  applied  after  rubbing  the  chest 
with  soap  liniment,  drvdng,  and  anointing  excoriations  with  an  ointment  of 
oxid  of  zinc.  The  dressing  is  worn  for  three  or  four  weeks.  The  patient 
avoids  cold,  damp,  and  drafts.  The  diet  must  be  nutritious  but  non-stimu- 
lating, and  any  cough  should  be  treated  by  opiates  and  expectorants.  A  per- 
son with  this  injury  who  has  reached  the  age  of  sixty  must  take  stimulant 
expectorants  (ammonii  carb.,  10  gr.,  in  infus.  senegge,  h  oz.,  /.  i.  d.)  or  employ 
a  steam-tent  several  times  a  day.  The  old  method  of  treatment,  in  which 
the  chest  was  included  in  a  forcibly  applied  broad  rib-roller,  is  not  to  be  used 
except  as  a  temporary  expedient;  it  compresses  the  entire  chest,  causes  pain 
and  dyspnea,  and  tends  to  loosen  and  slip. 

Fracture  of  the  ribs  compHcated  by  ^dsceral  injur}'  is  highly  dangerous, 
and  requires  confinement  to  bed.  The  treatment  is  that  of  the  \'isceral 
injury.  If  there  be  bloody  expectoration,  apply  adhesive  strips  as  above 
indicated,  put  the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the  circulation,  and  employ  opium,  diaphoretics,  and  expectorants 
(a  good  mixture  consists  of  squill,  ipecac,  ammonium  acetate,  and  chloroform; 
opium  is  given  separately).  Inflammations  of  the  lung  or  the  pleura,  fortu- 
nately, are  apt  to  be  localized,  and  are  treated  as  ordinar\"  inflammations  of 
these  parts.  If  signs  of  pulmonar\'  injun.^  are  severe  from  the  start  or  become 
worse  under  medical  treatment,  incise,  resect  a  rib,  arrest  hemorrhage,  and 
drain  the  pleura.  In  laceration  of  an  intercostal  arter\-  incise  and  try  to 
ligate;  if  unable  to  ligate,  resect  a  rib  and  apply  a  ligature.  If  the  signs 
point  to  uiternal  bleeding,  resect  a  rib,  search  for  the  bleeding  point,  and 
ligate.  Emphysema  usually  soon  disappears;  but  if  it  does  not,  make  many 
small  incisions  in  the  cellular  tissue,  dress  antisepticaUy,  and  employ  pressure. 
WTien  there  arises  a  sudden  attack  of  dyspnea,  which  is  prone  to  happen 
in  these  cases,  and  in  which  the  face  becomes  blue,  the  heart  labors,  and 
suffocation  seems  imminent,  bleed  the  patient  almost  to  s}Ticope. 

Fractures  of  the  costal  cartilages  are  not  common,  even  in  the  aged.  Such 
fractures  occur  either  through  the  cartilages  or  through  their  points  of  junc- 
tion -^-ith  the  ribs.  These  injuries  generally  arise  from  direct  \-iolence,  the 
cartflage  of  the  eighth  rib  being  most  prone  to  sufl'er.  Bennett,  of  Dublin, 
has  seen  over  25  specimens  of  fracture  of  the  first  costal  cartflage.  Indirect 
force  (such  as  a  blow  upon  the  shoulder)  is  occasionally  the  cause,  but  when  it 
is  the  cause  some  other  injur\'  besides  the  fracture  of  the  cartflages  is  apt 
to  be  noticed.     Muscular  action  is  a  possible  cause. 

Symptoms. — Displacement  is  often  absent;  but  if  present,  it  is  forward  or 
backward  of  either  fragment,  and  is  due  chiefly  to  the  force  of  the  injur\^, 
but  partly,  it  may  be,  to  muscular  action.  \\Tien  displacement  is  absent, 
crepitus  will  not  often  be  found;  in  fact,  crepitus  is  usuaUy  absent  in  these 
injuries.  Localized  pain,  swefling,  and  ecch\Tnosis  are  noted.  Preternatural 
mobility  may  or  may  not  be  detected.     Union  by  bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  tr\'  to  reduce  it.  If  the  fragment  is 
displaced  backward,  reduce  by  deep  inspirations;  if  the  fragment  is  displaced 
forward,  reduce  by  piflling  back  the  shoulders.  In  this  attempt  faflure  is 
the  rule,  and  the  surgeon  may  then  adopt  Malgaigne's  expedient  of  apphing 
a  truss  over  the  projection  for  a  day  or  two.  Dress  and  treat  the  case  as 
if  a  rib  were  broken,  dispensing  with  dressings  in  four  weeks. 

35 


546  Diseases  and  Injuries  of  the  Bones  and  Joints 

Fractures  of  the  Sternum. — The  sternum  may  be  broken,  along  with 
the  ribs  and  spine,  from  great  violence.  Fractures  of  the  sternum  alone 
are  infrequent,  because  the  bone  rests  on  a  spring-bed  of  ribs.  Fractures 
of  the  sternum  may  be  simple  or  compound,  complete  or  incomplete,  single 
or  multiple.  The  most  usual  injury  is  a  simple  transverse  fracture  at  or 
near  the  gladiomanubrial  junction,  at  which  point  dislocation  may  also 
occur.  Both  fracture  and  separation  of  the  ensiform  cartilage  are  very  rare. 
The  sternum  may  be  broken  along  with  the  ribs  or  clavicle. 

Causes. — These  are:  direct  force,  as  by  a  fall  of  an  embankment  or  of  a 
wall,  by  a  car-crush,  or  by  the  passing  of  a  cart-wheel  over  the  body;  indirect 
force,  as  by  a  fall  upon  the  head,  thus  driving  the  chin  against  the  chest;  by 
a  fall  upon  the  feet,  the  buttocks,  or  the  shoulder;  by  forced  flexion  or  ex- 
tension of  the  body  over  an  edge  or  angle  (as  may  occur  during  labor-pains). 

Symptoms. — In  fracture  of  the  sternum  displacement  is  not  always  present, 
but  when  it  does  occur  the  lower  fragment  is  apt  to  pass  forward;  displace- 
ment may,  however,  be  transverse  or  angular,  or  there  may  be  overriding. 
The  posterior  periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the  nature  of  the  acci- 
dent has  a  valuable  bearing  upon  the  question  of  diagnosis.  The  position 
assumed  by  the  patient  is  with  the  head  and  body  bent  forward,  as  attempts 
to  straighten  up  cause  much  suffering.  There  is  fixed  and  localized  pain, 
increased  by  deep  respiratory  action,  by  body  movements,  or  by  cough. 
Crepitus  is  sought  for  by  auscultation  and  by  placing  the  hand  over  the  in- 
jury and  directing  the  patient  to  make  quick  respirations.  Mobility  may 
become  manifest  on  external  pressure,  diiring  respiration,  or  while  attempts 
are  being  made  to  bring  the  body  erect.  Respiration  in  these  cases  is  usually 
much  interfered  with.  It  is  not  important  to  separate  diagnostically  diastasis 
from  fracture. 

Complications. — Other  fractures  generally  complicate  fracture  of  the 
sternum,  and  laceration  of  the  pleura  or  pericardiimi  and  hemorrhage  into 
the  anterior  mediastinimi  may  exist.  Abscess  of  the  mediastinum  and  necrosis 
of  the  sternum  may  appear  as  late  consequences.  The  prognosis  is  good  in 
imcomplicated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  sternimi  is  to  be 
corrected,  if  possible,  by  external  pressure.  If  overriding  is  foimd,  effect 
reduction  by  bending  the  body  back  over  a  firm  pillow  and  ordering  the 
patient  to  respire  deeply;  if  this  method  fails,  give  ether  and  then  bend  the 
body  backward.  The  deformity,  after  reduction,  tends  to  recur,  but  the 
bones  imite  well  even  in  deformity,  and  no  great  harm  results.  The  frag- 
ments need  not  be  cut  down  on  or  be  hooked  up  unless  there  be  internal 
injury.  After  reducing  the  deformity,  cover  the  front  of  the  chest  with 
adhesive  strips  extending  laterally  from  one  axillary  line  to  the  other,  and 
covering  a  region  from  above  the  fracture  down  to  the  ensiform  cartilage. 
Place  over  this  covering  an  anterior  figure-of-8  bandage  of  the  chest. 
In  some  cases,  where  deformity  recurs  after  reduction,  a  circular  bandage 
of  the  chest  is  applied  and  the  shoulders  are  pulled  strongly  back  with  a  pos- 
terior figure-of.-8  bandage.  The  plaster  is  to  be  reapplied  once  a  week. 
Some  surgeons  treat  these  cases  by  means  of  a  large  compress  held  by  adhesive 
plaster  and  a  broad  tight  roller. 

The  patient  goes  promptly  to  bed,  and  reposes,  erect  or  semi-erect,  on 
a  bed-rest.  This  position  favors  easy  respiration  and  antagonizes  the  tend- 
ency to  displacement.  The  diet  should  be  light,  nutritious,  and  non-stimu- 
lating. Convalescence  is  established  in  four  weeks,  and  the  plaster  should  be 
permanently  removed  in  five  weeks.  When  the  ensiform  cartilage  is  so  bent 
in  as  to  cause  intense  pain  or  to  injure  the  stomach,  it  should  be  exposed 


Fractures  of  the   True  Pelvis  547 

by  incision  and  resected.  Edema  of  the  skin  and  fever,  if  they  appear,  in- 
dicate pus,  in  which  case  an  incision  should  be  made  at  the  edge  of  the  ster- 
num and  the  pus-cavity  should  be  irrigated  and  drained. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fractures  serious  injure 
of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region  are  seldom  dan- 
gerous imless  comminuted.  There  may  be  fracture  of  the  iliac  crest  or  of  the 
anterior  superior  spine,  or  the  line  of  fracture  may  traverse  the  entire  length 
of  the  flanged-out  ilium,  or  the  bone  may  be  comminuted  with  the  association 
of  grave  visceral  damage.  The  anterior  superior  and  posterior  superior  spines 
may  be  broken  off. 

Causes. — The  cause  of  fracture  of  the  false  pehis  is  generally  \-iolent 
direct  force,  as  the  passage  of  a  wagon-wheel,  the  fall  of  a  wall,  the  kick  of 
a  horse  or  mule,  or  the  force  of  car-crushes.  Violent  contraction  of  the  rectus 
femoris  muscle  may  tear  off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pehis  the  histon,'  of  \-iolent  force  is 
noted.  The  patient  leans  toward  the  injured  side.  Pain  exists,  which  is 
aggravated  by  movements  (particularly  by  bending  forward),  by  coughing, 
or  by  straining  to  empty  the  bowels  or  the  bladder.  Ecch^tnosis  and  swelling 
are  manifest.  Crepitus  and  pretematiu-al  mobility  are  detected  by  mo^•ing 
the  niac  crest.  Deformity  is  ver\-  rarely  present.  Cases  uncomplicated  by 
\'isceral  injury-  make  good  recoveries. 

Complications. — The  fracture  may  be,  but  rarely  is,  compoimd,  as  the 
parts  are  well  protected  by  muscles.  The  colon  may  be  injured  when  com- 
minution has  taken  place. 

Treatment. — If  there  are  SAniptoms  of  injur\-  of  the  colon,  perform  lapar- 
otomy, search  for  the  injured  region,  and  suture  it.  In  treating  an  ordinary' 
fracture  of  the  false  peMs  put  the  patient  on  a  fracture-bed.  raise  the  shoul- 
ders, and  apply  a  canvas  binder  about  the  pelvis,  or  encase  the  pelvis  in 
broad  pieces  of  rubber  plaster,  or  employ  the  belt  or  girdle.  The  pressure 
of  the  binder,  girdle,  or  plaster  must  not  be  so  great  as  to  force  the  fragment 
of  nium  inward.  Place  the  knees  over  two  pillows  so  as  to  semiflex  the  legs 
and  thighs,  and  tie  the  knees  together.  To  restrain  thigh  movements  it 
may  be  necessan.'  to  encase  a  restless  patient  in  splints  or  bind  him  to  sand- 
bags. If  the  peh"ic  binder  displaces  the  fragments  or  causes  pain,  abandon 
it  and  trust  to  position.  If  the  fragment  cannot  be  retained  in  place,  wire 
it.  The  dressings  can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  simple,  uncomplicated  fracture  of  the  false 
peMs  the  prognosis  is  good.  In  compound  fractures  of  the  false  pehis  asep- 
ticize, drain  and  dress,  put  on  a  binder,  and  direct  the  same  position  to  be 
maintained  as  for  simple  fractures. 

Fractiires  of  the  True  Pelvis. — The  most  usual  seat  of  these  fractures 
is  through  the  obturator  foramen,  the  ascending  ischial  and  horizontal  pubic 
rami  being  broken.  A  fracture  may  occur  near  the  S}Tiiphysis  pubis,  the 
s}Tnphysis  may  be  separated,  a  line  of  fracture  may  run  near  to  or  into  the  sacro- 
iliac joint:  the  same  may  involve  each  side  of  the  body  of  the  pubis,  and  there 
may  be  multiple  fractures.  Fractures  of  the  acetabulum  and  of  the  tuber- 
osity of  the  ischiiuTL  may  occur.  Before  the  seventeenth  year  the  innominate 
bone  may  be  broken  into  its  three  anatomical  segments.  Fractures  of  the 
true  pehis  are  highly  dangerous  because  of  the  damage  which  is  apt  to  be 
inflicted  on  the  pehic  contents.  There  may  be  laceration  of  the  bladder 
or  membranous  urethra,  injur}-  of  the  vagina,  the  rectiun,  the  uterus,  or 
the  small  gut.  The  cause  of  pehic  fracture  is  \iolent  force,  direct  or  in- 
direct. Front  force  tends  to  produce  direct,  and  side  force  indirect,  frac- 
ture.    The  acetabulum  may  be  broken  by  falls  upon  the  feet. 


548  Diseases  and  Injuries  of  the  Bones  and  Joints 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent  force.  There 
are  great  shock,  ecchymosis  which  is  possibly  linear,  swelling,  and  intense 
pain  increased  by  attempts  at  motion,  coughing,  and  straining.  There  is 
also  inability  to  sit  or  to  stand.  Mobility  becomes  obvious  on  grasping  an 
ilium  in  each  hand  and  moving  the  hands.  Crepitus  may  be  noticed  by 
this  maneuver  or  by  moving  an  ilium  with  one  hand,  a  finger  of  the  other 
hand  being  inserted  in  the  rectum  or  vagina.  In  making  movements  for 
diagnostic  purposes  be  very  gentle,  as  rough  manipulation  may  cause  injury 
by  sharp  fragments.  There  may  be  doubt  as  to  whether  crepitus  is  to  be 
referred  to  pelvic  fracture  or  to  fracture  of  the  neck  of  the  femur;  in  this 
case  follow  the  rule  of  John  Wood:  "The  surgeon  grasps  the  femur  with  one 
hand  and  places  the  other  firmly  upon  the  anterior  superior  iliac  spine  or 
crest  or  upon  the  pubes;  then,  on  moving  the  femur  and  abducting  it  freely, 
if  a  crepitus  be  detected,  it  will  be  felt  the  more  distinctly  by  that  hand  which 
rests  on  or  grasps  the  fractured  bone." 


Fig.  2y4. — Rugh's  case  of  fracture  of  the  acetabulum  with  internal  dislocation  of  femur. 

Rupture  of  the  bladder  is  made  manifest  by  pain  in  the  hypogastric  region, 
intense  desire  to  micturate,  inability  to  pass  urine  in  quantity,  although  a 
few  drops  of  bloody  urine  may  be  voided,  great  shock,  sometimes  dulness  on 
percussion  in  the  loins,  and  evidences  of  extravasation  in  the  prevesical  space. 
The  condition  is  proved  to  exist  by  practising  the  maneuvers  suggested  under 
Rupture  of  Bladder.  The  symptoms  of  ruptured  urethra  are  set  forth  later. 
Bleeding  from  vagina  or  rectum  points  to  laceration  of  the  part  by  a  fragment. 
The  vagina  may  be  badly  lacerated  and  the  bowels  may  emerge  from  the 
laceration  (Maurice  H.  Richardson's  case).  Intestinal  injury  is  apt  to  induce 
septic  peritonitis.  Fractures  of  the  acetabulum  occur.  Fracture  of  the  brim 
of  the  acetabulum  permits  dorsal  dislocation  of  the  femur  to  occur,  which  dis- 
location will  not  remain  reduced,  and  causes  shortening,  which  at  once  recurs 
when  extension  is  abandoned;  also  inversion  and  adduction,  although  the  power 
of  eversion  and  abduction  is  preserved  (Stokes).     There  is  crepitus,  and  the 


Fractures  of  the  Coccyx  549 

head  of  the  bone  goes  with  the  fragment  upward  and  backward  (Stokes).  If 
the  head  of  the  femur  be  driven  through  the  acetabulum  into  the  pelvis,  the 
injury  is  very  grave;  there  are  then  found  shortening,  adduction,  and  semi- 
flexion of  the  thigh,  absence  of  the  prominence  of  the  great  trochanter,  and 
more  capacity  for  movement  than  is  noted  in  dislocation.  This  injury  is  called 
internal  dislocation  of  the  femur  (Fig.  294).  Fracture  of  the  ischium  rarely 
occurs  alone. 

Treatment. — Examine  carefully  to  determine  if  the  bowel,  the  bladder,  the 
urethra,  or  the  vagina  is  injured.  If  such  an  injury  exists,  radical  operation 
is,  of  course,  demanded.  Always  use  a  catheter  to  see  if  the  urine  is  bloody. 
Bloody  urine  suggests,  but  does  not  prove,  the  existence  of  a  torn  bladder. 
It  may  be  due  to  simple  contusion  of  the  bladder  or  to  contusion  of  the  kidney. 
In  treating  a  pelvic  fracture  endeavor  to  restore  the  parts  to  a  normal  position, 
employing  external  manipulation  and  inserting  a  finger  in  the  rectum  or 
in  the  vagina.  If  reduction  is  difficult,  administer  ether.  The  pelvis  should 
be  encircled  by  a  canvas  binder  and  the  patient  should  be  placed  upon  a 
Bradford  frame.  If  this  is  done  he  can  be  cleaned  readily  and  the  bed-pan 
can  be  easily  used.  If  movements  of  the  thighs  distort  the  pehic  bones,  each 
thigh  should  be  bound  to  the  frame.  In  fracture  ^\'ith  separation  of  the  pubic 
bones  the  bones  should  be  T\ired  together.  If  urinar\'  extravasation  from 
urethral  rupture  occurs,  perform  perineal  section.  If  there  are  signs  of  bowel 
injury  or  intraperitoneal  rupture  of  the  bladder,  perform  laparotomy;  and  if 
the  bladder  is  found  to  be  torn,  apply  sutures.  All  ^dsceral  injuries  are  treated 
by  general  rules.  Remove  the  dressings  in  six  weeks  and  allow  the  patient  to 
get  about  in  twelve  weeks.  In  fracture  of  the  acetabulum,  if  the  limb  is  short- 
ened, give  ether  and  reduce  by  extension  and  counterextension.  Treat  these 
fractures  in  the  same  way  as  intracapsular  fractures  of  the  femur.  Fractures 
of  the  ischium  are  best  treated  by  the  application  of  a  pad  and  adhesive  plaster, 
and  rest  in  bed. 

Fractures  of  the  Sacrum. — -This  bone  may  be  broken  by  direct  force, 
such  as  a  kick,  but  the  injury  is  rare.  The  sacral  plexus  is  usually  injured, 
and  if  it  is,  paralysis  is  observed  in  the  territor\'  of  its  branches. 

The  symptoins  of  fracture  of  the  sacrum  are  pain,  frequently  incontinence 
of  feces  and  retention  of  urine,  irregularity  of  the  sacral  spines,  ecchymosis, 
and  crepitus.  Crepitus  may  be  sought  for  with  one  hand  externally  and  a 
finger  of  the  other  hand  in  the  rectiim.  The  lower  fragment  passes  forv\'ard 
and  may  obstruct  or  may  tear  the  rectum.  Paralysis  may  be  found  in  the 
area  of  distribution  of  the  sacral  plexus. 

Treatment. — In  any  case  of  fracture  of  the  sacrum,  if  there  are  e\adences 
of  pressure  upon  nerves  by  displaced  bone,  expose  and  elevate  the  depressed 
bone.  If  the  rectum  is  lacerated,  sutures  must  be  inserted.  In  many  cases 
of  fracture  of  the  sacrum  the  older  conservative  treatment  is  sufficient.  The 
conservative  treatment  is  as  follows:  Press  the  fragments  into  place  \\dth  a 
hand  externally  and  a  finger  in  the  rectum.  Do  not  plug  the  rectimi.  Put  a 
pad  over  the  upper  fragment,  hold  it  by  a  plaster  or  a  binder,  place  the  patient 
recumbent  on  a  fracture-bed,  and  insert  a  large  cushion  underneath  the 
pad.  Some  surgeons  give  opium  to  induce  constipation,  and  allow  a  fecal 
support  to  accumulate  in  the  rectum.  Use  a  clean  catheter  regularly,  and  guard 
against  bed-sores.  Union  occurs  in  about  four  weeks,  when  the  dressing  can 
be  removed.  The  patient  can  get  about  again  in  sLx  weeks.  If  urinarv^  reten- 
tion persists,  or  if  intractable  bed-sores  form  after  eight  or  ten  weeks,  cut  doviTi 
on  the  seat  of  injury  and  elevate  or  remove  the  portion  of  bone  causing  pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken  or  be  separated 
from  the  sacrimi  by  a  fall,  a  blow,  a  kick,  or  the  straining  of  parturition. 
Its  mobility  is  so  great,  however,  that  it  does  not  often  break. 


55°  Diseases  and  Injuries  of  the  Bones  and  Joints 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx  is  pain,  which 
is  much  aggravated  by  sitting,  walking,  or  straining  at  stool.  If  the  index- 
finger  is  inserted  into  the  rectum,  the  displaced  bone  is  felt;  if  the  thumb  of 
the  same  hand  is  also  placed  externally,  a  rocking  motion  will  develop  crepitus 
and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx  reduce  by  external  pressure 
and  by  the  manipulations  of  a  finger  in  the  rectum  and  put  the  patient  to  bed. 
In  four  weeks  the  fracture  should  be  united.  If  union  does  not  take  place, 
defecation  and  all  movements  of  the  coccyx  will  cause  excruciating  pain  by 
pressure  on  the  last  sacral  nerve.     This  condition  is  known  as  coccygodynia. 

It  must  not  be  understood  that  coccygodynia  always  results  from  fracture 
of  the  coccyx,  or  that  fracture  of  the  coccyx  is  the  only  cause.  As  a  matter  of 
fact,  coccygodynia  is  a  rare  condition  and  is  seldom  a  result  of  fracture  of  the 
coccyx.  It  may  arise  after  confinement,  or  a  fall  or  blow  upon  the  region  of  the 
coccyx,  or  may  be  due  to  caries. 

In  most  cases  it  is  a  referred  pain  due  to  some  central  trouble,  and  is  common 
in  various  functional  disorders  of  the  nervous  system.  It  is  especially  common 
in  hysterical,  neurasthenic,  or  anemic  women.  In  the  traumatic  neuroses  it  is 
commonly  complained  of  and  it  is  frequently  associated  with  irritable  spine. 
In  very  rare  cases  it  is  a  neuralgia.  The  treatment  is  aimed  at  the  causative 
condition.  In  very  obstinate  cases  it  demands  a  subcutaneous  division  of  the 
nerve  or  of  the  muscles  which  move  the  coccyx,  or  a  resection  of  the  bone. 

Fractures  of  the  Vertebrae. — (See  page  852.) 

Fractures  of  the  Skull. — (See  page  789.) 

Fractures  of  the  Clavicle. — The  clavicle  is  more  often  fractured  than 
any  other  bone.  The  fracture  may  occur  at  any  age,  but  is  commonest 
before  the  sixth  year  (Hulke  says  one-half  of  the  recorded  cases).  It  may 
be  simple,  multiple,  comminuted,  oblique,  transverse,  complete,  incomplete, 
or,  very  rarely,  compound.  Both  clavicles  may  be  broken.  Fractures  are 
most  apt  to  occur  just  external  to  the  middle,  at  the  point  where  the  inner 
or  large  curve  meets  the  outer  or  small  curve,  at  which  junction  the  bone 
is  at  its  smallest  diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end,  and  less  frequent  than  fractures  of  the 
shaft.  The  causes  of  fracture  of  the  clavicle  are  direct  violence,  indirect 
violence,  and,  very  rarely,  the  contractions  of  "the  deltoid  and  clavicular 
fibers  of  the  great  pectoral"  (Treves,  in  "Applied  Anatomy,"  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  violence,  as  falls  upon 
the  shoulder  or  upon  the  outstretched  hand.  In  the  latter  accident,  which 
is  the  usual  mode  of  origin,  the  concusssion  of  the  fall  travels  up  and  the 
body  weight  travels  down,  and  these  two  forces  compress  the  bone,  which 
snaps  at  its  weakest  point.  Fractures  from  indirect  force  are  oblique,  and 
in  children  are  of  the  green-stick  form.  Fractures  from  direct  force  are 
usually  transverse,  and  are  occasionally  comminuted.  Fractures  from  mus- 
cular action  have  been  recorded  (Rubini,  the  tenor,  recorded  by  Melay). 

Symptoms. — In  fracture  of  the  shaft  of  the  clavicle  the  attitude  of  the 
patient  is  peculiar.  He  supports  the  elbow  or  wrist  of  the  injured  side  with 
the  hand  of  the  sound  side,  and  also  pulls  the  extremity  against  the  chest; 
the  head  is  turned  down  toward  the  shoulder  of  the  damaged  side,  as  if  try- 
ing to  listen  to  something  in  the  joint,  thus  relaxing  the  pull  of  the  sterno- 
cleidomastoid muscle  upon  the  inner  fragment.  The  shoulder  is  nearer  the 
sternum,  on  a  lower  level,  and  farther  front  than  that  of  the  sound  side.  Loss 
of  function  is  shown  by  inability  to  abduct  the  arm,  and  in  many  cases  by 
inability  to  place  the  hand  on  the  top  of  the  erect  head.  Considerable  pain 
exists,  which  is  increased  by  motion,  by  pressure,  and  by  the  extremity 
hanging  down  without  support. 


Fractures  of  the  Shaft 


551 


The  deformity  above  noted  is  described  by  stating  that  the  shoulder 
goes  downward,  inward,  and  forward  (d.  i.  f.).  The  downward  deformity 
is  chiefly  due  to  the  weight  of  the  extremity,  which  pulls  down  the  unsupported 
outer  fragment,  and  is  contributed  to  by  the  action  of  the  pectoralis  minor 
muscle.  The  inward  deformity  is  chiefly  due  to  the  contraction  of  the  pec- 
toralis minor  and  subclavius  muscles  assisted  by  the  action  of  the  pectoralis 
major.  The  forward  deformity  is  due  to  rotation  of  the  outer  fragment, 
which  is  brought  about  by  the  serratus  magnus  muscle  carrying  the  scapula 
forward.  In  this  deformity  the  inner  end  of  the  outer  fragment  is  below 
and  behind  the  outer  end  of  the  inner  fragment,  which  overrides  it.  The 
inner  fragment,  though  pulled  on  by  the  sternocleidomastoid  muscle  and  rela- 
tively higher  than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the  rhomboid  liga- 
ment. After  noting  the  deformity,  detect  -wdth  the  finger  the  irregularity  of 
bony  contour.  Examine  for  preternatural  mobility  and  crepitus  by  raising  and 
throwing  back  the  shoulder.  In  looking  for  these  signs  in  children  it  is  to  be 
remembered  that  the  fracture  is  probably  incomplete.  The  prognosis  is  good, 
the  bone  uniting,  but,  if  unoperated  upon,  with  some  shortening  or  inequality.' 

Complications. — Fractures  of  the  shaft  are  rarely  compound,  because  the 
sharp  end  of  the  outer  fragment  passes  backward  and  because  of  the  free 
play  the  skin  makes  over  the  bone  (Pickering  Pick).  Both  clavicles  may 
be  broken.  One  or  more  ribs  may  be  fractured  at  the  same  time.  In  frac- 
tures from  direct  force  deeper  structures  may  be  injured  by  fragments.  Thus, 
injur}'  of  the  brachial  plexus  will  induce  paralysis.  There  are  11  recorded 
cases  of  simple  fracture  of  the  clavicle 
complicated  by  laceration  of  a  large 
vessel.  Eight  of  these  cases  died. 
The  vessel  ruptured  may  be  the  sub- 
cla\dan  vein,  the  subcla\'ian  artery, 
or  the  jugular  vein.  After  a  rupture 
a  huge  blood-clot  forms  (Gallois  and 
Poillet,  in  "Rev.  de  Chir.,"  Jifly  and 
Aug.,  1 901). 

Treatment. — In  treating  a  fracture 
of  the  shaft  of  the  clavicle  correct  the 
deformity  as  soon  as  possible  by  throw- 
ing the  shoulder  upward,  outward,  and 
backward.  If  the  patient  is  a  girl,  it 
is  desirable  to  minimize  the  deformity. 
Place  her  upon  her  back  upon  a  hard 
bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the 
shoulders,  a  bag  of  shot  resting  over  the 
seat  of  fracture,  and  the  forearm  lying 

on  the  front  of  the  chest,  the  arm  being  held  to  the  side  by  a  sand-bag. 
In  three  wxeks  there  will  be  union,  practically  without  deformity.  In  a 
child  with  an  incomplete  fracture  a  handkerchief  sling  for  the  forearm, 
worn  three  weeks,  is  all  that  is  needed.  In  a  fracture  of  the  collar-bone  of  an 
adult  the  Velpeau  bandage  is  usually  efficient.  Before  applying  it,  place  lint 
around  the  chest  and  cotton  over  the  elbow.  Change  the  bandage  every- 
day for  the  first  week,  and  after  that  period  every  third  day.  Each  time  it  is 
changed  rub  the  skin  with  alcohol,  ethereal  soap,  or  soap  liniment,  dr>'  care- 
fully, and  examine  for  excoriations;  if  any  are  found,  they  are  anointed  with 
zinc  ointment  before  the  dressing  is  reapplied.  The  dressing  is  permanently 
removed   at   the  end  of  four  weeks,  the  arm  being  carried  in  a  sling  for 


Fig.  295. 


Fox's  apparatus  for  fractured  clav- 
icle. 


552 


Diseases  and  Injuries  of  the  Bones  and  Joints 


another  week.  The  classical  apparatus  of  Desault  is  now  rarely  used.  The 
posterior  figure-of-8  bandage  associated  with  the  second  roller  of  Desault, 
some  turns  being  made  from  the  elbow  of  the  injured  side  to  the  shoulder 
of  the  sound  side,  can  be  used  in  cases  in  which  the  forward  deformity  is 
apt  to  return.  The  apparatus  of  Fox,  which  is  very  comfortable  and  useful, 
consists  of  a  pad  for  the  axilla,  a  sHng  for  the  forearm,  and  a  ring  for  the 
opposite  shoulder,  to  which  ring  are  tied  the  tapes  from  both  the  pad  and 
the  sling  (Fig.  295). 

The  dressing  of  Moore,  of  Rochester,  is  valuable  in  an  emergency.  It 
consists  of  a  piece  of  cotton  cloth,  2  yards  long,  and  folded  like  a  cravat  un- 
til it  is  8  inches  in  width  at  the  middle.  The  center  of  the  bandage  rests 
upon  the  elbow,  the  posterior  tail  is  carried  across  the  front  of  the  shoulder 
of  the  injured  side.     The  forearm  is  at  an  acute  angle  with  the  arm,  and 

the  other  end  of  the  bandage  is  carried 
across  the  forearm,  across  the  back  over 
the  opposite  shoulder,  and  around  the 
axilla,  where  the  extremities  are  stitched 
together.  The  forearm  is  suspended  in 
a  bandage  sling  (S.  D.  Gross,  in  "A  Sys- 
tem of  Surgery  ").  The  four-tailed  band- 
age is  preferred  by  Pick.  Sayre's  dressing 
has  many  advocates  (Fig.  296).  For  this 
there  are  required  two  pieces  of  rubber 
plaster,  each  piece  being  3  inches  wide  and 
sufficiently  long  to  go  around  the  chest  one 
and  a  half  times.  The  end  of  one  piece  en- 
circles the  arm  of  the  injured  side  just  below 
the  arm-pit;  the  plaster  strip  is  pulled  across 
the  back  to  the  other  side,  to  the  front  of 
the  chest,  and  returns  again  to  the  middle  of  the  back.  This  procedure  piiEs  the 
elbow  back  and  throws  the  shoulder  out.  The  hand  of  the  injured  side  is  placed 
on  the  breast  of  the  opposite  side,  cotton  being  interposed,  and  the  second  strip 
of  plaster  runs  from  the  elbow  of  the  injured  side  to  the  front  of  the  opposite 
shoulder,  around,  and  back,  pressing  the  elbow  forward,  upward,  and  inward. 
In  children,  if  it  is  found  difficult  to  immobihze  the  parts,  the  most  satisfac- 
tory result  is  obtained  by  the  application  of  the  Velpeau  bandage,  which  is 
overlaid  by  a  thin  plaster-of-Paris  bandage.  If  the  fragments  cannot  be  coap- 
tated,  sterilize  the  parts,  administer  ether,  incise,  clear  away  the  muscle  from 
between  the  fragments,  saw  the  ends,  bore  each  end  and  hold  them  in  contact 
by  means  of  kangaroo-tendon  or  silver  wire.  The  same  procedure  should  be 
pursued  when  a  fracture  is  compound  or  threatens  to  become  so,  or  if  signs 
indicate  pressure  upon  vessels  or  nerves.  If  a  large  vessel  has  been  injured,  the 
operation  is  imperatively  necessary.  If  a  patient  suffering  under  a  fracture 
which  threatens  to  become  compound  refuses  the  aid  of  operation,  keep  him 
in  bed  and  hold  the  arm  in  abduction.  In  a  number  of  cases  I  have  wired 
the  fragments  with  excellent  results.  Year  by  year  I  become  more  inclined 
to  recommend  wiring  in  cases  of  fractured  collar-bone.  It  secures  union  with- 
out deformity,  saves  the  vessels  and  nerves,  and  obviates  the  necessity  of  pro- 
longed and  very  uncomfortable  fixation  of  the  arm  and  forearm. 

After  a  broken  collar-bone  has  united,  if  the  shoulder  is  found  to  be  stiff, 
make  passive  movements  daily;  if  these  fail,  move  the  joint  forcibly,  first  giv- 
ing ether  or  nitrous  oxid. 

Fractures  of  the  acromial  end  of  the  clavicle  are  due  to  direct  force.  If 
the  fracture  is  between  the  two  coracoclavicular  ligaments,  deformity  is  very 
slight,  crepitus  is  elicited  by  manipulating  with  the  fingers,  and  pain  exists,  but 


Fig.  296. — Sayre's  adhesive-plaster  dress- 
ing for  fracture  of  the  clavicle  (Stimson):  A, 
First  piece;  B,  second  piece. 


Fractures  of  the  Glenoid  Cavity  553 

loss  of  function  is  not  markedly  manifest  unless  it  is  due  to  pain.  These  frac- 
tures are  treated  by  interposing  cotton  between  the  arm  and  the  side,  binding 
the  arm  to  the  side  with  the  second  roller  of  Desault,  and  hanging  the  hand  in  a 
sling.  In  fractures  external  to  the  ligaments  crepitus  is  manifest  on  mo\'ing 
the  shoulder,  the  outline  of  the  bone  is  irregular,  severe  pain  is  developed  by 
movement,  and  deformity  is  pronounced.  The  deformity  is  due  to  the  ser- 
ratus  magnus  muscle  rotating  the  scapula  forward,  the  inner  end  of  the  outer 
fragment  of  the  clavicle  often  coming  in  contact  with  the  anterior  surface  of  the 
outer  portion  of  the  inner  fragment.  Fracture  of  the  acromial  end  of  the 
cla\-icle  is  reduced  by  pulling  both  of  the  shoulders  strongly  backward,  and  it 
is  kept  reduced  by  the  use  of  a  posterior  figure-of-8  bandage.  In  fracture 
external  to  the  ligaments  the  displacement  frequently  cannot  be  corrected  by 
position  and  manipulation.  Such  cases  demand  incision  and  wiring.  In 
either  variety  of  fracture  the  dressings  are  worn  for  four  weeks. 

Fractures  of  the  sternal  end  of  the  clavicle  are  vers*  rare.  They  are  caused 
by  either  direct  or  indirect  force.  In  such  a  fracture  there  are  found  crepitus, 
projection  at  the  seat  of  fracture,  rigidity  of  the  sternocleidomastoid  muscle, 
and  shortening  of  the  cla\icle.  The  inner  end  of  the  outer  fragment  always 
passes  fon\"ard,  and  often  also  downward  and  inward.  Reduce  these  frac- 
tures by  pulling  the  shoulders  back,  and  treat  them  by  means  of  the  posterior 
figure-of-S  bandage  worn  for  four  weeks.    Wiring  may  be  necessar}*. 

Fractures  of  the  Scapula. — This  bone  is  not  often  broken,  as  it  rests  upon 
thick  muscles  and  elastic  ribs:  it  is  freely  movable,  and  it  has  attached  to  it  a 
bone  which  easily  breaks. 

Fractures  of  the  Body  of  the  Scapula. — These  are  due  to  direct  \'iolence. 
The  symptoms  are  pain  iwhich  becomes  agonizing  on  attempting  to  rotate  the 
shoulder-bladeX.  ecch}Tnosis,  and  swelling.  Crepitus  is  sought  for  by  placing 
the  hand  over  the  bone  and  making  movements  of  the  arm :  also  by  holding  the 
point  of  the  shoulder  and  lifting  up  the  lower  angle  of  the  bone.  The  latter 
plan  may  develop  mobility.  The  spine  of  the  scapula  is  imeven  only  when  it 
is  itself  fractured.  Examine  for  unevenness  of  the  vertebral  border  of  the 
shoulder-blade.  In  fractures  of  the  body  of  the  scapula  a  shoulder-cap  is  ap- 
plied, a  gutta-percha  splint  is  molded  over  the  scapula,  the  arm  is  bound  to 
the  side,  and  the  hand  is  carried  in  a  sling.  The  apparatus  is  worn  for  four 
weeks. 

Fractures  of  the  spine  of  the  scapula  are  treated  as  fractures  of  the  body 
of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck  of  the  Scapula. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck  is  e\-inced  by  flat- 
tening of  the  shoulder,  prominence  of  the  acromion,  and  the  presence  of  a 
limap  in  the  axilla,  crepitus  being  developed  by  pressing  the  axillan.-  promi- 
nence upward  and  backward.  The  coracoid  process  descends  with  the 
humerus.  The  deformity  is  reduced  ^-ith  ease,  but  it  at  once  recurs.  The 
condition  is  treated  by  placing  a  pad  in  the  axilla,  a  shoulder-cap  on  the 
shoulder,  apphing  the  second  roUer  of  Desault,  and  supporting  the  forearm 
and  elbow  in  a  sling.  A  A'elpeau  dressing  can  be  used,  associated  -vs-ith  the 
application  of  a  folded  towel  in  the  axilla.  The  dressing  is  to  be  worn  for  five 
weeks. 

Fractures  of  the  glenoid  cavity  are  not  ver\-  unusual,  and  may  occur  with 
or  without  dislocation.  Fracture  of  this  region  arises  from  direct  force  applied 
to  the  shoulder.  The  existence  of  this  fracture  is  determined  by  excluding 
fractures  of  other  bones  and  by  detecting  crepitus  when  the  arm  is  at  a  right 
angle  to  the  body  and  the  humerus  is  pushed  against  the  glenoid  ca\-ity,  the 
crepitus  not  being  found  when  the  arm  hangs  by  the  side. 

Treatment  is  bv  the  second  roller  of  Desault  and  a  forearm  sling  worn 


554  Diseases  and  Injuries  of  the  Bones  and  Joints 

for  four  weeks;  careful  passive  movements  limit  ankylosis.  If  ankylosis  oc- 
curs, adhesions  must  be  broken  up  while  the  patient  is  imder  ether  or  nitrous 
oxid. 

Fractures  of  the  acromion  process  are  often  met  with  as  the  result  of 
direct  violence.  The  existence  of  fracture  of  the  acromion  is  indicated  by 
pain,  by  inability  to  abduct  the  arm,  by  flattening  of  the  shoulder,  by  sudden 
lowering  of  the  point  of  the  shoulder,  by  mobility,  and  by  crepitus.  To  treat 
a  case  of  this  kind,  put  a  large  pad  with  the  base  down  in  the  axilla,  bind  the 
arm  over  the  pad  with  the  second  roller  of  Desault,  lifting  the  elbow  with 
turns  of  the  roller  carried  over  it  and  the  opposite  shoulder,  thus  splinting 
the  bone  in  place  by  the  head  of  the  humerus  pushing  against  the  coraco- 
acromial  ligaments.    The  dressing  is  to  be  worn  for  four  weeks. 

Fractures  of  the  coracoid  process  rarely  happen  alone,  and  may  arise 
from  direct  force  or  from  muscular  action.  But  little  displacement  is  found. 
Crepitus  and  mobility  are  usually  detected.  Inability  to  shrug  the  shoulder 
inward  was  pointed  out  as  a  symptom  by  Byers.  Such  a  case  is  well  treated 
by  a  Velpeau  bandage,  which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  humerus  are  divided  into:  (i)  fractures  of  the  upper  ex- 
tremity; (2)  fractures  of  the  shaft,  and  (3)  fractures  of  the  lower  extremity. 
In  examining  any  fracture  of  the  humerus,  feel  at  once  for  the  pulse,  so  as  to 
ascertain  if  the  artery  has  been  torn;  in  any  fracture  near  the  head  of  the 
humerus  be  certain  that  dislocation  does  not  exist. 

Examination  of  the  Shoulder. — In  some  cases  ether  must  be  administered. 
Compare  the  injured  shoulder  with  the  sound  shoulder,  the  patient,  if  not 
anesthetized,  being  seated  on  a  chair  or  stool.  The  direction  of  the  axis  of 
the  arm  is  noted.  The  surgeon  grasps  the  flexed  elbow  with  one  hand  and 
the  shoulder  with  the  other;  he  thus  can  move  the  extremity  and  palpate  the 
joint  and  adjacent  points.  The  shoulder  is  moved  gently  in  every  direction, 
and  the  surgeon  notes  if  the  head  of  the  bone  moves  with  the  shaft.  Ex- 
amination shows  if  the  head  of  the  bone  is  in  place  or  if  the  glenoid  cavity 
is  vacant — if  the  head  of  the  bone  is  in  an  abnormal  situation,  if  it  is  altered 
in  contour,  if  there  is  crepitus  or  preternatural  mobility,  and  if  any  movement 
is  impaired.  The  acromion  process,  outer  end  of  the  clavicle,  coracoid  process 
of  the  scapula,  and  neck  of  the  scapula  are  also  investigated.  The  length 
of  the  arm  is  obtained  by  measuring  from  the  apex  of  the  acromion  process 
of  the  scapula  to  the  apex  of  the  external  condyle  of  the  humerus,  and  it  is 
compared  with  the  length  of  the  sound  extremity. 

Fractures  of  the  upper  extremity  of  the  humerus  include:  {a)  frac- 
tures of  the  anatomical  neck;  {b)  fractures  of  the  surgical  neck;  (c)  fractiures 
of  the  head,  oblique  and  longitudinal,  and  {d)  separation  of  the  upper  ep- 
iphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — The  anatomical  neck 
is  the  constricted  circumference  of  the  articular  surface,  and  fractures  of  it, 
though  rare,  do  occur,  especially  in  the  aged.  The  line  of  fractine  in  some 
cases  follows  the  insertion  of  the  capsule,  in  others  it  is  entirely  within  the 
capsule,  but  in  most  it  is  without  the  capsule  above  and  within  the  capsule 
below;  hence  the  term  "intracapsular"  is  rarely  correct  as  a  designation. 
Such  a  fracture  may  be  impacted.  The  cause  is  direct  violence  or  a  fall  or 
a  blow  upon  the  elbow  when  the  arm  is  abducted.  Polloson,  of  Lyons,^  has 
reported  a  case  due  to  muscular  action.  The  patient  died  in  eclampsia,  and 
at  the  necropsy  it  was  found  that  both  himieral  heads  were  fractured  and  im- 
pacted. The  fractures  must  have  been  produced  by  the  muscles  throwing 
the  heads  of  the  bones  violently  against  the  glenoid  cavities,  probably  by 
adduction. 

1  "Rev.  de  Chir.,"  vol.  viii,  1888. 


SPLINTS. 


I'LA  1  K   7 


I.  Fracture-box.  2.  Double  Inclined  Plane  Fracture-bo.\.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  S.  Shoulder-cap. 
9.  Dupuytren  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  the  Metacarpus.  11.  Agnew 
Splint  for  Fracture  of  the  Patella.  12.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Ribs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  E.xtension 
Apparatus. 


Fractures  of  the  Anatomical  Neck  of  the  Humerus 


555 


The  symptoms  of  fracture  of  the  anatomical  neck  are  pain,  tendinous  swell- 
ing, ecchymosis,  slight  irregularity  of  the  shoulder  (which  irregularity  is  soon 
hidden  by  tumefaction),  and  inability  to  actively  abduct  the  arm.  Deformity, 
as  a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely  entirely  torn  from 
the  lower  fragment.  If  deformity  exists,  it  is  due  to  the  muscles  inserted  on 
the  bicipital  groove  and  to  the  coracobrachialis,  which  pull  the  lower  fragment 
inward  and  forward.  Treves  says  that  a  tear  of  the  reflected  fibers  of  the  cap- 
sule leads  to  subsequent  necrosis  of  bone  because  this  joint  has  no  ligamentum 
teres.  In  miimpacted  cases  there  is  crepitus,  and  mobility  of  the  shaft  can 
be  detected  near  the  head  of  the  bone.  In  some  cases  impaction  occurs,  the 
upper  fragment  impacting  into  the  lower.  In  this  condition  there  are  very 
slight  shortening  and  trivial  shoulder-flattening,  no  crepitus  unless  the  tuber- 
osity is  broken  off,  no  mobility,  and,  as  Erichsen  says,  the  head  of  the  bone, 
while  it  can  be  felt  through  the  axilla,  is  not  in  the  axis  of  the  limb. 


Fig.  2g7. — Fracture  at  upper  end  of  the 
humerus.  Note  hand,  forearm,  and  elbow  ban- 
daged; axillao'  pad  and  strap,  plaster-of-Paris 
shoulder-cap,  sling  (Scudder). 


Fig.  2g8. — Fracture  at  upper  end  of  the 
humerus.  Arm  and  elbow  bandaged.  Axillary 
pad  and  shoulder-cap  in  position.  Application 
of  circular  bandage  to  trunk  and  shoulder. 
Sling  not  shown  (Scudder). 


The  prognosis  of  fracture  of  the  anatomical  neck  is  usually  good  for 
bony  union  (Hamilton,  Pick,  and  R.  W.  Smith),  but  a  stifif  joint  is  apt  to 
result. 

Treatment. — Feel  the  pulse  to  be  sure  the  artery  is  untorn.  In  most  cases 
an  anesthetic  should  be  given  in  order  to  examine  vnth.  ease  and  dress  with 
satisfaction.  Sometimes  the  fragments  are  readily  coaptated;  occasionally 
they  are  not.  In  a  case  reported  by  Carl  Beck  the  axes  of  the  fragments 
were  at  right  angles  and  they  could  only  be  kept  in  contact  by  holding  the 
arm  at  a  right  angle  to  the  body  ("New  York  Med.  Jour.,"  April  5,  1902). 
Albee,  of  New  York,  reported  a  series  of  these  fractm^es  treated  by  wiring  and 
maintaining  the  arm  at  a  right  angle  with  the  body.  The  result  was  com- 
plete preservation  of  function.  Some  surgeons  treat  this  fracture  by  simply 
hanging  the  wTist  in  a  sling  and  suspending  a  bag  of  shot  from  the  elbow  to 
make  extension.  The  usual  plan  of  treatment  is  as  follows:  abduct  the  arm  to 
a  right  angle  with  the  body,  and  carry  up  from  the  base  of  the  fingers  to  above 


556 


Diseases  and  Injuries  of  the  Bones  and  Joints 


the  elbow  the  turns  of  a  spiral  reversed  bandage  made  of  flannel.  Interpose 
lint  between  the  arm  and  the  side,  and  place  a  V-shaped  pad  with  the  apex 
upward  in  the  axilla,  tying  the  tapes  over  the  opposite  shoulder.  A  shoulder- 
cap  made  of  pasteboard  (PL  7,  Fig.  8)  or  plaster  of  Paris  (Fig.  297),  molded 
to  fit  and  well  lined  with  cotton,  is  applied.  The  plaster-of-Paris  cap  is  the 
most  satisfactory.  It  is  applied  "so  as  to  cover  the  whole  shoulder,  the  ante- 
rior and  posterior  aspects  of  the  chest,  and  the  outer  side  of  the  upper  arm 
down  to  the  external  condyle  of  the  humerus"  (Scudder,  on  "The  Treatment 
of  Fractures")  (Fig.  297).  The  arm  with  the  shoulder-cap  is  fixed  to  the 
side  by  the  second  roller  of  Desault,  and  the  wrist  is  hung  in  a  sling  (Fig. 
298).  The  edges  of  the  bandage  should  be  stitched  together.  This  appar- 
atus is  changed  daily  for  the  first  few  days,  the  body  and  arm  being  rubbed 
at  each  change  with  alcohol,  soap  liniment,  or  ethereal  soap.  After  this 
period  a  change  every  third  or  fourth  day  is  often  enough.  Massage  is 
begun  at  the  end  of  one  week,  but  rotation  and  motion  of  the  joint  are 
not  employed  until  after  three  weeks.  The  dressings  are  removed  at  the  end 
of  four  weeks,  the  forearm  being  carried  in  a  sling  for  two  weeks  more.  In 
impacted  fracture  do  not  pull  apart  the  impaction,  do  not  use  a  pad,  but 
apply  a  cap  to  the  shoulder  and  fix  the  arm  to  the  side  for  five  weeks.  The 
fracture  unites  with  deformity. 

Fractures   of  the   Surgical   Neck  of  the   Humerus.— The   surgical  neck 
is  the  constricted  portion  of  bone  between  the  tuberosities  and  the  upper 

line  of  the  insertion  of  the  muscles  on  the  bi- 
cipital groove.  Fractures  in  this  region  are 
usually  transverse,  but  they  may  be  oblique. 
The  causes  are:  direct  force  almost  always; 
indirect  force  occasionally;  and  muscular  ac- 
tion  in   rare   instances. 

The  symptoms  in  fracture  of  the  surgical 
neck  are:  pain  running  into  the  fingers  from 
pressure  upon  the  brachial  plexus;  crepitus; 
mobility  on  extension;  and  flattening,  which 
differs  from  the  flattening  of  dislocation  in  that 
it  occurs  farther  below  the  acromion  and  that 
this  process  is  not  so  prominent.  Shortening 
to  the  extent  of  an  inch  is  noted.  The  head 
of  the  bone  can  be  felt  in  the  glenoid  cavity, 
but  it  does  not  move  on  rotating  the  arm.  The 
upper  end  of  the  lower  fragment  is  felt  and 
moves  on  rotating  the  arm.  The  displacement 
is  pronounced.  The  lower  fragment  is  pulled  upward  by  the  deltoid, 
biceps,  coracobrachialis,  and  triceps;  inward  by  the  muscles  of  the 
bicipital  groove,  and  forward  by  the  great  pectoral;  thus,  the  upper  end  of  the 
lower  fragment  projects  into  the  axilla,  and  the  elbow  lies  from  the  side  and 
backward.  Pean  holds  that  the  violence  drives  the  lower  fragment  forward. 
The  upper  fragment  is  abducted  and  rotated  outward,  which  position  is  due, 
it  is  generally  taught,  to  the  action  of  the  supraspinatus,  infraspinatus,  and 
teres  minor  muscles.  In  some  cases  displacement  is  forward,  and  in  other  cases 
it  is  not  obvious.  The  lower  fragment  may  impact  into  the  upper,  in  which 
case  the  symptoms  are  obscure  and  the  diagnosis  is  made  by  exclusion.  If  the 
impaction  is  solid  and  complete,  there  are  the  history  of  direct  force,  the  im- 
paired movements,  the  slight  deformity,  and  the  absence  of  crepitus.  In  all 
fractures  of  the  upper  end  of  the  htunerus  the  distinction  can  be  made  from 
dislocation  by  feeling  the  head  of  the  bone  under  the  acromion  and  by  noting 
that  it  does  not  move  on  rotating  the  arm. 


Fig.  2g9  — Internal  angular 
splint  and  shoulder-cap  in  fracture 
of  the  surgical  neck  of  the  humerus. 


Longitudinal  and  Oblique  Fractures  of  the  Head  of  the  Humerus     557 


The  prognosis  of  fracture  of  the  surgical  neck  of  the  bone  is  good. 
Treatment. — Some  surgeons  treat  a  fracture  of  the  surgical  neck  in  exactly 
the  same  manner  as  a  fracture  of  the  anatomical  neck.  I  prefer  the  following 
plan:  In  many  cases  give  ether  in  order  to  examine  and  dress.  Feel  the  pulse 
to  see  that  the  artery  has  not  been  damaged.  Reduce  by  traction  and  manip- 
ulation ;  if  there  is  an  impaction,  pull  it  apart.  Take  an  internal  angular  splint 
(PL  7,  Fig.  6)  and  pad  it  well,  putting  on  extra  padding  at  the  points  that  are 
to  rest  against  the  palm,  the  inner  condyle,  and  the  axillary  folds.  Lay  the 
arm  and  pronated  forearm  upon  the  splint.  Apply  a  padded  shoulder-cap. 
Fix  the  splint  and  cap  in  place  with  a  spiral  reversed  bandage  terminating  as  a 
spica  of  the  shoulder,  and  hang  the  hand  or  forearm  in  a  sling  (Fig.  299). 
The  dressing  is  to  be  worn  for  four  weeks,  and  the  rules  to  be  followed  in 

changing  it  are  the  same  as  in  fracture  of 
the  anatomical  neck.  Massage  is  used 
after  one  week,  and  passive  motion  to 
amend  stiffness  after  four  weeks.  In 
rare  cases — those  with  strong  anterior 
projection  of  the  lower  end  of  the  upper 
fragment — apply  an  anterior  angular 
splint.  In  some  cases  when  the  de- 
formity strongly  tends  to  recur  support 
by  a  plaster-of-Paris  trough  on  the  back 
and  sides  of  the  arm  and  shoulder,  or 
maintain  extension  by  weights  and  pul- 
leys, the  patient  being  kept  in  bed  (Stim- 


Fig.  300. 


-Fracture  of  humerus  below  sur- 
gical neck. 


Fig.    301. — Preliminary    splinting   for   complete 
dressing  as  shown  in  Fig.  304. 


son).  In  a  case  with  great  deformity  abduction  with  extension  is  a  very 
useful  method.  I  have  reached  the  conclusion  that  many  cases  of  fracture 
of  the  surgical  neck  are  best  treated  by  incision  and  fixation. 

Longitudinal  and  Oblique  Fractures  of  the  Head  of  the  Humerus. — By 
this  term  may  be  designated  separation  of  the  great  tuberosity  or  separation 
of  a  portion  of  the  articular  surface,  together  with  the  great  tuberosity,  from 
the  shaft  and  lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston).  The 
cause  is  usually  direct  violence  to  the  front  of  the  shoulder,  but  the  greater 
tuberosity  may  be  torn  off  by  muscular  action. 

The  symptoms  in  longitudinal  and  oblique  fracture  of  the  head  are  broad- 
ening and  flattening  of  the  shoulder  with  projection  of  the  acromion.  The 
upper  fragment  passes  upward  and  outward,  and  the  lower  fragment  passes 


558  Diseases  and  Injuries  of  the  Bones  and  Joints 

upward  and  inward  to  rest  on  the  margin  of  the  glenoid  cavity  below  the 
coracoid  process.  The  elbow  is  drawn  from  the  side,  there  is  some  shortening, 
and  the  patient  cannot  abduct  his  arm.  If  the  surgeon  grasps  the  patient's 
elbow  and  holds  it  to  the  side  and  rotates  the  arm  while  with  his  other  hand  he 
grasps  the  upper  fragment,  crepitus  is  very  positive.  Examination  develops 
wide  separation  of  the  fragments.  The  deformity  cannot  be  entirely  corrected, 
because  the  biceps  tendon  is  apt  to  get  between  the 
fragments  (Ogston),  but  a  useful  limb  can  usually  be 
obtained. 

Treatment. — The  plan  which  gives  the  best  result 
in  treating  longitudinal  and  oblique  fracture  of  the 
head  of  the  bone  is  to  place  the  patient  on  his  back 
upon  a  hard  bed  with  a  small,  firm  pillow  under  his 
head,  abduct  the  arm  above  the  head,  rotate  it  out- 
ward so  that  the  back  of  the  hand  rests  on  the  bed^ 
and  hold  it  in  place  by  sand-bags.  This  position 
should  be  maintained  for  three  weeks,  at  the  end  of 
^.  J.         f     ,         which  period  the  fracture  can  be  treated  for  three 

Fig.    302.— Linear    fracture  ^  .  ^        •      1  i         xr 

of  humerus.  weeks  more  as  a  fracture  of  the  anatomical  neck.     If 

the  patient  refuses  to  go  to  bed,  treat  the  injury  as  a 
fracture  of  the  anatomical  neck,  padding  well  over  the  tuberosities.  The 
dressings  should  be  worn  for  five  weeks,  passive  motion  being  made  after  four 
weeks.  In  the  above  injury  feel  at  once  for  the  pulse,  to  see  if  the  artery  has 
been  torn. 

Separation  of  the  Upper  Epiphysis  of  the  Hxxmerus. — The  epiphysis  is 
united  during  the  twentieth  year.  Separation  is  a  rare  accident  and  is  pro- 
duced by  direct  force. 

Symptoms.— The  chief  symptom  in  separation  of  the  upper  epiphysis  is 
projection  of  the  upper  end  of  the  lower  fragment  inward,  forward,  and  up- 
ward beneath  the  coracoid,  and  consequently  a  projection  of  the  elbow  back- 
ward and  from  the  side.  If  the  lower  fragment  passes  forward  and  not  in- 
ward, the  elbow  simply  passes  back.  The  upper  end  of  the  lower  fragment  is 
smooth  and  convex.  Rotation  of  the  shaft  develops  soft  crepitus  when  the 
fragments  are  in  contact. 

The  prognosis  is  good  for  bony  union,  though  the  future  growth  of  the 
limb  may  be  impaired. 

The  treatment  for  separation  of  the  upper  epiphysis  is  a  pad  in  the  axilla^ 
a  shoiilder-cap,  binding  the  arm  to  the  side,  and  hanging  the  hand  in  a  sling. 
Wear  the  dressing  for  four  weeks,  and  begin  passive  motion  as  directed  when 
dealing  with  fracture  of  the  upper  end  of  the  humerus. 

Fracture  of  the  shaft  of  the  humerus  is  a  very  common  accident.  The 
cause  is  usually  direct  violence,  such  as  a  blow.  The  fracture  may  arise  from 
indirect  violence,  such  as  a  fall  upon  the  elbow.  Muscular  action  is  not  rarely 
also  a  cause,  as  in  throwing  a  ball,  in  catching  a  tree-limb  w^hile  falling,  or  in 
turning  another's  wrist  outward  as  a  test  of  strength  (Treves).  This  test  of 
strength  is  known  by  the  French  as  "le  tour  de  poignet." 

The  opponents  sit  opposite  to  each  other  and  each  rests  his  elbow  on  a 
table.  They  clasp  hands  and  each  one  strives  to  rotate  the  other's  hand  out- 
ward. Ashhurst  collected  57  cases  due  to  throwing  a  ball  and  23  cases  due  to 
*'le  tour  de  poignet."  He  believes  that  in  some  cases  the  hiunerus  is  broken  as 
a  stick  may  be  broken  by  holding  one  end  and  swinging  the  other  through  the 
air  and  that  in  other  cases  fracture  results  from  twisting  (Astley  P.  C.  Ash- 
hurst, in  "University  of  Pennsylvania  Med.  Bulletin,"  Feb.,  1906).  In  frac- 
ture due  to  muscular  action  the  break  is  nearly  always  below  the  deltoid  inser- 
tion and  the  line  of  fracture  approaches  the  transverse. 


Fracture  of  the  Shaft  of  the  Humerus 


559 


The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are  pain,  tendinous 
swelling,  ecchymosis,  inability  to  move  the  arm,  mobility,  and  distinct  crepitus. 
Shortening  to  the  extent  of  i  inch  occurs.  The  displacement  varies  with  the 
situation  of  the  fracture  and  the  direction  of  the  force.  If  the  fracture  is  above 
the  insertion  of  the  deltoid,  the  lower  fragment  is  pulled  up  by  the  triceps, 
biceps,  and  deltoid,  and  pulled  out  by  the  deltoid,  and  the  upper  fragment  is 
pulled  inward  by  the  arm-pit  muscles.  In  fracture  below  the  deltoid  this  mus- 
cle is  apt  to  pull  the  lower  end  of  the  upper  fragment  outward,  while  the  lower 
fragment  passes  inward  and  upward  because  of  the  action  of  the  biceps  and 
triceps.  Injury  of  the  muscidospiral  nerve  sometimes  occurs.  The  nerve  may 
be  contused,  producing  pain  at  the  seat  of  bruising,  and  tingling  and  numb- 
ness in  the  region  supplied  by  the  nerve.  In  most  cases  the  symptoms  soon 
pass  away,  but  sometimes  neuritis  ensues.  A  severe  contusion  produces  not 
only  pain,  but  paralysis  of  the  muscles  supplied  by  the  nerve,  and  surface 
anesthesia.  In  most  cases  this  condition  is  recovered  from  in  a  few  weeks, 
but  sometimes  it  lasts  a  long  while  or 
even  permanently.     In  musculospiral 


Fig.  303. — Fracture  of  middle  of  humerus. 


Fis 


304. — Apparatus  for  fracture  of  the  hume- 
rus at  any  point  above  the  condj'les. 


paralysis  the  patient  is  unable  to  extend  the  wrist  and  fingers  or  to  supinate 
the  forearm.  There  is  "complete  loss  or  impaired  sensation  in  the  lower 
half  of  the  outer  and  anterior  aspect  of  the  arm  and  in  the  middle  of  the  back 
of  the  forearm  as  far  as  the  wrist"  (Scudder,  in  "The  Treatment  of  Fractures"). 
The  ner\"e  may  be  diA^ided  by  a  sharp  fragment,  paralysis  of  motion  and  anes- 
thesia resulting  at  once.  In  some  cases  the  nerve  is  caught  in  and  compressed 
by  callus,  scar-tissue,  or  fragments,  motor  and  sensor}-  disturbances  resulting. 

The  prognosis  is  good,  but  the  fact  should  always  be  remembered  that 
imunited  fractures  are  commoner  in  the  humerus  than  in  any  other  bone. 
Treves  believes  this  to  be  due  to  entanglement  of  muscle  between  the  frag- 
ments, lack  of  fixation  of  the  shoulder-joint,  and  imperfect  elbow  support. 
Hamilton  believes  that  it  is  due  to  the  facts  that  the  elbow  soon  becomes 
fixed  at  a  right  angle,  and  that  any  movement  of  the  forearm  moves  the  seat  of 
fracture  and  not  the  elbow. 

Treatment. — It  is  rarely  necessar^^  to  anesthetize  unless  the  patient  be  a 
nerV'Ous  woman  or  an  excitable  child.  Feel  the  pulse,  to  be  certain  the  artery 
has  not  been  lacerated.  Reduce  the  fracture  by  extension,  counterextension, 
and  manipulation.    Appl}'  four  himieral  splints  (Fig.  301).    The  internal  splint 


56o 


Diseases  and  Injuries  of  the  Bones  and  Joints 


reaches  from  the  axilla  to  just  above  the  internal  condyle  of  the  humerus. 
A  short  straight  splint  is  appUed  front  and  another  back,  each  being  the 
length  of  the  arm.  A  shoulder-cap  is  appHed,  which  cap  "is  prolonged  be- 
low into  an  external  angular  splint  reaching  as  far  down  as  the  lower  third 
of  the  forearm"  (Fig.  304)  ("Manual  of  Surgical  Treatment,"  by  Cheyne  and 
Burghard).  The  elbow  is  brought  to  a  right  angle  with  the  arm  and  the  fore- 
arm is  placed  midway  between  pronation  and  supination.  As  Cheyne  and 
Burghard  say:  "It  is  necessary  that  the  arm  should  hang  vertically  at  the 
side  with  the  long  axis  of  the  forearm  parallel  with  the  anteroposterior 
diameter  of  the  trunk;  if  the  forearm  be  brought  at  all  forward  across  the 
chest,  rotation  of  the  lower  fragment  upon  its  vertical  axis  is  apt  to  take  place." 
Splints  are  to  be  worn  for  five  or  six  weeks,  and  after  the  removal  of  the  splints 
the  wrist  is  hung  in  a  sling.  The  sling  is  dispensed  with  eight  weeks  after  the 
infliction  of  the  injury.     Passive  movements  are  not  to  be  made  until  the 


Fig.  305. — Fracture  of  the  shaft  of  the  hume- 
rus. Note  bandage  to  hand,  forearm,  and  elbow; 
axillary  pad  and  strap;  coaptation  splints  and 
sling.    Bandage  does  not  cover  fracture  (Scudder) . 


Fig.  306. — Fracture  of  the  shaft'of  the  hume- 
rus. Note  bandage  to  hand,  forearm,  and  elbow; 
adhesive-plaster  swathe  holding  arm  upon  axil- 
lary pad  and  covering  coaptation  splints.  Sling 
(Scudder). 


fracture  is  well  united  (after  five  or  six  weeks) ,  for,  if  made  too  soon,  they  pre- 
dispose to  non-union,  and,  as  no  joint  is  involved,  genuine  ankylosis  wiU.  not 
occur.  Many  surgeons  treat  these  fractures  by  applying  plaster  of  Paris  to 
the  forearm  and  the  arm  (the  elbow  being  flexed  to  a  right  angle),  binding 
the  arm  to  the  side,  and  hanging  the  wrist  in  a  sling.  Others  apply  a  trough 
to  the  arm  and  forearm.  Scudder  prefers  to  bandage  the  hand,  forearm,  and 
elbow,  and  apply  an  axillary  pad,  coaptation  splints,  a  swathe  of  adhesive 
plaster  holding  arm  to  the  side,  and  a  sling  (Figs.  305,  306).  In  any  case  in 
which  it  is  impossible  to  obtain  and  maintain  correct  apposition  of  the  frag- 
ments, cut  down  upon  them,  and  apply  a  plate.  If  the  nerve  is  divided,  an 
incision  must  be  made  at  once,  the  nerve  sutured,  and  the  bone  plated.  If 
the  nerve  is  caught  in  the  callus,  after  repair  has  taken  place  it  must  be 
liberated  by  chiseling  the  callus  away.  Neuritis  is  treated  by  blisters  over 
the  nerve,  the  use  of  the  descending  galvanic  current,  and  the  administration 
of  salicylate  of  ammonium  and  the  bromids. 


Fractures  of  the  Inner  Epicondyle  of  the  Humerus  561 

Fractures  of  the  Lower  Extremity  of  the  Humerus. — These  fractures  are 

spoken  of  as  fractures  in,  or  in  the  neighborhood  of,  the  elbow-joint,  and 
they  include:  {a)  fractures  of  the  external  condyle;  (b)  fractures  of  the  in- 
ternal condyle;  {c)  fractures  of  the  internal  epicondyle;  (d)  fractures  at  the 
base  of  the  condyles;  {c)  T-  or  Y-shaped  fractures;  (/)  epiphyseal  separation, 
and  (g)  fractures  of  the  capitellum  and  trochlea.  There  may  be  more  than  one 
fracture,  or  there  may  be  also  a  dislocation  of  the  humerus,  of  the  ulna,  or  of 
both  bones.  Rarely  the  fracture  is  compound.  These  fractures  are  frequent 
injuries  in  childhood,  and  are  not  imcommon  in  adults. 

Method  of  Examination. — A  fracture  of  the  elbow  is  rapidly  followed  by 
great  swelling,  and  the  diagnosis  is  often  ver\-  difficult.  In  most  cases,  when 
possible,  the  .v-rays  should  be  used  in  arri\-ing  at  a  diagnosis.  In  ever}-  case 
in  which  the  .v-rays  are  not  used,  and  in  most  cases  in  wliich  they  are,  the  sur- 
geon examines  the  parts  carefully  while  the  patient  is  under  ether.  If  swelling 
is  xer\  great,  it  is  necessary  to  abate  it  in  order  to  reach  any  conclusion  as  to  the 
condition.  We  can  bandage  the  arm,  rest  it  semiflexed  on  a  piUow,  and  apply 
evaporating  lotions  or  even  an  ice-bag  for  a  day  or  two,  or,  what  is  better,  tem- 
porarily diminish  the  swelling  by  Gerster's  plan,  which  is  as  follows:  Apply  an 
Esmarch  bandage  from  the  hand  to  well  above  the  seat  of  fracture;  this  \n\[ 
drive  awav  extra-articular  swelling  and  permit  of  thorough  examination.  It 
is  a  great  advantage  to  have  the  patient  anesthetized,  for  then  not  only  can 
we  make  an  accurate  diagnosis,  but  we  can  reduce  the  fracture  satisfactorily 
and  apply  a  careful  first  dressing. 

Compare  the  injured  -nith  the  soimd  elbow.  Xote  swelling  and  local 
€Cch}Tnosis.  Feel  the  radial  pulse.  Note  the  "'carrx-ing  angle"  (^Fig.  30S). 
^Measure  each  arm  from  the  tip  of  the  acromion  process  of  the  scapula  to  the 
tip  of  the  external  cond>-le  of  the  humerus.  Feel  each  prominent  bony  pomt 
and  note  if  it  is  mobile  (^condyles,  olecranon,  head  of  ulna).  Feel  the  shaft 
just  above  the  condyles.  ]\Iark  with  mk  on  each  elbow  the  tip  of  the  ex- 
ternal condyle,  the  tip  of  the  internal  condyle,  and  the  tip  of  the  olecranon, 
and  obsen.-e  the  relation  between  these  points  of  each  elbow  in  flexion  and  m 
extension.  In  an  uninjured  elbow  a  straight  hne  transverse  to  the  long  axis  of 
the  limb  Tsith  the  joint  in  extension  will  pass  through  the  condyles  and  leave 
the  tip  of  the  olecranon  just  a  shade  above  it.  "When  the  elbow  is  at  a  right 
angle,  these  three  points  wiU  be  found  in  the  same  plane  with  the  back  of  the 
upper  arm"  (Scudder,  in  'The  Treatment  of  Fractures").  Rotate  the  radius 
while  a  thumb  is  held  against  the  head  of  the  bone.  ]Make  flexion  and  exten- 
sion of  the  elbow  and  determine  if  there  is  any  lateral  motion.  Test  for  mobility- 
just  above  the  condyles.  The  above  maneuvers  ^^"ill  determine  the  presence  or 
absence  of  crepitus,  preternatural  mobility,  deformity,  etc. 

Fractures  of  the  External  Condyle  of  the  Humerus. — A  fracture  of 
the  external  condyle  runs  into  the  joint  and  the  capiteUum  is  usually 
broken  off.  Such  an  injurs-  occurs  oftenest  in  children,  being  due  to  faU- 
ing  on  the  hand;  but  it  may  occur  from  direct  force,  and  may  happen  to 
adults. 

The  symptoms  of  fracture  of  the  external  condyle  are  severe  pam,  great 
swelling,  and  crepitus  (found  on  pressing  or  mo\-ing  the  condyle  and  on  ro- 
tating the  radius).  ^Mobility  may  also  be  discovered.  A  projection  is  felt  on 
the  outer  and  posterior  surface  of  the  elbow.  The  forearm  is  semiflexed  and 
supinated.     The  patient  cannot  use  the  joint. 

Fractiu:es  of  the  Inner  Epicondyle  of  the  Humerus. — The  inner  epicondyle 
is  an  epiphysis  which  unites  during  the  seventeenth  year.  It  not  infrequently 
lireaks  from  muscular  action  or  from  direct  violence,  and  the  fracture  does  not 
involve  the  joint.  Crepitus  and  mobihty  can  be  detected.  Displacement 
is  slight.  The  outer  epicondyle  is  never  fractured  alone. 
36 


562 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fractures  of  the  Internal  Condyle  of  the  Humerus.— The  hne  of  fracture 
after  a  break  of  the  internal  condyle  runs  into  the  joint,  tothe  trochlear  sur- 
face of  the  humerus.  The  cause  is  nearly  always  durect  violence.  Packard, 
of  Philadelphia,  observed  a  case  m  which  the  condyle  had  been  torn  off  while 

lifting  a  tub.  ,  ,     ■,     .  .  •  j 

Symptoms.— In  fracture  of  the  internal  condyle  the  fragment,  accompanied 

bv  the  ulna,  goes  upward  and  backward,  and  when  the  forearm  is  extended 

•^  the  ulna  pro j  ects  posteriorly, 

the  lower  end  of  the  hume- 
rus being  felt  in  front.  The 
fragment  forms  a  projection 
back  of  the  elbow.  Crepitus 
and  preternatural  mobility 
can  be  foimd  if  swelling  is 
not  too  great.  Crepitus  is 
detected  by  flexing  and  ex- 
tending the  forearm.  The 
>pace  between  the  condyles 
is  broader  than  normal,  and 
the  forearm  takes  a  bend 
toward  the  ulnar  side,  the 
"carrying  function"  of  the 
forearm  being  lost  (Fig. 
307).  When  a  person  car- 
ries a  heavy  object,  such  as 
a  bucket  of  coal,  he  instinct- 
ively rests  the  inner  condyle 
upon  the  pelvis,  and  the  nor- 
mal deviation  of  the  forearm 
outward  keeps  the  bucket 
from  striking  the  leg.  This 
deviation  outward  when  the 
inner  condyle  rests  against 
the  ilium  gives  us  the  carry- 
ing function.  In  fracture  of  the  inner  condyle  the  broken  condyle  ascends 
and  the  "carrying  function"  is  lost  (Fig.  308).  This  deformity  is  known  as 
gunstock  deformity. 

Fractures  at  the  Base  of  the  Condyles  of  the  Humerus  (Figs.  309  and 
310). — A  fracture  in  this  region  is  just  above  the  level  of  the  tip  of  the  olec- 
ranon and  is  on  a  higher  level  behind  than  in  front.  The  cause  is  direct  force 
acting  upon  the  olecranon. 

The  symptoms  are  loss  of  function,  and  pain  from  injury  to  the  median  or 
ulnar  nerve.  Crepitus  and  mobility  are  readily  foimd.  The  lower  fragment  is 
drawn  backward  and  upward  by  the  action  of  the  triceps,  biceps,  and  brachialis 
anticus  muscles.  The  lower  end  of  the  upper  fragment  projects  in  front  of 
the  joint.  This  lesion  may  be  mistaken  for  dislocation  of  the  bones  of^  the 
forearm  backward.  In  fracture  the  limb  is  mobile;  in  dislocation,  it  is  rigid. 
In  fracture  the  deformity  is  easily  reduced  and  strongly  tends  to  recur;  in 
dislocation  the  deformity  is  reduced  with  difficulty  and  does  not  tend  to  recur. 
In  dislocation  there  is  shortening  of  the  forearm,  but  not  of  the  arm;  in  fracture 
there  is  shortening  of  the  arm,  but  not  of  the  forearm.  In  dislocation  there 
is  a  smooth,  large  projection  below  the  crease  in  front  of  the  elbow;  in  fracture 
there  is  a  sharp  projection  above  the  crease.  In  fracture  there  is  crepitus;. 
in  dislocation  there  is  no  crepitus. 

The  diagnosis  can  be  settled  by  the  a;-rays. 


Fig.  307. — ^Loss  of  "carrying  function"  after  fracture  of  inner 
condyle  of  the  humerus. 


T-fractures  of  the  Humerus 


563 


Fig.  308. — Diagram  to  exhibit  the  "carrying  function"  of  the  forearm,  and  the  loss  of  this  func- 
tion in  fracture  of  the  inner  condyle  of  the  humerus:  a  and  b  show  the  normal  relation  of  the  parts 
when  carrying;  c  shows  the  alteration  of  axis  of  the  forearm  when  the  inner  condyle  is  fractured,  what 
is  known  as  gunstock  deformity  resulting  (after  AlHs). 

T-fractures  of  the  Humerus. — A  T-fracture  consists  of  a  transverse  fracture 
above  the  condyles  plus  a  vertical  fracture  between  them.  The  cause  is  violent 
direct  force  applied  posteriorly. 

The  symptoms  are  increase  in  breadth  of  the 
joint  (Fig.  311),  preternatural  mobihty,  crepitus, 
pain  and  swelling,  mounting  up  of  the  inner  con- 


Fig.  309. — Supracondylar  fracture  of  the  humerus. 


Fig.  310. — Fracture  of  the  humerus  above 
the  condyles. 


dyle  back  of  the  elbow  on  the  inner  side,  and  of  the  outer  condyle  back  of 
the  elbow  on  the  outer  side.  The  forearm  is  semiflexed  and  supinated,  and 
the  carrying  fimction  is  lost. 


564 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Prognosis  of  Fractures  In  or  Near  the  Elbow-joint. — In  many  fractures 
it  is  difficult  or  impossible  to  obtain  reduction,  and  in  some  it  is  impossible  to 
maintain  reduction.  Stimson  is  undoubtedly  right  when  he  says  that  "in 
intercondyloid  fracture  with  marked  separation  there  is  no  practicable  means 
merely  to  maintain  reduction."^  In  fracture  in  or  about  the  elbow-joint  I 
have  regarded  the  prognosis  for  complete  restoration  of  function  as  poor,  and 
believed  that  in  most  of  these  fractures  some  deformity  and  considerable  stiff- 
ness are  inevitable.  Of  late,  however,  influenced  largely  by  Astley  P.  C.  Ash- 
hurst's  study  of  "Fractures  of  the  Lower  End  of  the  Humerus"  ("Samuel  D. 
Gross  Prize  Essay  of  Phila.  Acad,  of  Surgery,"  1910),  I  have  been  studying 
this  question  anew,  and  as  a  result  take  a  less  gloomy  view  of  the  situation, 
and  am  disposed  to  agree  with  Ashhurst  that  "in  the  vast  majority  of  cases 
the  ultimate  results  will  be  perfectly  satisfactory."  Nevertheless  I  am  stiU 
cautious  as  to  what  I  can  safely  predict  to  the  patient  and  the  patient's 
family.  Ankylosis,  partial  or  complete,  is  always  a  possible  sequence.  Anky- 
losis may  result  from  prolonged 
immobilization,  the  muscles  con- 
tracting and  becoming  fibrous, 
the  fascia  and  ligaments  about 
the  joint  shortening,  the  cap- 
sule shrinking  and  thickening, 
some  of  the  cartilages  becom- 
ing fibrous,  and  the  joint  being 
partty  obliterated.  It  may  re- 
sult from  extravasation  of  blood 
into  the  joint  and  tendon- 
sheaths  with  subsequent  forma- 
tion of  fibrous  tissue.  It  may 
arise  from  organization  of  in- 
flammatory exudate  within  and 
about  the  joint  and  in  the 
sheaths  of  muscles  and  tendons. 
It  may  arise  from  the  formation 
of  an  excess  of  callus.  Brims 
claims  that  in  fracture  in  the 
joint  excess  of  callus  rarely 
forms,  and  that  masses  of  callus  form  chiefly  in  the  line  of  fracture  near  but 
not  in  a  joint.-  Excessive  callus  formation  is  sure  to  take  place  if  reduction 
is  not  thoroughly  accomplished  or  if  the  fragments  are  not  well  immobilized, 
but  move  upon  each  other.  A  mass  of  callus  in  or  about  a  joint  limits  or 
prevents  motion.  The  two  greatest  causes  of  impaired  function  are  blocking 
by  callus  and  stiffness  from  traumatic  arthritis  (Jones,  of  Liverpool). 

Treatment  of  Fractures  In  or  Near  the  Elbow-joint. — Thoroughly  set 
the  fracture  while  the  patient  is  under  ether.  It  is  advisable,  when  it  can  be 
done  conveniently,  to  use  the  a:-rays  to  confirm  the  diagnosis  and  to  use  them 
again  after  dressings  have  been  applied,  to  be  sure  that  the  bones  remain  in 
good  position.  If  swelling  is  very  great,  it  may  be  necessary  to  delay  setting  for 
two  or  even  three  days,  the  arm  being  bandaged  and  laid  upon  a  pillow  or 
lightly  supported  on  an  anterior  angular  splint  during  the  waiting  period. 

In  all  cases  except  transverse  fracture  above  the  condyles  and  fracture  of 
the  olecranon  reduction  is  best  effected  by  drawing  upon  the  forearm,  supi- 
nating  it,  extending  it,  and  then  bending  it  slowly  into  a  position  of  acute 
flexion,  the  degree  of  flexion  being  in  inverse  ratio  to  the  amount  of  swelling. 

1  "Transactions  .\merican  Surgical  Association,"  vol.  ix. 

2  Max  Oberst,  in  Volkmann's  "Sammlung  Vortrage." 


Fig.  311. 


-Deformity  following  fracture  of  the  liumcrus 
between  the  condyles. 


Treatment   of   Fractures   In   or   Xear   the   Elbow-joint  565 

In  transverse  fracture  above  the  condyles  reduction  is  efifected  by  drawing 
the  forearm  and  the  lower  fragment  downward  and  forward  and  at  the  same 
time  pushing  the  upper  fragment  back. 

Some  surgeons  advocate  dressing  the  fracture  on  an  anterior  angular  splint, 
the  forearm  being  fully  supinated  (Fig.  312 j.  The  advantage  claimed  for  this 
splint  is  that  if  ankylosis  occurs  the  joint  is  in  a  position  to  be  useful,  which  it  is 
not  if  ankylosed  in  extension.  Some  deformity  is  usually  apparent  after  treating 
a  case  vriih.  this  splint;  the  deformity 
following  fracture  of  the  inner  condyle 
is  not  corrected  by  it,  but  if  the  splmt 
is  carefully  applied  the  result  is  usually 
a  useful  extremity  in  all  cases  except 
fracture  of  the  inner  condyle.  In  trans- 
verse fracture  of  the  shaft  of  the  hu- 
merus above  the  condyles  the  anterior 
angular  splint  is  the  best  method  of 
treatment,  as  it  prevents  displacement. 
The  splint  must  not  be  appHed  when 
there  is  great  swelling,  and  swelling  must 
be   removed   by   resting   the   extremity 

on  a  pillow,  the  elbow  being  semiflexed. 

apphdng   evaporating    lotions    or    even     ,-..  .  ^   .  ,        ,•..-* 

^^  -.       ^  -t^        ,      9  ,      tiz.  312. — .\iitenor   angular   splint   tor   frac- 

an     ice-bag.     emplo\-mg     massage,     and  tures  in  or  near  the  elbow-joint. 

gently  compressing  by  bandaging.      In 

some  cases  the  joint  should  be  aspirated.  In  order  to  apply  this  dressing, 
take  a  right-angled  splint  and  pad  its  outer  surface.  beii:ig  careful  to  place  thick, 
soft  pads  over  the  convexity  which  will  press  in  front  of  the  elbow  and  over 
each  end  of  the  splint.  Fasten  the  upper  end  to  the  arm,  then  make  extension 
of  the  forearm,  and  if  the  fracture  is  found  to  be  well  reduced,  fasten  the  hand 
and  forearm  to  the  splint  (Fig.  312).  If  the  hand  and  forearm  are  first  fixed 
to  the  splint,  there  will  be  no  extension  from  the  elbow  and  deformity  will 
result.  If  posterior  projection  exists,  a  pasteboard  cup  is  molded  over  the 
elbow.  The  extremity  is  hung  in  a  triangular  sling.  At  night  the  extremity 
is  kept  in  the  sling  or  laid  on  a  pillow.  Ever}'  third  or  fourth  day,  while  the 
extremity  is  carefully  steadied,  the  splint  is  removed,  the  arm  and  forearm 
well  rubbed  with  alcohol,  massaged,  and  the  splint  reapplied.  The  splint 
is  worn  between  five  and  six  weeks.  At  the  end  of  the  third  week,  after  re- 
mo^dng  the  dressings,  slightly  flex,  slightly  extend,  and  slightly  pronate  the 
forearm,  and  reapply  the  splint.  At  the  end  of  the  fourth  week  repeat  this 
maneuver,  making  movements  of  greater  range.  In  the  middle  of  the  fifth 
week  and  at  the  end  of  the  fifth  week  do  it  again,  and  flex  and  extend  as  much 
as  possibe.  Yery  early  and  ver\-  frequent  passive  motion  is  objectionable,  as 
it  leads  to  overproduction  of  callus  and  ankylosis,  but  passive  motion  as  above 
described  is  imperatively  necessary".  ]Many  surgeons  at  the  end  of  the  second 
week  apply  a  Stromeyer  splint,  which  permits  the  patient  and  the  surgeon 
to  make  some  motion  by  means  of  the  screw  without  removing  the  dressings. 
In  ver>"  stout  persons  an  anterior  angular  splint  will  not  stay  in  place.  In 
such  a  case  the  forearm  may  be  placed  at  a  right  angle  to  the  arm  and  plaster 
of  Paris  be  used.  After  the  dressings  are  removed  employ  passive  motion, 
massage,  hot  and  cold  douches,  baking,  inunctions  of  ichthyol  or  mercurial  oint- 
ment, iodin  locally,  corrosive  sublimate  and  iodid  of  potassium  internally,  and 
direct  the  patient  to  systematically  use  the  arm.  If  in  any  case  after  four 
weeks  non-union  exists,  put  up  the  arm  in  a  plaster  splint  for  three  or  four 
weeks  more.  Some  surgeons  use  a  posterior  right-angled  trough  instead  of 
an  anterior  angular  splint  (Fig.  304). 


566 


Diseases  and  Injuries  of  the  Bones  and  Joints 


AUis  warmly  advocates  treating  fractures  in  and  about  the  joint  in  exten- 
sion. He  holds  that  the  extended  position  secures  the  best  circulation,  and 
if  either  condyle  is  unbroken  secures  the  benefit  derivable  from  a  natural  splint. 
Furthermore,  in  fractures  of  the  inner  condyle  it  restores  the  carrying  func- 
tion, which  the  flexed  position  does  not  do.  For  one  week  after  the  accident 
the  patient  stays  in  bed,  with  his  arm  extended  upon  a  pillow.  After  swell- 
ing subsides  the  limb  is  wrapped  firmly  m  a  spiral  flannel  bandage  and 
plaster  of  Paris  is  rubbed  in  or  the  bandage  is  covered  with  plaster. 

Some  surgeons  extend  the  limb  and  apply  an  ordinary  plaster  bandage, 
and  in  about  three  weeks  substitute  an  anterior  angular  splint.     The  trouble 

with  treatment  in  extension  is  that  if  ankylosis 
ensues  the  limb  is  nearly  useless.  Furthermore, 
treatment  in  extension  requires  confinement  to 
bed. 

Jones,  of  Liverpool,  thinks  that  splints  and 
bandages  are  largely  responsible  for  the  stiffness 
which  so  commonly  ensues  upon  an  elbow  injury. 
He  advocates  treatment  by  supination  and  acute 
flexion  in  all  elbow  injuries  except  fracture  of 
the  olecranon.  It  has  been  demonstated  that  the 
position  of  acute  flexion  forces  the  fragments  into 
place  and  holds  them  firmly  between  the  coronoid 
process  of  the  ulna,  the  trochlear  surface  of  the 
ulna,  the  fascia,  and  the  triceps  tendon.  The 
surgeon  must  be  certain  that  the  radial  pulse  is 
perceptible  after  the  elbow  has  been  flexed. 
Flexion  is  maintained  by  fastening  a  bandage 
around  the  wrist  and  neck.  The  bandage  around 
the  neck  passes  through  a  rubber  tube,  which 
serves  to  protect  the  neck.  The  ball  of  the 
thimib  should  rest  against  the  neck.  The  bandage  is  fastened  to  a  leather 
band  around  the  wrist  or  to  a  glove,  the  fingers  of  which  have  been  cut  off. 
The  most  convenient  dressing  to  maintain  Jones's  position  is  shown  in  Fig.  313. 
After  the  dressing  has  been  applied  certain  precautions  are  to  be  observed. 
For  the  first  week  or  ten  days  look  at  the  arm  daily.  If  the  swelling  grows 
worse,  diminish  the  degree  of  flexion,  and  do  the  same  if  there  is  severe  pain. 
If  the  radial  pulse  disappears,  diminish  the  flexion  until  free  circulation  is 
obtained.  This  position  is  maintained  from  three  to  six  weeks. ^  After  the 
first  two  weeks  lower  the  wrist  an  inch  or  two.  At  the  end  of  three  weeks 
make  a  little  passive  motion  (just  one  movement  in  each  direction).  Passive 
motion  and  massage  are  applied  as  if  an  anterior  splint  were  being  used.  The 
author  has  treated  many  cases  by  Jones's  method,  and  now  prefers  it  to  any 
other  plan  in  all  fractures  of  the  elbow  except  fracture  of  the  olecranon,  trans- 
verse fracture  above  the  condyles,  fracture  of  the  inner  condyle  near  the  line 
of  the  ulnar  nerve,  and  fracture  between  the  condyles  in  which  the  coronoid 
process  gets  between  the  fragments  in  flexion.  The  first-mentioned  injury 
must  be  dressed  in  extension,  the  transverse  fracture  above  the  condyles  re- 
quires an  anterior  angular  splint,  and  the  other  two  injuries  should  be  treated 
in  extension.  If  a  fracture  near  the  line  of  the  ulnar  nerv^e  is  treated  in  acute 
flexion,  the  callus  poured  out  wiU  be  apt  to  entangle  and  press  upon  the  nerve. 
If  it  is  found  impossible  to  reduce  the  fragments  or  to  maintain  reduction 
we  should  make  an  incision  and  nafl  or  screw  the  fragments  in  place.  A  com- 
minuted fracture  requires  operation. 

In  young  children  the  anterior  angular  splint  must  not  be  used.     It  will 
^  "Provincial  Medical  Jour.,"  Dec,  1894,  and  Jan.,  1895. 


Fig.  313. — ^Jones's  dressing  for  in 
juries  of  the  elbow-joint. 


Fractures  of  the  Coronoid  Process  of  the  Ulna 


567 


become  loosened,  and  motion  will  inevitably  take  place  at  the  seat  of  fracture. 
Such  cases  can  be  treated  satisfactorily  in  Jones's  position,  the  arm  being  held 
to  the  chest  by  plaster-of-Paris  bandages,  or  they  can  be  treated  in  extension. 
Bertomier's  plan  is  very  useful  in  young  children.'  The  extremity  is  dressed 
without  pressure  in  extension  and  supination.  This  can  be  effected  by  flannel 
bandages.  In  from  four  to  eight  days  a  silicate  of  sodium  bandage  is  applied 
in  order  to  prevent  pronation.  About  the  sixteenth  day  the  bandage  is  cut 
so  as  to  form  two  troughs.  From  this  period  every  third  day  the  splints  are 
removed  and  gentle  passive  motion  is  made.  The  splints  are  removed  perma- 
nently at  the  end  of  four  weeks. 

If  false  ankylosis  follows  fracture  of  the  elbow,  the  adhesions  should  be 
broken  up  under  ether,  and  for  some  time  the  hot-air  apparatus  should  be 
used  daily,  and  massage,  passive  motion,  and  the  hot  and  cold  douche  should 
be  employed.  In  true  ankylosis  an  operation  should  be  performed  and  the 
interlocking  callus  or  the  interposed  tissue  or  fragment  be  removed,  if  a  skia- 
graph shows  that  operation  promises  success.  If  gunstock  deformity  results 
and  produces  marked  disablement,  it  should  be  operated  upon.  An  osteot- 
omy is  performed  on  the  inner  condyle. 
The  arm  is  set  in  the  extended  position, 
plaster  of  Paris  applied,  and  is  not  re- 
moved for  sLx  weeks. - 

Separation  of  the  lower  epiphysis  of 
the  humerus  is  a  not  unusual  accident. 
The  inferior  extremity  of  the  humerus 
may  be  separated,  or  the  condyles  may 
be  separated  from  each  other  and  from 
the  shaft  of  the  bone. 

The  symptoms  are  prominence  in 
front  of  the  joint,  caused  by  the  lower 
end  of  the  shaft  of  the  humerus;  pro- 
jection backward  of  the  olecranon;  the 
forearm  rests  midway  between  prona- 
tion and  supination.  Epiphyseal  sepa- 
ration may  retard  growth  and  produce 
deformity. 

Treatment. — Jones's  position  or  an 
anterior  splint  as  above  directed. 

Fracttires  of  the  ulna  comprise  the 
follo\^dng  varieties:  (i)  fracture  of  the  coronoid  process;  (2)  fracture  of  the 
olecranon  process;  (3)  fracture  of  the  shaft,  and  (4)  fracture  of  the  styloid 
process. 

Fractures  of  the  coronoid  process  of  the  ulna  (Fig.  316)  are  rarely  observed, 
and  practically  occur  only  as  a  complication  of  backward  dislocation  of  the 
ulna  or  in  association  with  other  fractures. 

Symptoms. — When  fracture  of  the  coronoid  process  is  associated  with  a 
dislocation,  crepitus  is  appreciated  on  reduction,  and  it  is  found  that  the 
deformity  of  the  dislocation  promptly  returns  on  cessation  of  extension.  The 
upper  fragment  may  be  pulled  upward  by  the  brachialis  anticus  muscle,  and 
there  exists  an  inability  to  flex  the  forearm  completely.  The  position  is  one 
of  extension  with  posterior  projection  of  the  olecranon.  The  broken  piece 
is  felt  in  front  of  the  joint. 

The  treatment  is  by  an  anterior  splint  the  angle  of  which  is  less  than  a 
right  angle.  Jones's  position  may  be  used  in  treating  such  a  case.  A  stiff 
joint  may  follow. 

1  "Revue  de  Chir.,"  vol.  viii,  1S88.      2  g.  G.  Davis,  "Phila.  Med.  Jour.,"  May  13,  1889. 


Fig.  314. — Fracture  between  the  condyles 
treated  by  Jones's  position.  Degree  of  volun- 
tar>'  flexion  obtained. 


;68 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fractures  of  the  olecranon  process  of  the  uhia  occur  not  uncommonly 
in  adults.  Hulke  states  that  such  a  fracture  never  occurs  before  the  age  of 
fifteen,  but  the  writer  has  seen  in  the  Jefferson  Medical  College  Hospital  a 
girl  aged  fourteen  with  a  fractured  olecranon.  The  cause  is  direct  violence 
or  muscular  action.     Only  a  small  fragment  may  be  torn  away,  or  the  entire 


Fig-  315- — Fracture  between  the  condyles  treated  by  Jones's  position.     Degree  of  voluntary  exten- 
sion obtained. 

olecranon  may  be  broken  off,  and  the  break  may  be  comminuted  or  may  even 
be  compound. 

The  symptoms  of  most  fractures  of  the  olecranon  are:  swelling;  partial  flexion 
of  the  forearm;  separation  of  the  fragments,  the  upper  piece  being  pulled  up 
from  4  inch  to  2  inches   by  the  triceps;  the  space  between  the  fragments  is 


Fig.  316. — Fracture  of  coronoid  process. 

increased  by  flexion  at  the  elbow,  and  lessened  by  extension  at  the  elbow ;  and 
there  is  inabihty  to  extend  the  arm.  Bulging  of  the  triceps  and  crepitus  on 
approximating  the  fragments  are  observed.  In  some  few  cases  there  is  no 
separation,  the  periosteum  being  untorn  or  the  fascial  expansions  from  the 
triceps  holding  the  fragments  in  apposition.  In  such  cases  crepitus  can  be 
elicited  by  rocking  the  upper  fragment  from  side  to  side. 


Fractures  of  the  Olecranon  Process  of  the  Ulna 


569 


When  treated  by  non-operative  methods  the  prognosis  is  usually  fair, 
fibrous  union  being  the  rule.  Some  joint  stiffness  usually  occurs,  and  much 
ankylosis  may  be  unavoidable.  The  prospect  of  a  freely  movable  joint  is 
better  when  extra-articular  wiring  is  practised. 

Treatment. — Fracture  of  the  olecranon  is  usually  treated  with  a  well- 
padded  anterior  splint  almost,  but  not  quite,  straight.  A  perfectly  straight 
splint  is  uncomfortable,  and  by  opening  a  retiring  angle  between  the  fragments 
and  into  the  joint  favors  non-union  and  ankylosis.  The  splint  should  reach, 
from  a  level  with  the  axillary  margin  to  below  the  fingers.  If  the  upper  frag- 
ment does  not  come  in  contact  with  the  lower,  pull  it  down  by  adhesive  plas- 
ter and  fasten  the  strips  to  the  splint.  The  author  in  i  case  employed  a 
glove  to  which  strings  from  the  adhesive  plaster  were  attached.  After  apply- 
ing the  splint  keep  the  patient  in  bed  for  three  weeks.  The  danger  of  anky- 
losis in  this  fracture  is  very  great,  and,  in  case  it  occurs  in  the  position  of  exten- 


f/ 


e#-i-^'- 


^^1^ 


Fig.  317. — Murphy's  method  of  treating  fracture  of  the  olecranon  by  subcutaneous  esarticular 
wiring.  Lateral  view  and  posterior  view.  Wiring  the  fragments  of  the  olecranon  together:  a,  Incision; 
b,  twist  or  tie  of  wire;  c,  hole  drilled  in  bone  for  passage  of  wire;  d,  fracture;  e,  passage  of  mre  through 
tendon  of  triceps  (Murphy) . 

sion,  an  almost  useless  arm  results.  Follow  the  rule  of  T.  Pickering  Pick,  and 
at  the  end  of  three  weeks  anesthetize  the  patient,  press  the  thumb  firmly  down 
upon  the  top  of  the  olecranon,  earn,'  the  forearm  slowly  to  a  right  angle,  and 
apply  an  anterior  angular  splint  and  direct  it  to  be  worn  for  two  weeks.  When 
the  anterior  splint  has  been  applied,  passive  motion  should  be  made  every 
other  dav,  or  even.-  third  day,  and  massage  should  be  used  at  the  same  time. 
When  the  splint  is  removed,  try  to  increase  the  range  of  motion  as  previously 
directed.  Surgeons  usually  incise  and  apply  "^-ires  only  when  it  is  found 
impossible  to  secure  apposition  of  the  fragments  after  fracture  of  the  olec- 
ranon. Such  a  course  is,  I  am  persuaded,  injudicious  conservatism.  I  do  not 
advise  that  the  rule  should  be  to  treat  fractures  of  the  olecranon  as  a  routine 
by  opening  and  taring,  but  I  do  advdse  that  we  should  treat  them  by  extra- 
articular operation  and  -vN^ring  as  advocated  by  John  B.  Murphy  ("Jour. 
Am.  Med.  Assoc,"  Jan.  27,  1906).     The  consen-ative  non-operative  treatment 


570 


Diseases  and  Injuries  of  the  Bones  and  Joints 


often  fails.  Sometimes  the  fragments  cannot  be  approximated,  frequently  they 
cannot  be  maintained  in  approximation,  not  unusually  a  stiff  or  actually  anky- 
losed  joint  results.  Murphy  thus  describes  the  operation  which  should  be  done 
("Jour.  Am.  Med.  Assoc,"  Jan.  27,  1906)  (Fig.  317):  "A  longitudinal  incision 
I  inch  long  was  made  on  the  external  aspect  of  the  ulna,  i  inch  from  its  articular 
surface,  and  tissues  were  divided  to  the  bone.  A  smaller  incision  was  made 
on  the  corresponding  inner  side.      I  perforated  the  base  of  the  olecranon  with 

-  —     an  eyelet  drill,  which  ran    transversely 

from  outward  inward.     I  threaded  the 

drill  with  a  fine  aluminum-bronze  wire, 

;  drawing  it  through  this  transverse  canal. 

The  wire  was  carried  upward  under  the 
skin  on  the  inner  surface  of  the  elbow 
and  then  drawn  out  through  another 
small  incision,  y-g-  inch,  made  at  the 
level  of  the  apex  of  the  olecranon. 
The  wire  was  then  reinserted  and 
directed  transversely  from  inward  out- 
ward, passing  it  through  the  tendon  of 
the  triceps  above  the  olecranon,  and 
then  drawn  out  to  corresponding  out- 
ward point  through  a  very  small  inci- 
sion similar  to  that  made  on  the  inner 
side.  The  wire  was  again  reinserted 
and  pushed  downward  under  the  skin 
until  it  was  finally  brought  out  through 
the  initial  external  incision.  The  circle 
once  completed,  traction  was  exerted  on 
the  wire  until  I  was  sure  that  the  two 
fragments  were  in  perfect  coaptation, 
the  latter  being  easily  and  satisfactorily 
accomplished.  The  ends  of  the  wire  were 
twisted  several  times  and  then  di\dded  by 
scissors  close  to  the  bone.  By  this  pro- 
cedure the  skin  was  incised  at  four  points, 
the  largest  incision  being  -j  inch  in  length." 
The  extremity  is  placed  in  flexion  upon 
an  anterior  splint,  which  is  worn  for  four 
weeks.  Passive  motion  is  begun  on  the 
third  day.  A  compound  fracture  and  a 
comminuted  fracture  always  require  oper- 
ation, in  which  the  joint  is  freely  opened. 
Non-union  requires  opening  of  the  joint 
and  wiring  of  the  fragments. 
Fractures  of  the  shaft  of  the  ulna  alone  are  most  usual  near  the  middle 
of  the  bone,  are  always  due  to  direct  violence,  and  are  not  infrequently 
compound.  An  injury  which  breaks  the  ulna  is  very  apt  to  break  the 
radius  also. 

Symptoms. — By  running  the  finger  along  the  inner  surface  of  the  bone  there 
are  detected  inequality  and  depression;  crepitus  and  mobility  are  easily  devel- 
oped; there  are  pain  and  the  evidence  of  direct  violence.  The  long  axis  of  the 
hand  is  not  on  a  line  with  the  long  axis  of  the  forearm,  but  is  internal  to  it.  If 
deformity  exists,  it  is  due  to  the  lower  fragment  passing  into  the  interosseous 
space  because  of  the  action  of  the  pronator  quadratus;  the  upper  fragment, 
acted  on  by  the  brachialis  anticus,  passes  a  little  forward  (Fig.  318).     The 


Fig.  318. — Fracture  of  the  shaft  of  the 
ulna  (case  in  the  Pennsylvania  Hospital; 
skiagraphed  by  Dr.  Gaston  Torrance). 


Fracture  of  the  Head  of  the  Radius  571 

forearm  at  and  below  the  seat  of  fracture  is   narrower   and   thicker   than 
normal. 

Treatment. — In  treating  fracture  of  the  shaft  of  the  ulna  place  the  forearm 
midway  between  pronation  and  supination,  so  as  to  bring  the  fragments 
together  and  to  obtain  the  widest  possible  interosseous  space,  and  thus  limit 
the  danger  of  union  taking  place  between  the  radius  and  ulna.  The  position 
midway  between  pronation  and  supination  is  obtained  by  flexing  the  forearm 
to  a  right  angle  with  the  arm  and  pointing  the  thumb  to  the  nose.     Take  two 

well-padded  straight  splints,  one  

long  enough  to  reach  from  the 
inner  condyle  to  below  the  fin- 
gers, the  other  from  the  outer 
condyle  to  below  the  wrist; 
place  a  long  pad  of  lint  over 
the  interosseous  space  on  the 
flexor  side  of  the  limb,  and  an- 
other on  the  extensor  side ;  apply    Z-  "^      T~T^    ,.  ^  •   f     \       TTTTT 

1  ,.  ,    ,  '     r  Fig.  319. — Two  straight  splints  in  fracture  ot  both  bones 

the  splmts  and  bang  the  fore-  of  the  forearm. 

arm  in  a  triangular  sling  (Fig. 

319).     Passive  motion  is  to  be  begun  in  the  third  week,  and  the  splints  are 

to  be  worn  for  four  weeks.     Fractures  of  the  ulna  can  be  treated  very  efl&ciently 

by  plaster  of  Paris.     The  best  results  are  secured  by  wiring  or  plating. 

Fractures  of  the  styloid  process  of  the  ulna  are  due  to  direct  force.  The 
displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push  the  fragment 
back  into  place  and  use  a  Bond  splint  with  a  compress  for  four  weeks,  or 
apply  a  plaster-of-Paris  dressing. 

Fractxires  of  the  radius  include  the  following  varieties:  {a)  Fractures  of 
the  head;  {b)  fractures  of  the  neck;  (c)  fractures  of  the  shaft,  and  {d)  fractures 
of  the  lower  extremity. 

Fracture  of  the  head  of  the  radius  has  been  studied  by  Dr.  T.  Turner 
Thomas  ("University  of  Penna.  Med.  Bulletin,"  Oct.,  1905;  and  "Annals  of 
Surgery,"  August,  1907).  He  has  furnished  me  with  the  following  resume 
of  his  \dews,  with  which  I  entirety  agree: 

"Fracture  of  the  head  of  the  radius  is  not  infrequent,  and  is  usually  the 
result  of  a  fall  on  the  hand  with  the  elbow  in  extension  and  the  forearm  in 
pronation.  In  extension  of  the  elbow  the  capitellum  of  the  humerus  is  in 
contact  with  only  the  anterior  part  of  the  radial  head.  Since  the  carpus 
articulates  almost  entirely  with  the  radius,  the  force  of  the  usual  fall  on  the 
hand  is  transmitted  almost  entirely  through  this  bone,  and  at  the  elbow  is 
received  by  only  the  anterior  part  of  the  radial  head.  According  to  the  degree 
of  \aolence  applied  more  or  less  damage  may  be  done  to  the  head,  or  head  and 
neck.  The  anterior  portion  of  the  rim  may  be  split  off,  the  intact  ulna  pre- 
venting the  humerus  from  pursuing  the  detached  fragment  and  pushing  it  away 
from  its  fellow,  and  the  intact  orbicular  ligament  holding  the  two  in  close  apposi- 
tion. This  uncomplicated  fracture  is  the  most  common,  but  the  least  trouble- 
some. Union  with  ultimately  good  function  is  the  rule,  even  though  the  frac- 
ture go  unrecognized  and  untreated,  because  of  the  close  splinting  of  the 
untorn  orbicular  ligament.  Since  it  is  the  same  accident,  a  fall  on  the  out- 
stretched hand,  which  usually  produces  CoUes's  fracture,  fracture  of  the  ex- 
ternal condyle  of  the  humerus,  fracture  of  the  neck  of  the  radius,  fracture  of  the 
coronoid  process,  and  posterior  dislocation  of  both  bones  of  the  forearm, 
any  one  or  several  of  these  injuries  may  complicate  the  fracture  of  the  radial 
head.  When  the  anterior  part  of  the  head  breaks  off  the  bony  resistance  to  the 
descent  of  the  capitellum  by  the  radius  is  lost,  so  that  if  the  force  of  the  accident 


572  Diseases  and  Injuries  of  the  Bones  and  Joints 

is  severe  enough,  lateral  bending  of  the  elbow  to  the  radial  side  with  further 
descent  of  the  capitellum  may  result  with  greater  separation  of  the  fragments, 
tearing  of  the  orbicular  ligament,  and  more  damage  to  the  head.  The  descent 
of  the  condyle  in  a  posterior  dislocation  may  carry  before  it  the  detached  frag- 
ment of  the  head,  and  this  fragment  be  left  buried  in  the  tissues  of  the  forearm 
several  inches  below  its  normal  position  after  the  dislocation  has  been  reduced. 

"Prognosis. — In  the  vertical  or  oblique  fissured  fracture  of  the  head  with 
close  approximation  of  the  fragments,  after  union  takes  place,  limitation  of  all 
movements  of  the  elbow  results  from  adhesions  and  slight  irregiilarities  in  the 
bone.  The  function  rapidly  returns  in  the  succeeding  weeks,  although  some 
limitation  of  extension  will  continue  for  months.  More  marked  irregularity 
in  the  circumference  of  the  head  may  last  much  longer  and  may  produce 
permanent  limitation  of  rotation.  Bony  union  between  the  head  and  corre- 
sponding surface  of  the  ulna  will  prevent  all  rotation  of  the  forearm.  In 
either  case  flexion  and  extension  usually  return  almost  if  not  completely. 
Non-union  of  the  fragments  may  induce  pain  and  limitation  of  movement, 
especially  rotation;  but  with  close  approximation  of  the  fragments  and  an 
untorn  orbicular  ligament,  an  apparently  perfect  return  of  function  may  follow, 
the  fragments  moving  smoothly  as  one  piece  within  the  ligament.  The  prog- 
nosis will  depend  chiefly  upon  the  degree  of  damage  done  to  the  head  and  the 
separation  of  the  fragments. 

"Symptoms. — The  most  characteristic  feature  of  this  fracture  is  its  ob- 
scurity. The  thick  muscular  covering  of  the  radial  head,  except  posteriorly,  the 
sphnting  effect  of  the  orbicular  ligament,  and  the  close  contact  of  the  head  with 
the  humerus  and  ulna,  make  the  diagnosis  of  the  small  intra-articular  fracture 
particularly  difficult.  In  the  uncomplicated  vertical  fracture  there  will  usually 
be  no  movements  of  the  fragments  on  each  other,  and,  therefore,  no  crepitus, 
and  there  will  be  no  deformity.  A  history  of  a  fall  on  the  hand;  some  swelling 
of  the  elbow,  particularly  on  the  radial  side;  severe  pain  and  limitation  in  all 
movements  of  the  elbow,  particularly  in  rotation;  pain  and  tenderness  dis- 
tinctly localized  to  the  head  of  the  radius;  and  the  exclusion  of  fracture  of  the 
humerus,  ulna,  and  the  shaft  of  the  radius,  will  point  strongly  to  a  fracture  of 
the  head  of  the  radius.  If  the  injury  is  treated  as  a  fracture,  and  two  or  three 
weeks  later,  when  fixation  is  removed,  there  is  marked  limitation  of  all  move- 
ments of  the  elbow,  the  diagnosis  will  be  more  than  reasonably  assured.  The 
.T-ray  may  be  misleading  unless  directed  in  the  line  of  the  fracture,  and  this  is 
not  easy  to  accomplish,  since  the  position  of  the  fragments  in  their  relation  to  the 
humerus  vary  with  every  change  in  rotation  of  the  forearm.  In  most  cases  an 
exposure  to  the  x-ray  in  the  transverse  plane  of  the  humeral  condyles,  wdth  the 
forearm  in  pronation,  will  give  a  successful  skiagraph.  If  the  .t-ray  is  directed 
at  right  angles  to  the  line  of  fracture  the  skiagraph  will  usually  be  negative.  If 
the  fragments  are  freely  separated  and  if  crepitus  is  elicited,  the  diagnosis  will 
be  more  easily  determined. 

"Treatment. — In  the  imcomplicated  fracture  without  crepitus  or  deformity, 
Jones's  position  or  a  right-angled  spHnt  for  three  weeks  will  be  sufficient. 
The  resulting  fibrous  ankylosis  will  largely  disappear  from  forced  use  in  the  fol- 
lowing weeks,  but  several  months  will  be  necessary  before  extension  is  com- 
plete. If  crepitus  is  present,  four  or  five  weeks'  fixation  will  be  better,  and  in 
this  case  the  return  of  fujiction  will  probably  take  longer.  As  a  riile,  if  union 
is  obtained  function  will  return.  If  pain  on  movement  persists  for  many 
months,  a  detached  fragment  or  the  whole  head  shoifld  be  excised.  Marked 
limitation  of  movement  from  enlargement  of  the  head  or  bony  union  between 
it  and  the  ulna  calls  for  excision  of  the  head." 

Fracture  of  the  neck  of  the  radius  (Fig.  320)  is  by  no  means  so  rare  an 
accident  as  was  thought  before  the  discovery  of  the  x-rsiys.     It  seldom  occurs 


Fracture  of  the  Shaft  of  the  Radius 


573 


alone  and  is  usually  associated  with  fracture  of  the  radial  head.  These  frac- 
tures are  transverse  and  frequently  impacted.  The  cause  is  a  fall  upon  the 
pronated  hand  when  the  forearm  is  extended. 

Symptoms. — In  this  fracture  the  forearm  is  pronated  and  the  patient  is 
found  to  have  the  lost  power  of  voluntary  pronation  and  supination.  Under 
forced  pronation  and  supination  it  will  be  noted  that  the  head  of  the  radius  does 
not  mo\-e  unless  there  is  impaction.  Crepitus  is  sometimes  absent  because  of 
impaction.  Thomas  points  out  that  there  is  angulation  of  the  neck  due  to 
driving  of  the  radial  head  downward  and  forward  ("Annals  of  Surger}^," 
August,  1907).     Reduction  is  always  difficult  and  may  be  impossible. 

The  treatment  for  fracture  of  the  neck  of  the  radius  is  the  same  as  for 
other  fractures  of  the  elbow-joint— namely,  an  anterior  angular  splint  or 
Jones's  position. 

Fracture  of  the  shaft  of  the  radius  (Fig.  321)  is  far  commoner  than  fracture 
of  the  shaft  of  the  ulna.     It  mav  occur  above  or  below  the  insertion  of  the 


Fig.  320. — Fracture  of  the  neck  of  the  radius. 


Fracture  of  radius  alone. 


pronator  radii  teres  muscle.  It  may  arise  from  either  direct  or  indirect  force. 
Fracture  of  the  shaft  of  the  ulna  may  coexist  as  a  result  of  the  same  accident. 

Fracture  of  the  Shaft  of  the  Radius  Above  the  Insertion  of  the  Pronator 
Radii  Teres  Muscle. — Symptoms. — The  upper  fragment  is  drawn  forward  by 
the  biceps  and  is  fully  supinated  by  the  biceps  and  the  supinator  brevis.  The 
lower  fragment  is  fully  pronated  by  the  pronator  quadratus  and  pronator  radii 
teres,  and  its  upper  end  is  pulled  into  the  interosseous  space.  There  are  crepi- 
tus, mobility,  pain,  narrowing  and  thickening  of  the  forearm  below  the  seat 
of  fracture,  and  loss  of  the  power  of  pronation  and  supination.  The  head  of 
the  bone  is  motionless  during  passive  pronation  and  supination.  The  hand  is 
prone. 

Treatment. — In  treating  this  fracture  do  not  put  the  forearm  midway  be- 
tween pronation  and  supination,  as  this  position  will  not  bring  the  fragments 
into  contact,  the  upper  fragment  remaining  flexed  and  supinated.  To  bring 
the  lower  fragment  in  contact  with  the  upper,  flex  and  fully  supinate  the  fore- 
arm. Apply  an  anterior  angular  splint  to  the  extremity  for  four  weeks,  and 
begin  passive  motion  in  the  third  week. 


574 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fracture  of  the  Shaft  of  the  Radius  Below  the  Insertion  of  the  Pronator 
Radii  Teres  Muscle  (Fig.  321). — In  this  variety  of  fracture  the  upper  fragment 
is  acted  on  by  the  biceps,  the  supinator  brevis,  and  the  pronator  radii  teres,, 
and  it  remains  about  midway  between  pronation  and  supination,  passing  for- 
ward and  also  into  the  interosseous  space.  The  lower  fragment  is  acted  on  by 
the  supinator  longus  and  the  pronator  quadratus,  the  latter  being  the  more  pow- 
erful of  the  two,  hence  the  lower  fragment  is  moderately  pronated,  its  upper 
extremity  being  drawn  into  the  interosseous  space.  Other  symptoms  are  iden- 
tical with  those  of  fracture  above  the  insertion  of  the  pronator  radii  teres. 

Treatment. — In  treating  fracture  below  the  pronator  radii  teres  the  forearm 
is  flexed  and  is  placed  midway  between  pronation  and  supination;  two  inter- 

_  osseous    pads    and    two    straight 

^     splints  are  applied  as  for  fracture  of 

the  ulna  (see  Fig.  319).    The  splints 

are  worn  for  four  weeks,  and  passive 


Fig.  322.  Fig.  323- 

Figs.  322,  323. — Fracture  of  both  bones  of  the  forearm. 

motion  is  begun  in  the  third  week.  Plaster  of  Paris  is  a  most  satisfactory  dress- 
ing.    Loss  of  function  is  best  obviated  in  this  fracture  by  incision  and  fixation. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  (Figs.  322-326)  is  not 
frequently  seen.  It  is  caused  either  by  direct  or  indirect  force.  If  due  to 
indirect  force  the  radius  breaks  first. 

Symptoms. — After  fracture  of  both  bones  of  the  forearm  the  hand  is  pro- 
nated, and  the  two  lower  fragments  come  together  and  are  drawn  upward  and 
backward  or  upward  and  forward  by  the  combined  force  of  flexor  and  extensor 
muscles,  shortening  being  manifest  and  the  projection  of  the  lower  fragments 
being  detected  on  either  the  dorsal  or  the  flexor  surface  of  the  forearm.  The 
upper  fragment  of  the  ulna  is  somewhat  flexed  by  the  brachialis  anticus;  the 


Fractures  of  the  Lower  Extremity  of  the  Radius 


575 


upper  fragment  of  the  radius  is  flexed  by  the  biceps  and  is  pronated  and  drawn 
toward  the  uhia  by  the  pronator  radii  teres.  The  forearm  is  narrower  than  it 
should  be  (the  ends  of  the  fragments  having  passed  into  the  interosseous  space) 
and  is  thicker  than  normal  from  front  to  back  (the  contents  of  the  interosseous 
space  having  been  forced  out).  Crepitus,  mobility,  pain,  and  inequality  exist, 
the  power  of  rotation  is  lost,  and  on  passive  rotation  the  head  of  the  radius  does 
not  move.     The  forearm  is  prone  and  semiflexed. 

Treatment  of  this  fracture  usually  consists  in  the  application  of  two 
straight  splints  and  two  interosseous  pads,  the  forearm  being  flexed  to  a  right 
angle  and  placed  mid- 
way between  pronation 
and  supination  (see  Fig. 
319).  The  splints  are 
worn  for  four  weeks, 
and  passive   motion  is 

/ 


Fig.  324. — Fracture  of  both 
bones  in  the  lower  third  of  the 
forearm. 


Fig 


^:^    'A 

Fig.  325.  Fig.  326. 

325,  326. — Ununited   compound    comminuted  fracture   of 
both  bones  of  forearm  (.v-ray  by  Dr.  Senders) . 


begim  in  the  third  week.  Instead  of  these  splints  a  plaster-of-Paris  dressing 
can  be  used.  I  am  persuaded  that  pronation  and  supination  are  best  pre- 
serv^ed  by  incision  and  fixation  (Figs.  325  and  326). 

Fractures  of  the  Lower  Extremity  of  the  Radius. — CoUes's  fracture  is  a 
transverse  or  nearly  transverse  fracture  of  the  lower  end  of  the  radius,  between 
the  limits  of  \  inch  and  i\  inches  above  the  wrist- joint,  the  lower  fragment 
sometimes  mounting  upon  the  dorsum  of  the  upper  fragment  (Fig.  327),  the 
two  fragments  sometimes  impacting  (Fig.  32S).  An  oblique  fracture  begin- 
ning within  \  inch  of  the  joint  and  passing  mto  the  joint  is  known  as  Barton's 
fracture  (Fig.  329).  CoUes's  fracture  was  first  recognized  as  a  fracture  by  CoUes, 
of  Dublin,  in  1814.  Before  this  time  the  injurs^  was  called  backward  disloca- 
tion of  the  wrist.  It  is  a  ver\^  common  injur}-,  is  met  with  most  frequently  in 
those  beyond  the  age  of  forty,  and  oftener  in  women  than  in  men.  It  is  due  to 
transmitted  force  (a  fall  upon  the  palm  of  the  pronated  hand).  Some  think 
that  the  force  is  received  by  the  ball  of  the  thumb  and  passes  to  the  carpal 
bones  and  the  edge  of  the  radius;  a  fracture  beginning  posteriorly  rather  than 
anteriorly  and  the  force  driving  the  lower  fragment  upon  the  dorsal  surface  of 


576 


Diseases  and  Injuries  of  the  Bones  and  Joints 


the  radius,  the  carpus  and  lower  fragment  moving  upward  and  outward.     It 
is  much  more  Ukelv  that  this  fracture  is  due  to  cross-strain  on  the  bone.     There 


Fig.  327. — Colles's  fracture  before  reduction:  A,  Anteroposterior;  B,  lateral  views. 

is  sudden  traction  upon  the  anterior  ligaments,  which  drag  upon  the  bone  and 
break  it  at  a  point  where  the  cancellous  end  of  the  radius  joins  the  compact 

shaft  (Fig.  330).  The  fragments 
are  not  unusually  impacted  (Fig. 
328).  In  the  author's  experience 
dislocation  of  the  lower  end  of  the 


Fig.  328. — Impacted  Colles's  fracture. 


Fig.  32g. — Barton's  fracture. 


ulna  is  not  a  very  imusual  complication.      It  arises  from  a  fracture  of  the 
vilnar  styloid  or  tearing  off  of  the  internal  lateral  ligament  of  the  wrist. 


Fractures  of  the  Lower  Extremity  of  the  Radius 


577 


Symptoms. — In  Colles's  fracture  the  hand  is  abducted  (drawn  to  the  radial 
side  of  the  forearm)  and  pronated,  the  head  of  the  ulna  is  prominent,  the 
st}-loid  process  of  the  radius  is  raised,  and  the  lower  fragment  may  mount 
on  the  back  of  the  lower  end  of  the  upper  fragment,  causing  a  dorsal 
projection,  termed  by  Liston  the  ''silver-fork  deformity"  (Figs.  331,  332). 
The  lower  end  of  the  upper  fragment  can  be  felt  beneath  the  flexor  tendons 
above  the  wrist.  The  position  in  deformity  is  produced  by  the  force.  Some 
consider  it  is  maintained  by  the  action  of  the  supinator  longus  and  the  flexor 
and  extensor  muscles,  but  particularly  by  the  extensors  of  the  thumb.  Pilcher 
has  demonstrated  the  fact  that  in  this  fracture  a  portion  of  the  dorsal  perios- 
teum is  untorn,  and  this  untorn  portion  acts  as  a  binding  band  to  hold  the 
fragments  in  deformity.  Pronation  and  supination  are  lost.  In  this  fracture 
the  hand  can  be  greatly  h^-perextended  (Alaisonnetive's  symptom).  Crepitus, 
Avhich  is  best  obtained  by  alternate  h\'perextension  and  flexion,  can  be  secured 
unless  sweUing  is  great  or  impaction  exists.  Crepitus  on  side  movements  is 
rarely  obtainable.  Impaction  may  greatly  modify  the  deformity,  though  dis- 
placement generally  exists  to  some  extent,  and  the  fragments  do  not  ride 


Fig.  330. — Effect  upon  the  lower  end 
of  the  radius  of  the  cross-breaking  strain 
produced  by  extreme  backward  flexion 
of  the  hand  (Pilcher). 


Figs.  331,  332. — Deformity  at  the  wrist  consequent  upon 
displacement  backward  of  the  lower  fragment  of  the  radius 
after  fracture  at  its  lower  extremity  (Levis). 


easily  on  each  other.  The  styloid  process  of  the  ulna  may  be  broken,  or  the 
inferior  radio-ulnar  articulation  may  be  separated  (dislocation  of  the  lower 
end  of  the  ulna).  This  latter  complication  allows  the  lower  fragment  to  roll 
freely  upon  the  upper,  and  the  characteristic  silver-fork  deformity  does  not 
appear.  If  the  styloid  process  of  the  ulna  is  broken,  pressure  over  it  causes 
great  pain.  If  a  person  in  falling  strikes  the  back  of  the  hand  and  a  fracture 
of  the  radius  occurs,  the  lower  fragment  is  driven  upon  the  front  surface  of 
the  upper  fragment  and  is  felt  under  the  flexor  tendons  at  the  -wTist  (reversed 
deformity).  An  elaborate  study  of  fracture  of  the  radius  with  forward  dis- 
placement of  the  lower  fragment  has  been  published  by  John  B.  Roberts.^ 

Treatment.— In  treating  an  ordinary  Colles's  fracture  reduce  the  deformity 
by  hyperextension  to  unlock  the  fragments  and  relax  the  dorsal  periosteum,  fol- 
low by  longitudinal  traction  to  separate  the  fragments,  and  forced  flexion  to  force 
them  into  position.  This  formiila  was  introduced  many  years  ago  by  the  late 
R.  J.  Levis.  It  is  of  the  first  importance  to  thoroughly  reduce  this  fracture, 
and  very  often  it  is  not  thoroughly  reduced.  Imperfect  reduction  means  perma- 
nent deformity,  stiffness  of  the  tendons  and  wrist,  and  possibly  an  almost  useless 
^  "Am.  Jour.  Med.  Sci.,"  Jan.,  1S97. 
37 


578 


Diseases  and  Injuries  of  the  Bones  and  Joints 


hand.  The  extremity  can  be  placed  upon  a  Levis  spHnt  (Fig.  333),  the  posi- 
tion maintaining  reduction  and  the  tense  extensor  tendons  giving  dorsal  sup- 
port. Some  surgeons  use  Gordon's  pistol-shaped  splint.  The  favorite  splint  in 
Philadelphia  practice  in  the  past  has  been  Bond's  (PL  7,  Fig.  7).  It  places  the 
hand  in  a  natiu-al  position  of  rest  (semiflexion  of  the  fingers,  semi-extension  of 
the  wrist,  and  deviation  of  the  hand  toward  the  ulna).  Two  pads  are  used: 
a  dorsal  pad  which  overlies  the  lower  fragment,  and  a  pad  for  the  flexor  surface 
which  overlies  the  lower  end  of  the  upper  fragment.     A  bandage  is  applied, 


Fig-  333- — Levis's  radius-splints,  right  and  left,  for  fracture  of  the  lower  end  of  the  radius. 

the  thumb  and  fingers  being  left  free  (Fig.  334).  Passive  motion  is  begiin 
upon  the  fingers  in  three  or  four  days,  and  upon  the  wrist  during  the  second 
week.  The  splint  is  removed  in  three  weeks,  and  a  bandage  is  worn  for  a 
week  or  two  more  because  of  the  swelling.  In  applying  the  Bond  splint,  do 
not  puU  the  hand  too  much  up  on  the  block,  or  the  fracture  will  unite  with 
a  projection  upon  the  flexor  surface  of  the  extremity  and  the  tendons  of  the 
wrist  will  be  apt  to  be  caught  in  the  callus.  The  most  satisfactory  dressing 
is  the  straight  dorsal  splint  advised  by  Roberts  (Fig.  335).    It  runs  from  just 

below  the  external  condyle  to 
the  beginning  of  the  fingers.  I 
use  it  almost  invariably.  It 
prevents  the  recurrence  of  de- 
formity and  is  mechanically  the 
proper  mode  of  treatment.  It 
should  be  worn  for  three  weeks. 
Undoubtedly  more  or  less  stiff- 
ness often  follows  CoUes's  frac- 
ture, and  some  very  able  sur- 
geons have  been  so  impressed  with  the  frequency  of  crippling  stiffness  that 
they  have  dispensed  with  the  use  of  a  splint.  Sir  Astley  Cooper  long  ago 
spoke  of  simply  placing  the  arm  in  a  sling  as  proper  treatment  for  fracture 
of  the  radius.  Moore,  of  Rochester,  applied  a  cylindrical  compress  over  the 
ulna,  held  in  place  for  six  hours  by  adhesive  plaster,  then  cut  the  plas- 
ter, placed  the  forearm  in  a  sling,  and  let  the  hand  hang  over  the  edge  of 
the  sling.  Pilcher  applies  a  band  of  adhesive  plaster  around  the  wrist  and 
supports  the  wrist  in  a  sling,  but,  as  Storp  says,  dispensary  patients  are  apt 
to  disarrange  this  dressing.  Storp  wraps  a  piece  of  rubber  plaster  4  inches 
wide  around  the  wrist,  and  places  a  second  piece  around  the  first  so  arranged 


Fig.  334. — Bond's  sphnt  in  Colles's  fracture. 


Fractures  of  the  Carpus 


579 


as  to  form  a  fold  over  the  radius;  an  opening  is  made  through  the  fold  for  the 
passage  of  a  sling.  In  ten  days  the  plaster  is  removed  and  the  forearm  is  carried 
in  a  sling.  Massage  is  begun  in  the  third  week.  Impaired  function  follows  in 
about  40  per  cent,  of  these  fractures.  If  a  stiff  joint  and  limited  tendon  motion 
eventuate  from  the  fracture,  use  massage,  frictions,  sorbefacient  ointments, 
tincture  of  iodin,  electricity,  hot  and  cold  douches,  and  the  hot-air  apparatus, 
or  give  ether  and  forcibly  break  up  adhesions.  If  reduction  was  not  thoroughly 
effected  and  too  great  a  length  of  time  has  not  elapsed,  and  the  hand  is  helpless 
and  painful,  the  bone  should  be  refractured.  In  a  young  or  middle-aged  per- 
son, in  whom  a  useless  hand  has  folowed  an  ill-reduced  fracture,  osteotomy  is 
justifiable. 

Fracture  of  Both  the  Radius  and  Ulna  Near  the  Wrist. — Colles's  frac- 
ture may  be  complicated  by  a  fracture  of  the  ulna  other  than  of  its  styloid 
process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the  wrist  the  lower  ends 
of  the  upper  fragments  come  together,  the  upper  fragment  of  the  radius  is  pro- 
nated,  and  the  lower  fragment  of  the  radius  is  drawn  up.  Pain,  crepitus, 
mobility,  shortening,  and  loss  of  function  exist. 

Treatment. — Fracture  of  the  radius  and  ulna  near  the  wrist  should  be 
treated  by  the  straight  dorsal  splint,  as  is  Colles's  fracture. 


Spli  nt 


Fig.  335. — Diagram  showing  the  arrangement  of  compresses  and  splint  best  adapted  to  retain  frag- 
ments in  proper  position  after  reduction  (Pilcher). 

Separation  of  the  Lower  Radial  Epiphysis. — This  accident  occurs  in  chil- 
dren from  falling  upon  the  palm  of  the  hand.  It  never  happens  after  the  twen- 
tieth year. 

Symptoms.— In  separation  of  the  lower  radial  epiphysis  the  lower  fragment 
moimts  upon  the  upper  and  produces  a  dorsal  projection  like  that  found  in 
Colles's  fracture,  but  the  hand  does  not  deviate  to  the  radial  side.  The  de- 
formity resembles  that  of  a  backward  carpal  dislocation,  but  is  differentiated 
from  dislocation  by  the  unaltered  relation  in  the  fracture  between  the  styloid 
processes  and  the  carpal  bones. 

The  treatment  in  separation  of  the  lower  radial  epiphysis  is  the  same  as  for 
Colles's  fracture. 

Fractures  of  the  carpus  were  until  recently  thought  to  be  infrequent,  but 
the  a;-rays  have  taught  us  differently,  and  wx  now  know  that  many  supposed 
sprains  of  the  wrist  are,  in  reality,  simple  fractures  of  the  carpus.  Ernest 
Amory  Codman  and  Henry  MelviUe  Chase  show  that  a  majority  of  carpal 
injuries  "are  either  simple  fractures  of  the  scaphoid  or  anterior  dislocations 
of  the  semilunar  bone,"  the  two  injuries  being  frequently  combined  ("The 
Diagnosis  and  Treatment  of  Fracture  of  the  Carpal  Scaphoid  and  Dislo- 
cation of  the  Semilunar  Bone,"  in  "Annals  of  Surgery,"  March  and  Jime, 
1905).  The  cause  of  carpal  fracture  may  be  violent  direct  force  or  a  fall  upon 
the  extended  palm. 

Symptoms. — Fractures  of  the  carpus  in  general  are  indicated  by  pain, 


580  Diseases  and  Injuries  of  the  Bones  and  Joints 

tenderness,  swelling,  evidences  of  the  infliction  of  direct  force,  sometimes  crepi- 
tus, loss  of  power  in  the  hand,  and  a  very  little  displacement. 

Treatment. — Many  compound  comminuted  fractures  of  the  carpus  require 
amputation.  In  an  ordinary  compound  fracture  asepticize,  drain,  dress  with 
antiseptic  gauze  and  a  plaster-of-Paris  bandage,  cutting  trap-doors  in  the 
plaster  over  the  ends  of  the  drainage-tube.  In  a  simple  fracture  dress  the 
hand  upon  a  well-padded  straight  palmar  splint  (PL  7,  Fig.  10)  reaching 
from  beyond  the  fingers  to  the  middle  of  the  forearm,  and  place  the  hand 
and  forearm  in  a  sling.  The  splint  is  worn  for  four  weeks,  and  passive  motion 
of  the  wrist  is  begun  in  the  second  week. 

Fracture  of  the  carpal  scaphoid  (see  previously  quoted  article  by  Codman 
and  Chase)  usually  results  from  falls  upon  the  palm  of  the  extended  hand 
and  is  most  common  in  males  between  the  ages  of  twenty-five  and  thirty- 
five.  It  is  rarely  recognized  at  the  time  of  the  accident;  the  patient  com- 
plains of  severe  pain,  tenderness,  and  disabiHty  and  is  thought  to  have  a  sprain. 
According  to  Codman  and  Chase,  the  s\Tnptoms  improve  up  to  a  certain 
point,  but  not  beyond  it,  and  the  joint  remains  in  a  condition  of  irritation  and 
weakness.  After  months  or,  perhaps,  years  the  diagnosis  is  made.  In  one 
case  of  my  own,  a  locomotive  engineer,  the  injury  resiilted  from  a  blow  on 
the  palm  with  the  reverse  lever.  He  came  to  me  three  years  after  the  injur}% 
when  I  recognized  the  condition  as  the  one  described  by  Codman  and  Chase. 
These  writers  say  that  the  fingers  are  normally  flexible,  active  and  passive 
movements  of  the  wrist  are  restricted  to  one-half  or  more  of  the  normal  excur- 
sion, and  movements  of  flexion  or  extension  beyond  this  are  limited  by  muscular 
spasm,  resembling  the  spasm  occurring  in  a  tuberculous  joint.  Any  attempt 
to  forcibly  evercome  the  spasm  produces  violent  pain.  Crepitus  is  absent. 
The  radial  side  of  the  wrist-joint  exhibits  some  swelling,  which  obscures 
somewhat  the  flexor  tendons  of  the  thumb.  There  is  tenderness  on  pressure 
over  the  scaphoid  and  it  is  most  acute  in  the  anatomical  snuff-box.  The  x-ray 
shows  a  transverse  fracture  of  the  scaphoid  bone  ("Annals  of  Surgery,"  ]March 
and  June,  1905).  Professor  Dwight  considers  the  above-described  injury  to 
he  due  to  the  two  portions  of  the  bone  (there  are  two  centers  of  ossification) 
having  never  formed  a  bony  union  and  having  been  wrenched  apart  by  violence. 
Codman  believes  the  injury  is  the  result  of  \dolence  acting  on  a  normal  bone, 
the  resulting  non-union  being  due  to  lack  of  fixation  and  the  presence  of  synovial 
fluid  between  the  fragments. 

The  fracture  may  be  accompanied  by  forward  dislocation  of  the  semi- 
lunar bone.  If  for  several  weeks  after  an  accident  causing  fracture  of  the 
scaphoid  the  wrist  is  immobilized,  union  may  occur,  otherwise  non-union  will 
surely  result. 

Treatment. — This  injury  should  be  thought  of  when  violence  has  been 
applied  to  the  carpus.  It  may  be  treated  by  a  straight  palmar  splint  if  the 
case  is  seen  early.  If  seen  when  there  is  non-union,  the  proximal  half  of  the 
scaphoid  should  be  excised  (the  incision  being  posterior  and  external  to  the 
extensor  communis  digitorum  tendons)  and  passive  motion  should  be  begun 
within  one  week  (Codman  and  Chase,  Ibid.). 

Fractures  of  the  Metacarpal  Bones. — Fracture  of  the  metacarpus  is  very 
common.  One  or  more  bones  may  be  broken.  The  first  metacarpal  bone  is 
oftenest  broken;  the  third  is  seldom  broken  (Hulke).  The  cause  is  direct  or 
indirect  force.  Fracture  at  the  base  of  the  first  metacarpal  bone  was  described 
by  E.  H.  Bennett  in  1881.  It  is  called  Bennett's  fracture,  or,  as  its  discoverer 
named  it,  stave  of  the  thumb.  The  fracture  may  be  transverse  at  the  neck 
or  longitudinal,  "the  anterior  basal  projection  being  broken  off"  (Raymond 
Russ,  in  "Jour.  Amer.  Med.  Assoc,"  June  16,  1906).  This  injury  results  from 
violent  force  appHed  to  the  distal  end  of  the  metacarpal  (as  in  striking  "wdth 


Fractures  of  the  Phalanges 


581 


the  fist)  or  to  the  end  of  the  extended  thumb,  and  Russ  regards  it  as  the 
most  common  metacarpal  fracture.  It  is  usually  mistaken  for  a  sprain  of 
the  thumb  and  is  sometimes  regarded  as  subluxation  backward  of  the  first 
metacarpal. 

Symptoms. — The  signs  of  a  metacarpal  fracture  are:  dorsal  projection  of 
the  upper  end  of  the  lower  fragment  or  the  lower  end  of  the  upper  fragment; 
pain,  crepitus;  and  often  evidences  of  direct  violence.  In  fracture  of  the  first 
metacarpal  (Bennett's  fracture)  there  is  swelling,  particularly  evident  in  the 
flexor  tendon  sheaths  on  the  thenar  eminence  (Russ),  disability,  pain,  tender- 
ness near  the  base  of  the  metacarpal,  and  deformity,  apparent  shortening  of 
the  thumb,  and  crepitus  on  reduction.    The  rc-rays  solve  a  doubtful  case. 

Treatment. — To  treat  a  fracture  of  a  metacarpal  bone  reduce  by  extension ; 
place  a  large  ball  of  oakum,  cotton,  or  lint  in  the  palm  to  maintain  the  natural 
rotundity,  and  apply  a  straight  palmar  splint  like  that  used  for  fracture  of  the 
carpus.  It  may  be  necessary  to  apply  a  compress  over  the  dorsal  projection. 
The  duration  of  treatment  is  three  weeks,  and  passive  motion  is  begun  after 
two  weeks.  A  plaster-of-Paris 
dressing  is  often  used.  Raymond 
Russ  ("Jour.  Amer.  Med.  Assoc," 
Jime  16,  1906)  describes  the  fol- 
lowing splint  as  successfully  used 
in  a  case  of  Bennett's  fracture 
(Fig.  336).  I  have  used  it  in 
a  case  with  much  satisfaction. 
"The  thiunb  was  put  in  strong 
abduction  and  three  wooden 
butcher's  skewers  neatly  padded 
were  placed  about  the  metacar- 
pal, one  posteriorly  in  the  inter- 
osseous space,  one  along  the  outer 
border,  and  the  third  over  the 
thenar  eminence.  These  ex- 
tended from  well  above  the  meta- 
carpal bone  to  the  first  phalan- 
geal joint.  They  were  fastened 
tightly  in  place  by  two  strips  of 
adhesive  plaster.  Traction  was 
then  exerted  on  the  thumb  and 
maintained  by  strips  of  adhesive 
plaster  passing  about  the  first 
phalanx  and  the  projecting  ends 
of  the  three  skewers.  This  dress- 
ing was  reinforced  by  a  rectangu- 
lar cardboard  splint.     Accurate 

coaptation  and  sufficient  traction  to  overcome  the  deformity  and  muscular 
action  are  most  necessary  in  the  treatment  of  this  fracture.  Slate  pencils  or 
small  lead  pencUs  can  be  used  in  place  of  the  wooden  skewers.  The  soap- 
stone  slate  pencils  are  less  brittle  than  the  ordinary  kind." 

Fractures  of  the  Phalanges. — The  phalanges  are  often  broken.  The  frac- 
ture may  be  compound.    The  cause  usually  is  direct  force. 

Symptoms. — Fracture  of  a  phalangeal  bone  is  indicated  by  pain,  tenderness, 
bruising,  crepitus,  and  mobility,  with  very  little  or  no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken,  mold  on  a  trough- 
like splint  of  gutta-percha  or  of  pasteboard,  which  splint  need  not  reach 
into  the  palm.    If  the  proximal  phalanx  is  broken,  carry  the  splint  into  the 


Fig.  336. — Coaptation  traction  splint  of  Russ. 


582  Diseases  and  Injuries  of  the  Bones  and  Joints 

palm  of  the  hand.  Make  the  spUnt  of  gutta-percha,  pasteboard,  wood,  or 
leather.  The  splint  is  worn  three  weeks.  A  sling  must  be  worn,  otherwise 
the  finger  will  be  knocked  and  hurt.  Some  cases  require  a  dorsal  as  well  as  a 
palmar  splint.  These  cases  may  be  treated  very  satisfactorily  with  a  silicate 
of  sodium  or  plaster-of-Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.  The  divisions  of  the 
femur  are:  (i)  the  upper  extremity;  (2)  the  shaft;  (3)  the  lower  extremity. 

Fractures  of  the  upper  extremity  of  the  femur  are  divided  into:  (a)  intra- 
capsular; (b)  extracapsular;  (c)  of  the  great  trochanter,  and  (d)  epiphyseal  sepa- 
ration (either  of  the  great  trochanter  or  the  head) . 

Examination  of  the  Hip. — It  is  sometimes  though  seldom  necessary  to  give 
ether.     Remove  all  the  patient's  clothing  and  place  him  recumbent  upon  a 


Fig.  337. — Intracapsular  fracture  of  the  hip  (author's  case). 

table.  Note  the  position  of  the  extremity.  Feel  with  care  the  great  trochanter 
and  femoral  neck.  Very  gradually  and  gently  make  movements  to  determine 
if  there  is  impairment,  undue  mobility,  or  crepitus.  Never  make  sudden 
or  violent  movements  in  looking  for  crepitus.  The  diagnosis  can  be  made 
even  if  crepitus  is  not  obtained,  and  rapid  or  violent  movements  may  tear 
apart  an  impaction.  Measure  the  sound  extremity  and  the  injured  extremity. 
The  measurement  is  made  from  the  anterior  superior  spine  of  the  ilium  to  the 
inner  malleolus.  Other  symptoms  to  be  looked  for  are  set  forth  on  pages 
583  and  584. 

Intracapsular  Fracture  of  the  Femur. — Intracapsular  fracture  of  the  neck 
of  the  femur  is  transverse  or  only  slightly  oblique  (Fig.  337),  and  is  not  unu- 
sually impacted  (see  Figs.  267,  268,  269).    Stokes  follows  Gordon,  of  Belfast, 


Intracapsular  Fracture  of  the  Femur  583 

in  classifying  fractures  of  the  femoral  neck.  He  divides  them  into,  intracapsular 
and  extracapsular,  and  subdivides  intracapsular  fractures  into  fracture  with 
penetration  of  the  cervLx  into  the  head;  fracture  with  reciprocal  penetration; 
intraperiosteal  fracture  at  the  junction  of  the  cervLx  and  head;  intraperiosteal 
fracture  of  the  center  of  the  cervLx;  extraperiosteal  fracture,  with  laceration 
of  the  cervical  ligaments.  The  last-named  fracture  is  the  most  common. 
The  first  four  forms  may  unite  by  bone,  the  fifth  form  will  not  because  of 
non-apposition,  lack  of  nutrition,  effusion  of  blood,  synovitis,  or  interstitial 
absorption.^  Stokes  points  out  that  we  may  have  penetration  without  impac- 
tion. The  cause  is  often  slight  indirect  force,  of  the  nature  of  a  twist,  acting 
upon  a  person  of  advanced  years  (more  often  a  woman  than  a  man),  but  not 
imusually  a  fall  upon  the  great  trochanter  is  the  cause.  A  fall  upon  the  knees, 
a  trip,  or  an  attempt  to  prevent  a  fall  may  produce  this  fracture.  It  often 
happens  that  the  fall  is  due  to  the  fracture  rather  than  that  the  fracture 
arises  from  the  fall.  Intracapsular  fracture  is  never  caused  by  direct  force 
unless  it  is  due  to  gunshot  \iolence.  The  aged  are  more  hable  to  intracap- 
sular fracture  than  the  young  or  the  middle-aged,  because,  first,  the  angle 
which  the  neck  forms  with  the  axis  of  the  femur  becomes  less  obtuse  with 
advancing  years,  and  may  even  become  a  right  angle;  this  change  is  more 
pronounced  in  women  than  in  men;  second,  the  compact  tissue  becomes 
thinned  by  absorption,  the  cancelH  diminish,  the  spaces  between  them  enlarge, 
the  bony  portions  of  the  cancellous  structure  are  thinned  and  destroyed, 
and  the  cancellous  structure  becomes  fatty  and  degenerated.  The  injury  is  not, 
however,  limited  to  the  aged.  It  has  been  positively  showTi  that  this  fracture 
may  occur  in  the  young,  even  before  the  union  of  the  epiphyses.  In  fact, 
fracture  of  the  femoral  neck  is  not  very  uncommon  in  children  and  in  young 
and  vigorous  adults  (Royal  Whitman,  "Med.  Record,"  March  19,  1904).  I 
have  seen  one  case  in  a  man  of  twenty -five,  one  in  a  man  of  twenty-eight, 
and  several  cases  in  those  imder  forty-five.  In  the  aged  the  fracture  is,  of 
course,  complete,  but  in  children  and  even  in  young  adults  it  is  usually  in- 
complete, and  for  this  reason  the  fracture  is  often  not  recognized  in  children 
and  young  adults. 

Symptoms. — In  intracapsular  fracture  there  is  usually  shortening  to  the 
extent  of  from  §  to  i  inch,  but  in  some  cases  no  shortening  can  be  detected. 
Shortening  of  \  inch  does  not  count  in  making  a  diagnosis,  for  one  limb  is  often 
naturally  a  little  shorter  than  the  other.  If  the  reflected  portion  of  the  capsule 
is  not  torn,  the  shortening  is  trivial  in  amount  or  is  entirely  absent.  In  some 
cases  shortening  gradually  or  suddenly  increases  some  little  time  after  the  acci- 
dent. This  is  due  to  separation  of  a  penetration  or  of  an  impaction,  tearing 
of  the  previously  unlacerated  fibrous  syno\'ial  reflection,  or  restoration  of  mus- 
cular strength  after  traumatic  paresis  has  passed  away.  A  gradually  increasing 
shortening  arises  from  absorption  of  the  head  of  the  bone.  Shortening  is  due 
chiefly  to  pulling  upon  the  lower  fragment  by  the  hamstring,  the  glutei,  and 
the  rectus  muscles. 

'Pain  is  usually  present  anteriorly,  posteriorly,  and  to  the  side.  The  area 
of  pain  is  localized,  and  motion  or  presstu-e  greatly  increases  the  suffering. 
Pain  is  not  commonly  severe  except  upon  motion  or  from  pressure,  when  it 
may  be  locaHzed  in  the  joint.    In  some  cases  the  pain  is  \'iolent. 

Eversion  exists  and  is  spoken  of  as  helpless  eversion,  though  in  a  very  few 
instances  the  patient  can  stfll  invert  the  leg.  The  eversion  is  due  to  the 
force  of  gra\dty,  the  limb  rolling  outward  because  the  line  of  gra\dty  has 
moved  externally.  That  eversion  is  not  due  to  the  action  of  the  external 
rotator  muscles,  as  was  taught  by  Sir  Astley  Cooper,  is  proved  by  the  fact 
that  when  a  fracture  happens  in  the  shaft  below  the  insertion  of  these  muscles 
^  Stokes,  in  "Brit.  Med.  Jour.,"  Oct.  12,  1895. 


584  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  lower  fragment  still  rotates  outward.  This  is  further  demonstrated  by 
the  considerations  that  the  internal  rotators  are  more  powerful  than  the 
external,  that  some  patients  can  still  invert  the  limb  after  a  fracture,  and 
that  eversion  persists  during  anesthesia.^  In  some  unusual  cases  inversion 
attends  the  fracture.  Inversion,  if  it  exists,  is  due  to  the  fact  that  the  limb 
was  adducted  and  inverted  at  the  time  of  the  accident,  and  after  the  accident 
it  remains  in  this  position  (Stokes).  Besides  shortening  and  eversion,  the 
leg  is  somewhat  flexed  on  the  thigh  and  the  thigh  on  the  pelvis,  the  extremity 
when  rolled  out  resting  upon  its  outer  surface.  Abduction  is  commonly  pres- 
ent.    Limited  abduction  suggests  impaction. 

Loss  of  power  is  a  prominent  symptom :  the  limb  can  seldom  be  raised  or 
inverted;  although  in  rare  cases,  when  the  fibrous  synovial  envelope  is  untorn, 
the  patient  may  stand  or  even  take  steps.  Crepitus  often  cannot  be  found, 
either  because  the  fragments  cannot  be  approximated,  because  there  is  im- 
paction or  penetration,  or  because  the  bone  is  greatly  softened  by  fatty  change. 
To  obtain  crepitus  the  front  of  the  joint  must  be  examined  while  the  limb  is 
extended  and  rotated  inward.  But  why  try  to  obtain  crepitus?  The  diag- 
nosis is  readily  made  without  it;  in  many  cases  it  cannot  be  detected,  and  the 
endeavor  to  obtain  it  inflicts  pain  and  may  produce  damage.  These  fractures 
in  the  aged  have  a  not  very  flattering  chance  for  repair,  and  efforts  to  find 
crepitus  may  produce  serious  damage. 

Altered  Arc  of  Rotation  of  the  Great  Trochanter  {DesauWs  Sign). — The 
pivot  on  which  the  great  trochanter  revolves  is  no  longer  the  acetabulum, 
and  the  great  trochanter  no  longer  describes  the  segment  of  a  circle,  but 
rotates  only  as  the  apex  of  the  femur,  which  rotates  around  its  own  axis. 
It  is  needless  to  try  to  obtain  this  sign;  to  do  so  inflicts  violence  on  the  parts. 
Relaxation  of  the  fascia  lata  (Allis's  sign)  simply  means  shortening.  The 
fascia  lata  is  attached  to  the  ilium  and  the  tibia  (ilio tibial  band),  and  when 
shortening  brings  the  tibia  nearer  to  the  ilium,  this  band  relaxes  and  permits 
the  surgeon  to  push  his  fingers  more  deeply  inward  on  the  injured  side,  between 
the  great  trochanter  and  the  iliac  crest,  and  nearer  the  knee  above  the  outer 
condyle,  than  on  the  sound  side.  In  this  examination  each  limb  should  be 
adducted.  Allis  has  pointed  out  another  sign:  when  the  patient  is  recum- 
bent the  sound  thigh  cannot  be  lifted  to  the  perpendicular  without  flexing 
the  leg;  the  injured  thigh  can  be. 

Lagoria's  sign  is  relaxation  of  the  extensor  muscles. 

Ascent  of  the  Great  Trochanter  Above  Nelaton's  Line. — This  line  is  taken 
from  the  anterior  superior  iliac  spine  to  the  most   prominent   part    of    the 

ischial  tuberosity  (Fig.  338).  In  health  the  great 
trochanter  is  below,  and  in  intracapsular  fracture 
it  is  above,  this  line. 

Relation  of  the  Trochanter  to  Bryants  Triangle 
(Fig.  338). — Place  the  patient  recumbent,  carry  a 
line  around  the  body  on  a  level  with  the  anterior 
superior  iliac  spines,  draw  a  line  from  the  anterior 
iliac  spine  on  each  side  to  the  summit  of  the  cor- 
Fig.  338.— A-B,  Nelaton's     responding  great  trochanter,  and  measure  the  base 

I!f=fi%i"£i?Vn  Tf ' '"°^'"'"  of  the  triangle  from  the  great  trochanter  to  the 
oral  tnangle  (Owen).  j-ii-        ^j^-        ^i  i.r 

perpendicular  Ime  to  determme  the  amount  of  as- 
cent. The  difference  in  measurement  between  the  two  sides  shows  the  amount 
of  ascent  of  the  trochanter;  that  is,  shows  the  extent  of  shortening. 

Morris^  measurement  shows  the  extent  of  inward  displacement.  Measure 
from  the  median  line  of  the  body  to  a  perpendicular  line  drawn  through  the 
trochanter  on  each  side  of  the  body. 

'  Edmund  Owen,-  "A  Manual  of  Anatomy." 


Intracapsular  Fracture  of  the  Femur 


585 


Diaguosis. — The  .v-rays  are  a  valuable  aid  to  diagnosis  (Fig.  339).  Intra- 
capsular fracture  without  separation  of  fragments  may  be  mistaken  for  a  mere 
contusion,  and  the  diagnosis  may  continue  obscure  unless  the  fragments  sepa- 
rate. Loss  of  function  in  contusion  is  rarely  complete  or  prolonged,  although 
occasionally  the  head  of  the  bone  undergoes  absorption.  Early  after  a  con- 
tusion, and  usually  throughout  the  case,  there  is  no  alteration  between  the 
relation  of  the  spine  of  the  ilium  and  the  trochanter,  and  no  shortening. 
Some  time  after  a  severe  contusion  the  head  of  the  bone  may  be  absorbed. 
Contusion  of  a  rheumatic  joint  leads  to  much  difficulty  in  diagnosis.  Intra- 
capsular fracture  may  be  confused  with  extracapsular  fracture  or  with  dis- 
location of  the  hip-joint.     Extracapsular  fracture,  which  is  common  in  ad- 


Fig-  339- — Author's  case  of  recent  intracapsular  fracture  in  a  woman  aged  lorty  successfulb'  nailed. 
Nail  is  still  in  place  after  live  years. 

vanced  life,  but  is  met  with  not  unusually  in  middle  life  and  even  occasionally 
in  the  young,  results  usually  from  great  violence  over  the  great  trochanter; 
if  non-impacted,  there  are  noted  shortening  of  from  i|  to  3  inches,  crepitus 
over  the  great  trochanter,  and  usually,  but  not  invariably,  eversion;  if  im- 
pacted, there  is  less  eversion,  crepitus  is  absent,  and  the  shortening  is  lim- 
ited to  about  an  inch.  The  extensor  muscles  are  relaxed.  Great  tenderness 
exists  over  the  great  trochanter  in  both  impacted  and  non-impacted  fractures. 
In  dislocation  on  the  dorsum  of  the  ilium  the  patient  is  usually  a  strong  young 
adult.  There  is  a  histon'  of  forcible  internal  rotation.  There  are  inversion 
(the  ball  of  the  great  toe  resting  on  the  instep  of  the  sound  foot),  rigidity, 
ascent  of  the  great  trochanter  above  Nelaton's  line,  and  shortening  of  from  i 


586  Diseases  and  Injuries  of  the  Bones  and  Joints 

to  3  inches.  The  head  of  the  bone  is  felt  on  the  dorsum  of  the  ilium,  and 
the  trochanter  mounts  up  toward  the  spine  of  the  ilium,  and  pressure  upon 
it  causes  no  pain.  In  dislocation  into  the  thyroid  notch  there  is  possibly 
eversion,  but  it  is  linked  with  lengthening. 

In  fracture  of  the  brim  of  the  acetabulum  there  is  shortening,  which  occurs 
on  the  removal  of  extension,  inversion,  abduction,  flexion  of  the  knee,  the 
head  of  bone  is  drawn  upward  and  backward  with  the  acetabular  fragment, 
and  there  is  retention  of  the  power  of  eversion  and  of  adduction  (Stokes). 
Crepitus  is  most  distinctly  appreciated  by  a  hand  resting  on  the  ilium. 

In  fracture  of  the  fundus  of  the  acetabulum  (see  Fig.  294)  there  is  shortening, 
and  the  head  of  the  bone  enters  the  pelvis  (Stokes). 

The  prognosis  is  not  very  favorable.  Some  aged  patients  die  in  a  day 
or  two  from  shock.  Not  a  few  perish  later  from  hypostatic  congestion 
of  the  lungs,  kidney  failure,  or  exhausion.  The  majority  of  cases  recover 
with  a  little  shortening,  some  stiffness,  and  a  permanent  limp.  There  is 
a  much  better  chance  for  firm  union  if  the  fracture  is  impacted  than  if  it 
is  not.  Even  if  non-imion  results  after  an  intracapsular  fracture,  and  it  is 
not  unusual,  a  patient  may  get  about  fairly  well  with  a  proper  support.  In 
some  cases  after  intracapsular  fracture  rheumatoid  arthritis  develops.  Many 
surgeons  have  maintained  that  bony  union  never  occurs,  but  it  certainly  does 
sometimes  take  place.  Stokes  holds  that  bony  union  is  possible  in  fractures 
with  penetration,  and  even  in  fractures  without  penetration  when  the  frac- 
ture is  within  the  periosteum.^ 

Treatment. — In  treating  a  very  feeble  old  person  for  intracapsular  fracture 
make  no  attempt  to  obtain  union.  Keep  the  patient  in  bed  for  two  weeks; 
give  lateral  support  by  sand-bags ;  tie  around  the  ankle  a  fillet,  attach  a  weight 
of  a  few  pounds  to  the  fillet,  and  hang  the  weight  over  the  foot-board  of  the 
bed.  When  pain  and  tenderness  abate,  order  the  patient  to  get  into  a  reclining- 
chair,  and  permit  him  very  soon  to  get  about  on  crutches.  If  hypostatic  con- 
gestion of  the  lungs  sets  in,  if  bed-sores  appear,  if  the  appetite  and  digestion 
utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at  cure  in  any  case,  and 
get  the  patient  up  and  take  him  into  the  sunshine  and  fresh  air,  simply  immo- 
bilizing the  fracture  as  thoroughly  as  possible  by  means  of  pasteboard  splints 
or  plaster  of  Paris.  In  the  vast  majority  of  cases,  no  matter  how  old  the 
patient  may  be,  undertake  treatment.  We  may  be  forced  to  abandon  it,  but 
should  at  least  attempt  to  obtain  a  cure.  If  it  is  determined  to  treat  the  case, 
place  the  patient  on  a  hair  mattress,  several  boards  being  laid  transversely 
under  the  mattress  in  order  to  prevent  unevenness  and  the  formation  of 
hollows.     A  fracture-bed  is  a  valuable  adjunct  to  treatment. 

Treatment  by  the  Extension  Apparatus  of  Gurdon  Buck. — Extend  the  knee 
and  place  the  leg  in  a  natural  posture,  and  put  a  pillow  beneath  the  knee. 
Combine  extension  with  lateral  support  by  means  of  sand-bags.  The  extension 
should  be  gentle,  never  forcible.  It  is  not  wise  to  pull  apart  an  impaction  in 
an  old  person,  but  it  should  always  be  done  in  a  young  or  middle-aged  person. 
Place  the  subject  on  a  firm  mattress  or  a  fracture-bed.  If  the  patient  be  a  man, 
shave  the  leg.  Cut  a  foot-piece  out  of  a  cigar-box,  perforate  it  to  admit  the 
passage  of  a  cord,  wrap  it  with  adhesive  plaster  as  shown  in  Plate  7,  Figs.  15 
and  16,  run  the  weight-cord  through  the  opening  in  the  wood,  and  fasten  a  piece 
of  adhesive  plaster  on  each  side  of  the  leg,  from  just  below  the  seat  of  fracture 
to  above  the  malleolus  (PL  7,  Fig.  14).  The  plaster  is  guarded  from  sticking 
to  the  malleoli  by  having  another  piece  stuck  to  its  under  surface  opposite 
each  of  these  points.  Apply  an  ascending  spiral  reversed  bandage  over  the 
plaster  to  the  groin  (Fig.  340),  and  finish  the  bandage  by  a  spica  of  the  groin. 
Slightly  abduct  the  extremity.  Put  a  brick  under  each  leg  of  the  bed  at  its 
1  See  the  masterly  paper  by  Stokes,  before  quoted. 


Intracapsular  Fracture  of  the  Femur 


587 


foot,  thus  obtaining  counterextension  by  the  weight  of  the  body.  Run  a  cord 
over  a  pulley  at  the  foot  of  the  bed,  and  obtain  extension  by  the  use  of 
weights.  In  an  adult  from  1 5  to  20  pounds  will  probably  be  necessary  at  first, 
but  after  a  few  days  from  8  to  10  pounds  will  be  found  sufficient  (remember 
that  a  brick  weighs  about  5  pounds).  Dawbarn's  rule  as  to  the  proper 
weight  to  be  attached  is  i  pound  for  every  year  up  to  twenty.  When  the 
foot  of  the  bed  is  raised  and  the  weight  to  make  extension  is  applied,  very 
gently  rotate  the  extremity,  put  the  foot  at  a  right  angle  with  the  leg,  and  make 
a  bird's-nest  pad  of  cotton  or  oakum  to  save  the  heel  from  pressure.     Take 


Fig.  340. — Adhesive  plaster  apfplied  to  make  extension. 

two  canvas  bags,  one  long  enough  to  reach  from  the  crest  of  the  ilium  to  the 
outer  malleolus,  the  other  long  enough  to  reach  from  the  perineum  to  the  inner 
malleolus.  Fill  the  bags  three-quarters  full  of  dry  sand,  sew  up  their  ends, 
cover  the  bags  with  slips,  and  put  the  bags  in  place  in  order  to  correct  eversion. 
The  slips  may  be  changed  every  third  or  fourth  day.  Keep  the  bed-clothing 
from  coming  in  contact  with  the  extremity  by  means  of  a  cradle  (Figs.  341, 342). 
The  bowels  are  to  be  emptied  and  the  urine  is  to  be  voided  in  a  bed-pan,  unless 
using  a  fracture-bed.  For  two  weeks  the  patient  remains  recumbent,  after 
which  time  he  can  be  propped  up  on  pillows.     Maintain  extension  for  three 


Fig.  341.  Fig.  342. 

Figs.  341,  342. — Cradle  to  keep  clothing  from  leg,  made  from  two  barrel-hoops  (Scudder). 

weeks,  then  simply  maintain  support  by  sand-bags  or  molded  pasteboard 
splints  upon  the  part,  and  keep  up  this  support  three  to  five  weeks  more. 
After  removing  the  extension  he  can  be  transferred  daily  to  a  couch.  In  from 
six  to  eight  weeks  after  the  infliction  of  the  injury  he  can  be  moved  about  in  a 
wheeling-chair,  the  leg  being  extended  or  the  knee  flexed  in  accordance  with  the 
dictates  of  comfort.  After  a  week  or  so  of  such  movement  a  thick-soled  shoe 
is  placed  on  the  sound  foot  and  the  patient  is  allowed  to  use  crutches;  but  weight 
is  not  put  upon  the  injured  extremity  until  from  ten  to  twelve  weeks  have  elapsed 
from  the  time  of  the  accident.  For  many  months,  at  least,  and  possibly  per- 
manently, he  walks  with  the  aid  of  a  cane.     Union,  if  it  takes  place,  is  usually 


588 


Diseases  and  Injuries  of  the  Bones  and  Joints 


cartilaginous,  but  is  sometimes  bony,  and  there  will  surely  be  some  shortening 
and  also  some  stiffness  of  the  joint.  Passive  motion  is  not  made  until  at  least 
eight  weeks  have  elapsed  since  the  accident.  Treatment  by  the  extension 
apparatus  is  far  from  satisfactory,  as  it  does  not  afford  sufficient  immobil- 
ization. 

Senn's  Method. — Senn  claims  that  by  this  method  of  "immediate  reduction 
and  permanent  fixation"  bony  union  is  obtained  in  fractures  of  the  neck  of 
the  femur  within  the  capsule.  He  "places  the  patient  in  the  erect  position, 
causing  him  to  stand  with  his  sound  leg  upon  a  stool  or  box  about  2  feet 
in  height;  in  this  position  he  is  supported  by  a  person  on  each  side  until  the 
dressing  has  been  applied  and  the  plaster  has  set. 

"Another  person  takes  care  of  the  fractured  limb,  which  in  impacted 
fractures  is  gently  supported  and  immovably  held  until  permanent  fixation 
has  been  secured  by  the  dressing.  In  non-impacted  fractures  the  weight  of 
the  fractured  limb  makes  auto-extension,  which  is  often  quite  sufficient  to 
restore  the  normal  length  of  the  limb;  if  this  is  not  the  case,  the  person  who 
has  charge  of  the  limb  makes  traction  until  all  shortening  has  been  overcome 
as  far  as  possible,  at  the  same  time  holding  the  limb  in  position,  so  that  the 
great  toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella  and  the 
anterior  superior  spinous  process  of  the  ilium.  In  applying  the  plaster-of- 
Paris  bandages  over  the  seat  of  fracture  a  fenestrum,  corresponding  in  size 
to  the  dimensions  of  the  compress 
with  which  the  lateral  pressure  is  to 
be  made,  is  left  open  over  the  great 
trochanter. 

"To  secure  perfect  immobility  at 
the  seat  of  fractures  it  is  not  only 
necessary  to  include  in  the  dressing 
the  fractured  limb  and  the  entire  pel- 
vis, but  it  is  absolutely  necessary  to 
also  include  the  opposite  limb  as  far  as 
the  knee  and  to  extend  the  dressing 
as  far  as  the  cartilage  of  the  eighth  rib. 
"The  splint  (Fig.  343)  is  incorpo- 
rated in  the  plaster-of-Paris  dressing, 
and  it  must  be  carefully  applied,  so 
that  the  compress,  composed  of  a  well- 
cushioned  pad  with  a  stiff,  unyielding 
back,  rests  directly  upon  the  trochanter 
major,  and  the  pressure,  which  is  made  by  a  set-screw,  is  directed  in  the  axis 
of  the  femoral  neck.  Lateral  pressure  is  not  applied  until  the  plaster  has 
completely  set.  Syncope  should  be  guarded  against  by  the  administration 
of  stimulants. 

"As  soon  as  the  plaster  has  sufficiently  hardened  to  retain  the  limb  in 
proper  position  the  patient  should  be  laid  upon  a  smooth,  even  mattress, 
without  pillows  under  the  head,  and  in  non-impacted  fractures  the  foot  is 
held  in  a  straight  position  and  extension  is  kept  up  until  lateral  pressure  can 
be  applied. 

"No  matter  how  snugly  a  plaster-of-Paris  dressing  is  applied,  as  the  result 
of  shrinkage  it  becomes  loose,  and  without  some  means  of  making  lateral 
pressure  it  would  become  necessary  to  change  it  from  time  to  time  in  order 
to  render  it  efficient.  But  by  incorporating  a  splint  in  the  plaster  dressing 
(Fig.  344)  this  is  obviated,  and  the  lateral  pressure  is  regulated,  day  by  day, 
by  moving  the  screw,  the  proximal  end  of  which  rests  on  an  oval  depression 
in  the  center  of  the  pad." 


Fig.  343. — Senn's    ap- 
paratus. 


Fig.    344. — Senn's   ap- 
paratus applied. 


Intracapsular  Fracture  of  the  Femur 


589 


Treatment  by  Thomas's  Splint. — Scudder,  in  his  ^•aluable  treatise  on  "The 
Treatment  of  Fractures,"  advocates  in  intracapsular  fracture  the  use  of 
Thomas's  hip  splint.  If  the  bones  are  unimpacted,  the  fragments  are  brought 
into  apposition  by  extension,  inversion,  and  pressure  upon  the  great  tro- 
chanter, and  the  Thomas  splint  is  bent  to  fit,  is  padded,  and  is  applied  (Figs. 
345,  346).  When  the  bed-pan  is  to  be  used  or  the  bed  is  to  be  smoothed, 
the  patient  can  be  lifted  without  disturbing  the  fracture.  He  can  be  turned 
on  the  sound  side.  If  h^-postatic  congestion  is  developing,  raise  the  head  of 
the  bed  and  tie  the  splint  to  the  iron  of  the  head  of  the  bed.  In  addition 
to  the  use  of  the  splint  Scudder  advocates  the  making  of  lateral  pressure  over 
the  great  trochanter  by  a  graduated  compress  and  a  bandage.  The  splint  is 
worn  for  six  or  eight  weeks.  It  is  then  removed,  the  patient  remaining  in 
bed  four  weeks  longer  without  any  apparatus  (Scudder,  from  Ridlon). 

Jones,  of  Liverpool,  treats  fractures  of  the  femoral  neck  by  means  of  an 
extension  frame  (see  Fig.  357). 


Fig-  34S-- 


-Thomas's  single  hip-splint  in  position 
(Ridlon). 


Fig.  346.- 


-Thomas's  double  hip-splint  in  position 
(Ridlon). 


W hitman'' s  Treatment  in  Abduction. — The  plan  advocated  by  Royal  Whit- 
man ("Med.  Record,"  March  19,  1904)  is  a  most  excellent  one.  It  aims  to 
abolish  traumatic  depression  of  the  neck  of  the  femur. 

We  can  apply  this  plan  in  a  young  person  to  any  fracture  even  if  impacted. 
In  an  aged  person  we  apply  it  only  in  a  complete  non-impacted  fracture.  In 
a  young  person  we  usually  give  ether  and  pull  apart  an  impaction  by  abduc- 
tion.    In  an  aged  person  we  should  not  do  so. 

In  regard  to  impaction  Jones  says,  if  the  shortening  is  trivial  and  there  is 
no  rotation  an  impaction  is  not  to  be  pulled  apart;  if  there  is  marked  shorten- 
ing and  eversion,  it  is  to  be. 

Make  extension,  counter  extension,  and  internal  rotation  until  the  foot  is 
at  a  right  angle  with  the  table  and  shortening  is  abolished,  and  then  slowly 
abduct.  The  abduction  relaxes  the  muscles  which  interfere  with  reduction 
and  carries  the  outer  fragment  against  the  inner. 

The  extremity  is  set  in  extension  and  extreme  abduction  and  plaster  of 
Paris  is  applied.  The  tension  of  the  capsule  pushes  the  outer  fragment  against 
the  inner  and  holds  it;  fixation  is  obtained  by  the  neck  of  the  femur  being  in 


59©  Diseases  and  Injuries  of  the  Bones  and  Joints 

contact  with  the  acetabulum  and  the  great  trochanter  with  the  pelvis,  deformity 
cannot  be  caused  by  muscular  action,  and  the  psoas  helps  pull  the  fragments 
together  (Whitman). 

The  limb  is  kept  fixed  in  abduction  for  six  weeks  and  then  a  Thomas  splint 
with  extension  is  used. 

Extracapsular  Fracture  {Fracture  of  the  Base  of  the  Neck  of  the  Femur). — 
The  line  of  extracapsular  fracture  is  at  the  junction  of  the  neck  with  the  great 
trochanter,  and  is  partly  within  and  partly  without  the  capsule,  the  fracture 
being  generally  comminuted  and  often  impacted.  The  cause  is  violent  force 
over  the  great  trochanter  (as  by  falling  upon  the  side  of  the  hip).  This  frac- 
ture is  most  usual  in  elderly  people,  but  is  met  with  in  the  middle  aged  and 
is  not  very  uncommon  in  young  adults.  Stokes  has  described  six  forms  of 
extracapsular  fracture:  extracapsular  fracture  with  partial  impaction  posterior; 
fracture  with  complete  impaction ;  fracture  with  partial  impaction  above ;  frac- 
ture with  partial  impaction  below,  the  shaft  being  split;  splitting  of  the  neck 
longitudinally  without  impaction;  comminuted  non-impacted  fracture.^ 

Symptoms. — When  impaction  is  absent  there  is  marked  crepitus  on  motion, 
which  is  manifested  most  distinctly  when  the  fingers  are  placed  upon  the 
great  trochanter;  there  is  severe  pain,  pressure  upon  the  great  trochanter  is 
very  painful,  swelling  and  ecchymosis  are  marked;  there  is  absolute  inability 
on  the  part  of  the  patient  to  move  the  limb,  and  passive  movements  cause 
violent  pain;  there  is  shortening  to  the  extent  of  at  least  i|  inches,  and 
sometimes  to  the  extent  of  3  inches,  which  shortening  is  made  manifest  by 
noting  the  ascent  of  the  trochanter  above  Nelaton's  line,  by  a  comparison 
of  measurements  of  the  injured  limb  and  the  sound  limb,  and  by  measuring 
the  base-line  of  Bryant's  triangle  on  each  side.  Absolute  eversion  usually 
exists  with  slight  flexion  both  of  the  leg  and  the  thigh.  In  some  rare  cases 
there  is  inversion.  This  happens  if  at  the  time  of  the  accident  the  limb  was 
inverted  and  adducted  (Stokes).  Langoria's  sign,  Desault's  sign,  and  Allis's 
sign  are  present.  All  these  symptoms  follow  violent  direct  lateral  force  to 
the  great  trochanter.  In  the  impacted  form  of  extracapsular  fracture,  in  addi- 
tion to  the  aid  given  the  surgeon  by  the  history,  there  is  severe  pain,  which  is 
intensified  by  movement  or  pressure;  shortening  probably  to  the  extent  of  i 
inch,  which  is  not  corrected  by  extension;  limited  abduction;  great  loss  of 
function;  and  whereas  the  limb  may  be  straight  or  even  inverted,  it  is  usually 
everted.  The  trochanter  is  above  Nelaton's  line,  the  base-line  of  Bryant's 
triangle  is  shortened,  but  not  so  much  as  in  the  unimpacted  form;  there  is  no 
crepitus  unless  the  impaction  is  loose  or  is  pulled  apart,  and  the  arc  of  rota- 
tion of  the  great  trochanter  is  larger  than  in  a  non-impacted  fracture. 

Treatment. — In  impacted  extracapsular  fracture  it  is  best  to  pull  apart 
the  impaction  if  the  patient  is  in  good  physical  condition.  Southam,  of  Man- 
chester, in  an  impressive  article  has  insisted  on  the  absolute  necessity  of 
pulling  apart  an  impaction.  He  gives  ether,  and  when  the  patient  is  an- 
esthetized unlocks  the  fragments."  This  unlocking  is  best  accomplished  by 
abduction,  the  rim  of  the  acetabulum  acting  as  the  fulcrum  of  the  lever  (Whit- 
man). In  treating  extracapsular  fracture  we  can  use  the  extension  apparatus 
with  sand-bags  (see  page  586)  for  three  weeks  and  then  apply  a  plaster  dress- 
ing. Get  the  patient  on  crutches  after  the  plaster  has  been  in  place  for  two 
weeks.  Remove  the  plaster  at  the  end  of  four  weeks.  Thomas's  splint  may 
be  used  instead  of  Buck's  extension  or  the  treatment  suggested  by  Whitman 
may  be  employed  (see  page  589). 

Fractures  of  the  Femoral  Neck  in  Children. — Fracture  of  the  femoral 
neck  in  children  and  in  young  adults  can  scarcely  be  regarded  as  very  imusual, 
and  is  certainly  more  often  encovmtered  than  separation  of  the  upper  epiph- 

1  "Brit.  Med.  Jour.,"  Oct.  12,  1895.  ^  "Lancet,"  Dec.  21,  1895. 


Fractures  of  the  Femoral  Neck  in  Children 


591 


ysis.  The  accident  results  from  a  fall  rather  than,  as  so  often  in  an  adult,  from 
a  twist,  and  it  is  the  product  of  considerable  violence  rather  than  of  slight  force. 
In  children  such  fractures  may  be  impacted,  and  most  of  those  which  are  unim- 
pacted  are  of  the  green-stick  variety.     The  disability  is  not  nearly  so  great  as 


Fig.  347. — ^The  long  spica  as  applied  for  fracture  of  the  neck  of  the  femur  in  the  adult;  illustrating 
the  advantage  of  an  appliance  which  permits  movement  without  danger  of  displacing  the  fragments; 
an  opening  has  been  made  to  lessen  the  constriction  of  the  abdomen  (Whitman). 


in  an  adult;  in  fact,  it  is  not  unusual  for  the  victim  of  such  an  injury  to  be  able 
to  hobble  about  a  few  days  afterward.  The  symptoms  are  shortening,  some 
eversion,  impairment  of  joint  movements,  and  a  limp  when  the  patient  gets 
about.  Fractures  of  the  hip  in  children  are  often  imrecognized  and  lead 
frequently  to  permanent  impairment  be- 
cause of  the  development  of  coxa  vara. 
The  ac-rays  should  be  used  in  making  the 
diagnosis. 

A  green-stick  fracture  may  be  treated 
with  Thomas's  splint,  and  after  four  weeks 
in  bed  "the  child  may  be  allowed  up, 
wearing  a  traction  hip-splint  for  several 
months  until  union  is  so  firm  that  the 
danger  from  coxa  vara  is  practically 
eliminated.  A  light  plaster-of-Paris  spica 
bandage  from  the  calf  to  the  axilla  will 
maintain  immobility  after  the  splint  is 
omitted"  (Scudder,  on  "The  Treatment 
of  Fractures").  An  impacted  fracture, 
after  the  impaction  has  been  pulled 
apart,  is  treated  exactly  as  a  green-stick 
fracture.  Royal  Whitman's  plan  for 
treating  a  green-stick  fracture  is  very 
satisfactory.  This  surgeon  ("Med.  Rec- 
ord," March  19,  1904)  dresses  these 
cases  by  placing  the  limb  in  extreme  abduction  and  holding  it  so  by  means  of 
a  plaster-of-Paris  spica  (Figs.  347,  348).  In  a  case  of  acute  disability  of  the 
hip-joint  in  a  child,  following  some  time  after  fracture  of  the  femoral  neck, 
make  a  careful  differentiation  from  tuberculous  disease  of  the  joint  and  apply 


Fig.  348.^Reduction  and  fixation  in  abduc- 
tion, showing  security  assured  by  direct  bony 
contact  of  the  neck  and  trochanter  with  the 
pelvis,  also  the  effect  of  the  attitude  on  mus- 
cular action:  a,  Abductor  group;  b,  iliopsoas; 
c,  capsule  (Whitman). 


592  Diseases  and  Injuries  of  the  Bones  and  Joints 

a  traction  splint  to  support  the  body  and  give  rest  to  the  joint.  If  coxa  vara 
becomes  marked  and  causes  great  disability,  osteotomy  is  justifiable. 

Operative  Treatment  of  Fracture  of  the  Femoral  Neck. — I  have  practised 
this  but  once.  The  patient  was  a  woman  forty  years  of  age  and  the  result 
was  excellent  (see  Fig.  339).  The  operation  is  not  indicated  in  elderly  sub- 
jects. It  is  not  indicated  at  all  if  the  fragments  can  be  coaptated  and  retained 
by  extension  and  counterextension  or  by  abduction.  In  a  youth  or  a  middle- 
aged  person  in  whom  retention  in  correct  posture  is  impossible  it  is  indicated. 

Some  advocate  incision,  suture  of  the  torn  capsule,  and  nailing.  In  my 
case  I  nailed  through  a  very  small  skin  incision  and  did  not  suture  the  cap- 
sule. It  is  held  that  suture  of  the  capsule  improves  the  circulation  in  the 
broken  off  head,  but  possible  attainment  of  the  object  is  not  justification  for 
the  risk.  The  small  cutaneous  incision  and  nailing  answers  the  purpose. 
It  is  not  necessary  to  drill  the  trochanter  as  Konig  did. 


Fig.   349. — Comminuted  fracture   of   upper       Fig.  350. — Epiphyseal  separation  of  head  of  the  femur, 
third  of  femur. 

Before  operating  an  x-ray  picture  is  taken,  while  the  fragments  are  brought 
into  apposition  by  abduction  or  by  extension  and  counterextension.  From 
this  picture  the  angle  of  the  neck  is  noted  and  the  length  of  nail  required  is 
determined.  A  silver  -nail  is  used.  When  ready  to  operate,  the  fragments  are 
again  brought  into  apposition  by  extension  and  counterextension  or  abduc- 
tion. A  small  incision  is  made  through  the  skin  over  the  external  aspect  of  the 
great  trochanter,  and  the  nail  is  driven  through  the  trochanter  and  neck  into 
the  head.  The  wound  is  closed  and  dressed.  The  pelvis  and  extremity  are 
then  put  up  in  plaster,  a  trap-door  being  cut  over  the  seat  of  incision.  The 
plaster  dressing  is  retained  for  five  or  six  weeks.  Cure  is  obtained  without 
shortening  and  with  retention  of  joint  mobility.  This  operation  is  also  used 
for  ununited  fracture.  Dr.  G.  G.  Davis  was  the  first  to  do  a  nailing  operation 
for  a  recent  intracapsular  fracture  of  the  femur. 

Separation  of  the  upper  epiphysis  of  the  femoral  head  (Fig.  350)  is  a  very 
rare  result  of  accident;  it  occurs  most  often  from  disease.  It  is  met  with  in 
early  youth,  results  in  considerable  permanent  shortening,  and  perhaps  in  coxa 
vara. 


Fractures  of  the  Shaft  of  the  Femur 


593 


Symptoms  and  Treatment. — The  symptoms  are  Kke  those  of  fracture  of 
the  neck,  except  that  the  crepitus  is  soft.  The  treattnent  is  as  for  fracture  of 
the  neck. 

Fractures  of  the  Great  Trochanter. — This  is  a  very  rare  injury.  There 
seem  to  be  only  8  cases  on  record,  but  probably  the  diagnosis  has  been  missed  in 
some  cases  in  which  the  fragment  was  held  to  the  bone  by  periosteum.  This 
process  may  be  (i)  broken  off  without  any  other  injury.  In  some  cases  it 
is  completely  broken  off;  in  some  it  remains  attached  by  periosteum  and  fibrous 
tissue.  (2)  The  Une  of  fracture  may  run  through  the  trochanter  and  leave 
one  portion  of  the  trochanter  attached  to  the  head  and  neck  and  the  other 
part  attached  to  the  shaft  of  the  femur.  The  cause  is  violent  direct  force  over 
and  behind  the  great  trochanter  or 
a  fall  (Armstrong,  in  "Annals  of 
Surgery,"  August,  1907).  Neck  re- 
ported a  case  due  to  muscular  action 
("Zentralb.  fiir  Chir.,"  1903). 

Symptoms  and  Treatment. — The 
symptoms  of  the  first  form  resemble 
those  of  epiphyseal  separation  and, 
of  course,  there  is  no  shortening. 
The  symptoms  of  the  second  form 
are  similar  to  those  of  the  extracap- 
sular fracture.  On  rotating  the 
femur  the  lower  part  of  the  tro- 
chanter moves  with  it,  but  not  the 
upper.  The  lower  fragment  goes 
upward  and  backward  and  projects 
by  the  side  of  the  sciatic  notch. 
There  are  shortening,  eversion,  crepi- 
tus, and  altered  position  of  the  tro- 
chanter. The  treatment  of  the  sec- 
ond form  is  hke  that  in  extracap- 
sular fracture,  and  the  first  form  is 
treated  like  separation  of  the  ep- 
iphysis of  the  trochanter. 

Separation  of  the  epiphysis  of 
the  great  trochanter  is  a  rare  acci- 
dent.    The  cause  is  direct  violence 

and  the  injury  occurs  in  those  under  eighteen  years  of  age. 
collected  12  cases. 

Symptoms. — The  trochanter,  if  completely  separated,  is  found  to  have 
ascended  and  passed  posteriorly;  there  is  no  shortening  of  the  thigh;  all  the 
motions  of  the  hip-joint  can  be  obtained;  if  the  thigh  is  flexed,  abducted,  and 
rotated  externally,  and  the  fragment  is  pushed  downward  and  forward,  crepitus 
may  be  obtained — soft  in  epiphyseal  separation,  hard  in  fracture.  There  is  no 
shortening.  If  the  process  is  not  completely  separated,  diagnosis  is  impossible 
without  the  ic-rays. 

Treatment. — If  the  epiphysis  is  not  completely  separated,  immobilize  the 
limb  in  the  position  of  abduction.  If  it  is  completely  separated,  incise  the 
soft  parts  and  either  suture  or  nail  the  fragment  in  place. 

Fractures  of  the  shaft  of  the  femur  may  affect  any  portion  of  the  shaft, 
"but  especially  the  middle  third,  and  may  occur  at  any  age.  Fracture^  of 
the  upper  third  is  a  rare  accident.  AUis  estimates  that  each  year  in  Phila- 
delphia there  is  i  case  of  fracture  of  the  upper  third  of  the  femur  to  every 
100,000  inhabitants.  Separation  of  the  lower  epiphysis  occasionally  occurs. 
38 


Fig.  351. — Iiiti-TtrDrluinti-ric  fracture. 


Poland  in  1898 


594 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  cause  of  fractures  in  the  upper  third  is  usually  indirect  force;  fractures 
in  the  lower  third  are  due  to  direct  force;  and  in  fractures  of  the  middle  third 
these  two  causes  are  about  equally  potential.  Fracture  from  muscular  action 
occasionally  occurs.  Oblique  fracture  is  the  usual  variety.  In  many  cases 
the  soft  parts  are  badly  lacerated  and  sometimes  a  great  vessel  is  torn. 

Symptoms. — The  chief  symptom  in  fracture  of  the  shaft  of  the  femur 
is  great  displacement,  except  when  impaction  occurs,  when  the  break  is  due 
to  direct  force,  or  when  the  injury  is  in  a  child.  In  a  child  the  line  of  frac- 
ture is  often  transverse  and  the  periosteum  may  be  untorn.  Green-stick 
fractures  occur  in  children.  As  a  rule,  in  fracture  of  the  shaft  of  the  femur 
the  lower  fragment  is  drawn  upward  and  the  upper  end  of  the  lower  fragment 


Fig.  352. — Deformity  following  fracture  of  upper  third  of  femur. 

is  found  posterior  and  somewhat  to  the  inside  of  the  lower  end  of  the  upper 
fragment,  and  the  lower  fragment  also  undergoes  external  rotation  (the  draw- 
ing up  is  due  to  the  rectus  and  hamstrings;  the  passing  inward  is  due  to  the 
adductor  muscles;  the  rotation  outward  arises  from  the  weight  of  the  limb). 
If  a  fracture  of  the  lower  two-thirds  of  the  shaft  is  produced  by  direct  force, 
there  is  usually  but  little  deformity,  because  the  line  of  fracture  is  nearly  trans- 
verse. If  produced  by  indirect  force,  there  is  often  great  deformity,  the  line 
of  fracture  being  oblique.  In  fracture  of  the  lower  third  of  the  shaft  the  gas- 
trocnemius pulls  upon  the  condyles  and  tilts  the  lower  fragment,  so  that  its 
upper  end  projects  into  the  popliteal  space  and  may  damage  the  vessels.  In 
fracture  of  the  upper  third  the  upper  fragment  is  apt  to  be  thrown  strongly 
forward  and  outward  (Fig.  352).     Some  attribute  this  to  the  action  of  the 


Fractures  of  the  Shaft  of  the  Femur 


595 


psoas,  iliacus,  and  external  rotator  muscles,  but  Allis  thinks  it  is  due  chiefly 
to  the  lower  fragment  pushing  the  upper  fragment  into  this  position,  a  part 
of  the  tendon  of  the  gluteus  maximus  acting  as  a  hinge  for  the  fragments.^ 
In  rare  cases  the  angular  deformity  is  backward.  In  fracture  of  the  shaft  of 
the  femur  there  is  complete  loss  of  function,  the  thigh  and  leg  are  slightly  flexed 
and  usually  everted.  In  some  cases  the  leg  and  lowxr  fragment  are  inverted. 
There  are  shortening  to  the  extent  of  2  or  3  inches,  pain  on  movement,  preter- 
natural mobility,  crepitus,  and  obvious  deformity,  and  the  ends  of  the  fragments 
can  be  felt  by  the  surgeon.  In  impaction  there  is  alteration  of  the  axis  of  the 
limb  and  some  shortening.  Always  feel  for  the  pulse  below  the  fracture  to  learn 
if  the  arterv  is  damaged. 


Fig-  353- — Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double  inclined 

plane  (Agnew). 

Treatment. — In  setting  and  dressing  a  fracture  of  the  thigh  ether  should 
be  given  and  the  parts  must  be  handled  with  great  care  to  prevent  a  sharp 
end  of  bone  from  tearing  the  soft  parts  and  puncturing  the  skin.  In  frac- 
ture of  the  shaft  of  the  femur,  if  impaction  exists,  the  fragments  must  be 
pulled  apart,  when  the  case  should  be  treated  exactly  as  is  a  non-impacted 
fracture.  After  a  fracture  of  the  shaft  of  the  femur  some  amount  of  perma- 
nent shortening  is  almost  ine\dtable.  In  fracture  of  the  tipper  third  in  an  adult 
conservative  treatment  is  usually  unsatisfactory,  and  there  is  permanent  short- 
ening from  angular  union  or  from  over- 
lapping. In  youths  under  fifteen  a  good 
result  is  obtained  in  over  90  per  cent,  of 
cases.  Horizontal  extension  fails  to  cor- 
rect the  displacement  of  the  upper  frag- 
ment in  fracture  of  the  upper  third. 
The  double  inclined  plane  will  not  cor- 
rect the  tilting  of  the  upper  fragment 
while  shortening  exists.  Agnew  used  a 
double  inclined  plane  and  corrected 
shortening  by  the  use  of  extension  in  the 
axis  of  the  partly  flexed  thigh  (Fig.  353). 
This  plan  is  one  of  the  most  serviceable  of 
those  usually  employed,  but  it  too  fails 
to  completely  correct  the  displacement. 
If,  notwithstanding  position  and  exten- 
sion, the  upper  fragment  projects,  it 
should  be  pushed  into  place  and  be  re- 
tained if  possible  by  short  splints  botmd  upon  the  thigh.  In  many  cases  a 
Thomas  knee-sphnt  is  the  best  apparatus.  In  fracture  of  the  upper  third 
with  marked  projection  of  the  upper  fragment  the  abduction  frame  may  prove 
satisfactory'.     Extension  should  be  continued  for  four  weeks,  a  plaster-of-Paris 

^  "Fracture  in  the  Upper  Third  of  the  Femur  Exclusive  of  the  Neck,"  by  Oscar  H.  Allis, 
"Medical  News,"  Nov.  21,  1891. 


Fig-  354- — Smith's  anterior  splint. 


596  Diseases  and  Injuries  of  the  Bones  and  Joints 

bandage  being  used  for  four  weeks  more,  the  patient  being  then  allowed  to  go 
about  on  crutches.  Some  surgeons,  in  fracture  of  the  upper  third,  apply  a 
plaster-of-Paris  bandage  to  the  leg,  thigh,  and  pelvis,  extension  being  made  from 
the  foot  while  the  dressing  is  being  applied.  This  method  does  not  give  good 
results  because  such  extension  will  not  correct  the  tilting  of  the  upper  fragment. 
The  anterior  splint  of  Xathan  R.  Smith  is  used  by  some  in  treating  fractures  of 
the  upper  third  of  the  femur  (Fig.  354).  It  is  bent  to  the  desired  shape,  fast- 
ened to  the  anterior  surfaces  of  the  leg  and  thigh,  and  hung  to  a  gallows,  the 
limb  being  suspended  at  the  desired  height.     This  splint  is  open  to  the  same 


Fig-  355- — Hodgen's  apparatus  as  applied  by  Dr.  George  S.  Brown. 

objection  as  the  double  inclined  plane.  In  fact,  in  many  fractures  of  the 
upper  third  of  the  shaft  of  the  femur  no  apparatus  will  maintain  reduction. 
In  such  cases  it  is  advisable  to  incise,  separate  the  muscles  from  between 
the  fragments,  and  fasten  the  ends  of  the  bone-fragments  together  with  bone 
plates.  This  radical  treatment  has  certain  dangers  of  its  own,  but  it  is  the 
plan  which  promises  best  to  secure  a  thoroughly  good  limb.  In  fracture  of 
the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  of  the  femur  the 
Thomas  knee-splint  is  an  excellent  instrument.  The  extension  apparatus 
and  sand-bags  will  usually  secure  a  satisfactory  result  (PI.  7,  Fig.  14J.     The 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


597 


strips  of  adhesive  plaster  are  carried  to  just  below  the  seat  of  fracture,  and  the 
turns  of  the  roller  bandage  should  be  taken  to  a  little  above  this  point.  Ex- 
tension should  be  continued  for  four  weeks,  when  the  plaster-of-Paris  bandage 
ought  to  be  applied.  The  plaster  is  kept  in  place  for  four  weeks.  Many  sur- 
geons use  Hodgen's  splint  in  treating  fractures  of  the  thigh.  The  limb  is  sus- 
pended in  a  cradle  and  extension  is  obtained  by  strapping  the  foot  of  the  cross- 
bar of  the  frame  and  pulling  upon  the  frame  by  cords  (Fig.  355).  Hodgen's 
apparatus  as  applied  by  Brown,  of  Birmingham,  Ala.,  is  one  of  the  most  satis- 
factory methods  of  treatment  in  fracture  below  the  upper  third.  The  extremity 
can  be  raised  or  lowered  at  will  without  disturbing  the  approximation  of  the 
fragments,  extension  to  the  required  degree  can  be  obtained,  and  the  patient 
can  be  moved  in  bed.  I  consider  this  apparatus  one  of  the  most  comfortable 
appliances  which  can  be  worn  and  excellent  resiilts  are  obtained  by  its  use.  In 
fracture  of  the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  if  the 
line  of  fracture  is  transverse  and  there  is  little  deformity,  as  is  seen  often  after 
a  fracture  by  direct  force,  and  often  in  children,  immobilization  in  an  immov- 
able dressing  may  be  all  that  is  required;  but  if  shortening  exists,  exten- 
sion must  be  used.  If  extension  is  used,  continue  it  for  four  weeks  and  then 
substitute  a  plaster-of-Paris  dressing  for  four  weeks.     The  amount  of  weight 


Fig-  356. — Mclnfyre's  splint. 


required  is  pointed  out  by  Dawbarn — i  pound  for  each  year  up  to  twenty.^ 
In  fracture  near  the  knee-joint  {lower  part  of  the  lower  third  of  the  femur)  it 
may  be  impossible  to  effect  reduction  by  horizontal  traction.  In  such  a  case 
make  traction,  and  while  it  is  being  made  gradually  bring  the  leg  to  a  right 
angle.  Place  the  limb  in  a  double  inclined  plane  (PI.  7,  Fig.  2).  A  Mcln- 
tyre  spHnt  (Fig.  356)  is  a  useful  form  of  double  inclined  plane.  After  four 
weeks  of  the  use  of  a  double  inclined  plane  apply  a  plaster-of-Paris  dressing, 
which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  Shaft  of  the  Femur  in  Children. — In  children  imder 
three  years  of  age  the  extension  apparatus  will  not  satisfactorily  immobilize 
the  fragments.  Fractiures  of  the  thigh  in  children  are  reduced  by  extension 
and  counterextension;  a  well-padded  splint  reaching  from  the  axilla  to  below 
the  sole  of  the  foot  may  be  applied  to  the  outer  side  of  the  limb  and  body.  This 
splint  is  held  in  place  by  bandages  which  are  overlaid  by  plaster  of  Paris. 
It  is  worn  for  four  weeks,  at  which  time  it  is  removed  and  a  plaster  bandage, 
applied  so  as  to  include  the  entire  limb,  is  worn  for  four  weeks. 

The  abduction  frame  (Fig.  357)  is  a  very  useful  plan  of  treatment. 

Bryant's  extension  (Fig.  358)  is  very  satisfactory  in  treating  a  child.  Both 
1  "Annals  of  Surgery,"  Oct.,  1897. 


598 


Diseases  and  Injuries  of  the  Bones  and  Joints 


the  injured  limb  and  the  sound  limb  should  be  flexed  to  a  right  angle  with  the 
pehas,  fixed  by  light  splints,  and  fastened  to  a  bar  above  the  bed.  The  weight 
of  the  body  produces  counterextension  and  the  child  can  be  easily  cleaned.^ 

Another  plan  is  that  of  Theodore  Dunham.-    The  child  is  placed  upon  a 
table,  and  the  knee  and  hip  are  partly  flexed.    After  first  applying  flannel 

rollers,  plaster-of-Paris  bandages  are 
applied  from  the  roots  of  the  toes  to 
the  spine  of  the  tibia,  and  as  a  spica 
about  the  upper  part  of  the  thigh 
and  pehds.  Two  pieces  of  iron,  suit- 
ably bent,  are  used  to  anchor  the  two 
plaster  bandages  together.  One  end 
of  one  iron  is  attached  to  the  plaster 
over  the  groin  and  one  end  of  the 
other  iron  is  attached  to  the  plaster 
over  the  front  of  the  leg.  The  free 
ends  of  the  irons  overlap.  At  the 
points  over  the  joints  and  the  front 
of  the  leg  where  the  irons  are  to  rest 
masses  of  plaster  are  placed.  The 
iron  is  sunk  into  the  plaster  and  sup- 
ported at  each  spot  by  several  turns 
of  a  plaster  bandage.  \\Tiile  the  irons 
are  being  adjusted  the  thigh  is  so  held 
as  to  prevent  bending  or  rotation, 
and  the  hip  and  knees  are  semiflexed. 
WTien  the  plaster  has  set  an  assist- 
ant makes  extension  on  the  leg  and 
another  assistant  makes  counterex- 
tension by  pressing  on  the  pelvis.  Any  shortening  is  thus  reduced  and  the  two 
irons  are  lashed  together  by  strong  cord  (Fig.  359). 

Van  ArsdaWs  triangular  splint  is  a  very  useful 
appliance.  It  is  made  of  binders'  board.  A.  Ernest 
Gallant^  describes  its  preparation  and  application  as 
follows:  Pleasure  the  length  of  the  sound  thigh  from 
the  middle  of  the  groin  to  the  end  of  the  femur. 
Draw  upon  cardboard  an  outline  of  a  double  spade 
(playing-card  spade)  (Fig.  360).  Each  of  the  four 
sections  {A,  B,  C,  D)  must  be  equal  to  the  length  of 
the  child's  thigh,  the  flanged  portions  being  equal 
to  the  widest  part  of  the  thigh.  The  figure  is  then 
cut  out.  The  cardboard  is  moistened  on  one  side 
and  folded  on  the  dotted  line,  section  A  being  lapped 
over  D,  so  as  to  form  a  triangle.  It  is  fastened  to- 
gether by  adhesive  plaster.  The  thigh  is  flexed  and 
the  triangle  is  applied  so  that  one  flanged  portion 
embraces  the  thigh  and  the  other  flanged  portion 
rests  upon  the  abdomen  (Fig.  361).  The  triangle 
is  fixed  in  position  by  bandages,  figure-of-8  turns 
being  made  around  the  knee  and  around  the  thigh  and  body.  Plaster  or  starch 
bandages  are  then  applied  to  fix  the  splint  firmly.  The  leg  should  be  band- 
aged from  the  toe  to  the  knee  to  prevent  swelling  (Fig.  361).     This  splint 

1  Thomas  Bryant's  "Practice  of  Surgery." 

2  "Phila.  Med.  Jour.."  April  23,  1898. 

3  "Jour.  Amer.  Med.  Assoc,  Dec.  18,  1897. 


Fig.  357. — Jones's  abduction  frame,  showing 
continued  traction  and  counterextension  (cour- 
tesy of  Mr.  Robert  Jones,  Liverpool,  England^ 


Fig.  358. — Brj'ant's  exten- 
sion for  fracture  of  the  thigh 
in  a  child. 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


599 


is  worn  for  three  weeks.      A  child  wearing  this  splint  can  sit  on  a  chair, 

nurse,  play  on  the  floor  and  crawl  about,  may  sleep  on  either  side,  and  the 

dressing  is  not  soiled  by  the  evacuations. 

If  a  thigh  is  fractured  during  parturition,  or  during  the  first  few  weeks  of 

life,  Wyeth's  dressing  may  be  very  serviceable.  It  is  applied  as  follows:  The  leg 
is  flexed  on  the  thigh  and  the  thigh  on  the  abdomen. 
A  flannel  bandage  is  applied  so  as  to  include  the  leg, 
the  thigh,  and  the  body  from  the  axilla  to  the  peMs. 
Plaster  of  Paris  is  applied  over  this;  the  dressing  is 
worn  for  four  weeks.  A  better  dressing  than  the 
above  is  Ware's,  a  modification  of  Van  Arsdale's  splint 
("Annals  of  Surg.,"  August,  1905)  (Fig.  362).  It  is 
hghter,  the  patient  can  be  moved  about  with  ease, 
the  child's  toilet  can  be  easily  carried  out,  and  breath- 
ing is  not  embarrassed.    A  right-angled  triangle  is 


Fig.  359. — Diinham's  ap- 
paratus for  treating  fractures 
of  the  thigh  in  infants  and 
children. 


Fig.  360. — /,  Diagram  showing  outline  of  Van  Arsdale's 
splint;  the  end  band  to  be  folded  on  the  dotted  lines;  each 
section  to  equal  the  length  of  the  child's  thigh.  2,  Diagram, 
splint  folded,  fastened  h\  rubber  plaster,  flanges  bent  to  em- 
brace the  thigh  and  abdomen,  ready  for  adjustment  (GaUant). 


made  of  bookbinders'  board.  The  length  of  one  side  is  the  distance  from 
the  trimk  at  the  level  of  the  lower  angle  of  the  scapula  to  the  inguinal 
fold.  The  length  of  the  other  side  is  the  length  of  the  thigh.  The 
h>potenuse  is,  of  course,  longer  than  the  sides.  The  cardboard  is  marked, 
bent  into  the  triangle,  and  the  overlapping  edges  are  secured  by  means  of 


Fig.  361. — Showing  Van  Arsdale's  triangular  spUnt  in  position.    Note  the  wide  space  between  the 
dressings  and  the  excretorj'  passages  (Gallant). 

adhesive  plaster.  The  thigh  is  flexed  and  abducted,  the  inner  surface  of  the 
splint  is  padded,  the  apparatus  is  applied  and  retained  by  a  muslin  spica 
about  the  trunk  and  thigh.  Several  turns  of  a  dextrin  bandage  are 
applied  over  this  to  give  strength.  The  leg  hangs  free.  The  dressing  is 
worn  for  three  or  four  weeks.  Figure  362  shows  this  dressing  applied  for 
fracture  of  the  right  femur,  and  Fig.  363  shows  it  appUed  when  both  bones 
are  broken. 


6oo 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  362. — Ware's  combined  pasteboard  triangle  and  plaster-of-Paris  spica  apparatus  for  fracture  o£ 
the  femur  in  infancy  (Ware,  in  "Annals  of  Surgery,"  August,  1005). 


Fig.  363.— Ware's  apparatus  for  treatment  of  fracture  of  both  femora  (Ware,  in  "Annals  of  Surgery,' 

August,  1905). 


Separation  of  the  Lower  Epiphysis 


60 1 


''mM\ 


Fig.  364. — Mechan- 
ism of  fracture  of  the 
patella  by  muscular 
action  (after  Treves). 


Fractures  Just  Above  the  Condyles  of  the  Femur. — The  line  of  fracture 
above  the  condyles  is  well  above  the  epiphyseal  line.  The  popliteal  artery 
is  in  danger  from  the  fragments.  The  cause  of  the  break,  as  a  rule,  is  direct 
violence.  Indirect  force  is  sometimes  responsible  (falls 
upon  the  feet).  The  knee-joint  may  be  opened.  The 
fracture  is  sometimes  compound. 

Symptoms. — The  upper  end  of  the  lower  fragment  is 
drawn  upward  and  backward,  because  of  the  action  of  the 
rectus,  hamstrings,  gastrocnemius,  and  popliteus.  The 
upper  fragment  passes  inward,  and  .the  deformity  is  very 
manifest.  There  are  pain,  tenderness,  shortening,  crepitus, 
and  mobility.  The  ends  of  the  fragments  can  be  felt  by  the 
surgeon.  If  the  force  has  been  very  great,  a  T-fracture 
results.  In  T-fracture  the  knee  is  broadened  and  crepitus 
is  obtained  by  moving  the  condyles,  one  up  and  the 
other  down.  The  popliteal  vessels  may  be  torn.  Always  feel  for  the  pulse 
below  the  fracture. 

Treatment. — In  treating  fracture  above  the  condyles,  reduce  the  deformity 
by  horizontal  extension.  If  this  fails,  make  traction  at  the  same  time,  gradu- 
ally bringing  the  leg  to  a  right  angle  with  the  thigh.  Place  the  limb  on  a 
double  inclined  plane  for  five  weeks,  then  begin  passive  motion  once  every 
other  day,  reapplying  the  splint  after  the  movements  are  completed.  At 
the  end  of  eight  weeks  after  the  accident 
remove  the  dressings,  and,  if  the  knee- 
joint  be  stiff,  use  for  some  time  mas- 
sage, passive  motion,  hot  air,  hot  and  cold 
douches,  ichthyol  inunctions,  etc.  Bryant 
treats  this  fracture  in  extension,  cutting 
the  tendo  Achillis,  if  necessary,  to  amend 
deformity.  It  is  occasionally  necessary  to 
plate  the  fragments.  Some  cases  demand 
amputation  because  of  injury  to  the  struc- 
tures in  the  popliteal  space. 

Fracture  Separating  Either  Condyle. — 
The  cause  is  direct  force. 

Symptoms  and  Treatment. — ^The  broken 
piece  is  drawn  upward,  the  leg  bends  to- 
ward the  injury,  crepitus  exists,  the  knee 
is  much  broadened,  there  is  no  shortening, 
and  considerable  swelling  is  sure  to  arise. 
In  treating  a  fracture  separating  either 
condyle,  use  a  double  inclined  plane  as 
directed  above.  If  there  is  great  displacement,  the  condyle  should  be 
nailed  in  place. 

Longitudinal  fractures  run  upward  from  the  knee-joint.  The  cause  is  a 
fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  symptoms  of  longitudinal  fracture  are 
often  obscure.  The  femur  is  broadened  when  the  knee  is  flexed.  The  split 
may  be  detected  between  the  condyles.  The  treatment  is  the  straight  posi- 
tion in  plaster  for  eight  weeks. 

Separation  of  the  lower  epiphysis  occurs  only  before  the  twenty-first 
year.    It  is  not  a  very  rare  accident  in  children. 

The  symptoms  in  separation  of  the  lower  epiphysis  are  like  those  of  trans- 
verse fracture,  but  crepitus  is  moist.  The  lower  fragment  is  tilted,  so  that  the 
articular  surface  looks  forward.    The  lower  end  of  the  upper  fragment  pro- 


Fig-  365- — Fracture  of  the  patella. 


6o2 


Diseases  and  Injuries  of  the  Bones  and  Joints 


jects  into  the  pophteal  space.  There  is  danger  to  the  structures  in  the  pop- 
liteal space.  The  growth  of  bone  may  be  stunted.  Feel  for  the  pulse  in  the 
leg  or  foot. 

Treatment. — Reduction  may  be  effected  in  some  cases  by  horizontal  ex- 
tension. Occasionally  this  is  impossible.^  In  such  a  case  adopt  the  plan  of 
Hutchinson  and  Barnard,  make  extension,  and  while  it  is  being  made  gradually 
place  the  leg  at  a  right  angle  to  the  thigh.  This  is  effected  by  an  assistant 
making  traction  on  the  leg,  while  the  surgeon  clasps  his  hands  beneath  the 
lower  part  of  the  thigh  and  draws  upward.  The  treatment  for  separation  of 
the  lower  epiphysis  is  the  use  of  a  double  inclined  plane  as  above  directed. 
In  some  cases  replacement  is  impossible  without  incision.  In  a  case  of  my 
own  amputation  was  performed  because  of  laceration  of  the  popliteal  vessels. 


Fig.  366.— Fracture  of  the  patella,  showing  wide  separation  of  the  fragments  (author's  case). 

Fracture  of  the  patella  is  a  very  common  accident.  The  cause  is  direct  force 
(often  producing  vertical,  star-shaped,  or  oblique  lines  of  fracture,  but  not 
imcommonly  transverse)  or  muscular  action  (producing  a  transverse  line  of 
fracture) . 

Transverse  Fractures  of  the  Patella. — The  knee-cap  is  more  often  broken 
by  muscular  action  than  is  any  other  bone.  When  the  knee  is  partly  flexed 
the  middle  third  of  the  patella  rests  upon  the  condyles  of  the  femur  and  the 
upper  third  of  the  knee-cap  projects  above  them;  when  in  this  position  a 
contraction  of  the  quadriceps  may  easily  cause  a  fracture  near  the  center  of 
the  bone  (Fig.  364).  The  accident  may  be  caused  by  sudden  flexion  of  the  knee 
when  the  quadriceps  is  contracting.     The  most  usual  cause  is  a  fall  or  an 

1  See  the  case  reported  by  Jonathan  Hutchinson,  Jr.,  and  Howard  L.  Barnard,  "Lancet," 
May  13,  1899. 


Transverse  Fractures  of  the  Patella 


603 


attempt  of  the  patient  to  save  himself  from  a  fall  backward.  Both  patellae 
may  be  broken  at  once.  In  fracture  of  the  patella  the  joint,  and  often  the 
prepatellar  bursa,  is  opened.  Fractures  by  muscular  action  and  many  frac- 
tures from  direct  force  are  transverse.  The  injury  is  more  common  in  males 
than  in  females,  and  is  extremely  rare  in  the  very  young  and  the  old.  It  is 
usually  an  injury  of  active  manhood  and  middle  life,  but  I  have  seen  a  woman 
of  eighty-six  with  fracture  of  the  patella. 

Sy}}ipfoms. — When  the  accident  happens  there  is  often  an  audible  crack. 
As  a  rule,  the  patient  will  not  try  to  use  the  limb,  although  it  is  possible  for 
him  to  stand,  to  walk  backward,  and  to  move  slowly  forward  when  the  ex- 
tremity is  kept  straight.  After  the  accident  there  is  rapid  and  enormous 
swelling,  due  to  the  effusion  first  of  blood  and  then  of  synovia  and  inflamma- 


Fig.  367. — Fracture  of  the  patella  (Pennsylvania  Hospital  case;  skiagraphed  by  Dr.  Gaston  Torrance). 


tory  products  into  and  around  the  joint.  The  patient  is  absolutely  unable  to 
raise  the  limb  from  the  bed.  The  fragments  are  movable  and  usually  widely 
separated  (Fig.  366),  this  separation  being  distinctly  manifest  to  the  touch 
unless  swelling  is  great.  The  separation  is  accentuated  by  flexion  of  the  leg. 
The  separation  may  be  to  the  extent  of  i  inch  or  even  more.  In  cases  in 
which  the  lateral  fibrous  expansions  and  periostetim  are  but  slightly  torn,  there 
mtay  be  slight  separation  or  no  separation.  Separation  is  due  in  part  "to  the 
retraction  of  the  quadriceps  and  the  tension  of  the  fascia  lata,  and  in  part  to 
distention  of  the  joint  by  blood  and  exudate.^  If  fragments  are  not  approxi- 
mated and  union  does  not  occur,  the  separation  becomes  gradually  greater 
because  of  the  progressive  shortening  of  the  muscle  and  the  retraction  of  the 

1  Stimson's  "Treatise  on  Fractures  and  Dislocations." 


6o4 


Diseases  and  Injuries  of  the  Bones  and  Joints 


(  nllW 


ligamentum  patellag  (Stimson).  In  some  cases  an  anterior  angular  displace- 
ment occurs  because  of  the  intra-articular  distention  (Fig.  367).  It  may 
be  produced  by  the  pressure  of  bandages  or  strips  of  plaster  when  the  frag- 
ments have  been  brought  together.  Crepitus  is  detected  if  the  upper  frag- 
ment can  be  pushed  down  until  it  touches  the  lower  piece;  but  if  swelling  is 
great,  or  if  fibrous  tissue  is  interposed  between  the  bones,  crepitus  cannot  be 
elicited.  It  is  not  necessary  to  obtain  crepitus  in  order  to  make  the  diagnosis : 
the  condition  is  usually  obvious  without  this  sign.  The  anterior  fibroperiosteal 
layer  is  torn,  and  the  tear  does  not  correspond  exactly  with  the  line  of  frac- 
ture. A  portion  of  this  torn  fibroperiosteal  layer  may,  as  Macewan  pointed 
out,  drop  between  the  fragments  and  prevent  union  (Fig.  368).  The  lateral 
expansions  of  the  capsule  are  usually  extensively  torn.  If  union  occurs  after 
a  transverse  fracture,  it  will   probably  be  ligamentous,   and  if  the  patient 

gets  about  too  soon,  even  apparently  well- 
united  fragments  will  by  degrees  stretch  far 
asunder. 

Treatment  of  Transverse  Fractures  of  the 
PateUa.— TAe  Conservative  Plan. — If  the  swell- 
ing is  so  great  as  to  prevent  approximation 
of  the  fragments,  reduce  it  by  bandaging  for 
a  day  or  two,  by  using  ice-bags,  or  by  as- 
pirating the  joint.  As  a  rule,  the  blood  does 
not  coagulate  for  several  days.  After  it  coag- 
ulates it  cannot  be  withdrawn  by  aspiration, 
but  only  by  incision.  When  the  swelling 
diminishes,  bring  the  two  fragments  into  ap- 
position, pull  them  together  by  adhesive 
plaster,  and  put  on  a  well-padded  posterior 
splint.  Carry  a  piece  of  adhesive  plaster  over 
the  upper  end  of  the  upper  fragment,  draw  the 
bone  down,  and  fasten  the  plaster  to  the 
splint  behind  and  below  the  level  of  the  joint. 
Carry  another  piece  of  plaster  over  the  lower 
end  of  the  lower  fragment,  draw  the  bone  up, 
and  fasten  the  plaster  to  the  splint  behind  and 
above  the  joint.  Carry  a  third  piece  over  the  junction  of  the  fragments  to 
prevent  tilting.  Agnew's  splint  enables  us  to  satisfactorily  accomplish  this 
approximation  (PI.  7,  Figs.  11,  12).  A  bandage  holds  the  splint  in  place,  and 
may  be  carried  around  the  knee  by  figure-of-8  turns.  The  heel  is  sometimes 
raised  upon  a  pillow  so  as  to  extend  the  leg  and  to  semiflex  the  thigh,  but 
this  is  not  essential.  Remove  and  reapply  the  dressing  every  few  days,  as  it 
inevitably  becomes  loose.  At  each  removal  employ  massage.  At  the  end  of 
three  weeks  remove  the  splint  permanently  and  apply  a  plaster-of-Paris 
dressing  from  just  above  the  ankle  to  the  middle  of  the  thigh,  and  get  the 
patient  about  on  crutches.  Have  the  plaster  cut  so  that  it  may  be  easily 
removed  and  every  day  employ  massage  and  gentle  passive  movements,  the 
surgeon  fixing  the  upper  end  of  the  upper  fragment  by  his  thumb  during  the 
movements.  The  dressing  is  to  be  worn  for  five  weeks.  After  eight  weeks 
of  treatment  allow  the  patient  to  walk  about  on  crutches,  the  joint  being 
left  free  at  night,  but  kept  fixed  during  the  day  by  pasteboard  splints  or 
by  a  light  plaster-of-Paris  bandage.  After  four  weeks  more  he  gets  about 
with  canes  or  a  cane.  For  months  after  removing  the  spHnts  and  plaster 
a  lacing  knee-cap  of  leather  should  be  worn  in  the  daytime  to  support  the 
joint.  The  plan  of  prolonged  immobilization  render  more  or  less  muscular 
atrophy  and  joint-stiffness  certainties,  but  there  are  less  serious  impediments 


Fig.  368. — Transverse  fracture  of 
the  patella;  fractured  surface  partially 
covered  by  irregular  flaps  of  torn  apon- 
eurosis (Hoffa). 


Treatment  of  Transverse  Fractures  of  the  Patella  605 

than  the  wide  separation  of  the  fragments  that  inevitabl}'  attends  an  early  use 
of  the  joint.     Bryant,  of  Xew  York,  has  devised  an  ambulatory  dressing. 

Operative  Treatment. — ^lalgaigne's  hooks  are  obsolete. 

It  is  said  that  John  Rhea  Barton  wired  an  ununited  fracture  of  the  patella 
in  1843.  I^  1S77  Hector  Cameron  wired  an  ununited  fracture  of  the  patella, 
and  a  few  months  later  Lord  Lister  operated  on  a  fracture  of  the  knee-cap  two 
weeks  after  the  accident.  The  question  of  the  ad\'isability  of  suturing  a  recent 
fracture  has  been  very  much  disputed.  The  ordinary-  non-operative  plans  of 
treatment  do  not  endanger  life  and  generally  give  a  fairly  good  functional  result, 
although  the  joint  remains  insecure  on  extension,  the  patient  is  apt  to  fall,  and 
a  fall  may  refracture  the  bone.  The  operative  method  will  usually  succeed, 
and  is  capable  of  obtaining  a  better  functional  result  and  of  obtaining  it 
more  rapidly.  There  is  some  danger  of  infection,  and  if  infection  should 
occur,  the  results  may  be  most  disastrous.  Some  cases  ob\'iously  cannot  be 
treated  by  the  conservative  method  ■nith  any  chance  of  success;  cases,  for  in- 
stance, in  which  a  flap  of  fibroperiosteum  inter^-enes  between  the  fragments, 
or  cases  in  which  from  some  other  cause  the  bones  cannot  be  approximated. 
Such  cases  should,  of  course,  be  operated  upon.  But  in  the  great  majority  of 
cases  a  good  result  "uill  follow  conserv^ative  treatment,  and  conser\-ative  treat- 
ment should  be  trusted  unless  the  case  is  in  the  hands  of  a  surgeon  and  in 
a  place  where  ever\'  antiseptic  precaution  can  be  taken.  We  agree  with  Stim- 
son  when  he  says  that  operative  methods  can  be  used  with  confidence  when 
surrounded  by  ever\- protection;  he  habitually  uses  them,  but  he  never  teaches 


Fig.  36g. — ^Xeedle  specially  designed  to  cam-  a  thick  wire.    The  eye  is  drilled  obliquely,  and  shoiild 
receive  only  a  little  loop  on  the  end  of  the  ■nire;  this  loop  should  be  made  pre\'iou3ly. 

them  as  proper  routine  practice,  and  strongly  advises  against  their  use  except 
by  those  who  have  had  experience  in  operating,  who  have  formed  the  habit 
of  taking  precautions,  and  who  have  the  aid  of  skilled  assistants.^  Operation 
should  only  be  performed  on  healthy  persons  of  suitable  age,  when  the  separa- 
tion is  over  I  inch  or  when  there  is  much  laceration  or  interposition  of  the  cap- 
sule.- If  a  patient  is  still  able  to  extend  the  limb  and  the  lateral  expansions  of 
the  quadriceps  have  not  been  -widely  torn,  a  useful  limb  will  be  obtained  by 
conserv'ative  treatment  even  if  the  bone-fragments  separate,  and  operation  is 
not  demanded.  A  working  man  needs  the  operation  more  than  a  gentleman 
of  leisure  because  he  is  in  more  \'ital  need  of  a  soimd  knee-joint.  A  young 
or  middle-aged  person  is  more  active  than  an  elderly  person,  hence,  in  him 
operation  is  more  strongly  indicated  than  in  an  elderly  man.  Barker  believes 
strongly  in  -firing  recent  transverse  fractures.  He  does  it  with  antiseptic  care 
soon  after  the  accident,  and  permits  passive  motion  or  even  slight  active 
motion  immediately  after  the  operation.  ^Massage  is  begun  the  day  after  the 
operation,  and  is  practised  daily  for  two  weeks. 

Barker^  uses  a  special  needle  (Fig.  369)  and  silver  wire  of  the  thickness  of  a 
No.  I  English  catheter.  This  wire  is  straightened  and  softened  in  a  spirit-flame. 
He  rubs  the  bone-fragments  together  in  order  to  dislodge  blood  or  fibrous 

1  "Annals  of  Stirgen,-,"  August,  iSgS. 
-  Powers,  in  "Annals  of  Surger}',"  July,  1S98. 

3  See  the  objections  of  Sir  William  Stokes  to  Barker's  method,  in  "Brit.  ZSIed.  Jotir.," 
Dec.  3,  1898. 


6o6 


Diseases  and  Injuries  of  the  Bones  and  Joints 


material,  and  when  marked  grating  occurs,  introduces  the  wire.     A  punc- 
ture with  a  small  knife  is  made  through  the  middle  of  the  upper  attachment  of 


Fig.  370. — Needle  (a)  introduced  behind  the  frag- 
ments, and  receiving  one  end  (6)  of  the  silver  wire  (&,  c) 
(Barker). 


Fig.  371. — Needle  (a)  passed  in  front  of 
the  fragments  and  recei\ang  the  other  end  (c) 
of  the  silver  wire  (b,  c)  (Barker). 


the  patellar  ligament.     The  needle,  not  carrying  any  wire,  is  made  to  enter 
through  this  opening  into  the  joint,  is  passed  back  of  the  fragments,  pierces 

the  tendon  of  the  quadriceps  at 
the  upper  edge  of  the  upper  frag- 
ment, and  its  point  is  cut  upon 
with  a  knife.  The  wire  is  in- 
serted into  the  eye  of  the  needle 
and  the  needle  is  withdrawn  and 
unthreaded.  The  empty  needle 
is  pushed  through  the  lower  open- 
ing, is  carried  in  front  of  the 
patella,  is  made  to  emerge  at  the 
upper  opening,  is  threaded  with 
the  protruding  wire  and  with- 
drawn (Figs.  370,  371).  The  wires 
are  threaded  into  bars  and  twisted 
(Fig.  372),  the  ends  are  cut  off,  and 
antiseptic  dressings  are  applied. 
There  are  objections  to  Barker's 
operation :  It  does  not  allow  us  to 
remove  blood-clots  from  the  joint; 
if  a  bit  of  tissue  intervenes  between 
the  fragments,  it  cannot  be  re- 
moved; and  a  foreign  body  is  left 
permanently  in  the  joint.^     If  an 


Fig.  372. — ^Wire  in  position  around  fragments  and 
threaded  through  metal  bars.  The  lower  and  posterior 
wire  runs  upward  to  the  left  of  the  upper,  ready  for 

twisting  (Barker). 


operation  is  thought  advisable,  we  deem  it  best  to  do  an  open  operation,  mak- 
ing a  semilunar  or  a  central  longitudinal  incision,  freeing  the  joint  from  blood- 
1  "Brit.  Med.  Jotir.,"  April  11,  1896. 


Treatment  of  Transverse  Fractures  of  the  Patella 


607 


dots  by  irrigation  with  hot  salt  solution,  removing  all  tissue  from  between  the 
fragments,  drilling  the  fragments,  passing  silver  wire,  t-oisting  the  wire  and 
dra'\^'ing  the  fragments  together,  and  closing  the  wound  (Fig.  373).  Instead 
of  wire,  silk  may  be  used.  In  cases  in  which  there  is  no  ver\-  strong  tendency 
to  separation  the  fragments  can  be  held  together  by  several  catgut  sutures 
through  the  periosteum  at  the  fractured  edges  or  by  a  strong  catgut  suture 
passed  through  the  ligamentum  patellfe  and  the  quadriceps  tendon  and  carried 
in  front  of  the  fracture  i^Stimson).  The  limb  should  be  placed  on  a  posterior 
splint.  In  seven  or  eight  days  the  superficial  sutures  are  removed  and  a  plas- 
ter-of-Paris  splint  is  applied.     In  a  few  days  the  patient  gets  about  on  crutches. 


Fig.  373. — ^Wlred  fracture  of  the  patella 


St.  Joseph's  Hospital  case:  operated  up>on  and  skiagraphed 
bv  Dr.  Xassau\ 


In  a  month  the  dressing  is  cut  down  the  front  and  worn  only  in  the  daytime, 
and  passive  motion  is  begim.  The  splint  is  discarded  at  the  end  of  the  third- 
month.^  Among  other  operative  procedures  we  may  mention  the  following: 
EncircHng  the  fragments  by  a  silk  suture  (the  circumferential  sutured 
This  suture  may  impair  bone  nutrition  and  retard  union.  Ceci  drills  the 
bones  subcutaneously  and  passes  wire  through  the  drill-holes  in  the  form  of  a 
figmre  of  8.  Passing  subcutaneously  a  ligature  around  and  over  the  frag- 
ments (Butcher).  Incision  and  approximation  of  the  fragments  by  fixation 
hooks  or  metal  pins. 

1  Stimson.  ".Innals  of  Sursen-."  August,  1808. 


6o8  Diseases  and  Injuries  of  the  Bones  and  Joints 

Fractures  of  the  patella  by  direct  force  are  vertical,  stellate,  oblique,  V- 
shaped,  or  transverse;  are  often  incomplete  and  occasionally  compound  or  com- 
minuted (Fig.  374).  Ransohoff  maintains  that  fractures  from  direct  force  are 
more  common  than  from  muscular  action  and  are  usually  transverse  and  asso- 
ciated with  some  comminution  ("Jour.  Amer.  Med.  Assoc,"  Oct.  13,  1906). 

Compound  fracture  of  the  patella  is  very  rarely  seen  in  Philadelphia  hospitals. 
The  records  of  the  Boston  City  Hospital  (an  institution  in  which  multitudes  of 
fractures  are  treated)  show  only  8  compound  fractures  of  this  bone  in  forty- 
two  years  (Scannell,  in  "Boston  Med.  and  Surg.  Jour.,"  Nov.  15,  1906). 

Symptoms  of  Simple  Fracture. — -Fractures  of  the  patella  by  direct  force  are 
followed  by  discoloration,  swelling,  great  difficulty  in  movement,  and  much  pain. 
There  may  or  may  not  be  crepitus.  The  degree  of  separation  of  the  fragments 
depends  upon  the  direction  of  the  line  of  fracture  and  the  extent  of  bone  in- 
volved. Bony  union  is  apt  to  occur  after  such  a  fracture  when  there  was  not 
wide  separation. 

Treatment.— h  fracture  resulting  from  direct  force  may  often  be  treated 
by  a  posterior  splint  and  the  application  of  a  bandage.     If  there  is  any  separa- 


Fig-  374- — Comminuted  fracture  of  patella. 

tion,  the  fragments  should  be  approximated  by  adhesive  strips,  bandages,  and 
compresses.  At  the  end  of  three  weeks  remove  the  posterior  splint,  apply  a 
plaster-of-Paris  sphnt,  and  get  the  patient  about  on  crutches.  The  danger  in 
these  cases  is  ankylosis  rather  than  non-union;  hence,  in  the  fourth  week  cut 
the  plaster  sphnt  down  the  front  and  begin  passive  motion  of  the  knee-joint. 
At  the  end  of  six  weeks  cease  wearing  the  dressing  in  the  daytime,  and  at  the 
end  of  three  months  discard  it  entirely.  In  those  cases  in  which  an  oblique 
fracture  or  a  transverse  fracture  with  wide  separation  arises  from  direct  force, 
treat  as  advised  for  transverse  fracture  from  muscular  action.  The  question  of 
operation  is  practically  the  same  as  for  transverse  fracture  from  muscular  action. 
In  every  compound  fracture  of  the  patella,  if  amputation  can  be  avoided, 
incise  the  soft  parts  freely  and  irrigate  the  joint  with  hot  sahne  fluid.  Remove 
hopelessly  loosened  fragments.  Those  not  completely  separated  may  in  some 
cases  be  sutured  into  place.     Drain  for  twenty-four  or  forty-eight  hours. 

Ununited  and  Badly  United  Fracture  of  the  Patella. — There  is  usually 
a  band  of  union,  but  it  may  be  very  thin  and  the  fragments  may  be  far  asun- 
der.    It  is  commonly  taught  that  the  degree  of  functional  impairment  depends 


Separation  of  the  Tubercle  of  the  Tibia  609 

directly  on  the  amount  of  separation.  This  is  not  strictly  true.  There  mav 
be  great  separation  and  but  little  impairment  of  function,  the  fragments  being 
firmly  united  by  a  dense  fibrous  band.  There  may  be  little  separation  and 
yet  lameness,  stiffness  of  the  joint,  and  imperfect  power  of  extension.  The 
reason  for  this  has  been  pointed  out  by  Bruns,  of  Tiibingen.^  He  says  there 
may  be  complete  failure  of  union,  even  when  the  separation  is  tri\dal,  and 
failure  of  union  produces  impaired  function.  If  separation  is  considerable,  the 
fragments  are  apt  to  tilt  and  tissue  is  often  interposed  between  them.  Func- 
tional difficulty  is  more  often  met  with  when  the  fragments  are  far  apart  than 
when  they  are  near  together,  because  non-union  is  more  common.  Even  if 
non-union  occurs,  in  some  cases  the  quadriceps  is  still  able  to  act  upon  the  tibia 
by  means  of  the  fascia  lata,  ligaments  at  the  sides  of  the  joint,  or  bands  from 
the  vasti  to  the  lower  fragment.  Besides  non-vmion,  functional  impairment 
may  be  due  to  anchoring  of  the  upper  fragment  to  the  femur.  The  upper 
fragment  may  be  anchored  to  the  femur  by  the  interposition  of  the  fibrous 
investment  of  the  knee-cap,  which  covers  the  fractured  surface  of  the  upper 
fragment  and  may  grow  fast  to  the  capsule  of  the  joint  (Bruns). 

The  treatment  of  ununited  and  badly  united  fracti.u"e  is  discussed  on  page 

534- 

Fractures  of  the  Leg. — In  leg-fractures  both  bones  or  only  one  bone  may 
be  broken. 

Fractures  of  the  tibia  are  di\dded  into:  (i)  fractures  of  the  upper  end;  (2) 
separation  of  the  upper  epiphysis;  (3)  fractures  of  the  shaft;  (4)  fractures  of 
the  lower  end,  and  (5)  separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon.  They  may  be 
transverse,  oblique,  or  vertical,  running  into  the  joint.  The  cause  is  direct 
\'iolence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there  is  contusion  of 
the  soft  parts.  In  a  transverse  fracture  there  are  mobility  and  crepitus,  but 
there  is  Httle  displacement.  In  oblique  fracture  crepitus  and  mobility  are 
marked,  the  axis  of  the  limb  is  altered,  and  the  fragments  may  be  displaced. 
In  fractinres  entering  the  joint  there  is  great  swelling  of  the  knee-joint.  Com- 
minuted fractures  exhibit  marked  signs,  union  is  readily  obtained,  but  if  the 
joint  has  been  damaged,  stiffness  is  sure  to  ensue. 

Treatment. — Reduce  displacement  by  extension  and  manipulation.  The 
special  apparatus  used  for  treatment  depends  on  the  case.  In  some  cases 
extension  is  required,  in  some  a  posterior  splint  is  appHed  and  the  limb  is  sus- 
pended from  a  gallows,  in  some  a  double  inclined  plane  is  employed,  and  in 
some  a  plaster-of-Paris  splint  is  used. 

The  double  inclined  plane  in  the  form  of  Mclntyre's  splint  is  frequently 
employed,  or  a  double  inclined  plane  in  the  form  of  a  fracture-box  may  be 
preferred.  The  extremity  should  be  immobilized  for  four  weeks,  when  passive 
motion  should  be  begun.  Passive  motion  is  to  be  made  daily,  the  dressing 
being  reapplied  after  each  seance.  In  five  or  six  weeks  the  dressings  are  re- 
moved and  the  patient  allowed  to  go  about  on  crutches.  The  crutches  are 
soon  abandoned  for  a  cane,  and  later  all  support  is  dispensed  with.  If  a 
fracture  extends  into  the  knee-joint  and  the  ill-adjusted  fragments  block  the 
articulation,  the  joint  should  be  opened  and  the  fragments  placed  and  fixed 
in  proper  position. 

Separation  of  the  tubercle  of  the  tibia  is  due  to  \dolent  contraction  of  the 
quadriceps,  and  occurs  only  in  those  under  twenty  years  of  age.  The  frag- 
ment is  drawn  up  and  can  be  felt,  and  the  patient  is  unable  to  use  the  limb. 
In  a  case  in  which  the  tibial  spine  has  been  torn  off,  it  may  be  nailed  in  place, 

1  "Beitrage  zur  klinischen  Chinirgie,"  "Mittheilungen  aus  der  chinirg.  Klinik  zu  Tiibin- 
gen,''  Bd.  iii,  Heft  2,  188S. 

39 


6io  Diseases  and  Injuries  of  the  Bones  and  Joints 

or  the  limb  should  be  placed  on  a  posterior  straight  splint  and  the  fragment 
should  be  pulled  down  into  place  by  adhesive  strips  and  bandages.  The  splint 
should  be  worn  for  five  weeks. 

Avulsion  of  the  Spine  of  the  Tibia. — This  is  a  very  rare  accident.  There 
are  but  4  cases  on  record,  and  in  only  i  of  them  (Pringle's)  was  the  diagnosis 
made  during  life,  and  it  was  made  in  that  case  by  exploratory  incision.  The 
tibial  spine  is  torn  ofT  by  the  anterior  crucial  ligament.  The  causative  force 
is  probably  flexion,  abduction,  and  internal  rotation  of  the  leg  (J.  Hogarth 
Pringle,  "Annals  of  Surg.,"  August,  1907).  After  the  acccident  the  leg  at  the 
knee  is  in  extreme  abduction.  Exploratory  incision  may  be  necessary  for 
diagnosis.     The  treatment  is  to  suture  or  nail  the  bone-fragment  in  place. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This  is  an  injury  of  ex- 
treme rarity.  It  does  not  seem  to  occur  after  the  sixteenth  year.  It  is  caused 
by  a  twist  or  by  violent  abduction  or  adduction  of  the  leg.  It  may  lead  to 
lessened  growth  of  the  Hmb.  The  treatment  is  as  for  a  fracture  of  the  upper 
end  of  the  bone. 

Fractures  of  the  Shaft  of  the  Tibia. — The  causes  of  these  fractures  are 
direct  force,  indirect  force,  or  torsion.  A  fracture  in  the  upper  part  of  the 
bone  is  usually  transverse;  in  the  lower  part  it  is  usually  oblique  (T.  Picker- 
ing Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia  there  is  no  deform- 
ity, and  the  support  of  the  fibiila  may  even  permit  of  walking;  there  is  fixed 
pain;  there  may  or  may  not  be  inequality  of  the  fragments  felt  by  the  finger; 
and  there  are  pain,  tenderness,  crepitus,  mobiHty,  and  often  linear  ecchymosis. 
In  oblique  fractures  there  usually  exist  crepitus,  a  little  mobility,  and  distinct 
deformity.  The  deformity  depends  on  the  direction  of  the  line  of  fracture,  and, 
as  this  line  is  usually  from  above  downward,  inward,  and  a  little  forward,  the 
lower  fragment  usually  passes  behind  the  upper  fragment  and  rotates  inward. 

Treatment. — In  treating  fractures  of  the  shaft  of  the  tibia  effect  reduc- 
tion by  making  extension  from  the  foot  and  counterextension  from  the  knee, 
the  knee-joint  being  in  partial  flexion.  If  there  is  much  swelling,  put  the 
limb  in  a  fracture-box  (Figs.  375,  376,  and  PI.  7,  Fig.  i),  swing  the  box  from  a 
gaUows,  and  apply  an  ice-bag  for  twenty-four  hours.  A  silicate  of  sodium  or  a 
plaster-of-Paris  dressing  is  applied  when  the  swelling  subsides,  or  the  dressing 
may  be  used  at  once  instead  of  a  fractiire-box  if  swelling  is  slight.  As  soon  as 
the  limb  is  immobilized  in  a  silicate  or  plaster  dressing  the  patient  gets  about 
on  crutches.  The  dressing  is  removed  after  five  weeks,  and  the  patient  goes 
about  for  one  week  on  crutches,  lightly  using  the  foot,  and  then  for  a  time  walks 
with  the  aid  of  a  cane.  At  the  end  of  eight  or  nine  weeks  the  cane  may  often 
be  dispensed  with,  the  amount  of  use  of  the  leg  being  daily  augmented. 

Fractures  of  the  Lower  End  of  the  Tibia :  Fracture  of  the  Inner  Malleolus. — 
The  cause  of  fracture  of  the  inner  malleolus  is  direct  force  or  traction  upon  the 
internal  lateral  ligament. 

Symptoms  and  Treatment. — The  symptoms  of  fracture  of  the  inner  malleolus 
are  pain,  tenderness,  some  downward  displacement,  depression  above  the  ends  of 
the  fragments,  mobility,  and  crepitus.  The  treatment  is  to  push  the  fragments 
into  place  and  use  side-splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of- 
Paris  or  a  silicate  dressing  may  be  substituted  and  the  patient  ordered  to  use 
crutches.  Remove  the  plaster  four  or  five  weeks  after  it  is  applied,  and  direct 
the  patient  to  gradually  bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  rare  accident,  but  is 
commoner  than  separation  of  the  upper  epiphysis.  The  treatment  is  a  fixed 
dressing  for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is  fracture  of  the 
tibia  alone.     Fractures  in  the  upper  two-thirds,  which  are  rare,  are  usually 


Fractures  of  the  Lower  Third  of  the   Fibula 


6ii 


due  to  direct  force.  Fractures  in  the  lower  third  are  frequent,  and  arise  from 
indirect  force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In  these  fractures 
the  cause  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the  fibula  the  patient 
is  frequently  able  to  walk.  The  bone  is  deeply  situated,  and  displacement 
cannot  often  be  detected.  There  is  a  fixed  pain,  which  is  intensified  by  move- 
ment and  by  pressure.  Pressure  upon  the  lower  fragment  does  not  move 
the  upper  fragment.     Crepitus  is  sometimes  obtained,  and  linear  ecchymosis  is 


375,  376. — Fracture-box  in  fractures  of  the  bones  of  the  leg 


apt  to  appear.  The  bone  is  normally  elastic,  hence  slight  mobility  is  of  no 
value  diagnostically. 

Treatment. — In  treating  a  fracture  of  the  upper  two-thirds  of  the  fibula  apply 
a  plaster-of-Paris  or  a  silicate  bandage  and  direct  that  it  be  worn  for  five  weeks. 
Weight  is  not  to  be  put  upon  the  foot  for  sLx  weeks  after  the  accident. 

Fractures  of  the  Lower  Third  of  the  Fibula. — In  these  fractures  the  cause  is 
usually  indirect  force,  especially  twists  of  the  foot.  Forcible  inversion  of  the  foot 
puUs  upon  the  external  lateral  ligament  and  the  external  malleolus,  forces  the 
fibula  outward,  and  tends  to  break  it,  the  lower  fragment  being  displaced  out- 
ward. Forcible  eversion  pulls  the  internal  lateral  ligament  off  from  the  inner 
malleolus  (often  breaks  the  malleolus)  and  fractures  the  fibula  above  the  ankle, 
the  bone  being  displaced  inward. 


6l2 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Pott's  Fracture. — By  the  term  "Pott's  fracture"  is  meant  a  fracture  of  the 
lower  fifth  of  the  fibula  produced  by  eversion  and  abduction  of  the  foot.  Stim- 
son  points  out  that  the  production  of  Pott's  fracture  is  often  aided  by  the  weight 
of  the  body.  The  lesions  which  arise  depend  upon  whether  the  chief  force  is 
eversion  or  abduction.  "If  eversion  is  the  sole,  or  main,  movement,  the  force 
is  exerted  through  the  internal  lateral  ligament  and  breaks  the  internal  malleolus 
squarely  off  at  its  base;  then  it  presses  the  external  malleolus  outward,  rupturing 
the  tibiofibular  ligament,  and  breaks  the  fibula  close  above  the  malleolus. 
Sometimes  instead  of  pure  rupture  of  the  tibiofibular  ligament  there  is  avulsion 
of  the  portion  of  the  tibia  to  which  it  is  attached."^     Stimson  further  points  out 

that  if  abduction  is  the  preponderating 
force  there  is  an  oblique  fracture  of  the 
anterior  portion  of  the  internal  malleolus 
or  more  frequently  rupture  of  the  anterior 
portion  of  the  internal  lateral  ligament. 
There  are,  as  in  the  former  case,  rupture 
of  the  tibiofibular  ligament  and  an  oblique 
fracture  of  the  fibula  several  inches  above 
the  external  malleolus.  It  is  evident  that 
the  degree  of  injury  produced  by  eversion 
and  abduction  depends  on  the  point  at 
which  the  force  is  arrested.  It  may  be  ar- 
rested after  the  inner  malleolus  has  been 


Fig.  377. — Pott's  fracture.  Dupuytren's  splint. 
Note  length  of  splint;  position  of  straps;  arrange- 
ment of  padding;  space  between  foot  and  splint 
(Scudder). 


Fig.  378. — Pott's  fracture. 


separated  or  the  anterior  fibers  of  the  deltoid  ligament  torn,  and  in  this  case  the 
tibiofibular  articulation  remains  intact  and  the  fibula  is  not  broken.  It  may 
cease  after  separating  the  tibiofibular  articulation,  and  in  this  case  too  the  fibula 
escapes.  It  may  be  continued  until  the  fibula  breaks.  In  this  fracture  the 
astragalus  passes  outward,  somewhat  backward  and  also  upward,  the  later 
deviation  being  due  to  separation  of  the  tibiofibular  articulation.  The  chief 
trouble  in  reduction  and  treatment  is  this  outward  and  backward  dislocation  of 
the  foot. 

Symptoms. — The  foot  is  displaced  outward,  and  a  little  backward  and 
upward,  and  the  inner  malleolus  or  the  tibia  from  which  it  was  torn  is  ex- 
^  "A  Practical  Treatise  on  Fractures  and  Dislocations,"  by  Lewis  A.  Stimson. 


Pott's  Fracture  613 

tremely  prominent.  There  is  great  lateral  mobility  and  often  anteroposterior 
mobility  at  the  ankle-joint.  Stimson  points  out  that  there  are  three  points 
where  pressure  is  certain  to  provoke  pain:  in  front  of  the  tibiofibular  ligament, 
at  the  base  or  anterior  border  of  the  inner  malleolus,  and  over  the  seat  of 
fracture  through  the  fibula. 

Treatment. — Thorough  reduction  is  of  the  greatest  importance.  If  thor- 
ough reduction  is  effected,  a  good  result  will  probably  be  obtained;  but  if 
thorough  reduction  is  not  effected,  the  patient  will  be  permanently  crippled 
to  a  greater  or  less  extent.  In  order  to  effect  reduction  it  may  be  necessary 
to  anesthetize  the  patient.  The  patient's  knee  is  flexed,  the  heel  is  pulled 
strongly  for^vard  and  inward,  and  the  lower  end  of  the  tibia  is  pushed  backward. 
This  corrects  the  ankle  dislocation,  and  then  the  valgus  must  be  overcorrected 
(Jones).     Inversion  of  the  ankle  is  imperative. 

Some  surgeons  at  once  after  reduction  apply  a  plaster-of-Paris  bandage. 
This  treatment  is  objectionable  because  the  deformity  may  be  partially  re- 
produced after  the  application  of  the  dressing,  the  surgeon  being  unable  to  see 
it  and  unable  to  correct  it. 

If  there  seems  to  be  no  strong  tendency  to  a  recurrence  of  deformity,  a  frac- 
ture-box can  be  used.  After  reducing  displacement  in  such  a  case,  place  the 
limb  m  a  fracture-box  containing  a  soft  pillow.  A  bird's-nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (see  Figs.  375, 376).  A  fillet  arotmd  the  ankle  fastens 
the  foot  to  the  foot-piece  of  the  box;  a  pad  of  oakum  rests  between  the  foot-piece 
and  the  sole.  A  compress  is  placed  below  the  outer  malleolus  and  another  one 
above  the  inner  malleolus.  Close  the  sides  of  the  box  and  tie  them  together 
vnth.  a  bandage,  and  swdng  the  box  on  a  gallows.  Every  day  let  dow^n  the  sides 
of  the  box  and  rub  the  leg,  the  ankle,  and  the  foot  with  alcohol.  In  ten  days 
apply  a  plaster-of-Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  plaster  at  the  end  of  the  fifth  week  after  the  accident,  and  let  patient 
go  about  with  crutches  for  one  week  and  wath  a  cane  for  a  week  longer. 

I  am  accustomed  to  dress  most  cases  of  Pott's  fracture  with  a  Dupicytren 
splint.  This  is  a  straight  splint  (Fig.  377  and  PI.  7,  Fig.  9)  which  reaches  from 
above  the  head  of  the  tibia  to  below  the  sole  of  the  foot.  This  splint  is  padded, 
and  a  pyramidal  pad  wnth  the  base  down  is  laid  upon  the  inner  surface  of 
the  leg,  above  the  inner  malleolus,  the  splint  being  put  upon  the  inner  sur- 
face of  the  leg,  over  the  pad.  The  splint  is  fastened  as  shown  in  Plate  7, 
Fig.  0,  and  Fig.  377.  If  the  short  splint  shown  in  Plate  7  is  used  (it  only 
goes  to  the  head  of  the  tibia),  the  leg  is  semiflexed  upon  the  thigh  and  is 
laid  upon  the  outer  surface  on  a  pillow.  After  ten  days  of  Dupuytren's 
splint,  apply  the  plaster-of-Paris  bandage,  which  is  to  be  worn  as  above 
directed.  Bryant  treats  Pott's  fracture  with  a  posterior  splint,  two  lateral 
splints,  and  a  swing.  Stimson  uses  a  posterior  and  lateral  splint  of  plaster 
of  Paris.  This  splint  does  not  slip,  as  may  Dupuytren's  dressing,  and 
does  not  hide  the  seat  of  fracture  from  view,  as  does  complete  encasement 
with  plaster  of  Paris.  It  is  a  most  useful  dressing.  When  the  patient  begins  to 
walk  the  callus  may  bend.  If  it  does,  eversion  will  be  produced.  In  order  to 
prevent  this  make  the  patient  walk  for  a  number  of  weeks  upon  a  shoe  heel 
raised  on  the  inside  in  order  to  induce  the  position  of  varus.  A  very  hea\y  man 
shoiild  also  wear  for  several  weeks  an  iron  brace  on  the  outside.  I  have  given 
above  the  conservative  treatment  of  Pott's  fracture.  I  have  come  to  the  con- 
clusion that  operation  shoiild  be  the  rule  in  this  injury  and  not  the  exception. 
The  fracture  is  so  often  followed  by  pain,  swelling,  and  disability.  Pain  and  dis- 
ability are  so  largely  due  to  malunion  or  fibrous  union  of  the  broken  malleolus, 
and  it  is  so  easy  to  fix  the  fragment  in  place  by  nails  or  sutures,  that  the  con- 
clusion seems  obvious  that  in  proper  subjects  operation  should  be  performed. 
As  Heath  and  Selby  show,  in  an  important  article  ("Annals  of  Surg.,"  Jan., 


6i4 


Diseases  and  Injuries  of  the  Bones  and  Joints 


1908),  operation  also  allows  us  to  return  the  tibialis  posticus  to  its  normal  posi- 
tion and  thus  flat-foot  is  prevented.  The  plan  suggested  by  Heath  and  Selby 
("Annals  of  Surgery,"  Jan.,  1908)  is  excellent.  The  fragment  may  be  sutured 
in  place  by  silver  wire  or  chromic  gut.  If  the  tendon  of  the  posterior  tibial  is 
displaced,  the  torn  annular  ligament  is  sutured  so  as  to  hold  the  tendon  in  place, 
a  drain  of  rubber  tissue  is  carried  down  to  the  bone,  and  the  soft  parts  are 
sutured.  The  parts  are  dressed  and  a  fixation  apparatus  is  applied.  The  drain 
is  removed  in  twenty-four  hours.  In  eight  weeks  the  patient  should  be  walking 
freely  (see  cases  reported  by  Heath  and  Selby,  Ibid.).  Pott's  fracture  may  be 
compound,  a  portion  of  the  inner  malleolus  or  of  the  tibia  projecting  through 

the  wound.  If  it  is  necessary  to  intro- 
duce through-and-through  drainage,  the 
foot  must  be  placed  and  kept  at  a  right 
angle  to  the  leg.  If  a  compound  frac- 
ture exists,  the  malleolus  must  be  nailed 
in  place  or  sutured  by  silver  wire  or 
chromic  gut.  In  a  reported  case  the 
wire  was  passed  through  the  joint  and 
around  the  fragment,  and  the  result  was 
good.^     Nailing  seems  a  better  plan. 

Fracture  of  both  bones  of  the  leg  is 
a  very  common  injury,  is  often  com- 
pound, and  is  not  unusually  comminuted. 
Fractures  by  direct  force,  such  as  blows 
or  kicks,  are  commonest  in  the  upper 
half  of  the  leg.  Fractures  by  indirect 
force,  as  by  falls,  are  commonest  in 
the  lower  half  of  the  leg.  In  fractures 
from  indirect  force  the  tibia  breaks 
first,  and  then  the  fibula  breaks  at  a 
higher  level.  The  point  of  greatest 
liability  to  fracture  from  indirect  force 
is  the  junction  of  the  lower  and  middle 
thirds.  Fractures  of  the  leg  are  usually 
oblique,  but  they  may  be  transverse  if 
arising  from  direct  force.  Spiral,  tor- 
sion, or  V-shaped  fractures  and  longi- 
tudinal breaks  sometimes  occur.  In 
oblique  fractures,  as  a  rule,  the  line  of 
fracture  runs  from  behind,  downward, 
inward,  and  a  little  forward. 
Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of  recognition. 
The  fibular  fracture  is  detected  as  before  described.  By  running  the  finger 
along  the  crest  of  the  tibia  displacement  will  be  found,  except  in  transverse 
fractures,  when  it  may  not  occur.  The  common  displacement  is  for  the 
lower  fragment  to  ascend  and  pass  behind  the  lower  end  of  the  upper  frag- 
ment and  to  rotate  a  little  outward,  and  for  the  upper  fragment  to  project 
in  front.  The  ascent  of  the  lower  fragment  is  due  to  the  action  of  the  gas- 
trocnemius and  soleus  muscles.  If  the  line  of  fracture  is  in  a  direction  the 
reverse  of  that  which  is  usual,  the  lower  fragment  ascends  in  front  of  the 
lower  end  of  the  upper  fragment.  In  fracture  of  both  bones  of  the  leg  there 
are  marked  mobihty  and  crepitus,  severe  pain,  and  inability  to  walk.  In 
fractures  from  direct  force  there  is  more  or  less  damage  to  the  soft  parts. 
A  fracture  of  the  shaft  of  the  tibia  near  the  ankle  is  distinguished  from  a 
1  "Rev.  de  Chir.,"  vol.  viii,  1888. 


Fig.  379- 


-Fracture  of  both  bones  of  leg. 
Bad  position. 


Fractures  of  the  Bones  of  the  Foot  615 

dislocation  by  the  fact  that  the  deformity  is  easily  reduced,  but  tends  to 
recur  in  the  fracture,  and,  further,  that  in  a  fracture  the  relations  of  the  mal- 
leoli to  the  tarsus  are  unaltered,  whereas  in  a  dislocation  they  are  altered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the  action  of  the  tendo 
Achillis  may  maintain  deformity,  and  in  such  cases  the  tendon  should  be  di- 
vided. All  fractures  of  the  lower  third  are  difficult  to  reduce  and  often  require 
extension  by  the  pulley.  In  very  few  will  perfect  apposition  of  the  fragments 
be  brought  about,  and  the  best  we  can  usually  attain  is  good  alignment  (Jones). 
In  treating  a  simple  fracture  of  the  lower  two-thirds  of  the  bones  reduce  by 
extension  and  coimterextension,  and  use  a  fracture-box  (see  Figs.  375,  376). 
The  compresses  used  in  Pott's  fracture  are  not  required.  If  the  soft  parts 
are  bruised,  use  evaporating  lotions  for  a  day;  if  they  are  abraded,  apply  anti- 
septic dressings.  The  fracture-box  should  be  swung  upon  a  gallows.  After 
three  weeks  apply  a  plaster-or-Paris  or  silicate  of  sodium  dressing  and  let  the 
patient  sit  up  in  a  chair  daily  during  one  week;  at  the  end  of  this  time  the  patient 
may  get  about  on  crutches.  i\.t  the  end  of  six  weeks  after  the  accident  remove 
the  plaster,  and  let  the  sufferer  go  about  on  crutches  for  two  weeks  and  with  a 
cane  for  two  weeks  more.  Brinton  was  accustomed  to  dress  a  fracture  of  both 
bones  of  the  leg  for  two  weeks  in  a  fracture-box,  for  two  weeks  in  side-splints 
made  of  metal,  and  for  two  weeks  in  an  immovable  dressing,  allowing  the  pa- 
tient to  get  about  on  crutches  as  soon  as  the  plaster  is  put  on.  Instead  of  the 
fracture-box  we  may  use  a  posterior  splint,  two  lateral  splints,  and  a  swing. 
The  Thomas  bed-splint  is  a  ver}'  useful  dressing.  Nathan  R.  Smith's  anterior 
splint  is  used  by  some  in  the  treatment  of  fractures  of  the  leg.  Some  surgeons 
apply  plaster  of  Paris  in  the  form  of  an  ambiilatory  dressing.  In  this  dressing 
a  solid  apparatus  reaches  to  the  lower  third  of  the  thigh  and  below  the  sole 
of  the  foot.  When  the  patient  walks  the  weight  is  transmitted  to  the  thigh 
(see  Figs.  274  and  275).  In  fractures  of  the  upper  third  of  the  leg  the  Mcln- 
tyre  splint  or  the  double  inclined  plane  is  used.  If  the  fracture  is  compound, 
asepticize  thoroughly,  make  a  counteropening,  insert  a  drainage-tube,  dress 
with  bichlorid  gauze,  apply  a  plaster  bandage,  and  cut  trap-doors  over  the 
openings  of  the  tube  (see  Fig.  279),  or  dress  with  the  bracketed  sphnt  and 
plaster  of  Paris  (see  Fig.  280).  Remove  the  tube,  as  a  rule,  in  about  forty- 
eight  hours;  but  the  patient's  temperature  is  the  guide,  not  time  of  retention. 

In  many  fractures  of  the  lower  third  operation  is  indicated  to  accomplish 
reduction  and  fixation. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  accidents,  although 
not  so  unusual  as  we  once  thought,  for  the  .T-ray  has  taught  us  that  a  con- 
siderable number  of  supposed  sprains  are,  in  reality,  fractures.  Owing  to  the 
number  of  the  bones  and  to  the  elasticity  of  their  connections  the  force  of 
blows  and  falls  is  spread  and  dissipated.  The  bones  most  often  broken  are 
the  astragalus  and  the  os  calcis.  Fractures  from  direct  force  are  often  com- 
pound. The  cause  of  fracture  of  either  the  scaphoid,  the  cuboid,  or  one  of  the 
cuneiform  bones  is  direct  force.  Simple  fractures  of  the  os  calcis  and  astragalus 
may  arise  from  crushes  or  twists  of  the  foot,  but  result,  as  a  rule,  from  indirect 
force,  such  as  falls.  The  calcaneum  may  be  broken  by  a  direct  blow.  In  rare 
instances  the  os  calcis  has  been  broken  by  contraction  of  the  great  calf-muscles. 
Forcible  dorsal  flexion  of  the  foot  may  fracture  the  neck  of  the  astragalus 
(Eisendrath).  Compound  fractures  may  result  from  gunshot- wounds,  crushes, 
and  falls. 

Symptoms. — The  history  of  the  nature  of  the  accident  is  of  great  impor- 
tance. In  fracture  of  the  os  calcis  there  are  severe  pain,  tenderness,  swelling, 
crepitus,  mobility,  often  an  apparent  widening  of  the  bone,  and  not  unusually  a 
loss  of  the  arch  of  the  foot  (Pick) .  In  some  cases  the  posterior  fragment  is  drawn 
up  by  the  calf-muscles,  and  in  other  cases  there  is  no  deformity.     In  fracture 


6i6  Diseases  and  Injuries  of  the  Bones  and  Joints 

of  the  astragalus  displacement  may  occur  which  resembles  that  of  a  disloca- 
tion. Crepitus  may  or  may  not  be  detected.  It  can  be  elicited,  as  a  rule,  by 
rotating  the  foot  while  the  heel  is  firmly  held.  If  crepitus  cannot  be  detected 
we  are  not  certain  that  a  fracture  is  present,  even  though  the  patient  may  be 
unable  to  stand  and  there  are  swelling  and  pain  on  pressure.  The  malleoli 
may  seem  on  a  lower  level  than  normal  if  the  astragalus  and  os  calcis  have  been 
crushed.  Sometimes  the  foot  is  shortened  and  perhaps  the  fragments  have 
been  dislocated  (Eisendrath,  in  "Annals  of  Surg.,"  March,  1905).  The  a;-rays 
will  make  the  diagnosis  certain.  Fractures  of  the  other  bones  of  the  tarsus 
are  difScult  of  detection  except  by  the  x-rays.  There  may  or  may  not  be 
crepitus,  which,  if  it  exists,  is  difi&cult  to  localize;  there  is  pain  on  standing 
and  on  pressure,  and  there  is  bruising  of  the  soft  parts. 

Treatment. — In  simple  fracture  of  the  os  calcis  and  astragalus  without 
displacement  place  the  foot  at  a  right  angle  to  the  leg  and  apply  a  plaster 
cast.  This  is  cut  down  the  front  so  that  it  may  be  removed  easily.  On  the 
third  or  fourth  day  follow  Eisendrath's  advice  and  begin  massage  to  reduce 
swelling  and  prevent  muscular  atrophy  (Ibid.).  The  cast  is  worn  for  eight 
weeks,  when  the  patient  may  begin  to  put  weight  upon  the  extremity. 
If  a  fiat-foot  has  resulted  from  the  accident,  a  support  must  be  worn 
(see  page  742).  If  there  is  displacement  in  a  simple  fracture  of  the  os 
calcis  or  astragalus  it  is  wisest  to  operate.  Perfect  correction  is  not 
possible  otherwise  and  no  apparatus  is  satisfactory.  The  fragments  are 
restored  after  incision  and  may  be  nailed  or  wired  in  place.  A  fragment 
may  require  removal  or  the  badly  splintered  bone  itself  may  have  to  come 
away.  If  the  tendo  Achillis  is  torn  loose,  it  should  be  sutured  to  the  os  calcis. 
Fractures  of  the  other  bones  of  the  tarsus  are  almost  always  compound,  and 
the  injury  may  require  drainage  and  immovable  dressing,  excision  of  bones, 
p-,,.  g-.  -    or  even  amputation.     If  they  are  not  compound, 

''  they  may  be  treated  by  a  plaster-of-Paris  dressing 

'  or  may  require  incision  and  fixation  or  removal. 

Fractures  of   the  metatarsal   bones  are  almost 
invariably  due  to  direct  force  and   are  almost  al- 
jfKi^  ways  compound.     Robert  Jones  has  published  skia- 

"""^  graphs  of  a  fracture  of  the  fifth  metacarpal  bone 

from  indirect  force.  Crepitus  may  be  absent  be- 
cause of  impaction  or  fixation  by  interosseous  liga- 
ments. Jones  says  such  a  fracture  may  be  pro- 
duced by  the  pressure  of  the  body  weight  on  an 
inverted  foot  the  heel  of  which  is  raised  ("Annals 
of  Surgery,"  June,  1902).  When  only  one  bone  is 
broken,  displacement  is  slight,  there  is  severe  pain 

on  motion  and  pressure,  and  crepitus  can  generally 

FigTaSo.-Fracture  of  meta-     ^e  obtained.     Pain  is  produced  by  flexing  the  toes, 
tarsal  bones.  puttmg  weight  upon   the  toes,  as  in  walkmg,  and 

by  inverting  or  everting  the  foot.  Fracture  of  the 
third  metatarsal  is  apt  to  destroy  the  arch  of  the  foot.  A  simple  fracture  of 
a  metatarsal  bone  is  treated  by  an  immovable  dressing  for  four  weeks. 
Fractures  from  crushes  usually  demand  excision  or  amputation. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct  force  and  are 
often  compound.    They  may  require  immediate  amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is  unnecessary, 
drain  with  strands  of  catgut  for  forty-eight  hours  and  dress  antiseptically, 
at  the  end  of  this  time  apply  over  the  bichlorid  gauze  a  gutta-percha  or  a 
pasteboard  splint  extending  from  beyond  the  end  of  the  toe  to  well  up  upon 
the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a  spiral  bandage  of  the 


Acute  Simple   Synovitis  617 

toe  and  instep.  The  splint  is  to  be  worn  for  four  weeks.  In  a  simple  fracture 
fasten  the  injured  toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  and 
wear  the  dressing  for  three  weeks. 

Diseases  of  the  Joints 

Synovitis  is  a  primary  inflammation  of  the  synovial  membrane  alone. 
If  other  structures  besides  the  synovial  membrane  are  involved  the  con- 
dition is  kno^^^l  as  "arthritis."  Two  forms  of  simple  synovitis  exist — namely, 
acute  and  chronic.    Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple  syno\-itis  are  con- 
tusions, sprains,  t^-ists,  and  overuse.  The  causative  influence  of  exposure 
to  cold  or  damp  has  been  much  debated.  It  seems  probable  that  in  some 
cases  cold  produces  vasomotor  paresis  of  the  vessels  of  the  syno\ial  mem- 
brane, a  condition  which  may  be  foUowed  by  inflammation.  In  s}-no\-itis 
the  syno\dal  membrane  is  red  and  swollen,  and  the  joint  contains  an  excess 
of  turbid  fibrinous  fluid.  If  the  inflammation  advances,  arthritis  arises  and 
sometimes  blood  is  efl"used. 

Symptoms. — A  prominent  s\-mptom  of  acute  syno\-itis  is  pain,  which  is 
increased  by  motion  of  the  joint,  by  pressure  upon  the  articulation,  and  by  a 
dependent  position  of  the  limb.  The  pain  is  worse  at  night.  Pressure  upon  the 
edge  of  the  cartilage  does  not  cause  pain,  but  friction  of  the  syno\-ial  membrane 
at  once  develops  it.  The  patient  places  the  limb  in  the  position  which  gives 
the  greatest  ease,  and  the  part  becomes  more  or  less  fixed  in  this  position 
because  the  muscles  about  the  joint  are  rigid.  A  fluctuating  swelling  is  noted 
in  a  superficial  joint,  most  marked  between  the  Hgaments,  which  swelling  bulges 
out  the  syno\-ial  area  and  hides  or  obscures  the  articular  heads  of  the  bones. 
The  sweUing  is  due  early  to  excessive  secretion  of  syno\-ia,  and  later  to  effusion 
of  Hquor  sanguinis.  Bulging  takes  place  at  points  where  the  capsule  is  thin,  and 
at  such  points  fluctuation  may  be  detected.  Fluctuation  in  the  elbow  is  sought 
for  posteriorly.  Fluctuation  in  the  knee  is  sought  for  on  either  side  in  front.  A 
large  eft'usion  in  the  knee  floats  the  patella  up  from  the  condyles  {floating  patella). 
A  small  effusion  in  the  knee  can  be  detected  by  Fiske's  plan,  which  is  as  follows: 
Tell  the  standing  patient  to  bend  forward  at  the  hips,  resting  each  hand  on  the 
front  of  the  corresponding  thigh.  The  anterior  structures  of  the  joint  are  thus 
relaxed,  and,  by  tapping  the  patella,  even  a  small  eft"usion  can  be  discovered. 
Bulging  cannot  be  distinctly  recognized  in  the  hip  or  shoulder  unless  effusion  is 
great.  The  skin  OA'er  the  joint  is  rarely  reddened,  but  feels  hot  to  the  hand  of 
the  observ^er  (over  superficial  joints,  but  not  over  the  shoulder  and  hip) ;  the 
joint  is  partly  flexed;  fever  exists,  var^-ing  in  degree  -^ith  the  size  of  the 
joint,  the  acuteness  of  the  attack,  and  if  infection  occurs  fever  is  a  striking 
feature.  Suppuration  rarely  follows  simple  syno^-itis,  but  it  may  do  so,  the 
area  of  synovitis  being  a  point  of  least  resistance  to  organisms  carried  by 
the  blood  or  h-mph.  If  suppuration  takes  place,  rigors  occur,  there  is  a  septic 
temperature,  and  the  joint  soon  gives  evidences  of  containing  pus.  These  e\\- 
dences  are  violent  pain,  increased  tenderness,  dusky  discoloration  if  the  joint 
be  superficial,  greater  muscular  spasm,  periarticular  edema,  and  constitutional 
S}Tnptoms  of  sepsis.  Traumatic  syno\'itis  "^'ithout  infection  tends  toward  cure 
"without  suppuration  if  the  patient  is  healthy,  and  after  it  ankylosis  is  rare. 

Treatment. — In  treating  acute  syno^'itis  immobilize  the  joint.  In  severe 
cases  place  it  in  such  a  position  that  the  limb  will  stiU  be  useful  even  if  anky- 
losis occurs.  In  mild  cases  immobilize  in  the  position  of  rest,  apply  leeches, 
and  use  the  ice-bag  or  the  Leiter  coil.  After  a  day  or  two  apply  gentle  pressure, 
intermittent  heat,  and  iodin  and  ichthyol.  If  the  effusion  is  ver\'  great  and  per- 
sistent, and  pressure,  heat,  and  sorbefacients  fail  to  remove  it,  aspirate  with 


6i8  Diseases  and  Injuries  of  the  Bones  and  Joints 

aseptic  care.  If  effusion  recurs  after  aspiration,  use  massage  and  the  hot-air 
oven,  or  apply  plaster-of-Paris  dressing  or  use  flying  blisters.  If  there  is  any 
evidence  of  infection,  follow  Murphy's  advice,  that  is,  aspirate  the  joint  and 
inject  a  mixture  of  formalin  in  glycerin  (2  per  cent.).  As  a  rule  this  treatment 
will  rapidly  bring  about  a  cure.  The  mixture  of  formalin  and  glycerin  should 
have  been  made  at  least  twenty-four  hours  before  use.  A  rubber  bandage  is 
often  useful  toward  the  termination  of  a  case  of  acute  synovitis. 

Chronic  synovitis  follows  acute  synovitis  or  it  may  be  chronic  from  the 
start.  Many  cases  called  chronic  synovitis  are,  in  truth,  tuberculous  disease. 
The  synovial  membrane  looks  nearly  natural,  but  is  edematous,  and  the  joint 
contains  an  excess  of  fluid.  If  the  quantity  of  fluid  is  large,  the  disease  is 
called  hydrops  articuli,  or  dropsy.  A  large  amount  of  fluid  in  the  knee-joint 
"floats"  the  patella  upward.  Tuberculous  infection  may  occur  in  very  pro- 
longed cases.  In  prolonged  tuberculous  synovitis  the  synovial  membrane 
may  thicken  in  some  places,  soften  in  others;  it  is  often  adherent,  and  the 
villous  processes  hypertrophy.  If  the  membrane  becomes  extensively  softened 
(pulpy  degeneration) ,  the  softened  areas  bulge  and  caseation  eventually  occurs. 
In  the  knee-joint  a  traimiatic  synovitis  is  sometimes  linked  with  inflammation 
of  the  semilunar  cartilages.  Roux  tells  us  that  this  inflammation  may  be  pro- 
duced by  a  squeeze,  a  twist,  or  a  direct  force,  but  a  squeeze  is  the  common 
cause.  Hyperextension  of  the  knee  may  squeeze  the  cartilage,  and  so  may 
attempting  to  rise  from  a  stooping  posture.^  If  this  injury  has  taken  place,  the 
disability  will  be  prolonged. 

Symptoms. — In  chronic  synovitis  pain  may  be  absent  or  may  be  present 
only  during  exercise  or  from  pressure,  and  be  slight  even  then.  There  may  be 
seizures  of  pain;  there  is  some  limitation  of  movement;  passive  motion  may 
develop  creaking  or  joint-crepitus;  fluctuation  is  apparent  and  there  is  atrophy 
in  the  muscle  about  the  joint.  The  atrophy  of  the  muscles  associated  with  an 
inflamed  joint  is  a  reflex  atrophy  and  is  named  after  Charcot.  The  aspirating 
needle  will  give  exit  to  a  viscid  straw-colored  or  bloody  fluid  unless  the  mate- 
rial is  gelatinous. 

Treatment. — Rest  and  pressure  are  of  great  service.  Pressure  may  be  ob- 
tained by  the  application  of  Martin's  rubber  bandage.  A  plaster-of-Paris 
dressing  is  probably  the  best  way  to  combine  rest  and  compression.  Massage, 
douches,  frictions,  passive  movements,  and  flying  blisters  should  be  used.- 
Painting  the  joint  with  iodin  and  spreading  over  it  blue  ointment,  and  rub- 
bing in  ointment  of  ichthyol  (50  per  cent,  with  lanolin)  may  do  good.  Counter- 
irritation  by  the  actual  cautery  is  a  valuable  expedient.  The  Bier  treat- 
ment (see  page  112)  is  often  of  benefit.  Injections  of  dilute  carbolic  acid  in  the 
parts  about  the  joint  rapidly  relieve  the  pain  (see  page  640).  Some  sur- 
geons advise  aspiration,  washing  out  with  salt  solution,  injecting  a  5  per  cent, 
solution  of  carbolic  acid  or  formalin-glycerin  (2  per  cent.),  and  immobil- 
izing. Incision  and  drainage  constitute  a  radical  but  proper  plan  in  cases 
unamended  by  simpler  methods.  If  pulpy  degeneration  exists,  perform  an 
excision  or  an  erasion.  If  pus  forms,  incise  at  once  and  drain.  Internally, 
treat  any  existing  diathesis  and  give  nutritious  food,  tonics,  and  stimulants. 
Chronic  synovitis  is  often  greatly  benefited  by  the  use  of  a  hot-air  apparatus. 
The  limb  is  wrapped  in  flannel  and  is  placed  in  an  oven.  The  oven  is  heated 
by  Bunsen  burners.  The  temperature  is  raised  to  250°  or  even  300°  F,,  and  the 
limb  is  subjected  to  this  for  one  hour.  The  oven  should  be  used  daily,  and  as 
the  patient  becomes  accustomed  to  it  even  a  higher  degree  of  heat  can  be 
tolerated.  This  high  degree  of  heat  can  be  borne  only  when  it  is  perfectly  dry. 
Any  moisture  scalds  the  patient.  The  Lentz  oven  has  in  it  ventilation  open- 
ings to  get  rid  of  moisture  and  the  sweat  is  taken  up  by  the  flannel.  The 
1  "Gaz.  des  Hop.,"  No.  125,  1895. 


Poncet's  Tuberculous  Arthritis 


619 


flannel  must  not  be  applied  so  thickly  as  to  keep  the  heat  notably  from  the 
joint,  nor  must  so  little  of  it  be  used  as  to  permit  of  its  soaking  with  sweat. 
Fig.  381  shows  the  Sprague  hot  dry-air  apparatus.  Dr.  H.  A.  Wilson  inserts 
in  the  oven  humidin,  a  product  obtained  in  the  purification  of  salt,  which 
material  absorbs  the  moisture  entirely.  Cotton  should  not  be  used  to  wrap 
the  limb,  because,  if  the  bottom  of  the  oven  becomes  very  hot,  the  cotton  may 
ignite  and  burn  the  patient.  A  physician  or  nurse  should  constantly  watch  the 
apparatus  during  its  employment.^  Bier's  box  is  of  wood  lined  with  asbestos. 
It  is  heated  through  a  flue  by  gas  or  alcohol  lamps.  Aspiration  ajid  the  sub- 
sequent use  of  a  plaster- 
of-Paris  bandage  may  be 
tried  in  lingering  cases  of 
chronic  synovitis. 

Arthritis.  —  By  this 
term  is  meant  not  only 
inflammation  of  a  synovial 
membrane,  but  also  of 
other  structures  compos- 
ing and  surrounding  a 
joint.  It  may  follow  trau- 
matic synovitis;  it  may 
be  due  to  pus-organisms, 
to  tubercle  bacilli,  to  in- 
fectious diseases  (gonor- 
rhea and  typhoid  fever), 
to  rheumatism,  to  gout,  to 
syphilis,  and  to  lesions  of 
the  spinal  cord.  Arthritis 
may  be  either  acute  or 
chronic. 

Poncet's  Tuberculous 
Arthritis  {Tuberculous  Ar- 
ticular Rheumatism,  see 
page  250). — It  was  pointed 
out  by  Grocco  in  the  early 
8o's  that  tuberculous  pa- 
tients may  develop  joint 
disease  without  tubercles, 
cold  abscesses,  or  destruction  of  the  joint 
sively  on  this  subject. 


Fig.  381. — Sprague  hot  dry-air  apparatus. 


Poncet,  of  Lyons,  has  written  exten- 
He  maintains  that  joint  inflammation  is  often  the  first 
evidence  of  extra-articular  tuberculosis  or  of  a  distant  latent  lesion  of  tuber- 
culosis. The  joint  inflammation  is  due  to  toxins,  the  joint  fluid  does  not 
contain  bacilli,  and  tubercles  do  not  develop  in  the  joint  structures. 

Such  a  joint  may  eventually  develop  into  a  true  tuberculous  joint  with 
bacilli  and  tubercles.  In  many  cases  the  joint  recovers,  with  some  stiffness  or 
perhaps  even  ankylosis.  The  process  may  be  acute,  subacute,  or  chronic. 
One  joint  only  may  suffer.  Several  or  most  of  the  joints  may  be  simultaneously 
involved.  It  is  most  apt  to  arise  after  an  operation  on  tuberculous  glands  or 
bone.  Fever  exists  in  Poncet's  arthritis.  Matas  ("Southern  Med.  Jour.,"  Oct., 
191 1)  thus  describes  tuberculous  rhetmiatism: 

"It  may  be  a  flitting  arthralgia,  a  mere  soreness,  a  dropsical  synovitis,  or 

it  may  persist  as  a  hypertrophic  or  atrophic  arthritis.    It  may  present  itself  as 

a  progressive  polyarthritis  deformans  or  as  a  dry  senile  arthritis  (morbus 

coxarius  senilis).    The  acute,  as  well  as  the  chronic,  form  of  this  type  of  rheu- 

iH.  A.  Wilson,  in  "Annals  of  Surgery,"  Feb.,  1899. 


620  Diseases  and  Injuries  of  the  Bones  and  Joints 

matism  may  end  in  ankylosis.  Many  cases  of  spinal  rigidity,  spondylosis, 
scoliosis,  painful  fiat-foot,  genu  valgum,  coxa  vara,  and  even  certain  cases  of 
dry  otitis  media  with  ankylosis  of  the  ossicles  of  the  ear,  and,  in  fact,  all  the 
osteo-articular  affections  of  childhood  and  adolescence  associated  with  defect- 
ive osteogenesis,  may  owe  their  origin  to  the  disturbing  influence  of  a  latent 
or  obscure  tuberculous  toxemia. 

"The  most  benign  of  the  tuberculous  rheumatic  affections  is  a  simple 
arthralgia— a  sore  or  painful  joint.  There  is  pain  without  any  objective  signs, 
and  yet  this  is  often  the  precursor  of  a  manifest  visceral  tuberculosis.    The 

acute  and  subacute  forms  of 
the  disease  are  usually  confused 
at  the  bedside  with  the  mani- 
festation of  ordinary  acute 
rheumatism.  Nevertheless,  the 
clinical  picture  of  acute  tuber- 
culous rheumatism  is  distinctly 
graver;  there  are  fever,  rapid 
pulse,  profuse  sweats,  and  fre- 
quent attacks  of  dyspnea.  This 
is  brought  about  by  associate 
general  infections  involving  the 
serous  cavities,  the  pleura,  peri- 
toneum, pericardium,  and  the 
meninges.  But  in  the  majority 
the  evolution  of  the  disease 
is  slow  and  more  benign.  The 
joint  symptoms  appear  in  suc- 
cessive stages  separated  by  in- 
tervals of  rest  more  or  less  long, 
and  are  distributed  over  vari- 
ous joints,  ending  ultimately  in 
ankylosis.  The  disease  is  more 
often  chronic,  and  many  pa- 
tients either  recover  altogether 
or  remain  permanently  crippled 
or  deformed;  others  die  of 
marasmus  or  complications 
from  associate  visceral  disease. 
Therapeutically,  this  form  of 
rheumatism  is  not  reheved  by 
any  of  the  usual  antirheumatic 
remedies,  and  is  improved  or 
cured  solely  by  treatment  which 
Fig.  382.— Tuberculous  arthritis  of  wrist.  aims  at  the  cure  of  the  tubcrcu- 

lous  infection." 
Tuberculous  Arthritis  (White  Swelling,  so  christened  by  Richard  Wiseman ; 
Strumous  Joint;  Pulpy  Degeneration). — Pathology  and  Symptoms. — The  predis- 
posing causes  of  tuberculous  arthritis  may  be  strains,  blows,  twists,  or  cold  (see 
page  223).  The  real  cause  is  the  tubercle  bacillus.  A  single  joint  is  attacked. 
Other  joints  may  subsequently  become  involved  so  that  several  suffer  simul- 
taneously, but  it  is  rare  that  the  process  is  active  in  more  than  one  joint  at  the 
same  time.  During  the  course  of  tuberculous  disease  of  a  joint  (except  of  the 
shoulder-joint)  phthisis  is  not  common,  although  it  may  develop  after  the  joint 
gets  well.  The  same  is  true  of  tuberculous  glands.  During  the  existence  of 
phthisis  or  tuberculous  glands  tuberculous  arthritis  does  not  frequently  arise. 


Tuberculous  Arthritis  621 

The  primary  infection  with  tubercle  bacilli  is  usually  in  the  bone,  though 
it  may  be  in  the  synovial  membrane,  the  joint-capsule,  or  the  structures 
about  the  joint.  The  frequency  of  the  bony  origin  of  tuberculous  arthritis 
is  shown  by  John  B.  Murphy's  statement  that  in  128  cases  of  tuberculosis  of 
the  knee  it  was  demonstrated  in  all  but  2  that  the  condition  originated  in 
the  bone  (''Jour.  Am.  Med.  Assoc,"  May  20-27,  June  3,  1905).  If  the 
primary  infective  focus  is  in  the  bone,  a  portion  of  the  cartilage  imdergoes  de- 
struction and  the  joint  is  opened,  or  a  sinus  forms  and  perforates  the  syno\-ial 
membrane.  WTien  tuberculous  inflammation  attacks  the  synovial  membrane 
granulation  tissue  is  formed,  and  the  capsule  and  periarticular  structures  soon 
become  involved  in  the  process;  the  parts  thicken  and  soften  from  caseation, 
and  they  may  be  covered  with  tubercles,  though  but  little  fluid  is  usually  effused 
into  the  joint.  Some  few  cases  present  large  joint  eff'usions,  but  in  most  cases 
fluctuation  is  absent.  Capsular  thickening  may  or  may  not  be  manifest.  Soon 
after  tuberculous  arthritis  begins  the  joint  becomes  rigid,  irritation  having 
induced  muscular  spasm.  This  reflex  rigidity  fixes  the  joint  more  or  less  com- 
pletely, and  atrophy  of  the  rigid  muscles  soon  begins.  There  is  usuaUy  some 
pain  in  tuberculous  arthritis;  it  is  seldom  marked  except  on  motion  or  when 
the  epiphysis  is  involved,  and  it  may  be  referred  to  a  distant  part.  For  in- 
stance, in  hip-joint  disease  the  pain  is  often  referred  to  the  inner  side  of  the 
knee,  and  in  Pott's  disease  of  the  spine  the  pain  may  be  referred  to  the  abdo- 
men. A  cardinal  s}Tnpton  of  tuberculous  disease  of  a  joint  is  localized  tender- 
ness. In  other  t}'pes  of  infection  the  tenderness  is  widespread.  Attempts  at 
motion  demonstrate  the  limitation  of  movement  due  to  muscular  rigidity  and 
also  produce  pain.  A  child  that  suffers  from  a  tuberculous  joint  is  apt  to  be 
restless  in  sleep,  moaning  and  tossing,  and  to  wake  at  times  crying  out  in  terror 
{night-cries  and  night-terrors) .  In  the  ordinary  form  of  tuberculous  arthritis 
there  occurs  what  is  known  as  gelatiniform  degeneration;  the  graniflation  tis- 
sue is  formed  in  large  amount  as  fungous  growths ;  the  structures  are  markedly 
edematous  and  softened;  the  relaxed  ligaments  yield  under  pressure;  the  natural 
contoiu:  of  the  joint  is  lost  and  it  becomes  spindle  shaped;  all  the  structures, 
articular  and  periarticular,  are  glued  into  one  mass;  the  skin  about  the  joint 
is  white,  thick,  and  adherent,  and  in  it  one  or  more  large  veins  are  seen;  fluc- 
tuation or  pseudofluctuation  is  noted  when  caseation  has  occurred;  pain  is 
not  often  severe,  but  it  can  usuaUy  be  elicited  by  certain  motions  or  by  firm 
pressure,  but  the  pain  wiU  always  be  severe  when  the  epiphysis  is  involved; 
the  temperature  of  the  part  is  seldom  elevated ;  deformity  results  from  destruc- 
tion of  bone,  cartilage,  and  Hgament,  from  muscular  spasms,  and  from  the 
habitual  assumption  of  certain  attitudes  to  secure  relief  from  pain.  There 
is  soon  impairment  of  joint  motions.  WTien  the  products  of  a  tuberculous 
arthritis  caseate  the  thick  liquid  seeks  exit  by  forming  sinuses,  and  from  them 
caseous  pus  flows.  If  a  sinus  becomes  infected  with  pyogenic  cocci,  and  the 
joint  itself  becomes  their  prey,  acute  suppuration  arises  in  the  joint,  and 
constitutional  involvement  is  pronounced  and  perilous  to  life. 

In  pannoiis  synovitis  a  large  eff'usion  is  formed,  there  is  but  little  granu- 
lation tissue,  though  the  tubercles  are  present  in  large  numbers,  and  the  liga- 
ments and  structures  about  the  joint  are  slightly  or  not  at  all  implicated. 

Diagnosis  and  Prognosis. — Tuberculous  chronic  synovitis  produces  great 
swelling  and  distinct  thickening  of  the  capsule  with  obliteration  of  the  outlines 
of  the  joint,  no  severe  pain,  and  no  tendency  to  early  subluxation.  Tuberculous 
arthritis  rarely  causes  distinct  fluctuation,  does  not  thicken  the  capsiile,  causes 
reflex  muscular  spasm,  rigidity  of  the  joint,  muscular  atrophy,  severe  pain  on 
movement,  and  eventually  subluxation  (Shaffer).  In  sA-philitic  arthritis 
there  is  usually  some  fluctuation,  distinct  enlargement  of  the  joint,  limitation 
of  motion,  no  reflex  spasm,  trivial  atrophy,  but  distinct  pain  on  motion  (James 


622  Diseases  and  Injuries  of  the  Bones  and  Joints 

K.  Young,  "Therapeutic  Gazette,"  June  15,  1902).  Acute  rheumatism  at- 
tacks more  than  one  joint,  is  very  rare  in  children  under  live,  and  pro- 
duces high  fever.  The  :v;-rays  aid  in  the  diagnosis  of  tuberculous  arthritis 
and  enable  us  to  tell  the  extent  of  bone  involvement. 

The  diagnosis  of  a  tuberculous  joint  is  often  difficult,  and  sometimes 
impossible,  and  the  prognosis  is  always  grave.  In  only  a  very  few  cases,  even 
when  recognized  early,  is  a  cure  obtained  without  some  impairment  of  joint 
function.  The  best  that  can  usually  be  accomplished  is  a  cure  with  more 
or  less  ankylosis,  fibrous  or  bony;  and  often  ankylosis  is  complete.  Long 
after  the  disease  is  apparently  cured,  it  may  break  forth  anew.  Tuberculous 
lesions  may  arise  in  a  distant  organ  or  general  tuberculosis  may  occur.  Casea- 
tion is  apt  to  produce  severe  constitutional  disorder.  Infection  by  pus  organ- 
isms gives  rise  to  grave  danger  of  septicemia.  Death  is  not  unusual  from  ex- 
haustion, from  septicemia,  from  disseminated  tuberculosis,  from  tuberculosis 
of  an  important  organ,  or  from  amyloid  disease. 

Treatment. — Conservative  treatment  is  especially  successful  in  children. 
According  to  Hoffa,  in  75  per  cent,  of  cases  in  children  non-operative  treat- 
ment will  produce  cure  ("Die  Bekampfung  der  Knochen-  u.  Gelenktuberculose 
in  Kindesalter  Tuberculosis,"  iv,  i,  1905).  The  conservative  treatment 
consists  in  open-air  life,  if  possible  in  a  sanatorium,  the  following  of  the  plans 
outlined  under  Tuberculosis,  immobilization  and  extension  of  the  joint,  and 
injections  of  iodoform  emulsion  or  formaUn-glycerin  (2  per  cent.).  Even 
when  tuberculous  pus  forms,  the  same  treatment  may  be  followed  unless 
there  is  violent  pain  or  elevated  temperature  which  does  not  quickly  abate, 
in  which  case  operation  must  be  performed.  Cases  treated  early  by  con- 
servative methods  may  get  well  with  a  movable  joint,  but  in  most  cases 
there  is  a  stiff  joint  when  the  disease  is  arrested.  Constitutionally,  the  treat- 
ment is  directed  against  the  tuberculous  diathesis.  The  patient  should  be 
placed  under  good  hygienic  conditions.  A  change  of  climate  is  often  of  the 
greatest  importance.  Many  cases  do  well  at  the  seaside;  others  require  high 
altitudes,  and  all  should  live  in  the  open  air.  The  value  of  sunlight  is  set 
forth  on  page  231.  The  Finsen  light,  too,  is  of  service.  Treatment  by  tuber- 
culin is  considered  on  page  235.  Locally,  rest  is  of  the  first  importance, 
and  fixation  is  maintained  for  many  weeks.  Rest  is  best  secured  by  im- 
mobilization and  traction,  and  traction  is  applied  or  maintained  by  splints, 
by  Plaster-of-Paris  bandages,  or  by  extension  appliances.  The  hot-air  ap- 
paratus may  be  of  some  benefit.  If  it  is  employed,  it  should  be  used  daily,  the 
limb  being  immobilized  during  the  remainder  of  the  twenty-four  hours.  Fixa- 
tion must  be  maintained  as  long  as  pain  exists  or  muscular  spasm  is  present. 
Fixation  must  be  abandoned  gradually,  and  mobility  is  to  be  slowly  regained. 
During  restoration  to  mobility,  if  pain  arises,  the  part  must  be  immobilized 
temporarily.  Movements  should  never  be  violent,  prolonged,  or  repeated  at  too 
close  intervals.  Forcible  breaking  up  of  an  ankylosis  is  never  advisable  in  the 
knee,  ankle,  or  hip;  it  is  seldom  advisable  in  the  wrist,  elbow,  or  shoulder.  Such 
an  attempt  may  be  followed  by  a  fresh  outbreak  of  the  disease.  Osteotomy  or 
resection  will  more  safely  correct  a  faulty  and  disabling  deformity.  In  a  tuber- 
culous joint  injection  of  formalin-glycerin,  as  advised  by  Murphy,  is  a  valuable 
procedure.  Several  injections  or  a  number  may  be  made.  The  joint  is  aspirated 
and  the  mixture  introduced.  About  4  drams  are  used  in  the  knee,  about  2  drams 
in  the  ankle.  After  injection  extension  is  applied.  The  mixture  used  must  be 
at  least  twenty-four  hours  old.  In  tuberculous  joints  intra-articular  injec- 
tions of  iodoform  are  often  of  the  greatest  value.  This  drug  strongly  stimulates 
the  formation  of  fibrous  tissue.  If  sufficient  fibrous  tissue  is  formed  the  tuber- 
culous foci  will  be  firmly  encapsuled  and  the  case  will  be  cured.  Iodoform  is 
particularly  called  for  when  no  bone  disease  is  shown  by  the  x-ray  or  discovered 


Tuberculous  Arthritis  623 

by  incision.  The  joint  is  incised,  adhesions  are  gently  broken  up,  the  capsule 
is  sutured  except  for  a  small  space,  the  nozzle  of  a  syringe  is  inserted  and  a 
mattress  suture  draws  the  capsule  tightly  about  the  nozzle  (Brackett's  plan). 
The  emulsion  is  injected  under  tension  and  then  the  capsule  is  closed  tightly. 
In  a  large  joint  a  4  per  cent,  emulsion  is  used;  in  a  small  joint  a  10  per  cent, 
emulsion.  The  part  must  not  bear  weight  for  six  months.  Bier's  plan  of 
inducing  passive  h\^eremia  is  often  of  great  service  (see  pages  11 2-1 15).  As- 
piration or  incision  can  be  used  for  fluid  accumulations.  Caseous  masses  are 
often  let  alone,  or  an  aspirator  is  used  and  the  joint  drained,  washed  out  with 
saline  solution,  and  injected  with  an  emulsion  of  iodoform  and  glycerin  (10  per 
cent.).  From  i  to  2  drams  are  injected  into  the  joint  of  a  child,  from  2  to  5 
drams  into  the  joint  of  an  adult.  Even  surface  lesions  are  not  curetted.  Bier's 
treatment  should  be  associated  with  immobilization  and  systemic  treat- 
ment. It  is  more  serviceable  in  tuberculosis  of  the  small  joints  than  in  disease 
of  the  large  articulations.  There  are  certain  contra-indications  to  Bier's 
treatment,  viz. :  serious  pulmonary  involvement,  extensive  amyloid  degenera- 
tion, and  the  existence  of  such  an  unfavorable  position  of  the  parts  that  cure 
by  ankylosis  would  mean  a  less  useful  limb  than  cure  by  resection  (Bier  at 
Internat.  Surg.  Congress  of  1905).  One  advantage  of  this  treament  is  that  we 
can  employ  active  and  passive  motion  early,  except,  according  to  Bier,  when 
the  foot  or  knee  is  diseased.  Even  in  very  serious  cases  cure  may  be  obtained 
without  any  limitation  of  activity,  and  as  the  patient  can  get  about  it  is  not 
necessary  to  restrain  him  long  in  a  hospital.  Personally  I  believe  that  fixation 
should  be  the  basis  of  treatment  in  most  cases,  and  that  passive  h>^eremia, 
compression,  counterirritation,  and  intra-articular  injections  should  be  addi- 
tions to  fixation.  Injections  of  balsam  of  Peru  or  of  iodoform  emulsion  about  the 
joint  once  a  week  are  efficient  in  some  prolonged  cases,  but  are  not  to  be  used 
early.    It  is  not  wise  to  attempt  to  correct  faulty  position  until  the  focus  is  well. 

Fistulae  are  frequently  treated  by  the  method  of  Beck,  of  Chicago,  that  is, 
by  the  injection  of  a  paste  containing  bismuth.  In  early  cases  a  bismuth-vase- 
lin  paste  is  used,  in  late  cases  a  bismuth-wax-parafiin  paste. 

Beck  described  his  method  in  the  "Illinois  Med.  Jour.,"  April,  1908. 
The  vasehn  paste  is  composed  of  30  parts  of  subnitrate  of  bismuth  and  60 
parts  of  vaselin,  mixed  and  well  stirred  while  boiling.  The  paste  for  later  cases 
is  composed  of  30  parts  of  subnitrate  of  bismuth,  5  parts  of  white  wax,  5  parts  of 
soft  paraffin,  and  60  parts  of  vaselin,  mixed  while  boiling.  One  per  cent,  formalin 
is  often  added  to  these  pastes.  The  paste  is  injected  cold  before  an  .T-ray  picture 
is  taken,  and  the  picture  shows  all  the  ramifications  of  the  fistula.  The  paste 
is  left  in  for  treatment.  If  a  sequestrum  exists  it  should  be  removed  before 
the  paste  is  injected.  It  is  not  necessary,  but  is  advisable,  to  dry  the  fistula 
before  injecting. 

The  paste  is  sterilized  before  using.  It  is  sucked  up  into  the  syringe 
while  still  liquid  and  is  cooled  to  the  requisite  temperature  and  hardened  to  the 
proper  consistency  by  running  cold  water  over  the  syringe.  It  is  injected  very 
slowly  and  the  injection  is  continued  until  a  sense  of  pressure  annoys  the 
patient.  Then  the  syringe  is  laid  aside,  a  bit  of  gauze  is  held  for  a  time  over  the 
outlet  of  the  fistula  to  keep  the  paste  from  running  out,  and  an  ice-bag  is  put 
over  the  region  to  quickly  harden  the  injected  material.  There  is  no  pain 
from  such  an  injection.  Beck  employs  the  first  paste  until  pus  disappears  and 
then  uses  the  second. 

The  value  of  this  paste  is  that  it  distends  and  fills  the  abscess-cavity  and 
sinus,  and  affords  a  trestle  or  frame  for  granulations  to  grow  upon.  Con- 
siderable of  the  paste  may  run  out  of  the  fistula  during  the  first  twenty-four 
hours.  In  shallow  sinuses  it  all  runs  out.  In  deep  and  tortuous  fistulas  much 
of  it  remains  for  weeks  and  is  slowly  absorbed.     In  empyema  and  bone-cavities 


624  Diseases  and  Injuries  of  the  Bones  and  Joints 

it  is  slowly  absorbed.  Beck  holds  that  the  paste  is  bactericidal,  astringent, 
and  non-toxic.  Cases  of  pigmentation  of  the  lips,  gums  and  cheeks,  and  cases  of 
ulceration  in  the  mouth  from  absorption  of  bismuth  have  been  recorded,  and  at 
least  8  deaths  are  on  record  (Reich,  in  "Beitrage  Zur  klinischen  Chirurgie,"  Nov., 
1909).  Beck  limits  the  first  dose  to  100  gm.,  but  increases  the  amount  later. 
Because  of  possible  danger  of  poisoning  Blanchard  uses  a  paste  of  white  wax  and 
vaselin  without  bismuth.  Not  over  4  oz.  of  bismuth  paste  should  be  injected. 
As  Bell  points  out,  if  a  large  quantity  is  injected  an  opening  must  be  left.  This 
precaution  may  prevent  poisoning.  Some  think  the  poisoning  is  due  to  bis- 
muth, others  believe  it  is  due  to  arsenic  held  as  an  impurity.  David  and 
Kauffman  ("Illinois  Med.  Jour.,"  Oct.,  1909)  point  out  that  there  may  be  acute 
cases  of  poisoning  which  are  liable  to  be  fatal,  and  chronic  cases  which  tend 
to  recovery.  In  an  acute  case  of  bismuth-poisoning  there  is  pigmentation  of 
the  gimis,  ulcerative  stomatitis,  dyspnea,  delirium,  and  albuminuria.  David 
and  Kauffman  regard  pigmentation  of  the  gums,  lips,  or  cheeks  as  an  indication 
of  toxic  action  and  a  sign  to  discontinue  the  drug.  The  use  of  bismuth  paste 
is  undoubtedly  a  valuable  method.  I  have  seen  sinuses  heal  under  it  after 
they  had  resisted  various  other  plans  of  treatment.  It  may  be  used  in  sinuses, 
cold  abscesses,  empyemata,  tuberculous  joints,  and  other  conditions. 

If  these  means  fail,  if  the  patient  gets  worse,  if  there  is  persistent  fever  or 
violent  pain,  if  sequestra  exist,  if  there  is  mixed  infection,  or  if  the  condi- 
tion of  the  sufferer  renders  dangerous  the  prolonged  conservative  course, 
operate,  removing  the  entire  diseased  area  by  erasion,  by  excision,  or  possi- 
bly by  amputation.  If  the  .T-ray  picture  shows  extensive  sequestrum  forma- 
tion, operation  is  indicated.  If  amyloid  degeneration  exists,  conservative 
treatment  is  contra-indicated  and  so  is  resection.  Amputation  must  be  done. 
Always  remember  that  an  incomplete  operation  or  a  partial  removal,  unless  it 
consists  of  simple  drainage,  is  worse  than  no  operation,  as  it  opens  the  portals 
to  systemic  infection,  and  may  be  responsible  for  the  development  of  general 
tuberculosis,  septicemia,  or  pyemia.  Simple  drainage,  as  previously  stated,  is 
seldom  advisable.  Garre  is  of  the  opinion  that  the  hip,  wrist,  and  shoulder 
do  best  by  conservative  treatment;  the  knee,  elbow,  and  ankle,  by  operative 
treatment  (John  W.  Churchman,  in  "Am.  Medicine,"  April,  1906). 

Tuberculosis  of  Special  Joints;  Tuberculosis  of  the  Vertebrae 
(see  page  844). — Tuberculosis  of  the  Sacro-iliac  Joint  {Sacro-iliac  Disease). — 
This  is  an  uncommon  affection,  and  is  especially  rare  before  the  age  of  fifteen. 
The  disease  may  begin  in  the  joint,  may  arise  in  adjacent  bones,  or  may  result 
from  a  cold  abscess  burrowing  into  the  joint.  In  some  cases  it  is  associated  with 
extensive  disease  of  the  pelvic  bones.  The  disease,  if  undetected,  may  lead  to 
dissemination  of  tubercle,  to  abscess,  or  even  to  death. 

Symptoms  are  often  obscure.  The  disease  is  frequently  confounded  with 
vertebral  caries,  hip-joint  disease,  or  sciatica.  The  patient  limps  on  walking, 
but  can  stand  on  either  leg;  there  is  pain  in  the  sacro-iliac  joint,  about  the 
hip,  and  down  the  thigh;  tenderness  is  manifest  on  pressure  over  the  joint 
and  on  pushing  the  ilia  together;  there  is  fulness  over  the  sacro-iliac  joint, 
but  the  hip  is  not  flexed  unless  iliac  abscess  exists.^ 

Treatment. — Rest  in  bed  for  months,  using  also  a  felt  case  for  the  pelvis. 
Counterirritation  by  blisters  and  the  actual  cautery.  In  some  cases  injection 
of  formalin-glycerin  or  of  iodoform;  in  others,  incision  and  curetting.  I  have 
operated  on  9  cases,  with  i  death.  In  i  case  in  the  Jefferson  Medical  College 
Hospital  the  abscess  was  pointing  in  both  the  back  and  groin.  Both  areas  were 
incised,  the  diseased  bone  was  removed,  and  the  boy  ultimately  recovered.  In 
another  case  the  abscess  pointed  in  the  groin.  The  treatment  was  as  pre- 
viously set  forth,  and  the  patient,  a  woman,  recovered.  The  best  way  to  reach 
1  See  A.  G.  Miller,  "Edinburgh  Med.  Jour.,"  May,  1895. 


Tuberculosis  of  the  Hip-joint  625 

the  joint  is  to  chisel  or  bore  through  the  ilium  above  the  great  sacrosciatic 
foramen. 

Tuberculosis  of  the  Hip-joint  (Hip  Disease;  Morbus  Co.xarius;  Morbus 
Coxce;  Hip-joint  Disease). — The  primary  lesion  may  be  in  the  synovial  mem- 
brane, but  it  is  more  often  in  the  bone.  It  may  begin  in  the  acetabulum; 
it  may  begin  in  the  femur.  In  95  per  cent,  of  cases  it  begins  in  the  head  of  the 
femur.  If  it  begins  in  the  femur,  it  usually  arises  on  "the  distal  side  of  the 
epiphyseal  cartilage"  (Senn).  Sometimes  priman.-  tuberculosis  arises  in  the 
trochanter  major,  and  never  involves  the  joint.  \\'hen  the  s}'novial  mem- 
brane becomes  involved  at  any  point,  spread  throughout  the  joint  is  rapid. 
In  many  cases  the  articular  cartilages  are  attacked,  and  in  some  cases  the 
epiphyseal  cartilage  is  destroyed.  It  is  commonest  in  children,  but  it  may  arise 
in  adults  and  even  occasionally  in  those  of  advanced  years;  62  per  cent,  of 
cases  arise  in  children  under  ten  years  of  age  and  So  per  cent,  of  cases  occur 
before  the  twentieth  year  (Br^^ant).  Traumatism  and  cold  may  be  predis- 
posing causes.  The  disease  strongly  tends  to  caseation  and  the  formation  of 
sequestra. 

Symptoms. — It  has  been  usual  to  di^ide  the  disease  into  three  stages:  (i) 
the  stage  of  microbic  deposition  and  multiplication,  the  products  of  the  bacilli 
causing  irritation  and  new  growth;  (2)  the  stage  of  progression,  -uith  formation 
of  masses  of  granulation  tissue  and  effusion  into  the  joint,  and  (3)  the  stage 
of  caseation,  "^ith  destruction  of  the  joint  and  often  of  the  structures  about  it. 
Bradford  and  Lovett^  protest  against  this.  They  say:  'Tt  has  been  customary 
to  di^'ide  hip-disease  into  stages,  and  to  ascribe  to  these  stages  certain  definite 
symptoms.  Neither  from  a  chnical  nor  a  pathological  point  of  view  is  it 
desirable  to  attempt  such  a  di\'ision."  As  H.  Augustus  Wilson  says:  "Tu- 
berculous bone  and  joint  disease  should  be  considered  as  the  primary  invasion 
or  incipiency,  and  all  other  symptoms  should  be  regarded  as  results  and  not  as 
an  integral  and  necessary  part  of  the  trouble." 

The  s}Tnptoms  of  incipient  coxalgia  are  shght  and  may  be  overlooked 
entirely.  In  a  child  there  are  night-terrors;  on  getting  about  in  the  morning 
the  child  shows  no  lameness,  but  a  Hmp  develops  during  the  day,  and  the  Kttle 
one  soon  grows  tired  while  pla^dng  and  lies  down  to  rest.  There  is  a  shght 
limp;  some  muscle  spasm  may  be  noted,  and  pain  may  be  complained  of  at 
night  in  the  hip,  in  the  front  of  the  thigh,  or  at  the  inside  of  the  knee.  Tapping 
the  sole  of  the  foot,  the  thigh  and  leg  being  extended,  may  develop  pain,  just 
as  it  ^\-ill  develop  pain  in  any  inflammators'  involvement  of  the  joint,  but  the 
emplo}Tnent  of  this  method  is  objectionable.  It  may  injure  a  joint  already 
damaged  by  the  tuberculous  process,  and  it  gives  no  information  which  cannot 
be  obtained  by  a  safer  mode  of  investigation.  After  all,  pain  on  tapping  the 
sole  of  the  foot  means  only  what  muscular  rigidity  means,  and  muscular 
rigidity  is  always  present  and  is  easily  demonstrable  by  careful  manipulation. 
The  diagnosis  of  incipient  coxalgia  is  more  or  less  problematical. 

As  the  disease  progresses  more  positive  s}Tnptoms  are  obsen.'ed.  The 
limp  grows  worse;  the  hip  is  broadened  by  an  effusion  into  the  joint,  and 
fluctuation  may  possibly  be  detected;  the  thigh  muscles  atrophy;  the  extremity 
is  pushed  for^vard,  abducted,  and  everted.  The  position  is  described  as  flexion, 
abduction,  and  outward  rotation  (Fig.  383).  This  position  may  not  be  ob^-i- 
ous;  in  fact,  the  limb  may  be  extended  by  the  side  of  the  companion  extremity. 
When  it  is,  there  is  a  forward  cur\^e  of  the  Imnbar  spine  (lordosis)  and  a 
lateral  curve  of  the  lumbar  spine,  which  raises  the  pehis  on  the  sound  side 
and  depresses  it  on  the  diseased  side.  These  lumbar  cur\-es  ser\^e  to  bring 
the  femur  toward  the  middle  line,  give  the  extremity  the  appearance  of 
being  lengthened,  enable  the  sufferer  to  walk  (Fig.  383),  and  cause  him  to 

1  "Orthopedic  Surger>\" 
40 


626 


Diseases  and  Injuries  of  the  Bones  and  Joints 


rest  his  weight  on  the  sound  Hmb.  Apparent  lengthening  means  abduction. 
In  some  few  cases  adduction  exists  rather  than  abduction.  The  abduction, 
which  is  usual,  releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure 
upon  the  joint  through  lessening  of  pressure  upon  the  great  trochanter,  and 
also  relaxes  the  outer  portion  of  the  Y -ligament  and  the  ligamentum  teres. 
The  flexion  relaxes  the  anterior  portion  of  the  capsule  and  the  psoas  muscle 
and  prevents  pressure  of  its  tendon  upon  the  front  of  the  joint.  Outward 
rotation  relaxes  the  inner  portion  of  the'Y-ligament  and  the  posterior  portion 
of  the  capsule.  Pain  exists,  often  sudden  or  starting,  and  is  located  in  the 
joint,  on  the  front  of  the  thigh,  and  to  the  inner  side  of  the  knee  in  the 
course  of  the  obturator  nerve;  the  pain  is  aggravated  at  night,  and  full  exten- 
sion and  complete  abduction  are  not  possible.  The  gluteal  muscles  waste, 
and  the  gluteal  crease  is  on  a  lower  level  than  is  that  of  the  sound  side.  The 
gluteal  crease  may  be  nearly  or  quite  effaced  because  of  hypertrophy  of  the 
subcutaneous  layer  (Alexandroff ) ,  or  from  slight  flexion  of  the  leg  (McClellan). 
As  the  disease  progresses  adductor  spasm  causes  adduction,  and  the  limb  is 
flexed,  adducted,  and  apparently  shortened.  This  apparent  shortening  is 
accomplished  by  a  lateral  curvature  of  the  spine,  which  keeps  the  limb  from 
crossing  its  fellow  and  being  useless.     It  does  so  by  raising  the  hip  of  the 


Fig.  383. — Positions  in  hip-joint  disease,  a:  e-f,  lumbar  spine;  h-d,  limb  fixed  in  flexion  and  abduc- 
tion, useless  for  walking,  b:  e-f,  lumbar  spine.  Patient  corrects  the  condition  in  Figure  a  by  curv- 
ing the  lumbar  spine  forward  and  rotating  the  pelvis  on  its  transverse  axis,  thus  making  the  femur 
point  downward.  The  lumbar  spine  is  curved  laterally,  the  pelvis  ascending  on  the  sound  side  and 
descending  on  the  affected  side  (apparent  lengthening),  c:  h-d,  hmb  fixed  in  flexion  and  adduction. 
d:  e-f,  curve  of  lumbar  spine  to  correct  condition  in  Figure  C  (apparent  shortening).  (After  the  plan  of 
Howard  Marsh  and  Treves.) 

diseased  side  and  drawing  the  femur  outward  (Fig.  2>^z)-  This  causes  apparent 
shortening  (Howard  Marsh,  in  Treves's  "Manual  of  Surgery").  The  above 
symptoms  arise  chiefly  from  unconscious  efforts  to  obtain  ease,  from  joint- 
effusion,  reflex  irritation,  and  involuntary  or  spasmodic  muscular  contractions. 
There  is  an  appearance  of  lengthening  or  shortening,  but  it  is  only  apparent, 
not  real.  The  real  position  is  shown  on  Plate  8,  Fig.  4.  The  fluid  effusion 
may  be  absorbed  or  may  find  its  way  externaUy  by  means  of  sinuses.  The 
latter  condition  is  known  as  abscess  of  the  hip.  The  absorption  of  the  exu- 
date or  the  rupture  of  the  capsule  permits  the  contracting  muscles  to  bring  the 
head  of  the  femur  into  firm  contact  with  the  acetabulum  or  its  brim;  the 
bones  are  worn  away  and  destroyed,  real  shortening  results,  there  is  adduc- 
tion, and  flexion  is  increased  as  shortening  becomes  more  marked. 

In  advanced  cases  of  coxalgia  the  head  of  the  femur  passes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed  and  fixed,  and 
attempts  at  extension  when  the  patient  is  recimibent  cause  the  pelvis  to  tilt 
forward  and  occasion  a  marked  lumbar  curve  (lordosis)  (PI.  8,  Fig.  2) ,  which  is 
due  to  the  pelvis  moving  with  the  femur  as  if  ankylosed,  and  which  disappears 
on  flexion.  In  this  condition  adduction  occurs  because  of  the  ascent  and  move- 
ment outward  of  the  head  of  the  bone.  Shortening  is  marked.  After  a  hip 
abscess  finds  an  external  outlet  pyogenic  infection  is  very  apt  to  take  place 


Tuberculosis  of  the  Hip-joint  627 

and  suppuration  arises,  which  is  followed  by  that  state  which  is  designated 
as  "hectic."  If  a  cure  follows  advanced  coxalgia,  partial  or  complete  anky- 
losis takes  place;  if  death  ensues,  it  may  be  due  to  septicemia,  tuberculosis 
of  the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip-disease,  but  very 
difficult  when  the  disease  is  incipient.  Always  make  a  systematic  and  thor- 
ough examination.  Undress  the  patient  and  place  him  recumbent  with  his 
legs  extended  upon  a  table  or  a  hard  mattress.  Note  if  the  heels  are  level 
and  if  the  iliac  spines  are  on  the  same  level  (a  depressed  spine  on  the  affected 
side  means  abducted  extremity,  the  degree  of  which  is  determined  by  carn,-ing 
the  limb  out  until  the  spines  are  horizontal;  elevation  of  the  ihac  spine  on  the 
affected  side  means  adduction,  the  amoimt  of  which  is  determined  by  adducting 
the  limb  imtil  the  spines  are  horizontal,  Fig.  383).  The  amount  of  flexion 
is  ascertained  by  lifting  the  knee  until  the  curved  spine  has  become  straight. 
Try  all  the  movements  belonging  to  the  joint,  to  detect  any  limitations;  ob- 
ser\-e  if  bringing  down  the  knee  produces  lordosis;  look  for  swelling  and  for 
muscular  wasting;  feel  if  the  head  of  the  bone  is  enlarged;  determine  if  motion 
produces  pain  or  if  pressure  de^'elops  tenderness;  and  always  carefully  elicit 
the  histors'  of  the  attack,  of  the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  vrith.  spinal  caries  in  which  a  psoas  or  a 
lumbar  abscess  has  formed,  vrith.  sacro-iliac  disease,  with  infantile  paralysis, 
with  congenital  dislocation  of  hip,  with  lordosis  from  rickets,  with  gluteal 
abscess,  and  vrith  bursitis  of  the  gluteal  bursse.  In  hip  disease  there  is  always 
some  lameness ;  pain  may  be  severe,  may  be  tri\'ial,  or  may  be  absent  entirely, 
and  may  be  in  the  hip  or  be  referred  to  the  front  of  the  thigh  or  the  inner  side 
of  the  knee.  Always  remember  that  the  pain  is  not  characteristic,  and  that 
pain  in  the  same  localities  may  arise  from  aneur\'sm  of  the  femoral  or  iliac 
arteries,  from  abscess  in  Scarpa's  triangle,  from  caries  of  the  lumbar  vertebrae, 
from  sacro-iliac  disease,  and  from  cancer  of  the  rectum.  Altered  position  of 
the  limb,  limitation  of  movement  in  the  hip-joint,  muscular  wasting,  and 
swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-iliac  joint  examination  shows  that  the  movements 
of  the  hip-joint  are  unlimited  and  produce  no  pain,  and  that  pain  is  developed 
by  pressure  over  the  sacro-iliac  articulation  and  by  pressing  the  ilia  together. 
In  infantile  paralysis  there  is  no  pain,  but  there  is  paralysis  with  great  muscular 
atrophy,  which  comes  on  -^-ith  considerable  rapidity.  In  spinal  caries  with 
psoas  abscess  the  e^^dences  of  disease  of  the  vertebrae  are  clear  and  a  collection 
of  fluid  is  located  in  the  groin  external  to  the  femoral  vessels.  The  tuberculous 
pus  of  hip  abscess  generally  gathers  under  the  tensor  vagina  femoris  muscle, 
but  it  may  reach  Scarpa's  triangle  by  passing  through  the  cotyloid  notch  or 
through  the  bursa  under  the  psoas  muscle;  it  may  even  appear  under  the  glutei. 
Matter  from  a  caseating  acetabulum  may  reach  the  interior  of  the  pehis  and 
appear  above  Poupart's  Hgament. 

In  gluteal  bursitis  the  s>miptoms  last  for  many  months,  and  do  not  remit 
as  the  s}Tnptoms  of  early  hip  disease  are  apt  to  do.  The  pain  is  but  moderate, 
and  is  aggravated  by  exercise,  but  passes  away  on  going  to  bed,  and  is  felt  back 
of  the  hip  and  back  of  the  knee.  There  is  a  certain  amount  of  limitation  of 
motion  and  there  is  a  positive  limp,  which  arises  early.  In  marked  cases 
fluctuation  can  be  detected  in  the  upper  gluteal  region.^ 

Prognosis. — If  the  case  of  hip  disease  is  seen  early  the  chances  of  cure  are 
excellent  in  children,  in  whom  the  disease  may  be  arrested  at  any  stage.  The 
longer  the  duration  of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.     Many  months  will  be  required  to  elapse  before  a  cure 

1  See  E.  G.  Brackett's  important  paper  on  "Gluteal  Bursitis"  in  the  "Transactions  of  the 
American  Orthopedic  Association,"  vol.  x. 


628 


Diseases  and  Injuries  of  the  Bones  and  Joints 


can  be  effected,  and  advanced  cases  only  get  well  by  means  of  ankylosis  with 
shortening  and  deformity.  Hip  disease  may  recur  years  after  apparent  cure, 
and  a  person  who  has  or  has  had  hip  disease  runs  a  chance  of  developing 
visceral  tuberculosis. 

Complications. — ^The  complications  that  may  accompany  hip  disease  are 
the  following:  Abscess,  as  above  noted.  Tuberculous  meningitis,  or  the  con- 
dition known  as  ''acute  hydrocephalus"  or  "water  on  the  brain,"  may  arise 
during  the  progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  ensue 
upon  incomplete  operations.  It  is  almost  inevitably  fatal.  Phthisis  pulmo- 
nalis  is  a  rare  complication,  but  a  not  uncommon  sequence,  perhaps  arising, 
sooner  or  later,  after  the  hip  disease  has  been  cured.  Amyloid,  lardaceous,  or 
waxy  degeneration  of  viscera  (see  page  239)  follows  upon  profuse  and  long- 
continued  suppiiration  and  is  apt  to  arise  in  the 
liver,  spleen,  kidneys,  or  intestinal  mucous  membrane. 
Tuberculosis  is  not  the  only  cause  of  amyloid  de- 
generation, syphilis  being  responsible  for  at  least  30 
per  cent,  of  all  cases.  In  amyloid  disease  of  the 
liver  the  organ  is  much  enlarged,  smooth,  painless, 
and  of  increased  consistency;  there  is  no  jaundice, 
the  spleen  is  apt  to  be  enlarged,  and  albuminuria 
is  the  rule.  In  amyloid  kidney  large  amounts  of  pale 
urine  of  low  specific  gravity  are  voided;  albumin  is 
usually  present  in  large  amount,  but  may  be  absent; 
globulin  may  often  be  found,  as  may  also  hyaline, 
fatty,  or  granular  casts;  the  patient  is  anemic  and 
dropsy  usually  exists.  Test  the  hyaline  casts  with 
iodin  for  amyloid  material.  Amyloid  changes  are 
usually  slow  in  onset,  but  they  may  be  rapid;  they  are 
commoner  in  men  than  in  women,  and  are  most  fre- 
quently encountered  in  individuals  between  the  ages 
of  ten  and  thirty.  Slight  amyloid  change  may  be 
recovered  from,  but  an  extensive  degeneration  brings 
about  a  fatal  result. 
Treatment. — In  most  of  these  cases  conservative  treatment  is  advisable. 
Antituberculous  treatment  is  used  in  all  cases.  In  incipient  hip  disease  the 
treatment  usually  advocated  is  rest.  The  patient  is  placed  upon  a  solid  mat- 
tress and  extension  is  applied.  In  children  imder  ten  years  of  age  a  weight 
of  from  3  to  5  pounds  is  used;  in  individuals  between  ten  and  twenty 
a  weight  of  from  5  to  8  pounds  is  used.  A  long  splint  is  often  applied 
to  the  sound  side  to  keep  the  patient  recumbent  and  horizontal.  A  cradle 
is  employed  to  hold  up  the  bed-clothing.  The  extension  is  applied  in  the 
long  axis  of  the  limb,  the  extremity  being  placed  in  the  line  of  the  deformity  due 
to  disease  and  being  properly  supported.  In  lordosis  from  thigh-flexion  the 
limb  is  raised  until  the  iliac  spine  is  straight  (PI.  8,  Fig.  5).  If  the  spine  is 
depressed  on  the  affected  side,  the  limb  is  abducted  (PL  8,  Fig.  6) ;  if  the  spine  is 
elevated,  the  limb  is  adducted  until  the  spines  are  horizontal  (PI.  8,  Fig.  7). 
The  object  of  extension  is  to  overcome  muscular  spasm  and  so  put  the  part 
in  a  condition  of  physiological  rest.  Muscular  spasm  is  a  great  factor  in 
destroying  structures.  Spasm  presses  the  parts  together,  and  as  a  result  of 
pressure  plus  bacterial  action  destruction  occurs.  The  extension  and  traction 
tire  out  the  muscles  and  cause  spasm  to  cease.  Extension  will  remove  flexion 
in  two  weeks  in  a  recent  case  and  in  the  course  of  some  months  in  an  older  case. 
As  flexion  is  relieved  the  pillows  are  removed  and  the  leg  lowered,  but  extension 
is  maintained  in  the  long  axis  of  the  thigh.  Abduction  and  adduction  cannot 
be  removed  by  simple  extension  in  the  axis  of  the  limb. 


Fig.  384. — Thomas's  poste- 
rior splint. 


Tuberculosis  of  the  Hip-joint 


629 


Abduction  demands  no  special  treatment.  In  a  movable  joint  it  will  dis- 
appear, and  in  an  ankylosed  joint  it  is  an  advantage,  compensating  by  apparent 
lengthening  for  the  shortening  due  to  bone-absorption  or  to  stunted  groAvth 
of  the  limb.  Adduction  requires  an  addition  of  several  pounds  to  the  extension 
weight,  the  use  of  a  long  splint  on  the  sound  limb,  and  the  drawing  up  of 
the  sound  side  by  a  rope  and  pulley  toward  the  head  of  the  bed.  The  weight 
used  to  pull  the  sound  side  toward  the  head  of  the  bed  is  equal  to  that  used 
to  pull  the  diseased  side  to  the  foot  of  the  bed.  This  expedient  is  used  for  a 
month  or  six  weeks.     In  old  cases,  in  which  the  weight  ^ill  not  bring  about 

extension,  the  patient  is  anesthetized, 
the  limb  is  gently  straightened  a  very 
little,  and  the  weight  is  reapplied. 


Fig.  3S5. — SajTe's  long  splint. 


Fi2 


A\"yet±i's  combination  method. 


Extension  in  a  mild  case  must  be  continued  for  three  months  after  the 
s^Tuptoms  haA-e  disappeared,  and  in  a  severe  case  the  period  must  be  six 
months.  The  weight  is  gradually  taken  off;  if  s}-mptoms  recur,  the  weight 
is  reappHed;  if  they  do  not  recur,  apply  a  traction  splint  or  a  plaster  dressing, 
put  a  high-heeled  boot  on  the  soimd  limb,  and  send  the  patient  out  on  crutches. 
In  yoimg  children  extension  can  be  made  while  the  child  is  in  a  wheeled  car- 
riage, thus  enabling  the  patient  to  go  out  in  the  fresh  air  and  sunlight.  The 
general  treatment  is  tonic  and  restorative.  The  joint  is  so  deeply  placed 
that  external  applications  are  useless.  In  the  treatment  of  hip  disease 
Thomas's  splint  (Fig.  384)  is  used  by  many,  and  it  may  be  combined  with 
weight  extension;  or  Sa}Te's  splint  (Fig.  385)  may  be  employed.  Wyeth's 
apparatus  (Fig.  386)  is  a  favorite  with  many  .American  surgeons. 

If  the  limb  is  in  good  position,  or  has  been  brought  into  good  position,  either 
by  weight  extension  or  straightening  mider  ether,  plaster-of-Paris  is  a  useful 
dressing.  It  is  applied  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pehds.  A  patient  wearing  plaster  may  get  about  on  crutches  when 
the  sole  of  the  foot  of  the  soimd  extremity  is  raised  by  the  wearing  of  a  thick- 
soled  shoe. 


630  Diseases  and  Injuries  of  the  Bones  and  Joints 

Treatment  by  Weight-bearing  and  Fixation  by  Hip  Spica  of  Plaster  of  Paris 
(Lorenz's  Method). — This  plan  is  based  upon  the  principle  that  ankylosis  is  to 
be  secured  in  every  instance.  To  keep  the  patient  in  bed  is  to  keep  him 
from  the  open  air  and  sunlight,  which  are  so  necessary  in  tuberculosis.  Such 
confinement  favors  muscular  atrophy,  leads  to  anemia,  and  lessens  vital  re- 
sistance. The  hip  is  placed  in  20  degrees  of  flexion,  20  degrees  of  abduction, 
and  5  degrees  of  external  rotation,  and  is  fixed  by  a  short  plaster  spica  of  the 
hip.  The  patient  walks  and  so  antagonizes  muscular  spasm.  The  joint  sur- 
faces bear  weight,  which  leads  to  a  useful  increase  of  blood  supply  (curative 
hyperemia),  but  do  not  grind  upon  each  other,  hence,  the  spread  of  the  disease 
is  not  favored.  That  muscles  increase  in  size  is  shov/n  by  the  fact  that  the  cast 
gets  tight  and  must  be  changed  from  time  to  time.  The  open-air  life  and 
exercise  are  of  the  greatest  benefit  to  the  patient  and  a  gain  in  weight  is  the 
rule.  Cases  in  a  debilitated  condition  or  those  with  discharging  sinuses  must 
not  be  treated  by  this  plan  "without  the  temporary  use  of  crutches"  (H.  A. 
Wilson,  in  "Southern  Med.  Jour.,"  Dec,  1908).  The  plan  is  more  suitable  for 
incipient  than  for  advanced  cases.  The  average  duration  of  treatment  is 
claimed  to  be  about  ten  months  (H.  A.  Wilson,  Ibid.).  It  is  true  that  the 
method  affords  easier  access  to  the  open  air  than  does  the  bed  treatment,  but 
why  should  every  patient  be  doomed  to  ankylosis  when  we  know  that  in  many 
cases  joint  function  may  be  retained  by  treatment  looking  to  that  end? 

Intra-articular  Injections  and  Operation. — If  in  spite  of  treatment  the  con- 
dition does  not  improve  or  if  it  becomes  worse,  use  intra-articular  injections  of 
formalin-glycerin  or  iodoform.  Always  try  these  injections  before  doing  a 
resection  unless  the  ri;-rays  show  a  large  sequestrum.  Sometimes  they  succeed, 
and  if  they  do,  resection  is  unnecessary.  Asepticize  the  surface,  carry  a  small 
aspirating  needle  into  the  joint,  irrigate  the  joint  with  salt  solution,  and  inject 
a  sterile  emulsion  of  iodoform  and  glycerin  (see  page  622).  In  one  week,  if 
reaction  has  ceased,  repeat  the  injection.  In  another  week  repeat  it  again. 
It  may  be  necessary  to  give  from  ten  to  twenty  injections.  The  proper  spot  for 
puncture  is  thus  determined:  Draw  a  line  from  a  point  |  inch  outside  of  the 
middle  of  Poupart's  ligament  to  the  outer  edge  of  the  great  trochanter.  Punc- 
ture at  the  middle  of  the  outer  half  of  this  line  (De  Vos).  I  have  not  attempted 
to  remove  the  disease  surgically  early  in  any  case  and  greatly  doubt  the  wisdom 
of  doing  so.  Huntington  and  some  other  surgeons  advocate  early  operation  in 
children  instead  of  simply  fixation,  extension,  and  rest.  Huntington  ("Amer. 
Jour.  Med.  Sciences,"  July,  1905)  recalls  that  when  the  lesion  is  in  the  head 
of  the  femur  it  tends  to  perforate  into  the  joint,  and  he  advises  trephining  at 
the  lower  border  and  outer  aspect  of  the  great  trochanter  and  tunnelling  the 
neck  and  head  of  the  femur  with  a  curet.  Bradford  objects  to  this  method  in 
most  cases  on  the  ground  that  unless  the  disease  is  localized  and  the  cavity  is 
well  walled  off  and  unless  injury  to  the  localizing  barrier  is  avoided,  the  opera- 
tion may  be  responsible  for  dissemination  of  the  bacteria. 

If  an  abscess  forms,  incise  it  with  the  most  thorough  antiseptic  care,  let  the 
fluid  drain  away,  irrigate  the  cavity  with  salt  solution,  remove  any  sequestra, 
inject  with  iodoform  emulsion,  sew  up  without  drainage,  and  dress  antiseptic- 
ally.  In  some  cases  the  sequestrum  is  extra-articular.  In  many  cases  no 
sequestrum  is  found.  If  this  method  fails,  drainage  must  be  employed.  The  old 
plan  of  not  operating  until  rupture  was  seen  to  be  inevitable  would  be  wrong 
to-day.  To  open  early  and  antiseptically  often  means  rapid  healing,  the  preven- 
tion of  burrowing,  a  lessened  danger  of  visceral  infection,  and  an  earlier  cure. 
In  contrast  to  what  happens  when  a  very  large  cold  abscess  is  opened,  hectic 
will  rarely  arise  when  a  tuberculous  joint  is  opened  and  drained  with  aseptic  care. 

Excision  of  the  hip  is  to  be  performed  when  there  is  a  large  sequestrum 
or  severe  fistulse  (Garre,  "Deutsch.  med.  Woch.,"  1905,  Nos.  47  and  48); 


HIP-JOINT    DISEASE. 


Plate 


I,  ■2.  Effects  on  the  Lumbar  Spine  of  Flexing:  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,4.  Positions  in  Coxalg  a  (Albert).  5.  E.xtension  in  Hip  Disease  (Treves).  6  Ex- 
tension of  the  Lirnb  in  a  Flexed  and  Adducted  Position  (Treves).  7.  Extension  of  the  Limb  in  a 
Flexed  and  Abducted  Joint  (Treves). 


Knee-joint  Disease 


631 


when  the  head  of  the  femur  is  detached  and  lies  loose  in  the  joint;  when  profuse 
suppuration  continues  for  a  long  time,  and  other  methods  fail  to  arrest  it; 
when  amyloid  disease  is  threatening;  or  when  very  faulty  position  is  inevitable 
without  operation.  Excision  is  an  operation  of  considerable  danger,  and  the 
older  the  person,  the  greater  the  danger.  Schede  advocates  arthrectomy  in 
some  cases  as  a  substitute  for  resection.  Senn  tells  us  that  opinion  as  to  resec- 
tion has  greatly  changed  of  late,  and  it  is  now  taught  that  the  operation  is 
advisable  in  all  cases  where  fixation,  extension,  intra-articular  and  parenchy- 
matous injections  have  failed  to  arrest  the  disease  (Senn,  on  "Tuberculosis  of 
Bones  and  Joints").  Resection  of  the  hip  does  not  give  a  very  satisfactory 
functional  result.  When  there  is  extensive  disease  of  the  femur,  when  excision 
has  been  tried  and  has  failed,  when  the  patient  has  not  the  recuperative  power 
to  withstand  the  long  siege  of  illness  following  excision,  or  when  there  is  amyloid 
disease,  amputate.^  Amputation  of  the  hip-joint  for  tuberculous  disease  is  a 
very  successful  procedure. 

Knee-joint  Disease  (White  Swelling). — After  the  hip,  the  knee  is,  of  all 
joints,  the  commonest  site  for  tuberculous  disease.  Knee-joint  disease  can 
begin  as  a  synovitis,  but  oftener  begins  as  tuberculous  inflammation  of  the 
femoral  or  the  tibial  epiphysis.  Tuberculous  disease  rarely  attacks  the  bone 
on  the  diaphyseal  side  of  the  epiphyseal  line;  a  single  focus  only  exists,  as  a 
rule,  and  a  sequestrum  is  seldom  formed.  In  very  rare  instances  the  patella 
or  the  semilunar  cartilage  is  primarily  attacked.  It  may  begin  at  any  age, 
but  is  most  common  in  children  and  young  adults.  If  an  acute  synovitis 
ushers  in  the  case,  there  may  be  a  large  effusion  into  the  knee-joint  and  par- 
tial flexion,  but  swelling  is  usually  slight  in  knee-joint  disease.  Pulpy  degen- 
eration of  the  synovial  membrane  occurs;  the  joint  enlarges;  the  ligaments 
soften;  the  skin  becomes  edematous,  and  muscular  spasm  exists.  The  leg 
becomes  flexed;  the  tibia  displaced  backward  and  outward;  the  foot  is  everted; 
and  lameness  arises,  due  chiefly  to  deformity.  Muscle  atrophy  is  marked 
above  and  below  the  joint.  Pain  may  be  absent,  is  often  slight,  and  is  rarely 
severe.  Local  tenderness  is  very  common.  When  the  disease  begins  in  the  bone 
or  an  epiphysis  there  are  pain,  tenderness, 
lameness,  swelling,  inability  to  extend  the 
limb  completely,  sudden  spasmodic  mus- 
cular contractions,  and  final  involvement 
of  the  joint.  When  an  abscess  forms,  it 
may  destroy  the  joint  very  rapidly  or  it 
may  break  externally. 

Treatment. — In  treating  knee-joint  dis- 
ease conservative  treatment  is  usually  tried, 
but  often  fails.  A  plan  of  doubtful  value 
is  to  make  a  mixture  of  guaiacol  and  olive 
oil  (i  :  4).  Once  a  day  the  surface  of  the 
knee  is  exposed  by  removing  dressings, 
is  painted  with  this  mixture,  and  the 
painted  surface  is  covered  with  cotton-wool. 
Rest  is  of  the  first  importance,  and  may  be 
secured  by  the  application  of  splints  (Figs. 
387,  388),  the  use  of  extension  (Fig.  389), 
or  the  employment  of  a  plaster-of-Paris 
bandage.  In  any  case  the  patient  must 
be  kept  in  bed  for  a  few  weeks;  he  may 
then  be  permitted  to  go  out  upon  crutches,  wearing  a  high-heeled  shoe  upon 
the  foot  of  the  sound  limb.  In  cases  in  which  treatment  is  begun  early  the 
1  See  the  admirable  article  by  Howard  Marsh  in  Treves's  "JSIanual  of  Surgerj'." 


Fig.    387.  —  Sayre's 
knee  splint  applied. 


Fig.  388.— Hutch- 
inson's knee-joint 
spUnt. 


632 


Diseases  and  Injuries  of  the  Bones  and  Joints 


disease  may  often  be  arrested  in  from  eight  to  twelve  months.  If  the  symp- 
toms do  not  abate  after  a  number  of  weeks,  or  if  the  condition  grows  worse  and 
caseation  occurs,  aspirate,  irrigate,  and  inject  iodoform  emulsion  or  formaUn- 
glycerin.  Intra-articular  injections  are  not  unusually  curative.  Insert  the 
needle  in  the  angle  between  the  outer  edge  of  the  patella  and  the  ligament  of 
the  patella  (De  Vos).  Repeat  the  injection  in  one  week  if  reaction  has  abated, 
and  continue  as  directed  for  the  injection  of  the  hip-joint.  If  this  plan  fails,  in- 
cise the  capsule,  remove  all  fragments  and  tuberculous  foci,  irrigate  with  normal 
salt  solution,  inject  iodoform  emulsion,  and  sew  up  without  drainage  (Neuber's 
plan).  A  more  severe  case  requires  drainage.  If  these  means  fail,  or  if  the  case 
is  too  far  advanced  to  permit  of  their  use,  open  the  joint  and  perform  an  excision 
or  an  erasion  (see  pages  697  and  703).  Excision  gives  a  satisfactory  result  in 
most  cases,  although  it  leaves  a  rigid  knee  and  marked  shortening.  Garre 
considers  any  shortening  over  5  cm.  a  bad  result,  and  he  got  such  a  bad  result 
in  7.5  per  cent,  of  his  117  cases.  In  children  shortening  follows  even  con- 
servative treatment,  and  the  shortening  which  follows  excision  is  due  in  part 
to  removal  of  bone  and  in  part  to  impairment  of  the  nutritive  power  of  the 
epiphyseal  cartilage.  Some  cases  demand  amputation,  which,  if  the  patient's 
health  is  much  impaired  or  if  amyloid  disease  exists,  is  to  be  preferred  to  ex- 
cision. Amputation  is  preferred  to  excision  in  very  young  children  and  aged 
people. 


Fig.  38g. — Sayre's  double  extension  of  the  knee-joint. 

Ankle-joint  disease  may  begin  in  the  synovial  membrane,  in  the  tibial 
epiphysis,  or  in  the  tarsus.     The  origin  is  frequently  synovial. 

The  symptoms  are  pain,  swelling,  lameness,  limitation  of  joint-movements, 
and  atrophy  of  the  calf  muscles.    Caseation  often  occurs  and  sinuses  form. 

Treatment. — Conservative  treatment  with  injections  of  iodoform  or  of  for- 
malin-glycerin will  cure  many  cases.  Rest  is  obtained  by  means  of  splints  or 
plaster-of-Paris  bandages.  Caution  the  patient  to  avoid  standing  upon  the 
diseased  extremity.  In  making  an  intra-articular  injection  insert  the  needle 
below  the  outer  malleolus.  When  caseation  occurs,  it  is  advisable  to  open 
the  joint,  wash  out  with  normal  salt  solution,  inject  iodoform  emulsion,  sew 
up  the  incision,  and  put  up  the  ankle-joint  in  plaster.  When  there  is  con- 
siderable bone  disease,  when  fistulae  exist,  when  adjacent  joints  or  tendons 
are  diseased,  or  when  joint-disorganization  occurs,  perform  an  excision  or  an 
erasion.  Some  cases  demand  amputation  (Syme's  amputation  being  preferred 
by  some,  amputation  above  the  ankle  being  approved  by  many) .  Osteoplastic 
resection  is  sometimes  advised  (Wladimiroff-Mikulicz  operation).  Operative 
treatment  is  more  satisfactory  in  children  than  in  adults  (Garre). 

Shoulder-joint  disease  is  not  common;  it  is  rare  in  children  and  is  com- 
monest in  adults;  it  may  begin  in  the  synovial  membrane,  but  usually  begins 
in  the  head  of  the  himierus.  The  glenoid  cavity  is  rarely  attacked.  Pain 
is  slight,  atrophy  of  the  deltoid  and  other  muscles  is  noted,  the  joint  is  stiff, 
and  the  scapula  follows  the  motions  of  the  humerus.    Caries  sicca  is  the  usual 


Wrist-joint  Disease  633 

cause  of  destruction.  In  many  cases  swelling  is  not  obvious,  the  joint  shrink- 
ing because  of  destruction  of  the  head  of  the  bone  and  contraction  of  the 
capsule  (Senn).  Abscess-formation  is  unusual.  If  an  abscess  forms,  it  may- 
open  in  the  axilla,  through  the  deltoid  muscle,  or  at  some  far  distant  point. 
Shoulder-joint  disease  is  frequently  complicated  by  pulmonary  tuberculosis. 

Treatment. — A  majority  of  cases  recover  by  the  use  of  consers-ative  treat- 
ment, a  stiff  joint  resulting.  Put  on  a  shoulder-cap,  apply  the  second  roller  of 
Desault,  and  hang  the  hand  in  a  sling.  Maintain  rest  for  at  least  four  months. 
Arthur  Gillette's  plan  is  very-  efficient.  It  consists  in  placing  in  the  axilla  a 
wedge-shaped  pad  with  the  base  up.  The  arm  is  allowed  to  hang.  Aspiration 
and  injection  of  iodoform  emulsion  or  of  formalin-glycerin  are  of  great  service 
in  syno\ial  tuberculosis.  In  making  an  intra-articular  injection  the  needle  is 
entered  below  the  acromion,  while  the  arm  is  held  against  the  side  and  the 
forearm  is  at  right  angles  to  the  arm  and  across  the  front  of  the  chest  (De  Vos). 
If  caseation  occiurs,  open  the  joint,  remove  tuberculous  foci,  wash  with  hot 
saline  fluid,  inject  iodoform  emulsion,  and  close  without  drainage.  In  a 
decidedly  severe  case,  drain.  Caries  sicca  may  occur.  In  rare  instances  dead 
bone  will  have  to  be  gouged  away.  Excision  is  sometimes  required,  but  the 
results  are  seldom  satisfactory. 

Elbow-joint  disease  may  begin  in  the  himierus  or  the  ulna.  The  head 
of  the  radius  is  rarely  the  primary  focus.    In  some  cases  the  synovial  mem- 


Fig.  390. — Stromej'er's  anterior  angular  splint. 

brane  is  first  attacked.  The  disease  is  most  frequent  in  young  adults.  The 
joint  is  swollen,  its  movements  are  somewhat  limited,  muscular  wasting  is  pro- 
noimced,  and  pain  is  generally  slight.    Tuberculous  pus  may  form. 

Treatment. — In  treating  early  elbow-joint  disease,  especially  in  young 
children,  conserv-ative  treatment  is  verv^  successful.  Rest  is  secured  by  means 
of  an  anterior  angular  spUnt  (Fig.  390)  and  a  triangular  sling  or  a  plaster-of- 
Paris  dressing.  Splints  are  to  be  worn  for  from  four  months  to  a  year.  Injec- 
tions of  iodoform  e*nulsion  or  formalin-glycerin  are  usually  employed.  Insert 
the  needle  for  injection  by  the  outer  side  of  the  olecranon.  In  a  ciire  by  con- 
serv^ative  methods  a  stiS  joint  "^ill  usually  result.  It  may  be  necessary  to 
perform  resection  because  of  extensive  bone  disease.  Resection  gives  an 
excellent  functional  result. 

Wrist-joint  disease  may  arise  at  any  age,  and  is  sometimes  met  T\ith  in 
late  middle  life  or  even  in  old  age.  The  joint  presents  a  puffy  swelling,  loses 
its  normal  contour,  and  becomes  spindle  shaped.  Hand-movements  are 
impaired,  pronation  and  supination  cannot  be  performed  completely  or  satis- 
factorily-, the  joint  is  stiff  and  partly  flexed,  the  grasp  is  enfeebled,  pain  may  be 
severe  or  sHght,  the  skin  is  sometimes,  but  seldom,  hot,  and  muscular  atrophy 
is  marked.  This  form  of  tuberculosis  may  begin  in  the  syno\ial  membrane, 
in  the  bones,  or  iii  the  tendon- sheaths.  The  prognosis  is  better  than  in  tuber- 
culosis of  any  other  joint.  There  is  usually  preservation  of  considerable  func- 
tion on  recover}^ 


634  Diseases  and  Injuries  of  the  Bones  and  Joints 

Treatment  is  usually  conservative  and  very  successful,  giving,  as  a  rule,  a 
functionally  useful  joint  and  movable  fingers.  Garre  recommends  a  trial  of  the 
method  even  when  there  are  fistulae  and  when  there  is  necrosis  of  the  carpus. 
Apply  a  Bond  splint  and  sling  or  put  on  a  plaster-of-Paris  bandage  and  main- 
tain strict  rest  for  from  four  to  six  months.  Aspiration  and  injection  of  iodoform 
emulsion  or  formaUn-glycerin  may  be  practised.  Enter  the  needle  at  the 
dorsal  edge  of  the  radial  styloid  process,  and  again  at  the  upper  edge  of  the 
pisiform  bone  (DeVos).  In  some  cases  it  is  well  to  incise,  wash  with  salt  solu- 
tion, inject  iodoform  emulsion,  and  close  without  drainage.  Severe  cases 
demand  incision  and  drainage  with  the  maintenance  of  rest.  Resection  is  to 
be  avoided  if  possible.  It  gives  a  bad  functional  result,  the  amount  of  bone 
removed  leaving  the  tendons  'too  long  and  contractures  of  muscles  being 
common  (Garre).  It  may  be  demanded  because  of  extensive  caries  or  se- 
questra formation.    Amputation  is  occasionally  necessary. 

Non-tuberculous  Arthritis. — Most  of  these  cases,  acute  and  chronic,  are 
of  infectious  origin.  Some  of  them  are  non-infectious.  Among  the  non-infect- 
ive forms  are  the  joint  lesions  of  locomotor  ataxia  and  syringomyelia — con- 
stitutional conditions,  as  gout,  purpura,  hemophilia,  and  scurvy — functional 
derangements  expressed  by  articular  neuralgia  or  intermitting  hydrops  and 
traimiatic  states  (Hofifa,  in  "Zentralbl.  f.  Chir.,"  xxxiv,  1907;  and  Bloodgood, 
in  "Progressive  Medicine,"  Dec.  i,  1907). 

Traumatic  Arthritis. — This  may  be  due  to  a  single  injury  (a  sprain  or  a 
bruise)  or  to  some  continuing  cause  (genu  valgum  may  cause  arthritis  of  the 
knee;  flat-foot  may  be  responsible  for  arthritis  of  the  knee  or  hip). 

If  a  contusion  or  sprain  causes  relaxation  of  the  capsule  or  fixing  tendons, 
the  joint  becomes  loose  and  injures  itself  again  and  again  during  movement. 
It  does  the  same  thing  when  there  are  loose  bodies  or  enlarged  synovial  fringes. 
Traumatic  arthritis  usually  involves  but  one  joint.  Recent  traumatic  arthri- 
tis is  treated  by  protecting  the  joint,  massage,  hot  air,  and  passive  motions. 

If  a  continuing  cause  is  present  it  is  to  be  removed.  Distant  causes  may 
be  removed  by  orthopedic  apparatus  or  by  operation.  Causes  within  the  joint 
may  be  sought  for  by  arthrotomy,  and  when  found  they  should  be  removed. 
For  instance,  in  the  knee,  inflamed  synovial  fringes  may  be  responsible  for 
chronic  inflammation.  They  get  caught  between  the  joint  surfaces,  are 
squeezed,  and  trip  the  victim.  They  should  be  removed.  Lockwood  ("Brit. 
Med.  Jour.,"  July  3,  1909)  points  out  that  an  overgrowth  of  fat  may  get 
between  the  tibia  and  femur  and  be  squeezed.  This  surgeon  calls  attention 
to  the  fact  that  there  are  "adipose  pads  immediately  above  the  articular  sur- 
face of  the  femur,  and  on  either  side  of  the  upper  end  of  the  patella"  (Ibid.). 
He  calls  them  the  pads  of  Malgaigne,  after  the  French  surgeon  who  described 
them  in  1859.  If  they  are  subject  to  repeated  traumatism  they  should  be 
removed. 

Infective  Arthritis. — In  this  condition  the  inflammation  is  due  to  bac- 
teria. In  some  cases  pus  forms  and  pyogenic  bacteria  are  demonstrable  in 
fluid  removed  by  aspiration.  In  other  cases,  perhaps  exhibiting  as  acute 
symptoms,  no  pus  forms  and  no  bacteria  are  demonstrable  in  the  fluid  removed 
by  aspiration.  The  latter  cases  are  due  to  toxins  or  to  bacteria  of  attenuated 
virulence.  Secondary  infection  may  occur.  In  most  cases  the  disease  is  poly- 
articular, but  if  a  woimd  is  causal  the  arthritis  will  be  monarticular.  The 
bacteria  may  reach  a  joint  by  way  of  a  wound  from  an  adjacent  focus  of  osteo- 
myelitis, from  a  near  or  distant  area  of  infection,  from  the  genito-urinary 
tract,  or  by  way  of  the  tonsils.  Bacteria  not  directly  introduced  into  the  joint 
reach  it  by  way  of  the  blood  or  lymph. 

The  disease  may  arise  during  the  course  of  gonorrhea  or  any  infectious 
process.    It  may  arise  when  no  area  of  infection  can  be  discovered.    It  may 


Pyogenic  or  Acute  Suppurative  Arthritis  635 

arise- in  the  course  of  an  acute  infectious  disease  (such  as  er\-5ipelas.  t>phoid 
fever,  pneumonia,  influenza,  mumps,  dysentery,  diphtheria,  measles,  scarlatina, 
variola),  and  may  be  due  to  pyogenic  cocci,  to  the  specific  micro-organism  of 
the  acute  infectious  disease,  or  purely  to  microbic  products.  Joint  inflam- 
mation arising  in  the  course  of  or  as  a  sequel  to  an  acute  infectious  disease 
may  or  may  not  suppurate. 

Symptoms. — If  no  suppuration  takes  place,  the  symptoms  of  the  attack 
resemble  those  of  rheumatism:  if  suppuration  occurs,  the  s}'mptoms  are  the 
same  as  those  of  acute  suppurative  arthritis,  with  which  disease  this  form  of 
infective  arthritis  is  identical.  Suppuration  rarely  occurs.  Ashby  has  well 
described  the  arthritis  which  sometimes  follows  scarlatina.  It  involves  the 
■\\Tists,  flnger-joints,  tendons  of  the  forearms,  the  knees,  ankles,  or  spine. 
The  joints  are  painful,  but  are  rarely  much  swollen  or  discolored  (Howard 
Marsh).  We  can  distinguish  infective  arthritis  from  rheimiatism  by  the 
fact  that  it  does  not  migrate  and  is  uninfluenced  by  antirheumatic  remedies. 
Dislocation  may  follow  the  acute  manifestations  of  im"ective  arthritis.  In  the 
hip  it  may  simulate  congenital  misplacement. 

Treatment. — In  ever}'  case  in  which  we  suspect  the  condition,  diagnostic 
aspiration  is  penormed.  If  the  fluid  obtained  contains  bacteria  ]Murphys 
formalin  and  glycerin  should  be  injected  [2  per  cent.).  The  mixture  must  be 
at  least  twenty-four  hours  old.  In  many  cases  this  treatment  is  of  the  greatest 
value.  If  aspiration  and  injection  fail,  arthrotomy  and  irrigation  are  indi- 
cated. In  aU  chrdcaUy  severe  cases  and  in  aU  prolonged  cases,  open  and  irri- 
gate, first  with  corrosive  sublimate  solution  (i  :  1000),  then  with  normal  salt 
solution.  Recent  cases  which  are  not  ver}-  acute  and  are  free  from  pus  ma}-  be 
closed  "without  drainage. 

Pyogenic  or  Acute  Suppurative  Arthritis. — This  condition  is  a  form  of 
infective  arthritis  and  is  usually  due  to  the  Staphylococcus  pyogenes  aureus  or 
to  the  Streptococcus  pyogenes,  which  find  entrance  by  means  of  a  wound,  by 
the  spontaneous  evacuation  into  a  joint  of  the  products  of  an  osteomyelitis, 
by  extension  of  suppurative  inflammation  through  contiguous  structures,  or 
by  the  blood-stream.  It  is  necessar}-  to  remember  that  causative  bacteria 
may  have  entered  the  blood  or  hinph  at  a  point  near  to  or  distant  from  the 
joint  (tonsils,  ethmoid  cells,  urethra,  a  focus  of  osteomyehtis,  puerperal  sepsis, 
etc.).  Of  course,  a  wound  into  a  joint  may  be  the  open  gateway  for  infection. 
A  traiunatism  may  create  a  point  of  least  resistance  and  bacteria  may  be  de- 
rived from  the  blood  or  h-mph.  It  is  not  ven,-  unusual  for  traumatic  arthritis 
to  eventuate  in  pyogenic  arthritis.  Particularly  in  youths  and  young  children 
the  5}-mptoms  of  arthritis  may  overlie  and  hide  a  causative  osteomyehtis. 
Sometimes  gonorrhea  is  the  cause  and  in  rare  cases  septicemia  is  causal.  In 
pyogenic  arthritis  all  the  joint-structures  are  invoh^ed  and  suppuration  rapidly 
appears.  S}Tio\i.al  membrane  is  converted  into  granulation  tissue  and  cartilage 
is  destroyed  by  pus.  The  greater  the  intensity  of  the  inflammation,  the  larger 
the  amoimt  of  graniflation  tissue,  hence,  ultimately,  the  greater  the  amount  of 
scar  tissue  and  the  greater  impairment  of  joint  fimction. 

The  symptoms  of  acute  suppurative  arthritis  are  usually  a  chiU  followed 
by  fever  and  a  rapid  piflse.  There  are  severe  pain,  which  is  aggravated  by 
motion  and  is  worse  at  night:  discoloration,  heat,  and  edema  of  the  skin:  partial 
flexion  of  the  joint:  fluctuation,  and  marked  constitutional  s}'mptoms  of  sepsis. 
The  joint  tends  to  rapid  disorganization,  and  fatal  septicemia  is  ver}-  apt  to 
occur.     In  pyemic  arthritis  several  joints  become  infected. 

Treatment. — In  even.-  suspicious  case  immediately  aspirate.  If  bacteria 
are  found  in  the  aspirated  fluid,  at  once  open  the  joint  [arthrotomy)  and  ir- 
rigate it  with  corrosive  subHmate  solution  ( i  :  1000)  and  then  with  salt  solution. 
In  early  cases  which  are  not  ver}-  \iolent  formaUn-glycerin  may  be  injected. 


636  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  wound  closed,  and  the  limb  immobilized  after  the  operation.  In  a  late 
case  or  a  violent  case,  drain  by  rubber  tissue.  Always  be  sure  whether  or 
not  arthritis  is  the  result  of  osteomyeHtis.  If  osteomyelitis  exists  the  area 
of  bone  disease  must  also  be  operated  upon,  x^rthritis  due  to  staphylococci 
and  streptococci  is  often  secondary  to  bone  suppuration.  If  a  periosteal  ab- 
scess exists  the  joint  condition  is  almost  certainly  secondary.  If  osteomyeUtis 
exists  it  requires  prompt  and  radical  treatment  (see  page  507).  In  advanced 
cases  invohdng  the  knee  Allen  and  Alden  ("Surg.,  Gynecol.,  and  Obstet.,"  July, 
1909)  open  the  joint  by  a  transverse  incision  below  the  patella,  disinfect  with 
pure  carbolic  acid  followed  by  alcohol,  and  pack  \\dth  iodoform  gauze.  I 
would  onl}^  regard  this  as  justifiable  in  advanced  and  very  severe  cases,  as  it 
is  sure  to  be  followed  by  ankylosis.  Although  in  late  cases  which  recover  after 
arthrotomy  and  irrigation  there  is  always  more  or  less  ankylosis,  many  cases 
treated  early  recover  without  serious  impairment  of  joint  function.  Early 
arthrotomy  is  of  the  utmost  importance,  and  if  the  aspirated  fluid  contains 
bacteria  we  should  never  postpone  operation  or  hold  it  in  reserve  while  we 
employ  Bier's  hyperemic  or  any  other  conservative  method.  RadicaHsm  is 
here  the  course  which  promises  the  greatest  safety,  and  the  surest  retention 
of  joint  function. 

Typhoid  Arthritis. — This  disease  is  a  form  of  infective  arthritis.  That 
the  bacteria  of  t^^Dhoid  may  inflame  the  joints  is  proved,  and  it  seems  certain 
that  they  can  cause  suppuration,  although  their  pyogenic  power  has  been 
disputed.  Some  claim  that  mixed  infection  is  the  real  cause  of  pus  formation 
in  a  typhoid  joint.  The  tj^Dhoid  bacilli  enter  the  bones  in  many  t\^hoid  cases 
and  sometimes  cause  osteomyelitis.  Joint-disease  is  more  common  than  bone- 
disease.  Typhoid  disease  of  a  joint  begins  when  the  fever  is  abating,  and 
more  than  one  joint  may  be  involved.  T}'phoid  joints  may  recover  perma- 
nently, may  become  ankylosed,  may  dislocate,  or  the  joint-disease  may  lead 
to  fatal  sepsis.  In  most  cases  the  joints  recover.  In  slight  cases  the  synovial 
membrane  only  is  involved;  in  more  severe  cases  capsule,  cartilages,  ligaments, 
and  even  bones  are  involved.  Some  cases  suppurate.  Septic  tx-phoid  arthritis 
may  result  from  a  mixed  infection  ^^ith  typhoid  bacilli  and  pyogenic  bacteria, 
and  is  identical  in  symptoms  and  progress  with  ordinary  septic  arthritis. 
Typhoid  arthritis  proper  may  be  monarticular  or  polyarticular,  the  mon- 
articular form  being  the  most  common,  and  the  hip-joint  being  the  articu- 
lation most  Hable  to  be  attacked.  In  most  cases  typhoid  arthritis  causes 
little  pain.  The  swelling  is  marked,  although  in  the  hip  it  is  concealed.  Pus 
rarely  forms.  Keen  calls  attention  to  the  fact  that  in  the  84  cases  of  typhoid 
arthritis  which  he  collected  spontaneous  dislocation  occurred  in  43,  nearly  aU. 
in  the  hip.^  Fluid  from  a  typhoid  joint  may  be  sterile  (bacteria  haA-ing  died), 
may  show  mixed  infection,  or  may  give  a  pure  culture  of  typhoid  bacilli  (A. 
G.  Ellis,  in  "Jour,  of  Infectious  Diseases,"  April  i,  1909). 

Treatment. — A  mild  case  is  treated  as  a  simple  syno\dtis.  If  diagnostic 
pimcture  obtains  fluid  free  from  bacteria,  no  more  radical  method  than  aspira- 
tion and  irrigation  is  required.  If  the  fluid  contains  bacteria,  inject  formalin- 
glycerin.  If  this  fails,  incision  and  drainage  are  demanded.  In  some  cases  an 
autogenous  vaccine  appears  to  be  of  ser\ace,  in  others  it  fails  utterly. 

Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism. — During  the  prog- 
ress of  gonorrhea  the  development  of  a  painful  joint  does  not  of  necessity 
prove  the  existence  of  gonorrheal  rheumatism,  for  ordinary  rheumatism  is 
just  as  likely  to  arise  when  a  man  has  clap  as  when  he  has  not  this  malady. 
Furthermore,  the  term  is  inaccurate,  as  gonorrheal  rheumatism  is  not  rheu- 
matism at  all,  but  is  an  infective  disorder  of  the  joints  or  of  the  s}Tio\dal 
membranes,  the  infective  material  being  contained  primarily  in  the  mrethral 
1  Keen  on  "The  Surgical  Complications  and  Sequels  of  Tj-phoid  Fever." 


Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism  637 

discharge.  Gonorrheal  arthritis  is  one  of  the  forms  of  infective  arthri- 
tis. Occasionally  this  form  of  arthritis  arises  from  gonorrheal  ophthalmia 
(Heiman's  case);  it  sometimes,  though  rarely,  arises  during  the  height  of 
a  gonorrhea,  but  it  is  more  frequently  met  with  in  chronic  cases  or  when 
the  intensity  of  the  inflammation  is  abating  in  acute  cases.  Men  suffer 
from  gonorrheal  arthritis  far  more  frequently  than  do  women,  and  the  seizure 
is  very  apt  to  recur  again  and  again.  In  some  cases  many  joints  are  involved, 
but  in  most  cases  only  a  few  joints  suffer.  Osier  states  that  the  knees  and 
ankles  are  most  apt  to  be  involved  in  gonorrheal  rheumatism,  and  that  this 
form  of  arthritis  is  peculiar  in  often  attacking  joints  that  are  usually  exempt 
in  acute  rheimiatism  ("the  sternoclavicular,  the  intervertebral,  the  tem- 
poromaxillary,  and  the  sacro-iHac").  There  are  two  forms  of  gonorrheal 
rheumatism — an  acute  and  a  chronic  form.  The  poison  reaches  the  joint 
by  way  of  the  blood.  In  some  cases  gonococci  are  found  in  the  joint  fluid; 
in  other  cases  they  are  not  found.  I  am  inclined  to  believe  that  in  the  milder 
cases,  which  recover  without  genuine  pus  formation,  only  toxins  are  present 
in  the  joint.  In  the  severe  cases  the  organisms  themselves  exist  in  the  articu- 
lar fluid.  Osier  suggests  that  the  non-suppurative  cases  are  due  to  the  action 
of  toxins  taken  up  from  the  area  of  primary  infection,  and  that  the  suppura- 
tive cases  are  due  to  infection  with  pyogenic  bacteria.  Endocarditis  may 
occur,  and  it  is  due  to  micro-organisms  and  not  to  toxins. 

Changes  In  and  About  the  Joint. — The  inflammation  of  gonorrheal  arthritis 
may  be  located  around  rather  than  in  the  joint,  and  especially  in  the  ten- 
don-sheaths. Suppuration  is  unusual,  but  it  may  occur  in  joints  and  in 
tendon-sheaths.  Cultures  of  the  exudate  may  or  may  not  show  the  gono- 
cocci. Cover-glass  preparations  carefully  stained  may  or  may  not  show 
gonococci. 

Symptoms. — The  acute  form  attacks,  as  a  rule,  but  a  single  joint,  but  may 
attack  several  joints.  The  joint  trouble  begins  wdth  great  suddenness,  and 
is  often  ushered  in  by  chilly  sensations  or  by  a  distinct  chill.  Moderate 
fever  arises.  The  pain  in  the  joint,  severe  from  the  first,  becomes  excruciat- 
ing. If  superficial  joints  sufl"er,  the  skin  over  them  becomes  red  and  hot,  and 
periarticular  edema  soon  presents  itself.  The  fluid  in  the  joint  is  in  most 
cases  serous,  but  may  become  purulent.  If  pus  forms,  the  fever  becomes 
very  high  and  chills  may  occur. 

A.  chronic  condition  may  follow  the  acute,  but  the  condition  may  be 
chronic  from  the  start.  The  symptoms  resemble  those  of  the  acute  form, 
but  are  far  milder,  although  acute  exacerbations  may  occur.  The  joint  fluid 
is  usually  serous.^  In  gonorrheal  arthritis  there  may  be  transitory,  inter- 
mittent, and  wandering  pain  in  and  about  the  joint,  without  any  other  symp- 
tom; one  or  more  joints  may  become  swollen  and  painful,  and  moderate 
fever  may  develop.  One  joint,  especially  the  knee,  may  swell  to  an  enormous 
extent,  pain,  periarticular  edema,  redness,  and  fever  being  absent  (hydrar- 
throsis, or  dropsy  of  the  joint).  Suppuration  in  this  form  of  the  disease  sel- 
dom occurs.  The  tendons,  the  tendon-sheaths,  the  burs£e,  and  the  periosteum 
may  inflame.  Whether  the  joints  are  inflamed  or  not  inflamed,  the  tendon- 
sheaths  about  the  wTist  and  ankle  and  the  retrocalcaneal  bursae  may  suffer. 
In  some  cases  numerous  bursse  are  involved.  It  is  often  difficult  and  is  per- 
haps impossible  to  check  gonorrheal  arthritis.  It  may  last  for  a  long  period, 
and  tends  to  recur  again  and  again.  Iritis,  periostitis,  pleuritis,  endocarditis, 
and  pericarditis  have  been  observed  as  complications. 

The  diagnosis  between  gonorrheal  arthritis  and  acute  rheiunatism  rests 
chiefly  on  the  great  chronicity,  the  lesser  degree  of  fever,  the  excessive  tend- 
ency to  recurrence,  and  the  absence  of  profuse  acid  sweats  in  gonorrheal 
1  See  Schuller,  in  "Aertztl.  Pract.,"  No.  17,  1896. 


638  Diseases  and  Injuries  of  the  Bones  and  Joints 

arthritis;  and  on  the  shorter  course,  the  higher  fever,  the  profuse  acid 
sweats,  the  lesser  tendency  to  rapid  recurrence,  the  greater  proneness  to 
symmetrical  involvement,  and  the  great  liability  to  cardiac  and  visceral 
complications  in  rheumatic  fever.  Furthermore,  in  gonorrheal  arthritis  a 
gonorrheal  infection  (urethral  or  ocular)  certainly  exists  or  recently  existed; 
in  ordinary  rheumatism  a  urethral  discharge  may,  of  course,  happen  to  be 
present.  Gonorrheal  arthritis  is  apt  to  affect  certain  joints  which  acute 
rheumatism  seldom  attacks. 

Treatment. — Because  of  the  lingering  character  and  dangerous  nature  of 
gonorrheal  arthritis  and  because  if  unchecked  it  is  Hable  to  produce  grave  im- 
pairment of  function,  treatment  should  be  prompt  and  radical,  as  advocated 
by  Halsted  many  years  ago.  The  joint  should  be  aspirated  and  if  the  fluid 
obtained  contains  gonococci  or  any  pyogenic  bacteria,  formalin-glycerin  should 
be  injected.  If  this  fails,  the  joint  should  be  opened  and  irrigated.  If  pus  is 
absent  and  the  case  not  very  violent,  the  joint  may  be  injected  with  formaUn- 
glycerin  and  the  wound  can  be  closed  without  drainage.  If  pus  is  found  by 
incision,  irrigate,  drain,  and  immobilize.  In  cases  free  from  pus  Bier's  treat- 
ment is  of  value  (see  page  112).  Drug  treatment  is  of  little  value  in  gono- 
coccal arthritis.  The  salicylates,  the  alkalis,  and  salol  are  useless;  iron,  arsenic, 
and  strychnin  are  possibly  of  some  benefit.  Quinin  is  thought  to  be  helpful  in 
some  cases.  Large  doses  (i  dram)  of  syrup  of  iodid  of  iron  are  given  by  some 
clinicians,  associated  with  tonic  doses  of  corrosive  sublimate.  Iodid  of  potas- 
sium seems  to  be  of  a  certain  amount  of  value.  The  inflamed  joints  are  usually 
wrapped  in  cotton  and  bandaged,  and  every  day  a  little  blue  ointment  is 
rubbed  into  the  skin  about  them.  If  the  inflammation  lingers,  it  is  customary 
to  use  the  hot-air  oven,  massage,  and  gentle  passive  motion,  to  apply  blisters, 
or  to  counterirritate  with  the  hot  iron.  The  object  in  this  stage  is  to  absorb 
infiltrations  and  adhesions  and  thus  lessen  stiffness.  Early  passive  motion 
allays  reflex  muscular  contractures,  combats  atrophy,  and  prevents  adhesion 
(see  Bier  and  Baetzner,  in  "Practitioner,"  June,  1912).  It  is  thought  by  some 
competent  clinicians  that  antigonococcic  serum  possesses  distinct  value,  greatly 
alleviating  pain  and  favoring  the  restoration  of  joint  mobility.  My  experience 
with  it  is  as  yet  too  insignificant  to  justify  me  in  expressing  an  opinion. 

The  value  of  vaccine  treatment  is  estimated  highly  by  some,  but  many  have 
obtained  no  beneficial  results. 

Pneumococcus  Arthritis. — This  is  a  rare  condition,  although  Herrick 
collected  52  cases  ("Amer.  Jour,  of  Med.  Sciences,"  July,  1902).  Exami- 
nation of  the  blood  may  or  may  not  discover  pneimiococci,  and  pneumo- 
cocci  may  be  found  in  the  blood  during  pneumonia,  when  the  joints  are  free 
from  disease.  The  inflammation  may  attack  any  joint,  but  is  most  apt  to 
arise  in  a  joint  weakened  by  previous  injury  or  damaged  by  rheumatism  or 
gout.  Alcoholics  are  more  prone  to  suffer  than  others.  In  a  great  majority 
of  cases  the  disease  is  associated  with  lobar  pneumonia,  but  Cole's  case  proves 
that  the  lung  may  be  free  ("American  Medicine,"  May  31,  1902).  As  a 
rule,  a  single  large  joint  is  attacked,  and  the  knee  is  most  liable  to  suffer. 
The  synovial  membrane  alone  may  be  involved  or  cartilages  may  suffer 
and  bone  be  attacked.  The  fluid  may  be  serous,  but  is  usually  purulent 
(Herrick).  I  have  seen  2  cases:  in  i  case  the  knee  only  was  involved;  in 
the  other,  both  knees,  one  elbow,  and  one  shoulder  were  attacked.  In  Cole's 
series  of  41  cases,  13  exhibited  involvement  of  more  than  one  joint.  The 
inflamed  joint  is  frequently  completely  destroyed.  Pneumococcus  arthritis 
develops,  as  a  rule,  soon  after  the  crisis  of  pneumonia,  but  Herrick  says  it  may 
arise  as  late  as  three  weeks  after  the  crisis. 

The  diagnosis  is  made  by  the  history  of  pneumonia,  the  development 
of  septic  symptoms,  and  the  signs  of  joint  inflammation.     It  is  confirmed 


Chronic  Rheumatism  639 

by  aspiration  and  examination  of  the  fluid.  The  disease  is  very  fatal.  In 
Herrick's  series  of  cases  over  65  per  cent,  were  fatal.  In  Cole's  series  of 
cases  there  were  28  deaths  and  13  recoveries.  Even  if  the  patient  recovers, 
the  convalescence  is  prolonged  and  more  or  less  ankylosis  is  to  be  expected. 

Treatment. — A  non-purulent  effusion  may  be  treated  by  aspiration  if  bacteria 
are  not  found  in  the  fluid.  If  the  aspirated  fluid  contains  bacteria,  formalin- 
glycerin  is  injected.  If  this  fails,  or  if  pus  is  present,  the  joint  should  be 
opened  and  drained. 

Syphilitic  Arthritis. — (See  pages  326  and  331.) 

Acute  Rheumatic  Arthritis;  Rheumatic  Fever  or  Acute  Rheumatism. 
— Acute  rheumatism  is  a  self-limited  febrile  malady  whose  characteristic 
features  are  polyarthritis,  profuse  acid  sweats,  and  a  tendency  to  heart  in- 
volvement. There  is  some  evidence  to  indicate  that  acute  rheumatism  is 
a  form  of  infective  arthritis,  the  bacteria  being  deposited  in  the  synovial 
tissues  and  later  perhaps  entering  into  the  joint  cavity.  Arthritis  of  many 
joints  has  followed  intravenous  injection  into  anirnals  of  diplococci  obtained 
from  the  throat  of  a  man  suffering  from  rheumatic  angina  (Poynton  and  Paine 
at  Manchester  meeting  of  the  Brit.  Med.  Assoc,  1902).  John  O'Conor^ 
believes  that  acute  rheumatism  is  a  condition  "something  similar  to  gon- 
orrheal arthritis  and  pyemia,  the  germ  or  toxin  gaining  admission  to  the 
body  through  the  tonsil  or  other  microbic  trap-door,  and  that  the  joint  inva- 
sion is  promptly  followed  by  a  form  of  infective  arthritis  accompanied  with 
general  toxemia;  and,  furthermore,  the  infected  joints  serve  as  incubators, 
where  the  poison  is  elaborated  and  passed  into  the  circulation  and  thus  con- 
veyed to  other  articulations  and  to  the  heart." 

Symptoms  of  Acute  Rheumatism. — In  acute  rheumatism  the  case  begins 
with  malaise  and  fever,  and  one  or  more  joints  become  affected.  The  in- 
flammation spreads  from  joint  to  joint,  is  apt  to  be  symmetrical,  and  when 
it  arises  in  fresh  joints,  usually  disappears  quickly  in  those  previously  affected. 
The  temperature  is  high,  the  skin  sweats  profusely,  the  joints  are  red,  swollen, 
hot,  and  excruciatingly  painful,  and  the  structures  about  the  joints  are  edema- 
tous. After  a  short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions.  Suppuration 
does  not  take  place.  Anemia  is  pronounced,  exhaustion  is  profound,  the 
sweat  is  sour,  the  saliva  is  acid;  the  urine  is  acid,  scanty,  high  colored,  often 
contains  albumin,  and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to 
be  produced  (endocarditis,  pericarditis,  or  myocarditis).  Nodules  may  form 
upon  fibrous  structures,  hyperpyrexia  is  not  unusual,  and  cerebral  or  pul- 
monary complications  may  occur. 

The  treatment  of  acute  rheumatism  comprises  the  use  of  alkalis,  salic- 
ylates, etc.  (See  a  book  upon  practice  of  medicine.)  O'Conor  is  a  believer 
in  incising  and  draining  the  inflamed  joints;  and  if  the  theory  of  an  infective 
origin  is  correct,  this  treatment  is  rational.  I  have  never  ventured  to  do  it, 
but  would  consider  the  advisabiHty  of  doing  so  if  the  ordinary  treatment 
proved  futfle.  O'Conor  operates  early  and  believes  that  this  is  the  real  way 
to  arrest  the  disease  and  prevent  compHcations,  but  his  views  have  not  met 
with  general  acceptance.^ 

Chronic  rheumatism  sometimes  follows  repeated  attacks  of  acute  rheu- 
matism, but  oftener  arises  insidiously  in  people  who  have  been  exposed 
to  cold  and  damp,  who  have  suffered  from  poverty,  hardship,  and  privation, 
or  have  had  much  worry.  The  capsule  and  tendon-sheaths  thicken,  and 
there  is  usually  but  little  effusion  into  the  joint,  but  the  articulation  becomes 
stiff  and  painful.  The  joint-cartilages  are  occasionally  eroded.  Muscular 
atrophy  occurs. 

'  "Lancet,"  Jan.  24,  1903.  ^Ibid. 


640  Diseases  and  Injuries  of  the  Bones  and  Joints 

Symptoms  of  Chronic  Rheumatism. — In  chronic  rheumatism  the  affected 
joints  are  stiff  and  painful  and  are  a  little  swollen,  but  not  red.  Dampness 
and  cold  aggravate  the  symptoms.  One  joint  or  many  may  be  affected, 
but  usually  several  are  involved.  Passive  movements  cause  the  joint  to 
creak  and  develop  crepitus  in  the  tendon-sheaths.  The  muscles  are  wasted. 
Anemia  is  usually  pronounced.  The  smaller  blood-vessels  become  sur- 
rounded by  fibrous  tissue  which  progressively  contracts  and  lessens  the  blood- 
supply  of  the  synovial  structures.  The  joints  may  ankylose.  There  is  no 
fever  and  no  tendency  to  suppuration,  and  the  disease  is  incurable. 

Treatment. — In  chronic  rheumatism  maintain  the  general  health  of  the 
patient,  give  courses  of  iron,  arsenic,  and  strychnin,  and  an  occasional 
course  of  iodid  of  potassium  or  a  salt  of  lithium,  and,  if  possible,  send  him 
every  winter  to  a  warm  climate.  Turkish  baths  give  considerable  temporary 
relief.  The  waters  and  regimen  of  Carlsbad  and  Vichy  are  of  positive 
though  temporary  benefit,  and  the  sufferer  may  obtain  relief  at  the  hot 
springs  of  Virginia.  The  patient  must  avoid  damp  and  must  wear  woolens. 
Frictions,  the  douche,  massage,  flying  blisters,  counterirritation  with  the  hot 
iron,  ichthyol  ointment,  and  mercurial  ointment  are  of  benefit.  Subjecting 
the  diseased  joint  to  a  very  high  temperature  by  placing  it  daily  in  a  hot-air 
apparatus  often  does  great  good.  The  pains  of  chronic  rheumatism  may  be 
greatly  benefited  by  the  plan  communicated  to  me  by  Dr.  J.  T.  Rugh.  He 
makes  a  mixture  of  14  min.  of  glycerin,  14  min.  of  sterile  water,  and  i  gr.  of 
crystallized  carbolic  acid.  This  is  injected  at  two  points,  about  the  articulation 
and  in  the  extracapsular  structures.  As  soon  as  an  injection  has  been  made 
the  area  must  be  vigorously  rubbed  to  diffuse  the  fluid  and  prevent  sloughing. 
The  joint  must  be  kept  at  rest  for  three  days.  Injections  can  be  repeated  at 
intervals  of  five  days.  In  partial  ankylosis  it  is  proper  in  some  cases  to  give 
ether  and  break  up  the  adhesions. 

Gouty  arthritis,  which  appears  especially  in  the  smaller  joints  (as  the 
fingers  and  the  metatarsophalangeal  joints  of  the  great  toes),  is  due  to  a 
deposition  of  urate  of  sodium  in  the  joint  and  in  the  periarticular  structures. 
The  irritant  urate  of  sodium  causes  inflammation,  inflammation  leads  to  the 
formation  of  granulation  tissue,  granulation  tissue  is  converted  into  fibrous  tis- 
sue, and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint  and  limits  its 
mobility.     A  great  mass  of  urates  clinging  to  a  joint  constitutes  a  chalk-stone. 

Symptoms. — The  premonitory  symptoms  may  be  observed  for  a  day  or 
so,  but  the  acute  seizure  usually  occurs  early  in  the  morning,  the  patient, 
as  a  rule,  being  aroused  by  excruciating  pain  in  the  metatarsophalangeal 
articulation  of  one  of  the  great  toes.  The  joint  swells,  and  the  skin  over 
it  feels  hot  to  the  touch  and  becomes  red  and  shiny.  There  is  often  consider- 
able fever.  After  a  few  hours  the  intensity  of  the  seizure  abates,  only  to  recur 
again  with  renewed  violence  early  the  next  morning,  these  remissions  and 
recurrences  taking  place  during  six  or  eight  days,  until  the  attack  subsides. 
In  patients  with  chronic  gout  many  joints  are  stiffened  and  deformed  as  a  result 
of  repeated  attacks.  Chalk-stones  form,  and  the  skin  above  them  may  ulcer- 
ate. Such  patients  are  chronic  dyspeptics,  have  high-tension  pulses,  their 
hearts  are  hyper trophied,  and  their  urine  contains  albumin  and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician,  and  not  to  the 
surgeon,  although  to  the  latter  the  symptoms  of  the  disease  should  be  known, 
so  that  it  may  be  diagnosticated  from  other  maladies. 

Osteo-arthritis  {Rheumatoid  Arthritis;  Arthritis  Deformans;  Rheumatic 
Gout). — In  this  disease,  which  is  not  a  combination  of  gout  and  rheumatism^ 
the  synovial  membrane  and  cartilages  are  affected,  the  periarticular  struc- 
tures are  involved,  and  masses  of  new  bone  are  formed. 

Osteo-arthritis  possibly  has  in  certain  cases,  as  John  K.  Mitchell  long  ago 


Osteo-arthritis  641 

pointed  out,  a  nervous  origin.  It  arises  especially  in  persons  who  have  been 
worried,  driven,  and  harassed.  There  is  apt  to  be  muscular  atrophy,  trophic 
lesions  of  the  hair  and  nails  are  likely  to  appear,  and  the  symptoms  are  disposed 
to  be  sA-mmetrical.  The  causative  lesion  has  not  been  determined.  The  con- 
dition is  now  generally  regarded  as  of  toxic  origin.  The  foci  of  infection  mav 
lie  in  any  part  of  the  body,  but  are  most  frequent  in  the  tonsil,  accessors-  sinuses 
of  the  nose  and  nasopharynx,  the  middle  ear,  the  bronchial  glands,  the  mesen- 
teric glands,  and  the  intestines,  especially  the  large  intestine.  The  disease  is 
commoner  in  women  than  in  men.  The  greatest  liability  exists  between  the 
ages  of  twenty  and  forty,  but  children  may  acquire  the  disease,  and  it  may 
also  be  developed  in  people  far  beyond  middle  life.  Apes  in  capti^•ity  may  de- 
velop it.  Arthritis  deformans  may  attack  the  rich  or  the  poor;  it  does  not  result 
from  gout,  nor  does  it  often  follow  rheumatism ;  it  is  not  caused  by  damp  and 
cold,  and  only  in  rare  cases  does  it  arise  after  traumatism  of  a  joint. 

Osteo-arthritis  differs  from  gout  in  the  entire  absence  of  urate  deposit, 
and  it  differs  from  chronic  rheumatism  in  the  extensive  alterations  in  the 
joint  structures.  The  changes  begin  m  the  cartilage;  the  cartilage-cells 
multiply,  the  intercellular  substance  degenerates,  the  pressure  of  the  bone 
causes  thinning,  and  at  length  the  cartilage  is  entirely  destroyed  and  the  bone 
exposed.  The  exposed  bone  is  altered  in  shape,  is  hardened,  and  is  worn  away 
in  the  center,  the  periphery'  increasing  iii  thickness  by  ossific  deposit,  the  center 
deepening  by  absorption.  The  margins  are  not  only  thickened,  but  are  bulged 
and  lengthened  by  deposit.  The  fringes  of  the  syno\'ial  membrane  h}-per- 
trophy  and  multiply,  and  some  of  them  are  apt  to  break  oft"  (loose  cartilages). 
The  capsule  and  the  ligaments  of  the  joints,  as  a  rule,  become  fibrous  and  con- 
tract; but  they  may  soften,  relax,  and  permit  of  dislocation.  The  joint  usually 
contains  no  effusion,  but  in  some  cases  there  is  great  effusion  [hydrarthrosis). 
The  tendons  about  the  joint  may  become  fibrous  and  contracted,  they  may 
ossify,  they  may  be  separated  from  the  bone,  or  they  may  be  destroyed  entireb'. 
Deformity  is  marked  and  motion  is  limited.  The  fingers,  when  involved,  show 
nodules  on  the  sides  of  the  joints  (Heberden's  nodules).  The  vertebrae  may 
be  involved.     .Almost  all  the  joints  may  suft'er.     Suppuration  does  not  occur. 

Symptoms. — Charcot  di\-ides  osteo-arthritis  into  three  forms,  and  gives 
their  s}Tnptoms,  as  foUows: 

1.  Heberden's  nodosities,  which  condition  is  commoner  m  women  than  in 
men,  visually  begins  between  the  ages  of  thirty  and  forty,  and  is  especially 
common  in  neurotic  subjects.  The  interphalangeal  joints  become  the  ^•ictims 
of  attacks  of  moderate  swelling  and  of  some  tenderness,  which  attacks  are 
not  severe,  but  recur  again  and  again.  After  a  time  small  hard  swellings 
(nodosities)  appear  upon  the  sides  of  the  dorsal  surface  of  the  second  and  third 
phalanges,  remain  permanently,  and  slowly  increase  in  size.  The  joints 
become  stifi'  and  creak  on  movement,  the  cartilages  are  destroyed,  and  con- 
tractions and  rigidity  develop,  but  there  is  no  fever  and  the  larger  joints  are 
not  involved.     The  malady  is  incurable. 

2.  Progressive  rheumatic  gout,  which  may  be  acute  or  chronic.  The  acute 
form  begins  as  does  rheumatic  fever.  There  are  moderate  fever  and  swelluig, 
without  redness,  of  a  number  of  joints,  of  bursae,  and  of  tendon-sheaths; 
the  joints  are  stiff  and  crepitate,  and  are  apt  to  be  s}Tnmetrically  involved; 
muscular  atrophy  begins  early  and  rapidly  becomes  decided;  pain  is  slight. 
This  acute  form  is  apt  to  arise  in  young  women  after  pregnancy,  but  is  not 
unusual  at  the  climacteric  and  in  children.  Anemia  always  exists.  The  case 
is  apt  to  advance  progressively  until  a  number  of  joints  are  firmly  locked,  when 
it  may  become  stationary.  Another  pregnancy  "^dll  develop  anew  the  acute 
s}Tnptoma.  In  the  chronic  form  swelling  and  pain  on  movement  are  noted  in 
certain  joints.    The  involvement  is  apt  to  be  symmetrical.    Attacks  of  swelling 

41 


642  Diseases  and  Injuries  of  the  Bones  and  Joints 

and  pain  alternate  with  periods  of  apparent  quiescence,  but  the  disease  does 
not  cease  its  advance.  Articulation  after  articulation  is  attacked  by  the  mal- 
ady until  almost  all  the  joints  are  involved;  deformity  and  stiffness  become 
pronounced,  and  pain  may  or  may  not  be  severe.  There  is  no  fever.  Mus- 
cular atrophy  is  marked. 

3.  Partial  rheumatic  gout  or  monarticular  rheumatism  attacks  one  articu- 
lation, and  it  is  most  often  met  with  in  old  men.  It  may  fix  itself  on  the 
vertebral  column,  on  the  knee,  on  the  shoulder,  on  the  elbow,  or  on  the  hip. 
The  joint  grates  and  becomes  stiff,  swollen,  and  deformed;  the  muscles 
atrophy;  there  is  usually  pain,  but  fever  is  absent. 

Osteo-arthritis  or  partial  rheumatic  gout  of  the  hip- joint  seldom  occurs 
before  the  age  of  forty-five,  but  is  occasionally,  though  very  rarely,  met  with 
in  persons  under  twenty-five.  If  the  disease  arises  in  an  elderly  person,  it 
is  often  called  morbus  coxce  senilis.  In  some  cases  only  the  hip- joint  is  attacked; 
in  many  cases  other  joints  are  also  diseased.  Osteo-arthritis  of  the  hip  may 
follow  an  injury.  Usually  the  disease  is  unconnected  with  traumatism,  be- 
gins very  gradually,  and  advances  slowly.  There  is  pain,  often  mistaken 
for  sciatica,  in  and  about  the  joint,  and  there  is  increasing  stiffness.  The  pain 
and  stiffness  are  worse  when  the  patient  first  moves  after  resting.  Lameness 
becomes  noticeable,  and  grating  can  be  detected  in  and  about  the  joint.  The 
symptoms  become  gradually  worse,  although  at  times  they  may  seem  to  im- 
prove for  brief  periods.  The  lameness  and  the  stiffriess  are  greatly  aggravated, 
and  the  pain  becomes  very  severe,  even  when  at  rest.  Shortening  takes  place,, 
the  great  trochanter  ascends  above  Nelaton's  line,  the  limb  is  usually  abducted, 
but  in  very  rare  cases  is  adducted,  and  finally  ankylosis  occurs. 

Partial  rheumatic  gout  of  the  vertebral  articulations  causing  fixation  is 
called  spondylitis  deformans  (see  p.  848). 

Treatment. — Osteo-arthritis  cannot  be  cured,  but  in  some  cases  it  remains 
stationary  for  many  years.  I  have  seen  one  case  apparently  arrested  by  re- 
moval of  a  diseased  appendix.  It  is  claimed  by  some  that  Lane's  operation  of 
extirpation  of  the  large  intestine  may  arrest  it.  As  yet  I  would  not  feel  justified 
in  recommending  a  theoretical  operation  wdth  the  idea  of  directly  benefiting 
osteo-arthritis.  I  would,  however,  remove,  if  possible,  any  obvious  area  of  in- 
fection. The  usual  plan  of  medical  procedure  is  to  treat  the  anemia  by  iron,^ 
arsenic,  nourishing  food,  and  have  the  patient  out  in  the  fresh  air  as  much  as 
possible.  Debility  is  met  by  the  administration  of  strychnin.  Hot  baths  of 
mineral  water  do  good.  It  is  claimed  that  the  hot-air  apparatus  is  of  service. 
Douches  improve  these  cases,  but  electricity  is  useless.  Counterirritants  do 
no  good.  Massage  retards  the  progress  of  the  case,  relieves  the  pain,  aids  in 
the  absorption  of  effusion,  and  delays  fixation.  During  an  acute  exacerbation 
the  joint  shoiild  be  put  at  rest  for  a  time  and  evaporating  lotions  applied  for  a 
few  hours.  In  an  exacerbation  in  disease  of  the  hip  the  patient  should  be  put 
to  bed  and  have  extension  applied.  The  patient  is,  unfortunately,  liable  to 
develop  the  opiimi-habit.  If  dropsy  of  a  joint  arises,  try  compresson  by 
Martin's  bandage,  and,  if  this  fails,  aspirate  and  wash  out  the  joint  with  a  2 
per  cent,  solution  of  carbolic  acid.  Patients  with  rheumatic  gout  do  best  in 
a  warm,  dry  climate.  Cod-liver  oil  does  good,  as  it  improves  nutrition  and 
hence  retards  the  progress  of  the  disease.  Do  not  be  tempted  to  immobilize 
the  joints  beyond  a  day  or  two:  fixation  only  hastens  ankylosis.  Howard 
Marsh^  maintains  that,  as  a  rule,  but  little  good  comes  from  manipulation. 
He  makes  the  following  exceptions:  when  one  joint  only  is  affected;  when  the 
joint  is  very  stiff  but  not  very  painful;  when  the  patient  is  in  good  general 
health  and  is  not  beyond  middle  age.  If  only  one  joint  is  involved  it  may  be 
proper  to  produce  ankylosis  by  operation.  When  ankylosis  occurs  all  symp- 
1  "Diseases  of  the  Joints  and  Spine." 


Charcot's  Disease 


64- 


toms  subside.  Albee  describes  an  operation  for  osteo-arthritis  of  the  hip-joint. 
He  removes  a  thin  layer  from  the  top  of  the  head  of  the  femur  and  a  similar 
amount  of  bone  from  the  roof  of  the  acetebulum.  The  two  surfaces  are  held 
in  contact  until  imion  occurs.  In  the  knee-joint  Hibbs  bridges  the  front  part 
of  the  joint  with  the  denuded  patella.  Later  in  such  a  case,  after  all  s}-mp- 
toms  have  subsided,  it  may  be  justifiable  to  re-estabUsh  fimction  by  inter- 
posing a  connective-tissue  flap  or  chromicized  pig's  bladder  (R.  T.  Taylor). 

Trophic  Joint  Affections  {Arthropathies). — It  is  weU  known  that  certain 
diseases  and  mjiu^es  of  brain,  cord,  and  ner^-es  may  be  responsible  for  arthritic 
changes  (hemiplegia,  injury  of  the  cord,  locomotor  ataxia,  neuritis). 

From  three  to  six  weeks  after  an  apoplexy-  the  joints  of  the  palsied  side 
are  apt  to  suffer  from  inflammation.     The  condition  following  apoplexy-  is  one 
of  s}Tio\-itis.     i\ny  joint  may  suffer,  but  the  hip  eldom  does.     A  well-known 
arthropathy  is  Charcot's  joint 
(Figs.  391,  392). 

Charcot's  Disease  {Tabetic 
Arthropathy;  Charcot's  Joint: 
Xeiiropathic  Arthritis) . — This 
condition  is  an  osteo-arthritis 
due  to  trophic  disturbance, 
arising  in  a  sufferer  from  loco- 
motor ataxia,  and  is  anatom- 
ically identical  with  osteo- 
arthritis, which  was  described 
above.  The  knee  is  most  apt 
to  be  attacked,  and  the  hip 
suffers  more  often  than  any 
joint  but  the  knee.  The 
condition  may  develop  in 
the  shoulder  or  elbow.  The 
smaller  joints  sometimes, 
though  seldom,  are  involved. 
More  than  one  joint  may 
suffer.     The   disease  in  most 

cases  begins  acutely,  often  as  a  sudden  effusion,  which  after  a  time  may 
disappear.  In  most  cases,  however,  the  joint  becomes  rapidly  disorgan- 
ized. The  swelling  is  usually  ver\^  marked  and  is  sometunes  _  enormous. 
In  the  earliest  stages  it  is  due  to  periarticular  edema  and  to  articular  effu- 
sion. Pain  is  sUght  or  is  absent,  there  is  no  constitutional  involvement, 
and  the  condition  is  unconnected  with  injur\-.  Some  cases  begin  without 
this  preliminay  acute  swelling,  disorganization  being  manifest  from  the  be- 
ginning. WTien  disorganization  has  once  begun,  it  continues  inexorably. 
Bony  masses  form  aroimd  the  articular  ca^-ity,  in  the  ligaments,  and  in  the 
cartilages.  The  bones  and  cartilages  are  rapidly  destroyed  and  absorbed; 
fracture  is  apt  to  occur;  the  jouit  creaks  and  grates;  the  softening  and  relax- 
ation of  the  Hgaments  permit  an  extensive  range  of  movement;  great  deform- 
ity ensues;  dislocation  is  apt  to  occur;  muscular  atrophy  is  decided,  and 
pus  occasionally,  though  verv*  rarely,  forms.  There  is  sometimes,  but  seldom, 
repair.  Charcot's  joint  differs  from  rheimiatoid  arthritis  in  the  usual  acute 
onset  and  the  painless  course.  The  complete  or  nearly  complete  freedom 
from  pain  is  one  of  the  most  striking  features  of  the  condition.  In  sajdng  there 
is  freedom  from  pain  we  mean  freedom  from  pain  in  the  joint,  from  the  pain 
and  tenderness  in  the  regions  in  which  we  expect  to  find  them  in  an  inflamed 
joint.  Usually  these  patients,  though  free  from  pain  in  the  joint,  suffer  much 
from  the  Hghtning  pains  of  locomotor  ataxia.     Gastric  crises  are  not  uncom- 


91. — Charcot's  joint. 


644 


Diseases  and  Injuries  of  the  Bones  and  Joints 


mon  (Bramwell).  Charcot's  joint  is  more  common  in  female  than  in  male 
tabetics.  In  saying  that  Charcot's  joint  is  often  of  sudden  origin,  we  mean 
that  in  a  single  night,  as  Charcot  pointed  out,  swelhng  of  a  jomt  may  arise. 
In  a  day  or  two  the  joint  sweUing  becomes  great,  and  if  aspiration  is  per- 
formed, yellow  serum  is  obtained.  In  a  week  or  two  the  joint  begins  to  creak 
on  movement. 

The  treatment  of  Charcot's  disease  consists  in  the  wearing  of  an  appa- 
ratus to  sustain  the  joint.     Resection  is  recommended  by  some,  but_  most 

surgeons  do  not  advise  its 
performance.  Southam  ad- 
vocates amputation  for 
certain  cases  of  Charcot's 
joint.  He  has  performed 
the  operation  on  4  patients. 
He  amputated  twice  for 
ankle-joint  disease  and 
twice  for  disease  of  the 
tarsus.  In  every  case 
the  stumps  healed  quickly 
and  without  suppuration. 
Southam  was  led  to  per- 
form amputation  on  his 
first  case  by  the  report 
of  Jonathan  Hutchinson's 
case  of  amputation  of  the 
leg  for  perforating  ulcer 
and  disease  of  the  bones  of 
the  foot  in  a  tabetic. 

Osteo-arthropathie  Hy- 
pertrophiante  Pneumique 
{Marie's  Disease). — ^A  con- 
dition associated  with,  and 
possibly  springing  from, 
piilmonary  disease,  and 
characterized  by  enlarge- 
ment of  joints,  thicken- 
ing of  the  finger-ends,  and 
the  formation  of  a  dor- 
solumbar  kyphosis.  The 
joints  are  painful,  the  skin 
undergoes  pigmentation, 
and  profuse  perspiration  is 
often  present.  The  head 
entirely  escapes  in  this  disease,  which  immunity  marks  a  distinction  from 
acromegaly. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly  encountered  in 
young  women.  The  disease  occurs  most  commonly  in  the  knee  and  the 
hip,  and  often  follows  a  slight  injury  which  acts  as  an  autosuggestion,  a  latent 
hysteria  being  awakened  into  action  and  localized,  though  severity  of  the 
injury  does  not  determine  the  severity  of  the  symptoms.  The  disease  may 
ensue  upon  synovitis  or  arthritis,  or  may  arise  without  apparent  cause. 
The  patient  complains  of  pain  in  and  stiffness  of  the  joint,  resists  passive 
motion  strenuously,  and  claims  that  it  causes  much  pain.  There  is  occasion- 
ally some  muscular  atrophy  from  want  of  use,  and  the  joint  is  a  little  swollen. 
The  skin  is  hyperesthetic,  and  a  light  touch  causes  more  pain  than  does  deep 


392. — Charcot's  joint. 


Neuralgia  of  the  Joints  645 

pressure.  The  muscles  may  be  rigid.  The  joint  may  be  maintained  either 
in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree  of  flexion  assumed 
for  ease  in  a  true  joint  inflammation,  and  the  position  is  apt  to  be  changed 
from  day  to  day  or  from  hour  to  hour.  The  skin  is  usually  pale  and  cool, 
but  may  be  red  and  hot,  because  of  h\-peremia.  A  periodically  developed 
heat  may  be  observed,  especially  at  night,  accompanied  apparently  by  much 
pain.  The  alleged  pain  in  some  cases  is  neuralgia,  but  in  most  cases  is  a  pain 
hallucination.  There  is  no  eft"usion  into  the  joint,  and  swelling  does  not  exist, 
although  occasionally  there  is  slight  periarticular  edema.  In  some  rare  cases 
organic  disease  arises  in  a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  associated  with  certain 
stigmata  which  may  be  latent.  These  stigmata  are  concentric  contraction 
of  the  \'isual  fields,  phar}'ngeal  anesthesia,  con^'ulsions,  hysterogenic  zones, 
globus  hystericus,  clavicus  hystericus,  zones  of  anesthesia,  especially  hemi- 
anesthesia, and  h}-peresthetic  areas.  Such  patients  are  predisposed  by  in- 
heritance, and  have  previously,  as  a  rule,  had  nervous  troubles.  Hysterical 
phenomena,  be  it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  abolished  b}^  mental  influences  and  physical  sensations 
which  are  T\ithout  efl'ect  in  causing,  modif}'ing,  or  curing  organic  disease. 
The  general  health,  as  a  rule,  is  good,  but  neurasthenia  may  coexist.  In 
examining  these  patients  the  observer  will  note  that  the  s^-mptoms  disappear 
when  the  attention  is  diverted;  that  they  are  out  of  all  proportion  to  the 
local  evidences  of  disease;  that  there  is  no  sign  of  joint  destruction,  and  that 
a  light  touch  may  cause  more  pain  than  does  firm  pressure.  If  the  patient 
is  anesthetized,  perfect  joint  mobility  will  be  found  v\-ithout  any  e\-idences 
during  fimction  of  joint  changes. 

The  treatment  for  a  hysterical  joint  comprises  attention  to  the  general 
health,  the  emplo}Tnent  of  nourishing  and  easily  digested  food,  the  prevention 
of  constipation,  and  the  administration  of  tonics  if  they  are  needed.  The 
siu-geon  must  dominate  his  patient's  mind  and  make  her  reahze  that  he  is 
master  of  the  case.  He  is  to  be  an  inexorable  but  just  ruler — never  a  brutal 
or  a  cruel  one.  If  possible,  send  the  patient  away  from  the  harmful  sympa- 
thies of  her  home  and  let  her  have  the  rest  treatment  of  S.  Weir  ^Mitchell. 
Local  remedies  applied  to  the  jomt  do  harm,  as  a  rule,  by  concentrating  afresh 
the  patient's  attention  upon  the  articulation,  although  the  hot  iron  some- 
times does  good.  Suggestion  in  the  hypnotic  state  may  be  tried.  The  use  of 
morphin  should  be  avoided  as  being  the  worst  of  enemies.  Never  immobilize 
the  joint,  and  always  use  massage,  passive  motions,  and  frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated  afl'ection  is  ex- 
tremely rare,  though  as  a  complication  of  other  diseases  it  is  by  no  means 
uncommon.  Neuralgia  is  more  common  outside  of  the  joints  than  in  them,  and 
periarticular  neuralgia  is  especially  frequent  about  the  knee  and  the  ankle. 
Joint-neuralgia  may  arise  in  any  person,  but  it  is  more  commonly  present  in 
young  neurotic  females.  The  pain  ma}'  be  persistent,  or  it  may  occur  in  peri- 
odic storms,  and  it  is  often  associated  with  neuralgia  in  other  parts.  The  pain 
may  be  dull  and  aching,  but  it  is  more  often  sharp  and  shooting.  Joint- 
neuralgia  is  associated  with  tenderness  on  pressure,  soreness  on  motion,  often 
with  transitory-  swelling  without  redness,  and  sometimes  with  numbness  of  the 
extremities.  The  diagnosis  depends  on  the  temperament  of  the  patient,  the 
sudden  onset  of  the  pain,  the  absence  of  constitutional  symptoms,  and  the 
free  mobility  of  the  jomt,  especially  under  ether.  Articular  neuralgia  may 
depend  upon  disease  or  injur}^  of  the  central  nervous  system,  upon  malaria, 
s^-philis,  neurasthenia,  rheumatism,  gout,  hysteria,  and  neuritis,  and  may 
be  due  to  reflected  irritation,  especially  from  the  ovaries,  the  uterus,  or  the 
rectum. 


646  Diseases  and  Injuries  of  the  Bones  and  Joints 

The  treatment  to  be  obsen^ed  in  joint-neuralgia  is  to  maintain  the  general 
health.  Examine  for  a  possible  exciting  cause,  and,  if  found,  remove  it.  Give 
a  long  course  of  iron,  qmnin,  and  strychnin  or  arsenic.  In  rheumatic  or  gouty 
subjects  administer  suitable  drugs  and  insist  upon  the  use  of  a  proper  diet. 
During  the  attack  use  phenacetin.  Morphin  must  occasionally  be  given  in 
severe  cases,  but  be  sparing  of  it,  and  never  tell  the  patients  they  are  taking 
it,  as  there  is  a  possibility  of  their  forming  the  opium-habit.  Locally,  employ 
frictions,  ointment  of  aconite,  heat,  and  keep  upon  the  part  a  piece  of  flannel 
soaked  in  a  mixture  of  soap  liniment,  laudanum,  and  chloroform  (Gross). 
Never  allow  the  joint  to  stiffen;  any  tendency  to  stiffness  should  be  met  by 
daily  massage,  frictions,  passive  motion,  and  hot  and  cold  douches.  In  some 
rare  cases  nerve-stretching  or  neurectomy  becomes  necessar}^ 

Articular  Wounds  and  Injuries. — A  penetrating  wound  is  very 
serious,  and  it  may  be  due  to  a  compound  fracture,  to  a  compound  dislocation, 
to  a  gunshot-wound,  or  to  a  stab.  If  a  bursa  near  a  joint  be  opened,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a  penetrating  wound, 
besides  pain,  hemorrhage,  and  swelling  there  is  a  flow  of  syno\dal  fluid.  A 
small  amount  of  s>Tiovia  flows  from  an  injured  bursa,  a  large  amount  from  an 
open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  incised  by  the  sur- 
geon) the  woimd  heals  nicely  under  rest  and  asepsis.  If  a  joint  is  opened 
by  a  septic  body,  suppurative  arthritis  is  apt  to  arise,  and  the  surgeon  en- 
deavors to  prevent  it  by  asepticizing  the  surface,  irrigating  the  joint,  draining, 
applying  antiseptic  dressing,  and  securing  rest.  Normal  salt  solution  is  the 
best  agent  for  irrigation,  as  it  does  not  injure  joint  endothelium.  Active 
antiseptics  may  lessen  tissue  resistance,  and  thus  may  actually  favor  in- 
fection. In  gunshot-wounds  inflicted  by  pistol  bullets  or  sporting  rifle 
bullets,  if  antisepsis  is  not  employed,  suppuration  is  ine\dtable;  hence  mihtan.^ 
surgeons  in  the  past,  as  a  rule,  have  advocated  amputation  or  excision  in 
gunshot-splinterings  of  large  joints.  Recent  experience  shows  that  the  wound 
of  a  large  joint  produced  by  a  hard-jacketed  and  small-caliber  bullet  may  heal 
with  little  trouble.  In  articular  wounds  the  surface  is  sterilized,  and  usually 
the  wound  is  enlarged,  the  finger  is  introduced  to  discover  and  remove  foreign 
bodies,  through-and-through  drainage  is  secured,  a  tube  is  inserted,  the  joint 
is  irrigated,  antiseptic  dressings  are  applied,  and  the  extremity  is  placed  upon 
a  splint.  Very  severe  joint  injuries  demand  resection  or  even  amputation. 
Ankylosis,  more  or  less  complete,  often  foUows  a  gunshot-wound  of  a  joint. 
If  the  joint  suppurates,  the  drainage  must  be  made  more  free,  sinuses  must 
be  slit  up  and  packed,  sloughs  must  be  cut  away,  dead  bone  must  be  gouged 
out,  and  the  patient  must  be  placed  upon  a  stimulant  and  tonic  plan  of  treat- 
ment. The  above  remarks  do  not  apply  to  wounds  inflicted  by  the  modern 
mflitary  projectile.  Such  wounds  are  not  of  necessity  infected,  and  recovery 
may  be  prompt  and  uneventful  if  the  surface  is  sterilized  and  antiseptic  dress- 
ings and  splints  are  applied. 

Sprains. — A  sprain  is  a  joint-"^Tench  due  to  a  sudden  t'oist  or  traction, 
the  ligaments  being  pulled  upon  or  lacerated  and  the  surrounding  parts  being 
more  or  less  damaged.  A  sprain  is  often  a  self-reduced  dislocation  (Douglas 
Graham).  The  joints  most  liable  to  sprains  are  the  knee,  the  elbow,  and 
the  ankle.  The  smaller  joints  are  also  often  sprained,  but  the  ball-and-socket 
joints  are  infrequently  sprained,  their  normal  range  of  free  movement  saving 
them;  they  do  occasionally  suffer  severely,  however,  as  a  result  of  abduction. 
In  a  severe  sprain  the  ligami^nts  are  torn ;  the  syno\-iaI  membrane  is  contused  or 
crushed;  cartilages  are  loosened  or  separated;  hemorrhage  takes  place  into  and 
about  the  joint;  muscles  and  tendons  are  stretched,  displaced,  or  lacerated; 
vessels  and  nerves  are  damaged;  the  skin  is  often  contused;  and  portions  of 


Treatment  of  Sprains  647 

bone  or  cartilage  may  be  detached  from  their  proper  habitat,  though  still 
adhering  to  a  ligament  or  tendon  (sprain  fractures).  Sprains  are  commonest 
in  >-oung  persons  and  in  adults  with  weak  muscles.  They  happen  from  sudden 
twists  and  movements  when  the  muscles  are  relaxed.  A  large  part  of  the 
support  of  joints  comes  from  muscles,  and  when  muscles  are  suddenly  caught 
unawares  they  do  not  properly  support  the  joint,  and  a  spram  results.'  A  joint 
once  sprained  is  ver\-  liable  to  a  repetition  of  the  damage  from  sUght  force. 
Sprains  are  common  in  a  limb  -u-ith  weak  muscles,  in  a  deformed  extremity  in 
which  the  muscles  act  in  unnatural  hnes,  and  in  a  joint  with  relaxed  hgame'nts. 

Symptoms. — There  is  severe  pain  in  the  joint,  accompanied  bv  general 
weakness.  Nausea,  vomiting,  and  even  S}Ticope  may  occur.  There  is  im- 
pairment or  loss  of  ability  to  move  the  joint.  The  above-described  condition 
is  succeeded  by  a  season  of  relief  from  pain  while  at  rest,  nimibness  being  com- 
plained of,  and  pain  on  motion  being  severe.  Swelling  arises  vers*  earlv  if 
rnuch  blood  is  effused.  In  any  case  swelling  begins  in  a  few  hours.  Extensive 
effusion,  by  separating  joint  surfaces,  produces  sHght 'lengthening  of  the  limb. 
Movements  of  the  joint  become  difficult  or  impossible:  the  tear  in  the  ligament 
may  sometimes  be  distinctly  detected  by  the  examining  fingers;  pain  and  ten- 
derness become  intense;  joint-crepitus  will  be  manifested,  and  in  a  dav  or  two 
discoloration  becomes  marked.  ]\Ioullin  and  others  have  pointed  out  that 
when  a  muscle  is  strained  the  skin  above  it  becomes  sensitive,  especially  at 
tendinous  insertions  over  joints.  As  muscles  are  invariably  strained  when  a 
joint  is  sprained,  there  is  always  some  cutaneous  tenderness.  There  is  also 
tenderness  over  a  sprained  joint  due  to  capsular  injur}-,  bands  of  adhesions,  etc. 
Tenderness  is  apt  to  arise  at  certain  reasonably  iLxed  points:  in  a  hip-joint 
injur\-  it  is  found  behind  the  great  trochanter,  in  a  knee-joint  injury-  bv  the 
side  of  the  patella,  in  an  ankle-joint  injur\-  to  the  inner  side  of  the  external 
malleolus  (Culp).  \Mien  the  vertebral  articulations  are  sprained  the  muscles 
of  the  back  are  rigid,  the  skin  is  often  sensitive,  pain  may  be  awakened  by  pres- 
sure or  by  certain  movements,  but  there  is  no  sign  of  cord  injur\-  in  an  uncom- 
pHcated  case. 

Diagnosis  and  Prognosis. — Sprain-fractures  can  be  diagnosticated  -n-ith 
certainty  only  by  the  .v-rays.  In  the  diag}wsis  of  a  sprain,  fracture  and  dis- 
location must  be  considered.  In  fracture,  crepitus  and  mobility  exist;  in  dis- 
location, rigidity.  The  diagnosis  of  sprain  should  be  made  by  a  consideration 
of  the  joint  involved,  of  the  age,  of  the  nature  of  the  force,  of  the  length  of  the 
limb,  of  the  fact  that  the  patient  could  use  the  joint  for  at  least  a  short  time  after 
the  accident,  and  of  the  local  feel  and  movements  of  the  part.  In  some  cases 
examine  under  ether,  in  some  apply  the  .v-rays.  ]\Iany  injuries  about  the  ankle 
which  we  would  have  formerly  regarded  as  sprains,  are  sho-nm  b}-  the  .v-ra}-s 
to  be  fractures.  The  prognosis  depends  on  the  size  of  the  joint,  on  the 
extent  of  laceration,  on  the  amount  of  intra-articular  hemorrhage,  and  on 
the  age  of  the  patient.  The  danger  is  ankylosis.  A  sprained  joint  is  a  point 
of  least  resistance  to  tubercle  bacilli.  In  rare  cases  after  a  sprain  of  the 
hip-joint  osteo-arthritis  arises.  In  some  few  cases  after  a  sprain  of  the  hip  the 
head  of  the  bone  undergoes  absorption. 

Treatment. — In  a  mild  sprain  apply  at  once  a  silicate,  rubber  plaster,  or 
plaster-of-Paris  dressing.  The  first  indication  after  the  infliction  of  a  severe 
sprain  is  to  arrest  hemorrhage  and  limit  inflammation.  For  the  first  few  hours 
apply  pressure  and  an  ice-bag.  Wrap  the  joint  in  absorbent  cotton  wet  with 
iced  water,  apply  a  wet  gauze  bandage,  and  put  on  an  ice-bag.  After  some 
hours  place  the  extremity  upon  a  splint  and  to  the  joint  apply  flannel  kept 
wet  -^"ith  lead-water  and  laudanum,  iced  water,  tincture  of  arnica,  alcohol  and 
water,  or  a  solution  of  chlorid  of  ammonium.  These  evaporating  lotions  pro- 
duce cold.     Instead  of  them  an  ice-bag  mav  be  used  for  a  dav.     Leeches 


648  Diseases  and  Injuries  of  the  Bones  and  Joints 

around  the  joint  do  good.  Constitutionally,  employ  the  remedies  for  inflam- 
mation. Morphin  or  Dover's  powder  is  given  for  the  pain.  Judicious  band- 
aging limits  the  swelling. 

After  twenty-four  hours,  if  the  symptoms  continue  or  if  they  grow  worse, 
use  hot  fomentations,  the  hot- water  bag,  plunge  the  extremity  frequently  in  very 
hot  water,  or  apply  heat  by  Leiter's  tubes.  When  the  acute  symptoms  begin 
to  subside  rub  stimulating  liniments  upon  the  joint  once  or  twice  a  day  and 
employ  firm  compression  by  means  of  a  bandage  of  flannel  or  rubber.  Fric- 
tions should  be  made  from  the  periphery  toward  the  body.  Many  cases  do 
well  at  this  stage  under  the  local  use  of  ichthyol  and  lanolin  (50  per  cent.), 
tincture  of  iodin,  or  blue  ointment.  Later  in  the  case  use  hot  and  cold  douches, 
massage,  frictions,  passive  motion,  and  the  bandage.  Passive  motion  and 
massage  are  begun  a  day  or  so  after  swelling  ceases.  If  they  cause  the  swelling 
to  return,  abandon  them  for  several  days  and  then  try  them  again.  Blisters 
are  used  when  tender  spots  persist  and  stiffness  is  manifest.  If  stiffness 
becomes  marked,  move  the  joint  forcibly.  Give  iodid  of  potassium  and 
tonics  internally,  and  insist  on  open-air  exercise.     If  the  person  is  gouty  or 


Fig.  393-  Fig.  394. 

Figs.  393,  394. — Gibney's  method  of  strapping  in  sprains  of  the  ankle. 

rheumatic,  use  appropriate  remedies.  Van  Arsdale  treats  sprains  by  massage 
almost  from  the  start.  Gibney  treats  them  by  strapping  with  adhesive 
plaster.  Gibney's  dressing  is  of  great  service  in  a  sprain  of  the  ankle  (Figs. 
393,  394).  Many  sprains  may  be  put  up  in  an  immovable  dressing  the  first 
day  or  two  after  the  accident.  If  the  joint  contains  much  blood,  aspiration 
should  be  practised  before  the  dressing  is  applied. 

The  hot-air  oven  is  a  very  valuable  method  for  treating  recent  sprains,  and 
the  swelling,  pain,  and  stiffness  which  follow  sprains  of  the  extremities.  The 
sprained  extremity  is  placed  in  an  oven,  and  the  part  is  subjected  to  heat  for  an 
hour.  The  next  day  the  treatment  is  repeated,  and  on  as  many  subsequent 
days  as  may  be  necessary.  In  an  acute  sprain  the  pain  often  disappears  during 
the  first  application  of  heat.  In  the  intervals  between  the  use  of  the  oven  the 
extremity  should  be  at  rest,  perhaps  upon  a  splint. 

Sprain  of  the  Sacro=iliac  Articulation. — This  condition  was  first 
described  by  Goldthwait.  A  fall,  lifting  a  heavy  weight,  a  blow,  or  a  twist 
may  injure  the  articulation.  Normally  there  is  slight  motion,  rupture  or 
stretching  of  ligaments  may  lead  to  increased  motion,  and  any  considerable 


Rupture  of  the  Crucial  Ligaments  of  the  Knee  649 

range  of  motion  at  the  synchondrosis  means  lack  of  solidity  and  want  of  sup- 
port. A  sprain  may  arise  from  long-continued  standing,  bending,  lying,  or  sit- 
ting. A  sprain  of  this  articulation  may  be  caused  by  parturition,  and  also,  as 
shown  by  Dunlop,  it  may  develop  during  anesthesia  because  of  obliteration  of 
the  normal  lumbar  curve  by  lying  on  a  flat  table  •without  a  support  under 
the  lumbar  region  ("New  York  Med.  Jour.,"  July  10,  1909).  Dunlop  thus 
explains,  and  I  think  truly,  the  severe  backache  which  is  so  common  after 
anesthesia. 

A  sprain  causes  severe  pain,  greatly  aggravated  by  standing,  by  rising  up 
from  recumbency,  by  movements  of  the  ilia  which  jar  the  joint,  and  frequently 
by  direct  pressure  upon  the  synchondrosis.  There  is  often  lateral  spinal 
cur\'ature  due  to  spasm,  and  the  concavity  is  toward  the  injured  side. 

There  is  pain  in  the  injured  articulation,  but  there  may  be  a  general  back- 
ache, and,  just  as  in  sacro-iliac  tuberculosis  (see  page  624),  there  may  be 
pain  in  the  sciatic  ner\'e,  in  the  groin,  and  in  the  hip-joint. 

WTien  some  of  the  sacro-iliac  ligaments  are  ruptured  or  relaxed  we  get  the 
chronic  condition  described  by  John  Dunlop  (Ibid.)  and  which  he  calls  sacro- 
iliac relaxation.  WTien  this  exists  the  indi\-idual  may  injure  the  articulation 
again  and  again  because  of  its  unsteadiness,  he  may  now  and  then  have 
trouble,  he  may  be  in  a  constant  condition  of  helplessness,  'uith  backache, 
groinache,  pain  in  the  hip  and  over  the  ischial  tuberosity,  lumbar  rigidity 
producing  lateral  curvature,  etc.  I  believe  in  the  reality  of  the  con- 
dition. 

Treatment. — ^A  recent  sprain  is  treated  by  rest  in  bed  and  adhesive-plas- 
ter strapping,  reinforced  by  a  canvas  roller  around  the  peMs.  In  a  chronic 
case  (sacro-iliac  relaxation),  after  securing  by  manipulation  normal  relations 
in  the  articulation,  insist  on  rest  and  apply  a  spica  bandage  of  plaster  of  Paris. 
If  there  is  marked  tendency  to  displacement,  ankylosis  may  be  secured  by  opera- 
tion. Fixation  by  a  bone-graft  from  the  tibia  should  give  the  most  rapid  and 
permanent  result  (Rugh). 

Rupture  of  the  Crucial  Ligaments  of  the  Knee. — ^This  is  a  rare  injury. 
Rupture  of  both  ligaments  is  unusual  except  in  very  grave  injur}^,  such  as 
complete  dislocation,  and  then  other  ligaments  are  also  torn  or  destroyed. 

The  anterior  crucial  ligament  instead  of  rupturing  from  force  may  cause 
a\ailsion  of  the  tibial  spine  (see  page  610).  WTien  this  portion  of  bone  is  not 
torn  off,  the  ligament  itself  tears  off  from  the  femur  rather  than  from  the  tibia. 
The  posterior  ligament,  too,  tends  to  tear  off  from  femur  rather  than  tibia. 
Pagenstecher  ("Deutsch.  ]Med.  Wochenschrift,"  Bd.  xxix)  beheves  that  the 
anterior  ligament  may  be  ruptured  by  forced  flexion  of  the  knee  and  by  blows 
applied  to  the  posterior  part  of  the  head  of  the  tibia  when  the  knee  is  flexed. 
The  same  sm^geon  maintains  that  the  posterior  ligament  may  be  ruptured  by 
blows  applied  to  the  front  of  the  head  of  the  tibia  when  the  knee  is  flexed. 
Pringle  ("Annals  of  SurgerA^,"  August,  1907)  maintains  that  the  anterior  liga- 
ment may  be  ruptured  by  "flexion,  abduction,  and  internal  rotation  of  the  leg 
at  the  knee."  If  the  ligaments  are  ruptured  there  Vvill  probably  be  abnormal 
freedom  of  anteroposterior  movement  between  the  femur  and  tibia. 

Pringle  (Ibid.)  states  that  if,  after  an  injury,  the  knee-joint  becomes 
distended  "v^dth  blood,  the  inference  should  be  that  one  or  other  crucial  ligament 
has  been  injured  or  that  the  tibial  spine  has  been  torn  off,  unless  some  other 
lesion  is  obA'iously  present;  that  if  internal  rotation  of  the  extended  leg  is 
possible  at  the  knee,  or  if  the  head  of  the  tibia  can  be  brought  for^-ard  on  the 
femm",  or  if  there  is  unnatural  abduction,  the  indications  are  that  the  anterior 
crucial  ligament  has  been  injured  or  the  tibial  spine  torn  off;  that  injurs*  of  the 
posterior  crucial  is  suggested  by  the  possibility  of  pushing  the  head  of  the  tibia 
backward  during  flexion  of  the  knee-joint. 


650  Diseases  and  Injuries  of  the  Bones  and  Joints 

In  most  cases  exploratory  incision  is  required  to  make  the  diagnosis. 

The  treatment  is  to  open  the  joint  and  suture  the  torn  ligament. 

Ankylosis. — When  a  joint-inflammation  eventuates  in  the  formation  of 
new  tissue  in  and  about  the  joint,  contraction  of  this  tissue  limits  or  destroys 
joint  mobility,  producing  the  condition  known  as  "ankylosis."  Ankylosis  may 
be  complete  (bony)  or  incomplete  (fibrous) ;  it  may  arise  from  contractures  in 
the  joint  {true  or  intra-articular  ankylosis)  or  from  contractures  in  the  struc- 
tures external  to  the  joint  {false  or  extra-articular  ankylosis). 

There  are  qualifying  terms  to  indicate  the  extent  of  stiffness — viz.,  false, 
spurious,  true,  bony,  ligamentous,  partial,  complete,  or  incomplete  ankylosis. 
The  significance  of  the  above  terms  will  be  better  appreciated  if  ankylosis  is 
considered  as  meaning  a  stiff  joint.  It  may  be  stiff  without  being  rigid. 
Fibrous  adhesions  produce  stiff  joints  and  they  become  rigid  only  when  bony 
vmion  takes  place  between  the  bones  forming  a  joint. 

Spondylitis  deformans  is  bony  ankylosis  of  vertebrae  due  to  osteo-arthritis. 

Arthritis  ossificans  is  a  progressive  bony  ankylosis  in  which  numerous 
joints  are  involved  and  are  finally  completely  obliterated.  It  is  an  ossifying 
arthritis. 

Etiology. — There  are  various  causes — viz.,  traumatism,  eruptive  fevers 
resulting  in  acute  or  suppurative  synovitis  or  arthritis,  gonorrheal  arthritis, 
tuberculous  arthritis,  syphilitic  affections  of  joints,  bony  fixation  when  a 
fracture  is  near  or  extends  into  a  joint,  and  osteitis  deformans.  Simple  fixa- 
tion of  an  uninflamed  joint  cannot  cause  true  ankylosis. 

Pathology. — In  complete — i.  e.,  bony — ankylosis  the  bones  forming  a  joint 
become  united  by  callus  in  much  the  same  manner  as  bone-fragments  are 
united  after  a  fracture,  or  osseous  bridging  takes  place  at  one  or  more  places 
around  the  joint.  Osseous  ankylosis  is  preceded  by  a  more  or  less  prolonged 
stage  of  fibrous  or  partial  ankylosis.  In  fibrous  ankylosis,  bands  of  fibrous 
connective  tissue  unite  the  bones  forming  a  joint,  thereby  limiting  the  motion. 
In  cases  of  joint  stiffness  produced  by  extra-articular  fibrous,  tendinous,  or 
cicatricial  contracture  the  joint  proper  remains  free  from  adhesions  for  years, 
provided  it  is  not  and  has  not  been  involved  in  inflammatory  action. 

Diagnosis  of  bony  ankylosis  is  usually  made  without  difi&culty  except  where 
there  are  several  joints  near  together,  as  the  carpus,  tarsus,  and  the  spine. 
When  there  are  several  joints  near  together  the  limitation  of  motion  in  one 
joint  is  generally  compensated  for  by  the  excess  in  mobility  of  another,  thereby 
rendering  the  associated  parts  capable  of  closely  approaching  normal  function. 
Fibrous  ankylosis  is  more  difficult  to  recognize,  especially  if  pain  accompanies 
manipulative  measures.  It  is  most  apt  to  be  confused  with  fibrous,  liga- 
mentous, or  cicatricial  contractures  of  soft  parts  outside  of  a  joint,  but  having 
more  or  less  direct  functional  relations  therewith. 

Extra-articular  thickening  may  usually  be  detected  by  the  existence  of 
resistance  to  free  joint  motion  in  one  direction  only,  i.  e.,  that  produced  by  the 
fibrous  contracture  while  the  joint  moves  freely  in  other  directions.  Muscular 
contracture,  whether  voluntary  or  involuntary,  is  but  temporary,  and  is  easily 
detected  by  the  preternatual  rigidity  of  surrounding  parts.  In  bony  ankylosis 
no  voluntary  muscular  action  can  be  detected,  inasmuch  as  in  the  process  of 
the  formation  of  the  callus  uniting  the  bones  the  muscles  have  become  atro- 
phied from  disuse.  Conversely,  voluntary  muscle  action  about  a  joint  always 
indicates  that  joint  mobility  is  not  entirely  destroyed. 

As  muscular  rigidity  is  one  of  the  most  important  and  reliable  symptoms  of 
joint  inflammation  and  tuberculous  invasion,  it  is  a  serious  error  to  anesthetize 
a  patient  for  examination  of  a  joint  until  the  full  significance  of  the  muscular 
action  has  been  carefully  studied. 

Anesthesia  removes  the  pain  and  abolishes  muscle  fixation  and  thus  leaves 


Treatment  of  Intra-articular  Ankylosis  651 

the  unguarded  joint  free  for  manipulative  movements,  which  are  generally 
prejudicial  and  rarely  beneficial.  Where  no  muscle  fixation  is  present,  much 
may  be  learned  by  the  careful  study  of  a  joint  while  the  patient  is  anesthetized. 
We  thus  determine  the  character  of  the  adhesions,  whether  they  are  extra- 
articular or  intra-articular,  whether  they  are  fibrous,  cicatricial,  or  osseous,  and 
if  bony  union  exists,  whether  it  involves  the  entire  joint  or  onl\-  a  portion  of  it. 

Skiagraphs  are  invaluable  helps  in  making  an  accurate  diagnosis,  espe- 
cially when  stereoscopic  plates  are  made.  Definite  information  can  thus  be 
obtained  as  to  the  character  of  the  uniting  material,  its  extent,  and  definite 
location.  Positive  information  T\-ill  be  given  as  to  the  relationship  of  the  bones 
composing  the  joint,  whether  there  is  luxation,  subluxation,  flexion,  or  other 
abnormal  position  that  may  influence  decision  as  to  the  therapeutic  measures 
to  be  adopted.  It  is  important  to  remember  that  a  joint  ver}^  rarely  becomes 
ankylosed  in  the  position  of  extension  (the  elbow  may  if  treated  in  extension 
for  intra-articular  fracture).  The  almost  invariable  rule  is  that  flexion  is  the 
posture  of  such  joints,  and  the  tendency  is  toward  increase  of  the  flexion  until 
bony  ankylosis  occurs.  In  the  steady  progress  of  the  flexion  subluxation  is 
apt  to  be  induced. 

Treatment  of  Intra-articular  Ankylosis. — It  is  most  important  to  pre- 
vent the  occurrence  of  ankylosis,  or  in  the  event  of  its  becoming  ine^dtable, 
to  avoid  postures  that  vnll  render  the  parts  unfit  for  future  usefiflness  when 
ankylosed. 

The  most  useful  position  for  a  stift"  joint  is  a  matter  of  individual  opinion; 
no  definite  rules  have  been  accepted.  In  ankylosis  of  the  elbow  the  flexed  posi- 
tion is  more  useful  in  certain  occupations  than  the  fvflly  extended  arm.  In 
other  occupations  the  extended  arm  is  most  useful.  In  walking  when  the 
knee  is  ankylosed  and  does  not  tend  toward  flexion  the  extended  leg  is  more 
useful  than  the  flexed  leg,  but  it  is  more  difficult  to  manage  when  sitting. 

The  hip,  when  ankylosed  at  various  angles,  is  made  useful  by  the  increased 
latitude  of  motion  of  the  other  hip  and  by  the  compensator}'  motion  of  the  lum- 
bar spine.  To  such  an  extent  is  the  lower  spine  reciprocal  when  one  or  both 
hips  are  abnormal  that  it  has  been  termed  the  third  hip-joint.  For  general 
usefulness  the  best  position  for  an  ankylosed  hip  is  10  to  15  degrees  of  flexion, 
10  to  15  degrees  of  abduction,  and  5  degrees  of  external  rotation.  In  this  posi- 
tion, when  supplemented  by  reciprocal  action  of  the  other  hip  and  by  the  lower 
spine,  a  gait  ver\^  closely  approaching  normal  carriage  may  be  obtained  in 
walking,  and  the  sitting  posture  may  be  possible. 

Each  indi^•idual  joint  has  its  own  pecuhar  requirement  and  must  become  a 
subject  for  careful  study  in  determining  the  most  useful  posture  if  ankylosis 
is  to  be  permanent.  The  trend  of  modern  surgery  is  to  greatly  reduce  the 
time  of  fixation  of  a  fractined  bone  in  order  to  avoid  joint  stiffness  and  prevent 
muscular  wasting.  Early  passive  motion  when  judiciously  employed  does  not 
interfere  with  the  efficient  treatment  of  a  fracture,  but  does  lessen  the  joint 
stiffness  that  is  often  a  serious  and  painful  sequel. 

Stereo-arthrolysis  "is  that  branch  of  arthroplasty  whose  object  is  to  loosen 
stift"  joints  and  produce  new  joints  with  mobility,  following  ankylosis"  (R. 
TunstaU  Taylor,  "Surger\',  G^mecolog}-,  and  Obstetrics,"  April,  1912). 

Brisement  force  or  redressement  are  terms  applied  to  the  use  of  such  ma- 
nipulative force  as  the  siu-geon  can  judiciously  employ  in  freeing  a  joint  from 
fibrous  adhesions.  It  is  important  to  keep  constantly  in  mind  the  danger  of 
breaking  the  shaft  of  a  bone  or  of  separating  the  epiph}'sis  when  miguarded 
leverage  of  the  entire  shaft  of  the  bone  is  used.  It  is  of  paramount  importance 
to  avoid  brisement  force  in  aU  cases  where  the  ankylosis  has  resulted  from  tuber- 
culosis. The  plan  is  said  to  have  been  suggested  by  Lou\Tier,  of  Paris.  It  was 
advocated  bv  Langenbeck.    Brisement  force  is  onlv  curative  when  the  adhesions 


652  Diseases  and  Injuries  of  the  Bones  and  Joints 

are  limited  to  the  synovial  membrane.  When  portions  of  that  membrane 
have  been  destroyed  or  when  there  are  dense  fibrous  adhesions  the  ankylosis 
invariably  recurs  after  manipulative  force  and  often  becomes  worse  than 
before.     In  bony  ankylosis  the  method  is  out  of  the  question. 

In  applying  manipulative  force  it  is  not  always  advantageous  to  have  the 
patient  profoundly  anesthetized.  If  he  is  profoundly  anesthetized  we  may 
be  tempted  to  apply  too  violent  force.  Severe  lacerations  of  fibrous  adhesions 
produce  painful  joints  which  necessitate  fixation  or  rest  for  several  days  to 
permit  the  reunion  of  the  torn  structures.  A  Httle  gain,  care  being  taken  to 
maintain  the  motion  gained,  mobility  being  gradually  increased  by  short  pro- 
gressive steps,  is  always  better  than  attempts  to  do  a  great  deal  at  once.  Of 
course  the  patient's  co-operation  is  necessary. 

When  pain  is  great,  much  can  be  accomplished  during  primary  ether  anes- 
thesia or  while  the  patient  is  under  influence  of  nitrous  oxid.  Bromid  of  ethyl 
and  chlorid  of  ethyl  are  used  by  many  because  of  their  rapid  action  and  brief 
effect.     As  stated  elsewhere  (see  page  1209),  I  seldom  use  either  of  these  drugs. 

Fixation  appliances  of  any  kind  are  contra-indicated  during  corrective 
manipulations,  as  increased  freedom  of  motion  is  essential  rather  than  fixation. 
Voluntary  efforts  are  needed  to  maintain  the  joint  motion  already  secured  as 
well  as  to  increase  the  muscle  function  controlling  the  affected  joint. 

Among  the  operative  procedures  applicable  to  intra-articular  ankylosis  are 
excision  to  obtain  a  false  joint  (pseudo-arthrosis) ,  excision  to  obtain  a  better 
position  for  the  usefulness  of  the  limb,  breaking  the  bone  after  partially  cutting 
it  with  an  osteotome  (osteotomy) ,  and  breaking  the  bone  without  any  incision 
(osteoclasis).  These  several  procedures  have  special  advantages  in  different 
joints. 

Lexer  ("Zeit.  f.  Chir.  Med.  Orth.,"  Oct.,  1908,  p.  476),  after  resecting  a 
knee-joint  ankylosed  at  a  right  angle,  transplanted  the  entire  knee-joint  appa- 
ratus from  a  freshly  amputated  limb.  Complete  union  resulted.  Muscle 
training  was  subsequently  practised  to  improve  the  weak  muscular  control. 
Three  and  a  half  years  later  the  result  was  excellent. 

Weglowski  (''Zent.  f.  Chir.,"  April,  27  1907)  resorted  to  cartilage  transplan- 
tation in  a  case  of  ankylosis  of  the  elbow.  After  freeing  and  re-forming  the 
ends  of  the  three  bones,  two  plates  of  cartilage  (one-half  thickness  of  rib  car- 
tilage) with  perichondrium  were  taken  from  the  sixth  and  seventh  ribs  and 
placed  between  the  newly  formed  joint  surfaces,  the  perichondrial  surface 
being  turned  toward  the  humeral  epiphysis.  No  special  fixation  was  used.  No 
drainage  was  employed.  Active  and  passive  motion  was  begun  on  the  tenth 
day.  In  a  month  the  patient  had  60  degrees  of  free  flexion  and  extension  and 
full  pronation  and  supination.  Death  from  pleuropneumonia  of  three  days' 
duration  occurred  in  five  weeks.  Postmortem  showed  that  the  perichondrial 
surface  of  the  cartilage  was  united  to  the  himierus,  while  the  opposite  side  was 
smooth,  even  shining;  the  cartilage  was  enlarging  and  passed  without  definite 
margin  into  the  surface  of  the  humerus. 

Microscopic  examination  showed  new^ly  formed  blood-vessels  between  the 
cartilage  and  bone;  the  cartilage  was  well  preserved  in  its  entire  extent,  the 
cells  and  nuclei  staining  weU. 

Huguier  and  Murphy  revive  a  suggestion  fifty  years  old.  They  interpose 
soft  tissue  between  the  bone  ends  after  freeing  the  ends  from  ankylosing 
material  ("Traitement  des  Ankyloses  par  la  Resection  Orthopedique  et  L'inter- 
position  Musculaire,"  par  Le  Dr.  Alphonse  Huguier).  The  plan  was  first  sug- 
gested by  Verneuil  in  i860  ("Archives  de  Medicine,"  i860) .  He  cured  temporo- 
maxillary  ankylosis  by  the  interposition  of  temporal  muscle  and  fascia.  In 
1899  Helferich  suggested  inserting  a  portion  of  the  vastus  internus  muscle 
between  the  patella  and  femur,  and  two  years  later  Cramer  reported  some 


Treatment  of  Intra-articular  Ankylosis  653 

successful  cases.  Hoffa  followed  this  method.  Helfereich,  in  1893,  mobilized 
the  temporomaxillary  joint  by  the  insertion  of  a  flap  from  the  temporal  muscle. 
This  was  repeated  by  Lentz,  Henle,  and  others.  Mikulicz,  in  1895,  used  a  flap 
from  the  masseter  muscle.  Similar  procedures  were  employed  by  Bilezguski, 
Hoffa,  and  Kusnetzow.  Rochet  and  Schnudt  with  GlUck,  in  1902,  used  a 
skin-flap  and  had  previously  employed  ivory  joints  to  take  the  place  of  the 
excised  structures.     In  1901  ]\Iurphy  operated  by  Verneuil's  plan. 

J.  B.  Murphy  ("Jour.  Amer.  ]\Ied.  Assoc,"  May  20-27,  Jui^e  3,  1905) 
re\dews  the  literature  of  the  attempt  to  produce  new  joints  and  says:  'Tn 
our  work  we  have  been  able,  by  the  interposition  of  fascia  and  muscle, 
covered  with  a  layer  of  adipose  tissue,  to  produce  normal  movable  joints 
with  capsules  and  collagen  intra-articular  fluid."  In  cases  of  synovitis  with 
adhesions  he  resects  the  capsule  and:  replaces  it  by  aponeurosis  or  muscle, 
and  it  is  desirable,  when  possible,  that  the  replacing  piece  contains  fat,  which, 
under  pressure,  will  form  a  hygroma  or  artificial  syno\T[al  cavity.  In  bony 
ankylosis  he  operates,  separates  the  bones,  removes  adjacent  bony  promi- 
nences or  processes,  frees  the  soft  parts,  prevents  the  bones  coming  again  in 
contact,  and  interposes  between  them  tissue  which  ^^'ill  remain  fibrous  or  will 
form  a  hygroma  or  artificial  syno\dal  surface.  After  wound  healing  has  taken 
place,  passive  motion,  active  motion,  and  forcible  extension  are  required. 

W.  S.  Baer  ("Amer.  Jour.  Orthop.  Surg.,"  1907,  p.  234)  advocates  the  use 
of  sterilized  oil  injected  into  joints  to  prevent  the  formation  of  adhesions  and 
thus  increase  the  arc  of  motion.  It  may  also  be  poured  into  a  joint  after  arthrot- 
omy.  After  using  oil  in  the  manner  described,  Baer  summarizes  as  follows: 
"That  injection  of  oil  into  joints  under  proper  precautions  is  a  harmless  pro- 
cediu*e;  that  the  joint  vnll  apparently  tolerate  as  much  as  it  will  hold. 

"It  is  most  useful  in  cases  where  adhesions  have  followed  some  acute 
infectious  process,  or  in  those  stifl  joints  which  are  classified  as  arthritis  defor- 
mans of  the  infectious  t>'pe. 

"Passive  motions  are  made  with  less  pain  where  the  joint  contains  oil. 

"It  plays  some  part  in  preventing  adhesions,  so  that  the  mobility  of  the 
joint  is  increased  more  rapidly." 

W.  S.  Baer  (Ibid.,  August,  1909)  reviews  the  literature  of  the  operative 
treatment  for  mobilizing  joints,  and  advocates  the  use  of  chromicized  pig's 
bladder  as  the  most  satisfactory  material  to  place  between  the  surfaces  of 
the  recently  separated  bones. 

Chlumsky,  disappointed  with  the  results  of  muscle  flaps,  used  non-absorb- 
able  materials,  zinc,  rubber,  celluloid,  silver,  and  layers  of  coUoidin,  but  no 
permanent  mobility  was  obtained.  He  then  employed  absorbable  plates  of 
decalcified  bone,  ivory,  and  magnesium,  with  somewhat  better  results.  Baer's 
method  of  inserting  chromicized  pig's  bladder  followed  the  unsuccessful  em- 
plo}Tnent  by  him  of  Cargile  membrane.  The  pig's  bladder  is  tightly  stitched 
by  catgut  sutures  around  the  recently  denuded  bone  and  the  wound  is  closed. 
A  hip-joint  two  months  after  this  procedure  shoAved  a  voluntary  flexion  of  35 
degrees;  abduction  of  15  degrees;  adduction  of  10  degrees;  rotation  of  25 
degrees.  Seven  months  after  operation  the  mobility  was  better  than  that 
recorded  at  two  months.     Similar  results  are  recorded  of  the  knee  and  elbow. 

Baer  emphasizes  the  necessity  of  ha\ing  the  pig's  bladder  absorbable  in 
thirty  to  forty  days.  It  should  be  pHable  enough  to  be  adapted  to  the  contour 
of  the  joint.  Ever^^  raw  surface  should  be  absolutely  separated  by  it  from  that 
with  which  it  would  tend  to  come  in  contact. 

Thorn,  after  moblizing  the  joint,  transplants  a  free  flap  of  fascia  to  between 
the  bone  ends  ("Zeitschr.  f.  Chirurgie."  Bd.  cviii).  Hauer,  of  Baltimore,  has 
also  done  this  successfully.  R.  Tunstall  Taylor  has  experimented  elaborately 
in  the  endeavor  to  find  a  liqmd  and  absorbable  animal  substance  which,  when 


654  Diseases  and  Injuries  of  the  Bones  and  Joints 

injected  by  a  syringe  between  the  denuded  ends  of  the  bones,  would  immediately 
solidify  and  prevent  contact  of  bone  ends  for  six  or  eight  weeks.  He  finally 
selected  yellow  wax  i  part  and  lanolin  from  2  to  6  parts  (this  melts  at  from 
120°  to  135°  F.).  Taylor  has  had  some  excellent  results  from  this  method 
("Penna.  Med.  Jour.,"  Jan.,  1913).  He  cautions  us  not  to  operate  by  any 
method  for  ankylosis  due  to  infective  arthritis  until  joint  inflammation  has 
been  quiescent  for  a  year  or  more. 

Treatment  of  Extra-articular  Ankylosis. — The  treatment  of  false  anky- 
losis depends  upon  the  case.  Recently  contracted  muscles  or  tendons  require 
motion,  massage,  frictions  with  stimulating  liniments,  hot  and  cold  douches, 
and  the  use  of  the  hot-air  apparatus.  Violent  breaking  up  is  not  satisfactory, 
neither  is  tenotomy  nor  myotomy.  Old  contractions  of  tendons  require  tendon 
lengthening  by  tendoplasty  or  myoplasty.  Chronic  inflammation  of  tendon- 
sheaths  with  adhesion  of  tendons  requires  excision  of  the  sheaths.  Whenever 
possible,  excise  a  cicatrix  that  causes  false  ankylosis,  and  fill  the  gap  with 
sound  cutaneous  tissue  and  fat.  When  the  fixation  is  due  to  adhesive  synovitis 
of  the  capsule,  excise  the  capsule  and  attached  ligaments;  "the  head  and  neck 
of  the  bone  should  then  be  surrounded  by  an  aponeurosis  or  muscle  to  prevent 
the  re-forming  of  adhesions"  (JohnB.  Murphy,  in  "Jour.  Amer.  Med.  Assoc," 
May  20-27  and  June  3,  1905).  Bony  deposits  are  gouged  away  and  tumors 
are  removed.  Contractures  in  cases  of  paralysis  require  electricity,  passive 
motions,  frictions  with  stimulating  liniments,  the  hot-air  bath,  and  general 
treatment.  Constant  and  graduated  pressure  by  means  of  splints  and  braces 
(with  ratchet  or  screws)  will,  in  many  instances,  restore  function.  The  patient 
can  be  taught  to  alter  the  pressure  frequently,  making  it  as  powerful  as  he  is 
able  to  bear  it. 

Loose  Bodies  in  Joints  (Floating  Cartilages). — The  knee  is  the 
joint  affected  in  90  per  cent,  of  cases,  but  the  elbow,  shoulder,  hip,  wrist,  lower 
jaw,  and  ankle  may  suffer.  There  may  be  but  one  loose  body  in  a  joint, 
there  may  be  two  or  more,  there  may  be  many,  or  even  hundreds.  More 
than  one  joint  may  be  involved.  The  condition  is  commonest  in  adult  men. 
These  bodies  may  be  free  or  each  may  have  a  stalk  or  pedicle;  they  may 
move  about  and  occasionally  block  the  joint,  or  may  lie  quietly  in  a  joint- 
recess  or  diverticulum.  They  may  be  flat  or  ovoid,  smooth  or  irregular, 
as  small  as  peas  or  as  large  as  plums,  and  may  be  composed  of  fibrous  tissue, 
of  cartilage,  or  of  bone.  There  are  numerous  different  modes  of  origin  of 
these  bodies,  many  being  "detached  ecchondroses  or  pieces  of  hyaline  car- 
tilage hanging  by  narrow  pedicles"  (Sir  J.  Bland-Sutton),  and  they  result  from 
enlargement  and  chondrification  of  the  villi  of  the  synovial  membrane. 

Symptoms. — Some  bodies  give  rise  to  no  symptoms  for  a  long  time  and 
others  merely  cause  synovitis.  A  loose  body  may  produce  pain  and  inter- 
fere with  joint-function.  The  joint  is  weak  and  a  little  swollen,  and  the  patient 
can  perhaps  feel  the  body  and  can  even  push  it  into  a  superficial  area  of  the 
joint,  where  it  may  be  felt  by  the  surgeon.  From  time  to  time  the  body  may 
get  caught,  thus  suddenly  locking  the  joint  and  producing  intense  and  sick- 
ening pain,  extension  and  flexion  being  impossible  until  the  body  slips  out. 
It  may  slip  out  in  a  moment,  but  may  not  for  hours  or  even  for  many  days.  A 
rather  small  body  seems  more  apt  to  cause  locking  than  a  very  large  one,  but 
if  a  large  one  does  cause  locking,  it  is  more  difl&cult  to  dislodge  than  is  a  small 
one.  Locking  of  a  joint  by  a  loose  body  is  followed  by  inflammation  and 
effusion.  If  the  loose  body  is  dense  and  large,  the  x-ray  may  disclose  it.  Sesa- 
moid bones  in  the  gastrocnemius  muscle  must  not  be  confused  with  loose 
bodies  in  the  knee-joint.  In  some  cases  of  loose  body  in  the  knee  the  diagnosis 
is  impossible  from  dislocation  of  a  semilunar  cartilage,  inflamed  semilunar 
cartilage,  and  synovitis  with  proliferation  of  villi. 


Spontaneous,   Pathological,   or  Consecutive  Dislocations  655 

Treatment. — To  relieve  locking,  employ  forced  flexion  and  sudden  exten- 
sion. Cure  can  be  obtained  only  by  operation.  Let  the  patient  bring  the 
foreign  body  to  a  point  where  it  can  be  felt  by  the  surgeon,  so  that  he  can  deter- 
mine where  it  lodges.  Asepticize  the  knee  with  the  utmost  care.  Operate  if 
possible  under  cocain;  if  not,  give  ether.  If  the  body  is  felt  before  operating, 
fix  it  -VNdth  a  pin.  The  joint  is  now  opened,  explored  with  the  finger,  the  foreign 
body  extracted,  and  an  exploration  made  to  see  that  no  other  bodies  are  present. 
If  a  body  has  an  attachment  the  pedicle  is  snipped  through  by  scissors.  The 
wovmd  is  sutured  in  two  layers  and  the  leg  is  placed  upon  a  splint.  Asepsis 
must  be  most  rigid.  The  operation  does  not  cure  the  causative  process,  and 
these  bodies  are  apt  to  form  again.  When  the  knee  is  involved,  some  surgeons 
saw  the  patella  transversely,  open  the  joint  widely,  remove  all  foreign  bodies, 
and  seek  to  cure  any  causative  process. 

Lux.\TiONS  OR  Dislocations 

A  dislocation  is  the  persistent  separation  from  each  other,  partially  or  com- 
pletely, of  two  articular  surfaces.  A  self-reduced  dislocation  is  called  a  sprain 
(Douglas  Graham\  There  are  three  forms  of  dislocations:  (i)  traimiatic; 
(2)  spontaneous  or  pathological;  (3)  congenital. 

1.  Traumatic  dislocations  are  due  to  injur}-.  They  are  di\dded 
into — complete  dislocation,  in  which  the  two  articular  siu:faces  are  entirely 
separated  and  the  ligaments  are  torn;  incomplete  or  partial  dislocation  or 
subluxation,  in  which  the  two  articular  surfaces  are  not  completely  separated 
and  the  ligaments  are  rarely  lacerated;  simple  dislocation,  in  which  there  is 
no  woimd  leading  from  the  surface  to  the  articulation;  compound  dislocation, 
in  which  a  wound  leads  from  the  surface  to  the  joint;  complicated  dislocation, 
in  which,  besides  the  dislocation,  there  is  a  fracture,  extensive  damage  of  the 
soft  parts,  an  opening  which  makes  the  case  compound,  or  damage  of  a  nerv-e 
or  blood-vessel;  primitive  or  primary  dislocation,  in  which  the  bones  remain 
as  originally  displaced;  secondary  dislocation,  in  which  the  dislocated  bone 
assumes  a  new  position,  for  instance,  a  subglenoid  luxation  of  the  humerus  is 
primary,  and  it  may  become  secondarily  a  subcoracoid  luxation  because  of 
muscular  contraction  or  attempts  at  reduction;  recent  dislocation,  in  which 
the  displaced  bone  is  not  firmly  fastened  by  tissue  changes  in  its  new  situation, 
and  its  old  socket  is  not  obliterated;  old  dislocation,  in  which  the  displaced 
bone  is  firmly  fastened  by  tissue  changes  in  its  new  habitat,  and  the  old  socket 
is  to  a  great  extent  obliterated  (whether  a  dislocation  is  old  or  new  depends 
on  the  state  of  the  parts  rather  than  on  the  time  which  has  elapsed  since  the 
accident);  double  dislocation,  in  which  corresponding  bones  on  each  side  are 
dislocated;  single  dislocation,  in  which  only  one  joint  is  dislocated;  tmilateral 
dislocation,  in  which  one  articulation  of  one  bone  is  out  of  place;  bilateral 
dislocation,  in  which  s}Tnmetrical  articulations  are  dislocated;  and  relapsing 
or  habitual  dislocation,  which  recurs  frequently  from  slight  force  because  of 
relaxed  ligaments  or  lack  of  complete  repair  after  the  Hgamentous  rupture  of 
a  first  dislocation. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dislocations. — 
Spontaneous  dislocation  arises  from  such  very  sKght  force  that  the  cause  may 
not  be  identified,  and  it  acts  on  a  joint  rendered  lax  by  disease.  It  may  arise 
in  the  course  of  chronic  s\Tio\'itis,  tuberculous  joint-disease,  or  rheumatoid 
arthritis.  In  Charcot's  joint  a  spontaneous  dislocation  will  occur  sooner  or 
later.  In  t}-phoid  fever  spontaneous  dislocation  is  not  imcommon.  The 
hip-joint  is  most  often  the  one  attacked.  Dislocation  of  the  hip  in  typhoid  fever 
follows  a  severe  joint  inflammation,  is  usually  upon  the  dorsum  of  the  ilium, 
and  is  frequently  not  noticed  until  convalescence  has  set  in.    If  a  t>'phoid  dis- 


656  Diseases  and  Injuries  of  the  Bones  and  Joints 

location  is  seen  early,  reduction  is  easily  effected,  but  if  seen  late,  is  impossible. 
The  treatment  for  irreducible  typhoid  dislocation  is  the  same  as  for  any  other 
irreducible  dislocation.  Dislocation  may  occur  in  the  acute  infectious  arthritis 
of  scarlatina,  pneumonia,  etc.,  from  distention  of  the  joint  cavity  with  septic 
products  or  exudates.  In  infantile  palsy  muscular  atrophy  may  be  so  great 
that  a  shoulder  or  hip  may  be  easily  dislocated. 

3.  Congenital  Dislocations. — A  congenital  dislocation  is  due  to  a  con- 
genital joint  malformation  which  renders  it  impossible  for  the  bone  to  main- 
tain a  normal  position,  or  is  due  to  external  violence  during  the  period  of 
uterine  gestation.  Congenital  dislocations  should  not  be  confounded  with 
dislocations  produced  during  delivery.  The  hip  is  the  joint  most  often  in- 
volved. The  shoulder  suffers  occasionally.  Lannelongue  maintains  that 
congenital  dislocation  of  the  hip  is  due  to  atrophy  of  the  muscles  and  of  the 
acetabulum  following  spinal-cord  disease.  Verneuil  thinks  the  dislocation  is 
paralytic.  Broca  says  that  in  view  of  the  fact  that  the  liead  of  the  bone  is 
larger  than  the  cavity  in  which  it  belongs,  it  is  useless  to  attempt  reduction 
by  manipulation  or  extension,  but  many  successful  cases  by  the  Lorenz  blood- 
less method  prove  Broca's  condemnation  to  have  been  too  sweeping.  Lorenz 
and  Hoffa  have  each  devised  an  operation  for  this  condition  (see  page  711). 
Congenital  dislocation  of  the  shoulder  requires  incision,  possibly  excision,  or 
the  paring  down  of  the  head  to  fit  the  glenoid  cavity  (Phelps). 

Traumatic  Dislocations. — In  the  succeeding  pages  the  traumatic  form 
of  dislocation  will  be  particularly  considered. 

The  causes  of  traumatic  dislocations  are  divided  into  predisposing  and 
excitittg. 

Predisposing  causes  are:  (i)  age;  dislocations  are  commonest  in  middle  life, 
the  usual  lesion  of  the  young  being  green-stick  fracture,  and  that  of  the  old 
being  fracture;  dislocations  of  the  radius  are  not  imcommon  in  youth;  (2) 
muscular  development,  dislocations  being  commonest  in  those  with  powerful 
muscle;  (3)  sex,  males  being  more  predisposed  than  females,  because  of  their 
occupations  and  muscular  strength;  (4)  occuption  predisposes  as  a  cause 
according  as  it  demands  the  employment  of  muscular  force,  as  in  the  carrying 
of  burdens;  (5)  nature  of  the  joint,  ball-and-socket  joints  being  more  liable  to 
luxation  than  are  ginglymoid  joints,  because  of  their  wide  range  of  motion;  (6) 
joint-disease  predisposes  by  relaxing  the  ligaments;  (7)  situation  of  the  joint, 
some  joints  being  more  exposed  to  injury  than  others. 

Exciting  causes  are  divided  into — (i)  external  violence  and  (2)  muscular 
action.  External  violence  may  be  direct,  as  when  a  blow  upon  one  of  the  bones 
forces  it  directly  away  from  the  other;  or  it  may  be  indirect,  as  when  force 
applied  to  a  distant  part  of  a  bone  is  transmitted  to  its  end  and  drives  the 
bone  out  of  its  socket.  Muscular  action  is  a  cause  when  sudden  and  violent 
muscular  contraction  occurs  during  the  maintenance  of  a  position  of  the  joint 
which  gives  the  muscles  fuU  sway,  and  throws  the  head  of  the  bone  against 
the  weakest  part  of  its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  traumatic  dislocation  the 
ligaments  are  damaged,  and  may  perhaps  exhibit  extensive  laceration,  or  may 
show  only  a  buttonhole  laceration  through  which  a  bone  projects.  Exter- 
nal force  produces  much  laceration  and  little  stretching  of  the  ligaments; 
muscular  action  produces  little  laceration  and  much  stretching  of  the  liga- 
ments. In  some  cases  of  dislocation  due  to  external  violence  the  structures 
about  the  joint  are  bruised  or  otherwise  damaged;  the  old  socket  is  filled  with 
blood,  and  the  bone  in  its  new  situation  lies  in  a  bloody  area.  Large  vessels 
and  nerves  are  rarely  torn,  though  they  are  not  unusually  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises  in  the  old  joint  ca\dty 
and  about  the  displaced  bone,  and  the  whole  area  becomes  glued  together,  first, 


Treatment  of  Traumatic  Dislocation  657 

bv  coagulated  exudate,  and  finally  by  fibrous  tissue.  After  a  time,  in  ball-and- 
socket  joints,  the  old  socket  fills  with  fibrous  tissue,  contracts,  becomes  irreg- 
ular, and  may  even  be  obliterated;  the  head  of  the  dislocated  bone  is  altered  in 
shape,  its  cartilage  is  destroyed  or  converted  into  fibrous  tissue,  and  the  pres- 
sure of  the  head  of  the  bone  forms  a  hollow  in  its  new  situation,  which  hollow 
becomes  surrounded  by  fibrous  tissue  or  even  by  bone.  A  new  joint  may 
form,  the  surrounding  tissue  becoming  a  compact  capsule,  and  a  bursa  forming 
between  the  head  of  the  bone  and  its  new  socket.  In  a  dislocated  hinge- 
joint  the  ends  of  the  bone  alter  greatly  in  shape  and  their  cartilage  is  con- 
verted into  fibrous  tissue.  In  an  unreduced  dislocation  the  muscles  shorten 
or  lengthen  or  imdergo  atrophy  or  fatty  degeneration,  as  the  case  may  be. 
An  imreduced  dislocation  of  a  ball-and-socket  joint  may  give  a  fairly  movable 
new  joint,  but  an  unreduced  dislocation  of  a  hinge-joint  rarely  allows  of  much 
motion. 

General  Symptoms  of  Traumatic  Dislocation. — In  general,  traumatic  dis- 
locations are  indicated — (i)  by  pain  of  a  sickening,  nauseating  character;  (2) 
by  rigidity,  voluntary  motion  being  impossible  except  to  a  slight  extent  in  the 
direction  of  the  deformity.  (For  instance,  in  dislocation  of  the  inferior  maxil- 
lar>"  the  jaw  can  be  opened  a  little  more,  but  it  cannot  be  closed.)  This 
rigidity  brings  about  loss  of  fimction.  When  the  surgeon  attempts  to  move 
the  joint  he  finds  it  very  rigid;  (3)  by  change  in  the  shape  of  the  joint  (as  flat- 
tening of  the  shoulder  after  dislocation  of  the  humerus);  (4)  by  alteration  in 
the  mutual  relations  of  bony  prominences  about  a  joint  (as  the  alteration  of 
the  relation  between  the  olecranon  and  humeral  condyles  in  dislocation  of 
the  elbow  backward);  (5)  by  feeling  the  displaced  bone  in  its  new^  situation; 
(6)  by  missing  the  head  of  the  bone  from  its  p'-oper  situation ;  (7)  by  alteration 
in  the  length  of  the  limb  (in  dislocation  of  the  femur  into  the  thyroid  foramen 
the  limb  is  lengthened,  but  in  dislocation  on  to  the  dorsum  of  the  ilium  it  is 
shortened) ;  and  (8)  by  alteration  in  the  axis  of  the  bone  (in  dislocation  upon 
the  dorsiun  of  the  ilium  the  axis  of  the  injured  thigh  would,  if  prolonged,  pass 
through  the  lower  third  of  the  sound  thigh) ;  (9)  by  seeing  the  dislocation  with 
a  fluoroscope  or  looking  at  a  skiagraph  of  it. 

Diagnosis  of  Traimiatic  Dislocation. — A  dislocation  may  be  mistaken  for 
a  fracture.  In  dislocation  there  is  rigidity,  in  fracture  there  is  preternatural 
mobility;  in  dislocation  there  is  no  true  crepitus  (there  may  be  tendon-  or 
joint-crepitus),  in  fracture  there  usually  is  crepitus;  in  dislocation  the  deformity 
does  not  tend  to  recur  after  reduction,  in  fracture  it  does  recur  after  exten- 
sion is  relaxed.  In  a  sprain  the  movements  of  the  joint  are  only  limited,  not 
abolished,  by  the  almost  complete  rigidity  encountered  in  dislocation.  The 
change  which  a  sprain  may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or 
to  bleeding;  there  is  no  alteration  in  the  relation  of  the  bony  prominences  to 
one  another;  there  is  no  notable  alteration  in  the  length  of  the  limb  (a  slight 
increase  in  length  may  arise  from  joint-effusion,  or  the  head  of  the  bone  may 
subsequently  be  absorbed  and  thus  produce  shortening  after  some  wrecks); 
there  is  no  alteration  in  the  axis  of  the  bone;  the  bony  head  is  not  felt  in  a 
new  position,  and  it  is  foimd  in  its  normal  place.  Always  remember  that  a 
fracture  may  exist  with  a  dislocation.  In  any  doubtful  case — in  fact,  in  most 
cases — give  ether,  for  a  dislocation  should  be  reduced  while  the  patient  is  anes- 
thetized (except  in  dislocation  of  the  jaw,  of  a  finger,  of  the  carpus,  etc.). 
In  some  cases  swelling  renders  the  diagnosis  difficult  or  impossible.  Always 
compare  the  injured  joint  with  the  corresponding  joint  of  the  sound  side. 
The  .v-rays  constitute  an  invaluable  method  of  diagnosis. 

Treatment   of  Traxmiatic   Dislocation. — Recent  Simple   Dislocation. — Re- 
duce a  simple  dislocation  under  ether,  as  a  rule.    Try  manipulation,  a  pro- 
cedure which  seeks  to  make  the  bone  retrace  its  own  pathway.    If  this  pro- 
42 


658  Diseases  and  Injuries  of  the  Bones  and  Joints 

cedure  fails,  employ  extension  and  counterextension.  If  considerable  force 
is  needed,  an  assistant  makes  counterextension,  and  the  surgeon  fastens  to 
the  extremity  a  clove-hitch,  which  he  ties  about  his  waist,  and  thus  secures 
powerful  extension.  Counterextension  may  be  obtained  by  bands,  or,  in 
some  instances,  by  the  foot  of  the  surgeon.  The  clove-hitch  is  used  because 
it  will  not  tighten  by  traction ;  a  tightening  band  would  lacerate  the  soft  parts 
(Fig.  395).  If  great  power  is  needed,  compound  pulleys  may  be  employed, 
such  as  the  Jarvis  adjuster  or  some  similar  appliance,  but  at  the  present  day 
pulleys  are  rarely  used  (see  page  668).  If  these  means  fail,  cut  down  upon  the 
bone  and  restore  it  to  position;  operation  is  much  safer  than  the  application  of 
great  force.  After  reducing  a  dislocation,  immobilize  the  joint  for  a  time,  which 
varies  for  different  joints,  and  for  the  first  few  days  combat  swelling  and  in- 
flammation by  rest  of  the  part  and  the 
use  of  evaporating  lotions  or  an  ice-bag. 
If  there  exists  a  fracture  of  the  dislo- 
cated bone,  apply  splints  and  then  try 
to  reduce  by  manipulations,  grasping 
the  limb  and  the  splints  with  one  hand 
„.  ^,      ,.^  ,   ,       '     ;:-,    ,  below  and,  if  possible,  the  head  of  the 

Fig.  395- — Clove-mtcn  knot  appbed  above      ,  •  i    ^i      ^i        i         i     i  .i 

the  wrist.  In  dislocation  of  the  shoulder  this  bone  With  the  Other  hand  abovc  the  Seat 
knot  is  put  above  the  elbow  (after  Erichsen).        of  the  fracture.     Aliis  believes  that  a 

dislocation  can  be  reduced  even  when  a 
fracture  exists.  It  is  possible  to  pull  the  dislocated  head  down  to  the  joint, 
because  a  portion  of  periosteum  and  possibly  tendinous  material  and  muscle 
still  hold  the  two  fragments  as  a  strap  might  unite  two  sticks.  The  head  may 
be  forced  into  place  by  the  fingers  while  traction  is  being  made.  If  the  fracture 
is  near  the  joint  and  the  fragments  cannot  be  fLxed,  try  to  reduce  the  dislo- 
cation, first  striving  to  press  the  bone  into  place.  This  attempt  can  be  greatly 
aided  by  traction  upon  the  lower  fragment.  In  some  cases  with  fracture 
reduction  can  be  much  aided  by  making  a  small  incision,  screwing  a  gimlet 
into  the  head  of  the  bone,  and  using  this  tool  as  a  handle.  McBurney  incises, 
drills  a  hole  in  each  bone,  inserts  hooks  into  them,  and  pulls  the  dislocated 
bone  into  position  (see  Figs.  277,  278).  When  the  dislocation  has  been  re- 
duced, the  bone-fragments  should  be  wired  or  plated  together. 

Compound  Traumatic  Dislocation. — The  opening  in  the  soft  parts  may  be 
due  to  external  violence  or  to  projection  of  a  bone.  Compound  dislocations 
are  very  serious.  Hinge-joints  are  more  liable  to  these  injuries  than  are 
ball-and-socket  joints.  Many  cases  require  excision;  some,  amputation;  one 
that  does  not  demand  excision  or  amputation  should  be  treated  by  sterilizing 
the  parts,  restoring  the  dislocated  bone,  making  a  counteropening,  draining, 
dressing  antiseptically,  and  immobilizing.  Considerable  ankylosis  generally 
ensues,  except  sometimes  in  the  small  joints.  It  is  scarcely  ever  necessary 
to  cut  away  any  portion  of  the  protruding  bone  to  effect  reduction.  If  a 
joint  is  badly  splintered,  or  if  the  soft  parts  are  extensively  damaged,  it  may 
be  necessary  to  excise  or  amputate;  if  the  main  vessels  of  a  limb  are  seriously 
injured,  amputation  must  be  considered.  If  the  patient  is  so  old  or  so  feeble 
that  it  is  perilous  to  force  him  to  combat  a  long  illness,  amputation  should 
be  performed. 

Old  Traumatic  Dislocation. — The  problem  always  presented  in  an  old 
dislocation  is.  Shall  reduction  be  tried  or  shall  the  bones  be  let  alone?  Sir 
Astley  Cooper  laid  down  this  rule:  "Do  not  attempt  to  reduce  a  shoulder- 
dislocation  after  three  months,  nor  a  hip-dislocation  after  two  months";  but 
this  rule  was  put  forth  before  the  days  of  ether.  Do  not  select  any  fixed  period 
of  time  to  determine  what  action  is  advisable.  In  dislocation  of  a  ball-and- 
socket  joint  considerable  motion  may  become  possible  and  a  new  joint  may 


Special  Traumatic  Dislocations  659 

form.  If  movement  does  not  produce  pain,  a  useful  new  joint  may  be  obtained 
by  the  persistent  employment  of  active  and  passive  movements;  if  movement 
of  the  limb  does  produce  pain,  enough  motion  will  not  be  attempted  by  the 
patient  to  produce  a  useful  joint.  In  the  former  case  it  may  be  best  to  try  to 
obtain  a  useful  new  joint,  and  in  the  latter  case  the  surgeon  should  endeavor 
to  reduce  the  old  dislocation.  Always  remember  that  dislocation  of  a  hinge- 
joint,  if  left  unreduced,  will  never  eventuate  in  a  useful  new  joint. 

In  trying  to  reduce  an  old  dislocation  give  ether,  make  movements  to 
break  up  adhesions,  and  persist  in  making  these  motions  until  the  head  of 
the  bone  is  felt  to  move;  then  try  at  once  to  reduce  by  manipulation  or  exten- 
sion and  counterextension,  not  waiting  for  two  days,  .as  some  suggest.  If 
the  head  of  the  bone  cannot  be  made  to  move,  the  Dieffenbach  plan  has  been 
advised,  which  is  to  cut  the  tense  restraining  bands  with  a  tenotome.  Lord 
Lister,  being  much  impressed  with  the  danger  inevitably  linked  with  forcibly 
dragging  old  dislocations  into  place,  preferred  to  cut  down  and  restore  the  bone, 
employing,  of  course,  the  strictest  asepsis,  and  surgeons  in  general  have  adopted 
this  view.  In  some  old  dislocations  excision  of  the  head  of  the  bone  is  the 
proper  operation. 

Special  Traumatic  Dislocations.^ — Mandible. — A  dislocation  of  the 
lower  jaw,  when  there  is  no  fracture,  is  almost  invariably  forward.  Back- 
ward dislocation  without  fracture  is  extremely  rare,  and  some  have  main- 
tained that  it  cannot  occur.  Croker  King  reported  a  case  in  1858.  Theim 
has  observed  it  seven  times  in  five  women.  The  condyle  passes  under  the 
lower  surface  of  the  auditory  canal. ^  The  common  dislocation  is  forward,  and 
this  is  the  form  meant  when  we  simply  speak  of  dislocation  of  the  jaw.  There 
are  two  forms  of  forward  dislocation — the  unilateral,  which  is  rare,  and  the 
bilateral,  which  is  common.  Dislocations  of  the  jaw  are  commonest  in  women 
and  during  middle  life.  When  the  mouth  is  open,  contraction  of  the  external 
pterygoid  muscle  may  pull  the  condyle  over  the  articular  eminence;  this  con- 
traction may  be  brought  about  by  yawning,  vomiting,  scolding,  etc.  When  the 
mouth  is  open,  dislocation  of  the  lower  jaw  may  be  caused  by  a  blow  upon  the 
chin ;  it  may  also  be  caused  by  forcing  the  mouth  more  widely  open  by  pushing 
a  bulky  body  between  the  teeth. 

Symptoms  of  Lower-jaw  Dislocation.— In  the  bilateral  form  the  mouth  is 
open  and  fixed,  and  it  cannot  be  closed,  though  it  can  be  opened  a  little  more. 
The  condyles  are  in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid  processes  being 
wedged  against  the  malar  bones.  The  lower  jaw  is  advanced  in  front  of  the 
upper  jaw  and  the  face  looks  longer  than  natural.  The  lips  cannot  close, 
the  saliva  dribbles,  swallowing  and  speech  are  difficult,  there  is  a  depression  in 
front  of  each  ear,  the  condyles  are  recognizable  in  their  new  abodes,  the  coro- 
noid processes  are  detected  by  a  finger  in  the  mouth,  and  the  masseters  and 
temporals  stand  out  in  a  state  of  rigidity.  Pain  may  be  severe,  may  be  moder- 
ate, or  may  be  absent.  In  the  unilateral  form  the  chin  goes  toward  the  sound 
side,  and  the  mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither  is 
the  jaw  so  fixed.  The  S3Tnptoms  are  similar  to  those  of  a  bilateral  luxation, 
but  are  not  so  pronounced.  The  hollow  in  front  of  the  ear  and  the  abnormal 
situation  of  the  condyle  are  detected  upon  one  side  only.  In  an  unreduced 
dislocation  the  patient  may  after  a  time  establish  some  movements  of  the  jaw, 
but  the  power  of  mastication  will  always  be  seriously  impaired. 

Treatment  of  Lower-jaw  Dislocation. — In  reducing  a  dislocation  of  the  lower 

jaw  the  patient  is  usually  placed  with  his  head  against  the  back  of  a  chair  or 

against  the  body  of  an  assistant.    The  surgeon,  after  wrapping  up  his  thumbs 

to  protect  them  from  being  bitten,  stands  in  front  of  the  patient,  puts  his 

1  Theim,  in  "Rev.  de  Chir.,"  vo".  viii,  1888. 


66o  Diseases  and  Injuries  of  the  Bones  and  Joints 

thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin  with  his  free  fingers. 
He  now  presses  downward  and  backward  on  the  jaw,  and  as  soon  as  the  con- 
dyle is  loosened,  closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin,  using 
his  thumbs  as  levers.  For  the  last  year  I  have  followed  the  excellent  sugges- 
tion of  W.  J.  Young  ("Brit.  Med.  Jour.,"  March  23,  1913),  which  is  to  stand 
behind  the  patient,  with  the  patient's  head  against  the  surgeon's  chest, 
place  the  right  thumb  far  back  in  the  right  side  of  the  patient's  mouth  and 
grasp  the  chin  with  the  left  hand.  The  right  hand  easily  depresses  the  jaw  and 
the  left  guides  the  condyle  into  place.  Then  the  procedure  is  reversed  and  the 
left  side  reduced.  If  reduction  by  the  hands  fails,  wedges  should  be  put  be- 
tween the  molar  teeth  and  the  chin  should  be  pushed  up  either  by  the  hands 
or  by  a  tourniquet,  the  band  of  which  surrounds  the  head  and  chin.  In  a 
unilateral  dislocation  the  wedge  should  be  used  only  on  the  injured  side.  In 
difficult  cases  Sir  Astley  Cooper  pushed  a  round  wooden  ruler  between  the  molar 
teeth,  used  the  upper  teeth  as  a  fulcrum,  and  raised  the  end  of  the  ruler  as 
the  handle  of  a  lever.  The  forceps  used  by  an  anesthetist  may  depress  the  con- 
dyle from  its  point  of  fixation,  whereupon  the  chin  may  be  pushed  up  and  back. 
Nelaton  advises  that  the  surgeon  place  his  thumbs  in  the  mouth  of  the  patient 
and  push  the  coronoid  processes  backward.  After  reduction  a  Barton  bandage 
should  be  applied  and  worn  for  over  two  weeks.  The  dressing  should  be 
renewed  once  a  day,  and  passive  motion  be  begun  in  the  second  week.  The 
bandage  may  be  discarded  at  the  end  of  the  third  week.  Liquid  diet  is  ad- 
visable for  three  weeks  after  the  accident.  In  an  old  dislocation  reduction  is 
always  attempted,  at  least  up  to  a  period  of  six  or  seven  months  after  the 
accident.  An  irreducible  dislocation  requires  osteotomy  of  the  neck  of  the  bone 
if  the  part  cannot  be  restored  after  incision. 

Dislocation  of  the  Clavicle. — Sternal  End. — There  are  three  forms  of 
dislocation  of  the  sternal  end  of  the  clavicle,  namely:  (i)  forward;  (2)  back- 
ward, and  (3)  upward. 

Forward  Dislocation  of  the  Sternal  End  of  the  Clavicle  (Presternal  Dis- 
location).— ^The  causes  of  forward  dislocation  of  the  clavicle  are  blows,  falls,  or 
pulls  which  drive  or  draw  the  shoulder  backward. 

Symptoms  and  Treatment  of  Forward  Dislocation  of  the  Sternal  End  of 
the  Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavicle  are:  prom- 
inence in  front  of  the  sternum;  the  acromion  is  nearer  to  the  sternum  on  the 
injured  than  on  the  sound  side;  the  clavicular  origin  of  the  sternocleido- 
mastoid muscle  is  rigid;  movement  is  difficult  and  painful.  To  reduce  a  dis- 
location of  the  clavicle,  pull  the  shoulders  back  against  the  knee  of  the  surgeon, 
which  is  placed  between  the  scapulae.  Dress  with  a  posterior  figure-of-8  band- 
age (Fig.  833)  or  a  Velpeau  bandage  (Fig.  835),  the  dressing  to  be  worn  for 
three  weeks.  After  removal  of  the  dressing  apply  a  truss,  the  pad  of  which  is 
put  over  the  head  of  the  clavicle,  and  which  instrument  is  to  be  worn  for  a 
month.  Dislocation  of  the  clavicle  is  difficult  to  keep  reduced,  but  even  if  it 
becomes  fixed  in  deformity,  the  motions  of  the  arm  will  not  be  impaired  per- 
manently.   It  can  be  reduced  and  fixed  by  incision  and  wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle  is  very  rare.  The 
causes  are  direct  violence  and  indirect  force,  such  as  falls  or  blows  which 
drive  the  shoulder  forward  and  inward. 

Symptoms  and  Treatment  of  Backward  Dislocation  of  the  Sternal  End  of 
the  Clavicle. — The  symptoms  are:  pain,  loss  of  function  in  the  arm;  inclination 
of  the  head  toward  the  injured  side;  stiffness  of  the  neck;  the  shoulder  passes 
forward  and  inward,  and  often  falls  downward;  a  depression  exists  over  the 
sternoclavicular  joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found  back 
of  the  sternum.  The  displaced  clavicle  may  press  upon  the  trachea,  the 
esophagus,  or  the  great  vessels,  inducing  dyspnea,  dysphagia,  obliteration  of 


Dislocation  of  the  Acromial  End  of  the  Clavicle 


66i 


pulse  in  the  arm  of  the  injured  side,  or  great  venous  congestion  of  the  head 
(see  Pick).  The  usual  method  of  treatment  is  to  pull  the  shoulders  backward 
and  apply  a  posterior  ligure-of-S  bandage  (Fig.  833),  which  must  be  worn 
for  three  weeks.  If  pressure-symptoms  are  urgent,  it  is  the  rule  to  incise, 
restore  the  bone  to  place  and  wire  it.  or  resect  the  displaced  head. 

Upward  dislocation  of  the  sternal  end  of  the  clavicle  is  very  rare.  The 
cause  is  indirect  force,  which  carries  the  shoulder  downward,  inward,  and 
backward  (Smith). 

Symptoms  and  Treatment  of  Upivard  Dislocation  of  the  Sternal  End  of  the 
Clavicle. — The  chief  symptom  is  impaired  function  of  the  arm;  the  shoulder 
passes  do\\-nward  and  inward,  the  cla\'icular  axis  is  altered,  and  the  displaced 
head  is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dislocation,  put  a 
pad  in  the  axilla  and  press  the  elbow  to  the  side  (in  order  to  throw  the  bone 
outward),  and  try  to  push  the  head  into  place.  Apply  a  Desault  bandage 
(Fig.  836)  and  place  a  firm  pad  over  the  sternoclavicular  joint.  The  deformity 
is  apt  to  recur,  but  a  useful  limb  \\\\\  nevertheless  be  obtained.  The  best 
method  of  treatment  is  to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost  always  upward, 
but  it  may  be  below  the  acromion.     The  cause  is  \'iolent  force,  which,  if  so 


Fig.  3g6. — ^Dislocation  upward  of  acromial  end  of  clavicle. 

appKed  to  the  scapula  as  to  drive  the  shoulder  forward,  may  produce  a  dis- 
location upward.  A  dislocation  downward  is  due  to  blows  upon  the  upper 
surface  of  the  outer  end  of  the  clavicle. 

Symptoms  and  Treatment. — In  dislocation  of  the  acromial  end  of  the 
cla^'icle  upward  there  are  noted:  prominence  of  the  clavicle  upon  the  top  of 
the  acromion ;  impaired  function  of  the  arm  (it  cannot  be  lifted  over  the  head) ; 
the  shoulder  falls  dowTiward  and  passes  inward;  there  is  apparent  lengthening 
of  the  arm;  the  head  is  bent  toward  the  injured  side,  and  the  clavicular  origin 
of  the  trapezius  is  strongly  outlined  (Pick).  In  dislocation  dou')iward  both 
the  acromion  and  the  coracoid  are  very  prominent,  the  clavicular  axis  is 
altered,  and  there  is  depression  over  the  sternoclavicular  jomt.  The  surgeon 
usually  endeavors  to  reduce  a  dislocation  upward  by  placmg  the  patient 
supine  on  a  hard  table,  pulling  the  shoulder  back,  and  pushing  the  bone  into 
place.  After  reduction  the  old  method  of  treatment  was  to  apply  a  De- 
sault bandage,  which  was  kept  on  for  three  weeks,  and  decided  deformity, 
enduring  pain,  and  disability  were  looked  for  as  ine\4table.  Stimson  used  to 
apply  dressings  of  adhesive  plaster.  The  author  has  seen  several  cases  treated 
by  the  apparatus  of  Thomas  Leidy  Rhoads.  The  apparatus  completely  cor- 
rected the  deformity,  and  the  patients  made  a  most  satisfactory  recovery. 


662 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  essential  element  of  Rhoads's  apparatus  is  a  trunk-strap  applied  after  re- 
duction of  the  dislocation,  as  shown  in  Figs.  397,  398.  If  the  deformity  can 
be  completely  corrected,  Rhoads's  apparatus  will  serve  a  good  purpose,  but  in 
many  cases  it  is  impossible  really  to  reduce  the  deformity  or  after  apparent 


Fig.  397-  Fig.  398. 

Figs.  397,  39S. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end  of  the  clavicle. 

reduction  the  deformity  at  once  returns.  This  is  due,  as  Moore^  points  out, 
to  the  fact  that  the  superior  acromioclavicular  ligament  is  torn  from  the  clav- 
icle, but  remains  attached  to  the  scapula,  and  when  reduction  is  attempted,  is 

pushed  under  the  clavicle  and 
nothing  remains  to  hold  the 
clavicle  "in  place  but  the  skin 
and  superficial  fascia."  I  agree 
with  Moore  that  the  best  treat- 
ment is  incision,  replacement, 
and  suturing  the  acromion  to 
the  outer  end  of  the  clavicle. 
The  bones  are  sutured  with 
silver  wire  or  kangaroo  tendon, 
the  acromioclavicular  ligament 
is  sutured  with  catgut,  the 
wound  is  closed  with  sutures  of 
silkworm-gut,  and  the  patient  is 
kept  supine  in  bed  for  three 
weeks.  I  have  operated  suc- 
cessfully on  5  of  these  cases. 

Dislocation  downward  is  re- 
duced and  treated  in  the  same 
manner  as  dislocation  upward. 

Simultaneous    dislocation    of 

both   ends   of   the    clavicle    is    a 

very  rare  injury.     It  is  treated 

as  is  single  dislocation. 

The  so-called  dislocation  of  the  lower  angle  of  the  scapula  is  not,  as  was  long 

taught,  a  dislocation  at  all.     The  lower  angle  and  vertebral  border  deviate  from 

1 "  Annals  of  Surgery,"  May,  1902. 


Fig.  399.— Subcoracoid  dislocation  of  shoulder. 


Dislocation  of  the  Humerus 


663 


the  chest.  This  condition  was  thought  to  be  due  to  the  bone  slipping  from 
under  the  latissimus  dorsi  muscle,  but  it  is  now  known  to  be  due  to  paralysis  of 
the  serratns  magnus  muscle,  the  bone  being  acted  upon  by  the  trapezius,  pecto- 
ralis  minor,  levator  anguli  scapula?,  the  rhomboid  muscles.  Examination  shows 
that  the  scapula  will  not  rotate  normally  forward.  This  is  demonstrated  by  ex- 
tending the  arms  in  front  to  a  right  angle,  the  gliding  forward  of  the  scapula  upon 
the  sound  side  being  marked,  but  upon  the  diseased  side  being  slight  or  absent. 

Treatment  of  paralysis  of  the  serratus  magnus  muscle  comprises  massage, 
electricity,  passive  motion,  and  deep  injections  of  strychnin. 

Katzenstein  advocates  operation  for  serratus  palsy.  He  makes  an  incision 
near  to  the  midline  of  the  back,  exposes  portions  of  origin  of  the  trapezius  and 
rhomboideus  major,  divides  them,  carries  the  cut  muscles  downward  and  out- 
ward, and  sutures  them  to  the  periosteum  of  the  seventh,  eighth,  and  ninth  ribs 
and  to  the  latissimus  dorsi.     He  then  makes  an  "incision  along  the  inner  surface 


Fig.  400.- 


-Subcoracoid  dislocation  of  the  left  humerus  (St.  Joseph's  Hospital 

Dr.  Nassau). 


lie;  photographed  by 


of  the  arm  from  the  middle  up  through  the  axilla  to  end  on  the  thoracic  wall." 
He  divides  the  humeral  insertion  of  the  great  pectoral  and  sutures  its  tendon  to 
the  axillary  border  and  the  anterior  scapular  muscles  (Binnie's  "Operative 

Surgerv")-  ..... 

Dislocation  of  the  Humerus  (Shoulder-joint).— This  mjury  is  quite  fre- 
quent because  of  the  free  mobility  of  the  shoulder-joint,  its  anatomical  in- 
security, and  its  ex-posed  situation;  it  rarely  occurs  in  the  very  young  and  in 
the  aged,  and  is  oftenest  encountered  in  muscular  young  adults.  _  Shoulder 
dislocation  is  produced  by  throwing  the  arm  into  abduction.  In  this  position 
the  head  of  the  humerus  presses  against  the  lower  and  front  part,  that  is, 
agamst  the  thinnest  and  most  poorly  supported  portion  of  the  capsule.  In 
almost  ah  cases  the  tear  in  the  capsule  occurs  between  the  tendon  of  the  sub- 
scapularis  and  the  triceps.  Hence,  most  dislocations  are  primarily  subglenoid, 
although  the  bone  usually  moves  to  some  other  position,  being  dragged  or 


664 


Diseases  and  Injuries  of  the  Bones  and  Joints 


driven  there  by  the  injuring  force  or  being  pulled  there  by  muscular  action. 
Dislocation  forward  is  much  more  common  than  dislocation  backward  because 
the  long  head  of  the  triceps  keeps  the  head  of  the  bone  from  going  posterior  and 
because  the  anterior  are  stronger  than  the  posterior  muscles.  Four  chief  forms 
of  shoulder-joint  dislocation  exist,  namely:  (i)  forward,  inward,  and  downward, 
under  the  coracoid  process — subcoracoid;  (2)  downward,  forward,  and  inward, 
beneath  the  glenoid  cavity — subglenoid;  (3)  backward,  inward,  and  downward, 
under  the  spine  of  the  scapula — subspinous;  and  (4)  forward,  inward,  and 
upward,  under  the  clavicle — subclavicular. 

A  very  rare  form  of  shoulder- joint  dislocation  has  been  described,  which 
is  known  as  the  supracoracoid.     Another  rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation  (Figs.  399,  400). — The  subcoracoid  variety  of  disloca- 
tion embraces  three-fourths  of  all  shoulder-joint  luxations.  It  may  be  caused  by 
direct  force  driving  the  head  of  the  humerus  forward  and  inward,  or  by  indirect 
force,  such  as  falls  upon  the  hand  or  the  elbow.  In  this  dislocation  the  head 
of  the  bone  lies  against  the  anterior  surface  of  the  scapular  neck  below  the 

coracoid  process.  A  part  of  the  anatomical  neck 
of  the  humerus  lies  upon  the  anterior  margin  of 
the  glenoid  cavity,  and  the  head  of  the  bone  is 
above  the  tendon  of  the  subscapularis  muscle. 

Subclavicular  luxation  is  very  rare.  It  is  caused 
by  the  same  sort  of  violence  which  produces  sub- 
coracoid luxation.  The  head  of  the  bone  rests 
upon  the  thorax,  below  the  clavicle,  and  under- 
neath the  pectotalis  major  muscle. 

Subglenoid  or  Axillary  Luxation  (Fig.  401). — 
It  may  be  produced  by  contraction  of  the  great 
pectoral  and  latissimus  dorsi  muscles  when  the 
arm  is  at  a  right  angle  to  the  body,  but  it  is 
usually  due  to  falls  upon  the  hand  or  the  elbow 
when  the  arm  is  raised  and  the  head  of  the  bone  is 
against  the  lower  portion  of  the  capsule.  In  this 
dislocation  the  head  of  the  bone  rests  upon  the 
border  of  the  scapula,  below  the  tendon  of  the 
subscapularis,  in  front  of  the  long  head  of  the 
triceps,  and  above  the  teres  muscles.  Most  dislo- 
cations of  the  shoulder  are  primarily  subglenoid, 
the  position  perhaps  being  subsequently  altered 
by  muscular  action. 

Subspinous  luxation  is  a  rare  injury.  Pick  met 
with  this  accident  in  a  man  who,  while  having 
his  hands  in  his  pockets,  fell  upon  the  front  of 
the  point  of  the  shoulder.  The  head  of  the  bone  reposes  beneath  the 
scapular  spine,  between  the  infraspinatus  and  teres  minor  muscles. 

Supracoracoid  luxation  is  seldom  encountered.  The  head  of  the  humerus 
rests  upon  the  coraco-acromial  ligament  or  upon  the  acromion  process,  and 
the  acromion  or  the  coracoid  is  always  fractured. 

Luxatio  Erecta. — In  this  injury  the  arm  is  markedly  abducted  and  in  some 
cases  the  elbow  is  actually  raised  above  the  patient's  head.  •  As  a  rule,  the 
forearm  rests  behind  the  occiput,  sometimes  on  the  top  of  the  head.  The 
patient  holds  the  forearm  to  the  occiput  or  vertex  to  avoid  pain.  It  is,  in 
reality,  a  form  of  subglenoid  luxation.  In  such  an  injury  the  head  of  the 
bone  has  passed  under  the  subscapularis  muscle  and  also  under  the  teres 
major  or  the  lower  border  of  the  great  pectoral.  Judd,  Hulke,  Cleland,  and 
others  have  reported  cases. 


Fig.  401. — Axillary  dislocation  of 
the  right  humerus. 


Dislocation  of  the  Humerus 


66  = 


Symptoms  of  Dislocation  of  the  Shoulder-joint. — Dislocation  is  diagnos- 
ticated by — (i)  pain  of  a  sickening  character;  (2)  flattening  of  the  shoulder, 
the  head  of  the  bone  having  ceased  to  bulge  out  the  deltoid  muscle;  (3)  ap- 
parent projection  of  the  acromion  through  sinking  in  of  the  deltoid;  (4)  hol- 
low beneath  the  acromion,  over  the  empty  glenoid  cavity,  and  the  bone 
missing  from  its  normal  habitat.  This  hollow  may  be  easily  appreciated  by 
the  finger,  especially  when  the  extremity  is  somewhat  abducted;  (5)  rigidity 
(some  movement  is  possible  in  the  direction  especially  of  an  existing  de- 
formity, but  mobility  is  strictly  limited  and  attempts  at  motion  produce 
great  pain);  (6)  Dugas's  sign:  the  elbow  cannot  touch  the  side  when  the  hand 
is  placed  upon  the  sound  shoulder,  and  the  hand  cannot  be  placed  upon  the 
sound  shoulder  if  the  elbow  is  to  the  side  (this  is  due  to  the  rotundity  of  the 
chest.  In  a  dislocation  the  head  of  the  bone  is  already  touching  the  chest,  and 
the  bone,  being  approximately  straight,  cannot  touch  it  in  two  places  at  the 
same  time.  If  the  elbow  can  be  placed  against  the  chest  with  the  hand  on  the 
soimd  shoulder  there  cannot  be  dislocation;  if  it  cannot  be  so  placed,  there 
must  be  dislocation);  (7)  finding  the  head  of  the  bone  in  a  new  situation;  (8) 
examining  by  means  of  the  .-v-rays.  Symptoms  i  to  5  inclusive  may  be  grouped 
as  Erichsen's  list  of  signs.  The  form  of  dislocation  is  made  out  by  a  study  of 
the  direction  of  the  axis  of  the  limb,  the  existence  and  extent  of  lengthening 
or  of  shortening,  and  the  situation  of  the  head  of  the  bone. 

In  a  shoulder-joint  dislocation  the  head  of  the  bone  may  press  upon  the 
brachial  plexus  and  produce  pain  and  numbness,  and  occasionally  traumatic 
neuritis  or  paralysis;  sometimes  pressure  upon  the  axillary  vein  causes  intense 
edema,  and  pressure  upon  the  axillary  artery  diminishes  or  obliterates  the 
pulse.  The  axillary  vessels  may  be  torn  and  the  muscles  may  be  lacerated 
badly.  The  capsule  is  torn  and  considerable  blood  is  usually  effused.  Swell- 
ing is  due  first  to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
location sometimes,  though  rarely,  occurs.  What  is  usually  spoken  of  as 
"partial  dislocation"  or  "subluxation"  is  a  condition  in  which  the  head  of 
the  humerus  passes  forw^ard  utider  the  coracoid  because  of  rupture  of  the 
long  head  of  the  biceps  or  because  this  tendon  slips  out  of  its  groove,  the 
ligaments  of  the  shoulder- joint  being  intact. 

The  following  table  from  T.  Pickering  Pick's  work  on  "Fractures  and 
Dislocations"  makes  the  above  points  clear: 


Direction  of  the  Axis 
OF  THE  Limb. 


Alteration  in  the  Length  Presence  of  the  Head  of  the 
OF  THE  LmB.  I     Bone  in  New  Situation. 


Subcoracoid. 

Subglenoid. 
Subspinous. 

Subclavicular. 


The  elbow  is  carried 
backward  and  slightly 
a^Yay  from  the  side. 

The  elbow  is  carried 
away  from  the  trvmk 
and  slightly  backward. 

The  elbow  is  raised 
from  the  side  and  car- 
ried forward. 

The  elbow  is  carried 
outward  and  backward. 


Very  sUght  lengthen- 


Very       considerable 
lengthening. 

Lengthening  interme- 
diate in  degree  between 
the  subglenoid  and  the 
subcoracoid. 
Shortening. 


The  head  of  the  bone 
cannot  easily  be  felt;  it  is 
found  at  the  upper  and 
inner  part  of  the  axilla. 

The  head  of  the  bone 
can  easily  be  felt  in  the 
axilla. 

The  head  of  the  bone 
can  be  felt  and  be  grasped 
beneath  the  spine  of  the 
scapula. 

The  head  of  the  bone 
can  readily  be  seen  and  be 
felt  beneath  the  clavicle. 


Diagnosis   of  Shoulder-joint  Dislocation. — In  fracture  of  the  neck   of  the 
scapula  the  acromion  is  prominent,  a  hoUow  is  detected  below  it,  and  a  hard 


666 


Diseases  and  Injuries  of  the  Bones  and  Joints 


body  is  felt  in  the  axilla;  but  the  coracoid  process  descends  with  the  head 
of  the  humerus,  which  it  does  not  do  in  dislocation.  Furthermore,  in  frac- 
ture there  is  mobility;  in  dislocation,  rigidity.  In  fracture  crepitus  is  pre- 
sent; in  dislocation  it  is  absent.  In  fracture  the  deformity  is  easily  reduced, 
but  it  at  once  recurs;  in  dislocation  the  deformity  is  with  difi&culty  reduced, 
but  does  not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the  side 
when  the  hand  is  upon  the  sound  shoulder;  in  dislocation  it  cannot  be  so 
manipulated.  In  fracture  of  the  anatomical  neck  of  the  humerus  deformity 
is  slight;  the  head  of  the  humerus  is  found  in  place,  does  not  move  when 
the  shaft  is  rotated,  and  is  not  in  line  with  the  axis  of  the  bone.  Crepitus 
exists  in  the  fracture  if  impaction  is  absent.  In  paralysis  of  the  deltoid  mus- 
cle there  is  distinct  flattening,  but  the  bone  is  felt  in  place  and  there  is  no 
rigidity.     The  x-rays  are  invaluable  in  diagnosis. 

Treatment  of  Shoulder-joint  Dislocation. — Reduction  by  manipulation  is  usu- 
ally readily  accomplished  in  a  recent  case  of  shoulder-joint  dislocation.  If  a 
simple  trial  without  ether  fails,  an  anesthetic  should  be  administered.  Ether 
is  given,  but  not  chloroform,  for  chloroform  seems  to  be  particularly  dan- 
gerous to  life  when  given  to  enable  the  surgeon  to  reduce  a  dislocation  of 
the  shoulder.  Forward  dislocations  (subcoracoid,  subclavicular,  and  axillary) 
are  reduced  by  Kocher's  method  (Fig.  402).  This  method  w^as  introduced  by 
Kocher  in  1870  ("Sammlung  klin.  Vortrage,"  No.  83).     Reduction  by  this 


,^^Hls 


Fig.  402. — Kocher's  method  of  reduction  by  manipulation:  a,  First  movement,  outward  rotation; 
b,  second  movement,  elevation  of  elbow;  c,  third  movement,  inward  rotation  and  lowering  of  the  elbow 
(Ceppi). 

method  can  frequently  be  effected  without  the  aid  of  ether.  The  patient 
should  be  recumbent.  Slowly  but  forcible  adduct  the  abducted  elbow  and 
get  it  finally  against  the  side.  At  the  same  time  draw  it  slightly  backward. 
The  forearm  is  flexed.  If  there  is  much  muscular  resistance,  follow  Keetley's 
advice,  and  not  only  bring  the  elbow  to  the  side,  but  push  it  backward  and 
inward  toward  the  spine.  Grasp  the  elbow  with  one  hand,  and  the  wrist  with 
the  other,  and  slowly  make  external  rotation  until  the  forearm  points  outward 
from  the  body.  We  thus  carry  the  head  of  the  humerus  to  the  margin  of  the 
glenoid  cavity.  External  rotation  must  be  done  slowly  and  gently.  When 
we  first  try  it  there  is  much  muscular  resistance.  If  enough  force  is  used  to 
overcome  the  resistance  the  surgical  neck  of  the  bone  may  be  broken.  By 
gently  and  gradually  persisting  in  external  rotation  the  muscles  are  finally  tired 
out  and  relax.  Next  lift  the  elbow  anteriorly  as  far  forward  as  it  will  go,  so 
as  to  bring  the  head  of  the  humerus  to  the  glenoid  margin  just  opposite  the 
capsular  tear  (Keetley).  Then  throw  the  bone  into  place  by  gradually  swing- 
ing the  forearm  inward  across  to  the  other  side  of  the  chest,  that  is,  by  internal 
rotation.  The  formula  is,  flexion  of  the  forearm,  external  rotation,  lifting  the 
elbow  forward,  internal  rotation  of  the  arm,  and  lowering  the  elbow.  The 
motions  to  unlock  the  bone  and  start  it  to  retrace  the  steps  it  took  when 
emerging  should  be  gentle,  not  forcible,  slow,  not  sudden,  and  rigid  muscles 
should  be  tired  out  and  made  to  relax  by  steady  traction  upon  them.     Sudden 


Dislocation  of  the  Humerus  667 

and  violent  motions  increase  rigidity.  Adduction  stretches  the  upper  portion 
of  the  capsule  and  presses  the  head  against  the  glenoid.  External  rotation 
opens  the  tear  in  the  capsule.  Elevation  relaxes  the  untorn  part  of  the  cap- 
sule and  coracohumeral  ligament  and  stretches  the  torn  portion.  On  this 
fulcrum  the  head,  which  is  the  end  of  a  lever,  is  forced  into  place.  If  in 
tr}ing  Kocher's  plan  external  rotation  of  the  humerus  does  not  take  place,  aban- 
don the  method,  as  persistence  will  fracture  the  humerus.  Another  method  of 
manipulation  is  as  follows:  if  the  right  shoulder  is  dislocated,  the  surgeon  stands 
behind  the  patient  (who  is  sitting  erect);  if  the  left  shoulder  is  dislocated,  he 
stands  in  front  of  the  patient.  The  surgeon  holds  the  forearm  flexed  upon  the 
arm  with  his  right  hand  and  makes  external  traction  and  rotation,  and  with  the 
fingers  of  his  left  hand  he  tries  to  force  the  bone  into  place. 

In  Henry  H.  Smithes  method  for  forward  dislocation  the  surgeon  stands 
in  front  of  the  patient.  If  the  left  shoulder  is  dislocated,  the  surgeon  grasps 
it  with  his  left  hand;  if  the  right  shoulder  is  dislocated,  he  grasps  it  with  his 
right  hand,  the  thumb  resting  on  the  head  of  the  bone.  With  lus  disengaged 
hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes  traction  and  external 
rotation,  and  suddenly  sweeps  the  elbow  inward,  aiming  it  at  the  sternum, 
and  tries  %\'ith  his  thumb  to  push  the  bone  into  place.  In  subspinous  luxa- 
tions reduction  may  be  effected  if  the  surgeon  stands  behind  the  patient, 
makes  abduction,  traction,  and  internal  rotation,  sweeps  the  elbow  inward 
toward  the  spine,  and  with  the  thumb  aids  the  bone  in  its  return  into  position. 
Raising  the  elbow  far  above  the  head  and  sweeping  it  inw^ard  will  reduce 
some  dislocations.  As  the  head  of  the  bone  slips  back  a  distinct  jar  is  felt 
and  a  snap  is  heard,  the  motions  of  the  joint  are  again  obtainable,  and  with 
the  hand  on  the  opposite  shoulder  the  elbow  may  be  made  to  touch  the  side. 

Reduction  by  Extension. — -Before 
attempting  the  reduction  of  a  dislo- 
cation of  the  shoulder-joint  by  exten- 
sion the  patient  should  be  anesthetized 
and  placed  upon  a  low  bed  or  upon 
the  floor.  The  surgeon  then  places  his 
foot,  covered  only  by  a  stocking,  in 
the  axilla.  Place  the  sole  of  the  foot, 
not  the  heel,  against  the  chest  high 
up,  the  instep  being  made  to  touch  the 
humerus  and  the  heel  the  border  of  the 
shoulder-blade,  a  towel  bemg  first  put  Fig.  403.— Reduction  of  shoulder-joint  disloca- 
intO  the  axilla    to   rest  the  foot  against  tion  by  the  foot  in  the  axilla  (Cooper). 

(Fig.  403) .   If  the  left  arm  is  dislocated, 

use  the  left  foot,  and  vice  versa.  The  elder  Gross  approved  of  making  exten- 
sion while  sitting  between  the  patient's  limbs.  Make  steady  extension,  which 
will  in  many  cases  bring  about  the  reduction.  If  it  fails  to  cause  reduction, 
bring  the  patient's  arm  across  the  chest  and  use  the  foot  as  the  fulcrum  of  a 
lever.  If  the  humerus  is  pretty  firmly  fixed  in  its  abnormal  position,  make 
counterextension  with  a  foot  in  the  axilla  and  make  extension  by  fLxing  a 
clove-hitch  (see  Fig.  395)  above  the  elbow  and  fastening  to  it  bands  which  go 
over  one  shoulder  and  under  the  other  shoulder  of  the  surgeon.  The  back 
may  thus  be  used  for  extension,  the  hands  being  left  free  for  manipulation 
(Aliis's  and  Pick's  plan).  Lateral  extension  is  used  by  some  surgeons.  The 
patient  lies  down,  a  large  piece  of  canvas  is  split,  the  arm  is  passed  through 
the  split,  and  the  body  is  thus  fLxed.  The  arm  is  pulled  to  a  right  angle  with 
the  body  and  traction  is  applied. 

The  late  Prof.  Joseph  Pancoast  favored  Sir  Astley  Cooper's  method  of 
placing  the  unanesthetized  patient  in  a  chair  and  using  the  knee  as  a  fulcrum, 


668 


Diseases  and  Injuries  of  the  Bones  and  Joints 


pushing  the  elbow  to  the  side  (Fig.  404).  Brunus,  in  the  thirteenth  century, 
devised  the  method  of  upward  extension.  In  applying  this  method  the 
surgeon  takes  his  place  behind  the  patient,  steadies  the  scapula  with  his 
hand,  and  carries  the  patient's  arm  upward  and  backward  above  his  head, 
making  extension  and  external  rotation  (Fig.  405).  La  Mothers  method  is 
applied  with  the  patient  supine  upon  the  floor.  The  surgeon  places  his  foot 
upon  the  shoulder  to  make  counterextension,  and  makes  extension  as  in 
Brunus's  method.  It  is  a  useful  expedient,  when  either  of  these  plans  is 
applied,  to  have  an  assistant  make  the  traction  while  the  surgeon  manipu- 
lates the  head  of  the  bone.  Cock  advises, 
when  reduction  fails,  that  an  air-pad  be 
placed  in  the  axilla  and  the  arm  be  bound 
to  the  side — a  method  by  which  reduction  will 
sometimes  take  place  after  two  or  three  days. 


Fig.  404. — Reduction  of  shoulder- 
joint  dislocation  by  the  knee  in  the 
axilla  (Cooper). 


Fig.  405. — Reduction   of  shoulder-joint  dislocation  by  up- 
ward extension  (Cooper). 


Pulleys  shotild  not  be  used  to  pull  the  bone  into  place,  as  they  develop  a 
dangerous  force.  In  a  dislocation  irreducible  by  ordinary  force,  antiseptic 
incision  is  safer  and  better  than  the  pulleys.  After  incision  try  to  restore  the 
bone  to  place. 

In  reducing  a  dislocation  the  axillary  artery  or  vein  may  be  ruptured, 
fracture  of  the  neck  of  the  himierus  may  take  place,  injury  to  the  brachial 
plexus  may  occur,  or  the  soft  parts  may  be  badly  damaged.  After  reducing 
a  dislocation  apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for  one 
week,  then  make  passive  motion  daily,  reappljdng  the  dressing  after  each 
seance.  The  patient  may  wear  a  sling  alone  during  the  third  w^eek,  after 
which  period  he  may  use  the  arm.    (For  Compound  Dislocations,  see  page  658.) 

Unreduced  and  Irreducible  Dislocations  of  the  Shoulder. — In  some  cases 
where  we  find  there  is  considerable  movement  without  pain  we  can,  by  manipu- 
lation and  active  motion,  increase  the  range  of  movement  and  the  usefulness  of 
the  new  joint. 

As  a  rule,  in  a  youth  or  a  middle-aged  person  we  attempt  bloodless  reduction 
if  the  head  of  the  bone  is  movable  and  there  is  no  prospect  of  a  useful  new  joint. 
Give  ether,  break  up  adhesions  by  forced  flexion  and  extension,  and  try  Kocher's 
method,  and,  if  this  fails,  the  other  methods,  but  never  use  violent  force.  In 
reducing  an  old  dislocation  we  may  fracture  the  surgical  neck  of  the  hiunerus. 
I  have  seen  this  happen  twice.  The  proper  treatment  is  incision  and  pulling 
the  head  into  place  by  McBxurney's  hooks.  In  attempting  reduction  of  an  old 
dislocation  by  force  the  brachial  plexus  may  be  lacerated  or  one  or  both  of 
the  axillary  vessels  may  be  torn.  If  an  axillary  vessel  is  torn,  it  must  be 
at  once  exposed  by  incision.  A  large  tear  in  either  vessel  requires  a  ligature 
about  the  vessel  on  each  side  of  the  tear.  A  small  tear  may  be  sutured 
(Keetley,  in  "Lancet,"  Jan.  23,  1904).  Rather  than  use  sufficient  force  to 
endanger  the  vessels  in  attempting   to  reduce   an   old   dislocation,  practice 


Habitual  or  Recurrent  Dislocation  669 

incision.  In  some  cases  after  incision  the  head  of  the  bone  can  be  pulled  and 
pushed  into  place.  In  other  cases  the  head  must  be  resected.  After  reduction 
of  an  old  dislocation  immobilize  for  three  weeks,  and  begin  passive  motion 
after  seven  days. 

If  a  dislocation  is  complicated  by  a  fracture  of  the  humerus,  try  to  pull  the 
head  of  the  bone  opposite  the  joint.  This  may  be  possible  if  the  two  frag- 
ments are  held  partly  together  by  a  fair  amount  of  periosteum  and  muscle. 
Traction  is  exerted  upon  the  arm,  and  an  attempt  is  made  to  manipulate  the 
head  into  the  socket  (Allis's  plan  in  the  hip).  McBurney  incises,  fixes  a  hook 
in  the  scapula  and  a  hook  in  the  head  of  the  humerus,  pulls  the  head  into 
place,  and  wires  the  fragments  (see  Figs.  277,  278).  In  an  emergency  gimlets 
may  be  used  instead  of  the  hooks.  In  some  cases  it  is  necessary  to  excise 
the  head  of  the  bone. 

Habitual  or  Recurrent  Dislocation. — Habitual  or  recurrent  dislocation 
of  the  shoulder,  following  an  original  traumatic  dislocation,  results  usually 
from  a  slight  or  tri\aal  force.  It  is  apt  to  take  place  when  the  arm  is  in  ab- 
duction, sHght  rotation  frequently  being  necessary.  In  some  cases  rotation 
will  produce  a  dislocation  while  the  arm  is  near  the  side  of  the  body.  Little 
is  kno\\Ti  of  the  frequency  with  which  these  cases  occur,  but  they  are  probably 
much  more  frequent  than  is  generally  supposed.  The  frequency  of  the  recur- 
rences in  the  indi\-idual  cases  varies  widely.  In  some  they  occur  more  or  less 
regularly  every  two  or  three  years,  while  in  others  they  have  been  known  to 
take  place  daily  and  even  several  times  a  day.  In  most  cases  in  the  intervals 
between  the  recurrences  the  joint  functionates  normally  without  difficulty, 
although  the  patient  fears  abduction  because  of  its  influence  in  favoring  a  re- 
currence. In  rare  cases  pain  persists  a  long  time  after  each  dislocation,  so  that 
if  the  recurrences  are  frequent,  the  patient  may  be  compelled  to  give  up  work. 

Cause. — ^The  essential  cause  is  a  relaxation  of  the  capsule  at  the  site  of  the 
original  tear,  produced  by  the  addition  to  the  old  or  original  portion  of  capsule 
of  a  new  or  cicatricial  portion  bridging  over  the  gap  between  the  margins  of 
the  tear  produced  by  the  first  dislocation.  The  failure  of  these  margins  to 
unite  closely  is  due  to  the  repeated  emergence  of  the  humeral  head  forcing  them 
apart  before  union  is  complete.  The  defects  in  the  head  of  the  humerus  which 
have  been  found  at  autopsy  and  operation  have,  probably,  only  a  slight  and 
secondar}^  causal  importance,  while  the  fractures  of  the  greater  tuberosity  of 
the  humerus  sometimes  occurring  in  dislocations  of  the  shoulder  are  probably 
not  followed  by  recurrent  dislocations. 

Treatment. — Excision  of  the  head  of  the  humerus  has  been  abandoned  in 
these  cases.  Capsulorrhaphy  for  the  shortening  of  the  relaxed  anterior  por- 
tion of  the  capsule  has  given  excellent  functional  results.  Dawbarn,  of  New 
York,  did  this  operation  in  my  clinic,  upon  a  city  fireman,  and  the  result  w^as 
a  perfect  success.  The  capsule  may  be  exposed  through  the  usual  resection 
incision  along  the  anterior  margin  of  the  deltoid.  This  may  be  modified  by 
an  additional  incision  outw^ard  at  right  angles  to  the  first,  and  the  insertion 
of  the  pectorlais  major  may  be  partially  di\dded.  T.  Turner  Thomas  makes 
an  axillary  incision  along  the  inner  border  of  the  coracobrachialis,  passing 
between  this  muscle  and  the  axillary  vessels  and  nerves,  and  avoiding  par- 
ticularly the  circumflex  and  musculocutaneous  ner\^es.  The  subscapularis 
muscle  is  partially  di\dded  to  give  a  freer  exposure  of  the  capsifle.  This  route 
exposes,  by  a  small  incision,  the  site  of  the  original  tear  in  the  capsule.  It 
avoids  division  of  the  deltoid  and  gives  dependent  drainage  if  drainage  is 
necessary. 

The  relaxed  portion  of  the  capsule  may  be  shortened  by  taking  up  a  reef 
with  catgut  or  sflk  sutures,  \\dthout  opening  and  exploring  the  joint  for  loose 
pieces  of  bone;  the  capsule  may  be  incised  transversely  to  its  longitudinal 


670 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  406. — ^Dislocat 


of  the  forearm  backward. 


fibers  and  the  margins  of  the  incision  overlapped;  an  oval  piece  may  be  ex- 
cised and  the  edges  united  by  sutures;  or  the  margins  of  the  original  tear  may 
be  found  and  sutured  together. 

Dislocation  of  the  elbow-joint  is  not  infrequent,  and  is  commonest  in  chil- 
dren.   Both  bones  or  only  one  bone  of  the  forearm  may  be  dislocated,  and  the 

dislocation  may  be  partial  or 
complete. 

Dislocation  of  Both  Bones 
Backward  (Fig.  406). — ^The 
causes  of  backward  disloca- 
tion of  both  bones  of  the 
forearm  are  falls  upon  the 
extended  hand  or  twists  in- 
ward of  the  ulna  (Malgaigne). 
The  coronoid  process  lodges 
in  the  olecranon  fossa  of  the 
humerus. 

Symptoms  of  Backward 
Dislocation.  —  In  complete 
dislocation  of  both  bones  of 
the  forearm  the  olecranon  is 
very  prominent.  The  dis- 
tance between  the  point  of 
the  olecranon  and  the  apex  of 
the  inner  condyle  is  notably 
greater  than  on  the  sound  side;  the  forearm  is  flexed,  supinated,  and  shortened; 
the  lower  end  of  the  humerus  projects  in  front  of  the  joint,  below  the  skin- 
crease;  the  head  of  the  radius  is  found  back  of  the  outer  condyle;  and 
there  are  the  general  symptoms  of  dislocation.  Fracture  of  the  coronoid  rarely 
occurs  with  backward  dislocation,  but  if 
it  does  occur,  there  will  be  crepitus  and 
mobility.  Fracture  at  the  base  of  the 
condyles  is  distinguished  from  dislocation 
of  both  bones  of  the  forearm  backward 
by  the  following  points:  in  fracture 
there  are  found  the  ordinary  symptoms; 
measurement  from  the  condyles  to  the 
styloid  processes  does  not  show  shorten- 
ing; there  is  no  alteration  of  the  normal 
relation  between  the  olecranon  process 
and  the  condyles;  and  the  projection  in 
front  of  the  joint  is  above  the  crease  of 
the  bend  of  the  elbow. 

Treatment  of  Backward  Dislocation. - 
in  dislocation  of  both  bones  of  the  forearm,  because  it  will  soon  become  im- 
possible, and  an  unreduced  dislocation  means  a  limb  without  the  powers  of 
flexion,  pronation,  and  supination.  The  surgeon  may  place  his  knee  in  front 
of  the  elbow-joint,  grasp  the  patient's  wrist,  press  upon  the  radius  and  ulna 
with  his  knee,  and  bend  the  forearm  with  considerable  force,  the  muscle 
pulling  the  bones  into  place  (Sir  Astley  Cooper's  plan).  Forced  flexion, 
traction,  and  extension  may  be  tried  (Fig.  407).  Put  the  arm  in  Jones's  posi- 
tion for  two  weeks,  and  make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  forward  dislocation 
of  both  bones  of  the  forearm  is  a  blow  on  the  olecranon  when  the  arm  is  flexed. 
It  is  an  unusual  accident. 


Fig.  407. — Reduction  of  elbow-joint  disloca- 
tion. 

-Reduction  must  be  effected  early 


Dislocation  of  the  Radius  Forward  671 

Symptoms  and  Treatment. — The  symptoms  of  forward  dislocation  of  both 
bones  of  the  forearm  are:  the  forearm  is  flexed  and  lengthened;  some  slight 
motion  is  possible;  the  olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone;  the  humeral  condyles  are  felt  posteriorly,  and 
the  radius  and  ulna  are  felt  anteriorly.  The  treatment  of  this  injur\-  consists 
in  early  reduction,  which  is  accomplished  by  means  of  forced  flexion,  exten- 
sion, and  pressure,  placing  the  part  in  Jones's  position  for  two  weeks,  and 
making  passive  motion  daily  after  the  first  few  days. 

Lateral  dislocation  of  both  bones  of  the  forearm  is  usually  incomplete. 

Symptoms  and  Treatment  of  Outward  Dislocation. — The  symptoms  of 
outward  dislocation  of  both  bones  of  the  forearm  are:  the  forearm  is  flexed, 
fixed,  and  pronated;  the  joint  is  widened;  the  head  of  the  radius  projects  ex- 
ternally and  has  a  depression  above  it;  the  inner  condyle  projects  internally 
and  has  a  depression  below  it;  the  olecranon  is  nearer  than  normal  to  the 
external  condyle  and  further  than  normal  from  the  internal  condyle.  Reduc- 
tion is  effected  by  extension  of  the  forearm  and  pressure  inward  upon  the 
head  of  the  radius.  Apply  an  ascending  spiral  reversed  bandage  of  the  fore- 
arm, a  figure-of-S  bandage  of  the  elbow-joint,  and  a  sling.  Make  passive 
motion  after  a  few  days.    The  bandages  must  be  worn  for  two  weeks. 


Fig.  40S. — Forward  dislocation  of  the  radius. 

Symptoms  and  Treatment  of  Inward  Dislocation. — In  dislocation  inward 
of  both  bones  of  the  forearm  the  position  of  the  forearm  is  the  same  as  that 
in  dislocation  outward;  the  sigmoid  ca\'ity  of  the  ulna  projects  internally,  and 
the  external  condyle  projects  externally.  Reduction  is  effected  by  extension 
of  the  forearm  and  pressure  outward  on  the  ulna,  subsequent  treatment 
being  the  same  as  that  employed  in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  take  place  only  back- 
ward. 

Symptams  and  Treatment. — Dislocation  of  the  ulna  alone  is  indicated 
by  the  forearm  being  flexed  and  pronated.  The  head  of  the  radius  is  found 
in  place,  and  the  olecranon  projects  posteriorly.  The  treatment  of  this  injur\' 
is  the  same  as  that  for  dislocation  of  both  bones. 

Dislocation  of  the  radius  forward  (Fig.  40S)  is  the  commonest  form  of 
dislocation  of  the  elbow.  This  injury-  is  caused  by  a  f aU  upon  the  hand  with 
the  forearm  in  pronation  and  extension,  or  is  produced  by  blows  on  the  back 
of  the  joint;  forced  pronation  alone  will  not  cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation  of  the  radius 
forward  are:  the  forearm  is  midway  between  pronation  and  supination,  and 
is  semiflexed;  attempts  to  increase  flexion  cause  the  radius  to  strike  against 
the  hiunerus  T\-ith  a  distinct  blow;  the  head  of  the  radius  is  felt  in  front  of 
the  outer  condyle  and  is  missed  from  its  proper  abode.  Reduction  is  effected 
by  flexion  over  the  knee,  extension,  and  manipulation.     The  subsequent  treat- 


672 


Diseases  and  Injuries  of  the  Bones  and  Joints 


ment  is  Jones's  position  and  passive  motion.  Deformity  is  apt  to  recur  after 
reduction  because  of  rupture  of  the  orbicular  ligament.  If  permanent  disloca- 
tion exists,  resection  of  the  head  of  the  radius  is  necessary.  Passive  motion 
should  be  begun  in  two  weeks  after  the  resection.  The  results  as  to  function 
and  strength  are  usually  excellent. 

Dislocation  of  the  radius  backward  (Fig.  409)  is  caused  by  falls  on  the 
hand  or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the  radius  is  indicated 
by  the  forearm  being  slightly  flexed  and  fixed  in  pronation,  by  some  impair- 
ment of  flexion  and  extension, 
and  by  the  head  of  the  radius 
being  felt  behind  the  outer 
condyle.  Reduction  is  effected 
by  flexion  over  the  knee,  ex- 
tension, and  manipulation,  and 
the  subsequent  treatment  is 
the  same  as  that  given  for  the 
preceding  dislocation. 

Dislocation  of  the  radius 
outward  is  very  rare.  In  this 
injury  the  head  of  the  radius  is 
distinctly  felt.  Reduction  is 
effected  by  extension  and  pres- 
sure ;  the  subsequent  treatment 
is  the  same  as  that  for  the 
above-mentioned  dislocations. 

Subluxation  of  the  Head  of 
the  Radius.  —  This  name  is 
given  to  an  injury  which  is 
very  frequent  in  children  be- 
tween two  and  four  years  of 
age.  It  results  from  traction 
upon  the  hand  or  the  forearm, 
and  often  arises  when  the  nurse 
or  the  mother  pulls  upon  a 
child's  arm  to  save  it  from  a 
fall  or  to  lift  it  over  a  gutter. 
Some  writers  hold  that  prona- 
tion as  well  as  extension  is  re- 
quired to  produce  the  injury; 
many  surgeons  claim  that  ex- 
tension and  adduction  are  the 
causative  forces.  Hutchinson  asserts  that  supination  may  cause  subluxation. 
Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  very  characteristic.  The  history  points  to  the  injury. 
Pain  and  perhaps  a  click  may  be  felt  about  the  elbow,  and  pain  and  a 
click  may  also  be  felt  in  the  wrist  at  the  time  of  the  accident.  The  arm 
hangs  by  the  side,  with  the  elbow-joint  slightly  flexed  and  the  forearm  mid- 
way between  pronation  and  supination.  Flexion  to  an  angle  of  less  than  60 
degrees  and  complete  extension  are  resisted  and  are  very  painful,  but  movements 
between  60  and  130  degrees  are  free  and  painless.^  The  movements  of  the  wrist- 
joint  are  free  and  painless.  The  elbow-joint  presents  no  deformity.  Pressure 
over  the  head  of  the  radius  causes  pain.     Strong  pronation  is  painful;  strong 

1  See  the  instructive  article  by  W.  W.  Van  Arsdale,  in  "Annals  of  Surgery,"  vol.  ix, 
1880. 


Fig.  409. — Dislocation  of  the  radius  backward. 


Dislocation  of  Individual  Carpal  Bones 


673 


supination  is  very  painful,  and  there  seems  to  be  a  mechanical  obstacle  to  its 
performance.  Forced  supination  develops  a  distinct  cUck  at  the  head  of 
the  radius,  and  causes  pronation  and  supination  to  become  natural  and  free 
from  pain.  The  condition  will  be  reproduced  if  the  parts  are  not  immobilized 
for  a  time.  The  nature  of  the  lesion  is  not  miderstood,  and  \-arious  condi- 
tions have  been  thought  to  e.\ist  by  different  obser\-ers.  Among  them  mav 
be  mentioned  the  foUo-oing:  a  slight  anterior  displacement  of  a  head  of  the 
radius;  a  slight  posterior  displacement;  locking  of  the  tuberosity  of  the  radius 
behind  the  inner  edge  of  the  ulna;  dislocation  of  the  triangular  cartUage  of 
the  wrist;  intracapsular  fracture  of  the  radial  head;  painful  paralysis  from 
nerve-injur}-;  displacement  by  elongation,  the  return  of  the  bone  being  pre- 
vented by  collapse  of  the  capsule;  and  the  slipping  up  of  the  margin  of  the 
orbicular  ligament  over  the  rim  of  the  head  of  the  radius. 

Treatment. — Li  order  to  reduce,  place  the  forearm  at  a  right  angle  to  the 
arm  and  make  forcible  supination.  Apply  an  anterior  angular  splint,  and 
have  it  worn  for  four  or  five  days,  or  put  the  part  in  Jones's  position  for  an 
equal  period. 

Dislocation  of  the  wrist  is  very  micommon  and  is  caused  by  a  fall  upon 
the  hand. 

Backward  Dislocation  of  the  Wrist. — Symptoms. — The  deformity  in  back- 
ward dislocation  of  the  wrist  (^Fig.  410,  a)  resembles  that  of  CoUes's  frac- 
ture (Fig.  410.  b\  The  fingers  are  flexed,  the  wrist  is  bent  backward,  the 
radius  projects  on  the  front  of  the  "^Tist,  the  carpus  projects  on  the  dorsal 


Fig.  410. — Deformitj-  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (e)  (Stimson). 

siurface  of  the  forearm,  the  relation  of  the  styloid  process  of  the  radius  to  the 
styloid  process  of  the  ulna  is  unaltered  (it  is  altered  in  Colles's  fractureX,  there 
is  rigidity,  and  crepitus  is  absent. 

Forward  dislocation  of  the  wrist  is  ver\-  unusual  and  is  caused  by  a  fall 
upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the  -^Tist  the  radius 
and  ulna  project  posteriorly  and  the  carpus  projects  in  front.  The  treatment 
in  both  of  these  dislocations  is  reduction  by  extension  and  manipulation,  the 
use  of  a  Bond  splint  for  ten  days,  and  the  employment  of  passive  motion 
after  five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation  is  rare  and  is  caused 
"by  twisting. 

Symptoms  and  Treatment. — In  foncard  dislocation  at  the  inferior  radio- 
ulnar articulation  the  forearm  is  pronated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  forms  a  projection  posteriorly.  In 
backward  dislocation  the  forearm  is  supinated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  projects  in  front.  Reduction  is  accom- 
plished by  extension  and  manipulation.  Two  straight  splints  (as  in  fracture 
of  both  bones)  are  to  be  applied  for  four  weeks,  and  passive  motion  is  to 
be  made  in  the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says  there  is  one  weak 
spot,  which  is  "between  the  head  of  the  os  magnum  and  the  scaphoid  and 
semilunar  bones,"  and  the  os  magnum  may  be  forced  up.  The  lesion  is  called 
43 


674  Diseases  and  Injuries  of  the  Bones  and  Joints 

by  some  dislocation  of  the  os  magnum  backward.  Codman  and  Chase  ("An- 
nals of  Surgery,"  March  and  June,  1905)  regard  the  injury  as  really  disloca- 
tion of  the  semilunar  forward,  a  dislocation  which  may  be  associated  with 
fracture  of  the  carpal  scaphoid.  The  injury  is  caused  by  forcible  overex- 
tension or  by  twisting  of  the  wrist.  According  to  Codman  and  Chase,  the  in- 
jury is  most  frequently  met  with  in  men  between  the  ages  of  thirty  and  forty, 
results  from  violent  force,  immediately  produces  severe  pain,  soon  followed  by 
tenderness  and  ecchymosis.  On  examination  a  silver-fork  deformity  is  ob- 
served, the  posterior  projection  being  the  os  magnum,  this  projection  being 
separated  from  the  radius  by  a  groove  which  marks  the  former  situation  of 
the  dislocated  semilunar.  The  dislocated  bone  is  felt  under  the  flexor  tendons 
of  the  wrist,  the  palm  seems  shorter  than  its  fellow,  the  fingers  are  partly 
flexed,  active  or  passive  motion  causes  pain,  and  the  a;-rays  exhibit  the  dislo- 
cated bone  (Ibid.). 

Treatment. — According  to  Codman  and  Chase,  recent  dislocations  (even 
after  the  fifth  week)  may  be  reduced  by  hyperextension  followed  by  hyper- 
flexion  over  "the  thumbs  of  an  assistant  held  firmly  in  the  flexure  of  the  wrist 
or  the  semilunar"  (Ibid.). 

If  bloodless  reduction  fails,  the  author  advises  palmar  incision  and  re- 
duction, and  if  this  fails,  excision  of  the  bone.  If  in  excising  the  semilunar 
the  scaphoid  is  found  to  be  fractured,  the  proximal  part  or  the  entire  scaphoid 
must  also  be  removed. 

Dislocation  of  a  metacarpal  bone  is  seldom  encountered.  The  first  meta- 
carpal bone  is  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocation  of  a  metacarpal  bone  is  obvious 
because  of  projection.  It  is  reduced  by  extension  and  manipulation,  a  straight 
splint  and  large  pad  for  the  palm  are  applied  (as  in  fracture  of  the  metacarpus), 
and  the  splint  is  worn  for  three  weeks. 

Dislocation  at  a  metacarpophalangeal  articulation  is  uncommon.  Back- 
ward dislocation  is  the  most  common.     The  cause  is  a  fall  upon  the  hand. 

Symptoms  and  Treatment. — A  dislocation  at  a  metacarpophalangeal  articu- 
lation is  obvious.  Reduction  is  easily  effected  by  extension  and  manipulation, 
except  in  the  case  of  the  thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalangeal  Joint  of  the  Thumb. — In  this 
dislocation  the  phalanx  usually  passes  backward.  In  some  cases  the  long  flexor 
of  the  thumb  gets  to  the  ulnar  side  of  the  head  of  the  metacarpal  bone  and 
hinders  reduction  (J.  Hutchinson,  Jr.,  in  "Brit.  Med.  Jour.,"  Jan.  15,  1898). 
The  chief  impediments  to  reduction,  as  demonstrated  by  Farabeuf,  are  the 
sesamoid  bones  and  glenoid  ligament,  which  accompany  the  base  of  the  phalanx 
in  the  dislocation.  It  is  not  probable  that  the  catching  of  the  metacarpal  bone 
between  the  two  heads  of  the  flexor  brevis,  which  often  happens,  is  an  important 
impediment. 

The  symptoms  of  backward  dislocation  are  as  follows:  The  base  of  the 
first  phalanx  rests  upon  the  metacarpal  bone;  the  head  of  the  metacarpal 
bone  projects  forward  and  buttonholes  the  muscles  of  the  thumb ;  the  first 
phalanx  of  the  thumb  is  strongly  extended,  and  the  terminal  phalanx  is  semi- 
flexed. The  symptoms  of  forward  dislocation  are  as  follows:  The  base  of 
the  first  phalanx  is  felt  in  the  palm,  and  the  head  of  the  metacarpal  bone  is 
felt  posteriorly. 

Treatment. — In  treating  backward  dislocation  of  the  metacarpophalangeal 
joint  of  the  thumb  reduction  is  difficult.  Always  give  ether.  Keetley's 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm  (this  relaxes  the 
flexor  muscles)  and  to  have  an  assistant  hold  it;  bend  the  thumb  strongly 
back,  extend,  pull  the  thumb  toward  the  fingers,  and  suddenly  flex.  To 
get  a  firm  enough  grasp  for  these  manipulations  use  the  apparatus  of  Char- 


Pelvic  Dislocations 


675 


riere  or  of  Levis  (Figs.  411,  412).  If  the  above  maneuvers  fail,  incise  freely  on 
the  dorsum  and  reduce.  Tenotomy  is  seldom  of  ser\dce.  After  reduction  of 
this  dislocation  a  splint  must  be  worn  for  three  weeks.  In  fom'ard  dislocation 
reduction  is  easily  effected  by  strong  extension  and  forced  fle.xion.  A  splint  is 
to  be  worn  for  three  weeks. 

A  dislocation  of  a  phalanx  may  be  complete  or  may  be  partial.  It  is 
most  common  between  the  first  and  second  phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
In  reducing  such  dislocations  employ  extension  and  manipulation.  Use  a 
splint  for  one  week. 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The  ribs  may  be  dislocated 
from  the  vertebrae.     This  accident  is  seldom  uncomplicated,  and  cannot  be 


Fig.  411. — Le\"is's  splint  for  reducing  dislocation  of  phalanges. 

differentiated  from  fracture  without  a  skiagraph.  The  diagnosis  is  rarely 
made,  and  the  injury  is  treated  as  a  fracture.  The  ribs  may  be  dislocated  from 
their  cartilages,  one  or  more  ribs  being  displaced.  The  end  of  the  rib  forms  an 
anterior  projection,  there  is  a  depression  over  the  cartilage,  and  crepitus  is 
absent.  Treatment  is  the  same  as  that  employed  for  fractured  ribs.  The  cos- 
tal cartilages  may  be  displaced  from  the  sternum,  forming  an  anterior  projection 
upon  this  bone.  Reduction  is  brought  about  by  placing  the  patient  upon  a 
table,  ■ndth  a  sand-pillow  between  the  scapulae,  pushing  back  the  shoulders  and 
chest,  and  forcing  the  cartilage  into  place.  The  dressings  are  the  same  as  those 
used  for  fractured  sternum.  The  cartilages  of  the  lower  ribs  (sixth,  seventh, 
eighth,  ninth,  and  tenth)  may  be  separated.  The  inferior  cartilage  goes  for- 
ward and  can  be  felt.     Pick  states  that  reduction  is  brought  about  bv  causing 


Fig.  412. — Le%"is's  splint  applied. 


the  patient  to  hold  the  chest  fuU  of  air  while  efforts  are  made  to  push  the 
cartilage  into  place.     The  injurs-  is  dressed  as  are  fractured  ribs  (see  page  544). 

Dislocation  of  the  Sternum. — In  dislocation  of  the  body  of  the  sternimi 
the  manubrium  is  separated  from  the  gladiolus.  The  injurs'  is  a  rare  one,  is 
usually  associated  with  fracture,  and  is  most  common  in  the  young.  It  is  due 
in  most  cases  to  \-iolent  direct  force  inflicted  by  a  fall  or  hea\y  blow;  it  may  be 
due  to  indirect  force  and  arose  in  a  reported  case  of  acute  tetanus.  The 
symptoms  and  treatment  are  the  same  as  those  of  fractm-e  (see  page  546). 
Dislocation  of  the  ensiform  process  is  one  of  the  rarest  of  injuries.  It  is 
usuallv  due  to  direct  force,  but  PolaiUon  reports  a  case  caused  by  tight  lacing. 

Pelvic  dislocations  are  almost  always  complicated  by  fracture.  A  pubic  bone 
can  be  dislocated  by  falls  from  a  height  or  by  the  application  of  violent  force 


676 


Diseases  and  Injuries  of  the  Bones  and  Joints 


to  the  acetabula.  The  condition  may  happen  from  accident  while  riding  a  horse. 
The  dislocation  may  be  up  or  down,  front  or  back,  and  it  may  damage  the 
urethra  or  the  bladder.  The  patient  cannot  stand;  there  are  great  pain  and 
recognizable  deformity.  Treat  by  molding  the  bones  into  place,  by  applying 
a  pelvic  girdle,  and  by  rest  in  bed  for  four  weeks.  Pure  separation  or  relaxation 
of  the  symphysis  is  seldom  the  result  of  injury  and  is  usually  due  to  child- 
birth. In  this  condition  there  is  mobility,  pain  on  pressure  and  movement, 
and  pain  on  abduction  of  the  thighs.  The  treatment  is  rest  in  bed  and  the 
application  of  a  pelvic  girdle.  Occasionally  in  traumatic  and  also  in  post- 
obstetric  separation  it  is  necessary  to  wire  the  bones.  Dislocation  of  the  sacro- 
iliac joint  is  produced  by  falls.     Movement  on  the  part  of  the  patient  is  difE- 


Fig.  413. — Thyroid  dislocation  of  the  femur  eight  weeks  after  the  accident. 

(Rugh). 


Reduced  by  open  section 


cult  or  impossible;  there  is  violent  pain,  and  often  paralysis  (from  pressure 
upon  nerves).  In  dislocation  backward  there  is  apparent  shortening  of  the 
leg,  eversion  of  the  foot  exists,  and  the  ilium  moves  posteriorly  and  upward. 
In  dislocation  forward  the  anterior  superior  iliac  spine  projects  and  the  pelvis 
is  broadened.  Sacro-iliac  dislocation  is  reduced  by  holding  the  pelvis  firm  and 
making  extension  by  means  of  a  pulley.  The  patient  stays  in  bed  for  four 
weeks  and  wears  a  pelvic  belt  as  in  fracture. 

Dislocation  of  the  coccyx  is  considered  on  page  549. 

Dislocation  of  the  Femur  (Hip-joint). — Dislocation  of  this  joint  is  not  often 
encountered,  as  the  hip-joint  is  very  strong.  It  is  most  apt  to  occur  in  a  young 
adult.  In  forcible  extension  the  head  of  the  femur  presses  against  the  capsule 
of  the  joint,  but  the  capsule  here  is  very  thick,  and  certain  muscles,  the  rectus, 


Dislocation  Upon  the  Dorsum  of  the  Ilium 


677 


psoas,  and  iliacus,  are  pulled  tight  and  serve  to  strengthen  it.  The  head  of  the 
bone  cannot  go  directly  upward  because  of  the  acetabulum  (Edmund  Owen). 
The  weak  point  of  the  acetabular  rim  is  below;  the  weak  part  of  the  capsule  is 
also  below;  hence  forced  abduction  is  apt  to  push  the  head  of  the  bone  through 
the  lower  part  of  the  capsule,  a 
dislocation  occurring  primarily 
into  the  thyroid  foramen.  The 
signs  of  the  dislocation  depend 
upon  the  untorn  portion  of  the 
capsule.  The  anterior  portion  of 
the  capsule,  including  the  Y-liga- 
ment,  usually  escapes  laceration. 
Vessels  are  rarely  injured.  Mus- 
cles are  often  torn.  In  some  cases 
the  sciatic  nerve  is  lacerated, 
bruised,  or  caught  up  on  the  neck 
of  the  femur  during  the  circum- 
duction of  attempted  reduction. 
Four  forms  of  hip- joint  disloca- 
tion are  usually  described:  (i) 
upward  and  backward,  on  the 
dorsum  of  the  ilium;  (2)  back- 
ward, to  the  border  of  the  sciatic 
notch;  (3)  downward,  into  the 
obturator  foramen,  and  (4)  in- 
w^ard,  on  the  pubes. 

All  dislocations  are  primarily  inward  or  outward.  From  these  initial 
positions  the  head  may  be  shifted  to  any  region  about  the  socket  within  reach 
of  the  remnant  of  untorn  capsule  (Oscar  H.  AUis).  Allis  rejects  the  old  classi- 
fication and  suggests  the  following: 


Fis 


414- 


Dislocatioa  of  femur  upon  the  dorsum  of  the 
ihum  (Dr.  Ohnesorg's  case). 


Low  thyroid, ") 

3 


All  present  abduction  and  outward  rotation. 


Mid- 
High      " 
Reversed  thyroid: 
Low  dorsal,  ^ 

Mid-     "       r  All  present  adduction  and  inward  rotation. 
High     "       ) 

Dislocation  upon  the  dorsum  of  the  ilium  (Fig.  414)  is  the  commonest  form. 
One-half  of  all  hip  dislocations  are  of  this  variety.  It  is  caused  by  a  fall  or  a 
blow  when  the  limb  is  flexed  and  abducted  (as  in  carrying  a  weight  upon  the 
shoulder),  by  a  fall  upon  the  knees  or  feet,  by  a  weight  striking  the  back  while 
bending,  etc.  Allis  says  rotation  inward  is  the  chief  element  in  its  production. 
In  this  dislocation  the  head  of  the  femur  goes  upward  and  backward,  rests 
upon  the  ilium,  and  is  always  above  the  tendon  of  the  obturator  internus 
muscle.  This  dislocation  is  secondar}^  to  thyroid  dislocation,  muscular  action 
shifting  the  bone  from  its  initial  seat  of  displacement. 

Signs. — Dislocation  upon  the  dorsum  of  the  ilium  is  indicated  by  the  fol- 
lowing s}Tnptoms:  the  buttock  appears  flat  and  broad;  the  great  trochanter 
is  above  Nekton's  line  and  is  deeply  placed;  the  head  of  the  bone  can  be 
detected  in  its  new  situation ;  deep  pressure  in  front  of  the  joint  finds  a  hol- 
low; the  leg  is  shortened  by  about  2  or  3  inches;  the  fascia  lata  is  relaxed; 
in  some  thin  people  the  socket  can  be  outlined;  when  the  patient  is  recum- 
bent the  injured  extremity  can  be  brought  to  the  perpendicular  Avithout 
flexing  the  leg  (Allis);  the  knee  is  somewhat  flexed;  the  thigh  is  slightly  flexed. 


678  Diseases  and  Injuries  of  the  Bones  and  Joints 

inwardly  rotated,  and  adducted  (Fig.  415)  (this  is  shown  by  the  fact  that 
the  axis  of  the  thigh  of  the  injured  side,  if  prolonged,  would  pass  through 
the  lower  third  of  the  sound  thigh) ;  when  the  capsule  is  extensively  lacerated 
there  may  be  no  adduction  and  may  be  e version  (Allis) ;  the  heel  is  raised,  and 
the  great  toe  of  the  foot  of  the  injured  side  rests  upon  the  front  of  the  instep 
or  the  ankle  of  the  sound  side  (Fig.  415);  rigidity  exists;  voluntary  movement 
is  impossible,  though  some  passive  motion  is  possible  in  the  direction  of  the 
deformity  (the  deformity  can  be  made  more  marked).  If  a  patient  is  re- 
cumbent and  the  knees  vertical,  the  foot  of  the  sound  extremity  is  free  of 
the  bed,  but  the  foot  of  the  injured  extremity  touches  the  bed  {Allis's  sign). 
Diagnosis. — Examine  first  without  anesthesia.  The  a;-rays  are  invaluable 
in  diagnosis.  If  the  x-rays  are  not  obtainable,  examine  again  while  the  patient 
is  anesthetized.  Dislocation  is  distinguished  from  intracapsular  fracture  by 
noting  the  inversion,  the  great  shortening,  the  absence  of 
crepitus,  the  age  of  the  subject,  and  the  nature  of  the 
force.  The  nature  of  the  force,  the  inversion,  and  the 
absence  of  crepitus  mark  the  diagnosis  from  extracapsular 
fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dis- 
location upon  the  dorsum  of  the  ilium,  Bigelow  states, 
is  the  untorn  portion  of  the  capsule,  especially  the 
Y-ligament.  The  iliofemoral,  Y,  or  Bigelow's  ligament 
resembles  an  inverted  Y,  arises  from  the  anterior  inferior 
spine  of  the  ilium,  is  inserted  into  the  anterior  intertro- 
chanteric line,  and  is  incorporated  into  the  front  of  the 
capsule.  To  reduce  a  dislocation  this  ligament  must  be 
^.    .  .  ,     relaxed  by  manipulation  or  be  torn  by  extension.     Manip- 

Flg.  415. — Hip-]01Ilt  ,     ^.  -I  J_^  -I  T  c     ,1  ^  .  ^ 

dislocation  upon  the     ulation    makes    the    head    ot   the  bone  retrace  its  steps 
dorsum  of  the  ihum     over  the  Same  route  it  took  in  emerging.     Give  ether; 
°°^  place  the  patient  supine  upon  a  mattress  on  the  floor;  flex 

the  leg  on  the  thigh  (to  relax  the  hamstrings),  flex  the  thigh  on  the  pelvis;  in- 
crease the  adduction  over  the  middle  line;  strongly  abduct;  perform  external 
rotation  and  extension.  This  treatment  may  be  summed  up  as  flexion,  adduc- 
tion, external  circumduction,  and  extension;  or,  as  Pick  puts  it,  "bend  up,  roll 
out,  turn  out,  and  extend."  Allis's  advice  is  to  fix  the  pelvis  to  the  floor,  lift 
the  head  of  the  bone  to  the  level  of  the  socket,  rotate  outward  by  carrying  the 
leg  toward  the  pubis,  and  extend  the  femur.  If  extension  and  counterextension 
are  employed,  make  extension  in  the  axis  of  the  dislocated  limb  and  obtain 
counterextension  by  a  perineal  band.  The  extension  band  is  fastened  to  the 
thigh  by  a  clove-hitch.  After  reduction  put  the  patient  to  bed  and  use  sand- 
bags (as  in  fracture  of  the  hip)  for  four  weeks.  We  may  tie  the  knees  together 
instead  of  using  the  sand-bags.  Passive  motion  is  made  in  the  third  week. 
The  pulleys  must  not  be  used  in  reduction.  They  may  inflict  great  or  even 
fatal  injury.  If  the  surgeon  fails  to  reduce  the  deformity,  there  are  two 
courses  open  to  him.  He  may  let  it  alone.  He  may  operate.  If  he  lets  it 
alone,  the  limb  will  almost  certainly  become  ankylosed,  though  probably 
useful.  If  he  determines  to  operate,  he  must  recognize  that  tenotomy  is  use- 
less.    It  is  necessary  to  make  a  free  incision  in  order  to  restore  the  bone. 

Dislocation  Onto  the  Border  of  the  Sciatic  Notch. — In  this  dislocation  the 
head  of  the  bone  passes  backward  and  a  little  upward,  and  rests  upon  the 
ischium  at  the  margin  of  the  sciatic  notch  (not  in  the  notch),  below  the 
tendon  of  the  obturator  internus  muscle.  The  causes  are  the  same  as  those 
given  for  the  previous  dislocation. 

The  signs  in  dislocation  by  the  sciatic  notch  are  like  those  of  disloca- 
tion upon  the  dorsum  of  the  iliimi,  but  they  are  not  so  marked.     There 


Dislocation  Upon  the  Pubis 


679 


Fig.  416. — Hip-joint 
dislocation  onto  the 
sciatic  notch  (Cooper). 


are  flattening  and  broadening  of  the  hip;  ascent  of  the  trochanter  above 
Nelaton's  Une;  shortening  to  the  extent  of  an  inch;  relaxation  of  the  fascia 
lata.  If  the  knee  of  the  injured  side  is  vertical,  the  sole  of  the  foot  touches 
the  bed.  Flexion,  inward  rotation,  and  adduction  exist,  but  the  axis  of  the 
femur  of  the  injured  side  passes  through  the  knee  of  the  sound  side,  and  the 
ball  of  the  great  toe  of  the  injured  side  rests  upon  the  great  toe  of  the  sound 
side  (Fig.  416).  Other  symptoms  are  identical  mth  those  of  dislocation 
upon  the  dorsum  of  the  ilium,  but  are  less  pronounced. 
Allis's  signs  of  this  dislocation  are  of  value:  if,  with  the 
patient  recumbent,  the  thighs  are  brought  to  a  right  angle 
with  the  body,  shortening  on  the  affected  side  is  materi- 
ally increased;  if  the  dislocated  thigh  is  extended,  the 
back  arches  as  in  hip  disease. 

Diagnosis  and  Treatment. — The  signs  of  dislocation  on 
the  border  of  the  sciatic  notch  are  similar  to,  but  are  less 
marked  than,  those  of  dorsal  dislocation,  and,  being  a  back- 
ward dislocation,  the  reduction  and  treatment  are  the  same 
as  for  dislocation  backward  upon  the  dorsum  of  the  ilium. 
Dislocation  Downward  Into  the  Obturator  Foramen 
(Fig.  417). — Downward  dislocation  is  the  primary  position 
of  most  dislocations  of  the  hip,  the  bone  rarely  remaining  in 
the  thyroid  foramen,  but  usually  moimting  up  as  a  result  of 
muscular  action  or  of  the  initial  \dolence.  The  cause  is  a 
violent  abduction  by  falls  or  by  stepping  from  a  mo\dng  car. 

Signs. — Dislocation  dowTiward  into  the  obturator  foramen  is  indicated 
by  flattening  of  the  hip;  the  head  of  the  bone  is  felt  in  its  new-  position  and 
is  missed  from  the  acetabulum;  rigidity  exists;  passive  motion  is  only  possible 
in  the  direction  of  deformity,  and  that  to  a  slight  extent;  a  hollow  is  noted 
over  the  great  trochanter,  which  process  is  well  below  Nelaton's  Kne  and 
nearer  than  normal  to  the  middle  line.  The  gluteal 
crease  is  lower  than  is  the  crease  of  the  opposite  side; 
there  is  lengthening  to  the  extent  of  i  to  2  inches;  the 
bodv  is  bent  forward  by  the  traction  upon  the  psoas  and 
ihacus  muscles,  and  is  also  de\dated  to  the  side,  thus  causing 
great  apparent  lengthening;  the  limb  is  advanced  par- 
tially flexed  and  abducted,  and  the  foot  is  pointed 
straight  ahead  or  is  a  little  everted  (Fig.  417);  when  the 
patient  is  recumbent  extension  is  impossible,  the  knees 
cannot  be  pushed  together  without  great  pain,  and  the 
abductor  muscles  are  hard  and  rigid.  Allis's  signs  are 
absent.  Unreduced  dislocations  do  well,  the  patient  ob- 
taining a  verv'  useful  hip-joint  (Sedillot). 

Treatment. — In  treating  dislocation  downward  into 
the  obturator  foramen  give  ether  and  effect  reduction, 
if  possible,  by  manipulation,  and,  if  this  fails,  by  exten- 
sion. To  reduce  by  manipulation,  flex  the  leg  on  the 
thigh  and  the  thigh  on  the  pelvis,  and  then  perform,_  in 
the  following  order,  abduction,  internal  circumduction,  and  extension.  Allis's 
rule  of  reduction  is  as  follows:  fix  the  pelvis  to  the  floor;  pull  the  head  of  the 
femur  outward  and  above  the  socket;  fix  the  head;  push  the  knee  toward  sound 
knee  and  extend  the  femur.  If  extension  is  made,  make  traction  in  the  axis  of 
the  limb  by  means  of  muslin  fastened  around  the  thigh  by  a  clove-hitch.  Do 
not  use  pulleys ;  incise  rather  than  use  them. 

Dislocation  upon  the  pubis   is  a  ver\-  uncommon  accident.     The  head 
of  the  bone  usually  rests  just  internal  to  the  anterior  inferior  spine  of  the 


Fig.  417. — ^Hip-Joint 
dislocation  into  the  ob- 
turator or  thyroid 
foramen  (Cooper). 


68o 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  418. — Dislocation 
on  pubis  (Cooper) . 


ilium.  The  primary  position  of  the  bone  is  in  the  thyroid  foramen;  the  pubic 
dislocation,  when  it  occurs,  is  always  secondary,  and  is  due  to  the  initial  force 
and  to  muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone  can  be  felt  and 
seen  in  its  new  position;  the  hip  is  flattened;  there  is  a  hollow  over  the  great 
trochanter,  this  process  being  found  below  the  anterior  superior  spine  of  the 
ilium;  there  is  shortening  to  the  extent  of  i  inch;  the  limb  is  in  abduction  with 
eversion  (Fig.  418),  and  the  knees  cannot  be  approximated  without  great  pain. 
In  the  treatment  of  pubic  dislocation  give  ether  and  employ  manipula- 
tion as  for  thyroid  dislocation.  If  this  fails,  employ  extension.  The  limb 
is  well  abducted,  extension  is  made  downward  and  backward,  and  the  head 
of  the  femur  is  pulled  outward  "by  a  towel  around  the 
thigh,  just  beneath  the  groin"  (Keetley).  The  after- 
treatment  is  the  same  as  that  for  the  previous  forms. 

Central  or  Internal  Dislocation  (Fig.  419). — By  this  term 
we  mean  that  the  head  of  the  femur  has  been  displaced  and 
perhaps  forced  through  a  fractured  acetabulum  into  the 
pelvis.  It  is  not  a  genuine  dislocation.  There  is  neither 
tearing  nor  stretching  of  the  capsule  and  the  acetabular  floor 
may  remain  in  contact  with  the  femoral  head.  Skillern  and 
Pancoast  ("Annals  of  Surgery,"  Jan.,  191 2)  point  out  that 
"the  injury  varies  from  a  slight  depression  of  the  floor  of 
the  acetabulum  ...  to  the  passage  of  the  femoral  head 
into  the  pelvic  cavity."  For  the  first  injury  they  suggest 
the  term  fractura  acetabuli  perforans;  for  the  second,  frac- 
tura  acetabuli  perforata.  This  injury  is  due  to  violent 
force.  The  usual  cause  is  a  faU  upon  the  great  trochanter. 
The  symptoms  vary  with  the  degree  of  depression  or  frac- 
ture of  the  floor  of  the  acetabulum.  If  there  is  only  slight  depression  of  the 
floor,  there  may  be  no  appreciable  shortening  and  very  slight  approach  of 
the  trochanter  toward  the  symphysis  pubis.  The  a;-rays  may  be  needed  to 
make  a  diagnosis.  If  the  head  has  perforated,  shortening  will  be  evident, 
there  will  be  marked  approach  of  the  trochanter  toward  the  midhne,  and 
vaginal  or  rectal  palpation  will  discover  the  displaced  femoral  head.  In  both 
injuries  there  are  pain,  tenderness,  and  impaired  mobihty.  There  may  be 
serious  damage  within  the  pelvis.  Intrapelvic  hemorrhage  is  common.  The 
peritoneum  may  be  lacerated,  the  bowel  may  be  damaged,  the  bladder  in- 
jured, or  the  obturator  nerve  bruised  (Skillern  and  Pancoast,  Ibid.) . 

Treatment. — If  complications  such  as  are  mentioned  above  exist,  at  once 
open  the  abdomen  and  repair  the  injury.  Reduce  the  deformity  by  extension 
and  counterextension.  Treat  by  "extension  in  the  axis  of  the  limb  in  con- 
junction with  lateral  traction  upon  the  femoral  neck"  (Ibid.).  After  a  week, 
if  there  is  no  contra-indication,  apply  a  plaster-of-Paris  dressing  from  the  toes 
to  the  chest. 

Skillern  and  Pancoast  (Ibid.)  state  that  the  injury  was  first  described  by 
Callisen  in  1788,  and  that,  with  their  4  cases,  55  have  been  reported. 

Anomalous  Dislocations  of  the  Hip. — In  supraspinous  dislocation  the  dis- 
location of  the  hip  is  backward,  the  head  of  the  femur  resting  upon  the  ilium 
above  or  even  anterior  to  the  anterior  superior  spine.  In  ischial  dislocation 
the  dislocation  is  downward  and  backward,  the  head  of  the  femur  resting  on 
the  ischial  tuberosity  or  in  the  lesser  sciatic  notch.  Monteggia's  dislocation  is 
a  supraspinous  dislocation  with  eversion  of  the  limb.  In  perineal  dislocation 
the  head  of  the  femur  is  in  the  perineimi.  In  suprapubic  dislocation  the  head 
of  the  femur  passes  above  the  pubes.  In  subspinous  dislocation  the  femoral 
head  rests  on  the  horizontal  ramus  of  the  pubes. 


Dislocation  of  Head  of  Femur  with  Fracture  of  Shaft  of  Bone    68i 

Dislocation  with  Catching  Up  of  the  Sciatic  Nerve  During  Reduction. — 
This  accident  causes  severe  pain.  The  leg  is  flexed  on  the  thigh  and  the 
thigh  is  flexed  on  the  pelvis.  Allis  tells  us  that  the  task  of  reduction  is  very 
mipromising.  We  must  strive  to  put  the  neck  of  the  femur  in  such  a  position 
that  the  nerve  will  "drop  off,"  and  yet  often  the  nerve  cannot  drop  off  because 
it  is  held  by  adhesion  to  the  injured  muscles.  Allis  attempts  reduction  by 
the  followmg  plan: 

1.  Place  the  patient  upon  his  back  and  redislocate  the  femur. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh. 

4.  Turn  the  ankle  out  until  the  leg  is  horizontal  (this  causes  the  head  of 
the  bone  to  look  downward) . 

5.  "Shake,  shock,  jar,  adduct,  and  abduct,"  to  disengage  the  nerve. 

6.  Rotate  into  socket  without  flexing  leg  (without  making  nerve  tense). 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space,  and  draw  the 
nerv^e  out  of  the  wound.  Detach  the  head  of  the  bone  from  its  entangle- 
ment and  rotate  it  into  the  socket.^ 


Fig.  419. — Dislocation  of  left  hip.     Fracture  of  acetabulum,  ischium,  and  pubes  (right),  with  central 
dislocation  of  hip.     Separation  of  pubic  arch. 

Dislocation  of  the  Head  of  the  Femur  with  Fracture  of  the  Shaft  of  the 
Bone. — We  may  incise,  replace,  and  plate  the  fragments.  We  may  use 
McBurney's  hooks  as  in  the  shotilder.  We  may  be  forced  to  do  a  resection 
of  the  head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipulation.  He  states 
that  the  upper  fragment  is  the  entire  lever,  and  the  lower  fragment  "is  only 
the  agent  through  which  w^e  apply  our  force."  The  fragments  are  not  com- 
pletely separated,  but  are  connected  at  one  side  by  material  which  is  "partly 
periosteal,  partly  tendinous,  and  partly  muscular."  This  connecting  mate- 
rial enables  us  to  make  traction  upon  the  upper  fragment,  but  does  not  aUow 
"rotation,  circumduction,  and  leverage  through  the  agency  of  the  lower  frag- 

1  AHis's  views  will  be  found  in  "An  Inquiry  Into  the  Difficulties  Encountered  in  the  Reduc- 
tion of  Dislocations  of  the  Hip,"  by  Oscar  H.  Allis,  M.  D.  This  highly  original  and  valu- 
able treatise  received  the  Samuel  D.  Gross  Prize  of  the  Philadelphia  Academy  of  Surgery  in 
1895. 


682 


Diseases  and  Injuries  of  the  Bones  and  Joints 


ment."  Hence  "the  only  agency  at  our  command  is  traction."  If  the  disloca- 
tion is  inward  (forward),  draw  the  head  outward  and  have  an  assistant  make 
direct  pressure  upon  the  head  of  the  bone.  If  this  fails,  the  assistant  holds 
the  head  of  the  bone  to  prevent  its  slipping  into  the  thyroid  depression,  and 
the  surgeon  makes  traction  inward  or  inward  and  downward.  If  the  disloca- 
tion is  outw^ard  (backward),  make  traction  directly  upward  to  lift  the  head  of 
the  bone  to  the  level  of  the  socket,  and  try  to  place  the  head  over  the  socket  by 
traction  obliquely  upward  and  inward.  During  all  these  manipulations  an 
assistant  presses  upon  the  trochanter  to  prevent  the  head  of  the  bone  shpping 
back.  Traction  is  now  made  downward  and  inward,  and  the  tightened  liga- 
ment may  drag  the  head  of  the  bone  into  place. 

Dislocation  of  the  Knee. — It  is  a  rare  injury.  There  are  four  forms — 
forward,  backward,  outward,  and  inward.  Any  one  of  the  four  may  be  com- 
plete or  incomplete;  the  commonest  dislocations  are  lateral.    The  cause  is 

violent  force,  such  as  a  fall,  or  in 
jumping  from  a  moving  train,  or 
in  being  caught  by  the  foot  and 
dragged. 

Dislocation  Forward  of  the 
Knee-joint. — In  the  complete  form 
of  forward  dislocation  the  de- 
formity is  obvious.  The  limb  is 
usually  extended,  but  it  may  be 
flexed.  Much  shortening  exists; 
the  condyles  are  felt  posterior  and 
below;  the  head  of  the  tibia  is  felt 
anterior  and  above;  the  patella  is 
movable  and  the  quadriceps  is 
lax;  pressure  of  the  condyles  upon 
the  contents  of  the  pophteal  space 
arrests  the  tibial  pulse  and  causes 
edema  and  intense  pain.  In  in- 
complete dislocation  the  symptoms 
are  identical  in  kind,  but  are  less 
pronounced. 

Treatment. — Compound  dislo- 
cation of  the  knee-joint  often  de- 
mands excision  or  amputation.  In 
simple  dislocation  give  ether,  have 
one  assistant  extend  the  leg  while  another  makes  counterextension  on  the  thigh, 
and  the  surgeon  pushes  the  bone  into  place.  Reduction  is  easy  because  of  liga- 
mentous laceration.  Place  the  limb  on  a  double  inclined  plane,  and  combat 
inflammation  by  the  usual  methods  (see  Synovitis,  page  617).  Begin  passive 
motion  in  the  third  week.  The  patient  must  wear  a  knee-support  for  months. 
Ver}^  extensive  laceration  of  ligaments  calls  for  incision  and  suturing.  If  the 
popliteal  vessels  are  much  damaged,  gangrene  will  supervene  and  amputation 
will  be  demanded. 

Dislocation  Backward  of  the  Knee-joint. — In  the  complete  form  of  back- 
ward knee-joint  dislocation  displacement  is  not  so  great  as  in  dislocation  for- 
ward. The  head  of  the  tibia  projects  posteriorly  and  above,  the  femoral 
condyles  anteriorly  and  below ;  the  leg  is,  as  a  rule,  partly  flexed,  but  it  may  be 
extended,  and  there  is  moderate  shortening.  In  incomplete  dislocation  the 
symptoms  are  less  marked. 

The  treatment  of  backward  dislocation  of  the  knee-joint  is  the  same  as 
for  forward  dislocation. 


Fig.  420. — Old  dislocation  of  the  patella  outward. 


Dislocation  of  the  Patella  Inward 


683 


Dislocation  outward  of  the  knee-joint  is  usually  incomplete.  The  [inner 
tuberosity  of  the  tibia  in  outward  dislocation  lies  upon  the  outer  condyle  of 
the  femur  (Pick);  the  inner  condyle  of  the  femur  projects  internally;  the 
outer  tibial  tuberosity  and  fibular  head  project  externally,  the  former  having 
a  depression  below  it,  and  the  latter  above  it;  the  leg  is  semiflexed,  but 
shortening  is  absent. 

Dislocation  inward  of  the  knee-joint  is  usually  incomplete.  The  outer 
tuberosity  of  the  tibia  in  inward  dislocation  lies  upon  the  inner  condyle  of  the 
femur;  the  outer  condyle  of  the  femur  forms  an  external  prominence,  and  the 
inner  tuberosity  of  the  tibia  forms  an  internal  prominence.  Pick  cautions  us 
not  to  mistake  a  separation  of  the  lower  femoral  epiphysis  for  lateral  disloca- 
tion (the  former  is  reduced 
easily,  the  deformity  tends 
to  recur,  and  there  is  soft 
crepitus) . 

Treatment. — In  treating 
lateral  dislocation  of  the 
knee-joint,  effect  extension 
and  counterextension  as  in 
anteroposterior  dislocations. 
The  leg  is  moved  from  side 
to  side  and  attempts  are 
made  at  rotation.  The 
after-treatment  is  the  same 
as  that  for  anteroposterior 
luxations. 

Dislocation  of  the  patella 
is  seldom  congenital.  There 
are  35  congenital  cases  on 
record  (Bajardi).  There  are 
three  forms  of  dislocation 
of  the  patella:  outward,  in- 
ward, and  edgewise.  The 
so-called  dislocation  upward 
is,  in  reality,  rupture  of  the 
ligamentum  patellae  (see 
page  718). 

Dislocation  of  the  patella 
outward  (Fig.  420)  may  be 
due  to  muscular  action  or  to 
direct  force,  and  occurs  dur- 
ing extension  of  the  leg.  It 
occasionally  happens  in  a 
person  with  knock-knee.  If 
dislocation  is  complete  the 
bone  lies  upon  the  external 

surface  of  the  external  condyle;  if  incomplete,  the  patella  rests  upon  the 
anterior  surface  of  the  external  condyle.  The  leg  is  extended,  flexion  is  im- 
possible, and  attempts  at  flexion  produce  great  agony.  In  the  patient  shown 
in  Fig.  420  flexion  became  possible  ui  an  unreduced  dislocation,  but  not  until 
months  after  the  accident.  The  knee  is  wider  than  normal.  There  is  a 
hollow  in  front  of  the  joint.     The  bone  is  felt  in  its  new  position.  _ 

Dislocation  of  the  patella  inward  is  very  rare  (Fig.  421).     The  signs  are  like 
those  of  dislocation  outward,  except  that  the  patella  rests  upon  the  inner  condyle. 

Treatment  of  Lateral  Dislocations  of  the  Patella.— Give  ether.     Raise  the 


Fig.  421. — Dr.  Morris  Booth  Miller's  case  of  outward  dislo- 
cation of  the  patella  from  direct  force  six  months  after  the 
fall.     Failed  of  reduction  under  ether  anesthesia. 


684  Diseases  and  Injuries  of  the  Bones  and  Joints 

body  upon  a  bed-rest  and  flex  the  thigh.  Grasp  the  patella  and  depress 
the  margin  which  is  farthest  from  the  center  of  the  joint  (Pick).  The 
muscles  may  pull  the  bone  into  place.  Extend  the  extremity  and  immobilize 
for  three  weeks,  and  then  begin  passive  motion.  Incision  may  be  necessary 
in  order  to  effect  reduction. 

Dislocation  of  the  Patella  Edgewise. — The  patella  rotates  vertically, 
one  edge  resting  between  the  condyles.  As  a  rule,  the  outer  border  is  in  the 
intercondyloid  notch.  This  condition  is  produced  by  direct  force  when  the 
extremity  is  partly  flexed.  Twisting  and  muscular  action  have  been  assigned 
as  causes.    The  condition  is  obvious  at  a  glance. 

Treatment. — Give  ether.  Pick  recommends  "sudden  and  forcible  bending 
of  the  knee."  In  some  cases  the  bone  can  be  pushed  into  place,  the  limb 
being  extended  and  flexed  as  in  the  reduction  of  a  lateral  dislocation.  In  some 
cases  incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee-joint  (the  Internal 
Derangement  of  Hey;  Subluxation  of  the  Knee-joint). — The  condition  was 
described  by  Hey,  of  Leeds,  in  1803.  The  interarticular  cartilages  of  the  knee- 
joint  are  attached  in  front  of  and  behind  the  tibial  spine,  and  the  convexity 
of  each  cartilage  is  attached  to  the  edge  of  the  corresponding  tibial  tuberosity 
by  means  of  the  coronar}^  ligament.  The  internal  cartilage  is  fastened  to  the 
internal  lateral  ligament  and  has  a  moderate  freedom  of  movement.  The 
outer  cartilage  is  not  connected  with  the  external  lateral  ligament  and  is  not 
freely  movable.  It  has  been  stated  that  the  outer  cartilage  is  more  frequently 
dislocated  than  the  inner,  but  modern  experience  indicates  that  this  is  not  true, 
and  that  the  internal  cartilage  is  the  one  most  apt  to  suffer.  In  17  cases  oper- 
ated upon  by  Barker  the  internal  cartilage  was  involved  in  every  case  ("Lan- 
cet," Jan.  4,  1902).  Those  persons  whose  occupations  force  them  to  pass  con- 
siderable time  upon  their  knees  are  predisposed  to  this  accident  (Annandale). 
The  derangement  of  the  cartilage  is  usually  caused  by  a  sudden  external  ro- 
tation of  the  tibia  while  the  knee-joint  is  in  partial  flexion ;  for  instance,  when 
the  patient  stumbles  over  an  obstacle,  the  knee-joint  being  partially  flexed,  the 
tibia  is  twisted  outward.  When  the  joint  is  flexed  a  normal  cartilage  moves 
backward,  and  w^hen  it  is  extended  moves  forward  again.  When  the  cartilage 
is  thrown  out  by  the  sudden  eversion  and  flexion  of  the  tibia  it  is  caught  and 
does  not  move  into  place  readily  when  the  leg  is  extended.  The  tear  takes 
place  in  the  direction  of  the  fibers  of  the  cartilage. 

Symptoms. — The  first  indication  of  interarticular  cartilage  displacement  is 
a  sudden,  violent,  sickening  pain  in  the  knee,  which  may  be  so  severe  as  to 
cause  the  patient  to  fall  to  the  ground.  The  knee  is  in  a  position  of  fixed 
semiflexion.  Further  flexion  is  possible,  but  extension  is  impossible.  In 
some  cases  the  patient  can  voluntarily  make  further  flexion;  in  others,  the 
pain  is  so  severe  that  he  either  cannot  or  will  not  do  it;  but  increase  of  flexion 
can  be  obtained  by  passive  motion.  The  joint  is,  however,  blocked  both  to 
passive  and  to  voluntary  extension.  Attempts  at  passive  motion  are  pro- 
ductive of  fierce  pain.  If  either  cartilage  is  displaced  away  from  the  tibial 
spine,  a  prominence  may  be  found  on  one  or  the  other  side  of  the  knee-joint. 
If  the  displacement  takes  place  toward  the  tibial  spine  a  prominence  may  be 
found  on  one  side  of  the  ligament  of  the  patella.  Subluxation  is  rapidly  fol- 
lowed by  inflammation  of  the  synovial  membrane  of  the  joint  and  inflamma- 
tion of  the  cartilage  itself;  and  swelling  quickly  masks  the  projection  of  the  car- 
tilage. This  accident  is  frequently  mistaken  for  the  blocking  of  the  joint  by  a 
floating  cartilage;  but  a  dislocated  cartilage  always  remains  in  the  same  posi- 
tion, and  a  loose  cartilage  changes  its  position  from  time  to  time  (Turner). 
Loose  bodies  in  a  joint  produce  pain  of  a  shifting  character  and  interference 
with  both  flexion  and  extension,  or  with  either  flexion  or  extension  in  an 


Dislocation  of  the  Fibula  at  the  Superior  Tibiofibular  Articulation     685 

irregular  way  (Cotterill).  In  regard  to  the  diagnosis,  Cotterill  points  out  that 
in  a  sprain  of  the  joint  extension  is  not  painful,  but  flexion  is  interfered  with; 
whereas,  in  the  dislocation  of  a  cartilage  of  the  joint,  flexion  is  still  possible, 
but  extension  cannot  be  carried  out  ("Lancet,"  Feb.  22,  1902). 

Treatment. — To  reduce  a  displaced  semilunar  cartilage  I  have  used  with 
satisfaction  a  method  described  by  Henry  W.  Jacob  ("Brit.  Med.  Jour.," 
March  7,  1908).  It  is  not  followed  by  severe  synovitis  unless  the  patient 
has  walked  or  has  made  repeated  efforts  to  reduce  the  displacement,  and  as 
it  is  a  painless  method  ether  is  not  required.      Jacob  describes  it  as  follows: 

"The  patient  lies  on  a  bed  or  couch,  the  surgeon  standing  on  the  outer  side 
of  the  limb  affected,  with  his  face  toward  the  patient's  foot;  the  patient  then 
raises  his  leg  off  the  couch  in  the  semiflexed  position,  the  surgeon  grasps  the 
patient's  leg  in  both  hands,  and  using  his  own  thigh  as  a  fulcrum,  by  means  of  a 
steady  pulling  movement  draws  the  patient's  leg  outward  while  the  surgeon's 
thigh  keeps  the  patient's  femur  in  a  fixed  position;  directly  this  movement  is 
effected  the  patient  must  steadily  extend  the  limb,  and  the  displaced  cartilage 
wfll  probably  go  back  with  a  slight  click;  if  the  first  movement  of  extension  is 
not  successful  the  maneuver  must  be  repeated  without  any  hurry  or  unnecessary 
force,  and  after  a  few  attempts  the  cartflage  can  usually  be  felt  to  slip  in  with- 
'out  pain  or  inconvenience." 

In  treating  dislocation  of  a  semilunar  cartilage  of  the  knee  it  is  customary 
to  give  ether  and  reduce  by  forced  flexion  and  external  rotation.  Exten- 
sion becomes  possible  if  the  cartflage  is  freed.  During  these  maneuvers  an 
assistant  endeavors  to  push  any  projection  of  cartilage  into  place.  After 
reduction  apply  a  splint  for  two  weeks  and  combat  inflammation  by  proper 
remedies  (see  Synovitis);  then  begin  passive  motion.  At  the  end  of  two 
weeks  apply  a  firm  knee-cap  made  of  leather  and  let  the  patient  get  about  on 
crutches.  After  a  couple  of  weeks  the  crutches  can  be  laid  aside.  As  recur- 
rence of  the  displacement  is  usual,  the  patient  should  wear  a  knee-cap  during 
the  day  for  many  months.  A  partial  tear  may  entirely  heal  when  thus  treated 
by  rest  and  support;  an  extensive  tear  wfll  not,  although  even  in  such  cases 
a  useful  but  somewhat  stiff  joint  may  be  obtained.  If  it  is  found  impossible 
to  unlock  the  blocked  joint,  or  if  the  tear  is  extensive  and  redislocation  is  prone 
to  occur,  an  operation  is  advisable.  The  joint  is  opened  and  the  loose  cartflage 
is  pushed  into  place  and  held  by  stitches  to  the  periosteum,  or  the  loosened 
portion  is  excised.  Annandale,  in  1885,  sutured  through  a  transverse  incision. 
Freeman  and  others  used  sutures  to  fij^  the  cartilage.  Excision  is  just  as  satis- 
factory as  suturing,  and  after  excision  recurrence  of  the  trouble  is  impossible. 
After  excision  the  extremity  is  placed  upon  a  posterior  splint.  Passive  motion 
is  begtm  in  two  weeks. 

Dislocation  of  the  Fibula  at  the  Superior  Tibiofibular  Articulation. — This 
injury  is  rare.  The  head  of  the  fibula  may  go  forward  or  backward.  The 
causes  are  direct  force  and  violent  adduction  of  the  foot  with  abduction  of 
the  knee  (Bryant). 

Symptoms. — After  dislocation  of  the  fibula  the  position  is  one  of  semiflexion 
of  the  knee,  volimtary  extension  and  flexion  being  impaired  or  lost.  A  dis- 
tinct movable  projection  is  readily  noticed  in  front  or  behind,  which  is  found 
to  be  continuous  with  the  fibula.  There  is  a  depression  over  the  normal  posi- 
tion of  the  head  of  the  fibifla. 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the  knee  to  relax 
the  biceps,  and  proceed  to  push  the  bone  into  place.  Put  a  compress  over 
the  head  of  the  fibula,  apply  a  bandage,  and  put  the  limb  on  a  double  inclined 
plane.  The  peroneal  nerve  passes  over  the  fibula  just  below  the  head  of  the  bone 
and  care  must  be  taken  to  avoid  making  injurious  pressure  upon  the  ner\'e. 
At  the  end  of  three  weeks  put  a  lacing  knee-support  upon  the  knee  and  let  the 


686  Diseases  and  Injuries  of  the  Bones  and  Joints 

patient  up.  Displacement  being  liable  to  recur,  a  knee-cap  must  be  worn 
for  a  year. 

Dislocation  of  the  Ankle-joint. — This  injury  is  not  unusual.  Fracture  is 
a  frequent  complication.  There  are  five  forms  of  ankle-joint  dislocation — 
outward,  inward,  forward,  backward,  and  upward. 

Lateral  dislocation  of  the  ankle-joint  is  either  outward  or  inward,  and 
may  be  complete  or  incomplete.  In  these  dislocations  the  astragalus  rotates. 
In  incomplete  dislocation  "there  is  no  great  separation  of  the  trochlear  sur- 
face of  the  astragalus  from  the  under  surface  of  the  tibia,  but  the  outer  or 
inner  margin  of  this  surface  is  brought  into  contact  with  the  articular  surface 
of  the  tibia,  and  the  whole  foot  presents  a  lateral  twist"  (Pick).  The  causes 
of  these  dislocations  are  twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle-joint  occurs 
in  Potfs  fracture  (see  page  612).  Complete  outward  dislocation,  in  which 
the  articiilar  surface  of  the  astragalus  is  completely  displaced  outward  from 
the  articular  surface  of  the  tibia,  and  w^hich  condition  is  associated  with  a 
fracture  of  the  fibula  and  separation  of  the  inferior  tibiofibular  articulation, 
is  known  as  Dupuytren's  fracture.  In  incomplete  dislocation  the  foot  goes 
outward  and  upward,  the  fibula  is  fractured,  and  the  tibiofibular  hgaments 
are  torn  off.  In  Dupuytren's  fracture  the  ankle  is  broad,  the  inner  malleolus 
projects  and  looks  lower  than  natural,  the  outer  malleolus  ascends  with  the 
foot,  the  foot  rotates  outward,  and  crepitus  can  be  detected.  In  inward  dis- 
location which  is  associated  with  fracture  of  the  inner  malleolus  there  is  in- 
version, the  outer  malleolus  projects,  and  crepitus  can  be  detected.  In  in- 
complete separation  the  symptoms  are  similar,  but  are  not  so  marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle-joint  the  de- 
formity is  reduced  by  flexing  the  leg  on  the  thigh  and  the  thigh  on  the  pel- 
vis; an  assistant  makes  counterextension  from  the  knee;  the  surgeon  makes 
extension  from  the  foot,  and  at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's  fracture  (see  page 
61.3).  Dislocation  inward  is  treated  in  a  fracture-box  for  the  same  period  as 
Pott's  fracture. 

Anteroposterior  dislocation  of  the  ankle-joint  is  rare.  The  cause  is  the 
catching  of  the  foot  in  jumping  or  falling — direct  violence.  In  dislocation 
forward  the  foot  is  lengthened,  the  heel  is  not  conspicuous,  the  tibia  and 
fibula  project  against  the  tendo  Achillis,  and  the  relation  of  the  malleoli  to 
the  tarsus  is  altered.  In  incomplete  dislocation  the  symptoms  are  similar, 
but  less  pronounced.  In  dislocation  backward  the  foot  is  shortened,  the 
tibia  and  fibula  project  in  front,  the  heel  is  prominent,  and  the  relation  be- 
tween the  malleoH  and  the  tarsus  is  altered.  In  incomplete  dislocation  the 
symptoms  are  similar,  but  less  marked. 

Treatment. — In  anteroposterior  dislocation  of  the  ankle-joint  reduce  as 
in  lateral  dislocations.  Sometimes  the  tendo  Achillis  must  be  cut.  Apply 
a  plaster-of-Paris  dressing  and  let  it  be  worn  for  two  weeks;  then  begin  passive 
motion,  and  let  the  patient  wear  side-spHnts  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nelaton's  dislocation,  is  a  very 
rare  injury.  The  astragalus  is  wedged  between  the  widely  separated  tibia  and 
fibula.  This  dislocation  is  usually  associated  with  fracture.  The  cause  is  a 
faU  upon  the  feet  from  a  great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indicated  by  the  widen- 
ing of  the  ankle  and  by  the  flattening  of  the  foot.  The  malleoli  are  nearly  on 
a  level  with  the  plantar  surface  of  the  foot,  and  there  is  absolute  rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle-joint  give  ether, 
and  try  to  reduce  by  powerfiil  extension  and  counterextension.  Treat  the 
injury  afterward  in  the  same  manner  as  an  anteroposterior  luxation. 


Dislocations  of  the  Other  Tarsal  Bones  687 

Dislocation  of  the  Astragalus. — The  astragalus  may  be  displaced  from  the 
bones  of  the  leg  and  at  the  same  time  be  separated  from  the  rest  of  the  tarsus. 
The  displacement  may  be  forward,  backward,  outward,  inward,  or  rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is  caused  by  falls  or 
t^^ists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects  strongly;  there 
is  shortening  of  the  foot,  and  the  malleoli  approach  the  plantar  aspect  of  the 
foot;  the  foot  is  deviated  to  one  side  or  to  the  other,  and  there  is  absolute 
rigidity  of  the  ankle-joint.  In  incomplete  luxations  the  symptoms  are  similar, 
but  less  marked.  This  dislocation  may  be  obhquely  forward.  In  backward 
dislocation  of  the  astragalus  the  foot  is  not  deviated  to  either  side;  the  astragalus 
projects  between  the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achillis 
is  stretched  over  the  projection.  Rigidity  is  absolute.  This  dislocation  may 
be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — ^Lateral  disloca- 
tions of  the  astragalus  are  rare,  are  always  compound,  and  are  always  associ- 
ated with  fracture.  In  rotary  dislocation  the  astragalus  remains  in  its  normal 
habitat  after  rotating  on  its  own  axis,  either  horizontal  or  vertical.  The  causes 
of  rotary  dislocation  are  twists  of  the  foot  when  it  is  at  a  right  angle  to  the 
leg  (Barwell).  The  symptoms  of  rotary  dislocations  are  obscure.  There  is 
rigidity,  but  sometimes  the  position  of  the  astragalus  may  be  made  out. 

Treatment  of  Dislocation  of  the  Astragalus. — In  treating  astragalus  dislo- 
cation reduce  under  ether  by  flexing  the  knee  to  relax  the  gastrocnemius, 
extending  the  foot,  and  pushing  the  bone  into  place.  It  may  be  necessary 
to  cut  the  tendo  AchiUis.  After  reduction  put  up  the  foot  and  leg  in  a  plaster- 
of-Paris  dressing  for  two  weeks,  and  then  begin  passive  motion  and  apply 
side-splints,  which  are  to  be  worn  for  one  week  more.  If  reduction  fails, 
support  the  limb  on  splints,  combat  inflammation,  and  endeavor  to  bring 
about  union  between  the  dislocated  bone  and  the  tissues.  Often,  in  unre- 
duced dislocation,  the  skin  sloughs  over  the  projecting  bone.  Excision  is 
demanded  the  moment  sloughing  is  seen  to  be  inevitable.  Cases  of  com- 
poimd  dislocation  of  the  astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition  is  a  separation  of  the  astragalus 
from  the  os  calcis  and  scaphoid,  without  separation  from  the  bones  of  the 
leg.  Pick  states  that  the  usual  classification  for  these  dislocations  is  for- 
ward, backward,  inward,  and  outward,  but  that  the  displacement  is,  as  a  rule, 
obHque,  the  foot  passing  backward  and  outward  or  backward  and  inward. 
The  cause  is  twisting. 

Symptoms. — In  subastragaloid  dislocation  the  astragalus  projects  on  the 
dorsiun;  the  foot  is  everted  in  outward  dislocation  and  inverted  in  inward 
dislocation;  the  relation  of  the  malleoH  to  the  astragalus  is  unaltered;  the 
artkle-joint  is  not  absolutely  rigid;  the  foot  "is  shortened  in  front  and  is  elon- 
gated behind"  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make  extension  in  the 
direction  opposite  to  that  of  the  displacement.  In  dislocation  of  the  tarsus 
backward  fix  a  bandage  around  the  foot,  on  a  level  •with  the  heads  of  the 
metatarsal  bones,  which  bandage  the  surgeon  ties  around  his  shoulders.  The 
surgeon  puts  one  knee  in  front  of  the  ankle  and  thus  fixes  the  leg,  raises  him- 
self up  to  make  extension  upon  the  tarsus,  and  molds  the  bone  into  position. 
Tenotomy  may  be  necessary.  After  reduction  apply  a  plaster-of-Paris , 
dressing  and  have  it  worn  for  three  weeks.  The  ankle-joint,  fortunately,  is 
not  involved,  and  stiffness  of  this  articulation  need  not  be  apprehended. 
If  reduction  is  impossible,  take  the  same  course  as  in  luxations  of  the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare.  Single  bones  may 
be  dislocated,  or  the  luxation  may  occur  at  the  mediotarsal  articulation. 


688  Diseases  and  Injuries  of  the  Bones  and  Joints 

Symptoms  and  Treatment. — Projection  is  an  obvious  symptom  in  disloca- 
tion of  the  other  tarsal  bones.  The  treatment  is  to  reduce  by  extension  and 
molding,  the  part  being  put  up  in  plaster-of-Paris  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and  projection  of  the 
dislocated  bone  are  symptoms  of  dislocation  of  the  metatarsal  bones.  To 
treat  these  dislocations  reduce  by  extension  under  ether  and  put  up  in  a  plaster- 
of-Paris  dressing  for  two  weeks.  If  reduction  fails,  the  functions  of  the  foot 
wiU  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  very  rare.  The  first  phalanx  of  the 
big  toe  is  the  one  most  Hable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious.  The 
treatment  is  by  reduction  and  fixation,  as  in  dislocation  of  the  thumb.  Im- 
mobilize for  two  weeks. 

Operations  Upon  Bones  and  Joints 

Osteotomy. — By  the  term  osteotomy  the  modern  surgeon  means  Hterally 
the  sectioning  of  a  bone  for  the  purpose  of  straightening  a  limb  ankylosed 
in  a  bad  position,  correcting  a  bony  deformity,  or  amending  a  vicious  union 


Fig.  422. — Adams's  large  saw.     (In  this  day  of  surgery  the  saw  has  a  metal  handle.) 

of  a  fracture.  In  a  linear  osteotomy  the  bone  is  transversely  or  obliquely 
divided  at  one  spot ;  in  a  cuneiform  osteotomy  a  wedge-shaped  portion  of  bone  is 
removed.     The  operation  of  osteotomy  may  be  performed  with  a  saw  (Fig.  422) 

or  with  an  osteotome.     The  saw  creates  dust, 

draws  much  air  into  the  wound,  and  lacerates 

the  tissues  to  a  considerable  degree.     Most 

Fig.  423.— Osteotome.  surgeons  prefer  the  chisel  or  the  osteotome. 

The  osteotome  slopes  down  to  a  point  from 

each  side  (Fig.  423) ;  the  chisel  is  straight  on  one  side  and  on  the  other  is 

bevelled  to  a  point. 

Osteotomy  for  Genu  Valgum,  or  Knock-knee  {Macewen's  Operation,  Fig. 
424). — ^The  patient  lies  upon  his  back,  being  rolled  a  little  toward  the  diseased 
side.  The  leg  of  the  diseased  side  is  partly  flexed  upon  the  thigh  and  the  thigh 
upon  the  pelvis,  and  the  extremity  is  laid  upon  its  outer  surface,  a  sand-bag 
being  pushed  between  the  extremity  and  the  bed,  opposite  to  the  site  of  section. 
The  flexion  of  the  knee  relaxes  the  pophteal  vessels  and  saves  them  from  injury. 
The  surgeon,  if  operating  on  the  right  leg,  stands  outside  of  that  extremity;  if 
operating  on  the  left  leg,  he  stands  opposite  the  left  hip  (Barker).  The  knife 
is  inserted  into  the  tissues  and  carried  to  the  bone  at  the  inner  side  of  the  knee, 
just  in  front  of  the  adductor  tubercle  of  the  inner  condyle  and  on  a  level  with  the 
upper  border  of  "the  patellar  articular  surface  of  the  femur"  (Barker).  An  in- 
cision is  made  upward  i  inch  in  length,  in  the  direction  of  the  axis  of  the  femur. 
The  knife  is  left  in  as  a  guide  until  the  osteotome  is  inserted  at  the  lower 


Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint 


689 


angle  of  this  wound.  After  the  insertion  of  the  osteotome  the  knife  is  with- 
drawn and  the  blade  of  the  osteotome  is  turned  to  a  right  angle  with  the  shaft 
of  the  femur,  |  inch  above  the  epiphysis  (Fig.  424).  The  osteotome  is  struck 
several  times  with  a  mallet;  the  handle  is  moved  several  times  toward  and  from 
the  body,  so  as  to  widen  the  cut  in  the  bone  (Fig.  425);  the  osteotome  is  again 
struck  with  the  mallet  several  times;  it  is  again  moved  to  and  fro,  and  this 
process  is  continued  until  the  bone  is  cut  two-thirds  through.  If  the  osteotome 
becomes  tightly  fixed,  it  should  be  withdrawn  and  a  smaller  one  introduced. 
In  the  soft  bone  of  a  young  girl  this  to-and-fro  movement  of  the  chisel,  if 
carefully  executed,  is  not  liable  to  break  the  instrimient.  In  dense  bone  it 
may  break  the  instrument;  hence,  when  doing  an  osteotomy  in  dense  bone,  the 
osteotome  is  moved  to  and  fro  across  the  limb  and  slight  downward  press- 
ure upon  the  handle  will  to  a  great  extent  prevent  binding.  When  the  bone  is 
cut  two-thirds  through  the  osteotome  is  withdrawn,  a  piece  of  wet  antiseptic 
gauze  is  held  over  the  wound,  and  the  surgeon  fractures  the  femur  by  strong 
adduction.  The  wound  is  neither  sutured  nor  drained,  but  is  dressed  asep- 
tically,  the  entire  extremity  is  wrapped  in  cotton,  and  a  plaster-of-Paris  dress- 
ing is  applied  and  carried  up  to  the  groin. 
The  dressing  may  be  removed  in  two 
weeks,  and  the  patient  may  subse- 
quently be  treated  with  sand-bags,  as 
for  an  ordinary  fracture  of  the  thigh, 
but  ■without  extension.  This  operation 
is  scarcely  ever  fatal. 


Fig.  424. — Osteotomy  of  the  right  femur  in 
a  case  of  knock-knee:  a  b,  Epiphyseal  line;  c, 
section  of  Macewen;  d  e,  section  of  Ogston. 


Fig.  425. — ;\Iacewen"s  operation  for  genu 
valgum.  The  chisel  is  held  in  the  line  for  striking 
with  a  mallet;  the  arrow  shows  the  direction  in 
which  the  chisel  is  levered  up  and  down  so  as  to 
make  a  wide  gap  in  the  bone  (after  Barker) . 


Ogston'' s  Operation  for  Knock-knee  (Fig.  424). — In  this  operation  the  in- 
ternal condyle  is  sawed  off  obliquely  with  an  Adams  saw — a  proceeding 
which  permits  the  straightening  of  the  knee.  The  objection  to  the  pro- 
cedure is  that  it  opens  the  knee-joint,  and  that  this  cavity  fills  up  more  or 
less  with  a  mixture  of  blood  and  bone-dust.  Macewen's  operation  is  de- 
cidedly the  safer. 

Osteotomy  for  a  Bent  Tibia. — ^The  tibia  is  divided  transversely  or  obHquely 
(linear  osteotomy),  or  a  wedge-shaped  piece  is  removed  (cuneiform  osteotomy). 
The  oblique  incision  is  the  best.  If  the  convexity  of  the  tibial  curve  is  inward, 
cut  the  bone  from  above  downward  and  from  in  front  backward;  if  the  curve  is 
forward,  section  the  bone  from  above  downward  and  from  within  outward. 
The  fibula  need  rarely  be  interfered  with.  After  the  osteotomy  the  limb  is 
treated  just  as  it  would  be  for  a  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — This  operation  is 
performed  in  order  to  allow  straightening  of  a  limb  that  has  undergone  bony 
ankylosis  in  a  faulty  or  an  inconvenient  position.  In  some  cases  an  attempt 
is  made  to  obtain  a  movable  joint,  but  in  most  cases  the  surgeon  must  be 


690  Diseases  and  Injuries  of  the  Bones  and  Joints 

satisfied  with  ankylosis  in  extension.     Osteotomy  may  be  performed  through 
the  neck  of  the  femur  or  through  the  shaft  of  the  femur  below  the  trochanters. 
Osteotomy  through  the  neck  of  the  femur  is  performed  (i)  with  a  saw 
(Adams's  operation)  or  (2)  with  an  osteotome. 

Adams's  Operation  (Fig.  426,  a). — The  patient  Hes  upon  his  sound  hip;  the 
surgeon  stands  upon  the  side  to  be  operated  upon,  and  back  of  the  patient.  The 
knife  is  entered  a  finger's  breadth  above  the  great  trochanter,  is  pushed  in  until 
it  strikes  the  neck  of  the  bone,  is  then  carried  across  the  front  of  and  at  a  right 
angle  with  the  neck,  and  is  withdrawn,  enlarging  the  wound,  in  the  soft  parts 
as  it  emerges,  to  the  extent  of  i  inch.  The  saw  is  then  introduced  and  the 
neck  of  the  femur  is  entirely  divided.  After  the  osteotomy  dress  the  wound 
antiseptically  and  place  the  extremity  straight.  To  straighten  the  limb  it  may 
be  found  necessary  to  cut  contracted  tendons  and  fascial  bands.  After  secur- 
ing extension  and  applying  dressings  use  the  weight-extension  apparatus  and 
the  sand-bags.  Begin  passive  movements  from  the  start  if  a  movable  joint  is 
desired;  few  patients  can  tolerate  the  pain  necessary  to  bring  this  about.  If  it 
is  determined  to  aim  for  a  stiff  joint,  treat  the  case  as  an  intracapsular  fracture 
would  be  treated. 

With  an  Osteotome. — The  position  of  the  patient  is  the  same  as  that  for 
Adams's  operation.  An  incision  i  inch  long  is  made,  starting  just  above  the 
great  trochanter,  ascending  in  the  axis  of  the  femoral  neck,  and  reaching  to 
the  bone.  An  osteotome  is  introduced,  is  turned  to  a  right 
angle  with  the  neck  of  the  bone,  and  is  struck  with  a  maUet 
until  the  bone  is  completely  divided.  (It  is  not  to  be  di- 
vided partially  and  then  broken.)  The  after-treatment  is 
the  same  as  that  for  Adams's  operation.  The  operation 
by  the  osteotome  is  to  be  preferred  to  that  by  the  saw. 

Osteotomy  of  the  Shaft  of  the  Femur  Below  the 
Trochanters  (Ganfs  Operation). — In  this  operation  (Fig. 
426,  b)  the  saw  may  be  used,  but  the  osteotome  is  to  be  pre- 
ferred. The  position  in  Gant's  is  like  that  in  Adams's  op- 
eration. A  longitudinal  incision  i  inch  long  is  made  upon 
the  outer  aspect  of  the  femur  and  on  a  level  with  the 
Fig.  426.— Osteot-  lesser  trochanter.  The  osteotome  is  inserted  and  the 
omy  through  the  neck     bone  is  Completely  divided  below  the  lesser  trochanter. 

of     the    femur:    A,     rj.^   after-treatment  is  the  same  as  that  for  Adams's  opera- 
Adams  s  operation  ;b,        .  ^,  .         .       t      ^  iir  ^• 
Gant's  operation.           tion.     Gant  s  operation  IS  the  best  method  tor  correctmg 

faulty  position  in  bony  ankylosis,  and  Adams's  operation 
can  only  be  employed  in  those  cases  in  which  the  femur  still  has  a  neck  which 
is  practically  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — This  operation  is  per- 
formed for  bony  ankylosis  of  a  knee  in  a  position  of  flexion.  In  these  cases 
it  is  nearly  always  necessary  to  cut  contracted  tendons  and  fascia.  These 
contractures  tend  to  draw  the  tibia  backward  as  in  a  posterior  dislocation. 
The  patient  lies  upon  his  back  with  his  thighs  flat  upon  the  bed,  the  legs 
hanging  over  the  end  of  the  bed.  The  surgeon  stands  on  the  patient's  right 
side.  Just  above  the  patellar  articular  surface  upon  the  femur  a  transverse 
incision  is  made,  i  inch  in  length  and  reaching  to  the  bone.  The  osteotome 
is  introduced  and  the  bone  is  cut  nearly  through.  The  leg  is  then  forcibly  ex- 
tended. It  must  not  be  extended  too  violently  or  the  popliteal  vessels  may  be 
injured.  In  cases  in  which  the  structures  of  the  popliteal  space  are  tense  and 
have  not  been  divided  the  leg  must  not  be  brought  at  once  into  extension,  but 
this  position  should  be  attained  gradually  by  means  of  weights.  The  wound  is 
dressed  aseptically,  and  the  extremity  is  placed  upon  a  double  inclined  plane 
and  is  treated  as  for  fracture  near  the  knee-joint. 


Osteotomy  for  Talipes  Equinus  691 

Osteotomy  for  vicious  union  of  a  fracture  is  performed  in  case  of  angular 
deformity,  and  is  carried  out  in  the  same  manner  as  are  the  above  procedures. 
It  is  best,  when  possible,  to  enter  the  osteotome  upon  the  concavity  of  the  bent 
bone,  so  that  the  periosteum  will  not  rupture  when  extension  is  made,  and  the 
patient  will  in  consequence  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear  osteotomy  is 
made  through  the  neck  of  the  metatarsal  bone  of  the  great  toe,  the  toe  is 
forcibly  adducted,  and  a  splint  is  applied  to  the  inside  of  the  foot  and  the  toe. 
A  cuneiform  osteotomy  may  be  done  instead  of  a  linear  osteotomy.  The 
osteotomy  is  made  through  the  neck  of  the  metatarsal  bone.  A  wedge-shaped 
piece  of  bone  (the  base  of  which  is  to  the  inner  side  of  the  foot)  is  removed. 
Charles  H.  Mayo  makes  a  flap  of  the  bursal  sac  and  capsular  ligament, 
divides  the  metatarsal  bone  with  a  Gigli  wire  saw,  sutures  the  flap  over 
the  bone  end,  closes  the  skin  incision,  and  fixes  the  toe  in  the  adducted 
position. 

Osteotomy  for  Talipes  Equinovarus  {After  Barker). — The  patient  lies  upon 
his  back,  the  thigh  is  semiflexed,  the  knee  is  bent,  and  the  sole  of  the  foot  rests 
upon  the  table.  The  surgeon  stands  to  the  right  side  if  it  is  the  right  limb 
which  is  to  be  operated  upon,  and  to  the  left  side  if  it  is  the  left  limb.  He 
feels  for  the  outer  surface  of  the  cuboid  bone,  and  cuts  away  from  over  the  latter 
a  piece  of  skin  corresponding  in  size  with  the  bone-wedge  intended  to  be 
removed  (this  piece  of  skin  must  include  the  bursa 
w^hich  forms  in  these  cases).  The  foot  is  then 
turned  outward,  the  astragaloscaphoid  articula- 
tion is  located,  and  over  this  an  incision  is  made 
"from  the  lower  to  the  upper  dorsal  border  of 
the  scaphoid  bone"  (Barker),  reaching  through  Fig.  427.-Davy's  director  (PyZ 
the  skin  only;  the  foot  is  placed  again  in  the  first 

position,  all  the  soft  parts  are  raised  from  off  the  superior  surface  of  the  tarsus, 
and  a  triangular  surface  corresponding  with  the  base  of  the  wedge  to  be  re- 
moved is  cleared;  a  "kite-shaped"  director  (Fig.  427)  is  passed  into  the  external 
wound  and  projected  from  the  internal  wound;  the  saw  is  pushed  through  the 
groove  of  the  director  nearest  the  toes,  and  is  made  to  cut  through  the  tarsus, 
from  the  dorsum  to  the  sole,  at  right  angles  to  the  metatarsal  bones;  the  saw  is 
pushed  through  the  groove  of  the  director  nearest  the  ankle,  and  is  made  to 
cut  from  the  dorsum  to  the  sole,  at  right  angles  to  the  long  axis  of  the  cal- 
caneum;  the  wedge-shaped  piece  of  bone  is  grasped  by  sequestrum  forceps 
and  cut  out  by  scissors,  by  bone-forceps,  or  by  a  blunt  bistoury.  The 
wound  is  well  irrigated,  the  foot  is  straightened,  the  internal  wound  is  sewed 
up,  the  external  wound  is  sutured  except  at  its  lowest  portion,  where  a  drainage- 
tube  is  to  be  retained  for  twenty-four  hours,  and  dressings  are  applied  to  the 
woimd.  The  foot  is  put  up  in  plaster  or  upon  a  Davy  splint.  Some  surgeons 
insert  the  wedge  of  bone  into  the  opening  made  by  a  linear  osteotomy  on  the 
inner  side  of  the  foot. 

Osteotomy  for  Talipes  Equinus. — This  operation  is  described  by  Mr. 
Davy,  who  devised  it,  as  follows:^  "Taking  the  line  of  the  transverse  tarsal 
joint  as  a  guide,  on  the  outer  and  inner  sides  of  the  foot,  and  immediately 
over  the  joint,  two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to  the  amount  of  bone  demanded.  The  soft  structures  are  freed  on  the  dor- 
sum of  the  foot  in  the  way  previously  described ;  but,  as  the  base  of  the  osseous 
wedge  for  equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole,  the  parallel 
wire  director,  instead  of  the  kite-shaped  varus  one,  is  used.  The  saw  is  suc- 
cessively inserted  in  its  grooves,  and  by  keeping  in  mind  the  idea  of  a  keystone 
a  clean  wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole  of  the  foot." 
1  Barker's  "Manual  of  Surgical  Operations." 


692 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  wedge  is  extracted,  and  the  foot  is  straightened  and  is  put  up  in  plaster 
of  Paris  or  is  placed  on  a  Davy  sphnt. 

The  Question  of  Operation  for  Recent  Fractures. — (See  page  533.) 
Operation  for  Recent  Simple  Fracture. — Very  early  after  the  injury  is 
a  fairly  safe  period  for  operation.  Lane  favors  very  early  operation.  During 
the  first  week,  excluding  the  early  hours  after  the  injury,  is  a  dangerous  period 
to  operate  because  the  area  of  injury  has  a  low  resistance  to  infection.  About 
the  tenth  day  is  a  safer  period  for  operation.  Very  careful  sterilization  is 
imperatively  necessary.  Make  a  free  incision  and  expose  the  fracture.  Re- 
move all  tissue  from  between  the  bone  ends.  Konig  disagrees  with  Lane  that 
all  blood-clot  should  be  removed.  Arrest  bleeding.  Bring  the  fragments  into 
apposition  by  extension  and  by  using  Lane's  powerful  forceps  (see  Fig.  283) 
as  a  lever.     Apply  nails,  screws,  or  what  apparatus  we  desire. 

The  Lane  plate  is  an  excellent  device  (see  Fig.  281).  Select  a  suitable 
plate,  remove  the  lever,  fix  the  plate  and  bones  by  Lowman's  clamp  (see  Fig, 
284),  bore  the  bone  by  a  drill  (see  Fig.  282)  at  each  screw  hole,  insert  and 
fix  the  screws,  remove  the  clamp,  and  close  the  wound  without  drainage  or 
with  a  cigarette  drain.     The  part  is  placed  upon  a  splint. 

Figure  325  shows  Lane's  plate  applied.  If  it  does  not  loosen  and  does 
not  give  trouble  a  plate  is  not  removed  surgically. 

Recent  Transverse  Fracture  of  the  Patella. — (See  page  604.) 
Recent  Fracture  of  the  Olecranon  Process  of  the  Ulna. — (See  page  568.) 
Bone=grafting,  or  Transplantation. — (See  pages  503  and  536.) 
Operative  Treatment  of  Ununited  Fracture. — A  method  of  operation 
long  in  vogue  and  still  used  is  as  follows:   Incise  longitudinally  down  to  the 


Fig.  429. — Brainard's  drills  with  Wyeth's  adjustable  handles. 

seat  of  fracture,  retract  the  periosteum  from  the  bone,  drill  the  bones  before 
cutting  them,  chisel  away  the  material  of  imperfect  union,  saw  through  each 
bone  end  far  enough  from  the  seat  of  fracture  to  reach  sound  tissue,  pass 
large  silver  wire  through  the  holes  (this  wire  should  be  y'o  inch  in  diam- 
eter for  the  femur,  yV  inch  for  the  patella,  etc.)  (Fig.  430),  twist  the  wires 
a  fixed  number  of  times  (two  complete  turns)  in  the  direction  that  the  hands 
of  a  watch  move  (this  is  Keen's  direction;  in  case  removal  of  the  wires  should 
be  demanded  later  we  know  how  to  untwist  them;  of  course  the  surgeon  must 
remember  where  he  stood  in  relation  to  the  Kmb  and  regard  the  hypothetical 
watch  as  being  face  up  upon  the  part),  sever  the  ends  of  the  wires,  and  ham- 
mer their  stems  against  the  bones.  The  wires  may  never  require  removal. 
The  soft  parts  are  sutured,  no  drain  or  a  cigarette  drain  is  used,  and  the  limb  is 
encased  in  plaster  of  Paris.  The  objection  to  wire  in  fracture  of  a  long  bone 
is  that  the  wire  acts  as  a  hinge  and,  as  a  consequence,  alignment  is  apt  to  be 
disturbed.     Various  plans  besides  wiring  have  been  employed  in  ununited 


Ununited  Fractures  of  the  Femoral  Neck 


69- 


fracture.  Gussenbauer's  clamp  is  used  by  some.  Clayton  Parkhill's  bone- 
clamp  is  a  useful  appliance,  and  holds  the  fragments  firmly  in  contact.  Some 
surgeons  unite  the  fragments  with  kangaroo-tendon  instead  of  wire  (suturing 
of  bone) ;  others  use  nails  of  bone  or  ivory ;  others  use  screws.  Senn  asserted 
that  the  above  methods  will  not  hold  fragments  in  contact  if  these  fragments 
have  a  tendency  to  become  displaced. 
Senn  fastened  the  bones  together  by 
hollow  cylinders  of  decalcified  bone  or 
ivor}^,  the  cylinders  being  perforated 
in  many  places  (bone-ferrules).  I  re- 
gard the  silver  plate  of  Halsted  and 
steel  plate  of  Lane  as  the  most  satis- 
factory appliances  in  use. 

Ununited  Fractures  of  the  Femoral 
Neck. — Loreta  did  the  first  successful 
operation  for  this  condition  a  number 
of  years  ago.  The  operation  is  not 
adapted  to  the  aged,  but  should  cer- 
tainly be  employed  in  3'ouths  and 
middle-aged  indiAiduals  if  the  general 

condition  of  the  patient  or  some  particular  diseased  state  does  not  forbid, 
and  if  pain  is  severe  and  disability  is  pronounced. 

Leonard  Freeman  ad^^ses  an  anterior  incision  beginning  below  and  ex- 
ternal to  the  anterior  superior  iliac  spine  and  extending  dowoiward,  external  to 
the  sartorius,  for  3  or  4  inches  ("Annals  of  Surg.,"  Oct.,  1904).  When  the 
fragments  are  exposed,  the  connective  tissue  between  them  is  cut  away  by 
means  of  scissors,  the  surfaces  of  the  fragments  are  freshened  by  a  chisel  or 


Fig.  430. — ^\Viring  of  bones  for  ununited  frac- 
ture: a,  a,  SawTi  surfaces  approximated  after  re- 
moval of  old  material  which  was  interposed  be- 
tween the  fragments;  h-b,  b-b,  perforations  drilled 
completelj'  across  the  bone;  c,  c,  ^^ares  ready  for 
t'n'isting. 


Fig.  431. — IMethod  of  securing  screw  of  Freeman's  apparatus  in  fracture  of  neck  of  femur;  the  wooden 
plates  embracing  screws  (Freeman,  in  "Annals  of  Surgerj^"  Oct.,  1904). 

a  ctu-et,  oozing  is  arrested  by  presstu*e  and  hot  water,  and  loose  osseous  splinters 
are  removed  (Freeman).  Some  surgeons  have  fixed  the  fragments  together 
by  nails,  screws,  or  pegs  of  bone  or  ivory,  access  to  the  trochanter  being  best  ob- 
tained for  this  purpose  b}^  making  a  second  incision  over  the  outer  portion 
of  that  bony  process.  As  Freeman  points  out,  however,  the  head  is  often  so 
ver}^  soft  that  none  of  these  appliances  will  secure  fixation. 

Freeman  has  de\dsed  a  clamp  for  this  purpose  (Figs.  431,  432).     An  addi- 
tional incision  is  made  over  the  trochanter  and  holes  are  bored  for  the  clamp 


694 


Diseases  and  Injuries  of  the  Bones  and  Joints 


screws,  one  hole  being  drilled  "through  the  base  of  the  trochanter,  the  exter- 
nal fragment  of  the  neck,  and  into  the  head  of  the  bone"  ("Annals  of  Sur- 
gery," Oct.,  1904).  The  wound  is  closed,  dressings  are  applied,  and  extension 
is  made  on  a  long  side  splint,  a  pad  being  placed  beneath  the  trochanter  to 
prevent  the  disposition  to  pass  backward,  which  movement,  if  it  occurs,  will 


Fig.  432. — Completed  screw  and  clamp  of  Freeman's  apparatus  for  fixation  of  fracture  of  neck  of  femur 
(Freeman,  in  "Annals  of  Surgery,"  Oct.,  igo4). 

cause  external  rotation  of  the  limb  and  separation  of  the  fragments.  In  about 
eight  weeks  the  extension  is  removed  and  the  patient  is  allowed  about  on 
crutches.  Dr.  H.  Augustus  Wilson  has  succeeded  by  simply  nailing  the 
fragments  together  without  attempting  to  freshen  their  faces.     He  got  his 

patient  up  on  crutches  in   two  weeks   ("Amer. 
Jour.  Orthopedic  Surgery,"  Jan.,  1908). 

In  Freeman's  case  the  screws  were  removed 
in  two  weeks  because  of  infection  of  the  cancel- 
lous tissue.  A  similar  condition  arose  in  Davis's 
case,  in  which  two  steel  drills  were  used.  Dr.  H. 
Augustus  Wilson  has  collected  36  cases  of  direct 
fixation  of  old  intracapsular  fractures  (Ibid.). 

Ununited  Fracture  of  Patella. — A  semilunar  in- 
cision is  made  about  the  fragments,  the  convexity 
pointing  up  or  down  (this  avoids  the  prepatellar 
bursa),  or  an  incision  is  made  in  the  long  axis  of 
the  limb,  over  the  middle  of  the  space  between  the 
fragments,  from  well  above  the  upper  fragments  to 
well  below  the  lower  piece.  The  soft  parts  are  re- 
tracted, but  the  periosteum  is  undisturbed;  each 
fragment  is  bored  (Fig.  433,  i)  in  one  or  two  places; 
the  surfaces  of  the  fragments  are  cut  square  through 
sound  bone  with  a  saw;  all  old  reparative  material 
is  cut  away ;  the  wires  are  passed  through  the  per- 
forations, twisted,  cut  off,  and  hammered  down  (Fig.  433,  2).  If  the  bone-frag- 
ments cannot  be  approximated,  it  may  become  necessary  to  incise  the  muscle 
around  and  above  the  patella  or  partially  to  separate  the  tuberosity  of  the  tibia 
and  bend  this  process  upward.  A  small  drain  is  inserted  above  the  bone, 
the  wound  is  sutured,  aseptic  dressings  are  applied,  and  the  limb  is  put  upon 
a  Macewen  splint. 


Fig.  433. — Wiring  of  the  pat- 
ella: I,  Fragments  cut  and  cleaned 
and  the  wires  passed;  2,  wires 
twisted  and  hammered  down  upon 
the  bone  (after  Barker). 


Aspiration  of  Joints 


695 


Treves's  Operation  for  Caries  of  the  Lumbar  and  Last  Dorsal 
Vertebrae,  with  Abscess  in  the  Psoas  Magnus  or  Quadratus  Lum= 
borum  Muscle. — The  patient  lies  upon  his  left  side,  with  the  knees  drawn  up 
and  a  sand-bag  under  the  left  loin.  The  surgeon  stands  behind  the  patient 
(Barker).  An  incision  is  made  at  the  outer  border  of  the  erector  spinae  mass, 
reaching  from  the  last  rib  to  the  iliac  crest  and  going  down  at  once  to  the  lum- 
bar fascia.  The  lumbar  aponeurosis  is  opened,  the  erector  spinse  muscle  is 
retracted  inward,  and  the  anterior  portion  of  the  erector  spinae  sheath  is  in- 
cised. The  quadratus  lumborum  muscle  is  next  cut,  and  then  the  anterior 
leaflet  of  the  lumbar  aponeurosis  is  slit.  The  abscess  is  thus  reached  and 
opened  and  tuberculous  pus  flows  out.  The  abscess-cavity  is  irrigated  with 
quantities  of  warm  corrosive  sublimate  solution  (i  :  5000).  The  cavity  is 
filled,  the  fluid  is  allowed  to  flow  out,  its  exit  being  aided  by  pressure  in 
front  and  changes  of  posture;  the  cavity  is  filled  again,  and  so  on,  and, 
after  all  loose  debris  is  removed,  the  bodies  of  the  vertebrae  are  carefully 
examined  with  the  finger  and  diverticula  are  opened.  Loose  pieces  of  bone 
are  removed  by  spoons  or  forceps,  and  cavities  are  thoroughly  but  lightly 
curetted,  as  in  some  places  the  wall  is  very  thin.     By  means  of  properly 


434. — Aspirator  and  injector. 


shaped  spoons  carious  bone  can  be  removed  even  from  the  anterior  sur- 
face of  the  column  (Treves).  Thus  the  wall  of  the  abscess  is  completely 
removed.  Finally,  all  debris  is  washed  out  by  irrigation  with  mercurial  solu- 
tion; any  mercurial  solution  which  might  remain  is  washed  out  by  warm 
water  or  salt  solution,  and  the  interior  of  the  cavity  is  wiped  dry.  At  this 
stage  most  operators  introduce  iodoform  emulsion.  Whether  or  not  this  is 
done,  "the  wound  is  closed  by  a  series  of  silkworm-gut  sutures,  passed  suffi- 
ciently deep  to  include  the  greater  part  of  the  muscular  and  tendinous  struc- 
tures with  the  skin"  (Treves's  "Operative  Surgery").  Treves's  operation 
gives  a  high  mortality. 

Aspiration  of  Joints. — In  certain  cases  of  joint-effusion  from  inflamma- 
tion, tuberculous  or  otherwise,  and  sometimes  in  hemorrhage  into  a  joint,  it  is 
desirable  to  remove  the  fluid  by  aspiration.  The  pneimiatic  aspirator  (Fig. 
434)  is  used.  The  trocar  and  cannula  are  thoroughly  asepticized  and  the  joint 
is  prepared  as  for  a  set  operation.  The  needle  is  entered  at  a  surface  free  from 
vessels.  The  directions  for  using  an  aspirator  are  as  follows:  insert  the  stopper 
firmly  into  a  strong  bottle  (preferably  a  clear  glass  one),  then  attach  the  short 
elastic  hose  to  the  stopcock  B  of  the  tube  projecting  from  the  stopper,  and  at- 
tach the  other  end  of  the  same  elastic  hose  to  the  exhausting  or  inward-flowing 
chamber  of  the  pump.    Next,  attach  one  end  of  the  longer  elastic  hose  to  the 


696  Diseases  and  Injuries  of  the  Bones  and  Joints 

stopcock  A  projecting  from  the  stopper  and  the  other  end  to  the  needle. 
Care  should  be  taken  that  all  the  fittings  or  attachments  are  placed  firmly 
into  their  respective  places.  Now  close  the  stopcock  A  and  open  the  stopcock 
B.  By  giving  from  thirty-five  to  fifty  strokes  of  the  pump  a  sufficient  vacuum 
can  be  produced  to  fill  with  the  fluid  from  the  joint  a  bottle  holding  from  a  pint 
to  a  quart.  After  having  formed  the  vacuum,  close  the  stopcock  B,  and  insert 
the  needle  in  the  joint.  When  the  stopcock  A  is  opened,  suction  through  the 
needle  draws  the  fluid  from  the  joint.  The  trocar  may  also  be  used  to  inject 
antiseptic  agents.  After  the  completion  of  aspiration  the  part  is  dressed  anti- 
septically  and  the  extremity  is  put  at  rest  upon  a  splint. 

Excisions  of  Bones  and  Joints. — The  ancients  practised  excision  and 
resection  for  compound  dislocations  and  fractures.  For  centuries  surgeons 
removed  pieces  of  diseased  bone  from  joints.  The  operation  was  set  forth  as 
a  definite  procedure,  and  was  first  formally  advised  as  a  substitute  for  ampu- 
tation in  joint  disease  by  Mr.  Park,  of  Liverpool,  in  1781.  In  1782  the  elder 
Moreau,  of  Bar-sur-Ornain,  independently  devised  a  like  operation.  The 
terms  "excision"  and  "resection"  are  usually  employed  as  synonymous,  but 
such  a  use  is. not  strictly  accurate.  According  to  Professor  Ashhurst,  the 
term  excision  means  "the  removal  of  an  offending  part  without  that  total 
ablation  of  the  affected  portion  of  the  body  which  is  implied  by  the  term 
'amputation.'  Hence  we  speak  of  excisions  of  tumors,  of  joints,  of  the  eye- 
ball, etc."  Resection  has  a  more  restricted  meaning;  it  signifies  "an  opera- 
tion which  takes  away  a  middle  portion  and  brings  the  ends  together  again, 
and  is  thus  in  strict  surgical  language  limited  to  partial  excisions  of  the  long 
bones"  ("International  Encyclop.  of  Surgery,"  edited  by  John  Ashhurst,  Jr.). 
Excision  of  a  joint  is  the  removal  of  the  articular  portions  of  the  bones  of  the 
joint,  and  also  the  cartilage  and  synovial  membrane.  In  the  hip-joint  and 
shoulder-joint  only  the  head  of  the  long  bone  may  be  removed,  and  not  the 
articular  surfaces  of  both  bones.  In  partial  excision  of  a  long  bone,  excision 
(resection)  for  bone  disease,  enough  bone  is  known  to  have  been  removed  only 
when  the  remaining  bone  bleeds.  Complete  excision  of  a  bone  is  the  removal 
of  an  entire  bone.  Partial  excision  or  resection  is  the  removal  of  a  portion  only 
of  a  bone.  Excision  is  a  conservative  operation  which  often  averts  amputa- 
tion. 

Excision  may  be  performed  by  the  open  method,  in  which  the  periosteum 
is  not  preserved,  or  it  may  be  performed  by  the  subperiosteal  method,  in  which 
the  periosteum  is  carefully  separated  by  a  rugine  and  the  capsular  ligament  is 
preserved.  This  method  was  devised  by  Oilier,  of  Lyons.  Arthrectomy,  or 
erasion,  is  the  excision  of  the  diseased  synovial  membrane  and  ligament,  and 
also  small  foci  of  disease  of  bone  and  cartflage. 

Excision  may  be  employed  for  compound  dislocation,  and  in  compound 
dislocations  of  the  elbow  and  the  shoulder  it  is  usually  performed.  Exci- 
sions for  compound  dislocations  in  other  large  joints  are  very  dangerous; 
they  are  rarely  attempted  in  battlefield  practice,  and  are  to  be  avoided  even 
in  civil  practice  unless  the  patient  is  young  and  vigorous  and  every  advantage 
can  be  given  him  during  the  operation  and  convalescence.  Excision  for  de- 
formity is  rarely  performed  except  upon  the  hip,  the  knee,  and  the  shoulder, 
and  these  excisions  must  not  be  employed  if  the  patient's  condition  leads  one 
to  fear  the  result  of  a  protracted  convalescence.  Excision  of  the  elbow,  how- 
ever, is  usually  a  safe  operation.  In  excising  for  deformity  always  consider 
the  patient's  trade  and  the  demands  of  habitual  position  which  it  makes  upon 
him.^ 

Excision  is  largely  employed  for  joint-disease,  especially  for  tuberciflous 
joints.  Bell  states  that  attempts  to  preserve  the  limb  without  excision  are 
1  Joseph  Bell,  in  his  "Manual  of  Surgical  Operations." 


Excision  of  the  Shoulder-joint  697 

more  justifiable  in  the  lower  than  in  the  upper  limbs,  because  operation  in 
the  lower  extremity  is  more  dangerous  than  in  the  upper,  and  because  a  cure 
without  operation  in  the  lower  limbs,  if  this  cure  can  be  brought  about,  gives 
as  good  a  result  as  a  cure  by  excision.  In  the  upper  extremity  the  danger 
from  operation  is  less  than  is  the  danger  from  waiting.  In  a  young  sul^ject 
an  excision  may  remove  the  epiphysis,  and  thus  lead  to  permanent  shorten- 
ing, which  is  productive  of  less  inconvenience  and  deformity  in  the  arm  than 
in  the  leg.  A  danger  of  excision  operations  is  that  the  section  may  be  made 
through  cancellous  bony  tissue;  hence,  if  infection  takes  place,  disastrous 
suppuration,  phlebitis,  myelitis,  septicemia,  or  pyemia  will  follow;  further, 
in  excision  the  cut  is  often  made  through  diseased  tissue,  and  a  protracted 
convalescence  is  then  inevitable.  Amputation  is  effected  through  |healthy 
tissue,  and  the  convalescence  is  short.  Excision,  however,  when  successful, 
gives  the  patient  a  very  useful  limb. 

Erasion,  or  Arthrectomy. — This  operation  was  suggested  by  Cross,  of  Bris- 
tol, and  was  perfected  and  established  by  Wright,  of  Manchester,  between 
1 88 1  and  1888.  Erasion  is  the  complete  removal  of  diseased  synovial  mem- 
brane, ligaments,  and  small  foci  of  disease  in  bone  and  cartilage.  This  opera- 
tion seeks  to  remove  a  depot  of  infection  in  an  early  stage  of  tuberculous 
synovitis,  and  it  possesses  the  conspicuous  merit  of  not  interfering  with  the 
epiphysis.  The  term  "erasion"  is  also  used  by  some  to  designate  the  opera- 
tion of  removing  healthy  synovial  membrane,  ligaments,  etc.,  for  the  purpose 
of  producing  fixation  of  a  flail-joint  due  to  infantile  paralysis,  but  in  such  cases 
arthrodesis  is  the  proper  term  for  the  operation.  Erasion  is  oftenest  practised 
upon  the  knee-joint. 

Erasion  of  the  Knee-joint. — The  patient  lies  upon  his  back;  the  leg  is 
flexed,  with  the  sole  of  the  foot  planted  upon  the  table,  and  an  Esmarch  band- 
age is  applied  at  a  point  well  up  on  the  thigh.  The  surgeon  stands  to  the 
right  of  the  patient.  The  incision  is  begun  in  the  midline  of  the  thigh  (on 
the  side  opposite  to  that  occupied  by  the  surgeon),  about  3  inches  above  the 
patella;  it  is  carried  down  across  the  ligament  of  the  patella  and  up  to  a  corre- 
sponding point  on  the  opposite  side  of  the  thigh.  This  incision  goes  down 
to  the  bone;  the  flap  is  turned  up  and  the  joint  exposed;  the  knee-joint  is 
strongly  flexed,  and  the  synovial  membrane  and  diseased  ligaments  are  dis- 
sected away  with  scissors  and  forceps,  great  care  being  taken  that  the  posterior 
ligaments  (which,  fortunately,  are  rarely  implicated  early  in  the  case)  are  not 
divided  and  that  the  contents  of  the  popliteal  space  remain  intact.  After  re- 
moving the  diseased  ligaments  and  synovial  membrane  the  cartilage  is  examined 
and  any  diseased  portion  is  removed.  The  bone  is  then  examined  and  any 
tuberculous  foci  are  gouged  away.  Exposed  vessels  are  ligated.  The  wound  is 
irrigated  by  salt  solution,  the  extremity  is  straightened,  and  the  ends  of  the 
ligamentum  patellae  are  sutured,  a  drainage-tube  is  inserted  at  each  angle  of  the 
wound,  the  skin  is  sutured,  and  antiseptic  or  sterile  dressings  are  applied.  The 
limb  is  placed  upon  a  posterior  sphnt  for  a  few  days,  then  the  drainage-tubes 
are  removed,  the  dressings  are  changed,  and  a  plaster-of-Paris  cast  is  applied, 
trap-doors  being  cut  on  each  side,  and  the  joint  is  kept  immobile  for  two  or  three 
weeks.  This  operation  is  only  suited  to  early  cases  in  which  the  lesion  involves 
chiefly  or  purely  the  synovial  membrane  and  ligaments,  and  in  these  cases  it 
frequently  gives  a  good  result,  some  capacity  for  motion  being  not  unusually 
preserved. 

Excision  of  the  Shoulder-joint.— Bent,  of  New  Castle,  performed  the  oper- 
ation in  1771  ("Manual  of  Operative  Surgery,"  by  Sir  Frederick  Treves). 
Syme  really  established  the  operation  in  surgical  confidence.  In  the  shoulder- 
joint  partial  excision  is  often  performed,  the  head  of  the  humerus  being  re- 
moved and  the  glenoid  being  undisturbed;  but  some  patients  require  complete 


698  Diseases  and  Injuries  of  the  Bones  and  Joints 

excision,  the  entire  glenoid  depression,  as  well  as  the  head  of  the  humerus, 
being  removed  by  the  surgeon.  Excision  of  the  shoulder-joint  is  made,  if  pos- 
sible, an  intracapsular  operation,  the  capsule  being  opened,  but  the  capsular 
attachment  to  the  anatomical  neck  of  the  humerus  not  being  interfered  with. 
In  advanced  cases,  however,  the  capsular  attachment  must  be  destroyed. 
Excision  of  the  shoulder-joint  for  trauma  is  a  far  less  common  operation  in 
civil,  than  in  militar}',  practice.  It  is  performed  for  gunshot- wounds,  compound 
dislocations,  tuberculous  disease,  and  tumors  of  the  head  and  upper  portion  of 
the  humerus. 

Operation  by  Anterior  Incision. — The  patient  lies  supine;  a  pillow  is  placed 
beneath  the  shoulders,  and  a  sand-pillow  is  put  beneath  the  shoulder  to  be 
operated  upon.  The  arm  is  held  to  the  side  with  the  outer  condyle  forward 
and  the  bicipital  groove  inward  (Barker's  directions).  The  surgeon  stands 
by  the  affected  side.  An  incision  3  or  4  inches  in  length  is  made  from  just 
external  to  the  coracoid  process  of  the  scapula,  running  straight  down  the  hu- 
merus (Fig.  435,  a).  This  incision  divides  the  border  of  the  deltoid  muscle 
and  brings  into  sight  the  long  head  of  the  biceps.  The  tendon  of  the  biceps 
is  retracted  inward,  vmless  it  is  diseased,  in  which  case  it  is  resected.  The 
knife  is  carried  up  the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant  rotates  the  elbow 
to  make  the  muscles  tense.  In  some  places,  if  the  periosteum  tears,  muscular 
insertions  must  be  cut  with  a  knife.  The  head  of  the  bone  is  sawn  off  while 
the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back,  and  the  head  of  the 
bone  is  forced  out  of  the  wound,  and  is  then  sawn  off  at  the  point  required.  In 
ordinary  cases  only  the  articular  head  is  removed;  in  other  cases  the  section  is 
made  just  above  the  surgical  neck;  in  yet  others  a  portion  of  the  shaft  must  also 
be  cut  away.  If  the  glenoid  cavity  is  found  slightly  diseased,  the  dead  bone 
must  be  removed  by  the  chisel  and  mallet  or  by  the  cutting  forceps.  If  the 
cavity  is  seriously  diseased,  the  entire  glenoid  should  be  removed.  Scrape 
away  all  damaged  tissue;  ligate  bleeding  points;  irrigate  the  woimd  with  cor- 
rosive sublimate  solution;  swab  it  out  with  a  solution  of  chlorid  of  zinc  (20  gr, 
to  I  oz.);  dust  with  iodoform;  close  the  upper  portion  of  the  wound  and  insert 
a  drainage-tube  in  the  lower  angle;  dress  the  wound  antiseptically ;  place  a  small 
pad  in  the  axilla;  apply  the  second  roller  of  Desault;  and  put  the  patient  in  bed 
with  a  pillow  under  the  affected  shoulder.  In  seven  days  the  hand-sling  is  sub- 
stituted for  the  bandage,  and  with  the  elbow  hanging  free  the  patient  is  per- 
mitted to  get  up  and  is  advised  to  move  his  arm  frequently.  Drainage  is  main- 
tained until  the  wound  is  well  healed  from  the  bottom.  Great  limitation  of 
movement  inevitably  follows  a  shoulder-joint  resection. 

Excision  by  the  deltoid  flap  is  performed  when  the  head  of  the  bone  is  much 
enlarged  (as  by  a  tumor)  or  when  the  tissues  are  thick  and  indurated.  The 
deltoid  flap  is  in  the  shape  of  a  U  or  is  semilunar  (Fig.  436,  a).  Raising  this 
flap  exposes  the  head  of  the  bone  most  satisfactorily.  Bell  states  that  when  the 
glenoid  cavity  is  chiefly  involved  the  incision  should  be  posterior  (Fig.  436,  b). 

Senn's  Method.— Senn^  described  an  incision  which  does  not  damage  im- 
portant vessels,  muscles,  tendons,  or  nerves,  and  which  is  followed  by  good 
functional  results.  A  semilunar  skin-flap  is  formed,  the  incision  running  from 
the  coracoid  process  to  the  posterior  border  of  the  axillary  space.  The  flap  is 
turned  up,  exposing  the  upper  half  of  the  deltoid  muscle.  The  acromion  is 
sawn  off  and  turned  down  with  the  attached  deltoid.  The  capsule  is  now 
freely  exposed;  it  is  opened,  and  either  arthrectomy  or  excision  is  performed, 
accordmg  to  conditions.  In  closing  the  wound  it  is  not  necessary  to  bore  the 
acromion  and  pass  silver  wires  to  join  the  fragments;  it  is  enough  to  suture  the 
periosteum  with  catgut. 

1  "Phila.  Med.  Jour.,"  Jan.  i,  1898. 


Excision  of  the  Elbow-joint 


699 


Excision  of  the  Elbow-joint. — This  operation  was  suggested  by  Park  in 
1782,  but  the  first  employment  of  it  was  by  Moreau  in  1794.  It  is  performed 
for  wounds,  faulty  ankylosis,  and  chronic  articular  disease.  Excision  must  be 
complete.  Endeavor  to  make  a  subperiosteal  resection;  this  maintains  the 
shape  of  the  articulation  and  gives  the  best  chance  for  a  movable  joint.  The 
patient  is  "supine,  but  inclining  to  the  sound  side,  the  affected  arm  being  held 
almost  vertical,  with  the  forearm  flexed  and  nearly  horizontal"  (Barker). 
The  incision  is  made  on  the  posterior  surface  of  the  joint.  A  single  poste- 
rior incision  is  usually  employed  (Fig.  436,0).  An  incision  is  made  a  little 
internal  to  the  long  axis  of  the  olecranon,  beginning  2  inches  above  and  ter- 
minating 2  inches  below  the  tip  of  the  olecranon.  This  incision  goes  down 
to  the  bone,  and  throughout  the  entire  operation  the  surgeon  must  guard 


Fig.  435.  Fig.  436. 

Fig.  435. — i-g,  Amputations  (Joseph  Bell) :  i,  i,  of  arm  by  double  flaps;  2,  at  shoulder-joint;  3,  at 
ankle-joint  by  internal  flap  (Mackenzie's);  4,  s,  of  leg  just  above  the  ankle-joint  (Syme's);  6,  7,  below 
the  knee  (modified  circular);  8,  through  condyles  of  femiu:  (Syme's);  9,  at  lower  third  of  thigh  (Syme's). 
A,  excision  of  head  of  humerus;  b,  of  knee-joint  (semilunar  incision). 

Fig.  436. — 1-8,  Amputations  (Joseph  Bell):  i,  at  elbow-joint  (posterior  flap);  2,  at  shoulder-joint, 
posterior  incision  (first  method);  3,  at  ankle-joint  (Mackenzie's);  4,  through  condyles  of  femur  (Syme's); 
5,  at  lower  third  of  thigh  (Syme's);  6,  at  knee  (posterior  incision);  7,  of  thigh  (Spence's);  8,  athip- 
joint.  A-G,  Excisions:  a,  excision  of  shoulder-joint  (deltoid  flap) ;  b,  of  shoulder-joint  (posterior  incision) ; 
c,  of  elbow-joint  (H -shaped  incision);  D,  of  elbow-joint  (hnear  incision);  e,  of  hip-joint  (Gross's);  F,  of 
OS  calcis;  G,  of  scapula. 

and  shield  the  ulnar  nerve.  The  periosteum  and  soft  parts  are  well  separated; 
the  olecranon  is  sawn  off;  forced  flexion  exposes  the  joint-cavity  freely,  and 
enables  the  surgeon  to  lift  the  periosteum  and  soft  parts  from  the  humerus;  the 
humerus  is  sawn  through  at  the  beginning  of  its  condyloid  processes;  the  radius 
and  ulna  are  cleared  and  are  sawn  at  a  level  below  that  of  the  base  of  the  coro- 
noid  process  of  the  ulna.  Diseased  tissues  are  cut  and  scraped  away;  the  wound 
is  irrigated,  sutured,  drained,  and  dressed.  In  some  cases  an  H -shaped  incision 
is  employed  (Fig.  436,  c),  but  the  cicatrix  of  a  transverse  cut  will  limit  flexion 
of  the  limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and  the  arm  is  laid 
upon  a  pillow,  the  elbow  being  placed  midway  between  a  right  angle  and 
complete  extension,  the  forearm  being  placed  midway  between  pronation 


700 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  supination.  No  splint  is  used,  as  a  rule.  Esmarch  used  the  splint 
shown  in  Fig.  437.  The  aim  in  treatment  is  to  obtain  a  freely  movable  joint. 
Passive  motion  is  begun  in  one  week,  at  which  time  the  patient  gets  up.  The 
hand  is  carried  in  a  sling  for  a  time  after  heaUng  of  the  wound  is  complete. 

Excision  of  the  Head  of  the  Radius.— This  operation  is  practised  for  irre- 
ducible dislocation  of  the  radius.  An  incision  is  made  through  the  supinator 
longus  muscle  down  to  the  head  of  the  radius,  and  the  neck  of  the  bone  is 
divided  by  means  of  a  Gigli  saw  or  bone-cutting  forceps.  The  musculospiral 
nerve  lies  to  the  inner  side.  Some  bone  is  always  taken  from  the  external 
condyle  in  order  to  make  a  sufficient  gap  to  prevent  subsequent  ankylosis 
("The  Operations  of  Surgery,"  by  Jacobson  and  Rowlands). 

Excision  of  the  Wrist-joint. — This  operation  was  first  performed  by  Moreau 
in  1794.  Bell  states  that,  whatever  method  of  excision  is  chosen,  three  car- 
dinal rules  must  be  borne  in  mind:  (i)  remove  all  the  diseased  bone,  in- 
cluding the  portions  of  the  radius,  ulna,  carpus,  and  metacarpus  which  are 
covered  with  cartilage;  (2)  interfere  with  the  tendons  to  the  least  possible 
degree,  and  (3)  begin  passive  motion  of  the  fingers  very  early.  Many  sur- 
geons prefer  the  simple  gouging  away  of  diseased  foci  and  the  scraping  of 
sinuses  instead  of  a  formal  resection  of  the  wrist,  amputation  being  employed 
in  severe  cases  or  when  scraping  fails  after  several  trials.  Formal  excision  is  not 
frequently  performed,  and  the  results  cannot  be  regarded  as  very  favorable. 


Fig.  437. — Esmarch's  splint  for  the  treatment  of  a  limb  after  excision  of  the  elbow-joint. 

Lister's  Open  Method  of  Excision. — Break  up  adhesions  as  completely  as 
possible  by  forcible  movements.  Apply  a  tourniquet  or  an  Esmarch  appa- 
ratus. The  patient  lies  upon  his  back,  the  arm  and  the  forearm  being 
brought,  from  stage  to  stage,  into  the  most  desirable  positions.  Begin  an 
incision  over  the  middle  of  the  dorsum  of  the  radius,  on  a  level  with  the 
styloid  process;  carry  it  downward  in  the  direction  of  the  inner  edge  of 
the  articulation  of  the  thumb  with  its  metacarpal  bone,  and  when  the 
knife  reaches  the  radial  side  of  the  second  metacarpal  bone  alter  the  direc- 
tion of  the  incision  and  carry  it  downward  in  the  long  axis  of  the  meta- 
carpal bone  to  about  its  middle  (Fig.  438,  a).  This  is  known  as  the  radial 
incision,  and  the  only  tendon  divided  is  that  of  the  extensor  carpi  radialis 
brevior  muscle.  The  tissues  upon  the  radial  aspect  of  the  incision  are  dis- 
sected up,  the  tendon  of  the  extensor  carpi  radialis  longior  muscle  is  divided 
at  its  point  of  insertion  (Bell),  and  all  the  soft  structures  are  retracted  out- 
ward, exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the  carpus, 
but  which  is  left  in  place,  as  its  removal  at  this  stage  endangers  the  radial 
artery  (Barker).  By  extending  the  hand  the  tendons  are  loosened  and  the 
carpus  is  cleared  in  the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface  of  the  wrist, 
2  inches  above  the  articular  surface  of  the  ulna,  and  midway  between  the 
ulna  and  the  flexor  carpi  ulnaris  tendon.     This  incision,  which  is  known. 


Excision  of  the  Wrist-joint 


701 


as  the  ulnar  incision,  is  carried  down  until  it  is  opposite  the  middle  of  the 
fifth  metacarpal  bone  in  the  palm  (Fig.  438,  b).  'The  dorsal  hp  of  this 
incision  is  raised"  (Bell),  and  the  extensor  carpi  ulnaris  tendon  is  divided 
and  dissected  from  its  depression,  but  is  not  separated  from  the  mtegument 
The  extensor  tendons  are  lifted;  the  ligaments  upon  the  dorsum  and  sides  of 
the  wrist-ioint  are  cut;  the  flexor  tendons  are  raised  from  the  carpal  bones; 
the  pisiform  bone  is  cut  from  the  carpus,  but  is  not  yet  removed;  and  the 
unciform  process  of  the  unciform  bone  is  cut  with  forceps  The  anterior 
radiocarpal  ligament  is  divided,  the  carpometacarpal  articulations  are  cut 
through,  and  the  carpus  is  pulled  out  with  bone-forceps  The  ends  of  the 
radius  and  ulna  are  forced  out  of  the  ulnar  mcision.  All  that  portion  of  the 
ulna  which  is  crusted  with  cartilage  is  to  be  removed,  the  saw-cut  is  to  be 
oblique,  and  the  base  of  the  styloid  process  is 
to  be  left  behind.  A  thin  section  is  to  be  sawn 
from  the  radius,  and  the  tendon-grooves  are 
not  to  be  impinged  upon.  The  articular  sur- 
face of  the  ulna  is  cut  away  by  pliers  (Bell). 


Fig.  438.  --o-^...  _ 

17-         R      T   tR   Amputations  (Joseph  Bell):  i,  amputation  at  wrist-joint  (dorsal  incision);  2,  at 

Fig.  438.— i-i8,_  AMPUTATIONS  yosepa    .  ,^     ,' j     j^j     )    4,  at  forearm  (palmar  incision);  5,  at 

wrist-  oint  (palmar  incision);  3,  at  ^o^^™,    "f °^^^'  thmi  der  ioint  (first  method);  8,  g,  of  metatarsus 

elbow-joint  (anterior  flap);  6,  at  arm  (Teale   )    7   ^^  J°?Wer  jom^  (far     me       ^^      ^^^  (Garden's); 

?T;iLS(K'B\VstxS^^^^^^ 

cision  of  wrist  (radial  incision) ;  b,  of  wrist  (uhiar  incision) . 

Fig.  43..-X-XO,  AMPUTATIONS  (Joseph  Bdl)  ;.  oHo--^^^^^^^^^^  SS;  lia?  ftm  dd- 

g,  10,  of  thigh  (Teale's).     a,  excision  of  hip;  b,  b,  of  ankle-]oint  (Hancock  s  incision;. 

If  foci  of  disease  are  discovered  beyond  these  P^t^'f^^^. ^^^/^^^^^ 
The  ends  of  the  metacarpal  bones  are  sawn  off,  and  their  articular  facets  are 
rut  awav  bv  means  of  pliers.  The  trapezium  is  dissected  out  the  end  of  the 
fir  t  rLa^rpTbone  i^sawn  off  and  its  facet  is  cut  away  with  pliers,  and  a 
portion  of  thT  pisiform  bone  is  removed  (the  entire  bone  bemg  removed  if  it  be 
diseased)  The  wound  is  irrigated,  vessels  are  tied,  the  _  radial  mcision  is 
d  Lt  tlie  ulnar  incision  is  partly  closed,  a  drainage-tube  - --f^^^by  ^^^^ 
the  uliar  incision,  the  wounds  are  dressed  antiseptical ly,  and  the  Esmarch  ap 
mratusL  taken  off.  The  forearm  and  hand  are  placed  upon  a  splint  which  un- 
mobmzes  tW^^  and  leaves  the  fingers  semiflexed.  Passive  motion  of  the 
&.ge  s  is  begun  after  thirty-six  hours.      The  splint  is  worn  for  many  months 


702 


Diseases  and  Injuries  of  the  Bones  and  Joints 


until  the  wrist-joint  is  immobile  and  solid.     Esmarch  uses  the  splint  shown  in 
Fig.  440.^ 

Excision  of  Metacarpal  Bones  and  of  Phalanges. — Excision  of  a  meta- 
carpal bone,  except  in  cases  of  necrosis  with  the  formation  of  large  quantities 
of  new  bone,  usually  leaves  a  useless  finger;  hence  amputation  is  usually 
preferred  to  excision.     This  rule  does  not  apply  to  the  metacarpal  bone  of 


Fig.  440. — Esmarch's  interrupted  splint  applied. 

the  thumb,  which  is  occasionally  excised.  The  incision  for  this  operation 
is  made  upon  the  dorsum,  and  is  straight.  Excision  of  the  proximal  phalanx 
of  the  thumb  is  sometimes  performed.  Excision  for  disease  is  rarely  per- 
formed upon  the  finger-joints,  amputation  being  preferred,  though  the  opera- 
tion is  sometimes  undertaken  for  compound  dislocation.  In  the  metacarpo- 
phalangeal joint  of  the  thumb  excision,  if  it  can  be  performed,  is  preferred  to 

amputation.     The  incision  for  resection  of  this 
joint  is  placed  upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — Treves  and  Jona- 
than Hutchinson,  Jr.  ("Manual  of  Operative 
Surgery"),  tell  us  that  the  operation  was  first 
performed  by  Anthony  White,  of  the  Westminster 
Hospital,  in  1 81 8.  Sir  William  Fergusson  estab- 
lished the  operation  in  surgical  confidence.  Some 
surgeons  advocate  this  operation;  others,  notably 
Marsh,  are  emphatically  opposed  to  it.  Excision 
should  be  performed  in  the  early  stage  of  tuber- 
culous disease  if  less  radical  treatment  has  failed. 
In  this  stage  the  usual  position  of  the  limb  is 
one  of  flexion,  abduction,  and  eversion.  In  cases 
of  long  duration,  especially  where  dislocation  ex- 
ists, excision  is  an  easy  and  a  comparatively  safe 
operation ;  in  recent  cases  it  is  difficult  and  carries 
with  it  decided  dangers,  but  the  peril  of  delay 
may  be  greater  than  the  peril  of  an  early  excision. 
In  cases  of  hip  disease  with  involvement  of  the 
acetabulum  the  mortality  is  50  per  cent.,  whether 
operation  is  or  is  not  attempted.  Excision  is 
performed  especially  for  tuberculous  disease  and 
for  gunshot-injuries. 
Operation  hy  Anterior  Incision  (Fig.  441)  {Barker's  Operation). — In  this 
operation  the  patient  is  supine,  with  the  thighs  extended  as  thoroughly  as 
circumstances  permit.  The  surgeon  stands  to  the  right  of  the  patient.  An 
incision  is  begun  ^  inch  below  and  |  inch  external  to  the  anterior  superior  iliac 
spine,  and  it  is  carried  downward  and  a  little  inward  for  about  3  inches  (Fig. 
441,  d).  If  dislocation  exists,  the  incision  need  not  be  so  long.  This  incision 
is  carried  at  once  deeply  between  the  muscles,  and  the  capsule  of  the  joint  is 


Fig.  441. — Excision  of  the  hip- 
joint:  A,  Gluteus  muscle;  b,  tensor 
vaginae  femoris  muscle;  c,  sar- 
torius  muscle;  D,  anterior  incision. 


Excision  of  the  Knee-joint  703 

opened.  The  neck  of  the  bone  is  divided  from  its  upper  surface  downward  by 
a  saw  or  an  osteotome,  and  without  dislocating  the  bone  through  the  wound  by 
forcible  extension  and  eversion.  The  head  of  the  bone  is  removed.  All  tuber- 
culous foci  must  be  scraped  away,  and  the  flushing  gouge  is  used  upon  tubercu- 
lous areas  of  the  acetabulum.  All  sinuses  should  be  thoroughly  scraped. 
Bleeding  is  arrested,  the  wound  is  irrigated  with  normal  salt  solution,  mopped 
with  chlorid  of  zinc  solution,  and  dusted  with  iodoform.  A  drainage-tube 
is  inserted  at  the  lower  angle  of  the  incision,  and  the  upper  portion  of  the  cut 
is  closed.  The  wound  is  dressed  antiseptically.  Extension  is  made  by  the 
extension  apparatus  until  healing  has  obtained  good  headway,  when  a  double 
Thomas  splint  is  applied,  so  that  the  patient  may  be  taken  out  daily  in  the  air 
and  sunlight.  As  a  rule,  rigid  ankylosis  results  from  resection  of  the  hip,  but 
occasionally  a  joint  results  with  a  small  range  of  movement. 

Operation  by  Lateral  Incision  {Langenbeck' s  Operation). — In  this  operation 
a  straight  incision  2  inches  in  length  is  made  in  the  direction  of  the  axis  of  the 
femur,  and  passing  downward  from  the  apex  of  the  great  trochanter.  From  the 
beginning  of  this  incision  a  curved  incision  is  carried  toward  the  head  of  the 
bone,  the  convexity  of  the  curve  being  backward  (see  Fig.  439,  a).  Bell  advises 
the  use  of  the  saw  after  bringing  the  head  of  the  bone  into  the  wound  by  ab- 
duction and  eversion  of  the  thigh.  Barker  applies  the  saw  with  the  bone  in 
situ,  and  strongly  opposes  wrenching  the  bone  out  of  the  incision  because  of 
the  danger  of  peeling  off  the  periosteum,  which  peeling,  if  it  takes  place,  favors 
necrosis. 

Incision  of  Gross. — In  Gross's  operation  a  semilunar  flap  is  made  with  the 
convexity  backward  (see  Fig.  436,  e). 

Excision  of  the  Knee-joint. — The  complete  operation  was  first  performed 
by  Park,  of  Liverpool,  in  1781.  In  this  operation  a  complete  excision  should 
be  performed,  and  the  patella  ought  to  be  removed.  The  operation  is  per- 
formed for  tuberculous  disease,  some  compound  fractures  and  compound 
dislocations,  and  some  cases  of  angular  ankylosis.  It  is  rarely  employed  for 
gunshot-injuries. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies  upon  his  back, 
and  the  joint,  if  not  ankylosed  in  extension,  should  be  semiflexed.  The 
surgeon  stands  to  the  right  side.  An  incision  is  made  which  at  once  opens 
the  joint.  The  incision  begins  at  one  condyle  and  reaches  the  other  con- 
dyle by  a  curve  which  passes  through  the  ligamentum  patellje  midway  between 
the  tuberosity  of  the  tibia  and  the  inferior  margin  of  the  patella  (see  Fig.  435,  b). 
The  flap  is  dissected  up,  the  knee  is  thrown  into  forced  flexion,  the  lateral 
ligaments  and  crucial  ligaments  are  cut,  and  the  end  of  the  femur  is  well  cleared. 
The  blade  of  Butcher's  saw  is  passed  beneath  the  bone,  which  is  sawn  from  below 
upward  (Ashhurst).  The  end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off. 
If,  after  sawing,  diseased  foci  are  discovered,  another  section  can  be  sawn  off  or 
the  foci  can  be  gouged  away.  Ashhurst,  who  had  a  vast  experience  with  this 
operation,  insisted  that  in  sawing  through  the  femur  the  natural  obliquity  of 
the  bone  must  be  borne  in  mind  and  the  section  must  be  made  in  "a  line 
parallel  to  that  of  the  free  surface  of  the  condyles."  If  the  section  is  made 
transverse  to  the  axis  of  the  femur,  "the  limb,  after  adjustment,  wiU  be  found 
to  be  markedly  bowed  outward."  The  same  surgeon  said  that  the  epiphyseal 
line  is  somewhat  higher  on  the  front  than  it  is  on  the  back  of  the  femur,  and  in 
consequence  the  following  rule  is  formulated  for  section  of  the  condyles:  the 
section  of  the  condyles  should  be  "in  a  plane  which,  as  regards  the  axis  of  the 
femur,  is  oblique  from  behind  forward,  from  below  upward,  and  from  within 
outward."  Ashhurst  advocated  section  of  the  tibia  "in  a  plane  transverse  to 
the  long  axis  of  the  bone,  with  a  slight  anteroposterior  obliquity,  so  as  to  corre- 
spond with  that  of  the  section  of  the  condyles,"  and  he  further  says  that  the 


704  Diseases  and  Injuries  of  the  Bones  and  Joints 

patella  must  be  removed  whether  it  is  diseased  or  not,  and  quotes  Peniere's 
observations  to  the  effect  that  excision  of  the  patella  diminishes  the  risk  of 
death  one-third,  and  its  retention  doubles  the  probability  of  an  amputation 
becoming  necessary  in  the  future. 

After  removing  the  patella  the  diseased  synovial  membrane  is  clipped  away 
with  scissors  and  all  sinuses  and  diseased  territories  are  well  curetted.  The 
posterior  ligament  of  the  joint  is  not  removed  unless  it  is  diseased;  its  retention 
prevents  displacement  and  guards  the  popliteal  space.  In  some  cases  tenotomy 
is  required  to  permit  extension.  In  children  the  fragments  should  be  wired 
together;  in  adults  this  need  not  be  done.  After  hemostasis,  irrigate  by 
salt  solution,  insert  a  drainage-tube,  suture,  dress  antiseptically,  and  adjust 
the  limb  upon  Price's  splint  or  Ashhurst's  bracketed  wire  spHnt.  Instead 
of  the  bracketed  spHnt,  a  long  fracture-box  may  be  used.  If  the  femur  tends 
to  project  anteriorly,  use  an  anterior  splint.  If  there  be  a  tendency  to  outward 
bowing,  adopt  Ashhurst's  expedient  of  carrying  a  strip  of  adhesive  plaster 
around  the  outside  of  the  limb  and  fastening  it  to  the  inner  side  of  the  splint. 
The  splint  is  kept  on  until  bony  union  is  complete,  as  in  this  operation  a  movable 
joint  is  never  sought.  Many  surgeons  use  a  fenestrated  or  interrupted  plaster- 
of-Paris  splint,  which  is  employed  until  the  parts  have  become  apparently  firm 
and  solid  (Fig.  442).     Even  for  many  months  after  the  parts  have  apparently 


Fig.  442. — Watson's  plaster-of-Paris  swing-splint. 

become  solidly  united  bending  may  occur.  How  long  fixation  should  be  used 
has  been  much  debated.  In  order  to  avoid  the  danger  of  flexion  or  other  de- 
formity fixation  by  some  form  of  apparatus  should  be  maintained  for  "at 
least  a  year  and  probably  nearly  two  years  after  excision"  (J.  Torrance  Rugh, 
"Am.  Jour.  Orthopedic  Surgery,"  Feb.,  1909). 

Excision  of  the  Ankle-joint, — Excision  of  the  ankle  was  first  performed 
by  Moreau  in  1792.  This  operation  is  performed  chiefly  for  gunshot-wounds, 
compound  dislocations,  and  in  some  cases  of  tuberculous  joint  disease.  Ex- 
cision of  the  ankle  is  an  operation  which  is  seldom  performed. 

Operation  hy  Hancock's  Method. — In  this  operation  the  patient  lies  upon 
his  back,  the  foot  rests  upon  its  inner  side,  and  the  surgeon  stands  to  the 
outer  side  of  the  damaged  limb.  Begin  an  incision  just  behind  and  2 
inches  above  the  external  malleolus,  and  carry  it  across  the  front  of  the  joint 
to  a  corresponding  point  above  and  behind  the  internal  malleolus  (see  Fig.  439, 
b);  this  incision  goes  only  through  the  skin,  and  the  flap  thus  marked  out  is 
reflected.  "Cut  doAAoi  upon  the  external  malleolus,  carrying  the  knife 
close  to  the  edge  of  the  bone  both  behind  and  below  the  process,  dislodge 
the  peronei  tendons,  and  divide  the  external  lateral  ligaments"  (Joseph  BeU). 
Cut  the  fibula  i  inch  above  the  malleolus  by  means  of  pliers;  divide  the 
tibiofibular  ligament;  turn  the  foot  upon  its  outer  side;  dissect  from  their 


Astragalectomy,  or  Excision  of  the  Astragalus  705 

habitat  back  of  the  inner  malleolus  the  tendons  of  the  posterior  tibial  and 
the  common  flexor  of  the  toes;  carry  the  knife  around  the  inner  malleolus 
close  to  the  bony  edge;  separate  the  internal  lateral  ligament,  and  dislocate 
the  lower  end  of  the  tibia  through  the  wound  by  turning  the  sole  of  the  foot 
downward;  saw  off  the  lower  end  of  the  tibia  and  the  articular  process  of 
the  astragalus,  sawing  away  from  the  tendo  Achillis,  and  removing  the  frag- 
ments by  bone-forceps.  Cut  away  diseased  synovial  membrane,  and  curet 
all  sinuses  and  tuberculous  areas.  Arrest  bleeding,  irrigate,  and  drain.  Sew 
up  the  wound,  insert  a  tube  at  the  outer  angle,  and  cause  it  to  emerge  at  the 
inner  angle.  Apply  antiseptic  dressings,  and  put  up  the  foot  in  fixed  dressing 
or  in  splints  at  a  right  angle  to  the  leg  (Fig.  443).  In  Langenbeck's  operation 
the  excision  is  subperiosteal.  ^  If,  in  an  excision  of  the  ankle-joint,  the  astrag- 
alus is  found  extensively  diseased,  remove  the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os  calcis  most  surgeons 
prefer  to  gouge  away  the  dead  bone,  leaving  the  periosteum  and,  if  possible, 
a  shell  of  healthy  bone,  and  draining  thoroughly.  Others  advocate  excision 
in  some  cases.  Extensive  disease  limited  purely  to  the  os  calcis  is  rare,  and 
most  surgeons  ad\-ise  gouging  for  limited  caries,  and  S}Tne's  amputation  in 
the  event  of  the  disease  extendmg  beyond  the  periosteum  or  reaching  adjacent 
bones. 


Fig.  443. — Volkmann's  dorsal  splint  for  excision  of  the  ankle. 

Operation  by  Subperiosteal  Method. — In  this  operation  the  position  as- 
siuned  by  the  patient  is  supine,  with  the  leg  extended  and  the  foot  resting 
on  its  inner  side.  The  incision,  which  cuts  the  tendo  Achilhs  and  reaches 
the  bone  at  once,  is  begun  at  the  upper  border  of  the  os  calcis  and  the  inner 
margin  of  the  tendo  Achillis,  and  is  taken  outward  and  horizontally  forward 
to  a  point  in  front  of  the  calcaneocuboid  articulation  (see  Fig.  436,  f).  A  ver- 
tical incision  is  begun  near  the  forward  termination  of  the  initial  incision,  is 
carried  across  the  outer  edge  and  plantar  surface  of  the  foot,  and  terminates  at 
the  external  margin  of  the  inner  surface  of  the  os  calcis.  Some  surgeons  carry 
the  vertical  incision  a  Httle  upward,  toward  the  dorsum.  The  periosteum 
is  entirely  stripped  by  an  elevator,  the  os  calcis  is  removed,  the  cavity  is 
packed  with  iodoform  gauze,  the  wound  is  stitched,  a  drain  is  inserted  pos- 
teriorly, the  foot  is  dressed  antiseptically,  is  placed  at  a  right  angle  to  the  leg, 
and  plaster  of  Paris  is  applied,  trap-doors  being  cut  for  drainage. 

Astragalectomy,  or  excision  of  the  astragalus,  is  seldom  performed.  As- 
tragalectomy is  employed  occasionally  for  relapsed  and  inveterate  cases  of 
club-foot.  The  indications  are  pointed  out  by  Willard  ('  Tnternational  Chnics, 
vol.  iii,  i2th  series):  "(i)  Adtilts  ^dth  great  bony  deformity;  (2)  neglected 
children  of  five  to  fifteen  years,  who  have  markedly  distorted  their  tarsi  by 
locomotion;  (3)  relapsed  cases  which  have  resisted  the  milder  forms  of  opera- 
tion, or  which  have  been  neglected  by  parents  after  pre\'ious  operation;  (4) 


7o6  Diseases  and  Injuries  of  the  Bones  and  Joints 

only  occasionally,  young  children  in  whom  from  infancy  the  bones  of  the  foot 
have  been  exceedingly  rigid  and  unyielding,  and  where  there  is  practically  but 
little  motion  either  at  the  ankle-joint  or  in  the  tarsus." 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an  incision  going  at 
once  to  the  bone,  from  the  "tip  of  the  external  maUeolus  forward  and  a  little 
inward,  curving  toward  the  dorsum  of  the  foot."  The  foot  is  extended  and 
turned  inward,  the  periosteum  is  lifted,  the  astragalus  is  removed,  and  the 
wound  is  treated  and  the  foot  is  dressed  as  is  done  after  excision  of  the  os 
calcis. 

In  cases  of  paralytic  calcaneus  Whitman  ("Orthopedic  Surgery")  recom- 
mends removal  of  the  astragalus  through  a  curved  external  incision;  freeing 
the  malleoli  and  making  new  sockets  for  them  beside  the  cuboid  and  scaphoid 
bones.     He  puts  the  foot  in  marked  plantar  flexion  and  holds  it  by  plaster. 

Excision  of  the  Metatarsophalangeal  Articulation  of  the  Great  Toe. — 
In  this  operation  make  a  lateral  incision  and  cut  off  or  saw  off  the  proximal  end 
of  the  first  phalanx  and  the  distal  third  of  the  first  metatarsal  bone.  (See 
Mayo's  Operation  for  Bunion,  page  691.) 

Excision  of  the  Metatarsal  Bone  of  the  Great  Toe  (Butcher^s  Method)^ 
— In  this  operation  a  lateral  straight  incision  is  made,  the  periosteimi  is  elevated,, 
and  the  shaft  is  sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  for  dislocation,  caries,  necrosis, 
gunshot-wound,  tumor  of  this  bone,  as  a  preliminary  to  ligation  of  the  artery 
and  vein  in  certain  cases  of  amputation  at  the  shoulder-joint,  or  in  cases  of 
removal  of  the  entire  upper  extremity.  In  excision  of  the  clavicle  the  position 
of  the  patient  is  the  same  as  that  for  ligation  of  the  third  part  of  the  subclavian 
artery  (see  page  475).  An  incision  is  made  down  to  the  bone,  from  the  sterno- 
clavicular joint  to  the  acromioclavicular  articulation.  If  the  case  is  suitable, 
the  periosteum  is  stripped  and  the  bone  is  sawn  and  removed;  if  not,  the  bone 
is  sawn  and  each  half  is  separately  disarticulated.  The  wound  is  sutured  and 
dressed,  and  the  limb  is  put  up  in  a  Velpeau  bandage.  McCreary,  of  Ken- 
tucky, in  181 1  performed  the  first  complete  excision  of  the  clavicle. 

Excision  of  the  Scapula.- — Complete  excision  of  the  scapula  is  usually 
performed  for  tumors.  Partial  excision  requires  no  detailed  description. 
In  excision  of  the  scapula  the  patient  lies  upon  his  sound  side.  Treves  suggests 
the  following  incisions:  one  outside  the  vertebral  border  of  the  scapula,  from 
its  superior  to  its  inferior  angle;  another  from  over  the  acromioclavicular 
joint,  along  the  acromion  process  and  spine  of  the  scapula,  to  meet  the  first 
incision.  Syme  used  an  incision  carried  transversely  inward  from  the  acromion 
process  to  the  vertebral  border  of  the  scapiila,  and  another  cut  directly  do\vn- 
ward  from  the  center  of  the  first  incision  (see  Fig.  436,  g).  In  the  method  of 
Treves^  the  upper  flap  is  reflected  and  the  trapezius  muscle  is  divided ;  the  lower 
flap  is  reflected  and  the  deltoid  muscle  is  divided.  The  patient's  hand  is  placed 
on  the  sound  shoulder;  the  muscles  of  the  vertebral  border  are  divided,  the  pos- 
terior scapular  artery  is  tied,  and  while  the  vertebral  border  of  the  scapula  is 
pulled  toward  the  surgeon,  the  serratus  magnus  muscle  is  cut,  the  upper  border 
of  the  shoulder-blade  is  cleared,  and  the  suprascapular  artery  is  tied.  The 
hand  is  now  brought  down  to  the  side;  the  acromioclavicular  joint  is  disartic- 
ulated; the  conoid  and  trapezoid  ligaments  are  divided;  the  muscles  of  the 
coracoid  process  are  cut;  the  capsifle  is  incised,  wuth  the  supraspinatus  and  in- 
fraspinatus, the  subscapularis,  and  the  scapular  origins  of  the  biceps  and  triceps 
muscles;  and  finally  the  teres  major  and  minor  muscles  are  divided,  the  sub- 
scapular artery  is  tied,  and  the  bone  is  removed.  The  wound  is  stitched,  a 
drain  is  introduced,  and  antiseptic  dressings  are  applied.  The  patient  lies 
upon  his  back  until  healing  is  well  under  way,  when  the  arm  is  placed  in  a  sling. 
1  "Manual  of  Operative  Surgery." 


Preliminary  Closure  of  the  External   Carotid  Artery'  707 

The  drainage-tube  may  be  removed  in  twenty-four  hours.  Langenbeck,  of 
Berlin,  in  1S55  performed  the  first  complete  excision  of  the  scapula. 

Excision  or  Resection  of  a  Rib  (Fig.  572). — In  caries  the  gouge  and  ron- 
geur may  remove  the  disease.  In  other  cases  excision  is  performed.  In  this 
operation  the  patient  lies  upon  his  sound  side  unless  the  operation  is  performed 
for  empyema,  in  which  case  he  lies  on  his  back  or  only  partl}^  on  the  sound  side. 
(See  Empyema,  Operation  for.)  The  surgeon  faces  the  patient.  Make  an 
incision  down  to  the  bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not 
diseased,  is  lifted  from  the  bone,  and  the  intercostal  artery  is  lifted  out  of  the 
way  wdth  the  periosteum  and  is  thus  saved  from  being  cut.  After  dividing  the 
bone  beyond  the  limits  of  disease,  remove  it.  During  the  sawing  a  metal  re- 
tractor is  held  beneath  the  rib,  between  the  rib  and  the  periosteum.  It  is  better 
to  saw  it  than  cut  it  with  ordinary  biting  forceps,  because  the  latter  splinters  the 
bone.  The  author  usually  uses  a  forceps  known  as  a  costotome,  which  cuts  the 
rib  without  splintering.  If  the  periosteum  is  diseased,  remove  it  after  tying 
the  intercostal  artery.  It  should  be  removed  in  a  case  of  empyema,  otherwise 
bone-formation  may  interfere  with  drainage.  In  empyema,  after  removing  the 
periosteum,  open  into  the  pleural  cavit}^,  allow  pus  to  flow  out  slowly,  remove 
fibrinous  masses,  employ  a  finger  to  feel  if  there  are  adhesions  and  if  the  lung 
will  probably  expand,  and  insert  a  drainage-tube.  In  resection  for  rib  disease 
curet  sinuses  and  pack  with  iodoform  gauze  for  some  days.  Sew  up  the  wound 
except  at  one  end.  Dress  antiseptically  and  apply  a  binder.  (See  Operations 
Upon  the  Chest  and  Estlander's  Operation.) 

In  removing  a  cervical  rib  make  an  incision  along  the  posterior  edge  of 
the  sternocleidomastoid,  avoid  the  pleura,  subclavian  vessels,  and  brachial 
plexus,  and  remove  the  periosteum  with  the  rib  in  order  that  the  bone  will 
not  be  reproduced. 

Complete  Excision  of  One-half  of  the  Upper  Jaw. — The  whole  upper 
jaw  has  been  removed,  but  in  what  follows  only  resection  of  one-half  the 
jaw  will  be  described.  This  operation  is  performed  for  malignant  tumors 
of  the  superior  maxillary  bone  or  its  antrum.  Up  to  1826,  at  which  time 
Lizars,  of  Edinburgh,  suggested  the  operation,  tumors  of  the  antrum  were 
treated  by  scraping  them  away  with  a  sharp  spoon.  Gensoul,  of  Lyons,  in 
1827  performed  the  first  operation  for  resection  of  the  upper  jaw.  Heyf elder, 
in  1844,  removed  both  superior  maxillary  bones.  Excision  of  a  superior  maxil- 
lary bone  is  not  justifiable  except  as  a  palliative  measure,  if  the  orbit  is  invaded, 
if  the  skin  and  subcutaneous  tissues  are  infiltrated,  or  if  the  disease  extends 
widely  beyond  the  superior  maxillary  and  palate  bones. 

Preliminary  Closure  of  the  External  Carotid  Artery. — Some  surgeons  ligate 
the  external  carotid  artery  or  compress  it  temporarily.  In  a  number  of  exci- 
sions of  the  upper  jaw  I  have  always  found  the  hemorrhage  readily  con- 
trollable as  soon  as  the  bone  is  removed,  and  have  never  felt  it  necessary  to 
resort  to  preliminary  ligation  or  compression. 

Operation  by  Median  Incision. — ^The  patient,  whose  face  has  been  shaved, 
is  placed  in  the  Trendelenburg  position,  thus  avoiding  the  possible  need  of 
instant  tracheotomy;  or,  what  is  even  better,  he  lies  horizontal  or  with  the 
head  a  little  raised  and  takes  ether  by  intratracheal  insufflation  (see  page 
1 199).  The  surgeon  stands  to  the  right  side  of,  and  faces,  the  patient.  The 
incisor  tooth  on  the  diseased  side  is  pulled  out.  The  incision,  which  is 
really  Weber's  incision  (called  by  some  Nekton's,  by  some  Fergusson's, 
by  some  Liston's)  (Fig.  444,  line  a-b),  is  begun  h  inch  below  the  inner 
canthus  of  the  eye,  and  is  carried  along  the  side  of  the  nose,  around  the 
ala  of  the  nose,  by  the  margin  of  the  nostrfl,  and  through  the  middle  of  the 
lip.  While  the  lip  is  being  incised  the  assistant  arrests  hemorrhage  by  grasp- 
ing the  corners  of  the  mouth,  and  after  the  lip  has  been  divided  the  coronary 


7o8 


Diseases  and  Injuries  of  the  Bones  and  Joints 


arteries  are  at  once  ligated.  Some  operators  approach  the  mucous  mem- 
brane cautiously  and  ligate  the  vessels  before  opening  the  cavity  of  the 
mouth.  The  upper  portion  of  the  wound  having  been  compressed  by  another 
assistant  during  these  manipulations,  pressure  is  now  removed  and  bleeding 
points  are  ligated.  Another  incision  is  now  carried  outward  from  the  be- 
ginning of  the  first  incision,  along  the  orbital  margin  to  well  over  the  malar 
bone.  The  flap  is  lifted  from  the  periosteum,  and  the  bleeding  from  the  in- 
fra-orbital artery  and  the  small  vessels  is  restrained  by  pressure.  The  nasal 
cartilage  is  separated  from  the  bone,  and  the  nasal  process  of  the  superior 
maxillary  is  sawn  (hne  a-b.  Fig.  445).  The  orbital  periosteimi  is  lifted  up, 
and  the  orbital  plate  is  cut  by  forceps  from  the  saw-cut  in  the  superior 
maxillary  bone  to  the  sphenomaxillary  fissure  (line  b-c,  Fig.  445).  The  malar 
bone  is  sawn  or  is  bitten  through  about  its  center,  the  cut  running  into  the 
sphenomaxillary  fissure  and  taking  a  downward  and  outward  direction  (line 
c-D,  Fig.  445) .  The  soft  parts  covering  the  hard  palate  are  incised  in  the  median 
line,  a  corresponding  incision  is  made  along  the  floor  of  the  nose  near  the  septum, 
and  the  soft  palate  is  separated  from  the  hard  palate  by  a  transverse  cut. 


Fig.  444. — A-B,  Incision  of  the  soft  parts  pre- 
liminary to  excision  of  the  upper  jaw;  C-D-E,  in- 
cision of  soft  parts  prelinainary  to  excision  of  the 
lower  jaw. 


Fig.  445. — I,  Excision  of  the  upper  jaw:  a-b, 
Section  of  the  nasal  process;  b-c,  section  of  the 
orbital  plate;  D,  section  of  the  malar  bone  and 
orbital  plate;  e,  section  of  the  alveolus  and  hard 
palate.  2,  Excision  of  the  lower  jaw:  g,  Section 
of  the  inferior  maxillary;  h,  section  of  the  ramus 
in  partial  resection. 


The  saw  is  introduced  through  the  nose,  and  the  palate  is  sawn  (Ime  e,  Fig. 
445).  The  upper  jaw-bone  is  grasped  by  Fergusson's  lion-jaw  forceps  and 
removed,  the  removal  being  aided  by  the  use  of  the  scissors  and  bone-cutters; 
the  latter  are  used  to  separate  the  upper  jaw  from  the  pterygoid  process 
(Treves).  Every  vessel  that  can  be  seen  is  tied,  and  severe  blee(Hng  from  bone 
is  arrested  by  antiseptic  wax.  Oozing  is  controlled  by  hot  water  and  pressure 
or  by  Paquelin's  cautery.  Examine  carefully  to  see  if  all  the  diseased  area  is 
removed;  if  it  is  not,  use  the  gouge,  scissors,  chisel,  and  saw  until  healthy  tissue 
is  reached.  The  wound  is  packed  with  iodoform  gauze,  and  the  end  of  the 
strip  is  so  placed  as  to  be  accessible  through  the  mouth.  The  wound  is  sutured 
(the  mucous  membrane  of  the  lip  must  be  stitched,  as  well  as  the  skin)  and  is 
dressed  antiseptically  (the  eye  being  protected  by  aseptic  gauze),  and  a  crossed 
bandage  of  the  angle  of  the  jaw  is  applied.  After  this  operation  it  is  common 
to  have  the  eye  sink  to  a  lower  level  (causing  double  vision) ,  to  have  per- 
sistent swelling  of  the  lower  lid,  and  to  have  the  tears  flow  over  the  lid  instead 
of  down  the  duct. 

Excision  of  One-half  of  the  Lower  Jaw. — In  some  rare  instances  the  entire 
inferior  maxillary  bone  is  removed.     The  lesions  necessitating  removal  of  the 


Operation  for  Dislocation  of  Semilunar  Cartilages  of  Knee-joint    709 

lower  jaw  are  of  the  same  nature  as  cause  us  to  remove  the  upper  jaw.  The 
names  of  many  surgeons  are  connected  with  this  operation,  viz.,  Deadrick, 
White,  Dupuytren,  Sir  Astley  Cooper,  and  Valentine  Mott. 

In  this  operation  the  patient  is  placed  in  the  same  position  as  for  excision 
of  the  upper  jaw,  the  chin  having  been  previously  shaved.  A  vertical  cut 
is  made  through  the  chin-tissue,  starting  below  the  margin  of  the  lip  and 
reaching  to  below  the  border  of  the  jaw  (c-d.  Fig.  444).  From  the  point  d 
an  incision  is  carried  outward  below  the  border  of  the  jaw  and  then  back 
of  the  ramus,  as  shown  in  the  line  i>-e  (Fig.  444).  Treves's  advice  is  to  carry 
this  incision  down  to  the  bone,  except  at  the  line  of  the  facial  artery,  at  which 
point  it  must  go  through  the  skin  only.  The  facial  artery  is  now  to  be  sought 
for,  tied  in  two  places,  and  di\dded.  Except  in  malignant  cases  the  perios- 
teimi  is  lifted  from  the  external  surface  of  the  bone,  from  the  s}Tnphysis  out- 
ward. Hemorrhage  is  arrested.  The  buccal  mucous  membrane  is  cut  from 
the  alveolus.  A  lateral  incisor  tooth  is  pulled,  and  the  bone  is  sawn  in  the  line 
G  (Fig.  445).  The  bone  is  grasped  in  a  lion-jaw  forceps  and  is  drawn  outward. 
The  mylohyoid  insertion  is  cut ;  the  internal  pterygoid  muscle  is  cut  or  the  peri- 
osteimi  at  this  spot  is  lifted;  the  inferior  dental  artery  is  cut  and  tied;  the  jaw 
is  pulled  down;  the  insertion  of  the  temporal  muscle  upon  the  coronoid  proc- 
ess is  cut  away,  and  the  external  pterygoid  muscle  is  divided.  The  capsule 
of  the  joint  is  opened,  and  the  bone  is  separated  from  the  ligaments  which  still 
hold  it  in  place.  Bleeding  is  arrested,  the  woimd  is  sutured,  a  tube  is  intro- 
duced in  the  posterior  portion  of  the  wound  and  retained  for  twenty-four 
hom^s,  and  antiseptic  dressings  and  a  Gibson  or  a  Barton  bandage  are  applied. 
Partial  excisions  of  the  alveolus  may  be  performed  through  the  mouth  by 
means  of  chisels  and  rongeur  forceps,  and  Wyeth  has  thus  removed  half  of 
the  jaw;  but  if  any  considerable  part  of  the  body  of  the  jaw^  is  to  be  removed, 
it  is  usually  best  to  make  an  incision  below  the  inferior  maxillary. 

Partial  Excision. — This  operation  is  frequently  made  necessary  by  epithe- 
lioma invohdng  the  periosteimi  or  bone.  After  this  operation,  unless  means 
are  taken  to  prevent  deformity,  there  will  be  as\Tnmetry  of  the  two  portions  of 
jaw  bone  remaining  and  malrelation  of  the  teeth.  Various  attempts  have  been 
made  to  fill  up  this  gap  at  the  time  of  operation  by  some  material,  or  to  hold  the 
two  portions  of  the  mandible  in  s^inmetrical  relation  by  the  insertion  of  trusses 
of  silver  wire,  or  by  fastening  each  piece  of  bone  to  a  metal  plate. 

John  B.  Murphy  suggested  the  use  of  a  bridge  of  sUver  wire.  All  of 
my  trials  mth  such  a  bridge  failed.  It  always  ulcerated  out  and  usually 
through  the  skin,  but  did  some  good  by  keeping  the  bone  ends  further  apart 
than  they  other-^ise  would  have  been. 

Stanley  StiUman  ("Annals  of  Surgery,"  July,  191 2)  advocates  bone-grafting 
as  the  only  proper  method,  in  order  to  prevent  contraction  during  healing 
after  the  removal  of  the  jaw  bone.  "When  the  teeth  on  the  sound  side  are 
ntmaerous  and  firm  enough  to  stand  the  strain,  they  may  be  prepared  before- 
hand with  the  aid  of  a  dentist,  so  that  a  few  days  after  the  operation  they  may 
be  clamped  firmly  to  those  of  the  upper  jaw"  (Ibid.).  When  the  w^ound  heals, 
StiUman  separates  the  flap,  freshens  the  bone  ends,  and  w^edges  a  section  of 
rib  between  them.  The  clamps  are  left  in  place  until  the  bones  unite,  which 
reqmres  sLx  to  eight  weeks.  In  cases  in  which  the  teeth  cannot  be  used  to 
clamp,  a  silver  bridge  is  inserted,  which  is  left  in  place  until  the  parts  are 
ready  for  the  insertion  of  the  bone. 

Barker's  Operation  for  Dislocation  of  the  Semilunar  Cartilages  of  the 
Knee-joint.i — Begin  the  mcision  over  the  ligament  of  the  patella,  |  inch  above 
the  articular  surface  of  the  tibia,  and  carry  it  in  a  curv^e  do\\Tiw^ard  and  outward 
to  the  anterior  edge  of  the  internal  ligament.    The  periosteum  should  be  divided 

^  "Lancet,"  Jan.  4,  1902. 


7IO 


Diseases  and  Injuries  of  the  Bones  and  Joints 


by  the  cut.  This  incision  forms  a  flap  the  lower  edge  of  which  is  |  inch  below 
the  border  of  the  articular  surface  of  the  tibia.  The  flap  is  lifted  until  the  car- 
tilage is  seen  "under  the  attachment  of  the  meniscus,  which  if  partially  attached 
will  rise  with  the  flap  until  its  under  surface  is  seen."  If  partially  torn  ante- 
riorly it  is  stitched  to  periosteum  by  a  few  silk  sutures.  The  periosteum  is  then 
stitched  in  place,  no  drain  is  used,  the  joint  is  immobilized,  and  for  one  week  ice 
is  kept  upon  the  part.  If  the  meniscus  is  found  completely  separated  and  curled 
up,  it  may,  if  the  injury  was  recent,  be  reduced.  If  the  injury  was  old  and  if 
the  cartilage  is  shrunken,  it  should  be  completely  cut  away  (Barker). 

Operation  for  Congenital  Dislocation  of  Hip. — Lorenz's  Bloodless  Method 
of  Reduction. — The  method  of  reducing  by  manipulation  a  congenital  dislo- 
cation of  the  hip  was  advised  by  Paci  and  modified  and  improved  by  Lorenz. 
It  has  long  been  known  that  reduction  is  easy  at  birth  because  an  acetabulum, 
though  probably  a  shallow  one,  exists,  and  the  head  of  the  bone  is  not  firmly 
held  in  its  new  situation.  In  an  older  child  the  problem  is  far  more  difficult, 
because,  even  if  reduction  is  effected,  the  acetabulum  may  be  extremely  shallow 
or  absent,  and  redislocation  may  readily  occur.  Lorenz  aims  to  effect  thorough 
reduction  and  then  fixes  the  limb  in  abduction  for  months,  so  that  the  acetabu- 
lum will  deepen  and  the  bone 
will  become  firm  in  its  proper 
socket.  This  operation  is  rarely 
successful  in  children  over  six 
years  of  age.  The  child  is  anes- 
thetized and  an  attempt  is  made 
to  draw  the  femoral  head  on  to 
a  line  with  the  acetabulum.  If 
the  child  has  never  walked,  this 
is  readily  accomplished.  If  it 
has  walked,  the  procedure  may 
be  very  difficult,  and  it  may  be 
necessary  to  make  extension  by 
a  fillet  fastened  above  the  knee, 
and  counterextension  by  a  screw 
and  a  perineal  band.  The 
drawing  down  of  the  head  is 
made  easier  by  stretching  and 
massaging  the  adductor  muscles. 
The  next  step  is  to  strongly 
flex  the  thigh,  rotate  it  a  trifle  internally,  and  then  abduct  it  while  flexion  is 
maintained.  This  causes  the  head  of  the  femur  to  pass  around  the  posterior 
margin  of  the  acetabulum  and  frequently  produces  reduction.  "Full  abduc- 
tion being  kept  up,  the  thigh  is  rotated  out,  thus  forcing  the  head  of  the  femur 
more  firmly  into  the  socket."  (See  the  description  of  the  Lorenz  method  in 
J.  Jackson  Clarke's  "Orthopedic  Surgery.")  The  strongly  abducted  limb  is 
put  up  in  plaster  of  Paris.  In  about  three  months  the  plaster  is  removed,  the 
abduction  is  diminished,  the  plaster  is  reapplied,  and  is  retained  for  another 
three  months.  During  the  continuance  of  immobiHzation  of  the  hip  the  child 
walks  about,  with  the  knees  bent.  When  the  plaster  is  finally  removed,  ma- 
nipulation, massage,  and  exercise  strengthen  the  muscles  and  give  freedom  to 
the  joint.  In  a  double  dislocation  one  joint  may  be  cured  before  the  other  is 
operated  upon,  or  both  may  be  operated  upon  at  the  same  seance.  In  double 
dislocation  plaster  must  be  worn  more  than  six  months.  The  Lorenz  opera- 
tion is  safe  when  applied  to  very  young  children,  but  has  elements  of  danger 
which  increase  with  the  years  of  the  subject.  A  patient  may  suffer  grave 
lacerations  of  muscles  and  ligaments,  and  even  vessels  and  nerves.     Death 


Fig.  446. — Lorenz  method.  Unilateral  congenital  dis- 
location of  hip  (reduced).  Cast  applied  with  leg  in  "frog 
position." 


Reduction  by  Means  of  Mechanical  Appliances  711 

may  result  from  shock,  and  extensive  deep-seated  hemorrhage  may  occur. 
In  fact,  it  is  a  mistake  to  call  it  a  bloodless  method.  The  blood  flows,  though 
we  do  not  see  it.  An  untrained  man  may  do  fearful  mischief  by  this  opera- 
tion, and  it  should  only  be  attempted  by  an  experienced,  skilful  manipulator  and 
upon  properly  selected  cases,  when  it  is  a  very  successful  procedure.  I  am 
satisfied  that,  except  in  the  case  of  a  very  young  child,  in  whom  reduction  is 
easy,  one  who  performs  the  Lorenz  operation  should  be  something  more  than 
skilful  and  experienced.  He  should  be  physically  strong,  so  that  traction  and 
abduction  will  be  powerful  and  steady.  A  weak  man  will  jerk,  will  throw  his 
weight  upon  the  part,  and  will  be  apt  to  tear  structures  instead  of  stretching 
them.     Sudden  forcible  movements  are  apt  to  break  the  bone. 

Hofa's  Cutting  Operation. — Make  the  external  incision  of  Langenbeck  to 
open  the  joint  (see  page  703).  The  capsule  is  incised  at  its  insertion  into  the 
neck,  and  the  periosteum  and  muscles  are  lifted  from  the  great  trochanter. 
Hoffa  claims  that  in  children  less  than  five  years  of  age  the  head  of  the  bone 
can  be  readily  replaced  into  the  acetabulum  by  flexing  the  thigh  and  making 
direct  pressure  upon  the  head  of  the  bone.  After  replacing  the  femoral  head 
it  is  held  in  place  while  an  assistant  extends  the  leg  in  order  to  stretch  the 
muscles.  In  children  over  five  years  of  age  cut  with  a  tenotome  the  muscles 
which  spring  from  the  ischial  tuberosity  and  also  the  adductors;  cut  the  fascia 
lata  and  muscles  which  arise  from  the  anterior  superior  iliac  spine  by  incision; 
open  the  joint  and  liberate  the  head  of  the  bone;  remove  the  ligamentum  teres; 
scrape  out  the  acetabulum,  removing  "cartilage,  fat,  and  considerable  spongy 
tissue"  (Tubby);  and  replace  the  head  of  the  bone  in  the  acetabulum.  The 
limb  is  maintained  in  inversion,  abduction,  and  extension  for  several  weeks, 
when  it  is  straightened.  Massage  and  passive  motion  are  begun  in  the  fifth 
week.  The  patient  now  gets  about,  wearing  an  apparatus  for  many  weeks. 
This  apparatus  permits  the  head  of  the  bone  to  move  in  the  socket,  but  pre- 
vents redislocation. 

Lorenz' s  Cutting  Operation. — This  is  a  modification  of  Hoffa's.  The  muscles 
inserted  into  the  greater  and  the  lesser  trochanter  are  not  cut;  the  sartorius, 
the  hamstrings,  and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby).  _ 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior  superior  spine. 
Another  incision  is  carried  inward  from  this  at  the  level  of  the  lesser  trochanter. 
The  capsule  is  opened  by  a  crucial  cut;  the  acetabulum  is  enlarged ;_  the  head 
of  the  bone,  if  it  remains,  is  inserted  into  the  acetabulum;  if  there  is  no  true 
head,  a  new  one  is  formed  and  inserted  into  the  cavity.  The  limb  is  im- 
mobiHzed  in  a  position  of  moderate  abduction.  Massage  and  passive  motion 
are  begun  in  the  fifth  week,  and  are  continued  for  months.'^ 

Reduction  by  Means  of  Mechanical  Appliances.— As  the  chief  factor  in 
the  reduction  of  a  congenital  dislocation  is  thorough  stretching  of  the  muscles 
and  ligaments  before  attempting  replacement,  numerous  forms  of  levers  have 
been  devised  to  accomplish  this.  The  best-known  one  is  that  of  Bartlett,  of 
Boston.  It  consists  of  a  pelvic  rest  with  perineal  support,  rods  to  fix  the  pelvis 
and  traction  rods  to  make  extension.  Great  care  is  necessary  in  the  use  of  all 
such  appliances  because  of  the  danger  of  injury  to  vessels  and  nerves  or  of 
fracturing  bony  parts.  After  the  parts  have  been  thoroughly  stretched  re- 
placement is  accomplished  by  manipulation,  as  in  the  usual  methods  of  manual 
reposition. 

1 1  have  drawn  upon  the  very  lucid  description  of  these  operations  in  A.  H.  Tubby's 
treatise  upon  "Deformities." 


712  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


XXI.  DISEASES  AND  INJURIES  OF  MUSCLES,  TENDONS,  AND 

BURS/E 

Myalgia,  or  muscular  rheumatism,  is  a  painful  disorder  of  the  volun- 
tary muscles  and  of  the  fibrous  and  periosteal  areas  where  they  are  attached. 
The  term  "muscular  rheumatism"  is  not  strictly  correct.  It  is  possible  that 
in  some  cases  the  muscular  structure  is  inflamed,  but  it  is  certain  that  in  many 
cases  the  pain  is  distinctly  neiiralgic.  Muscular  rheumatism  may  be  due  to 
cold  and  wet,  to  overexertion  and  strain,  to  acute  infectious  disorders,  to  syph- 
ilis, to  chronic  intoxications  (lead,  mercury,  and  alcohol),  and  to  disturbances  of 
the  circulation.  Gouty  and  rheumatic  persons  are  especially  predisposed,  men 
being  more  liable  to  the  disease  than  women.  The  disease  is  usually  acute,  but 
it  may  be  chronic. 

Symptoms. — Muscular  rheimaatism  is  apt  to  come  on  suddenly.  The 
pain,  which  may  be  very  acute  and  lancinating  or  dull  and  aching,  is  in 
some  cases  constantly  present;  in  other  cases  it  is  awakened  only  by  muscu- 
lar contraction,  and  it  is  frequently  relieved  by  pressure,  though  there  is  often 
some  soreness.  The  skin  above  the  muscle  is  sometimes  tender  to  light  pres- 
sure. The  disease  usually  lasts  for  a  few  days,  but  it  tends  to  recur.  There 
is  little,  if  any,  fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rheumatic  torticollis  is 
myalgia  of  the  muscles  of  the  neck.  Usually  one  side  of  the  neck  is  attacked. 
The  chin  is  turned  from  the  affected  side  and  the  neck  is  stiff.  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very  severe,  is  aggravated 
by  deep  respiration,  by  coughing,  and  by  yawning,  there  may  be  tenderness, 
and  the  patient  tries  to  limit  chest-movement.  In  intercostal  neuralgia  the 
pain  is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms,  and  is  linked 
with  the  presence  of  the  tender  spots  of  Valleix.  Pleurodynia  lacks  the 
physical  signs  of  pleurisy.  Cephalodynia  is  myalgia  of  the  muscles  of  the 
scalp.  The  muscles  of  the  shoulder,  upper  dorsal  region,  abdomen,  and 
extremities  may  also  be  attacked  by  myalgia.  Myalgia  must  not  be  confused 
with  the  pains  of  locomotor  ataxia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  existing  diathesis, 
such  as  gout  or  rheumatism.  Rest  is  of  the  first  importance.  For  lumbago, 
put  the  person  to  bed.  For  pleurodynia,  strap  the  side  of  the  chest.  A 
hypodermatic  injection  of  morphin  and  atropin  into  the  affected  muscles  at 
once  allays  the  pain,  and  a  deep  injection  of  distilled  water  is  sometimes 
curative.  Relief  may  be  afforded  by  painting  the  surface  with  30  drops  of 
a  mixture  of  equal  parts  of  guaiacol  and  glycerin  and  covering  the  painted 
area  with  cotton.  The  introduction  of  four  or  five  aseptic  needles  into  the 
muscles,  and  their  retention  for  a  few  minutes,  sometimes  acts  most  favor- 
ably. Ironing  the  skin  above  the  painful  muscles  with  a  very  warm  iron,  a 
piece  of  flannel  being  interposed,  is  a  useful  domestic  remedy.  Vigorous 
rubbing  of  the  area  with  a  piece  of  ice  allays  the  pain.  Hot  poultices  do  good. 
If  the  pain  is  widely  diffused,  alters  its  seat,  or  is  very  obstinate,  order  hot 
baths  or  Turkish  baths  and  administer  diuretics.  In  chronic  cases  employ 
blisters  or  counterirritation  by  the  cautery,  give  iodid  of  potassium  and 
nux  vomica,  and  have  the  patient  take  a  Turkish  bath  every  week.  The 
constant  electric  current  finds  advocates.  In  an  ordinary  severe  case  order 
a  hot  bath,  put  the  patient  to  bed  with  a  hot-water  bag  over  the  part,  and 
administer  10  gr.  of  Dover's  powder;  the  next  morning  order  to  be  taken  four 
times  daily  a  capsule  containing  5  gr.  of  salol  and  3  gr.  of  phenacetin,  until  the 
pain  disappears.  Citrate  of  potassium,  citrate  of  lithium,  chlorid  of  ammonium, 
or  the  salicylate  of  colchicin  may  be  ordered  instead  of  salol  and  phenacetin. 


Trichinosis  or  Trichiniasis 


713 


Infective  myositis  is  a  widespread  inflammation  of  the  \-oluntary  mus- 
cles, due  to  an  unknown  infective  cause.  It  is  a  disorder  accompanied  by 
pain  and  stiffness,  by  cutaneous  edema,  and  by  various  paresthesige.  Myo- 
sitis resembles  trichinosis,  and  can  be  distinguished  from  it  only  by  spearing 
out  a  bit  of  muscle  and  examining  it  microscopically.  Occasionally  diffuse 
suppuration  occurs. 

Ordinary  myositis  arises  from  injuries,  from  s^-philis,  or  from  rheu- 
matism, and  it  presents  the  usual  inflammatory  symptoms.  Contraction 
and  adhesions  may  follow.  I  operated  upon  a  case  of  myositis  of  the  rectus 
abdominis  in  a  boy  of  eight.  There  was  a  large  mass  like  a  full  bladder. 
There  had  not  been  an  attack  of  t}^hoid  and  there  was  not  hereditary-  s}^h- 
ilis.  Caseation  existed.  The  condition  was  possibly  tuberculous,  although 
no  baciUi  were  found. 

Treatment  of  Myositis. — Infective  myositis  is  treated  by  anodynes,  stim- 
ulants, nutritious  food,  hot  applications,  and  rest.  If  pus  forms,  it  should  be 
evacuated.  Rheumatic  myositis  calls  for  the  administration  of  the  salicylates, 
the  alkalis,  or  salol.  Syphilitic  myositis  is  treated  with  mercury-  and  iodid 
of  potassiiun.  The  remedies  employed  for  myalgia  are  used  in  traumatic 
myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  increased  use.  In 
pseudohypertrophic  paralysis  the  muscle  is  greatly  augmented  in  bulk,  but  it 
contains  less  muscle-structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  use,  from  injury,  from 
continuous  pressure,  from  interference  \di\i  the  blood-supply,  from  disease  of 
the  nerves  or  their  centers,  or  from  lead-poisoning. 

Degeneration  of  Muscles. — The  muscles  may  undergo  granular 
degeneration,  wax\^  degeneration,  fatty  degeneration  and  calcareous  degen- 
eration, and  may  become  pigmented. 

Local  Ossification  and  Myositis  Ossificans. — It  is  not  unusual 
for  a  small  portion  of  bone  to  form  in  the  periosteal  insertion  of  a  muscle 
which  is  subjected  to  frequent  strain.  In  persons  who  ride  many  hours  a 
day  there  not  infrequently  develops  the  riders^  hone,  which  is  an  area  of 
ossification  in  the  adductor  muscles  of  the  thigh.  Myositis  ossificans,  a 
widespread  ossification  of  the  muscles,  is  a  rare  disorder  the  cause  of  which 
is  unknown,  and  which,  though  not  congenital,  usually  begins  in  early  life. 
In  some  local  cases  a  traumatic  origin  seems  certain.  It  is  seen  more  often 
among  males  than  females.  Colimins  of  inflammator\"  swelling  and  induration 
slowly  develop,  each  column  running  in  the  direction  of  the  muscular  fibers, 
and  ossification  of  the  indurated  columns  takes  place.  It  is  stated  that  the 
thimibs  and  great  toes  shorten  (J.  Jackson  Clarke's  "Orthopedic  Surger>^")- 
In  traumatic  cases  the  condition  is  localized.  I  operated  upon  a  traumatic 
case  by  remo\dng  an  ossified  area  in  the  thigh  muscles.  The  laboratorv^  report 
was  myositis  ossificans.  Growth  quickly  recurred  after  operation,  but  the 
new  growth  showed  ven,^  Httle  ossification.  The  laboratory  report  was  spindle- 
celled  sarcoma.  This  case  and  also  another  one  reacted  to  Coley's  flmd.  It 
seems  possible  that  local  myositis  ossificans  may,  in  some  cases  at  least,  be 
a  sarcoma  in  which  rapid  ossification  occurs. 

Tumors  of  the  Muscles. — Primary  tumors  of  the  muscles  are  rare. 
Among  those  which  may  occur  are  sarcoma,  fibroma,  lipoma,  osteoma,  angioma, 
myxoma,  and  enchondroma.  Most  cases  of  supposed  primar}^  sarcoma  of 
muscle  are,  in  reality,  cases  of  syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form,  or  gumma- 
tous infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the  embryos  of  the  Tri- 
china or  Trichinella  spiralis.    Sir  James  Paget  recognized  the  nature  of  the  pre- 


714  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

viously  known  encysted  or  larval  form.  It  was  long  believed  that  the  Trichina 
spiralis  was  a  harmless  parasite,  but  in  i860  Zenker,  of  Dresden,  proved  that 
it  might  be  responsible  for  dangerous  epidemics.  The  trichina  is  normally  a 
parasite  of  the  rat.  Man  is  infected  by  eating  flesh  which  contains  trichinae 
and  has  been  insufficiently  cooked.  The  flesh  of  the  pig  is  the  medium  of 
infecting  man.  The  pig  becomes  infected  by  eating  rats  suffering  from  the 
disease  or  offal  and  slaughter-house  refuse  containing  trichinallized  flesh. 
Dr.  Joseph  Leidy  discovered  the  trichina  in  pork.  People  are  most  commonly 
affected  by  eating  raw  sausage,  smoked  sausage,  or  underdone  pork.  Im- 
perfectly boiled  ham  may  be  responsible.  Albert  reported  14  cases  from  eat- 
ing boiled  ham.  W.  Oilman  Thompson  found  records  of  52  sporadic  cases 
occurring  in  New  York  City  during  six  years  ("Amer.  Jour.  Med.  Sciences," 
August,  1910).  These  nematodes  are  carried  into  the  intestine,  there  to  de- 
velop and  multiply.  In  from  seven  to  nine  days  a  horde  of  embryos  develop 
in  the  bowel,  and  leave  the  alimentary  canal  by  passing  through  the  perito- 
neum or  by  means  of  the  blood,  and  finally  reach  the  connective  tissue  of  the 
muscles.  From  the  connective  tissue  the  embryos  migrate  into  the  primitive 
muscle-fibers,  where  they  dwell  and  enlarge.  Myositis  develops,  and  in  the 
course  of  five  or  six  weeks  the  parasites  become  encapsulated  and  devlop  no 
further.  The  cyst-walls  may  calcify  and  the  worms  may  become  calcified, 
or  may  live  for  years.  The  eating  of  infected  meat  is  not  inevitably  fol- 
lowed by  the  disease,  and  a  few  embryos  lodged  in  muscle  may  cause  no 
symptoms. 

The  symptoms  of  trichinosis  often  appear  in  a  day  or  two  after  eating 
infected  meat.  The  symptoms  of  acute  gastro-intestinal  catarrh  or  of  cholera 
morbus  are  common,  but  in  some  cases  no  gastro-intestinal  manifestations 
usher  in  the  disease.  In  from  seven  to  fourteen  days  after  the  infected  meat  is 
eaten  the  migration  of  the  parasites  develops  obvious  symptoms.  A  chill  may 
be  noted;  there  is  usually  fever;  muscular  pain,  tenderness,  swelling,  and  stiff- 
ness are  complained  of.  This  condition  may  be  widespread.  Involvement  of 
the  muscles  of  mastication  interferes  with  chewing;  of  the  larynx,  with  talking 
and  respiration;  of  the  intercostals  and  diaphragm,  with  respiration.  Skin- 
edema  and  itching  are  marked.  In  some  cases  delirium  exists.  The  writer 
saw  in  the  Philadelphia  Hospital  one  fatal  case  which  was  mistaken  for  ery- 
sipelas because  of  the  high  fever,  the  delirium,  and  the  edematous  redness  of 
the  face  and  neck.  Dyspnea  is  frequent.  Mild  cases  get  well  in  a  week  or 
two;  severe  cases  may  last  many  weeks.  The  mortality  varies  in  different  epi- 
demics from  I  to  30  per  cent.  (Osier).  The  diagnosis  is  made  by  spearing  out 
a  piece  of  muscle,  which  is  then  examined  for  trichinae  under  a  microscope;  or 
the  worms  may  perhaps  be  detected  in  the  feces  by  means  of  a  pocket-lens. 
In  a  case  under  the  care  of  the  author,  in  St.  Joseph's  Hospital,  there  was  no 
record  of  any  attack  of  gastro-intestinal  disturbance  and  the  first  manifesta- 
tion was  enlargement  of  the  calf  of  the  left  leg.  In  most  cases  of  trichinosis 
there  is  eosinophilia,  but  in  the  author's  case,  previously  referred  to,  eosino- 
philia  was  not  present. 

Treatment.— To  treat  trichinosis  employ  purgatives  (senna  and  calomel) 
early  in  the  case,  and  give  glycerin,  and  also  santonin  or  filix  mas.  When 
muscular  invasion  has  taken  place,  sedatives,  hypnotics,  nourishing  diet,  and 
stimulants  are  indicated. 

Ischemic  Myositis,  or  Volkmann's  Contracture  (Volkmann's  Par- 
alysis; Ischemic  Paralysis;  Ischemic  Muscular  Atrophy,  with  Contractures 
and  Paralysis,  Fergusson  calls  it). — It  is  occasionally  noticed,  particularly 
in  children,  after  prolonged  fixation  of  the  forearm,  especially  after  pro- 
longed fixation  of  the  elbow-joint  by  some  appliance  that  impedes  the  free- 
dom of  circulation  in  the  part.     Contracture  of  the  fingers  occurs  and  per- 


Treatment  of  Ischemic  Myositis,  or  Volkmann's  Contracture      715 

haps  rigidity  and  flexion  of  the  wrist.  In  1875  Volkmann  described  severe 
contractures  of  the  hand  observed  in  some  cases  as  a  result  of  the  use  of  tight 
bandages  to  hold  splints  in  place  in  treating  fractures  of  the  arm.  He  believed 
that  the  condition  was  due  to  deprivation  of  arterial  blood,  that  the  muscles 
perished  for  want  of  oxygen,  and  that  rigor  mortis  occurred.  He  pointed  out 
that  paralysis  and  contracture  occur  simultaneously,  whereas  in  primary 
nerv^e  lesion  paralysis  precedes  contracture.  The  condition  may  come  on 
after  the  application  of  an  Esmarch  band,  after  a  severe  injury  in  the  neigh- 
borhood of  the  elbow-joint,  may  follow  ligation  of  the  main  artery  of  a  limb, 
venous  embolism,  venous  thrombosis  from  injury  or  infectious  disease,  Ray- 
naud's disease,  or  exposure  to  cold.  One  of  Jones's  cases  followed  a  rapidly 
developing  traumatic  myositis  ossificans;  two  followed  crushes;  in  one  an 
elastic  tourniquet  had  been  kept  on  a  child's  arm  to  prevent  bleeding  after  an 
operation  for  webbed-fingers;  in  one  pad  pressure  had  been  maintained  for 
twenty-four  hours  to  check  bleeding  ("Amer.  Jour.  Orthop.  Surg.,"  April, 
1908).  A  case  of  mine  resulted  from  embolism  of  the  brachial  artery.  There 
are  two  forms,  one  due  to  almost  complete  arterial  ischemia,  lasting  for 
several  hours  at  least;  another  due  to  interference  with  venous  return.  Volk- 
mann's contracture  is  due  to  muscular  degeneration,  infiltration,  induration, 
and  contraction,  the  result  of  marked  and  prolonged  arterial  ischemia  or 
interrupted  venous  return,  and  it  is  frequently  spoken  of  as  ischemic  myositis 
(Dudgeon,  "Lancet,"  Jan.  11,  1902).  In  some  cases  distinct  neuritis  with  pa- 
ralysis also  exists.  One  characteristic  of  ischemic  contracture  is  the  rapidity 
with  which  it  comes  on.  Dudgeon  points  out  that  in  half  a  day,  or  even  in  less 
time  in  some  cases,  the  symptoms  appear,  these  symptoms  being  paralysis 
of  the  part  with  contracture.  Pain  is  unusual,  unless  the  nerves  are  seriously 
involved.  In  some  cases  the  fingers  and  hand  swell  and  become  discolored. 
The  absence  of  pain  frequently  prevents  the  recognition  of  the  condition; 
therefore,  the  causative  splint  or  bandage  pressure  may  be  maintained  for  days 
after  the  trouble  has  become  serious.  When  the  splints  and  bandages  are 
removed  and  the  forearm  is  examined,  there  is  almost  always  tenderness  over 
the  muscles  and  the  nerve-trunks;  and  in  the  majority  of  cases  in  which  a 
splint  w^as  the  cause  a  portion  of  the  skin  will  have  sloughed.  Dudgeon  points 
out  the  characteristic  position  of  the  deformity  as  follows:  When  the  wrist 
is  extended,  the  metacarpophalangeal  joints  are  also  extended;  but  the  inter- 
phalangeal  joints  of  the  fingers  and  the  terminal  joint  of  the  thmnb  are  so 
strongly  bent  that  the  tips  of  the  fingers  touch  the  palm,  and  this  position 
cannot  be  corrected  by  any  justifiable  amount  of  force.  As  soon  as  the  wrist- 
joint  is  bent  to  a  right  angle,  the  interphalangeal  joints  can  readily  be  ex- 
tended. In  a  very  severe  case  the  wrist  itself  will  become  markedly  flexed, 
and  it  will  be  impossible  to  extend  it.  The  forearm  is  usually  semiflexed 
and  the  hand  pronated.  The  ulceration  or  sloughing  so  frequently  present 
causes  a  splint-sore.  There  is  always  marked  induration  about  a  splint-sore. 
The  flexor  muscles  themselves  are  indurated  and  usually  wasted.  The  con- 
dition of  sensation  depends  upon  the  state  of  the  nerves  of  the  part.  When 
neuritis  is  absent,  sensation  will  be  normal;  but  in  accordance  with  the  amount 
of  neuritis  and  degeneration  there  will  be  hyperesthesia,  partial  anesthesia, 
or  complete  anesthesia.  A  curious  feature  of  these  cases  that  is  dwelt  upon 
by  Dudgeon  and  commented  upon  by  Turner  is  the  fact  that  in  yovmg  children 
there  is  a  cessation  of  growth  of  the  bone.  Robert  Jones  (Loc.  cit.)  reports 
that  19  cases  out  of  40  were  associated  with  fracture.  In  13  of  the  19  cases 
there  was  pronounced  malunion. 

Treatment. — The  old  view  of  this  condition  was  that  it  is  practically  hope- 
less. Anderson  and  Dudgeon,  however,  maintain  that  restoration  may  usually 
be  obtained,  the  treatment  consisting  in  regular,  active  motion,  passive  move- 


7i6  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursse 


ment,  massage,  and  electricity.    Forcible  extension  under  ether  is  of  no  benefit 
whatever. 

Jones's  plan  of  treatment  is  very  beneficial  ("Amer.  Jour.  Orthop.  Surg.,'^ 
April,  1908). 

Operative  procedures  on  arms  that  necessarily  have  deficient  circulation  are 
hazardous,  and  Jones  has  discontinued  all  operative  correction  and  relies  upon 
purely  mechanical  and  manipulative  routine,  as  follows: 

Five  splints  are  cut  out  of  zinc,  tin,  or  sheet  wire,  to  fit  each  finger  and 
thumb.    The  wrist  is  forcibly  flexed  and  held  while  each  finger  is  separately 

^   splinted.    It  will  be  observed  that  in 

the  fully  flexed  position  of  the  wrist 
the  fingers  are  all  relaxed. 

When  the  finger  splints  have  been 
applied  the  wrist  is  released,  and  the 
patient  is  directed  to  systematically 
extend  the  metacarpophalangeal  joints. 
In  a  few  days  the  second  splinting  may 
usually  be  employed  by  embedding  the 
entire  hand  to  the  wrist  and  the  already 
splinted  fingers  in  plaster  of  Paris,, 
while  the  wrist  is  again  flexed.  Several 
days  are  devoted  to  systematic  volun- 
tary efforts  at  extension  of  the  hand  in 
a  similar  manner  employed  for  the 
metacarpophalangeal  joints. 

The  third  splinting  embraces  that 
already  employed  and  in  addition  em- 
braces the  wrist  in  the  fullest  extension 
possible,  which  in  a  few  days  may  be 
increased  until  full  extension  is  ob- 
tained. The  latter  position  of  fuU  ex- 
tension of  wrist,  hand,  and  fingers  is 
maintained  for  some  weeks  until  all 
contractible  elasticity  has  disappeared. 
It  is  usually  observed  that  when 
the  hand  can  be  held  in  hyperextension 
without  tendency  to  relapse,  the  circu- 
lation will  almost  invariably  improve 
and  the  fingers  resume  their  normal 
function  and  appearance  except  in  cases 
of  nerve  destruction.  Jones  has  found 
that  in  many  cases  in  which  the  nerves 
had  lost  their  function  during  contracture,  the  extension  of  the  hand  was  the 
starting-point  of  recovery. 

In  making  any  splint  pressure  to  straighten  the  fingers  the  greatest  care 
must  be  exercised.  The  skin  of  the  dorsum  of  the  fingers  will  not  endure  pro- 
longed pressure.  I  have  used  Rugh's  splint  with  much  satisfaction  (Figs. 
447,  448).  It  is  best  in  the  beginning  to  apply  the  splint  for  five  or  ten 
rninutes  twice  a  day.  The  time  of  each  seance  is  gradually  increased  as  the 
tissues  develop  resistance.  Frequent  bathing  with  alcohol'  aids  the  skin  to 
bear  pressure. 

R.  H.  Sayre  ("Volkmann's  Ischemic  Paralysis  and  Contracture,"  "Amer. 
Jour.  Orthop.  Surg.,"  Nov.,  1908,  p.  221)  advocates  the  Jones  method  in  all 
cases,  inasmuch  as  cutting  operations  may  be  employed  later  if  the  results 
of  Jones's  treatment  are  not  entirely  satisfactory.     The  improvement  in  the 


NiH 


Fig.  447. — Rugh's  splint  for  Volkmann's  con 
tracture.  Splint  applied.  Looking  at  the  pal 
mar  surface. 


Strains  717 

circulation  and  function  obtained  by  the  Jones  method  will  make  the  operative 
field  more  capable  of  rapid  recovery. 

In  a  persistent  and  long-continued  case  an  operation  may  be  necessarv. 
The  operation  may  consist  in  dividing  in  the  forearm  the  flexor  muscles  of  the 
fingers,  as  advised  by  Davies  CoUey,  and  then,  at  a  later  period,  dividing  the 
flexor  tendons.  The  objection  to  his  procedure  is  that  it  destroys  the  capacitv 
to  flex  the  fingers  for  all  time.  Another  suggestion  has  been  to  excise  a  piece 
from  both  the  radius  and  the  ulna,  and  wire  the  fragments  together.  The 
best  surgical  treatment  is  probably  exposing  the  nerves,  separating  them  from, 
adhesions,  stretching  them,  and  then  doing  tendon-lengthening,  but  this  should 
not  be  done  until  all  the  improvement  possible  to  secure  by  conservative  treat- 
ment has  been  obtained  by  at  least  three  months  of  effort. 

Wounds  and  Contusions  of  the  Muscles. — Wounds  of  muscles  may 
be  either  open  or  siihcutaneous.  In  a  longitudinal  wound  the  edges  lie  close 
together,  and  hence  drainage  must  be  pro\'ided  for  by  the  surgeon.  In  a 
transverse  wound  the  edges  separate  widely,  and  catgut  stitches  must  be 
inserted.  Contusions  of  muscles,  like  contusions  of  other  tissues,  vary  in 
extent  and  in  severity.  There  are  pain  (which  is  increased  by  attempts  to 
use  the  muscle),  loss  of  function,  swelling  beneath  the  deep  fascia,  and  dis- 
coloration, which  may  appear  at  once  because  of  superficial  damage  from 


Fig.  44S. — Lateral  view  of  splint  shown  in  Fig.  447. 

the  initial  injury,  or  which  may  appear  in  dependent  parts  after  many  days 
because  of  gra\'itation  of  blood  and  blood-stained  serum.  As  a  result  of  con- 
tusion, suppuration,  inflammation,  or  atrophy  may  arise. 

Treatment. — In  a  longitudinal  woimd,  drain;  in  a  transverse  woimd, 
suture  the  muscle.  The  further  indications  in  wounds  and  contusions  of 
muscles  are  to  obtain  rest  by  means  of  splints  and  to  secure  relaxation.  Limi- 
tation of  swelling  is  secm-ed  by  bandaging.  Inflammation  is  combated  first 
by  cold  and  lead-water  and  laudanum;  later  by  iodin,  blue  ointment,  ichthyol, 
and  intermittent  heat.  To  prevent  loss  of  function  employ,  as  soon  as  the 
acute  s\'mptoms  subside,  massage,  passive  motion,  and  stimulating  liniments, 
and,  later  in  the  case,  electricity  (galvanism  if  the  reactions  of  degeneration 
exist;  faradism,  if  they  are  absent). 

Strains. — A  muscular  strain  is  a  stretching  of  a  muscle  with  a  small 
amount  of  rupture.  It  is  caused  by  traction  in  the  long  axis  of  the  muscle. 
The  muscle  becomes  swoUen,  tender,  stiff,  weak,  and  sore,  and  attempts 
at  motion  produce  sharp  pain.  A  strain  of  a  tendon  is  a  tri\dal  or  partial 
rupture.  It  leads  to  the  development  of  acute  thecitis,  with  fluid  swelling 
and  pseudocrepitation.  Strains  are  common  in  the  deltoid,  the  ham-string 
muscles,  the  back,  the  calf,  the  biceps,  and  the  great  pectoral.  Strain  of  the 
psoas  muscle  causes  pain  on  voluntary  flexion  of  the  thigh,  and  is  associated 


7i8  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursse 

with  tenderness  in  the  iliac  fossa.  Strain  of  the  right  psoas  may  be  mistaken  for 
appendicitis,  but  it  lacks  the  intense  local  tenderness,  the  abdominal  rigidity, 
and  the  constitutional  symptoms.  Lawn-tennis  arm  is  a  strain  of  the  pro- 
nator radii  teres  muscle.  Riders''  leg  is  a  strain  of  the  adductor  muscles  of 
the  thigh.  A  strain  of  the  long  head  of  the  biceps  flexor  cubiti  produces  the 
condition  called  by  ball  players  a  glass  arm.  A  strain  may  be  the  only 
injury,  or  may  be  associated  with  some  other  condition  (fracture  of  bone, 
dislocation,  sprain,  contusion,  etc.).  A  strain  may  be  followed  by  periostitis 
.  at  the  point  of  insertion  of  the  muscle.  Atrophy  of  the  muscle  occasionally 
follows  a  strain. 

A  strained  muscle  is  usually  rigid,  is  tender,  and  pains  greatly  when  an 
attempt  is  made  to  use  it.  The  skin  over  it,  especially  over  its  point  of  inser- 
tion, is  usually  tender. 

A  strain  of  the  back  is  a  very  common  accident,  which  is  often  associated 
with  sprains  of  the  vertebral  articulations.  There  is  great  pain  when  the 
patient  voluntarily  straightens  up.  If  the  vertebral  ligaments  are  not  damaged, 
the  patient  can  be  straightened  by  passive  motion  without  pain.  The  skin 
is  tender  in  certain  areas.  The  muscles  are  often  rigid.  There  may  be  uni- 
lateral rigidity.  In  a  back  injury  make  a  careful  examination  to  be  sure  no 
damage  has  been  inflicted  upon  the  vertebrae  or  cord. 

Treatment. — Relaxation  by  suitable  position;  rest  by  the  use  of  splints 
or  by  putting  the  patient  to  bed;  bandages  for  compression;  hot  fomentations 
or  a  hot-water  bag,  and  ichthyol.  As  soon  as  acute  symptoms  subside,  employ 
friction  and  massage.  Strapping  with  adhesive  plaster  is  of  service  in  strain 
of  the  back  and  of  the  calf.  If  there  is  severe  pain  after  a  strain,  administer 
Dover's  powder,  or  even  morphin. 

Rupture  of  Muscles  and  Tendons. — Rupture  of  a  muscle  is  an- 
nounced by  a  sudden  and  violent  pain  and  by  loss  of  function,  arising  dur- 
ing powerful  muscular  contraction  or  strong  traction  in  the  long  axis  of  a 
muscle.  The  rupture  may  be  announced  by  a  clearly  audible  snap  (A.  Pearce 
Gould).  A  distinct  gap  is  felt  between  the  ends;  great  pain  develops  on  move- 
ment; there  are  tenderness,  loss  of  power,  and  swelling.  Rupture  may  be 
followed  by  atrophy,  as  is  a  contusion.  Among  the  muscles  which  occa- 
sionally rupture  we  may  mention  the  quadriceps,  biceps,  triceps,  deltoid, 
plantaris,  etc. 

Rupture  of  the  biceps  flexor  cubiti  or  its  tendon  is  not  very  common;  72 
cases  have  been  collected  (W.  W.  Keen,  in  "Annals  of  Surgery,"  May,  1905). 
It  is  much  more  common  in  men  than  in  women.  Loos's  table  of  66  cases 
contains  records  of  only  2  women  (Doane,  in  "Jour.  Amer.  Med.  Assoc,"  May 
16,  1908).  The  rupture  may  be  where  the  muscular  belly  passes  into  the 
lower  tendon,  through  the  muscular  belly,  in  the  muscular  part  passing  either 
to  the  long  or  short  head,  or  at  the  part  where  the  muscular  belly  joins  the  long 
or  short  head.  The  tendon  of  the  long  head  may  be  torn  through  or  the  long 
head  may  be  torn  from  the  glenoid  cavity.  The  muscular  portion  is  far  more 
often  injured  than  the  tendinous.  In  rupture  of  the  muscle  belly  a  part  of  the 
muscle,  in  rupture  of  the  long  head  the  entire  muscle,  becomes  soft  and  relaxed. 
In  rupture  of  the  belly  there  is  a  gap  between  the  two  portions  and  each  por- 
tion causes  a  lump.  In  rupture  of  the  tendon  there  are  not  two  lumps  with 
a  gap  between,  but  there  will  be  a  single  muscular  lump.  In  rupture  of  the 
long  head  the  muscular  belly  is  much  nearer  the  elbow  than  in  health  (Figs. 
449  and  450).  If  rupture  takes  place  at  the  lower  part  of  the  belly,  the  muscle 
passes  toward  the  shoulder.  Rupture  of  the  long  head  of  the  biceps  allows  the 
humerus  to  pass  somewhat  forward  and  upward. 

Flexion  with  the  forearm  supinated  is  much  less  powerful  than  flexion, 
with  the  forearm  pronated  {Hitter's  sign). 


Rupture  of  Muscles  and  Tendons 


719 


In  a  case  of  my  own  in  the  Blockley  Hospital  the  accident  had  occurred 
while  carrying  a  heavy  bucket.  Forearm  iiexion  was  possible,  but  slow, 
feeble,  partial,  and  incomplete.  On  flexion  the  short  head  contracted,  but  the 
musciilar  "bunch"  of  the  belly  was  nearer  the  elbow  than  normally.  Rup- 
ture of  the  plantaris  muscle  {coup  de  fouef;  lawn-tennis  leg)  is  an  injury  which 
is  frequently  not  diagnosticated.  It  occurs  during  exercise  (walkings  bicy- 
cling, jumping,  playing  tennis)  or  is  first  complained  of  after  exercise.     It 


Fig.  44g. — Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

produces  sudden  pain  in  the  middle  of  the  calf,  swelling,  and  often  ecchymosis 
and  inability  to  walk  except  with  a  rigid  ankle  and  everted  toes.  Rupture 
of  the  quadriceps  extensor  femoris  teiuion  results  occasionally  from  force  which 
in  other  cases  fractures  the  patella.  The  rupture  is  just  above  the  patella. 
The  patient  cannot  extend  the  thigh  and  cannot  walk  or  stand  and  there  is 
severe  pain.  A  gap  can  be  felt  just  above  the  patella,  unless  it  is  hidden  by 
synovial  effusion,  and  the  muscle  is  bunched  above. 


Fig.  450. — Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

Treatment.— In  limited  rupture  treat  as  a  severe  strain.  In  treating 
extensive  rupture  of  an  important  muscle,  when  the  ends  are  widely  sepa- 
rated, expose  by  incision,  unite  the  divided  ends  by  sutures  of  chromicized 
catgut  (Fig.  109),  and  sew  up  the  skin  with  silkworm-gut.  _  Treat  the  part  in 
any  case  by  rest  and  relaxation  and  combat  inflammation  by  appropriate 
means.  Passive  motion  and  massage  are  employed  as  soon  as  union  is  firm. 
In  rupture  of  the  quadriceps  extensor  femoris,  operation  should  be  undertaken, 
because  mechanical  treatment  frequently  gives  a  bad  result  and  confines  the 
patient  to  bed  for  weeks.     Rupture  of  the  biceps  requires  incision  and  suture. 


720  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 

In  a  case  in  the  Blockley  Hospital  (Figs.  449,  45°)  I  operated  and  found 
that  the  long  head  with  a  portion  of  periosteum  had  been  torn  off  from  the 
glenoid  cavity.  A  portion  of  the  upper  end  of  the  tendon  was  cut  away 
and  the  tendon  was  fastened  to  the  short  head  by  splitting  and  suture.  Nine 
months  later  the  result  was  perfect  (Keen,  in  "Annals  of  Surgery,"  May, 
1905).  Rupture  of  the  plantaris  is  treated  at  first  by  rest  on  a  posterior  splint 
and  compression  and  later  by  massage  and  the  use  of  an  elastic  bandage. 
The  patient  is  allowed  to  walk  with  the  aid  of  a  cane  in  one  week,  but  he 
should  not  raise  the  heel  for  several  weeks. 

Hernia  of  Muscles. — When  a  tear  takes  place  in  a  muscular  sheath, 
a  portion  of  the  muscle  protrudes. 

The  treatment  is  incision,  restoration  or  extirpation  of  the  protruding 
mass  of  muscle,  and  suturing  of  any  muscle  woimd  and  of  the  sheath. 

Contractions  of  muscles  may  result  from  injury,  from  joint  disease, 
from  malposition  of  parts  (as  in  old  dislocation  or  torticollis),  or  from  diseases 
of  the  nervous  system. 

The  treatment  in  some  cases  is  sudden  extension,  in  other  cases  gradual 
extension,  tenotomy,  or  myotomy.  Macewen  recommends  the  making  of  a 
nimiber  of  V-shaped  incisions  in  the  muscle.  In  some  cases  of  spasmodic  con- 
traction nerve-stretching  is  of  value. 

Dislocations  of  Muscles  and  Tendons. — The  long  head  of  the  biceps 
is  oftenest  displaced.  The  flexor  carpi  ulnaris,  the  peroneus  brevis,  the  per- 
oneus  longus,  the  tibialis  posticus,  the  sartorius,  the  plantaris,  the  quad- 
riceps extensor  femoris,  and  the  extensors  back  of  the  wrist  may  be  dislocated. 
What  is  known  as  dislocation  of  the  latissimus  dorsi,  a  condition  in  which 
that  muscle  no  longer  Kes  upon  the  angle  of  the  scapula,  is,  in  reality, 
paralysis  of  the  serratus  magnus  (see  page  751).  Most  of  these  accidents 
are  associated  with  chronic  joint  disease  or  with  fracture,  but  displacement 
may  exist  as  a  solitary  injury.  Dislocation  of  the  long  head  of  the  biceps  may 
occur  tolerably  early  in  the  progress  of  rheumatoid  arthritis  of  the  shoulder- 
joint,  and  the  displaced  tendon  may  be  absorbed. 

Symptoms. — After  dislocation  of  a  tendon  the  muscle  of  the  tendon  can 
still  contract,  but  it  acts  at  a  disadvantage;  thus  the  corresponding  joint 
exhibits  partial  loss  of  function.  The  displaced  tendon  can  be  felt,  and  a 
hollow  exists  where  it  normally  resides. 

When  the  muscle  contracts,  the  tendon  is  felt  to  slip  from  its  groove. 
When  the  tendon  of  the  biceps  is  dislocated,  the  head  of  the  bone  passes 
forward  (so-called  subluxation  of  the  humerus). 

Treatment. — In  tendon  dislocation  reduction  is  easy,  but  the  displace- 
ment is  apt  to  recur  because  of  laceration  of  the  sheath.  The  treatment 
usually  advised  is  to  effect  reduction  by  relaxation  of  the  limb  and  manipiila- 
tion  of  the  tendon,  to  place  the  part  upon  a  splint  so  that  the  muscle  belonging 
to  the  tendon  will  be  relaxed,  and  to  apply  pressure  over  the  point  of  injury. 
This  treatment  generally  fails,  and  if  the  tendon  does  not  become  firmly 
anchored  in  its  proper  situation  in  four  weeks  we  should  operate.  In  some 
tendons  it  is  enough  to  incise,  freshen  the  edges  of  the  torn  sheath,  and  sew 
up  with  kangaroo-tendon  or  chromicized  catgut.  In  a  tendon  lying  in  a  long 
groove  make  a  halter  for  the  tendon  by  incising  the  periosteum  and  suturing 
it  over  the  tendon.^  Passive  movements  are  begun  at  the  end  of  the  first 
week.  Even  if  the  tendon  will  not  remain  reduced,  a  useful  joint  will  proba- 
bly be  obtained. 

Wounds   of   Tendons. — Subcutaneous  wounds  of  tendons  are  usually 
inflicted  by  the  surgeon,  and  they  heal  well.     Open  wounds  require  rigid  anti- 
sepsis and  suturing  of  the  tendon.     In  wounds  of  the  wrist  especially  always 
1  Walsham's  case  of  dislocation  of  the  proneus  longus,  "Brit.  Med.  Jour.,"  Nov.  2,  1895. 


Palmar  Abscess 


721 


suture  the  divided  tendons  (see  Fig.  no),  and  be  sure  to  bring  the  proper  ends 
into  apposition. 

Rupture  of  Tendons. — A  violent  muscular  effort  may  rupture  a  tendon, 
and  as  the  accident  occurs  a  snap  may  often  be  heard. 

The  symptoms  are  sudden  pain  and  loss  of  power,  fulness  of  the  associated 
muscle  from  retraction,  and  absolute  inability  to  bring  the  tendon  into  action. 
A  gap  ma}^  often  be  felt  in  the  tendon  (see  page  718). 

Treatment. — The  best  procedure  in  treating  rupture  of  a  tendon  is  exposure 
by  incision  and  the  introduction  of  sutures.  Some  surgeons  relax  the  parts 
and  apply  splints  (see  page  718). 

Thecitis,  or  tenosynovitis,  is  inflammation  of  the  sheath  of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion^  from  a  woimd,  from  repeated 
overaction  in  working  or  w^hile  engaged  in  some  sport,  from  rheumatism, 
from  gonorrhea,  from  pyogenic  infection,  from  influenza,  from  a  continued 
fever,  or  from  s}^hilis.  In  early  s}^hilis  certain  tendon-sheaths  may  rapidly 
develop  effusion  because  of  h^'peremia  of  the  sheaths  (Taylor). 

Symptoms. — In  nonsuppurative  cases  of  thecitis  the  sjTnptoms  are  pain, 
swelling,  tenderness,  and  moist  crepitus  along  the  tendon-sheath,  due  to  in- 
flammatory roughening.     The  crepitus  disappears  as  the  swelling  increases, 
but  it  reappears   as  the  swelling  diminishes. 
In  suppurative  cases  (phlegmon  of  the  tendon- 
sheaths)  the  s>Tiiptoms  are  great  sw^elling,  pul- 
satile pain,  dusky  discoloration,  inflammation 
spreading  up    the   tendon-sheaths,  and  often 
the  constitutional  s>Tnptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative 
thecitis  employ  splints,  use  the  hot-air  oven, 
and  apply  locally  iodin,  blue  ointment,  or  ich- 
thyol,  and  administer  suitable  remedies  to  com- 
bat any  causative  constitutional  disease.  In 
the  suppurative  form  inject  i  c.c  of  formahn- 
glycerin  (2  per  cent.)  after  withdrawal  of  part 
or  all  of  the  exudate.  If  this  fails,  make  free 
incisions,  irrigate,  drain,  dress  with  hot  anti- 
septic fomentations,  and  employ  Bier's  method 
(see  page  112).     (See  Felon,  page  724.) 

Palmar  Abscess. — ^We  mean  by  this 
term  an  abscess  beneath  the  palmar  fascia 
and  not  a  superfical  collection  of  pus.  Palmar 
abscess  may  arise  after  wounds,  abrasions, 
burns,  or  inflammations  of  the  skin  of  the 
palm.  A  thecal  abscess  in  a  flexor  tendon 
of  a  finger  travels  rapidly  upward  and  may 

produce  a  palmar  abscess.  A  thecal  abscess  of  either  the  index,  ring,  or  middle 
finger  is  usually  arrested  at  the  lower  end  of  the  palm,  but  suppurative  thecitis 
of  the  thumb  or  the  little  finger  conducts  pus  along  the  tendon  sheath  and  up  the 
arm  (Fig.  451).  If  the  theca  ruptures,  pus  is  diffused  over  the  palm.  Abscess 
produces  great  swelling  of  the  hand  and  fingers,  the  dorsum  being  swollen  as 
w^ell  as  the  palm.  The  fingers  become  flexed  and  rigid.  Violent  pulsatile  pain 
and  decided  constitutional  disturbance  exist.  Discoloration  is  late  in  appear- 
ing. Related  lymph-glands  enlarge.  Palmar  abscess  is  a  most  serious  affec- 
tion. The  pus  may  dissect  up  all  the  structures  of  the  palm,  may  pass  between 
the  bones  and  reach  the  dorsum,  or  may  pass  beneath  the  anterior  annular 
ligament  into  the  connective-tissue  planes  of  the  forearm.  In  some  cases  it 
leaves  a  clawed,  stiff,  and  useless  hand. 
46 


Fig.  451. — Palmar  synovial  sheaths 
(vaginas  tendinum),  normal  adult  type 
(Poirier  and  Charpy). 


722  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

Treatment. — A  palmar  abscess  demands  radical  treatment  at  the  earliest 
possible  moment;  delay  will  be  responsible  for  stiiJ  and  contracted  fingers  and 
hyperesthetic  skin,  a  damaged  and  perhaps  a  useless  hand.  The  patient 
should.be  placed  under  the  influence  of  ether.  The  incision  is  made  in  the 
line  of  the  metacarpal  bone  and,  if  possible,  below  the  palmar  arches.  A 
line  transverse  with  the  web  of  the  thumb  is  below  the  palmar  arches.  In  an 
incision  above  this  line  try  not  to  cut  either  arch ;  but  if  one  should  be  cut,  at 
once  take  means  to  arrest  the  hemorrhage  (see  page  449).  In  a  severe  case  it 
may  be  necessary  to  make  several  palmar  incisions,  to  open  the  tendon-sheaths 
on  the  flexor  surface  of  the  forearm  above  the  wrist,  and  to  make  counter- 
openings  in  the  back  of  the  hand,  and  it  is  sometimes  necessary  to  introduce 
tubes,  and  drain  through  and  through  the  hand.  After  operation  apply  hot 
antiseptic  fomentations  and  put  the  part  upon  a  splint.  Bier's  passive  hy- 
peremia is  very  useful.  When  granulations  begin  to  form,  dry  dressings 
are  substituted  for  hot  moist  dressing.  It  may  be  necessary  to  give  morphin 
for  pain,  and  stimulants  may  be  needed.  There  is  great  danger  of  stiff- 
ness of  the  fingers  occurring,  the  tendons  becoming  adherent  to  their  sheaths. 
Hence  passive  movements  are  inaugurated  as  soon  as  granulations  begin  to 
form. 

Chronic  thecitis  may  follow  acute  thecitis,  but  may  be  due  to  injury, 
to  rheumatism,   to  gummatous  infiltration,   to  rheumatoid  arthritis,   or  to 


Fig.  452. — Tuberculous  thecitis  (compound  ganglion). 

tuberculous  inflammation  of  a  tendon-sheath.  Chronic  thecitis  is  commonest 
in  the  tendons  at  the  wrists,  the  ankles,  and  the  knees;  it  may  spread  to  a 
joint  or  it  may  arise  from  a  tuberculous  joint.  This  condition  causes  very 
little  pain.  In  ordinary  non-tuberculous  thecitis  the  part  is  weak,  tender, 
painful  and  stiff,  crepitates  on  motion,  and  is  swollen.  In  tuberculous  thecitis 
there  is  at  first  distention  of  the  tendon-sheath  with  serum.  The  serum 
contains  rice,  riziform,  or  melon-seed  bodies,  and  the  wall  of  the  tendon- 
sheath  is  here  and  there  thickened  and  caseating.  Later  in  the  case  the 
interior  of  the  tendon-sheath  becomes  lined  with  tuberculous  granulations 
and  a  tuberculous  abscess  may  form.  Rice  bodies  are  sometimes  fibrin- 
ous masses,  are  sometimes  pieces  of  separated  and  dead  recently  formed 
fibrous  tissue,  and  are  sometimes  masses  of  proliferating  cells.  In  tubercu- 
lous cases  the  swelling  is  firm  or  doughy  when  due  to  granulation  tissue, 
but  is  fluctuating  when  due  to  fluid.  Grating  is  marked.  Tubercle  baciUi 
are  present  in  the  fluid  or  in  the  granulation  tissue.  Tuberculous  thecitis  is 
most  common  about  the  wrist,  constituting  the  so-called  compound  ganglion 
(Fig.  452)- 

Treatment. — Tuberculous  cases  are  treated  as  follows:  If  there  is  a  fluid 
effusion  and  no  rice  bodies,  make  a  small  incision,  wash  out  with  salt  solu- 
tion, introduce  iodoform  emulsion  or  formalin-glycerin,  and  close  the  wound. 
In  cases  in  which  there  are  rice  bodies,  open  the  sheath,  evacuate  the  con- 


Treatment  of  Simple  Ganglia  723 

tents,  scrape  the  walls  thoroughly,  inject  iodoform  emulsion  or  formalin- 
glycerin,  and  close  the  wound.  (If  the  annular  ligament  requires  division, 
stitch  it  before  closing  the  wound — Fig.  453.)  In  cases  with  extensive  thick- 
ening apply  an  Esmarch  bandage,  make  a  large  incision,  and  remove  all  in- 
fected tissue  from  the  sheath,  around  the  sheath,  and  from  the  tendon.  In 
tuberculous  thecitis  Bier's  method  (see  page  112) 
may  be  of  service  and  so  may  the  jc-rays.  In  or- 
dinary traumatic  thecitis  use  for  the  first  few  days 
rest  associated  with  applications  of  ichthyol.  Later 
employ  hot  and  cold  douches,  massage  and  passive 
movements,  strapping  of  the  part,  inunctions  of 
ichthyol,  and  the  hot-air  bath.  If  effusion  is  per- 
sistent or  rice  bodies  exist,  make  an  incision  and 
scrape  the  interior  of  the  tendon-sheaths.  In  rheu- 
matic cases  give  antirheumatic  remedies  and  em-  ing  tlfe  Inn^f ligament  of  the 
ploy  the  hot-air  bath.  In  syphilitic  cases  admin-  wrist. 
ister  mercury  and  iodid  of  potassium. 

Simple  Ganglia. — In  connection  with  tendon-sheaths  and  joints  simple 
ganglia  may  develop.  They  are  small,  tense,  round  swellings,  which  are  firm, 
grow  progressively  though  slowly,  are  painless  when  uninflamed,  and  contain  a 
fluid  of  the  appearance  and  consistence  of  glycerin- jelly  (Bowlby).  Ganglia  are 
commonest  upon  the  dorsum  of  the  wrist  and  they  occur  especially  in  those 
who  constantly  use  the  wrist  muscles.  Ganglia  are  occasionally  seen  on  the 
dorsum  of  the  foot.  Paget  states  that  a  simple  ganglion  is  due  to  cystic  de- 
generation of  a  sjmovial  fringe  inside  a  tendon-sheath,  and  that  the  fluid  of 
the  ganglion  does  not  communicate  with  the  fluid  of  the  tendon-sheath.  Other 
pathologists  have  maintained  that  a  simple  ganglion  is  a  hernia  of  synovial 
membrane  through  a  rent  in  a  tendon-sheath,  all  communication  between  the 


Fig.  454. — Ganglion  of  extensor  tendon-sheaths  of  the  wrist. 

herniated  part  and  the  tendon-sheath  being  soon  obliterated.  The  belief  is 
now  general  that  a  ganglion  is  due  to  cystic  degeneration  of  an  area  of  con- 
nective tissue  adjacent  to  a  joint  or  a  tendon,  this  area  of  tissue  having  been 
rendered  extremely  cellular  by  traumatism.  A  number  of  minute  cysts 
form  and  they  coalesce  into  one  cyst.  The  cyst  may  form  a  secondary  com- 
munication with  the  interior  of  a  tendon-sheath  or  joint.  Ganglia  occasionally 
diminish  in  size  or  even  disappear  spontaneously. 

Treatment. — A  ganglion  is  treated  by  aseptic  puncture  by  a  tenotome, 
evacuation,  scarification  of  the  walls,  antiseptic  dressing,  and  pressure.  An 
old-time  method  of  treatment  was  subcutaneous  rupture  brought  about  by 


724 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 


striking  with  a  heavy  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hypodermatic  needle.  The  cyst  is  not  evacuated 
before  injection.  The  parts  are  dressed  antiseptically,  and  cure  is  obtained 
in  one  week.  Recurrent  gangha,  very  large  gangUa,  and  ganglia  with  very 
thick  contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  violent,  rapidly  spreading  pyogenic  inflamma- 
tion of  a  finger  or  a  toe  which  resembles  cellulitis,  and  which  is  sometimes 
followed  by  gangrene  of  the  soft  parts  or  by  necrosis  of  bone  (Fig.  455). 
An  injury  precedes  the  whitlow — an  abrasion  of  the  surface  which  admits 
pus-organisms  or  a  contusion  which  creates  a  point  of  least  resistance. 
The  commonest  seat  of  a  felon  is  the  last  digit  of  a  finger  or  the  thimib. 
An  abrasion  of  the  surface  at  this  point  absorbs  pus-organisms  and  the  super- 
ficial lymphatics  carry  the  bacteria  directly  inward,  the  micro-organisms  lodg- 
ing, it  may  be,  in  the  skin,  in  the  subcutaneous  tissues,  in  the  tendon-sheath,  or 
beneath  the  periosteum.     The  perpendicular  direction  of  the  fibers  of  the 

subcutaneous    tissue    favors 
'  ^      this  passage  inward. 

Felons  are  very  rare  in 
infants,  but  may  occur  in 
children.  Women  are  more 
liable  to  them  than  men. 
The  fingers  are  much  more 
prone  to  infection  than  the 
toes,  because  they  are  more 
exposed  to  injury.  Several 
fingers  may  be  attacked  at 
once  or  successively  in  per- 
sons of  dilapidated  consti- 
tution. Whitlow  is  most 
apt  to  occur  and  is  most 
severe  in  persons  broken 
down  by  disease,  alcoholism, 
overwork,  or  worry.  In  cer- 
tain cases  of  neuritis  painless 
suppuration  may  arise.  In 
syringomyelia  painless  felons 
are  common,  and  they  are  apt 
to  be  associated  with  necrosis  of  bone.  Painless  and  destructive  whitlows 
constitute  a  characteristic  part  of  Morvan's  disease. 

There  are  two  forms  of  felons,  the  superficial  and  the  deep. 
Superficial  Felons. — One  form  of  superficial  felon  is  between  the  cuticle 
and  the  true  skin  and  is  rarely  followed  by  involvement  of  deeper  parts.  The 
infection  is  in  the  skin.  The  point  of  infection  becomes  dark  red,  swollen, 
painful,  and  tender.  The  epidermis  is  lifted  up  into  a  pustule  by  the  seropus 
which  forms,  and  a  considerable  area  may  be  attacked  before  the  spread  of  the 
process  is  arrested.  The  commonest  form  of  superficial  felon  is  subcutaneous 
suppuration,  the  pus  collecting  in  the  fibrofatty  pad  at  the  palmar  surface 
of  the  last  digit  (G.  B.  Mower  White,  in  "Brit.  Med.  Jour.,"  Feb.  24,  igo6). 
This  form  often  spreads  deeply.  If  the  subcutaneous  tissues  only  are  involved 
the  symptoms  are  those  of  an  ordinary  cellulitis.  There  is  severe  pain,  increased 
by  motion,  pressure,  and  a  dependent  position.  Swelling  and  discoloration 
are  early  and  marked.  Pus  forms  within  forty-eight  hours.  Paronychia, 
or  ring  around,  is  cellulitis  starting  at  the  end  or  side  of  the  digit,  and  in- 
volving the  parts  around  and  below  the  nail.  The  pus-organisms  obtain  en- 
trance by  means  of  an  abrasion,  a  puncture,  or  an  ulcerated  "step-mother." 


Fig.  455. — Deep  felon,  with  sloughin, 
necrosis  of  bone. 


of  soft  parts  and 


Deep  Felons 


725 


In  paronychia  pain  is  throbbing  and  violent;  is  increased  by  motion,  pres- 
sure, or  a  dependent  position ;  the  skin  is  dusky  red,  but  the  swelling  is  slight. 
In  about  forty-eight  hours  pus  forms  in  the  superficial  parts,  the  epidermis 
being  lifted  into  pustules  or  blebs,  and  pus  may  also  form  under  the  nail.  A 
portion  of  the  nail  or  the  entire  nail  may  be  lost. 

If  the  tendon-sheath  becomes  involved  as  well  as  the  subcutaneous  tissue, 
the  s\Tnptoms  are  those  of  suppurative  thecitis,  with  more  marked  discoloration 
of  the  skin. 

Deep  Felons  (Fig.  455). — There  are  two  forms  of  deep  felon.  One  is  a 
thecal  suppuration  involving  the  flexor  tendon-sheath,  arising  secondarily  to 
subcutaneous  suppiu"ation  and  spreading  widely.  In  suppurative  thecitis  of 
the  three  middle  fingers  the  process  seldom  reaches  the  palm;  in  suppurative 
thecitis  of  the  theca  of  the  thumb  or  little  finger  the  pus  may  pass  above  the  wrist 
and  a  true  palmar  abscess  may  form  (see  Fig.  451).  Another  form  is  suppuration 
beneath  the  periosteum.  This  form  is  the  so-called  hone  felon.  It  is  occasion- 
ally primar}',  but  more  often  arises  secondarily  to  suppurative  thecitis  or  to  sub- 
cutaneous suppuration.  In  some  cases  a  deep  felon  involves  most  of  the  struc- 
tures of  the  finger  (periosteum,  bone,  tendon,  tendon-sheath,  and  cellular  tissue), 
and  may  destroy  the  digit  or  the  finger.  The  bacteria  causative  of  a  deep 
felon  are  lodged  in  the  deeper  parts.  The  pain  is  agonizing,  entirely  pre- 
venting sleep,  pulsatile  in  character,  associated  with  excruciating  tender- 
ness, greatly  aggravated  by  motion  or  a  dependent  position,  and  often  extend- 
ing up  the  hand  and  forearm.  The  skin  is  dusky  red  and  edematous,  and 
the  part  is  enormously  swollen.  Pus  forms 
quickly;  diffuse  cellulitis  may  arise;  slough- 
ing of  the  tendon  and  subcutaneous  tissue  may 
take  place;  necrosis  of  one  or  more  bones  may 
ensue,  and  in  some  cases  gangrene  of  the  finger 
follows. 

In  deep  whitlow  hTnphangitis  of  the  fore- 
arm and  arm  is  not  unusual,  adenitis  of  the  axil- 
Ian,-  glands  is  common,  and  almost  always 
there  is  fever.  In  superficial  felon  consti- 
tutional s}Tnptoms  are  slight  or  absent,  and 
l}Tnphangitis  and  adenitis  arise  in  a  minority 
of  cases. 

Treatment.  —  In  a  subcuticular  felon,  after 
cleansing,  soften  the  parts  well  in  an  antiseptic 
fluid  and  then  pare  off  the  cuticle  \\At\i  a  very 
sharp  knife.  This  plan  of  \Miite's  is  an  excellent 
one;  it  gives  vent  to  pus  and  prevents  the  inocu- 
lation of  the  deeper  tissues  which  may  follow  in- 
cision. In  subcutaneous  suppuration  incise  the 
abscess,  but  be  careful  not  to  open  the  tendon- 
sheath  or  periosteum,  as  this  would  diffuse  infection  (White,  in  "Brit.  ]Med. 
Join-.,"  Feb.  24, 1906).  In  neither  of  the  above  instances  is  it  necessary-  to  give  an 
anesthetic.  After  operating,  the  parts  must  be  irrigated,  dressed  with  hot  anti- 
septic fomentations,  the  hand  must  be  placed  upon  a  splint,  and  Bier's  passive 
hyperemia  is  to  be  induced  daily.  In  a  deep  felon  I  am  convinced  that  we 
should  operate  immediately.  AUay  tension  and  prevent  pus  formation  by 
early  incision.  Do  not  waste  time  T\dth  poultices;  to  wait  means  agonizing 
pain,  sleepless  nights,  constitutional  involvement,  and,  perhaps,  sloughing 
of  tendons  or  death  of  bone.  Incision  and  drainage  constitute  the  treatment, 
but  incision  conducted  in  a  particular  manner.  I  have  only  lately  learned 
how  to  treat  a  deep  felon.     I  formerly  treated  all  cases  by  incisions  do^-n  to 


456.^1,  2,  and  3,  Incisions 
for  felon  of  finger  and  for  ordinarj' 
suppuration;  4,  palmar  incision. 


726  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

the  bone  alongside  of  the  tendon  (Fig.  456),  and  was  frequently  disappointed 
by  a  spread  of  the  suppuration  in  spite  of  incisions,  by  necrosis  of  bone,  or 
by  extensive  sloughing  of  tendons.  I  obtained  new  light  upon  this  subject 
from  an  article  on  "Whitlow,"  by  G.  B.  Mower  White  ("Brit.  Med.  Jour.," 
Feb.  24,  1906).  I  immediately  put  in  practice  the  common-sense  sugges- 
tions in  this  valuable  article  and  have  seen  a  surprising  improvement  in 
results.  The  chief  points  in  White's  plan  of  treatment  are  as  follows:  To 
plunge  a  knife  through  an  area  of  infection  into  a  tendon-sheath,  if  that  sheath 
is  not  infected,  will  lead  to  infection,  and  the  way  to  be  sure  whether  it  is  or 
is  not  infected  is  to  look  through  a  carefully  made  incision  and  see.  After 
careful  sterilization,  anesthetize,  drain  the  extremity  of  blood  by  elevation, 
and  apply  an  Esmarch  band  to  the  arm.  This  enables  us  to  see  what  we  are 
doing.  Slowly  and  carefully  make  an  incision  by  the  side  of  the  tendon-sheath 
(Fig.  456),  and  on  reaching  it  see  if  it  is  distended.  If  in  doubt,  insert  a 
hypodermatic  needle  and  withdraw  fluid.  If  we  get  turbid  serum,  the  theca 
is  infected.  If  the  theca  is  not  infected,  do  not  open  it,  but  incise  the  subperi- 
osteal area  of  suppuration  if  it  exists.  If  the  theca  is  infected,  remember  that 
this  infection  has  surely  ascended  more  or  less,  and  we  must  not  only  open  at 
the  lower  point,  but  must  also  incise  at  the  upper  point.  Do  not  incise  the 
theca  over  the  length  of  the  tendon,  as  sloughing  will  follow.  If  one  of  the  three 
middle  fingers  is  involved,  incise  the  distal  end  of  the  theca  and  also  the  proximal 
end  over  the  head  of  a  metacarpal  bone  in  the  midline,  wash  from  opening  to 
opening,  and  drain.  If  the  theca  of  the  thumb  or  little  finger  is  involved,  open 
distally  and  then  proximally  above  the  wrist.  To  reach  the  proximal  end  of 
the  theca  of  the  thumb  cut  at  the  radial  side  of  the  tendon  of  the  flexor  carpi 
radialis.  Also  open  the  palmar  sac  of  the  flexor  longus  poUicis,  making  the  cut 
along  the  inner  border  of  the  outer  head  of  the  flexor  brevis  pollicis. 

To  reach  the  proximal  end  of  the  theca  of  the  little  finger  begin  an  incision 
at  the  upper  margin  of  the  annular  ligament  and  carry  it  up  along  the  inner 
border  of  the  flexor  sublimis.  Retract  the  tendons  and  pus  will  usually 
be  found  between  the  tendons  of  the  superficial  and  deep  flexor.  Look  beneath 
the  profundus  tendons  for  the  bursa  and  open  it.  Then  open  the  palm  by  an 
incision  in  the  line  of  the  axis  of  the  ring-finger.  Thus  three  openings  are  made 
in  either  case,  and  the  theca  can  be  thoroughly  washed  and  drained.  If 
either  the  thumb  or  little  finger  bursa  is  found  infected,  the  other  must  be 
exposed  and  examined,  as  they  usually  communicate  at  their  proximal  ends 
or  a  communication  may  form  as  a  result  of  suppuration.  Rupture  of  either 
bursa  may  diffuse  pus  widely.  White,  in  order  to  prevent  secondary  hem- 
orrhage, ligates  the  radial  artery  in  two  places  and  removes  i|  inches  of  it 
(if  operating  on  the  thumb  bursa);  and  ligates  the  superficial  arch  and  re- 
moves I  inch  of  it  (if  operating  on  the  palmar  expansion  of  the  little  finger 
theca).  These  arterial  ligations  seem  a  serious  and  perhaps  unnecessary  addi- 
tion to  the  operation  and  I  have  not  practised  them.  After  thorough  irriga- 
tion apply  antiseptic  fomentations,  splint  the  extremity,  and  induce  Bier's 
passive  hyperemia  daily.  If  the  patient  cannot  sleep,  give  morphin.  See 
that  the  bowels  are  moved  once  a  day.  Give  quinin,  iron,  and  milk-punch. 
As  soon  as  granulations  begin  to  form,  use  dry  dressings  and  make  passive 
motion  daily.  If  bone  undergoes  necrosis,  let  it  loosen  and  then  remove  it. 
Amputation  is  sometimes  necessary. 

Bursitis  is  inflammation  of  a  bursa.  Acute  bursitis  arises  from  strain,  from 
traumatism,  or  from  infection.  The  symptoms  of  acute  bursitis  are  pain, 
limited  swelling,  moist  crepitus,  fluctuation,  and  discoloration  in  the  anatom- 
ical position  of  a  bursa.  In  chronic  bursitis  there  is  intermittent  pain,  tender- 
ness, and  progressive,  fluctuating  swelling.  Bursitis  of  the  retrocalcaneal  bursa 
(Albert's  disease)  is  a  painful  affection  which  is  often  overlooked.    It  is  rather 


Bursitis 


727 


common  in  storekeepers  who  rise  often  on  the  toes  to  reach  shelves,  in  motor- 
men  who  use  a  foot  gong,  in  street-car  conductors,  and  in  clerks  who  stand  at 
desks.  It  may  follow  gonorrhea  and  may  be  tuberculous.  Walking  causes  great 
pain  in  the  heel.  Raising  up  on  the  toes  is  exceedingly  painful.  It  is  usually 
associated  with  flat-foot.  In  these  cases  osteophytes  often  form  within  the 
bursa.  There  are  numerous  bursas  about  the  hip.  Some  anatomists  count 
twenty-one.^  The  two  most  important  bursae  and  the  ones  usually  affected  are 
the  iliac  and  the  deep  bursa  over  the  great  trochanter."  Inflammation  of  the 
iliac  or  iliopsoas  bursa  produces  swelling  below  Poupart's  ligament,  which  swell- 
ing is  tense,  but  exhibits  fluctuation  on  careful  examination.  Often  the  swell- 
ing attains  large  size.  In  some  cases  the  sac  can  be  emptied  by  pressure,  the 
fluid  passing  into  an  adjacent  bursa  or  into  the  joint.  The  swelling  is  beneath 
the  femoral  artery  and  consequently  lifts  that  vessel  (F.  B.  Lund,  in  "Boston 
Med.  and  Surg.  Jour.,"  Sept.  25,  1902).  The  enlargement  often  presses  on 
the  anterior  crural  nerve  and  causes  spasmodic  pain  throughout  the  nerve's 
trajectory.  The  limb,  according  to  Zuelzer,  is  usually  slightly  flexed,  abducted 
and  rotated  outward,  and  movement  in  an  opposite  direction  causes  pain. 
Inflammation  of  the  bursae  about  the  hip  may  produce  symptoms  resembling 
those  of  incipient  coxalgia,  but  in  bursitis  the  symptoms  do  not  remit,  as  in  hip- 
disease.  Iliopsoas  bursitis  occasionally 
results  from  gonorrhea.  The  bursa  is 
sometimes  involved  in  joint-disease.  In 
inflammation  of  the  iliac  bursa  flexion  is 
not  so  marked  as  in  coxalgia,  and  the 
trochanter  is  never  above  Nelaton's 
line.  In  inflammation  of  the  deep 
trochanteric  bursa  the  position  is  the 
same  as  in  iliac  bursitis,  and  resem- 
bles that  of  coxalgia.  In  coxalgia, 
however,  there  is  pain  on  pressure 
upon  the  front  of  the  joint  or  directly 
on  the  trochanter  or  on  tapping  the 
sole  of  the  foot.  These  manipula- 
tions do  not  cause  pain  in  bursitis 
(Zuelzer).  In  inflammation  of  the 
gluteal  hurs(E  there  is  moderate  pain 
back  of  the  thigh  and  knee,  which  dis- 
appears when  the  patient  is  at  rest ;  there 

are  a  marked  limp,  limitation  of  motion,  and  an  area  of  deep  fluctuation  in  the 
buttock  (Brackett). 

It  is  difficult  to  differentiate  between  inflammation  of  a  deep  bursa  and 
synovitis;  indeed,  in  bursitis  the  joint  is  apt  to  be  secondarily  affected.  This 
difficulty  is  especially  vexatious  in  distinguishing  between  joint-injury  and 
injury  of  the  bursa  beneath  the  deltoid.  In  subdeltoid  bursitis  there  is  a 
tender  spot  over  the  bursa  when  the  arm  is  by  the  side.  When  the  surgeon 
abducts  the  patient's  arm  the  bursa  slips  up  under  the  acromion  and  no 
tender  spot  can  be  found.  Suppuration  may  take  place  in  a  bursa.  Direct 
force  may  rupture  a  bursa.  The  bursa  beneath  the  deltoid  is  frequently 
ruptured.  When  this  accident  happens,  there  are  pain,  marked  swelHng, 
a  large  area  of  moist  crepitus,  and  later  extensive  discoloration  from  blood. 
Chronic  bursitis  may  follow  acute  bursitis,  or  the  disease  may  be  chronic 
from  the  start.  It  may  be  due  to  tuberculosis.  Bursae  particularly  apt  to 
become  tuberculous  are  those  about  the  hip,  the  subdeltoid,  the  olecranon, 
the  prepatellar,  and  the  retrocalcaneal.  In  tuberculous  bursitis  during  the 
1  Synnestvedt,  of  Sweden.  2  Zuelzer,  in  "Zeit.  f.  Chir.,"  vol.  1. 


Fig.  457. — Olecranon  bursitis. 


728 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 


Fig.  458. — Housemaids"  knee 


first  stage  the  bursa  is  distended  by  fluid,  due  to  oversecretion,  the  walls 
are  thickened  here  and  there,  and  perhaps  contain  caseous  foci  and  rice 
bodies  are  found  in  the  bursal  fluid.    In  a  more  advanced  stage  the  bursal 

wall  is  lined  with  caseating 
granulation  tissue  and  the  bursa 
may  become  a  tuberculous  ab- 
scess, the  walls  may  give  way 
with  diffusion  of  the  process,  or 
mixed  infection  wdth  pyogenic 
organisms  may  occur.  In  some 
cases  of  tuberculous  bursitis 
tending  to  cure  the  bursal  walls 
become  enormously  thickened  by 
fibrous  tissue. 

The  symptom  of  chronic  bursi- 
tis is  swelling  but  little  or  no  pain 
unless  acute  inflammation  arises. 
Chronic  bursitis  of  the  prepatel- 
lar bursa  is  known  as  housemaids^ 
knee  (Fig.  458).  Chronic  bursitis 
of  the  subhyoid  bursa  is  known 
as  Bayer's  cyst.  There  are  six 
bursae  about  the  ham,  the  larg- 
est of  which  is  the  bursa  of 
the  semimembranosus  muscle. 
Treatment. — Acute  bursitis  is  treated  by  rest,  pressure,  and  the  appli- 
cation of  iodin,  blue  ointment,  or  ichthyol.  If  the  swelling  persists,  aspirate 
and  apply  pressure,  or  incise  the  sac  and  remove  it  partly  or  completely. 
If  pus  forms,  incise,  paint  the 
interior  of  the  sac  mth  pure 
carbolic  acid,  and  pack  with 
iodoform  gauze.  Chronic  bur- 
sitis may  be  cured  by  the  use 
of  pressure  and  the  application 
of  blue  ointment,  and  with  treat- 
ment of  any  causative  diathesis, 
but  most  cases  require  incision 
and  packing.  A  ruptured  bursa 
is  treated  as  an  acute  bursitis. 
In  bursal  tuberculosis  the  best 
treatment  is  excision.  If  we 
are  dealing  with  a  very  deep 
biu"sa  the  proper  treatment  is 
incision,  scraping  with  a  sharp 
spoon,  mopping  with  carbolic 
acid,  and  packing  with  iodo- 
form gauze. 

Bursitis  of  the  subacro= 
mial  bursa  has  been  considered 
by  A.  E.  Codman  ("Boston 
Med.  and  Surg.  Jour.,"  Oct. 
22  and  2g,  Nov.  5,  12,  19,  and 
26,  and  Dec.  3,  1908),  who  points  out  that  the  deltoid  and  the  subacromial 
bursa  are  one  and  the  same  thing.  When  the  arm  is  abducted,  the  entire 
bursa  is  subacromial;  when  it  is  adducted,  a  large  portion  of  the  bursa  is 


Fig.  45g. — Diagram  from  a  frozen  section.  Notice 
the  deltoid  and  its  origin,  from  the  edge  of  the  acromion. 
Notice  the  subdeltoid  or  subacromial  bursa  with  its  roof 
made  by  the  under  surface  of  the  acromion  and  by  the 
fascia  beneath  the  upper  portion  of  the  deltoid.  Its  base 
is  on  the  greater  tuberosity  and  the  tendon  of  the  supra- 
spinatus,  which  separates  it  like  an  interarticiilar  fibro- 
cartilage  from  the  true  joint  (Codman) . 


Treatment  of  Bursitis  of  the  Subacromial  Bursa 


729 


subdeltoid.  Codman  describes  three  types  of  conditions  associated  with 
inflammation  of  this  bursa,  first:  The  acute,  or  spasmodic  type,  in  which 
there  is  local  tenderness  on  the  point  of  the  shoulder,  just  below  the  acro- 
mion process  and  outside  the  bicipital  groove.  In  some  cases  Dawbarn  has 
shown  that  the  tender  point,  which  is  the  base  of  the  bursa,  disappears  under 
the  acromion  when  the  arm  is  abducted.  Codman  goes  on  to  show  that  in 
attempting  abduction  about  ten  degrees  of  motion  can  be  obtained  without 
moving  the  scapula.  Then  the  scapula  is  locked  by  spasm  and  moves  with 
the  humerus.  This  spasm  may  be  temporary  in  mild  cases.  Sometimes  pain 
prevents  the  patient  from  voluntarily  raising  the  arm,  though  it  may  be  raised 
by  passive  motion.  The  pain  may  run  down  the  outer  side  of  the  arm,  even 
into  the  hand;  the  patient  frequently  locates  the  pain  about  the  insertion  of  the 
deltoid,  and  may  be  able  to  note  swelling  of  the  bursa. 

Codman  describes  type  two,  the  subacute  or  adherent  type,  in  which 
there  are  adhesions  between  the  roof  and  floor  of  the  bursa  and  a  definite 
mechanical  hindrance  to  abduction  and  external  rotation.  There  may  or  may 
not  be  local  tenderness,  but  Dawbarn's  sign  is  absent,  owing  to  the  presence 
of  the  adhesions.  Abduction  is 
limited  to  such  a  great  degree 
that,  as  a  rule,  the  tuberosity  will 
not  pass  beneath  the  acromion. 
Any  movement  in  abduction 
beyond  ten  degrees  causes  the 
scapula  to  move.  The  pain  is 
located  as  in  type  one,  and  fre- 
quently also  passes  into  the  neck. 
In  some  cases  it  is  very  severe. 

Codman 's  third  form  is  the 
chronic  and  non-adherent.  In 
this  the  full  arc  of  motion  is  re- 
tained, but  motion  is  painful. 
The  bursa  is  thickened  and  ir- 
regular. There  may  or  may  not 
be  local  tenderness;  and  if  this 
is  present,  one  will  find  Daw- 
barn's  sign.  Abduction  and  ex- 
ternal rotation  are  limited  little, 
if  at  all,  but  at  some  point  dur- 
ing abduction  there  is  severe 
tenderness,  which  disappears  as 
soon  as  the  tuberosity  passes  be- 
neath the  acromion.  The  scapula  does  not  accompany  the  motions  of  the 
humerus.     There  is  often  considerable  pain  after  motion. 

Codman  points  out  that  the  prognosis  in  type  one  is  very  favorable  if 
treatment  is  correct.  In  t3^e  two  the  disability,  even  without  treatment, 
seldom  lasts  more  than  two  years.  He  says  that  even  severe  or  adherent 
cases,  if  there  are  no  secondary  contractures  in  the  forearm  muscles,  wiU 
recover  in  from  one  to  two  years.  In  infective  cases  the  prognosis  is  far  worse 
than  in  traumatic  cases.  In  chronic  cases,  in  which  the  arc  of  mobility  is  not 
affected,  the  prognosis  is  fairly  good. 

Treatment. — Acute  cases  of  subacromial  bursitis  should  be  treated  by 
keeping  the  arm  abducted  in  a  splint  (Fig.  461).  Monks  suggests  that  the 
patient  may  sit  by  a  table,  the  arm  being  abducted  and  placed  upon  a  pillow 
that  is  on  the  table.  This  relaxes  the  short  rotators  and  the  deltoid,  and  keeps 
the  base  of  the  biursa  from  being  in  contact  with  the  acromion.    At  night 


Fig.  460. — Showing  incision  used  for  demonstration  of 
the  bursa  (Codman). 


730  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

Codman  places  the  arm  on  a  pillow,  with  its  lonj^;  axis  at  right  angles  to  the 
patient's  body  as  he  lies  recumbent.  If  the  patient  has  to  get  about,  he  niay 
use  a  sling  most  cautiously.  He  should  take  the  arm  out  from  time  to  time 
and  rest  it  on  a  table.  Massage  should  be  used  about  the  bursa,  but  not 
directly  over  it.  In  the  more  severe  cases  with  adhesions  one  may  employ 
massage,   passive   and   active   movements,   baking,   forcible   movement   and 


Fig.  461. — Showing  the  abduction  splint  in  position,  the  patient  standing.  It  is  held  by  a  fig- 
ure-of-8  bandage,  which  crosses  behind  the  shoulders  and  by  a  belt  about  the  hips.  The  arm  is  at  rest 
(Codman). 

Description  of  Splint. — ^The  frame  of  the  splint  which  I  use  is  made  of  iron  wire  (diameter,  \  inch), 
stiff  enough  to  maintain  its  form  and  to  carry  the  weight  of  the  arm  securely.  SufiScient  cotton  wadding 
to  thoroughly  pad  it  is  bandaged  over  it  and  the  whole  covered  with  cotton  or  linen  cloth.  The  general 
shape  is  shown  in  the  photograph.  It  should  be  just  long  enough  to  extend  from  the  axilla  to  the  seat 
of  the  chair  on  which  the  patient  sits.  It  is  best  held  in  position  by  a  belt  around  the  pelvis  and  a 
fig\ire-of-8  flannel  bandage  about  the  shoulders  crossing  back  of  the  neck.  A  pad  should  be  placed  in 
the  opposite  axilla  to  prevent  excoriation  of  the  skin  by  the  bandage. 

During  the  first  twenty-four  hours  and  afterward,  if  worn  at  night,  the  arm  should  also  be  Ughtly 
bandaged  to  the  projecting  part  of  the  splint.  Additional  security  is  given  by  the  appUcation  of  a  swathe, 
which  may  be  pinned  to  the  bandage  of  the  axilla. 

When  properly  adjusted  it  is  perfectly  comfortable.  Unless  it  is  comfortable  it  is  useless.  The 
use  of  the  spUnt  is  not  essential  and  is  even  harmful  if  not  skilfully  cared  for. 

manipulation  under  an  anesthetic,  followed  by  fixation  in  the  position  of 
abduction  (Fig.  461),  or  perhaps  incision  of  the  bursa  with  division  of  the 
adhesions  or  excision  of  the  subdeltoid  portion  of  the  bursa  (Codman).  In 
the  cases  in  which  there  is  irregularity  of  the  surface  of  the  bursa,  one  should 
excise  and  remove  the  thickened  folds  or  other  irregularities. 

Housemaids'  knee  (see  Fig.  458)  is  thickening  and  enlargement  of  the 
prepatellar  bursa,  the  result  of  intermittent  pressure.    In  effusion  into  the  knee- 


Treatment  of  Special  Forms 


731 


loint  the  fiuid  is  behind  the  patella  and  the  bone  floats  up;  in  housemaids' 
knee  the  fluid  is  above  the  bone  and  the  osseous  surface  can  be  felt  beneath  it. 


Fig.  462. — Bursitis  of  left  olecranon  bursa  of  three  years'  duration. 

In  bursitis  of  the  deep  infrapatellar  bursa  the  swelling  is  under  the 
hgament  of  the  patella. 

Miners'  elbow  (Figs.  457  and  462),  which  is  a  condition  similar  to  house- 
maids' knee,  afl'ects  the  olecranon  bursa. 

Weavers'  bottom  is  enlargement 
of  the  bursa  over  the  tuberosity  of 
the  ischium.  A  bursa  which  is  simply 
thickened  and  enlarged  rarely  gives  rise 
to  annoyance;  but  when  it  inflames,  as 
it  is  apt  to  do,  it  causes  the  ordinary 
symptoms  of  bursitis. 

The  bursa  of  the  semimem= 
branosus  muscle  is  the  largest  one 
about  the  ham.  It  lies  between  the 
inner  femoral  condyle  and  inner  head 
of  the  gastrocnemius  and  the  semimem- 
branosus muscle.  It  commimicates  with 
the  knee-joint.  When  the  joint  is 
flexed,  it  partly  empties  into  the  joint 
and  becomes  smaU  and  lax.  When  the 
joint  is  extended,  it  becomes  large  and 
tense. 

Treatment  of  Special  Forms. — 
Some  few  cases  of  housemaids'  knee 
may  be  cured  by  rest  and  blistering, 
but  in  most  cases  it  is  necessary  to  incise 
and  pack  with  iodoform  gauze.  In 
enlargement  of  the  bursa  beneath  the 
ligamentum  patellae,  if  rest  and  blister- 
ing fail  to  cure,  aspirate  or  incise.  In 
enlargement  of  the  bursa  beneath  the  tendon  of  the  semimembranosus  and 
also  in  "weavers'  bottom"  and  in  "miners'  elbow,"  incise  and  pack.  In 
operating  for  iliopsoas  bursitis  I  follow  Lund's  ad^'ice  and  make  a  vertical 


Fig.  463. — Enlargement  of  the  deep  infra- 
patellar bursa;  chronic  and  the  result  of  trau- 
matism. 


732  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 

incision  below  Poupart's  ligament,  and  between  the  anterior  crural  nerve 
and  the  femoral  artery.  The  fibers  of  the  iliopsoas  muscle  are  separated 
and  the  bursa  is  opened  and  drained.  Some  few  cases  of  retrocalcaneal 
bursitis  recover  after  rest,  but  most  of  them  require  incision  and  drainage. 
If  osteophytic  formations  exist,  the  bony  stalactites  must  be  removed  by 
means  of  the  rongeur.  Flat-foot,  if  it  exists,  is  treated  by  a  support  (see 
page  742).  The  treatment  of  subacromial  bursitis  is  considered  on  page  729. 
A  bunion  is  a  bursa  due  to  pressure,  and  it  is  most  commonly  situated 
above  the  metatarsophalangeal  articulation  of  the  great  toe,  but  is  occasionally 
seen  over  the  joint  of  another  toe.  When  the  big  toe  is  pushed  toward  the 
other  toes  by  ill-fitting  boots  a  bunion  forms.  When  a  bunion  is  not  inflamed 
it  may  cause  but  little  trouble,  but  when  it  inflames  the  bursa  enlarges  and 
the  parts  become  hot,  tender,  and  exceedingly  painful.  Suppuration  may  occur 
and  pus  may  invade  the  joint,  and  the  bone  not  unusually  becomes  diseased 
and  very  greatly  enlarged. 

Treatment. — In  treating  a  bunion  the  patient  must  wear  shoes  that  are 
not  pointed,  that  have  the  inner  border  straight,  and  that  have  rounded 
toes  (Jacobson).  For  a  mild  case  a  bunion-plaster  gives  comfort.  Sayre 
advises  the  use  of  a  linen  glove  over  the  toe,  the  toe  being  drawn  inward 
by  a  piece  of  elastic  webbing,  one  end  of  which  is 
fastened  to  the  glove  and  the  other  end  to  a  piece  of 
strapping  from  the  heel.  A  special  apparatus  may  be 
worn  (Fig.  464).  In  many  cases  osteotomy  of  the  first 
phalanx  or  of  the  first  metatarsal  bone  is  required;  in 
some  cases  excision  of  the  joint  is  necessary;  in  others 
amputation  must  be  performed.  Charles  H.  Mayo  has 
operated  on  65  cases  successfully.  He  removes  the  head 
of  the  metatarsal  bone  and  with  it  two-thirds  of  the  hy- 
pertrophy on  the  inner  side,  and  turns  the  bursa  into 
^  paratus'fo^bmik.ns.^'  ^^^  j°^^t  ^^^^  ^  front  of  the  bone.  He  sutures  this  bursa 
in  place  and  now  has  a  S3Tiovial  membrane  for  a  joint 
which  becomes  satisfactorily  movable  ("Annals  of  Surgery,"  August,  1908). 
When  the  bursa  is  not  inflamed,  but  only  thickened,  blisters  should  be  em- 
ployed over  it,  or  there  should  be  applied  tincture  of  iodin,  ichthyol,  or  mer- 
curial ointment.  When  the  bursa  inflames,  ichthyol  ointment  is  applied,  and 
intermittent  heat  by  foot-baths  gives  relief.  Suppuration  demands  imme- 
diate incision  and  antiseptic  dressing.  If  an  ulcerated  bunion  does  not  heal 
by  antiseptic  dressing,  stimulate  it  with  nitrate  of  silver  and  dress  it  with 
imguent.  hydrarg.  nitrat.  (i  part  to  7  of  cosmolin).  Jacobson  recommends 
skin-grafting  for  some  cases. 

Operations  Upon  Muscles  and  Tendons 

Tenotomy  is  the  cutting  of  a  tendon.  It  may  be  open  or  suhcutaneouSy 
the  open  operation  being  preferred  in  dangerous  regions. 

Open  Division  of  the  Sternocleidomastoid  Muscle  for  Wry=neck. 

— Subcutaneous  tenotomy  for  wry-neck  has  been  largely  abandoned.  It  is 
not  only  more  unsafe  than  the  open  operation,  but  it  never  completely  divides 
all  the  contracted  band. 

The  patient  is  placed  recumbent,  the  chin  being  drawn  more  than  is 
habitual  toward  the  opposite  side.  A  transverse  incision  is  made  over  the 
muscle  about  \  inch  above  the  clavicle.  The  superficial  parts  are  divided, 
the  muscle  is  exposed  and  sectioned,  bleeding  is  arrested,  and  the  skin  is 
sutured.  Avoid  the  anterior  jugular  vein,  which  is  underneath  the  muscle, 
and  also  the  external  jugular,  which  is  close  to  the  outer  edge  of  the  muscle. 
Mikulicz  advocates  the  removal  of  almost  the  entire  muscle,  leaving,  however. 


Subcutaneous  Fasciotomy  of  the  Plantar  Fascia  733 

the  upper  and  posterior  portion  where  the  spinal  accessory  nerve  passes.  After 
operation  for  wry-neck  plaster  of  Paris  is  used  to  secure  fixation  for  from  four 
to  eight  weeks.     Then  inaugurate  motions,  active  and  passive. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis. — This  operation 
is  performed  for  club-foot,  in  which  the  heel  is  raised.  The  tendon  is  cut 
about  I  inch  above  its  point  of  insertion.  The  instrument  used  for  the 
first  pimcture  is  a  sharp  tenotome.  The  patient  lies  upon  his  back,  "with 
his  body  rolled  a  little  toward  the  affected  side"  (Treves),  the  foot  being 
placed  upon  its  outer  side  on  a  sand-pillow.  The  surgeon  stands  to  the  outer 
side.  The  tendon  is  rendered  moderately  rigid,  and  a  sharp  tenotome,  with  its 
blade  turned  upward,  is  inserted  along  the  anterior  border  of  the  tendon  until 
the  surgeon's  finger  feels  the  knife  approachmg  the  outer  side.  The  sharp- 
pointed  instrument  is  withdrawn  and  a  blunt-pointed  tenotome  is  inserted 
in  its  place.  The  tendon  is  drawn  into  rigidity,  and  the  surgeon  turns  the 
blade  of  his  knife  toward  the  tendon,  places  his  finger  over  the  skin,  and  saws 
toward  his  finger.  The  tendon  gives  way  with  a  snap.  Treves  states  that  a 
beginner  is  apt  not  to  push  the  knife  far  enough  toward  the  outside,  or  he  may 
in  the  first  puncture  push  the  knife  through  the  tendon ;  in  either  case  the  ten- 
don is  not  completely  cut.  Another  method  is  to  insert  the  tenotome  between 
the  skin  and  the  tendon  and  cut  the  tendon  by  a  sawing  motion.  In  this 
method  the  danger  of  cutting  through  the  skin  is  ob\'iated.  The  little  wound, 
which  is  covered  by  a  bit  of  gauze,  will  be  entirely  closed  in  forty-eight  hours. 
In  club-foot  cases  after  tenotomy  some  surgeons  at  once  correct  the  deformity 
and  immobilize  the  limb  in  plaster;  some  partially  correct  the  deformity  and 
apply  plaster  for  one  week,  at  which  time  they  remove  the  plaster,  correct 
the  deformity  further,  reapply  the  plaster,  and  so  on;  other  surgeons  do  not 
attempt  correction  of  the  deformity  until  the  cut  tendon  has  begun  to  unite, 
when  they  gradually  stretch  the  new  material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Anticus 
Muscle. — The  tendon  is  divided  about  i^  inches  above  its  point  of  insertion. 
It  can  be  made  tense  by  extending  and  abducting  the  foot.  The  sharp- 
pointed  tenotome  is  entered  upon  the  outside  of  the  tendon,  and  is  passed  well 
aroimd  it.     The  blunt-pointed  tenotome  is  used  to  cut  the  tense  tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the  Peroneus  Lon= 
gus  and  Brevis  Muscles. — These  two  tendons  are  cut  together  back  of  the 
external  malleolus,  and  1^  inches  above  the  tip  of  the  malleolus,  so  as  to 
avoid  the  synovial  sheath  (Treves).  The  patient  lies  upon  the  sound  side, 
the  outer  aspect  of  the  deformed  foot  being  upward  and  the  inner  aspect  of 
the  ankle  resting  upon  a  sand-pillow.  A  sharp  tenotome  is  introduced  close 
to  the  fibula,  and  is  carried  around  the  loose  tendons.  A  blunt-pointed  teno- 
tome is  now  introduced,  its  edge  is  turned  toward  the  tendons,  and  these 
structures  are  cut  as  they  are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Posticus 
Muscle. — This  tendon  is  sectioned  above  the  point  where  its  synovial 
sheath  begins;  that  is,  above  the  internal  annular  ligament  (Treves).  The 
tendon  is  made  tense  and  the  pointed  knife  is  entered  above  the  base  of  the 
inner  malleolus.  The  knife  is  entered  just  back  of  the  inner  edge  of  the  tibia, 
and  is  carried  around  the  muscle  and  is  kept  close  to  the  bone.  The  tendon  is 
sectioned  with  a  blunt  knife. 

Subcutaneous  Fasciotomy  of  the  Plantar  Fascia. — The  contracted 
bands  are  discovered  by  motions  which  render  them  tense,  and  they  are  diAdded 
just  in  front  of  the  attachments  to  the  os  calcis.  The  sharp  knife  passes  be- 
tween the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the  foot.  The  fascia  is 
cut  from  without  inward  by  the  blunt-pointed  tenotome.  It  is  usually  neces- 
sa.ry  to  section  the  fascia  at  more  than  one  point. 


734 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


Tendon=suture  and  Tendon=lengthening. — Chromicized  gut,  kanga- 
roo-tendon, or  silk  is  used  for  an  ordinary  case,  silver  wire  for  a  suppurating 
wound.  In  performing  tendon-suture  make  the  part  aseptic  and  bloodless. 
It  is  wise  to  apply  a  rubber  bandage  on  the  proximal  side,  the  bandage 
being  applied  centrifugally,  forcing  the  proximal  end  of  the  tendon  into  view 
(Haegler).  If  searching  for  the  proximal  end  of  a  flexor  of  the  finger,  flex 
the  injured  finger  and  hyperextend  the  adjoining  fingers  (Filiget).  If  this- 
expedient  fails,  enlarge  the  incision  or,  what  is  better,  make  a  large  flap 
in  the  skin.  After  finding  the  ends,  approximate  them,  being  sure  the 
proper  ends  are  brought  into  contact;  stitch  them  together  by  a  con- 
tinuous suture  or  by  one  of   the   sutures   shown  in  Fig.   465,  i,  2,  and  3. 

L 


B^ 


1 


Fig.  465. — Tendon-sutures:    i,  Of  Le  Fort;  2,  of 
Le  Dentu;  3,  of  Lejars. 


Fig.  466. — Anderson's  method  of  tendon-length- 
ening. 


Fig.  467. — Czerny's  method  of  tendon-length 
ening. 


In  a  suppurating  wound  suture  by  silver  wire  should  be  tried,  though  it 
usually  fails.  After  suturing,  remove  the  Esmarch  apparatus,  arrest  bleed- 
ing, close  the  wound  and  dress  it  antiseptically,  relax  the  parts,  and  place 
the  limb  on  a  splint.  If,  after  suturing,  there  is  much  tension,  stitch  the 
cut  tendon  above  the  sutures  to  an  adjacent  tendon,  and  apply  a  splint, 
the  finger  which  was  injured  being  flexed,  the  others  being  extended.  If 
only  the  distal  end  of  the  tendon  can  be  found,  graft  it  upon  the  nearest 
tendon  with  a  like  anatomical  course  and  function.      After  a  tendon  has 

been  sutured,  begin  gentle  massage  in 
two  weeks.  Positive  passive  motion 
is  begun  in  three  or  four  weeks.  In 
old  injuries,  when  the  ends  cannot  be 
brought  into  apposition,  lengthen  one 
end  or  both  ends,  either  by  the  method 
of  Anderson  (Fig.  466)  or  by  the  method  of  Czerny  (Fig.  467).  Dr.  J.  Neely 
Rhoads  ("Med.  News,"  Nov.  28,  1891)  suggested  that  slight  lengthening 
could  be  accomplished  by  "cutting  half  through  the  tendon  at  different  levels 
and  from  opposite  sides,  leaving  some  longitudinal  fibers  to  slip  on  each  other, 
thus  gaining  slight  elongation"  (H.  Augustus  Wilson,  in  "International  Clinics," 
vol.  i,  4th  series).  Poncet  makes  several  zigzag  incisions  on  each  side  of  the 
tendon,  and  when  the  tendon  is  pulled  upon  it  elongates  decidedly.  Hibbs's 
method  is  shown  in  Fig.  468.  One  of  these  methods  of  lengthening  may  be 
used  if  there  is  deformity  from  tendon  contraction.  If  the  tendon  cannot  be 
lengthened  sufficiently,  make  a  bridge  of  catgut  from  one  cut  end  of  it  to  the 
other,  or  graft  in  another  tendon  from  one  of  the  lower  animals,  or  graft  the 
distal  end  to  a  tendon  of  like  function  (tendon-grafting). 
The  annular  ligament  is  sutured  as  shown  in  Fig.  453. 
Tendon=transplantation  and  Silk  Inserts. — Tendon-transplantation 
is  the  transplantation  of  the  tendon  of  a  healthy  muscle  to  take  the  place 
of  the  tendon  of  a  paralyzed  muscle.  Silk  inserts  are  used  to  take  the  place  of 
paralyzed  muscles,  "to  lengthen  normal  tendons  for  the  purpose  of  using  them 


Tendon-transplantation  and  Silk  Inserts  735 

in  transplanting,  and  to  reinforce  joints  as  artificial  ligaments,  in  place  of  arthro- 
desis" (James  W.  Sever,  "Jour.  Am.  Med.  Assoc,"  May  11,  1912).  Tendon- 
transplantation  is  usually  said  to  have  been  devised  by  Nicoladoni  in  1882; 
as  a  matter  of  fact,  Duplay  did  the  operation  in  1876,  endeavoring  to  secure 
function  in  an  arm  rendered  nearly  powerless  by  an  injury  (Elting,  in  "Albany 
Med.  Annals,"  April,  1902). 

The  first  American  surgeon  to  do  the  operation  was  Parrish,  of  New  York, 
who  in  1892  transplanted  tendons  in  a  case  of  club-foot.  In  some  cases  in 
which  a  muscle  has  been  paralyzed  surgeons  have  divided  the  tendon  of  the 
paralyzed  muscle  and  have  united  its  distal  end  with  the  tendon  of  a  normal 
muscle,  the  normal  tendon  being  split  to  receive  it.  It  has  also  been  stated 
that  when  a  muscle  or  the  tendon  of  a  muscle  is  sutured  to  a  paralyzed  antag- 
onistic muscle,  the  transplanted  structure  will  actually  execute  the  functions 
of  the  paralyzed  muscle.  For  instance,  a  flexor,  when  so  transplanted,  may 
become  an  extensor  and  act  under  the  mental  impulse  of  extension ;  a  pronator 
may  become  a  supinator  (H.  A.  Wilson,  in  "American  Med.,"  April  8,  1905). 
These  principles  have  been  utilized  when  some  or  many  of  the  muscles  of  a 
limb  have  been  paralyzed,  the  tendon  of  an  unparalyzed  muscle  or  the  tendons 
of  an  unparalyzed  group  of  muscles  being  fastened  to  the  tendons  of  the  par- 
alyzed muscle.  It  has  been  shown  that  the  success  of  the  procedure  depends 
upon  the  accuracy  of  diagnosis,  the  division  of  secondary  contractures,  the 
correction  of  existing  deformities,  and  careful  after-treatment.  (See  the  article 
by  Dr.  J.  Hilton  Waterman^  in  "Med.  News,"  July  12,  1902.)     In  a  paralysis 


Fig.  468. — Hibbs's  method  of  tendon-lengthening. 

of  the  lower  extremity,  as  Goldthwait  points  out,  the  sartorius  usually  retains 
power,  and  it  may  be  advisable  in  such  a  case  to  divide  the  sartorius  and 
suture  its  upper  end  to  the  quadriceps  above  the  patella.  A  strip  of  the  tendo 
Achillis  may  be  grafted  upon  the  peronei  in  certain  cases.  An  artificial  tendon 
may  be  made  of  silk,  the  silk  being  passed  from  the  sound  to  the  paralyzed 
tendon.  This  method  was  devised  by  Auger  in  1875.  The  silk  must  have 
been  boiled  in  paraffin,  otherwise  it  will  slough  out.  The  silk  eventually  be- 
comes surrounded  by  fibrous  tissue.  Some  maintain  that  silk  is  eventually 
absorbed.  Lange  showed  that  tendon  regeneration  may  take  place  along  the 
strands  of  silk.  Strands  of  silkworm-gut  may  be  used  for  the  same  purpose 
(Kummell).  It  is  useless  to  make  a  silk  insert  on  a  tendon  in  a  patient  under 
nine  or  ten  years  of  age.  Cooperation  between  surgeon  and  patient  is  essential 
if  we  would  develop  function,  and  cooperation  is  sure  to  be  lacking  before  that 
period  of  life.  The  operation  of  tendon-transplantation  is  occasionally  of  dis- 
tinct benefit,  but  I  agree  with  Ridlon,  and  am  not  usually  sanguine  of  results. 
Ridlon  wisely  reminds  us  that  in  such  cases  much  good  may  perhaps  result  from 
the  proper  use  of  braces,  tenotomy,  and  hand  stretching,  followed  by  pro- 
longed retention  in  plaster,  the  patient  using  his  limb  actively. 

Ridlon  points  out  that  most  brace  treatment  is  not  curative  because  it 
only  aims  to  prevent  deformity  developing,  and  tenotomy  and  stretching 
fail  because  they  only  seek  to  remove  existing  deformity.  The  object  should 
be  some  restoration  of  function.  This  is  often  obtained  by  following  Thomas's 
direction  and  "posturing"  the  limb  so  as  to  permit  structural  shortening  of 
the  paralyzed  muscles  and  then  fixing  them  for  months. 


736  Orthopedic  Surgery 


XXII.  ORTHOPEDIC  SURGERY 

This  branch  of  surgery  formerly  dealt  only  with  the  treatment  of  de- 
formities by  means  of  mechanical  appliances,  but  of  recent  years  its  domain 
has  been  enlarged  to  include  the  treatment,  surgical  and  mechanical,  of  de- 
formities, contractures,  and  many  joint  diseases. 

Torticollis  (wry=neck)  is  a  condition  in  which  contraction  of  certain  of 
the  neck  muscles  causes  an  alteration  in  the  position  of  the  head.  The  disease 
is  one  sided;  the  sternocleidomastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  the  splenius,  and  other  muscles  sometimes  suffer.  Acute  torti- 
collis, which  is  rare,  is  a  temporary  condition,  and  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital  (due  to  injury 
before  birth  or  during  birth),  may  be  due  to  nerve  irritation,  to  an  assimied 
attitude  because  of  eye  defect,  to  polio-encephalitis  (Golding  Bird),  to  in- 
flammation of  the  glands  or  to  disease  of  the  vertebrae,  and  it  may  be  inter- 
mittent, but  is  usually  persistent.  The  muscle  stands  out  in  bold  outline, 
the  head  is  turned  to  the  opposite  side,  the  ear  of  the  disordered  side  is  turned 
toward  the  shoulder,  the  chin  is  thrown  forward,  and  spinal  curvature  may 
arise.  The  corresponding  side  of  the  face  atrophies.  There  is  no  pain.  In 
many  cases  the  head  may  be  restored  to  its  normal  position  by  passive  move- 
ment or  by  voluntary  effort,  but  it  at  once  returns  to  its  habitual  position. 
Mikulicz  asserts  that  torticollis  is  a  chronic  fibrous  myositis,  due  often  to 
compression  during  labor.  He  further  says  that  the  lesion  known  as  hema- 
toma of  the  sternomastoid,  which  occasionally  follows  labor,  is  not  hematoma, 
but  thickening  due  to  myositis.  D'Arcy  Power  reported  the  autopsy  on  a 
child  one  month  of  age.  The  sternomastoid  muscle  contained  a  fibrous 
mass,  the  result.  Power  believes,  of  a  hemorrhage  into  the  muscle  prior  to  birth 
("Med.  Chir.  Trans.,"  vol.  Ixxvi).  Power,  Clutton,  and  Owens  have  all  traced 
cases  of  hematoma  of  the  sternomastoid  from  early  infancy  to  the  time  when 
tenotomy  was  required  for  torticollis.  W.  W.  Richardson  ("Surg.,  Gynec, 
and  Obstet.,"  1906)  believes  that  interstitial  myositis  is  always  present,  but 
doubts  the  causal  influence  of  the  lateral  position  of  the  head  in  utero.  In 
some  cases  hereditary  influence  is  evident.  One  woman  gave  birth  success- 
ively to  7  wry-necked  children  (Nove-Jusserand  and  Vianny,  in  "Revue  D'- 
Orthop.,"  1906).  Many  writers  advocate  the  ischemic  theory  as  explanatory 
of  the  causation  of  torticollis.  This  theory  is,  that  during  labor  lateral 
flexion  of  the  head  with  elongation  of  the  neck  or  lateral  flexion  with  torsion 
produces  occlusion  of  the  sternomastoid  branch  of  the  superior  thyroid  artery, 
which  vessel  supplies  the  sternocleidomastoid  muscle  (see  Tubby 's  "Orthop. 
Surgery").  In  congenital  torticollis  the  muscle  and  the  cervical  fascia  are 
shortened,  and  the  muscle  does  not  relax  under  the  influence  of  an  anesthetic. 
In  torticollis  due  to  rheumatism  and  reflex  causes  the  tonically  contracted 
muscle  relaxes  when  the  patient  is  anesthetized.  In  spasmodic  wry-neck  the 
muscle  is  thrown  repeatedly  into  clonic  contractions. 

Symptoms. — Congenital  wry-neck  is  due  to  central  nervous  disease,  to 
spinal  deformity,  or  to  injury  during  birth,  and  in  this  form  the  sternomastoid 
is  shortened,  hardened,  and  atrophied.  It  may  not  be  noticed  for  some 
years  because  of  the  short  neck  of  infancy.  It  is  associated  with  asym- 
metrical development  of  the  face,  and  is  almost  invariably  upon  the  right 
side.  Spasmodic  wry-neck  may  present  tonic  spasm  only,  intermittent  spasm 
alone,  or  both  may  appear  alternately.  It  sometimes  arises  in  those  whose 
occupation  demands  frequent  rotation  of  the  head,  but  more  often  no  such 
cause  can  be  discovered.  It  is  probably  a  disease  of  the  cortical  area  which 
presides  over  rotation  of  the  head.     (See  article  by  C.  A.  Hamann,  in  "Buffalo 


Dupuytren's  Contraction  737 

Med.  Jour.,"  Dec,  1901.)  It  is  a  disease  especially  of  adults;  in  women  it 
is  often  linked  with  hysteria.  Pahl  ("California  State  Med.  Soc,"  1906) 
analyzed  68  reported  cases.  Men  and  women  appeared  equally  liable,  it  was 
most  frequent  between  the  ages  of  twenty  and  thirty,  and  the  right  side  was 
affected  in  twice  as  many  cases  as  the  left  side.  The  exciting  cause  may  be  a 
cold,  a  blow,  or  a  mental  storm ;  the  predisposing  cause  is  the  neurotic  tempera- 
ment. It  may  be  due  to  enlarged  glands,  to  carious  teeth,  or  to  eye-strain. 
In  some  rare  cases  bilateral  spasm  occurs,  the  head  being  pulled  backward 
and  the  face  being  turned  upward.  Clonic  spasms  may  come  on  unannounced, 
or  they  may  be  preceded  by  pain  and  stiffness ;  the  head  can  be  held  still  for  a 
moment  only;  there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the 
contractions  cease.  The  attack  will  probably  pass  away,  but  will  almost 
certamly  occur. 

Treatment. — Congenital  wry-neck  is  treated  by  myotenotomy  through  a 
superficial  incision  which  is  vertical  or  transverse  (see  page  732).  The  muscle 
is  divided  in  a  line  parallel  to  and  just  above  the  clavicle  or  just  below  the  mas- 
toid attachment.  The  flaps  are  raised,  access  is  free  to  the  origin  of  the  muscle, 
the  muscle  is  readily  divided,  the  wounds  in  the  skin  and  fascia  are  closed. 
This  incision  leaves  a  trivial  scar.  After  operation  plaster  of  Paris  is  used  to 
secure  fixation  and  fixation  is  maintained  from  four  to  eight  weeks.  Early  opera- 
tion favors  the  establishment  of  muscular  co-ordination  before  the  development 
of  permanent  bony  deformity  of  the  vertebrje.  Some  surgeons  cut  the  scalene 
muscles  as  well  as  the  sternocleidomastoid.  Gerdes  Rowland  lengthens  the 
sternomastoid  and  carefully  sutures  it  ("Practitioner,"  Sept.,  1908).  The  old 
subcutaneous  myotenotomy  should  be  abandoned,  as  aseptic  incision  enables 
the  surgeon  to  see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle,  and 
tendon,  and  to  avoid  vital  structures  (see  page  732).  In  spasmodic  wry-neck 
there  is  a  fair  chance  of  recovery.  Pahl's  table  (Loc.  cit.)  shows  that  out  of 
68  cases,  28  recovered,  17  were  improved,  and  11  were  not  improved  by  treat- 
ment. Results  in  12  were  not  stated.  Treat  the  neurotic  temperament  and 
remove  any  obvious  irritation  (eye-strain,  carious  teeth,  enlarged  glands). 
Drugs  usually  are  practically  useless,  although  Chas.  S.  Potts  reported  a  cure 
after  the  hypodermatic  use  of  atropin.  The  rest  cure  is  sometimes  beneficial. 
Tenotomy  is  not  to  be  employed.  In  1890  Mayo  Collier  suggested  ligation  of 
the  spinal  accessory  nerve  with  silver  wire.  In  persistent  cases  stretch  or 
di\ade  and  exsect  a  part  of  the  spinal  accessory  nerve  (Keen).  To  reach  this 
nerve  make  an  incision  along  the  posterior  edge  of  the  sternocleidomastoid 
muscle,  find  the  nerve  as  it  emerges  from  under  the  middle  of  the  muscle, 
about  1 1  inches  below  the  tip  of  the  mastoid  process,  retract  the  muscle  at 
this  point,  and  remove  at  least  i  inch  of  nerve.  Neurectomy  of  the  spinal 
accessory  nerve  paralyzes  the  sternocleidomastoid  muscle,  in  spite  of  the  fact 
that  that  muscle  has  also  a  nerve-supply  from  the  cervical  nerves.  The  paral- 
ysis is  followed  by  atrophy,  and  if  the  spasm  affected  the  sternomastoid  mus- 
cle only  the  operation  will  cure  the  case.  Unfortunately,  other  muscles  are 
usually  involved,  and  cure  wiU  only  be  obtained  by  performing  neurectomy  on 
the  nerves  which  innervate  the  affected  muscles.  (For  the  treatment  of  rheu- 
matic wry-neck,  see  Myalgia,  page  712.) 

Dupuytren's  contraction  is  a  contraction  of  the  palmar  fascia,  of  its 
digital  prolongations,  and  of  the  fibers  joining  the  fascia  and  skin.  Fixed  con- 
traction of  one  or  more  fingers  occurs  (Fig.  469) .  The  ring-finger  and  the  little 
finger  most  often  suffer,  but  any  finger  or  the  thumb  may  be  involved.  The 
condition  may  be  symmetrical.  It  is  far  more  common  in  men  than  in  women. 
The  disease  arises  oftenest  in  men  beyond  middle  age,  but  is  sometimes  met 
with  in  youths.  The  cause  of  this  disease  is  unknown;  some  refer  it  to 
gout,  rheumatism,  or  osteo-arthritis ;   others,  to  traiunatism,  syphilis,  organic 

47 


738 


Orthopedic  Surgery 


nervous  diseases,  arteriosclerosis,  reflex  irritation,  or  neuritis.  In  one-fourth 
of  the  cases  heredity  seems  to  be  influential.  If  due  to  traumatism,  the  right 
hand  should  suffer  most  frequently;  but  it  occurs  in  the  left  hand  nearly  as 
often  as  in  the  right  (P.  Jansen,  in  "Arch.  f.  klin.  Chir.,"  Bd.  Ixvii,  H.  4). 
Jansen  examined  specimens  from  7  cases  and  found  connective-tissue  hyper- 
trophy and  circulatory  disturbance,  the 
contraction  being  a  result  of  the  above- 
named  processes. 

Symptoms. — Dupuytren's  contrac- 
tion is  indicated  by  a  small  hard  lump 
or  crease  which  appears  over  the  palmar 
surface  of  the  metacarpophalangeal 
joint.  This  nodule  grows  and  the  cor- 
responding finger  is  gradually  pulled 
down.  In  some  cases  the  tip  of  the 
finger  is  forced  against  the  palm.  The 
skin  becomes  dimpled  or  puckered. 

Treatment. — Fibrolysin,  which  is  a 
soluble  combination  of  thiosinamin  and 
salicylate  of  sodium,  has  been  used 
hypodermatically  in  Dupuytren's  con- 
traction and,  it  is  claimed,  with  success 
(Schwalbach) .  In  treating  Dupuy- 
tren's contraction  subcutaneous  multi- 
ple incisions  may  be  made,  the  tense 
fascia  and  the  fasciocutaneous  fibers 
being  cut.  The  finger  is  straightened 
and  is  placed  upon  a  straight  splint,^ 
which  is  worn  continuously  for  a  week 
or  ten  days  and  is  worn  at  night  for  at  least  a  month.  A  more  satisfactory 
operation  is  that  of  Keen.  He  divides  the  skin  by  a  V-shaped  cut,  the  base 
of  the  V  being  downward,  lifts  up  the  flap,  and  dissects  out  the  contracted 
tissue.  A  valuable  method  is  that  of  McCurdy.  He  makes  a  long  incision 
which  crosses  the  contracture  obliquely,  stretches  thoroughly,  closes  the  wound, 
and  keeps  up  mechanical  fixation  for  a  time.  A  cure  is  most  certain  to  be 
obtained  by  Lexer's  radical  operation.  This  surgeon  excises  the  entire  aponeu- 
rosis and  considerable  portions  of  the  palmar  skin  adherent  to  the  aponeurosis. 


Fig. 


469. — Dupuytren's    contraction    of    the 
middle  finger. 


Fig.  470.- 


-Agnew's  operation  for  webbed  fingers 
(Pye). 


Fig.  471- 


-Diday's  operation  for  webbed  fingers 
fPye). 


In  order  to  cover  this  wound  it  may  be  necessary  to  slide  a  pedimculated 
flap  into  the  raw  surface. 

Syndactylism  (webbed  fingers)  is  always  congenital,  and  may  persist 
through  several  generations.  Simple  incision  of  the  web  is  useless;  the  opera- 
tion to  be  performed  is  that  of  Agnew  or  of  Diday  (Figs.  470,  471). 

In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is  inserted  between 
the  fingers  and  sutured  in  place. 


Treatment  of  Genu  Valgum  739 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  surface  and  another 
flap  is  raised  from  the  palmar  surface,  and  each  flap  is  sutured  to  the  finger 
to  which  it  is  attached. 

Polydactylism  (supernumerary  digits)  is  always  congenital,  is  often 
hereditary,  and  is  usually  symmetrical.  There  may  be  an  incomplete  digit, 
or  there  may  be  an  entire  and  well-developed  finger  or  toe  with  a  meta- 
carpal or  metatarsal  bone.  The  connection  to  the  metacarpus  or  meta- 
tarsus may  be  by  a  fibrous  pedicle  only.  If  the  digit  is  complete,  with  a 
metacarpal  bone,  no  operation  is  required;  if  it  is  incomplete  or  is  ill-developed, 
it  should  be  removed. 

Trigger=finger  or  Jerk=finger  (Lock=finger,  Snapping=finger). 
— The  patient  can  usually  close  the  fingers,  but  on  trying  to  open  them  one 
finger  remains  closed.  It  can  be  opened  by  grasping  it  with  the  other  hand, 
but  flies  open  with  a  snap,  like  opening  a  knife  (Abbe).  In  some  cases  two 
fimgers  are  involved.  In  a  reported  case  (Frederick  Griffith,  "Annals  of 
Surgery,"  1904)  the  ring  and  middle  fingers  of  the  left  hand  locked  at  the 
knuckle-joints  on  attempting  flexion.  The  locking  occurred  when  about  one- 
third  the  amount  of  flexion  necessary  to  grasp  an  object  was  achieved.  By 
bending  the  fingers  with  the  other  hand  unlocking  was  accompHshed  and 
flexion  was  finished  A'oluntarily.  In  attempting  extension  blocking  occurred 
at  the  same  point  and  unlocking  was  accomplished  in  the  same  manner.  In 
most  cases,  but  not  in  all,  there  is  pain  when  locking  occurs.  The  condition 
is  gradual  in  onset.  Trigger-finger  is  often  associated  with  rheumatism  (in 
52  cases  out  of  121,  according  to  Necker).  It  is  said  by  Tubby  to  be  due  to  en- 
largement of  the  flexor  tendon,  or  to  contraction  of  the  groove  in  the  trans- 
verse ligament  in  the  palm.  It  may  be  due  to  a  ganglion,  enchondroma,  or 
tenosynovitis.  Traumatism  or  irritation  may  produce  it.  The  tendon-sheath 
may  be  thickened  or,  according  to  Marcano,  there  may  be  a  nodule  on  the 
tendon  which  rubs  against  the  sesamoid  bone.  It  may  result  from  occupa- 
tion. 

Treatment. — If  a  ganglion,  a  loose  cartilage,  or  a  tendon  nodule  exists, 
treat  by  excision.  A  sesamoid  bone  may  be  excised.  If  there  is  inflammation, 
use  massage  and  counterirritation.  If  there  is  no  obvious  cause,  put  a  com- 
press over  the  tunnel  in  the  ligament  and  apply  a  splint. 

Mallet=finger. — This  is  called  also  drop-finger  and  rupture  of  the  extensor 
tendon.  It  is  due  to  a  blow  in  the  direction  of  flexion  when  the  finger  is  extended. 
It  is  supposed  to  be  due  partly  to  stretching  and  partly  to  rupture  of  the 
extensor  tendon  at  the  point  at  which  it  is  the  posterior  ligament  of  the  distal 
interphalangeal  joint.  Abbe  has  shown  that  baseball  players  are  liable  to  a 
condition  which  is  the  reverse  of  this,  in  which  the  last  phalanx  is  dislocated 
backward.  Drop-finger  is  treated  by  incision  and  suture  of  the  tendon  to  the 
periosteum. 

Genu  valgum  (knock=knee)  results  from  an  unnatural  growth  of  the 
internal  condyle,  causing  the  shaft  of  the  femur  to  curve  inward  and  the 
internal  lateral  ligament  of  the  knee-joint  to  stretch,  the  knees  coming  close 
together  and  the  feet  being  widely  separated.  The  condition  may  also  be 
caused  by  curving  of  the  tibial  shaft  just  below  the  epiphysis.  This  deformity 
is  usually  noted  when  the  child  begins  to  walk,  but  it  may  not  appear  until 
puberty  or  even  long  after.  Knock-knee  may  arise  from  rickets,  from  an  occu- 
pation demanding  prolonged  standing,  or  from  flat-foot.  It  may  occur  in  one 
knee  or  in  both  knees. 

Treatment. — Mild  rachitic  cases  of  knock-knee  may  remain  in  slight  de- 
formity, or  may  get  well  from  improvement  of  the  general  health,  though  they 
seldom  do.  In  an  early  case  properly  applied  braces  will  correct  deformity. 
In  a  later  case  operation  wiU  be  necessary.     In  ordinary  cases  simply  treat  the 


740 


Orthopedic  Surgery- 


rickety  condition.  The  patient  is  forbidden  to  stand  or  to  walk,  and  the  limb, 
after  being  put  as  straight  as  can  be,  is  fixed  on  an  external  splint  and  a  pad  is 
put  over  the  inner  condyle.  Later  in  the  case  plaster  of  Paris  is  used.  Some 
surgeons  prefer  to  immobilize  while  the  leg  is  flexed  to  a  right  angle  with  the 
thigh.  In  a  severe  case  the  surgeon  can  immobilize  after  forcibly  straightening 
(causing  an  epiphyseal  separation)  or  after  the  performance  of  osteotomy  (see 
page  688).  Osteotomy  is  preferable  to  fracture  by  a  mechanical  appliance 
(osteoclasis) . 

Genu  varum  (bow=Iegs)  is  the  opposite  of  knock-knee.  It  tends  much 
more  to  self-correction  than  knock-knee  because  of  the  arrangement  of  the 
thigh  muscles,  the  powerful  adductors  acting  strongly  on  the  knee  and  mid- 
dle of  the  leg  (J.  Torrance  Rugh,  in  "Am.  Jour.  Orthop.  Surg.,"  April, 
1908).     Usually  both  legs  are  bowed  out,  the  knees  being  widely  separated,  the 

tibiae  and  femora,  as  a  rule,  be- 
ing curved,,  and  the  feet  being 
turned  in.  This  disease  in  early 
Hfe  is  due  to  rickets,  the  weight 
of  the  body  producing  the  de- 
formity. In  older  people  incur- 
able bow-legs  may  arise  from 
arthritis  deformans. 

Treatment. — Some  mild  cases 
of  genu  varum  recover  as  a 
result  of  improvement  in  the 
health.  Ordinary  cases  are 
treated  by  braces,  by  plaster-of- 
Paris  bandages,  and  by  attention 
to  the  general  health.  Braces 
usually  suffice  prior  to  three 
and  a  half  years  of  age.  Later, 
when  the  bones  have  hardened 
in  severe  deformity,  osteotomy 
is  necessary. 

CIub=hand  (Fig.  472). — ^A 
congenital  deformity  in  which 
the  hand  deviates  from  the 
normal  relation  to  the  forearm. 
It  is  usually  associated  with 
other  deformities.  In  some  cases  the  radius  and  possibly  some  of  the  carpal 
bones  are  absent. 

Treatment. — By  massage  and  passive  motion,  by  immobilization,  by 
tenotomy  or  osteotomy,  or  by  bone-grafting. 

Talipes  (club=foot)  is  a  permanent  deviation  of  the  foot  into  deformity. 
There  are  several  forms:  talipes  equinus  (Fig.  473)  is  a  confirmed  extension; 
talipes  calcaneus  (Fig.  474)  is  a  confirmed  flexion;  talipes  varus  is  a  confirmed 
adduction  and  inversion,  and  talipes  valgus  is  a  confirmed  abduction  and 
eversion.  Two  of  these  forms  may  be  combined,  as  in  talipes  equinovarus 
(Fig.  475),  tab'pes  equinovalgus,  talipes  calcaneo varus,  and  talipes  cal- 
caneovalgus.  The  causes  of  talipes  are  congenital  or  acquired.  The  con- 
genital form  is  due  to  persistence  of  the  fetal  form  of  the  foot.  There  are  three 
theories  of  the  cause  of  the  deformity:  viz.,  the  nervous  theory,  the  mechanical 
theory  (intra-uterine  pressure),  and"  arrest  of  development.  Acquired  cases 
may  arise  from  infantile  paralysis,  from  spastic  contractions,  from  cicatrices, 
from  traumatisms,  from  arrest  of  bony  growth  following  upon  the  inflamma- 
tion of  bone,  or  from  hysterical  contractures. 


Fig.  472. — Club-hari' 


Treatment  of  Talipes 


741 


Talipes  equinus  is  rarely  congenital.  In  this  condition  the  patient  walks 
upon  the  toes  and  cannot  bring  the  heel  to  the  ground. 

Talipes  Calcaneus. — The  patient  walks  upon  the  heel  and  cannot  bring 
the  toes  to  the  ground.  The  true  form  is  seen  in  congenital  cases,  the  flexors 
of  the  foot  being  shortened  and  the  tendo  AchilUs  being  lengthened. 

Talipes  varus  is  rarely  met  with  without  equinus.  In  this  condition  the 
patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks  on  the  inner 
edge  of  the  foot. 

Talipes  Equinovarus. — The  heel  is  raised  and  the  patient  walks  upon  the 
outer  edge  of  the  foot.     This  is  the  usual  congenital  form. 

Talipes  equinovalgus  is  very  rarely  congenital.  The  heel  is  raised  and 
the  patient  walks  upon  the  inner  side  of  the  foot. 

Talipes  calcaneovarus  is  a  combination  of  calcaneus  and  varus. 

Talipes  calcaneovalgus  is  a  combination  of  calcaneus  and  valgus. 

Treatment. — In  congenital  cases  the  condition  is  usually  manifest  on 
both  sides,  and  is  nearly  always  talipes  equinovarus.  It  is  better  that  both 
sides  should  be  affected,  as  the  feet  will  then  be  symmetrical  through  life.  Con- 
genital club-foot  should  be  treated  in  infancy,  and  when  a  restoration  to  position 
can  be  effected  by  the  hands  of  the  surgeon,  is  treated  by  plaster-of-Paris 


Fig.     473. — ^Talipes 
equinis  (Albert). 


Fig.    474. — ^Talipes    cal- 
caneus   (Albert). 


Fig.  475. — Double  equinovarus  ("American  Text- 
Book  of  Surgery"). 


bandages.  If  a  child  has  begun  to  walk,  it  may  still  be  possible  to  correct  the 
deformity  eventually  by  manipulations,  by  plaster-of-Paris  bandages,  or  by 
club-foot  shoes,  but  most  cases  require  tenotomy  of  the  tendo  Achillis  before  the 
application  of  the  shoe  or  the  plaster.  The  club-foot  shoe  may  do  good  service, 
but  in  many  instances  it  is  painful  and  is  not  so  efficient  as  plaster  of  Paris. 
In  severe  cases,  before  applying  the  plaster,  the  patient  is  given  ether;  the 
surgeon  cuts  the  tendons  of  the  anterior  and  posterior  tibial  muscles,  the 
plantar  fascia,  the  tendo  Achillis,  and  the  long  flexor  of  the  toes,  in  the  order 
named,  and  forcibly  corrects  the  deformity.  In  old  cases,  with  alteration  in  the 
shape  of  the  bones,  cuneiform  osteotomy,  or  the  removal  of  the  cuboid  or  other 
tarsal  bones,  may  be  indicated.  In  these  cases  Phelps  advises  an  open  trans- 
verse division  of  all  rigid  plantar  soft  parts.  Buchanan  employs  subcutaneous 
division  of  all  resistant  structures.  Occasionally,  in  relapsed  and  inveterate 
cases,  astragalectomy  is  performed.  It  is  seldom  practised  upon  young  children 
(see  page  705).  In  some  cases  of  talipes  calcaneus  shortening  of  the  tendo 
Achillis  is  advised;  but  such  an  operation  is  only  of  temporary  value,  as 
stretching  occurs  after  two  years  or  more.  In  talipes  due  to  infantile  paral- 
ysis the  operative  treatment  is  the  same,  but  we  should  not  immobilize  in 
plaster,  but  rather  in  some  apparatus  which  can  easily  be  removed  to  permit  the 
use  of  massage  and  electricity.  In  paralytic  cases  tendon-transplantation  is 
occasionally  employed.     This  consists  in  transferring  the  tendon  of  an  active 


742  Orthopedic  Surgery 

muscle  so  that  it  will  take  the  place  of  the  tendon  of  a  paralyzed  muscle.  The 
transferred  tendon  should  be  always  attached  to  the  periosteum  (Tubby  and 
Jones  on  the  "Surgery  of  Paralysis"). 

Pes  planus  (f lat=foot)  is  a  condition  in  which  there  is  loss  of  the  arch  of 
the  foot  due  to  muscular  paralysis  or  ligamentous  weakness,  to  prolonged 
standing,  or  to  trauma.  Flat-foot  is  especially  apt  to  occur  in  rickets.  Spu- 
rious flat-foot,  or  inflammatory  flat-foot,  occurs  in  Pott's  fracture  and  in  inflam- 
mation of  the  ankle-joint  or  of  the  tendon  of  the  peroneus  longus  muscle. 
Paralytic  flat-foot  is  seen  after  infantile  paralysis.  Static  flat-foot  is  due  to  dis- 
proportion between  the  body  weight  and  the  support  of  that  weight.  All 
children  are  born  with  pronated  feet;  the  arch  usually  begins  to  form  soon 
after  birth,  but  in  some  individuals  it  never  forms.  Flat-foot,  according  to 
de  Vlaccos,  is  thus  produced:  If  we  suppose  a  straight  line  prolonged  down- 
ward from  the  center  of  the  leg,  most  of  the  astragalus  and  os  calcis  will 
be  external  to  it;  hence  the  body  weight  presses  on  the  inner  side  of  the  foot, 
and  tends  to  flatten  the  arch  and  cause  outward  rotation,  tendencies  which 
are  antagonized  by  the  flexors  of  the  toes  and  by  the  tibialis  posticus  muscle. 
The  OS  calcis  is  pronated  and  is  pushed  to  the  side,  the  astragalus  moves  after 
the  OS  calcis,  and  the  ligaments  are  stretched  ("Rev.  de  Chir.,"  Aug.,  1901). 
A  very  common  cause  is  contraction  of  the  tendo  Achillis.  In  childhood  the 
condition  is  seldom  recognized,  but  in  an  adult  with  con- 
tracted Achilles  tendon  long  hours  of  standing  will  quickly 
precipitate  the  acute  symptoms  of  flat-foot.  Pes  planus  is 
productive  of  much  pain  upon  standing  or  walking;  in  fact, 
the  individual  may  be  completely  crippled.  Pain  is  quickly 
relieved  upon  sitting  down.  Walking  upon  the  toes  is  not 
painful.  A  marked  flat-foot  can  at  once  be  recognized  by 
wetting  the  sole  of  the  patient's  foot  with  a  colored  fluid 
and  causing  him  to  step  firmly  upon  a  piece  of  paper  (Fig. 
476,  b).  Beginning  flat-foot  cannot  be  thus  recognized 
Fig.  476.— Print  of  and  is  frequently  overlooked,  the  patient  being  treated  for 
L°d  oTa  flaHoofsde  "  S^ut  or  rheumatism.  Even  a  slight  case  can  be  detected 
(b)  (Albert).  by  Carefully  observing  the  inner  surface  of  the  foot.    When 

weight  is  placed  upon  it,  it  is  seen  to  descend  as  the  arch 
falls.  A  more  accurate  method  is  measurement,  to  find  the  middle  of  the 
foot.  In  flat-foot  the  extremity  is  lengthened.  Golding-Bird  points  out  that 
the  middle  of  the  normal  foot  is  the  point  of  articulation  of  the  inner  cunei- 
form and  the  metatarsal  bone  of  the  great  toe.  In  flat-foot  the  greatest  change 
is  in  the  posterior  half  of  this  line.  The  extent  to  which  the  posterior  measure- 
ment exceeds  the  anterior  is  the  degree  of  flat-foot.  The  excess  may  reach 
f  inch. 

Treatment.— In  paralytic  flat-foot,  which  arises  from  infantile  paralysis, 
employ  exercise,  electricity,  and  massage.  To  maintain  a  correct  position  of 
the  ankle  and  to  facilitate  normal  muscular  action,  apply  suitable  braces.  In 
some  cases  of  paralytic  flat-foot  it  is  advisable  to  permanently  stiffen  the 
ankle-joint  by  operation.  Operation  is  not  indicated  before  the  twelfth  year, 
because  during  the  earlier  years  of  life  union  will  probably  fail  to  occur.  Gold- 
thwait  removes  the  cartilage  from  the  articular  surfaces  of  the  astragalus, 
calcaneus,  tibia,  and  malleoli,  and  seeks  to  obtain  permanent  bony  ankylosis. 
In  static  flat-foot  it  has  long  been  customary  to  advise  rest  in  bed  for  two  weeks, 
and  then  exercise  for  several  hours  a  day  to  increase  the  arch.  The  usually 
recommended  exercise  has  been  to  rise  upon  the  toes  and  lower  again  and  again, 
with  the  ankles  turned  outward.  The  patient  rests  for  a  time  after  each 
seance  of  exercise  by  sitting  tailor-fashion  with  the  legs  crossed  under  him  or  by 
standing  on  the  outer  edges  of  the  feet.     Massage  is  ordered  and  a  special  shoe 


Treatment  of  Pes  Planus 


743 


is  made  to  raise  the  arch  of  the  foot.  The  shoe  must  fit  the  heel  snugly  and 
have  a  firm,  broad  heel.  In  some  cases  it  is  necessary  to  use  a  Thomas  heel; 
in  others,  a  steel  shank.    The  patient's  general  health  is,  of  course,  attended  to. 

Many  orthopedic  surgeons  have  come  to  regard  this  usual  treatment  as 
unphilosophical  and  improper  for  many  cases. 

In  static  fiat-foot  it  is  essential  to  understand  that  a  fiat-foot  may  be  a 
fully  functionating  foot,  free  from  pain  and  disability,  and,  therefore,  not  a 


Fig.  477. — H.  Augustus  Wilson's  flat-foot  correction  screw. 

subject  for  treatment.  For  convenience,  flat-foot  is  divided  into  rigid  and 
flexible.  Either  form  may  be  from  pain.  The  pain  of  flat-foot  is  usually 
the  result  of  excessive  use.  It  must  be  differentiated  from  Albert's  disease 
(achillodynia) ,  metatarsalgia,  osteophytes  on  the  under  surface  of  the  os  calcis, 
and  Raynaud's  disease.  Rigid  flat-foot  can  be  made  flexible  by  manipu- 
lative measures  (according  to  Whitman's  method)  or  by  the  employment 
of  H.  Augustus  Wilson's  flat-foot  correction  screw  (Fig.  477).     This  appa- 


Fig.  478. — Whitman's  plate  to  support  the  arch  of  the  foot  in  flat-foot  (Fowler's  "Surgery"). 

ratus  pulls  down  on  the  posterior  part  of  the  os  calcis  and  the  distal  extremi- 
ties of  the  metatarsal  bones  and  pushes  up  beneath  the  tarsus.  The  force 
employed  is  very  great  and  much  care  should  be  exercised  when  it  is  used  upon 
a  patient  under  anesthesia.  It  is  preferable  to  use  it  without  ether,  relying 
upon  the  patient  to  state  when  the  pressure  becomes  unendurable.  A  flexible 
flat-foot  is  capable  of  correction  by  exercises. 

It  was  formerly  customary  to  always  prescribe  various  forms  of  steel  plates 


744  Orthopedic  Surgery 

to  correct  the  broken-down  arch,  but  some  orthopedic  surgeons  are  discouraging 
their  use,  beheving  that  they  destroy  the  muscular  control  of  the  foot,  and  by 
weakening  the  foot  render  it  susceptible  to  sprains  and  other  injuries.  It  is  my 
behef  that  steel  plates  should  often  be  used,  but  never  abused  (Fig,  478). 
When  plates  are  necessary  because  the  patient  is  heayy  or  because  he  must  con- 
tinue a  trying  occupation,  they  must  be  fitted  to  the  individual  case  and  must  be 
worn  until  such  time  as  the  use  of  exercise  has  enabled  the  patient  to  properly 
maintain  the  body  weight  with  the  strengthened  arches.  If  the  tendo  Achillis  is 
shortened  it  must  be  lengthened  by  operation  or  else  the  heel  of  the  shoe  must 
be  raised  to  permit  the  fullest  range  of  dorsal  flexion  the  tendon  allows.  When 
muscle  tone  is  low  and  there  is  smaU  chance  of  restoring  it,  H.  A.  Wilson  ("Amer. 
Medicine,"  May  6,  1905,  page  725)  advocates  the  employment  of  the  method 
de\dsed  by  Professor  Miiller  ("Central,  f.  Chir.,"  January  10,  1903,  page  40) 
for  paralytic  valgus.  It  consists  of  an  arthrodesis  of  the  astragaloscaphoid 
joint,  and  transplantation  of  the  tendon  of  the  extensor  proprius  hallucis  into  a 
hole  drilled  free  from  above  downward  through  the  scaphoid.  Fixation  in 
plaster  of  Paris  in  an  overcorrected  position  is  maintained  for  four  weeks  and 
then  corrective  exercises  are  employed.  The  anterior  tibial  tendon  is  supple- 
mented in  its  action  by  the  transplanted  tendon. 

Gleich  shortens  the  foot  and  raises  the  arch  by  sawing  through  the  os  calcis 
and  fastening  the  posterior  part  of  this  bone  at  a  lower  level.  Trendelenburg 
advises  supramalleolar  osteotomy.  This  operation  permits  of  adduction,  and 
the  adducted  foot  should  be  put  up  in  an  immovable  dressing  of  plaster  of 
Paris.  Ogston  resects  the  astragaloscaphoid  joint.  Golding-Bird  and  Da\'y 
remove  the  scaphoid  bone.  Stokes  removes  a  wedge-shaped  piece  from  the 
head  and  neck  of  the  astragalus.  Rugh  has  taken  a  wedge-shaped  piece  of 
bone  from  the  inner  side  and  inserted  it  in  the  outer  side. 

Pes  cavus  (hollow  foot)  is  an  increase  in  the  arch  of  the  foot,  due,  pos- 
sibly, according  to  Golding-Bird,  to  paralysis  of  the  peronei  muscles.  When 
the  peronei  muscles  are  paralyzed  the  adductors  act  imopposed,  and  sec- 
ondary contraction  of  the  plantar  fascia  occurs.  Certain  it  is  that  a  con- 
tracted plantar  fascia  is  the  chief  obstacle  to  correction.  In  many  cases  the 
cause  is  the  wearing  of  shoes  which  are  too  short  for  the  feet.  The  pressure 
made  upon  the  toes  causes  spasm  of  the  plantar  flexors  and  this  spasm  per- 
mits the  fascia  to  contract. 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in  the  sole,  and 
pressure  is  applied  over  the  instep.  Tenotomy,  division  of  the  plantar  fascia, 
or  excision  of  bone  may  be  required.  In  paralytic  cases  apply  electricity 
and  massage  to  the  paralyzed  muscles.  Transplantation  of  the  tendons  of 
the  dorsal  flexors  into  the  ends  of  the  metatarsal  bones  has  proved  very 
satisfactory. 

Hallus  valgus  or  varus,  a  displacement  of  the  great  toe  outward  or 
inward,  may  occur  in  the  yoimg,  but  it  is  most  frequent  in  old  persons,  espe- 
cially old  women.  It  arises  often  from  wearing  pointed  shoes,  shoes  that 
are  too  short,  or  high  heels,  but  may  be  due  to  gout  or  to  rheumatic  gout. 
In  many  cases  an  exostosis  forms  in  the  inner  portion  of  the  distal  end  of 
the  metatarsal  bone.  In  hallux  valgus  a  bunion  (bursa)  is  apt  to  form  over 
the  metatarsophalangeal  joint  and  it  may  inflame  or  ulcerate. 

Treatment. — An  arrangement  may  be  worn  to  straighten  the  toe  and 
to  protect  the  bunion  (see  Fig.  464).  The  prominent  and  h>'pertrophied  inner 
portion  of  the  head  of  the  metatarsal  bone  may  be  removed  by  means  of  a 
chisel,  osteotomy  may  be  performed  upon  the  metatarsal  bone,  the  joint 
may  be  excised,  or  amputation  may  be  required.  H.  A.  Wilson  advocates 
lateral  excision.  By  means  of  bone-forceps  he  cuts  away  that  part  of  the 
distal  extremity  beyond  the  phalanx,  and  by  a  chisel  removes  the  remaining 


Coxa  Vara  and  Coxa  Valga 


745 


J 


479. — Hammer- 
toe. 


Fig.  480.- 


X-ray  of  hammer- 
toe. 


sharp  line  edge.  He  places  the  phalanx  in  normal  position  and  holds  it  so 
for  two  weeks  ("Am.  Jour.  Orthopedic  Surgery,"  Jan.,  1906).  Mayo's  opera- 
tion is  described  on  page  732. 

Hammer=toe  (Figs.  479  and  480)  is  a  condition  in  which  there  is  flexion 
of  one  or  more  toes  at  the  first  interphalangeal  joint.  Shattuck  shows  that 
this  condition  is  due  to  contraction  of  "the  plantar  fibers  of  the  lateral  ligaments 
of  the  joint. "^  This  disease  usuaUy  begins  in  youth  and  may  be  congenital. 
A  bunion  is  apt  to  form,  and  the  joint  may  become  dislocated. 

Treatment. — Subcutaneous  division  of  the  lateral 
ligaments  and  flexor  tendon  usually  allow  of 
straightenmg  of  the  toe.  After  the  operation  the 
toe  must  be  held  in  extension  for  several  months 
by  means  of  a  short  splint  and  adhesive  plaster. 
Terrier's  plan  of  treatment  consists  in  making  a 
dorsal  flap,  removmg  a  bursa  if  one  is  found,  divid- 
ing the  extensor  tendon,  opening  the  articulation, 
removing  each  articular  surface  by  cutting  forceps, 
suturing  the  soft  parts,  and  applying  a  plantar 
splint  for  two  weeks."  Some  surgeons  simply 
excise   the   joint.      In   some   cases  amputation   of 

the  toe  is  the  best  treatment. 
Metatarsalgia    (Morton's 

Disease).  —  This    disease  was 

first  described  by  Dr.  Thomas  G. 

Morton,  of  Philadelphia,  in  1876. 

It  is  a  painful  condition  of  the 

foot,  due  to  jamming  of  a  nerve 

between  the  heads  of  the  fourth 
and  fifth  metatarsal  bones.  The  head  of  the  fifth  metatarsal  bone  is,  by 
lateral  pressure,  forced  against  and  below  the  neck  of  the  fourth  metatarsal, 
arid  as  a  result  the  superficial  branch  of  the  external  plantar  nerve  and  its 
two  digital  branches  are  squeezed.  It  is  usually  associated  with  flat-foot. 
Loss  of  the  metatarsal  arch  wiU  jam  other  nerv^es  than  that  between  the  fourth 
and  fifth  metatarsals,  and  will  produce  a  condition  similar  to  Morton's  disease, 
the  pain  being  differently  situated.  Pain,  in  Morton's  disease,  is  produced  by 
walking,  and  the  suffering  may  be  so  severe  that  the  patient  is  obliged  to  sit 
down  at  once.  When  the  shoe  is  removed  and  the  foot  is  rested  the  pain  soon 
abates.  The  pain  is  felt  on  the  outer  and  inner  sides  of  the  little  toe,  the  outer 
side  of  the  fourth  toe,  and  about  the  head  of  the  fifth  and  the  neck  of  the 
fourth  metatarsal  bones.  Pain  can  be  developed  by  grasping  the  foot  in 
the  hand  and  squeezing  it.  If  flat-foot  exists,  there  is  also  pain  due  to  this 
trouble. 

Treatment. — Mild  cases  may  be  cured  by  wearing  weU-fitting  shoes  and 
employing  massage.  The  shoe  should  have  a  small  elevation  in  the  sole  to 
restore  the  metatarsal  arch  and  so  relieve  lateral  pressure  on  the  nerve.  Some 
cases  require  a  brace.  Severe  cases  demand  resection  of  the  fourth  meta- 
tarsophalangeal joint,  or  amputation  of  the  fourth  toe,  and  with  it  the 
head  of  the  fourth  metatarsal  bone.  Graham,  of  Washington,  has  cured 
cases  by  excising  a  portion  of  the  superficial  branch  of  the  external  plantar 
nerve. 

Coxa  Vara  and  Coxa  Valga.- — Coxa  vara  {incurvation  or  infraction  of  the 
neck  of  the  femur)  (Fig.  481)  is  a  disease  characterized  by  bending  of  the  neck  of 
the  femur,  the  femoral  neck  being  depressed  below  its  normal  obtuse  angle  with 

1  "American  Text-Book  of  Surgery." 

2  "Rev.  de  Chir.,"  July,  1895. 


746  Orthopedic  Surgery 

the  shaft,  the  hip-joint  being  perfectly  healthy,  and  the  condition,  as  a  rule,  being 
unilateral,  but  sometimes  bilateral.  This  condition  was  described  by  Miiller 
in  1889.  Coxa  vara  is  first  noticed,  as  a  rule,  between  the  thirteenth  and 
twentieth  years,  and  the  commonly  accepted  view  has  been  that  the  deformity 
is  rachitic,  but  Kredel  has  reported  2  congenital  cases.^  Traimiatic  coxa 
vara  may  follow  impacted  fracture  of  the  neck  of  the  femur  in  a  child.  An 
individual  with  coxa  vara  develops  a  limp,  and  grows  tired  after  slight  ex- 
ertion, but  there  is  no  swelling,  no  tenderness,  and  little  or  no  pain.  Shorten- 
ing after  a  time  becomes  apparent,  the  great  trochanter  can  be  detected 
above  Nelaton's  line,  and  the  head  of  the  bone  is  in  the  acetabulum.  If  the 
head  is  in  the  acetabulum  it  can  be  recognized  as  being  there  by  locating  the 
femoral  artery  |  inch  below  Poupart's  hgament  and  making  pressure  directly 
backward  at  that  point.  The  head,  if  in  place,  will  be  felt.  The  extremity  is 
adducted  and  usually  rotated  outward.  Abduction  is  limited.  In  some  cases 
in  which  there  is  joint  irritation  all  joint  motions  may  be  distinctly  limited. 


Fig.  481. — Congenital  dislocation  of  the  hip  on  one  side  and  coxa  vara  on  the  other. 

In  a  bilateral  case  there  is  lordosis,  but  shortening  may  not  be  detected 
because  both  legs  are  the  same  length.  Each  great  trochanter,  however,  is 
above  Nelaton's  line  and  the  head  of  each  bone  is  in  the  acetabulum. 

Coxa  valga  is  a  condition  in  which  the  angle  of  the  neck  to  the  shaft  of 
the  femur  is  more  obtuse  than  normal.  The  neck  may  assume  a  position  in 
line  with  the  long  axis  of  the  shaft.  It  occurs  particularly  in  children  who 
have  had  infantile  palsy,  but  it  may  be  congenital,  may  occur  in  rickets  and 
osteomalacia,  and  after  a  prolonged  period  of  disuse  of  a  limb.  The  patient 
has  pain  and  a  limp,  the  extremity  is  lengthened,  abducted,  and  in  external 
rotation  there  is  limitation  of  adduction  and  the  trochanter  is  flattened.  Coxa 
valga  is  usually  unilateral,  but  may  be  bilateral. 

Without  the  a;-rays  the  differential  diagnosis  in  coxa  vara  and  coxa  valga  is 
often  very  difficult,  and  the  accompanying  table  will  materially  aid  in  contrast- 
ing the  conspicuous  features  of  the  various  conditions  with  which  these  two 
deformities  of  the  neck  of  the  femur  may  be  confounded: 
i"Centralbl.  f.  Chir.,"  Oct.  17,  1896. 


Symptoms  of  Neuritis 


747 


Hip 

Intantile 

Congenital 

Psoas 

Coxa  Vara 

Knee 

Disease. 

Paralysis. 

Dislocation. 

Abscess. 

OR  Valga. 

Disease. 

Age. 

Four  to  six. 

Four  to  six. 

Any  age. 

Four  to  six. 

Any  age. 

Four  to  six. 

Onset. 

Insidious. 

Sudden. 

From  birth. 

Insidious. 

Childhood. 

Insidious. 

Pain. 

Referred     to 
knee. 

None. 

None. 

Referred  to 
abdomen. 

None. 

Referred  from 
knee. 

History. 

Tuberculous. 

Inflammatory 
disease. 

Limp       from 
birth. 

Tuberculous. 

Limp. 

Tuberculous. 

Posture. 

Fle.xion, 

Uncontrolled. 

Shortening 

Flexion, 

Great 

Knee  flexed. 

abduction, 

and  adduc- 

adduction. 

trochanter 

external  ro- 

tion. 

external  ro- 

higher     in 

tation. 

tation. 

vara      and 
lower       in 
valga. 

Muscular  rigidity. 

Present  in  all 
directions. 

Absent. 

Absent. 

In  one  direc- 
tion. 

None. 

About  knee. 

Temperature. 

I  degree  high. 

Normal. 

Normal. 

I  degree. 

Normal. 

I  degree. 

Local  tenderness. 

In  hip. 

None. 

None. 

In  spine. 

None. 

In  knee. 

Night  cries. 

Present. 

Absent. 

Absent. 

Present. 

Absent. 

Present. 

Tendency  to  abscess . 

Yes. 

No. 

No. 

Yes. 

i  No. 

Yes. 

X-Tny. 

Diseased 

Atrophy. 

Alteration  in 

Normal  hip. 

Alteration  in 

Normal  hip. 

focus  in  hip. 

joint. 

'      neck  angle. 

focus  in  knee. 

The  .r-rays  clearly  show  the  deformed  bone  in  either  coxa  vara  or  coxa  valga. 

Treatment. — In  coxa  vara,  as  long  as  bending  is  progressing,  employ  rest. 
When  the  bone  hardens,  it  may  be  necessary  to  perform  osteotomy  below  the 
trochanters.  In  coxa  valga  Galeazzi  performs  osteotomy  through  the  neck 
of  the  femur  and  allows  the  trochanter  to  ascend. 

Flail=joints. — After  an  attack  of  infantile  paralysis  invohdng  the 
entire  lower  extremity  of  each  side  the  limbs  become  limp  and  saving  flail- 
Hke  when  the  extremity  is  made  to  move,  and  the  joints  are  much  relaxed. 
In  such  cases  the  psoas  and  iliacus  muscles  are  never  completely  paralyzed, 
and  the  aim  of  the  surgeon  is  to  utilize  these  muscles  in  enabling  the  patient 
to  walk.  In  many  cases  the  application  of  apparatus  is  sufficient.  In  others 
ankylosis  may  be  established  in  the  ankles  and  knees  by  operation.  If  anky- 
losis is  established  in  these  joints,  the  psoas  and  iliacus  muscles  become  able 
to  move  the  legs.  (For  more  elaborate  discussion,  see  a  work  on  Orthopedic 
Surger}^,  and  Tubby  and  Jones  on  the  "Surgery  of  Paralysis.") 


XXIII.  DISEASES   AND    INJURIES   OF   NERVES 


Diseases  of  Nerves 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited  or  be  mdely 
distributed  (^multiple  neuritis).  The  first-mentioned  form  will  here  be  con- 
sidered. The  causes  of  neuritis  are  traumatism,  wounds,  overaction  of  mus- 
cles, gout,  rheumatism,  syphilis,  fevers,  and  alcoholism. 

The  symptoms  of  neuritis  are  as  follows:  excessive  pain,  usually  in- 
termittent, in  the  area  of  nerve-distribution.  The  pain  is  worse  at  night, 
is  aggravated  by  motion  and  pressure,  and  occasionally  diffuses  to  adja- 
cent nerve-areas  or  awakens  sympathetic  pains  in  the  opposite  side  of 
the  body.  The  nerve  is  very  tender.  The  area  of  nerve-distribution  feels 
numb  and  is  often  swollen.  Early  in  the  case  the  skin  is  h>'peresthetic; 
later  it  may  become  anesthetic.  The  muscles  atrophy  and  present  the  re- 
actions of  degeneration;  that  is,  the  muscles  first  cease  to  respondto  a  rapidly 
interrupted  faradic  current,  and  next  to  one  \\dth  slower  interruptions;  faradic 
excitabUity  diminishes,  but  galvanic  excitability  increases.  When,  in  neuritis, 
faradism  produces  no  contraction,  a  slowly  interrupted  galvanic  ciurrent 
which  is  so  weak  that  it  would  produce  no  movement  in  the  healthy  muscle 
causes  marked  response  in  the  degenerated  muscle.     In  health   the  most 


748 


Diseases  and  Injuries  of  Nerves 


vigorous  contraction  is  obtained  by  closing  with  the  —  pole;  in  degenerated 
muscles  the  most  vigorous  contraction  is  obtained  by  closing  with  the  +  pole. 
When  voluntary  power  returns,  galvanic  excitability  declines;  but  power  is 
often  nearly  restored  before  faradic  excitability  becomes  manifest  (Buzzard). 
The  treatment  of  neuritis  consists  of  rest  upon  splints  and  the  use  of  an 
ice-bag  early  in  the  case  and  a  hot-water  bag  later.  Blisters  over  the 
course  of  the  nerve  are  of  value,  especially  in  traumatic  neuritis.  Mas- 
sage and  electricity  must  be  used  to  antagonize  degeneration.  A  descend- 
ing galvanic  current  allays  pain  to  some  extent.  Deep  injections  of  chloro- 
form or  cocain  may  allay  pain.  Treat  the  patient's  general  health,  especially 
any  constitutional  disease  or  causative  diathesis.  The  salicylate  of  ammo- 
nium or  phenacetin  may  be  given  internally.  In  some  cases  nerve-stretching 
is  advisable. 

Neuralgia  is  manifested  by  violent  paroxysmal  pain  in  the  trajectory  of 
a  nerve.  This  disease,  unless  it  is  exceedingly  severe  and  persistent,  is  treated, 
as  a  rule,  by  the  physician.  Injections  of  alcohol  or  osmic  acid  into  the  nerve 
may  secure  relief  or  cure.     If  neuralgia  is  due  to  adhesions  about  the  nerve 

or  to  the  pressure  of  scar  or  callus, 
these  conditions  should  be  amended 
surgically.  There  is  some  evidence  that 
neuralgia  arises,  at  least  occasionally, 
from  dilatation  of  the  vessels  of  the 
sheath  and  subsequent  edema  and  exu- 
dation. If  this  be  the  case  cure  may 
follow  opening  the  sheath  and  separat- 
ing adhesions  between  the  sheath  and 
nerve  (Robert  M.  Simon,  in  "Brit. 
Med.  Jour.,"  April  lo,  1909).  Neural- 
gia of  stumps  and  scars  is  a  surgical 
condition,  and  is  due  to  neuromata,  or 
entanglement  of  nerve-filaments  in  a 
cicatrix.  Tic  douloureux  and  other  in- 
tractable neuralgias  require  careful  re- 
moval of  any  cause  of  reflex  irritation. 
Causal  reflex  irritation  may  arise  from 
disease  of  the  stomach,  eyes,  teeth, 
uterus,  nose,  throat,  etc.  Tic  doulou- 
reux has  been  treated  by  removal  of  the 
Gasserian  ganglion;  intracranial  neu- 
rectomy of  the  second  and  third  divi- 
sions; division  of  the  sensory  root; 
removal  of  Meckel's  ganglion;  ligation 
of  the  common  carotid  artery ;  neurec- 
tomy of  terminal  branches  of  the  fifth 


Fig.  482. — Distribution  of  the  cutaneous  sensi- 
tive nerves  upon  the  head:  oma,  omi,  The  occipit. 
maj.  and  minor  (from  the  N.  cervical.  II  and  III); 
am,  N.  auricular  magn.  (from  N.  ceryic.  Ill);  cs, 
N.  cervical,  superfic.  (from  N.  cervic.  Ill);  V^, 
first  branch  of  the  fifth  (50,  N.  supraorbit.;  st.  N. 
supratrochl.;  N.  infratrochl.;  e,  N.  ethmoid.; 
I,  N.  lachrymal.);  V2,  second  branch  of  the  fifth 
{sm,  N.  subcutan.  malae  seu  zygomaticus) ;  V^, 
third  branch  of  the  fifth  {at,  N.  auriculotempor.; 
h,  N.  buccinator;  m,  N.  mental.);  B,  posterior 
branches  of  the  cervical  nerves  (SeeligmiiUer). 


nerve;  division  of  motor  nerves;  in- 
jections of  osmic  acid  (seepage  762);  injections  of  alcohol  (see  page  763); 
advancing  doses  of  strychnin  (Dana)  and  purgatives  (Esmarch).  The  dis- 
tribution of  the  fifth  nerve,  the  seat  of  pain  in  tic  douloureux,  is  shown  in 
Fig.  482. 

Treatment  of  Neuralgia  of  Stumps. — Excise  the  scar;  find  the  bulbous 
end  of  the  nerve  and  cut  it  off.  Senn  tells  us  to  section  the  nerve  by  V-shaped 
cuts,  the  apex  of  the  V  being  toward  the  body,  and  to  suture  the  flaps  together. 
Senn's  method  will  prevent  recurrence.  In  some  cases  reamputation  is 
performed.  In  entanglement  of  a  nerve  in  a  scar  remove  a  portion  of  the 
nerve  above  the  scar  and  also  the  neuroma  in  the  scar. 


General  Symptoms  After  Section  of  Nerves  749 

Wounds  and  Injuries  of  Nerves 

Section  of  Nerves  (as  from  an  incised  wound). — After  nerve-section 
sensation  and  motor  power  are  lost  at  once.  The  entire  peripheral  portion  of 
the  nerve  degenerates  and  ceases  structurally  to  be  a  nerve  in  a  few  weeks, 
but  after  many  months,  or  even  years,  the  nerve  may  regenerate.  The  proxi- 
mal end  degenerates  only  in  the  portion  immediately  adjacent  to  the  section; 
it  rapidly  regenerates,  and  if  it  does  not  adhere  to  the  peripheral  segment 
a  bulb  or  enlargement  composed  of  librous  tissue  and  small  nerve-fibers  forms 
just  above  the  line  of  section;  this  bulb  adheres  to  the  perineural  tissues. 
The  entire  distal  end  degenerates,  but  new  axis-cylinders  form  in  this  segment 
by  proliferation  of  the  nuclei  on  the  sheath  of  Schwann.  Union  of  a  divided 
nerve  is  brought  about  by  the  projection  of  axis-cylinders  from  the  proximal 
end  or  from  each  end  and  the  fusion  of  these  cylinders.  The  nearer  the  two 
ends  are  to  each  other,  the  better  the  chance  of  union.  When  a  nerve  has  been 
divided  and  has  not  been  sutured,  abolition  of  function  may  be  permanent 
or  restoration  may  occur.  Sensation  may  return  in  from  sLx  weeks  to  several 
months.  Motor  powder  may  never  return.  If  it  does  return  it  will  do  so  long 
after  sensory  restoration.  Restoration  of  motor  power  requires  from  twelve 
weeks  to  three  and  one-half  years.  It  is  seldom  noted  before  six  months. 
The  return  is  always  slow  (John  B.  Murphy,  in  "Surg.,  Gynec,  and  Obstet.," 
April,  1907).  Failure  of  return  means  that  the  ends  are  separated  by  a  wide 
interval  or  that  fascia  is  interfused  between  them.  In  some  recorded  cases 
motion  and  sensation  have  returned  with  great  rapidity,  due,  some  have  said, 
to  anastomoses  with  adjacent  nerves.  Murphy  shows  that  when  restoration 
begins,  trophic  energy  returns  even  before  sensation,  and  when  trophic  energy 
returns  the  blueness  and  coldness  of  the  limb  lessen. 

The  nerve-fibers  which  convey  impressions  of  cutaneous  pain  and  of  ex- 
treme heat  and  cold  regenerate  far  more  rapidly  than  those  which  subserve 
sensations  of  light  touch  and  slight  degrees  of  heat  and  cold. 

The  investigations  of  Head  and  others  show  that  restoration  of  sensation 
does  not  begin  at  the  normal  area  and  spread  from  there  over  the  anesthetic 
area,  but  that  the  reverse  is  the  case.  It  begins  from  the  confines  of  the 
anesthetic  area  and  spreads  toward  the  normal  part. 

General  Symptoms. — Immediately  after  nerve-section  vasomotor  paral- 
ysis comes  on,  and  for  a  few  days  the  paralyzed  part  presents  a  temperature 
higher  than  normal.  It  then  becomes  blue  and  cold.  Pronoimced  changes 
occur  in  the  trajectory  of  a  divided  nerve.  The  muscles  degenerate,  atrophy 
and  shorten,  and  develop  the  reactions  of  degeneration.  When  union  of  the 
nerve  occurs  the  muscles  are  restored  to  a  normal  condition.  If  the  nerve 
contains  sensory  fibers,  complete  anesthesia  (to  touch,  pain,  and  temperature) 
usually  f oUows  its  di\asion ;  but  if  a  part  is  supplied  by  another  nerve  as  well  as 
by  the  divided  one,  anesthesia  will  not  be  complete.  Trophic  changes  arise 
in  the  paralyzed  parts.  Among  these  changes  are  muscular  atrophy;  glossy 
skin;  cutaneous  eruptions;  ulcers;  dry  gangrene;  painless  felons;  falling  of  the 
hair;  brittleness,  furrowing,  or  casting  off  of  the  nails;  joint  inflammations, 
and  anklylosis.  The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  motor  and  sensory  paralysis. 

A  curious  fact  that  was  pointed  out  by  Letievant  is  that  after  di\dsion  of  a 
ner^'e  blimt  pressinre  may  be  appreciated  over  the  entire  analgesic  area.  This 
phenomenon  was  long  thought  to  be  due  to  nerve  anastomoses,  the  sensory  areas 
from  different  nervxs  overlapping.  The  explanation  now  given  is  founded  on 
Sherrington's  demonstration  that  the  motor  branches  of  a  mixed  nerve  carry 
sensory  fibers  through  muscles  and  tendons,  and  Head's  proof  that  certain 
afferent  fibers  convey  impressions  of  deep  sensibility  as  produced  by  pressure. 


75©  Diseases  and  Injuries  of  Nerves 

The  Symptoms  of  Division  of  Nerves.^Brachial  Plexus. — If  one  or  more 
cords  of  the  brachial  plexus  are  divided,  motor  paralysis  and  anesthesia  appear 
in  the  limb,  the  extent  of  the  paralysis  and  the  area  of  the  anesthesia  depending 
upon  the  cord  or  cords  involved.  It  should  be  remembered  that  the  inner 
cord  of  the  brachial  plexus  gives  origin  to  the  ulnar  nerve ;  the  inner  and  outer 
cords  give  branches  which  fuse  to  form  the  median  nerve.  The  posterior  cord 
gives  origin  to  the  subscapular,  the  circumflex,  and  the  musculospiral  nerves. 
The  outer  cord  gives  origin  to  the  external  anterior  thoracic  and  the  musculo- 
cutaneous, as  well  as  to  the  outer  trunk  of  origin  of  the  median. 

Avulsion  or  rupture  of  the  brachial  plexus  is  sometimes  effected  by  an  injury, 
when  the  arm  is  not  lost.  Most  cases  are  due  to  indirect  violence  and  are 
associated  with  skeletal  injury,  for  instance,  dislocation  of  the  shoulder,  frac- 
ture of  the  humerus,  or  fracture  of  the  clavicle  (Frazier  and  Skillern,  paper 
before  Section  on  Surgery,  "Amer.  Med.  Assoc,"  191 1).  Bristow  ("Annals 
of  Surgery,"  Sept.,  1902)  reported  3  cases  of  avulsion  of  the  plexus  and  col- 
lected 24  more.  Frazier  and  Skillern  (Loc.  cit.)  collected  23  cases  of  avulsion 
without  skeletal  injuries  and  confirmed  by  operation.  In  each  of  these  cases 
the  rupture  was  between  the  clavicle  and  the  transverse  process  of  the  ver- 
tebra. In  the  case  of  Frazier  and  Skillern  the  rupture  was  within  the 
dura.  The  patient  was  seen  by  them  three  months  after  the  accident.  He 
suffered  from  horrible  pain  in  the  arm  and  hand.  Sensations  to  touch  and 
pain  were  entirely  lost  in  the  hand  and  forearm  and  in  the  arm  to  2  or  3  inches  ■ 
above  the  elbow.  From  this  point  to  about  4  inches  below  the  shoulder 
they  were  much  impaired.  Sensation  was  impaired  in  the  entire  distribu- 
tion of  the  intercostohumeral  nerve,  and  of  the  fifth  and  sixth  cervical  roots, 
as  well  as  in  the  distribution  of  the  brachial  plexus.  There  was  flaccid  palsy  of 
the  entire  extremity,  including  the  deltoid.  On  the  injured  side  the  pupil  was 
contracted  and  the  palpebral  fissure  narrowed.  One  of  Bristow's  cases  was 
operated  upon  the  third  day  after  the  accident  (Loc.  cit.).  In  this  case  there 
was  complete  paralysis  of  the  upper  extremity,  with  the  exception  of  the 
sensory  area  of  the  intercostohumeral  and  the  circumflex  nerves.  The  acci- 
dent had  been  inflicted  by  the  patient's  forearm  becoming  entangled  in  a  rope, 
which  was  pulled  upon  by  a  steam  winch.  On  reaching  the  hospital  he  felt 
severe  pain,  referred  to  the  arm.  There  was  much  swelling  in  the  inner 
portion  of  the  subclavian  triangle,  the  left  pupil  was  contracted,  and  it  seemed 
likely  that  the  nerves  had  been  avulsed  close  to  the  intervertebral  foramina. 
From  the  fact  that  sensation  was  preserved  in  the  skin  of  the  convexity  of 
the  shoulder  down  to  the  insertion  of  the  deltoid,  Bristow  concluded  that 
some  fibers  of  the  posterior  cord  of  the  plexus  had  escaped  division;  but  when 
the  operation  was  performed  this  conclusion  was  found  to  be  erroneous. 
An  incision  was  made,  and  it  was  foimd  that  the  plexus  had  given  way  at  the 
point  where  the  four  cervical  nerves  and  the  last  dorsal  imite  to  form  the 
three  trunks.  In  order  to  reach  the  lower  ends  it  was  necessary  to  saw 
the  clavicle  and  divide  the  two  pectoral  muscles;  and  the  torn  ends  of  the 
nerve-trunks  were  found  underneath  the  clavicle.  Suturing  was  performed. 
The  ends  of  the  sawn  clavicle  were  sutured  together,  the  wound  was  closed  and 
dressed,  and  the  arm  was  put  up  in  Sayre's  dressing. 

After  the  performance  of  this  operation  sensation  over  the  entire  upper 
arm  returned.  The  author  once  operated  upon  a  patient  that  had  developed 
paralysis,  motor  and  sensory,  after  violent  stretching  of  the  arm.  In  the  light 
of  Bristow's  case  I  assumed  that  avulsion  of  the  plexus  had  probably  taken 
place.  Incision  disclosed  the  fact  that  the  plexus  was  intact,  but  was  surrounded 
with  dense  scar-tissue.  The  tissue  was  removed,  so  as  to  loosen  the  nerves, 
which  felt  like  hard  cords;  but  I  have  lost  track  of  the  patient,  and  do  not  know 
the  result.     My  patient  was  operated  upon  many  months  after  the  injury. 


The  Symptoms  of  Division  of  Nerves  751 

I  operated  upon  another  case  and  found  intravertebral  rupture.  I  anasto- 
mosed two  divided  nerves  to  a  sound  one.  The  operation  was  done  months  after 
the  injury  and  the  patient  is  apparently  sUghtly  improved  three  months  after 
operation.  The  location  of  the  seat  of  injury  is  of  great  importance.  Lesion 
within  the  vertebrae  is  positively  indicated  by  contraction  of  the  pupil,  nar- 
rowing of  the  palpebral  fissure,  and  enophthalmos  on  the  affected  side  (Frazier 
and  Skillern,  ''Amer.  Med.  Assoc,"  191 1),  but  there  can  be  intravertebral 
injury  without  these  phenomena.  The  ciliospinal  fibers  on  which  these  phe- 
nomena depend  usually  accompany  the  eighth  cervical  and  first  thoracic  nerves. 

Injury  above  the  clavicle  will  involve  the  circumflex  and  musculospiral. 
As  the  great  pectoral  is  supplied  from  both  the  external  and  internal  cords  of  the 
plexus,  complete  paralysis  of  the  great  pectoral  proves  that  both  cords  are  in- 
volved, and  unimpaired  movements  of  the  diaphragm  on  the  side  of  the  lesion 
(observed  with  the  fluoroscope)  show  that  the  cords  of  the  plexus  are  not  divided 
within  the  foramina,  but  well  outside  of  them  (John  B.  Murphy,  in  "Surg.,. 
Gynec,  and  Obstet.,"  April,  1907).  In  all  cases  of  rupture  prompt  operation 
is  indicated.     Long  delay  means  a  hopeless  prognosis. 

In  injury  without  complete  rupture  the  nerves  become  fibrous  and  embedded 
in  scar-tissue.  If  operation  is  done  before  scar-tissue  forms  follow  the  advice  of 
Frazier  and  incise  the  sheaths  of  the  trunks  or  cords  to  liberate  inflammatory 
exudate.  If  scar-tissue  has  formed,  excise  it.  It  may  be  necessary  to  excise 
portions  of  nerves  or  trunks  with  it.  If  this  is  done,  suture  the  divided 
ends  together.  It  may  be  necessary  to  do  nerve-lengthening,  suture  a  dis- 
tance, or  grafting  in  of  a  nerve  from  a  recently  amputated  limb  (if  one  can  be 
obtained),  or  the  sciatic  of  a  rabbit.  In  accessible  rupture  suture  the  divided 
nerves.  In  some  cases  a  divided  cord  or  trunk  may  be  anastomosed  into  a 
sound  one.  Ruptures  near  to,  in,  or  within  the  intervertebral  foramina  do  not 
admit  of  suturing.  If  a  sound  nerve  is  left  the  divided  nerve  or  nerves  should  be 
anastomosed  to  it.  If  the  entire  plexus  is  ruptured  we  should  consider  the  plan 
of  Alexinsky  (quoted  by  Frazier  and  Skillern,  Loc.  cit.) :  effect  anastomosis  be- 
tween nerves  of  the  injured  side  and  nerves  of  the  sound  side.  When  intracta- 
ble neuralgia  follows  rupture  the  posterior  roots  may  be  divided. 

Brachial  Birth  Palsy. — It  has  been  pointed  out  by  Clark,  Taylor,  and 
Prout  ("Am.  Jour.  Med.  Sciences,"  Oct.,  1905)  that  brachial  birth  palsy  results 
from  tension  on  the  nerve-trunks  by  overstretching  during  delivery,  the  nerve- 
sheath  first  rupturing  and  then  the  nerve-fibers.  When  the  sheath  ruptures 
hemorrhage  occurs,  fibrous  tissue  forms,  and  the  scar  presses  on  the  intact, 
slightly  stretched,  or  actually  lacerated  nerve,  and  prevents  repair.  The 
authors  tell  us  that  the  fifth  cervical  root  first  gives  way,  then  the  sixth,  and 
so  on  down  the  plexus  if  there  is  sufiicient  force.  In  the  milder  cases  the  fifth 
root  alone  suffers.  They  call  it  brachial  birth  palsy,  or  laceration  palsy,  and 
sum  up  the  s>Tnptoms  in  a  severe  case  as  follows:  The  arm  hangs  powerless; 
abduction  at  the  shoulder  is  impossible  because  of  deltoid  and  supraspinatus 
palsy;  the  forearm  is  extended  and  flexion  is  impossible  because  of  biceps, 
brachialis  anticus,  and  supinator  longus  palsy;  palsy  of  supinator  brevis  and 
biceps  causes  pronation  of  hand;  there  is  inward  rotation  of  the  humerus 
because  of  palsy  of  the  supraspinatus,  infraspinatus,  and  teres  minor. 

Brachial  birth  palsy  is  manifest  soon  after  its  infliction  by  evidences  of 
pain  on  handling  the  extremity,  the  pain  being  due  to  neuritis  (authors  above 
quoted).  Medical  treatment  is  reHed  on  for  one  year,  and  then,  if  improve- 
ment is  not  manifest,  operation  is  indicated  (see  page  769). 

Posterior  (Long)  Thoracic  Nerve. — Division  of  this  nerve  causes  paralysis  of 
the  serratus  magnus  muscle,  which  is  made  evident  by  eversion  from  the  thorax 
and  rotation  of  the  scapula  when  the  arm  is  taken  forward  {wing-like  scapula). 
In  paralysis  of  this  muscle  the  arm  cannot  be  raised  above  the  horizontal. 


752 


Diseases  and  Injuries  of  Nerves 


Suprascapular  Nerve. — Division  of  this  nerve  produces  some  anesthesia 
over  the  scapula  and  paralysis  of  the  supraspinatus  and  the  infraspinatus 
muscles.  The  supraspinatus  is  but  an  adjuvant  to  the  deltoid  and  palsy  of 
it  is  not  manifestly  disabHng.  Palsy  of  the  infraspinatus  renders  external 
rotation  of  the  humerus  unpossible,  and  writing  becomes  most  difficult  because 

the  pen  cannot  be  moved 
along  the  paper.  Sewing, 
too,  is  greatly  interfered  with. 
Circumflex  Nerve. — Divi- 
sion of  the  circumflex  nerve 
produces  paralysis  of  the  del- 
toid muscle,  so  that  it  be- 
comes impossible  to  lift  the 
arm  to  a  right  angle  with  the 
body.  There  is  some  slight 
retention  of  power  in  the 
anterior  fibers,  which  are  sup- 
plied by  the  anterior  thoracic 
ner\'e.  The  skin  over  the 
lower  part  of  the  muscle  is 
usually  anesthetic. 

Musculocutaneous  Nerve. 
— Division  of  this  ner^^e  pro- 
duces paralysis  of  the  biceps 
and  of  the  brachiaKs  anticus 
muscles  (paralysis  of  the  fore- 
arm flexors).  This  palsy 
becomes  especially  evident 
when  the  forearm  is  supin- 
ated,  because  in  this  position 
the  supinator  longus  can  no 
longer  act  as  a  flexor  of  the 
elbow.  There  is  anesthesia 
of  the  radial  side  of  the  fore- 
arm anteriorly  and  poste- 
riorly. 

The  Musculospiral  or  Ra- 
dial Nerve. — Division  of  this 
nervQ  high  up  near  the  plexus 
causes  paralysis  of  the  exten- 
sor muscles  of  the  elbow  and 
the  wrist,  of  the  supinators, 
and  of  the  long  extensors  of 
the  thumb  and  fingers.  When 
divided  near  the  middle  of 
the  humerus,  the  triceps 
usually,  but  not  invariably, 
escapes.  If  the  injury  is 
below  the  branch  going  to 
the  supinator  longus,  that 
muscle  wiU  escape;  otherwise  it  wall  become  paralyzed.  The  extensor  palsy 
causes  wrist-drop  and  loss  of  the  power  of  extending  the .  first  phalanges 
of  the  fingers  and  thimib;  and,  as  Gow^ers  has  pointed  out,  flexion  is  re- 
duced to  one-third  of  the  normal,  the  flexors  ha\dng  lost  power  "from  the 
loss  of  antergic  support."     As  a  rule,  in  musculospiral  palsy  there  is  loss 


Anterior  surface. 


Posterior  surface. 


Fig.  483  .^Distribution  of  the  cutaneous  nerves  to  the 
shoulder,  arm,  and  hand.  The  region  of  the  N.  radiahs  k 
represented  by  the  unbroken  hatched  hue,  that  of  the  _N. 
uhiaris  by  the  broken  hatched  lines,  a,  Anterior,  h,  posterior 
surface;  sc,  Nn.  suprascapular  (plexus  cervicahs);  ax,  chief 
branch  of  N.  axiUar.;  cps,  cpi,  Nn.  cutanei  post.  sup.  and 
inf.  (from  N.  radiahs);  ra,  terminal  branches  of  N.  radialis; 
cm,  cl,  Nn.  cutanei  medius  (also  to  the  plexus)  and  laterahs 
(chiefly  to  the  N.  medianus);  cp,  N.  cutan.  pahnar.,  N.  rad.; 
cmd,  N.  cutan.  mediaUs;  me,  N.  medianus;  u,  N.  ukiaris;  epu, 
N.  cutan.  palm,  vdnaris  (Henle). 


The  Symptoms  After  Division  of  Nerves 


753 


of  supination.  Sensibility  is  sometimes  greatly  affected,  and  sometimes 
very  slightly.  If  the  injury  is  above  the  level  of  the  musculospiral  groove 
there  will  be  anesthesia  in  the  area  supplied  by  the  sensory  fibers  of  the  nerve 
(Fig.  483).  If  the  nerve  is  injured  in  the  musculospiral  groove  there  are  seldom 
sensory  disturbances.  Anesthesia  rarely  occurs  in  the  upper  arm  in  any  case, 
and  even  after  an  injury  in  the  groove  sensation  in  the  hand  may  be  normal  or 
nearly  so.  Fig.  484  shows  the  position  of  the  parts  in  musculospiral  palsy  and 
Figs.  483  and  485  the  sensory  distribution  of  the  nerve.  Fracture  of  the 
humerus  may  cause  division  of  the  musculospiral  nerve. 

The  Median  Nerve. — After  division  of  this  nerve  there  is  paralysis  of  the 
pronators;  the  flexor  carpi  radiahs;  the  finger  flexors,  except  the  ulnar  por- 
tion of  the  deep  flexor;  the  abductors,  and  the  flexors  of  the  thumb;  and 
the  two  radial  lumbricales.  The  forearm  can  be  placed  in  a  position  midway 
between  pronation  and  supination;  but  further  pronation  cannot  be  volun- 
tarily effected.  In  executing  flexion  of  the  wrist  a  strong  deviation  toward  the 
ulnar  side  takes  place.  The  thumb  is  in  a  position  of  extension  and  abduction, 
and  cannot  be  brought  into  apposition  with  the  finger-tips.  The  second 
phalanges  of  the  fingers  cannot  be  flexed  on  the  first,  and  the  distal  phalanges 


Fig.  484. — Paralysis  of  musculospiral  nerve 
after  fracture  of  the  humerus  ("wrist-drop"); 
but  when  fingers  have  been  flexed  into  palm,  a, 
they  can  be  extended,  h,  at  first  interphalangeal 
joints  by  lumbricals  and  interossei,  which  are 
suppHed  by  the  ulnar  and  median  nerves  (Erich- 
sen). 


Fig.  485. — Distribution  of  sensory  nerves 
on  the  backs  of  the  fingers:  r,  Musculospiral 
or  radial  nerve;  u,  ulnar  nerve;  m,  median 
nerve  (Krause). 


of  the  first  and  second  fingers  cannot  be  voluntarily  flexed.  The  corresponding 
phalanges  of  the  third  and  fourth  fingers  can  be  flexed,  this  being  accomplished 
by  the  unparalyzed  i.flnar  half  of  the  deep  flexor.  Flexion  of  the  first  pha- 
langes is  still  possible,  as  it  is  accomplished  by  means  of  the  interossei.  The 
extensor  action  of  the  interossei  muscles  upon  the  middle  and  distal  phalanges, 
being  unopposed,  may  eventually  cause  subluxation.  The  sensory  distri- 
bution of  the  median  nerve  is  shown  in  Figs.  483  and  485-487.  It  is  the 
sensorv^  nervx  of  the  radial  side  of  the  palm,  the  front  of  the  thumb,  the  first 
and  second  fingers  and  half  of  the  third  finger,  and  the  back  of  the  last  phalanx 
of  the  index  and  the  middle  finger  (Gowers).  The  sensory  changes  after 
median  paralysis  are  quite  variable — sometimes  widespread  and  complete, 
at  other  times  trivial,  and  occasionaUy  absent.  Gowers  says  that  if  there 
is  anesthesia  it  is  usually  of  the  palmar  surface,  but  it  may  also  occur  on  the 
dorsal  aspect  of  the  ends  of  the  first  two  fingers. 

The  Ulnar  Nerve. — When  this  nerv^e  is  divided  there  is  paralysis  of  the 
flexor  carpi  iflnaris,  of  the  ulnar  portion  of  the  deep  flexor,  of  the  muscles 
of  the  little  finger,  of  the  abductor  poUicis,  and  of  the  inner  end  of  the  flexor 
brevis  poUicis  (Gowers).  It  becomes  impossible  to  adduct  the  thumb,  and 
the  majority  of  the  movements  of  the  Httle  finger  are  aboHshed.  Flexion  of 
48 


754 


Diseases  and  Injuries  of  Nerves 


the  fingers  is  impossible  at  the  first  joints,  and  extension  is  impossible  at  the 
other  joints;  but,  as  Gowers  points  out,  the  loss  is  shghter  in  the  first  two 


Fig.  486. — Section  of  median  nerve;  areas 
of  anesthesia  (hea\T^  shading)  and  of  dyses- 
thesia (light  shading)  on  palmar  surface  of 
hand  (Bowlby). 


Fig.  487. — Section  of  median  nerve;  re- 
gions of  anesthesia  and  dysesthesia  on  dorsal 
surface  of  hand  (Bowlby). 


fingers  than  in  the  others  because  the  lumbricales  of  the  first  two  fingers  are 
supplied  by  the  median  nerve.     Interosseal  flexion  is  impossible,  and  the  op- 


Fig.  488. — Division  of  ulnar  nerve. 

ponents  of  the  interossei,  acting  without  normal  antagonism,  contract  and  pro- 
duce what  is  known  as  claw-hand  (Figs.  488,  489),  a  condition  in  which  the 


Fig.  489.- 


-Paralysis  of  ulnar  nerve  from  wound  at  A ;  contracture  of  common  extensor  with  posterior 
luxation  of  first  phalanges;  B,  head  of  metacarpal  bone  (Duchenne). 


first  phalanges  are  overextended  and  the  others  are  flexed.     The  sensory 
loss  in  ulnar  paralysis  is  extremely  variable.     The  sensory  distribution  is 


The  Symptoms  After  Division  of  Nerves 


755 


to  the  ulnar  side  of  the  hand,  both  back  and  front,  involving  the  little  finger, 
the  ring-finger,  and  the  ulnar  half  of  the  middle  finger  (Figs.  483,  485,  490,  and 
491). 

The  lumbar  plexus  supplies  the  cutaneous  surface  of  the  lower  portion  of 
the  abdomen,  of  the  front  and  the  sides  of  the  thigh,  and  of  the  inner  por- 
tion of  the  leg  and  foot  (Fig.  492).  It  innervates  the  flexors  and  adductors 
of  the  hip-joint,  the  extensors  of  the  knee,  and  the  cremaster  muscle.  The 
branches  sent  to  the  leg  are  the  obturator  and  the  anterior  crural  nerves. 

The  sacral  plexus  supplies  the  extensors  and  rotators  of  the  hip,  the  knee- 
flexors,  and  all  the  muscles  of  the  foot ;  also  the  skin  of  the  gluteal  region,  the 
back  of  the  thigh,  the  outer  portion  and  the  posterior  part  of  the  lower  leg, 
and  most  of  the  foot  (Gowers)  (Fig.  492).  Its  chief  branches  are  those  to  the 
external  rotators  of  the  hip — the  gluteal  nerve,  the  small  sciatic,  and  the  great 
sciatic. 

The  Anterior  Crural  Nerve. — When  this  nerve  is  divided  the  extensor 
muscles  of  the  knee  are  paralyzed.     The  psoas  muscle  is  not  affected,  even  if 


Fig.  4go.  Fig.  4gi. 

Figs.  490,  491. — Showing  sensory  loss  and  ordinary  position  in  injiiries  of  the  uhiar  nerve  (Bowlby). 

the  nerve  is  divided  within  the  abdomen;  but  high  division  may  produce 
paralysis  of  the  ihacus  muscle.  In  anterior  crural  palsy  the  skin  is  anesthetic 
over  almost  the  entire  thigh,  the  inner  surface  of  the  leg  and  foot,  and  the  inner 
sides  of  the  first  and  second  toes  (Fig.  492). 

The  Obturator  Nerve. — In  obturator  palsy  the  adductor  muscles  of  the 
thigh  are  paralyzed,  and,  in  consequence,  the  patient  is  unable  to  cross  one 
leg  over  the  other.  Gowers  points  out  that  external  rotation  of  the  thigh  is 
also  interfered  with. 

The  Superior  Gluteal  Nerve. — The  division  of  this  nerve  paralyzes  the  gluteus 
medius  and  the  gluteus  minimus  muscles,  and  there  is  "loss  of  abduction  and 
circumduction  of  the  thigh"  (Gowers). 

The  Small  Sciatic  Nerve. — Division  of  this  nerve  paralyzes  the  gluteus  maxi- 
mus  muscle  and  produces  anesthesia  of  the  upper  half  of  the  calf  of  the  leg  and 
of  the  middle  third  of  the  back  of  the  thigh  (Gowers)  (Fig.  492). 

The  Great  Sciatic  Nerve. — If  this  nerve  is  divided  near  the  sciatic  notch 
there  is  a  paralysis  of  the  flexor  muscles  of  the  leg.  These  muscles,  as  Gowers 
points  out,  are  also  extensors  of  the  hip.    There  is  likewise  paralysis  of  all  the 


756 


Diseases  and  Injuries  of  Nerves 


muscles  below  the  knee.  If,  however,  the  injury  is  below  the  upper  third  of  the 
thigh,  there  is  no  paralysis  of  the  flexors  of  the  leg.  If  the  nerve  is  damaged 
on  a  level  below  the  small  sciatic,  there  is  anesthesia  of  the  outer  portion  of  the 
leg,  of  the  sole  of  the  foot,  and  of  most  of  the  dorsum  of  the  foot  (Fig.  492). 

The  External  Popliteal  Nerve. 
— When  this  nerve  is  divided, 
there  is  paralysis  of  the  tibialis 
anticus  muscle,  the  extensor  longus 
digitorum,  the  extensor  brevis 
digitorum,  and  the  peronei;  and 
the  patient  is  unable  to  flex  the 
ankle  and  extend  the  first  phalan- 
ges of  the  toes.  When  he  tries  to 
walk  he  cannot  lift  the  foot  from 
the  ground ;  and  eventually  there  is 
the  development  of  talipes  equinus 
(Gowers) .  The  anesthesia  is  mani- 
fest on  the  outer  portion  of  the 
anterior  surface  of  the  leg,  and 
also  on  the  dorsima  of  the  foot 
(Fig.  492). 

The  Internal  Popliteal  Nerve. 
— Damage  to  this  nerve  paralyzes 
the  posterior  tibial  muscle,  the 
flexor  longus  digitorum,  the  mus- 
cles of  the  calf,  the  popliteus 
muscle,  and  the  muscles  of  the 
plantar  surface  of  the  foot.  The 
toes  become  flexed  at  the  two  dis- 
tal joints,  and  extend  at  the  proxi- 
mal joints.  Walking  is  greatly 
interfered  with.  There  is  loss  of 
the  power  of  rotating  the  flexed 
leg  inward,  if  the  damage  is  above 
the  branch  to  the  popliteus  mus- 
cle; and  extension  of  the  ankle- 
joint  is  lost.  As  the  conse- 
quence, talipes  calcaneus  develops 
(Gowers) .  The  anesthesia  is  vari- 
able, but  usually  involves  the  sole 
of  the  foot  and  the  outer  surface 
and  lower  portion  of  the  back  of 
the  leg  (Fig.  492). 

The  Plantar  Nerves. — Division 
of  the  internal  plantar  nerve 
paralyzes  the  short-toe  flexor,  the 
two  inner  lumbricales,  and  the 
plantar  muscles  of  the  great  toe, 
except  the  adductor  (Gowers). 
There  is  anesthesia  of   the  inner 

portion  of  the  sole  of  the  foot  and  of  the  plantar  surface  of  the  three  inner 

toes  and  of  half  of  the  fourth  toe  (Fig.  492). 

Division  of  the  external  plantar  nerve  causes  paralysis  of  the  muscles  of 

the  little  toe,  of  the  adductor  of  the  great  toe,  of  all  the  interossei,  of  the 

two  outer  lumbricales,   and  of  the  flexor  accessorius   (Gowers).     There  is 


Anterior  surface.  Posterior  surface. 

Fig.  4g2. — Distribution  of  the  cutaneous  nerves  of 
the  lower  extremity:  ii,  N.  ilio-inguinal.  (plex.  lumb.); 
li,  N.  lumbo-inguinal.  (to  the  genitocrural,  plex.  lum- 
bal.); se,  N.  spermat.  ext.  (to  the  genitocrural);  cp, 
N.  cutan.  post.  (plex.  ischiad.);  cl,  N.  cutan.  lateral, 
(plex.  lumb.);  cr,  N.  cruralis  (plex.  lumbal.);  obt,  N. 
obturator,  (plex.  Imnb.);  sa,  N.  saphen.  (plex.  lum- 
bal.); cpe,  N.  commun.  peron.  (N.  peron.  tibial.);  cli, 
N.  commun.  tibial;  per',  per",  N.  peronaei  ram.  su- 
perfic.  et  prof.;  cpm,  N.  cutan.  post.  med.  (plex. 
ischiad.);  cpp,  N.  cut.  plant,  propr.  (N.  tib.);  plm, 
pll,  N.  plantar,  medial,  et  lateral.  (N.  tib.)  (Henle). 


The  Treatment  After  Division  of  Nerves  757 

anesthesia  of  the  skin  of  the  outer  half  of  the  sole  of  the  foot,  of  the  little  toe, 
and  of  half  of  the  fourth  toe  (Fig.  492). 

The  Facial  Nerve. — This  nerve  may  be  divided  during  the  mastoid  opera- 
tion or  may  be  lacerated  by  a  fracture  of  the  petrous  portion  of  the  temporal 
bone,  and  a  peripheral  palsy  results.  The  face  is  asymmetrical  and  is  drawn 
to  the  sound  side.  Asymmetry  becomes  more  marked  on  attempting  to  smile 
or  to  show  the  teeth.  Whistling  and  frowning  are  impossible.  The  sense  of 
taste  may  be  less  acute  or  lost  on  the  anterior  two-thirds  of  the  tongue.  There 
is  relaxation  of  the  palate  and  deviation  of  the  uvula.  Reactions  of  degenera- 
tion can  be  demonstrated  in  the  palsied  muscles.  In  some  cases  there  are 
sensory  disturbances  (hyperesthesia  or  anesthesia)  and  in  some  there  are  vaso- 
motor perturbations  on  the  palsied  side.  On  the  paralyzed  side  the  muscles 
are  relaxed,  the  nasolabial  fold  is  to  a  great  extent  gone,  the  nostril  cannot 
be  dilated.  The  brow  wrinkles  have  been  smoothed  out,  the  eyelids  cannot 
be  closed;  on  attempting  to  close  the  eye  the  globe  tilts  upward  and  outward. 
The  cornea  and  conjuntiva  inflame,  the  lower  lid  droops,  and  tears  run  down 
the  cheek. 

Treatment. — In  every  wound  in  which  a  nerve  or  nerves  might  be  damaged 
make  careful  search  and  examination  to  determine  the  matter.  Always  suspect 
nerve  injury  in  wounds  of  the  wrist.  In  all  recent  cases  of  nerve-section  try, 
if  possible,  to  suture  the  ends  of  the  divided  nerve.  The  earlier  suture  is  done 
the  better  the  chance  for  restoration  of  function.  For  instance,  in  fracture  of 
the  humerus,  with  division  of  the  musculospiral,  operate  at  once.  After-care  is 
of  the  greatest  importance  in  all  cases  of  nerve  suture.  Primary  suture  means 
suture  within  twenty-four  hours  of  the  accident.  Suture  may  fail.  There  may 
be  partial  or  complete  restoration  of  function.  In  123  reported  cases  of 
primary  suture,  119  were  cured  in  from  one  day  to  one  year  (Willard).  The 
return  of  sensation  may  be  rapid  or  may  be  slow;  muscular  power  returns  more 
slowly  than  sensation.  If  the  patient  is  not  seen  until  long  after  the  accident, 
incise  and  apply  sutures  {secondary  sutures) ;  if  the  nerve  cannot  be  found,  ex- 
tend the  incision,  find  the  trunk  above  and  trace  it  down,  and  find  the  trunk 
below  and  follow  it  up.  The  results  are  not  nearly  so  good  as  are  those  of 
primary  suture.  After-care  for  months  is  highly  important.  In  130  reported 
cases  of  secondary  suture  80  per  cent,  were  more  or  less  improved  (Willard). 
Even  after  primary  suture  loss  of  function  is  bound  to  occur  for  a  time.  After 
secondary  suture  sensation  may  return  in  a  few  days,  but  it  may  not  return 
until  after  a  much  longer  period;  in  any  case  muscular  function  is  not  restored 
for  months.  After  partial  section  of  a  nerve  the  ends  should  be  sutured.  In 
performing  secondary  suture  it  may  be  necessary  to  effect  lengthening  in 
order  to  approximate  the  ends  (see  page  759).  Transplantation  of  a  portion  of 
nerve  is  sometimes  practised  {implantation  or  anastomosis).  Nerve- grafting  is 
bridging  the  gap  by  means  of  a  portion  of  nerve  from  one  of  the  lower  animals 
or  from  a  recently  amputated  himian  limb.  Nerve-transplantation  may  fail 
utterly;  it  may  be  followed  by  great  improvement,  but  absolute  and  perfect 
restoration  of  function  cannot  be  obtained.  R.  Peterson^  has  made  a  study  of 
the  20  recorded  cases  of  nerve-grafting;  8  of  the  operations  were  primary  and  12 
were  secondary.  The  periods  after  the  injury  at  which  operation  was  performed 
varied  from  forty-eight  hours  to  a  year  and  a  quarter;  4  of  the  8  primary  cases 
improved;  8  of  the  12  cases  of  secondar}^  operation  showed  improvement  in 
motion  or  sensation.  The  distance  between  the  nerves  did  not  seem  to  affect 
the  results.  No  case  recovered  completely,  but  in  i  case  sensation  returned 
completely  and  only  the  abductors  of  the  thumb  remained  weak.  In  most  of 
the  cases  that  were  benefited  sensation  returned  by  the  tenth  day  and  motion 
within  two  and  a  half  months.  In  one  of  the  successful  cases,  that  of  A.  W. 
1  "Amer.  Jour.  Med.  Sciences,"  April,  1899. 


75^  Diseases  and  Injuries  of  Nerves 

Mayo  Robson/  the  spinal  cord  of  a  rabbit  was  used.  A  facial  nerve  divided  in 
the  aqueduct  of  Fallopius  may  perhaps  be  sutured  at  the  site  of  the  injury. 
This  should  be  attempted  as  soon  as  the  palsy  is  observed,  as  was  suggested,  I 
believe,  by  Frederick  Sydenham  ("Brit.  Med.  Jour.,"  May  8,  1909).  If  the 
ends  of  the  divided  nerve  cannot  be  approximated,  suture  a  distance  may  be 
practised,  as  was  done  successfully  by  Sydenham  (Ibid.).  If  suture  at  the 
site  of  injury  is  impossible  the  end  of  the  peripheral  segment  of  the  divided 
nerve  may  be  anastomosed  to  the  hypoglossal,  glossopharyngeal,  or  spinal 
accessory  nerve  (see  page  760). 

Pressure  upon  nerves  may  arise  from  callus,  scars,  a  dislocated  bone, 
a  timior,  or  an  external  body. 

The  symptoms  may  be  anesthetic,  paralytic,  or  trophic. 

The  treatment  is  as  follows:  Remove  the  cause  (reduce  a  dislocated  bone, 
chisel  away  callus,  excise  a  scar,  etc.);  then  employ  massage,  douches,  exer- 
cise, and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Elbow.— This  condition 
is  very  rare.  It  may  occur  as  a  complication  of  a  fracture  or  a  dislocation, 
or  as  an  uncomplicated  condition.  It  may  be  produced  by  violence  or  by 
muscular  effort,  which  ruptures  the  fascia,  the  function  of  which  is  to  retain 
the  nerve  back  of  the  inner  condyle  of  the  humerus.  In  some  cases  the 
symptoms  are  slight  and  transitory,  the  nerve  functionating  well  in  its  new 
situation.  As  a  rule,  there  are  pain,  numbness,  or  anesthesia  of  the  iilnar 
trajectory,  some  stiffness  of  the  elbow,  and  stiffness  of  the  little  finger  and 
ring-finger.  The  nerve  can  be  felt  in  front  of  the  inner  condyle  of  the  humerus. 
In  some  cases  neuritis  follows,  with  trophic  changes. 

Treatment. — Expose  the  nerve  by  an  incision,  incise  the  fibrous  tissue 
back  of  the  inner  condyle,  and  press  the  nerve  into  the  bed  prepared  for  it 
and  hold  it  in  place  by  sutures  of  chromic  catgut  passing  through  the  triceps 
tendon.  Wharton  advises  suturing  also  "the  margin  of  the  fascial  expan- 
sion of  the  triceps  tendon  superficial  to  the  nerve. "^ 

Contusion  of  Nerves. — The  symptoms  of  contusion  of  nerves  may 
be  identical  with  those  of  section.  Sensation  or  motion,  or  both,  may  be 
lost.  The  case  may  recover  in  a  short  time,  or  the  nerve  may  degenerate  as 
after  section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage,  friction,  and 
douches. 

Punctured  Wounds  of  Nerves. — The  symptoms  of  punctured  wounds 
of  nerves  may  be  partly  irritative  (hyperesthesia,  acute  pain,  and  muscular 
spasm)  and  partly  paralytic  (anesthesia,  muscular  wasting,  and  paralysis). 

The  treatment  after  the  puncture  has  healed  is  the  same  as  that  for  con- 
tusion. 

Operations  Upon  Nerves 

Neurorrhaphy,  or  Nerve=suture.— When  a  nerve  is  completely  or 
partially  divided  by  accident  it  should  be  sutured  at  the  first  possible  moment. 
If  there  is  no  tension  the  best  suture  material  is  fine  plain  catgut;  if  there  is  any 
tension,  lightly  chromicized  catgut  (Sherren,  in  "Brit.  Med.  Jour.,"  Jan.  15, 
1910).  Sherren  points  out  that  if  silk  or  linen  is  used  it  interferes  with  complete 
recovery  and  may  cause  symptoms  months  after  the  operation.  In  primary 
suture  render  the  part  bloodless  and  aseptic.  Enlarge  the  incision  if  necessary. 
If  the  ends  can  readily  be  approximated,  pass  two  or  three  sutures  through  the 
sheath  and  connective  tissue  outside,  and  tie  them  (Figs.  493, 494).     If  the  ends 

1  "Amer.  Jour.  Med.  Sciences,"  April,  1899. 

2  A  report  of  14  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow,  by  H.  R.  'WTiarton, 
"Amer.  Jour.  Med.  Sciences,"  Oct.,  1895. 


Neurorrhaphy,  or  Nerve-suture 


759 


cannot  be  approximated,  stretch  each  end  and  then  suture.  The  sutures  do 
not  traverse  the  nerve,  but  go  through  the  perineurium  and  adjacent  connective 
tissue.  After  suturing,  wrap  the  suture  hne  in  Cargile  membrane  to  prevent 
adhesions  to  adjacent  structures  (Sherren,  "Brit.  Med.  Jour.,"  Jan.  15,  1910). 
Suture  the  deep  fascia.  Remove  the  Esmarch  band,  arrest  bleeding,  suture  the 
skin,  dress  antiseptically,  and  put  the  part  in  a  relaxed  position  on  a  splint.  After 
union  of  the  wound  continue  the  use  of  the  splint  to  maintain  muscular  relaxation 
as  long  as  the  muscles  are  paralyzed  (Ibid.),  and  use  mas- 
sage, friction,  electricity,  and  the  douche.  When  volun- 
tary power  returns  remove  the  splint  and  insist  on  active 
exercise.  The  operation  in  some  instances  fails,  but  in 
many  cases  succeeds.  In  some  few  cases  sensation  returns 
in  a  few  days,  but  in  most  cases  does  not  return  for  many 
weeks  or  months.  Sensation  is  restored  before  motor 
power.  After  successful  suturing  of  a  divided  median  nerve  sensations  of  skin 
pain  and  of  extreme  heat  and  cold  appeared  in  fifty-six  days  and  were  restored  in 
two  himdred  and  seven  days.  Sensations  of  light  touch  and  slight  degrees  of 
heat  and  cold  appeared  in  two  hundred  and  sLxty  days  and  were  not  completely 
restored  for  one  year  (Kenneth  A.  J.  Mackenzie,  in  "Annals  of  Surg.,"  July, 
1909).  Secondary  suture  is  performed  upon  cases  long  after  division  of  a  nerve. 
If  operation  is  not  done  for  three  years  or  more  after  division  it  is  very  im- 
probable that  complete  regeneration  will  ever  occur,  and  yet  it  is  always  worth 
trying,  for  muscular  control  has  been  regained  after  suturing  in  i  case  twenty- 
nine  years  subsequent  to  nerve  division  (Alfred  S.  Taylor,  in  "Jour,  of  Ortho- 
pedic Surg.,"  Nov.,  1908).  The  part  is  rendered  aseptic  and  bloodless;  an 
incision  is  made;  the  bulbous  proximal  end  is  easily  found  and  loosened  from 


Fig.   493. — Nerve-suture. 


Fig.  494. — Nerve-suture:  a,  Direct;  b,  perineurotic;  c,  paraneurotic;  d,  e,  neuroplasty  (Senn). 

its  adhesions;  the  shrunken  distal  end  is  sought  for  and  loosened  (it  may  be 
necessary  to  expose  the  nerve  below  the  wound  and  trace  its  trunk  upward) ; 
the  entire  bulb  of  the  proximal  end  is  cut  off;  about  i  inch  of  the  distal  end  is 
removed.  AU  scar-tissue  between  the  ends  is  most  carefully  removed.  If  the 
gap  between  the  ends  is  not  wide,  each  end  is  gently  stretched,  and  the  ends  are 
approximated  and  sutured  together,  and  the  suture  line  is  covered  by  Cargile 
membrane.  If  stretching  does  not  permit  of  approximation,  adopt  the 
expedient  shown  in  Fig.  494,  d,  or  in  Fig.  495.  This  operation  is  neuroplasty 
by  the  flap  method.  Another  method  is  to  make  a  bridge  of  strands  of  catgut 
running  from  one  divided  end  to  the  other.  We  speak  of  this  plan  as  suture 
a  distance  (Fig.  494,  e).  The  catgut  bridge  supports  the  growing  reparative 
material. 


r^. 


760  Diseases  and  Injuries  of  Nerves 

AUis  suggested  shortening  the  limb  by  resecting  a  piece  of  bone.  This  has 
been  done  successfully  by  Keen,  Rose,  and  others. 

Letievant  attaches  the  peripheral  portion  of  a  divided  nerve  into  a  longi- 
tudinal slit  in  a  sound  nerve  (end  to  side). 

Guelliot  suggested  tubulization,  that  is,  erecting  barriers  along  the  path  of 
reparative  material  to  save  the  ends  of  the  nerve  from  cellular  invasion  from 
the  perineural  structures  (which  would  block  repair)  and  to  guide  the  new 

growth.  Vanlair  uses  a  piece  of  artery  which  has 
just  been  removed  or  surrounds  the  ends  with  de- 
calcified bone.  Payr  uses  a  tube  of  absorbable 
magnesium.  Hashimoto  and  Toknoka  use  a  vein 
or  artery  from  a  recently  slaughtered  calf,  hardened 
in  formalin.  Implantation  or  anastomosis  is  ad- 
visable in  some  cases. 
Fig.  49s.— Suture  of  a  nerve  by  Gelatin  tubes  have  been  used,  silver-foil   has 

splitting  the  ends  (Beach).  been  tried,  and  Cargile  membrane  has  been  em- 
ployed. None  of  these  plans  is  entirely  satisfactory. 
Murphy  covers  the  line  of  nerve-suture  with  fascia,  muscle,  or  fat.  In  regions 
where  he  cannot  obtain  suitable  covering  tissue  he  wraps  about  the  suture 
line  a  material  composed  of  equal  parts  of  paraffin  and  oil  of  sesame.  This 
mixture  can  be  flattened  out  very  thin  ("Surg.,  Gynec,  and  Obstet.,"  AprU, 

1907)- 

The  operation  of  anastomosis  is  employed  after  an  exsection  which  leaves 
a  very  large  gap,  for  facial  palsy,  for  infantile  palsy,  for  avulsion  of  the  brachial 
plexus,  and  for  brachial  birth  palsy. 

Nerve=grafting  is  practised  by  some.  A.  W.  Mayo  Robson  used  the 
spinal  cord  of  a  rabbit  to  fill  a  gap  between  the  ends  of  the  divided  median 
nerve  of  a  man.  The  restoration  of  function  was  almost  complete.  Some 
surgeons  have  grafted  in  bits  of  nerve  obtained  from  a  recently  amputated 
limb.  It  makes  no  difference  whether  the  grafted  nerve  is  motor,  sensory, 
or  mixed.  The  results  of  grafting  are  seldom  good.  Chas.  A.  Powers 
("Transactions  of  the  American  Surgical  Assoc,"  1904)  collected  22  cases  from 
literature,  20  from  Peterson's  paper,  i  case  of  Durante's,  and  i  of  his  own.  In 
this  series  there  were  3  good  results  and  3  "fair"  results.  The  bit  of  nerve 
grafted  does  not  participate  in  repair — it  is  a  mere  bridge,  and  acts  as  does  the 
suture  a  distance. 

•  Neurectasy,  Neurotomy,  and  Neurectomy. —  Neurectasy,  or  nerve- 
stretching,  may  be  applied  to  motor,  sensory,  or  mixed  nerves.  A  nerve 
can  be  stretched  about  one-twentieth  of  its  length.  Nuerectasy  has  been 
employed  for  neuralgia,  neuritis,  muscular  spasm,  hyperesthesia,  anesthesia, 
painful  ulcer,  perforating  ulcer,  the  pains  of  locomotor  ataxia,  and  many  other 
conditions.  The  operation,  which  was  once  the  fashion,  seems  to  benefit  some 
cases,  but  it  is  not  now  thought  so  highly  of  as  formerly.  The  incision  for  neu- 
rectasy is  identical  with  the  incision  for  neurectomy  or  neurotomy  of  the  same 
nerve.  Neurotomy,  or  section  of  a  nerve,  is  performed  only  upon  small  and 
purely  sensory  nerves  (in  spasmodic  wry-neck  a  motor  nerve  is  cut).  It  is 
performed  chiefly  for  peripheral  neuralgia  or  for  some  other  painful  malady. 
It  is  almost  useless  in  painful  conditions,  because  sensation,  as  a  rule,  soon 
returns.  Paget  saw  complete  return  of  sensation  in  four  weeks  after  division 
of  the  median  nerve.  Corning  endeavors  to  prevent  this  regeneration  by 
inserting  oil  between  the  ends.  He  uses  oil  of  theobroma  containing  enough 
paraffin  to  make  the  melting-point  105°  F.  The  oil  is  melted,  is  injected 
around  the  nerve,  and  cold  is  applied.  The  nerve  is  now  sectioned  with  a 
canaliculated  knife,  the  ends  are  separated  widely,  more  oil  is  injected,  and 
cold  is  again  applied.     The  theory  is   that    this   oil,  which  is  solid  at  the 


Stretching  of  the  Sciatic  Nerve  761 

temperature  of  the  body,  devitalizes  the  nerve  at  the  point  of  section  and 
acts  as  a  barrier  to  the  passage  of  regenerating  fibers.  This  method  has  been 
appHed  especially  in  cervicobrachial  neuralgia.^  Neurectomy,  or  excision  of 
a  portion  of  a  nerve-trunk,  is  applicable  to  sensory  nerves  and  to  painful 
affections. 

Sympathectomy. — Jonnescd's  Operation. — It  has  long  been  known  that 
division  of  the  sympathetic  nerve  in  the  neck  may  produce  important  changes 
in  the  eye  and  in  the  cerebral  circulation.  In  1893  Jaboulay  divided  the 
sympathetic  on  each  side  for  the  purpose  of  treating  epilepsy.  The  removal 
of  the  gangUa  of  the  sympathetic  was  proposed  by  Baracz;  and  the  operation 
was  first  performed  by  Jonnesco,  in  1896,  for  epilepsy.  The  operation  is 
performed  by  some  surgeons  for  epilepsy,  for  exophthalmic  goiter,  for  glau- 
coma, and  for  trifacial  neuralgia.  In  operating  for  glaucoma  the  superior 
cervical  ganglion  on  each  side  is  removed,  as  it  is  from  this  that  the  sympa- 
thetic fibers  that  pass  to  the  eye  are  derived.  If  the  operation  is  done  at  all, 
it  should  be  a  bilateral  one. 

This  operation  is  used  in  epilepsy  on  the  theory  that  there  is  an  anemic 
condition  of  the  brain  in  this  disease  which  is  corrected  by  producing  a  hy- 
peremia, and  that  the  hyperemia  improves  cerebral  nutrition.  The  opera- 
tion in  epilepsy  is  largely  theoretical,  although  Jonnesco  claims  12  per  cent, 
of  cures  in  a  large  number  of  operations.  In  exophthalmic  goiter  there 
seems  to  be  some  distinct  evidence  that  the  operation  may  be  beneficial, 
but  Curtis  shows  that  the  mortality  is  high.  Personally,  I  have  not  employed 
it  in  epilepsy,  and  at  the  present  time  I  should  not  be  inclined  to  do  so.  In 
exophthalmic  goiter,  if  any  operation  is  necessary,  I  perform  partial  thyroid- 
ectomy or  ligation  of  the  thyroid  arteries;  but  in  progressive  glaucoma,  which 
is  always  so  absolutely  hopeless,  the  operation  is  a  justifiable  procedure  and 
occasionally  seems  to  have  a  distinct  influence  in  retarding  the  development 
of  the  disease. 

The  incision  should  be  made  along  the  posterior  margin  of  the  sterno- 
cleidomastoid muscle.  I  have  become  convinced,  in  performing  two  opera- 
tions of  this  kind  and  through  studies  made  upon  the  dead  body,  that  the 
ganglion  may  be  more  easily  reached  from  behind  the  sternocleidomastoid 
than  from  in  front  of  it.  The  internal  jugular  vein  and  the  carotid  artery 
are  Hfted  upward  and  forward;  and  the  superior  ganglion  will  usually  ad- 
here to  the  under  portion  of  the  carotid  sheath  and  be  Hfted  up  with  it.  Theo- 
retically, it  is  not  necessary  to  open  the  carotid  sheath  in  this  operation,  but, 
practically,  this  had  better  be  done,  so  that  one  may,  without  any  possibility 
of  doubt,  distinguish  between  the  pneumogastric  and  the  sympathetic  nerve. 
The  moment  the  nerve  is  cut  the  pupil  on  that  side  will  contract. 

Stretching  of  the  Sciatic  Nerve. — Some  surgeons  stretch  the  sciatic 
nerve  by  anesthetizing  the  patient  and  holding  the  leg  and  thigh  in  line, 
strong  flexion  being  made  upon  the  hip,  the  entire  lower  extremity  being^ 
used  as  a  lever.  This  method,  which  has  caused  death,  inflicts  needless  dam- 
age, and  stretching  after  an  incision  has  been  made  is  safer  and  better. 
The  patient  Hes  prone,  the  thigh  and  legs  being  extended.  An  incision  4 
inches  in  length  is  made  a  little  external  to  the  middle  of  the  thigh,  and  going 
at  once  through  the  deep  fascia;  the  biceps  muscle  is  found  and  is  drawn  out- 
ward; the  n^ve  is  discovered  between  the  retracted  biceps  on  the  outside  and 
the  semitendinosus  on  the  inside,  resting  upon  the  adductor  magnus  muscle. 
The  nerve,  which  is  caught  up  by  the  finger,  is  first  pulled  down  from  the  spine 
and  then  up  from  the  periphery,  and  finally  the  hook  of  a  scale  is  inserted 
beneath  the  trunk  and  the  nerve  is  stretched  to  the  extent  of  40  pounds. 

1  "Medical  Record,"  Dec.  5,  1896. 


762  Diseases  and  Injuries  of  Nerves 

Very  rarely  is  even  a  single  ligature  needed.  The  wound  is  sutured  and 
dressed.  If  the  incision  is  made  at  a  higher  level,  just  below  the  gluteo- 
femoral  crease,  the  sciatic  nerve  will  be  found  just  by  the  outer  border  of  the 
biceps. 

Neurectomy  of  the  Infra=orbital  Nerve. — This  operation  was  first 
performed  by  Abernethy  in  1793.  The  patient  lies  upon  his  back,  the  head 
being  raised  a  little  by  pillow^s.  The  surgeon  stands  to  the  outside  of  and 
faces  the  patient.  A  curved  incision  i|  inches  long  is  made  below  the  lower 
border  of  the  orbit.  The  nerve  lies  in  a  line  dropped  from  the  supra-orbital 
notch  to  between  the  two  lower  bicuspid  teeth  and  is  found  upon  the  levator 
labii  superioris  muscle.  A  piece  of  silk  is  passed  under  the  nerve  by  an 
aneurysm  needle  and  firmly  fastened.  The  upper  border  of  the  incision  is 
drawn  upward;  the  periosteum  of  the  floor  of  the  orbit  is  elevated  and  held 
by  a  retractor;  the  roof  of  the  infra-orbital  canal  is  broken  through;  the  nerve 
is  picked  up  far  back  by  the  blunt  hook  and  is  divided  by  scissors,  and  the 
entire  nerve  in  front  of  the  section  is  drawn  out  by  making  traction  upon  the 
silk.  The  bleeding  in  the  orbit  is  checked  by  pressure.  The  wound  is  stitched 
without  drainage. 

Neurectomy  of  the  Supra=orbital  Nerve. — Before  sterilizing  the  parts 
shave  off  the  eyebrow.  A  curved  incision  i  inch  long  discloses  the  nerve  as 
it  emerges  from  the  supra-orbital  notch  or  foramen  at  the  junction  of  the 
inner  and  middle  thirds  of  the  eyebrow.  The  nerve  is  pulled  forward  and  cut 
off  above  and  below. 

Neurectomy  of  the  Inferior  Dental  Nerve. — Make  a  curved  incision 
around  the  angle  of  the  jaw.  Lift  the  supramaxillary  branch  of  the  facial 
nerve  downward  (Kocher).  Separate  the  masseter  muscle  by  a  periosteum 
elevator  and  slight  touches  of  the  knife.  Chisel  an  opening  in  the  center 
of  the  ascending  ramus  (Velpeau's  rule).  This  opening  exposes  the  beginning 
of  the  dental  canal.  If  necessary,  the  opening  may  be  enlarged  by  a  rongeur. 
Pull  the  nerve  out  by  a  hook  and  remove  a  piece  from  it. 

Extracranial  Operation  for  Neuralgia  of  the  Fifth  Nerve. — 
The  operation  for  removal  of  the  Gasserian  ganglion  is  difiFicult,  bloody,  and 
dangerous.  Removal  of  portions  of  the  pain-haunted  nerve-trunks  some- 
times cures  the  condition  and  often  ameliorates  it  for  a  considerable  time. 
The  injection  of  osmic  acid  into  the  peripheral  nerves,  or  of  alcohol  into  the 
nerves  as  they  emerge  from  the  cranium,  may  actually  cure  or  secure  pro- 
longed relief.  The  serious  operation  of  removing  the  ganglion  may  be  per- 
formed if  peripheral  operations  and  injections  fail,  or  in  violent  and  intractable 
cases  of  long  standing  in  which  pain  is  felt  in  more  than  one  branch.  Re- 
moval of  nerves  by  ordinary  neurectomy  of  ten  gives  comfort  for  a  few  months, 
but  rarely  gives  prolonged  relief.  If  we  seek  striking  benefit  by  an  extracranial 
operation,  it  must  be  thoroughly  done. 

Injection  of  Osmic  Acid. — This  method  was  suggested  by  Bennett,  of 
London,  in  1897.  Osmic  acid  had  been  used  for  many  years  in  a  sort  of 
haphazard  way,  being  thrown  into  tissues  about  the  nerves  by  means  of  a 
hypodermatic  syringe.  Bennett  suggested  exposure  of  the  nerve  and  the  in- 
jection of  5  to  10  min.  of  a  i  per  cent,  solution.  Acid  when  so  used  actually 
destroys  nerve-fibers,  and  a  considerable  amount  of  fibrous  tissue  forms  which 
intercepts  regenerating  fibers.  It  is  probable  that  secondary  degenerative 
changes  occur  in  the  nerve-trunks,  but  they  do  not  ascend  and  reach  the 
ganglion.  Murphy  warmly  advocates  the  method.  It  certainly  produces  im- 
mediate relief  by  causing  anesthesia,  but  such  relief  is  very  seldom,  if  ever, 
permanent.  I  have  used  it  in  several  cases  with  satisfaction.  In  i  case 
in  which  I  exposed  the  ganglion  I  injected  that  structure,  and  the  result 
seemed  to  be  the  same  as  if  I  had  removed  the  ganglion.     In  neuralgia  of 


Injections  of  Alcohol  Into  Second  and  Third  Divisions  763 

the  fifth  nen'e  the  painful  nerve  or  nen.-es  should  be  exposed,  and  from  5  to 
10  min.  of  a  2  per  cent,  solution  of  osmic  acid  injected  into  several  different 
parts  of  the  nerve  and  also  between  the  nerve-sheath  and  the  bony  canal 
(Murphy).     The  osmic  acid  method  does  not  seem  to  grow  in  favor. 

Injections  of  Alcohol  Into  the  Second  and  Third  Divisions. — This  method 
was  devised  by  Schlosser  in  1903.  The  injections  are  made  into  peripheral 
branches  or  divisions  of  the  ganglion,  and  have  even  been  made  into  the 
ganglion.  Siccard  and  others  have  warmly  praised  the  method.  It  acts 
similarly  to  osmic  acid.  It  produces  local  necrosis  of  the  nerv^e  and  fibrosis 
about  it.  The  necrosis  does  not  tend  to  ascend  (May,  "Brit.  Med.  Jour.," 
Aug.  31,  1912).  It  gives  relief  sometimes  after  one  injection,  sometimes  after 
two  or  more.  The  permanence  of  the  relief  is  uncertain.  Usuall}-  it  is  com- 
plete for  sLx  months  and  then  recurrent  pain  may  require  renewed  injection. 
Recurrences  are  milder  than  the  previous  condition.  Apparent  cure  may  last 
for  three  or  four  years. 

I  have  used  the  method  many  times  and  am  satisfied  as  to  its  value  in  proper 
cases.  It  is  superior  to  peripheral  operations.  It  is  used  in  very  old  subjects, 
feeble  subjects  the  \ictims  of  grave  organic  disease,  and  in  those  who  refuse 
radical  operation.  In  strong  young  persons  removal  of  the  ganglion  may  still 
be  preferred.  In  some  cases  it  is  used  before  a  ganglion  extirpation  in  order 
to  remove  pain  and  permit  of  such  impro\'ement  in  health  and  strength  as  to 
make  the  radical  operation  safer.  Never  attempt  to  make  a  deep  injection 
about  the  ophthalmic  branch.  To  do  so  may  damage  a  great  vessel,  the  optic 
ner\-e,  the  third,  fourth,  or  sixth  ner\'e,  or  the  alcohol  may  enter  the  orbit  and 
destroy  the  eye.  If  there  is  pain  in  the  supra-orbital  and  supratrochlear 
branches,  inject  them  where  they  are  superficial. 

Injection  of  the  Supra-orbital  Branch. — Use  an  ordinarv'  hypodermatic 
needle  and  inject  10  to  20  min.  of  the  fluid  recommended  below.  Throw  the 
fluid  about  the  nerve  at  the  foramen.  After  withdrawing  the  needle  make 
pressure  at  the  puncture.  Such  pressure  is  ad^dsed  by  Patrick  to  stop  bleed- 
ing, prevent  a  black  eye,  keep  the  tissues  exsanguine,  and  add  to  the  effect 
("Jour.  xAm.  Med.  Assoc,"  Jan.  20,  1912).     The  lids  always  swell. 

I  used  for  a  time  80  per  cent,  alcohol,  each  dram  of  which  contained  |  gr. 
of  stovain,  but  this  hardens  the  tissues  so  much  that  they  become  resistant  to 
reinjection.  I  now  use  Patrick's  formula,  viz. :  2  gr.  of  muriate  of  cocain,  2^ 
drams  of  alcohol,  and  distiUed  water  sufficient  to  make  |  oz.  The  usual  dose  is 
2  c.c.  A  special  needle  is  used.  It  is  straight,  is  graduated  in  centimeters, 
and  carries  a  stylet  which  is  flush  T\ith  the  point.  The  stylet  is  pulled  back 
slightly  while  the  needle  is  being  driven  through  the  skin  and  fascia ;  it  is  then 
pushed  aU  the  way  in.  I  follow  the  method  of  'Levy  and  Baudoin  ("Presse 
Med.,"  April  17,  1906),  which  is  as  follows: 

Stiperior  Maxillary  Division. — Drop  a  perpendicular  from  the  posterior 
border  of  the  orbital  process  of  the  malar  bone  (the  beginning  of  the  z^-goma) 
to  the  inferior  edge  of  the  z\'goma;  1%  c.c.  back  of  this  point  is  where  the 
needle  should  be  introduced.  It  is  carried  in  and  ver\'  slightly  upward.  At 
a  depth  of  2  cm.  the  coronoid  process  may  obstruct:  at  a  greater  depth,  the 
external  pter\-goid  plate.  Either  obstruction  may  be  avoided  by  inclining  the 
needle  ver\'  slightly  fon\^ard  (never  much  or  alcohol  might  enter  the  orbit). 
At  a  depth  of  5  cm.  the  needle  encoimters  the  ner^-e  as  it  emerges  from  the 
foramen  rotimdum.  The  injection  usually  causes  decided  but  brief  pain.  If 
the  injection  reaches  the  nerve  there  will  be  immediate  analgesia  throughout 
its  trajector\\     This  should  last  two  or  three  days. 

Inferior  Maxillary  Division. — The  point  for  entrance  of  the  needle  is  at  the 
lower  border  of  the  z^-goma,  2.5  cm.  in  front  of  the  anterior  root  of  the  z\'goma. 
The  needle  is  carried'  inward,  somewhat  backward,  and  slightly  upward.     At  a 


764 


Diseases  and  Injuries  of  Nerves 


depth  of  4  cm.  the  nen,^e  is  reached.     Be  sure  the  nerve  has  been  reached  by- 
finding  analgesia  throughout  its  trajectory^  after  injection. 

Rose's  Method  of  Neurectomy.^ — This  operation  is  a  modification  of 
the  Braun-Lossen  method,  and  is  employed  when  the  second  division  of  the 
fifth  nerve  is  the  seat  of  pain.  The  infra-orbital  nerve  is  exposed  by  an 
incision,  a  ligature  is  tied  around  it,  the  roof  of  the  infra-orbital  canal  is 
opened  by  a  chisel,  and  the  nerve  is  traced  back  as  far  as  possible.  The 
woimd  is  then  packed  temporarily  -^dth  gauze.  The  next  step  in  this  opera- 
tion is  to  open  a  way  into  the  sphenomaxillary  fossa  (Fig.  496).  The  knife 
is  inserted  sHghtly  below  the  external  angular  process  of  the  frontal  bone, 
is  carried  back  along  the  zygoma,  doT\Ti  in  front  of  the  ear  to  just  above 
the  angle  of  the  jaw,  and  then  forward  for  2  inches.  This  flap,  which  is  com- 
posed of  skin  and  subcutaneous  fat  only,  is  dissected  forward,  and  Steno's  duct 
and  branches  of  the  facial  nerv^e  are  not  damaged.  The  flap  is  wrapped  in 
gauze  and  temporarily  stitched  to  the  side  of  the  nose.  The  zygoma  is  ex- 
posed by  a  transverse  incision.  At  the 
root  of  the  zygoma  two  holes  are  drilled 


Fig.  4g6. — a,  The  Braim-Lossen  incision;  c, 
Rose's  incision  for  reaching  the  sphenomaxillary 
fossa  (Rose). 


Fig.  497. — ^Lower  jaw  and  zygoma.    Drill-holes 
and  saw-cuts  are  shown  (Rose) . 


\  inch  apart,  and  two  more  holes  \  inch  apart  are  drilled  through  the  zygomatic 
process  of  the  malar  bone.  The  zygoma  is  then  divided  by  a  saw  (Fig.  497). 
The  posterior  saw  line  runs  between  the  two  drill-holes  at  the  root  of  the  zygoma. 
The  anterior  cut  passes  between  the  two  anterior  drill-holes.  The  direction  of 
the  first  cut  is  directly  downward.  The  direction  of  the  second  cut  is  downward 
and  fonA'ard  from  above.  The  arch  is  freed  and  detached  do\\Tiward  and  back- 
ward. The  exposed  tendon  of  the  temporal  muscle  is  retracted  backward. 
The  removal  of  a  little  fat  exposes  the  pter\'gomaxillar\^  fossa.  The  internal 
maxillary  arter\^  is  exposed,  two  ligatures  are  appHed,  and  the  vessel  is  di\dded 
between  them.  The  finger  feels  for  the  sphenomaxillary"  and  pter^'gomaxiUary 
fissures.  The  external  pter\^goid  muscle  is  separated  from  the  greater  wing  of 
the  sphenoid  and  from  the  root  of  the  external  pter\'goid  process.  On  the 
edge  of  the  greater  -^ing  of  the  sphenoid  a  long  prominence  is  usually  detectable. 
It  overhangs  the  sphenomaxillary^  fossa  and  should  be  cut  away  by  the  use  of  a 
chisel.  The  superior  maxillary  ner\^e  is  lifted  on  a  blimt  hook,  is  grasped  by 
forceps,  and  is  t-^isted  off  as  near  the  ganglion  as  possible  (Fig.  498).  The 
^  See  article  by  Wm.  Rose,  "Practitioner,"  March,  1900. 


Removal  of  the  Gasserian   Ganglion 


765 


distal  end  is  drawn  upon,  and  the  nerve,  having  been  previously  loosened  is 
drawn  back  through  the  infra-orbital  canal.  The  zygomatic  arch  is  wired  in 
place,  the  temporal  fascia  is  sutured  with  buried  sutures,  and  the  skin-wound  is 
closed.  If  the  pain  involved  not  only  the  second  division,  but  also  the  third 
division,  the  operation  previously  described  should  be  performed  first,  and  the 
third  division  should  be  attacked  a  few  weeks  later.  The  third  division  is 
reached  by  removmg  the  coronoid  process.  The  inferior  dental  and  lingual 
nerves  are  found,  and  are  traced  up  to  the  foramen  ovale,  and  are  twisted  off 
close  to  the  ganglion,  and  the  distal  portions  are  removed. 

Removal  of  the  Gasserian  Ganglion. — This  formidable  procedure 
was  first  suggested  by  J.  Ewing  Mears  in  1884,  and  was  first  performed  by  Wm. 
Rose  in  1890.  The  operation  is  often  bloody  and  difficult,  and  is  only  un- 
dertaken in  very  severe  cases  of  tic  douloureux  in  which  the  first  division  is 
involved,  or  in  cases  upon  which  less  grave  procedures  have  failed.  Jaboulay 
and  Cavaillin  ("Lyon.  Med.,"  May  17,  1908)  speak  of  it  as  a  grave  operation 
of  difficult  technic  which  should  be  left 
as  a  final  resort.  Many  operators  deny 
that  there  is  a  large  mortality  after  gas- 
serectomy  and  claim  that  it  is  only  about 
5  per  cent.  Some  operators  report  a 
mortality  of  from  10  to  17  per  cent.  The 
greater  the  experience  of  the  surgeon  in 
this  operation,  the  smaller  will  be  the 
mortality.  Knowledge  of  the  region  and 
parts,  dexterity  from  frequent  repetition, 
and  special  training  count  for  much.  The 
operation  usually  cures  the  pain  if  the 
patient  recovers  from  the  actual  proced- 
ure. It  is  claimed  that  the  pain  may 
recur  even  after  complete  removal  of  the 
gangHon.  I  have  never  seen  this  occur 
and  am  disposed  to  think  that  recurring 
pain  is  apt  to  mean  that  there  was  a 
partial  jemoval.  Carson  collected  100 
cases;  Minphy  and  NeS,  42  cases.  The 
mortality  in  this  group  of  142  cases  was 
15  per  cent.  Most  of  the  cases  reported 
by  Murphy  and  Neff  were  operated  upon 
during  or  after  1899,  and  in  this  group  the 
mortahty  was  10  per  cent.  ("Progressive 
Medicine,"  March,  1903).  In  Lexer's  series  of  201  cases,  referred  to  below, 
the  mortality  was  17  per  cent.  In  many  cases  a  perfect  cure  is  obtained.  In 
some  few  the  pain  returns  upon  the  side  operated  upon.  Occasionally  it 
arises  on  the  side  not  operated  upon.  |*  In  some  cases  ulceration  of  the  cornea 
foUow^s  operation.  Such  ulceration  may  be  trivial,  may  result  in  opacity,  or 
may  destroy  the  eye.  Paralysis  of  the  abducens  occurs  in  some  cases.  The 
hemorrhage  may  be  so  profuse  as  to  require  packing  of  the  woimd  and  suspen- 
sion of  the  operation  for  a  few  days.  The  bleeding  may  come  from  the  menin- 
geal artery,  from  the  sinus,  or  from  the  veins  of  Santorini.  Lexer  ("Arch.  f. 
klin.  Chir'.,"  Bd.  Lxv,  H.  4)  gives  a  table  of  201  cases.  Of  the  survivors,  93.4 
per  cent,  were  apparently  cured.  In  two-thirds  of  the  cases  the  trouble  was 
right  sided.  In  10  the  operation  was  temporarily  abandoned  because  of 
hemorrhage.  The  experience  of  surgeons  in  general  is  that  after  the  removal  of 
the  ganghon  there  is  apt  to  be  some  atrophy  of  the  tongue  and  the  eye  usually 
becomes  insensitive  and  watery.     The  masseter  muscle  will  be  paralyzed. 


■a,  The  zygomatic  arch,  turned 
down  after  sawing;  b,  tendon  of  the  temporal 
muscle  retracted;  c,  superior  maxUlary  nerve 
and  Meckel's  ganglion;  d,  infra-orbital  nerve 
emerging  from  canal;  e,  internal  maxillary 
artery. 


766 


Diseases  and  Injuries  of  Nerves 


The  Hartley  Operation  for  Removal  of  the  Gasserian  GangUon. — This 
operation  was  first  performed  by  Hartley  in  1891,  five  months  before  Krause 
performed  it.  An  electric  forehead-light  is  required.  Long  strips  of  gauze 
must  be  ready  for  packing  in  case  of  hemorrhage.  The  patient  is  placed 
recumbent,  with  head  turned  to  the  opposite  side.  The  application  of  a 
provisional  ligature  or  clamp  to  the  external  carotid  artery  is  advocated  by 
some,  but  this  step  will  not  control  the  venous  bleeding,  which  is  the  most 
harassing  hemorrhage  encountered.  Many  operators  form  a  large  osteoplastic 
flap  in  front  of  the  ear  (Fig.  499)  and  break  it  out.  I  do  not  beheve  that 
an  osteoplastic  flap  is  necessary.  The  temporal  fascia  is  so  thick  and  tense 
that  when  the  wound  in  it  is  carefully  sutured  protection  is  perfect  and  safety 
is  secured.  Hemorrhage  is  to  be  carefully  arrested.  It  may  be  found  that 
the  meningeal  artery  has  been  ruptured.  If  this  accident  has  happened  and 
the  vessel  lies  in  a  bony  canal,  plug  with  Horsley's  wax.  If  the  vessel  is  bleed- 
ing upon  the  dura,  ligate 
by  passing  suture-ligaments 
around  it.  If  it  is  torn  off  at 
the  foramen  spinosum,  pack 
the  foramen  with  iodoform 
gauze,  and  postpone  the  con- 
clusion of  the  operation  for 
forty-eight  hours.     It  may  be 


Fig.  499. — Hartley's  osteoplastic 
flap  in  removal  of  Gasserian  ganglion 
(Tiffany). 


Fig.  500. — Removal  of  Gasserian  ganglion:  a,  Middle 
meningeal  artery;  //,  ophthalmic  division;  ///,  submax- 
illary division;  G,  ganglion  (Krause). 


necessary  at  any  stage  of  this  operation  to  pack  the  wound  and  postpone  com- 
pletion for  two  days.  Some  surgeons  (Krause,  Bergmann)  ligate  the  meningeal 
artery  as  a  routine  procedure,  but  this  operation  may  be  diSicult  and  require 
much  time.  If  the  imligated  vessel  is  divided,  the  hemorrhage  can  be  arrested 
by  gauze  packing  or  by  plugging  the  foramen  spinosum  with  a  bit  of  sterile 
wood,  but  it  is  best  to  ligate  the  vessel.  The  head  and  body  of  the  patient 
should  now  be  elevated.  This  allows  the  brain  to  drop  posteriorly  and  renders 
forcible  retraction  unnecessary,  and,  further,  it  lessens  venous  bleeding  (Lexer). 
The  next  step  is  to  lift  up  the  dura  and  with  it  the  brain  (Fig.  500).  Find  the 
inferior  maxillary  nerve  and  clamp  it  with  hemostatic  forceps.  Find  the 
superior  maxillary  nerve  and  clamp  it.  Uncover  the  ganglion.  Loosen  the 
nerves  from  their  beds  by  a  dry  dissector  and  divide  each  one  at  its  fora- 
men of  exit.  Twist  the  clamp  forceps  so  as  to  reel  up  the  nerves.  This 
pulls  out  the  ganglion  intact  with  the  motor  root  and  the  root  of  origin, 
as  far  back  as  the  pons  (Krause's  method).     Arrest  bleeding;  close  the  flap; 


Division  of  the  Auditory  Nerve  for  Tinnitus  Aurium  767 

sew  together  by  a  couple  of  stitches  the  lids  of  the  affected  side  in  order  to 
keep  them  temporarily  closed,  and  cover  the  eye  with  a  watch-crystal.  The 
eye  is  to  be  frequently  washed  out.     Thus  irritants  are  excluded. 

Gushing  has  modified  the  Hartley  operation  so  as  to  permit  of  extra- 
dural manipulation  below  the  arch  made  by  the  middle  meningeal  artery 
and  thus  lessen  the  danger  of  laceration  of  the  artery  ("Jour.  Amer.  Med. 
Assoc,"  April  28,  1900).  The  anterior  arm  of  the  incision  of  the  soft  parts  is 
so  placed  that  it  does  not  cut  the  nerve  to  the  occipitofrontalis  muscle.  Thus 
drooping  of  the  lid  and  oblation  of  brow  wrinkles  on  that  side  are  avoided. 
He  trephines  the  wall  of  the  temporal  fossa  very  low  down,  opens  into  the  skull 
below  the  arch  of  the  meningeal  vessels,  and  thus  avoids  the  meningeal  at  the 
foramen  spinosum  of  the  sphenoid  bone  and  the  sulcus  arteriosus  of  the  parietal 
bone. 

Horsley's  Intradural  Method. — An  opening  is  made  into  the  middle 
fossa  of  the  skull,  the  dura  is  opened,  and  the  ganglion  is  found  and  removed. 
This  operation  is  easier  than  the  extradural  method,  but  is  believed  to  be 
more  dangerous. 

The  Frazier=Spiller  Operation  of  Intracranial  Neurotomy  of 
the  Sensory  Root  of  the  Trigeminus. — If  experience  shows  that  after 
division  of  the  sensory  root  the  nerve  does  not  regenerate,  and  it  seems  prob- 
able that  it  does  not,  the  operation  must  be  regarded  as  a  valuable  addition 
to  our  resources.  This  operation  is  by  many  surgeons  preferred  to  removal 
of  the  ganglion.  In  this  operation  the  z\'goma  is  temporarily  resected.  The 
temporal  fossa  is  exposed,  the  bony  wall  is  trephined,  and  the  trephine  open- 
ing is  enlarged  by  the  use  of  a  rongeur.  The  dura  is  separated  and  the  ganglion 
is  reached.  The  dural  envelope  of  the  ganglion  is  opened,  separated,  and  the 
sensory  root  exposed.  The  sensory  root  is  then  picked  up  on  a  blunt  hook  and 
di\dded.  It  is  frequently  possible,  Frazier  tells  us,  to  separate  the  sensory  root 
from  the  motor  root.  In  this  operation  we  avoid  the  venous  hemorrhage  from 
the  foramen  ovale  and  foramen  rotundum  which  is  apt  to  be  encountered  when 
remo\dng  the  ganglion. 

Abbe's  Operation  of  Intracranial  Neurectomy  of  the  Second  and 
Third  Divisions. — This  operation  is  preferred  by  Charles  A.  Ballance,  who 
opposes  exposure  of  the  ganglion  or  division  of  the  sensory  root  unless  the 
first  di\dsion  of  the  ner\'e  is  the  seat  of  pain.  He  advocates  this  in  spite  of 
kno'VNang  full  well  that  the  pain  may  return  in  a  few  years.  He  advocates  it 
because  of  its  safety,  its  simplicity,  its  freedom  from  serious  hemorrhage,  its 
avoidance  of  opening  the  intradural  space  and  of  all  danger  of  corneal  anesthe- 
sia, and  also  because  if  pain  returns  the  operation  can  be  repeated.  The 
operation  is  performed  as  follows:  Ligate  the  external  carotid  artery  of  the 
diseased  side,  make  a  vertical  incision  over  the  middle  of  the  z^^goma  down  to 
the  bone.  An  opening  into  the  skull  is  made  by  a  mallet  and  gouge,  and  this 
opening  is  enlarged  by  a  rongeur  until  it  is  i^  inches  in  diameter.  The  dura  is 
liited  from  the  middle  fossa  and  the  nerves  are  exposed.  Each  ner\^e-trunk  is 
clamped,  is  divided  near  its  foramen  of  exit,  and  is  separated  from  the  gangHon 
by  cutting  or  twisting  by  the  forceps.  A  strip  of  sterile  rubber  tissue,  i|  inches 
in  length  and  |  inch  in  width,  is  laid  over  the  round  foramen  and  the  oval  fora- 
men and  is  pressed  into  place  by  gauze.  In  a  few  moments  the  gauze  is  ^-ith- 
drawn  and  the  ganglion  is  allowed  to  descend  upon  the  rubber  tissue.  The  wound 
is  then  closed.  (See  Robert  Abbe,  in  "Annals  of  Surger}^,"  Jan.,  1903.)  The 
rubber  tissue  is  used  to  block  the  foramina  of  exit  and  prevent  future  emergence 
of  regenerating  nerves.  Mayo  Robson  blocks  the  foramina  by  a  thin  plate  of  lead 
or  silver,  a  knob  of  the  plate  entering  the  oval  foramen  to  prevent  displacement. 

Division  of  the  Auditory  Nerve  for  Tinnitus  Aurium  and  for 
Aural   Vertigo. — This  operation  was  proposed  for  tinnitus  by  Krause  in 


768  Diseases  and  Injuries  of  Nen^es 

1902.  Ballance  did  it  on  the  right  side  with  success  in  a  most  distressing 
case  of  painful  tinnitus.  When  the  cerebellar  hemispheres  were  displaced  by 
sponges  the  ner\''es  of  the  posterior  fossa  were  brought  into  view.  He  divided 
the  eighth  nerve,  but  made  no  attempt  to  preserve  the  nerve  of  Wrisberg. 
Five  months  after  operation  the  patient  was  well  except  for  deafness  and  de- 
viation of  the  tongue  to  the  left.  (See  Ballance,  in  "Lancet,"  1908,  vol.  ii.) 
Frazier  has  divided  the  auditor}^  nerve  for  aural  vertigo,  with  partial  rehef. 

Operation  for  Facial  Paralysis  of  Extracerebral  Origin  (Facio= 
accessory  Anastomosis  and  Faciohypoglossal  Anastomosis;. — fSee 
"Remarks  on  the  Operative  Treatment  of  Facial  Palsy  of  Peripheral  Origin," 
by  Chas.  A.  Ballance,  Hamilton  A.  Ballance,  and  Pur\'-es  Stewart,  "Brit.  Med. 
Jour.,"  May  2,  1903;  and  also  the  "Surgical  Treatment  of  Facial  Paralysis  by 
Nerve  Anastomosis,"  by  Har^^-ey  Gushing,  "Annals  of  Surgery,"  May,  1903.) 
In  1898  Furet  suggested  to  Faure  that  he  should  anastomose  the  peripheral 
end  of  a  di\aded  facial  nerv^e  to  that  portion  of  the  spinal  accessory  nerve 
which  goes  to  the  trapezius  muscle.  Faure  did  this,  but  the  operation  failed. 
Robert  Kennedy,  of  Glasgow,  did  the  first  successful  operation.  He  divided 
the  facial  for  the  relief  of  spasm  and  at  once  anastomosed  to  a  partly  divided 
spinal  accessory.  The  procedure  first  employed  by  Ballance  was,  after  noting 
by  galvanism  that  muscular  fiber  still  remained,  to  expose  the  facial  nerve  at 
its  point  of  exit  from  the  stylomastoid  foramen,  to  cut  the  nerve-trunk  across 
as  high  up  as  possible,  to  expose  the  spinal  accessory,  and  to  suture  the  distal 
end  of  the  facial  into  the  trunk  of  the  spinal  accessory.  The  spinal  accessory 
was  cut  half  through  to  make  a  bed  for  the  end  of  the  facial.  The  paper 
of  the  Ballances  and  Stewart  above  referred  to  recommends  end-to-side 
anastomosis  between  the  divided  facial  and  the  h^^-poglossal.  The  authors 
have  operated  five  times  for  facial  palsy.  Gushing,  Keen,  Hackenbruch, 
Korte,  Gurrie,  Beck,  Vidal,  Girard,  Lund,  Alt,  Frazier,  and  others  have  done 
similar  operations.  Marked  improvement  may  follow  operation  even  if  palsy 
has  lasted  for  a  considerable  time.  Improvement  followed  operation  in  Gur- 
rie's  case,  although  the  palsy  was  nearly  a  year  old.  The  period  when  improve- 
ment should  be  expected  is  uncertain.  Signs  of  improvement  may  not  be 
evident  for  sLx  months  or  longer.  In  Gushing's  case  they  began  in  thirteen 
days;  in  Kennedy's  case,  in  seven  days.  In  most  cases  operation  restores 
facial  symmetry  when  at  rest  and  in  many  cases  during  volitional  movements. 
The  patient  "^oll  often  become  able  to  close  the  eye  and  raise  the  angle  of  the 
mouth.  Gurious  associated  movements  may  occur.  In  Gurrie's  case  when  the 
patient  lifted  his  shoulder  there  was  contraction  of  the  occipitofrontalis  muscle 
("South  African  Med.  Record,"  1907).  Grant  operated  upon  a  case  of  trau- 
matic facial  paralysis  over  four  months  after  the  injur^^  He  anastomosed  the 
facial  to  the  spinal  accessory  and  the  peripheral  end  of  the  accessory  to  the 
descendens  hypoglossi.  At  the  end  of  fifteen  weeks  there  were  feeble  associa- 
tion movements  of  the  face  and  shoulder,  which  later  disappeared.  At  the  end 
of  a  year  the  result  was  most  gratif}dng  ("Jour.  Am.  Med.  Assoc,"  Oct.  22, 
1910). 

Facio-accessory  anastomosis  does  not  restore  emotional  movements,  but 
faciohypoglossal  anastomosis  may  restore  them.  Kiister  reports  a  case  which 
confirms  this. 

Operation  is  indicated  when  a  complete  facial  palsy  is  of  such  duration  that 
recovery  is  not  to  be  hoped  for  by  longer  delay.  The  Ballances  and  Stewart 
believe  that  when  palsy  has  lasted  six  months  ^\dthout  sign  of  recovery, 
operation  is  indicated.  A  paralysis  due  to  traimiatism  gives  a  much  better 
prognosis  after  operation  than  does  a  paralysis  due  to  a  septic  process  (Ghas.  A. 
Ballance,  Hamilton  Ballance,  and  Pur^^es  Stewart,  in  "Brit.  Med.  Jour.," 
May  2,  1903).     Murphy  has  collected  33  cases  of  anastomosis  of  the  facial 


Diseases  and  Injuries  of  the  Head  769 

nerve  with  the  spinal  accessory,  hypoglossal,  or  glossopharyngeal,  and  Joseph 
Beck  has  added  5  cases  of  his  own  in  which  he  performed  faciohypoglossal 
anastomosis. 

The  h\-poglossal  is  preferred  to  the  accessory.  Its  trunk  is  larger  and  its 
cortical  center  is  adjacent  to  the  facial  cortical  area.  After  such  an  operation 
associated  movements  are  not  observed  when  the  mouth  is  kept  closed,  and, 
if  Gowers  is  correct,  the  fibers  of  the  facial,  which  supply  the  muscles  closing  the 
tnouth,  may  take  origin  from  the  hypoglossal  nucleus  (John  B.  Murphy,  in 
''Surg.,  Gynec,  and  Obstet.,"  April,  1907).  Murphy  points  out  that  an 
anastomosis  may  be  end  to  end,  implantation  of  the  facial  into  a  sHt  in  the  other 
nerve,  implantation  of  the  facial  into  a  partial  transverse  di\dsion  of  the  other 
nerve,  or  end  to  side  (Ibid.). 

Operation  for  Brachial  Birth  Palsy. — (See  article  by  L.  P.  Clark, 
A.  S.  Taylor,  and  T.  P.  Prout,  in  "Am.  Jour.  Med.  Sciences',"  Oct.,  1905.) 
These  authors  report  8  cases  of  operation  with  some  notable  improvements  and 
with  2  deaths.  In  these  cases  they  found  great  thickening  of  the  fascia  and  in 
some  cases  fibrous  tissue  almost  completely  obscured  the  remains  of  lacerated 
trunks  or  roots.  They  advise  that  the  patient  be  placed  recumbent,  with  a 
sand-pillow  beneath  the  shoulders  and  with  the  head  extended  and  bent  toward 
the  opposite  shoulder.  An  incision  is  made  at  the  posterior  border  of  the  sterno- 
cleidomastoid and  the  plexus  is  exposed  and  explored.  If  the  lesion  is  above 
the  cla\dcle,  it  is  at  once  attacked;  if  below  that  bone,  the  incision  is  carried 
down  and  the  bone  is  sawed  in  two.  The  scar  tissue  with  the  lacerated  nerves 
is  removed  and  the  nerves  or  nerve-roots  are  sutured.  The  wound  is  closed, 
the  cla\icle  being  wired  if  it  was  divided.  After  dressings  are  appHed  the  head 
is  bent  toward  the  shoulder  of  the  damaged  side  and  fixed  with  plaster  of  Paris. 

I  operated  on  a  case  of  Dr.  Charles  S.  Potts's  in  the  Philadelphia  Hospital. 
The  roots  were  not  torn,  but  were  found  embedded  in  a  thin  layer  of  scar 
which  it  was  possible  to  remove.  The  result  was  good.  Nerv-e  anastomosis 
may  be  necessarv^  if  exsection  of  scar  leaves  an  imbridgable  gap  or  if  nerve- 
roots  were  di\ided  within  the  foramina. 

Operation  for  Avulsion  of  the  Brachial  Plexus. — (See  page  750.) 


XXIV.  DISEASES  AND    INJURIES  OF  THE   HEAD 

Diseases  of  the  Head 

In  approaching  a  case  of  brain  disorder,  first  endeavor  to  locate  the  seat 
of  the  trouble;  next,  ascertain  the  natiure  of  the  lesion;  and,  finally,  deter- 
mine the  best  plan  of  treatment,  operative  or  otherwise.  In  aU  operations 
upon  the  brain  the  surgeon  must  be  able  to  determine  accurately  the  situations 
of  certain  fissures  and  convolutions,  the  finding  of  the  situations  of  these  convo- 
lutions and  fissures  comprising  the  science  of  craniocerebral  topography. 

The  regional  terms  used  in  craniocerebral  topography  are  derived  from 
Broca  (Fig.  501).  The  middle  meningeal  artery  is  found  at  the  pterion,  i\ 
inches  posterior  to  the  external  angular  process,  on  a  level  with  the  roof  of  the 
orbit  (Fig.  502).  The  fissiires  and  convolutions  of  the  brain  are  shown  in 
Figs.  503-505.  Th.e  fissure  of  Bichat  is  marked  by  a  line  on  each  side  drawn 
from  the  inion  to  the  external  auditory  process.  A  line  from  the  glabella  to  the 
inion  overUes  the  median  fissure  and  the  superior  longitudinal  sinus.  The 
fissure  of  Rolando  is  very  important,  as  marking  the  posterior  limit  of  the  motor 
region  of  the  brain.  It  begins  near  the  median  line,  |  inch  posterior  to  the 
middle  of  the  distance  betw^een  the  inion  and  glabella  (Thane).  This  fissure 
runs  downward  and  forward  at  an  angle  of  67.5°  for  a  distance  of  3!  inches. 

49 


770 


Diseases  and  Injuries  of  the  Head 


Chiene  finds  the  fissure  of  Rolando  by  the  following  method:  He  takes  a  square 
piece  of  paper  and  folds  it  into  a  triangle  (Fig.  506,  i) ;  the  angle  b-a-c  of  this 
triangle  is  45°;  the  edge  d-a  is  folded  back  on  the  dotted  Une  a-e;  the  angle 


Fig.  501. — Skull,  showing  the  points  named  by  Broca:  As,  Asterion  (junction  of  the  occipital, 
parietal,  and  temporal  bones);  basion,  middle  of  anterior  wall  of  foramen  magnum;  B,  bregma  (junc- 
tion of  the  sagittal  and  coronal  sutures);  G,  ophryon  (on  a  level  with  the  superior  border  of  the  eye- 
brows, and  corresponding  nearly  to  the  glabella,  the  smooth  swelling  between  the  eyebrows) ;  g,  gonion 
(angle  of  the  lower  jaw);  /,  inion  (external  occipital  protuberance);  L,  lambda  O'unction  of  sagittal  and 
lambdoidal  sutures);  N,  nasion  (junction  of  the  nasal  and  frontal);  Ob,  obeUon  (the  sagittal  between 
the  parietal  foramina) ;  P,  pterion  (point  of  junction  of  great  wing  of  sphenoid  and  the  frontal,  parietal, 
and  squamous  bones — this  may  be  H-shaped  or  K-shaped  or  "retoume,"  in  which  the  frontal  and 
temporal  just  touch) ;  S,  stephanion  (or,  better,  the  superior  stephanion,  intersection  of  ridge  for  temporal 
fascia  and  coronal  suture) ;  S',  inferior  stephanion  (intersection  of  ridge  for  temporal  muscle  and  coronal 
suture). 

D-A-E  equals  half  of  45°,  or  22.5°,  and  the  angle  c-a-e  equals  the  same  (Fig. 
506,  2) ;  the  paper  is  unfolded  in  the  line  c-a  ;  in  the  figure  thus  formed  b-a-c  = 
45°  andE-A-c  =  22.5°;  e-a-b  =  67.5°,  which  is  the  angle  desired.  Place  the 
point  A  in  the  midline  of  the  head,  over  the  point  of  origin  of  the  Rolandic 
fissure;  the  side  a-b  is  laid  along  the  mid- 
dle line  of  the  head,  and  the  line  a-e 
corresponds  to  the  fissure  of  Rolando.^ 
Horsley  determines  the  situation  of  the 
Rolandic  fissure  by  the  use  of  his  metal 
cyrtometer  (Fig.  507).  He  places  the 
point  marked  zero  over  the  inioglabel- 
lar  line  and  midway  between  the  inion 


Fig.   502. — ^The  meningeal   artery  exposed 
by  trephining  (after  Esmarch). 


Fig.  503. — View  of  the  brain  from  above  (Ecker). 


and  the  glabella.    To  find  the  fissure  of  Sylvius  (Fig.  504,  S,  S',  S"),  draw  a  line 

from  the  external  angular  process  to  the  occipital  protuberance.     The  fissure  of 

Sylvius  begins  on  this  line  i^  inches  behind  the  external  angular  process; 

^  "American  Text-Book  of  Surgery." 


Craniocerebral  Topography 


771 


t±ie  main  branch  of  the  fissure  runs  toward  the  parietal  eminence;  the  ascend- 
ing branch  of  the  fissure  corresponds  to  the  squamosphenoidal  suture,  and 
continues  upward  in  the  same 
line  A  inch  above  the  suture.  , 

The  prcccntral  sulcus  (Fig.  504, 
f)  limits  anteriorly  the  ascend- 
ing frontal  convolution ;  it  runs 
parallel  %A'ith  and  just  behind 
the  coronal  suture,  and  a  fin- 
ger's breadth  in  front  of  the 
fissure  of  Rolando.  The  iutra- 
parietal  fissure  (Figs.  503,  504, 
ip)  limits  the  ascending  pa- 
rietal convolution  posteriorly. 
It  begins  opposite  the  junction 
of  the  lower  and  middle  thirds 
of  the  fissure  of  Rolando,  passes 
upward  in  a  line  parallel  with 
the  longitudinal  fissure  and 
midway  between  the  Rolandic 
fissure  and  the  parietal  emi- 
nence, passes  by  the  parieto- 
occipital   fissiu-e,    and    do-v\*n- 

ward  and  backward  into  the  occipital  lobe.     The  motor  areas,  which  on  the 
outer  surface  are  adjacent  to  the  fissure  of  Rolando,  are  shown  in  Figs.  503 


Fig. 


504. — Outer  surface  of  the  left  hemisphere  of  the 
brain  (Ecker). 


Fig.  505. — ^Inner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 


Fig.  506. — Chiene's  method  of  fixing  position  of  Rolandic  fissure  ("American  Text-Book  of  Sirrgery"). 


and  504.^    The  superior  longitudinal  sinus  is  overlaid  by  a  line  from  the  inion  to 

the  glabella.     The  lateral  sinus  is  indicated  by  a  line  running  from  the  occipital 

^  Recent  studies  indicate  that  the  motor  region  is  entirely  in  front  of  the  Rolandic  fissure. 


772 


Diseases  and  Injuries  of  the  Head 


protuberance  horizontally  outward  to  a  point  i  inch  posteriorly  to  the  external 
auditory  meatus,  and  from  this  point  by  a  second  line  dropped  to  the  mastoid 
process.  The  suprameatal  triangle  of  Macewen  is  bounded  by  the  posterior  root 
of  the  zygoma,  the  posterior  bony  wall  of  the  auditory  meatus,  and  a  line  join- 


^,  ■■^I../6|,,.S|.,.4|.  ,.3|  .|.a|  .  ,,i|  .,p| 


1 1  n  I  .  I  .  I  I 


Fig.  507. — Horsley's  cyrtometer. 

ing  the  two.  The  mastoid  antrum  is  opened  through  Macewen's  triangle  to 
avoid  injury  to  the  lateral  sinus.  Barker's  point,  the  proper  spot  to  apply  the 
trephine  for  abscess  of  the  temporosphenoidal  lobe,  is  i^  inches  above  and  i^ 
inches  behind  the  middle  of  the  external  auditory  meatus.    Fig.  508  shows 

clearly  the  main  points  of  craniocerebral  to- 
pography, obtained  by  methods  approved  by 
many  scientists. 

Kronlein's  method  for  localizing  certain 
areas  is  the  most  generally  serviceable  (Figs. 
509,  510).  A  line,  known  as  the  base  line,  z-m, 
is  carried  horizontally  backward  from  the  lower 
border  of  the  orbit  through  the  upper  border 
of  the  external  auditory  meatus.  Another  hori- 
zontal line,  k-k',  is  drawn  parallel  with  this,  on 
a  level  with  the  supra-orbital  ridge.  A  line  z-k 
is  erected  from  the  middle  of  the  zygoma  to  the 
supra-orbital  line.  A  vertical  line  is  drawn 
from  the  articulation  of  the  lower  jaw,  A,  and 
is  prolonged  to  r.  A  vertical  line  is  drawn 
from  the  posterior  border  of  the  mastoid  base 
(m-k')  and  is  taken  to  p,  the  middle  line  of 
the  skull.  A  line  is  drawn  from  k  to  p,  and 
between  the  points  R  and  p'  it  overlies  the 
fissure  of  Rolando.  The  angle  p-k-k'  is  bi- 
sected by  the  line  K-s,  which  corresponds  to 
the  fissure  of  Sylvius  from  its  point  of  bifurca- 
tion to  its  posterior  termination;  k  marks  the 
bifurcation  of  the  fissure  of  Sylvius.  To  reach 
the  anterior  branch  of  the  middle  meningeal 
artery  trephine  at  k;  to  reach  the  posterior 
branch,  trephine  at  k'. 
Head  Injuries  During  Labor. — Caput  Succedaneum. — This  condi- 
tion is  edema  of  the  scalp  due  to  prolonged  pressure.  The  edema  is  circular 
and  circumscribed  and  occupies  the  part  not  subjected  to  continued  pressure 
during  the  uterine  contractions  of  labor.  The. ring  of  tissues  which  are  im- 
pressed around  project  like  a  cup  into  the  birth  canal.  The  veins  become 
congested  and  edema  results.  The  parts  subjected  to  pressure  may  appear 
normal  or  may  exhibit  ecchymoses  or  even  excoriations.      The  pressure  is 


Fig.  508.— Head,  skiiU,  and  cere- 
bral fissures:  B  corresponds  to  Broca's 
convolution;  EAP,  external  angular 
process;  FR,  fissure  of  Rolando;  IF, 
inferior  frontal  sulcus;  IPF,  intrapa- 
rietal  sulcus;  MMA,  middle  menin- 
geal artery;  OPr,  occipital  protuber- 
ance; PE,  parietal  eminence;  POF, 
parieto-occipital  fissure;  SF,  Sylvian 
fissure;  A,  its  ascending  limb;  TS, 
tip  of  temporosphenoidal  lobe.  The 
pterion  (to  the  left  of  B)  is  the  region 
where  three  sutures  meet,  viz.,  those 
bounding  the  great  wing  of  the 
sphenoid  where  it  joins  the  frontal, 
parietal,  and  temporal  bones  (adapted 
from  Marshall  by  Hare). 


Cephalhematomata 


773 


usually  made  by  the  os,  and  its  situation  varies  with  the  presentation,  but 
because  the  most  frequent  presentation  is  left  occipito-anterior,  the  common 
position  of  the  caput  is  over  the  superior  and  posterior  portion  of  the  right 
parietal  bone.  In  a  face  presentation  great  disfigurement  may  occur.  It  is 
seldom  that  a  double  caput  is  encountered.  It  always  means  that  the  pre- 
sentation has  shifted.  The  worst  cases  of  caput  follow  prolonged  labor.  The 
edematous  swelling  contains  bloody  serum,  pits  on  pressure,  does  not  fluctu- 
ate, is  not  limited  to  the  outline  of  one  bone,  and  the  skin  above  it  is  usually 


Supra-orbital  line  (upper  horizontal) 


Auriculo-orbital  line  {lower  horizontal) 


Figs.  5og,  510. — Kronlein's  method  of  locating  the  fissure  of  Rolando  {R-P')  and  Sylvius  {K-S); 
Kronlein's  point  of  trephining  for  hemorrhage  from  the  middle  meningeal  {K-K');  and  yon  Berg- 
mann's  region  for  trephining  for  abscess  of  the  temporosphenoida!  lobes  (A-a-K'-M)  ("American  Text- 
Book  of  Surgery"). 

discolored  by  ecch3Tnoses.     No   treatment  is  necessary,   as  the   condition 
will  disappear  in  from  a  few  hours  to  three  days. 

Cephalhematomata. — By  this  term  we  mean  extravasations  of  blood 
beneath  the  untorn  pericranium.  It  is  supposed  b}^  many  to  be  always  due 
to  pressure  and  venous  congestion,  as  is  a  caput  succedaneum.  As  Gushing 
points  out,  the  condition  cannot  result  from  the  venous  stasis  of  prolonged  pres- 
sure alone.  If  it  did  it  would  always  exhibit  above  it  a  caput  succedaneum, 
"and  this  is  far  from  our  actual  experience"  (Harv^ey  Gushing,  in  "Keen's 


774  Diseases  and  Injuries  of  the  Head 

Surgery,"  vol.  iii).  It  is  certainly  due  in  some  cases  to  bending  or  breaking  of 
a  cranial  bone.  The  condition  is  said  to  occur  in  i  labor  out  of  200.  In  most 
cases  there  is  but  one  cephalhematoma,  but  there  may  be  two,  three,  or 
even  four.  The  commonest  situation  is  over  the  right  parietal  bone  (the 
common  seat  of  caput  succedaneum) ,  and  caput  succedaneum  may  be  asso- 
ciated with  a  cephalhematoma.  The  blood  begins  to  flow  beneath  the  peri- 
cranium during  labor  and  the  swelling  increases  during  the  first  few  days  after 
birth;  in  fact,  it  is  frequently  not  noticed  for  a  day  or  two.  The  swelling  is 
tense  and  smooth,  with  a  convex  outline.  It  may  cover  but  a  small  portion 
of  a  bone  or  an  entire  bone,  but  never  extends  beyond  the  bounding  sutures. 
This  limitation  is  due  to  the  fact  that  the  pericranium  is  adherent  to  the 
sutures.  In  the  course  of  a  couple  of  weeks  the  tumor  may  become  sur- 
rounded by  a  hard  ring  due  to  the  formation  of  new  bone,  and  a  shell  of  bone 
may  eventually  surround  and  cover  over  the  clot,  an  area  of  permanent  bony 
thickening  remaining.  In  other  cases  no  bone  forms,  but  the  clot  gradually 
disappears.  Extradural  and  even  subdural  hemorrhage  may  be  associated 
with  a  subpericranial  cephalhematoma. 

Cephalhematomata  unassociated  with  cerebral  symptoms  usually  disappear 
without  operation.  If  there  is  no  sign  of  subsidence  after  two  weeks,  follow 
Cushing's  rule,  evacuate  by  a  puncture-like  incision  and  apply  pressure.  If 
suppuration  occurs,  incision  is  necessary.  Suppuration  may  occur  if  the  scalp 
was  excoriated.  In  cephalhematoma  with  cerebral  symptoms  operation  is 
indicated  (incision  of  the  scalp  and  removal  of  a  piece  of  bone). 

Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin,  subcutaneous 
fat,  the  occipitofrontalis  muscle  and  aponeurosis,  the  subaponeurotic  cellular 
tissue,  and  the  pericranium.  The  scalp  is  liable  to  inflammation  from  vari- 
ous causes,  and  also  to  certain  diseases — namely,  tumors,  cysts,  warts,  moles 
(local  cutaneous  hj^Dertrophies),  cirsoid  aneurysm  (see  page  434),  nevi,  and 
lupus.  Abscesses  of  the  scalp  are  common.  If  an  abscess  forms  beneath  the 
pericranium,  the  pus  diffuses  over  the  area  of  one  bone,  being  limited  by  the 
attachment  of  the  pericranium  in  the  sutures.  In  cranial  osteomyelitis  pus 
may  gather  between  the  dura  and  bone  and  between  the  bone  and  pericra- 
nium. The  condition  is  known  as  Pott's  puffy  tumor.  If  an  abscess  forms  in 
the  tissue  between  the  occipitofrontalis  and  the  pericranium,  it  is  widely  dif- 
fused. Treves  calls  this  subaponeurotic  connective  tissue  "the  dangerous  area.'' 
Abscess  of  the  subcutaneous  tissue  is  apt  to  be  limited  because  of  the  great 
amount  of  fibrous  tissue.  Abscess  beneath  the  pericranium  does  not  spread 
beyond  the  suture  lines.  It  is  limited  by  the  sutural  membrane  which  runs 
from  pericranium  to  dura.  Abscess  is  treated  by  instant  incision  at  the  most 
dependent  part  and  drainage.  In  abscess  beneath  the  occipitofrontalis  ap- 
oneurosis it  is  necessary  to  open  and  drain  above  the  eyebrows,  above  the 
superior  curved  line  of  the  occipital  bone,  and  at  each  side  above  the  line  of 
origin  of  the  temporal  fascia. 

Diseases  and  Malformations  of  the  Bones  of  the  Skull. — The  bones 
of  the  skull  are  liable  to  caries,  necrosis,  osteitis,  periostitis,  osteomyelitis, 
atrophy,  hypertrophy,  tumors,  etc.     (See  Diseases  of  Bones.) 

Cranial  Pneumatocele. — This  rare  condition  is  a  result  of  perforation 
of  a  bone  which  permits  air  to  collect  beneath  the  periosteum.  It  may  occur 
in  the  mastoid  or  occipital  region  or  over  the  frontal  region.  These  pro- 
trusions vary  greatly  in  size;  and  as  their  shape  depends  upon  the  periosteal 
attachment  to  sutures  in  the  neighborhood,  they  vary  in  shape.  The  over- 
lying tissues  are  natural  in  appearance.  The  protrusion  is  tense,  but  may 
lessen  or  disappear  on  pressure.  McArthur  C'Jour.  Am.  Med.  Assoc,"  May 
6,  1905)  points  out  that  if  diminished  by  pressure,  the  patient  may  hear  a 
sound  like  rushing  air  or  water  in  the  ear  if  the  protrusion  is  occipital  or 


Treatment  of  Microccphalus  775 

mastoid;  and  in  the  nose,  if  it  is  frontal.  An  elevated  ridge  of  bone  sur- 
rounds a  pneumatocele.  The  protrusion  is  tympanitic  on  percussion.  The 
condition  is  due  to  perforation  of  the  bony  wall  of  an  air  sinus  by  disease, 
injury,  or  rupture.  McArthur  points  out  that  in  half  of  the  reported  cases 
the  rupture  was  not  preceded  by  any  history  of  inflammation  or  injury.  The 
condition  is  not  dangerous. 

Treatment. — Incision,  finding  the  opening  in  the  bone,  enlarging  it,  remov- 
ing osteophytes ;  bringing  the  walls  of  the  cavity  together  and  applying  pressure. 

Microccphalus. — By  "microccphalus"  is  meant  unnatural  smallness  of 
the  head  due  to  imperfect  development.  Marked  microcephalus  is  not  a 
common  condition,  but  it  is  an  occasional  cause  or  associate  of  idiocy.  A 
child  may  be  born  with  a  skull  completely  ossified  even  at  the  fontanels, 
or  the  ossification  may  become  complete  soon  after  birth,  but  in  many  cases 
of  microcephalus  ossification  takes  place  late  or  not  at  all.  In  microcephalus 
the  face  is  usually  fairly  well  developed;  the  jaws  are  prominent;  the  fore- 
head is  flat;  the  cranium  and  brain  are  small;  the  convolutions  of  the  brain 
are  simpler  than  is  natural;  there  is  apt  to  be  marked  asymmetry  of  the  two 
sides  of  the  brain;  internal  hydrocephalus  may  exist;  areas  of  sclerosis  and 
atrophy  are  common;  porencephaly  is  not  unusual.  Some  patients  have 
perfect  motor  power;  others  are  slow  and  incoordinate.  Epilepsy,  chorea, 
and  athetosis  frequently  complicate  the  case.  Idiots  of  this  type  often  pre- 
sent deformities  such  as  cleft  palate,  strabismus,  distorted  ears,  hypertrophied 
tongue,  deform.ed  genitals  or  extremities,  ill-shaped  and  irregularly  developed 
teeth.  They  exhibit  irregular  muscular  movements,  are  frequently  paralyzed 
in  childhood  (infantile  paraplegia  or  hemiplegia),  and  suffer  from  subsequent 
contractures.  They  are  active,  destructive,  excitable,  and  are  liable  to  be 
violent  and  almost  demoniacal.  As  Clous  ton  says,  they  look  impish  and 
unearthly. 

Treatment. — Skilled  training  in  a  school  for  the  feeble  minded  or  in  an  in- 
stitution for  idiots  is  necessary  in  treating  microcephalic  idiocy.  Idiots  have 
but  little  power  of  attention,  and  sensory  impressions  give  rise  to  but  few 
concepts,  and  these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "the  more  strongly  the 
attention  can  be  aroused,  the  more  perfect  does  speech  become"  (Kirchhoff). 
The  principle  of  the  education  of  idiots  is  to  stimulate,  coordinate,  and  guide 
sight,  hearing,  feeling,  taste,  and  smell. 

Lannelongue,  of  Paris,  suggested  an  operation  for  idiocy  with  premature 
ossification  (see  Linear  Craniotomy,  page  831).  In  this  procedure  the  author 
has  no  confidence.  Idiocy  is  a  general  disorder  and  not  a  local  brain  dis- 
ease. Soft  parts  mold  bone,  and  bone  does  not  control  soft  parts.  There 
is  no  evidence  that  the  brain  is  being  compressed;  in  fact,  the  simplicity 
of  the  convolutions  suggests  the  contrary.  In  many  typical  cases  of  micro- 
cephalic idiocy  there  is  no  synostosis  even  years  after  birth.  The  opera- 
tion has  been  much  abused.  It  is  sometimes  fatal,  and,  although  a  fatality 
may  gratify  the  family,  a  surgeon  is  not  a  legal  executioner.  The  remark- 
able improvement  which  has  been  reported  in  some  cases  is  wrongly  sup- 
posed to  be  due  to  the  operation.  As  a  matter  of  fact,  the  new  surround- 
ings, the  strange  faces,  the  firm  discipline,  the  effect  of  the  anesthetic,  and  the 
shock  of  the  operation  attract  the  feeble  attention  and  rouse  the  sluggish  senses. 
Many  cases  are  brought  for  operation  because  they  are  for  the  time  being 
unusually  intractable  and  excitable,  and  the  return  to  the  usual  level  of  con- 
duct after  operation  is  regarded  as  a  permanent  gain,  when  it  is  often  but 
a  temporary  alleviation.  We  believe  that  scientific  training  is  the  proper 
treatment,  and  that  the  efficiency  of  training  is  not  increased  by  the  previous 
performance  of  craniotomy,  and  we  follow  the  precept  of  Agnew,  that  a 


776  Diseases  and  Injuries  of  the  Head 

surgeon  might  as  well  cut  a  piece  out  of  a  turtle's  back  to  make  a  turtle  grow 
as  to  cut  a  piece  out  of  the  skull  to  make  the  brain  grow.  It  would  be  as  wise 
to  take  a  piece  out  of  the  dome  of  a  cathedral  to  increase  the  stature  of  the 
dean  and  chapter. 

Diseases  and  Malformations  Involving  the  Brain. — Cephaloceles. 
— A  cephalocele  is  a  congenital  protrusion  of  intracerebral  contents  through 
a  defect  in  the  skull.  These  protrusions  are  covered  with  skin.  The  defect 
through  which  the  protrusion  occurs  is  always  in  the  median  line,  although 
in  some  cases  (as  at  inner  angle  of  the  orbit)  the  visible  protrusion  may  be 
at  the  side.  Nearly  all  such  protrusions  are  either  frontal  or  occipital,  although 
now  and  then  one  presents  in  the  pharynx,  having  emerged  from  the  skull 
between  the  body  of  the  sphenoid  and  the  ethmoid. 

Frontal  cephaloceles  are  divided  into: 

1.  Nasofrontal — those  which  are  in  the  region  of  the  glabella. 

2.  Naso-orbital — those  at  the  inner  angle  of  the  orbit. 

3.  Naso-ethmoidal — those  below  the  nasal  bone. 

Each  one  of  the  above  forms  passes  through  the  horizontal  plate  of  the 
ethmoid. 

Occipital  cephaloceles  are  divided  into: 

1.  Superior— those  above  the  external  occipital  protuberance.  In  these 
the  bony  gap  may  join  the  posterior  fontanel. 

2.  Inferior — those  below  the  external  occipital  protuberance.  In  these 
the  bony  gap  may  join  the  foramen  magnum. 

The  above  regional  classification  is  that  advocated  in  von  Bergmann's 
"System  of  Practical  Surgery"  (translated  and  edited  by  Wm.  T.  Bull  and 
Walton  Martin). 

The  commonest  form  is  hydrencephalocele,  and  all  other  forms  result 
from  retrograde  changes  in  this. 

Hydrencephalocele. — This  is  by  far  the  commonest  and  is  also  the  most 
dangerous  form  encountered.  The  protrusion  consists  of  arachnoid,  a  layer 
of  brain  tissue,  and  a  cavity  containing  ventricular  cerebrospinal  fluid  and 
connected  with  the  lateral  ventricle.  It  is,  in  reality,  a  protrusion  of  the 
lateral  ventricle.  It  is  covered  with  skin — natural  skin — rniless  the  protrusion 
is  very  large,  in  which  case  the  skin  is  more  or  less  atrophied.  Beneath  the 
skin  is  fascia,  and  beneath  this,  arachnoid.  The  pericraniimi  and  dura  do 
not  cover  it,  but  each  has  a  gap  in  it  and  these  two  tissues  join  each  other 
around  the  bone  margins. 

Encephalocele  results  from  retrograde  changes  in  a  hydrencephalocele. 
The  protrusion  of  the  ventricle  has  become  reduced  and  the  hernia  consists 
of  a  portion  of  brain  covered  by  arachnoid.  Encephalocele  is  only  seen  in 
the  nasofrontal  region.  If  there  is  any  fluid  in  this  protrusion  it  is  not  in 
its  interior,  but  on  its  surface,  and  results  from  a  cyst  of  the  arachnoid. 

Meningocele. — We  formerly  understood  by  a  meningocele  a  protrusion 
of  the  membranes  alone;  we  now  regard  it  as  a  condition  resulting  from  retro- 
grade changes  in  a  hydrencephalocele.  The  brain  tissue  of  the  latter  disap- 
pears; beneath  the  arachnoid  is  a  layer  of  cells  identical  with  those  which  line 
the  ventricles;  the  connection  with  the  ventricle  is  entirely  or  almost  completely 
cut  off;  a  cyst  forms  in  the  subarachnoid  tissue,  and  thickened  pia  surrounds 
the  cyst.  (See  "System  of  Practical  Surgery,"  by  E.  von  Bergmann,  vol.  i, 
translated  and  edited  by  Wm.  T.  Bull  and  Walton  Martin.)  The  above  con- 
dition is  called  by  von  Bergmann  encephalocysto-meningocele. 

Diagnosis. — The  congenital  origin  and  situation  make  certain  that  the  con- 
dition is  cephalocele.  The  bony  gap  can  usually  be  felt;  whether  it  can  or  can- 
not, an  x-ray  picture  should  be  taken.  Such  a  picture  may  indicate  that  the 
mass  contains  brain  matter.     The  protrusions  vary  greatly  in  size  and  shape. 


Spurious  Meningocele  777 

Some  are  rounded,  some  are  flattened,  some  are  stalked.  The  skin  covering 
them  may  be  natural,  atrophied,  tilled  with  vessels,  scarred,  or  ulcerated. 
Sometimes  the  cephalocele  is  verv^  tense;  sometimes  it  is  loose.  In  naturally 
hair\'  regions  the  skin  over  the  summit  of  the  protrusion  is  bald,  but  that  around 
the  base  is  hair\\  If  there  is  connection  between  the  interior  of  the  protrusion 
and  the  ventricle,  the  mass  can  be  diminished  in  size  by  compression.  If  it 
shrinks  rapidly  from  compression,  the  opening  into  the  ventricle  is  large.  In 
such  cases  compression  of  the  mass  quickly  causes  signs  of  cerebral  pressure. 
Lumbar  puncture  may  cause  the  protrusion  to  diminish  in  size;  crying  may 
cause  it  to  increase  in  size.  Large  cephaloceles  fluctuate  and  perhaps  pulsate. 
jNIeningocele  feels  and  looks  like  a  cyst  (is  translucent  and  fluctuates) ;  it 
does  not  usually  pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible 
expiration,  and  some  cases  can  be  very  slowly  diminished  by  compression. 

Encephalocele  is  small,  opaque,  does  not  fluctuate,  has  a  broad  base, 
does  pulsate,  becomes  tense  on  forced  expiration,  and  attempts  at  reduction 
fail  and  cause  pressure  symptoms. 

Hydrencephalocele  is  larger  than  a  meningocele,  is  translucent,  fluctuates, 
rarely  pulsates,  is  pedunculated,  is  rendered  a  little  tense  on  forced  expiration, 
and  can  be  lessened  in  size  by  compression,  but  cannot  be  reduced. 

Treatment. — In  von  Bergmann's  "System  of  Practical  Surgery"  we  find 
the  -^-ise  caution  to  attempt  no  operation  for  an  occipital  protrusion  beneath 
the  protuberance  when  the  cleft  enters  the  foramen  magnum  and  is  associated 
with  cleft  of  the  cer\dcal  vertebrae — for  a  condition  in  which  the  soft  parts 
are  defective  and  the  brain  is  exposed  (cranioschisis) — on  a  case  complicated 
by  hydrocephalus  or  on  a  case  complicated  by  some  other  condition  which 
is  of  necessity  fatal.  We  no  longer  refuse  to  operate  because  the  mass  con- 
tains some  brain  matter  or  because  it  communicates  with  the  ventricle,  although 
if  it  does  so,  the  prognosis  is  much  worse.  For  a  large  hydrencephalocele 
nothing  can  be  done  and  early  death  is  ine\itable.  In  rare  instances  an 
encephalocele  is  converted  into  a  meningocele,  and  the  bony  aperture  closes, 
thus  bringing  about  a  cure.  Among  the  expedients  for  treating  meningocele 
are  electrolysis,  injection  of  Morton's  fluid  (10  gr.  of  iodin,  30  gr.  of  iodid  of 
potassiimi,  i  oz.  of  glycerin),  pressure,  and  excision.  In  cases  of  cephalocele, 
when  portions  of  the  nerve-centers  are  not  contained  in  the  sac,  A.  W.  Mayo 
Robson  ad\ises  the  performance  of  a  plastic  operation.  He  Hgates  the  neck  of 
the  sac,  excises  the  sac,  sutures  the  skin-flaps  separately,  and  leaves  the  stump 
outside  the  line  of  superficial  sutures.  It  is  usually  possible  to  teU  by  palpa- 
tion if  ner\-e-centers  are  in  the  sac,  but  if  in  doubt,  make  an  exploratory  in- 
cision, and  sweep  the  finger  around  inside  of  the  sac.^  Meningoceles  should 
be  operated  upon  by  Robson's  plan. 

Spurious  Meningocele. — It  occasionally  happens,  after  a  fracture  of  a 
child's  skull,  that  cerebrospinal  fluid  gathers  beneath  the  pericranium  and 
bulges  the  pericranium  and  scalp.  This  condition  is  called  spurious  men- 
ingocele. When  a  spurious  meningocele  forms,  the  bone  must  have  been 
broken  and  the  dura  and  arachnoid  ruptured.  This  protrusion  fluctuates, 
pulsates,  and  is  influenced  by  respiration.  In  some  cases  there  is  commu- 
nication vrith.  the  ventricles  of  the  brain.  The  parietal  and  frontal  regions 
are  the  most  usual  seats  of  the  trouble.  The  opening  in  the  skuU  may  close; 
it  may  remain  stationary;  it  may  actually  enlarge  by  bone-absorption.  In 
some  cases  the  spurious  meningocele  undergoes  spontaneous  cure;  in  some  cases 
rupture  occurs;  in  other  cases  death  takes  place  as  a  result  of  the  cerebral 
injury.  (See  Joseph  Sailer  on  "Spurious  Meningocele,"  "University  Med. 
Magazine,"  Sept.,  1900.) 

Treatment. — Close  the  opening  by  a  plastic  operation. 
1  "-\iner.  Jour.  Med.  Sciences,"  Sept.,  1895. 


778  Diseases  and  Injuries  of  the  Head 

Hydrocephalus. — -In  external  hydrocephalus  the  fluid  is  on  the  surface  of 
the  brain;  in  internal  hydrocephalus  the  fluid  is  in  the  ventricles.  Hydro- 
cephalus may  be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus  is  usually  internal,  but  may  be  external.  It  results 
from  meningitis— usually  tuberculous  meningitis  of  the  base.  The  symp- 
toms are  headache,  elevated  temperature,  delirium,  stupor,  convulsions, 
paralysis,  and  choked  disk. 

Treatment  of  acute  hydrocephalus  by  medical  means  is  of  no  avail.  Tap- 
ping of  the  ventricles  may  be  tried.  Drainage  of  the  cisterna  magna  has  been 
suggested. 

Chronic  internal  hydrocephalus  is  usually  congenital,  but  may  arise  after 
birth  in  children  imder  seven.  In  congenital  hydrocephalus  the  condition 
may  be  due  to  circulatory  disturbances  in  the  brain  of  the  embr^^o  resulting 
from  uterine  disease  or  injury  during  pregnancy.  Syphihs  and  alcoholism 
in  parents  seem  sometimes  to  be  responsible.  Chronic  acquired  hydrocephalus 
results  from  inflammation,  especially  tuberculous  inflammation.  A  tumor 
pressing  on  the  veins  of  Galen  may  cause  it.  In  chronic  acquired  internal 
hydrocephalus  there  is  overproduction  or  underabsorption  of  cerebrospinal 
fluid  and  perhaps  both  conditions  may  exist.  The  usually  causative  condition 
is  an  inflammation  of  the  interior  of  the  ventricles,  particularly  of  the  choroid 
plexuses,  and  as  a  consequence  venous  return  is  obstructed  and  oversecretion 
occiirs.  In  very  rare  cases  one  or  both  foramina  of  Monro  may  be  closed,  and 
if  only  one  is  closed,  unilateral  hydrocephalus  may  arise  (Alfred  S.  Taylor, 
in  ^'Km..  Jour.  Med.  Sciences,"  August,  1904).  The  aqueduct  of  SyMus, 
the  foramen  of  Magendie,  and  the  central  canal  of  the  cord  may  be,  but  sel- 
dom are,  occluded.  Guthrie  (''Practitioner,"  July,  1910)  studied  182  cases 
of  meningitis  at  autopsy.  In  about  40  per  cent,  of  the  tuberculous  cases 
and  in  56  per  cent,  of  the  non-tuberculous  cases  hydrocephalus  existed.  A 
tumor  may  cause  hydrocephalus  by  directly  obstructing  the  flow  of  fluid 
from  the  ventricles,  but  a  tumor  far  away  from  such  a  position  may  cause 
it  by  so  increasing  the  intracerebral  tension  that  the  brain  stem  is  forced 
down  into  the  foramen  magnum.  Such  a  position  of  the  pons  and  cere- 
bellum cuts  off  the  flow  of  cerebrospinal  fluid  between  the  subarachnoid 
spaces  of  the  brain  and  cord.  In  hydrocephalus  the  cranium  enlarges  enor- 
mously and  the  bones  of  the  skull  are  widely  separated.  The  brain  is  dis- 
tended and  thinned  and  the  sulci  are  obliterated.  The  broad  forehead  over- 
hangs the  eyes;  the  fontanels  are  elevated.  The  fontanels  and  sutures  are 
open.  The  chfld  is  mentaUy  weak  or  is  an  idiot,  and  very  often  does  not  learn 
to  walk  or  to  talk.  Convulsions,  palsies,  and  contractures  are  common,  and 
blindness  is  frequent.     Such  children  usuaUy  die  young. 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much  avail.  Pressure 
by  strapping  with  adhesive  plaster  has  been  tried.  Tappings  through  a  fon- 
tanel may  be  performed  by  means  of  a  trocar  (only  2  or  3  oz.  of  fluid  being 
withdrawn  at  a  time).  If  much  fluid  is  allowed  to  flow  out,  the  head  must  be 
strapped  with  adhesive  plaster  after^vard.  If  the  skull  ossifies,  the  lateral  ven- 
tricles may  be  tapped  after  trephining.  It  has  been  proposed  to  drain  by  tap- 
ping the  theca  of  the  spinal  cord  (Quincke).  This  last  operation  is  called 
lumbar  puncture  (see  pages  861,  862).  It  will,  of  course,  fail  if  the  foramina  in 
the  floor  of  the  fourth  ventricle  or  the  aqueduct  of  Syhdus  are  blocked.  Even  if 
they  are  open,  it  is  of  Httle  ser^dce.  The  operation  which  promises  most  was 
devised  by  Sutherland  and  Cheyne,  and  is  known  as  intracranial  drainage 
("Brit.  Med.  Jour.,"  Oct.  15,  1898).  Their  theory  is  that  in  hydrocephalus 
fluid  distends  the  ventricles  because  the  channels  of  communication  between 
the  ventricles  and  the  subarachnoid  spaces  are  closed.  The  subarachnoid 
spaces  communicate  directly  vidth  veins,  hence  fluid  cannot  collect  under  pres- 


Contusions  of  the  Head  779 

sure  in  these  spaces.  Intracerebral  drainage  estabhshes  a  communication 
between  the  subarachnoid  space  and  one  ventricle.  It  is  not  necessary  to 
operate  on  both  sides  in  bilateral  hydrocephalus,  because  the  lateral  ven- 
tricles communicate.  A  small  opening  is  made  in  the  skull.  The  dura  is 
incised.  A  number  of  strands  of  catgut,  which  are  tied  together,  are  pushed 
through  the  brain  so  that  one  end  of  the  catgut  mass  lies  in  a  ventricle  and  the 
other  end  beneath  the  dura.  The  dura  and  scalp  are  then  sutured.  Brewer 
makes  an  osteoplastic  occipital  flap,  also  a  dural  flap,  lifts  the  cerebral 
lobe,  and  pushes  a  drain  of  rubber  tissue  into  a  lateral  ventricle. 

The  elder  Senn  passed  a  rubber  tube  into  the  ventricle  and  put  the  outer 
end  of  the  tube  beneath  the  skin  of  the  scalp. 

Alfred  S.  Taylor  ("Am.  Jour.  Med.  Sciences,"  August,  1904)  makes  an 
osteoplastic  flap  with  its  base  over  the  right  mastoid,  cuts  a  dural  flap,  passes 
a  slender  aspirating  needle  through  the  second  temporosphenoidal  con- 
volution into  the  lateral  ventricle,  draws  off  a  little  fluid,  and  measures  the 
thickness  of  the  brain.  He  then  takes  6  strands  of  No.  2  forty-day  catgut,  each 
strand  |  inch  longer  than  the  thickness  of  the  brain.  The  strands  are  tied 
together  with  a  spiral  of  catgut,  i^  inches  of  the  loop  being  left  free.  Three 
layers  of  Cargile  membrane  are  wrapped  about  the  shaft,  but  the  tip  remains 
free.  It  is  carried  into  the  ventricle  along  the  needle  track  by  thumb  forceps, 
and  the  loops  are  slipped  here  and  there,  but  chiefly  downward,  under  the 
dura.  Cargile  membrane  is  placed  between  the  loops  and  dura  and  the  dura 
and  skin  are  sutured.  Taylor  operated  on  6  cases  and  2  recovered,  with  reUef 
of  all  signs  of  pressure. 

The  cisterna  magna  may  be  drained.  Cotterill  actually  opened  the  foramen 
of  Majendie,  and  the  patient  distinctly  improved  ("Lancet,"  Nov.  12,  1910). 

Cushing,  after  determining  by  lumbar  puncture  that  the  ventricles  can  be 
emptied,  obtains  retroperitoneal  drainage  by  a  combined  laparotomy  and 
laminectomy.  Marmion  establishes  drainage  from  the  ventricles  into  the  highly 
lymphatic  tissues  about  the  parotid  gland  ("Zentralb.  fiir  Chirurgie,"  August 
12,  191 1),  and  Payr,  with  the  internal  jugular  vein  by  means  of  a  transplanted 
artery  or  vein  ("Archiv.  fiir  Klin.  Chirurgie,"  August  26,  191 1). 

Puncture  of  the  corpus  callosum  has  been  recommended  by  Anton  and 
others 

Injuries  of  the  Head 

Caput  Succedaneum. — (See  page  772.) 

Cephalhematoma. — (See  page  773.) 

Scalp=wounds  bleed  profusely  because  the  scalp  is  very  vascular,  because 
many  of  the  blood-vessels  are  in  fibrous  tissue  and  cannot  contract  and  retract, 
and  because  even  blunt  force  splits  the  scalp  almost  like  an  incision.  Scalp- 
wounds  are  treated  as  are  other  wounds.  Even  a  large  piece  of  scalp  with  only 
a  narrow  pedicle  may  not  slough ;  hence  try  to  save  any  piece  that  has  an  attach- 
ment. Always  shave  a  wide  area  and  disinfect  the  shaved  area  and  the  wound. 
Arrest  hemorrhage,  and  exercise  great  care  in  cleansing  the  wound  and  the 
parts  about  it.  Stitch  the  wound  with  silkworm-gut.  Very  few  sutures  are 
needed  if  the  wound  is  longitudinal,  but  many  are  required  if  it  is  transverse. 
Deep  vessels  are  ligated.  The  permanent  arrest  of  hemorrhage  from  the  skin 
and  subcutaneous  tissue  is  rarely  affected  by  ligatures,  but  rather  by  sutures 
judiciously  placed.  If  drainage  is  required,  use  a  few  strands  of  silkworm-gut; 
but  drainage  is  rarely  used  unless  we  know  the  wound  is  grossly  infected.  Wet 
antiseptic  dressings  are  used  for  the  first  few  days  and  moderate  pressure  is 
applied  by  wet  gauze  bandages.    Avulsion  of  the  Scalp  is  discussed  on  page  273. 

Contusions  of  the  Head. — Scalp  swelling  from  hemorrhage  is  usually 
considerable.     The  patient  may  be  stunned  or  dazed.     The  sweUing  of  hema- 


780  Diseases  and  Injuries  of  the  Head 

toma  of  the  scalp  must  not  be  mistaken  for  fracture  with  depression.  In  hema- 
toma there  is  a  central  depression;  hard  pressure  on  the  center  iinds  bone  on 
a  level  with  the  general  contour  of  the  bone,  and  the  margin  of  a  hematoma 
is  circular,  is  not  quite  hard,  and  is  elevated  above  the  general  contour.  In 
depressed  fracture  the  edge  is  on  a  level  with  the  central  depression,  is  below 
the  level  of  the  general  bony  contour,  and  the  margin  is  sharp  and  irregular. 
The  treatment  is  by  bandage-pressure.     If  suppuration  arises,  at  once  incise. 

Concussion,  Contusion,  and  Laceration  of  the  Brain. — For  many 
years  it  was  customary  to  regard  concussion  as  a  condition  produced  by  molec- 
ular vibrations  in  the  nervous  substance  of  the  brain.  Buret's  classical  obser- 
vations profoundly  modified  surgical  thought,  and  led  to  the  opinion  that  in 
concussion  of  the  brain  there  is  injury  to  the  brain  itself,  a  rupture  of  cere- 
bral vessels  brought  about  by  the  advance  and  recession  of  waves  of  cere- 
brospinal fluid.  This  wave,  it  is  thought,  first  flows  in  the  direction  of  the 
force.  Keen  says  that  there  may  be  slight  brain  injuries  which  can  properly  be 
called  "concussions,"  but  it  is  better  to  consider  concussion  as  synonymous 
with  laceration  of  the  brain.  Kocher  considers  concussion  as  identical  with 
contusion  of  the  brain.  It  seems,  however,  highly  improbable  that  shght 
cases  of  concussion  are  accompanied  by  vascular  rupture  or  organic  mis- 
chief; the  symptoms  are  too  transitory  and  reaction  too  rapid  and  com- 
plete to  permit  of  any  such  view.  Experiments  on  animals  show  we  can 
develop  concussion  without  laceration  or  contusion.  Autopsies  have  been 
carefully  made  in  some  cases  of  death  from  concussion,  and  no  organic  lesion 
has  been  discovered.  It  is  quite  true  that  the  same  force  which  causes  the  con- 
cussion may  cause  contusion  or  multiple  lacerations,  and  a  severe  force  is  apt  to 
do  so.  But  we  are  not  then  justified  in  assuming  that  concussion  is  contu- 
sion or  laceration:  we  should  rather  conclude  that  the  individual  had  both 
concussion  and  a  demonstrable  injury.  Both  conditions  arise  from  violence, 
but  the  tw^o  conditions  are  not  identical.  I  believe,  with  von  Bergmann,  that 
there  is  such  a  condition  as  concussion,  which  may  be  pure  concussion  or 
may  be  associated  with  organic  damage,  and  even  if  a  man  dies  and  is  found 
to  have  an  organic  injury,  the  concussion  may  have  caused  or,  at  least,  have 
hastened  the  fatal  result.  I  believe,  with  von  Bergmann,  that  it  is  not  repeated 
waves  of  force  from  the  blow,  but  the  concussion  of  the  blow  itself  that  does 
the  harm.  The  brain  is  momentarily  displaced  by  the  blow.  The  blow  acts 
on  the  entire  brain ;  the  centers  are  first  stimulated  and  then  depressed,  and  in 
fatal  cases  are  not  only  depressed,  but  are  parah^zed.  The  cause  of  concussion 
is  violent  force,  either  direct  (as  a  blow  upon  the  head)  or  indirect  (as  a  fall 
upon  the  buttocks).  This  force  momentarily  displaces  the  brain,  giving  rise 
to  stimulation  and  then  to  exhaustion  of  the  nerve-centers,  and  perhaps  to 
rupture  of  vascular  twigs,  large  vessels,  or  even  the  membranes.  In  the  less 
severe  cases  concussion  only  exists ;  in  the  more  severe  cases  there  is  also  con- 
tusion or  laceration  or  compression  soon  arises. 

As  von  Bergmann  points  out,  the  entire  cortex  in  concussion  is  momentarily 
stimulated  and  then  depressed.  The  momentary  stimulation  exists  when  a 
man  "sees  stars"  as  a  result  of  a  blow.  The  depression  or  exhaustion  is 
manifested  by  heaviness,  dulness,  stupor,  perhaps  by  unconsciousness.  The 
stimulation  of  the  medullary  centers,  von  Bergmann  points  out,  lasts  longer,  as 
a  ride,  than  the  stimulation  of  the  cortex,  and  is  manifested  particularly  by  a 
slow  pulse.  If  the  pulse  grows  rapid  and  weaker,  the  pneumogastric  center 
is  becoming  exhausted  and  the  patient  is  in  danger  of  death.  In  slight  cases 
of  concussion  only  the  cortex  may  be  involved,  the  medullary  center  escap- 
ing. In  rapidly  fatal  cases  of  concussion  the  medullary  centers  are  quickly 
paralyzed. 

Symptoms. — In  very  trivial  cases  the  patient  is  slightly  and  momentarily 


Symptoms  of  Concussion,  Contusion,  and  Laceration  of  the  Brain     781 

dazed  and  the  pulse  is  temporarily  slow  and  weak,  but  he  is  otherwise  im- 
affected.  In  a  rather  slight  case  of  brain  concussion  the  patient  may  or  may  not 
fall;  his  face  is  pale;  he  feels  weak,  giddy,  nauseated,  and  confused,  but  he 
soon  reacts,  and  often  vomits.  The  pulse  is  slow  for  a  time  and  then  becomes 
normal.  In  a  severe  case  he  lies  in  a  state  of  complete  muscular  relaxa- 
tion. The  extremities  are  cold;  the  skin  is  pale  and  cold;  the  pulse  is  small 
and  slow.  The  slow  pulse  is  due  to  stimulation  of  the  pneumogastric  cen- 
ter; the  respiration  varies,  being  sometimes  deep,  sometimes  superficial, 
sometimes  rapid,  and  sometimes  irregular.  He  seems  unconscious,  but  can 
usually  be  roused  to  monosyllabic  response  by  shouting,  pinching,  or  holding 
a  bright  light  near  his  face.  Occasionally,  however,  there  is  complete  uncon- 
sciousness. The  urine  and  feces  are  often  passed  involuntarily.  The  pupils 
may  be  unaltered,  may  be  dilated  or  contracted,  may  be  equal  or  unequal,  but 
in  any  case  they  will  react  to  light.  Paralysis  rarely  exists,  but  if  there  is 
paralysis,  it  is  temporary.  The  temperature  at  first  is  subnormal.  In  a  very 
severe  concussion  in  which  there  is  great  danger  of  death  the  pulse  is  very 
rapid,  small,  weak,  and  probably  irregular  because  of  exhaustion  of  the  medul- 
lary center,  and  the  patient  is  absolutely  unconscious  because  of  depression  of 
the  cortex.  If  there  is  a  severe  cortical  laceration  there  will  be  twitchings 
or  even  general  convulsions,  or  the  patient  will  lie  curled  up  with  limbs 
flexed  and  eyelids  shut,  and  will  resist  all  attempts  to  open  his  eyes  or  mouth 
or  to  move  his  limbs  (A.  Pearce  Gould).  Erichsen  called  this  condition  "cere- 
bral irritability."  If  a  patient  with  very  severe  concussion  and  very  rapid 
pulse  is  going  to  get  better,  the  pulse  will  become  slower.  If  a  patient  with 
severe  concussion  and  a  slow  pulse  is  improving,  the  pulse  will  become  nor- 
mally rapid;  if  he  is  getting  worse,  it  will  become  abnormally  rapid  and  weaker. 
How  long  may  concussion  last?  As  von  Bergmann  well  says:  Concussion  is 
transient  in  its  manifestations.  It  is  a  matter  of  a  few  minutes  or,  at  most,  a 
few  hours,  and  any  prolongation  of  severe  symptoms  beyond  this  time,  especi- 
ally if  they  are  intensifying  as  time  goes  on,  indicates  an  associated  injury. 
When  the  patient  reacts  from  concussion  he  will  probably  vomit.  Within 
twenty-four  hours  he  usually  improves,  but  is  feverish  and  complains  of  head- 
ache and  lassitude,  sometimes  becomes  delirious,  and  in  rare  cases  develops 
mania.  If  the  patient  in  concussion  recedes  from,  instead  of  advances  toward, 
recovery,  coma  will  set  in  or  inflammation  will  develop.  The  prognosis  is 
always  uncertain.  Any  concussion  producing  more  than  very  temporary  un- 
consciousness is  almost  surely  a  serious  injury,  because  considerable  laceration 
has  probably  occurred.  Recovery  from  concussion  may  be  complete  and 
permanent,  but,  on  the  contrary,  the  entire  nature  may  undergo  a  change. 
Such  a  change,  which  may  not  be  evident  for  weeks  or  months,  is  apt  to  be 
manifested  by  egotism,  selfishness,  censoriousness,  mendacity,  great  irritabil- 
ity, outbreaks  of  violent  rage  about  trivial  things,  and  forgetfulness.  The 
forgetfulness  is  particularly  as  to  recent  events.  There  are  headaches,  in- 
somnia, attacks  of  depression,  lassitude,  and  vertigo.  Such  a  patient  is  very 
susceptible  to  alcohol,  the  heat  of  the  sun,  and  physical  or  mental  strain. 
He  can  do  nothing  requiring  mental  effort. 

After  concussion  a  patient  may  develop  hysteria,  epilepsy,  amnesia,  or 
actual  insanity.  A  condition  resembling  Korsakow's  psychosis  may  develop 
(a  condition  of  confusion  with  gaps  in  memory  which  are  fiUed  up  spontane- 
ously by  fabrications,  the  patient  also  having  multiple  neuritis),  melancholia, 
confusional  insanity,  or  mania  may  arise,  or  a  condition  like  hallucinatory 
paranoia  or  mental  weakness,  which  may  resemble  paresis.  Concussion  may 
pervert  or  wipe  out  all  memory  of  the  causative  accident  and  also,  strange  to 
say,  of  a  varying  period  preceding  the  accident.  The  loss  of  memory  of  the 
accident  is  permanent;  the  amnesia  for  a  period  preceding  the  accident  may 


782  Diseases  and  Injuries  of  the  Head 

be  permanent  or  may  only  be  temporary.  Statements  made  regarding  an 
accident  by  one  who  has  had  concussion  must  be  received  with  many  grains 
of  salt.  A  man  may  tell  a  story  he  believes  himself,  and  yet  it  may  be  a  mass 
of  dream  fancies  without  a  word  or  with  scarcely  a  word  of  truth. 

Treatment. — In  treating  brain  concussion  bring  about  reaction  by  the  ad- 
ministration of  aromatic  spirits  of  ammonia  (no  alcohol,  as  this  agent  excites 
the  brain),  by  pouring  a  few  drops  of  ammonia  on  a  handkerchief  and  holding 
it  near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed  with  his  head  on 
a  pillow)  with  hot  bottles,  by  hot  irrigation  of  the  head,  by  the  application  of 
mustard  over  the  heart,  and  by  the  administration  of  enemata  of  hot  coffee  or 
hot  saline  fluid.  Do  not  pour  fluid  into  the  patient's  mouth  until  be  becomes 
able  to  swallow  easily.  If  he  cannot  easily  swallow,  rely  on  hot  enemata  and 
hypodermatic  injections  of  strychnin.  Place  the  patient  in  bed  in  a  quiet  room 
and  watch  him.  If  reaction  is  inordinate,  apply  cold  to  the  head,  give  arterial 
sedatives  and  diuretics,  and  purge.  For  some  days  or  for  some  weeks,  accord- 
ing to  the  case,  insist  on  a  very  quiet  life.  For  many  weeks  after  a  grave  con- 
cussion a  patient  must  be  kept  away  from  business  and  be  watched,  because  of 
the  possibility  of  an  abscess  of  the  brain  arising,  and  because  of  the  liability 
of  such  patients  to  develop  hysteria,  neurasthenia,  or  insanity.  Give  a  plain 
diet  containing  a  minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  Sleep  can  often  be  obtained  by  some  simple  expedient,  such  as  the 
administration  of  warm  milk,  placing  a  hot-water  bag  to  the  abdomen  or  feet, 
or  applying  a  mustard  plaster  for  a  short  time  to  the  back  of  the  neck.  In 
cases  in  which  obstinate  wakefulness  exists,  it  becomes  necessary  to  give  bromid, 
chloral,  sulphonal,  trional,  or  some  other  hypnotic.  Morphin  is  avoided  be- 
cause it  is  thought  to  increase  venous  congestion  of  the  brain,  but  the  elder 
Gross  often  used  it,  especially  in  cerebral  irritation.  If  signs  of  compression 
arise,  it  is  best  to  trephine,  as  the  compressing  agent  may  be  a  clot  (see  page 
786).  If  inflammation  arises,  some  surgeons  will  not  trephine;  but  most  regard 
it  as  wise  and  proper,  especially  if  the  damage  seems  to  be  localized,  to  incise 
the  scalp  and  inspect  the  bone.  If  a  fracture  is  discovered  and  the  symptoms 
are  serious,  perform  an  exploratory  trephining,  open  the  dura,  and  secure 
drainage  for  inflammatory  products.  Personally,  I  believe  that  trephining 
for  drainage  is  indicated  in  such  cases  even  when  there  is  no  fracture. 

In  any  severe  concussion  of  the  brain  with  contusion  of  the  scalp  the  sur- 
geon should  at  once  incise  the  scalp  and  inspect  the  bone. 

Compression  of  the  Brain. — The  combination  of  symptoms  indica- 
tive of  cerebral  compression  may  be  present  in  a  number  of  different  condi- 
tions. We  find  these  symptoms  in  abscess  of  the  brain,  tumor  of  the  brain, 
intracranial  hemorrhage,  foreign  bodies,  inflammatory  exudate,  and  fracture 
of  the  skull  with  marked  depression.  The  symptoms  of  compression  are 
expressive  of  impairment  of  the  functions  of  the  entire  brain  by  insufi&cient 
and  imperfect  circulation  of  blood,  this  impairment  of  circulation  being  the 
result  of  a  lessening  in  capacity  of  the  cavity  containing  the  brain,  its  mem- 
branes, the  blood-vessels,  and  the  cerebrospinal  fluid  (von  Bergmann).  Duret 
injected  wax  within  the  cranium  of  an  animal  and  showed  that  a  diminution  of  5 
per  cent,  in  the  intracranial  capacity  produced  somnolence,  and  a  diminution  of 
8  per  cent,  caused  death.  If  a  brain  tumor,  abscess,  blood-clot,  or  portion  of 
depressed  bone  occupies  space  previously  given  to  brain  matter,  vessels,  etc., 
there  is  less  room  within  the  skull  to  contain  the  special  structures.  The  bones 
cannot  yield,  the  brain  is  incompressible,  so  the  cerebrospinal  fluid  is  displaced, 
the  vessels  are  squeezed,  and  the  circulation  is  greatly  impeded.  Pressure  upon 
either  arteries  or  veins  causes  compression.  This  condition  of  cerebral  pressure 
or  compression  is  one  of  anemia.  In  reality  it  is  compression  of  the  vessels 
which  feed  the  brain  with  blood,  and  such  compression  grievously  disturbs 


Symptoms  of  Compression  of  the  Brain  783 

tJie  normal  relationship  between  the  blood-supply  of  the  brain  and  the  circula- 
tion of  cerebrospinal  fluid.  Compression  begins  in  obstruction  to  the  onflow 
of  venous  blood.  It  extends  gradually  to  the  arteries.  The  circulation  is 
slowed,  and  because  of  slow  circulation  the  activity  of  the  centers  is  finally 
inhibited.  It  is  stated  by  Cushing  that  the  rise  which  occurs  in  the  blood- 
pressure  is  conservative  and  is  expressive  of  Nature's  effort  to  maintain  the  cir- 
culation in  the  compressed  medullary  centers.  Increased  vascular  tension  is 
made  manifest  by  estimating  the  blood-pressure  and  observing  venous  stasis 
in  the  optic  disk.  Increased  tension  of  cerebrospinal  fluid  is  shown  by  lumbar 
puncture.  The  fluid  flows  out  rapidly  or  jets  out.  The  cortex  is  temporarily 
stimulated  and  then  depressed,  because  of  impairment  of  nutrition.  The 
medullary  centers  are  first  stimulated.  The  respiratory  center  is  stimulated 
by  retention  of  CO.  in  the  blood,  then  the  vasomotor  center  is  stimulated,  then 
the  vagus,  and  finally,  perhaps,  the  convulsive  center  (von  Bergmann's  "System 
of  Practical  Surgery").  The  stimulation  of  the  cerebral  centers  is  followed 
after  a  time  by  weakening  or  actual  paralysis.  The  centers  are  said  to  suffer 
in  regular  order,  viz.,  the  cortex,  the  corona  radiata,  the  gray  matter  of  the  cord, 
and,  finally,  the  medulla  (Huguenin).  As  von  Bergmann  points  out,  by  the 
time  the  con\-ulsive  center  becomes  stimulated  the  cortex  is  usually  exhausted 
and  the  patient  is  unconscious.  In  compression  the  sensitive  cortex  first  feels 
the  effect  and  feels  it  most  gravely,  and  the  cortical  impairment  may  last  long 
after  other  trouble  has  passed.  In  some  cases  the  cortex  alone  seems  to  be  dis- 
tinctly involved.  When  the  vagus  center  is  stimulated  the  pulse  becomes 
slow;  later,  as  the  center  becomes  exhausted,  it  becomes  rapid  and  weak,  and 
this  change  has  the  same  unfavorable  significance  as  in  concussion.  If  death 
occurs  it  results  from  paralysis  of  respiration  and  not  of  circulation.  The 
displaceable  cerebrospinal  fluid  is  a  great  safeguard  against  compression,  but 
Cushing  has  sho^Ti  us  that  in  intracranial  obstruction  of  the  venous  circulation 
the  flow  of  cerebrospinal  fluid  into  the  space  about  the  cord  is  prevented 
because  the  meduUa  and  cerebellum  are  jammed  down  in  the  foramen 
magnimi. 

Symptoms. — Pressure  symptoms  are  divided  into  those  occurring  during 
the  period  of  stimulation  and  those  occurring  during  the  period  of  increas- 
ing exhaustion.  The  symptoms  of  the  first  stage  are  headache,  vomiting, 
flushing  of  the  face,  contraction  of  the  pupils,  choked  disk,  mental  excite- 
ment, elevation  of  blood-pressure,  restlessness,  and  slo"s\dng  of  the  pulse. 
The  pulse  becomes  slow,  regular,  and  strong.  The  symptoms  of  the 
second  stage  are  hea\dness,  dulness,  drowsiness,  passing  into  stupor,  and 
finally  into  coma.  The  respirations  are  stertorous  and  after  a  time  be- 
come Cheyne-Stokes.  The  pulse  is  weak,  intermittent,  compressible,  and  in- 
creasingly rapid.  There  are  involuntary  evacuations  of  feces  and  urine,  and 
finally  paralysis  of  respiration  which  causes  death,  the  heart  beating  for  a 
time  after  respiration  has  ceased  (von  Bergmann's  "System  of  Practical 
Surgen,^"). 

The  headache  usually  present  in  the  first  stage  of  compression  is  intense, 
persistent,  sometimes  general  and  sometimes  more  or  less  localized,  and  often 
aggravated  by  percussion  of  the  craniimi.  It  persists  even  in  delirium,  and 
the  patient  ceases  to  appreciate  it  only  when  unconsciousness  begins.  The 
vomiting  is  usually  without  nausea  and  is  due  to  stimulation  of  the  medullary- 
center.  At  first  vomiting  may  arise  from  taking  food,  but  it  soon  continues 
independent  of  food.  The  tongue  is  probably  clean.  Cerebral  vomiting 
is  usuaUy  associated  mth  severe  headache.  Restlessness  is  a  pressure  s}Tnptom 
in  the  stage  of  stimulation,  and  the  patient  rolls  his  head,  tosses  his  body,  and 
groans  with  pain.  The  heart  does  not  begin  to  slow  until  the  patient  begins 
to  be  dull  and  drowsy,  or  until  stupor  arises,  when  the  pulse  slows  and  the 


784  Diseases  and  Injuries  of  the  Head 

tension  rises.  Finally  it  becomes  very  slow — perhaps  less  than  40  in  a  minute. 
If  the  condition  grows  worse,  the  pulse  after  a  time  suddenly  becomes  rapid 
and  of  low  tension,  instead  of  slow  and  of  high  tension,  a  most  unfavorable  sign, 
indicating  exhaustion  and  approaching  paralysis  of  the  vagus.  In  the  stage 
of  stimulation  the  patient  is  excited,  unstable,  delirious,  and  the  condition 
of  delirium  gradually  gives  way  to  drowsiness,  stupor,  and  coma.  In  some 
cases  of  compression  there  is  distinct  protrusion  of  the  eyeballs.  Before  the 
patient  becomes  unconscious  the  pupils  are  contracted.  When  the  patient 
is  comatose,  they  are  usually  dilated,  but  may  be  contracted.  In  coma  the 
pupils  respond  slowly  to  light  or  not  at  all.  If  the  conjunctival  reflex  is  gone, 
they  will  not  respond  at  all  (Gowers).  In  a  lesion  making  unilateral  compres- 
sion toward  the  base  the  pupil  on  the  side  of  the  compressing  cause  is  apt  to  be 
much  dilated  and  even  immobile.  Choked  disk  begins  in  the  stage  of  stimula- 
tion and  continues  to  the  end.  That  choked  disk  is  due  to  intracranial  pressure 
seems  demonstrated  by  numerous  operation  reports,  especially  by  Gushing,  of 
Harvard,  in  which  relief  of  pressure  abated  choked  disk  (see  page  811).  The 
existence  of  choked  disk  is  determined  by  the  use.  of  the  ophthalmoscope. 
The  respirations  become  stertorous  or  snoring  as  coma  develops  because  of  the 
vibrations  of  the  relaxed  palate  in  the  air-current,  and  the  cheeks  flap  during 
expiration.  As  the  activity  of  the  respiratory  center  fails  from  increasing 
anemia,  the  respirations  become  shallow  and  infrequent,  or,  perhaps,  of  the 
Gheyne-Stokes  type.  Gowers  defines  Gheyne-Stokes  breathing  as  "alternating 
periods  of  decreasing  and  increasing  depth  of  breathing,  separated  by  a  pause" 
("Lectures  on  Diseases  of  the  Brain").  The  unconsciousness  of  compression 
may  be  sudden  or  gradual,  may  be  partial  or  complete.  Apoplexy  and  many 
traimiatisms  cause  immediate  unconsciousness:  the  irritation  of  such  a  sudden 
lesion  at  once  inhibits  the  cortex.  A  meningeal  hemorrhage  causes  a  gradually 
increasing  unconsciousness.  A  brain  tumor  may  cause  heaviness,  dulness, 
stupor,  or,  perhaps,  after  a  long  time,  even  coma.  If  compression  comes  on 
gradually,  the  brain  more  or  less  accommodates  itself,  and  unconsciousness,  if  it 
occurs  at  all,  is  considerably  deferred.  A  sudden  increase  of  pressure  may  pro- 
duce immediate  unconsciousness.  Stupor  is  partial  unconsciousness,  a  con- 
dition in  which  a  person  hes  as  though  asleep,  though  he  arouses  partially 
and  temporarily  when  positively  spoken  to.  In  profound  coma  the  limb 
reflexes  are  usually  but  not  always  diminished  or  lost.  The  superficial  reflexes 
are  impaired  or  lost.  The  muscles  are  flaccid  and  swallowing  is  impossible. 
In  coma  there  is  incontinence  of  feces  and  either  incontinence  or  retention  of 
urine.  There  may  be  the  incontinence  of  retention.  The  temperature  of  a 
patient  suffering  from  compression  varies.  In  traumatic  cases  it  may  be  at 
fiffst  subnormal  and  later  normal  or  elevated.  In  inflammatory  conditions  it 
is  elevated,  except  in  abscess  of  the  brain,  in  which  it  is  subnormal,  for  a  time 
at  least,  in  half  the  cases.  After  an  apoplexy  it  is  for  a  time  subnormal,  but  as 
shock  passes  away  it  becomes  somewhat  elevated.  Any  sudden  compression 
causes  shock  and  temporarily  subnormal  temperature.  Lesions  of  the  pons 
and  medulla  cause  elevation — ^perhaps  remarkable  elevation — of  temperature. 
In  great  or  sudden  brain  compression  complete  coma  always  exists  and  there  is 
no  voluntary  movement.  In  cerebral  compression  paralysis  may  exist,  which 
may  be  very  limited  (monoplegia) ,  may  be  of  one  side  (hemiplegia) ,  or  may  be 
general.  In  hemorrhage  into  the  interior  of  the  brain  the  unconsciousness  is  im- 
mediate or  nearly  so.  In  bleeding  from  the  middle  meningeal  artery  a  period  of 
consciousness  intervenes  between  the  injury  and  the  coma,  during  which  period 
blood  coUects  and  the  coma  comes  on  gradually.  In  compression  from  de- 
pressed fracture  or  from  a  foreign  body  the  symptoms  usually  come  on  at  once, 
but  they  may  be  deferred  for  some  hours.  Gompression  from  inflammation 
or  pus  begins  gradually  after  a  considerable  time  has  elapsed.     The  symptoms 


Determination  of  the  Cause  of  Coma  in  a  Patient  785 

described  as  pressure  symptoms  are  those  of  pure  compression.  When  trau- 
matism causes  the  condition,  the  compression  symptoms  are  mingled  with 
those  of  concussion,  or  perhaps  of  contusion  or  hemorrhage.  The  brain 
adjacent  to  any  lesion  causing  compression  suffers  more  than  the  brain  distant 
from  it.  The  blood-supply  of  the  entire  brain  is  affected,  but  the  adjacent  brain 
has  its  capillaries  particularly  and  directly  compressed.  Hence  limited  paral- 
ysis is  sometimes  produced  by  compressing  lesions.  The  course  of  compression 
depends  on  the  nature  and  persistence  of  the  cause.  Great  temporary  pressure 
may  produce  no  permanent  harm.  Moderately  severe  pressure  may  be  re- 
covered from  even  after  weeks  of  stupor.  Great  pressure,  sufi&cient  to  induce 
coma,  if  not  relieved  quickly,  will  cause  death.  Persistent  cerebral  symptoms 
after  a  head  injury,  when  no  obvious  lesion  can  be  made  out,  are  probably  due 
to  edema  of  the  brain. 

Determination  of  the  Cause  of  Coma  in  a  Patient. — A  diagnosis  must 
be  made  between  coma  due  to  brain  injury  and  the  comatose  condition  of 
apoplexy,  uremia,  epilepsy,  hysteria,  diabetes,  opium-poisoning,  and  alcoholic 
intoxication.  In  hospital  practice  cases  of  unconsciousness  without  a  known 
history  are  frequent.  In  attempting  to  diagnosticate,  examine  carefully 
for  any  evidence  of  traumatism,  and  inquire  as  to  how  and  where  the  patient 
was  found,  if  any  fit  occurred,  and  if  a  bottle  or  a  pill-box  was  found  near  by 
or  in  the  pockets.  The  surgeon  should  himself  examine  the  pockets.  Smell 
the  breath  to  notice  alcohol  or  opium,  but  always  remember  that  an  alco- 
holic is  often  a  victim  of  Bright's  disease,  that  a  man  with  Bright's  disease 
is  liable  to  apoplexy,  that  a  man  may  be  stricken  with  apoplexy  while  he 
is  drimk,  and  may  fracture  his  skull  by  falling  when  under  the  influence  of 
opium  or  of  alcohol.  The  odor  of  acetone  (violets)  on  the  breath  or  in  the 
urine  indicates  the  existence  of  diabetes.  Draw  the  urine  with  the  catheter 
if  any  water  is  in  the  bladder.  Examine  the  urine  for  albumin,  acetone, 
and  sugar,  and  take  the  specific  gravity.  In  doubtful  cases  of  coma  have 
an  ophthalmologist  use  the  ophthalmoscope.  He  might  find  optic  atro- 
phy, indicative  of  Bright's  disease,  or  choked  disk,  indicating  compression. 
The  cerebrospinal  fluid  obtained  by  lumbar  puncture  should  contain  blood  if 
hemorrhage  has  taken  place  beneath  the  cerebral  dura  or  in  a  ventricle  of  the 
brain.  This  test  is  valuable  in  fracture  of  the  base  of  the  skull,  for  in  this  con- 
dition cerebrospinal  fluid  is  usually  bloody.  In  postepileptic  coma  the  tem- 
perature is  never  below  normal,  there  are  no  unilateral  symptoms,  the  condition 
resembles  sleep,  and  the  patient  can  be  aroused.  Hysterical  coma  occurs 
in  boys  and  women;  there  are  no  objective  symptoms,  and  the  patient,  though 
swallo-^ing  what  is  put  into  his  mouth,  cannot  be  aroused.  In  uremia,  besides 
the  condition  of  the  urine  (and  always  remember  that  a  person  with  albimiinuria 
is  apt  to  develop  apoplexy),  there  is  a  persistent  subnormal  temperature,  and 
convulsions  are  prone  to  occur.  There  is  perhaps  edema  of  the  legs,  but 
paralysis  and  stertor  are  absent.  In  apoplexy  hemiplegia  exists,  and  the  initial 
temperature  is  for  a  short  time  subnormal.  A  single  convulsion  may  have 
ushered  in  the  case.  Alcoholic  unconsciousness  is  often  diagnosticated  when 
apoplexy  really  exists.  A  man  will  smell  of  alcohol  w^ho  has  had  one  drink, 
but  one  drink  will  not  produce  coma;  hence  the  smell  of  alcohol  is  not  con- 
clusive. In  any  case  of  doubt  some  hours  of  watching  will  clear  up  the  diagno- 
sis. Regard  a  doubtful  case  as  serious  until  the  truth  is  clear.  In  opium- 
poisoning  the  pupils  are  contracted  to  a  pin-point,  the  respirations  are  usually 
slow,  shallow  and  quiet,  and  may  be  stertorous,  but  there  is  no  paralysis. 
Always  remember  that  hemorrhage  into  the  pons  will  produce  pin-point 
pupils,  but  it  also  causes  paralysis  (crossed  paralysis  if  in  the  lower  half  of  the 
pons)  and  high  temperature  with  sweating.  In  opium-poisoning  the  tem- 
perature is  subnormal.  In  diabetic  coma  the  pupils  will  react  to  a  very  bright 
50 


786 


Diseases  and  Injuries  of  the  Head 


light,  the  temperature  is  subnormal,  and  the  breath  and  the  urine  smell  of 
acetone.     (See  Acidosis,  page  1207,  and  Diabetic  Coma,  page  175.) 

Treatment  of  Brain  Compression. — The  treatment  of  brain  compres- 
sion depends  on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding;  coma  from  depressed  fracture  demands 
trephining  and  elevation;  foreign  bodies  must  be  removed;  abscesses  must 
be  evacuated;  some  tumors  are  to  be  removed.  In  many  tumor  cases  the 
growth  is  not  removed,  but  a  decompression  operation  is  performed  (see  page 
831).  In  cerebral  compression,  if  death  is  threatened  by  respiratory  failure, 
make  artificial  respiration  and  at  once  trephine  over  the  supposed  region 
of  compression.  Horsley  has  shown  that  irrigation  of  the  head  with  hot 
water  is  of  great  value  in  bringing  about  reaction  from  shock  in  cases  of  brain 
injury. 

Intracranial  hemorrhage  may  be  either  spontaneous  or  traumatic.  In 
the  vast  majority  of  instances  spontaneous  hemorrhage  comes  from  the  len- 
ticulostriate  artery  (Charcot's  artery  of  cerebral  hemorrhage),  and  produces 
apoplexy,  a  disease  belonging  to  the  physician,  except  in  some  ingravescent 
cases,  for  which  ligation  of  the  common  carotid  on  the  same  side  as  the  rupture 
has  been  advised.  In  adults  traumatism  is  almost  always  the  cause  of  a  men- 
ingeal hemorrhage.  The  blood  may  flow  from  a  sinus,  from  the  middle 
meningeal  artery  or  one  of  its  branches,  or  from  vessels  of  the  pia.  Trauma- 
tism during  delivery  is  an  occasional  cause  of  hemorrhage  from  the  middle 
meningeal  artery  (Richardiere)  and  a  not  unusual  cause  of  hemorrhage  from 
cortical  veins.  Violent  paroxysms  of  coughing  in  whooping-cough  occasionally 
produce  extradural  hemorrhage  or  subdural  hemorrhage.  Geo.  S.  Brown 
reported  such  a  case.  He  diagnosticated  the  condition 
and  operated  successfully  ("New  York  Med.  Jour.," 
April  25,  1903). 

Traumatic  Intracranial  Hemorrhage. — Hemor- 
rhage may  take  place — (i)  between  the  bone  and  the 
dura  {extradural) ;  (2)  between  the  dura  and  the  brain 
{subdural),  and  (3)  in  the  brain  substance  {cerebral). 

Extradural  meningeal  hemorrhage  arises  usually 
from  the  middle  meningeal  artery  or  from  one  of  its 
branches.  A  spicule  of  bone  may  penetrate  a  venous 
sinus  and  produce  extradutal  hemorrhage,  or  a  sinus 
may  rupture.  Rupture  of  the  meningeal  artery  or  one 
of  its  branches  is  usually,  but  not  always,  accompanied 
by  fracture  (Fig.  511);  in  fact,  in  some  cases  not  even 
a  bruise  can  be  found  (Fig.  512).  The  ruptured  vessel 
may  be  upon  the  opposite  side  to  that  on  which  the 
force  was  applied,  hence  the  evidence  of  scalp  injury 
is  not  a  certain  sign  of  the  side  of  the  skull  involved. 
The  accident  may  or  may  not  cause  temporary  uncon- 
sciousness; but  even  if  it  does,  from  this  unconsciousness 
the  patient  almost  always  reacts  unless  there  are  other 
grave  injuries,  and  there  is  usually  a  distinct  period  of 
consciousness  between  the  accident  and  the  lasting  coma, 
the  coma  being  due  to  pressure  from  a  continually  in- 
creasing mass  of  extravasated  blood  (Fig.  513).  If  the 
main  trunk  or  a  large  branch  is  ruptured  the  period  of  consciousness  is  short ;  if 
a  small  branch  is  ruptured  the  period  of  consciousness  is  prolonged  for  hours 
or  perhaps  for  days.  As  the  clot  forms  and  enlarges  the  patient  becomes 
heavy,  dull,  stupid,  and  sleepy;  he  sleeps  so  soundly  he  can  scarcely  be 
aroused,  and  snores  loudly,  and  finally  passes  into  stupor  and  then  into  coma. 


-Fracture  of 
skull  with  middle  menin- 
geal hemorrhage.  Com- 
pression of  brain  by  blood 
(Scudder) . 


Subdural  Meningeal  Hemorrhage 


787 


The  other  signs  of  this  condition  are  paralysis  of  the  side  opposite  the  blood- 
clot  (not  necessarily  of  the  side  opposite  the  point  of  application  of  the 
force,  for  the  artery-  may  rupture  from  contre-coup  on  the  uninjured  side); 
this  paralysis  is  apt  at  first  to  be  localized,  but  it  gradually  and  progressively 
widens  its  domain.  If  the  clot  extends  toward  the  base,  the  pupil  on  the  same 
side  as  the  clot  ceases  to  react  to  light,  and  the  immobile  pupil  dilates  widely. 
If  the  clot  be  on  the  left  side,  aphasia  may  be  noted.  As  the  clot  enlarges 
adjacent  centers  become  involved.  The  face  becomes  paralyzed,  then  the 
arm,  and  finally  the  leg.  Not  unusually  epileptiform  attacks  occur,  starting  in 
discharges  from  the  centers  which  are  irritated  by  the  advancing  clot  before 
their  function  is  abolished  by  pressure.  The  pulse  becomes  full,  strong,  usually 
slow,  but  occasionally  frequent;  the  breathing  becomes  stertorous;  the  tempera- 
ture rises,  that  of  the  paralyzed  side  exceeding  that  of  the  sound  side.  In  a 
compound  fracture  the  pressure  of  es- 
caping blood  may  force  brain  matter 
out  of  the  wound.  In  extradural  hemor- 
rhage from  a  sinus  the  symptoms  cannot 
be  difi'erentiated  from  those  produced 
b}'  arterial  rupture. 


<:^^^^^>,        ilaekbri:tl£ir.Ltin£n. 


Fig.  512. — ^A  case  of  rupture  of  middle  men- 
ingeal arten.-.  Preparation  of  dura.  In  the 
Warren  Museum.  The  specimen  is  viewed 
from  the  outer  side  (Scudder). 


Fig.  513. — Frontal  section  of  skull.  Mid- 
dle meningeal  hemorrhage.  The  dura  bulges 
inward    toward    the    skuU    cavity     (diagram) 

(Scudder). 


Treatment. — In  treating  extradural  hemorrhage  localize  the  clot,  not  by 
the  seat  of  the  wound  or  contusion,  but  entirely  by  the  symptoms.  In  a 
doubtful  case  endeavor  to  bring  about  reaction;  but  if  the  state  of  shock  deepens 
or  does  not  improve  and  if  pressure  SATuptoms  increase,  operate  at  once. 
To  reach  the  middle  meningeal  arter}-  or  its  anterior  branch  trephine  i^ 
inches  back  of  the  external  angular  process,  at  the  level  of  the  upper  border  of 
the  orbit  (see  Figs.  502,  509,  510).  If  the  incision  does  not  expose  the  clot, 
trephine  again  at  the  level  of  the  upper  border  of  the  orbit  and  just  below  the 
parietal  eminence  (see  Figs.  509.  510).  The  first  incision  gives  access  to  the 
main  tnmk  and  to  the  anterior  branch;  the  second  incision  exposes  the  posterior 
branch.  If  signs  indicate  that  the  clot  is  traveling  to  the  base,  the  trephine 
should  be  used  \  inch  lower  than  the  point  first  directed.  Arrest  bleeding  by  a 
suture  Hgament  or  by  packing  (see  page  452),  and  always  open  the  dura  and 
inspect  the  brain.  By  this  procedure  a  subdural  hemorrhage  may  be  discov- 
ered which,  ■v\'ithout  it,  would  have  been  missed.     Drainage  must  be  employed. 

Subdural  meningeal  hemorrhage  is  usually  due  to  depressed  fracture  and 
rupture  of  the  middle  cerebral  arter\-  or  of  a  number  of  small  vessels. 

The  symptoms  are  identical  with  those  of  extradural  bleeding,  but  are 
usually  ver}-  rapid  in  onset  and  are  accompanied  by  a  more  distinct  drop  in 
temperature  and  graver  depression.  The  cerebrospinal  fluid  obtained  by 
lumbar  pimcture  is  bloody. 


788  Diseases  and  Injuries  of  the  Head 

The  treatment  is  trephining  for  exploration  at  a  point  1  \  inches  back  of  the 
external  angular  process,  enlarging  the  opening  upward  and  backward  by  a  ron- 
geur, opening  the  dura,  turning  out  the  clot,  ligating  the  bleeding  point  or  pack- 
ing, elevating  any  depression  of  bone,  draining,  and  stitching  the  dura  by  cat- 
gut.   Hemorrhage  from  internal  pachymeningitis  requires  the  same  treatment. 

Cerebral  Hemorrhage. — The  symptoms  of  cerebral  hemorrhage  are  identical 
with  those  of  apoplexy.  The  treatment  is  the  same  as  that  for  apoplexy,  ex- 
cept in  ingravescent  cases,  when  the  common  carotid  on  the  same  side  as  the 
clot  may  be  ligated. 

Rupture  of  a  sinus  may  arise  without  a  bone  injury,  but  is  usually  due 
to  a  compound  fracture.  A  sinus  may  be  wounded  during  a  brain  operation. 
The  treatment,  if  the  rupture  happens  from  fracture,  is  trephining.  Enlarge 
the  bone  opening  by  the  rongeur,  pack  with  one  large  piece  of  iodoform  gauze, 
or  catch  the  rent  with  hemostatic  forceps,  leaving  them  in  place  for  three  or 
four  days,  or  apply  a  lateral  ligature  or  a  suture  ligature.  Elevate  depressed 
bone.  If  during  an  operation  a  sinus  should  be  wounded,  use  a  lateral  liga- 
ture, a  suture-ligature,  or  control  hemorrhage  by  packing. 

Intracranial  Hemorrhage  in  the  Newborn. — Certainly  most  of  the  cases 
of  birth  palsy  seen  in  children  are  the  result  of  subdural  and  subarachnoid 
hemorrhage  at  birth  and  damage  of  the  cortical  motor  area.  In  such  condi- 
tions there  is  spastic  paralysis  of  the  hemiplegic  type,  or  if  both  hemispheres 
suffered  there  is  plastic  diplegia  and  usually  amentia  (Gushing,  in  "Amer. 
Jour.  Med.  Sciences,"  Oct.,  1905).  It  has  not  been  the  custom  to  operate 
for  hemorrhage  in  the  newborn;  most  of  the  cases  do  not  die,  but  remain  for 
life  weakened  and  paralyzed,  epileptic,  or  idiotic. 

The  hemorrhage  in  cases  of  birth  palsy  is,  as  Gushing  points  out,  usually 
venous  and  due  to  "rupture  of  some  of  the  delicate  and  poorly  supported 
venous  radicles  of  the  cerebral  cortex"  (Ibid.).  It  may  result  from  trauma- 
tism due  to  bone  overlapping  or  forceps  pressure  during  parturition,  or  may 
arise  during  asphyxia  after  birth.  Gushing  discovered  in  examining  stillborn 
infants  and  infants  that  died  soon  after  birth  that  many  of  them  died  from 
cortical  hemorrhage.  In  some  the  extravasations  were  very  large,  in  fact,  com- 
pletely overlying  a  cerebral  hemisphere.  In  some  they  were  much  smaller.  In 
one  the  clot  was  in  the  cerebellar  fossa. 

The  vessels  usually  torn  are  on  one  side  and  are  the  unsupported  venous 
radicles  which  enter  the  longitudinal  sinus,  hence  the  leg  center  of  one  side 
is  the  cortical  area  most  apt  to  be  gravely  damaged.  If  the  vessels  of  both 
sides  are  torn,  a  bilateral  cortical  lesion  results. 

Symptoms  of  Hemorrhage  in  the  Newborn. — In  Gushing's  masterly  paper 
(Ibid.)  the  symptoms  of  recent  hemorrhage  are  set  forth.  There  is  the  history 
of  a  long  and  difficult  labor,  forceps  perhaps  having  been  used,  or  a  history  of 
postpartum  asphyxiation.  The  fontanel  bulges  and  perhaps  does  not  pulsate. 
The  fluid  obtained  by  lumbar  puncture  contains  blood-corpuscles.  There  is 
usually  twitching  and,  as  a  rule,  convulsions  occur.  They  may  occur  soon  after 
birth  or  not  for  several  days.  When  they  occur  soon,  they  may  be  general; 
when  they  occur  later,  they  may  be  unilateral.  Paralysis  is  rare  in  the  early 
days  after  birth.  There  may  be  alterations  in  the  circulation  and  respiration. 
Pupillary  alteration  and  ocular  palsy  seldom  occur.  If  the  child  is  not  operated 
upon  it  may  die  or  it  may  apparently  recover.  If  it  apparently  recovers  after 
a  considerable  hemorrhage,  several  months  may  pass  before  ominous  symptoms 
are  recognized.  The  late  manifestations  of  the  disease  may  be  "spastic  palsies, 
or  blindness,  or  deafness,  or  feeble-mindedness,  or,  in  severe  cases,  even  com- 
plete amentia"  (Gushing).     Epilepsy  may  be  a  result. 

Treatment. — Osteoplastic  craniotomy  in  the  parietal  region,  on  one  side 
or  both,  according  to  the  unilateral  or  bilateral  nature  of  the  hemorrhage; 


Fractures  of  the  Vault 


789 


opening  of  the  dura;  washing  out  and  turning  out  the  clot;  suturing  the  dura 
and  closing  the  scalp  without  drainage.  Gushing  reports  4  cases,  in  i  of 
which  operation  was  done  on  both  sides.  He  says  chloroform  should  be  given 
and  that  the  parietal  bone  can  be  cut  with  blunt,  curved  scissors. 

Fractures  of  the  skull  maybe  simple,  compound,  depressed,  non-depressed, 
or  punctured.  Fracture  by  diastasis  means  separation  of  a  suture  or  of  sutures 
by  violence.  A  fracture  of  the  skull  may  be  produced  by  a  bending  force,  by  a 
bursting  force,  or  by  an  explosive  force  (see  Gunshot- wounds). 

A  bending  force  is  usually  applied  by  the  forcible  impact  of  a  body  of 
small  area.  It  produces  a  fracture  and  seldom  causes  distant  injuries.  The 
fracture  may  be  of  the  inner  table  only,  or  of  both  tables.  If  both  tables  are 
fractured  the  broken  bone  is  displaced  and  remains  so. 

In  fracture  by  bursting,  lines  of  fracture  run  to  distant  points  from  the  seat 
of  application  of  the  force.  Such  an  injury  is  inflicted  by  the  impact  of  a  flat 
surface  of  considerable  area.  In  some  cases  we  have  a  force  which  first  is  bend- 
ing in  character,  but  causes  bursting  to  also  occur,  because  there  is  no  rebound. 

Falls  of  large  heaw  objects  or  falls  on  the  head,  blows  on  the  head  from 
large  flat  objects,  crushes  in  railroad  accidents,  etc.,  may  burst  the  skull. 
In  bursting  fracture  there  is 
often  widespread  injury.  The 
skull  may  be  fractured  during 
labor. 

Fractiures  are  divided  into 
fractures  of  the  vault,  usually 
due  to  direct  force,  and  frac- 
tmres  of  the  base,  due  to  ex- 
tension of  fractures  of  the 
vault,  to  indirect  violence  (a 
fall  upon  the  feet,  the  but- 
tocks, or  the  vault),  to  forc- 
ing of  the  condyles  of  the 
lower  jaw  against  or  through 
the  base,  or  to  foreign  bodies 
breaking  through  the  orbit, 
vault  of  the  pharynx,  the  ear, 
or  the  roof  of  the  nostrils. 
Fracture  by  contre-coup  was  the 
name  long  given  to  a  fracture 
which  was  supposed  to  occur  on  the  side  opposite  the  point  of  application  of 
the  violence.  It  is  very  doubtful  if  such  a  fracture  ever  occurs.  I  have  seen 
meningeal  hemorrhage  by  contre-coup,  but  not  fracture.  Fractures  of  the  skull 
are  uncommon  in  earlv  vouth,  but  they  are  much  more  frequent  in  the  aged. 
Usuallv  the  entire  thickness  of  the  bone  is  fractured,  but  either  the  outer 
or  the' inner  table  (Fig.  514)  may  be  broken  alone.  In  complete  fractures 
the  mner  table  is  broken  more  extensively  than  is  the  outer  table,  because  the 
inner  table  is  the  more  brittle,  because  the  force  diffuses,  and  also,  as  Agnew 
taught,  because  the  inner  table  is  part  of  a  smaller  curve  than  is  the  outer 
table,  and  violence  forces  bone-elements  together  at  the  outer  table,  but  tears 
them  asimder  at  the  inner  table  (Figs.  515,  516). 

Fractures  of  the  Vault.— A  fracture  may  involve  the  vault  alone,  but  in  over 
60  per  cent,  of  such  fractures  the  base  is  involved.  A  fracture  of  the  vault  of 
the  skull  mav  be  simple  and  undepressed,  or  it  may  be  depressed  (Fig.  514), 
compound,  or  comminuted  (Fig.  517).  A  mere  crack  may  exist  in  a  bone,  and 
if  a  rent  exists  in  the  soft  parts,  a  bit  of  dirt  or  a  hair  may  be  caught  in  the  crack. 
Fractures  of  the  vault  arise  from  direct  force.    A  fissure  may  escape  recogni- 


Fig.  514. — Fracture  of  the  vault  with  extensive  depression 
of  the  inner  table  (".\merican  Text-Book  of  Surgery"). 


79° 


Diseases  and  Injuries  of  the  Head 


tion,  although  in  some  cases  percussion  gives  a  "cracked-pot"  sound.  Any- 
considerable  depression  can  be  detected.  In  a  simple  fracture  occasionally  the 
cerebrospinal  fluid  collects  under  the  scalp  and  forms  a  tumor  which  pulsates 
and  becomes  tense  on  forcible  expiration  (see  Spurious  Meningocele,  page  777). 
Compound  fracture  can  be  readily  recognized,  but  do  not  mistake  a  suture,  a 


Fig.  515- — Section  of  outer  and  inner  tables,  with 
two  parallel  lines  (after  Agnew). 


Fig.  516. — Greater  yielding  of  the  inner 
table  than  of  the  outer  after  the  appUcation  of 
violence  (after  Agnew). 


Wormian  bone,  or  a  tear  in  the  pericranium  for  a  fracture.  A  fracture  bleeds, 
a  suture  does  not.  Even  a  narrow  fracture  is  marked  by  a  dark  line  of  blood 
which  sponging  will  not  remove.  Fracture  of  the  inner  table  alone  can  only  be 
suspected  imless  the  x-roys  make  it  evident.  The  prognosis  of  fracture  of 
the  vault  depends  upon  the  extent  of  intracranial  injury  rather  than  upon  the 
extent  of  bone  injury.  Simple  fractures  may  unite  by  bone;  compound  frac- 
tures with  loss  of  bone  unite  only  by  fibrous  tissue.  The  dangers  may  be  imme- 
diate (hemorrhage,  brain  injury,  and  septic  inflammation)  or  be  distant  (epi- 
lepsy, insanity,  and  persistent  headache).  In  an  open 
fracture  the  danger  of  infection  is  added  to  the  danger 
of  brain  injury. 

Treatment. — The  mortality  of  fracture  of  the  skull 
was  formerly  much  greater  than  at  present.  Before 
the  days  of  antisepsis  it  was  51  per  cent.  (Harte). 
Trephining  is  performed  much  oftener  than  was  once 
the  custom,  and  is  vastly  safer.  Out  of  26  trephined 
cases,  3  died  (Harte).  In  any  case  of  fracture  of  the 
skull  endeavor  to  bring  about  reaction  before  operat- 
ing, unless  the  signs  of  pressure  continually  increase  or 
the  evidences  of  shock  remain  unimproved  or  become 
graver.  A  simple  fracture  without  depression  and  with- 
out brain  symptoms  is  treated  expectantly  (by  rest,  quiet, 
low  diet,  purgation,  moderate  elevation  of  and  cold  to 
the  head,  and  arterial  sedatives).  A  simple  fracture 
with  moderate  depression  and  without  cerebral  symptoms 
is  treated  expectantly,  and  so  also  is  a  simple  fracture 
in  which  symptoms  existed  but  are  abating.  Simple  frac- 
ture with  marked  depression  requires  immediate  trephin- 
ing, even  when  brain  symptoms  are  absent.  We 
make  an  exception  in  young  children,  and  wait  a 
while  before  trephining,  in  the  expectation  that  the 
expansile  brain  will  lift  the  depressed  but  elastic  bone 
up  to  the  level.  Trephining  in  cases  in  which  no  symptoms  exist,  although 
there  is  marked  depression,  often  prevents  disastrous  consequences  arising 
in  the  future,  and  is  known  as  preventive  trephining  (Agnew,  Keen,  Horsley, 
Macewen,  von  Bergmann,  and  others).  In  all  com^pound  fractures  shave  and 
asepticize  the  entire  scalp,  enlarge  the  incision,  and  explore  the  bone.  If  a 
fissure  exists,  it  must  be  asepticized,  and  if  a  hair  or  other  foreign  body  is 
found  in  it,  in  order  to  effect  removal  and  secure  asepsis  the  outer  table  of  the 


Fig.  517. — Fracture  of 
skull  with  depressed  frag- 
ments. Compression  of 
brain  by  bone  (Scudder). 


Fractures  of  the  Base 


791 


skull  at  this  spot  must  be  cut  away  by  a  chisel,  the  fissure  being  thus  converted 
into  a  broad  groove.  In  a  compoimd  fracture  with  much  depression  trephine, 
elevate,  and  irrigate.  In  any  fracture  trephine  if  distinct  symptoms  exist. 
In  punctured  wounds  of  the  brain  {punctured  fractures)  always  trephine,  open 
the  dura,  and  disinfect.  In  a  comminuted  fracture  the  usual  custom  is  to 
remove  loose  fragments.  Schaak  has  recently  advocated  their  reimplantation 
("Archiv.  fiir  klin.  Chir.,"  April  6,  191 2).  My  usual  custom  has  been  to  re- 
move them.  In  any  case  of  fracture  of  the  vault  in  which  trephining  has  been 
performed  it  is  wise  to  open  the  dura  and  examine  the  brain.  In  an  open  frac- 
ture and  after  every  operation  of  trephining  in  which  the  dura  was  opened 
administer  urotropin  in  order  to  make  the  cerebrospinal  fluid  bactericidal. 

Fractures  of  the  Base. 
— A  fracture  of  the  base 
of  the  skull  may  exist  in 
only  one  of  the  three  fossae, 
in  two  of  them,  or  it  may 
involve  all.  Figure  518 
shows  an  extensive  frac- 
ture of  the  base  of  the 
skull.  The  middle  fossa  is 
oftenest  involved.  Frac- 
ture of  the  posterior  fossa 
is  the  most  fatal.  These 
fractures  may  be  due  to 
direct  violence,  to  indirect 
force,  and  to  extension  of 
a  fracture  of  the  vault. 
Extension  from  the  vault 
is  always  by  the  shortest 
route.  Fractures  of  the 
base  may  extend  up  into 
the  vault,  and  do  so  in  over 
80  per  cent,  of  cases.  Frac- 
ture by  direct  violence  may 
arise  from  the  penetration 
of  the  nasal  roof,  the 
orbital  roof,  or  the  pharyn- 
geal   roof    by    a    foreign 

body.  The  posterior  fossa  may  suffer  from  a  fracture  by  direct  violence  applied 
to  the  neck.  Fractures  by  indirect  force  may  arise  from  blows  upon  the  frontal 
bone  (the  orbital  portion  of  the  frontal  or  the  cribriform  process  of  the  ethmoid 
breaking),  from  falls  upon  the  chin  (the  condyle  of  the  jaw  breaking  the 
middle  fossa),  or  from  falls  upon  the  buttocks,  the  knees,  or  the  feet  (fracture 
occurring  in  the  posterior  fossa).    The  base  is  not  broken  by  contre-coup. 

Symptoms. — Fractures  of  the  base  of  the  skull  are  apt  to  be  compound.  A 
solution  of  continuity  in  the  pharynx,  roof  of  the  nares,  orbit,  or  ear  permits 
access  of  air  to  the  seat  of  fracture  and  allows  blood  and  cerebrospinal  fluid  to 
flow  externally.  In  fracture  of  the  anterior  fossa  the  fracture  may  be  com- 
pound because  of  laceration  of  the  mucous  membrane  of  the  nares  or  of  the 
conjunctiva.  Blood  may  run  from  the  nose,  its  source  being  the  vessels  of 
the  mucous  membrane  or  the  dura,  the  fracture  being  compound.  Epistaxis 
does  not  prove  the  fracture  to  be  compound,  but  only  suggests  it;  but  if  the 
epistaxis  is  prolonged,  the  probability  is  greatly  increased;  and  if  the  flow  of 
blood  is  succeeded  by  a  flow  of  cerebrospinal  fluid  the  diagnosis  of  compound 
fracture   is   positive.      Cerebrospinal   fluid   appears  only  when  the  mucous 


Fig.  SI 8.- 


-Extensive  fracture  of  the  base  of  the  skull  ("American 
Text-Book  of  Surgery"). 


792  Diseases  and  Injuries  of  the  Head 

membrane,  the  dura,  and  the  arachnoid  are  each  lacerated.  In  fractures 
of  the  anterior  fossa  blood  is  apt  to  flow  into  the  orbit,  producing  s2ibcon- 
jimctival  ecchymosis,  and  perhaps  pushing  the  globe  of  the  eye  forward.  Some 
blood  is  often  swallowed  and  vomited.  In  fractures  of  the  middle  fossa  blood 
may  flow  from  the  ear  through  a  tear  in  the  tympanum,  its  source  being  the 
vessels  of  the  tympanum,  the  meningeal  vessels,  or  a  sinus.  Blood  may  flow 
through  the  Eustachian  tube  and  come  from  the  nose,  may  be  spat  up,  or  may 
be  swallowed  and  vomited.  In  some  cases  a  quantity  of  cerebrospinal  fluid 
flows  from  the  ear,  the  discharge  being  increased  by  expiratory  effort  and  a 
position  which  favors  gravity.  Cerebrospinal  fluid  is  at  first  blood-stained, 
but  later  becomes  clear.  The  cerebrospinal  fluid  must  not  be  confused  with 
either  blood-serum  or  liquor  Cotimnii.  The  cerebrospinal  fluid,  if  it  flows 
at  all,  is  always  present  in  large  amount;  the  liquor  Cotimnii  can  be  pres- 
ent only  in  minute  amount.  Blood-serum  is  highly  albuminous;  cerebro- 
spinal fluid  is  a  serous  fluid  of  very  low  specific  gravity,  never  shows  more 
than  a  trace  of  albumin,  and  contains  considerable  chlorid  of  sodiimi  and 
a  carbohydrate  now  known  to  be  a  dextrose  which  reduces  the  copper  of 
Fehling's  solution  and  reacts  to  Trommer's  and  to  Moore's  tests,  but  does 
not  refract  polarized  light  nor  easily  ferment  with  yeast.  Treves^  states  that 
cerebrospinal  fluid  cannot  flow  from  the  ear  in  fractures  of  the  middle  fossa 
— (i)  imless  the  line  of  fracture  crosses  the  internal  meatus;  (2)  unless  the 
prolongation  of  the  membranes  into  the  meatus  is  torn;  (3)  unless  a  com- 
munication exists  between  the  internal  ear  and  tympanimi,  and  (4)  unless 
the  drum-membrane  is  torn.  Miles,  of  Edinburgh,^  claims  that  bleeding  from 
the  ear  followed  by  a  flow  of  cerebrospinal  fluid  is  not  pathognomonic  of 
fracture  of  the  middle  fossa  of  the  base.  He  maintains  that  when  the  drum  is 
ruptured  we  may  have  these  signs;  when  bone  is  not  broken  the  chief  source 
of  the  blood  being  the  vessels  of  the  pia  and  temporosphenoidal  lobe,  the  blood 
and  cerebrospinal  fluid  flowing  inside  the  sheath  of  the  auditory  nerve,  passing 
into  the  vestibule,  through  the  lamina  cribrosa,  and  from  the  vestibule  into  the 
middle  ear,  finding  exits  from  this  space  by  way  of  the  Eustachian  tube  and  also 
through  the  rent  in  the  drum-membrane.  Profuse  mucous  discharge  may  flow 
from  the  ear  after  an  injury  without  fracture  when  the  drum  is  ruptured,  the 
fluid  coming  from  the  cells  of  the  mastoid.  It  must  be  understood  that  frac- 
ture of  the  base  may  exist  when  there  is  no  flow  of  blood  or  of  serous  fluid.  A 
fracture  of  the  middle  fossa  is  usually  compound,  made  so,  even  when  the 
drum  is  not  ruptured,  by  the  Eustachian  tube,  and  there  is  often  paralysis 
of  the  seventh  or  eighth  nerve  or  of  both  of  them.  In  fracture  of  the  posterior 
fossa  there  is  usually  respiratory  derangement  and  blood  accumulates  beneath 
the  deep  fascia  and  produces  discoloration  in  the  line  of  the  posterior  auricular 
artery  {Battle's  sign),  the  discoloration  first  appearing  near  the  tip  of  the 
mastoid.  The  discoloration  appears  in  the  line  of  nerves  and  vessels  which 
emerge  from  the  deep  fascia,  the  vessels  passing  through  openings  and  the 
extravasated  blood  emerging  from  the  same  openings.  Fractures  of  the 
posterior  fossa  are  apt  to  be  compound  through  the  pharynx,  and  in  such 
cases  the  patient  spits  or  vomits  blood.  Fractures  of  the  posterior  fossa  are 
more  fatal  than  fractures  in  either  of  the  other  fossas  because  of  the  adjacenc}^ 
of  vital  centers.  Fractures  of  the  base  are  apt  to  be  associated  with  paralysis 
of  cranial  nerves.  The  palsy  indicates  the  situation  of  the  fracture.  In  frac- 
ture of  the  anterior  fossa  the  olfactory  nerve  may  suffer.  In  fracture  of  the 
middle  fossa  the  fascial  nerve  most  often  suffers.  The  eighth  is  sometimes 
injured.  Other  nerves  which  may  siiffer  alone  or  in  combination  in  fracture  of 
the  base  are  the  abducens,  the  motor  oculi  communis,  the  trigeminus,  the  pneu- 
mogastric,  the  optic,  the  spinal  accessory,  the  hypoglossal,  and  the  glossopha- 
^  "Applied  Anatomy."  2  "Edinburgh  Med.  Jour.,"  Nov.,  1895. 


Fractures  of  the  Base  793 

ryngeal.  Optic  neuritis  often  arises  after  the  first  week.  In  fractures  of  the 
base  the  temperature  is  subnormal  during  the  shock,  rises  to  100°  to  101°  F., 
falls  again  to  about  normal,  and  remains  normal  or  subnormal  unless  there  is 
inflammation  or  sepsis.  Lumbar  puncture  may  obtain  bloody  fluid.  Such  a 
finding  means  subarachnoid  bleeding  and  indicates  fracture.  In  any  fracture 
injur}-  of  the  brain  may  exist.  Such  an  injury  will  be  made  manifest  by  s\TTip- 
toms,  and  we  may  or  may  not  be  able  to  diagnosticate  and  localize  it.  The 
prognosis  is  greatly  influenced  by  the  nature  and  extent  of  the  intracranial 
damage.  Harte  (''Annals  of  Surger\',"  Oct.,  1901)  has  collected  46  positive 
cases  of  fracture  of  the  base  of  the  skull  from  the  records  of  the  Pennsylvania 
Hospital;  35.5  per  cent,  recovered.  Ransohoff  collected  190  cases  of  fracture 
of  the  base  of  the  skifll.  The  mortality  was  65  per  cent.  Over  one-hafl"  of  the 
fatalities  were  within  twelve  hours.  Only  15  per  cent,  died  after  the  second 
day.  Of  98  cases  with  profound  coma  and  respiraton,-  disturbance  70  per  cent, 
died  ("Annals  of  Surgery,"  Jifly,  1910).  According  to  Hartley,  in  cases  treated 
expectantly  the  mortality  is  90  per  cent.,  in  cases  treated  by  operation  it  is 
less  than  35  per  cent.  ("Am.  Jour,  of  Surgen,',"  Dec,  1910). 

Treatment. — In  fracture  of  the  base  I  now^  always  do  a  subtemporal  de- 
compression, usually  on  both  sides,  as  Gushing  advocates.  This  is,  first  of  all, 
exploratory,  and  may  disclose  a  bleeding  meningeal  artery.  i\fter  the  dura  is 
opened  it  enables  us  to  evacuate  fluid  causing  pressure  and  in  which  bacteria 
could  multiply,  and  to  prevent  recurrence  of  pressure  after  the  wound  has  been 
closed.  If  there  is  bleeding  under  the  dura  the  brain  should  be  lifted  to  let 
the  blood  out,  and  a  drain  of  rubber  tissue  should  be  inserted.  If  there  is  only 
brain  edema  no  drain  is  required.  In  some  cases  drainage  has  been  obtained 
from  the  anterior  fossa  by  breaking  through  the  cribriform  plate  and  intro- 
ducing a  tube  by  way  of  the  nostril  (Allis),  and  from  the  middle  fossa  by  tre- 
phining above  and  behind  the  external  auditory-  meatus.  In  a  compound 
fracture  of  the  orbit  disinfect  and  drain.  It  may  be  necessary  to  trephine  the 
roof  of  the  orbit  to  secure  drainage. 

In  addition  to  performing  decompression  I  always  give  lu-otropin,  as 
ad\'ised  by  surgeons  in  Johns  Hopkins  Hospital  (S.  J.  Crowe,  in  "The  Johns 
Hopkins  Hospital  BuUetin,"  April,  1909).  This  drug  renders  the  cereborspinal 
fluid  bactericidal.  Other  methods  of  treatment  are  secondary  to  the  above. 
My  experience  is  that  this  plan  saves  many  cases  which  would  otherwise 
perish.  In  treating  a  compound  fracture  of  the  base  of  the  skuU  disinfect 
any  ca\-ity  involved.  In  fractures  of  the  middle  fossa  with  ruptured  drum 
clean  the  ear  mechanically,  wash  it  out  by  a  stream  of  warm  salt  solu- 
tion (turn  the  head  toward  the  affected  side  while  washing,  so  that  the 
solution  will  not  run  down  the  Eustachian  tube),  insufflate  iodoform,  insert 
a  piece  of  iodoform  gauze,  and  apply  an  antiseptic  dressing.  Several  times 
daily  the  ear  is  to  be  irrigated  and  insufflated  with  iodoform.  The  naso- 
pharynx must  be  frequently  irrigated  by  normal  salt  solution  or  boric  acid 
solution  and  insufflated  with  iodoform.  The  conjunctival  sac  is  frequently 
irrigated  by  boric  acid  solution.  If  after  a  head  injury  blood  accumulates 
back  of  the  drmn,  this  membrane  should  be  incised  to  permit  of  drainage  and 
disinfection.  In  fractures  of  both  the  middle  and  anterior  fossae  and  in  fractures 
of  the  posterior  fossa  communicating  "^ith  the  phar\'nx  the  nasophar\-nx  must 
always  be  cleaned.  The  exact  method  depends  on  the  choice  of  the  surgeon. 
We  may  wash  out  these  ca\'ities  frequently  by  hot  water,  next  by  peroxid 
of  hydrogen,  and  finally  by  boric  acid  solution,  or  can  simply  use  normal 
salt  solution.  After  washing,  insufflate  the  nasopharynx  -^-ith  iodoform.  Re- 
peat the  cleansing  at  regular  intervals  and  also  cleanse  the  conjunctival  sac  fre- 
quently. In  fracture  of  the  posterior  fossa  examine  to  see  if  the  fracture  is  com- 
pound^ into  the  phar>-nx,  and  if  it  is,  cleanse  with  great  care  the  nasopharynx 


794 


Diseases  and  Injuries  of  the  Head 


and  mouth,  as  previously  directed.  In  a  very  extensive  fracture  of  the  base, 
besides  use  of  the  methods  set  forth  above,  the  entire  head  should  be  shaved 
and  a  plaster-of-Paris  cap  be  applied.  A  patient  with  fracture  of  the  base  must 
be  put  into  a  quiet  and  darkened  room  and  be  kept  upon  a  low  diet,  sleep  being 
secured,  and  the  bowels  and  bladder  being  attended  to.  If  we  are  uncertain 
as  to  whether  a  fracture  exists  or  not,  keep  the  patient  quiet,  in  a  darkened 
room  and  on  a  low  diet.  Attend  to  the  bladder,  keep  the  bowels  loose,  examine 
the  nasopharynx  with  a  mirror  and  the  ear-drum  through  a  speculum,  and  make 
a  lumbar  puncture. 

Obstetric  Depressions  of  the  Skull. — These  lesions  seem  to  have  been 
first  studied  by  Danyau  in  1 849.  The  depression  may  be  of  the  parietal  or  frontal 
bone  and  may  or  may  not  be  accompanied  by  fracture.  It  may  have  been  caused 
by  the  promontory  of  the  mother's  sacrum  or  by  obstetric  forceps.  A  slight  de- 
pression does  no  harm,  because  it  is  gradually  and  spontaneously  corrected.  A 
marked  depression,  especially  if  accompanied  by  fracture,  places  the  child  in 
danger  of  epilepsy,  idiocy,  and  non-development  of  body,  and  requires  treat- 
ment.    The  usual  treatment  is  trephining  and  elevation.     Some  claim  to 

elevate  by  an  apparatus 
making  pneumatic  suc- 
tion. Some  make  a  small 
incision,  insert  a  screw 
(Heine's  screw),  and  ele- 
vate by  making  traction 
on  the  screw.  Hanch  ele- 
vated by  means  of  a  cork- 
screw. (See  Frazier,  in 
"Progressive  Medicine," 
March,  19 13.) 

Wounds  of  the  brain 
are  produced  by  violence 
and  especially  by  foreign 
bodies  (knives,  bullets, 
etc.).  Except  when  due 
to  penetration  of  a  fonta- 
nel in  a  child  or  of  a  pa- 
rietal foramen  in  adults, 
wounds  of  the  brain  are 
accompanied  by  fracture 
of  the  skull.  These 
wounds  are  very  danger- 
ous; foreign  bodies  (bone, 
hair,  clothing,  etc.)  are 
often  lodged  in  the  brain, 
hemorrhage  is  usually  severe,  and  without  proper  treatment  sepsis  is  almost 
inevitable.  Such  cases  are  very  fatal,  though  some  astonishing  recoveries  are 
on  record.     Figs.  519  and  520  show  gunshot-fractures  of  the  skull. 

The  symptoms  of  a  brain  wound  may  be  slight  and  long  deferred  or  may 
be  immediate  and  overwhelming;  they  depend  upon  the  site  and  extent  of  the 
injury.  Localizing  symptoms  may  exist,  and  encephalitis  with  coma  is  apt 
to  arise.     Abscess  may  follow. 

In  treating  wounds  of  the  brain  always  shave  the  entire  scalp  and  examine  the 

weapon,  if  possible,  to  see  if  a  piece  were  broken  off.     Asepticize,  enlarge  the 

wound,  trephine,  arrest  bleeding,  elevate  any  depression,  remove  foreign  bodies, 

irrigate  the  wound  with  salt  solution,  drain  by  gauze,  suture  the  dura,  and  dress. 

Wounds  in  War. — When  the  bullet  of  a  military  rifle,  fired  at  very  close 


Fig.  sig. — Extensively  comminuted  gunshot-fracture  of  the  skull 
(after  von  Bergmann). 


Treatment  of  Wounds  in  War 


795 


range,  crosses  the  brain  it  may  blow  the  skull  into  fragments,  but  often  it  does 
not,  but  produces  fracture  of  the  skull  and  wound  of  the  brain.  The  "ex- 
plosive effect"  is  far  less  marked  on  the  head  of  a  living  man  than  on  the  head 
of  a  corpse  and  may  even  be  absent  when  the  range  was  only  loo  yards.  At 
moderate  range,  at  the  point  of  initial  contact  of  the  bullet  with  the  skull, 
a  fracture  is  produced,  the  opening  is  slightly  larger  than  the  bullet,  and  short 
fissures  commonly  radiate  from  it.  Fragments  from  the  internal  table  are 
usually  displaced  and  driven  into  the  brain.  The  wound  of  exit  is  more  ir- 
regular and  is  apt  to  exhibit  more  and  longer  fissures  than  the  wound  of  en- 
trance. When  a  bullet  strikes  a  glancing  blow  it  may  fracture  the  outer  table 
alone;  it  may  produce  a  "gutter-fracture"  (two  scalp  openings,  and  "a  gutter 
ploughed"  through  both  tables  of  a  portion  of  the  skull,  as  O'Reilly  expressed 
it),  very  seldom  a  fracture  of  the  inner  table  only,  penetration  of  the  skull,  and 
lodgment  of  the  bullet,  or  perforation  of  the  skull,  the  bullet  passing  through 
the  head  and  emerging.  Nearly  half 
the  cases  are  instances  of  perforating 
wound. 

In  all  of  these  injuries  there  is  great 
shock  and  usually  concussion,  but  con- 
cussion symptoms  may  be  absent.  The 
patient  may  die  at  once  or  almost  at 
once,  but  if  he  is  alive  a  few  hours 
after  the  injury  he  has  still  to  face  the 
danger  of  infection  and  resulting  in- 
flammation. The  danger  depends  on 
the  brain  injury  and  the  amount  of 
infection  and  not  on  the  extent  of  the 
bone  damage.  The  symptoms  vary 
according  to  the  part  of  the  brain  in- 
jured and  the  extent  of  the  damage. 

In  practically  all  cases  bone-frag- 
ments are  driven  into  the  brain,  and  as 
the  scalp  is  a  dirty  region,  the  wound  is 
more  or  less  infected. 

The  mortality  from  these  injuries  is 
very  large.  In  the  American  Civil  War 
it  was  61.2  per  cent.  In  the  Franco- 
Prussian  War  it  was    51.3    per   cent. 

In  the  Boer  War,  among  the  British  it  was  only  33.1  per  cent.,  a  very  notable 
improvement.  (See  "Military  Surgery,"  by  Surgeon  General  Robert  M.  O'- 
Reilly, U.  S.  A.,  in  "Keen's  Surgery,"  vol.  iv.)  In  the  Russo-Japanese  War  the 
mortality  seems  to  have  been  something  over  37  per  cent. 

In  estimating  mortality  those  killed  outright  and  those  dying  before  reach- 
ing the  hospital  are  not  counted  by  makers  of  statistics.  Much  brain  matter 
may  ooze  out  from  such  a  wound.  Cerebral  hernia  (Fig.  522)  is  common  after 
these  injuries,  especially  if  much  bone  was  destroyed  by  the  injury  or  removed 
by  the  surgeon. 

Treatment  of  Wounds  in  War. — At  the  first-aid  station  antiseptic  dress- 
ings are  applied.  On  reaching  the  field  hospital  the  wound  is  explored,  if 
time,  situation,  and  military  necessities  permit.  Every  wound  of  this  sort  is  re- 
garded as  being  complicated  by  infection  and  by  depression  or  wide  disf^rsion 
of  bone-fragments.  The  patient  is  reacted  from  shock  and  a  flap  of  scalp  is 
turned  down  to  permit  of  exploration.  Depressed  fragments  of  bone  are 
elevated  or  removed  and  loose  pieces  are  removed.  Treatment  is  the  same 
as  for  wounds  from  revolver  bullets  (see  page  796). 


Fig.  520. — Gunshot-fracture  of  internal  table  of 
the  skull  (after  von  Bergmann). 


796  Diseases  and  Injuries  of  the  Head 

Wounds  from  Revolver  Bullets. — The  bullet  may  strike  the  skull 
and  glance  (if  fired  at  an  angle)  with  or  without  the  production  of  a  fracture. 
A  small  bullet  (No.  .22)  may  even  strike  perpendicularly  and  fail  to  enter, 
sometimes  causing  a  fracture  and  sometimes  not  doing  so.  Even  a  No.  .22 
may  enter  the  skull.  I  removed  a  bullet  of  this  size  which  had  entered  and 
crossed  the  skull  and  lodged  beneath  the  cortex  on  the  opposite  side  of  the 
brain.  A  bullet  may  cause  a  "gutter-fracture" — may  enter  the  cranium  and 
lodge — or  may  cause  a  complete  perforation.  A  revolver  bullet  is  much  more 
apt  to  lodge  than  a  military  bullet. 

The  wound  of  entrance  is  small;  the  wound  of  exit  is  larger.  At  the  wound 
of  entrance  the  inner  table  is  more  extensively  fractured  than  the  outer  table; 
at  the  wound  of  exit  the  outer  table  is  more  widely  broken  than  the  inner  table. 
In  these  cases  there  is  always  great  shock  and  usually  concussion,  and  con- 
cussion symptoms  may  exist  even  when  the  bullet  has  not  entered  the  brain. 
In  moderate  concussion  the  action  of  the  heart  is  retarded;  in  severe  con- 
cussion it  is  accelerated  (see  page  781).  A  bullet  may  be  lodged  within  the 
cranium  when  merely  a  fracture  without  a  bullet-hole  can  be  detected.  In 
these  cases  the  bullet  produced  a  fracture  and  entered  the  cranium,  and  then 
the  depressed  bone  flew  back  into  place  (von  Bergmann) .  In  such  cases,  if  com- 
plete perforation  occurs,  the  one  existing  opening  in  the  bone  is  the  opening  of 
exit.  A  bullet  may  lodge  in  the  bone,  between  the  dura  and  the  bone,  be- 
tween the  dura  and  brain,  in  the  brain,  between  the  dura  and  the  brain  or  the 
dura  and  the  bone  of  the  opposite  side,  or  in  the  bone  of  the  opposite  side,  in 
the  nasal  fossa,  maxillary  antrum,  or  orbit.  Always  examine  the  side  of  the 
head  opposite  to  the  wound  of  entrance  to  determine  if  there  is  a  wound  of  exit 
or  any  bulging  or  fracture.  A  bullet  may  pass  across  the  brain  and  be  de- 
flected from  the  inner  surface  of  the  skull.  Ruth  does  not  beheve  the  bullet 
can  rebound  from  the  opposite  wall.^  If  certain  regions  are  injured,  localizing 
symptoms  may  arise.  Much  brain  matter  may  ooze  out  from  the  wound. 
Loss  of  brain  matter  sometimes  causes  great  impairment  of  function,  some- 
times little  or  none.  The  secondary  symptoms  of  gunshot- wounds  of  the  head 
are  varied  and  uncertain,  and  may  not  be  observed  at  all  before  death.  Fow- 
ler wisely  points  out  that  a  patient  with  a  gunshot-wound  of  the  head  may 
have  also  received  other  injuries,  and  the  other  injuries  may  be  in  part,  at 
least,  responsible  for  cerebral  symptoms. 

Treatment  of  Wounds  from  Revolver  Bullets. — Endeavor  to  bring  about 
reaction  (see  Concussion).  In  severe  cases  appty  heat  to  the  head  and  make 
artificial  respiration.  It  will  sometimes  be  necessary  to  operate  while  artificial 
respiration  is  being  made.  In  treating  gunshot-wounds  of  the  head  shave  and 
asepticize  the  whole  scalp,  disinfect  the  entire  track  of  the  ball,  and  arrest 
hemorrhage  at  the  wounds  of  entrance  and  exit,  using  the  rongeur  to  expose 
the  bleeding  points  if  the  bullet  be  large,  employing  the  trephine  if  it  be  small. 
If  the  bullet  has  emerged  and  has  been  picked  up,  examine  it  to  see  if  it  is  entire. 
The  bullet,  if  retained,  is  to  be  sought  for.  The  x-rays  are  invaluable  in  locat- 
ing the  missile.  Place  the  head  in  such  a  position  that  the  track  of  the  ball 
will  be  vertical,  then  introduce  Fluhrer's  aluminum  probe  or  Senn's  probe, 
and  let  it  find  its  way  by  gravity.  The  probe  may  find  the  ball  near  the  wound 
of  entrance,  in  which  case  extract  the  ball  with  forceps;  or  the  probe  may  find 
the  ball  near  the  opposite  side  of  the  head,  in  which  case  make  a  counteropening 
through  the  bone  at  a  point  the  probe  would  touch  if  it  were  pushed  entirely 
across.  Take  a  new  and  clean  rubber  catheter  (No.  9,  French),  insert  a  stylet, 
and  carry  the  catheter  through  the  wound  (Keen).  Knowing  the  depth  of 
the  ball,  search  for  it  around  the  catheter-tube  as  an  axis,  and  when  found, 
extract  it.  After  extraction  drain  the  wound  by  means  of  a  tube.  When 
1  See  the  instructive  article  by  Fowler,  in  "Annals  of  Surgery,"  Nov.,  1895. 


Prolapse  of  the  Brain  and  Hernia  of  the  Brain 


797 


a  counteropening  exists,  drain  through  and  through.  If  the  ball  cannot  be 
detected,  drain  by  a  tube  carried  to  the  depths  of  the  wound.  After  dressing 
always  place  the  head  in  a  position  favorable  to  drainage.  Fluhrer  tells  us 
that  when  a  counteropening  fails  to  disclose  the  bullet,  use  the  new  opening 
as  a  doorway  through  which  to  search  for  the  ball.  He  beliex^es  the  bullet  is 
not  unusually  deflected.  The  angle  of  deflection  is  somewhat  greater  than  the 
angle  of  incidence,  and  the  bullet  is  apt  to  fall  a  little  toward  the  base.    Splinters 


m 


Fig.  521. — Senn's  modification  of  Nelaton's  bullet-probe. 

of  bone  are  often  driven  into  the  brain  by  a  bullet,  and  these  should  be  re- 
moved whether  the  ball  is  found  or  not.  Several  varieties  of  probes  have  been 
recommended.  Fluhrer  uses  a  large-sized  aluminum  probe.  Senn  used  an 
instrument  shaped  like  the  Nelaton  probe,  but  of  the  same  diameter  as  the 
bullet  (Fig.  521).  (Of  course,  the  porcelain  probe  will  not  show  a  black  mark 
from  contact  with  a  hard-jacketed  bullet.)  Fowler  uses  a  graduated  pres- 
sure probe;  so  long  as  the  pressure  is  within  the  limits  of  the  spring,  as  shown 
by  the  scale,  the  probe  is  in  the  bullet- 
track.  Girdner's  telephonic  probe  has 
been  used  as  an  aid  to  localization. 
Bullets  are  now  certainly  located  by 
the  Rontgen  rays.  There  can  be 
no  doubt  that  many  gunshot-wounds 
have  been  recovered  from  without 
operation,  and  it  is  beyond  question 
that  many  deaths  follow  operation 
(about  33 1  per  cent.,  according  to 
Hahn).  Von  Bergmann  is  so  im- 
pressed with  these  facts  that  he  does 
not  operate  when  cerebral  s\Tnptoms 
are  absent.     I  usually  operate. 

Prolapse  of  the  Brain  and  Hernia 
of  the  Brain. — In  a  compound  frac- 
ture, especially  a  gunshot-fracture, 
with  torn  dura  and  pia,  brain  matter 
may  emerge  from  the  wound.  In 
fracture  of  the  base  brain  matter 
ma}-  enter  the  orbit,  the  nose,  or 
the  ear.  A  flow  of  brain  matter 
may  continue  from  a  wound  for 
many  hours.    A  week  or  more  after 

an  injury  a  portion  of  the  brain  may  protrude  or  prolapse.  To  this  con- 
dition the  term  prolapse  of  the  brain  should  be  applied.  In  many  instances 
the  protrusion  is  covered  ^Yith.  pia,  but  if  the  pia  were  torn  or  cut,  it  wiU 
not  be  a  covering.  This  protrusion  emerges  from  the  opening  in  the  skull, 
mounts  up,  growing  larger  and  larger,  until  it  may  become  the  size  of  a  fist. 
It  usually  pulsates.  When  bare  it  is  soft,  lobulated,  of  a  dirty-white  color, 
pulsating,  painless  to  the  touch,  often  bleeding,  and  sometimes  discharging 
cerebrospinal  fluid.  Death  may  soon  follow  such  protrusion,  but  the  pro- 
truding mass  mav  become  necrotic  and  be  sloughed  off,  a  granulating  surface 


Fig.  522. — Hernia  cerebri  under  scalp  after  opera- 
tion for  brain  tumor  (W.  W.  Keen). 


798 


Diseases  and  Injuries  of  the  Head 


remaining,  which  heals.  Hernia  cerebri  (Fig.  522)  sometimes  follows  operations 
upon  the  brain  or  injuries  of  the  skull  and  dura,  when  large  pieces  of  borre  have 
been  removed  or  when  the  dura  has  been  widely  cut  or  torn  and  has  not  been 
carefully  sutured.  The  condition  is  due  to  increased  cerebral  pressure.  Hernia 
of  the  brain  is  protrusion  through  the  dura,  but  not  through  the  scalp,  the  scalp 
wound  being  healed  above  the  protrusion.  In  a  decompression  operation  we 
deliberately  create  a  hernia  of  the  brain.  Prolapse  of  the  brain  is  treated  by 
antiseptic  dressings  and  perhaps  by  a  decompression  operation.  Skin-grafting 
benefits  some  cases.  Pressure  is  dangerous.  Excision  by  the  knife  or  cautery 
seldom  does  any  good.  Hernia  in  some  cases  can  be  treated  by  repeated  lum- 
bar punctures,  in  some  others  by  craniotomy  of  the  opposite  side  of  the  skull. 

Fungus  Cerebri  (Fig. 
523). — When  the  brain  is 
exposed,  a  granuloma  may 
grow  from  the  neuroglia 
and  fungate  through  the 
opening  in  the  skull.  This 
condition  is  fungus  cerebri 
and  is  not  composed  of 
brain  matter.  It  is  due  to 
infection  of  the  brain,  and 
is  most  frequent  when  a  bit 
of  bone  or  some  other  foreign 
body  is  retained.  A  fungus 
is  soft  to  the  touch,  is  livid 
in  hue,  bleeds  easily,  fre- 
quently contains  multiple 
foci  of  suppuration,  and  pul- 
sates. It  often  attains  the 
size  of  a  small  orange.  It  is 
treated  by  removing  the 
granulations  and  any  foreign  body,  and  applying,  with  moderate  pressure, 
aseptic  dressing  soaked  in  alcohol.  After  healing,  a  depression  marks  the 
site  of  the  fungus. 

Traumatic  inflammation  of  the  brain  and  its  membranes  is 
divided  into  encephalitis  or  cerebritis,  inflammation  of  the  cerebrum;  cere- 
bellitis,  inflammation  of  the  cerebellum;  meningitis,  inflammation  of  the 
meninges;  arachnitis,  inflammation  of  the  arachnoid;  pachymeningitis,  in^SLm- 
mation  of  the  dura;  and  leptomeningitis,  inflammation  of  the  arachnoid  and  pia. 
Meningitis. — Of  recent  years  our  views  regarding  meningitides  have 
changed.  We  no  longer  regard  each  form  as  a  separate  and  distinct  disease, 
but  we  regard  all  the  forms  as  different  phases  of  one  disease,  that  disease 
being  a  reaction  to  infection  on  the  part  of  the  membranes  of  the  brain  and 
cord.  We  must  still,  for  clinical  convenience,  classify  meningitides  into  many 
types.  We  speak  of  meningitis  as  serous  or  purulent,  local  or  diffuse.  We 
speak  of  it  as  basilar,  leptomeningitis,  etc.,  or  as  tuberculous,  meningococcic, 
etc.  But,  after  all,  meningitis  is  an  infection  for  which  many  varieties  of  bac- 
teria may  be  responsible,  and  in  which  there  are  many  different  routes  for  the 
entrance  of  the  causal  micro-organisms,  but  the  effects  of  these  organisms  upon 
the  tissues  are  similar  and  the  variety  of  the  symptoms  produced  depend  upon 
the  region  diseased  and  the  power  and  nature  of  the  toxins. 

This  view  has  been  most  ably  set  forth  by  Kopetzky  ("The  Laryngoscope," 
June,  1912).  The  same  carefiil  observer  points  out  that  in  every  form  of 
meningitis  there  is  increased  tension  of  the  cerebrospinal  fluid  and  poisoning  of 
the  central  nervous  system  by  toxins  and  products  of  tissue  metabolism. 


Fig.  523. — Fungus  cerebri  (W.  W.  Keen). 


Treatment  of  Pachymeningitis  Interna  799 

The  chief  factors  in  causing  increased  tension  of  cerebrospinal  fluid  are 
edema  of  brain  tissue  and  edema  of  the  membranes. 

Kopetzky  ("The  Laryngoscope,"  June,  191 2)  further  points  out  that  very 
early  in  the  progress  of  every  case  of  meningitis  there  is  a  disappearance  from 
the  cerebrospinal  fluid  of  the  copper-reducing  substance  dextrose.  Bacteria 
are  greedy  for  carbohydrates  and  eat  up  dextrose.  The  disappearance  of  dex- 
trose is  highly  significant  of  the  existence  of  meningitis.  Its  reappearance 
indicates  abatement  of  the  inflammation. 

Treatment. — Kopetzky  (Ibid.)  in  acute  cases  advocates  the  administration 
of  serum  or  antitoxin  and  the  early  performance  of  an  operation  to  reduce 
intracranial  tension.  Lumbar  puncture  is  of  high  diagnostic,  but  small  thera- 
peutical, value.  The  most  promising  operation  is  one  which  drains  the  cisterna 
magna  (see  Haynes's  Operation,  page  832). 

Pachymeningitis  Externa. — Inflammation  of  the  external  layer  of  the 
dura  is  caUed  pachymeningitis  externa.  It  may  arise  from  tumor,  caries, 
necrosis,  middle-ear  disease,  sunstroke,  or  traumatism.  Syphilis  is  a  not 
unusual  cause.  The  other  membranes  may  become  involved.  Suppuration 
may  arise,  having  extended  by  contiguity  from  neighboring  parts. 

The  symptoms  of  pachymeningitis  externa  are  uncertain.  They  resemble 
often  those  of  leptomeningitis  (see  page  800).  Pressure  symptoms  may  arise. 
Headache  is  always  present.  Paralysis  may  or  may  not  exist.  If  pus  forms, 
the  ordinary  constitutional  symptoms  of  suppuration  are  evident  (high  tem- 
perature and  sweats),  not  the  usual  symptoms  of  abscess  in  the  brain.  In  a 
severe  case  the  other  membranes  become  involved. 

The  treatment  consists  in  removing  the  cause  (carious  bone,  pus,  middle- 
ear  disease).  In  pachymeningitis  from  traumatism  it  is  sometimes  advisable 
to  trephine  in  order  to  drain  inflammatory  products;  in  a  case  with  localizing 
symptoms  always  trephine;  in  an  ordinary  case,  without  pus  and  with  no 
evidences  of  traumatism,  use  wet  cups  back  of  the  mastoid  processes,  apply  an 
ice-bag  to  the  head,  and  purge  by  means  of  calomel.  Administer  iodid  of 
potassium  in  most  cases.  If  sunstroke  is  the  cause,  treat  according  to  ordi- 
nary medical  rules. 

Pachymeningitis  Interna.^ — This  term  means  inflammation  of  the 
inner  layer  of  the  dura.  ■  Inflammation  may  extend  from  the  pia  or  from  the 
outer  layer  of  the  dura.  The  disease  is  most  often  met  with  in  infants  and 
in  the  chronic  insane,  but  may  occur  in  those  not  insane  in  late  middle  age  or 
beginning  old  age.  The  form  known  as  hematoma  of  the  dura  mater,  or  pachy- 
meningitis interna  hcemorrhagica,  may  arise  during  infectious  disease  (typhoid 
fever  or  rheumatism),  in  persons  of  the  hemorrhagic  diathesis,  in  diseases 
causing  atrophy  of  the  brain,  in  chronic  diseases  of  the  heart  and  kidneys, 
and  in  syphilitics.  Among  the  exciting  causes  are  traumatism,  inflamma- 
tion in  adjacent  parts,  and,  especially,  the  abuse  of  alcohol.  In  this  disease 
blood  is  extravasated  on  the  inner  surface  of  the  dura.  Many  observers  do  not 
class  hemorrhagic  pachymeningitis  as  inflammation,  but  regard  the  hemor- 
rhage as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very  chronic,  come  on 
gradually,  are  not  characteristic,  and  may  be  absent.  They  consist  usually  of 
mental  irritabflity  or  excitement,  followed  perhaps  by  hebetude  and  persistent 
headache;  and  apoplectiform  attacks,  with  contraction  of  the  pupfls,  slow 
pulse,  and  vomiting;  there  may  also  be  muscular  rigidity  and  spasm  of  the  ex- 
tremities. Choked  disk  is  not  infrequent;  localizing  symptoms  may  be  made 
out,  and  coma  is  apt  to  arise.    Cranial  nerves  are  seldom  affected. 

The  treatment  is  operation,  which  removes  the  clot.  This  is  unpromis- 
ing, but  Munro  saved  i  case  out  of  5  ("Chicago  Med.  Recorder,"  Dec, 
1902). 


8oo  Diseases  and  Injuries  of  the  Head 

Acute  leptomeningitis  is  a  purulent  inflammation  of  the  soft  mem- 
branes of  the  brain.  The  pathological  changes  can  be  noted  in  the  pia  and  in 
the  brain  substance.  The  brain  is  edematous,  the  pia  purulent,  the  convolu- 
tions are  flattened,  the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain  substance.  Pus  may  be  localized  upon  the  pia,  but  it  is 
usually  diffused  over  one  hemisphere  or  over  both.  Various  organisms  may 
be  foimd,  especially  streptococci,  staphylococci,  and  diplococci.  In  some 
cases  we  find  the  Bacillus  pyocyaneus  or  the  Bacillus  pyocyaneus  foetidus, 
which  is  identical  with  the  colon  bacillus  and  with  the  Bacillus  meningitidis 
purulentae  (Park).  Saprophytic  organisms  are  occasionally  present.  This 
disease  may  be  acute  or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis. 
Secondary  leptomeningitis  is  apt  to  affect  the  convexity;  primary  leptomen- 
ingitis is  apt  to  affect  the  base. 

The  causes  of  leptomeningitis  are  epidemic  cerebrospinal  fever,  tuber- 
culosis, acute  general  diseases  (pneumonia,  typhoid,  erysipelas,  and  rheu- 
matism), bone  diseases,  traimiatism,  middle-ear  disease,  syphilis,  and  sun- 
stroke. In  diplococcic  meningitis  the  tissues  of  the  pia  and  the  cerebrospinal 
fluid  contain  diplococci  identical  with  pneumococci.  Infection  may  take  place  by 
various  avenues.  It  may  pass  from  the  pharynx  by  way  of  the  Eustachian  tube 
to  the  ear,  or  from  the  nose  to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt),  and 
from  these  situations  to  the  brain.  It  may  pass  from  the  middle  ear  or  mastoid 
to  the  membranes  of  the  brain.  In  fractures  at  the  base  the  organisms  enter 
by  way  of  the  pharynx  and  the  Eustachian  tube,  or  the  ear.  The  symptoms 
of  acute  leptomeningitis  early  in  the  case  are:  rising  blood-pressure  (determined 
by  the  sphygmomanometer),  edema  of  the  optic  papillae,  absence  of  carbohy- 
drates from  the  cerebrospinal  fluid  (obtained  by  lumbar  puncture),  "an  irritable 
or  clouding  sensorium"  (Irving  S.  Haynes,  in  "The  Laryngoscope,"  June,  191 2). 
The  same  author  adds  that  vagus  pulse  and  respirations  irregular  in  depth 
and  rate  may  also  be  present.  As  the  case  progresses  there  are  violent  headache 
persisting  during  delirium,  flushing  of  the  face,  rigidity  of  the  neck,  cerebral 
vomiting,  a  pulse  small  and  irregular  in  force  and  frequency,  but  often  slow, 
elevated  temperature,  leukocytosis,  photophobia,  contraction  and  perhaps 
inequality  of  the  pupils,  intolerance  of  sound,  hyperesthesia  of  the  skin  and 
muscles,  and  delirium  passing  into  stupor  and  coma.  There  are  rigidity  of  the 
muscles  of  the  neck,  retraction  of  the  head,  retraction  of  the  abdominal  muscles 
(boat-shaped  abdomen),  inability  to  extend  the  legs  when  sitting  up,  though  it 
can  be  done  when  recumbent.  If,  while  lying  down,  the  thigh  is  flexed  on  the 
belly  the  leg  cannot  be  extended  on  the  thigh  {Kernig's  sign).  If  a  dull  point 
is  drawn  along  the  skin  a  red  line  follows  it  {tache  cerehrale) .  A  chill  or  a  suc- 
cession of  chills  may  occur.  Choked  disk,  strabismus,  and  nystagmus  are  not 
unusual.  Twitching  convulsions  or  paralyses  may  occur.  Death  is  the  rule 
within  one  week.  In  a  case  of  meningitis  the  fluid  obtained  by  lumbar  punc- 
ture may  contain  bacteria  and  may  be  actually  purulent.  The  presence  of 
mmierous  leukocytes  is  usual,  there  being  an  excess  of  polymorphonuclear 
forms  in  pyogenic  infections.  • 

Treatment. — Flexner's  serum  is  valuable  in  cerebrospinal  meningitis,  a 
condition  caused  by  the  Diplococcus  intracellularis,  but  is  useless  in  all  other 
conditions.  Lumbar  puncture  is  of  immense  diagnostic  importance,  but  is 
useless  therapeutically.  It  is  not  entirely  safe.  The  rapid  withdrawal  of  fluid 
may  cause  death  by  allowing  the  foramen  magnum  to  be  plugged  by  the  brain 
stem.  Ordinary  trephining  with  tapping  of  the  ventricle  is  practically  useless. 
An  operation  which  promises  is  the  exposure  and  drainage  of  the  cisterna  magna 
(see  page  832).  If  employed  it  should  be  done  early,  that  is,  when  what  we 
regard  as  early  s\Tnptoms  are  present.  Late  operations  are  of  no  avail.  Any 
causal  condition,  for  instance,  suppurative  otitis  media,  must  also  be  treated  by 


Treatment  of  Tuberculous  Meningitis  8oi 

operation.  After  operating  administer  urotropin.  Should  the  patient  recover, 
he  must  be  guarded  for  a  long  time  from  physical  exertion,  mental  excite- 
ment, worry,  irritation,  constipation,  and  insomnia. 

Chronic  Leptomeningitis  {or  Chronic  Encephalitis). — The  causes  of 
chronic  leptomeningitis  are  the  same  as  those  of  the  acute  form.  If  trauma- 
tism is  the  cause,  the  inflammation  arises  at  a  later  period  than  it  would  in 
acute  encephalitis.  The  symptoms  of  concussion  follow  a  head  injury.  Days, 
or  even  weeks,  after  the  accident  a  series  of  symptoms  may  occur,  namely,  local- 
ized pain  at  the  seat  of  injury,  often  accentuated  by  tapping;  listlessness; 
irritability;  apathy  regarding  business  affairs  and  home  obligations,  or  pro- 
found depression  and  hypochondria  with  inability  to  attend  to  business. 
Choked  disk  may  exist.  In  any  case  acute  encephalitis  may  arise,  with  or 
without  a  chill.  The  treatment  of  this  disease  is  symptomatic  unless  local 
symptoms  exist.  Always  trephine  if  localizing  symptoms  are  found.  Intense 
local  pain  justifies  trephining. 

Tuberculous  Meningitis  (Acute  Hydrocephalus;  Water  on  the 
Brain). — This  inflammatory  condition  is  due  to  the  bacilli  of  tuberculosis. 
In  a  child  affected  with  tuberculous  meningitis  there  is  often  a  record  of  a 
fall,  the  injury  acting  as  an  exciting  cause  by  establishing  an  area  of  least 
resistance.  Prodromal  symptoms  lasting  several  weeks  are  common  (restless- 
ness, irritability,  anorexia,  loss  of  flesh,  change  of  character).  The  attention 
of  the  physician  is  attracted  to  the  meninges  by  a  convulsion  or,  what  is  more 
common,  by  headache,  fever,  and  vomiting.  The  fever  is  persistent,  but 
irregular.  The  child  cries  out  from  pain  {the  hydrencephalic  cry)  and  the  bowels 
are  constipated.  The  pulse  is  rapid  in  the  beginning,  but  later  becomes  slow, 
irregular,  and  of  high  tension.  The  pupils  are  contracted,  there  is  muscular 
twitching,  and  the  sleep  is  impaired.  The  temperature  is  about  103°  F.  There 
is  usually  edema  of  the  optic  papillae  and  carbohydrate  disappears  from  the 
cerebrospinal  fluid  (see  page  799).  In  the  second  period  of  the  disease  the 
vomiting  ceases,  constipation  becomes  more  marked,  the  belly  retracts,  head- 
ache is  not  so  violent,  and  the  patient  lies  in  a  soporose  condition  interspersed 
with  episodes  of  delirium.  In  this  stage  the  pupils  dilate  and  are  often  un- 
equal, the  head  is  retracted,  convulsions  occur  or  limited  rigidity  is  noted,  the 
respirations  are  sighing,  and  if  a  finger-nail  is  drawn  along  the  skin,  a  red  line 
develops  (the  tache  cerebrate,  due  to  vasomotor  paresis).  Kernig's  sign  is 
present  (see  page  800).  Squint  and  consequent  double  vision  are  usual.  In 
the  last  stage  coma  becomes  absolute  and  general  convulsions  or  limited 
spasms  are  apt  to  occur.  Optic  neuritis  exists,  and  the  child  passes  to  death 
along  a  road  identical  with  that  of  typhoid  collapse.  In  some  cases  the 
examination  of  cerebrospinal  fluid  withdrawn  by  lumbar  puncture  throws  light 
upon  the  diagnosis.  The  fluid  is  devoid  of  carbohydrate  and  usually  contains 
an  excess  of  lymphocytes.  It  may  contain  the  bacilli.  It  may  be  sterile. 
Sterile  fluid  from  a  patient  with  symptoms  of  meningitis  suggests  that  the 
condition  is  tuberculous.  In  children  the  base  of  the  brain  is  usually  involved, 
and  the  disease  is  apt  to  last  from  two  to  four  weeks;  in  adults  the  convexity  is 
usually  involved,  and  death  is  apt  to  occur  in  a  few  days.  When  the  meningitis 
is  basilar,  occipital  headache,  rigidity  of  the  neck,  and  vomiting  are  severe, 
paralysis  of  various  cranial  nerves  may  occur,  and  there  may  be  hemiparesis 
from  pressure  on  the  crus.  Absence  of  leukocytosis  points  to  a  tuberculous 
cause  for  a  meningitis.  The  existence  of  leukocytosis  does  not  disprove  the 
tuberculous  cause  of  the  disease. 

The  treatment  is  like  that  for  traumatic  meningitis.  The  operation  of 
trephining,  perhaps  with  tapping  a  ventricle,  seldom  offers  any  chance  of  im- 
provement, and  never  does  unless  the  process  is  limited  in  area  and  confined 
to  the  convexity.  Lumbar  puncture  is  performed  for  diagnostic  rather  than 
51 


8o2  Diseases  and  Injuries  of  the  Head 

for  therapeutic  reasons.  Draining  the  cisterna  magna  should  be  tried  (see 
page  832). 

Abscess  of  the  brain  is  a  localized  collection  of  pus.  The  bacteria  which 
may  be  found  are  noted  upon  page  800  (Acute  Leptomeningitis).  The  causes 
are  suppurative  otitis  media  (in  half  of  all  the  cases),  fracture  of  the  skull, 
osteomyelitis  of  the  cranial  bones,  erysipelas  of  the  scalp,  subaponeurotic 
abscess  of  the  scalp,  abscess  of  the  lung,  gangrene  of  the  lung,  empyema, 
concussion  or  wound  of  the  brain,  and  general  infections.  As  Ballance  points 
out,  abscess  of  the  brain  complicating  head  injury  is  not  really  an  abscess 
of  the  brain  unless  the  wounding  material  entered  into  the  brain  substance. 
In  most  cases  the  abscess  is  "a  local  meningeal  suppuration  with  participa- 
tion of  the  adjacent  brain  cortex,  a  meningocortical  abscess  rather  than  a 
brain  abscess  proper"  ("Some  Points  in  the  Surgery  of  the  Brain,"  by  Chas. 
A.  Ballance).  General  infections  may  cause  abscess  (pyemia,  tuberculosis, 
and  specific  fevers).  A  tuberculous  mass  may  caseate  (tuberculous  abscess). 
The  abscess  may  be  between  the  dura  and  the  skull  (extradural),  adhesions 
forming  and  preventing  general  leptomeningitis,  between  the  dura  and  brain 
(subdural),  or  in  the  brain  substance  (cerebral  or  cerebellar).  Leptomenin- 
gitis may  arise  because  no  adhesions  are  created,  because  septic  clots  form  in 
veins  or  sinuses,  or  because  infected  blood  regurgitates  into  the  sinuses  (Park). 
A  traumatic  abscess  is  generally  beneath  the  area  to  w^hich  the  traumatism  was 
applied,  but  it  may  be  on  the  opposite  side.  Source  of  infection  may  be  the 
nose,  the  orbit,  or  the  middle  ear  (see  page  800) .  Roswell  Park  says  infection 
may  pass  along  blood-vessels,  lymph- vessels,  nerve-sheaths,  or  the  prolonga- 
tions of  the  membranes  which  extend  outside  of  the  skull.  An  acute  inflam- 
mation of  the  middle  ear  rarely  causes  abscess,  because  an  acute  inflamma- 
tion in  sound  tissue  causes  the  formation  of  granulation  tissue,  which  acts  as 
a  barrier  to  infection.  Chronic  inflammation  of  the  middle  ear  is  the  most  fre- 
quent cause  of  abscess.  Park  tells  us  that  if  the  roof  of  the  tympammi  is 
involved,  it  may  perforate  and  abscess  of  the  middle  fossa  may  form;  if  the 
tympanum  is  perforated  toward  the  mastoid  antrum,  the  abscess  arises  in  the 
temporosphenoidal  lobe;  if  the  perforation  is  toward  the  sigmoid  groove  the 
abscess  forms  in  the  cerebellum.^ 

Chronic  bone  disease  is  seldom  followed  by  spreading  meningitis,  often  by 
abscess.  When  infection  reaches  the  brain  by  direct  extension  from  a  sup- 
purating bone  it  must  pass  through  the  membranes,  but  it  is  usually  limited 
by  adhesions.  The  cortex  is  very  vascular,  strongly  resists  infection,  and 
is  seldom  extensively  destroyed,  but  the  white  matter  is  far  less  resistant  and 
abscess  tends  to  form  in  it  (Ballance,  Ibid.).  In  some  cases  of  abscess  of  the 
temporosphenoidal  lobe  following  ear  disease  the  cortex  seems  normal,  in  others 
the  membranes  and  cortex  are  fused  over  a  narrow  area  which  constitutes  the 
stalk  of  an  abscess  in  the  white  substance  of  the  lobe.  This  is  the  mush- 
room abscess  of  Ballance.  An  abscess  may  increase  rapidly  in  size  and  finally 
break  into  a  ventricle  or  through  the  cortex.  It  may  become  encapsulated  and 
latent.  A  slow-growing  abscess  may  push  aside  nerve-fibers  as  does  an  en- 
capsulated tumor,  but  a  rapidly  growing  abscess  destroys  them. 

In  the  cerebrum,  multiple  abscesses,  except  in  cases  of  general  infection,  are 
seldom  seen.  In  the  cerebellum  they  are  not  uncommon.  One  or  several  ab- 
scesses may  arise  from  a  primary  one.  If  they  are  adjacent  to  the  primary  one 
they  are  called  satellite  abscesses  and  tend  to  break  into  the  older  purulent  area. 

Ballance,  in  considering  the  onset  of  abscess,  adopts  the  views  as  to  the  five 
types  set  forth  by  Brissaud  and  Souques.  These  types  are  as  follows  (Bal- 
lance, Ibid.): 

(i)  A  subacute  evolution.  In  this  there  is  a  febrile  onset,  like  the  onset  of  a 
1  Park,  in  "Chicago  Med.  Record,"  Feb.,  1895. 


Symptoms  of  Abscess  of  Cerebral  Substance  or  of  Cerebellum    803 

specific  fever,  with  headache,  vomiting,  and  elevated  temperature.  After  a  few 
days  there  comes  a  remission,  the  period  of  delusive  calm.  In  this  period 
symptoms  are  absent  or  trivial.  Though  there  may  be  progressive  emaciation, 
there  is  no  elevation  of  temperature  in  this  period. 

Suddenly  convulsions  occur  which  are  followed  by  coma,  or  coma  arises 
without  antecedent  convulsions.  The  patient  may  die  in  coma  or  the  coma 
may  pass  away,  "the  symptoms  indicating  a  local  brain  lesion"  (Ballance, 
"Some  Points  in  the  Surgery  of  the  Brain").  In  this  stage  elevated  tempera- 
ture may  appear  again. 

(2)  Evolution  with  violent  general  infection,  the  symptoms  of  abscess 
being  merged  and  usually  lost  in  the  symptoms  of  general  infection. 

(3)  Evolution  with  complete  latency.  The  patient  presents  no  symptoms 
until  a  few  hours  before  death,  or  he  may  die  suddenly  without  a  symptom 
having  been  observed.  In  this  connection  Ballance  speaks  of  the  difference 
between  "symptoms  not  noticed  and  symptoms  not  present"  (Ibid.). 

(4)  Only  when  symptoms  were  not  present  does  he  use  the  term  "com- 
plete latency"  to  indicate  the  condition.  Ransoholf  has  reported  the  case  of 
a  boy  in  whom  an  abscess  in  the  frontal  lobe  was  latent  for  three  years,  and  an- 
other case  in  a  man  due  to  gunshot-injury,  which  was  latent  for  four  and  a  half 
years  and  in  which  nearly  ten  years  elapsed  between  the  injury  and  death 
("Annals  of  Surgery,"  July,  1909). 

(5)  Onset  not  to  be  distinguished  from  a  brain  tumor. 

(6)  Onset  with  headache  and  fever,  or  with  mental  excitement.  Then 
the  patient  appears  to  get  completely  well  and  remains  so  for  weeks,  for  months, 
or  for  a  year  or  more.  This  condition  may  occur  in  abscess  secondary  to  in- 
fluenza (Ibid.). 

Symptoms  of  Abscess  of  the  Cerebral  Substance  or  of  the  Cerebellum. — 
The  symptoms  due  to  pus  formation  are  as  follows:  There  is  an  initial  rise 
of  temperature,  but  (except  in  extradural  abscess)  the  temperature  may 
quickly  become  normal  or  even  subnormal.  Years  ago  Sir  Samuel  Wilks 
called  attention  to  the  depression  of  temperature  frequently  noted  in  cerebral 
abscess.  Subnormal  temperature  is  not  nearly  so  common  as  is  supposed. 
It  has  been  present  in  about  one-half  of  the  cases  I  have  seen.  Toward  the 
end  of  the  case  the  temperature  may  rise  and  the  fever  become  linked  with 
delirium.  Surface  elevation  of  temperature  over  the  seat  of  the  abscess  is 
occasionally  observed.  A  chill  may  occur,  but  seldom  does.  Anorexia  and 
vomiting  are  present.  Urinary  chlorids  are  diminished  and  the  phosphates  are 
increased  (Somerville).  Certain  symptoms  are  due  to  pressure:  Headache 
begins  (which  at  first  is  general,  then  local,  and  grows  worse  later  in  the  case, 
and  exists  even  in  delirium;  this  fact  distinguishes  it  from  the  headache  of  fever, 
which  ceases  in  delirium) ;  pulse  is  full,  regular,  and,  in  the  absence  of  compli- 
cations, becomes  very  slow;  respiration  tends  to  alterations  of  rhythm  and  the 
Cheyne-Stokes  type;  drowsiness  lapses  into  stupor  and  stupor  passes  into  coma; 
paralysis  of  the  sphincters  takes  place ;  superficial  reflexes  gradually  disappear  on 
the  side  opposite  to  the  lesion;  convulsions  are  common;  sensation  is  rarely  im- 
paired, and  paralysis  of  the  basal  nerves  may  occur  (third  and  sixth  especially). 
The  pupil  on  the  same  side  as  the  abscess  is  sometimes  dilated  and  fixed. 
Choked  disk  is  not  invariably  found.  It  may  be  more  marked  on  the  same  side 
as  the  abscess.  It  is  more  moderate  in  degree  than  in  meningitis.  LocaHzing 
symptoms,  spasmodic  and  paralytic,  depend  upon  the  center  which  is  irritated 
or  destroyed.  In  abscess  of  the  temporosphenoidal  lobe  hemiplegia  of  the 
opposite  side  is  apt  to  develop.  The  face  is  most  and  first  involved,  next  the 
arm,  next  the  trunk,  and  finally  the  leg  (Sir  Victor  Horsley,  "Lancet,"  Jan.  27, 
191 2).  In  an  abscess  far  posterior  the  motor  palsy  may  be  so  slight  as  to 
almost  escape  recognition,  but  there  is  loss  of  the  sense  of  position  of  a  limb 


8o4  Diseases  and  Injuries  of  the  Head 

and  loss  of  power  to  localize  touch.  In  cerebellar  abscess  there  are  vertigo, 
vomiting,  occipital  headache,  rigidity  of  the  postcervical  muscles,  and  inco- 
ordination. Choked  disk  may  be  present  or  absent.  A  cerebral  or  a  cere- 
bellar abscess  causes  a  decidedly  high  leiikocytosis. 

Meningitis  arises  soon  after  an  accident;  a  traumatic  abscess  cannot  arise 
until  more  than  a  week  has  elapsed  after  an  accident,  and  mp-ny  weeks  may 
elapse.  Meningitis  presents  high  temperature  and  the  general  symptoms  before 
outlined.  Mastoid  disease  may  occasion  cerebral  symptoms  without  abscess,  or 
it  may  cause  abscess.  It  is  curious  that  in  some  cases  of  mastoid  disease  with- 
out brain  abscess  choked  disk  arises.  In  sinus-thrombosis  there  is  septic  tem- 
perature, the  veins  of  the  face  and  neck  are  enlarged,  and  a  clot  can  usually  be 
felt  in  the  jugular.  A  tumor  grows  slowly,  may  present  localizing  symptoms, 
and  double  choked  disk  is  frequently  present.  In  tumor  the  temperature  is  apt 
to  be  normal. 

Treatment. — If  abscess  is  due  to  ear  disease  with  implication  of  the  mastoid 
cells,  at  once  open  and  clear  out  the  mastoid  (see  Fig.  535),  and  after  doing  this 
proceed  to  trephine  the  skull  in  order  to  reach  the  abscess.  In  any  case,  if 
symptoms  of  abscess  exist,  trephine  the  skull  at  once.  If  locaHzing  symptoms 
are  present,  open  over  the  suspected  region.  If  locaUzing  symptoms  are  not 
present,  and  the  cause  is  ear  disease,  trephine  at  Barker's  point  (see  Fig.  535). 
If  no  pus  is  found  between  the  bone  and  dura,  open  the  membrane.  When 
the  dura  is  opened,  if  the  abscess  is  subdural,  pus  wUl  be  evacuated;  if  the 
abscess  is  in  the  brain  substance,  the  brain  will  bulge  very  much  and  will 
not  pulsate.  A  grooved  director  is  plunged  into  the  brain,  in  the  direc- 
tion of  the  abscess,  for  2  or  2^  inches.  It  is  pointed  to  the  external  angular 
process  of  the  opposite  side.  If  pus  is  not  found,  withdraw  the  director 
and  introduce  it  at  another  point,  pointed  to  the  nostril  of  the  opposite  side. 
If  pus  is  not  found,  withdraw  the  director  and  introduce  it  again,  pointing 
to  the  angle  of  the  jaw  of  the  opposite  side.  When  pus  is  discovered,  incise 
the  brain  with  a  knife,  enlarge  the  opening  by  inserting  a  closed  pair  of  forceps 
and  withdrawing  the  instrument  with  the  blades  open.  Scrape  away  the  gran- 
ulation tissue  lining  the  abscess-cavity,  irrigate  with  hot  salt  solution,  and 
introduce  a  rubber  drainage-tube  and  suture  it  to  the  scalp;  stitch  the  dura, 
but  leave  an  ample  opening  for  the  tube;  bring  the  tube  out  through  a  button- 
hole in  the  scalp,  and  after  the  first  two  days  pull  the  tube  out  a  little  every  day 
and  cut  off  a  piece.  If  the  first  trephining  does  not  find  pus,  trephine  at  another 
point.  If  we  are  seeking  for  an  abscess  due  to  middle-ear  disease  and  fail  to 
find  it  in  the  temporosphenoidal  lobe,  seek  for  it  in  the  cerebellum.  In  cere- 
bellar abscess  make  a  flap  with  the  base  up,  and  trephine  or  gouge  away  the 
bone  just  below  the  line  of  the  lateral  sinus.  Puncture  the  brain  for  explora- 
tion as  for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Ear  Disease. — Acute  otitis  media 
sometimes,  and  chronic  otitis  media  much  more  often,  cause  meningitis  {otitic 
meningitis).  This  may  be  a  circumscribed  inflammation  of  the  dura  eventu- 
ating perhaps  in  an  extradural  abscess,  a  serous  leptomeningitis,  or  a  purulent 
leptomeningitis.  There  may  or  may  not  be  involvement  of  the  mastoid. 
There  is  always  fever  and  pain  and  tenderness  over  the  region  of  meningitis. 
The  pain  and  tenderness  are  above  the  zygoma  or  back  of  the  mastoid  (Bench, 
in  "New  York  Med.  Jour.,"  August  27,  1910).  With  these  symptoms  there 
may  or  may  not  be  signs  of  mastoid  involvement.  Dench  points  out  that  the 
occurrence  of  sudden  and  profound  deafness  during  middle-ear  suppuration 
usually  means  beginning  meningitis  (Ibid.).  Chronic  disease  of  the  middle 
ear  is  apt  to  destroy  the  bone  between  the  tympanum  and  the  middle  fossa 
of  the  skull,  and  thus  produce  meningitis,  thrombosis  of  the  petrosal  or  lateral 
sinuses,  abscess  of  the  temporosphenoidal  lobe  or  of  the  cerebellum,  or  extra- 


Infective  Sinus-thrombosis  805 

dural  abscess.  In  chronic  otitis  media  the  reflexes  of  the  opposite  side  of  the 
body  are  frequently  altered  (Russell  Reynolds,  Sir  Victor  Horsley).  In  some 
cases,  even  without  any  other  evidence  of  cerebral  involvement,  there  is  choking 
of  the  disk.  In  many  cases  the  infection  is  direct,  by  bone  involvement  or  by 
the  lateral  sinus.  In  many  other  cases  the  infection  is  through  the  labyrinth.  If 
labyrinthine  infection  arises,  it  produces  symptoms  (disturbances  of  equilibrium 
and  nystagmus).  Chronic  otitis  media  is  apt  to  induce  inflammation  or  sup- 
puration of  the  mastoid  cells  {empyema  of  the  mastoid).  Pus  in  the  mastoid 
may  discharge  itself  into  the  middle  ear,  and  from  this  point  into  the  external 
auditory  canal,  through  a  perforation  in  the  drum-membrane  (especially  in  acute 
cases).  In  some  cases  the  pus  becomes  blocked  up  within  the  mastoid  process. 
Pus  in  the  mastoid  may  after  a  time  break  into  the  cavity  of  the  cranium  or 
into  the  groove  for  lateral  sinus,  or  may  find  its  way  externally  and  open  into 
the  sheaths  of  muscles  arising  from  the  mastoid.  It  not  unusually  opens  into 
the  sheath  of  the  digastric  muscle  (Bezold's  abscess).  These  facts  teach  the 
surgeon  that  inflammation  of  the  middle  ear  should  never  be  neglected,  but 
should,  if  possible,  receive  the  closest  attention  of  the  specialist.  If  no  per- 
foration exists  in  the  drum,  the  surgeon  must  make  one.  In  ordinary  cases 
cleanliness  and  antisepsis  are  sufficient,  the  ear  being  syringed  every  day  with 
a  warm  2  per  cent,  solution  of  common  salt.  If  only  a  small  drum-perforation 
exists,  10  drops  of  pure  alcohol  or  of  corrosive  sublimate  solution  (i :  5000)  are 
dropped  into  the  ear  daily;  but  if  a  large  drum-perforation  exists,  boric  acid 
and  iodoform  (7  to  i)  are  insufflated.  Never  inject  alum.  A  strong  silver  solu- 
tion is  not  safe;  if  it  is  used,  wash  the  ear  out  afterward  with  warm  salt  water. 
If  granulations  or  poh^ai  exist,  they  must  be  removed.  Some  cases  require 
the  removal  of  the  drimi-membrane  and  the  ossicles  of  the  ear.  Some  cases 
of  mastoid  necrosis  are  due  to  tuberculosis.  If  headache,  vomiting,  and  mas- 
toid tenderness  exist,  open  the  mastoid  (see  page  830)  in  order  to  prevent  ab- 
scess of  the  brain.  In  acute  otitis  media  it  is  very  rarely  necessary  to  open  the 
mastoid.  The  middle  ear  is  on  a  lower  level  than  the  antrum  of  the  mastoid, 
and  in  most  acute  cases  both  the  middle  ear  and  mastoid  cells  drain  safely 
through  a  drum-perforation.  Because  a  man  has  chronic  otitis  media  it  is  by 
no  means  always  necessary  to  trephine  the  mastoid.  In  many  cases  removal 
of  the  ossicles  and  driun-membrane  effects  a  cure.  In  chronic  otitis  media,  even 
if  the  mastoid  is  trephined,  the  ossicles  and  membrane  ought  to  be  removed 
in  most  cases. 

Cerebral  abscess  from  ear  disease  (see  page  804)  is  almost  always  in 
the  temporosphenoidal  lobe,  but  may  arise  in  the  cerebellum.  The  symptoms 
are  a  regular,  fuU,  slow  pulse  (except  in  complicated  cases),  a  transient  rise  of 
temperature,  followed  in  many  cases  by  a  normal  or  subnormal  temperature; 
vomiting;  mastoid,  frontal,  and  temporal  pain.  The  mind  is  dull,  and  stupor 
arises  which  passes  into  coma;  the  bowels  are  constipated;  choked  disk  may  be 
present;  and  convulsions  or  spasms  or  paralyses  may  exist.  Trephine  and 
clean  out  the  mastoid,  and  asepticize  (see  Operations  Upon  the  Skull  and 
Brain).  Also  trephine  at  Barker's  point,  i^  inches  behind  and  the  same  dis- 
tance above  the  middle  of  the  external  auditory  meatus,  open  the  dura,  and 
seek  for  pus  in  the  brain.    If  pus  is  not  found,  open  the  cerebellum. 

Extradural  Abscess. — The '  eye-symptoms  and  pain  are  the  same  in 
this  as  in  cerebral  or  subdural  abscess,  but  the  temperature  is  different,  rising 
to  103°  or  104°  F.,  and  never  being  subnormal.  There  is  often  considerable 
tenderness  above  and  behind  the  mastoid.  In  extradural  abscess  follo-v^-ing 
disease  of  the  middle  ear  trephine  and  clear  out  the  mastoid;  follow  up  a 
bone-sinus  to  the  abscess,  rongeur  away  the  bone,  being  careful  to  avoid 
injuring  the  lateral  sinus;  curet,  irrigate,  and  drain. 

Infective  Sinus=thronibosis. — Any  sinus  may  be  attacked.    The  dis- 


8o6  Diseases  and  Injuries  of  the  Head 

ease  may  result  from  scarlet  fever,  small-pox,  diphtheria,  influenza,  typhoid,  or 
any  acute  suppuration.  In  erysipelas  of  the  scalp,  subaponeurotic  abscess 
of  the  scalp,  and  cranial  osteomyeHtis  septic  clots  may  form  in  the  veins 
which  pass  through  the  bone  and  reach  the  longitudinal  sinus.  Infective 
thrombosis  of  the  superior  longitudinal  sinus  is  thus  produced. 

In  carbuncle  of  the  lip  and  orbital  suppuration  the  cavernous  sinus  may 
become  involved. 

In  caries  of  the  basilar  portion  of  the  occipital  bone  the  circular  sinus 
or  the  cavernous  sinus  may  siiffer.  In  caries  of  the  petrous  portion  of  the 
temporal  bone,  and  in  suppuration  of  the  middle  ear  and  mastoid  process, 
infective  thrombosis  of  the  lateral  sinus  may  occur. 

In  any  case  the  symptoms  are  those  of  pyemia.  The  lateral  sinus  is  the 
one  most  fre.quently  attacked.  In  infective  thrombosis  of  the  lateral  sinus 
there  is  usually  a  history  of  an  old  discharge  from  the  ear. 

Infective  thrombosis  of  the  lateral  sinus  may  result  from  a  specific  fever, 
but  is  usually  due  to  chronic  suppuration  of  the  middle  ear  associated  in 
most  cases  with  carious  bone  and  pus  in  the  mastoid  process.  Thrombosis 
of  the  lateral  sinus  occasionally  follows  an  operation  upon  a  suppurating 
mastoid,  or  develops  in  an  individual  who  suffers  from  middle-ear  disease, 
who  has  been  struck  upon  the  head,  who  has  had  the  ear  syringed  with  force, 
or  who  has  had  injected  a  corrosive  or  very  irritant  fluid.  Tuberculous  bone 
disease  is  an  occasional  cause. 

Symptoms. — In  most  cases  there  is  a  history  of  chronic  ear  disease.  In 
children  the  symptoms  are  more  acute  than  in  adults.  In  any  case  the  symp- 
toms may  rapidly  become  violent.  In  some  cases  there  are  preliminary  symp- 
toms of  extradural  abscess,  pus  being  lodged  in  the  groove  of  the  sinus.  It 
has  been  pointed  out  that  pus  in  the  jugular  foramen  may  make  pressure  upon 
the  pneumogastric,  spinal  accessory,  and  glossopharyngeal  nerves,  producing 
aphonia,  hoarseness,  dyspnea,  dysphagia,  and  slow  pulse  (George  F.  Cott^). 
Marked  headache  and  often  an  initial  chill  usher  in  sinus-thrombosis.  The  pain 
is  apt  to  be  localized  about  the  ear  and  mastoid  process,  but  may  become  gen- 
eral. There  is  usually  acute  tenderness  of  the  mastoid.  There  is  high  fever 
from  the  start,  but  when  the  clot  begins  to  soften  and  break  down,  hard  rigors 
develop  and  the  temperature  fluctuates  violently.  The  temperature  varies 
greatly  each  day,  fluctuating  it  may  be  between  subnormal  and  io6°  to  107°  F. 
A  chill  may  occur  once  or  even  twice  a  day,  and  it  lasts  from  ten  to  twenty 
minutes.  The  pulse  is  soft  and  usually  rapid.  The  patient  is  nauseated,  labors 
under  vertigo,  is  very  restless,  is  sometimes  delirious,  may  become  dull  and 
stupid,  and  the  muscles  of  the  neck  are  stiff.  Tenderness  and  marked  edema  are 
detected  over  the  mastoid,  and  the  veins  of  the  neck  and  mastoid  region  may 
be  enlarged.  When  the  clot  extends  into  the  jugular  vein  there  is  pain  on 
moving  the  head  and  on  swallowing,  the  cervical  glands  are  swoUen,  and  a 
cord-like  clot  may  be  felt  in  the  neck.  Choked  disk  exists  in  about  half  of  all 
cases.  There  is  often  a  profuse  discharge  of  pus  from  the  ear,  but  in  some 
cases  a  discharge  is  found  to  have  abated  or  ceased.  Exophthalmos  and 
swelHng  of  the  eyelids  point  to  involvement  of  the  cavernous  sinus  in  the 
process.  In  early  cases  there  is  thrombosis  of  the  lateral  sinus  alone,  or  of 
the  lateral  sinus  and  jugular  vein.  In  advanced  cases  other  sinuses  become 
involved  (superior  petrosal,  inferior  petrosal,  both  cavernous,  the  lateral  sinus 
of  the  opposite  side,  the  ophthalmic  veins,  and  the  torcular  HerophiH).  In 
sinus-thrombosis  there  is  leukocytosis  unless  the  patient  is  profoundly  septic. 
A  patient  with  sinus-thrombosis  is  in  great  danger  of  developing  pulmonary 
metastasis  and  septic  meningitis  (Jansen).  Septic  meningitis  is  accompanied 
by  abscess  about  the  sinus.  Infective  sinus-thrombosis  is  a  very  fatal  disease 
1  "Am.  Med.,"  April  19,  1902. 


Postoperative  Insanity  807 

and  usually  runs  its  course  in  from  seven  to  ten  days,  but  occasionally  lasts 
for  several  weeks.  It  is  a  form  of  pyemia,  and  death  arises  from  the  causes 
which  have  been  referred  to  in  discussing  that  disease. 

Infective  thrombosis  of  the  cavernous  sinus  occurs  when  an  infected  clot 
comes  from  another  sinus,  from  disease  of  the  nasal  sinuses,  from  orbital 
infection,  or  from  a  pyogenic  process  of  the  face  or  lids.  It  causes  pain  and 
the  general  symptoms  of  pyemia,  and  also  edema  of  the  lids,  chemosis,  and  an 
extreme  degree  of  exophthalmos.  Choked  disk  exists.  Vision  may  be  nor- 
mal or  impaired.  The  condition  almost  invariably  spreads  to  the  other  eye 
along  the  circular  sinus. 

Infective  thrombosis  of  the  petrosal  sinus  produces  pyemic  symptoms,  but 
no  characteristic  signs. 

The  prognosis  largely  depends  upon  early  recognition.  The  surgeon 
should,  whenever  it  is  possible,  open  a  mastoid  before  sinus-thrombosis  arises, 
and  should  evacuate  an  abscess  about  the  sinus  before  a  clot  forms  in  the 
venous  channel,  or  at  least  before  that  clot  becomes  septic  (Jansen). 

Treatment. — In  1880  Zaufal  proposed  the  operation  now  practised,  and 
Horsely  did  it  in  1886.  (See  article  by  Geo.  F.  Cott,  in  "American  Medi- 
cine," April  19,  1902.)  Infective  thrombosis  of  the  lateral  sinus  is  treated  as 
follows:  Open  and  clear  out  the  mastoid,  and  expose  the  sinus  by  the  use  of  the 
chisel  or  rongeur  (see  Fig.  535).  Follow  Mr.  Ballance's  advice  and  expose  the 
sinus  from  the  bulb  to  the  torcular.  The  jugular  vein  should  now  be  exposed 
at  the  level  of  the  cricoid  cartilage  and  ligate^  below  any  clot  which  may  exist. 
This  is  done  to  prevent  propagation  of  an  infected  clot  and  diffusion  of  sepsis. 
Even  if  a  clot  does  not  exist  in  the  jugular,  the  vein  should  be  tied  in  two  places 
and  divided,  because  the  sinus  contains  infected  clot  or  putrid  material 
even  when  the  vein  as  yet  does  not.  According  to  Ballance,  the  portion  of  the 
vein  above  the  point  at  which  it  was  divided  should  be  extirpated.  Some  sur- 
geons after  ligating  the  jugular  do  not  excise  it,  but  if  it  contains  or  comes  to 
contain  a  septic  clot,  incise  the  vein  up  to  the  base  of  the  skull  and  pack  the 
wound.  After  attacking  the  vein  open  the  sinus,  and  if  a  clot  is  found  to  exist, 
cut  away  the  wall  of  the  sinus.  Introduce  a  small  spoon  into  the  lumen  and 
carry  it  toward  the  torcular  Herophili,  and  scrape  away  the  clot  until  blood 
flows.  Arrest  hemorrhage  by  forcing  a  piece  of  iodoform  gau^e  into  the  wound 
and  toward  the  torcular.  Jansen  opposes  removing  the  entire  clot  toward  the 
jugular,  and  does  not  tie  the  jugular,  believing  that  to  do  so  increases  the 
danger  of  thrombosis  of  the  inferior  petrosal  and  cavernous  sinuses.  He 
simply  removes  the  soft  clot,  but  does  not  disturb  the  solid  clot  toward  the 
heart.  Most  surgeons  differ  from  him.  Surgeons  are  of  the  opinion  that  it  is 
futile  to  do  any  operation  if  pulmonary  metastasis  has  taken  place.  In  a  case 
of  the  author's  in  the  Jefferson  Medical  College  Hospital  the  patient  recovered 
after  operation  in  spite  of  the  fact  that  endocarditis  had  developed. 

Until  recently  it  was  thought  that  the  lateral  sinus  was  the  only  sinus 
which  should  be  attacked  surgically,  but  in  one  case  Knapp,  of  New  York, 
requested  Hartley  to  remove  from  the  cavernous  sinus  a  clot  which  was  causing 
blindness  and  was  due  to  sarcoma.  The  operation  was  successfully  executed 
by  Hartley,  the  incision  being  the  same  as  is  employed  to  reach  a  Gasserian 
ganglion  in  the  Hartley  operation.  This  patient  lived  several  months.  Dwight 
operated  upon  another  case  by  incision  of  the  sinus  (E.  W.  Dwight  and  H.  H. 
Germain,  "Boston  Med.  and  Surg.  Jour.,"  May  i,  1902).  Some  surgeons  advise 
removal  of  the  eyeball  and  curettement  of  the  sinus. 

Postoperative  Insanity. — ^Various  mental  disturbances  may  follow  sur- 
gical operation  (delirium,  obsessions,  hysterical  excitement,  morbid  fears,  illu- 
sions, hallucinations,  amnesia,  confusion,  hypochondria,  psychasthenia,  melan- 
choly, and  genuine  insanity).    Insanity  is  no  more  frequent  after  abdominal 


8o8  Diseases  and  Injuries  of  the  Head 

operations  than  after  other  operations  if  we  exclude  operations  involving  the 
ovaries.     Removal  of  the  testicles  and  ovaries  are  peculiarly  provocative. 

Postoperative  insanity  is  most  common  in  females  and  in  adults.  The  pre- 
disposing elements  connected  with  a  surgical  operation  are:  Apprehension, 
fear,  pain,  insomnia,  and  exhaustion  before  operation.  The  effects  of  the 
anesthetic,  shock,  and  hemorrhage.  Postoperative  pain,  insomnia,  worry,  and 
perhaps  homesickness.  There  is  always  predisposition,  hereditary  or  acquired. 
The  patient  may  have  been  on  the  brink  of  an  outbreak  when  the  operation 
was  performed.  The  insanity  may  be  apparent  as  the  patient  awakes  from  the 
anesthetic  sleep  (Savage),  and  in  these  very  rare  cases  the  anesthetic  is 
blamed.  Most  acute  insanities  come  on  in  from  three  to  five  days  after  opera- 
tion. 

If  a  man  has  ever  had  an  attack  of  insanity  operation  exposes  him  to  dis- 
tinct danger  of  another  attack.  No  special  mental  condition  characterizes 
postoperative  insanity.  There  may  be  mania,  melancholia,  stupor,  delusional 
insanity,  or  acute  confusion.  Acute  confusional  insanity  is  the  most  usual  form. 
In  some  cases  sepsis  is  present,  in  others  it  is  not.  We  must  not  mistake  in- 
sanity for  febrile  delirium,  delirium  tremens,  delirium  from  opium  deprivation, 
delirium  from  taking  morphin  or  cocain,  delirium  of  iodoform-poisoning, 
delirium  of  the  senile,  traumatic  delirium,  hysterical  delirium,  uremic  coma,  or 
bromism. 

Many  cases  of  postoperative  insanity  must  be  sent  to  a  hospital  for  the 
insane.  Only  cases  of  brief  duration  can  be  properly  cared  for  in  a  general 
hospital. 

Intracranial  Tumors.— An  encephaHc  tumor  may  originate  within 
the  skull.  It  may  have  arisen  from  an  external  growth  invading  the  cranial 
cavity,  or  may  be  metastatic.  A  tumor  that  arises  within  the  cranium  may 
take  origin  from  the  periosteum,  from  one  of  the  membranes  of  the  brain, 
from  the  vessels,  from  the  neuroglia,  or  from  the  brain  substance. 

No  region  of  the  body  is  so  liable  to  tumors  as  the  brain.  During  the 
course  of  a  number  of  years  the  autopsies  of  the  Mimich  Pathological  Insti- 
tute are  stated  by  Bollinger  to  have  shown  i  tumor  of  the  brain  in  every 
85  autopsies.  Hale  White's  experience  is  that  such  tumors  are  even  more 
common  than  this,  and  he  estimates  them  at  i  in  every  59  autopsies. 

In  endeavoring  to  determine  the  causes  of  intracranial  tumors  we  must 
accredit  heredity  with  considerable  influence  in  tuberculoma,  and  possibly 
with  some  force  in  sarcoma  and  carcinoma.  Tumors  of  the  brain  are  decidedly 
more  common  in  males  than  in  females,  probably  because  of  the  greater 
male  liability  to  injury,  syphilis,  and  alcoholism. 

The  majority  of  cases  of  tumor  of  the  brain  occur  between  the  ages  of 
twenty-five  and  fifty.  Children  are  particularly  prone  to  suffer  from  gHoma 
and  from  tuberculous  growths.  In  aged  persons  a  timior  of  the  brain  very 
rarely  develops.  In  100  cases  of  brain-tumor  collected  by  Hale  White  only 
2  were  aged  seventy  or  over.  In  100  cases  collected  by  Mills  and  Lloyd  only 
I  was  over  seventy. 

Injury  may  be  responsible  for  the  development  of  sarcoma,  of  fibroma, 
and  possibly  of  other  forms;  in  fact,  a  syphiloma  may  arise  in  a  syphilitic 
person  at  the  seat  of  an  injury. 

We  use  the  terms  "intracranial "  or  "  encephalic  tumor"  not  only  to  include 
true  neoplasms,  but  also  to  designate  growths  of  parasitic,  syphilitic,  or  tuber- 
culous origin.  It  is  of  importance  to  attempt  to  make  a  diagnosis  as  to  the 
form  of  tumor  that  is  present,  and  this  may  be  possible  on  account  of  the 
fact  that  in  many  cases  the  form  affects  the  symptoms.  A  useful  classifica- 
tion of  these  growths  has  been  made  by  Knapp,  and  is  as  follows:  (i)  The 
infective  granulomata,  including  tuberculous  growths,  gummata,  and  actino- 


Intracranial  Tumors  809* 

mycotic  areas;  (2)  connective- tissue  growths;'  (3)  epithelial  growths;  (4) 
aneurysms.  The  most  common  of  all  these  tumors  is  undoubtedly  that 
due  to  tubercle.  In  fact,  Gowers  estimates  that,  if  we  exclude  syphiloma, 
tubercle  is  responsible  for  one-half  of  the  cases,  and  glioma  and  sarcoma 
together  for  one- third. 

Ttiberculous  Tumors  {Tuberculous  Gummata;  Tuherculomata) . — Tuber- 
culous growths  may  be  primary,  but  are  usually  secondary  to  tuberculosis 
in  some  other  region  of  the  body.  Tuberculous  tumors  are  the  most  common 
form  met  with.  They  are  at  least  four  times  as  common  in  children  as  in  adults. 
They  may  be  single,  especially  in  adults,  but  are  often  multiple,  especially  in 
children;  and  multiple  growths  may  be  very  widespread.  According  to  Allan 
Starr,  these  growths  are  most  common  in  the  cerebral  axis  (especially  in  the 
basal  ganglia),  next  in  the  cerebellum,  next  in  the  cerebral  cortex,  and  are  least 
common  in  the  centrum  ovale.  A  tuberculous  tumor  usually  arises  in  the  pia 
mater,  particularly  in  an  arterial  distribution,  but  may  begin  in  a  ventricle,  or 
even  in  the  brain  substance.  Some  of  these  growths  are  distinctly  subcortical. 
The  tubercle  bacilli  responsible  for  the  condition  are  carried  by  the  blood. 
Some  of  these  growths  are  small  aggregations  of  miliary  tubercles  in  thickened 
pia.  Others  are  large  masses.  A  large  tuberculous  tumor  is  due  to  the  coa- 
lescence of  many  foci.  It  undergoes  caseation  in  the  center,  and  is  surrounded 
by  a  zone  of  softened  or  sclerotic  brain  substance.  Tuberculous  meningitis  is 
present  in  two-thirds  or  three-fourths  of  the  cases  of  tuberculoma. 

Gummatous  Tumors  (Syphilomata) . — As  gumma  seldom  arises  from  inher- 
ited syphilis,  the  condition  is  very  rare  in  children.  There  may  be  a  single 
gumma,  but,  far  more  often,  syphilitic  growths  are  multiple.  A  gumma  may 
be  round  or  ma}^  be  irregular  in  outline;  in  fact,  the  outline  is  frequently  blurred 
and  indistinct.  Some  of  these  growths  are  soft,  and  some,  which  contain  a 
quantity  of  connective  tissue,  are  hard.  A  syphiloma  usually  arises  from  the 
membranes,  and,  hence,  is  generally  on  the  surface  of  the  brain;  and  the 
membranes  in  the  region  of  the  growth  usually  show  distinct  inflammation. 
Soft  gummata  are  most  common  at  the  base;  hard  gummata,  in  the  cortex 
of  the  cerebrum  or  cerebellum. 

Actinomycosis. — This  is  a  very  rare  condition,  in  which  the  mass  may 
remain  solid  like  a  tumor,  but  is  far  more  apt  to  break  down  into  an  actino- 
mycotic abscess. 

Sarcomata. — Injury  seems  to  play  a  considerable  part  in  the  production 
of  intracranial  sarcoma.  Any  variety  of  sarcoma  may  arise.  It  may  be 
primary  or  secondary.  As  a  rule,  at  least  in  the  beginning,  the  growth  is 
single ;  but  it  may  be  multiple  or  may  become  so.  The  majority  of  sarcomata 
arise  from  the  membranes  or  from  the  periosteum,  but  some  cases  take  origin 
from  beneath  the  cortex.  Early  in  their  progress  these  growths  may  be  encap- 
sulated, but  some  of  them,  from  the  very  start,  are  infiltrating;  and  even  those 
that  were  at  first  encapsulated  later  infiltrate.  The  cortex  and  the  cerebellum 
are  the  most  common  seats  for  sarcoma.  Endothelioma  is  sometimes  met  with. 
What  is  called  angioma  of  the  brain  is,  in  reality,  angiosarcoma.  A  psammoma  is 
usually  sarcomatous. 

Gliomata. — A  glioma  is  a  growth  which  is  often  so  ill  defined  and  so  slightly 
differentiated  in  appearance  from  the  brain  substance  that  it  may  easily  be 
overlooked  in  an  exploratory  operation.  It  arises  much  more  frequently  from 
the  white  than  from  the  gray  matter,  and  develops  from  the  neuroglia  of 
the  cerebrum,  of  the  cerebellum,  of  the  pons,  or  of  the  medulla  oblongata. 
A  glioma  may  be  soft  or  may  be  hard;  and  soft  gliomata  are  probably,  in  reality^ 
sarcomata  (gliosarcomata).  Hemorrhage  is  very  apt  to  occur  in  these  growths. 
They  have  a  tendency  to  become  cystic.  They  destroy  tissue  as  they  grow^ 
hence  pressure  signs  are  late  or  absent. 


8io  Diseases  and  Injuries  of  the  Head 

Fibromata. — Intracranial  fibroma  is  a  rare  growth.  Tumors  of  the  cere- 
bellopontile  angle  are  apt  to  be  of  this  character.  It  is  of  firm  consistence, 
is  encapsulated,  and  may  grow  to  a  large  size.  Such  growths  can  be 
readily  enucleated.  Injury  seems  occasionally  to  be  responsible  for  their 
formation. 

Osteomata. — Osteophytic  growths  not  uncommonly  take  origin  from  the 
inner  surface  of  the  skull,  but  the  osteomata  arising  in  the  dura  or  in  the 
brain  substance  are  rare.     Such  growths,  however,  occasionally  occur. 

Cholesteatomata. — These  tumors  are  fibrous  growths  covered  with  endo- 
thelium and  containing  layers  of  cholesterin.  They  are  particularly  apt  to 
arise  in  the  pia  mater,  but  may  begin  in  either  of  the  other  membranes  or 
in  the  brain  substance.     A  cholesteatoma  is  commonly  called  a  pearl  tumor. 

Enchondromata  and  true  neuromata  are  rare,  and  lipojnata  are  exceedingly 
imcommon. 

Adenomata. — ^An  adenoma  occasionally  springs  from  the  conarium  or 
the  pituitary  body. 

Carcinomata. — Primary  intracerebral  carcinoma  is  rare,  but  does  occur. 
Secondary  carcinoma  is  more  common,  and  may  follow  cancer  of  any  part 
of  the  body,  although  it  is  most  apt  to  follow  cancerous  growths  about  the 
face  or  neck.  A  primary  growth  may  begin  in  the  meninges  or  in  the  lining 
of  the  ventricle.  Intracerebral  carcinomata  may  be  single  or  multiple.  They 
are  soft  and  non-encapsulated  growths,  infiltrating  and  very  vascular. 

Cy5/5.— Mills  says  that  cysts  arise  about  an  old  hemorrhage,  are  small 
retention-cysts  of  a  vascular  plexus,  or  are  porencephalic.  Dermoid  cysts 
are  extremely  rare.  Hydatid  cysts  are  very  rare  in  the  United  States.  A  cyst 
may  result  from  the  degeneration  of  a  glioma  or  a  sarcoma. 

Symptoms. — They  are  divided  into  two  sets:  (i)  General,  due  to  increase 
of  pressure,  and  (2)  local,  localizing,  or  special,  arising  because  of  the  part  of 
the  brain  involved. 

In  some  cases  general  symptoms  are  absent,  in  some  special  symptoms 
are  absent,  in  others  even  tumors  of  large  size  produce  no  recognizable  symp- 
toms, either  general  or  special.  A  large  infiltrating  growth,  a  ghoma,  for 
instance,  may  produce  no  s3nnptoms  at  all  if  situated  in  a  silent  region,  and 
if  it  destroys  brain  substance  as  it  grows,  so  that  intracerebral  pressure  is  not 
increased. 

General  Symptoms. — The  chief  general  symptoms  are  headache,  vomiting, 
and  choked  disc.  All  of  these  may  be  present,  any  one  of  them  may  be  absent, 
any  two  of  them  may  be  absent,  and  in  some  cases  all  of  them  are  absent. 
Other  general  symptoms  that  may  or  may  not  be  present  are  vertigo,  general 
convulsions,  insomnia,  mental  failure,  and  somnolence  or  partial  stupor. 

Headache. — ^This  is  the  symptom  most  commonly  present.  It  occurs 
sooner  or  later  in  a  very  great  majority  of  cases. 

At  first  it  may  be  noted  only  at  certain  times  of  the  day  and  it  is  usually 
complained  of  most  on  rising  in  the  morning.  The  headache  of  brain  tumor 
when  once  established  is  intense  in  most  cases,  and  as  a  general  thing  it  is 
practically  continuous,  with  episodes  of  increased  violence.  In  rare  cases  it  is 
paroxysmal.  In  some  cases  it  is  trivial,  in  some  few  cases  it  never  arises  at 
all.  The  headache  of  brain  tumor  usually  interferes  wdth  sleep.  It  may  be 
general,  one  sided,  frontal,  or  occipital.  The  situation  of  the  pain  is  without 
localizing  value  unless  there  is  tenderness  on  percussion  or  pressure  over  the 
seat  of  pain,  which  is  sometimes  noted  in  growths  of  the  meninges  or  cortex. 

Headache  is  less  common  in  children.  In  very  young  children  the  ex- 
planation of  this  is  found  in  the  open  fontanels  and  the  expansile  cranium. 
In  older  children  in  the  fact  that  gliomata  are  common  in  children  and  gliomata 
may  not  cause  intracerebral  pressure. 


Symptoms  of  Intracranial  Tumors  8ii 

The  dura  is  sensitive,  as  Gushing  says,  to  "pull  or  pressure,  not  to  an  inci- 
sion."    The  headache  of  brain  tumor  is  due  to  stretching  of  the  dura. 

Vomiting  is  present  at  times  in  many  of  the  cases.  It  may  happen  occa- 
sionally or  it  may  never  occur. 

It  is  usually  cerebral,  that  is,  vomiting  with  a  clean  tongue  without  nausea, 
and  without  any  relation  to  the  taking  of  food.  In  some  cases  it  is  projectile, 
quantities  of  vomitus  being  suddenly  projected  from  the  mouth.  It  may, 
however,  be  associated  with  nausea,  and  in  some  cases  there  is  nausea  without 
vomiting.  It  is  apt  to  be  most  severe  on  getting  up,  especially  on  rising  in 
the  morning".     It  is  usually  most  severe  when  headache  is  most  intense. 

The  worst  attacks  of  vomiting  occur  in  cases  of  cerebellar  tumor. 

The  cause  of  vomiting  is  uncertain.  Some  beHeve  it  to  be  due  to  stimula- 
tion of  the  vagus  center;  others,  to  reflex  stimulation  of  a  vomiting  center  in  the 
medulla.     If  associated  with  vertigo  it  may  arise  from  the  auditory  centers. 

Choked  Disk  (Optic  Neuritis,  Papillitis,  Descending  Neuritis,  Papillo- 
edema) . — This  is  a  most  important  symptom.  When  present  it  is,  as  Gushing 
says,  one  of  the  "most  reliable"  signs  of  tumor.  It  is  present  in  80  per  cent, 
of  all  cases.  It  may  be  noted  in  a  few  weeks  after  a  tumor  begins  to  grow, 
in  a  few  months,  or  longer.     It  may  come  on  rapidly  or  gradually. 

It  is  particularly  common  and  severe  in  growths  beneath  the  tentorium.  It 
is  decidedly  less  common  in  tumors  of  the  motor  cortex.  It  is  nearly  always 
bilateral,  but  it  is  common  to  find  it  more  marked  in  one  eye  than  in  the  other. 
That  it  is  worse  on  one  side  suggests,  but  only  suggests,  that  the  tumor  may  be 
on  the  side  on  which  the  choked  disk  is  worst.  Monocular  choked  disk  is 
very  rare.  When  it  exists  it  indicates  that  the  growth,  in  all  likelihood,  is 
.situated  near  the  back  of  the  orbit  on  the  same  side  as  the  choking  of  the  disk. 
Gowers  recorded  a  case  of  unilateral  choked  disk  due  to  a  tumor  compressing 
the  left  optic  nerve  ("Lancet,"  July  10,  1909). 

Ghoked  disk  may  exist  for  some  time  and  attain  a  high  grade  without 
noticeably  impairing  vision,  but  ultimately  it  leads  to  retinal  hemorrhage, 
white  atrophy,  and  blindness.  When  atrophy  begins,  vision  wanes.  The 
presence  of  choked  disk  does  not  prove  the  existence  of  tumor.  The  cerebral 
edema  of  Bright's  disease  may  cause  a  condition  known  as  albuminuric  retinitis, 
"which  practically  is  not  to  be  distinguished  from  the  choked  disk  caused  by 
tumor.  Gushing  believes  that  the  processes  are  identical  in  tumor  and  Bright's 
disease.  Ghoked  disk  may  occur  in  meningitis,  brain  abscess,  cerebral  syphilis, 
sinus-thrombosis,  myelitis,  infectious  diseases  (typhoid,  influenza,  diphtheria, 
and  other  conditions),  toxemias  from  lead,  arsenic,  and  alcohol,  anemia,  dia- 
betes, or  as  an  hereditary  or  family  disease. 

The  cause  of  choked  disk  has  been  much  disputed.  Some  beheve  that  the 
■condition  is  a  neuritis  due  to  a  toxic  condition  of  the  cerebrospinal  fluid. 
Others  believe  that  it  is  not  inflammatory,  but  is  a  papillo-edema  due  purely  to 
mechanical  pressure,  and  is  an  edema  or  dropsy.  The  latter  theory  is  largely 
held  by  surgeons  because  they  have  become  convinced  by  experience  that  rehef 
of  intracranial  pressure  relieves  or  cures  choked  disk.  De  Schweinitz  and 
HoUoway  ("Therapeutic  Gazette,"  July  15,  1909)  make  the  following  state- 
ment in  regard  to  mechanical  pressure  causing  choked  disk:  "That  this  is 
the  only  etiologic  factor  may  with  propriety  be  disputed;  indeed,  it  seems  cer- 
tain that  a  combination  of  factors  must  be  active  in  the  production  of  this 
condition,  but  increased  intracranial  pressure  is  the  one  of  which  we  have 
most  certain  knowledge." 

Gushing,  of  Harvard,  who  has  done  such  notable  work  on  this  subject,  be- 
lieves that  "almost  all,  if  not  all,  cases  of  choked  disk  are  primarily  of  mechan- 
ical origin  and  do  not  justify  the  term  '  neuritis'  "  ("Keen's  Surgery,"  vol.  iii). 
The  presence  of  choked  disk  is  disclosed  by  the  ophthalmoscope. 


8i2  Diseases  and  Injuries  of  the  Head 

Convulsions. — Generalized  convulsions  may  occur,  and  children  are  especi- 
ally liable  to  them.  Many  cases  of  supposed  general  convulsions  have  an  un- 
observed local  beginning  which  is  a  focal  symptom. 

Vertigo. — Mills  .says  it  is  noted  in  one-third  of  all  cases  and  is  due  to  dural, 
ocular,  or  labyrinthine  irritation. 

Insomnia  is  often  due  to  headache  and  is  apt  to  be  associated  with  rest- 
lessness, lack  of  emotional  control,  and  irritability.  It  is  most  pronounced  in 
cases  of  syphiloma  and  some  forms  of  malignant  disease,  and  is  worse  in  adults 
than  in  children. 

In  rare  cases  there  is  somnolence  or  partial  stupor  rather  than  insomnia. 
In  such  cases  slow  speech  is  often  noted. 

Mental  Failure. — There  is  often  great  lack  of  emotional  control,  charac- 
terized by  irritabihty  and  outbreaks  of  anger.  Failure  of  memory  is  common 
and  change  of  character  is  the  rule.  There  may  be  great  slowness  of  thought 
and  of  mental  response  to  stimuli,  with  defective  power  of  orientation.  Pro- 
gressive mental  deterioration  may  occur.  There  may  be  mental  depression, 
apathy,  or  mental  excitement.  Tumors  in  certain  regions  may  cause  delusions, 
illusions,  or  hallucinations. 

Hysteria  and  neurasthenia  sometimes  arise. 

Pulse  and  Respiration. — Whereas  the  pulse  is  often  slow,  it  is  very  variable, 
and  I  agree  with  Gushing  that  "pressure-symptoms  which  characterize  acute 
lesions  (namely,  rise  in  blood-pressure;  slow,  vagus  pulse,  and  Gheyne-Stokes 
respiration)  are  conspicuous  by  their  absence"  ("Keen's  Surgery,"  vol.  iii). 

Special  Focal  or  Localizing  Symptoms. — These  symptoms,  when  present, 
indicate  the  situation  of  the  growth.  If  the  tumor  is  in  a  silent  region  there  will 
be  no  focal  symptoms.  General  symptoms  may  exist  without  focal  symptoms 
and  focal  symptoms  may  exist  without  general  symptoms. 

Among  localizing  symptoms  we  should  mention  various  forms  of  aphasia, 
hemianopsia,  paralysis,  Jacksonian  epilepsy,  sensory  disturbances  (to  touch, 
pain,  or  temperature),  sensory  aura,  disturbances  of  taste  and  smell,  impair- 
ment of  muscular  sense,  alteration  or  impairment  of  reflexes,  nystagmus,  and 
incoordination. 

Exophthalmos  means  direct  pressure  upon  the  cavernous  sinus.  A  uni- 
lateral exophthalmos  is  nearly  always  upon  the  side  of  the  tumor.  In  bilateral 
exophthalmos  the  protrusion  is  usually  worst  on  the  side  of  the  lesion  (Weisen- 
berg,  in  "Jour.  Amer.  Med.  Assoc,"  vol.  Iv). 

Diagnosis. — In  many  cases  a  diagnosis  is  made  at  a  period  so  late  that 
irreparable  damage  has  already  been  inflicted.  Early  diagnosis  is  of  the  first 
importance.  A  careful  and  painstaking  study  of  the  patient  and  of  his  history 
will  usually  enable  us  to  make  a  diagnosis  before,  and  often  long  before,  the 
attainment  of  a  degree  of  pressure  which  causes  papillo-edema,  headache, 
and  vomiting.  In  doubtful  cases  an  exploratory  operation  should  be  performed. 
Exploration  is  always  called  for  in  advancing  cerebral  palsy  and  in  focal  epi- 
lepsy. 

In  abscess  the  symptoms  usually  develop  much  more  acutely  than  in  tumor. 
It  is  true  that  some  cases  of  abscess  last  for  months,  but  in  them  intervals  of  com- 
plete remission  of  symptoms  occur,  which  is  not  the  case  in  tumor.  An  abscess 
follows  middle-ear  disease  or  some  other  pyogenic  process  or  perhaps  a  head 
injury.  There  may  be  fever  and  leukocytosis.  Ghoked  disk  is  far  less  common 
than  in  tumor. 

Chronic  meningitis  from  syphilis  exhibits  periods  of  increase  and  periods 
of  subsidence  of  the  symptoms,  and  usually  palsy  of  one  or  more  cranial  nerves. 
The  symptoms  may  pass  away  under  the  use  of  mercury  and  iodid  of  potassium. 
There  may  be  clinical  evidences  of  syphilis.  There  should  be  a  positive  Was- 
sermann  reaction. 


Diagnosis  of  Intracranial  Tumors 


813 


Chronic  tuberculous  meningitis  causes  a  headache  which  is  apt  to  be  general 
and  more  violent  than  that  of  tumor,  and  there  is  more  commonly  cutaneous 
hyperesthesia  and  hyperesthesia  of  the  organs  of  sight  and  hearing.  Optic 
neuritis  may  be  absent.  When  present  it  is  of  less  intensity  than  that  observed 
in  tumor.  In  some  cases  the  ophthalmoscope  discloses  tubercles  on  the  choroid. 
In  meningitis  there  is  a  continued,  irregular  fever.  The  cerebrospinal  fluid 
obtained  by  lumbar  puncture  usually  exhibits  an  excess  of  lymphocytes.  It 
may  contain  the  bacilli.  Carbohydrate  is  absent.  It  may  be  sterile.  Of 
course,  a  tumor  might  exist  with  meningitis. 

In  Bright' s  disease  symptoms  strongly  suggestive  of  tumor  may  arise 
(headache,  vomiting,  and  choked  disk)  with,  perhaps,  but  little  change  in  the 
urine.    The  difficulty  in  diagnosis  becomes  evident  when  we  recall  that  in  cases 


Fig.  524. — Professor  Gibbon's  case  of  brain  tumor. 

of  brain  tumor  the  urine  may  contain  casts  and  albumin.  A  sudden  onset  and 
brief  duration  of  the  symptoms  suggest  uremia. 

Ependymitis  with  ventricular  dropsy  may  cause  s^Tiiptoms  resembling 
timior  with  hydrocephalus.  Optic  neuritis  is  not  so  common  as  in  tumor. 
Bilateral  spastic  paralysis  may  arise. 

Severe  anemia  is  capable  of  producing  symptoms  which  suggest  tumor. 
It  can  even  produce  choked  disk.  A  blood  examination  and  the  rapid  im- 
provement under  proper  treatment  makes  the  diagnosis  e\ddent. 

In  some  cases  of  brain  tumor  (especially  frontal  lobe  tumors)  there  are 
striking  evidences  of  hysteria  and  neurasthenia.  Always  think  of  this  when 
inclined  to  make  a  diagnosis  of  hysteria  or  neurasthenia. 

The  .T-rays  may  aid  us  in  diagnosis  and  many  brain  tumors  can  be  skia- 
graphed  (Fig.  524).    Lumbar  puncture  ma}^  aid  in  the  diagnosis,  but  it  must  be 


8i4  Diseases  and  Injuries  of  the  Head 

used  with  the  greatest  care,  because  in  tumor  the  withdrawal  of  any  con- 
siderable quantity  of  fluid  may  be  followed  by  sudden  death  due  to  the  brain 
stem  sinking  into  the  foramen  magnum.     . 

Cause,  Duration,  and  Termination. — A  brain  tumor,  unless  caused  by 
syphilis,  is  a  certainly  fatal  lesion  if  not  removed  by  operation. 

Some  brain  tumors  grow  for  years  before  they  produce  symptoms.  Some 
grow  with  great  rapidity.  When  pressure  symptoms  appear  the  patient's  life 
will  terminate  within  a  few  months  unless  an  operation  is  performed.  It  is 
usually  stated  that  the  average  duration  of  life  is  three  years. 

Sudden  death  may  occur  at  any  time. 

Horsley  states  that  in  a  very  few  cases  brain  tumors  have  disappeared 
after  mere  operative  exposure,  the  tumor  not  having  been  removed.  Gushing 
has  had  the  same  experience,  and  regards  such  an  amazing  disappearance  as 
due  to  the  cystic  degeneration  of  a  glioma. 

Localization  of  a  Tumor. — The  situation  of  a  tumor  is  determined  not  only 
by  localizing  symptoms,  but  also  from  their  rnode  of  onset  and  manner  of 
combination.  In  some  cases  the  symptoms  are  not  characteristic,  in  others 
they  are  definite.  The  more  marked  the  signs  of  compression,  the  less  the  value 
of  localizing  symptoms.  The  nature  of  the  tumor,  its  depth,  and  whether  it 
is  single,  and  if  other  tumors  exist  is,  if  possible,  determined.  Localizing  symp- 
toms may  be  due  to  irritation  or  destruction  of  functionating  power.  Irrita- 
tion causes  spasm,  and  destruction  induces  paralysis.  Convulsions  which  are 
local  or  which  begin  locally  are  known  as  Jacksonian  epilepsy.  A  local  convul- 
sion points  to  an  irritative  lesion  of,  or  immediately  adjacent  to,  the  center 
which  presides  over  the  muscular  movements  of  the  part  convulsed.  Local 
paralysis  points  to  a  destructive  lesion  of  the  center  which  presides  over  the 
movements  of  the  paralyzed  part.  In  some  cases  a  center  is  damaged  and  the 
muscular  movements  it  controls  are  paralyzed,  but  the  adjacent  brain-areas 
are  irritated  and  the  muscles  they  represent  are  attacked  with  spasms.  In 
some  cases  an  apparently  paralyzed  part  becomes  convulsed,  the  center  not 
being  completely  destroyed  and  sudden  hyperemia  serving  to  awaken  spasm. 
Always  note  the  order  of  invasion  of  different  regions  and  observe  if  spasm  is 
followed  by  muscular  weakness  or  anesthesia. 

Lesions  in  the  Cortical  Motor  Area. — ^A  slow-growing  tumor  which  irri- 
tates the  cortex  will  cause  tonic  or  clonic  convulsions  on  the  opposite  side  of 
the  body.  These  convulsions  have  a  local  beginning  (Jacksonian  epilepsy). 
After  a  time  paralysis  may  develop  (monoplegias  and  perhaps,  ultimately, 
hemiplegia) .  An  irritative  lesion  of  the  lower  third  of  this  area  causes  spasm  of 
the  opposite  side  of  the  face,  angle  of  mouth,  or  tongue;  and  this  condition  is 
often  associated  with  tingHng.  The  spasm  may  remain  limited  or  may  extend 
widely,  and  may  even  become  general.  An  irritative  lesion  of  the  middle  third 
of  the  cortical  area  causes  spasm,  which  is  limited  to  or  begins  in  the  fingers, 
thumb,  wrist,  or  shoulder.  An  irritative  lesion  of  the  upper  third  of  the  cortical 
motor  area  causes  spasm,  which  is  limited  to  or  begins  in  the  toes,  ankle,  leg, 
or  thigh.  If  such  lesions  exist,  an  aura  is  occasionally  felt  in  the  affected  region 
before  the  spasm  begins,  and  there  is  often  numbness  after  the  spasm.  De- 
structive lesions  of  the  motor  area  cause  local  paralysis,  which  may  be  preceded 
by  local  spasm  of  the  same  parts,  and  is  often  associated  with  local  spasm  of 
other  parts.  If  paralysis  comes  on  unpreceded  by  convulsions  the  lesion  is 
subcortical  rather  than  cortical,  that  is,  it  is  in  the  white  matter  between  the 
motor  area  and  the  internal  capsule. 

Tumors  of  the  anterosuperior  portion  of  the  prefrontal  region  give  no 
definite  localizing  symptoms,  but  produce  general  symptoms.  Mental  disor- 
ders may  arise  in  tumors  of  any  area  of  the  brain,  but  in  tumors  of  the  pre- 
frontal region  they  are  most  apt  to  occur.    The  intelligence  is  nearly  always 


Tumors  In  or  About  the  Optic  Thalamus  815 

impaired,  and  there  is  apt  to  be  mental  apathy,  loss  of  memory,  hysteria, 
irascibility,  and  pronounced  change  of  character.  As  the  tumor  grows  it  may 
subsequently  inyolve  the  motor  region,  which  in  all  probability  lies  entirely  in 
front  of  the  fissure  of  Rolando. 

In  tumors  of  the  prefrontal  region  there  may  be  focal  conyulsions  or  local 
palsy  on  the  opposite  side,  due  either  to  a  spread  of  irritation  from  a  super- 
ficial tumor  to  the  motor  cortex  or  to  involvement  by  a  deep  tumor  of  the 
commissural  fibers  which  join  the  frontal  lobe  and  the  motor  cortex. 

Tumors  of  the  Antero-inferior  Portion  of  the  Prefrontal  Region. — In  a 
right-handed  man  tumor  of  the  second  left  frontal  convolution  causes  agraphia, 
and  of  the  third  left  frontal  convolution,  motor  aphasia.  In  a  left-handed 
person  these  localizations  are  on  the  right  side  of  the  brain. 

Tumors  of  the  parietal  lobe  may  occupy  a  silent  region  of  this  lobe. 
The  centers  for  general  sensibility  and  for  the  muscular  sense  are  back  of  the 
fissure  of  Rolando  in  the  parietal  lobes.  Hence  a  tiunor  in  this  region  may 
cause  disturbance  of  muscular  sense  and  general  sensibility  in  the  Hmbs  with- 
out spasm  or  palsy  (Durante).  There  may  be  word-blindness  when  the  left 
angular  g}Tus  is  affected. 

The  extension  forward  of  a  parietal  tumor  will  involve  the  motor  zone  and 
produce  spasm  or  palsy.  Extension  backward  will  involve  the  occipital  lobe 
and  produce  hemianopsia. 

Tumors  of  the  occipital  lobe  are  apt  to  produce  lateral  homonymous 
hemianopsia  (blindness  of  the  nasal  half  of  one  retina  and  the  temporal  half 
of  the  other  retina.  If  the  right  side  of  the  brain  contains  the  lesion  the  right 
side  of  each  retina  is  blind,  and  \\ce  versa).  Wernicke's  pupillarv^  sign  is  absent. 
By  this  sign  we  mean  loss  of  pupillary  light  reflex  when  light  is  cast  upon  the 
blind  part  of  the  retina.  This  sign  only  occurs  in  lesion  in  or  in  front  of  the 
centers  for  pupillary  reflex.  Lesions  of  the  cuneus  and  of  the  calcarine  fissure 
are  especially  apt  to  produce  hemianopsia.  A  lesion  of  the  occipital  cortex 
may  produce  it.  Timiors  of  both  occipital  lobes  cause  blindness.  In  tumor  of 
an  occipital  lobe  color  vision  only  may  be  affected  (Gushing).  Tumor  of  the 
optic  radiation  may  produce  hemianopsia  (that  is,  growths  of  the  chiasm, 
optic  ner\"e,  or  puhinar  may,  but  it  is  not  certain  that  a  growth  of  the  quadri- 
geminal  bodies  or  of  the  external  geniculate  body  can). 

In  a  tumor  of  the  occipital  lobe  (the  left  lobe  in  right-handed  persons  and 
vice  versa)  there  may  be  mind-blindness,  that  is,  an  inability  to  know  what  is 
seen.  He  may  fail  to  understand  written  or  printed  words  (uvrd-blindness), 
the  nature  of  things  (apraxia),  or  signs  (asemia). 

Tiimors  of  the  temporo sphenoidal  lobe  frequently  produce  no  symp- 
toms. In  the  temporal  lobes  the  cortical  centers  for  hearing  are  placed,  and 
each  center  is  connected  with  both  auditorv^  nerves,  but  the  crossed  auditory 
bundle  is  larger  and  more  active  than  the  direct  (Francesco  Durante,  "Brit. 
Med.  Jom-.,"  Dec.  13,  1902).  Timaors  in  the  left  lobe  are  particularly  apt  to 
cause  deafness  and  may  cause  word-deafness.  Tumors  at  the  apex  of  the  lobe 
may  cause  perversion  or  impairment  of  taste  and  smell.  Tumors  of  the  tem- 
porosphenoidal  lobe  may  make  pressure  on  the  motor  tract  and  cause  paralysis 
of  the  opposite  side. 

Timiors  of  the  Corpus  Callosum. — These  growths  affect  mentality  as  do 
tumors  of  the  frontal  lobes  and  frequently  cause  hemiplegia  of  each  side. 

Tximors  of  the  Cms. — These  tmnors  cause  hemiplegia  of  the  opposite 
side  and  paralysis  of  the  third  nerve  on  the  side  of  the  lesion.  If  the  optic  tract 
is  pressed  upon  there  will  be  hemianopsia.  If  the  tegmentum  is  involved  there 
will  be  hemianesthesia. 

Tumors  In  or  About  the  Optic  Thalamus. — On  the  side  of  the  lesion 
there  are  nystagmus  and  impairment  in  the  movements  of  the  eyebaU.    There 


8i6  Diseases  and  Injuries  of  the  Head 

is  muscular  weakness  and  impairment  of  sensation  in  the  Umbs  of  the  opposite 
side.  There  may  be  sudden  and  uncontrollable  movements,  astereognosis, 
mental  dulness,  emotional  outbreaks,  and  impairment  of  emotional  control 
of  the  facial  muscles.  A  lesion  of  the  posterior  part  of  the  thalamus  causes 
hemianopsia  and  the  pupillary  reaction  of  Wernicke. 

Tumors  of  any  size  in  or  about  the  corpus  striatum  cause  hemiplegia  of  the 
■opposite  side  by  pressure  upon  the  internal  capsule.  Pressure  upon  the  optic 
thalamus  produces  homonymous  hemianopsia  and  hemianesthesia.  Growths 
near  the  basal  ganglia  produce  intense  choking  of  the  disk  and  early  pressure 
because  of  distention  of  the  ventricles. 

Tumors  of  the  Corpora  Quadrigemina. — These  tumors  produce  cerebellar 
ataxia,  palsy  of  the  eye  muscles,  and  sometimes,  perhaps,  hemianopsia. 
Hearing  may  be  impaired  in  the  ear  opposite  to  the  lesion.  Tumors  of  the 
corpora  quadrigemina  are  apt  to  involve  the  crura,  and  later  the  third  nerve. 
Ocular  symptoms  are  always  present  (loss  of  pupillary  reflex  and  nystagmus) . 
If  the  third  nerve  is  involved  there  are  paralysis  of  the  motor  ocuh  area  on 
the  side  of  the  lesion  (external  strabismus,  dilated  pupil,  and  drop-hd)  and 
hemiplegia  of  the  opposite  side  of  the  body  from  pressure  upon  the  crus.  This 
condition  is  a  form  of  crossed  paralysis. 

Tumors  of  the  Pons. — Pontine  lesions  produce  symptoms  by  pressure 
upon  the  particular  nerves  which  come  from  this  region,  with  or  without 
the  evidences  of  pressure  upon  the  motor  path.  Forms  of  crossed  paralysis 
may  exist.  Lesions  in  the  lower  half  of  the  pons  may  affect  the  fifth,  sixth, 
and  seventh  nerves  on  the  side  of  the  lesion  and  the  limbs  on  the  opposite 
side.  The  auditory  nerve  may  be  involved  in  the  lesion.  In  crossed  paralysis 
the  face  on  the  side  of  the  limb  paralyzed  is  usually  not  affected,  but  in  ex- 
tensive tumors  it  may  be  paralyzed.  Conjugate  deviation  of  the  eyes  may 
occur  away  from  the  facial  paralysis.  In  tumors  of  the  upper  part  of  the  pons 
the  pupils  may  be  first  contracted  because  of  irritation  of  the  third  nerve 
nuclei,  and  later  dilated  by  destruction  of  these  nuclei.  Anesthesia  as  a  result 
of  pontine  tumors  is  not  nearly  so  common  as  motor  paralysis,  and  convul- 
sions are  rare.  There  may  be  hemiplegia  with  crossed  hemianesthesia.  A 
tumor  on  the  side  of  the  pons  which  involves  the  peduncles  causes  ataxia  and 
sudden,  uncontrollable  movements.  Knee-jerk  may  be  absent  in  a  case  of 
pontine  tumor. 

Tumors  of  the  Medulla. — An  extensive  lesion  inevitably  causes  death. 
Cranial  nerves  only  may  be  involved,  but  crossed  paralysis  may  take  place. 
There  may  be  hemiplegia  with  crossed  paralysis  of  the  h3^oglossal  nerve. 
Vomiting  is  common,  retraction  of  the  head  is  not  unusual;  respiratory  and 
circulatory  disturbances  and  dysphagia  are  usually  noted;  sometimes  there 
is  numbness  and  occasionally  there  are  convulsions;  usually  there  is  inco- 
ordination because  of  pressure  upon  the  cerebellum. 

Tumors  of  the  Cerebellum. — They  often  cause  internal  hydrocephalus.  In 
general  it  may  be  said  that  tumors  of  the  cerebellum  cause  headache,  vomit- 
ing, vertigo,  choked  disk,  and  early  blindness.  Tumors  of  the  middle  peduncle 
cause  sudden  uncontrollable  movements  of  the  trunk,  either  toward  the  side 
of  the  tumor  or  away  from  it.  Vertigo  and  nystagmus  are  common.  Symp- 
toms are  frequently  complicated  by  evidences  of  pontinie  disease  proper. 

Tumors  of  the  middle  lobe  of  the  cerebellum  cause  a  sense  of  lost  equilibrium 
and  obvious  unsteadiness  in  attempting  to  walk  or  even  to  stand.  The  knee- 
jerks  vary.  The  Babinski  reflex  is  absent  in  an  uncomplicated  case.  The 
patient  has  a  tendency  to  fall  backward;  there  are  giddiness  and  vomiting, 
early  and  violent  choked  disk  and  occipital  headache,  nystagmus,  inability  to 
stand  steady  when  the  feet  are  together  and  the  eyes  shut,  and  perhaps  tem- 
porary palsies  of  the  eye  muscles. 


Treatment  of  Intracranial  Tumors 


817 


"^^ 


Tumors  of  the  cerebellar  hemisphere  produce  no  localizing  symptoms.  The 
usual  unsteadiness  of  gait  is  due  to  pressure  upon  the  middle  lobe  (Nothnagel). 

Tumors  of  the  Cerebellopontile  Angle. — Tumors  of  this  region  are  usu- 
ally attached  to  the  acoustic  nerve,  sometimes  to  the  fifth  nerve.  They 
produce  general  pressure-symptoms  and  may  cause  cerebellar  or  pontine 
symptoms  by  making  direct  pressure  on  those  parts.  If  the  tumor  involves 
the  acpustic  nerve  there  will  be  tinnitus,  objective  vertigo  (sometimes  with, 
sometimes  without,  forced  movements),  a  liability  to  sudden  attacks  of  falling 
to  the  ground,  failure  of  hearing  or  actual  deafness,  perhaps  sudden  blindness 
or  sudden  unconsciousness,  and  sometimes  tonic  extensor  spasms.  If  the 
timior  involves  the  trigeminal  nerve  there  will  be  violent  neuralgia  in  the 
course  of  the  nerve. 

Tumors   of  the  Hypophysis  Cerebri. — The  pituitary  body  may  be  sub- 
jected to  pressure  from,  or  become  involved  in,  tumors  of  the  region  about  it 
or  tumors  or  cysts  may  spring  from 
it   directly.     Tumors   of   or   tumors 
making  pressure  upon  the  hypophysis 

may  in  some  cases  cause  acromegaly,         .  J  \ 

and  in  others  impotence,  genital  in-  1^  .|^ . 

fantilism,  a  tendency  to  fat  deposit 
and  stunted  stature,  and  amenorrhea 
in  women .  There  is  intense  headache, 
amblyopia  due  to  primary  atrophy 
(no  preceding  choked  disk) ,  appearing 
often  as  a  bitemporal  hemianopsia 
(Gushing,  "Jour.  Amer.  Med.  Assoc," 
July  24,  1909).  In  some  cases  ex- 
treme drowsiness  has  been  noted,  and 
in  some  cases  there  has  been  binasal 
hemianopsia.  When  there  is  stimu- 
lation of  the  pituitary  (h3p)erpitui- 
tarism)  acromegaly  develops;  when 
there  is  lessened  secretion  (hypo- 
pituitarism) there  are  obesity  and 
genital  atrophy. 

Any  brain  tumor  which  causes  in- 
ternal hydrocephalus  may  thus  cause 
pressure  on  the  hypophysis  and  lead 
to  the  development  of  hypophyseal 
symptoms.  (For  full  information  regarding  the  hypophysis  see  the  classic 
monograph  by  Harvey  Gushing,  called  "The  Pituitary  Body  and  Its  Dis- 
orders").^ 

Treatment. — If  any  doubt  exists  as  to  the  existence  of  brain  S3TDhilis,  and 
if  the  Wassermann  reaction  is  positive,  give  the  patient  a  dose  of  salvarsan 
(intravenous)  and  a  course  of  iodid  of  potassium.  Give  the  iodid  at  first  in 
small  amounts,  but  rapidly  increase  it  until  heroic  doses  are  taken  (100  or 
more  grains  a  day).  Mercury  should  also  be  given  hypodermatically  or  by 
inunction.  If  salvarsan,  iodid  of  potassium,  and  mercury  really  relieve  the  symp- 
toms, and  if  the  improvement  is  not  merely  temporary,  operation  is  unneces- 
sary, although  it  may  be  demanded  later  in  order  to  remove  an  irritant  scar. 
If  antisyphilitic  treatment  fails,  the  question  of  operation  must  be  considered. 
The  test  of  success  is  improvement  in  the  choked  disk.    If  this  improves,  the 

1  For  full  consideration  of  localizing  symptoms  see  particularly  the  writings  of  Gowers, 
Mills,  Allan  Starr,  Potts,  Lloyd,  Burr,  Dana,  Dercum,  Osier,  and  Gushing,  which  have  been 
freely  used  in  the  above  section. 

53 


Fig.  525. — Case  of  cerebellar  tumor.      Bulging  of 
flap  after  osteoplastic  exploratory  operation. 


8i8  Diseases  and  Injuries  of  the  Head 

treatment  is  succeeding;  if  it  does  not,  the  treatment  is  a  failure.  It  should 
not  be  persisted  in  over  six  weeks  if  there  is  no  improvement  in  the  eye-grounds. 
To  delay  operation  further  may  mean  blindness.  We  must  always  bear  in 
mind  that  in  certain  cases  of  gUoma  the  symptoms  temporarily  improve  under 
antis^-philitic  treatment.  The  term  operable  case  does  not  of  necessity  mean  a 
tumor  which  can  be  entirely  removed  by  operation.  Some  tumors  which  can 
be  only  partially  removed  should  be  operated  upon.  An  operable  case  is  one 
in  which  an  attempt  may  be  made  to  remove  the  tiimor  and  in  which  the  timior 
can  be  entirely  removed  or  in  which  a  part  can  be  removed,  the  removal  of 
this  part  promising  rehef.  We  are  justL&ed  in  being  radical,  because  without 
operation  a  brain  tumor  is  a  certainly  fatal  malady.  In  many  cases  of  un- 
doubted tumor  excision  for  cure  is  not  attempted  because  of  the  absence  of 
localizing  s>Tnptoms  or  because  of  the  inaccessible  situation  of  the  growth. 
In  all  cases  operation  is,  first  of  all,  exploratory.  Tumors  of  the  dura  which 
have  not  infiltrated  the  brain,  many  cortical  and  some  subcortical  growths, 
are  operable.  Cerebral  and  cerebellar  cysts  may  be  opened  and  drained  in 
hope  that  benefit  will  result.  Tumors  of  the  lateral  lobe  of  the  cerebellum 
and  tumors  of  the  cerebellopontile  angle  have  been  removed.  Byrom  Bram- 
well  maintains  that  tumors  at  the  base,  tumors  of  the  pons  and  medulla,  of 
the  corpus  callosum,  of  the  basal  gangha,  and  of  the  deeper  parts  of  the  cen- 
trum ovale  are  irremovable.  Surgeons  now  regard  some  tumors  of  the  cerebello- 
pontine angle  as  operable,  but  agree  with  Bramwell's  views  as  to  growths  in 
the  other  situations  he  mentions.  Frazier  has  concluded  that  "if  the  timior 
is  found  to  be  very  vascular  and  of  the  infiltrating  type,  it  is  very  questionable 
...  as  to  whether  any  attempt  whatsoever  should  be  made  to  extirpate" 
("University  of  Penna.  Med.  Bull.,"  April-May,  1906),  and  with  this  opinion 
I  certainly  agree.  In  tumors  which  are  very  extensive  complete  removal  is 
usually  out  of  the  question.  There  is  no  use  in  removing  secondary  mahgnant 
tumors.  It  often  happens  that  the  brain  itself  fas  in  syphilis)  is  so  extensively 
diseased,  or  that  other  organs  (as  in  tuberculosis)  are  so  involved,  as  to  render 
attempts  at  removal  of  the  tumor  futUe  or  actual  removal  useless.  Mills 
thinks  that  50  per  cent,  of  cerebellar  tumors  can  be  attacked  surgically  ("New 
York  and  Phila.  Med.  Jour.,"  Feb.  11-18,  1905).  He  classifies  operable  tumors 
of  the  cerebellimi  as  follows:  i.  Tumors  situated  entirely  or  chiefly  in  the 
lateral  lobe.  2.  Tumors  upon  or  even  invading  a  part  of  the  vermis  or  middle 
lobe.  3.  Tiunors  of  the  cerebello-oblongatopontile  angle.  The  most  favorable 
timiors  for  removal  are  fibromata  and  encapsuled  sarcomata.  Gliomata  and 
ghosarcomata  have  been  removed,  but  are  very  apt  to  return.  A  syphiloma 
requires  removal  as  truly  as  a  real  tumor.  The  cases  are  commonly  unfavorable, 
as  there  is  often  widespread  brain  disease.  The  same  is  true  of  tuberculoma. 
Among  inoperable  tumors  are  most  gliomata  and  all  infiltrating  sarcomata, 
metastatic  tumors,  and  multiple  tumors.  BramwelP  tells  us  that  he  has  studied 
82  cases  of  intracranial  tumor,  and  he  considers  that  in  only  5  of  them  could 
the  tumor  have  been  entirely  removed.  In  157  reported  cases  the  tumor  was 
either  not  found  or  not  removed;  in  104  reported  cases  the  tumor  was  found, 
and  in  some  of  them  it  was  removed  (Ransohoff,  in  "Jour.  Amer.  Med.  Assoc," 
Oct.  II,  1902).  The  conclusion  is  that  though  some  tumors  of  the  brain  may 
be  successfully  removed,  extirpation  is  feasible  in  only  a  small  minority  of 
cases  and  is  to  be  decided  on  only  after  careful  study  of  all  the  indications  and 
contra-indications  offered  by  the  case.  When  about  to  operate,  apply  an  appa- 
ratus to  the  arm  and  take  the  blood-pressure  just  before  the  operation  and 
at  frequent  intervals  during  it.  Thus  by  noting  a  great  fall  in  blood-pressure 
the  surgeon  gets  early  warning  of  dangerous  shock,  learns  when  to  hasten, 
and  if  the  operation  should  be  temporarily  abandoned  and  be  completed  at 
^  "Edinburgh  Med.  Jour.,"  June,  1894. 


Treatment  of  Intracranial  Tumors  819 

another  time  (two-stage  operation).  We  may  be  driven  to  abandon  operation 
after  cutting  the  bone  and  dural  flaps,  and  if  we  are  forced  to  stop,  we  restore 
the  bone  and  dura  to  position,  and  complete  the  operation  after  a  day  or 
two.  I  agree  with  Frazier  that  the  lessening  of  hemorrhage  by  temporarily 
clamping  the  common  carotids  in  the  neck  is  not  free  from  danger,  and  it  is  not 
proper  to  do  more  than  apply  Crile's  clamp  to  the  vessel  on  the  side  operated 
upon.  In  a  brain  tirnior  when  the  dura  is  first  opened  there  is  usually  at  once 
marked  bulging  of  the  brain,  which  is  called  initial  bulging;  after  working 
for  a  time  on  a  brain,  even  when  there  is  no  tumor,  bulging  occurs  from  trau- 
matic edema,  which  is  called  consecutive  bulging.  That  consecutive  bulging 
may  occur  is  a  sound  reason  for  operating  rapidly  (Frazier).  The  mortality 
from  tumor  operations  is  large,  death  being  due  to  shock  and  hemorrhage. 
Haas  collected  122  cases  in  which  the  tvunor  was  removed;  the  mortality  was 
60  per  cent.  Operations  completed  at  one  seance  give  a  larger  mortality  than 
two-stage  operations.  During  the  operation  an  erect  posture  causes  the  brain 
to  recede  and  permits  of  extensive  e.xploration  under  the  dura  (Ransohoff- 
Cushing).  The  same  thing  is  accomplished  by  lumbar  puncture  (Gushing). 
The  fibromata  constitute  the  bext  cases  for  operation.  In  operating  on  a 
cerebral  timior  make  a  large  osteoplastic  flap.  If  on  opening  the  dura  the  tumor 
is  not  \'isible,  and  if  the  localizing  sjTnptoms  were  reasonably  positive,  the 
surgeon  is  justified  in  making  an  exploratory^  incision  through  the  cortex  to 
see  if  there  is  a  subcortical  growth.  Operations  for  cerebellar  tumors  are 
pecuharly  diSicult  because  of  the  large  blood  sinuses,  because  of  the  limited 
space  obtained  to  work  through,  because  of  the  great  bulging  after  the  dura 
has  been  opened,  because  of  the  impossibility  of  reaching  the  anterior,  mesial, 
or  upper  surfaces  through  the  incision,  because  of  the  Hability  to  injiu-e  the 
pons  and  medulla,  and  because  of  the  difficult}^  of  retracting  the  parts  (Frazier, 
"New  York  and  Philadelphia  Med.  Jour.,"  Feb.  11-18,  1905).  In  approaching 
tumors  which  are  not  wdthin  a  cerebellar  hemisphere  by  a  one-sided  exposure 
of  the  cerebellum,  it  may  be  best  to  remove  a  considerable  portion  of  the  hemi- 
sphere in  order  to  obtain  free  access  to  the  growth.  I  prefer  Cushing's  "cross- 
bow" incision  and  bilateral  exposure  (see  Fig.  537).  This  enables  the  surgeon  to 
dislocate  the  sound  lobe  outward  and  so  obtain  room  to  work  upon  the  lobe 
containing  the  tumor.  The  diagnosis  of  cerebellar  tumor  is  usually  doubtful, 
hence  practically  aU  operations  are  at  first  exploratory-  and  are  then  made 
palliative  or  radical  as  the  case  demands.  Operation  must  be  early  because 
cerebellar  growths  quickly  cause  blindness.  Sir  Victor  Horsley,  McArthur, 
Hochenegg,  von  Eiselsberg,  Gushing,  Frazier,  and  others  have  operated  for 
tumor  of  the  h\^ophysis.  Removal  of  a  healthy  pituitarv'  body  from  dogs  is 
sure  to  be  fatal,  as  the  gland  is  necessar\'  to  the  life  of  the  dog.  Removal  of  a 
healthy  pituitary-  in  man  would  in  all  probability  prove  fatal.  The  entire  an- 
terior lobe  should  not  be  removed.  If  the  timior  is  associated  T\ith  acromeg- 
aly, removal  of  the  tumor  may  arrest  the  acromegaly.  One  route  of  approach 
to  the  h^-pophysis  is  from  the  side,  just  as  we  reach  the  Gasserian  ganglion 
(Garton,  Paul,  Horsley).  Another  route  is  by  way  of  osteoplastic  frontal  re- 
section, the  longitudinal  sinus  being  ligate'd  and  the  frontal  lobes  lifted 
(Krause,  Hartley,  Borchardt).  Another  method  involves  osteoplastic  resec- 
tion of  the  anterior  wall  of  the  frontal  sinus  and  nose.  This  is  called  the 
transphenoidal  route.  The  transphenoidal  route  has  been  variously  modi- 
fied. Gushing's  plan  of  approach  through  a  sublabial  incision  is  described 
on  page  834.  Though  thorough  extirpation  of  a  brain  timior  is  feasible  in 
only  a  minority  of  cases,  operation  should  often  be  performed  for  palliative 
purposes  when  the  tumor  cannot  be  located,  when  it  is  in  a  region  from 
which  it  cannot  be  removed,  or  when  its  nature  forbids  removal.  Grainger 
Stewart,  Annandale,  Horsley,  INIacewen,  Gushing,  and  Keen  have  advocated 


820  Diseases  and  Injuries  of  the  Head 

palliative  trephining  in  certain  cases.  Simple  trephining  is  of  little  value.  In 
order  to  really  relieve  pressure  the  dura  must  be  opened  and  left  unsutured, 
so  that  hernia  cerebri  may  follow.  Gushing  has  had  some  cases  of  extraordinary 
improvement  in  cases  of  cerebral  tumor  after  trephining  in  the  right  temporal 
region  and  removing  a  piece  of  the  dura.  The  operation  is  called  by  Gushing  a 
decompression  operation.  The  brain  bulges  through  the  dural  opening,  but  the 
dense  temporal  fascia  stitched  together  over  it  prevents  fungation.  It  is  the 
temporosphenoidal  lobe  that  bulges,  and  the  right  side  is  selected  because 
word-deafness  might  ensue  if  the  operation  were  done  on  the  left  side.  I  have 
seen  several  of  Gushing's  cases.  One  of  them,  a  colored  man,  had  been  almost 
bhnd  for  some  time,  and  was  imconscious  and  had  rapidly  failing  respiration 
when  the  operation  was  performed.  He  was  so  much  benefited  that  he  returned 
to  work  and  has  useful  vision  and  no  pain.  I  have  had  several  very  gratifying 
results  in  my  own  practice.  A  decompression  may,  in  rare  cases,  cause  a 
glioma  to  degenerate  and  pass  away.  Horsley  saw  such  a  case.  In  cases  of 
cerebral  tumor  subtemporal  decompression,  and  in  cases  of  cerebellar  tumor 
suboccipital  decompression,  may  be  performed.  Sir  Victor  Horsley  beheves 
that  the  opening  for  decompression  should  be  near  the  tumor  and  not  always 
in  the  subtemporal  region.  He  believes  an  opening  near  the  tumor  possesses 
the  advantage  of  aiding  us  later  if  the  tumor  should  become  operable.  He 
maintains  that  subtemporal  decompression  may  later  confuse  the  localizing 
symptoms  should  such  symptoms  develop. 

Decompression  may  reheve  choked  disk  and  thus  retard  or  prevent  optic 
atrophy  and  blindness.  Gushing  demonstrates  that  intracerebral  pressure  is 
the  chief  element  in  choked  disk. 

This  procedure  is  of  value  in  diminishing  excessive  intracranial  pressure, 
and  thus  relieving  headache  and  choked  disk,  and  decreasing  the  tendency 
to  sudden  death  from  inhibition  of  the  heart  or  from  respiratory  failure. 
The  usual  method  of  decompression  will  not  relieve  the  headache  caused  by 
tumor  of  the  hypophysis.  This  headache  is  due  to  distention  of  the  dural 
box  in  which  the  gland  is  placed,  and  can  be  relieved  only  by  incision  of  the 
dural  box  (Harvey  Gushing,  "Jo^r.  Amer.  Med,  Assoc,"  July  24,  1909). 

We  conclude  that  in  most  cases  of  brain  tumor  operation  should  be  per- 
formed for  exploration;  in  some  cases  extirpation  may  be  performed;  in  most 
cases  extirpation  is  impossible,  and  the  surgeon  must  be  content  with  the  palli- 
ative influence  of  Gushing's  decompression  operation.  A  tumor  of  the  brain  if 
not  cured  by  antisyphilitic  treatment  is  of  necessity  fatal  if  unoperated  upon, 
and  exploratory  operation  is  not  very  dangerous. 

In  a  case  of  brain  tumor  if  operation  is  refused,  if  extirpation  is  impossible, 
or  if  decompression  fails,  it  may  be  necessary  to  use  the  bromids  for  convul- 
sions and  morphin  for  headache.  The  headache  is  often  benefited  by  pur- 
gatives, courses  of  potassium  iodid,  and  the  ice-bag  to  the  head. 

Operative  Treatment  of  Epilepsy. — The  shock  of  an  accident  or 
a  cerebral  concussion  may  estabUsh  epilepsy,  especially  in  those  predisposed 
by  heredity  or  other  causes.  Traumatic  epUepsy,  Le  Dentu^  tells  us,  may 
be  due  to:  (i)  Bone-fragments  from  skull  fracture;  (2)  outgrowths  of  bone 
due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from  laceration  of  mem- 
branes by  bone-fragments;  (4)  chronic  meningitis  which  ends  in  sclerosis 
of  membranes;  (5)  cysts  resulting  from  intracranial  hemorrhage  at  the  point 
of  fracture;  (6)  arteriovenous  aneurysm.  We  would  add:  (7)  tumors  of  the 
brain;  (8)  sclerosis  of  the  cortex.  We  refer  here,  in  speaking  of  traumatic 
epilepsy,  purely  to  the  condition  when  it  follows  a  head  injury,  and  this 
is  the  common  meaning  of  the  term.  Remember  that  epilepsy,  as  shown  by 
Sachs,  may  follow  a  long-forgotten  injury.  Before  undertaking  a  brain  opera- 
1  "La  Presse  medicale,"  June  9,  1894. 


Essential  or  Idiopathic  Epilepsy  821 

tion  for  epilepsy  it  is  a  sound  rule  to  remove  all  sources  of  definite  peripheral 
irritation.  I  have  seen  apparent  cure  follow  the  removal  of  a  tender  cicatrix 
and  follow  circumcision  of  a  patient  laboring  under  phimosis.  Briggs  reported 
a  case  of  epilepsy  in  which  there  was  a  distinct  depression  of  a  portion  of  the 
skull.  There  was  also  necrosis  of  the  tibia,  and  after  the  cure  of  the  necrosis 
the  convulsions  ceased.  The  removal  of  supposed  peripheral  irritation,  how- 
ever, is  only  occasionally  beneficial.  Are  operations  upon  the  skull  and  brain 
curative?  Surgeons  are  much  less  enthusiastic  than  they  were  a  few  years 
ago.  I  believe  operation  can  cure  less  than  5  per  cent,  of  cases,  but  it  is  im- 
portant to  remember  that  in  some  cases  in  which  operation  seems  to  have 
failed  medical  treatment  becomes  much  more  efiScient  than  it  was  before  the 
operation.  The  high  rate  of  cure  (70  per  cent.)  once  claimed  for  operations 
was  due  to  failing  to  follow  the  patient  sufiiciently  long.  A  patient  should 
not  be  reported  as  cured  until  at  least  three  years  or,  better,  five  years  have 
passed  without  any  evidence  of  the  disease.  Another  source  of  error  was  a 
failure  to  understand  that  any  traumatism  may  improve  epilepsy  for  a  time. 
"The  administering  of  an  anesthetic,  the  shock  of  an  injury,  the  traumatism 
of  an  operation,  just  like  a  febrile  seizure,  may  interrupt  an  epileptic  habit 
and  cause  a  patient  to  go  for  weeks  or  months  without  an  attack"  (the  author, 
in  "Medicine,"  Feb.,  1904). 

Operation  must  never  be  indiscriminately  applied.  In  some  cases  it  gives 
hope  of  rehef,  in  others  it  is  obvious  that  it  would  be  utterly  futile.  In  order 
to  determine  if  a  case  is  or  is  not  suitable  for  operation  it  must  be  studied 
wdth  great  care.  The  history  must  be  carefully  obtained,  particularly  as  to 
hereditary  predisposition,  the  first  convulsion,  and  its  supposed  cause.  The 
question  of  injury,  recent  or  old,  should  be  thoroughl}-  investigated,  and 
it  is  a  sound  rule  to  have  the  head  shaved  and  then  examine  for  a  scar 
and  for  a  depression.  Convulsive  seizures  must  be  studied  by  an  expert, 
hence  the  patient  should  be  in  a  hospital,  constantly  watched  by  a  trained 
nurse,  until  one  or  two  fits  have  occurred.  The  nurse  watches  the  con- 
vulsion and  describes  it  in  writing,  noting  particularly  if  it  had  a  local 
beginning.  The  general  health  must  be  investigated.  An  a;-ray  should  be 
taken. 

I  am  accustomed,  for  surgical  purposes,  to  make  the  following  classification 
of  epilepsy.  It  is  a  modification  of  Sir  Victor  Horsley's  classification  (the 
author,  in  "Medicine,"  Feb.,  1904): 

1.  Reflex  epilepsy,  the  surgical  treatment  of  which  I  shall  not  discuss  in 
detail. 

2.  The  common  non- traumatic,  idiopathic,  or  essential  epilepsy,  in  which 
the  attacks  are  general  and  are  without  a  local  onset. 

3.  Idiopathic  epilepsy  with  a  local  onset  of  attacks  (focal  or  Jacksonian 
epilepsy) . 

4.  Traumatic  epilepsy.  This  may  be  subdivided  into  two  forms:  (a) 
attacks  without  a  local  onset,  and  {b)  attacks  with  a  local  onset  (focal  or 
Jacksonian  epilepsy). 

5.  Jacksonian  epilepsy  due  to  gross  brain  disease  (tumor,  aneurysm,  etc.). 

6.  Epilepsy  following  infantile  cerebral  palsy. 

7.  The  posthemiplegic  epilepsy  of  adults. 

1.  Reflex  Epilepsy. — Remove  the  supposed  cause  of  irritation.  When 
epilepsy  follows  traumatism  and  a  scar  is  found  on  the  scalp,  excise  the  scar. 
This  is  an  imperative  duty  if  the  scar  is  tender  or  the  seat  of  an  aura. 

2.  Essential  or  Idiopathic  Epilepsy. — Operation  upon  the  brain  is  useless. 
If  persistent  headache  exists,  it  may  be  proper  to  trephine  and  open  the 
dura  for  exploration.  Such  an  operation  is  done  to  relieve  headache.  Some 
claim  remarkable  results  from  bilateral  excision  of  the  cervical  gangUa  of  the 


822  Diseases  and  Injuries  of  the  Head 

sympathetic  (see  page  761).  The  operation  is  a  theoretical  one  and  of  doubtful 
utility.  It  was  founded  upon  a  misconception  as  to  the  cause  of  epilepsy, 
and  favorable  reports  are  no  more  favorable  than  have  been  set  forth  regarding 
various  other  now  abandoned  procedures. 

3.  Idiopathic  Epilepsy  with  Local  Onset  of  Attacks  {Focal  or  Jacksonian 
Epilepsy). — Many  of  these  cases  begin  in  young  children  who  have  had  infan- 
tile palsy,  the  traces  of  the  palsy  having  disappeared.  In  such  cases  the  con- 
vulsions may  begin  on  one  side,  and,  in  fact,  may  be  nearly  limited  to  one  side. 
If,  from  the  very  beginning,  the  attacks  began  in  one  group  of  muscles  or  in 
one  extremity,  whether  or  not  they  spread  to  the  rest  of  the  body,  and  if  the 
case  is  seen  within  two  years  of  the  first  attack,  the  surgeon  is  justified  in 
exposing  the  brain  and  excising  the  irritated  portion  of  cortex.  This  operation, 
it  is  true,  cures  very  few  cases,  but  it  benefits  many  for  a  considerable  time 
and  seems  to  make  them  more  amenable  to  medical  treatment.  In  the  vast 
majority  of  cases  fits  recur,  but  rarely  as  severely  as  before.  After  fits  have 
been  going  on  for  two  years  operation  offers  no  prospect  of  cure,  as  the  associa- 
tion fibers  have  surely  degenerated.  But,  even  in  very  old  cases,  if  the  attacks 
are  frequently  repeated  and  thus  threaten  life,  the  excited  center  should  be 
removed  to  save  life. 

In  cortical  excision  more  of  the  cortex  than  the  excited  center  is  of  neces- 
sity removed,  because,  in  order  to  get  the  entire  center,  we  must  go  wide 
of  it.  Paralysis  of  the  parts  controlled  by  the  extirpated  cortical  area  follows. 
The  paralysis  is  seldom  permanent  except  to  the  finer  movements.  The 
operation  gives  the  best  prognosis  in  young  persons,  and  when  done  early 
in  the  case.  The  return  of  fits  after  apparent  cure  is  thought  to  be  due,  at 
least  in  some  cases,  to  the  formation  of  adhesions  between  the  brain  and  its 
membranes.  Various  unsatisfactory  attempts  have  been  made  to  prevent 
adhesion  by  the  insertion  of  sUver-foil,  gold-foil,  rubber  tissue,  egg-shell  mem- 
brane, and  Cargile  membrane.  In  operating  for  cortical  epilepsy  a  large 
osteoplastic  flap  is  required.  In  the  previous  remarks  we  dealt  wdth  partial 
epilsepsy  and  with  generaHzed  epilepsy  in  which,  from  the  first,  the  attacks 
had  a  local  beginning.  If  cases  of  apparent  idiopathic  epilepsy  develop  Jack- 
sonian attacks  (attacks  with  a  local  beginning),  it  is  useless  to  excise  the 
cortex.  The  entire  cortex  is  diseased,  though  one  region  is  particularly  un- 
stable. 

4.  Traumatic  Epilepsy. — Always  remember  that  a  traumatism  to  a  person 
who  becomes  epileptic  may  have  been  only  a  coincidence;  the  condition  may 
be  essential  epilepsy  and  the  traumatism  may  have  had  nothing  to  do  with 
it.  Epilepsy  ensuing  upon  traumatism  may  not  begin  until  months  or  even 
several  years  after  the  injury.  In  the  earliest  attacks  consciousness  may  or 
may  not  be  lost.  The  causative  injury  may  have  been  slight  or  severe.  ''An 
injury  may  cause  a  hemorrhage  or  a  depressed  fracture;  may  be  followed  by  a 
scar  upon  the  membranes;  may  occasionally  lead  to  the  development  of  an 
innocent  or  malignant  tumor  or  a  cyst,  or  may  merely  induce  some  trivial 
change  in  the  subtle  chemistry  of  the  nerve-cells"  (the  author,  in  "Medicine," 
Feb.,  1904).  Injury  may  produce  general  epilepsy  or  Jacksonian  epilepsy. 
If  an  identified  traumatism  exists,  the  surgeon  should  operate  even  after  years. 
When  the  traumatism  has  not  left  definite  evidence,  the  surgeon  is  justified 
in  making  an  exploration  any  time  up  to  the  termination  of  the  third  year  after 
the  accident.  The  earlier  the  operation,  the  better  the  prognosis.  The  best 
prognosis  of  any  form  of  epilepsy  is  given  by  Jacksonian  epilepsy  of  traumatic 
origin. 

"In  focal  epilepsy  with  evidences  of  skull  injury  or  depression,  trephining 
is  imperative  and  somewhat  promising.  The  dura  should  invariably  be 
opened,  even  if  it  seems  in  good  condition.    A  dural  scar  should  be  extirpated. 


The  Posthemiplegic  Epilepsy  of  Adults  823 

The  brain  should  be  examined  by  sight  and  by  touch,  and  should  be  explored 
with  the  little  finger  and  with  the  dural  separator  to  well  beyond  the  limits 
of  the  opening  in  the  dura.  If  a  tumor  is  found,  it  should  be  removed;  if  a 
scar  upon  the  brain  exists,  it  should  be  extirpated;  if  a  cyst  is  discovered,  it 
should  be  drained;  and  if  there  is  any  obviously  damaged  area  in  the  brain 
tissue,  it  should  be  unhesitatingly  cleared  away.  If  nothing  obvious  is  found  on 
exploration,  and  if  the  attacks  have  been  distinctly  local  in  origin,  it  is  justifi- 
able to  extirpate  the  motor  center  from  which  the  discharge  seems  to  originate. 

"When  Jacksonian  epilsepy  has  followed  an  injury  in  the  motor  region, 
the  chances  of  effecting  a  cure  are  much  better  than  they  are  when  the  epilepsy 
has  followed  an  injury  in  the  sensory  region.  When  it  has  followed  an  injury 
in  the  frontal  region,  operation  affords  very  little  hope  of  cure. 

"When  the  condition  is  not  focal  but  essential  epilepsy,  the  surgeon  will 
remove  a  scalp  scar;  and  if  there  is  any  evidence  of  bone  injury,  he  will  tre- 
phine the  bone,  open  the  dura,  and  explore  the  brain.  It  is  needless  to  say, 
however,  that  in  such  a  case  he  will  not  extirpate  any  of  the  cortex. 

"In  cases  of  focal  epilepsy  I  use  the  osteoplastic  method  of  operating. 
In  cases  of  generalized  epilepsy  I  use  the  simple  trephine  and  leave  the  button 
of  bone  out,  as  a  means  of  effecting  a  prolonged  modification  in  the  intra- 
cerebral pressure"  (the  author,  in  "Medicine,"  Feb.,  1904). 

Bramwell  maintains  that  when  traumatism  is  followed  by  epilepsy  and 
the  epileptic  discharge  starts  from  a  cortical  center  which  is  not  beneath 
the  scar,  the  surgeon  should  trephine  first  at  the  seat  of  injury,  and  if  this 
fails,  he  should  trephine  over  the  excited  center. 

5.  Jacksonian  Epilepsy  Due  to  Gross  Brain  Disease. — The  treatment 
of  this  condition  is  the  treatment  of  the  brain  disease. 

6.  Epilepsy  Following  Infantile  Cerebral  Palsy. — In  this  group  of  cases 
the  palsy  is  manifest.  It  is  justifiable  to  operate  upon  a  chUd,  but  not  later  in 
life.    The  prospect  of  benefit  is  poor  even  in  a  child. 

7.  The  Posthemiplegic  Epilepsy  of  Adults. — Operation  is  useless. 

Our  conclusions  are  that  these  operations  sometimes  seem  to  cure  epilepsy, 
but  so,  occasionally,  does  any  operation.  White^  records  90  trephinings  in 
which,  though  no  cause  was  found  for  the  epilepsy,  great  relief  followed,  and 
2  cases  were  apparently  cured;  he  mentions  benefit  or  apparent  cure  fol- 
lowing tracheotomy,  ligation  of  the  carotid  artery,  incision  of  the  scalp,  etc. 
The  same  effect  may  be  obtained  by  a  great  shock,  high  fever,  the  adminis- 
tration of  an  anesthetic,  or  an  accident.  The  fact  seems  to  be  that  any  opera- 
tion, by  means  of  nervous  shock,  may  interrupt  the  epileptic  habit;  but  in 
ordinary  operations  the  fits  tend  after  a  time  to  recur  and  soon  reach  their 
old  standard  of  frequency.  In  the  special  brain  operations  with  removal  of 
obvious  lesions  or  extirpation  of  discharging  centers  the  fits  usually  recur, 
but  they  will  rarely  reach  the  old  standard  of  frequency,  and  wiU  be  more 
amenable  to  medical  treatment. 

In  non-traumatic  chronic  epilepsy  without  localizing  symptoms  trephining 
is  not  justifiable  unless  persistent  headache  calls  for  it  as  a  means  of  relief 
from  intracranial  pressm^e.  Annandale  advised  us  to  consider  experimental 
operation  in  such  cases  when  the  drug-treatment  has  failed  and  when  the 
patient's  condition  seems  hopeless.  He  says  there  is  no  chance  of  improve- 
ment without  operation,  and  operation  may  possibly  disclose  a  removable 
lesion.^  After  trephining  for  epilepsy  five  years  should  elapse  without  a  con- 
vulsion before  cure  is  resaonably  assured;  and  if  convulsions  arise,  they  must 
at  once  be  met  by  medical  treatment.  A  man  having  once  had  a  convulsion 
may  at  any  time  have  others;  hence  he  should  always  be  watched.    It  is  not 

1  "The  Supposed  Curative  Effects  of  Operations  per  se,"  "Annals  of  Surgery,"  Aug.  and 
Sept.,  1891.  2  "Edinburgh  Med.  Jour.,"  April,  1894. 


824  Diseases  and  Injuries  of  the  Head 

unusual  for  a  few  convulsions  to  occur  soon  after  an  operation  for  epilepsy, 
and  then  to  cease  for  a  considerable  time.  These  early  fits  result  from  habit 
{habit  fits) .  Among  the  operative  procedures  suggested  for  the  treatment  of 
epilepsy  may  be  mentioned  circumcision,  clitoridectomy,  ocular  tenotomy,  liga- 
tion of  the  vertebral  arteries,  removal  of  the  cervical  ganglia  of  the  sym- 
pathetic (see  page  761)  (Alexander,  Jonnesco,  Jaboulay),  and  the  actual 
cautery  to  the  head  (Fere). 

Operative  Treatment  of  Insanity. — (See  the  author,  in  "Journal  of 
Nervous  and  Mental  Diseases,"  June,  1904.) 

1.  Epileptic  Insanity. — The  conditions  which  call  for  operation  on  a  non- 
insane  epileptic  (see  page  821)  call  for  it  on  an  insane  epileptic.  It  is  sometimes 
justifiable  to  operate  if  there  has  been  a  head  injury,  and  operation  may 
lessen  the  mmiber  and  diminish  the  violence  of  the  attacks.  If  focal  seizures 
exist,  we  may  proceed  as  for  focal  seizures  in  the  sane.  In  status  epilepticus 
we  may  operate  to  relieve  pressure.  It  will  be  observed  that  operation  is  for 
the  convulsions  and  not  for  the  insanity. 

2.  Paresis. — I  do  not  advocate  operation  in  paresis.  If  we  believe  in 
traumatic  paresis,  we  may  be  inclined  to  advise  operation.  Personally  I  do 
not  believe  that  genuine  paresis  is  ever  cured;  the  lesions  of  the  disease  are 
widely  disseminated;  the  pons,  medulla,  and  even  the  cord  may  be  diseased 
and  the  lesions  cannot  be  removed. 

3..  Non- traumatic  Insanity  and  Paranoia. — -Operation  cannot  cure  the 
insanity  and  is  not  to  be  advised. 

4.  Hypochondriacal  Delusions. — Operation  is  useless.  Some  practice  it 
with  the  idea  of  getting  rid  of  a  delusion  by  removing  a  part  to  which  the 
attention  is  directed.  Such  attempts  always  fail,  because  it  is  the  insanity 
which  causes  the  delusion,  not  the  delusion  which  causes  the  insanity. 

5.  Operations  for  Traumatic  Insanity. — ^A  psychosis  constructed  on  the 
basis  of  a  traumatic  neurosis  never  calls  for  operation.  The  only  cases  in 
which  operation  is  ever  justifiable  are  those  in  which  traumatism  is  the  direct 
cause.  Insanity  may  begin  at  once  or  soon  after  an  injury,  but  is  often  unrecog- 
nized for  weeks  or  even  months.  Nearly  all  of  these  cases  are  predisposed 
to  insanity  and  the  injury  has  been  only  an  exciting  cause.  Traumatism 
is  the  direct  cause  in  about  2  per  cent,  of  cases  of  insanity. 

"An  antecedent  injury  may  have  directly  induced  the  alienation;  it  may 
have  had  no  bearing  at  all  upon  the  latter;  or  it  may  have  produced  an  insanity 
by  fear  and  shock,  and  not  by  creating  a  direct  brain  lesion.  Again,  the 
head  injury,  by  increasing  the  individual's  susceptibility  to  alcohol  and  to 
the  effects  of  the  sun,  may,  if  this  person  drinks  alcohol  or  exposes  himself  to 
the  rays  of  the  sun,  be  indirectly  responsible  for  lunacy. 

"In  insanity  following  an  injury  to  the  head  there  may  be  various  sup- 
posed causative  lesions:  A  fracture  of  the  skull,  with  or  without  depression; 
the  development  of  an  exostosis;  sclerosis  or  softening  of  the  cortex;  edema 
of  the  membranes  or  of  the  brain  itself;  cerebral  hyperemia  or  congestion; 
thickening  of  the  membranes;  adhesion  of  the  membranes  to  the  skull,  to 
each  other,  or  to  the  brain;  new  growth;  inflammation  of  the  membranes; 
or  minute,  slowly  developing,  widespread  nutritive  changes.  The  injury 
may  be  assumed  to  be  the  cause  of  the  insanity  if  the  insane  condition  becomes 
manifest  almost  at  once  or  soon  after  the  accident;  but  if  the  symptoms  do 
not  appear  until  long  after  the  accident  the  traumatism  may  be  considered 
to  be  the  directly  exciting  cause  in  some  cases,  and  not  in  others.  It  may  be 
blamed  if,  between  the  time  of  the  accident  and  the  appearance  of  the  insanity, 
there  has  been  a  marked  change  in  the  patient's  disposition,  temperament, 
or  character;  if  he  has  developed  headache,  insomnia,  irritability,  passionate 
outbreaks  of  temper,  moodiness,  or  lapses  of  memory;  if  he  has  plunged  into 


Operations  On  the  Skull  and  Brain  825 

immorality  or  excesses  in  alcohol;  if  he  has  displayed  a  tendency  to  neglect 
business  or  family  obligations,  and  if  he  has  shown  increased  susceptibility 
to  alcohol  and  to  the  sun.  Sometimes  epilepsy  may  develop  during  this 
period,  (Richardson,  'American  Journal  of  Insanity,'  July,  1903.  The 
author's  'Address  on  Surgery,'  delivered  before  the  meeting  of  the  Aledical 
Society  of  the  State  of  Pennsylvania,  May  iS,  1S97).  If  there  was  none  of 
these  intermediate  changes  in  the  normal  mode  of  thinking  and  way  of  acting, 
one  cannot  count  the  traumatism  as  causative.  jSIany  persons  that  have 
received  severe  head  injuries  have  shown  these  changes,  but  have  never  gone 
insane.  I  have  been  studying  this  point  for  a  mmaber  of  years,  and  have 
decided  that  quite  a  few  patients  that  have  been  trephined  for  fracture  or 
for  meningeal  hemorrhage  have  subsequently  shown  pronounced  and  per- 
manent changes  in  character  and  disposition.  Of  the  number  that  show 
such  changes,  many  never  go  insane,  but  some  do.  Such  an  insanity  is 
distinctly  traumatic  in  origin"  (the  author,  in  "Journal  of  Nervous  and 
]Mental  Diseases,"  June,  1904).  The  prognosis  is  very  imfavorable;  some 
recover  sanity  after  operation,  many  do  not.  Some  recover  sanity  without 
operation.  Sometimes  operation  cures  by  remo\'ing  a  lesion;  sometimes  by 
shock,  etc.    Some  cures  following  operation  did  not  result  from  the  operation. 

On  what  cases  should  we  operate? 

We  should  operate  on  cases  "in  which  insanity  has  soon  followed  a  head 
injur}'.  If  the  site  of  the  trauma  is  indicated  by  a  scar,  a  depression  of  bone, 
local  tenderness,  fixed  headache,  or  some  localizing  symptom — motor  or 
sensor}- — operation  should  positively  be  undertaken.  In  a  case  in  which 
the  insanitv  has  developed  later,  in  which  the  intermediate  period  between 
the  injur\^  and  the  development  of  the  insanity  has  shoT\-n  the  change  from 
the  normal  mode  of  thuiking  and  way  of  acting  pre\iously  aUuded  to,  and 
in  which  the  site  of  trauma  is  indicated  by  any  of  the  e\adences  mentioned 
above — operation  should  positively  be  performed.  One  should  not  operate 
upon  a  case  simply  because  there  is  a  dubious  record  of  an  antecedent  fall 
or  blow,  which  merely  suggests  the  possibility  of  a  traumatic  origin  for  the 
insanity.  In  anv  case  in  which  there  are  positive  signs  of  increased  pres- 
sure it  mav  be  considered  proper  to  trephine  as  a  palliative  measure"  (the 
author.  Ibid.). 

Abdominal,  Gynecological,  and  Genito-virinary  Operations. — If  an  insane 
person  has  a  disease  which  is  dangerous  to  Ufe  or  which  is  productive  of  pain, 
discomfort,  or  ill  health,  he  or  she  is  entitled  to  be  cured,  if  possible,  by  a  surgical 
operation.  The  removal  of  pain  and  other  depressing  influences  may  result 
in  great  improvement  in  the  general  health  and  in  notable  mental  improve- 
ment. The  operation  may  thus  indirectly  exercise  a  beneficial  influence  on  the 
insanity,  but  the  influence  is  not  direct  and  it  is  never  justifiable  to  do  such 
an  operation  as  oophorectomy  upon  an  insane  woman  unless  the  condition  of 
the  ovaries  would  call  for  it  in  one  not  insane. 

Operations  On  the  Skull  and  Brain. — As  a  preliminan,-  it  is  weU  to 
note  that  urotropin  (hexamethylenamin)  given  by  the  mouth  quickly  appears 
in  the  cerebrospinal  fluid,  and  that  the  fluid  contains  the  maximum  amomit 
in  from  one-hah  hour  to  an  hour  after  ingestion.  The  presence  of  this  drug  de- 
cidedly inhibits  the  growth  of  bacteria  in  the  fluid.  This  is  Crowe's  discover^^. 
We  believe  it  wise  to  give  this  drug  in  aU  cases  in  which  meningitis  is  threat- 
ened or  exists  (S.  J.  Crowe,  in  "Johns  Hopkins  Hospital  Bulletin,"  April^ 
1909).  It  should  be  given  for  twenty-four  hours  preceding  and  for  several 
days  after  an  operation  upon  the  brain  or  spinal  cord.  From  40  to  60  gr.  a 
day  are  given  by  mouth.  Cushing  has  subjected  this  drug  to  the  severest 
test  in  his  operations  to  reach  the  pituitary  body.  He  gave  60  gr.  a  day  of  this 
drug  "on  the  day  preceding  and  for  some  days  after  the  operation"  ("The 


826 


Diseases  and  Injuries  of  the  Head 


Pituitary  Body  and  Its  Disorders,"  by  Harvey  Gushing).  After  33  trans- 
sphenoidal operations  there  were  2  cases  of  meningitis.  One  of  these  cases 
(which  was  inaugurated  by  violent  sneezing)  was  fatal. 

Trephining  for  a  Fracture  of  the  Skull. — The  patient  should  be  anes- 
thetized unless  he  is  unconscious,  and  should  be  placed  upon  the  back  with 
the  shoulders  a  httle  raised.  A  sand-pillow  is  placed  under  the  neck,  and 
his  head  is  turned  away  from  the  side  to  be  operated  upon.  The  position 
of  the  surgeon  is  such  that  the  patient's  head  is  a  Httle  to  his  left.  A  large 
semilunar  incision  is  made  with  the  base  down,  which  incision  goes  through 
the  periosteum,  and  the  flap  is  lifted.  The  bleeding  vessels  of  the  flap  are 
caught  by  forceps.  The  fracture  is  sought  for  and  found.  The  pin  of  the  tre- 
phine is  projected  beyond  the  crown  and  is  set  upon  sound  bone,  the  crown 
overhanging  the  line  or  edge  of  the  fracture.  The  surgeon  tries  to  avoid  the 
region  of  a  sinus  or  large  artery.  A  gutter  is  cut  in  the  bone,  the  pin  of  the  in- 
strument is  withdrawn,  and  the  trephining  is  completed.  In  going  through  the 
diploe  bleeding  is  copious.     The  inner  table  feels  very  dense.     Stop  from  time 

to  time,  clean  out  the  gutter  in 
the  bone  with  gauze,  and  try  the 
bone  Tvith  an  elevator  to  see  if  it 
is  loose.  When  the  fragment  is 
loose  enough,  pry  it  out.  If  the 
Fig.  526.— Gait's  conical  trephine.  suTgeon    dcsires    to    replace    the 

button,  hand  it  to  an  assistant, 
who  places  it  at  once  in  a  bowl  of  warm  normal  salt  solution,  kept  warm 
by  standing  in  a  basin  of  water  at  105°  F.,  or  in  warm  carbolized  towels. 
The  edges  of  the  opening  should  be  rounded  by  a  rongeur,  and  the  bone, 
if  depressed,  must  be  elevated.  Sometimes  it  may  be  necessary  to  remove 
spUnters  and  fragments  of  bone.     After  removing  the  fragments  the  edges 

of  the  opening  should  be 
smoothed  by  the  use  of  the 
rongeur  forceps.  The  dura 
should  be  examined  to  see 
if  injury  exists,  and  hemor- 
rhage must  be  stopped.  Bleed- 
ing from  the  dura  is  arrested 
by  passing  a  ligature  of  silk  or 


Fig.  527- 


Fig.  528. 
Figs.  527-529. — Hudson's  burrs. 


Fig.  529. 


catgut  threaded  in  a  small  curved  needle  under  the  vessel  on  each  side  of  the 
wound,  and  tying  the  hgatures  {suture-ligatures).  Bleeding  from  the  pia  is 
arrested  by  direct  ligation,  by  suture  ligature,  or  by  gauze  packing.  Bleed- 
ing from  the  diploe  is  arrested  by  the  use  of  Horsley's  wax.  The  wound  is 
cleansed,  the  edges  of  the  dura  are  sutured  by  catgut  or  fine  silk;  in  some 


Osteoplastic  Resection  of  the  Skull 


827 


cases  the  button  of  bone  is  reintroduced;  in  other  cases  some  chips  are  cut 
from  the  bone  and  scattered  upon  the  dura,  but  in  most  cases  no  attempt  is 
made  to  fill  up  the  gap  in  the  bone.  The  scalp  is  sutured  b>'  silkworm-gut, 
and  horse-hair  or  gauze  drainage  is  employed  for  a  da>-  or  two.  Sterilized 
gauze  dressings  are  put  on,  a  rubber-dam  is 
laid  over  them,  and  a  gauze  bandage  wet 
with  bichlorid  of  mercury  is  applied. 

Instead  of  the  trephine  some  surgeons 


Fig.  530. — Hudson's  modified  DeVilbiss  forceps. 


Fig.  531. — Combined  osteoplastic 
operation.  First  step.  Incision  through 
superficial  tissues  and  bone.  Flap  held 
in  place  on  the  bone  by  tacks. 


use  the  chisel  or  gouge  and  hammer  to  remove  a  portion  of  the  bone.  Other 
operators,  believing  that  this  procedure  may  cause  concussion,  employ  the 
surgical  engine. 

I  now  seldom  use  the  old  trephine,  preferring  instead  the  instruments  of 
Hudson  (Figs.  527-530). 

Osteoplastic  Resection  of  the  Skull. — Wolflt  suggested  this  operation, 
and  in  18S9  Wagner  performed  it.  It  is  employed  for  the  removal  of  tumors 
and  the  Gasserian  gangHon,  for  focal  epilepsy,  and  for  exploration.  It  is  the 
operation  of  choice  when  a  large  opening  is  needed,  as  when  the  operation  is. 


Fig.     532. — Combined     osteoplastic     operation. 
Second  step.    Bone  flap  turned  down. 


Fig-  533. — Combined  osteoplastic  operation. 
Third  step.  Showing  exposure  of  brain  bj"  re- 
moval of  dural  flap. 


first  of  all,  for  diagnosis.     The  incision  shown  in  Fig.  531  is  made  through 
the  scalp  and  periosteum,  and  the  flap  is  tacked  to  the  bone,  ordinar\^  long 


828  Diseases  and  Injuries  of  the  Head 

tacks  being  used.  Otherwise  our  manipulations  may  separate  the  flap  from 
the  bone  (Fig.  531).  A  groove  corresponding  to  this  incision  may  be  cut 
in  the  bone  by  special  gouges  or  chisels.  I  do  not  use  chisels.  I  am  con- 
vinced that  the  blows  of  the  mallet  add  to  shock,  may  cause  hemorrhage 
or  add  to  existing  hemorrhage,  may  extend  a  hne  of  fracture  or  cause  a 
fracture,  may  diffuse  a  purulent  collection,  or  produce  concussion  of  the 
brain.  Some  surgeons  use  the  surgical  engine.  It  is  difficult  to  keep  it  sterile, 
it  runs  at  too  high  a  speed  to  be  readily  controlled,  and  it  is  troublesome  to 
cut  a  bevel  with  it.  The  instrument  is  dangerous  except  when  in  very 
skilful  and  highly  trained  hands.  Some  surgeons  make  trephine  openings 
and  then  cut  from  within  outward  by  the  Gigli  wire  saw  (Obalinski).  Gush- 
ing, of  Harvard,  does  what  is  called  the  combined  method.  I  prefer  this  to 
any  other  plan.  It  is  rapid  and  free  from  all  danger  of  wounding  the  dura, 
I  make  two  or  several  openings  with  Hudson's  burr.  This  excellent  instru- 
ment divides  bone  with  great  rapidity,  but  does  not  divide  the  dura.  In 
fact,  one  cannot  divide  the  dura  with  it,  for  the  burr  binds  as  soon  as  it 
is  through  the  bone.  Figs.  527  to  529  show  Hudson's  burrs.  The  sides  of 
this  bone-flap  are  rapidly  cut  by  Hudson's  improvement  of  the  DeVilbiss 
forceps  (Fig.  530).  The  upper  margin  is  cut  on  a  bevel  with  the  Gigli  saw. 
Because  of  this  bevel  when  the  flap  is  restored  to  place  the  upper  edge  of  the 
flap  rests  on  a  shelf  of  bone  and  does  not  press  on  the  brain.  By  whatever 
method  performed,  three  sides  of  the  bone-flap  are  cut  through,  but  the  bone 
is  left  attached  to  the  scalp.  It  is  a  good  plan  to  save  the  scalp  from  detach- 
ment by  temporarfly  nailing  it  in  place  (Fig.  531).  The  bone  is  then  broken 
outward,  the  fracture  taking  place  at  the  base  of  the  bone-flap,  the  dura  is 
opened  a  little  distance  from  the  edge  (sufScient  space  being  retained  for 
sutures),  and  the  exploration  is  made  and  the  operation  is  performed  (Figs. 
532  and  533).  When  we  are  ready  to  suture  the  dura  we  note  if  the  brain 
bulges  greatly.  If  it  does,  manipulation  will  surely  injure  it,  and  we  should 
cause  the  brain  to  recede  before  suturing  by  placing  the  patient  nearly  erect 
or  by  performing  lumbar  puncture.  After  suturing  the  dura  the  bone  which 
is  stiU  adherent  to  the  pericranium  and  scalp  is  restored  to  its  proper  place, 
and  the  scalp  is  sutured. 

Besides  restoring  a  flap  of  bone  into  position,  or  replacing  a  button  of 
bone,  or  strewing  the  dura  with  bone-fragments,  other  methods  of  closing  the 
opening  have  been  practised — for  instance,  heteroplasty  with  a  decalcified 
bone-plate,  with  a  celluloid  plate,  or  other  foreign  material.^ 

Trephining  the  Frontal  Sinus. — ^This  operation  may  be  employed  for 
inflammation  of  the  lining  membrane  of  the  sinus  or  for  empyema.  Make 
a  vertical  incision  in  the  middle  of  the  forehead,  starting  i^  inches  above 
the  nasion  and  terminating  at  the  root  of  the  nose.  The  button  of  bone  is 
removed  and  the  opening  is  enlarged  if  necessary.  The  mucous  membrane  is 
incised,  the  opening  into  the  nose  is  found  and  is  dilated,  and  a  drainage-tube 
is  passed  into  the  nose  from  the  sinus,  the  upper  end  being  left  in  the  sinus. 
In  some  severe  cases  Jacobson  advises  us  to  curet  the  sinus,  to  disinfect  it  by 
the  use  of  silver  nitrate  or  chlorid  of  zinc,  and  to  insiifflate  an  "aseptic  powder." 
In  some  cases  resect  the  mucous  membrane.  I  prefer  an  osteoplastic  resection 
to  trephining  the  frontal  sinus. 

Trephining  the  Mastoid. — (See  Operation  for  Mastoid  Suppuration,  page 
830.) 

Technic  of  Brain  Operations. — In  focal  epflepsy  a  faradic  battery  is  required. 

Always  shave  the  scalp  and  alw^ays  antisepticize  it.    In  localizations,  mark  out 

the  fissure  upon  the  scalp  with  an  anilin  pencil,  with  iodin,  or  with  silver  nitrate. 

Have  the  patient  semirecumbent.    Mark  three  points  upon  the  bone  with  the 

1  See  Bretano,  in  "Deutsche  med.  Woch.,"  May  17,  1894. 


Technic  of  Brain  Operations  829 

center-pin  of  the  trephine  before  incising  the  scalp  (both  ends  of.  the  Ro- 
landic  fissure  and  the  point  at  which  the  trephine  is  to  be  applied).  Make 
a  semilunar  flap  3  inches  in  diameter,  with  the  base  below.  Control  bleed- 
ing in  the  flap  by  forceps  pressiire.  If  the  operation  is  by  trephining  the 
i^-inch  trephine  should  be  employed,  but  if  a  smaller  trephine  or  the  Hud- 
son burr  is  used  the  opening  must  be  enlarged  with  a  rongeur.  Before  en- 
larging the  opening  separate  the  dura  from  the  bone  by  a  dural  separator. 
In  most  cases  an  osteoplastic  flap  is  preferable  to  trephining.  It  is  always 
employed  in  explorations  for  tumor.  As  a  rule,  open  the  dura  and  examine 
the  brain.  The  dura  is  lifted  by  mouse-toothed  forceps  and  is  opened  by 
scissors  along  a  line  I  inch  from  the  bone  edge,  a  broad  pedicle  of  dura  being 
left  uncut.  Hemorrhage  is  arrested  by  pressure  and  hot  water  or  bypassing 
suture-ligatures  of  silk  or  catgut  around  any  bleeding  vessel  by  means  of  a 
cur^^ed  needle.  In  some  cases  packing  must  be  retained  or  forceps  must  be 
kept  on.  In  packing,  endeavor  to  use  but  one  piece  of  gauze,  so  as  to  avoid 
lea\ing  in  a  forgotten  piece.  Upon  opening  the  dura  cerebrospinal  fluid  flows 
out,  the  stream  being  increased  at  each  expiration.  Absence  of  pulsation 
of  the  brain  points  to  abscess  or  tumor,  and  a  n\"id  color  indicates  subcortical 
growth.  An  old  laceration  is  brownish.  If  the  brain  bulges  through  the 
opening,  it  means  increased  pressure  (tumor,  abscess,  effusion  into  the  ven- 
tricles, etc.).  After  opening  the  dura  employ  no  antiseptics,  especially  when 
the  surgeon  intends  using  electricity  to  locate  a  center.  Irrigate  only  by 
warm  salt  solution.  In  operating  for  tumor  the  dura  is  opened  and  in  some 
cases  the  brain  is  incised.      The  tumor  is  turned  out  by  the  finger  or,  if  this 


Fig.  534. — 51io\'.ing   terminal  and  connection  of  Cushing's  electrode   (|  natural  size).     Instrument 
should  be  i6  inches  or  more  in  length. 

is  impossible,  by  the  dr}-  dissector,  the  scissors,  the  dull  knife,  or  the  sharp 
spoon.  If  the  entire  tumor  cannot  be  removed,  it  is  sometunes  proper  to 
take  away  as  much  as  possible.  The  removal  of  a  portion  may  retard  the 
growth  of  the  remainder,  and  the  trephining,  by  lessening  cerebral  pressure, 
may  relieve  the  s}Tnptoms  and  prolong  life.  After  remcning  a  tumor  ar- 
rest distinct  points  of  bleeding  by  ligatures  or  by  suture-Hgatures.  Pack 
the  timior  ca\-ity  T^ith  gauze  and  bring  the  end  of  the  strand  out  of  the 
wound.  Stitch  the  dura  with  silk  and  suture  the  scalp  ^viih  silkworm-gut. 
In  electrif}dng  the  brain  faradism  is  employed  of  a  strength  about  suf- 
ficient to  move  the  fibers  of  the  exposed  temporal  muscle.  The  best  elec- 
trode is  that  of  Gushing  (Fig.  534).  It  is  a  "glass  -unipolar  electrode  carr}-- 
ing  a  fine  platinum  -^ire  core,  coiled  into  a  spiral  at  the  end"  (Gushing,  in 
"Keen's  Surger\',"  vol.  iii).  The  other  pole  is  attached  to  an  extremity, 
"preferably  on  the  homolateral  side."  During  the  electrical  test  the  patient 
must  not  be  deeply  anesthetized.  A  careful  observer  watches  the  muscular 
movements.  If,  for  instance,  the  surgeon  vi-ishes  to  remove  the  thumb  center, 
he  moves  the  electrode  from  pomt  to  point  imtil  he  obtains  thumb  movements. 
The  region  is  sliced  away  bit  by  bit  until  the  center  which  is  responsible  for 
the  conclusive  movements  is  removed.  It  ^dll  be  found  impossible  to  remove 
onlv  the  thimib  center.  Adjacent  centers  are  sure  to  be  more  or  less  damaged, 
and  a  certain  amount  of  paralysis  follows  the  operation.  If  we  wish  to  tap  the 
ventricles,  Keen  directs  the  trephine  opening  to  be  li  inches  behind  the  external 


830 


Diseases  and  Injuries  of  the  Head 


auditory  meatus  and  the  same  distance  above  the  base-line  of  Reid  (Fig.  535,  a). 
A  grooved  director  or  metal  tube  is  passed  into  the  brain  in  the  direction  of  a 
point  "2I  to  3  inches  above  the  opposite  meatus."  The  normal  ventricle  will 
be  entered  at  a  depth  of  2  to  2  ^  inches,  but  the  dilated  ventricle  will  be  en- 
tered sooner.  The  moment  of  entry  is  marked  by  lessened  resistance  and  a 
flow  of  cerebrospinal  fluid.  Drainage  can  be  maintained  by  introducing  a 
rubber  tube.  This  operation  has  been  employed  in  hydrocephalus.  Kocher 
punctures  the  ventricle  2I  cm.  from  the  midline  and  3  cm.  in  front  of  the 
fissure  of  Rolando.  After  an  aseptic  cerebral  operation,  as  a  rule,  do  not  drain 
unless  hemorrhage  has  been  considerable.  In  many  cases  after  trephining 
replace  the  bone,  but  not  when  the  bone  is  diseased,  is  infected,  is  very  com- 
pact, or  if  we  desire  to  alter  pressure. 


Fig.  535. — Opening  the  mastoid  antrum  and  the  lateral  sinus;  exposure  of  the  temporosphenoidal' 
lobe  and  puncture  of  the  descending  horn  of  the  lateral  ventricle:  a,  Temporosphenoidal  lobe  (de- 
scending comu  of  lateral  ventricle  is  i  cm.  deeper);  b,  inner  surface  of  periosteum;  c,  mastoid  antrum; 
d,  lateral  sinus  (Kocher). 

Operation  for  Mastoid  Suppuration. — Place  a  sand-bag  under  the  neck. 
An  incision  is  made  J  inch  posterior  to  the  auricle  and  down  to  the  bone, 
and  in  the  direction  of  the  long  axis  of  the  mastoid.  The  bone  is  bared 
and  examined,  especially  at  a  point  in  the  line  of  the  incision,  which  is  on  a 
level  with  the  roof  of  the  meatus  (Fig.  535,  c).  The  bone  will  usually  be 
found  softened.  Gouge  it  away  and  thus  open  the  mastoid  antrum.  The 
bone-opening  is  within  the  limits  of  Macewen's  suprameatal  triangle,  a  space 
bounded  by  the  posterior  root  of  the  zygoma,  the  posterior  bony  wall  of  the 
meatus,  and  an  imaginary  line  joining  the  two.  If  the  mastoid  is  opened  in  this 
triangle  the  antrum  is  entered  directly  and  there  is  no  chance  of  wounding 
the  lateral  sinus.  If,  in  the  adult,  pus  is  not  found  on  opening  the  mastoid 
antrum,  gouge  downward  and  backward,  but  with  great  care,  so  as  to  avoid  the 


The  Decompression  Operation  831 

lateral  sinus.  If  there  be  any  possibility  of  the  existence  of  pus  in  the  groove 
of  the  sinus,  the  sinus  should  be  unhesitatingly  exposed.  After  evacuating 
the  pus  from  the  mastoid,  gouge  away  bony  septa,  enlarge  the  opening  be- 
tween the  mastoid  and  the  middle  ear  with  the  gouge  and  remove  the  superior 
half  of  the  posterior  bony  wall  of  the  meatus  (avoid  the  facial  nerve  on  the 
floor  of  the  meatus),  turn  the  head  toward  the  side  operated  upon,  and  irri- 
gate the  mastoid  with  salt  solution,  dust  with  iodoform,  pack  with  iodoform 
gauze  for  a  few  days,  and  then  introduce  a  silver  drainage-tube.  Treat  the 
causative  ear  disease.  Sheild  and  Macewen  operate  on  inveterate  cases  of 
mastoid  disease  as  follows:  A  thick  flap  is  raised  behind  the  auricle,  the  flap 
including  the  orifice  of  any  sinus  and  being  "left  attached  by  its  stalk."  The 
auricle  is  "detached  forward  and  the  soft  parts  over  the  mastoid  are  turned 
backward  by  horizontal  incision."  The  "lining  membrane  of  the  canal  is  sep- 
arated from  the  bone. ' '  The  mastoid  is  opened  and  dead  bone  and  caseous  matter 
are  removed,  overhanging  edges  are  chiseled  down,  and  the  posterior  bony 
wall  of  the  external  auditory  meatus  is  gouged  away.  The  skin-flap  is  pushed 
into  the  cavity  and  is  held  in  place  by  pads  of  gauze.  The  margins  of  the 
flap  may  be  sutured,  but  this  is  not  necessary.  Macewen  calls  this  procedure 
"papering"  the  cavity  with  skin.^ 

If  mastoid  suppuration  has  established  abscess  in  the  temp  or  0  sphenoidal 
lobe,  trephine,  i  j  inches  behind  and  i  ^  inches  above  the  middle  of  the  external 
meatus  (Barker's  point),  and  search  for  pus  as  directed  on  page  804.  If  abscess 
of  the  cerebellum  exists,  trephine  below  the  line  of  the  lateral  sinus.  "The  posi- 
tion of  the  lateral  sinus  is  indicated  by  a  line  running  horizontally  outward  from 
the  occipital  protuberance  to  within  about  i  inch  of  the  external  auditory 
meatus,  and  thence  downward  to  the  mastoid  process"  (Owen's  "Manual  of 
Anatomy").  If  infective  sinus-thrombosis  exists,  break  into  the  lateral  sinus 
(Fig.  535,  d)  from  the  mastoid  opening  and  proceed  as  directed  on  page  807. 

Linear  Craniotomy. — Make  a  large  flap.  Trephine  the  skull  a  finger's 
breadth  from  the  sagittal  suture,  and  the  same  distance  back  of  the  coronal 
suture.  Rongeur  the  bone  away  in  a  line  parallel  with  the  sagittal  suture 
and  a  safe  distance  from  the  longitudinal  sinus,  up  to  a  point  in  front  of  the 
lambdoidal  suture.  Remove  the  pericranium  which  covered  the  bone  excised. 
Insert  the  dural  separator  or  pass  it  along  the  margins.  In  some  cases 
an  additional  portion  of  the  bone  is  removed  over  the  fissure  of  Rolando. 
Various  suggestions  have  been  made  as  to  the  direction  and  situation  of  bone- 
sections.    Bleeding  is  arrested  and  the  flap  is  closed  without  drainage. 

Removal  of  Gasserian  Ganglion. — (See  page  766.) 

Operation  for  Infective  Sinus- thrombosis. — (See  page  807.) 

The  Decompression  Operation  (Decompressive  Trephining)  .—This  opera- 
tion is  employed  particularly  in  cases  of  inoperable  brain  tumor.  It  differs 
from  palliative  trephining  in  the  fact  that  the  dura  is  incised  and  an  opening 
left  to  permit  of  bulging  of  the  brain.  The  bulging  reheves  pressure.  By 
Cushing's  method  we  get  a  hernia  of  the  brain,  but  not  a  fungus  cerebri.  I 
have  followed  Cushing's  recommendation  in  tumors,  and  have  used  it  in  frac- 
tures of  the  base  of  the  skuU,  and  I  beheve  it  often  saves  vision  and  fife  (in  the 
latter  condition  it  is  done  on  both  sides). 

Gushing  and  Bordley  have  performed  it  in  cases  of  uremia  and  improve- 
ment has  followed  ("Amer.  Jour.  Med.  Sciences,"  Oct.,  1908).  They  sug- 
gest that  the  operation  be  used  in  certain  cases  of  renal  disease  when  medical 
treatment  and  limibar  puncture  have  fafled  to  abate  uremic  symptoms,  or 
when  blindness  is  impending.     It  has  been  used  in  apoplexy. 

The  effect  of  the  operation  in  cases  of  brain  tumor  is  sometimes  extra- 
ordinary.   Its  most  prominent  benefit  is  in  abolishing  choked  disk.    It  must 

1  "Lancet,"  Feb.  8,  1896. 


S32 


Diseases  and  Injuries  of  the  Head 


not  be  done  directly  over  a  tumor,  because  the  bulging  tumor  might  become 
the  seat  of  hemorrhage.  It  may,  however,  be  done  near  the  tumor  (see  page 
820). 

It  is,  of  course,  useless  in  relieving  blindness,  for  blindness  means  atrophy, 
but  it  is  often  very  valuable  in  preventing  blindness.  When  choked  disk  exists 
operation  should  be  done  early  even  if  there  is  good  vision.  If  in  advanced 
cases  any  sight  remains,  it  should  be  performed.  Now  and  then  there  is  an  un- 
favorable result,  for  instance,  the  development  of  retinal  hemorrhages  or  the  loss 
of  vision,  which  was  good  previous  to  operation.  (See  deSchweinitz  and  Hol- 
loway  on  "Operative  Treatment  of  Papillo-edema  Dependent  Upon  Increased 
Intracranial  Tension,"  "Therapeutic  Gazette,"  July  15,  1909.)  The  perma- 
nence of  the  relief  to  the  choked  disk  is  variable.    It  is  not  always  permanent. 

Cushing's  subtemporal  decompression  is  done  upon  the  right  side,  as  a  rule, 
but  in  some  cases  on  the  left  side.    An  objection  to  doing  it  on  the  left  side  is 


Fig.  536.- 


-Sketch  of  the  intermusculotemporal  field  of  operation,  showing  exposure  with  subtemporal 
bone  defect  partly  made  (Gushing,  in  "Keen's  Surgery"). 


that  the  bulging  of  the  left  temporosphenoidal  lobe  may  cause  word-deafness. 
A  curved  incision  is  made  through  the  skin  and  subcutaneous  tissue,  the  flap 
is  turned  down,  the  temporal  fascia  is  incised  in  the  direction  of  the  muscle- 
fibers  beneath  it,  the  temporal  muscle  is  split  and  not  cut,  the  periqsteimi  is 
separated  from  the  bone,  the  soft  parts  are  retracted,  the  bone  is  opened  as  the 
surgeon  prefers,  and  the  opening  is  enlarged  by  a  rongeur  (Fig.  536).  The 
dura  is  opened  and  radiating  incisions  are  made  through  it  toward  the  edges 
of  the  bone  gap.     The  wound  is  closed  by  four  layers  of  fine  silk  sutures. 

Figure  537  exhibits  the  exposure  for  suboccipital  depression  as  done  for 
subtentorial  tumors.  The  same  exposure  is  obtained  in  order  to  remove  a 
cerebellar  tumor. 

Drainage  of  the  Cistema  Magna  (Haynes's  Operation). — An  incision  is 
made  in  the  middle  line  from  the  occipital  protuberance  to  the  posterior  arch 


Methods  of  Reaching  the  Pituitary  Body 


833 


of  the  atlas.  The  periosteum  is  strii:)ped  from  a  portion  of  the  occipital  bone  at 
and  above  the  foramen  magnum.  The  bone  is  trephined  and  is  cut  away  into 
the  foramen  magnum.  The  occipital  sinus  may  not  be  present.  If  present 
as  a  double  sinus,  incise  the  dura  between  the  two  sinuses.  If  there  is  one  sinus, 
divide  the  dura  between  two  ligatures.  Open  the  dura  and  arachnoid  by  a  very 
small  incision.  As  soon  as  excess  of  fluid  has  escaped  enlarge  the  incision.  By 
lifting  and  separating  the  cerebellar  lobes  the  surgeon  can  determine  if  the 
foramen  of  Magendie  is  patent.  Gutta-percha  tissue  is  used  as  a  drain.  The 
muscles  are  sutured  together  by  catgut.    The  skin  is  closed  below  the  drain 


Fig.  537. — ^The  suboccipital  exposure,  showing  opening  partly  made  and  Cushing's  "cross-bow"  incision 

(Gushing,  in  "Keen's  Surgery"). 

by  silkworm-gut   (abbreviated  from  Haynes's  description  in  "The    Laryn- 
goscope," June,  1912). 

Methods  of  Reaching  the  Pituitary  Body. — The  subtemporal  route  was  sug- 
gested by  Carton  and  Paul.  Horsley  has  operated  in  this  way.  The  bone  is 
removed  from  the  subtemporal  region,  the  dura  is  opened,  the  brain  is  lifted, 
the  dural  box  of  the  hypophysis  is  incised.  It  may  be  necessary  to  remove  bone 
from  each  subtemporal  region  and  raise  the  brain  from  both  sides.  Borchardt 
performed  osteoplastic  frontal  resection,  ligated  the  superior  longitudinal 
sinus,  and  lifted  the  brain. 
53 


834 


Diseases  and  Injuries  of  the  Head 


Giordano  suggested  a  transsphenoidal  operation,  and  Schloffer  improved 
his  method.  Schloffer  freed  the  nose  so  as  to  turn  it  toward  the  right  side  and 
then  excised  the  turbinates,  orbital  wall,  maxillary  sinus,  the  middle  septum, 
the  left  nasal  process  of  the  superior  maxillary,  and  the  ethmoid  cells  (Gushing, 
"The  Pituitary  Body  and  Its  Disorders").  In  the  inferior  route  of  Kanavel 
most  of  these  structures  are  preserved  and  the  incision  is  within  the  mouth. 

McArthur  ("Jour.  Amer.  Med.  Assoc,"  June  29,  191 2)  trephines  the  frontal 
eminence  of  one  side  4  cm.  above  the  supra-orbital  notch  and  preserves  the 
button  in  warm  salt  solution.  By  means  of  the  DeVilbiss  forceps  and  the 
chisel  he  cuts  away  a  bone-fragment,  which  brings  with  it  a  considerable  part 
of  the  roof  of  the  orbit.  This  fragment,  too,  is  placed  in  warm  salt  solution. 
The  rest  of  the  orbital  roof  is  cut  away  by  a  rongeur.  The  dura  covering  the 
inferior  surface  of  the  frontal  lobe  is  separated  from  the  bone,  while  the  lobe  is 
raised  and  the  orbital  contents  are  held  out  of  the  way.    Between  the  clinoid 


Fig-  538. — Homer  B.  Smith's  head-rest  for  operations  upon  the  cerebellum  (modified  by  William  J. 

Taylor) . 

processes  the  dura  is  divided  by  Krause's  hook-shaped  knife.  An  enlarged 
hypophysis  will  now  be  accessible.  At  the  conclusion  of  the  operation  on  the 
hypophysis  the  bone-fragments  are  replaced.  Frazier  has  modified  McArthur's 
operation  ("Annals  of  Surgery,"  Feb.,  1913). 

The  Combined  Method  of  Harvey  Gushing  (From  Gushing's  "The  Pitui- 
tary Body  and  Its  Disorders"). — This  surgeon,  whose  experience  is  very  large, 
operates  as  follows:  Intratracheal  anesthesia.  Place  the  patient  with  the 
shoulders  slightly  raised  so  that  the  head  drops  back.  Pack  the  posterior  nares 
with  a  sea-sponge.  Insert  cotton  wet  with  adrenalin  in  each  nostril.  Lift 
the  upper  lip.  Make  a  transverse  incision  across  the  frenum,  and  carry  it  down 
to  the  anterior  nasal  spine.  By  blunt  dissection  raise  the  soft  parts  on  each 
side  from  the  inferior  margin  of  the  osseous  nasal  opening  until  the  cartilaginous 
septimi  is  exposed.  From  now  on  the  operation  is  submucous.  Separate  the 
membrane  on  each  side  from  the  bony  and  cartilaginous  septum.  Introduce 
a  retractor  on  each  side  between  the  separated  mucous  membrane  and  the 
septum.    Separate  the  blades  of  the  instrument.    Remove  "rnost  of  the  vomer, 


Congenital  Deformities  835 

the  lower  edge  of  the  median  plate  of  the  ethmoid,  and  a  small  strip  of  cartilage." 
It  may  be  necessary  to  remove  by  means  of  a  rongeur  the  anterior  maxillary 
spine.  With  the  retractors  retained,  a  series  of  dilating  plugs  are  introduced. 
These  "flatten  the  turbinates."  The  largest  dilator  has  a  diameter  of  1.8  cm. 
The  retractors  are  removed  and  a  bivalve  speculum  is  inserted.  An  electric 
head-light  must  now  be  used.  It  may  now  be  found  necessary  to  remove 
"the  prow  of  the  vomer." 

The  body  of  the  sphenoid  is  identified  and  "the  anterior  and  lower  walls 
of  the  sinuses  are  chipped  away  with  long-handled  nasal  rongeurs."  The 
lining  of  mucous  membrane  is  removed,  when  the  protrusion  of  the  sella  can  be 
identified.  The  floor  of  the  pituitary  fossa  is  then  clipped  away.  The  dural 
case  of  the  gland  (or  tumor)  is  divided  by  a  hook-shaped  knife. 

Removal  of  the  entire  anterior  lobe  must  never  be  done,  as  this  lobe  is 
necessary  to  life. 


XXV.  SURGERY   OF  THE   SPINE 

Congenital  Deformities. — Myelocele  or  Rachischisis. — This  condition 
is  due  to  deficiency  in  the  formation  of  the  vertebral  arches,  the  cord  being 
rudimentary,  the  medullary  plates  having  failed  to  coalesce,  the  central 
canal  not  having  formed,  and  the  endotheliimi  which  should  line  it  being 
exposed.  If  the  entire  cord  is  involved,  the  condition  is  called  amyelia  or 
total  rachischisis.  If  a  part  of  the  cord  is  involved,  the  condition  is  called 
partial  rachischisis.  In  partial  rachischisis  a  portion  of  skin  is  absent  in  the 
midline.  At  this  area  is  a  circular,  dark-red  focus  surrounded  by  a  very  thin 
and  glistening  membrane  which  becomes  continuous  with  the  skin.  A  dimple 
at  the  upper  part  and  a  dimple  at  the  lower  part  of  the  dark  area  indicates  the 
situation  of  the  central  canal  above  and  below.  Victims  of  rachischisis  are 
usually  stillborn  or,  at  most,  live  but  a  few  days. 

Spina  Bifida. — This  is  a  deformity  similar  to  the  one  just  discussed,  but 
in  it  the  cord  is  much  more  developed.  The  first  accurate  description  of  it 
was  given  by  Tulpius  in  1685.  It  is  a  congenital  sac  of  fluid  due  to  vertebral 
deficiency,  permitting  protrusion  of  the  contents  of  the  spinal  canal  in  the 
median  line.  In  this  condition  the  cutaneous  epiblast  is  adherent  to  the  spinal 
exiblast,  because  structures  from  the  mesoblast  have  failed  to  grow  between. 
The  laminae  or  spines  of  one  vertebra  or  of  several  vertebras  or  of  many  vertebrae 
may  be  deficient,  most  frequently  in  the  lumbosacral  region.  In  very  rare 
cases  there  is  division  of  the  vertebral  bodies  and  the  projection  is  forward  and 
to  the  side.  A  case  in  which  there  are  ununited  laminae  but  no  protrusion  is 
called  spina  bifida  occulta.  Sometimes  there  are  two  protrusions  in  one  person. 
In  spina  bifida  the  dura  does  not  cover  the  sac  because  it  is  cleft  as  well  as  the 
laminae.  There  are  three  distinct  varieties  of  spina  bifida:  i.  Meningocele. 
In  this  condition  the  dura  is  cleft  (Hildebrand) ,  there  is  a  protrusion  of  the 
arachnoid,  fluid  gathers  in  the  arachnoid  meshes  and  "distends  this  so  as  to 
form  one  continuous  cavity  which  is  traversed  by  nerve-roots"  (Henle,  in  "A 
System  of  Practical  Surgery,"  by  von  Bergmann,  Bruns,  and  von  MikuHcz. 
Translated  and  edited  by  Wm.  T.  BuU  and  Carlton  P.  Flint).  The  cord  is  not 
in  the  sac.  2.  Meningomyelocele  (the  commonest  form)  is  a  protrusion  of 
arachnoid,  the  sac  containing  cerebrospinal  fluid,  nerves,  and  cord-substance. 
The  cord  may  spread  upon  the  sac  wall  or  it  may  pass  through  the  sac  and  re- 
enter the  canal.  A  cutaneous  dimple  or  furrow  indicates  that  the  cord  is  at- 
tached and  hence  is  within  the  sac.  3.  Syringomyelocele  is  great  distention 
of  the  central  canal,  the  sac  wall  being  formed  of  the  thinned  cord  and  the  spinal 
membranes.    A  spina  bifida  varies  in  size  from  that  of  a  walnut  to  that  of 


836  Surgery  of  the  Spine 

an  infant's  head;  it  grows  rapidly  during  the  early  weeks  of  life;  it  is  usually 
sessile,  but  may  present,  where  it  joins  the  body,  a  definite  constriction  or 
even  a  pedicle,  the  base  of  the  sac  is  covered  with  healthy  skin,  and  the  fundus 
is  covered  only  by  thin  epidermis  or  by  the  spinal  membranes  themselves. 
Pressure  upon  the  tumor  may  diminish  its  size  and  increase  the  tension  of  the 
anterior  fontanel,  and  possibly  cause  convulsions  or  stupor.  The  cyst  is 
translucent  and  the  margins  of  the  bony  aperture  are  distinct.  Crying, 
coughing,  or  pressure  upon  the  anterior  fontanel  makes  the  tumor  more 
tense.  Spina  bifida  is  apt  to  be  associated  with  club-foot,  with  hydrocephalus, 
and  with  rectal  or  vesical  paralysis.  Spina  bifida  usually  causes  death  (90 
per  cent,  of  cases  die  during  the  first  year  of  life).  A  few  meningoceles  and  a 
very  few  meningomyeloceles  undergo  spontaneous  cure  by  growth  of  the 
vertebral  arches  constricting  the  neck  of  the  sac.  The  sac  may  remain  dis- 
tended with  fluid  or  may  shrink.  Syringomyelocele  is  invariably  fatal.  The 
cause  of  death  may  be  rupture  of  the  sac  or  marasmus.  The  r^c-rays  show  the 
bony  gap.  Spina  bifida  occulta  is  a  cleft  in  the  vertebral  column  without  any 
protrusion  of  the  cord  or  the  membranes.  In  this  condition  there  is  usually 
a  profuse  growth  of  hair  in  the  skin  over  the  bony  gap  and  the  hairy  condition 
may  be  much  more  widespread.  In  some  cases  the  hair  is  present  at  birth; 
in  others  it  appears  at  puberty.  Trophic  changes  and  deformities  may  exist 
in  the  lower  extremities. 

Treatment. — Very  small  protrusions  which  grow  slowly  and  are  covered 
with  sound  skin  may  be  treated  by  the  use  of  a  compress  and  bandage,  by  an 
elastic  bandage,  or  by  applications  of  contractile  collodion.  It  was  formerly 
regarded  as  proper  to  tap  and  drain  the  sac.  Injection  was  used  by  many. 
The  skin  being  cleansed,  the  child  was  placed  on  its  side  and  a  little  chloroform 
was  given.  A  fine  trocar  was  plunged  obliquely  in  at  the  side  of  the  sac  through 
sound  skin,  little  or  no  fluid  being  drawn  off,  and  i  dram  of  Morton's  fluid  in- 
jected (iodin,  10  gr.;  iodid  of  potassium,  30  gr. ;  glycerin,  i  oz.).  The  trocar 
was  withdrawn  and  the  puncture  was  sealed  with  a  bit  of  gauze  and  iodoform 
collodion.  The  child  was  put  to  bed.  If  injection  proved  successful,  the  sac 
was  found  to  shrink;  if  the  injection  failed,  it  was  the  custom  to  repeat  it  at 
intervals  of  from  seven  to  ten  days  (Jacobson,  White).  Surgeons  now  prefer 
excision  of  the  sac  (see  page  859).  Whenever  possible  the  incision  should  be 
through  healthy  skin.  If  the  sac  contains  nerves  they  should  be  placed  within  the 
canal.  Bayer  treats  it  as  he  would  a  hernia.  Robson  in  some  cases  excises  the 
entire  sac.  Operations  upon  children  much  under  the  age  of  five  have  an  enorm- 
ous mortality.  Operations  are  comparatively  safe  when  the  child  reaches  the  age 
of  five.  Operations  for  spina  bifida  have  been  done  successfully  immediately 
after  birth  (Lovett,  in  "Amer.  Jour.  Orthop.  Surg.,"  Oct.,  1907).  We  should 
not  operate  if  there  is  hydrocephalus  or  extensive  paralysis,  if  the  mass  is  very 
large  and  growing  rapidly,  or  if  there  are  other  marked  deformities.  A  rup- 
tiu"ed  sac  should  be  operated  on  at  once,  otherwise  death  is  practically  certain. 

Sacrococcygeal  Tumors. — Dermoids  external  to  the  sacrum  are 
occasionally  seen  in  this  region.  Dermoids  also  arise  between  the  rectum  and 
sacrum.  In  the  lower  sacral  or  coccygeal  region  the  cutaneous  structures 
sometimes  fail  of  complete  coalescence  and  a  postanal  dimple  or  sinus  is  the 
result.  Such  a  sinus  is  lined  with  skin  and  its  wall  contains  numerous  glands 
and  often  hairs.  It  may  inflame  or  suppurate.  If  it  blocks  up  at  the  outlet, 
a  form  of  dermoid  develops.  Teratomata,  lipomata,  and  hydatid  cysts  may 
develop  in  the  sacrococcygeal  region. 

Treatment. — Dermoids  require  extirpation.  If  a  postanal  dimple  causes 
no  trouble,  it  islet  alone;  otherwise  it  should  be  dissected  out.  It  mayor 
may  not  be  possible  to  remove  teratomata.  Lipomatq,  and  hydatids  are 
extirpated. 


Extramedullary  Tumors  837 

Anosacral  Cysts. — These  cysts  develop  between  the  sacrum  and  rec- 
tum and  originate  from  remnants  of  the  postanal  gut  and  neurenteric  canal. 
Such  cysts  may  be  multilocular  or  unilocular.  They  can  be  detected  by  a 
finger  in  the  rectum. 

Treatment. — Some  of  these  growths  are  removed  after  osteoplastic  resec- 
tion of  a  portion  of  the  sacrum;  others  are  removed  by  incising  the  rectal 
wall. 

Tumors  of  the  Spinal  Cord. — Tumors  may  arise  from  the  cellular 
tissue,  fatty  tissue,  the  nerve-roots,  the  membranes  of  the  cord,  or  from  the 
vertebra  {extra medullary  tumors).  They  may  arise  within  the  cord  (cord 
tumors  proper  or  intramedullary  tumors). 

Extramediillary  Tumors. — S>-philomata,  hydatid  cysts,  tuberculomata, 
and  inflammatory  masses  or  adhesions  may  compress  the  cord  and  produce 
s}Tnptoms  indistinguishable  from  genuine  tumor.  Among  extramedullary 
tumors  are  secondary  carcinoma,  sarcoma  (primary  or  secondar}^),  fibroma, 
myxoma,  lipoma,  chondroma,  and  neuroma.  Dermoid  sacral  cysts  ma}^  exist. 
Lipoma,  fibroma,  and  certain  cysts  may  be  congenital.  Injury  of  the  back 
sometimes  seems  to  bear  a  causal  relation  to  extramedullar}^  tumors. 

The  symptoms  are  due  to  pressure  upon  nerve-roots  and  the  cord.  The 
most  prominent  symptoms  are  pain  in  the  back  and  evidences  of  nerve-root 
irritation. 

The  early  or  irritative  symptoms  are  pain  and  stiffness  of  the  back,  usually 
very  severe  and  interfering  with  sleep,  shooting  pains  in  the  area  of  the  im- 
pUcated  nerve-roots,  and  sensory  abnormalities  in  the  same  area.  There  may 
be  hyperesthesia  of  a  limited  area.  The  area  of  distribution  from  one  or  two 
roots  is  involved  in  pain,  sensor}^  disturbance,  and  slight  motor  impairment. 
In  some  cases  the  ner\^e-roots  of  one  side  only  exhibit  irritation  and  the  s\Tnp- 
toms  are  strictly  unilateral.  In  other  cases  the  s}Tnptoms  are  bilateral,  but 
are  most  marked  on  one  side.  In  some  cases  the  s}Tnptoms  are  s\Tnmetrically 
bilateral  and  indicate  pressure  upon  the  cord  rather  than  upon  nerve-roots. 
Muscular  spasms  may  occur.  There  may  be  lateral  ciu"vature  of  the  back,  the 
conca^dty  of  the  curve  being  on  the  side  of  the  tiunor.  Sooner  or  later  para- 
lytic s}Tnptoms  come  on  (motor  and  sensor}'  paralysis).  They  may  be  due  to 
pressvire  upon  and  destruction  of  nerve-roots  or  to  compression  of  the  cord. 
When  anesthesia  exists  there  may  be  a  zone  of  h^-peresthesia  above  its  upper 
limit.  As  motor  palsy  develops  from  root  compression  the  pain  usually  abates. 
The  muscles  undergo  atrophy. 

A  timior  may,  by  cord  pressiu"e,  produce  the  s>Tnptoms  of  compression- 
myelitis,  locomotor  ataxia,  or  myelitis.  Contractures  or  paraplegia  may  arise 
from  tumor.  The  location  of  the  growth  can  be  inferred  by  a  study  of  the  terri- 
tory of  paralysis  and  the  zone  of  sensor\'  disturbance.  The  tumor  is  always 
situated  somewhat  above  the  upper  limit  of  anesthesia.  In  many  cases  the 
diagnosis  is  impossible.  Gradually  increasing  painful  paraplegia,  with  pain  in 
the  back  and  with  hyperesthesia  or  anesthesia  after  a  time  appearing  and  as- 
cending from  the  feet  toward  the  trunk,  points  to  tumor  as  a  cause.  The  paral- 
ysis is  usually  spastic,  but  may  be  flaccid,  or  it  may  be  spastic  at  first  and  be- 
come flaccid.  In  spastic  paraplegia  the  reflexes  are  increased.  In  flaccid  para- 
plegia they  are  decreased.  In  spastic  paraplegia  there  are  ankle  clonus,  the 
Babinski  sign  (extension  of  the  great  toe  or  all  the  toes  when  the  sole  of  the  foot 
is  irritated),  Gordon's  paradoxical  reflex  (extension  of  the  great  toe  or  aU  the  toes 
when  pressure  is  made  upon  the  deep  calf  muscles),  and  Oppenheim's  reflex 
(extension  of  the  great  toe  or  all  the  toes  when  the  handle  of  the  percussion 
hammer  is  drawn  along  the  inner  edge  of  the  tibia  so  as  to  make  pressure 
from  above  downward).  Trophic  lesions  are  apt  to  arise  in  the  trajectorA-  of 
nen,-e  involvement.     The  sphincters  are  usually  involved.     Growths  outside 


838  Surgery  of  the  Spine 

the  membranes  produce  particularly  pain  and  spasm;  growths  within  the  mem- 
branes produce  especially  motor  paralysis  and  anesthesia.  Symptoms  that 
are  unilateral,  were  at  first  unilateral,  or  which  are  most  marked  on  one  side, 
are  very  signiiicant. 

Intramedullary  Tumors. — These  tumors  develop  in  the  substance  of  the 
cord.  They  are  far  less  common  than  extramedullary  growths  and  are  more 
often  benign.  These  growths  are,  as  a  rule,  primary  and  solitary  and  do  not 
produce  symptoms  of  pressure  until  they  attain  the  size  of  a  hazelnut.  The 
most  common  tumors  are  glioma,  sarcoma,  and  tuberculoma.  Syphiloma  occa- 
sionally arises.  Most  tumors  in  cord-substance  are  small,  but  the  glioma  may 
involve  practically  the  entire  cord.  A  tumor  is  often  for  a  time  limited  to  one 
side  of  the  cord,  but  later  it  presses  upon  and  finally  involves  the  opposite 
side.  When  the  cord  is  pressed  upon,  degeneration  occurs.  In  some  cases  a 
wrench  or  bruise  of  the  back  is  supposed  to  be  causal.  Glioma  may  be 
congenital. 

Symptoms. — ^They  are  at  first,  in  most  cases,  very  uncertain.  In  some 
cases,  however,  paralysis  develops  early. 

There  is  often  pain  in  the  back,  but  it  is  not  nearly  so  severe  as  in  extra- 
medullary  tumor.  The  most  prominent  symptom  is  a  slow-developing  motor 
palsy.  In  some  cases  the  palsy  is  at  first  unilateral,  but  later  becomes  bilateral. 
Irritative  root  symptoms  are  absent  (spasm  and  darting  pain).  Anesthesia  or 
hyperesthesia  develop.  The  sphincters  are  involved  and  trophic  disturbances 
arise.  There  may  be  spastic  paraplegia  or  flaccid  paraplegia.  If  the  tiunor 
is  in  or  presses  upon  the  anterior  cornu  there  will  be  limited  muscular  atrophy. 
Tuberculoma  produces  the  symptoms  of  transverse  myelitis. 

In  glioma  there  are  paresis  and  muscular  atrophy.  Although  sensibility 
to  pain,  heat,  and  cold  are  lost,  sensibility  to  touch  is  preserved  (sensory  dis- 
sociation) . 

Treatment  of  Tumors  of  the  Cord. — If  syphilis  is  suspected,  give  the 
patient  a  course  of  heroic  doses  of  iodid  of  potassium,  and  administer  mer- 
cury hypodermatically  or  by  inunction.  Intravenous  injection  of  salvarsan 
is  advisable.  In  a  focal  lesion  not  due  to  dissemination  of  a  known  malig- 
nant growth,  perform  the  operation  of  laminectomy  to  permit  of  explora- 
tion and  possibly  of  removal.  The  laminae  of  at  least  three  vertebrae  should 
be  removed  and  the  tumor  looked  for  distinctly  above  the  upper  level  of 
the  zone  of  anesthesia.  It  is  not  necessary  for  the  patient  to  wear  a  spinal 
support  after  the  performance  of  laminectomy.  Extramedullary  tumors  are 
usually  removable.  Localized  intramedullary  tumors  should  be  removed  if 
they  can  be  located  and  if  removal  can  be  accomplished  without  serious  injury 
to  the  cord.  After  exposing  the  cord  and  discovering  an  intramedullary  tumor, 
follow  the  advice  of  Elsberg  and  Bier  ("Amer.  Jour.  Med.  Sciences,"  Nov., 
191 1 )  and  make  a  short  incision  in  the  posterior  median  column  a  little  external 
to  the  posterior  median  fissure.  The  cut  reaches  the  tumor,  which  bulges 
through  it.  Do  not  attempt  removal  now.  Suture  the  skin  and  muscles  and 
wait  one  week.  On  opening  the  wound  the  tumor  will  be  found  almost  com- 
pletely extruded  from  the  cord.  In  order  to  remove  it  it  is  only  necessary  to 
divide  a  few  strands  of  tissue.  Extrusion  by  this  method  probably  inflicts 
little  injury  upon  nerve-fibers.  McCosh  truly  said  that  operation  for  spinal- 
cord  tiunor  was  decidedly  more  hopeful  than  for  brain  tumor,  because  localiza- 
tion was  much  more  accurate  and  removal  could  be  effected  with  less  perma- 
nent damage.  Lloyd  collected  51  operations:  10  per  cent,  died  and  31  per 
cent,  were  actually  cured  or  improved.  Joseph  Collins  ("Med.  Record,"  Dec. 
6,  1902)  collected  70  cases  of  spinal  tumor,  30  of  which  were  operated  upon.  In 
1 2  the  operation  was  a  success,  that  is,  the  pain  disappeared  and  motor  power 
returned;  in  8  the  operation  was  partly  successful,  that  is,  the  pain  disappeared 


Typhoid  Spine  839 

and  the  motor  power  improved;  in  10  the  operation  failed  and  death  occurred 
within  a  few  weeks.  If  the  tumor  is  found  to  be  irremovable,  McCosh  suggests 
division  of  several  nerve-roots  to  relieve  the  pain. 

Acute  osteomyelitis  of  the  vertebrae  is  a  rare  disease;  it  may  be 
associated  with  osteomyelitis  of  other  bones,  may  be  secondary  to  some 
distant  suppurative  focus,  or  may  occur  alone.  Infections  of  the  viscera  not 
imusually  accompany  it.  In  many  cases  there  is  a  history  of  trauma.  Any 
part  of  a  vertebra  may  suffer  from  it.  This  condition  may  follow  cold,  over- 
exertion, or  traumatism,  and  is  more  common  in  the  first  two  decades  of  life 
than  in  elderly  people.  The  process  may  be  superficial  or  it  may  involve  the 
bone  deeply  and  widely.  Suppuration  always  occurs;  sequestra  generally 
form,  and  phlebitis  is  a  dangerous  complication.  Any  region  of  the  spine  may 
be  attacked,  but  the  lumbar  region  is  particularly  liable  to  invasion,  next  the 
dorsal,  next  the  cervical.  The  sacral  region  is  least  often  affected.  The 
situation  of  the  abscess  varies  with  the  situation  of  the  disease.  If  the  verte- 
bral bodies  are  diseased  the  pus  passes  forward  (retropharyngeal,  mediastinal, 
psoas,  or  pelvic  abscess).  If  the  vertebral  arches  suffer  the  pus  passes  back- 
ward (lumbar  or  dorsal  abscess).  The  membranes  of  the  cord,  the  cord  itself, 
the  nerves,  and  the  vertebral  articulations  are  frequently  involved  in  the  proc- 
ess. Staphylococci,  streptococci,  or  other  pyogenic  bacteria  may  be  cultivated 
from  the  pus. 

Symptoms. — The  general  symptoms  are  those  of  osteomyelitis.  The 
local  symptoms  depend  on  the  seat  of  disease.  If  the  posterior  portion  of  the 
column  is  diseased  there  is  a  hard  swelling  which,  in  the  neck,  is  in  the  middle 
line;  in  the  dorsal  and  lumbar  regions,  in  the  middle  or  to  the  side;  and  in  the 
sacral  region,  invariably  to  one  side. 

Rigidity  of  the  spine  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms  appear,  their 
nature  dependent  on  the  region  affected  (retropharyngeal  abscess,  etc.). 
Occasionally  symptoms  of  meningomyelitis  are  noted.  The  constitutional 
symptoms  of  sepsis  are  marked.  The  condition  is  sudden  in  onset,  and  puru- 
lent collections  diffuse  widely  and  rapidly.  These  points  enable  the  surgeon 
to  make  a  diagnosis  between  osteomyelitis  and  Pott's  disease.  In  osteomyelitis 
angular  deformity  very  rarely  arises,  because  the  patient  is  obliged  to  be 
recimibent  and  because  hyperostosis  is  taking  place.  The  mortality,  accord- 
ing to  Hahn,  is  60  per  cent.  Death  may  be  due  to  pachymeningitis,  pneumonia, 
empyema,  retropharyngeal  abscess,  invasion  of  the  cord,  or  amyloid  disease 
(H.  S.  Warren,  "Boston  Med.  and  Surg.  Jour.,"  May  7,  1903). 

Treatment. — The  patient  is  kept  recumbent.  His  constitutional  treat- 
ment is  such  as  will  combat  sepsis  (food,  stimulants,  etc.).  A  puriform  area 
must  be  incised  and  disinfected.  If  bone  denuded  of  periosteum  is  found,  it  is 
touched  with  a  solution  of  chlorid  of  zinc  or  with  the  actual  cautery.  If  a 
sequestrum  exists,  it  is  removed.  A  drainage-tube  is  inserted  and  dressings 
are  appHed  (Miiller,  Makins,  Abbot,  and  Chipault). 

Typhoid  Spine. — It  was  pointed  out  by  Gibney  in  1889  that  typhoid 
fever  may  leave  as  a  legacy  a  painful,  stiff,  and  weak  back;  74  cases  of  the 
condition  have  been  reported  (F.  W.  White,  in  "Jour.  Amer.  Med.  Assoc," 
Feb.  13,  1908).  The  muscles  of  the  back  are  found  to  be  rigid  and  there  is 
tenderness  of  one  or  more  vertebrae.  The  pain  may  only  be  appreciated  on 
motion,  but  in  some  cases  there  is  aching  even  when  the  patient  is  at  rest. 
The  pain  may  be  localized,  may  run  into  one  or  both  thighs,  or  may  be  felt 
in  the  abdomen.  The  symptoms  arise  at  an  uncertain  period  after  the  fever, 
develop  rapidly,  and  are  occasionally  associated  with  transient  episodes  of 
fever.  Kyphosis  or  lateral  curvature  may  develop.  (See  L.  W.  Ely,  "Medical 
Record,"  Dec.  20,1902.)    Many  of  the  patients  are  hysterical.    The  condition 


840 


Surgery  of  the  Spine 


is  due  to  osteitis  and  periosteitis,  or  chronic  osteomyeHtis.  The  prognosis  is 
excellent. 

Treatment. — The  use  of  a  plaster  or  leather  jacket;  counterirritation  by 
the  hot  iron;  later,  massage  and  electricity. 

Cervical  Rib. — This  condition  was  first  described  by  Hunauld  in  1743. 
The  anterior  limb  of  the  transverse  process  of  the  seventh  cervical  vertebra, 
which  has  an  independent  center  of  ossification,  may  develop  into  a  separate 
bone  of  large  size,  known  as  a  cervical  rib.  Such  a  rib  may  form  on  one  side 
or  on  both.  It  may  scarcely  reach  beyond  the  transverse  process,  it  may 
project  w^ell  beyond  the  transverse  process  and  have  a  free  end,  or  it  may  con- 
stitute a  complete  rib  which  fuses  anteriorly  with  the  sternum,  the  cartilage  of 
the  first  rib,  or  with  a  cervical  rib  of  the  opposite  side. 

Most  instances  described  were  found  in  the  dead  body,  although  Tillmanns 
collected  26  cases  among  the  living  (Carl  Beck,  in  "Jour.  Amer.  Med.  Assoc," 
June  17,  1905).     Of  late  .T-ray  findings  indicate  that  the  condition  is  much 


F 


Fig.  539. — Cervical  ribs. 

more  common  than  was  formerly  supposed.  I  have  seen  4  cases.  It  may 
never  produce  any  uneasiness,  and  hence  may  escape  detection  and  seldom 
does  produce  trouble  in  youth.  It  may  lead  to  damage  of  the  subclavian 
artery  (Keen's  case  developed  aneurysm),  or  gangrene  of  the  hand  may  result 
from  bending  or  blocking  of  the  vessel,  or  neuritis  of  the  brachial  plexus  may 
arise  from  pressure.  When  sufiiciently  large  to  produce  venous  or  vascular 
trouble,  a  cervical  rib  can  be  felt  and  the  pulsating  artery  over  it  is  yer}^  dis- 
tinct and  higher  than  natural  in  the  neck.  The  x-rays  confirm  the_  diagnosis. 
The  treatment,  when  the  rib  is  causing  trouble,  is  excision  of  the  rib  with  its 
periosteum  (see  page  707).  (See  Kammerer,  in  "Annals  of  Surgery,"  Nov., 
igoi,  on  "The  Diagnostic  Difficulties.") 

Spinal  Curvature. — There  are  four  chief  forms  of  spinal  curvature: 
(i)  Lateral  cur\^ature  (the  scoliosis  of  the  older  surgeons);  (2)  posterior  cur- 
vature (the  excurvation,  gibbosity,  or  kj-phosis  of  the  older  surgeons);  (3) 


Scoliosis 


841 


anterior  curvature  (the  lordosis  of  the  older  surgeons),  and  (4)  angular  cur- 
vature (from  spinal  caries).  The  normal  spine  has  four  curves:  the  cervical 
curve,  the  convexity  of  which  is  forward;  the  dorsal  curve,  the  convexity  of 
which  is  backward;  the  lumbar  curve,  which  is  convex  anteriorly,  and  the 
pelvic  curve,  which  is  concave  anteriorly.  The  dorsal  and  the  pelvic  curves, 
which  are  primary,  are  due  to  the  formation  of  the  cavities  of  the  chest  and 
peMs,  and  depend  upon  the  shape  of  the  bones  (Treves).  The  cervical  and 
lumbar  curves,  which  are  compensatory,  depend  upon  the  shape  of  the  inter- 
vertebral disks,  and  only  appear  after  birth  when  the  erect  position  is  assimied. 

CONDENSED    DIFFERENTIAL   DIAGNOSIS   TABLE   OF    SPINAL   DISEASES   AND    CONDITIONS 
WITH  WHICH  THEY   MAY  BE   CONFOUNDED. 


Rachitic 

Spine. 

Hyper- 

Arthritis 

Torticol- 

Hip 
Disease. 

Scoliosis. 

Pott's 
Disease. 

esthetic 
Spine. 

Defor- 
mans. 

lis,  Con- 
genital. 

Age. 

8  to  16. 

4  to  6. 

4  to  6. 

16  to  20. 

After  30. 

Any  age. 

4  to  6. 

Onset. 

Insidious. 

Insidious. 

Insidious. 

Sudden. 

Insidious. 

From  birth. 

Insidious. 

Pain. 

In  back. 

None. 

Referred    to 
anterior 
abdomen. 

Severe  in 
spine. 

In  spine. 

None. 

In  knee. 

History. 

None. 

Rachitic. 

Tuberculous. 

Trauma. 

None. 

From  birth. 

Tuberculous. 

Posture. 

Free. 

E.xcessively 

Guarded 

Guarded. 

Guarded 

Typical. 

Guarded 

free. 

spine. 

spine. 

hip. 

Muscular 

None. 

Free. 

In  spine. 

In  spine. 

In  spine. 

In    one    di- 

In     hip      in 

rigidity. 

rection 
only. 

all       direc- 
tions. 

Temperature. 

Normal. 

Normal. 

I  degree  rise. 

Varies. 

Normal. 

Normal. 

I  degree  rise. 

Local  tender- 

None. 

None. 

In  spine. 

Painful     all 

All  over 

None. 

In  hip. 

ness. 

over. 

spine. 

Night  cries. 

Absent. 

Absent. 

Present. 

Absent. 

Absent. 

None. 

Present. 

Tendency  to 

None. 

None. 

Probable. 

None. 

None. 

None. 

Probable. 

abscess. 

X-ray. 

Character- 

Normal. 

Focus  in 

Normal. 

Late 

Distortion 

Spine    nor- 

istic defor- 

spine. 

bridges 

of  cervical 

mal. 

mity. 

of  bone. 

spine. 

Hot-water 

No    tender- 

None. 

Localized 

Sensitive 

No  necrosed 

No    tender- 

No     tender- 

test. 

ness. 

in  spine. 

all  over 
spine. 

sensitive- 
ness. 

ness. 

ness    in 
spine. 

General 

Constant. 

Constant. 

Intermit- 

Constant. 

Constant. 

Constant. 

Intermit- 

symptoms. 

tent. 

tent. 

Scoliosis  is  a  non-pathological  distortion  of  the  spine  characterized  by  rota- 
tion and  lateral  bending,  hence  the  name,  rotary  lateral  curvature  (Plate  9).  It 
is  either  functional  or  organic. 

Functional  scoliosis  is  caused  by  any  prolonged  alteration  in  the  relation- 
ship normally  existing  between  the  axis  of  the  shoulders  and  the  axis  of  the  hips. 
The  etiological  factors  depend  upon  the  maintenance  of  faulty  postures  in  occu- 
pations, especially  during  period  of  growth.  School-life  is  especially  influential 
in  producing  the  condition  because  school  furniture  is  adapted  to  the  average 
requirements  of  a  given  class,  and  therefore  a  very  small  proportion  of  pupils 
are  able  to  find  desks  and  benches  that  are  suitable.  Properly  furnished 
modern  schools  are  supplied  with  desks  and  seats  that  are  adjustable  to  each 
occupant.  Gould  ("The  Ocular  Factors  in  the  Etiology  of  Spinal  Curvature," 
H.  Augustus  Wilson,  ''New  York  Medical  Journal,"  July  12,  1906)  has  directed 
attention  to  the  errors  of  refraction  that  produce  head  tilting  and  thereby  induce 
scoliosis.  In  adults,  scoliosis  is  observ^able  in  blacksmiths,  fencing  masters,  and 
waiters,  in  whom  excessive  use  of  the  right  arm  produces  an  as3Tnmetrical 
posture  of  the  body. 

When  functional  scoliosis  is  not  corrected  or  occurs  in  rachitic  or  indolent 
children,  it  results  in  organic  or  permanent  changes  in  the  contour  of  the  bones 
composing  the  spinal  colimin.  Organic  scoliosis  may  be  congenital,  caused  by 
prenatal  deficiencies  or  augmentations  of  the  spinal  column. 

Postmortem  examinations  reveal  a  confirmation  of  Wolfe's  law  that  pro- 
longed alteration   of   the   normal    fimctions    always    results   in   changes   of 


842 


Surgery  of  the  Spine 


Fig.  540. — Lateral 
dorsal  curvature  to  the 
right,  and  compensa- 
tory lumbar  curve  to 
the  left. 


anatomical  structures.  In  extreme  cases  the  bones  of  the  spinal  column  become 
extensively  altered  in  shape,  the  ribs  are  altered  in  contour,  and  the  thoracic 
and  abdominal  viscera  are  forced  into  unnatural  positions  and  assume  abnormal 
shapes,  their  functions  often  being  materially  altered. 

Diagnosis. — The  patient  is  usually  taken  to  the  physician  because  of  appar- 
ent elevation  of  one  shoulder,  or  because  one  hip  is  thought  to  be  larger  than 
its  mate,  or  one  mamma  higher  than  the  other.  Dressmakers  and  corset 
makers  are  generally  the  first  ones  to  direct  attention  to  the  faulty  posture 
(as  scoliosis  occurs  in  8  girls  to  i  boy).  A  patient  suspected  of  having  sco- 
liosis should  be  nude  at  the  time  of  inspection,  as  clothing 
hampers  the  normal  action  and  tends  to  conceal  the 
movements  of  the  body.  The  accompanying  diagnostic 
table  (see  page  841)  is  a  condensed  comparative  statement 
of  the  important  features  in  diseases  and  conditions  that 
may  resemble  scoliosis  in  some  respects.  It  is  only  by  care- 
fully studying  the  symptom-complex  that  a  definite  decision 
can  be  reached.  It  is  frequently  observed  that  patients 
with  mild  types  of  functional  scoliosis  can  sit  or  stand 
erect  for  a  few  minutes  and  thereby  deceive  even  a  critical 
observer.  The  habitual  posture,  and  also  the  rapidity 
with  which  the  patient  returns  to  the  distorted  position  after 
temporary  voluntary  correction,  demand  careful  attention. 
Young  children,  when  chided  by  parents  or  teachers,  often 
temporarily  assume  an  approach  to  a  normal  posture 
without  actual  correction.  The  ease  with  which  their  sur- 
rounding joints  yield  in  compensatory  action  is  often  overlooked.  A  patient 
with  contracture  of  the  pectoral  muscles  will  elevate  the  shoulders  into  an 
apparent  correction  of  stoop  or  round  shoulders  instead  of  throwing  the  shoul- 
ders well  back,  a  posture  that  is  to  them  impossible. 

Goldthwait  has  directed  attention  to  forward  curves  of  the  scapula  that 
are  often  present  in  patients  who  are  stoop-shouldered  and  has  devised  an 
operation  for  correction. 

In  the  same  way,  a  patient  who  has  preternatural  contracture  of  the  ham- 
string tendons,  either  unilateral  or  bilateral,  will  often  conceal  that  condition 
by  bending  the  knee  or  knees  enough  to  permit  the  pelvis  and  trunk  to  bend 
forward. 

Treatment  consists  especially  in  removing  the  cause.  If  the  eyes  produce 
head-tilting,  proper  refraction  will  be  necessary.  Adenoids  should  be  re- 
moved. The  clothing  should  be  regulated  to  avoid  constriction  and  the 
shoulder  straps  should  fit  close  to  the  neck  and  not  be  allowed  to  slip  on  to  the 
shoulder-joint. 

Contractures  of  the  pectoral  muscles  should  be  stretched  by  corrective  ma- 
nipulations. Hamstring  contracture  should  be  removed  by  corrective  manipu- 
lation. Hoke  ("A  Study  of  a  Case  of  Lateral  Curvature  of  the  Spine:  A  Report 
On  an  Operation  for  the  Deformity,"  "Amer.  Jour.  Orthop.  Surg.,"  vol.  i, 
November,  1903,  p.  169)  has  devised  an  operation  of  rib  resection  for  cosmetic 
purposes.  Every  effort  should  be  made  to  prevent  the  occurrence  of  scoliosis. 
The  successful  treatment  of  scoliosis  depends  on  preventing  its  progress. 
Each  individual  patient  requires  careful  study  to  determine  the  special  char- 
acteristics that  may  be  present. 

Remedial  measures  should  be  employed  that  meet  the  peculiar  individual 
requirements  of  each  case. 

School  gymnastics  are  generally  more  harmful  than  beneficial  in  cases  of 
scoliosis.  No  one  but  a  physician  should  prescribe  the  gymnastic  work.  The 
soft  bones  may  be  still  further  distorted  by  injudicious  exercises. 


SPINAL    CURVATURE. 


Plate  9. 


Rotary  lateral  curvature  of  the  spine. 


Anteroposterior  Curvature  843 

The  first  requirement  in  the  application  of  applied  physical  culture  is  to 
secure  the  hearty  cooperation  of  the  patient.  Without  such  cooperation  prog- 
ress cannot  be  expected. 

No  gymnastic  apparatus  of  any  kind  is  required  when  the  patient  can  be 
instructed  in  the  proper  methods  of  autoresistance.  There  are  over  four 
thousand  movements  of  the  body  that  may  be  employed  in  remedial  physical 
culture.  From  this  vast  assortment  those  may  be  selected  that  are  suitable  to 
the  peculiar  conditions  of  the  patient.  At  first  the  least  tiresome  forms  are  to 
be  employed,  and  gradually  and  progressively  others  are  resorted  to  until  the 
patient  presents  a  strong  robust  development.  Usually  about  a  year  is  required 
for  the  purpose,  as  the  progress  must  be  essentially  educational.  Training 
in  developing  muscle  action  goes  hand  in  hand  with  instruction  in  walking,  in 
sitting,  and  in  all  the  postures  assumed  by  the  human  body  in  the  various  occu- 
pations of  the  patient. 

In  organic  scoliosis,  in  which  the  distortion  is  more  or  less  of  a  permanent 
character,  much  can  be  accomplished  in  preventing  the  progress  of  the  condi- 
tion as  well  as.  in  aiding  correction  by  removing  any  rigidity  that  may  be  pres- 
ent. By  increasing  the  flexibility  we  facilitate  muscular  development  in  much 
the  same  manner  as  in  functional  scoliosis. 

When  rigidity  is  present  it  must  be  considered  in  the  same  light  as  rigidity 
of  any  other  joints.  Its  presence  prevents  muscular  development.  Manipu- 
lative measures  are  similar  in  effect  to  those  employed  in  fibrous  ankylosis  of 
any  joint,  and  are  peculiar  to  the  parts  involved.  In  the  majority  of  cases  the 
force  for  manipulative  correction  must  be  applied  through  the  interposition  of 
the  ribs,  and  the  great  danger  of  producing  fractures  of  these  structures  should 
be  realized. 

If,  however,  there  is  any  tendency  to  increase  of  the  deformity,  a  suitable 
brace  or  removable  jacket  of  plaster  or  celluloid  should  be  applied  to  maintain 
correction  until  the  musculature  has  been  strengthened  and  trained  to  perform 
its  full  functions. 

Organic  or  structural  scoliosis  has  been  shown  by  Abbott,  of  Portland, 
to  be  capable  of  correction  by  several  types  of  fixed  jackets  (E.  G.  Abbott, 
"New  York  Med.  Jour.,"  191 2,  and  A.  M.  Forbes,  Ibid.,  July  6,  191 2).  The 
keynote  of  the  treatment  in  each  method  is  flexion  of  the  spine,  as  in  that 
position  the  vertebrae  are  unlocked.  Partial  correction  is  secured  by  means 
of  bandages  pulling  in  various  directions  and,  after  proper  padding,  a  plaster 
jacket  is  appHed.  Further  progress  to  overcorrection  is  continued  by  means  of 
pads  of  felt  slipped  under  the  jacket  to  increase  the  pressure  in  certain  direc- 
tions. After  overcorrection  has  been  obtained,  a  celluloid  jacket  is  worn  to 
maintain  this  and  exercises  are  assiduously  employed  to  restore  muscle  function. 
These  methods  of  treatment  constitute  the  greatest  advances  in  this  work  in 
many  years,  but  to  secure  the  best  results  they  must  be  followed  out  most  care- 
fully by  a  skilled  physician.  Special  forms  of  apparatus  are  essential  in  the 
appHcation  of  these  jackets.  The  combination  of  the  gymnastic  and  mechan- 
ical treatment  in  severe  functional  and  in  organic  scoliosis  proves  the  most 
satisfactory  in  that  it  not  only  restores  muscle  balance,  but  also  corrects  de- 
formity, and  secures  as  great  correction  of  the  deformity  as  possible  before 
ankylosis  occurs.  Any  appliance  used  in  these  cases  shoiild  be  made  to  order 
to  fit  the  peculiarities  of  the  patient  and  should  never  be  the  shop-kind  that 
are  so  extensively  advertised.  Much  valuable  time  is  often  lost  while  unme- 
chanical  and  unsuitable  apparatus  is  being  used,  during  which  time  the  bony 
changes  may  become  permanent  and  beyond  repair. 

Anteroposterior  curvature  (not  from  spinal  caries  or  from  hip-joint  dis- 
ease) is  an  increase  of  the  normal  anteroposterior  curves.  Increase  of  the 
dorsal  curve  is  posterior  curvature,  kyphosis,  or  excurvation  (Fig.  541,  a);  in- 


844  Surgery  of  the  Spine 

crease  of  the  lumbar  curve  is  anterior  curvature,  lordosis,  or  saddle-back  (Fig. 
541,  b).  Both  lordosis  and  kyphosis  are  apt  to  be  present.  Scoliosis  has 
nearly  always  some  anteroposterior  curvature  associated  with  it.  Lordosis  is 
apt  to  be  compensatory,  to  prevent  the  center  of  gravity 
going  too  far  forward.  Lordosis  is  found  in  pregnant 
women  and  in  very  fat  men.  In  an  old  man  kyphosis 
arises  because  of  flattening  out  of  the  vertebral  disks  from 
pressure.  Rheumatic  gout  may  cause  anteroposterior 
curvature.  Anteroposterior  curvature  is  often  due  to 
paralysis  of  the  erector  spinae  mass  (from  infantile  paral- 
ysis).    Pseudohypertrophic  paralysis  causes  lordosis. 

Symptoms  and  Treatment. — The  symptoms  of  antero- 
posterior curvature  are  as  follows:  the  thorax  is  flattened 
or  pigeon  breasted;  the  shoulder-blades  are  widely  sepa^ 
Fie  ijAi —Kyphosis  ^^.tcd  and  the  scapular  angles  project;  the  abdomen  is 
(a)  and  lordosis  (b).  protuberant;  the  patient  complains  of  backache  and  soon 
tires.  A  recent  kyphosis  disappears  when  the  patient  lies 
upon  his  stomach.  The  facts  that  the  erector  spinae  muscles  are  soft  and  that 
pain  is  absent  on  concussion  transmitted  to  the  back  separate  kyphosis 
from  caries.  Lordosis  is  unmistakable.  When  the  spine  is  movable,  em- 
ploy the  same  plan  of  treatment  as  in  lateral  curvature,  suiting  the  gym- 
nastics to  the  deformity.  In  painful  kyphosis  with  partial  ankylosis  endeavor 
to  make  the  ankylosis  complete  in  order  to  prevent  pain,  obtaining  this 
result  by  applying  a  plaster  jacket  which  laces  up  and  letting  the  patient 
wear  it  for  several  years. 

Angular  curvature  {spinal  caries;  spondylitis;  Potfs  disease)  is  usually 
due  to  tuberciilous  caries  of  the  vertebral  bodies,  and  occurs  particularly 
in  children  who  are  the  victims  of  tuberculosis,  but  it  may  arise  at  any  age. 
Any  portion  of  the  spinal  colimin  may  be  attacked.  The  dorsolumbar  region 
is  most  prone  to  suffer.  The  chief  cause  is  tuberculosis,  but  syphilis  and  sec- 
ondary cancer  of  the  vertebrae  are  occasional  causes,  and  acute  osteomyelitis 
is  a  very  rare  cause  (see  page  839).  Blows  or  sprains  appear  to  have  a 
causal  influence  in  some  cases  (see  Trauma  in  Tuberculosis,  page  223).  An- 
gular curvature  may  develop  after  an  exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  the  vertebral  body  becomes 
primarily  carious,  or  the  inflammation  begins  in  an  intervertebral  disk.  (The 
changes  of  tuberculous  osteitis  have  previously  been  set  forth — -see  pages  249, 
494,  and  495.)  The  body  of  the  vertebra  and  the  vertebral  disk  are  destroyed, 
and  the  process  extends  to  adjacent  vertebrae.  The  weight  which  rests  upon 
the  spinal  column  causes  softened  bone  to  crumble,  compresses  the  diseased 
vertebrae  and  disks,  and  produces  angular  deformity  (the  anterior  part  of  the 
column  formed  by  the  vertebral  bodies  is  shortened,  the  posterior  part  is  not, 
and  hence  the  spines  project).  In  some  cases  the  disease  is  spontaneously 
arrested  by  organization  of  inflanmiatory  products,  and  ankylosis  (fibrous  or 
bony)  in  deformity  is  Nature's  cure.  In  most  cases,  however,  the  disease 
spreads  and  caseous  pus  is  formed,  which,  according  to  the  point  of  formation 
and  the  route  it  takes,  causes  limibar  abscess,  dorsal  abscess,  psoas  abscess, 
or  postpharyngeal  abscess  (see  pages  241  and  242).  In  some  cases  the  spinal 
cord  is  compressed,  but  in  most  cases  it  is  not,  and  even  when  it  is  compressed 
paraplegia  is  rare  and  is  usually  temporary.  Compression  of  the  cord  may 
be  caused  by  the  displaced  vertebrae,  by  inflammatory  material  or  caseous  mat- 
ter between  the  bone  and  dura  mater,  but  is  most  often  due  to  pachymen- 
ingitis. Caries  of  the  cervical  region  constitutes  a  more  dangerous  disease 
than  caries  of  either  the  dorsal  or  the  lumbar  region  {dangerous  pressure 
occurs  more  easily).     Death  may  be  caused  by  exhaustion,  sepsis,  hemorrhage, 


Angular  Curvature  845 

amyloid  disease,  pneumonia,  peritonitis,  pleuritis,  tuberculous  dissemination, 
pressure  upon  the  cord,  or  inflammation  of  the  cord  or  its  membranes. 

Sytnptoms. — The  sufferer  from  Pott's  disease,  if  a  child,  grows  tired  easily. 
The  disposition  alters.  The  ^•ictim  becomes  moody  and  irritable,  and  com- 
plains of  vague  pains  in  many  places,  is  disposed  to  lean,  rest,  or  lie  down,  and 
walks  ^^ith  the  back  rigid,  which  produces  a  peculiar  gait.  A  painful  spot  may 
be  found  by  pressing  upon  the  spines.  Faradism  to  the  back  causes  pain. 
Spasm  of  the  erector  spinae  mass  is  detected  (Hilton,  Gol ding-Bird).  It 
is  not  proper  to  seek  to  develop  pain  by  jarring  the  back  or  by  pressing  the 
head  dowmward.  The  posture  of  the  child  and  the  muscular  rigidity  prove 
the  existence  of  inflammation,  and  to  seek  to  develop  pain  by  the  methods 
referred  to  may  do  harm,  and  at  best  can  only  caU  attention  to  what  is  already 
known.  Pain  in  the  back,  which  is  increased  by  motion,  by  pressure,  and 
by  vertebral  jars,  may  be  absent  mitil  late  in  the  case.  Distinct  pain  and 
tenderness  in  the  back  often  mean  abscess  formation.  Neuralgic  pains  pass 
into  distant  parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked  with 
muscular  spasm.  A  chronic  bilateral  pain  in  the  trunk  or  extremities  is 
suggestive  of  Pott's  disease.  "Chronic  bilateral  bellyaches  in  children  are 
almost  diagnostic"  (Jordan  Lloyd).  The  pain  of  dorsal  caries  can  be  re- 
lieved by  lifting  the  shoulders;  the  pain  of  cer\dcal  caries,  by  traction  on 
the  head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  liunbar  caries.  The 
presence  of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle  is  a  ver\- 
important  sign  of  the  disease.  In  many  cases  angular  deformity  appears 
late;  in  some  cases  it  does  not  appear  at  all.  An  angular  deformity  is  de- 
tected sooner  in  those  regions  where  the  normal  curves  are  posterior  than 
where  the  normal  curves  are  anterior.  The  deformity  appears  early  in 
the  dorsal  region,  but  late  in  the  cen.-ical  and  limabar  regions.  In  many 
cases  lateral  deformity  occurs.  Rigidity  is  an  early  sign  of  great  import- 
ance. It  is  always  present.  Rigidity  is  manifest  ver\^  early  in  cer%dcal 
caries,  tolerably  early  in  lumbar  caries,  late  in  dorsal  caries.  Lloyd  gives 
the  follo-uing  practical  rules  to  enable  us  to  detect  rigidity.^  In  the  cer\-ical 
region:  seat  the  patient  in  a  chair  and  tell  him  to  nod  the  head  affirmatively. 
Stiffness  in  nodding  points  to  occipito-atloid  disease.  Tell  him  to  look  far 
to  the  right  and  then  far  to  the  left.  Stiffness  of  these  motions  suggests 
atlo-axoid  disease.  TeU  him  to  place  his  shoulders  against  the  back  of  the 
chair  and  carry  his  eyes  back  along  the  ceiling.  Stiffness  in  this  movement 
indicates  disease  below  the  second  cer^dcal  vertebra.  It  is  practically  useless 
to  examine  the  dorsal  region  of  an  adult  for  rigidity,  but  such  an  examination 
can  be  made  in  a  child.  Place  the  patient  prone  on  an  adult's  lap,  mark  the 
tip  of  each  spinous  process  vdth.  an  anilin  pencil,  then  make  the  child  stand  up 
straight  on  the  floor,  and  obsen,^e  if  any  of  the  pencil  marks  fail  to  come  nearer 
together.  If  it  is  seen  that  two  or  more  marks  do  not  approach  each  other,  there 
is  rigidity  which  prevents  approximation.  To  test  for  rigidity  in  the  lumbar 
region  la}^  the  naked  patient  prone  upon  a  couch.  Grasp  the  patient's  ankles 
and  raise  the  pehds  from  the  couch.  If  the  lumbar  spine  is  flexible,  the 
peh-is  can  be  lifted  -^-ithout  raising  the  chest  from  the  bed,  and  the  maneuver 
deepens  the  hollow  of  the  loin.  If  the  lumbar  spine  is  stiff,  the  maneuver 
lifts  the  triuik  and  produces  no  alteration  in  the  vertical  outline  of  the  lumbar 
spines.  If  a  child  \^-ith  Pott's  disease  is  asked  to  pick  up  something  from 
the  ground,  because  of  rigidity  or  pain  on  movement  he  vrHl  not  bend  the 
back,  but  v,-iR  bend  the  knees  or  get  upon  the  kness.  Paralysis  may  exist, 
and  it  is  due  to  pach>Tneningitis  more  often  than  to  pressure  from  bone. 
Cervical  caries  causes  dyspnea  and  torticoUis,  the  head  requiring  support 
-v\-ith  the  hands.  Dysphagia  indicates  abscess.  In  adults  the  first  signs  of 
^  "Birmingham  Med.  Re\aew."'  April.  1897. 


846 


Surgery  of  the  Spine 


Pott's  disease  to  attract  attention  are  headache,  backache,  neuralgia,  girdle- 
pain,  cramp,  or  even  paralysis.  In  abscess  due  to  caries  of  the  dorsolumbar 
vertebrae  the  pus  usually  enters  the  psoas  muscle  and  passes  out  of  the  pelvis 
below  the  junction  of  the  middle  and  outer  thirds  of  Poupart's  ligament. 
It  may  point  here  or  may  pass  to  the  inner  aspect  of  the  thigh  and  point 
a  little  below  the  spot  where  a  femoral  hernia  is  met  with  if  it  exists.  In 
a  psoas  abscess  a  mass  is  always  felt  in  the  iliac  fossa  above  Poupart's  lig- 
ament; in  a  hernia  no  such  mass  exists  (J.  T.  Rugh).  In  sacral  caries  there 
is  no  deformity  and  frequently  no  pain.  The  diagnosis  becomes  apparent 
when  bilateral  abscess  is  detected  in  the  buttocks  or  groins  (Jordan  Lloyd). 
If  an  abscess  due  to  spinal  caries  opens  spontaneously,  healing  will  not  occur, 
mixed  infection  takes  place,  and  death  often  follows. 

Treatment  of  Caries  of  the  Spine. — When  recent  caries  of  the  spine  is  active 
and  affects  a  child;  when  it  is  accompanied  by  pain  and  fever;  and  when 
paralysis  threatens,  insist  upon  perfect  rest.  Place  the  child  supine  on  a 
hard  mattress,  and,  if  possible,  take  it,  while  in  a  rolling  bed,  out  of  doors 
daily.    Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain  may  do  good. 


Fig.  542. — Plaster-of-Paris  jacket  (Sayre). 


Fig.  543. — Plaster-of-Paris  jacket  and  jury-mast 
applied  (Sayre). 


When  the  activity  of  the  process  abates,  apply  a  fixation  apparatus.  In 
diseases  at  or  near  the  vertebro-occipital  articulation,  as  long  as  dyspnea 
persists,  keep  the  patient  supine  with  a  small  hard  pillow  imder  the  nape 
of  the  neck  (Hilton)  and  a  sand-bag  on  each  side  of  the  head  and  neck.  After 
several  months  mechanical  support  can  be  given  by  Furneaux  Jordan's  method. 
Jordan  applies  his  support  as  follows:  The  patient  lies  on  a  fiat,  hard  table, 
his  arms  are  raised  above  his  head,  and  traction  is  made  upon  the  head  by 
means  of  a  pulley  and  a  weight.  Cotton  pads  are  placed  over  the  ears,  the 
back  of  the  neck  and  the  clavicles,  and  are  held  in  place  by  a  broad  flannel 
bandage  applied  as  a  figure-of-8  on  the  head,  neck,  and  chest.  The  flannel  band- 
age is  overlaid  with  plaster-of-Paris  bandages.^  In  disease  of  the  cervical  region 
below  the  axis,  or  of  the  dorsal  region  above  the  seventh  vertebra,  use  Sayre's 
jury-mast  (Fig.  543),  or  some  other  form  of  head  support.  Instead  of  the 
jury-mast  a  steel  upright  may  be  used  to  hold  the  head  rigid.  Sayre's  ap- 
pliance relieves  the  spine  from  the  weight  of  the  head  and  acts  admirably. 
In  most  cases  of  dorsal  and  lumbar  caries  a  steel,  leather,  or  plaster  jacket 
as  a  fixation  apparatus  must  be  employed.  The  best  of  all  fixation  apparatus 
^  See  "Children's  Deformities,"  by  Walter  Pye. 


Paralysis  in  Pott's  Disease  847 

is  Sayre's  plaster-of-Paris  jacket  applied  while  the  patient  is  suspended  (Fig. 
542)  or,  better,  while  the  column  is  in  hyperextension.  The  Sayre  appa- 
ratus applied  in  this  manner  is  used  for  the  treatment  of  caries  of  the  lumbar 
region  and  the  lower  half  of  the  dorsal  region,  or  a  plaster  jacket  may  be  applied 
while  the  patient  is  lying  prone  in  a  hammock  or  stretched  between  two  tables. 
Greater  corrective  pressure  over  the  deformity  is  secured  by  this  method  than 
by  suspension.  When  all  subjective  signs  cease,  substitute  for  the  plaster-of- 
Paris  jacket  a  felt  or  sole-leather  jacket  which  laces  down  the  front.  Caries 
of  the  upper  half  of  the  dorsal  region  is  often  treated  by  a  Sayre's  jury-mast 
(Fig.  543) ;  but  if  the  jury-mast  fails,  it  may  be  necessary  to  place  the  patient 
horizontally  in  "an  open  cuirass,  fitted  to  the  back  from  occiput  to  sacrum, 
and  combined  with  pulley  extension  to  the  head  and  pelvis."^ 

During  the  course  of  caries  of  the  spine  have  the  patient  eat  fat-forming 
and  nutritious  food,  insist  on  a  plentiful  supply  of  fresh  air  day  and  night, 
and  administer  tonics.  Full  antituberculous  treatment  is  imperative  (see 
page  230).  Sea-air  is  very  beneficial.  When  all  active  disease  ceases  and 
only  angular  curvature  remains,  use  an  apparatus  to  combine  extension  with 
mechanical  support,  the  plaster  jacket  being  generally  employed. 

Albee's  Bone  Transplantation  Method  of  Treatment. — ^The  ordinary 
ambulatory  treatment  of  Pott's  disease  is  seldom  satisfactory.  It  is  particu- 
larly unsatisfactory  in  the  upper  dorsal  region.  Ridlon  and  Jones  emphasize 
this  fact  and  declare  that  when  the  disease  is  situated  in  that  region  only 
prolonged  recumbency  prevents  increase  of  the  deformity.  Albee  reached  the 
conclusion  that  the  treatment  should  be  one  which  secures  bony  union  and 
hence  perfect  immobility.     Perfect  bony  fixation  means  cure. 

Albee  was  accustomed  to  see  perfect  cure  in  hip  tuberculosis  after  anky- 
losing the  joint,  and  in  knee  tuberculosis  after  erasion.  He  has  secured  a 
like  result  in  vertebral  caries  by  grafting  into  the  spinous  processes  a  large 
piece  of  bone  cut  from  the  patient's  tibia.  This  graft  usually  becomes  fixed 
to  the  spinous  processes.  It  at  least  unites  with  the  surrounding  ligamentous 
structures  and  gives  unyielding  support  which  produces  cure  (see  page  860). 
It  is  a  highly  useful  method  (Albee,  in  "New  York  Med.  Jour.,"  March  9, 
I9i2;in  "Post-Graduate,"  Nov.,  1912). 

Spinal  abscesses  are  treated  as  indicated  on  pages  245  and  246. 

Paralysis  in  Pott's  Disease. — Partial  or  complete  motor  and  sensory 
paralysis  may  develop  in  the  course  of  vertebral  caries.  It  may  be  due  to 
the  pressure  of  tuberculous  material  or  to  pachymeningitis  with  thickening 
of  the  membrane.  In  only  2  per  cent,  of  cases  of  paralysis  is  the  paralysis 
due  to  the  pressure  of  angled  bone  (Willard).  The  paralysis  may  come  on 
gradually.  There  are  weakness  in  walking  or  actual  inability  to  walk,  exag- 
gerated reflexes,  muscular  rigidity,  and  impaired  sensation  in  the  legs,  and 
loss  of  control  of  the  bladder  and  rectum.  Caries  in  the  high  dorsal  region 
is  more  apt  to  result  in  paralysis  than  in  any  other  region  because  of  the  small 
size  of  the  canal.     Pressure  in  the  cervical  region  is  highly  dangerous. 

Treatment. — We  must  remember  that  angulation  is  the  rare  cause,  tubercu- 
lous masses  the  common  cause.  Treatment  for  paralysis  due  to  tuberculous 
masses  is  the  full  open-air  treatment  of  tuberculosis,  with  rest,  fixation,  and 
progressive  straightening  of  the  spine.  The  patient  is  kept  in  bed  (see  Treat- 
ment of  Tuberculosis,  page  230)  on  a  Bradford  frame  and  with  his  head 
overextended.  If  after  one  year  the  condition  is  not  notably  improved,  do 
laminectomy  and  clear  away  tuberculous  masses.  If  angulation  is  the  cause 
of  the  paralysis,  consider  gradual  correction,  laminectomy,  and  Albee's  bone 
transplantation.  In  several  of  the  cases  reported  by  Albee  recovery  from 
paralysis  occurred  soon  after  bone-grafting. 

1  Jordan  Lloyd,  in  "Birmingham  Med.  Review,"  April,  1897. 


848  Surgery  of  the  Spine 

Gradual  Correction  of  Angular  Deformity. — Pressure  is  made  upon  the 
hump  with  the  hand,  and  while  the  hand  is  thus  held  the  weight  of  the  body  is 
allowed  to  bear  upon  it  above  and  below.  Something  is  perhaps  gained  and 
then  plaster  of  Paris  is  applied,  somewhat  later  a  little  more  gain  is  obtained, 
and  so  on.     This  method  is  safer  and  more  satisfactory  than  forcible  correction. 

Forcible  correction  of  angular  deformity  was  advocated  by  Chipault  and 
Calot  in  cases  of  Pott's  disease  without  abscess.  It  was  only  used  in  angu- 
lar deformity  of  the  middle  and  lower  part  of  the  dorsal  region  and  was  not 
advised  in  the  cervical,  upper  dorsal,  or  lumbar  regions.  The  operation  is  not 
safe,  and  a  number  of  deaths  have  been  reported.  Gabaert^  pointed  out 
certain  disasters  which  may  follow  forcible  correction;  they  are:  death  during 
anesthesia;  rupture  of  an  abscess;  subsequent  paralysis  of  the  legs  and  bladder; 
disseminated  tuberculosis,  and  shock,  with  convulsions  and  death.  I  do  not 
believe  in  forcible  correction  and  I  do  beheve  that  the  alleged  dangers  are 
real  dangers,  that  the  operation  is  unsafe,  and  that  it  should  never  be  done. 

Laminectomy  is  warmly  advocated  by  some  surgeons  for  paraplegia  from 
spinal  caries.  This  operation  is  rarely  necessary,  but  in  some  few  cases  it 
is  imperatively  demanded.  Many  cases  recover  from  paraplegia  without 
operation.  Operation  for  paraplegia  has  a  very  heavy  mortality  (25  per  cent.), 
and  many  are  not  benefited  at  all  by  it.  If  degeneration  of  tracts  in  the 
cord  has  occurred,  operation  cannot  help  the  paralysis.  Nevertheless,  in  some 
cases  laminectomy  has  certainly  cured  palsy  and  saved  life.  Menne  has 
collected  132  cases  of  laminectomy.  Of  these  56  per  cent,  were  cured  or  perma- 
nently improved  and  18  per  cent,  were  temporarily  improved. 

Laminectomy  should  not  be  imdertaken  imtil  treatment  by  rest,  fixation, 
and  extension  has  been  appHed  for  at  least  one  year.  Laminectomy  may 
become  necessary  in  cervical  caries  to  prevent  asphyxia.  The  operation 
enables  the  surgeon  to  remove  masses  of  inflanmiatory  material  which  make 
pressure  on  the  cord,  and  also  to  free  the  cord  from  pressure  due  to  angulation. 
The  dura  should  not  be  opened  unless  there  is  evidently  trouble  beneath  it,  in 
which  case  it  is  incised  and  any  tuberculous  area  removed,  the  dura  being 
subsequently  sutured.  Menard  removes  the  transverse  processes  of  the 
diseased  vertebrae  and  the  heads  and  necks  of  the  associated  ribs  in  order  to 
give  the  surgeon  access  to  diseased  vertebral  bodies. 

Spondylitis  Deformans  (Bechterew's  Disease). — ^This  is  the  name 
usually  applied  to  osteo-arthritis  of  the  spine  (seepage  642).  In  this  disease 
osteophytic  formation  takes  place  at  the  vertebral  borders,  and  the  vertebrae 
become  ankylosed.  The  vertebral  bodies,  as  a  rule,  are  most  affected  by  the 
disease,  but  any  portion  of  a  vertebra  may  be  attacked,  and  often  the  heads 
of  the  ribs  are  anchored  to  the  spine  by  bone. 

The  disease  may  begin  in  infancy,  childhood,  youth,  adult  life,  or  old  age. 

Symptoms. — There  are  decided  and  persistent  pain  and  tenderness  of 
the  spine,  and  occasionally  evidence  of  pressure  on  the  nerve-roots.  Early 
in  the  case  deformity  is  apt  to  occur,  because  at  this  period  there  is  inflam- 
matory softening.^  The  deformity  is  not  angular,  but  is  usually  a  total 
kyphosis,  the  column  being  bent  forward  from  above  and  made  into  a  single 
curve.  Lateral  curvature  may  occur.  In  many  advanced  cases  and  in  some 
comparatively  recent  cases  the  spine  becomes  rigid  and  ankylosed,  and  when 
it  does,  there  may  be  evidences  of  irritation  of  the  posterior  nerve-roots.  In 
this  condition  there  is  rigidity  of  part  or  of  the  entire  spine,  other  joints  es- 
caping. If  the  entire  spine  is  involved,  there  is  rigid  cervicodorsal  kypho- 
sis, a  condition  which  causes  the  neck  to  stick  forward  and  the  head  to  appear 
as  if  forcibly  driven  down  between  the  shoulders.     If  the  entire  spine  is  in- 

1  "Ann.  de  la  Soc.  Beige,"  July  15,  1898. 

2  J.  Jackson  Clarke's  book  on  "Orthopedic  Surgery." 


Traumatic  Neurasthenia  849 

volved,  the  lumbar  spine  is  rigid  and  the  normal  lumbar  curve  disappears. 
As  a  consequence  the  patient  stands  in  an  unnatural  attitude,  the  hips  and 
knees  being  partly  flexed,  and  the  legs  and  feet  being  in  a  condition  of  external 
rotation.  In  Bechterew's  disease  there  are  compression  of  the  posterior  nerve- 
roots,  severe  pain,  muscular  atrophy,  and  ascending  degeneration  of  the  cord. 
What  Marie  calls  spondylitis  rhizonielique  is  said  by  Osier  to  be  a  form  of 
ajthritis  deformans.  There  is  rigidity  of  the  spine,  shoulders,  and  hips,  but 
no  ner\-ous  lesions,  as  in  Bechterew's  disease. 

Treatment. — Cure  is  impossible,  but  amelioration  can  be  obtained. 

The  local  and  constitutional  treatment  is  as  for  osteo-arthritis  in  any 
region  (see  page  642).  If  spinal  curvature  begins,  a  mechanical  support  must 
be  appUed  or  Albee's  bone-grafting  operation  performed.  Rugh  operated  on 
such  a  case  mth  gratifying  results  ('Tnternat.  Clinics,"  Vol.  I,  Twenty-third 
Series). 

Injuries  of  spinal  ligaments  and  muscles,  which  may  complicate 
more  serious  injuries  or  may  exist  alone,  are  caused  by  wrenches,  twists, 
and  \dolent  muscular  efforts  (as  in  Hf ting) .  Railway  accidents  may  be  respon- 
sible for  these  sprains  and  strains.  The  injury  is  called  railway  spine  when  it 
is  caused  by  a  railway  accident. 

Symptoms. — Injuries  of  the  back,  even  ^\-ithout  cord  injury,  are  fre- 
quently linked  with  very  deceptive  nerv^ous  s\TQptoms.  Symptoms  are  often 
severe,  but  are  usually  temporary.  In  some  few  cases  the  symptoms  are 
persistent.  Secondarv'  disease  of  the  cord  is  extremely  rare.  Any  region 
may  be  affected,  but  the  lumbar  is  most  usually  injured,  and  the  entire  spine 
may  suffer.  The  three  marked  s\Tnptoms  are  pain,  tenderness,  and  stiffness 
of  the  back.  At  the  time  of  injury  and  for  a  while  after  there  is  often  marked 
shock,  and  hysterical  excitement  is  occasionaUy  observed.  The  cardinal 
S}Tnptoms  may  arise  ver\^  soon,  but  may  not  become  severe  for  a  day  or 
two.  The  pain  is  not  acute  when  at  rest,  but  becomes  acute  on  movement.^ 
The  pain  is  felt  in  the  back  and  sometimes  darts  into  the  extremities.  The 
muscles  of  the  back  are  rigid,  the  spasm  being  due  to  pain.  The  patient 
is  very  carefvil  not  to  twist  or  bend  the  spine,  because  to  do  so  increases  pain. 
In  a  one-sided  injury  the  rigidity  is  umlateral,  and  this  s}Tnptom  cannot 
be  simulated.  Often,  but  by  no  means  always,  the  region  of  the  back  is 
swollen  and  the  skin  is  discolored.  The  tenderness  is  not  of  the  skin,  but 
of  the  muscles.  Firm  pressure  on  a  spot  of  real  tenderness  causes  rapid 
pulse  {Mannkopfs  sign).  The  vertebral  spines  are  regular  and  are  not  mobile. 
There  is  no  distant  paralysis  or  hyperesthesia  unless  the  cord  is  damaged 
(though  in  some  rare  cases  the  bladder  and  the  rectimi  are  paralyzed  when  no 
cord  lesion  can  be  detected,  and  hyperesthesia  may  exist  over  the  spines). 
MouUin  tells  us  that  the  extremities  feel  weak  because  they  are  deprived 
of  proper  support  on  account  of  the  immobility  of  the  muscles  of  the  back. 
For  the  same  reason  the  action  of  the  abdominal  muscles  is  interfered  with, 
and  the  power  of  micturition  and  of  defecation  is  impaired  (there  are  constipa- 
tion and  difficulty  in  emptying  the  bladder) . 

The  treatment  of  recent  injuries  comprises  rest,  the  application  of  an 
ice-bag,  and  leeching  over  the  painful  area.  After  a  day  or  two  hot  fomenta- 
tions, tincture  of  iodin,  compression  by  adhesive  strips,  and  inunctions  of 
ichthyol  and  lanolin  are  used;  and,  later  stiU,  massage,  douches,  and  frictions 
with  a  stimulating  liniment  are  employed.  Phenacetin  helps  to  reheve  pain, 
though  in  some  cases  opium  is  temporarily  necessary-. 

Traumatic  neurasthenia  is  apt  to  arise  after  the  immediate  effects  of  the 
accident  subside.  In  this  condition  the  patient  grows  tired  easily  and  com- 
plains of  pains  and  aches  in  the  back  and  loins,  interfering  with  or  preventing 

^  Moullin  on  "Sprains." 
54 


850  Surgery  of  the  Spine 

work;  paresthesia  and  numbness  exist  in  the  extremities;  in  many  cases  sexual 
intercourse  is  impossible  because  of  premature  ejaculation  or  of  incapacity 
for  erection.  There  are  dyspepsia,  eye-strain,  insomnia,  loss  of  memory,  rapid 
and  irregular  pulse,  cardiac  palpitation,  and  mental  depression  or  confusion. 
The  reflexes  are  usually  exaggerated,  but  they  can  be  exhausted  more  easily 
than  can  the  exaggerated  reflexes  of  organic  cord  disease  (because  of  irritable 
weakness).  Some  rigidity  and  tenderness  exist  in  the  back,  and  the  skin  over 
this  region  is  often  hyperesthetic.  Attacks  of  retention  of  urine  may  occur. 
Hypochondriasis  is  not  unusual. 

Treatment  of  Traumatic  Neurasthenia. — Employ  rest,  tonics,  massage, 
douches,  and  frictions  to  the  back.  Secure  sleep,  and  endeavor  to  bring 
about  a  gain  in  weight.  If  sexual  incapacity  or  seminal  emissions  worry 
the  patient,  dilate  the  urethra  with  steel  sounds. 

Traumatic  hysteria  develops  only  in  those  predisposed  by  a  neuropathic 
hereditary  tendency;  traumatic  neurasthenia  may  arise  in  any  one.  In  the  first 
named  disease  the  accident  is  only  the  exciting  cause;  in  the  second  disorder 
it  is  the  cause.  Many  cases  of  so-called  "railway  spine"  are  really  examples 
of  traumatic  hysteria.  Traumatic  hysteria  and  neurasthenia  may  be  asso- 
ciated. Neurasthenia  is  a  condition  of  exhaustion  associated  with  a  number 
of  chronic  disorders;  it  forms  a  foundation  on  which  hysteria  is  apt  to  build 
its  structure.  The  structure  of  hysteria  is  made  up  of  morbid  impression- 
ability, hyperesthesia  of  centers,  lowered  self-control,  and  sensitiveness  of 
the  peripheral  nervous  system.  The  accident  plays  a  double  part  in  pro- 
ducing traumatic  hysteria — first,  by  its  effect  on  the  mind  (psychical  trau- 
matism); second,  by  its  effect  on  the  body,  which  anchors  the  attention  to 
one  point.  An  area  of  pain  or  stiffness  often  serves  as  an  autosuggestion 
which  undergoes  morbid  magnification  when  viewed  through  the  distorting 
medium  of  hysteria.  Erichsen  taught  that  the  symptoms  of  what  he  named 
"railway  spine"  arose  from  inflammation  of  the  cord  and  its  membranes, 
a  view  now  abandoned.  A  blow  given  to  a  hysterical  person  causes  a  feeling 
of  numbness,  and  thus  negative  sensation  from  local  shock  may  establish 
the  idea  of  paralysis,  or  traimiatism,  acting  as  a  suggestion,  may  inhibit 
motor  representations  and  destroy  the  normal  ideas  of  motion  and  feeling 
(Charcot  and  Pitre).  Terror  always  causes  a  feeling  of  loss  of  power  in 
the  legs,  and  the  terror  of  the  accident  may  thus  develop  the  idea  of  para- 
plegia. The  site  of  a  traumatism  may  localize  symptoms;  for  instance,  a  blow 
upon  the  eye  may  cause  amaurosis  or  blepharospasm.  It  is  important  to 
remember  Charcot's  saying  that  a  hysteria  long  latent  and  unrecognized 
may  be  awakened  into  obvious  activity  by  a  blow  or  an  accident.  Pitre 
shows  the  same  to  be  true  of  epilepsy.  A  not  unusual  lesion  is  hysterical 
traumatic  monoplegia,  not  coming  on  at  once  after  the  accident,  but  usually 
some  days  afterward,  and  presenting  flaccid  muscles,  the  electrical  reactions 
and  reflexes  remaining  normal,  but  the  muscular  sense  being  lost  (Pitre). 
The  muscles  usually  waste.  The  skin  of  the  paralyzed  limb  is  anesthetic 
or  analgesic.  There  may  be  anesthesia  limited  to  a  limb,  hemianesthesia, 
or  general  anesthesia.^  Hysterical  paralysis  is  usually  associated  with  the 
permanent  stigmata  of  hysteria — concentric  contraction  of  the  visual  field, 
pharyngeal  anesthesia,  convulsive  seizures,  and  hysterogenic  zones  (Clarke 
and  Pitre).  The  permanent  stigmata  may  be  latent.  Hysterical  phenomena 
lack  regularity  of  evolution,  and  they  may  be  produced,  altered,  or  abolished 
by  mental  influences  or  by  physical  forces  which  produce  no  effect  on  organic 
disease.  In  most  hysterical  conditions  the  general  health  is  not  profoundly 
impaired.^  In  making  a  diagnosis  of  hysteria  we  must  be  most  careful  to 
1  J.  Mitchell  Clark,  in  "Brain." 
^  Read  the  works  of  Thorburn  and  Pitre. 


Wounds  of  the  Spinal  Cord  851 

exclude  both  malignant  disease  and  imposture,  because  hysteria  is  a  sort  of 
diagnostic  waste-basket  into  which  we  cast  most  things  which  we  fail  to  under- 
stand. Babinski  proposes  that  we  should  call  phenomena  hysterical  only 
when  they  can  be  produced  or  can  be  cured  by  suggestion  ("Brit.  Med.  Jour.," 
Jan.  23,  1909,  p.  234).     Brain  tumor  may  cause  hysterical  symptoms. 

Treatment  is  by  moral  means  chiefly.  Gain  the  confidence  of  the  patient. 
Suggestion  is  of  great  value.  In  many  cases  separation  from  family  and  friends 
is  necessary  and  isolation  is  desirable.  The  Weir  Mitchell  rest-cure  is  often 
the  best  plan  of  treatment,  and  all  its  details  should  be  carried  our  faithfully. 

Malingering. — Persons  often  pretend  to  suffer  from  maladies  of  the  spinal 
cord  or  column  as  a  result  of  accident  when  no  diseases  of  those  parts  exist. 
Some  get  well  upon  the  rendering  of  a  favorable  verdict  by  a  jury  (litigation 
backs).  In  any  case  always  examine  carefully,  so  as  to  be  able  to  exclude 
malingering.  Note  the  patient's  behavior  and  motions  when  his  attention 
is  diverted  from  his  disease.  Meningomyelitis  can  be  excluded  if  there  be  no 
spasm,  paralysis,  hyperesthesia,  paresthesia,  or  anesthesia  at  a  distance  (A. 
Pearce  Gould),  If  pain  has  lasted  for  months;  if  pressure  downward  upon 
the  head  or  shoulders  does  not  increase  pain ;  if  the  vertebrae  are  movable  and 
there  is  no  angular  displacement,  exclude  caries.  Gould  states  that  when 
there  are  wasted  muscles,  when  moderate  spine  movement  is  painless,  but  effort 
in  bringing  the  body  erect  causes  pain  in  the  erector  spinae  region,  the  trouble 
is  a  strain  of  the  erector  spina  muscle.  If  the  muscle  is  not  wasted  and  the  pain 
is  in  bending  forward  rather  than  in  straightening  up,  the  vertebral  ligaments 
are  the  seat  of  trouble.  Unilateral  spasm  cannot  be  simulated.  The  ad- 
ministration of  ether  may  dispose  of  a  pretended  paralysis,  the  patient  moving 
the  suspected  extremity  while  drunk  from  the  anesthetic. 

Concussion  of  the  Spinal  Cord. — This  term  has  no  definite  patho- 
logical meaning.  It  is  probable  that  there  is  such  a  condition,  but  it  is  usu- 
ally associated  with  laceration  of  capillaries  and  of  cord  substance. 

The  symptoms  are  shock,  intense  pallor,  nausea,  often  vomiting,  and 
sometimes  syncope.  With  this  condition  special  symptoms  may  be  linked — 
as  temporary  paralysis,  a  girdle  sensation,  numbness  and  loss  of  power  in  the 
limbs,  hiccup,  torticollis,  coarse  tremors,  pains  in  the  back  and  limbs,  areas  of 
anesthesia  and  analgesia — depending  on  the  portion  of  cord  lacerated. 

The  treatment  in  concussion  of  the  spinal  cord  is  the  same  as  that  for 
sprains.  Traumatic  neurasthenia  and  hysteria  or  organic  cord  disease  may 
follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  blow  or  a  sprain,  but 
it  is  usually  due  to  extreme  flexion  of  the  spine.  It  causes  hemorrhage  into 
the  gray  matter  of  the  cord  (hematomyelia) .  The  symptoms  are  motor  and 
sensory  palsy  and  diminished  reflexes.  Some  cases  recover,  but  others  end 
in  myelitis. 

Wounds  of  the  spinal  cord  are  rare  and  are  very  dangerous.  A  knife 
is  sometimes  thrust  in  between  the  occiput  and  atlas.  Wounds  above  the 
origin  of  the  phrenic  nerves  cause  almost  instant  death.  Gunshot-wounds  are 
the  most  usual  form,  the  cord  being  damaged  by  the  bullet  and  by  bone-frag- 
ments. 

In  the  American  Civil  War  gunshot  injuries  of  the  cord  were  very  rare  (j  of 
I  per  cent,  of  all  wounds),  but  at  the  present  day  in  war  they  represent  more 
than  I  of  I  per  cent,  of  all  wounds,  the  increase  in  frequency  being  due  to  the 
increased  penetrating  power  of  the  modern  military  bullet  (Surgeon-General 
Robert  M.  O'Reilly,  in  "Keen's  Surgery,"  vol.  iv).  The  mortality  is  about 
60  per  cent. 

A  revolver  bullet  or  a  small-caliber  bullet  fired  at  long  range  may  produce 
vertebral  fracture  without  cord  injury,  and  any  bullet  may  fracture  a  process 


852  Surgery  of  the  Spine 

of  a  vertebra  without  cord  injury.  If  the  laminae  are  fractured  the  cord  is 
almost  sure  to  be  injured.  The  cord  may  be  concussed,  lacerated,  or  cut 
across  by  bone  or  bullet,  or  compressed  by  bone  or  blood.  The  bullet  may 
lodge  or  may  perforate. 

Treatment. — In  a  suspected  wound  of  the  cord  perform  exploratory  laminec- 
tomy, arrest  hemorrhage,  and  if  the  cord  is  divided,  suture  it.  If  a  bullet  is 
lodged,  remove  it. 

Compression  of  the  spinal  cord  may  be  due  to  blood  or  to  inflammatory 
exudate,  as  well  as  to  displaced  bone  (see  page  844).  Compression  from  blood 
may  be  due  to  extramedullar y  hemorrhage  or  to  intramedullary  hemorrhage. 
Extramedullary  hemorrhage  causes  sudden  pain  in  the  back,  the  pain  radiating 
from  compressed  nerve-roots ;  hyperesthesia  and  paresthesia  in  the  area  of  the 
radiated  pain;  spasm  of  muscles  supplied  by  the  compressed  nerves,  some- 
times of  muscles  whose  nervous  supply  is  below  the  lesion;  tremors;  con- 
vulsions; retention  of  urine;  paralytic  symptoms  following  the  signs  of 
irritation,  but  no  absolute  paralysis  (Mills).  A  girdle  sensation  is  usual. 
Intramedullary  hemorrhage  causes  pain,  a  girdle  sensation,  abolition  of  re- 
flexes, and  paralysis.  Spasms,  rigidity,  and  paralysis  come  on  early.  Bed- 
sores may  form,  and  retention  of  urine  and  incontinence  of  feces  may  be  ob- 
served. Paralysis  from  hemorrhage  is  rapidly  progressive  from  below  upward 
{crawling  paralysis).  Compression  from  extramedullary  hemorrhage  may  be 
recovered  from  without  operation,  and  in  some  cases  recovery  is  rapid. 

Treatment. — If  paralysis  from  spinal  bleeding  extends  rapidly  and  life 
is  endangered  through  the  probable  involvement  of  a  vital  center,  perform 
a  laminectomy,  remove  the  clot,  and  arrest  hemorrhage.  It  is  wise  always 
to  open  the  dura  and  inspect  the  cord.  Extramedullary  hemorrhage 
may  be  arrested  by  sutures  or  by  packing.  Intramedullary  hemorrhage 
may  be  arrested  by  suture-ligatures  or  by  packing.  If  an  extrameduUary 
clot  is  extensive  it  is  proper  to  make  a  second  laminectomy  near  the  lower 
end  of  the  spinal  column  in  order  to  permit  the  surgeon  to  wash  it  out  thor- 
oughly. The  dura  must  be  sutured  and  drainage  is  to  be  employed.  If 
there  is  paraplegia,  complete  anesthesia  of  the  paralyzed  parts,  and  entire 
abolition  of  the  deep  reflexes,  operation  is  probably  useless,  but  it  is  justi- 
fiable to  try  it  because  of  a  possibility  that  the  cord  is  not  completely  divided. 
In  some  cases  with  persistent  paraplegia  the  operation  should  be  imder- 
taken.  If  operation  is  not  undertaken,  have  the  patient  lie  upon  his  side, 
apply  a  spinal  ice-bag,  and  give  morphin  hypodermatically.  If  hemorrhage 
continues  in  the  cord  and  if  the  patient  be  plethoric,  perform  venesection. 
To  promote  absorption  of  the  clot  and  exudate  give  a  combination  of  carbon- 
ate and  acetate  of  ammonium,  order  pilocarpin,  and  employ  spinal  galvanism 
and  hot  douches.     lodid  of  potassium  may  be  given. 

Fractures  and  dislocations  of  the  spine  are  very  rare.  The  spinal 
regions  most  liable  to  injury  are  the  atlo-axial,  the  cervicodorsal,  and  the 
dorsolumbar  (Treves).  A  vertebra  may  be  fractured  alone,  but  dislocation 
without  fracture,  except  in  the  upper  cervical  region,  very  rarely  occurs.  These 
two  lesions,  dislocation  and  fracture,  are  so  often  associated  that  the  term 
fracture-dislocation  is  used  by  many  surgeons  to  include  them  both.  The 
causes  of  fracture  and  dislocation  are  direct  force  (seldom)  and  indirect 
violence  (commonly).  In  fracture  by  direct  force  the  laminae  and  spinous 
processes  are  most  apt  to  suffer.  In  most  cases  the  fragments  are  not  greatly 
displaced.  A  fracture  by  indirect  force  may  restdt  from  a  fall  on  the  shoulders, 
from  a  weight  falling  on  the  shoulders,  or  from  a  fall  on  the  buttocks.  Forced 
flexion  or  overextension  is  the  commonest  cause.  In  fractures  from  indirect 
force  the  cord  generally  suffers.  In  some  cases  the  displacement  of  the  ver- 
tebrae lacerates  the  cord,  the  vertebrae  return  into  place,  and  no  deformity  is 


Symptoms  of  Fractures  and  Dislocations  of  the  Spine 


853 


detectable.  Fracture-dislocation  from  direct  force  may  occur  at  any  part  of 
the  column,  and  in  this  accident  the  posterior  vertebral  segments  are  driven 
together,  and  the  cord,  as  a  rule,  escapes  injury'.  Fracture-dislocations  from 
indirect  force  most  commonly  happen  in  the  dorsolumbar  region,  but  are  met 
with  in  the  cervical  and  dorsal  regions.  In  the  cervical  region  reduction  can 
usually  be  secured,  but  in  the  lumbar  region  reduction  is  impossible. 

Symptoms. — In  fracture-dislocation  great  displacement  is  unusual,  but 
some  is  almost  always  recognizable  (irregularity  of  the  spines  or  angular 
deformity).  There  are  pain  (which  is  increased  by  motion),  tenderness, 
ecchymosis,  and  motor  and  sensor\-  paralysis.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  Horsley  has  pointed  out  that  in  many  cases 
paralysis  passes  away  only  to  recur  subsequently,  the  recurrence  being  due  to 


Fig.  544. — Fracture  of  third  lumbar  \-ertebra. 

edema  of  the  cord.  In  some  cases  of  spinal  injur}'  there  is  temporary  paral- 
ysis due  to  shock.  Persistent  paralysis  may  be  due  to  laceration  of  the  cord, 
di\dsion  of  the  cord,  or  compression  of  the  cord  by  bone,  blood-clot  (Fig. 
545),  or  products  of  inflammation.  The  extent  of  paralysis  depends  on  the 
seat  of  the  cord  injurv'.  We  must  always  trv'  and  decide  if  the  spinal  cord  is 
completely  divided  or  hopelessly  crushed  (Fig.  546) .  When  the  s^Tiiptoms  are 
not  immediate  in  onset;  when  all  the  muscles  below  the  seat  of  injury  are  not 
completety  paralyzed;  when  there  is  some  retention  of  sensation;  when  reflexes 
are  present  and  muscular  rigidity  exists,  we  may  be  sure  that  the  cord  is  not 
completely  di\-ided.  When  the  cord  is  completely  divided  the  s^onptoms 
are  immediate,  there  are  absolute  flaccid  motor  paralysis  and  complete  sen- 
sory paralysis  (loss  of  appreciation  of  pain,  touch,  and  temperature).      The 


854 


Surgery  of  the  Spine 


line  of  anesthesia  is  definite  and  suddenly  terminates  (Walton).  The  bladder 
and  rectum  are  paralyzed  and  there  may  be  priapism.  All  the  reflexes,  su- 
perficial and  deep,  except,  perhaps,  the  plantar  have  disappeared.  There  is 
pain,  there  are  no  muscular  spasms, 
there  is  vasomotor  paralysis  with 
sweating  of  the  paralyzed  parts,  and 
the  symptoms  persist  and  do  not 
vary  (J.  J.  Thomas,  in  "Boston 
City  Hospital  Med.  and  Surg.  Re- 
ports") .  There  is  usually  tympanites 
(Walton).  If  this  latter  symptom- 
group  is  due  to  shock,  it  will  usually 
be  temporary,  but  occasionally,  even 
when  so  caused,  it  persists  some 
considerable  time.  It  is  also  prob- 
able that  concussion  of  the  cord  may 
in    some    cases    simulate    complete 


Fig.  545. — Fracture  of  the  cervical 
spine,  cord  compressed  by  bone  and  blood. 
Hemorrhage  into  the  cord  at  the  seat  of 
the  lesion  and  below  the  lesion  (Warren 
Museum).  (From  Scudder's  "Treatment 
of  Fractures."     Drawn  by  Byrnes.) 


Fig.  546. — Spine  sawed.  Fracture  of  the 
spinous  processes  of  the  seventh  cervical  and  first 
and  second  dorsal  vertebree.  Fracture  of  the 
bodies  of  the  fifth,  sixth,  and  seventh  cervical  ver- 
tebrae with  displacement  backward  of  the  upper 
fragment.  Total  crush  of  the  cord.  The  section 
passes  a  httle  to  one  side  of  the  cord,  which  is  seen 
in  place,  and  the  staining  of  the  cord  by  hemor- 
rhage into  its  substance  shows  plainly  through  the 
membranes  even  in  photograph.  The  spinous 
processes  of  the  second  and  third  dorsal  vertebrae 
were  found  fractured  at  the  operation,  and  were 
removed  (Thomas). 


division.  As  Walton  says,  no  symptoms  prove  a  hopeless  crush  of  the  cord: 
it  is  the  persistence  of  the  symptoms  which  does  prove  it  ("Jour.  Nervous 
and  Mental  Diseases,"  Jan.,  1902);  I  would  add,  the  unchanging  persistence  of 
the  symptoms  proves  it. 


Prognosis  of  Fractures  and  Dislocations  of  the  Spine 


855 


A.  J.  McCosh  C'Jour.  Amer.  Med.  Assoc,"  Aug.  31  and  Sept.  7,  1901) 
points  out  that  definite  pressure  is  indicated  by  marked  symptoms  and  ab- 
sence of  reflexes.  When  there  is  not  definite  pressure  the  symptoms  are 
irregular;  there  is  incomplete  palsy,  or  muscles  of  the  same  group  show  differ- 
ent degrees  of  paralysis;  anesthesia  is  partial;  signs  of  irritation  are  not  dis- 
tinct, and  there  are  patches  of  hyperesthesia  and  zones  of  paresthesia.  If  in 
doubt  at  the  end  of  twelve  hours,  perform  an  exploratory  operation. 


Fig.  547. — Fracture  of  the  odontoid  process  of  the  second  vertebra  and  dislocation  between  the  first  and 
second  vertebra  a  number  of  years  after  injury.     (From  X-ray  Dep't.  of  Jefferson  Hospital.) 


The  prognosis  depends  on  the  amount  of  damage  done  to  the  cord.  Frac- 
ture-dislocations in  the  cervical  region  produce  obvious  deformity,  stiffness 
of  the  neck  and  irregularity  of  the  spines,  and  a  displaced  vertebra  may  occa- 
sionally be  detected  by  a  finger  in  the  pharynx.  Crepitus  can  rarely  be 
detected  unless  a  spinous  process  is  frac- 
tured. The  Rontgen  rays  aid  diagnosis 
immensely.  The  seat  of  cord  injury  may 
be  determined  by  a  study  of  the  palsy 
and  other  symptoms. 

Fracture-dislocation  of  the  atlas  or 
axis  usually  causes  instant  death.  When 
the  displacement  is  only  trivial,  the  pa- 
tient may  actually  recover,  but  will  prob- 
ably die  of  secondary  cord  disease.  Dr. 
N.  J.  Blackwood  of  the  U.  S.  Navy  records 
a  case  of  fracture  of  the  atlas  and  axis  and 
forward  dislocation  of  the  occiput  on  the 
spinal  coliunn,  life  having  been  maintained 
for  thirty-four  hours  and  forty  minutes 
by  artificial  respiration,  during  which  time 

laminectomy  was  performed  on  the  third  cervical  vertebra  ("Annals  of  Siir- 
gery,"  May,  1908).  Lofton  has  recorded  a  case  of  recovery  after  dislocation 
of  the  anterior  arch  of  the  atlas  on  to  the  odontoid  process  ("New  York  Med. 
Jour.,"  April  18,  1908).  Fig.  547  exhibits  a  case  which  recovered  after  fracture 
of  the  odontoid  and  dislocation  between  the  first  and  second  vertebrae.    In 


Fig.  548. — Lesion  of  spine  between  fifth 
and  sixth  cervical  vertebrae.  Note  position 
of  arms,  due  to  paralysis  of  subscapularis. 
Brachialis  anticus,  supinator  longus,  and  del- 
toid muscles  intact.  Elbow  flexed,  shoulders 
abducted  and  rotated  outward  (after  Thor- 
bum). 


856  Surgery  of  the  Spine 

injury  of  the  third  cervical  vertebra  the  phrenic  nerve  is  involved,  the  dia- 
phragm is  paralyzed,  and  death  soon  occurs.  In  fracture-dislocation  of  the 
fifth  cervical  vertebra  the  subscapularis  muscles  are  paralyzed,  but  the 
biceps,  brachialis  anticus,  supinator  longus,  and  deltoid  muscles  escape, 
and  the  patient  assumes  a  characteristic  attitude  (Fig.  548).  In  Jones's 
case  of  fracture  of  the  fifth  cervical  vertebra  no  operation  was  performed, 
but  the  patient  partly  recovered  and  became  able  to  walk,  but  with  a  spastic 
gait  ("Lancet,"  Nov.  28,  1903).  If  the  sixth  cervical  vertebra  is  dislocated 
there  is  palsy  of  the  muscles  of  the  hand.  In  injuries  below  the  sixth  cer- 
vical vertebra  no  muscle  of  the  arm,  forearm,  or  hand  is  paralyzed  at  first, 
although  after  some  days  paralysis  may  develop.  Damage  to  the  cord  above 
the  sixth  cervical  vertebra  produces  anesthesia  of  the  body  below  the  in- 
jury and  of  the  entire  upper  extremity  except  the  shoulder.  In  injury  just 
above  the  upper  level  of  the  seventh  cervical  there  are  body  anesthesia  and 
anesthesia  of  the  outer  surfaces  of  the  arms  and  ulnar  margins  of  the  fore- 
arms and  hands.  In  any  cervical  injury  there  are  body  anesthesia  and 
diaphragmatic  respiration,  and  in  cases  without  paralysis  of  the  arms  there 
is  sure  to  be  pain.  Injuries  of  the  dorsal  spine  can  be  accurately  located. 
There  is  paralysis  of  motion  and  sensation  up  to,  or  almost  up  to,  the  seat 
of  injury.  The  arms  are  not  paralyzed.  Very  great  pain  in  the  legs  occurs 
if  the  limibar  enlargement  is  involved.  In  injury  of  the  twelfth  dorsal  or 
upper  lumbar  vertebrae  there  are  paralysis  of  the  bladder  and  rectum,  incom- 
plete anesthesia,  and  partial  motor  paralysis  of  the  limbs. 

Treatment  of  Fracture-dislocations. — When  dislocation  of  the  body  of 
the  vertebra  obviously  exists  the  surgeon  may  attempt  reduction  by  exten- 
sion and  rotation.  The  maneuver  is  very  dangerous  in  the  cervical  region, 
and,  as  deaths  have  happened,  some  eminent  surgeons  advise  against  reduc- 
tion when  the  injury  affects  that  region.  Walton's  plan  for  a  unilateral  cervical 
dislocation  is  as  follows:  Give  the  patient  ether  and  hold  him  erect  and  sit- 
ting on  a  chair.  The  surgeon  stands  behind  the  patient  and  holds  the  head 
with  both  hands.  The  first  motion  is  a  slight  degree  of  rotation  to  carry  the 
dislocated  process  forward  and  "unlock"  it.  The  head  is  then  rocked  toward 
the  sound  side  and  somewhat  backward  and  finally  the  process  is  replaced  by 
rotation.  No  force  is  used  (Clop ton,  in  "Interstate  Med.  Jour.,"  Jan.,  1908. 
Quoted  in  "General  Surgery,"  by  John  B.  Murphy,  1909).  After  reducing 
a  fracture-dislocation  of  the  cervical  region,  place  the  patient  in  bed,  elevate 
the  head  of  the  bed  a  few  inches,  and  immobilize  the  neck  and  head.  In 
fracture-dislocation  of  the  dorsal  or  liunbar  region  the  traditional  plan  is 
to  straighten  the  spine,  gently  if  possible,  and  to  put  the  patient  upon  his 
back  upon  a  water-bed  or  upon  air-cushions.  Empty  the  bladder  every 
six  hours  with  a  soft  catheter,  which  is  kept  strictly  aseptic.  Take  every 
precaution  to  prevent  bed-sores.  Some  surgeons  advocate  reduction  of  the 
deformity  by  extension  and  coimter extension,  and  the  application  of  a  firmly 
fitting  but  removable  jacket  with  the  suspension  collar  (as  used  in  Pott's 
disease).  If  this  plan  is  employed,  the  head  of  the  bed  is  raised  and  the 
collar  is  fastened  to  it.  Every  day  extension  is  made  gently — from  the  shoulders 
in  dorsolimibar  fracture  and  from  the  chin  and  occiput  in  cervical  fractures. 
Extension  may  be  maintained  permanently  until  cure.  Surgeons  have  come 
rather  slowly  to  a  belief  in  laminectomy.  One  deterrent  factor  has  been 
the  high  mortality:  Lloyd  collected  the  records  of  159  operations  and  found 
that  59  patients  died  almost  at  once  and  39  died  later.  In  Lloyd's  collection 
of  185  cases  there  were  but  24  recoveries  and  40  improvements.  In  82  im- 
mediate operations  only  5  recovered.  In  103  late  operations  there  were  19 
recoveries  (John  B.  Murphy,  in  "Surg.,  Gynecol.,  and  Obstet.,"  April,  1907). 
Some  employ  purely  expectant  treatment  in  vertebral  fractures.     My  own 


Treatment  of  Fracture-dislocations  857 

feeling  is  that  when  simply  a  spinous  process  or  some  other  part  is  fractured,  and 
there  are  no  cord  symptoms,  we  may  treat  the  patient  expectantly,  following 
Burrell's  advice,  and  fixing  the  patient  in  bed  on  a  Bradford  frame  and  having 
him  carefully  nursed  and  watched.  Reduction  by  extension  and  counterex- 
tension  is  dangerous  and  unjustifiable  if  there  is  marked  kyphosis  and  if 
cord  symptoms  exist.  I  agree  with  Burrell  that  it  should  only  be  done  if 
operation  is  refused,  or  if  there  are  no  cord  symptoms  and  no  marked  ky- 
phosis ("Annals  of  Surgery,"  Oct.,  1905).  If  it  is  attempted  it  must  be  done 
slowly  and  as  gently  as  possible  because  it  may  cause  grave  or  even  irreparable 
damage  to  the  cord.  I  fear  to  delay,  and,  with  Burrell,  Lloyd,  Walton,  and 
others,  operate  when  the  patient  recovers  from  shock,  if  there  seems  to  be  even  a 
gleam  of  hope  that  operation  may  help  him.  To  wait  when  pressure  exists 
means  that  during  every  hour  of  delay  the  pressure  is  damaging  the  cord. 
Another  reason  for  operating  is  that  we  cannot  know  the  condition  of  the  cord 
without  direct  inspection.  The  operation  to  be  performed  is  laminectomy.  As 
before  stated,  this  is  to  be  done  even  if  we  suspect  division  or  hopeless  crush 
of  the  cord.  In  some  cases,  it  is  true,  we  may  commit  the  error  of  operating 
when  there  is  only  concussion,  but  such  a  mistake  is  less  grave  than  to  fail  to 
operate  when  there  is  bone-pressure  or  hemorrhage.  An  objection  filed  by  the 
neurologist  against  laminectomy  is  that  portions  of  cord  above  and  below  the 
level  of  the  fracture  may  be  damaged  (see  Fig.  545) ,  but,  as  Lloyd  says,  this  fact 
does  not  forbid  operation,  but  renders  it  necessary  to  make  a  wider  explora- 
tion than  has  been  the  custom.  In  many  cases  after  prompt  laminectomy 
we  get  some  considerable  improvement,  and  this  improvement  may  be  suffi- 
cient to  enable  a  man  to  earn  a  living.  It  is  true  that  statistics  would  indicate 
that  late  operations  have  been  more  successful  than  early  ones,  but  these 
figures  must  be  analyzed  in  the  light  of  the  knowledge  that  many  of  the  fatali- 
ties after  early  operation  would  have  occurred  if  no  operation  had  been  done, 
and  some  improvements  after  late  operation  would  have  occurred  to  as  great 
or  a  greater  degree  after  early  operation.  The  prognosis  of  any  operation, 
early  or  late,  is  never  gratif5dng,  and  Thorburn  feels  no  confidence  in  obtain- 
ing improvement  except  in  injuries  of  the  laminae,  hemorrhage,  or  injuries  of 
the  Cauda  equina,  as  he  says  laminectomy  in  the  cervical  region  is  followed 
by  death,  and  laminectomy  in  the  dorsal  region,  though  not  commonly  fatal, 
is  seldom  followed  by  recovery  of  function.  Our  statistics  of  early  laminec- 
tomy will  show  fewer  deaths  and  fewer  useless  operations  if  we  do  not  operate 
till  shock  abates.  As  Lloyd  ("Phila.  Med.  Jour.,"  Feb.  5,  1902)  says:  "It 
is  therefore  evident  that  if  we  operate  immediately  after  the  injury  we  will 
have  failures  that  should  not  be  charged  against  the  operation  itself,  and,  if 
possible,  we  should  wait  before  operating  until  the  question  can  be  settled 
whether  the  patient  will  overcome  the  shock  or  will  succumb  directly  to  the 
effects  of  the  injury."  All  surgeons  operate  for  compound  fracture,  for  hem- 
orrhage, and  for  cases  with  marked  bone  pressure.  If  early  operation  were 
not  performed  and  if  pachymeningitis  arises,  operation  is  called  for. 

My  own  convictions  are  that  if  symptoms  are  significant  we  should  ex- 
plore as  soon  as  shock  has  passed  away,  even  if  we  think  it  probable  that 
the  cord  has  been  divided;  and  if  it  is  found  divided,  it  should  be  sutured.  If 
in  any  case  we  are  in  doubt  twelve  hours  after  the  injury  as  to  whether  or  not 
pressure  exists,  we  should  explore.  If  soon  after  the  accident  we  think  pressure 
by  bone  exists,  we  should  operate.  If  the  case  is  improving,  we  should  not 
operate  even  if  there  are  pressure  signs,  unless  there  is  a  chance  that  pressure 
is  due  to  bone,  in  which  case  we  should  operate.  As  McCosh  says,  pressure 
by  blood  or  inflammatory  exudate  may  pass  away;  pressure  by  bone  cannot. 
Even  long  after  an  injury  laminectomy  may  be  productive  of  some  benefit. 

The  rather  radical  views  set  forth  above  regarding  the  advisability  of 


858  Surgery  of  the  Spine 

operating  even  if  the  symptoms  point  to  complete  division  of  the  cord  arose 
largely  from  a  knowledge  of  the  well-known  case  operated  upon  by  Stewart 
for  total  division  of  the  cord.  In  a  case  of  gunshot-wound  of  the  dorsal 
spine  treated  at  the  Pennsylvania  Hospital  by  Francis  T.  Stewart,  and  re- 
ported by  Francis  T.  Stewart  and  Richard  H.  Harte  ("Phila.  Med.  Jour.," 
June  7,  1902),  an  exploratory  incision  made  three  hours  after  injury  showed 
that  the  spinal  cord  was  completely  divided.  There  was  a  fracture  of  the 
laminae  of  the  seventh  dorsal  vertebra.  The  spines  and  laminae  of  the  seventh 
and  eighth  dorsal  vertebrae  were  removed.  The  bullet-hole  was  recognizable 
in  the  membranes,  and  the  bullet  and  some  bone-fragments  were  removed. 
When  the  dura  was  opened,  the  ends  of  the  completely  divided  dorsal  cord 
were  found  to  be  f  inch  apart.  Stewart  freshened  these  ends  and  brought  them 
together  with  two  sutures  of  chromicized  catgut.  In  this  case  a  considerable 
degree  of  restoration  of  function  took  place.  At  the  time  of  the  operation, 
three  hours  after  the  injury,  there  were  complete  paralysis  and  absence  of 
reflexes  below  the  seat  of  injury;  but  sixteen  months  later  the  patient  was 
able  voluntarily  to  flex  the  toes,  flex  and  extend  the  legs,  flex  and  extend  the 
thighs,  and,  while  sitting,  lift  an  extended  leg  from  the  floor.  The  movements 
of  the  lower  extremity  became  more  forcible  when  reinforced  by  contracting 
the  muscles  of  the  upper  extremity  while  making  them.  The  patient  could 
stand  with  one  hand  resting  on  the  back  of  a  chair,  and  could  get  herself  from 
her  bed  to  her  chair  by  sliding.  The  bowels  were  under  perfect  control,  and 
there  was  no  incontinence  of  urine  when  she  was  awake,  although  there  was 
occasionally  some  when  she  was  asleep.  There  were  occasional  cramp-like 
pains  in  the  lower  limbs.  The  sense  of  touch,  temperature,  pain,  and  position 
were  perfect  all  over  the  previously  paralyzed  parts.  Below  the  knee  the 
localization  of  sensation  was  not  so  accurate.  There  was  a  slight  amount  of 
muscular  rigidity;  and  on  each  side,  an  ankle  and  patella  clonus,  which  was 
easily  exhausted.  When  the  sole  of  the  foot  was  tickled,  the  big  toe  flexed,  the 
thigh  abducted,  and  there  was  slight  contraction  of  the  anterior  tibial,  the 
hamstring,  and  the  tensor  vaginae  femoris  muscles.  There  were  no  reactions 
of  degeneration  and  no  trophic  changes.  There  had  never  been  any  bed-sores. 
George  Ryerson  Fowler  ("Annals  of  Surgery,"  Oct.,  1905)  operated  on  a  gun- 
shot-wound of  the  dorsal  spine  eleven  days  after  the  injury.  He  removed  the 
laminae  of  the  tenth,  eleventh,  and  twelfth  dorsal  vertebrae  and  found  the  cord 
divided,  the  buUet  lying  between  the  severed  ends.  A  piece  of  dura  ^  inch 
wide  was  intact.  The  bullet  and  blood-clot  were  removed.  The  cord  was 
sutured  by  three  sutures  of  chromicized  gut,  which  included  the  dura,  and 
more  sutures  were  taken  through  the  dura  only.  The  ends  of  the  cord  were 
easily  approximated.  The  patient  recovered  from  the  operation.  Twenty-six 
months  later  voluntary  motion  was  found  to  be  practically  lost  in  the  area 
below  the  injury,  although  when  supported  by  the  hands  he  could  stand  and 
when  in  a  frame  could  move  a  little  by  a  swinging  movement.  He  is  able  to  tell 
when  his  bowels  or  bladder  are  about  to  move,  and,  if  furnished  promptly 
with  a  utensil,  does  not  soil  himself.  When  asleep,  he  passes  urine  involun- 
tarily. Both  legs  exhibit  spastic  rigidity,  but  there  are  no  reactions  of  de- 
generation. Patella  reflex  on  each  side  exaggerated.  Ankle  clonus  is  found 
on  one  side,  but  not  on  other.  There  is  complete  anesthesia  of  the  affected  area, 
except  in  a  region  5  inches  in  length  on  the  outer  side  of  the  right  thigh.  Touch 
is  appreciated,  but  not  correctly  localized.  In  connection  with  the  fore- 
going important  cases  we  would  note  that  Dr.  Estes,  of  Bethlehem,  has  also 
operated  upon  a  case  of  complete  division  of  the  spinal  cord,  in  which  suturing 
was  apparently  foUowed  by  some  restoration  of  function. 

In  the  light  of  these  positive  reports  we  must  ask  ourselves  if  we  have  not 
been  wrong  in  the  view  that  the  spinal  cord  cannot  regenerate.    If  there 


Operation  for  Spina  Bifida  859 

is  even  a  chance  that  we  have  been  wrong,  we  must  reverse  our  former  con- 
servative treatment  and  follow  a  radical  plan.  The  3  cases  strongly  sug- 
gest the  possibility  of  some  regeneration,  but  do  not  prove  it.  The  cord  may 
have  appeared  to  be  completely  divided  and  yet  minute  undivided  bundles 
may  have  escaped  recognition.  Again,  as  Fowler  suggests,  there  may  be  a 
nerve  anastomosis  through  uninjured  portion  of  the  dura  or  between  adja- 
cent nerve-trunks  which  arise  above  and  below  the  lesion.  At  my  request 
Dr.  Samuel  Lloyd,  of  New  York,  kindly  wrote  me  a  personal  communication 
setting  forth  his  views  on  this  important  subject.  They  are  as  follows:  "The 
question  of  the  regeneration  of  the  spinal  cord  after  traumatism  of  the  spine 
deserves  careful  consideration  in  all  cases  that  are  operated  upon.  Up  to 
the  present  time,  however,  although  a  number  of  operators  have  reported 
improvement  following  suture  of  the  spinal  cord  in  these  cases,  a  careful 
analysis  does  not  substantiate  the  fact  that  that  improvement  is  due  to  an 
actual  regeneration.  It  is  a  recognized  fact  on  the  part  of  all  who  have  had 
experience  with  the  surgery  of  the  spinal  cord  that  in  almost  every  instance 
a  certain  amount  of  improvement  is  noted  during  the  first  few  months.  This 
is  probably  due  to  the  fact  that  at  the  time  of  the  injury  minute  hemorrhages 
occur  into  the  adjoining  segments,  and  that  pressure  is  also  increased  in  those 
portions  of  the  cord  by  the  inflammatory  exudate  and  edema.  Within  a  short 
time  after  the  injury  these  conditions  improve,  and  there  seems  to  be  an 
improvement  in  function;  but  in  every  case  of  spinal  suture  yet  reported  the 
amount  of  improvement  may  be  explained  by  these  facts.  In  no  instance  has 
there  been  a  complete  recovery  of  function,  but  in  every  one  there  has  re- 
mained more  or  less  permanent  disabihty.  This,  however,  should  not  dis- 
courage attempts  at  spinal  suture,  and  in  every  case  operated  upon  the  diira 
should  be  opened  and  the  condition  of  the  cord  examined.  In  those  cases 
where  a  complete  destruction  has  occurred  and  where  the  extent  of  it  is  not 
over  f  inch,  it  may  be  possible  to  cut  out  the  lacerated  portions  and  coaptate 
the  surfaces  by  a  series  of  sutures  placed  in  the  dura.  In  all  these  cases  the 
patient  should  be  put  up  in  a  plaster  retaining  bandage  in  extreme  extension, 
even  the  head  being  thrown  back  so  as  to  relax  as  much  as  possible  the  tension 
on  the  line  of  suture.  The  operator  should  be  very  sure,  however,  that  there 
are  no  undestroyed  fibers  traversing  the  lacerated  area,  for  the  destruction  of 
these  in  case  regeneration  did  not  occur  would  increase  the  amount  of  paral- 
ysis." With  the  views  of  Lloyd  I  am  in  entire  agreement,  and  now  I  always 
follow  this  plan,  bearing  in  mind  that  it  is  often  impossible  to  tell  whether  the 
spinal  cord  is  completely  divided  or  seriously  damaged  without  examining 
it,  and  it  can  be  examined  only  by  exploratory  operation;  therefore,  if  the 
serious  symptoms  already  indicated  exist  after  shock  has  passed  away,  ex- 
ploratory operation  should  be  performed;  if  pressure  exists,  it  should  be 
removed;  and  if  the  spinal  cord  is  found  to  be  completely  divided,  it 
should  be  sutured.  It  is  well  to  remember  that  Abbe's  experiments  have 
shown  that  there  may  be  great  difficulty  in  bringing  the  divided  ends  of 
the  cord  into  apposition.  In  order  to  effect  this  it  may  be  necessary  to 
resect  a  vertebra. 

Operations  on  the  Spine. — Operation  for  Spina  Bifida. — A.  W.  Mayo 
Robson^  maintains  that  operation  is  not  demanded  when  the  sac  is  of  small 
size  and  is  well  protected  by  sound  integument;  that  operation  is  improper  when 
a  large  portion  of  the  column  is  fissured,  or  when  paraplegia  or  hydrocephalus 
exists;  that  operation  is  advisable  only  in  meningocele,  in  cases  in  which 
the  integimient  is  thin  and  translucent,  in  cases  in  which  the  cord  is  flattened 
out  or  the  nerves  are  fused.  Robson  has  closed  the  osseous  defect  by  trans- 
planting periosteum. 

^  "Annals  of  Surgery,"  vol.  xxii.  No.  i. 


86o  Surgery  of  the  Spine 

Surround  the  sac  by  elliptical  incisions.  Find  the  neck  of  the  sac,  and 
if  it  contains  no  visible  nerves,  ligate  it  and  cut  off  the  protrusion.  Push 
the  stump  into  the  canal.  Freshen  the  bone-margins  and  spring  a  piece 
of  celluloid  beneath  them  to  close  the  gap  (Park).  Suture  over  the  stump 
with  small  sutures  of  catgut.^ 

Treves's  Operation  for  Vertebral  Caries. — (See  page  695.) 

Laminectomy. — The  patient  lies  prone  and  a  sand-pillow  is  placed  under 
the  lower  ribs.  Make  a  vertical  incision  over  and  down  to  the  vertebral  spines, 
the  middle  of  the  incision  corresponding  to  the  seat  of  injury  or  disease.  The 
sides  of  the  spinous  processes  and  the  laminae  are  cleared.  The  periosteum 
is  incised  in  the  angle  between  the  laminae  and  spines,  and  is  lifted  away 
from  the  arches.  It  is  my  custom  to  bore  through  a  lamina  on  each  side  of 
a  spinous  process  by  means  of  Hudson's  burrs.  When  this  has  been  done 
the  spinous  process  and  lamina  are  easily  bitten  through  and  removed.  The 
usual  method  of  operating  is  as  follows:  The  spinous  processes  are  cut  off  close 
to  their  bases  by  means  of  bone-cutting  forceps,  the  laminae  are  removed  on 
each  side  with  the  same  instrimient  or  the  rongeur,  and  the  dura  is  exposed. 
In  some  cases  of  fracture  fragments  will  be  found  on  exposing  the  vertebra, 
or  a  blood-clot  will  be  seen  between  the  dura  and  the  bone;  in  other  cases  the 
dura  must  be  opened  by  scissors  vertically  in  the  middle  line  while  it  is  grasped 
by  mouse-toothed  forceps.  After  reaching  and  removing  the  compressing 
cause,  or  after  failing  to  find  or  remove  it,  it  is  best  not  to  close  the  dura  com- 
pletely, because,  if  we  do  so,  cord  pressure  may  result  from  hemorrhage.  The 
dural  wound  is  left  open  or  is  partly  closed.  I  used  to  insert  a  drain  of  rubber 
tissue,  but  have  given  it  up.  Horsley  shows  that  it  is  not  necessary,  and  if  we 
refrain  from  draining  we  lessen  the  tendency  to  headache,  temporary  pyrexia, 
and  rapid  pulse,  which  frequently  follow  laminectomy.  The  superficial  parts 
are  stitched  with  silkworm-gut  and  dressings  are  applied. 

Albee's  Method  of  Bone-grafting  for  Pott's  Disease  of  the  Spine. — In 
i8gi  Hadra,  of  Galveston,  advocated  the  treatment  of  Pott's  disease  of  the  spine 
by  wiring  the  spinous  processes  of  the  diseased  vertebrae  to  adjacent  vertebrae 
for  the  purpose  of  securing  fixation.  Chipault,  in  1895,  and  Calot,  in  1896,  did 
this  after  forcible  correction  of  angular  deformity.  Lange  buried  steel  wires 
on  each  side  of  the  spine  and  anchored  each  one  at  each  end  by  silver  wire 
(J.  T.  Rugh,  in  "Internat.  Clinics,"  Vol.  I,  Twenty-third  Series).  The  object 
of  these  operations  was  to  do  away  with  the  necessity  for  an  external  supporting 
jacket  or  brace.  The  objection  to  them  was  the  introduction  of  a  foreign 
material,  and  the  fact  that  strain  caused  that  material  to  cut  through  the 
tissues  and  permit  relaxation. 

In  191 1  both  Hibbs  and  Albee,  working  independently,  reported  methods 
for  producing  fusion  of  the  arches  of  the  vertebrae. 

Hibbs  ("New  York  Med.  Jour.,"  May  27,  1911,  and  "Annals  of  Surgery," 
May,  191 2)  takes  strips  of  the  periosteum  from  the  spines  and  laminae,  trans- 
poses the  spinous  processes,  and  sutures  the  periosteum  and  the  supraspinous 
ligament  over  these  processes.  The  periosteum  is  depended  upon  to  produce  new 
bone,  which  fuses  the  parts  together.  This  operation,  if  successful,  lessens  ky- 
phosis and  produces  fusion  of  spines  and  laminae.  Albee,  doubting  the  reliability 
of  the  periosteum  as  a  bone  producer,  practises  bone-grafting.  The  patient  is 
placed  prone.  An  incision  is  made  to  expose  the  spines  of  the  diseased  vertebrae 
and  also  one  or  two  vertebrae  above  and  one  or  two  below.  Some  make  a 
straight  incision.  Rugh  makes  a  curved  incision  at  one  side  of  the  spine  and 
turns  back  a  flap.  Each  spine  is  split  vertically  by  a  chisel  and  each  split 
portion  is  broken  and  pushed  over  to  the  same  side.     The  interspinous  liga- 

1  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an  article  by  Marcy, 
in  "Annals  of  Surgery,"  March,  1895. 


Puncture  of  the  Spinal  Meninges,  or  Lumbar  Puncture  86i 

ments  are  cut  so  as  to  correspond  to  the  split  in  the  spines.  We  thus  obtain 
a  wedge-shaped  incision  through  bone  and  ligament. 

The  length  of  the  cut  is  measured  on  a  probe.  The  wound  is  packed  tem- 
porarily. The  leg  is  flexed  upon  the  thigh.  An  incision  is  made  over  the  an- 
terior surface  of  the  tibia.  A  wedge-shaped  graft  of  bone  is  cut  by  means  of 
a  surgical  engine,  a  Gigli  saw,  or  a  chisel  and  mallet.  The  graft  is  covered  with 
periosteum  on  one  side  and  contains  some  medullary  tissue  on  the  other.  It 
is  ^  inch  thick  at  its  base.  This  graft  is  fitted  to  the  unbroken  sides  of  the 
spinous  processes.  If  the  kyphosis  is  marked,  numerous  cross-cuts  are  made  with 
a  saw  into  the  thin  edge.  Thus  the  graft  will  be  made  flexible.  No  attempt 
is  made  to  forcibly  correct  the  deformity.  Here  and  there  the  periosteum  is 
incised  to  favor  the  emergence  of  osteoblasts.  The  interspinous  ligaments  are 
sutured  over  the  graft  by  sutures  of  kangaroo  tendon.  The  incision  is  closed. 
The  patient  is  put  on  a  Bradford  frame  or  plaster  of  Paris  is  applied.  The 
patient  remains  recumbent  for  from  six  to  twelve  weeks,  then  he  is  allowed  to 
sit  up  and  soon  after  to  walk,  of  course  wearing  a  brace  or  plaster. 

The  brace  or  jacket  is  removed  in  five  or  six  months.  The  results  of  this 
operation  are  excellent.  The  fate  of  the  bone-graft  is  a  matter  of  dispute. 
Some  hold  that  it  really  lives.  Others  hold  that  it  is  simply  a  scaffold  for  new 
bone.  One  thing  is  certain — it  strongly  stimulates  the  production  of  new  bone 
from  the  raw  surfaces  of  the  split  spinous  processes.  New  bone  comes,  and  new 
bone,  however  formed,  constitutes  the  permanent  splint  (Albee,  in  the  "Post- 
Graduate,"  Nov.,  1912,  and  in  "N.  Y.  Med.  Jour.,"  March  9, 1912;  J.  Torrance 
Rugh,  in  "Monthly  Cyclopedia  and  Medical  Bulletin,"  Feb.,  1913,  and  in 
"International  CHnics,"  Vol.  I,  Twenty- third  Series). 

Puncture  of  the  spinjil  meninges,  or  lumbar  puncture,  was  devised  by 
Quincke,  and  has  been  carefully  tested  by  many  surgeons.  It  is  the  operation 
for  withdrawing  cerebrospinal  fluid  from  the  subarachnoid  space  of  the  cord. 
It  is  employed  as  a  means  of  diminishing  cerebral  pressure  in  hydrocephalus, 
cerebral  tumor,  uremia,  and  tuberculous  meningitis,  but  in  these  cases  it  has 
proved  of  little  or  only  of  temporary  therapeutic  value.  It  may  be  of  some 
service  in  cerebrospinal  meningitis.  The  condition  of  a  patient  with  a  frac- 
ture of  the  base  of  the  skull  is  sometimes  temporarily  improved  by  the  operation. 
Pain  is  often  temporarily  relieved.  In  the  performance  of  a  brain  operation  the 
brain  may  bulge  so  that  the  dura  cannot  be  sutured.  Lumbar  puncture  makes 
suturing  possible.  Puncture  is  the  preliminary  step  of  spinal  anesthesia.  In 
some  cases  the  examination  of  the  fluid  has  been  of  great  diagnostic  value.  The 
fluid  is  not  only  subjected  to  a  naked-eye  study,  it  is  also  studied  microscopic- 
ally and  bacteriologically.  If  the  fluid  from  the  puncture  gives  no  positive  find- 
ing, the  operation  should  be  repeated  (Lorgo).  When  a  diagnostic  tap  is  made 
we  must  know  the  appearance,  nature,  and  pressure  of  the  fluid  normally. 

Normally  the  fluid  is  clear,  transparent,  alkaline,  and  under  a  pressure  of 
from  40  to  60  mm.  of  mercury  (Dana)  its  specific  gravity  is  from  1.006  to 
1.008,  and  from  5  to  10  c.c.  will  flow  out  at  a  tap.  It  contains  a  very  few 
endothelial  cells  and  leukocytes.  In  cases  of  increased  tension  it  flows  out 
more  forcibly,  rapidly,  and  profusely  (brain  tumor,  hydrocephalus,  menin- 
gitis, and  some  infectious  conditions).  When  there  is  meningeal  inflammation 
the  specific  gravity  is  increased.  In  apoplexy  and  other  hemorrhages  beneath 
the  cerebral  arachnoid,  in  fracture  of  the  base  of  the  skull,  and  in  hemorrhage 
beneath  the  arachnoid  of  the  cord,  the  fluid  contains  blood.  Laceration  of 
the  brain  tissue  without  subarachnoid  or  ventriciilar  hemorrhage  does  not 
make  the  fluid  bloody.  The  fluid  is  turbid  in  purulent  meningitis  of  the  cord 
or  brain,  may  contain  many  polymorphonuclear  leukocytes,  and  also  bacteria. 
Lumbar  puncture  is  of  great  diagnostic  use  in  the  cerebral  hemorrhage  of  the 
newborn  and  in  some  fractures  of  the  base  of  the  skull. 


862  Surgery  of  the  Spine 

The  chemical  study  of  the  fluid  is  sometimes  of  value. 

In  intracranial  tumor,  purulent  meningitis,  subarachnoid  hemorrhage 
of  the  brain  or  cord,  and  apoplexy  albumin  is  increased.  The  normal  fluid 
contains  a  carbohydrate  substance  resembling  glucose.  This  is  absent  in  men- 
ingitis and  is  increased  in  saccharine  diabetes. 

In  uremia  the  chlorids  are  diminished. 

Cytodiagnosis  (a  microscopical  study  of  the  cells  of  the  fluid)  may  furnish 
useful  information;  numerous  polymorphonuclear  leukocytes  are  found  in 
meningitis.  Lymphocytosis  suggests  a  tuberculous  lesion  rather  than  an 
acute  meningeal  inflammation.  Lymphocytosis  occurs  also  in  syphilis  of 
the  brain  and  cord,  locomotor  ataxia,  paresis,  and  uremia. 

Bacteriologic  study  by  cover-glass  preparations  or  cultures  may  give  im- 
portant information.  In  over  75  per  cent,  of  cases  of  tuberculous  meningitis 
of  the  brain  membranes  the  fluid  contains  bacilli.  Stadelmann  has  reported 
37  cases  in  which  tubercle  bacilli  were  found  in  the  fluid.^  In  tuberculous 
meningitis  the  fluid  may  or  may  not  contain  tubercle  bacilli.  In  cerebrospinal 
meningitis  the  cerebrospinal  fluid  contains  the  meningococcus.  In  this  disease 
diagnostic  puncture  is  unnecessary  if  the  nasal  mucus  contains  the  Diplococcus 
intracellularis.  The  operation  of  lumbar  puncture  is  simple,  and  if  done  with 
proper  precautions  is  harmless.  The  back  should  be  carefully  sterilized  and 
thorough  asepsis  must  be  preserved  in  every  detail.  The  patient  may  lie  on  the 
right  side  with  the  left  knee  well  drawn  up,  may  lie  prone,  with  a  pillow  under 
the  belly,  or  may  sit  in  a  chair,  with  the  body  bent  forward.  The  site  of  the 
intended  puncture  may  be  frozen  with  ethyl  chlorid,  but  no  general  anesthetic 
is  required.  A  Pravaz  syringe  is  employed.  The  needle,  which  should  be 
3  inches  in  length,  is  guarded  by  the  surgeon's  index-finger  and  the  point 
is  inserted  |  inch  to  the  right  of  the  median  line  and  between  the  third  and 
fourth  lumbar  vertebrae.  It  is  pointed  upward  and  a  little  inward  under  a 
spinous  process.  It  enters  the  canal  in  the  middle  line.  In  a  child  the 
needle  enters  the  canal  at  a  depth  of  from  2  to  3  cm. ;  in  an  adult,  at  a  depth 
of  from  4  to  6  cm.  The  fluid  is  permitted  to  fall  drop  after  drop  into  a  sterile 
test-tube.  In  some  cases  only  a  few  drops  of  fluid  can  be  obtained;  in  other 
cases  many  cubic  centimeters  may  be  removed.  It  is  not  wise  to  draw  for 
diagnostic  purposes  over  5  c.c.  from  a  child  and  10  c.c.  from  an  adult.  If  we 
evacuate  too  much  cerebrospinal  fluid,  the  ventricles  are  emptied  and  com- 
pression of  the  cerebellum  may  arise.  The  flow  should  be  spontaneous  and 
suction  ought  not  to  be  used.  Sometimes  nausea,  vertigo,  and  severe  head- 
ache follow  the  operation,  and  sudden  deaths  have  been  reported.  For  a 
number  of  hours  after  tapping  the  patient  should  remain  recumbent. 

The  Mingazzini-Foerster  Operation  in  Tabes. — Mingazzini  suggested 
intradiu-al  division  of  the  posterior  sacrolumbar  nerve-roots  for  unbearable 
pain  in  the  lower  extremities  due  to  tabes. 

Foerster  foUows  a  like  method  in  treating  gastric  crises.  He  divides  the 
posterior  dorsal  roots  from  the  sixth  to  the  ninth.  Some  of  these  operations 
have  been  notably  successful.  Others  have  failed.  In  at  least  one  case  the 
condition  was  aggravated  (Doerr,  in  the  "Wien.  med.  Woch.,"  No.  45,  191 1). 
For  the  pains  and  crises  of  tabes  some  surgeons  advise  extradural  division  of 
the  posterior  roots  (Guleke).  The  posterior  roots  may  be  divided  for  intract- 
able neuralgia  and  for  athetosis.  The  roots  selected  depend  upon  the  seat  of 
pain  or  the  region  of  athetosis. 

Intradural  Root  Anastomosis  in  Cases  of  Vesical  Paralysis. — Kilvington 
("Brit.  Med.  Jour.,"  1907,  vol.  i)  suggested  intraspinal  anastomosis  of  nerve- 
roots.  He  found  by  experiments  on  dogs  that  the  last  lumbar  root,  when  joined 
to  the  roots  of  the  second  and  third  sacral  nerves,  gives  contraction  to  a  palsied 
^  "Berliner  klinische  Wochenschrift,"  July  8,  1895. 


Asphyxia  863 

bladder.  Bird,  at  the  suggestion  of  Kilvington,  did  the  operation  on  a  human 
being,  but  it  was  a  failure.  Frazier,  in  a  case  of  Mills's,  anastomosed  the  root 
of  the  last  lumbar  to  the  roots  of  the  third  and  fourth  sacral  nerves.  There  was 
decided  improvement  (Frazier  and  Mills,  "Jour.  Am.  Med.  Assoc,"  Dec.  21, 
1912). 

Horsley's  Operation  for  Chronic  Spinal  Meningitis. — Sir  Victor  Horsley 
("Brit.  Med.  Jour.,"  Feb.  27,  1909)  states  that  during  the  past  ten  years  he 
has  operated  on  a  number  of  cases  for  what  he  calls  chronic  spinal  meningitis. 
Such  cases  are  commonly  confused  with  tiunor,  are  much  more  frequent  than 
tumors,  and  are  often  cured  or  greatly  improved  by  operation.  The  first 
published  case  of  this  sort  was  reported  by  Spiller,  Musser,  and  Martin  ("Univ. 
of  Penna.  Med.  Bulletin,"  March,  1903).  Martin  performed  laminectomy, 
foimd  a  "circumscribed  meningitis,"  and  cured  the  patient.  In  these  cases 
a  fluid  accumulation  is  found  and  this  fluid  is  stagnating  and  under  pressure. 
The  cord  passes  into  a  condition  of  scler ©gliosis.  The  s\anptoms  are  pain, 
advancing  loss  of  power  in  the  legs,  perhaps  slight  k>T3hosis,  and  eventually 
progressive  and  fatal  paraplegia  (compression  paraplegia). 

The  pain  in  these  cases  involves  an  extensive  area,  not  as  in  extramedullary 
tumor  a  small  area  suppHed  by  one  or  two  nerv-e-roots,  and  there  may  be 
hyperesthesia  over  an  entire  extremity,  which  does  not  occur  in  extramedullary 
timior  (Horsley,  Loc.  cit.).  Horsley  has  never  seen  absolute  abolition  of  tactile 
sense.  The  operation  consists  in  laminectomy,  opening  the  theca,  washing 
it  out  with  mercurial  solution  (i  :  500  foUow^ed  by  i  :  2000),  and  closing  i^ith- 
out  drainage.  Bailey  and  Elsberg  ("Jour.  Am.  Med.  Assoc,"  jSIarch  9,  1912) 
suggest  the  term  spinal  decompression  for  laminectomy  and  opening  of  the  dura 
when  no  lesion  is  located  or  found.  They  believe  that  in  such  cases  as  Hors- 
ley describes  the  laminectomy  and  opening  of  the  dura  do  the  good.  A  nmn- 
ber  of  other  intradural  conditions  may  perhaps  be  benefited  by  the  operation. 


XXVI.  SURGERY   OF  THE   RESPIRATORY   ORGANS 

Asphyxia. — In  drowning,  strangulation,  suffocation,  and  hanging  the  mode 
of  death  is  by  the  same  proc-ess,  that  is,  by  asphyxia  or  apnea.  "Asphyxia," 
though  the  commonly  used  designation,  is  an  imfortunate  term,  and  apnea  is  the 
more  correct  one.  By  asphyxia  we  mean  the  non-oxA^genation  or  the  incomplete 
oxygenation  of  the  blood,  and  yet  even  in  this  condition  death  is  not  immediate, 
for  the  heart  may  continue  to  beat  for  some  little  time  after  all  breathing  has 
ceased.  A  man  may  be  apparently  dead  from  asphyxia  and  yet  be  capable  of 
resuscitation.  In  general,  it  may  be  said  that  asphyxia  produces  liAddity,  a 
struggle  like  a  con\ailsion  to  obtain  breath,  and  finally,  in  many  cases,  genuine 
con\ailsions.  In  the  very  beginning  of  non-ox\'genation  the  senses  may  be 
remarkably  acute,  but  consciousness  is  soon  lost.  The  veins  stand  out  and 
the  pulse  becomes  weaker  and  weaker.  The  indi-\ddual  may  bleed  from  the 
nose,  from  the  rectum  and  other  mucous  membranes,  and  there  may  be  in- 
voluntary passage  of  mine.  For  a  short  time  the  chest  heaves,  making  res- 
pirator}^ attempts,  and  after  a  short  time  the  heart  stops  beating. 

Asphyxia  is  a  common  mode  of  death.  It  is  the  mode  of  death  occasioned 
by  a  foreign  substance  in  the  air-passages,  by  paralysis  or  by  tetanic  fixation  of 
the  respiratory  muscles,  by  great  pressure  upon  the  chest  or  abdomen,  by  acute 
tramnatic  pnemnothorax,  by  a  clot  in  the  pulmonars^  artery  which  cuts  off  the 
blood-supply  of  the  lungs,  by  hanging,  throttling,  drowning,  absence  of  sufiS- 
cient  oxygen  from  the  gases  breathed,  presence  of  quantities  of  irrespirable 
gases  (CO,  CO2),  or  the  presence  of  irritant  gases  (CI,  SO2)  which  cause  spasm 
of  the  glottis. 


864  Surgery  of  the  Respiratory  Organs 

The  terms  smothering,  stifling,  and  suffocation  mean  prevention  of  entry  of 
air  into  the  lungs  in  sufficient  quantity  to  properly  aerate  the  blood. 

Treatment  in  General. — Of  course,  each  form  requires  some  particular 
method  of  care.  In  general,  it  may  be  said  that  the  surgeon  should  at  once 
endeavor  to  determine  the  cause  of  the  asphyxia  and  should  particularly  ascer- 
tam  if  it  came  on  gradually  or  suddenly.  As  a  rule,  a  gradual  asphyxia  is  due 
to  some  intrathoracic  lesion.  If  the  asphyxia  were  sudden  the  surgeon  must 
examine  the  neck  and  chest  externally  to  see  if  there  is  any  sign  of  injury. 
Then  the  mouth  is  opened,  the  tongue  pulled  forward,  and  the  glottis  felt  by 
the  finger  to  see  that  no  foreign  material  is  blocking  the  air-passages.  The 
patient  will  do  best  in  a  free  draft  of  fresh  air,  and  it  may  be  possible  to  excite 
respiratory  activity  by  dashing  hot  water  and  then  cold  water  on  the  face  and 
chest  and  making  a  number  of  these  alternate  appHcations.  The  appHcation 
of  electricity  to  the  phrenic  nerve  may  do  good  (the  anode  at  the  root  of  the  neck 
and  the  cathode  over  the  epigastric  region).  If  there  is  cardiac  dilatation, 
bleeding  is  urgently  indicated.  When  the  patient  is  breathing,  inhalations  of 
oxygen  do  good.  If  there  is  laryngeal  obstruction,  tracheotomy  or  intubation 
should  be  done.  In  most  cases  of  threatened  asphyxiation  artificial  respiration 
is  necessary.     There  are  several  different  methods. 

Artificial  respiration  is  resorted  to  in  case  of  suspension  of  breathing 
from  any  cause;  among  the  more  frequent  causes  are  the  inhalation  of  smoke 
or  poisonous  gases,  drowning,  profound  anesthesia,  opium-poisoning,  and  electric 
shock. 

There  are  several  methods  of  giving  artificial  respiration.  One  method  may 
have  an  advantage  over  another  in  a  certain  type  of  case,  as  will  hereafter  be 
described. 

Before  resorting  to  any  method  the  clothing  about  the  neck,  chest,  and 
abdomen  must  be  free  and  loose;  the  mouth  unobstructed  by  foreign  bodies, 
as  false  teeth,  etc.,  the  throat  clear  of  mucus,  etc. 

If  edema  of  the  glottis,  malignancy  of  the  tongue,  or  an  immovable  foreign 
body  should  obstruct  the  air-passages,  tracheotomy  should  be  performed  be- 
fore attempting  artificial  respiration. 

When  giving  artificial  respiration  the  operator  should  not  desist  because 
respirations  are  not  established  in  a  few  minutes,  but,  on  the  contrary,  should 
persist  (even  using  relays  of  men  if  necessary)  for  an  houi  or  more.  Many 
cases  of  drowning,  opium-poisoning,  asphyxia  from  smoke,  etc.,  have  been 
resuscitated  after  an  almost  incredible  period  of  time,  during  which  time 
artificial  respiration  was-  carried  on. 

During  the  manipulations  of  artificial  respiration  it  should  be  remembered 
that  the  patient  must  be  cared  for  as  in  shock:  the  body  kept  warm,  frictions 
applied  by  the  hands  or  rough  towels,  and  massage  over  the  heart  be  practised. 
Enemas  of  coffee  by  rectum  and  stimulating  hypodermatic  injections  are  im- 
portant. The  author  prefers  an  enema  of  5  oz.  of  hot  coffee  with  i  oz.  of  brandy 
and  a  hypodermatic  injection  of  atropin  sulph.,  gr.  y^o";  or  strychnin,  gr.  -^. 
One  of  the  oldest  methods  of  artificial  respiration  and  the  one  most  applicable  in 
children  is  mouth-to-mouth  inflation.  In  this  method  the  operator  holds  the 
victim's  tongue  forward  with  a  suture  or  with  a  piece  of  string  tied  around  the 
tongue;  with  the  other  hand  he  closes  the  nostrils,  and  then,  after  taking  a  deep 
inspiration,  blows  directly  into  the  patient's  mouth.  The  air  is  then  expelled 
from  the  patient's  lungs  by  direct  pressure  on  the  walls  of  the  thorax.  This 
procedure  is  repeated  16  times  a  minute.  Instead  of  the  direct  mouth-to- 
mouth  inflation  a  soft-rubber  catheter  may  be  passed  through  the  mouth  into 
the  trachea  and  the  patient's  lungs  be  expanded  by  the  operator  blowing 
through  the  catheter. 

Artificial  respiration  must  not  be  stopped  when  the  patient  has  taken  one  or 


Artificial  Respiration 


86:; 


two  breaths,  but  should  be  continued  until  the  respiratory  movements  are 
regular  and  normal.  The  patient  must  be  carefully  watched  for  fear  of  second- 
an,'  apnea. 

'  Sylvester's  method  is  a  popular  one,  and  is  probably  the  best  in  many  cases 
in  severe  electric  shock,  but  if  there  is  any  fluid  in  the  lungs  or  air-passages 
(as  in  cases  of  drowning)  another  method  may  be  preferred. 


Fig.  sV->- — S^'lvester'i  mfthL"i.     Inspiration. 


To  make  artificial  respiration  by  this  method  the  patient  is  placed  on  his 
back  with  a  folded  coat  or  blanket  under  his  shoulders.  The  tongue  is  pulled 
forward  and  held  by  forceps,  a  suture,  or,  in  an  emergency,  may  be  tied  v^-ith  a 


iig.  550. — Sj'lvesters  method.     Expiration. 


String,  or  even  a  necktie  can  be  used.  The  operator,  kneeling  at  the  head  of  the 
patient,  grasps  the  forearms  just  below  the  elbows  and  circumducts  the  arms 
outward  and  upward,  meanwhile  making  traction  until  the  arms  are  perpendicu- 
lar to  the  bodv  (Fig.  549).     By  this  movement  the  chest  is  expanded  and  in- 


866  Surgery  of  the  Respiratory  Organs 

spiration  is  caused.  The  arms  are  now  brought  slowly  to  the  sides  of  the  chest 
and  firm  pressure  is  made  for  two  or  three  seconds,  thus  forcing  the  air  from 
the  lungs  and  causing  expiration  (Fig.  550).  This  procedure  should  be  re- 
peated about  15  or  16  times  a  minute. 

This  method  is  best  suited  to  those  overcome  by  gas,  smoke,  or  apnea  other 
than  that  due  to  drowning. 

Howard's  Method. — This  method  is  now  used  by  the  United  States  Life 
Saving  service  in  cases  of  drowning.  The  procedure  as  laid  down  by  Dr. 
Howard  is  as  follows: 

"Rule  I :  To  expel  water  from  the  stomach  and  lungs,  strip  the  patient  to 
the  waist,  and,  if  the  jaws  are  clinched,  separate  them  and  keep  them  apart  by 
placing  between  the  teeth  a  cork  or  a  small  piece  of  wood.  Place  the  patient 
face  downward,  the  pit  of  the  stomach  being  raised  above  the  level  of  the 
mouth  by  a  roll  of  clothing  placed  beneath  it.  Throw  your  weight  forcibly  two 
or  three  times  upon  the  patient's  back  over  the  roll  of  clothing  so  as  to  press  all 
fluids  in  the  stomach  out  of  the  mouth." 


Fig.  SSI. — Howard's  method  of  artificial  respiration. 

"Rule  2:  To  perform  artificial  respiration  quickly  turn  the  patient  upon  his 
back,  placing  the  roll  of  clothing  beneath  it  so  as  to  make  the  breast  bone  the 
highest  point  of  the  body.  Kneel  beside  or  astride  of  the  patient's  hips.  Grasp 
the  front  part  of  the  chest  on  either  side  of  the  pit  of  the  stomach,  resting  the 
fingers  along  the  spaces  between  the  short  ribs  (Fig.  551).  Brace  yoiir  elbows 
against  your  sides,  and  steadily  grasping  and  pressing  forward  and  upward, 
throw  your  whole  weight  upon  the  chest,  gradually  increasing  the  pressure  while 
you  count  'one,  two,  three.'  Then  suddenly  let  go  with  a  final  push,  which 
springs  you  back  to  your  first  position.  Rest  erect  upon  your  knees  while  you 
count  'one,  two';  then  make  pressure  as  before,  repeating  the  entire  motions 
at  first  about  4  or  5  times  a  minute,  gradually  increasing  them  to  about  10  or 
1 2  times.  Use  the  same  regularity  as  in  blowing  bellows  and  as  seen  in  natural 
breathing,  which  you  are  imitating.  If  another  person  is  present  let  him, 
with  one  hand,  by  means  of  a  dry  piece  of  gauze,  hold  the  tip  of  the  tongue  out 
of  one  corner  of  the  mouth,  and  with  the  other  hand  grasp  both  wrists  and  pin 
them  to  the  ground  above  the  patient's  head." 

Schdfer^s  Method  or  the  Prone  Method. — In  this  method,  instead  of  lying  on 
his  back  as  in  the  Howard  method,  the  patient  lies  on  his  stomach,  his  face 
being  turned  to  one  side.     The  arms  are  placed  above  the  head.     A  roll  of 


Artificial  Respiration  by  the  Pulmotor  867 

blankets  or  clothing  are  placed  under  the  chest.  The  operator  now  kneels  astride 
of  the  patient  and  grasps  the  thorax  with  both  hands,  the  fingers  running  par- 
allel with  the  ribs.  Brace  your  elbows  against  your  sides  and  press  firmly 
inward  and  upward,  throwing  your  whole  weight  against  the  chest.  Release 
your  pressure  after  two  or  three  seconds,  count  "one,  two,"  and  again  make 
pressure  as  before.  This  sequence  should  be  repeated  about  15  times  a 
minute. 

The  advantage  of  this  method  is  that  fluid  in  the  air-passages  will  gravitate 
out  through  the  mouth  and  the  tongue  falls  forward  without  being  held. 

Marshall  Hall's  method  is  more  easily  applied  on  the  operating  table  than 
any  other  method  of  artificial  respiration.  On  the  other  hand,  it  is  not  as 
efi&cient  and  is  only  justifiable  when  the  patient's  normal  respirations  are  re- 
sumed after  three  or  four  applications  of  pressure.  The  patient  lies  on  his 
back,  and  the  operator,  with  a  hand  on  either  side  of  the  thorax  near  the  costal 
region,  makes  pressure  upward  and  inward.  This  pressure  is  continued 
for  two  or  three  seconds,  then  suspended  for  the  same  length  of  time,  and 
then  pressure  again  made.  This  procedure  is  repeated  about  15  times  a 
minute. 

Laborde's  method  is  not  as  efficacious  as  the  foregoing,  but  has  its  uses  in 
cases  in  which,  because  of  injury  to  the  chest,  shoulders,  or  arms,  Sylvester's 
or  Schafer's  method  or  their  modifications  cannot  be  employed. 

Laborde's  method  rests  on  the  assimaption  that  "systematic  and  rhythmic 
traction"  upon  the  tongue  produces  respiratory  reflexes  and  causes  contrac- 
tions of  the  diaphragm,  hence  establishing  respirations. 

The  tongue  is  grasped  by  tongue-forceps  or  a  piece  of  gauze  held  between 
the  forefinger  and  thumb,  and  is  pulled  well  out  of  the  mouth  with  considerable 
traction.  It  is  held  for  two  or  three  seconds  and  then  relaxed.  This  pro- 
cedure is  repeated  about  15  times  a  minute. 

When  a  certain  amount  of  resistance  is  felt,  it  is  a  sign  that  respiratory 
fimction  is  being  restored.  Noisy  respiration  first  occurs,  termed  inspiratory 
hiccup. 

When  the  condition  of  the  chest  will  allow,  that  is,  if  there  are  no  fractured 
ribs,  empyema,  etc.,  Laborde's  method  and  Marshall  Hall's  method  may  be 
combined. 

It  can  be  readily  realized  that  Laborde's  method  cannot  be  used  when 
there  is  disease  or  injury  of  the  tongue. 

Intratracheal  Insxifflation. — This  consists  in  forcing  air  by  external  pressure 
through  a  tube  which  passes  through  the  mouth  and  larynx  into  the  trachea. 
The  air,  under  the  influence  of  the  same  force  which  drove  it  in,  emerges  between 
the  tube  and  tracheal  wall.  "The  air-stream  has  to  be  interrupted  several  times 
a  minute  for  only  about  two  seconds  at  a  time"  (S.  J.  Meltzer,  in  "Keen's 
Surger}^,"  vol.  \d).     (See  Insufflation  Anesthesia,  p.  1199-) 

Artificial  Respiration  by  the  Pulmotor. — The  pulmotor  is  a  most  ingenious 
apparatus.  It  is  for  two  purposes:  (i)  To  give  artificial  respiration;  (2)  to 
administer  ox^^gen. 

Both  the  administration  of  oxy^gen  and  the  production  of  artificial  respira- 
tion are  accomplished  by  means  of  oxy^gen  which  is  under  pressure.  This  fact 
makes  the  instrument  especially  valuable  in  cases  of  asphyxiation  from  illu- 
minating gas  or  other  poisonous  vapors.  The  apparatus  should  be  a  part  of 
the  equipment  of  every  modern  hospital  (for  work  on  the  ambulance,  in  the 
accident  ward,  and  in  the  operating  room),  every  gas  and  electric  company, 
every  mine,  should  be  accessible  at  resorts  where  bathers  congregate  in  any 
large  number,  and  should  be  on  the  ground  at  every  city  fire. 

The  apparatus  is  contained  in  a  narrow  wooden  case  w^hich  can  be  carried 
by  one  person.     The  weight  of  the  case  with  the  apparatus  is  less  than  50 


868 


Surgery  of  the  Respiratory  Organs 


pounds.     A  diagram  of  the  apparatus  (Fig.  552)  is  here  given  which  shows 
its  mechanism:  C  is  a  cylinder  containing  ii|  cubic  feet  of  oxygen,  which  will 

keep  the  apparatus  in  operation  and  create 
artificial  respiration  for  forty  minutes;  V  is 
a  valve  which  opens  and  closes  the  oxygen 
tank  and  which  is  the  sole  governor  of  the 
apparatus. 

The  mask  is  fitted  on  the  patient's  head 
as  in  Fig.  553.  The  oxygen  is  then  turned 
on  by  the  valve  V.  The  oxygen  passes 
through  the  reducing  valve  D  to  the  in- 
jector S,  which  has  the  property  of  drawing 
in  a  large  volume  of  air  with  a  certain  force 
of  suction,  and  propelling  that  air  forward 
with  equal  force  through  the  flexible  tube 
in  front  of  the  injector.  This  suction  and 
delivery  injector  therefore  serves  as  a  motor, 
automatically  filling  the  lungs  by  pressure 
and  empt^dng  them  by  suction.  The  suc- 
tion is  accomplished  by  the  leather  accordion 
bellows  B,  which  effects  without  cessation 
the  automatic  reversal  of  the  apparatus 
from  suction  to  dehvery  and  vice  versa. 
During  inflation  the  same  pressure  obtains 
in  the  beUows  as  in  the  lungs,  but  as  soon 
as  the  latter  are  filled  the  beUows  be- 
comes inflated,  and  in  moving  forward 
throws  over  the  valve  in  the  reversing 
chamber  L,  which  becomes  reversed  into 
position  for  suction.  This  operation  is  now  reversed,  and  as  soon  as  the 
lungs  have  been  emptied  the  bellows  contracts  and  automatically  reverses 
the  valve  into  position  for  inflation. 


V£y 


Fig.  552. — Diagrammatic  illustration 
showing  the  action  of  the  pulmotor. 
(See  text  for  explanation  of  letters.) 


Fig.  553. — Application  of  mask  of  pulmotor,  the  tongue  being  held  forward  by  forceps,  and  oxygen 
prevented  from  entering  esophagus  by  pressure  with  right  hand. 

The  apparatus  adapts  itself  to  any  pulmonary  capacity.     The  rhythm  will 
be  slow  when  the  lungs  are  capacious  and  faster  when  they  are  of  less  capacity. 


Drowning 


869 


It  causes  all  the  movements  of  respiration  without  any  assistance  being  re- 
quired from  the  hands  other  than  to  keep  the  windpipe  of  the  patient  open  and 
the  gullet  closed  in  order  that  air  will  not  be  forced  into  the  stomach.  This 
latter  maneuver  is  accomplished  by  placing  the  hand  on  the  windpipe,  as  in 
Fig.  553,  and  making  pressure  sufl&cient  to  close  the  esophagus.  The  tongue 
must,  of  course,  be  held  forward,  as  in  Fig.  553. 

The  apparatus  is  de\dsed  so  that  no  residual  air  from  the  system  can  find 
its  way  into  the  lungs  again.  In  this  way  no  air  contaminated  with  poison- 
ous or  asphyxiating  gas  is  breathed. 

After  respiration  has  been  established,  the  lever,  which  is  seen  in  Fig.  552, 
is  thrown  from  pulmotor  to  inhalation,  and  oxygen  is  then  given  as  shown  in 

Fig.  554- 

In  addition  to  this  regular  sized  pulmotor,  there  is  an  infant  pulmotor  which 
is  especially  adapted  for  use  in  maternity  hospitals  and  by  obstetricians.     Both 


Fig.  554. — Administration  of  oxygen  after  respirations  have  been  established. 

the  adult  and  the  infant  apparatus  have  a  lever  with  which  the  operator  can 
regulate  expiration  and  inspiration  at  -^-iil,  instead  of  using  the  automatic 
bellows. 

If  the  mask  fits,  the  pulmotor  works  admirably.  If  it  does  not  fit,  it  fails. 
The  mask  fits  some  faces  and  not  others.  The  great  need  of  the  instrument 
is  a  certainly  adjustable  mask. 

Drowning  is  asphyxia  brought  about  by  ha\-ing  the  mouth  and  nose  sub- 
merged in  fluid,  air  being  thus  excluded  from  the  lungs.  It  is  not  only  water 
that  may  be  responsible  for  drowning.  An  individual  may  be  drowned  in 
mud  or  in  a  cesspool. 

Phenomena  of  Drowning. — As  asph\^a  begins  the  ^dctim  struggles  fright- 
fully and  clutches  at  anything  that  seems  to  be  within  reach.  He  usually 
sinks  and  rises  an  uncertain  number  of  times.  The  old  rule  of  three  times 
has  no  particular  force.  It  may  be  that  the  ^-ictim  sinks  and  rises  oftener,  it 
may  be  that  he  does  so  less  frequently.  He  may  not  rise  at  all.  During  this 
awful  struggle  air  and  water  are  inhaled,  and,  as  a  rule,  some  of  the  water  is  cast 


870  Surgery  of  the  Respiratory  Organs 

out  by  vomiting  and  violent  cough.  During  drowning  water  is  certain  to  be 
drawn  into  the  bronchial  tubes  and  air-cells.  While  this  struggle  is  going  on  the 
blood  becomes  less  and  less  oxygenated,  exhaustion  deepens ;  finally  the  patient 
sinks  to  rise  no  more,  some  air  is  forced  from  the  lungs  causing  bubbles  on  the 
surface  of  the  stream,  the  ears  ring,  the  muscles  are  convulsed,  the  mind  wanders, 
merciful  insensibility  arrives,  and  death  follows.  During  the  mental  wandering 
the  memory  may  take  clear  and  extensive  or  irregular  and  incoherent  journeys 
through  the  events  of  years  or  a  lifetime,  but  this  does  not  always  happen. 

The  duration  of  the  death  struggle  is  uncertain:  it  may  be  very  brief,  it 
may  last  a  considerable  time.  The  weaker  a  person  is,  the  sooner  it  is  over.  It 
is  probable  that  death  occurs  in  two  minutes  after  the  final  sinking.  In  spite 
of  some  specially  trained  divers  being  able  to  remain  in  water  as  long  or  even 
longer  than  this,  "we  may  conclude,  from  all  data,  that  fatal  asphyxia  is  prob- 
able at  the  end  of  two  full  minutes'  submersion  of  the  head"  (Draper's  "Legal 
Medicine"). 

Treatment. — ^Because  it  is  probable  that  a  person  is  dead  after  two  minutes' 
continuous  immersion  is  not  a  sufficient  reason  for  refusing  to  attempt  resusci- 
tation when  it  is  alleged  that  the  body  has  been  immersed  for  longer  than  that 
period. 

As  Draper  says,  "the  evidence  as  to  time  may  be  incorrect,  and  there  are 
probably  exceptional  people  who  would  not  drown  in  two  minutes.  Resusci- 
tation has  been  successful  after  five  minutes  and  i  case  is  recorded  of  recov- 
ery after  twenty-five  minutes"  (Draper's  "Legal  Medicine").  The  ordinary 
emergency  treatment  should  be  conducted  out  of  doors.  The  mouth  is  emptied 
by  turning  the  body  on  the  face,  with  the  head  on  a  lower  level  than  the  body, 
and  holding  it  so  for  a  few  seconds.  While  this  is  being  done  the  mouth  is 
opened  and  the  tongue  is  drawn  out.  The  body  is  turned  upon  the  back,  the 
head  and  shoulders  being  slightly  elevated.  The  clothing  is  rapidly  removed, 
and,  while  artificial  respiration  is  being  made  (see  page  866),  hot  bottles  and 
hot  blankets  are  being  placed  around  the  body  and  legs,  and  the  mouth  and 
nostrils  are  kept  free  of  froth.  If  the  individual  makes  an  effort  to  breathe,  help 
each  respiration  along.    Give  hypodermatic  injections  of  brandy  and  strychnin. 

Artificial  respiration  is  continued  until  the  patient  breathes  naturally  and 
all  cyanosis  has  passed  away.  As  soon  as  he  can  swallow  he  should  be  given 
hot  coffee  and  brandy.  If  minute  follows  minute  and  the  patient  does  not 
attempt  to  breathe,  we  must  still  continue  our  efforts.  Artificial  respiration 
should  not  be  abandoned  for  a  full  hour.  Even  after  he  begins  to  breathe  he 
must  be  carefully  watched  for  some  time,  as  secondary  respiratory  failure  is  not 
uncommon. 

On  a  battleship  and  upon  the  beach  of  a  large  seaside  resort,  where  every 
preparation  has  been  made  to  treat  such  accidents,  more  can  be  done  than  is 
described  above.  Artificial  respiration  can  be  made  by  the  pulmotor  or  by 
the  insufflation  apparatus  of  Meltzer  and  Auer  (see  page  867).  Adrenalin  may 
be  injected  centripetally,  as  advised  by  Crile  (see  page  468).  Hot  enemata 
may  be  given  and  galvanism  may  be  applied  to  the  phrenic  nerve. 

After  resuscitation  there  is  danger  of  exhaustion  and  of  bronchopnemnonia. 

Hanging. — A  physician  is  occasionally  called  to  a  case  of  attempted  suicide 
by  hanging.  In  these  cases  there  is  no  fracture  and  no  dislocation  of  cer- 
vical vertebras,  as  may  occur  in  legal  execution  by  the  drop.  The  victim  is 
dead  or  almost  dead  because  of  obstruction  to  the  pulmonary  air-way,  the 
pressure  upon  the  great  vessels  of  the  neck,  and  perhaps  also  upon  the  pneu- 
mogastric  nerves. 

Treatment. — ^The  subject,  after  being  cut  down,  is  treated  much  like  a  case 
of  drowning.  Resuscitation  is  always  difiicult,  no  matter  how  soon  the  victim 
is  cut  down.     It  is  impossible  if  asphyxiation  is  far  advanced. 


Smoke  Asphyxia  871 

The  neck  and  chest  are  bared,  cold  water  may  be  applied  to  the  head  or  face, 
as  it  sometimes  will  incite  respiration.  Artificial  respiration  is  begun  at  once, 
external  heat  is  applied,  a  hot  enema  containing  brandy  and  hypodermatic 
injections  of  brandy  are  given.  When  there  is  distinct  lividity,  bleed  from  a 
vein  of  the  leg  (to  do  so  from  a  vein  of  the  arm  might  interfere  with  artificial 
respiration).  Galvanism  of  the  phrenic  nerve  is  advisable.  Even  when 
breathing  begins  there  is  for  some  time  the  gravest  danger  of  relapse  and 
death. 

Throttling. — When  the  assailant  grasps  the  opponent's  throat  with  the  hands 
and  squeezes  the  wind-pipe  or  larynx  and  forces  it  against  the  vertebrae  the 
victim  is  said  to  be  throttled.  The  ordinary  fighter  makes  the  attack  from  in 
front.  The  garroter  seizes  the  throat  from  behind.  Death  from  throttling  is 
death  from  asphyxia  plus  an  influence  from  the  pressure  upon  the  great  vessels. 

Treatment. — ^As  for  hanging. 

Smoke  Asphyxia.^ — One  of  the  first  duties  required  of  an  intern  in  a  hospital 
of  a  large  city  is  ambulance  service,  and  in  performing  such  duty  he  is  not 
infrequently  called  upon  to  attend  fires.  In  fact,  any  physician  may  be  called 
upon  in  such  an  emergency,  and  while  on  the  fire  ground  may  meet  cases  of 
asphyxiation  by  smoke.  The  clinical  aspect  and  the  treatment  of  such  cases  is 
not  taught  in  the  classroom.  Literature  on  the  subject  is  scanty.  It  is  for 
these  reasons  that  the  author  has  deemed  it  expedient  to  insert  a  few  words 
regarding  it. 

There  are  several  factors  which  govern  the  character  of  smoke  cases.  In 
the  first  place,  there  are  many  different  kinds  of  smoke.  All  smoke  is  hard 
to  bear,  but  some  kinds  are  worse  than  others.  Some  smoke  is  merely  irre- 
spirable,  while  other  smoke  is  not  only  irrespirable,  but  is  highly  poisonous. 
Smoke  from  lumber,  varnish,  furniture,  paper,  rags,  and  wet  hay  is  diffi- 
cult to  tolerate,  whereas  smoke  from  pitch,  tar,  and  oils  is  not  so  pungent. 
Smoke  impregnated  with  the  fumes  of  ammonia,  sulphur  dioxid,  chlorin,  or 
pepper  and  other  spices  is  frightfully  irritant.  Smoke  containing  nitric  acid 
is  highly  irritant,  and  is  apt  to  produce  edema  of  the  glottis  and  lungs.  The 
hotter  the  smoke,  the  more  irrespirable  it  is. 

Again,  the  individual  idiosyncrasy  or  susceptibility  of  the  person  plays  an 
important  part.  It  is  remarkable  how  firemen  can  accustom  themselves  to 
remaining  in  a  smoke-ladened  atmosphere.  The  older  members  of  a  fire  depart- 
ment can  tolerate  smoke  much  longer  than  those  recently  appointed.  Fire- 
men learn  that  the  best  air  is  near  the  floor  or  near  the  nozzle  of  the  hose.  There 
is  a  current  of  air  along  the  floor,  as  the  smoke  natiu-ally  tends  to  rise,  and  the 
water  carries  through  the  hose  a  certain  amount  of  air. 

For  clinical  purposes,  smoke  asphyxia  may  be  divided  into  three  stages: 
the  first  stage  is  that  in  which  the  victim  is  conscious;  the  second  is  when 
consciousness  is  lost,  but  respirations  are  stiU  present;  the  third  stage,  when 
respirations  have  ceased. 

The  first  S3anptoms  which  occur  are  a  choking  sensation,  severe  throbbing 
in  the  head,  dizziness,  nausea,  and  muscular  weakness.  If  at  this  time  one  is 
able  to  reach  a  window  or  able  to  leave  the  building  and  get  fresh  air  he  will 
probably  recover  quickly.  His  eyes  are  red  and  watery.  He  coughs  and 
tries  to  vomit,  and  although  his  face  may  be  hot  and  sweaty,  yet  his  hands 
will  be  cold  and  clammy.  His  pulse  is  slow  but  bounding.  Headache  is 
intense  and  the  eyes  burn  violently. 

A  patient  in  this  condition  should  be  rapidly  removed  to  a  spot  where  the 

air  is  free  from  smoke.     He  should  be  laid  on  a  blanket.     All  constricting 

clothing  should  be  loosened  and  he  ought  to  be  fanned.     If  he  gags  or  attempts 

to  vomit,  but  cannot  do  so,  he  may  be  given  a  drink  of  an  effervescing  salt,  such 

1  The  author,  in  "Therapeutic  Gazette,"  March,  1903. 


872 


Surgery  of  the  Respiratory  Organs 


Fig.  555- — Fire  carry.  Step  one. 


Fig.  556. — Fire  carry.  Step  two. 


Fig.  557. — Fire  carry.  Step  three. 


as  a  Seidlitz  powder  or  a  dessertspoonful  of  effervescent  sodium  phosphate  in 
a  tumbler  of  water.  Firemen  have  great  faith  in  weiss  beer.  It  usually  makes 
them  belch  and  vomit  and  thus  relieves  them  of  much  of  the  mucus  and  the 


Smoke  Asphyxia  873 

gases  in  their  lungs  and  in  their  stomach.  In  this  manner  it  acts  as  does  an 
emetic  dose  of  ipecac  in  the  first  stage  of  bronchitis.  A  drink  which  is  often 
given,  but  which  is  most  injurious,  is  whisky.  The  fireman  who  is  a  whisky 
drinker  stands  smoke  poorly,  and  to  take  whisky  after  ha\'ing  been  over- 
come with  smoke  only  adds  to  the  headache  and  nausea.  Usually  after  vom- 
iting has  been  induced  and  after  he  has  had  fresh  air  the  fireman  is  able  to 
return  again  to  his  work.  If  he  does  not  rapidly  recuperate  or  should  he  be 
overcome  a  second  time,  he  should  not  be  allowed  to  return  to  the  smoky  at- 
mosphere. If  a  man  who  has  been  overcome  by  smoke  has  a  chill  he  must  be 
sent  to  a  hospital.  His  usefulness  is  at  an  end  for  that  fire.  When  a  man 
becomes  unconscious  his  comrades  carrs^  him  to  the  street.  Pictures  of  a  very 
quick  and  satisfactory  fire  carr}-  are  given  in  Figs.  555-557.  It  is  unusual  for 
a  man  to  leave  a  smoky  building  conscious  and  to  lose  consciousness  after 
reaching  the  fresh  air  iinless  the  smoke  was  impregnated  with  illuminating 
gas,  which  condition  is  discussed  on  page  874. 

\Vhen  an  unconscious  man  is  carried  from  a  smoky  building  he  must  be 
taken  to  a  spot  where  the  air  is  free  from  smoke,  his  clothing  must  be  loosened, 
and  his  body  kept  warm  ^dth  blankets.  His  hands  and  face  should  be  rubbed 
with  a  coarse  towel,  and  o.wgen  (which  should  be  carried  on  all  ambulances 
and  on  all  patrol  wagons)  should  be  administered.  If  the  circulation  or  respira- 
tion is  weak,  he  shoiild  be  given  a  h^qDodermatic  injection  of  str}^chnin  or  atropin, 
and  when  he  is  able  to  swallow  he  can  be  given  a  stimulant  by  mouth  (as  Hoff- 
mann's anodyne  or  aromatic  spirits  of  ammonia),  or  if  he  is  tr}-ing  to  vomit  he 
may  be  given  weiss  beer,  eft"er\'escent  sodium  phosphate,  or  Seidlitz  powder. 
He  should  not  be  given  anything  by  mouth  imtil  he  is  entirely  conscious  and 
able  to  swallow.  I  mention  this  emphatically  because  I  have  often  seen 
attempts  made  to  pour  whisky  or  some  other  stimulant  dovm  the  throat  of  an 
unconscious  fireman.  The  danger  of  such  a  procedure  is  ob\ious.  As  soon 
as  practical  he  should  be  removed  to  the  nearest  hospital.  The  man  should 
be  taken  to  the  nearest  hospital  unless  the  recei\dng  ward  of  that  hospital  is 
overcrowded.     He  should  then  be  taken  to  the  next  nearest  hospital. 

The  third  stage  of  asphyxiation  by  smoke  is  that  in  which  respirations  have 
been  suspended.  The  lips  are  cyanotic,  the  skin  is  cold  and  clammy,  the  pupils 
are  fixed,  and  usually  dilated.  The  conjunctival  reflex  ma}'  be  gone.  The 
mouth  may  be  open  or,  on  the  other  hand,  the  teeth  may  be  tightly  clenched. 
The  pulse  is  weak  and  fluttering,  even  imperceptible.  There  is  frequently 
bleeding  from  the  nose  and  mouth  and  involimtray  evacuations  of  urine  and 
feces  may  occur.  A  man  in  this  state  should  never  be  placed  in  an  ambulance 
to  be  taken  to  the  hospital  until  respirations  have  been  re-established.  _  I 
have  seen  stupid  and  assertive  policemen  on  many  occasions  insist  on  putting 
such  cases  in  ambulances.  He  should  be  quickly  laid  on  his  back,  aU 
mucus  cleared  from  his  throat  and  mouth,  all  constricting  clothing  loosened, 
torn,  or  cut  away.  Artificial  respiration  is  started  at  once.  The  pulmotor 
described  on  page  867  is  most  useful  under  such  circumstances.  If  Sylvester's 
method  is  used,  ox>^gen  may  be  administered  ^dth  a  tube  through  the  nostrils. 
The  body  must  be  covered  with  blankets  and  the  man  must  be  stimulated 
with  strychnm,  atropin,  camphor,  etc.  When  respirations  have  been  estab- 
lished he  may  then  be  removed  to  the  nearest  hospital.  As  a  rule,  the  man 
should  be  kept  in  a  hospital  at  least  twelve  to  twenty-four  hours  and  may 
then  be  allowed  to  go  home  if  there  is  no  complication  or  sequel.  In  severe 
smoke  cases  there  is  a  tympanitic  percussion  note  extending  well  above  each 
coUar-bone  and  due,  I  believe,  to  blocking  of  bronchial  tubes  by  spasm.  It 
lasts  often  for  several  hours  and  then  fades  away. 

In  cases  of  edema  of  the  glottis  from  the  inhalation  of  fi-ritant  vapor, 
tracheotomy  should  be  performed  and  artificial  respiration  given,  ox}^gen  pass- 


874  Surgery  of  the  Respiratory  Organs 

ing  in  through  the  tracheotomy  tube.  It  is  imperative  that  the  first-aid  kits  of 
all  ambulances  should  contain  a  tracheotomy  set.  I  have  been  compelled  to 
do  a  tracheotomy  with  a  penknife  upon  a  fireman  lying  on  the  pavement. 

A  chill  or  a  series  of  chills  not  infrequently  follows  smoke  asphyxiation,  and 
a  man  who  has  or  has  had  a  chill  must  always  be  sent  to  a  hospital.  If  the 
smoke  has  been  impregnated  with  ammonia,  a  piece  of  gauze  or  a  handkerchief 
should  be  saturated  with  vinegar  and  held  over  the  face  so  that  the  vapor  may 
be  inhaled.  On  the  other  hand,  a  few  whiffs  of  diluted  ammonia  should  be 
given  after  the  inhalation  of  fumes  from  acids.  The  eyes  should  be  carefully 
treated.  Ice-compresses  are  most  grateful.  Pieces  of  lint  or  gauze  are  placed 
on  ice  and  are  transferred,  when  cold,  to  the  eyes.  They  are  changed  at  fre- 
quent intervals.  The  eyes  must  be  washed  with  a  saturated  solution  of  boric 
acid  at  frequent  intervals.  Even  after  the  acute  symptoms  have  subsided 
it  may  be  necessary  to  wear  blue  glasses  for  several  days  and  to  use  an  astrin- 
gent eye-wash  twice  a  day. 

To  relieve  headache  an  ice-bag  can  be  applied  to  the  head  and  bromid  should 
be  administered  by  mouth.  Bromid  also  relieves  the  severe  nervousness  which 
often  ensues.  Occasionally  bronchitis  or  even  bronchopneumonia  may  occur. 
Even  after  mild  smoke  cases  there  is  usually  a  cough  for  several  days,  the 
sputum  being  streaked  with  black,  carbonaceous  material. 

Inhalation  of  the  vapor  of  nitric  acid  is  apt  to  cause  edema  of  the  lungs  and 
glottis  and  death.  The  acute  edema  may  not  come  on  for  some  hours  after 
the  inhalation.  The  treatment  of  edema  of  the  lungs  consists  in  venesection, 
hypodermatic  injection  of  camphorated  oil,  the  administration  of  alcohol  and 
digitalis,  and  counterirritation  of  the  chest.  The  treatment  of  edema  of  the 
glottis  is  set  forth  on  page  873. 

Illuminating  Gas-poisoning. — Poisoning  by  illuminating  gas  is  becoming 
more  common.  The  statistics  for  the  city  of  Philadelphia  during  191 2  showed 
that  152  cases  died  from  illuminating  gas-poisoning.  Of  these  77  were  suicides 
and  75  wxre  accidental.  The  number  of  cases  has  increased  since  the  sub- 
stitution of  the  so-called  water-gas  for  coal-gas.  The  coal-gas  formerly  used 
was  not  nearly  so  dangerous.  Coal-gas  contains  a  small  amount  (about  7 
per  cent.)  of  carbon  monoxid.  In  comparatively  recent  years,  however,  in 
order  to  reduce  the  cost  and  simplify  the  manufacture  the  new  water-gas  has 
been  used.  This  is  developed  by  forcing  steam  through  hot  coals  or  coke. 
To  this  water-gas  hydrocarbons  are  added  (methane,  ethane,  etc.).  The 
amount  of  carbon  monoxid  in  water-gas  is  about  38  per  cent. 

Jones  ("Amer.  Jour.  Med.  Sci.,"  1909,  vol.  cxxxvii)  gives  as  further 
reasons  for  the  marked  increase  in  poisoning  by  illuminating  gas:  first,  con- 
centration of  population  in  cities;  second,  increased  susceptibility  to  emotional 
states  and  insanity. 

Suicide  from  illuminating  gas  is  growing  in  frequency,  due  to  the  means 
being  at  hand,  the  known  painless  nature  of  the  death,  and  also  to  the  fact  that 
the  sale  of  toxic  drugs  to  laymen  is  now  forbidden. 

Carbon  monoxid  has  a  marked  afl&nity  for  hemoglobin.  It  completely 
destroys  the  oxygen-carrying  power  of  the  red  blood-cells  and  thus  deprives 
the  tissues  of  oxygen.  It  enters  the  system  solely  through  the  lungs.  An 
atmosphere  becomes  dangerous  when  it  contains  .05  per  cent,  of  carbon  mon- 
oxid (Gruber,  cited  by  Edsall,  in  Osier's  "System  of  Medicine";  Haldane,  "An 
Investigation  of  Mine  Air,"  1895).  It  is  not  proved  whether  carbon  mon- 
oxid has  any  direct  action  of  its  own,  or  whether  it  acts  solely  by  robbing  the 
blood  of  its  oxygen.  Edsall  ("Amer.  Jour.  Med.  Sci.,"  1907,  and  Osier's 
"System  of  Medicine")  says  it  is  highly  probable  that  both  conditions  occur. 
McCombs  ("Amer.  Jour.  Med.  Sci.,"  1912,  vol.  cxliv)  says  that  carbon  monoxid 
has  a  direct  toxic  action  on  a  human  being. 


Illuminating  Gas-poisoning  875 

Suicide  cases  make  up  approximately  one-half  of  all  the  fatalities  from 
illuminating  gas  in  Philadelphia  and  in  Massachusetts  (]\IcCombs,  "Amer. 
Jour.  Med.  Sci.,"  191 2,  vol.  cxliv).  Cases  of  accidental  poisoning  are  due 
either  to  a  leak  from  a  gas-pipe  or  failure  to  close  a  gas-jet.  Pettenkofer 
(cited  by  Edsall,  in  Osier's  "  System  of  ^Medicine  ")  has  shown  that  the  leak 
may  not  be  in  the  building  itself,  but  the  gas,  having  escaped  from  a  broken 
main,  may  travel  through  the  ground  for  some  distance  and  finally  enter 
a  house.  This  is  especially  liable  to  occur  in  the  winter  when  the  heating 
of  the  building  causes  active  motion  of  the  atmosphere,  thus  dra-^ing  gas 
into  the  house  by  aspiration.  Numbers  of  the  employees  of  the  large  gas 
companies  are  overcome  while  working  in  the  ditches  in  the  city,  yet  among 
all  such  cases  that  have  occurred  in  the  city  of  Philadelphia  there  has  been  but 
one  fatality.  This  is  due  to  the  careful  instruction  to  the  men  by  the  phys- 
icians connected  with  the  gas  company.  The  men  are  not  only  instructed, 
but  the}-  also  carr}^  a  first-aid  kit  and  are  competent  to  give  immediate  treat- 
mient. 

Illuminating  gas-poisoning  has  been  di\-ided  into  the  acute  and  chronic 
forms.  There  is  little  e\ddence,  however,  to  support  the  theor\-  of  chronic  gas- 
poisoning.  ]\IcCombs  (Loc.  cit.)  has  examined  the  blood  of  men  who  are  con- 
stantly in  contact  with  carbon  monoxid,  some  of  whom  have  been  frequently 
overcome  by  it.  He  has  found  the  average  blood-count  shows  polycythemia. 
He  has  not  noted  any  cases  of  muscular  weakness,  irregularity  of  the  heart. 
bradycardia,  lack  of  concentration,  poor  memor\',  cardiac  dilatation,  splenic 
enlargement,  or  pleural  efl'usion.     The  acute  cases  are,  of  course,  well  known. 

The  s}Tnptoms  of  an  acute  case  are  ushered  in  by  a  sensation  of  vertigo 
or  dizziness,  headache,  and  muscular  weakness.  They  are  often  accompanied 
or  even  preceded  by  a  throbbing  sensation  in  the  head  and  throbbing  of  the 
vessels  of  the  neck.  McCombs  (Ibid.)  states  that  at  first  the  pulse  is  slow, 
from  stimulation  of  the  pneumogastric.  I  ha\'e  probably  never  seen  a  case  in 
so  early  a  stage,  as  every  case  I  have  examined  has  had  a  rapid  and  weak  pulse. 

During  the  early  stage  there  is  occasionally  cerebral  excitement.  The 
pupils  are  dilated  and  the  respirations  are  increased,  both  in  depth  and  in 
frequency.  There  is  no  irritation  of  the  mucous  membranes.  The  victim 
has  an  odor  of  gas  emanating  from  him.  Unconsciousness  now  ensues.  In 
some  cases,  however  (as  in  the  case  of  firemen  working  in  smoke  impregnated 
with  illuminating  gas),  the  irritant  and  sufi'ocative  qualities  of  smoke  may 
overshadow  all  early  s\-mptoms  of  illuminating  gas,  and  the  \-ictim  may  drop 
as  suddenly  as  though  he  had  been  shot. 

The  foregoing  symptoms  have  been  called  by  ]\IcCombs  the  first  stage 
of  gas-poisoning.  He  then  states  that  the  second  stage  begins  with  s}Ticope 
and  ends  ^dth  apnea.  In  the  second  stage,  therefore,  the  patient  is  uncon- 
scious, but  respirations  are  still  in  progress. 

The  respirations  may  be  rapid  and  stertorous  or  may  be  of  the  Cheyne- 
Stokes  t\-pe.  The  face  is  cyanosed.  There  is  often  frothing  at  the  mouth. 
The  froth  may  contain  blood.  The  blood-pressure  falls,  but  the  temperature 
is  usually  elevated.  There  may  be  general  tetaniform  comTilsions.  The 
pulse  is  rapid  and  weak.  The  temperature  varies  from  99°  to  103°  F.  Occa- 
sionally the  temperature  may  rise  rapidly,  reaching  105°  to  110°  F.,  these 
cases  usually  terminating  fatally.  A  great  rise  of  temperature  is  usually  co- 
incident -^-ith  the  development  of  edema  of  the  lungs.  The  high  temperature 
is  not  due  to  the  edema,  but  is  probably  due  to  the  overwhelming  toxemia. 
The  toxemia  is  purely  hemolytic  in  origin.  The  tongue  is  swollen  and  is 
cherr}'  red,  and  the  same  peculiar  cherr\--red  color  makes  its  appearance  on  the 
skin  of  the  neck,  trunk,  and  buttocks.  The  blood,  if  drawn,  is  bright  cherry- 
red  in  color  and  will  show  by  the  spectroscope  the  presence  of  carbon  monoxid. 


876  Surgery  of  the  Respiratory  Organs 

Edsall  ("Amer.  Jour.  Med.  Sci.,"  1907)  believes  that,  with  the  exception 
of  the  spectroscope,  the  best  test  for  carbon  monoxid  in  the  blood  is  the  Hoppe- 
Seyler  test.  The  blood  containing  carbon  monoxid,  if  treated  with  twice  its 
volume  of  a  solution  of  sodiiun  hydrate,  yields  a  beautiful  red  color  when 
spread  on  a  porcelain  plate,  while  blood  not  containing  carbon  monoxid  is 
changed  into  a  dirty,  brownish  mass. 

Katagama's  test  consists  in  adding  to  10  c.c.  of  blood,  diluted  with  water, 
2  c.c.  of  ammonium  sulphate  solution  and  0.2  c.c.  of  30  per  cent,  acetic  acid. 
Carbon  monoxid  blood  gives  a  bright  red  precipitate,  while  normal  blood  gives 
a  greenish  precipitate.  These  tests  should  be  used  in  cases  of  coma  of  un- 
certain origin. 

Pettenkofer  insists  upon  the  importance  of  searching  for  gas-poisoning  as 
the  cause  of  the  trouble,  when  various  persons  in  the  same  house  have  a  tend- 
ency to  wake  with  headache  or  nausea. 

In  the  third  stage  there  is  coma  with  apnea.  The  pulse  is  more  rapid  and 
is  weaker.  It  is  often  impossible  to  count  the  rate.  The  skin  is  usually 
cyanosed,  is  cold  and  dry,  and  occasionally  there  appear  on  the  extremities 
the  back  blebs.  Blebs  usually  occur  in  chains  and  are  most  apt  to  appear  in 
cases  in  which  the  coma  persists  for  twelve  hours  or  longer.  The  blebs  con- 
tain clear  serum  and  have  frequently  been  mistaken  for  burns  from  the  ap- 
plication of  hot-water  bags.  There  flexes  are  abolished.  There  is  paralysis  of 
the  sphincters.     Coma  may  last  for  days  and  yet  be  followed  by  a  recovery. 

Oilman  Thompson  ("N.  Y.  Med.  Record,"  July  9,  1904)  considers  it  a  bad 
sign  if  leukocytosis,  which  is  usually  present,  is  of  high  degree.  Reported 
cases,  however,  do  not  seem  to  substantiate  this  belief.  The  leukocytosis 
varies  from  10,000  to  22,000.  Thompson,  moreover,  reports  an  increase  in 
the  number  of  red  blood-cells.  The  same  observation  is  made  by  McCombs, 
but  is  denied  by  Glenn  Jones. 

Glenn  Jones  ("Amer.  Jour.  Med.  Sci.,"  1909,  vol.  cxxxvii)  found  the  red 
cells  reduced  in  number.  The  specific  gravity  and  the  coagulability  of  the 
blood  are  increased. 

The  pathology  of  gas-poisoning  consists  principally  of  the  characteristic 
cherry-red  spots  on  the  surface  of  the  body,  the  cherry-red  color  of  the  blood, 
and  the  same  color  of  many  or  all  of  the  organs.  There  is  usually  intense 
hyperemia  of,  and  occasionally  small  free  hemorrhages  into,  all  the  organs. 
Nephritis  is  usually  present  and  is  apt  to  be  of  the  acute  hemorrhagic  type. 
There  may  be  small  scattered  hemorrhages  throughout  the  brain  and  cysts 
may  form  as  the  result  of  softening.  Cardiac  dilatation,  fatty  degeneration 
of  the  heart,  and  splenic  enlargement  have  been  described  by  Koren  in  cases  of 
supposed  chronic  gas-poisoning. 

The  sequelae  of  gas-poisoning  are  principally  nervous  manifestations.  In 
the  milder  class  of  cases  nervousness,  insomnia,  and  headache  are  usually 
present  for  several  days;  in  the  more  severe  cases,  intention  tremors,  loss  of 
sexual  power,  delirium,  neuritis,  transient  hemiplegia,  confusional  insanity, 
leptomeningitis,  and  encephalomyelitis  have  been  reported.  Prolonged  fever 
and  glycosuria  have  also  been  found. 

There  may  be  acute  congestion  of  the  lungs,  edema,  emphysema,  or  bron- 
chopneumonia. McCombs  states  that  all  of  the  sequelae  usually  clear  up  within 
six  months  or  less,  and  that  cases  with  sequelae  constitute  less  than  2  per  cent, 
of  all  cases,  and  are  usually  confined  to  those  persons  who  have  absorbed  large 
amounts  of  the  carbon  monoxid.  Sequelae  are,  of  course,  more  apt  to  occur  in 
those  of  advanced  years. and  feeble  condition  than  in  those  who  are  young  and 
vigorous. 

The  prognosis  should  be  based  upon  the  duration  of  the  exposure,  the  age  of 
the  victim,  the  degree  of  coma,  the  condition  of  the  blood,  and  the  character 


Foreign  Bodies  in  the  Nose  877 

of  the  pulse  and  respiration.  Usually  a  short  exposure  to  illuminating  gas 
means  a  case  amenable  to  treatment  and  which  will  promptly  recover.  Longer 
exposure,  or  exposure  of  the  aged  and  feeble,  means  a  far  worse  prognosis. 

Edsall  cites  39  cases  treated  in  the  Episcopal  Hospital  of  Philadelphia,  of 
which  34  recovered.  Of  the  5  fatalities,  several  were  due  to  sequelae.  If  the 
onset  of  the  symptoms  are  rapid,  if  edema  develops,  or  if  pronounced  hemolytic 
changes  are  present,  the  prognosis  is  mifavorable.  The  persistence  of  coma  is 
highly  mifavorable,  and  Jones  states  that  all  cases  that  develop  cutaneous 
blebs  end  fatally. 

The  treatment  of  poisoning  by  illuminating  gas  must  be  prompt  and  heroic. 
In  the  milder  cases,  in  which  there  is  neither  coma  nor  apnea,  the  patient  must 
be  removed  to  an  atmosphere  free  from  the  poison  and  must  be  given  oxy^gen 
freely.  The  object  of  all  treatment  is  to  give  oxy^gen  in  sufficient  quantities  to 
displace  the  carbon  monoxid  from  the  blood.  Nausea  and  the  feeling  of  fulness 
in  the  stomach  can  be  relieved  by  the  administration  of  effer^'escent  sodium 
phosphate,  Seidlitz  powder,  or  a  bottle  of  weiss  beer.  These  procedures  will 
usually  cause  vomiting  and  give  relief.  The  patient  should  be  kept  quiet,  an 
ice-bag  being  applied  to  the  head  to  relieve  the  headache.  Doses  of  bromid  of 
potash  will  give  comfort.  Hoffmann's  anodyne  and  aromatic  spirits  of  ammo- 
nia act  as  useful  stimulants  and  carminatives.  Caffein,  digitalis,  strychnin, 
and  camphor  should  be  given  if  necessar\' .  They  will  hardly  be  necessary, 
however,  unless  the  \dctim  is  in  the  second  stage  or  the  stage  of  unconsciousness. 
When  the  patient  is  unconscious,  venesection  should  be  performed,  followed  by 
transfusion,  or  by  the  intravenous  injection  of  salt  solution. 

The  patient  must  be  kept  quiet,  as  many  victims  have  died  from  sudden 
exertion.  \'enesection  "^"ithout  the  injection  of  salt  solution  or  A\-ithout  trans- 
fusion is  usually  condemned,  but  Halsted  reported  2  cases  in  which  he  thought 
it  did  good.  Transfusion  of  defibrinated  blood  was  practised  in  the  70's  and 
8o's  and  successful  cases  were  reported.  Reinf usion  of  blood  was  attempted  by 
Halsted  in  1S84,  at  which  time  he  reported  a  successful  case:  512  c.c.  of  blood 
were  withdrawn  from  the  radial  arter\^,  defibrinated  and  stramed,  and  280  c.c. 
were  reinf  used  into  the  artery.  In  1907  Crile  and  Lenhart  reported  their 
studies  of  transfusion,  which  procedure  has  supplanted  all  former  methods  of 
treatment. 

Of  course,  in  the  third  stage,  that  of  coma  with  apnea,  artificial  respiration 
must  be  made,  and  for  this  purpose  the  pulmotor  is  most  valuable,  as  it  not 
only  gives  artificial  respiration,  but  at  the  same  time  administers  large  quanti- 
ties of  ox\-gen  under  pressure. 

Massage  is  an  important  feature  of  treatment.  It  increases  circulation  in 
the  extremities.  Transfusion,  of  course,  requires  the  presence  of  a  skilled  sur- 
geon, whereas  intravenous  injection  of  saline  solution  is  not  nearly  so  difficult  a 
procedure.  It  is  most  important  that  artificial  respiration  should  not  be  aban- 
doned for  a  number  of  hours,  as  cases  have  been  reported  in  which  artificial  res- 
piration was  finally  successful  after  a  period  of  six  hours.  In  conditions  which 
lead  one  to  suspect  that  chronic  poisoning  may  be  present,  the  cause  should  be 
sought  and,  if  foimd,  removed,  and  the  case  be  treated  s^miptomatically.  The 
general  public  should  be  instructed  as  to  the  danger  of  acute  gas-poisoning. 

Diseases  and  Injuries  of  the  Nose  and  Antrum 

Foreign  bodies  in  the  nose  (see  Poulet  on  "Foreign  Bodies  in  Surger\^") 
are  usually  introduced  through  the  anterior  nares,  but  in  rare  instances  dur- 
ing swallowing  they  enter  by  way  of  the  posterior  nares,  a  sudden  expiration 
being  the  cause  of  the  entr^^  During  vomiting  foreign  bodies  may  enter  the 
posterior  nares.     SmaU  particles  are  often  expelled  spontaneously;  larger 


878  Surgery  of  the  Respiratory  Organs 

pieces  collect  mucus  and  epithelium  and  become  fixed.  Some  materials  swell 
after  lodgment.  Others  become  encrusted  with  lime  salts.  Seeds  may 
sprout.  In  very  rare  cases  insects  enter  and  lodge.  Cases  are  on  record  of 
leeches,  taken  in  with  drinking-water,  passing  into  the  nasal  fossae  from  the 
pharynx.  In  the  tropics  flies  may  deposit  larvae  within  the  anterior  nares  and 
they  develop  with  great  rapidity.  A  foreign  body  is  usually  near  the  floor  and 
may  be  between  the  vomer  and  turbinate  bones.     It  may  shift  after  lodgment. 

Treatment. — In  many  cases  general  anesthesia  is  required.  Illuminate  the 
nostril,  and,  if  the  foreign  body  can  be  seen,  insert  a  hook  back  of  it  and  effect 
its  removal  by  means  of  forceps.  Some  foreign  bodies  require  to  be  pushed 
back  into  the  nasopharynx.  Occasionally  expulsion  may  be  effected  by 
inserting  a  rubber  tube  into  the  imblocked  nostrfl  and  teUing  the  patient 
to  blow  forcibly  through  the  tube.  In  serious  cases  a  speciaUst  should  be 
summoned  to  remove  a  portion  of  the  turbinated  bone  or  to  perform  what- 
ever operation  he  thinks  best. 

Inflammation  and  Abscess  of  the  Antrum  of  Highmore  (the  Maxil- 
lary Antrum). — The  source  of  this  disease  may  be  inflammation  within 
the  nose  or  periostitis  around  the  roots  of  the  teeth.  In  some  cases  the 
natiu"al  opening  into  the  meatus  is  patent;  in  other  cases  it  is  partly  or  com- 
pletely blocked.  Caries  and  necrosis  may  arise.  The  symptoms  are  pain, 
edematous  swelling  of  the  face,  and  thinning  of  the  bone  so  that  it  may  crepi- 
tate under  pressure.  When  pus  has  formed,  if  the  antral  opening  is  patent, 
certain  positions  of  the  head  will  cause  a  purulent  flow  from  the  nose,  and  if  a 
speculum  is  inserted  pus  may  be  seen  as  it  flows  into  the  nose.  The  opening 
of  the  maxfllarv'  antrum  into  the  nasal  channel  is  at  the  summit  of  the  antrum; 
hence  the  antrum  drains  when  the  head  is  inverted.  The  ethmoidal  cells  and 
frontal  sinus  drain  best  when  the  patient  is  upright.  Wipe  the  interior  of  the 
nose  and  place  the  patient  with  his  head  between  his  knees.  If  the  nostril 
fills  with  pus,  it  comes  from  the  antrum  (Cobb).  In  severe  cases  the  jaw  ex- 
pands, the  eye  protrudes,  and  great  tenderness  of  the  alveolus  exists.  Percus- 
sion exhibits  a  dull  note.  In  making  a  diagnosis  it  is  w^ell  to  take  the  patient 
into  a  dark  room,  insert  an  electric  hght  into  the  mouth  and  note  the  diminu- 
tion of  light  transmission  on  the  diseased  side  as  contrasted  wdth  the  sound 
side.  Transillumination  may  be  easfly  practised  by  the  use  of  a  cautery 
electrode,  protected  by  a  small  glass  vial.  Any  cautery  batter}'  may  be 
employed  (plan  suggested  by  Ohls).  Exploratory  puncture  will  settle  a 
doubtful  diagnosis.  This  may  be  by  way  of  the  lower  meatus,  the  canine 
fossa,  or  the  alveolar  process.^ 

Treatment. — Before  pus  forms  order  the  use  of  hot  fomentations  and 
remove  any  diseased  teeth.  When  pus  has  formed,  evacuate  it  at  once. 
Before  performing  a  severe  operation  try  the  effect  of  opening  into  the  antrum 
from  the  nose,  by  means  of  Krause's  trocar,  followed  by  insufflation  of  iodo- 
form. If  this  procedure  fafls,  other  means  may  be  employed.  If  the  disease 
arises  from  a  carious  tooth,  pull  the  tooth  and  push  a  trocar  through  its  socket 
into  the  antrum.  If  the  teeth  are  sound,  bore  a  hole  with  a  large  gimlet  or 
with  a  bone-drill  above  the  root  of  the  second  bicuspid  tooth  and  i  inch  above 
the  edge  of  the  gum.  A  coimteropening  should  be  made  into  the  inferior  nasal 
meatus.  A  drainage-tube  is  pulled  from  the  first  opening  into  the  nose  and  is 
allowed  to  protrude  from  the  nostrfl.  Irrigate  dafly  with  normal  salt  solution. 
In  three  or  four  days  discontinue  through-and-through  drainage,  but  prevent 
the  first  opening  closing  untfl  the  discharge  ceases  to  be  puriflent.  In  severe 
cases  make  a  free  incision  through  the  canine  fossa  by  means  of  a  chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus. — The  usual  cause  is  an 
injury  which  may  long  antedate  the  symptoms.  This  injury  causes  or  leads 
1  Cobb,  in  "Boston  Med.  and  Surg.  Jour.,"  May  7,  1896. 


Treatment  of  Wounds  and  Injuries  of  the  Larynx  870 

to  blocking  of  the  inf undibulum ;  secretion  accumulates  and  distends  the  sinus, 
and  in  some  cases  pus  forms.  In  many  cases  the  fluid  slowly  accumulates,  and 
it  may  require  years  to  produce  marked  symptoms.  In  other  cases  infection 
takes  place  early  or  existed  from  the  start,  and  the  symptoms  are  positive  and 
violent.  If  the  outlet  into  the  nose  is  not  permanently  blocked,  the  fluid 
may  discharge  itself  from  time  to  time.  In  the  chronic  cases  there  is  seldom 
much  pain.  The  chief  sign  is  a  swelling  of  the  inner  or  upper  part  of  the  orbit, 
which  swelling  progressively  increases  and  finally  displaces  the  eye.  If  at 
any  time  acute  symptoms  supervene,  there  will  be  pulsatile  pain,  discoloration, 
and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar  upward  from  the 
nose  into  the  sinus,  and  so  drain  and  irrigate.  In  most  cases  an  incision  should 
be  made  through  the  soft  parts,  and  the  sinus  be  opened  by  a  trephine  or  chisel. 
After  the  sinus  has  been  opened  it  must  be  curetted.  The  opening  into  the 
meatus  should  be  restored  and  enlarged,  and  a  drainage-tube  must  be  passed 
from  the  forehead  incision  into  the  nostril.  I  usually  prefer  to  open  the 
sinus  by  making  an  osteoplastic  flap  in  the  anterior  wall. 

Diseases  and  Injuries  of  the  Larynx  and  Trachea 

Edema  of  the  Larynx  {Edema  of  the  Glottis). — The  causes  of  edema 
of  the  larynx  are:  acute  laryngitis;  chronic  diseases,  such  as  tuberculosis, 
malignant  disease,  or  syphilis;  inflammatory  disorders,  such  as  diphtheria  and 
erysipelas;  acute  infectious  diseases;  Bright's  disease;  aneurysm;  whooping- 
cough;  pneumonia;  quinsy;  wounds  of  the  larynx;  wounds  of  the  neck;  scalds 
and  burns  of  the  larynx,  and  the  inhalation  of  irritating  vapors,  such  as  those 
of  ammonia,  nitic  acid,  or  sulphur. 

The  symptoms  are  sudden  and  rapidly  increasing  dyspnea,  respiratory 
stridor,  huskiness  of  the  voice,  and  finally  aphonia.  The  swollen  epiglottis 
may  be  felt  with  the  finger  and  may  be  seen  with  the  help  of  a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is  not  excessively  acute, 
introduce  a  gag  between  the  teeth,  hold  the  mouth  open,  take  a  knife  wrapped 
to  within  \  inch  of  its  point,  make  multiple  punctures  into  the  epiglottis,  and 
favor  bleeding  by  the  inhalation  of  steam.  In  severe  cases  perform  intubation 
or  tracheotomy. 

Wounds  and  Injuries  of  the  Larynx. — The  larynx  may  be  injured 
internally  by  foreign  bodies,  and  externally  by  blows  and  cuts.  A  condition 
often  met  with  is  cut  throat,  the  result  usually  of  a  suicidal  attempt  on  the  part 
of  the  patient  or  a  homicidal  effort  on  the  part  of  an  assailant.  The  cut  of  the 
suicide  is  usually  in  front;  as  a  rule,  it  misses  the  great  vessels,  but  divides  the 
cricothyroid  or  thyrohyoid  membrane.  The  epiglottis  may  be  incised,  or 
even  be  cut  off.  If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  immediate 
dangers  of  cut  throat  are  hemorrhage,  suffocation  by  blood  in  the  wind-pipe 
and  bronchi,  or  by  displacement  of  parts,  and  entrance  of  air  into  veins.  The 
secondary  dangers  are  bronchopneumonia,  infection  and  sepsis,  exhaustion, 
and  secondary  hemorrhage.  The  remote  dangers  are  stricture  and  fistula 
(Keetley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage,  remove  clots 
from  the  larynx  and  trachea,  bring  about  reaction,  asepticize  the  parts  as  well 
as  possible,  suture  the  deeper  structures  with  silver  wire,  catgut,  or  kangaroo- 
tendon,  and  the  superficial  parts  with  silkworm-gut,  dress  antiseptically,  and 
place  a  bandage  around  the  head  and  chest  so  as  to  pull  the  chin  toward  the 
stermmi.  If  laryngeal  breathing  is  much  interfered  with,  perform  tracheot- 
omy. Feed  the  patient  through  a  tube  until  union  is  well  advanced.  The  old 
method  of  leaving  the  wound  open  is  to  be  condemned.     When  sutures  are 


88o  Surgery  of  the  Respiratory  Organs 

used,   primary  union  may  be  obtained.     This  fact  was  proved  by  Henry 
Morris. 

Scalds  of  the  Glottis. — (See  section  on  Burns  and  Scalds.) 

Foreign  Bodies  in  the  Air=passages. — The  lodgment  of  foreign 
bodies  in  the  air-passages  is  a  frequent  accident.  A  multitude  of  different 
things  have  been  reported  as  having  lodged  in  the  air-passages.  Small  solid 
bodies  are  usually  expelled  by  coughing.  Liquids  and  solids  rarely  pass  beyond 
the  larynx  (except  in  laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the 
mouth,  cut  throat,  and  in  people  unconscious  or  very  drunk).  In  vomiting 
during  or  after  the  administration  of  an  anesthetic  or  in  the  vomiting  of  drunk- 
ards the  vomited  matter  may  find  its  way  into  the  larynx  or  lungs.  There 
is  great  danger  of  this  accident  in  an  operation  upon  a  patient  with  intestinal 
obstruction  who  has  stercoraceous  vomiting.  In  most  instances  of  foreign 
bodies  lodged  in  the  air-passages  it  will  be  found  that  the  object  was  being  held 
in  the  mouth  when  a  sudden  deep  inspiration  was  taken  (often  during  laughter) . 

The  symptoms  are  immediate,  due  to  obstruction  by  the  body  and  by  spasm; 
and  secondary,  due  to  the  situation  of  the  body  and  the  changes  it  undergoes 
or  induces. 

Lodgment  in  the  pharynx  causes  \iolent  dyspnea.  The  body  can  be  seen 
or  felt. 

Lodgfnent  in  the  Larynx. — A  foreign  body  may  lodge  in  the  superior  open- 
ing of  the  larynx,  in  the  rima,  or  in  the  ventricle.  In  a  severe  case  the  patient 
fights  madly  for  air;  his  face  becomes  livid  and  cyanotic;  his  veins  stand  out 
prominently;  speech  is  impossible,  though  he  may  make  noises  and  utter  harsh 
cries;  violent  coughing  begins,  and  then  vomiting;  he  tries  to  force  a  finger 
down  his  throat  and  clutches  at  his  neck;  sweat  pours  from  him;  he  feels  a  sense 
of  impending  dissolution,  and  he  falls  unconscious,  with  incontinence  of  feces 
and  urine.  ^  In  a  less  severe  case  violent  dyspnea  gradually  departs  and  the 
patient  Hes  exhausted;  but  dyspnea  and  cough  are  liable  to  recur  suddenly  at 
any  time  because  of  spasm,  and  they  may  be  induced  by  a  change  of  position. 
These  attacks  of  fierce  spasmodic  cough  are  not  at  first  linked  with  expecto- 
ration, but  after  inflammation  begins  there  is  a  profuse  and  often  bloody 
expectoration.  Inflammation  follows  more  rapidly  the  lodgment  of  a  sharp 
or  irregular  body  than  it  does  that  of  a  round  or  smooth  one.  Inflamma- 
tion is  apt  to  produce  edema  of  the  glottis,  bronchopneumonia,  or  ulceration 
and  necrosis  of  the  larynx.  Any  sort  of  foreign  body  in  the  larynx  may  at 
any  moment  produce  spasmodic  dyspnea,  and  is  always  very  Hable  to  cause 
edema  of  the  glottis.  The  body  if  bony  or  metallic  can  be  detected  by  the 
r\;-rays.  A  body  may  remain  lodged  in  the  ventricle  for  a  long  time  without 
producing  symptoms. 

Lodgment  in  the  Trachea. — The  immediate  symptoms  of  a  foreign  body 
in  the  trachea  depend  on  the  shape  and  weight  of  the  body,  and  whether  it  be- 
comes fixed  in  the  mucous  membrane  or  moves  to  and  fro  with  the  air-current. 
A  smooth,  heavy  body  faUs  to  the  tracheal  bifurcation,  and,  if  it  does  not  enter 
a  bronchus,  moves  with  every  breath,  and  by  its  movement  causes  violent  laryn- 
geal spasm,  cough,  and  whooping  inspiration  without  aphonia.  The  patient  is 
often  conscious  of  the  movements  of  the  foreign  body,  and  the  surgeon  may 
detect  them  by  the  stethoscope.  The  foreign  body  may  be  found  by  the 
Rontgen  rays.  A  foreign  body  in  the  trachea  is  liable  to  cause  death  by 
suffocation,  or  it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even  be 
expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous  membrane,  produce 
inflammation,  frequent  cough  and  expectoration,  and  finaUy  lead  to  ulcera- 
tion. Bodies  which  sweU  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

^  See  Moullin's  graphic  description  in  his  "Treatise  on  Surgery." 


Treatment  of  Foreign  Bodies  in  the  Air-passages  88i 

Lodgment  in  a  Bronchus. — Foreign  bodies  in  the  bronchi  seriously  en- 
danger life.  They  usually  lodge  in  the  right  bronchus.  The  right  bronchiis 
is  more  nearly  the  direct  continuation  of  the  trachea  than  the  left  bronchus. 
When  a  small  area  of  lung  is  obstructed  the  obstructed  side  shows  diminished 
respirator}-  movement  and  murmur  with  occasional  whistling  sounds  and  large 
moist  rales;  the  percussion-note  is  at  first  normal  and  later  dull.     When  an 


Fig.  558. — Author's  case  of  pin  in  bronchus  removed  by  low  tracheotomj'. 

entire  lobe  is  obstructed  all  respiratory  sounds  are  absent  over  it,  and  over  the 
unobstructed  lung  respiration  is  exaggerated;  the  percussion-note  over  the 
obstructed  area  is  at  first  resonant,  but  becomes  dull.  The  .v-rays  ^ill  enable 
the  surgeon  to  detect  many  foreign  bodies  in  a  bronchus.  Lodgment  in  a  bron- 
chus may  cause  bronchopneumonia,  abscess,  hemorrhage,  and  even  gangrene. 
In  some'  cases  the  body  has  been  expelled  spontaneously.     In  rare  instances 


Fig.  55g.— Gibbon's  case  of  tack  in  the  right  bronchus  removed  by  low  tracheotomy,  child  six  years  old. 

people  have  lived  for  years  with  lodged  foreign  bodies.     If  death  does  not  soon 
follow  the  lodgment  of  a  foreign  body,  an  abscess  is  ven,^  apt  to  form. 

Treatment. — If  a  foreign  body  lodges  in  the  phar\-nx,  tr^-  to  pull  it  for- 
ward: if  this  fails,  it  may  be  wise  to  push  it  back  into  the  esophagus.     In 
lodgment  in  the  lar\-nx'or   below,  if   the    s>Tnptoms    are  ver>'  urgent,   at 
once   perform  quick  lar>Tigotomy  or  tracheotomy.      If  the  symptoms  are 
:;6 


882  Surgery  of  the  Respiratory  Organs 

not  so  urgent,  get  a  complete  history  of  the  accident  and  find  out  the 
nature  of  the  foreign  body.  Be  sure  that  a  foreign  body  is  really  retained 
in  the  respiratory  tract,  and  then  try  to  determine  what  its  situation  may 
be.  A  person  sometimes  imagines  a  body  is  lodged  when  it  has  been  ex- 
pelled or  even  when  it  was  never  in  the  larynx,  trachea,  or  bronchus  at  all,  but 
was  swallowed.  Often  a  laryngologist  can  remove  a  foreign  body  from  the 
larynx  by  means  of  forceps,  a  mirror  and  lamp  being  used  for  illumination. 
The  fauces  and  upper  portion  of  the  larynx  should  have  cocain  applied  to  them 
to  lessen  pain  and  spasm.  If  the  surgeon  fails  in  extraction  by  forceps,  and 
laryngotomy  has  been  performed,  continue  the  search  through  the  opening  in 
the  cricoth^Toid  membrane;  if  laryngotomy  has  not  been  performed,  let  the 
larynx  be  opened  by  thyrotomy  (a  vertical  incision  between  the  alae  of  the  thy- 
roid cartilage,  and  the  separation  of  these  alse  to  permit  of  exploration).  After 
a  thyrotomy  suture  the  perichondrium  with  catgut.  If  the  foreign  body  is  in 
the  trachea,  perform  ordinary  tracheotomy;  if  it  is  in  a  bronchus,  perform  low 
tracheotomy.  Tracheotomy  prevents  suffocation  from  laryngeal  spasm  or 
edema  of  the  glottis.  It  may  be  possible  to  remove  the  body  in  the  bronchus 
through  the  incision  of  a  low  tracheotomy,  and  this  ought  to  be  tried.  By  this 
method  I  succeeded  in  5  cases,  removing  a  pin,  a  bone,  a  bean,  a  tack,  and  a 
broken  tracheotomy  tube  from  the  right  bronchus.  The  foreign  body  may  be 
expelled  through  the  tracheotomy  wound;  if  it  is  not  expelled,  search  the  trachea 
and  bronchi  with  Gross's  forceps,  with  probes,  with  hooks,  or  with  the  finger.  If 
the  foreign  body  cannot  be  found,  put  the  patient  to  bed  and  maintain  a  moist 
atmosphere  in  the  room.  As  a  rule,  when  the  foreign  body  is  not  found,  insert 
a  tube.  If  the  foreign  body  be  extracted,  do  not  insert  a  tube  (unless  edema 
of  the  glottis  exists  or  is  likely  to  come  on),  do  not  suture  the  wound,  but  cover 
it  with  moist  gauze  and  let  it  heal  by  granulation.  Morphin  and  sedative 
cough-mLxtures  are  given.  Gross  says  that  even  when  a  foreign  body  has  long 
been  retained  an  operation  should  be  performed  if  the  air-passages  are  not 
seriously  diseased.  What  shall  be  done  when  a  foreign  body  is  lodged  in  a 
bronchus  and  we  are  unable  to  extract  it  through  a  tracheotomy  wound 
or  by  tracheobronchoscopy?  True  said  if  "the  patient  is  in  danger  of  death" 
cut  through  the  chest-waU  and  attempt  to  remove  the  body.  He  said  this  with 
a  fuU  knowledge  of  the  difficulty  of  locating  the  body.  This  difficulty  has  been 
partly  overcome  by  the  .r-rays,  and  it  seems  now  more  certainly  our  duty  to 
operate  than  it  was  a  short  time  ago.  Nasiloff  proposed  to  reach  the  ob- 
struction by  the  posterior  route  after  rib  resection.  Curtis  attempted  this, 
and  though  the  patient  died,  his  operation  proves  that  the  method  is  feasible. 
An  operation  by  the  posterior  route  should  be  performed  at  once  if  low  trache- 
otomy fails.  The  danger  of  pulmonary  coUapse  will  be  aboHshed  by  the  use 
of  a  suitable  apparatus  to  prevent  it  (see  pages  895  and  904). 

Tracheobronchoscopy. — Killian,  of  Freiburg,  devised  a  bronchoscope  for 
introduction  through  a  tracheotomy  wound.  I  have  used  the  endoscope  in 
this  manner.  Later  KiUian  devised  a  straight  instrument  which  could  be  used 
through  the  mouth  and  larynx,  tracheotomy  being  imnecessary.  During  its 
introduction  the  head  was  held  far  back. 

Briining,  of  Freiburg,  improved  the  instrument.  His  tube  is  long  enough  to 
reach  between  the  vocal  cords  to  the  divisions  of  the  bronchi.  In  1907  Killian 
was  able  to  collect  164  cases  of  foreign  bodies  removed  by  this  direct  method. 

Dr.  Chevalier  Jackson,  of  Pittsburgh,  has  devised  a  tracheobronchoscope 
through  which  he  has  succeeded  in  removing  foreign  bodies  from  the  trachea 
and  from  a  bronchus.  In  10  cases  of  foreign  body  in  the  bronchus  he  removed 
the  ofiender  in  7.  In  7  cases  of  foreign  body  in  the  trachea  he  was  successful 
in  each  case,  but  2  of  the  cases  required  tracheotomy.  Whenever  there  is 
dyspnea  he  always  prepares  to  do  tracheotomy  ("Annals  of  Surgery,"  March, 


High  Tracheotomy 


883 


1908).  In  Jackson's  trained  hands  the  instrument  is  most  useful,  but  an 
imtrained  man  with  it  would  be  like  an  untrained  man  with  a  cystoscope. 
When  used  by  a  fully  trained  man  the  instrument  prevents  many  cutting  opera- 
tions and  saves  many  lives  (see  page  S85). 

Operations  On  the  Larynx  and  Trachea 

Tracheotomy. — In  a  formal  operation  give  ether  or  chloroform,  but  in  an 
urgent  emergency  this  cannot  be  done.  The  patient  may  be  placed  supine  with  a 
sand-pillow  under  the  neck  and  with  the  head  thrown  over  the  end  of  the  table. 
If  a  child,  Liston  used  to  wrap  it  up  to  the  neck  in  a  sheet  to  prevent  movements 
of  the  limbs,  would  seat  himself  on  a  chair,  place  the  child  upon  the  nurse's 
lap,  and  take  its  head  between  his  knees.  The  head  must  be  exactly  in  the 
middle  line  and  extended  (in  an  adult  this  gives  af  inches  of  trachea  above  the 
manubrium;  in  a  child  of  ten,  2^  inches;  in  a  child  of  sLx,  about  2  inches).  The 
operator  stands  to  the  right  side  when  the  patient  is  supine.  If  bleeding  is 
profuse  when  the  surgeon  is  ready  to  open  the  trachea,  place  the  patient  in  the 
Trendelenburg  position  \\dth  the  neck  extended.  The  trachea  may  be  opened 
above  or  below  the  isthmus  of  the  thyroid  gland.     The  isthmus  in  an  adult 


^^ThyrtnJ.    Y{ 


Fig.  560. — Blood-supply  of  the  larj'-nx  and  trachea 
(Esmarch  and  Kowalzig). 


Fig.  561. — Parts  exposed  in  tracheotomy  (Es- 
march and  Kowalzig). 


usually  lies  over  the  second  and  third  rings  (Figs.  560  and  561).  The  isthmus 
in  a  child  usually  lies  over  the  first  ring  or  even  over  the  space  between  the 
cricoid  cartilage  and  the  first  rmg.  The  high  operation  is  always  chosen  ex- 
cept in  cases  in  which  it  is  desired  to  search  for  a  foreign  body  in  a  bronchus. 
High  tracheotomy  is  preferred  because  in  this  region  the  muscles  are 
distinctly  separated  (Fig.  561),  the  main  vessels  of  the  neck  and  the  mferior 
thyroid  vessels  are  not  encountered,  the  anterior  jugular  veins  are  small  and 
have  very  few  transverse  branches,  and  the  trachea  is  near  the  surface  (Treves). 
The  surgeon  accurately  locates  the  cricoid  and  thyroid  cartilages.  An  incision 
is  begun  at  the  upper  border  of  the  cricoid  cartilage,  and  is  carried  do-v\Ti  pre- 
ciselv  in  the  middle  line  for  about  i|  inches.  Treves  ad\ases  the  operator  to 
steady  the  skin  of  the  neck  with  the  fingers  of  the  left  hand  and  to  cut  with  the 
unsupported  right  hand  (if  the  hand  be  supported,  the  respirations  will  inter- 
fere with  the  operation) .  The  skin,  the  superficial  fascia,  and  the  anterior  layer 
of  the  cervical  fascia  are  incised,  the  sternohyoid  and  sternothyroid  muscles  are 
separated,  and  the  fascia  over  the  trachea  is  di\dded.  This  fascia  is  attached 
above  to  the  cricoid  cartilage,  and  it  di\ddes  below  into  two  layers  to  invest  the 
th\Toid  bodv  and  its  isthmus.     If  veins  are  in  the  line  of  the  incision,  they  are 


884  Surgery  of  the  Respiratory  Organs 

pushed  aside,  but  it  is  not  necessary  to  take  the  time  to  apply  double  ligatures. 
Even  if  bleeding  is  profuse,  as  soon  as  the  trachea  is  opened  and  air  enters 
freely  into  the  lungs,  venous  congestion  is  relieved  and  bleeding  is  apt  to  cease. 
If  hemorrhage  be  violent  and  the  veins  are  not  at  once  caught  by  forceps,  it 
may  be  well  to  place  the  patient  in  the  Trendelenburg  position  before  incis- 
ing the  windpipe,  in  order  to  prevent  the  entrance  of  blood  into  the  lungs. 
Before  opening  the  trachea  the  isthmus  of  the  thyroid  gland  is  pushed  down- 
ward; if  it  cannot  be  pushed  down  sufficiently,  a  transverse  incision  is  made 
through  the  fascia  at  the  upper  border  of  the  cricoid  cartilage,  and  the  fascia 
and  the  isthmus  with  it  are  Hfted  off  the  trachea  (Bose's  method).  A  tenac- 
iilum  is  inserted  into  the  cricoid  cartilage  in  order  to  steady  the  tube.  The 
back  of  the  knife  is  turned  toward  the  sternum,  a  finger  being  held  upon 
the  blade  to  prevent  too  deep  a  cut  being  made.  The  knife  is  plunged,  as  if 
it  were  a  trocar,  into  the  midline  of  the  trachea  above  the  isthmus,  and  two 
or  three  rings  are  divided  from  below  upward.  The  hook  is  not  removed  until 
the  operation  is  completed.  If  a  foreign  body  is  present,  an  attempt  is  made 
to  remove  it;  if  success  attends  the  effort,  no  tube  need  be  worn;  but  if  the 
body  is  not  found,  a  tube  must  be  used.  In  croup  or  diphtheria  remove 
membrane  (by  means  of  a  feather  and  a  solution  composed  of  bicarbonate  of 
sodium  2  oz.,  glycerin  i  oz.,  water  10  oz. — Parker)  and  insert  a  tube.  The 
edge  of  the  cut  is  grasped  with  the  dissecting  forceps,  the  mucous  membrane 
being  included  in  the  bite;  the  head  is  placed  erect,  the  tube  is  introduced,  and 
the  tenaculum  is  removed.  Seciu^e  the  tube  by  tapes,  and  suture  the  wound 
below  the  tube.  Remove  the  tube  at  the  first  moment  consistent  with  safety. 
After  tracheotomy  put  a  screen  around  the  bed;  have  the  air  kept  moist  by 
steam;  remove  the  inner  tube  and  clean  it  every  few  hours  at  first;  clean  the 
outer  tube  whenever  required.  In  croup  or  diphtheria  put  the  patient  in  a 
croup  tent  and  keep  the  air  moist  by  a  steam  atomizer  or  a  croup  kettle.  Re- 
move and  clean  the  inner  tube  every  two  hours.  Clean  the  larynx  and  trachea 
from  time  to  time  by  means  of  a  feather  and  Parker's  solution. 

Quick  laryngotomy  must  never  be  attempted  upon  a  child  under  thir- 
teen years  of  age,  because  of  the  small  size  of  the  cricoth^nroid  space  before  this 
age  (Treves) .  In  view  of  the  difficulty  of  introducing  a  tube  and  of  wearing  it 
so  near  the  vocal  cords,  laryngotomy  should  not  be  performed  for  croup,  diph- 
theria, or  for  any  condition  in  which  a  tube  must  be  long  worn.  The  operation 
is  performed  as  follows:  Make  an  incision  i|  inches  in  length  in  the  middle 
line,  from  above  the  lower  edge  of  the  thyroid  to  below  the  lower  border  of  the 
cricoid  cartilage.  Divide  the  skin,  superficial  fascia,  and  deep  fascia,  separate 
the  cricothyroid  and  sternothyroid  muscles,  divide  the  deep. layer  of  fascia, 
and  cut  the  cricothyroid  membrane  transversely  just  above  the  cricoid  cartilage. 
The  tube  must  be  shorter  than  the  ordinary  tracheotomy  tube.  An  operation 
which  opens  vertically  the  cricothyroid  membrane,  the  cricoid  cartUage,  and 
the  upper  rings  of  the  trachea  is  called  laryngotracheotomy. 

Intubation  of  the  Larynx  (O'Divyer's  Operation). — Bouchot  conceived 
the  idea  of  intubation;  O'Dwyer  perfected  it  and  made  it  a  genuine  scientific 
proceding.  The  instruments  required  for  the  performance  of  this  operation 
are  a  mouth-gag,  an  instrument  to  hold  the  tube  and  introduce  it,  and  an 
instrument  for  extracting  the  tube.  The  collar  of  the  tube  has  a  perforation 
through  which  a  piece  of  silk  is  fastened  to  draw  out  the  tube.  The  child  is 
wrapped  in  a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's  lap,  and  its  head 
is  held  by  an  assistant.  The  jaws  are  opened  and  held  apart  by  the  self-retain- 
ing mouth-gag.  The  surgeon  sits  in  front  of  the  patient,  wraps  a  piece  of 
rubber  plaster  about  the  index-finger  of  his  left  hand,  and  passes  the  finger  into 
the  child's  mouth  until  its  tip  touches  the  epiglottis.  He  introduces  the  holder 
and  tube  (observing  if  the  siik  is  free)  along  the  surface  of  the  tongue  until  the 


Chevalier  Jackson's  Tracheobronchoscopy 


885 


obturator  touches  the  epiglottis;  raises  the  epiglottis  with  the  left  index-finger, 
and  passes  the  tube  into  the  larynx;  places  the  left  index-finger  against  the 
tube,  and  withdraws  the  holder  with  the  right  hand.  The  silken  thread  is 
tied  to  the  ear,  and  the  nurse  is  directed  to  employ  the  thread  to  remove  the 
obturator  if  it  becomes  obstructed  or  is  coughed  up.  The  tube  is  removed  in 
two  or  three  days;  if  breathing  is  easy,  it  is  not  reintroduced;  but  if  dyspnea 
recurs,  it  is  replaced  for  two  or  three  days  more.  If,  in  introducing  the  tube,  a 
mass  of  false  membrane  is  pushed  before  it  into  the  trachea,  breathing  ceases, 
and,  if  the  mass  is  not  at  once  coughed  up,  tracheotomy  must  be  performed. 
Feed  these  patients  on  semisolids  rather  than  upon  liquids  (mush,  soft  eggs, 
and  cornstarch) ;  and  if  trouble  occurs  in  swallowing  these  articles,  feed  by  the 
rectum  or  by  means  of  a  nasal  or  an  oral  tube.  In  opium-poisoning,  in  asphyxia, 
in  acute  traimiatic  pneumothorax,  and  in  cerebral  injuries,  intubation  may 
be  associated  with  the  use  of  Fell's  apparatus  (see  page  896). 


.)^_:        .«-^-J  W 


(■:::.> 


Fig.  562. — Direct  larj'ngoscopy  for  the  introduction  of  a  tube  for  intratracheal  insufHation  anesthesia. 
The  patient's  head  is  on  the  table,  with  the  forehead  pushed  strongly  down  backward,  so  that  the  ver- 
tex is  under  the  chin,  the  head  in  extreme  extension,  and  the  hyoid  bone  thrown  upward  (Chevalier 
Jackson). 


Chevalier  Jackson's  Tracheobronchoscopy  (Dr.  Chevalier  Jackson 
did  me  the  honor  and  the  favor  to  write  for  me  the  following  description  of 
his  operation). — "Direct  inspection  of  the  trachea  and  bronchi  by  means  of 
a  suitably  illmninated  tube  passed  through  the  mouth  is  now  well  established 
as  a  procedure  of  great  value  for  the  removal  of  foreign  bodies  and  for  diag- 
nosis and  direct  local  treatment  of  disease.  In  the  earlier  days  of  bronchoscopy 
a  tracheotomy  was  done  for  the  insertion  of  the  bronchoscope,  but  this  is 
now  quite  vmnecessary,  because  perfection  of  instrumentarium  and  technic 
have  rendered  it  very  easy  for  those  who  have  acquired  the  knack  to  insert 
the  bronchoscope  through  the  mouth  and  larynx.  The  first  step  in  bronchos- 
copy is  the  exposure  of  the  larynx  by  direct  laryngoscopy. 

"Direct  laryngoscopy  is  so  called  in  contradistinction  to  the  ordinary  methods 
of  examination  of  the  reflected  image  in  a  throat  mirror.     The  latter  pro- 


886 


Surgery  of  the  Respiratory  Organs 


cedure  is  invaluable  for  diagnosis,  but  for  operative  work  the  anteroposterior 
reversal  of  the  image  involves  extreme  difficulties.  By  direct  laryngoscopy 
the  larynx  is  exposed  to  direct  view  for  operative  work,  removal  of  specimens 
of  tissue,  and  for  insertion  of  tubes  for  intratracheal  insufflation  anesthesia 
(Fig.  562).  For  laryngeal  operative  work  direct  laryngoscopy  is  usually  done 
under  local  anesthesia  in  the  sitting  position  in  adults;  and  without  anes- 
thesia, general  or  local,  in  children.  General  anesthesia  is  particularly  dan- 
gerous in  any  condition  of  the  larynx  associated  with  even  a  slight  degree  of 
dyspnea.  The  patient  is  usually  in  the  sitting  position  for  direct  laryngoscopy 
in  adults  with  local  anesthesia  (Fig  563),  recumbent  for  direct  laryngoscopy 
in  children,  and  usually  recumbent  for  bronchoscopy  regardless  of  anesthesia, 


Fig.  563. — ^Direct  laryngoscopy  with  the  patient  in  the  sitting  position,  for  diagnosis  and  for  endo- 
laryngeal  operation,  and  removal  of  specimens  of  tissue.  For  endobronchial  diagnosis  and  local 
medication  the  bronchoscope  may  be  passed  in  this  position,  but  for  foreign-body  work  in  larynx  or 
bronchus  the  recumbent  position  is  better,  in  order  to  have  the  aid,  instead  of  the  opposition,  of  gravity 
(Chevalier  Jackson). 

though  occasionally  diagnostic  bronchoscopies  are  done  in  the  sitting  position 
in  adults.  The  technic  of  direct  laryngoscopy  and  bronchoscopy  is  easily 
understood  from  Fig.  564,  which  represents  the  procedure  in  the  recumbent 
position.  The  patient's  head  is  fully  extended  by  forcing  the  ^occiput  down 
backward  toward  the  shoulders,  which  throws  the  anterior  part  of  the  neck 
high  up,  elevating  the  hyoid  bone  and  its  attached  structures.  In  doing  this 
the  head  must  be  raised,  never  lowered.  For  this  reason  the  schema  is  drawn 
with  the  head  on  the  table,  because  the  head  should  never  be  below  the  level 
of  the  table.  For  bronchoscopy  the  head  and  neck  should  be  out  in  the  air 
beyond  the  table  and  supported  by  an  assistant,  so  that  the  head  may  be 
freely  movable  as  needed.     For  instance,  it  must  be  moved  to  the  right  for 


Chevalier  Jackson's  Tracheobronchoscopy 


887 


the  bronchoscope  to  enter  the  left  bronchus,  and  vice  versa  to  enter  the  right 
bronchus;  and  it  must  be  slightly 
lowered  to  enter  the  middle  lobe 
bronchus  of  the  right  side,  raised  to 
enter  the  posterior  branch  bronchi. 
For  direct  laryngoscopy  only,  how- 
ever, the  head  should  be  on  the 
table,  and  for  the  insertion  of  intra- 
tracheal insufflation  tubes  should  be 
precisely  as  shown  at  A  in  Fig.  564. 
With  the  head  properly  placed,  the 
next  point  of  importance  is  to  expose 
the  lar}'nx  to  direct  view.  To  pass 
the  speculum  posterior  to  the  tongue 
and  to  identify  the  epiglottis  are 
easy.  Now  comes  the  most  import- 
ant movement  in  all  peroral  endo- 
scopic procediu"es.  The  beak  of  the 
direct  laryngoscope  is  passed  pos- 
terior to  the  epiglottis  for  about  i 
cm.,  when  a  strong  lifting  motion  is 
given  by  the  heak  of  the  instrument, 
as  if  to  lift  the  epiglottis  out  an- 
teriorly through  the  neck  in  the 
direction  of  the  dart.  The  upper 
teeth  must  not  be  used  as  a  fulcrum. 
With  the  vocal  cords  in  full  view,  the 
bronchoscope  is  inserted,  with  the 
handle  horizontal,  into  the  laryngo- 
scope. The  eye  is  now  transferred 
from  the  laryngoscope  to  the  bron- 
choscope. When  the  vocal  cords 
separate  at  the  next  inspiration  the 
bronchoscope  is  quickly  passed 
through  the  glottis  into  the  trachea, 
as  shown  at  B.  The  bite-block  is 
now  inserted  to  prevent  the  patient 
damaging  the  thin-walled  broncho- 
scope. The  slide  is  then  removed, 
as  shown  at  C,  leaving  the  broncho- 
scope in  the  trachea,  as  shown  at  D. 
The  bronchial  tree  is  exceedingly 
elastic  and  flexible,  and  may  be  ex- 
plored by  following  the  limien  by 
sight.  Secretions  may  be  removed 
by  the  sponge-holder  (Fig.  565,  C) 
uncontaminated  by  the  secretions 
from  the  mouth  for  diagnosis  or 
vaccine  therapy.  Suspected  tissue 
may  be  carefully  removed  for  ex- 
amination by  means  of  biting  forceps 
(Fig.  565,  E).  Foreign  bodies  may 
be  extracted  from  the  trachea  or 
bronchi  with  suitable  forceps  (Fig. 
565,  D).     Compressive  stenosis  by  the  thymus  gland,  mediastinal  tumors. 


Fig.  564. — Schema  showing  the  technic  of  direct 
laryngoscopy  and  bronchoscopy.  The  upper  illus- 
tration (A)  shows  also  the  position  of  the  patient 
and  the  direction  of  the  force  to  be  exerted  on  the 
direct  larjTigoscope  in  exposing  the  larjTLx  for  the 
insertion  of  intratracheal  insufflation  tubes  for 
anesthesia  (Chevalier  Jackson). 


888  Surgery  of  the  Respiratory  Organs 

and  adenopathic  mass'es  may  be  diagnosticated.  Deviation  or  compres- 
sion of  the  trachea  by  goiter  can  be  determined,  and  valuable  aid  can  be 
rendered  the  surgeon  by  an  accurate  localization  of  the  stenosis  in  all  cases 
associated  with  dyspnea.  No  dyspneic  case  should  ever  be  generally  anes- 
thetized without  a  preliminary  examination  of  the  larynx  and  trachea. 

"Esophagoscopy. — For  the  passage  of  the  esophagoscope  no  anesthetic, 
general  or  local,  is  really  necessary,  and  none  should  be  given  in  children, 
because  cocain  is  dangerous  in  the  very  young,  and  general  anesthesia  assumes 
a  graver  risk  especially  in  foreign-body  cases  in  children  because  of  the  com- 
pression of  the  trachea  by  the  bulk  of  the  bube  plus  the  bulk  of  the  foreign 


Fig.  565. — Jackson's  instruments  for  direct  laryngoscopy,  bronchoscopy,  and  esophagoscopy:  A, 
Bronchoscope;  B,  olive  bougie  for  esophagoscopic  bouginage;  C,  sponge-holder  for  sponging  the  field 
and  obtaining  specimens  of  secretion;  D,  forceps  for  removing  foreign  bodies;  E,  forceps  for  removing 
tissue;  F,  laryngeal  speculum,  called  also  slide  speculiun  and  direct  laryngoscope;  G,  bite-block;  H, 
esophagoscope  with  tubing  (I)  leading  to  aspirator  (J,  K)  for  removal  of  secretions.  The  tubing  (L) 
is  connected  with  the  positive  pressure  side  of  the  syringe  (K)  for  use  when  needed  to  blow  out  obstruc- 
tions, such  as  clots  of  pus,  food,  etc.,  that  have  been  aspirated  into  the  drainage  canal  of  the  esopha- 
goscope.    At  M  is  shown  a  gastroscope. 


body,  especially  if  the  latter  is  overriden  or  displaced.  Respiratory  arrest  is 
likely  to  follow  and  the  respiration  can  rarely  be  started  except  by  broncho- 
scopic  insufflation.  In  adults  the  lower  pharynx  and  mouth  of  the  esophagus 
may  be  anesthetized  with  an  8  per  cent,  solution  of  cocain.  There  is  no  need 
of  anesthetizing  the  esophagus  below  the  orifice,  because  it  is  quite  insensitive 
there.  Until  the  knack  is  acquired,  the  operator  will  find  it  difScult  to  pass 
the  esophagoscope  without  deep  general  anesthesia,  which  should  be  by  ether, 
never  chloroform.  The  patient  is  placed  in  the  Boyce  position,  previously 
described,  the  bite-block  being  held  by  the  index  of  the  assistant's  right  hand. 
The  esophagoscope  is  inserted  at  the  right  side  of  the  patient's  tongue  (Fig.  566) 
and  the  pyriform  sinus  sought  immediately  to  the  right  of  the  right  arytenoid. 


Chevalier  Jackson's  Tracheobronchoscopy 


889 


Once  the  tube  mouth  is  in  the  sinus,  very  gentle  pressure  is  used,  and  the 
lumen  of  the  mouth  of  the  esophagus  is  watched  for  and  followed  at  the  moment 
of  inspiration.  Absolutely  no  force  should  be  used,  and  no  attempt  to  advance 
the  tube  should  be  made  except  at  the  moments  when  the  patient  takes  a 
deep  breath,  which  he  must  be  encouraged  to  do.  It  is  the  spasm  of  the 
inferior  constrictor  at  the  cricoid  level  that  gives  the  trouble.  Once  this  is 
passed,  the  lumen  of  the  cervical  esophagus  is  easily  explored,  and  the  thoracic 
esophagus  opens  widely  at  each  recurrence  of  the  inspiratory  negative  intra- 
thoracic pressure.  Passing  the  hiatus  esophageus  requires  a  moment  for  the 
relaxation  of  spasm  and  the  tube  must  be  directed  slightly  upward  (recumbent 
patient)  to  the  left.     Esophagoscopy  is  useful  for  the  detection  of  acute  and 


Fig.  566. — ^Introduction  of  the  esophagoscope  under  guidance  of  the  eye.  The  tube-mouth  is  just 
entering  the  pyriform  sinus.  The  assistant  is  holding  the  head  in  extreme  extension  and  elevated. 
The  nurse  at  the  left  is  manipulating  the  aspirator  for  the  removal  of  secretions  without  interruption 
of  the  operator's  work  (ChevaHer  Jackson). 


chronic  esophagitis,  ulceration,  diverticulum,  dilatation,  paralysis,  and  various 
stenotic  diseases,  such  as  cicatricial  stenosis  following  the  ulceration  of  s>T)hilis, 
typhoid  fever,  corrosive  poisoning  by  bichlorid  of  mercury,  caustic  alkalis, 
acids,  etc.  Cicatricial  stenoses  are  dilated  under  guidance  of  the  eye  with 
olives,  divulsers,  and  silkworm  bougies  left  in  situ  for  a  few  hours.  Obstinate 
cases  may  require  endoscopic  esophagotomy.  Stenosis  may  be  due  to  neoplas- 
tic involvement  of  the  esophageal  wall  when  the  growth  will  be  visible  endo- 
scopically,  or  the  stenosis  may  be  compressive,  when  the  esophageal  walls 
will  be  seen  to  be  covered  with  normal  mucosa,  but  the  lumen  is  obliterated 
by  the  compression,  the  place  of  the  lumen  being  occupied  by  a  slit-Hke  crevice, 
the  long  axis  of  which  is  often  curved  and  is  almost  always  at  right  angles  to 


890  Surgery  of  the  Respiratory  Organs 

the  direction  of  pressure.  Specimens  of  endo-esophageal  growths  may  be  re- 
moved for  examination,  and  it  is  reasonable  to  hope  that  when  patients  shall 
be  esophagoscoped  early  for  any  abnormal  sensation  in  the  esophagus  the 
surgeon  will  have  a  fair  chance  to  resect  the  intrathoracic  esophagus.  Spastic 
stenosis  of  the  esophagus,  especially  hiatal  and  abdominal  esophagismus  (so- 
called  cardiospasm),  is  not  only  easily  diagnosticated  esophagoscopically,  but 
esophagoscopic  divulsion  of  the  abdominal  esophagus  will  cure  almost  all 
cases.  The  esophagoscopic  removal  of  foreign  bodies  is  possible  in  all  cases, 
no  matter  how  large  the  foreign  body.  The  mortahty  is  practically  nil  in 
careful  hands." 

Diseases  and  In'juhies  of  the  Chest,  Pleura,  and  Lungs 

Traumatic  Asphyxia  {Pressure  Stasis;  The  Ecchymotic  Mask). — ^This 
is  a  condition  that  occasionally  arises  when  the  trunk  is  subjected  to  sudden 
and  violent  compression  (caught  under  an  elevator,  ca'ught  under  a  heavy 
box,  cave  in  of  earth,  crushed  in  the  rush  of  a  panic,  etc.).  The  compression 
may  be  upon  the  chest,  the  abdomen,  or  both;  and  in  the  majority  of  cases  it  has 
been  very  temporary.  The  discoloration  arises  immediately,  and  is  mani- 
fested over  the  head  and  neck  down  to  and  sometimes  below  the  clavicle.  The 
hue  is  a  \dolet  li\'idity.  There  are  a  great  many  spots  in  the  skin  in  w^hich  the 
color  is  much  deeper,  which  have  been  supposed  to  be  hemorrhages,  and  similar 
spots  exist  on  the  labial,  buccal,  glossal,  palatine,  and  pharyngeal  mucous  mem- 
branes. Subconjtmctival  hemorrhage  is  the  rule.  There  may  be  bleeding  from 
the  nose,  mouth,  and  ears.  There  is  brief  or  prolonged  unconsciousness,  circula- 
tory and  respiratory  depression,  sometimes  cough  and  bleeding  from  the  lungs. 
There  has  never  been  a  reported  instance  of  intracerebral  hemorrhage.  There 
are  (rarely)  convulsions,  there  is  no  paralysis  and  no  delirium.  The  U\ddity 
may  clear  up  in  a  few  hours.  The  spots  seldom  fade  for  days.  The  spots  do 
not  fade  at  all  from  pressure,  the  li\dd  area  fades  but  slightly. 

If  death  occurs,  it  results  from  associated  injuries.  The  condition  in  the 
cases  wdthout  severe  associated  injuries  has  soon  disappeared,  and  entire  re- 
covery has  followed.  The  \'iew  generally  taught  is  that  traumatic  asphyxia 
is  the  result  of  compression  of  the  abdominal  veins,  causing  distention  of  the 
superior  cava  and  its  tributary  veins,  this  region  of  the  body  showing  the  effect 
more  than  the  limbs,  because  of  the  comparative  feebleness  of  the  valves 
(Villemin).  The  blood  is  forced  back  along  the  veins  and  into  the  capillaries, 
and  capillary  paresis  ensues.  One  thing  is  sure,  and  that  is,  that  the  condition 
is  particularly  apt  to  arise  if  the  patient  struggles  \dolently  to  free  himself 
from  the  compression;  and  many  obsen,'ers  have  held  the  opinion  that  actual 
vascular  ruptures  take  place.  There  are  certainly  some  cases,  however,  in 
which  there  is  simply  great  venous  and  capillar}'  distention  in  the  skin  without 
rupture,  because  pieces  of  skin  have  been  excised  and  microscopical  examination 
has  indicated  that  there  had  been  no  blood  effused.  The  selection  of  the  face 
and  neck  as  the  regions  of  discoloration  is  due,  perhaps,  to  absence  or  incom- 
petence of  valves  in  the  jugular  and  facial  veins.  The  fluid  state  of  the  blood 
which  has  been  noted  occurs  in  all  forms  of  asphyxia.  (See  Winslow,  "Medical 
News,"  Feb.  4,  1906;  Birge,  "Cleveland  Medical  Journal,"  Sept.,  1905;  Beach 
and  Cobb,  in  "Annals  of  Surgerv',"  April,  1904;  Villemin,  "Bull,  et  mem.  de 
la  Soc.  Chir.  de  Paris,"  No.  9,  1906.)  Despard  ("Annals  of  Surgery,"  June, 
1909)  has  reported  i  case  and  collected  17  from  recent  literature.  Ettinger  in 
1907  collected  36  cases  and  added  i  of  his  own  ("Wien.  kHn.  Wochen.,"  1907, 
vol.  xx).     I  have  seen  2  cases. 

Pleuritic  effusion  may  arise  from  the  lodgment  of  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from  inflammation  of  the 


Empyema  891 

lung,  but  most  usually  is  due  to  pleuritis.  The  commonest  cause  of  primary 
pleuritis  is  tuberculosis.  Inflammatory  effusion  is  nearly  always  unilateral 
(except  in  tuberculous  pleuritis;  but  even  in  this  form  it  is  often  one-sided 
in  origin). 

The  signs  of  pleuritic  effusion  are:  dulness  on  percussion  over  the  area  of 
effusion,  this  dulness,  when  the  patient  is  erect,  being  at  the  lower  part  of  the 
chest  and  ascending  higher  posteriorly  than  anteriorly  (alteration  of  position 
alters  the  situation  of  the  dulness);  the  intercostal  spaces  are  widened,  the 
intercostal  depressions  are  obliterated,  the  intercostal  muscles  are  rigid,  and 
their  rigidity  lessens  the  mobility  of  the  ribs  (Przewalski) .  No  breath-sounds 
can  be  detected  in  the  area  of  percussion  flatness  when  the  collection  of  fluid 
is  large,  but  in  small  effusions  deeply  situated  the  breath-sounds  are  often 
audible;  the  percussion-note  above  the  liquid  is  h^-perresonant  or  t^nnpanitic, 
and  is  often  associated,  at  the  edge  of  the  Uquid,  with  a  friction-sound;  pos- 
teriorly, high  up  and  near  the  spine,  there  are  bronchial  respiration  and  bron- 
chophony. In  cases  of  pleurisy  with  effusion  pain  almost  or  quite  disappears 
with  the  advent  of  effusion,  dyspnea  comes  on,  and  the  patient  lies  upon  the 
diseased  side.  Cough  always  exists  if  there  is  pleuritic  effusion,  and  fever  is 
usuaUy  present.  In  serous  effusions  the  diagnosis  may  be  confirmed  by  the 
aseptic  introduction  of  a  clean  aspirating-needle.  Ramond  has  pointed  out 
that  in  serofibrinous  plevu-isy  the  iliocostal  and  longus  dorsi  muscles  are  always 
noticeably  enlarged  on  the  side  of  the  effusion  ("Bull,  de  la  Soc.  Med.  des  hop.," 
1910,  vol.  xx\*ii). 

The  treatment  in  this  stage  is  to  discontinue  arterial  sedatives  and  to 
stimulate  if  the  circulation  calls  for  it.  The  exudation  is  removed  by  the 
administration  of  salines,  compound  jalap  powder,  or  elaterium.  If  these 
means  fail,  if  the  effusion  is  excessive,  or  if  it  is  producing  severe  dyspnea,  at 
once  aspirate.  Aspiration  should  be  performed  for  an  effusion  which  fOls  the 
whole  chest,  which  produces  great  dyspnea,  or  which  has  lasted  for  three  weeks. 
In  tuberculous  pleuritis  early  aspiration  is  not  ad\-isable,  but  aspiration  should 
be  performed  if  the  fluid  becomes  punflent,  if  the  effusion  displaces  the  heart 
considerably,  and  if  it  adds  notably  to  the  dyspnea.  If  a  non-tuberciflous 
effusion  becomes  purulent,  the  proper  procedure  is  incision,  resection  of  a 
portion  of  a  rib,  and  drainage. 

Empyema  is  a  coUection  of  pus  in  the  pleural  ca\-ity  displacing  and  com- 
pressing the  lung.  It  may  begin  suddenly,  but  rarely  does  so.  Among  the 
causes  of  empyema  are  those  of  serous  effusion.  Empyema  is  due  to  infection 
of  the  pleura,  and  in  ever\'  case  a  bacteriological  study  should  be  made  of  the 
pus  to  discover  the  causative  bacterium.  The  pneiunococcus  is  the  causative 
micro-organism  in  many  of  the  cases  which  follow  pneumonia.  Pneumococci 
live  but  a  short  time,  a"nd  in  empyema  due  to  pneumococci  these  micro-organ- 
isms may  not  be  discoverable  when  the  pus  is  evacuated.  In  most  cases  of 
empyema  streptococci  or  staphylococci  can  be  found  in  the  pus.  These 
micro-organisms  may  appear  in  an  empyema  induced  originaUy  by  pneumococci 
(Stephen  Paget).  In  empyema  developing  during  or  after  tT.'phoid  fever 
typhoid  bacilli  may  be  discovered.  In  putrid  empyema  various  bacteria  are 
found.  Bouchard  thinks  acute  empyema  has  a  special  organism.  Bacilli  of 
tuberculosis  are  present  for  a  time  at  least  in  tuberculous  empyema,  but  may 
disappear,  and  are  particularly  apt  to  after  mixed  infection  with  pyogenic 
bacteria.  In  adults  many  cases,  in  chfldren  few  cases,  are  secondary-  to 
tuberculosis.  Empyema  may  be  due  to  a  woimd  or  contusion,  an  attack  of 
pneinnonia,  tuberciilous  pleuritis,  phthisis,  influenza,  pyogenic  infection  of  a 
serous  effusion,  caries  of  a  rib,  specific  fevers,  especially  t\-phoid,  peritonitis, 
abscess  of  the  liver,  suppurating  hydatid  cyst  of  the  liver,  subphrenic  abscess, 
malignant  disease  of  the  pleiura,  gangrene  of  the  limg,  and  pneumothorax. 


892  Surgery  of  the  Respiratory  Organs 

Pneumonia  is  the  common  cause  in  children.  In  them  we  find  streptococci  in 
only  15  per  cent,  of  the  cases,  and  sterile  fluid  in  20  per  cent.  In  65  per  cent, 
of  the  cases  we  find  pneumococci.  In  adults  the  pus  is  often  thin  and  very 
putrid.  In  children  the  pus  is  nearly  always  thick.  Pneumococcic  pus  is 
fairly  thick,  contains  some  clots,  and  is  white  or  greenish  white. 

Acute  Empyema. — The  signs  are,  in  reality,  those  of  pleuritis  with  effusion 
— viz.,  dulness  on  percussion,  absent  breath-sounds  over  the  purulent  matter, 
bulging  of  the  intercostal  spaces,  and  sometimes  edema  of  the  skin  of  the  chest. 
The  symptoms  of  acute  empyema  are  dyspnea,  pallor,  cough,  sweats,  chills,  and 
usually  irregular  fever,  but  fever  may  be  absent.  There  is  marked  leukocyto- 
sis. The  fingers  may  become  clubbed.  An  empyema  may  pulsate,  particu- 
larly an  empyema  of  the  left  side.  The  cause  of  pulsating  empyema  has  been 
much  debated.  The  most  probable  explanation  is  that  of  W.  J.  Calvert 
("Am.  Jour.  Med.  Sciences,"  Nov.,  1905).  He  says  the  requirements  for  such 
a  condition  are:  "A  firmly  iLxed,  pulsating  organ;  distention  of  the  pleural  sac 
with  fluid  or  air  or  soHd  material;  and  a  collapsed  condition  of  the  lung."  In 
all  probability  the  thoracic  aorta  is  the  "fixed  pulsating  organ."  The  left  pa- 
rietal pleura  is  in  elose  relation  with  the  aorta,  and  most  pulsating  empyemas 
are  left  sided.  The  right  parietal  pleural  may  be  "pushed  against  the  aorta." 
If  a  lung  contains  air,  it  is  elastic  and  compressible  to  a  degree  that  enables 
it  to  absorb  the  aortic  impulse;  if  it  is  collapsed  and  solid  it  cannot,  and  aortic 
pulsations  are  transmitted  to  fluid  in  the  pleural  cavity  and  the  thoracic  wall 
pulsates.  A  neglected  empyema  may  break  into  the  lung,  esophagus,  or  peri- 
cardium, through  an  intercostal  space,  or  may  point  in  the  lumbar  region: 
When  an  empyema  is  pointing  externally,  the  condition  is  called  empyema 
necessitatus.  A  total  empyema  is  a  condition  involving  the  entire  pleural 
sac.  In  a  partial  or  localized  empyema  the  purulent  matter  is  encapsulated. 
A  closed  empyema  is  one  in  which  no  opening  has  been  made  by  the  sur- 
geon and  no  opening  has  formed  spontaneously.  In  a  closed  empyema  the 
pus  is  rarely  putrid;  in  an  open  empyema  the  pus  is  often  putrid.  After 
an  empyema  ruptures  spontaneously  it  rarely  heals  without  surgical  inter- 
ference, a  pleural  fistula,  as  a  rule,  persisting.  A  subphrenic  abscess  may 
follow  an  empyema.  When  an  empyema  ruptures  into  a  bronchus,  pneu- 
mothorax arises,  as  a  rule.  Empyema  may  cause  death  by  compression  of 
the  heart  and  lung,  puhnonary  embolism,  pericarditis,  peritonitis,  cerebral 
embolism,  cerebral  abscess,  septicemia,  exhaustion,  or  rupture  into  a  bronchus. 
Empyema  is  particularly  fatal  in  childhood.  In  empyema  of  the  early  months 
of  life  nearly  all  the  victims  die.  In  those  under  one  year  of  age  50  per  cent, 
of  the  affected  will  die  (Holt).     In  older  children  30  per  cent.  die. 

A  smaU  empyema  due  to  pneumococci  occasionally,  though  very  rarely, 
undergoes  spontaneous  cure,  the  pus  being  absorbed  (Stephen  Paget). 

A  small  empyema  is  occasionally  cured  by  encapsulation  by  fibrous  tissue. 

Under  exceptional  circumstances  even  a  large  empyema  may  be  cured  by 
breaking  externally  or  into  a  bronchus. 

Empyema  is  so  rarely  cured  spontaneously  that  it  does  not  do  to  trust  to 
Natiu-e  at  all,  and  practically  almost  all  cases  die  without  surgical  treatment. 

Double  empyema  is  a  rare  and  extremely  fatal  condition. 

Chronic  empyema  may  follow  acute  empyema,  or  the  condition  may  be 
chronic  from  the  beginning.  It  is  more  common  in  adults  than  in  children. 
In  chronic  empyema  the  lung  is  compressed,  shrimken,  does  not  expand  and  is 
strongly  adherent,  and  the  pleura  is  very  thick.  In  some  cases  the  pleura  is 
over  an  inch  thick.  This  thickening  is  brought  about  by  the  deposition  of 
layer  after  layer  of  fibrin.  In  not  a  few  cases  a  chronic  empyema  succeeds  an 
acute  one.  Sometimes  chronic  empyema  is  maintained  because  a  drainage- 
tube  has  slipped  into  the  pleural  cavity  and  remains  lodged. 


Treatment  of  Empyema  893 

Treatment  of  Empyema. — The  treatment  is  purely  surgical,  and  the  ear- 
lier it  is  applied  the  better.  To  delay  allows  the  pleura  to  thicken  and  per- 
mits adhesions  to  form,  conditions  which  prevent  lung  expansion  and  retard  or 
even  prevent  cure.  The  results  of  operation  for  chronic  empyema  are  better  in 
children  that  are  not  very  young  than  in  adults.  In  acute  empyema  the  prog- 
nosis is  better  in  small  collections  than  in  large;  in  recent  than  in  advanced  cases; 
in  pneumococcus  empyema  than  in  empyema  due  to  other  organisms.  The  sur- 
gical methods  for  various  stages  of  empyema  comprise  aspiration,  incision,  rib- 
resection,  the  operation  of  Schede,  the  operation  of  Estlander,  and  the  operation 
of  Fowler  (see  pages  908  to  912  inclusive). 

I  do  not  believe  in  any  of  the  appliances  to  drain  with  a  small  tube  and  main- 
tain negative  pressure  in  the  chest  to  favor  lung  expansion.  The  Thiersch 
method  consists  in  introducing  a  trocar  into  the  cavity,  passing  a  Nelaton 
catheter  through  the  trocar,  and  removing  the  trocar.  The  external  end  of  the 
catheter  is  attached  to  an  easily  collapsible  rubber  tube,  the  other  end  of  which 
is  in  a  bottle  of  water.  The  catheter  is  fixed  to  the  side  by  rubber  tissue  and 
rubber  plaster.  "The  theory  is,  that  when  the  patient  expires,  the  pus  runs 
out  through  the  tube,  and  on  inspiration  the  collapsible  walls  of  the  tube  are 
sucked  together  and  prevent  the  entrance  of  air,  and  cause  negative  pressure 
in  the  chest,  favoring  expansion  of  the  lung"  (Lund,  "Jour.  Am.  Med.  Assoc," 
August  26,  191 1).  In  any  method  of  suction  so  far  devised  the  tube  is  so  small 
that  it  blocks  up,  and  though  the  drainage-tube  may  at  first  make  an  air-tight 
joint  with  the  chest,  it  always  loosens  sooner  or  later  and  leaks  air. 

In  acute  empyema  general  practitioners  are  very  apt  to  aspirate,  and  yet 
aspiration  is  almost  never  curative.  It  may  cure  a  pneumococcus  empyema 
in  a  child  and  an  encysted  empyema,  but  even  in  these  it  will  usually  fail. 
Aspiration  is  not  to  be  considered  a  method  of  curative  treatment.  It  is  to  be 
regarded  as  the  surgical  treatment  only  in  a  tuberculous  empyema  in  a  young 
persontwith  rapidly  progressing  phthisis,  because  in  such  a  case  incision  will 
probably  prove  fatal  (Lockwood).  It  is  a  very  useful  diagnostic  expedient, 
and  enables  the  surgeon  to  prove  the  existence  of  pus,  and  the  pus  which  is 
obtained  can  be  examined  bacteriologically.  In  a  very  large  effusion  it  is  wise 
to  aspirate  and  withdraw  part  of  the  effusion  a  short  time  before  operating. 
This  enables  the  patient  to  take  an  anesthetic  with  greater  safety  and  obvi- 
ates the  danger  attending  the  rapid  evacuation  of  a  large  amoimt  of  pus. 

In  a  recent  empyema,  incision  and  drainage  or  rih  resection  and  drainage 
will  often  cure  the  case,  and  yet  many  of  the  results  are  unsatisfactory.  In 
some  cases  the  discharge  ceases  and  yet  pulmonary  function  is  not  completely 
restored.  In  other  cases  a  pleural  fistula  persists.  If  a  profuse  discharge  is 
maintained,  amyloid  disease  may  arise.  An  acute  empyema  is  to  be  drained 
by  intercostal  incision  or  by  resection  of  a  rib  (see  page  908).  A  chronic  closed 
empyema  is  drained  in  the  same  manner,  and  if  the  lung  will  not  fully  expand 
and  remains  stationary  for  one  year,  Schede's  or  Estlander's  operation  is  re- 
quired. An  open  chronic  empyema,  in  which  the  lung  will  not  expand, 
requires  the  operation  of  Schede,  Estlander,  or  Fowler  (see  pages  910  and  911). 
The  results  are  best  in  children  almost  in  the  teens.  Extensive  decortication 
is  sometimes  impossible,  and  then  Ransohoff's  operation  may  be  done.  _  He 
calls  it  discission  of  the  pulmonary  pleura  (see  page  912).  When  there  is  an 
external  opening  which  persists  and  which  joins  a  long,  narrow  cavity,  the  con- 
dition is  spoken  of  as  pleural  fistula,  and  pleural  fistula  is  often  produced  by  the 
prolonged  use  of  a  drainage-tube  and  sometimes  by  caries  of  a  rib.  Even  if 
there  is  no  opening  on  the  cutaneous  surface,  there  may  be  one  into  a  bronchus. 
A  pleural  fistula  may  sometimes  be  cured  by  dilatation  of  the  sinus.  If 
this  fails,  and  it  usually  does,  it  is  the  custom  to  resect  one  or  more  ribs. 

Before  resorting  to  operative  treatment  in  chronic  empyema  we  may  try,  in 


894  Surgery  of  the  Respiratory  Organs 

some  open  cases  at  least,  the  injection  of  bismuth  paste.  We  owe  this  method 
to  Dr.  Emil  Beck.  This  plan  will  sometimes  succeed.  Ochsner  has  strongly 
commended  it  ("Annals  of  Surgery,"  July,  1909).  The  injection  is  made  by 
a  glass  syringe  and  the  material  should  iiil  but  not  stretch  the  cavity.  After 
injecting  the  paste  the  external  opening  of  the  fistula  is  plugged  with  gauze. 
The  treatment  is  begun  with  solution  No.  1(1  part  of  subnitrate  of  bismuth 
devoid  of  arsenic  and  2  parts  of  yellow  vaselin). 

This  is  used  every  second  day  imtil  pus  has  practically  disappeared.  Then 
solution  No.  2  (30  parts  of  bismuth,  60  parts  of  yellow  vaselin,  and  10  parts 
of  paraf&n)  is  substituted  for  it.  The  injections  are  made  often  enough  to 
keep  the  sinus  and  pocket  full.  They  are  made  at  first  every  day,  then  every 
other  day,  and  so  on  until,  finally,  every  eighth  or  tenth  day  is  often  enough. 
If  poisoning  should  arise  from  these  injections  Beck  advises  the  injection  of  olive 
oil  at  a  temperature  of  110°  F.  to  dissolve  the  paste  and  favor  its  evacuation. 
McKelvey  Bell  recommends  a  paste  which  is  more  stimulating  than  Beck's. 
He  takes  i  oz.  of  subnitrate  of  bismuth  and  2  oz.  of  white  petrolatum,  dissolves 
over  a  hot-water  bath,  and  stirs  until  cool.  Then,  while  stirring,  he  adds  72  gr. 
of  iodoform  (5  per  cent.).  This  must  be  kept  in  a  dark  place  to  prevent  decom- 
position of  the  iodoform  ("New  York  Med.  Jour.,"  May  4, 191 2) .  (See  page  623.) 

Non=traumatic  Pneumothorax. — By  the  term  "pneumothorax"  is  meant 
the  presence  of  air  in  the  pleural  cavity.  As  a  rule,  besides  air  there  is  serous 
fluid  or  pus.  It  may  be  due  to  the  rupture  of  an  empyema  into  a  bronchus; 
to  the  rupture  into  the  pleural  sac  of  a  tuberculous  area,  an  area  of  gangrene, 
an  abscess  of  the  lung,  an  air-cell  in  a  state  of  emphysema,  or  of  pulmonary 
tissue  softened  because  of  hemorrhagic  infarction.  The  condition  is  by  no 
means  uncommon  in  phthisis.  In  473  autopsies  held  in  the  Henry  Phipps 
Institute  of  Philadelphia  upon  persons  dying  of  pulmonary  tuberculosis  there 
were  41  cases  of  pneumothorax,  or  in  8.6  per  cent,  of  the  autopsies  this  lesion 
was  found  (J.  M.  Cruice,  "Med.  Record,"  Sept.  23,  191 1).  In  60  per  cent,  of 
the  cases  the  lesion  is  on  the  left  side.  It  is  inaugurated  by  cough,  straining 
at  stool,  vomiting,  or  lifting.  It  is  more  frequent  in  men  than  in  women  and 
is  most  common  between  the  ages  of  thirty  and  forty.  The  immediate  effect  of 
the  entrance  of  air  into  the  pleural  sac  is  to  compress  the  lung,  the  degree  of 
compression  being  in  proportion  to  the  amount  of  air  present.  In  severe  cases 
the  limg  is  squeezed  against  the  vertebral  column,  and  the  heart  and  diaphragm 
are  displaced.  In  a  right-sided  case  the  liver  may  be  displaced.  In  some  cases, 
when  the  admission  of  air  does  not  continue,  the  amount  set  free  in  the  pleural 
sac  is  absorbed.     In  most  cases  pyopneumothorax  (empyema)  follows. 

The  symptoms  usually  arise  suddenly  (in  three-fourths  of  the  cases),  and 
consist  of  distressing  dyspnea,  pain  in  the  chest,  lividity,  and  rapidity  and 
weakness  of  the  pulse.  In  some  cases  of  phthisis  the  symptoms  are  grad- 
ual and  not  very  severe.  There  may  be  pain  and  dyspnea  or  only  dysp- 
nea. In  the  latter  case,  if  dyspnea  existed  before,  the  accident  may  be  un- 
recognized. It  has  been  pointed  out  that  occasionally  in  phthisis  pneumo- 
thorax seems  actually  to  benefit  the  tuberculous  area  in  the  lung.  There  is 
nothing  characteristic  in  the  attitude.  The  patient  usually  lies  on  the  opposite 
side,  but  may  lie  on  the  side  of  the  trouble  or  on  the  back.  He  may  sit  erect  or 
semi-erect.  He  may  place  himself  in  a  knee-chest  position.  The  physical 
signs  of  pneumothorax  are  as  follows:  The  affected  side  of  the  chest  is  often 
bulged,  movements  are  lessened  or  absent,  and  the  heart  is  displaced,  especially 
if  the  condition  affects  the  left  side.  Palpation  discovers  that  vocal  fremitus 
is  lessened  or  absent.  On  auscultation  it  is  found  that  the  breath-sounds  are 
very  feeble  or  absent  in  70  per  cent,  of  cases.  Occasionally  they  are  amphoric, 
bronchovesicular,  or  cavernous.  The  voice  may  be  transmitted  as  a  metallic 
soimd  (this  is  present  in  about  half  the  cases) ,  rales  may  sound  metallic,  and 


Symptoms  of  Acute  Traumatic  Pneumothorax  895 

on  coughing  there  may  be  metallic  tinkling.  The  percussion-note  is  hyper- 
resonant  or  t}-mpanitic  in  95  per  cent,  of  cases.  Very  seldom  it  is  normal.  In 
some  rare  cases  the  percussion-note  is  dull.  When  fluid  gathers,  there  is  a 
positively  dull  note  on  ^^ercussion  o\'er  the  fluid. 

Treatment. — Osier  says  the  treatment  should  be  the  same  as  that  for 
pleurisy  with  effusion.  In  many  cases  it  is  wise  to  perform  paracentesis 
without  suction  to  remove  air  and  serous  eft'usion.  If  pus  forms,  a  rib  should 
be  resected  and  a  tube  inserted  (see  Empyema).  In  pneumothorax  occur- 
ring during  chronic  phthisis  operation  is  of  service.  In  cases  with  rapidly 
progressive  phthisis  it  is  practically  useless. 

If  the  opening  into  a  bronchus  or  air-cell  remains  patent,  aspiration  wiU 
not  get  rid  of  air ;  the  air  will  enter  into  the  pleura  as  rapidly  as  the  aspirator 
removes  it.  Incision  has  dangers  of  its  own:  the  diaphragm  is  flapping  dur- 
ing respiration  and  may  be  injured  (Fowler),  and  when  the  pleura  is  opened 
there  is  a  great  alteration  produced  in  the  air-pressure  in  the  chest,  and  the 
patient  may  "drown  in  his  own  secretions."  After  incision  irrigation  is  not 
justifiable,  because  the  fluid  may  enter  a  bronchus  and  produce  suffocation 
(Fowler).  ^ 

West's  rules^  are  those  I  follow.  West  says  early  incision  is  dangerous. 
In  an  early  stage  use  paracentesis  without  suction.  This  will  often  relieve  the 
patient.  If  paracentesis  does  relieve  him,  wait  a  while  and  perhaps  repeat  the 
operation  if  the  symptoms  again  become  severe.  If  paracentesis  does  not 
reheve,  incise,  resect  a  portion  of  a  rib,  and  drain.  If  pus  forms,  an  incision 
must  be  made  and  a  portion  of  a  rib  be  resected  to  afford  exit  to  the  fluid. 

Fowler  pointed  out  that  if  the  lung  is  bound  down  by  adhesions,  incision  is 
dangerous  but  justifiable.  Operation  at  the  proper  time  often  prevents  the 
lung  being  bound  down  by  adhesions. 

Acute  Traumatic  Pneumothorax. — This  is  produced  by  the  sudden 
admission  of  a  quantity  of  air  into  the  pleural  ca\dty  as  a  resiflt  of  a  woimd  of 
the  chest  wall.  A  small  quantity  of  air,  or  the  gradual  introduction  of  con- 
siderable air,  does  not,  as  a  rule,  produce  very  serious  symptoms.  The  sudden 
admission  of  a  quantity  of  air  causes  ver}^  dangerous  symptoms  and  even 
death.  A  quantity  of  air  may  be  admitted'  rather  suddenly  as  a  result  of  an 
accident  or  during  the  performance  of  a  surgical  operation  which  opens  the 
pleura.  It  sometimes  arises  during  the  removal  of  tumors  from  the  chest  wall, 
during  operations  upon  the  limg,  and  during  empyema  operations.  As  a  rule,, 
when  pulmonary  adhesions  exist,  dangerous  symptoms  do  not  arise,  even  when 
the  pleura  is  widely  opened,  and  adhesions  exist  in  25  per  cent,  of  empyema 
cases  seen  by  the  surgeon.- 

It  w^as  formerly  taught  whenever  the  pleura  is  opened  there  is  a  strong 
tendency  to  the  development  of  pneumothorax,  but  West  has  shown  that  the 
surfaces  of  the  pleura  often  cohere  with  a  force  superior  to  pulmonary  elas- 
ticity, and  in  such  cases  pneumothorax  does  not  arise. 

In  surgical  operations  in  which  it  is  necessary  to  open  the  pleura  widely 
(as  in  operation  for  sarcoma  of  the  chest  wall)  the  surgeon  endeavors  to 
prevent  acute  pneumothorax,  which  may  prove  fatal.  This  may  be  done 
by  operating  in  the  Sauerbruch  negative  pressure  chamber  (see  page  905)  or 
by  appMng  positive  pressure  (see  page  905). 

Symptoms. — WTien  the  pleura  is  opened  during  an  operation  or  by  an 
injury,  the  symptoms  may  be  tri\dal  and  transitory,  may  be  tolerably  severe, 
may  be  extremely  grave,  and  the  patient  may  quickly  die  (Quenu  and  Longuet).. 
Rudolph  Matas^'sets  forth  the  symptoms  as  presented  by  the  French  observers. 

1  "British  Medical  Journal,"  Nov.  27,  1897. 

2  Rudolph  Matas,  "Annals  of  Surgery,"  April,  1899. 

3  Ibid. 


896 


Surgery  of  the  Respiratory  Organs 


The  mild  symptoms  are  weak,  slow  pulse  and  irregular,  noisy  respiration. 
The  severe  symptoms  are  slow  pulse,  slow  and  irregular  respiration,  and 
dyspnea,  continuing  after  the  anesthetic  has  been  withdrawn. 

The  grave  symptoms  are  cyanosis;  collapse;  small,  weak  pulse;  shallow 
and  noisy  respiration;  and  spells  of  syncope.  Death  may  occur  suddenly 
from  inhibition,  or  later  from  mechanical  asphyxia  (Matasj. 

Treatment. — Various  plans  have  been  adopted:  suturing  the  opening  in 
the  pleura;  plugging  the  opening;  pulling  the  diaphragm  into  the  wound  in  the 
chest  wall  and  suturing  it ;  and  grasping  the  lung  and  suturing  it  to  the  wound. 
Whenever  the  pleura  is  to  be  mdely  opened,  operate  in  a  Sauerbruch  chamber 
or  use  a  positive  pressure  apparatus,  and  when  the  operation  is  complete,  su- 
ture the  lung  to  the  margin  of  the  opening 
in  the  pleura  with  a  continuous  catgut  su- 
ture. The  apparatus  for  insufSation  anes- 
thesia accomplishes  the  object.  Parham, 
Keen,  and  the  author  followed  this  plan, 
using  the  Fell-0'D\wer  emergency  appara- 
tus, and  the  lung  was  kept  from  collapsing.^ 
This  apparatus  is  shown  in  Fig.  567. 

O'Dwyer's  tube  is  introduced  into  the 
glottis  as  is  the  tube  in  intubation,  and  is 
attached  to  a  bellows,  the  lung  is  inflated, 
respiration  is  maintained  by  the  use  of 
the  bellows,  and  collapse,  mth  all  its 
dangers,  is  avoided.  The  modern  positive 
pressure  apparatus  or  the  apparatus  for 
insufflation  anesthesia  is  better  (see  page 
905).  So  is  the  pulmotor  (see  page  867). 
Contusions  and  Wounds  of  the 
Chest. — Contusions. — A  contusion  may 
be  trivial  and  limited  to  the  superficial 
parts  of  the  chest  waU;  it  may  involve  the 
muscles;  it  may  be  associated  with  frac- 
tiure  of  the  ribs  or  sternum  or  T\ith  \ds- 
ceral  injury. 

Synnptoms. — In  an  ordinar\^  contusion 
without  \dsceral  injury  there  are  consider- 
able pain,  discoloration,  and  often  much 
sweUing.  The  patient  prefers  to  lie  upon 
the  back  and  the  respiration  is  abdominal. 
After  a  severe  blow  upon  the  chest  there  is 
great  shock  and  may  even  be  instant  death. 
The  condition  of  shock  so  produced  is 
called  concussion  of  the  chest.  After  a  severe 
blow  upon  the  chest  a  Hmited  area  of  inflammation  may  arise  in  the  pleiira 
{traumatic  pleuritis).  Severe  \dsceral  injiuy  is  announced  by  positive  symp>- 
toms.  A  contusion  of  the  lung  causes  extravasation  of  blood  and  leads  to  pain, 
cough,  expectoration  of  bloody  mucus,  dyspnea,  and  possibly  distinct  hemo- 
phthisis.  Over  the  contused  region  the  percussion-note  is  dull  and  on  ausculta- 
tion crepitus  is  audible.  It  may  be  mistaken  for  phthisis,  but  complete  and 
early  recovery  soon  dispels  this  fear.  Traumatic  pneumonia  always  follows. 
This  usuaUy  involves  a  limited  area  of  lung  tissue,  but  genuine  croupous  pneu- 

^  F.  W.  Parham's  paper  on  "Thoracic  Resection  for  Tiimors  Gro^'ing  from  the  Bony  Walls 
of  the  Chest."     Read  before  the  Southern  Surgical  and  Gynecological  Association,  November, 


Fig.  567. — The  Fell-0  Dwyer  apparatus. 
This  illustration  shows  an  early  model;  since 
then  the  bellows  has  been  improved  by  the 
addition  of  a  strong  wooden  frame,  which 
holds  it  steadily,  and  is  provided  with  a  long 
arm  that  acts  as  a  powerful  foot-piece  for 
compressing  the  machine  with  the  least 
amount  of  muscular  effort. 


Treatment  of  Contusions  of  the  Chest  897 

monia  may  arise  after  injury  of  the  chest  even  when  no  rib  was  broken.  The 
physical  signs  and  symptoms  are  not  evident  until  two  or  three  days  after  the 
accident  (Sir  Thomas  Oliver,  in  ''Brit.  Med.  Jour.,"  April  30,  1910).  Trau- 
matic pneumonia  may  be  caused  by  other  things  than  external  violence,  viz., 
inhalation  of  illuminating  gas,  of  dust,  or  of  a  foreign  body. 

In  rupture  of  the  lung  the  physical  signs  are  dependent  on  the  extent 
and  situation  of  damage.  A  minute  rupture  would  not  produce  definite 
physical  signs.  If  the  lung  is  ruptured  and  the  pulmonary  pleura  is  not,  there 
will  not  be  pneumothorax,  but  there  may  be  cellular  emphysema  first  becoming 
evident  at  the  root  of  the  neck.  If  the  pleura  is  torn  as  well  as  the  lung, 
there  will  be  pneumothorax  and  hemothorax,  the  amount  of  hemorrhage  de- 
pending upon  the  situation  and  extent  of  the  injury. 

Robt.  G.  Le  Conte  ("Annals  of  Surgery,"  March,  1908)  points  out  five  ways 
in  which  rupture  may  be  caused:  (i)  Bruising  (simply  causes  subpleural  ec- 
chymosis);  (2)  bursting  (violent  force — a  lung  unable  to  empty  itself  of  air 
is  broken  as  an  inflated  paper  bag  is  broken  by  a  sharp  blow) ;  the  question 
as  to  whether  the  glottis  must  be  closed  for  such  an  injury  to  occur  is  not  set- 
tled; (3)  penetration  by  a  green-stick  fracture  of  a  rib;  (4)  compression  of  the 
limg  against  some  resistant  structure;  (5)  tearing  (when  the  lung  has  previously 
been  adherent  to  the  wall  of  the  chest). 

These  five  causes  might  be  sententiously  designated  as  bruising,  bursting, 
puncturing,  squeezing,  and  tearing. 

The  symptoms  are  shock,  dyspnea,  cough  with  or  without  bloody  expectora- 
tion, rapid  and  irregular  pulse,  cyanosis,  emphysema  (appearing  first  over  the 
region  of  injury  if  a  broken  rib  penetrated  the  lung,  and  first  at  the  root  of  the 
neck  is  the  lung  is  ruptured,  but  the  pleura  is  not),  and  in  some  cases  pneumo- 
thorax and  hemothorax  (Le  Conte,  Ibid.) . 

Rupture  of  the  diaphragm  causes  pain,  dyspnea,  and  often  vomiting. 
The  stomach  or  intestine  may  pass  into  the  pleural  sac.  If  this  happens,  there 
will  be  a  tympanitic  percussion-note  over  the  displaced  viscus  and  symptoms 
Mill  vary  with  the  viscus  involved.  Such  a  diaphragmatic  hernia  may  be- 
come strangulated  (see  page  11 52).  In  a  case  in  the  Jefferson  Medical  Col- 
lege Hospital,  in  which  the  stomach  passed  into  the  left  pleural  sac,  there 
w^ere  persistent  vomiting,  violent  pain  in  the  chest  and  upper  abdomen,  great 
thirst,  and  displacement  of  the  apex-beat.  The  condition  may  be  confused 
with  pulmonary  rupture  causing  pneumothorax,  but  in  rupture  of  the  dia- 
phragm persistent  nausea  and  vomiting  are  prominent  features;  whereas,  in 
pulmonary  rupture,  if  they  exist  at  all,  they  are  early  and  temporary;  further, 
in  rupture  of  the  diaphragm  the  tympanitic  percussion-note  is  not  found  oyer 
the  pleural  apex,  but  in  pulmonary  rupture  with  pneumothorax  a  tympanitic 
note  is  found  all  over  the  entire  pleural  cavity  (Le  Conte,  Ibid.) . 

Treatment  of  Contusions  of  the  Chest. — A  contusion  of  the  chest  wall 
is  treated  as  directed  in  the  section  on  Contusions  (see  page  259),  and  the  chest 
is  strapped  with  adhesive  plaster,  as  in  the  treatment  of  fractured  ribs.  In  con- 
cussion of  the  chest  the  treatment  for  shock  is  applied.  It  may  be  necessary 
to  employ  artificial  respiration  for  a  time.  If  a  diaphragmatic  hernia  is  diag- 
nosticated, the  abdomen  should  be  opened,  the  displaced  viscera  restored  to 
their  proper  abode,  and  the  diaphragm  sutured.  The  diaphragm  may  alsobe 
reached  by  resecting  several  ribs  and  opening  the  pleural  sac.  In  contusion 
of  the  lung  cold  is  appUed  to  the  chest  early  in  the  case,  and  any  inflammation 
which  arises  is  treated  according  to  general  rules.  In  rupture  of  the  lung  the 
case  may  be  treated  expectantly,  but  dangerous  and  continued  bleeding  or 
pneumothorax  may  render  surgical  interference  necessary.  For  pneumothorax 
paracentesis  without  suction  is  employed.  If  this  fails,  it  may  be  repeated.  If 
it  fails  again,  resect  a  portion  of  a  rib  and  put  in  a  tube.  If  bleeding  is  danger- 
57 


898  Surgery  of  the  Respiratory  Organs 

ously  profuse  resect  a  portion  of  a  rib  and  insert  a  drainage-tube  into  the 
pleural  cavity. 

Wotinds  of  the  Chest. — Non-penetrating  wounds  are  not  particularly 
grave,  and  are  treated  according  to  general  principles,  the  chest  being  immo- 
bilized. Penetrating  wounds  are  extremely  grave,  as  viscera  are  apt  to  be 
injured.  In  such  a  wound  an  intercostal  artery  may  be  severed  or  the  internal 
mammary  artery  may  be  divided.  An  intercostal  artery  is  rarely  divided 
unless  a  rib  is  broken.  The  surgeon  should  always  examine  carefully  in  order  to 
determine  whether  an  intercostal  artery  or  the  internal  mammary  artery  has 
been  divided,  and,  in  doing  so,  should  bear  in  mind  the  admonition  of  Matas — 
that  is,  the  bleeding  from  these  vessels  may  be  internal,  the  blood  collect- 
ing in  the  pleural  sac.  The  pericardium  or  heart  may  be  injured  (see  page  404). 
A  wound  of  the  pleura  is  usually,  but  not  always,  associated  with  a  wound  of 
the  lung.  If  the  lung  is  injured,  there  are  usually  great  shock,  pain  in  the 
chest,  dyspnea,  and  cough.  In  a  large  wound,  damage  to  the  lung  will  be 
indicated  if  air  is  sucked  into  the  wound  during  inspiration  and  expelled  during 
expiration,  and  if  blood  is  forced  out  of  the  wound  by  coughing.  The  lung  may 
be  visible  or  may  protrude  (protrusion  of  the  lung).  In  a  small  wound  it  is  often 
difficult  and  sometimes  impossible  to  determine  whether  the  lung  has  been 
injured.  Pneumothorax  with  pulmonary  collapse  proves  it  has.  Severe 
hemothorax  strongly  suggests  it.  Spitting  blood  does  not  prove  it.  In  some 
severe  cases  there  is  no  hemoptysis ;  in  some  slight  bruises  the  amount  of  blood 
coughed  up  is  large.  Emphysema  about  the  wound  does  not  prove  lung 
injury.  An  incised  wound  of  the  lung  is  apt  to  produce  rapid  death  from 
hemorrhage,  especially  if  the  wound  is  at  the  root  of  the  lung.  A  pistol-bullet 
or  a  sporting-rifle  bullet  may  not  be  productive  of  great  primary  hemorrhage; 
but  infection  will  probably  follow,  and  secondary  hemorrhage  will  be  apt  to 
occur.  The  modern  military-rifle  ball  passes  through,  rarely  lodges,  is  aseptic, 
and  often  produces  astonishingly  little  trouble.  A  pistol-bullet  and  an  old-time 
rifle-bullet  may  lodge  or  may  perforate. 

Treatment. — Bring  about  reaction  as  previously  directed  (see  page  262). 

An  incised  wound  of  the  chest,  if  large,  shoifld  be  carefiilly  inspected. 
If  the  wound  is  small,  cut  down  layer  by  layer  untfl  the  depths  of  the  wound 
are  reached.  Disinfect  the  wound  and  arrest  hemorrhage.  If  the  pleura  is 
not  open,  proceed  according  to  general  rules.  If  the  pleura  is  found  to  have 
been  opened,  suture  it  with  catgut,  close  the  superficial  wound,  dress  with 
gauze,  and  immobilize  the  chest  wall. 

The  above  proceeding  should  be  carried  out  whether  it  is  or  is  not  beUeved 
that  the  lung  has  been  damaged,  provided  there  is  no  pneumothorax  and  no 
violent  hemorrhage.  What  course  shall  be  pursued  if  the  lung  has  been 
injured  by  a  stab?  If  hemorrhage  does  not  threaten  life  and  there  is  no  pneu- 
mothorax, the  patient  is  kept  at  rest  and  observed.  If  pneimiothorax  occurs, 
the  pleural  sac  must  be  drained  by  means  of  a  tube,  because  clots  must  be 
evacuated  and  infection  should  be  anticipated.  If  hemorrhage  into  the  pleural 
sac  persists,  active  measures  become  necessary.  The  use  of  ice-bags  and  drugs 
is  but  waste  of  time.  Some  surgeons  beheve  that  the  mere  closure  of  the 
external  wound  leads  to  arrest  of  hemorrhage,  blood  accumulating  and  making 
pressiu-e.  It  is  true  that  hemorrhage  often  ceases  after  suturing  or  plugging  a 
wound  and  strapping  the  chest,  but  it  is  not  probable  that  it  ceases  because  of 
these  measures.  Blood  in  the  pleura  usually  remains  unclotted  for  several  or 
many  days.  Further,  as  Le  Conte^  shows,  as  the  blood  is  forced  against  the 
root  of  the  lung  the  right  heart  is  engorged,  the  blood-pressure  is  raised,  and 
the  bleeding  continues. 

Bleeding  from  the  lung  can  often  be  arrested  by  inserting  the  end  of  a  drain- 
1  "Annals  of  Surgery,"  April,  1899. 


Occluding  Pulmonaty  Embolism  899 

age-tube  into  the  pleural  sac.  In  cases  in  which  a  drainage-tube  is  inserted 
into  the  pleural  cavity  and  free  drainage  established  the  pleura  is  immediately 
filled  with  air,  and  the  muscles  of  respiration  are  kept  from  acting  on  the  lung. 
The  lung  contracts  by  its  own  elastic  tissue,  as  well  as  by  the  pressure  exerted 
by  the  pneumothorax,  and  at  the  same  time  the  presence  of  the  air  favors 
clotting  in  the  severed  vessels.^  Baudet  maintains  that  all  grave  wounds  of 
the  lung  should  be  operated  upon.  If  the  insertion  of  a  tube  fails,  or  if  the 
bleeding  is  rapid  and  obviously  seriously  threatens  life,  several  ribs  must  be 
rapidly  resected  and  the  bleeding  part  explored.  In  some  cases  the  bleeding 
may  be  arrested  by  ligation,  in  some  cases  by  packing  a  small  wound  with  gauze, 
in  some  cases  by  the  suture-ligature.  Two  cases  of  lung  suture  have  been  re- 
corded by  Philadelphia  colleagues  (Jopson,  in  "Annals  of  Surgery,"  1906,  vol. 
xliii;  Kelly,  in  "Annals  of  Surgery,"  1910,  vol.  li).  In  a  violent  secondar\^ 
hemorrhage  foUomng  a  gunshot-wound  of  the  lung  I  packed  the  entire  pleural 
cavity  wdth  sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the  bleeding 
by  carrying  iodoform  gauze  directly  against  the  oozing  surface."  The  man  re- 
covered. I  did  the  same  thing  on  a  Chinaman  suffering  from  a  gunshot-wound  of 
the  lung.  The  hemorrhage  was  arrested  and  he  lived  three  weeks,  dying  finally 
from  pericarditis.  After  directly  arresting  hemorrhage  from  the  lung,  turn  clots 
out  of  the  pleural  sac  and  insert  a  drainage-tube.  In  a  perforating  wound 
inflicted  by  a  bullet,  reaction  must  be  brought  about,  the  wound  dressed  anti- 
septically,  the  chest  strapped,  and  the  patient  kept  quiet.  If  pneumothorax 
occurs,  the  pleura  should  be  drained  with  a  tube.  If  hemorrhage  occurs,  it 
should  be  met  as  directed  above.  In  a  wound  in  which  the  bullet  has  lodged, 
an  examination  should  be  made  to  see  if  the  bullet  is  under  the  skin,  and  if  it 
is,  it  is  removed  after  the  patient  has  reacted.  It  should  always  be  borne  in 
mind  that  a  pistol-buUet  may  be  deflected  by  a  rib  or  may  pass  from  the  front 
to  the  back  part  of  the  chest  by  making  a  biu*row  under  the  skin  (a  contour 
wound) .  If  a  bullet  is  lodged,  no  attempt  should  be  made  to  remove  it  unless 
an  operation  must  be  done  for  bleeding,  unless  the  bullet  causes  trouble,  or 
unless  it  is  felt  under  the  skin.  Under  no  circumstances  conduct  a  long  search 
for  a  bullet.  If  emphysema  of  the  chest  walls  is  moderate,  strapping  or 
a  bandage  \\dll  control  it;  if  it  is  great,  make  multiple  pimctures  and  then 
apply  pressure.  In  protrusion  of  a  portion  of  the  lung  try  to  restore  the  pro- 
trusion; but  if  restoration  is  impossible  or  if  gangrene  seems  Likely  to  occur, 
ligate  the  base  of  the  protrusion  \vdth  silk  and  cut  away  the  mass. 

MoUer  ("Archiv.  f.  khn,  Chirurgie,"  1909-10,  vol.  Ivi)  collected  26  cases  of 
gimshot- wounds,  which  were  operated  upon,  and  1 1  died  (42  per  cent.) .  In  20 
suturing  was  done,  with  7  deaths.  In  2  the  wound  was  sutured  to  the  pleural 
opening,  \\dth  i  death.  In  2  lung  resection  was  followed  by  death.  One,  in 
which  pleural  packing  was  used,  recovered.  He  collected  10  stab-wounds:  7 
were  sutured,  with  i  death.     In  3  the  pleura  was  packed  and  all  recovered. 

"Wounds  of  the  Chest  Involving  the  Diaphragm. — In  such  a  case  abdominal 
viscera  may  pass  through  the  wound  in  the  diaphragm  and  appear  in  the  woimd 
of  the  chest.  If  there  is  no  indication  of  a  wound  of  the  abdominal  \dscera 
some  surgeons  would  suture  the  wound  of  the  diaphragm  by  way  of  the  thorax. 
If  there  are  indications  of  injury  of  abdominal  viscera  the  abdomen  must  be 
opened.  Personally,  I  prefer  to  open  the  abdomen  in  everv^  chest  woimd  im- 
phcating  the  diaphragm,  even  when  symptoms  of  injury  to  abdominal  \ascera 
are  not  as  yet  manifest. 

Occluding  Pulmonary  Embolism. — By  this  term  we  mean  an  embolism 
which  completely  blocks  the  pulmonary  artery  or  some  of  its  chief  branches. 
Such  cases  occasionally  foUow  a  surgical  operation.    They  are  more  frequent 

iLe  Conte,  in  "Annals  of  Surgery,"  April,  1899. 
-  The  author,  in  ".\nnals  of  Surgery,"  Jan.,  1898. 


900  Surgery  of  the  Respiratory  Organs 

than  used  to  be  thought.  The  clot  is  derived  from  a  vein.  The  calamity  is 
most  apt  to  occur  between  the  second  and  fourth  weeks  after  an  operation 
(Bartlett  and  Thompson,  in  ''Annals  of  Surgery,"  May,  1908).  Pulmonary 
embolism  may  arise  from  fractures,  inflamed  hemorrhoids,  or  inflamed  veins 
anywhere,  and  during  or  after  pneumonia,  erysipelas,  typhoid  fever,  and  any 
acute  infection.  In  malignant  endocarditis  and  mitral  stenosis  small  emboli 
are  common.  If  the  pulmonary  artery  is  completely  blocked  death  occurs  at 
once.  If  one  branch  only  is  blocked  the  patient  may  recover  if  the  heart  is 
sound  and  strong.  If  the  artery  proper  is  partly  blocked  the  patient  has  a 
period  of  suffering  and  dyspnea  before  death,  but  death  is  sure  to  occur  from 
subsequent  complete  blocking. 

Bartlett  and  Thompson  (Ibid.)  report  22  cases  of  occlusive  pulmonary 
embolism,  20  of  which  were  fatal.  The  greatest  cause  in  a  surgical  operation 
seems  to  be  varicose  veins,  especially  about  an  abdominal  or  pelvic  tumor. 
I  am  convinced  that  most  sudden  deaths  in  infected  cases  are  due  to  pulmonary 
embolism. 

The  symptoms  of  a  mild  case  of  embolism  are  rapid  pulse,  dyspnea,  after 
some  hours  dulness  of  the  base  and  impaired  breath  sounds,  and,  perhaps  later, 
spitting  of  blood.  In  a  real  occluding  embolism  there  are  sudden  collapse, 
cyanosis  or  pallor  with  livid  lips,  the  pulse  at  the  wrist  is  absent  or  very  rapid, 
and  irregular.  There  are  pain  in  the  chest,  intense  dyspnea,  dilated  pupils, 
and  early  unconsciousness.  The  right  side  of  the  heart  distends  greatly  and 
the  second  sound  is  accentuated  in  the  pulmonary  area. 

Schumacher  in  discussing  these  cases  says  there  are  three  classes  of  them: 
Those  in  which  almost  immediate  death  occurs;  those  in  which  death  occurs  in  a 
few  minutes,  and  those  which  last  much  longer.  In  the  latter  cases  a  main  branch 
becomes  blocked  and  total  obstruction  is  gradual  (Willy  Meyer,  in  "Annals  of 
Surgery,"  August,  1913).  Only  the  latter  cases  are  suitable  for  operation. 
The  surgeon  must  bear  in  mind  the  danger  of  embolism  and  endeavor  to 
prevent  it  in  operations  by  handling  and  exposing  viscera  as  little  as  possible, 
by  applying  ligatures  above  all  clots  in  veins  and  all  varicosities,  and  removing 
the  affected  structures.  Quenu  proposed  to  lessen  the  danger  of  postoperative 
thrombosis  by  administering  citric  acid  before  operation.  This  agent  lessens 
the  coagulability  of  the  blood.  Tuffier  fears  this  remedy,  believing  that  it 
makes  an  existing  thrombus  more  apt  to  break  up  and  form  emboli  ('Tresse 
Medicale,"  April  20,  1910). 

Treatment. — In  small,  non-occluding  emboli,  in  which  condition  the  only 
symptoms  are  dyspnea,  pain,  rapidity  of  pulse,  and,  after  some  hours,  dulness 
at  the  base  and  impaired  breath  sounds,  give  stimulants,  dry  cup  the  chest,  and 
administer  morphin  if  there  is  no  cyanosis.  In  a  very  severe  case  death  is 
rapid  and  there  is  nothing  to  do  medically. 

Trendelenburg,  of  Leipzig,  suggests  surgical  treatment  (German  Congress 
of  Surgery,  1908).  He  points  out  that  death  is  not  always  sudden  (in  7  cases 
out  of  9  the  victim  lived  from  ten  minutes  to  one  hour),  and  advises  opening  of 
the  pulmonary  artery  and  removal  of  the  embolus.  The  first  patient  operated 
on  died  before  the  completion  of  the  operation.  "Since  then  it  was  done, 
twelve  times  in  all,  at  the  Leipzig  clinic,  without  one  permanent  recovery" 
(Willy  Meyer  in  "Annals  of  Surgery,"  August,  1913).  One  patient  lived  four 
days;  i  died  on  the  table;  i  died  in  fifteen  hours  from  cardiac  failure;  i 
lived  for  thirty-seven  hours  and  died  of  reactionary  bleeding  from  the  internal 
mammary  artery.  Kruger  did  one  operation  for  embolism.  The  early  result 
was  apparently  successful,  but  the  patient  died  of  infection  on  the  eighteenth  day 
("Zentral.  fur  Chir.,"  May  22, 1909).  In  Sauerbruch's  clinic  at  Zurich  the  opera- 
tion has  been  performed  four  times  without  a  recovery  (Willy  Meyer,  Loc.  cit.). 

Trendelenburg  thinks  that  the  surgeon  has  about  fifteen  minutes  in  which  to 


Gangrene  of  the  Lung  goi 

work.  The  operation  is  done  under  differential  pressure.  The  pleura  is 
opened,  then  the  pericardium.  A  rubber  tube  is  passed  through  the  transverse 
sinus  of  the  pericardium  and  the  aorta  and  pulmonary  artery  are  constricted. 
This  constriction  must  be  released  within  forty-live  seconds.  The  artery  is 
opened,  the  clot  removed,  the  arterial  wound  clamped,  and  the  elastic  constric- 
tion released.     The  arterial  wound  is  then  sutured. 

Abscess  of  the  lung  may  foUow  ordinary  pneumonia.  It  is  more  apt  to 
follow  aspiration-pneumonia.  It  is  usually  caused  by  streptococci  or  staphy- 
lococci, but  it  may  result  from  pneumococci  or  colon  bacilli.  These  germs 
may  reach  the  pulmonary  tissue  by  direct  entrance  from  adjacent  organs, 
by  way  of  the  blood,  or  by  way  of  the  bronchi  and  alveoli.  Osler^  tells  us 
that  pulmonary  abscess  may  result  from  the  aspiration  of  septic  particles 
after  "wounds  of  the  neck,  operations  upon  the  throat,"  and  suppurative 
lesions  of  the  nose,  larjmx,  or  ear.  Aspiration-pneumonia  may  develop  when 
there  is  difficulty  in  swallowing  from  any  cause,  when  there  is  profound  ex- 
haustion, and  when  there  is  palsy  or  incoordination  of  any  of  the  muscles 
of  deglutition.  Cancer  of  the  esophagus  may  be  a  cause;  so  may  perforation 
of  the  lung  by  an  abscess,  wound  of  the  lung,  impaction  of  a  foreign  body  in 
the  lung,  suppuration  about  a  focus  of  tuberculosis  or  a  metastatic  abscess.  A 
pulmonary  abscess  may  be  of  trivial  size  or  it  may  be  very  large,  involving  an 
entire  lobe.  There  may  be  one  abscess,  several,  or  many.  When  suppu- 
ration results  from  aspiration-pneumonia  or  blood-infection,  there  are  usually 
multiple  abscesses. 

Symptoms. — The  expectoration  is  not  frequent,  but  is  profuse,  and  dur- 
ing a  paroxysm  mouthfuls  are  coughed  up  in  rapid  succession.  The  expecto- 
rated matter  is  sour  or  very  offensive  in  odor  and  contains  fragments  or  shreds 
of  pulmonar}"  tissue,  which  can  be  identified  as  such  by  the  microscope.  The 
patient  lies  upon  the  diseased  side  in  order  to  keep  the  pus  from  running  into 
the  bronchi  and  causing  cough.  When  the  cavity  fills  and  pus  reaches  the 
bronchi,  violent  cough  and  expectoration  begin,  continue  until  the  cavity 
is  partly  or  entirely  emptied,  and  then  subside,  perhaps  for  several  hours. 
If  the  abscess-cavity  is  large  and  full  of  pus,  an  area  of  dulness  on  percussion 
can  be  mapped  out.  When  the  pus  is  coughed  out  and  the  air  enters,  physical 
signs  of  a  cavity  are  clear.  The  .T-rays  often  show  the  situation  of  such  a 
ca\dty. 

The  course  of  abscess  of  the  lung  is  usually  acute.  There  are  fever  of 
the  hectic  type,  rapid  loss  of  weight,  weakness  and  rapidity  of  circulation, 
dyspnea,  pallor,  sleeplessness,  and  great  weakness.  Gangrene  may  arise; 
empyema  or  pyopneumothorax  may  develop;  very  rarely  the  abscess  breaks 
through  the  chest  wall;  recovery  may  follow  spontaneous  evacuation  or 
drainage  by  coughing  up  pus;  death  may  result  from  exhaustion  or  second- 
ary septic  lesions.  If  operation  is  performed,  from  70  to  80  per  cent,  of 
the  patients  will  recover. 

The  treatment  is  purely  surgical  (pneumotomy).  Make  an  incision  over 
the  cavity.  Resect  a  portion  of  one  or  more  ribs.  Expose  the  pleura.  If 
the  two  layers  of  the  pleura  are  not  adherent,  suture  them  together  and  either 
wait  two  days,  or  surround  the  area  to  be  incised  by  a  coffer-dam  of  gauze 
and  then  operate.  If  they  are  adherent,  always  proceed  at  once.  Search  for 
the  abscess  with  an  aspirating  needle.  When  the  cavity  is  found,  open  into 
it  with  the  actual  cautery  and  insert  a  drainage-tube  (see  page  912).  The 
direct  mortality  is  about  20  per  cent. 

Gangrene  of  the  Lung. — This  term  means  the  putrefaction  of  ade\-ital- 
ized  portion  of  pulmonary  tissue.  The  tissue  is  devitalized  by  the  action  of 
pyogenic  micro-organisms.     Gangrene  may  follow  abscess,  bronchitis,  or  pneu- 

^  "Practice  of  Medicine." 


902  Surgery  of  the  Respiratory  Organs 

monia,  or  may  be  due  to  diabetes,  to  embolism  of  a  branch  of  the  pulmonary 
artery,  bronchiectasis,  tuberciilosis,  malignant  disease,  wounds,  or  the  lodgment 
of  foreign  bodies.  Gangrene  may  be  circumscribed  or  diffused.  There  may  be 
one  cavity,  small  or  large,  or  multiple  cavities  may  form.  The  gangrenous  area 
putrefies,  softens,  and  the  softened  matter  may  be  expectorated,  a  gangrenous 
cavity  being  formed.  In  the  rare  cases  which  undergo  spontaneous  cure  the 
cavity  is,  after  a  time,  surrounded  by  fibrous  tissue  and  obliterated  by  granu- 
lations.    The  mortality  from  operation  is  about  30  per  cent. 

Symptoms. — Expectoration  occurs  only  now  and  then,  but  at  each  seizure 
a  great  quantity  of  matter  is  brought  up  and  this  matter  is  horribly  offen- 
sive. Occasionally  there  is  no  expectoration.  The  patient,  as  in  lung  ab- 
scess, lies  upon  the  diseased  side.  The  expectorated  matter  is  mucopurulent, 
contains  particles  or  shreds  of  pulmonary  tissue,  bacteria,  and  altered  blood. 
The  fetor  of  the  pus  is  much  greater  than  is  the  fetor  of  the  pus  of  an  abscess. 
The  breath  is  very  io\A.  Physical  signs  may  indicate  either  consolidation  or  a 
cavity.  There  are  hectic  fever,  great  exhaustion,  deathly  pallor,  and  diarrhea. 
Pulmonary  hemorrhage  is  not  unusual,  and  complications  spoken  of  in  the 
article  upon  Abscess  may  occur  (see  page  901).  Recovery  sometimes  ensues, 
the  cavity  closing  by  granulation.  Death  may  take  place  in  a  few  days.  Often 
the  patient  lives  for  weeks,  being  sometimes  better  and  sometimes  worse,  dying 
finally  from  exhaustion  or  from  the  effects  of  a  complication. 

The  treatment  is  to  operate  as  for  pulmonary  abscess. 

Surgical  Treatment  of  Pulmonary  Tuberculosis. — For  a  number 
of  years  past  surgical  thought  has  been  actively  directed  toward  placing 
on  a  scientific  footing  operations  for  pulmonary  phthisis.  The  matter  is 
still  in  a  transition  stage,  and  operations  at  present  have  a  very  Umited 
field  of  appHcation,  although  Sonnenberg  and  others  have  reported  cures. 
Baglivi,  in  1643,  endeavored  to  tap  and  inject  tuberculous  cavities.  Hast- 
ings and  Stucke  did  the  same  thing  in  the  eighteenth  century.  Hosier, 
a  number  of  years  ago,  attempted  to  treat  cavities  by  introducing  a  trocar 
into  the  cavity  and  injecting  permanganate  of  potassium  solution  through 
the  cannula.  Patients  were  not  benefited  by  this  procedure.  The  plan 
was  revived  by  Pepper  in  1874.  The  results  are  bad  and  the  operation  is 
dangerous.  Hillier  tried  injection  of  corrosive  sublimate  into  the  lung  paren- 
chyma, but  the  effect  of  the  injections  was  disastrous.  Vidal  advocates  coun- 
terirritation  by  the  actual  cautery  and  maintains  that  congestion  improves 
nutrition.  When  the  strength  of  the  patient  is  well  preserved  and  the  pulmon- 
ary lesion  is  circumscribed  and  slowly  progressive,  it  may,  in  some  few  cases, 
be  justifiable  to  perform  an  operation,  open  the  cavity,  and  treat  it  directly 
ipneumotomy).  That  pneumotomy  might  be  performed  successfully  was  sug- 
gested to  surgeons  by  observing  that  some  patients  recovered  after  sword- 
thrusts  into  the  lung.  Fowler  said  it  is  not  justifiable  to  operate  if  the  dis- 
ease has  come  "to  a  standstill."  The  same  surgeon  stated  that  the  only  acces- 
sible region  is  bounded  above  by  the  clavicle,  to  the  inner  side  by  the  manu- 
briimi,  to  the  outer  side  by  the  lesser  pectoral  muscle,  and  below  by  the  second 
rib.^  This  operation  does  not  cure  any  one,  but  it  may  cause  distinct  improve- 
ment when  there  is  hectic  from  an  ill-drained  cavity  containing  the  products 
of  a  mixed  infection.  In  an  advanced  case  there  is  usually  more  than  one 
cavity,  and  if  there  is,  the  operation  is  contra-indicated.  Before  attempting 
it,  be  sure  the  case  is  advanced  and  not  incipient  and  that  the  cavity  is 
single.  Locate  the  cavity  by  auscultation,  percussion,  and  the  x-rays.  (See 
Willard,  "Jour.  Amer.  Med.  Assoc,"  Sept.  20,  1902.)  Tuffiier  collected  45 
cases  and  only  i  was  a  success. 

1  See  the  very  fiill  and  thoughtful  article  by  George  Ryerson  Fowler  on  "The  Surgery 
of  Intrathoracic  Tuberculosis,"  "Annals  of  Surgery,"  Nov.,  1896. 


Plastic  Operations  on  the  Chest  Wall  903 

Mauclaise"^  says  that  pneumotomy  is  justifiable  only  in  circumscribed 
tuberculous  ca^'ities  without  peripheral  infiltration  and  in  pulmonary  ab- 
scesses. Bronchiectatic  cavities  are  usually  multiple;  they  are  exceedingly 
difficult  to  locate,  and  treatment  by  pneumotomy  should  not  be  attempted. 
In  the  teatment  of  pulmonary  tuberculosis  resection  of  the  diseased  area  was 
proposed  by  Ruggi  (pneumedomy) .  Tuffier  successfully  performed  this 
operation.  Surgeons,  as  a  rule,  do  not  believe  in  pneumectomy.  Reclus- 
voices  the  general  opinion  when  he  says  the  operation  is  not  required  if  the 
area  of  disease  is  very  limited,  as  such  a  condition  is  frequently  curable  by 
medicinal  means,  and  it  does  no  good  if  the  area  of  disease  is  extensive. 

Only  two  methods  of  surgical  treatment  seem  to  have  won  a  distinct  place: 
one  is  the  artificial  production  of  pneumothorax;  the  other,  some  form  of 
plastic  operation  upon  the  thorax  to  collapse  and  immobilize  the  lung. 

Artificial  Pneumothorax. — It  has  long  been  known  that  pneumothorax 
might  benefit  a  tuberculous  limg.  Carson,  of  Edinburgh,  in  1843  tried  to  create 
artificial  pneumothorax  by  making  a  puncture  in  the  visceral  pleura  to  allow 
the  passage  of  air  into  the  pleural  sac.  Farlanini  suggested  the  introduction 
of  a  gas  into  the  pleural  sac  and  reported  a  successful  case  in  1894.  In  1898 
Murphy  began  the  use  of  nitrogen.  There  are  now  on  record  about  400  cases 
(Mar}'  E.  Lapham,  in  "Am.  Jour.  Med.  Sciences,"  April,  1912).  The  method 
should  only  be  used  in  unilateral  cases  which  are  not  far  advanced.  It  is  used 
when  the  patient  continues  to  grow  worse  in  spite  of  medical  treatment.  The 
method  is  useless  if  there  are  adhesions ,  and  is  contra-indicated  if  diabetes  exists 
or  if  there  is  uncompensated  valvular  disease  of  the  heart  (Lapham,  Ibid.). 
Adhesions  forbid  because  they  prevent  piilmonary  collapse.  It  is  maintained 
that  the  operation  occludes  the  lymph-channels,  lessens  the  absorption  of 
toxins  (shown  by  the  abatement  of  fever),  prevents  bleeding,  compresses  the 
lung,  arrests  its  mobility,  approximates  the  walls  of  cavities,  squeezes  masses 
of  bacteria  out  of  the  tubes,  favors  the  development  of  fibrous  tissue,  and  leads 
to  healing  of  cavities. 

Certainly  it  seems  that  the  once  widely  condemned  therapeutic  pneumotho- 
rax is  of  real  value  in  proper  cases.  Nitrogen  is  the  best  gas  to  use.  It  is  non- 
irritant  and  remains  long  in  the  pleural  cavity.  Our  aim  is  to  keep  the  limg  com- 
pressed for  one  year.  The  nitrogen  is  introduced  by  means  of  a  special  appa- 
ratus (Lapham,  Ibid.).  At  first  injections  are  made  daily,  then  every  other 
day,  then  twice  a  week,  then  twice  a  month.  The  injection  is  made  "over  an 
area  where  the  breath  sounds  and  resonance  are  best"  (Lapham,  Ibid.).  There 
is  Httle  danger  in  the  method,  but  trouble  may  follow.  There  may  be  shock, 
dyspnea,  or  spasm  of  the  glottis  from  pleural  reflex.  Other  dangers  are:  gas 
emboHsm,  con\nilsions,  edema  of  the  lung,  empyema,  pulmonary  abscess  (if 
the  lung  is  stuck),  cerebral  embolism,  and  emphysema  of  the  chest  wall.  A 
danger  is  an  unfavorable  influence  on  the  other  lung.  (See  Lapham,  Ibid. ; 
Mauclaire,  "Abstract  in  Brit.  Med.  Jour.,"  from  "Jour,  des  prat.,"  xxvi,  191 1; 
Editorial  in  "N.  Y.  Med.  Jour.,"  Oct.  26,  191 2;  Sorge,  in  "Wien.  klin.  Woch.," 
No.  xxxiv,  1912.)     (See  page  907.) 

Plastic  Operations  on  the  Chest  Wall  (MobiUzation  of  the  Thorax). — 
Freund  and  others  asserted  that  a  rigid  thorax  is  a  cause  of  phthisis.  AUis^ 
suggested  that  in  extensive  umlateral  tuberculosis  of  the  lung  resection  of  a 
mmiber  of  ribs  wiU  favor  cure  by  permitting  retraction  of  the  chest  w^all. 
This  operation  is  founded  on  the  belief  that  the  chief  element  in  effecting  a 
cure  is  the  formation  and  contraction  of  fibrous  tissue.  Pulmonar}^  collapse 
and  abolition  of  movements  favor  the  formation  of  fibrous  tissue.     In  this 

1  "La  Tribiine  medicale,"  Sept.  21,  1893. 
-  "Revue  de  Chirurgie,"  Nov.  11,  1895. 
^  To  State  Med.  Soc.  of  Penna.,  in  189 1. 


904 


Surgery  of  the  Respiratory  Organs 


operation  the  pleura  is  not  opened.  Quincke,  Landerer,  and  others  remove 
portions  of  ribs  with  periosteum  along  the  axillary  Hne.  Some  surgeons 
remove  portions  of  ribs  and  periosteum  from  directly  over  the  lesion.  In 
tuberculosis  of  the  apex  in  a  person  -with  a  narrow  and  rigid  chest  the  followers 
of  Freund  remove  the  first  rib.  Freeman  removes  portions  of  ribs  without 
periosteum  and  applies  a  truss  to  push  in  the  chest  wall  ("Annals  of  Surgery," 
July,  1909).  Friedrich,  of  Marbiu-g,  removes  all  the  ribs  from  the  second  to 
the  tenth  inclusive  and  mobilizes  the  first  rib  {thoracico plastic  pleuro pneumolysis 
with  subcostal  apicolysis).  The  pleura  is  not  opened.  He  used  to  remove 
the  periosteum,  but  does  so  no  longer.  He  now  leaves  the  periosteum  so  that 
after  a  time  enough  bone  will  re-form  to  prevent  lung  bulging  on  coughing. 
Sauerbruch,  Wilms,  and  others  have  individual  operations.  The  results  of 
none  of  the  above  operations  seem  very  encouraging  (Mauclaire,  "Abs.  in  Brit. 
Med.  Jour.,"  from  "Jour,  des  prat.,"  xxvi,  191 1;  Editorial  in  "N.  Y.  Med. 
Jour.,"  Oct.  26,  1912;  Sorge,  in  "Wien.  klin.  Woch.,"  No.  xxxiv,  1912). 

Operations  On  Pleura  and  Lungs 

Intrathoracic  Operations  Under  Positive  or  Negative  Air=pres= 
sure. — (This  subject  has  been  fully  and  judicially  discussed  by  Jopson  in 
"Annals  of  Surgery,"  May,  191 1.)     When  under  ordinary  conditions  the  chest 


Fig.  568. — Sauerbnich's  cabinet:  Position  of  patient  in  chamber  ready  for  operation  under  negative 

pressure. 

wall  is  widely  opened  the  lung  often  rapidly  collapses  and  the  patient  is  placed 
in  deadly  peril  (see  Acute  Traumatic  Pneumothorax  on  page  895).  The 
reality  of  the  danger  has  to  a  great  extent  retarded  progress  in  the  surgery  of  the 
heart,  lungs,  and  lower  portion  of  the  esophagus.  Of  late,  however,  methods 
have  been  devised  for  maintaining  normal  respiratory  movements  and  prevent- 
ing pulmonary  collapse  during  operations  which  open  the  pleiu"a.  There  are 
two  forms  of  pressure  apparatus  and  each  form  finds  warm  advocates.  Nega- 
tive pressure  is  the  form  that  is  advocated  by  Sauerbruch.  In  Sauerbruch's 
negative  pressure  chamber  the  lung  is  kept  from  collapse  by  suction  exerted 
upon  its  exposed  surface.  Positive  pressure  is  advocated  by  Brauer.  Positive 
pressure  keeps  the  lung  from  collapsing  by  distending  it  from  within.  The 
two  methods  act  similarly  in  many  respects.     Clinical  observations  and  numer- 


Intratracheal  Insufflation 


905 


ous  experiments  seem  to  prove  that  '^emphysema,  persistent  pneumothorax, 

difficulty  of  narcosis,  and  infection  of  the  pleura  are  not  dangers  associated 
v\"ith  the  use  of  positive  pressure  as  such"  (Samuel  Robinson  and  George  Adams 
Leland,  in  ''Surg.,  Gynecol.,  and  Obstet.,"  March,  1909). 

The  Sauerbruch  Chamber  (Fig.  568). — This  is  an  air-tight  cabinet.  The 
sides  are  of  boards  covered  with  tin,  the  corners  being  soldered.  The  roof  is 
of  glass.     The  sides  contain  air-tight  windows.     There  is  one  air-tight  door. 

The  room  is  lighted  by  electricity  and  contains  a  telephone.  The  larger 
chambers  have  a  communicating  room.  Instruments  which  are  wanted  can 
be  placed  in  this  room  so  that  the  surgeon  may  reach  them.  The  patient's 
head  projects  outside  of  the  cabinet  and  a  tightly  fitting  rubber  collar  is  placed 
around  the  neck.  The  body  and  legs  are  surroimded  by  a  canvas-covered  rub- 
ber sac  the  interior  of  which  is  in  commimication  with  the  external  air. 

The  chamber  is  sufficiently  large  to  hold  the  patient,  the  surgeon,  and  the 
assistant.  By  means  of  an  electric  suction  air  pump,  the  valve  of  which  is  in  the 
wall,  negative  pressm"e  is  obtained  and  is  continuously  maintained  in  the 
cabinet.  The  patient's  thorax  is  exposed  to  the  suction  of  negative  pressure, 
but  the  bronchioles  are  subjected  to  ordinan,-  atmospheric  pressure,  hence, 
even  when  a  wide  opening  is  made  in  the  chest  wall,  the  limg  does  not  collapse. 
The  operator  does  not  sufi'er  from  the  negative  pressure. 

The  Positive  Pressiire  Apparatus. — Xumerous  apparatuses  have  been  de- 
xdsed.  Positive  pressure  used  to  be  obtained  by  the  Fell-0'Dw\'er  apparatus 
(see  Fig.  567).  The  lar^-nx  was  intubated  and  bellows  were  used.  It  can  be 
obtained  \\-ith  this,  but  the  apparatus  is  uncertain  and  difficult  to  use. 


Fig.  569. — Scheme  of  apparatiis  for  the  maintenance  of  distention  of  the  lung  by  positive  pressure 

(Robinson  and  Leland). 

Brauer  advocated  the  following  plan:  WTien  the  patient  has  been  anes- 
thetized and  the  surgeon  is  ready  to  open  the  pleura,  a  glass  case  is  placed  over 
the  patient's  face  and  the  air  in  the  case  is  condensed  by  means  of  an  apparatus. 

Bauer  subsequently  modified  the  head  chamber  so  that  the  hands  and 
WTists  of  the  anesthetist  are  admitted  within  it.  Some  surgeons  have  given 
compressed  air  by  the  nose,  the  mouth  being  sealed.  Some  give  it  by  intuba- 
tion from  the  mouth.  The  trouble  with  this  method  in  man  is  that  no  com- 
pletely satisfactory  tube  has  yet  been  made.  As  a  general  thing  the  best 
way  to  give  it  is  by  a  well-fitting  face  mask.  A  small  motor  rims  a  rotary 
air  pump  and  thus  we  dispense  -nith  the  trouble  and  imcertainty  of  clumsy 
reser\-oirs.  Robinson  and  Leland  (Ibid.)  state  that  any  positive  pressiu-e  ap- 
paratus consists  of  four  elements:  (i)  A  supply  of  compressed  air;  (2)  an 
anesthetizing  segment ;  (3)  a  de^"ice  for  introducing  air  and  ether  into  the  res- 
piratory- tract;  (4)  a  means  of  var^-ing  the  resistance  of  exhaled  air  (Fig.  569). 

Intratracheal  Insufflation  (Method  of  Meltzer  and  Auer). — This  method  is 
highly  valuable.  It  can  be  used  to  maintain  respiration  and,  at  the  same 
time,  to  give  ether.  The  patient  is  first  anesthetized  by  the  ordinary-  method. 
A  flexible  and  elastic  tube  is  then  carried  through  the  lar\Tix  well  into  the 
trachea.  In  order  to  get  it  into  the  lar\-nx  use  a  tube  director  (Cotton  and 
Boothby),  or  use  ChevaHer  Jackson's  direct  lar}-ngoscope,  as  do  Elsberg  and 


9o6 


Surgery  of  the  Respiratory  Organs 


Peck.  The  tube  usually  enters  the  right  bronchus  before  it  blocks.  When  it 
blocks  it  should  be  drawn  back  5  or  6  cm.  (Meltzer,  in  "Keen's  Surgery,"  vol. 
vi).  The  tube  is  an  English  catheter  or,  as  Elsberg  prefers,  a  woven  silk 
catheter.  The  eye  should  be  at  the  end.  It  is  always  decidedly  less  in  di- 
ameter than  the  trachea.  Meltzer  says  the  largest  size  used  should  not  exceed 
8  mm.  in  diameter.  The  tube  is  attached  to  the  insufHation  apparatus.  This 
forces  the  air,  the  air  and  ether,  or  the  oxygen  and  ether  into  the  lungs,  and 
the  vapor  returns  between  the  tube  and  the  tracheal  wall. 

Elsberg's  apparatus  is  shown  in  Fig.  570.  An  electric  current  is  turned  on 
at  the  switch  A.  It  is  carried  by  wire  to  the  motor  C.  This  motor  drives 
blower  D.  The  air  passes  through  a  tube  E,  an  oil  filter  F,  and  a  tube  G, 
into  a  bottle  H,  containing  hot  water.    The  air  is  then  forced  through  the  tube 

I  to  a  rubber  tube  connected  to  the  tracheal 
catheter.  The  tube  I  is  also  connected  to 
the  ether  jar  J.  The  tube  P  is  joined  to  a 
foot  bellows.  This  is  a  "safety  device," 
for  use  if  the  motor  or  blower  fails  or  if 
electricity  is  not  available. 

Exploratory  Puncture  of  the  Pleural 
Sac.  —  Puncture  often  gives  valuable  in- 
formation as  to  the  existence  of  iiuid  in  the 
pleural  sac  and  as  to  the  nature  of  the 
fluid.  The  operation  must  be  performed 
with  aseptic  care,  otherwise  a  serous  effu- 
sion might  be  converted  into  a  purulent 
effusion,  and  either  a  serous  or  a  piu^ulent 
/  •' '  1     *"    ^(^   ^Y"    1        effusion  might  be  rendered  putrid.     A  large 

/  J(q     aLq  1        hypodermatic    syringe    with    a    long    and 

/  H  r-/ibi_j  1       \       strong  needle  is  used  for  exploratory  punc- 

ture. A  slender  needle  breaks  easily  and 
is  unsafe.  In  order  to  prevent  breaking 
the  needle  impress  upon  the  patient  the 
absolute  necessity  of  keeping  quiet  and 
avoiding  any  violent  respiratory  or  general 
movement  during  the  operation.  It  is  not 
desirable  to  stick  the  lung,  although  harm 
rarely  results  from  such  an  accident.  If  no 
...  .        fluid  is  found  in  the  pleura  on  one  trial, 

f  u  (       several   other   punctures   should  be  made. 

/  '      M  \       What  is  known  as  a  dry  tap  may  be  due 

to  the  entire  absence  of  fluid,  to  encapsula- 
tion of  fluid  in  a  region  not  invaded  by  the 
needle,  to  the  lodgment  of  the  point  of  the 
needle  in  thickened  pleura  or  in  an  adhesion,  or  to  blocking  of  the  lumen 
of  the  needle  with  coagula.  Fowler^  points  out  that  if  a  person  has  been 
recumbent  for  a  long  time  the  upper  layer  of  fluid  may  be  clear,  while  the 
lower  layer  is  purulent.  The  fluid  should  be  coUected  in  a  sterfle  glass  tube 
and  subjected  to  a  careful  bacteriological  study. 

Paracentesis  Thoracis. — The  operation  of  tapping  with  a  trocar  and  al- 
lowing the  fluid  to  flow  out  through  the  cannula  is  no  longer  practised  except 
in  an  emergency,  when  an  aspirator  cannot  be  obtained,  or  in  an  early  stage 
of  non-traumatic  pneumothorax.  An  aspirator  is  a  much  better  instrimient. 
Aspiration  consists  in  the  introduction  into  the  pleural  sac  of  the  tip 
of  a  hollow  needle,  the  other  end  of  which  is  attached  by  means  of  a  rub- 
1  "Annals  of  Surgery,"  November,  1896. 


Fig-  570. — ^Diagram  of  Elsberg's  apparatus 
showing  essential  parts. 


The  Operation  for  Creating  Artificial  Pneumothorax  907 

ber  tube  to  a  bottle  from  which  the  air  has  been  exhausted.  The  fluid 
does  not  run  out,  but  is  sucked  out,  air  is  excluded,  and  bacteria  do  not 
enter  the  pleural  sac.  Fig.  434  shows  a  pneumatic  aspirator.  No  anes- 
thetic is  required.  The  patient's  skin,  the  instruments,  and  the  surgeon's 
hands  must  be  thoroughly  asepticized.  The  patient  is  given  a  little  whisky, 
and,  unless  he  is  very  weak,  he  assumes  a  semi-erect  attitude,  with  the  arm 
hanging  by  the  side.  The  trocar  is  introduced  in  the  fifth  interspace,  just 
in  front  of  the  angle  of  the  scapula.  The  surgeon  marks  the  upper  bor- 
der of  the  sLxth  rib  with  the  index-finger,  and  plunges  in  the  trocar  just  above 
the  finger,  thus  avoiding  the  intercostal  artery,  which  lies  along  the  lower 
border  of  the  rib  above.  He  guards  the  needle  with  the  index-finger  to  pre- 
vent its  going  in  too  far.  The  fluid  is  withdrawn  rather  slowly  in  order  that 
the  patient  may  escape  syncope  and  violent  cough.  If  the  patient  becomes 
very  faint  the  operation  should  be  abandoned.  All  the  fluid  present  should 
not  be  removed  at  one  sitting — complete  removal  of  a  large  effusion  is  not 
safe.  The  operation  can  be  repeated  if  necessary.  After  withdrawing  the 
cannula  place  iodoform  collodion  over  the  opening  in  the  chest.  In  an  early 
stage  of  non-traumatic  pneumothorax  perform  paracentesis  without  suction. 
In  non-purulent  pleuritic  effusion,  if  the  lungs  will  not  expand  after  tappings, 
perform  thoracotomy.  In  some  cases  aspiration  is  followed  by  pulmonary 
embolism  or  embolism  at  a  distance.  Syncope  is  a  not  unusual  result.  Con- 
vulsions occasionaUy  occur.  In  rare  cases  the  sudden  withdrawal  of  a  large 
effusion  is  followed  by  albuminous  expectoration,  as  was  pointed  out  by  Pinault 
in  1853.  It  usually  begins  from  a  few  minutes  to  half  an  hour  after  aspiration. 
When  this  complication  arises  the  pulse  is  very  weak,  there  are  severe  dyspnea, 
cyanosis,  cough,  and  the  expectoration  of  quantities  of  a  yellow,  frothy  fluid. 
Riesman  ("Amer.  Jour.  Med.  Sciences,"  Aprfl,  1902)  demonstrates  that  the 
condition  is  due  to  pulmonary  edema  and  not  to  puncture  of  the  lung.  The 
sudden  withdrawal  of  fluid  by  aspiration  relieves  the  pressure  which  was 
compressing  the  lung,  the  lung  becomes  congested  with  blood  (congestion  by 
recoil,  Riesman  caUs  it),  the  blood  distends  weakened  vessels,  and  profuse 
transudation  takes  place  into  the  air-ceUs.  Most  cases  recover  in  a  few  hours 
or  a  day  or  two.  Severe  cases  die  from  asphyxia.  Terrilon  collected  23  cases, 
with  2  deaths.  If  albtmiinous  expectoration  arises,  dry  cup  the  chest  and 
counterirritate  with  mustard  plasters.  Perform  venesection.  Give  oxygen  by 
inhalation.  Administer  atropin  hypodermatically.  Employ  artificial  respira- 
tion if  necessary. 

The  Operation  for  Creating  Artificial  Pneumothorax. — Murphy's 
apparatus  as  modified  by  Brauer  is  shown  in  Fig.  571.  The  manometer  is  on 
the  left-hand  side  of  the  figure.  The  jar  for  nitrogen  (A)  contains  a  solution  of 
corrosive  sublimate  through  which  the  gas  flows.  The  water  jar  (B)  is  lowered 
and  the  nitrogen  tube  is  opened,  and  as  the  stream  of  nitrogen  passes  along  the 
glass  tube  it  goes  through  a  filter  of  sterile  cotton.  The  tube  from  the  jar  of 
nitrogen  joins  a  three-way  stopcock  (C).  The  nitrogen  may  be  made  to  flow 
through  the  needle  (if),  or  deliver  the  intrapleural  pressure  to  a  water  man- 
ometer and  a  mercury  manometer.  After  determining  that  the  functional 
capacity  of  the  other  lung  is  sufficient  to  sustain  the  demands  about  to  be  put 
upon  it,  proceed  with  the  operation.  Follow  Brauer's  plan  because  it  is  the 
safest.  Select  a  spot  where  the  healthy  sounds  and  resonance  are  best  heard 
(INIary  E.  Lapham,  "Amer.  Jour.  Med.  Sciences,"  April,  191 2).  Expose  the 
pleura  by  an  incision.  If  adhesions  are  absent,  puncture  by  a  blunt  instrument 
and  explore  by  a  catheter  to  be  sure  there  is  a  pleural  cavity.  If  a  cavity 
exists  attach  the  needle  to  the  apparatus  and  inject  the  nitrogen.  After  in- 
jection suture  the  wound.  Subsequent  injections  are  made  by  the  needle  alone, 
no  incision  being  required. 


9o8 


Surgery  of  the  Respiratory  Organs 


Thoracotomy  is  an  incision  into  the  cavity  of  the  pleura.  It  may  be 
merely  an  intercostal  incision,  or  may  be  an  opening  into  the  chest  after 
resecting  a  portion  of  a  rib.  Often  in  a  child  with  empyema  good  drainage 
can  be  obtained  by  an  intercostal  incision,  but  in  most  children  and  in  all 
adults  a  rib  should  be  resected. 

If  there  is  very  little  dyspnea,  ether  may  be  given.  If  there  is  considerable 
dyspnea,  chloroform  should  be  given.     If  there  is  severe  dyspnea,  no  general 


u,- 


Fig.  571.— Brauer  and  Spengler's  modification  of  Murphy's  apparatus  for  nitrogen  injections. 


anesthetic  is  admissible.  In  severe  dyspnea  the  patient  is  using  certain 
voluntary  muscles  to  aid  him  in  obtaining  air.  A  general  anesthetic  abolishes 
the  activity  of  the  voluntary  muscles  of  respiration,  and  so  might  cause  suffo- 
cation. In  such  cases  the  operation  can  be  done  with  fair  satisfaction  after 
the  injection  of  eucain  or  after  infiltrating  the  superficial  tissues  of  the  chest 
wall  with  Schleich's  fluid,  or,  w^hat  is  better,  preliminary  aspiration  can  be 
performed.  Aspiration  will  permit  of  the  subsequent  administration  of  a 
general  anesthetic.  The  patient  on  whom  thoracotomy 
is  to  be  performed  is  placed  supine,  the  diseased  side  being 
at  or  over  the  edge  of  the  table.  He  must  never  be  placed 
on  the  sound  side,  because  he  breathes  only  with  that  side, 
and  pressure  on  it  may  be  dangerous. 

The  arm  of  the  diseased  side  should  be  elevated  to  a 
right  angle  with  the  body.     If  the  surgeon  desires  to  ob- 
tain only  intercostal  drainage,  he  should  make  a  longitudi- 
nal incision  about  3  inches  in  length  at  the  upper  bor- 
der of  the  sixth  or  seventh  rib,  and  the  middle  of  this  inci- 
sion should  correspond  to  the  midaxillary  Hne.     This  inci- 
sion is  carried,  layer  by  layer,  to  the  pleura.     If,  as  will 
usually  be  the  case,  he  wishes  to  remove  a  portion  of  a  rib, 
he  will  make  an  incision  about  3  inches  in  length  directly 
upon  the  outer  surface  of  the  rib  he  wishes  to  remove, 
and  the  middle  of  this  incision  corresponds  to  the  midaxillary  line.     Some 
surgeons  resect  a  portion  of  the  fifth  rib,  some  remove  a  bit  of  the  eighth  rib, 
and  Munro^  shows  that  at  the  level  of  the  eighth  rib  there  is  no  danger  of 
1  "Medical  News,"  Sept.  2,  1899. 


Fig.  572. — Resection 
of  a  rib  (Esmarch  and 
Kowalzig). 


Thoracotomy  909 

injuring  the  diaphragm.     By  many  operators  a  portion  of  the  seventh  or  eighth 
rib  is  removed  in  front  of  the  line  of  the  posterior  a>dllary  fold. 

I  agree  with  Hutton  that  a  portion  of  the  sixth  rib  in  the  inidaxillar\- 
line  should  be  removed.^  The  reasons  given  by  Hutton  for  the  selection 
of  this  rib  are:  (i)  It  is  over  the  portion  of  the  lung  which  expands  last.  An 
empvema  is  drained  only  partly  by  gra\'ity,  and  most  of  the  fluid  is  really 
forced  out  and  the  cavit}-  is  obliterated  by  lung  expansion.  If  an  incision  is 
made  anterior  or  posterior  to  this  point  the  expanding  lung  will  block  the  drain- 
age opening,  and  a  pus-cavity  -nithout  drainage  -^ill  remain  in  the  midaxillary 
line.  (2)  Such  an  incision  permits  a  patient  to  lie  on  his  back  without  mak- 
ing pressure  on  the  drainage-tube. 

"The  periosteum  of  the  outer  surface  of  the  rib  must  be  di\-ided  in  the 
same  direction  as  the  superlicial  incision.  The  exposed  rib  is  stripped  of 
periosteum  front  and  back  by  means  of  a  periosteal  separator,  and  ^^ith 
the  periosteum  at  the  lower  border  of  the  rib  the  intercostal  sutery  is  lifted 
out  of  harm's  way.  The  rib  can  be  di\-ided  b}*  means  of  cutting  forceps 
or  a  Gigli  saw.  The  usual  method  is  to  push  a  periosteal  separator  imder 
the  rib  and  saw  the  bone  in  two  places  by  means  of  a  metacarpal  saw  (Fig. 
572).  I  prefer  a  costotome,  as  it  accomplishes  the  section  most  rapidly. 
An  inch  or  more  of  the  rib  should  be  removed.  The  intercostal  artery-  is 
ligated  at  each  end  of  the  incision,  the  periosteum  is  removed,  and  the  pleura 
is  opened.  The  object  of  remo^ing  the  periosteum  is  to  prevent  the  rapid 
formation  of  bone  which  might  narrow  the  opening  and  interfere  with  drain- 
age. The  actual  opening  of  the  pleura  is  carried  out  in  the  same  way  in  inter- 
costal incision  and  after  rib  resection.  A  grooved  director  is  pushed  into  the 
pleural  sac,  and  the  opening  is  enlarged  by  means  of  the  forceps  and  the  finger. 

The  finger  removes  all  masses  of  tuberculous  material  or  aplastic  h-mph 
■within  reach.  If  the  finger  finds  the  lung  firmly  bound  down  by  dense  ad- 
hesions so  that  it  cannot  expand,  simple  rib-resection  ^^ill  not  cure  the  patient. 
If  the  adhesions  between  the  parietal  and  ^-isceral  pleura  can  be  separated  by 
the  linger  the  lung  may  expand.  In  order  to  accomplish  this  separation  a 
piece  of  more  than  one  rib  must  be  removed,  because  it  is  necessary-  to  insert 
more  than  two  fingers  (Samuel  Lloyd,  quoted  by  Limd,  in  "Jour.  Am.  !Med. 
Assoc.,''  August  26,  1911).  If  adhesions  cannot  be  separated  so  that  the 
lung  can  expand,  Estlander's,  Schede's,  or  Fowler's  operation  should  be  done. 
Some  surgeons  advocate  immediate  irrigation  after  opening  an  acute  empyema, 
but  this  procedure  is  unsafe.  It  is  true  that  in  most  cases  irrigation  does  no 
harm,  but  in  no  case  vnll  it  sterilize  the  ca^'ity,  and  in  some  cases  it  is  ver\- 
dangerous.  The  pleura  is  ver\-  susceptible  to  the  action  of  irritants.  This  is 
especially  true  of  young  children.  It  happens  occasionally  that?  the  injection 
of  the  blandest  fluid  is  followed  by  intense  dyspnea,  great  shock,  disturbances 
of  respiration  and  circulation,  con\-ulsions,  and  even  death  (Quenu).  The 
con\-ulsions  which  occasionally  foUow  pleural  irrigation  were  called  by  de 
Ceren%-ille  pleural  epilepsy.  In  putrid  empyema  it  is  proper  to  irrigate. 
Irrigation  wiU  remove  part  of  the  actively  poisonous  putrid  matter,  and 
the  retention  of  putrid  matter  is  a  greater  danger  than  irrigation.  It  was 
formerly  a  common  custom  to  make  a  counteropening  by  cutting  doTs-n 
upon  the  long  probe  pushed  against  the  chest  wall  after  being  introduced 
through  the  incision,  but  a  counteropening  is  of  no  particular  use.  A  drain- 
age-tube about  2  inches  in  length  is  introduced  and  stitched  in  place.  The 
tube  must  not  be  long  enough  to  touch  the  lung.  A  safety-pin  is  clamped 
upon  the  tube  to  keep  it  from  slipping  into  the  chest.  A  tape  should  be 
fastened  to  each  side  of  the  tube  and  tied  about  the  chest  to  prevent  it 
from  slipping  out.  Arrest  bleeding,  suture  the  skin,  dress  with  gauze  and 
1  See  W.  Menzies  Hutton  on  "Empyema.""  in  '"Brit.  Med.  Jour.,"  Oct,  29,  1S98. 


Qio  Surgery  of  the  Respiratory  Organs 

a  binder,  and  have  the  dressings  changed  as  soon  as  they  become  soaked 
at  one  point.  Several  times  a  day  change  the  patient's  position.  At  each 
change  of  dressings  direct  him  to  lie  on  the  diseased  side  with  the  foot  of 
the  bed  raised  for  half  an  hour.  Healing  takes  place  by  ascent  of  the  dia- 
phragm, expansion  of  the  lung,  and  retraction  of  the  chest  wall.  Expansion 
of  the  lung  is  favored  by  expiratory  acts ;  hence  cause  the  patient  several  times 
a  day  to  blow  through  a  rubber  tube  into  a  i-gallon  Wolff  bottle  filled  with 
water.  The  water  is  blown  into  another  bottle  attached  to  the  first  by  a 
tube.  Remove  the  drainage-tube  when  the  discharge  becomes  thin  and 
scanty  (about  the  eighth  or  tenth  day,  as  a  rule).  If  an  empyema  ceases 
to  improve  and  remains  stationary  for  months  after  it  has  been  drained, 
firm  adhesions  exist.  If  after  one  year  has  passed  a  cavity  stUl  exists  and 
there  is  a  flow  of  pus,  the  surgeon  must  perform  the  operation  of  Schede, 
Estlander,  Fowler,  or  Ransohoff. 

Thoracoplasty  (Estlander's  operation)  was  first  proposed  by  Warren 
Stone,  an  American  surgeon,  but  was  set  forth  in  detail  by  Estlander,  of 
Helsingfors,  in  1879.  It  is  employed  in  old  cases  of  empyema  in  which 
drainage  has  failed  and  in  cases  with  retracted  chest  wall,  collapsed  lung, 
thickened  pleura,  and  cavities  whose  rigid  walls  wHl  not  collapse.  The  pro- 
cedure recognizes  the  fact  that  after  pus  is  evacuated,  if  the  lung  is  adhe- 
rent, it  cannot  expand  to  fill  the  space  once  occupied  by  fluid,  and  that 
the  rigid  chest  wall  cannot  faU  in  as  a  substitute  for  the  lung.  It  seeks  to 
destroy  the  rigidity  of  the  chest  wall  and  to  permit  it  to  collapse  and  thus 
obliterate  the  cavity  of  the  empyema.  In  this  operation  a  piece  is  removed 
from  every  rib  which  overlies  the  cavity.  When  the  surgeon  resects  a  rib  and 
finds  a  cavity  with  iincoUapsible  walls,  or  a  lung  bound  down  with  firm  ad- 
hesions, he  should  perform  thoracoplasty.  This  operation  causes  the  oblitera- 
tion of  the  cavity  by  collapsing  that  portion  of  the  chest  wall  overlying  it. 
The  cavity  is  usually  in  the  upper  or  central  part  of  the  pleural  space.  The 
instruments  required  are  the  same  as  those  for  resection  of  a  rib.  The  posi- 
tion is  the  same  as  that  for  rib  resection.  The  length  of  the  incision  depends 
on  the  size  of  the  cavity.  The  surgeon  usually  removes  portions  of  the  second, 
third,  fourth,  fifth,  sixth,  and  seventh  ribs.  Make  a  transverse  incision  along 
the  center  of  an  intercostal  space,  and  through  this  incision  remove  the  ribs 
above  and  below  by  the  method  set  forth  on  page  908  (the  removal  of  six  ribs 
will  require  three  incisions).  Instead  of  this  incision,  we  can  make  a  vertical 
incision  or  a  U-shaped  flap.  Always  take  away  the  periosteum  in  order  to 
prevent  reproduction  of  the  ribs.  In  cavities  which  are  surrounded  by  firm 
adhesions,  and  in  old  cases  in  which  the  pleura  is  greatly  thickened,  irrigation 
is  safe.  If  the  cavity  is  small,  it  should  be  packed  with  iodoform  gauze  and 
allowed  to  granulate;  if  large,  it  should  be  drained  by  a  large  tube,  the  skin 
being  sutured  by  silkworm-gut. 

Schede's  Operation. — Schede,  of  Hamburg,  showed  that  when  the  pleura  is 
much  thickened,  even  Estlander's  operation  will  not  permit  the  chest  wall  to 
collapse  and  fiU  the  cavity  once  occupied  by  the  fluid.  The  instruments  used 
are  the  same  as  for  Estlander's  operation.  A  U-shaped  flap  is  made  from 
the  level  of  the  axflla  in  front  to  the  level  of  the  second  rib  and  between  the 
scapula  and  spine  behind.  The  lowest  level  of  this  incision  corresponds 
to  the  lowest  limit  of  the  pleura  (Fig.  573).  The  flap  is  loosened  and  raised 
and  the  scapiila  is  lifted  with  it.  The  ribs  from  the  second  rib  down  and 
from  the  costal  cartilages  to  the  tubercles  are  removed,  along  with  the  inter- 
costal muscles  and  the  pleura.  This  is  accomplished  by  cutting  with  bone- 
shears  and  scissors.  Hemorrhage  is  arrested.  The  pleura  is  curetted.  A 
drainage-tube  or  a  piece  of  iodoform  gauze  is  introduced,  and  the  raw  flap 
is  laid  against  the  visceral  layer  of  the  pleura.     The  superficial  incision  is 


Total  Pleurectomy  or  Pulmonary  Decortication 


911 


sutured,  except  at  the  point  where  the  tube  or  the  gauze  emerges.  The 
average  mortality  from  Schede's  operation  is  from  15  to  20  per  cent.  The 
operation  is  far  more  often  necessary  in  adults,  but  the  results  are  much  better 
in  children. 

Total  Pleurectomy  or  Pulmonary  Decortication  (Fowler's  Oper- 
ation).— In  the  spring  of  1893  de  Lorme,  of  the  Val  de  Grace,  performed  some 
experiments  on  dogs  looking  to  the  development  of  the  operation.  In  October, 
1893,  the  late  George  Ryerson  Fowler,  of  Brooklyn,  having  no  knowledge  of 
de  Lorme's  investigation,  operated  on  a  man  and  cured  a  chronic  empyema. 
The  French  surgeon's  first  operation  was  months  later.  De  Lorme  sought  to 
do  without  the  great  mutilation  of  the  Schede  operation.  His  idea  was  to 
make  an  opening  in  the  chest  wall  large  enough  to  work  through  (but  not 
nearly  so  large  as  that  caused  by  Schede's  operation),  incise  the  dense  fibrous 
membrane  which  binds  down  the  lung,  and 
allow  the  lung  to  expand  and  fill  the  cavity. 
De  Lorme  makes  a  trap-door  incision. 
Fowler  resected  ribs  extensively  to  obtain 
room.  The  thickened  fibrous  membrane  is 
removed  from  the  chest  wall,  lung,  pericar- 
diimi,  and  diaphragm,  any  sinus  is  extirpated, 
and  all  granulation  tissue  is  taken  away. 
The  shrunken  lung  expands  to  fill  the  cavity. 

Lund  describes  the  operation  as  follows 
("Jour.  Am.  Med.  Assoc,"  August  26, 191 1): 
"In  regard  to  the  technic  of  the  operation,  the 
method  of  the  resection  of  i^  inches  of  five 
or  six  ribs,  through  an  incision  running  up- 
ward and  forward  from  the  anterior  end  of 
the  old  drainage  incision,  has  proved,  to  my 
mind,  very  satisfactory.  In  slitting  up  the 
thickened  pleura  beneath  the  ribs  I  have 
had,  in  one  or  two  cases,  to  grab  the  inter- 
costal artery,  but  have  been  very  much  sur- 
prised to  find  how  little  trouble  there  has 
been  from  bleeding.     The   visceral   pleura. 


Fig-  573- — ^Incision  for  Schede's  oper- 
ation of  thoracoplasty  (Esmarch  and 
Kowalzig). 


shoe  than  anything  else,  is  carefully  incised  with  a  knife  over  the  lower  part 
of  the  lung.  The  finger  is  inserted  through  the  incision  and,  as  soon  as  the 
soft  surface  of  the  lung  is  felt,  is  swept  to  an  fro  with  the  pulp  of  the  finger  to- 
ward the  pleura  and  pressing  outward  so  as  to  cause  the  least  possible  damage 
to  the  lung.  Then  a  pair  of  blunt-pointed  scissors  is  inserted  and  the  mem- 
brane slit  clear  up  to  the  top  of  the  chest,  and  cleared  off  from  the  lung  with  the 
finger.  A  wound  of  one  or  two  of  the  air-cells  resulted  in  2  or  3  of  my  cases, 
allowing  the  escape  of  bubbles  of  air  on  exploration,  but  so  small  an  area  of  the 
lung  was  affected  that,  apparently,  no  harm  resulted.  In  regard  to  the  after- 
treatment,  it  is  probable  that  after  the  patient  is  put  to  bed  the  lung  does 
retract  to  a  certain  extent,  but  the  occasional  coughing  keeps  up  the  expan- 
sion. The  thick,  pus-soaked  dressing,  if  tightly  applied,  to  my  mind,  acts  as 
a  more  efficient  valve  than  any  mechanical  valve  which  one  could  employ." 

Fowler  made  a  report  of  30  cases.  Eleven  cases  were  completely  cured. 
In  17  cases  the  empyema  was  cured,  but  6  of  them  had  tuberculosis.  There 
were  3  deaths.  The  combined  statistics  of  Fowler,  de  Lorme,  and  Cestan 
show  35.7  per  cent,  cured,  19.7  per  cent,  improved,  33.9  per  cent,  not  cured, 
and  10  per  cent,  died  (Kurpjweit,  in  "Beitrage  fiir  klinischen  Chirurgie,"  Bd. 
xxxiii,  H.  3). 


912  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

Discission    of    the    Pulmonary    Pleura    (Ransohoff's   Operation). — 

This  operation  was  devised  by  Ransohoff,  of  Cincinnati.  It  can  be  employed 
when  decortication  is  impossible,  and  it  may  be  used  as  a  substitutedtor  decor- 
tication in  certain  cases.  It  permits  the  shrunken  lung  to  expand.  It  is 
founded  on  the  observation  that  if  the  thickened  pleura  over  a  shrunken  lung 
is  incised  the  cut  widens  with  each  respiration  and  quickly  becomes  a  groove 
(Ransohoff,  in  "Annals  of  Surgery,"  April,  1906).  The  pulmonary  pleura  is 
divided  by  numerous  parallel  incisions  j  inch  apart,  and  then  similar  incisions 
are  made  to  cross  these.  An  incision  is  also  carried  through  the  costal  side 
of  the  angle  of  reflection  of  the  pulmonary  and  costal  pleura. 

Pneumotomy  for  Abscess  and  Gangrene  of  the  Lung. — Pneumotomy 
is  employed  for  abscess,  gangrene,  and  bronchiectasis.  Give  chloroform 
or  use  a  local  anesthetic.  Place  the  patient  recumbent  with  the  shoulders  a 
little  raised.  Make  a  U-shaped  flap  over  the  seat  of  disease.  Resect  a  portion 
of  a  rib.  If  it  is  found  that  adhesions  do  not  exist  between  the  pulmonary  and 
costal  layers  of  the  pleura,  stitch  these  layers  together  with  catgut,  and  either 
postpone  further  operation  for  forty-eight  hours  or  surround  the  area  by  gauze 
and  operate  at  once.  If  adhesions  exist,  proceed  at  once.  Chloroform  can  be 
put  aside  when  the  pleura  is  exposed.  Fowler  called  attention  to  the  fact  that 
lung  tissue  is  so  insensitive  that  the  administration  of  an  anesthetic  can  be 
suspended  as  soon  as  the  pleura  has  been  opened.  Incise  the  agglutinated 
layers  of  the  pleura,  and  pass  an  aspirating  needle  into  the  lung  in  various 
directions.  When  the  abscess  is  located,  open  it  by  the  cautery.  Carry  the 
Paquelin  cautery  slowly  into  the  lung  in  the  direction  of  the  abscess-cavity. 
The  cautery  knife  should  be  at  a  dull-red  heat. 

When  the  cautery  opens  the  cavity  of  the  abscess,  withdraw  the  instrimient 
and  insert  a  drainage-tube,  and  suture  the  flap  of  superficial  tissue.  If  the 
abscess  is  not  found  after  one  or  two  punctures  by  the  aspirating  needle, 
abandon  the  attempt. 

Tuffier  explores  for  an  abscess  by  what  he  calls  decollement  of  the  parietal 
pleura.  He  exposes  the  parietal  layer  of  the  pleura,  passes  his  hand  between 
this  layer  and  the  chest  wall,  strips  the  pleura  off  over  a  considerable  area, 
and  is  able  to  feel  the  lung  beneath  and  thus  determine  its  condition. 

Hartmann  ("Presse  Medicale,"  April  27,  191 2)  states  that  Garre  collected 
96  cases  of  abscess,  with  19  deaths,  and  122  cases  of  gangrene,  with  42  deaths. 
In  bronchiectasis  pneimiotomy  may  be  employed.  Hartmann  (Ibid.)  combines 
the  cases  of  Korte  and  Sauerbruch,  and  states  that  in  149  cases  there  were  46 
cures.  In  Sauerbruch's  133  cases  there  were  40  cures,  43  deaths,  and  7  were 
improved. 


XXVII.    DISEASES    AND    INJURIES    OF    THE    UPPER 
DIGESTIVE  TRACT 

Injuries  and  Diseases  of  the  Face,  Nose,  Mouth,  Salivary  Glands, 
Tongue,  Jaws,  and  Esophagus. — Closure  of  the  Jaws. — This  condition  may 
be  caused  by  tetanus,  by  the  irritation  of  a  non-erupted  wisdom  tooth,  carious 
teeth,  by  cancer  of  the  mouth,  sarcoma  of  the  jaws,  alveolar  abscess,  cicatricial 
contractions  due  to  burns  or  noma,  and  temporomaxillary  ankylosis. 

Temporomaxillary  Ankylosis. — Ankylosis  of  the  temporomaxillary  joint 
may  result  from  gonorrheal  arthritis,  rheumatoid  arthritis,  or  fracture  of  the 
condyle.  Even  when  one  joint  is  completely  ankylosed,  the  jaws  upon  the 
sound  side  can  be  somewhat  separated  because  of  the  elasticity  of  the  mandible. 

Treatment. — Gradual  dilatation  by  means  of  box-wood  screws  is  useless. 
Violent  separation  is  without  value.    After  either  method  the  condition  always 


Phosphorus  Necrosis  913 

recurs  rapidly.  Esmarch  removed  a  wedge-shaped  piece  of  bone  from  the 
angle  of  the  jaw  in  order  to  form  a  false  joint.  Other  operators  do  a  like 
operation  on  the  ramus.  A  simple  osteotomy  is  certain  to  fail  because  bony 
union  will  occur.  That  is  the  trouble  with  Swain's  operation  (sawing  the  body 
at  the  angle).  Bony  union  may  be  prevented  by  resecting  the  zygoma  and 
putting  a  flap  of  temporal  muscle  between  the  fragments  (Helferich).  Re- 
moval of  the  condyle  and  a  portion  of  the  neck  is  usually  efficient.  In  double 
ankylosis  both  condyles  should  be  resected.  Verneuil,  in  i860,  suggested 
mobilizing  the  joint  and  interposing  an  attached  flap  of  temporal  muscle 
between  the  condyle  and  the  socket.  Such  an  operation  may  give  a  grati- 
fying result. 

Alveolar  Abscess. — ^This  condition  is  caused  by  a  decayed  tooth.  A  super- 
ficial abscess  is  known  as  a  gum-boil.  The  process  may  spread  to  the  jaw- 
bone, causing  necrosis.  From  the  maxilla  the  suppuration  may  enter  the 
antrum.     From  the  lower  jaw  pus  may  track  into  the  neck. 

Treatment. — Early  and  free  incision,  usually,  but  not  always,  the  extraction 
of  the  offending  tooth,  and  drainage. 

Necrosis  of  the  Jaw. — Extensive  necrosis  is  much  more  common  in  the  lower 
than  in  the  upper  jaw.  Necrosis  of  the  alveolar  process  of  either  jaw  may  be 
due  to  suppurative  periostitis,  the  result  of  carious  teeth.  In  suppurative 
periostitis  of  this  form  an  alveolar  abscess  arises  which  is  followed  perhaps 
by  circumscribed  necrosis.  In  rare  cases  widespread  suppurative  periostitis 
occurs  which  may  result  in  extensive  necrosis. 

Syphilis  produces  periostitis  and  osteomyelitis,  but  more  commonly  causes 
caries  than  necrosis.  Tuberculous  periostitis  may  result  in  limited  necrosis. 
Its  most  common  site  is  the  orbital  margin  of  the  maxilla. 

Actinomycosis  is  a  rare  cause  of  necrosis.  In  mercurial  salivation  extensive 
necrosis  is  prone  to  occur.  A  child  suffering  during  dentition  from  an  exan- 
thematous  fever  or  other  virulent  infection  is  liable  to  a  violently  acute  sup- 
purative periostitis  and  osteomyelitis  with  evidence  of  severe  general  infection. 
In  the  lower  jaw  particularly  extensive  and  usually  symmetrical  necrosis  follows. 

Treatment. — In  an  acute  suppurative  periostitis  remove  a  carious  tooth  (if 
one  exists),  incise  the  gum  to  the  bone;  if  osteomyeHtis  exists  open  the  outer 
plate  of  the  bone,  order  frequent  cleansing  of  the  mouth  by  antiseptic  washes. 
In  S3^hilitic  caries  place  the  patient  on  antisyphilitic  treatment  and  use  a 
curet  to  remove  carious  bone.  In  tuberculous  caries  use  a  curet  and  employ 
antituberculous  treatment. 

When  necrosis  occurs  it  is  usual  to  wait  until  the  sequestrum  loosens  and 
to  then  remove  it  through  the  mouth  or  nose.  Early  sequestrectomy  is  a 
better  plan.  If  there  is  profuse  suppuration,  remove  the  dead  bone  by  sub- 
periosteal resection  (Tillmanns's  "Text-Book  of  Surgery"). 

Phosphorus  Necrosis. — ^This  condition'  was  first  described  in  1845  by 
Lorinser.  It  is  seen  among  those  who  make  matches  from  yellow  phosphorus. 
Recent  legislation  against  yellow  phosphorus  is  wiping  out  the  disease.  It  is 
most  common  in  the  lower  jaw.  The  fumes  enter  carious  teeth.  About  such 
teeth  ossifying  periostitis  or  suppurative  periostitis  and  osteomyelitis  occur. 
Even  when  the  process  begins  as  ossifying  periostitis  suppuration  occurs, 
either  between  the  periosteum  and  the  new  bone  or  between  the  new  bone  and 
the  older  bone.  The  bone  enlarges  enormously  and  verv^  extensive  necrosis  takes 
place.  The  entire  lower  jaw  may  be  lost.  Bones  of  the  base  of  the  skull  may 
be  destroyed.  Tillmanns  (quoting  Maas,  Binz,  and  others)  says  that  arsenic 
and  pyrogaUic  acid  tend,  like  phosphorus,  to  produce  ossifying  periostitis. 

Treatment. — Entire  removal  of  the  victim  from  the  fumes,  living  in  the 
open  air,  the  frequent  use  of  antiseptic  mouth-washes,  incisions  if  pus  forms, 
early  subperiosteal  sequestrectomy  by  means  of  a  chisel  and  mallet. 


914  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


Wounds  of  the  Salivary  Glands. — An  aseptic  wound  usually  heals  and 
rarely  results  in  a  salivary  fistula,  although  after  healing  it  is  not  unusual  for 
an  encysted  collection  of  saliva  to  gather  under  the  skin.  Such  a  collection  of 
saliva,  if  it  does  not  disappear  spontaneously,  can  usually  be  gotten  rid  of  by 
continued  pressure.  When  a  wound  of  a  salivary  gland  is  infected  a  single 
fistula  or  multiple  fistulae  may  be  left  as  a  legacy.  A  saUvary  fistula  is  very 
annoying,  because  the  saliva  flows  constantly.  A  fistula  of  a  gland  usually 
heals  spontaneously  after  a  long  time,  but  healing  may  be  quickly  brought 
about  by  touching  the  orifice  with  the  PaqueUn  cautery. 

Wound  of  Steno's  duct  is  apt  to  cause  a  fistula,  and  the  condition  is  often 
difficult  to  cure.  In  this  condition,  when  the  duct  was  cut  across,  the  central 
end  grows  fast  to  the  cutaneous  surface.  Fistiila  of  Steno's  duct  may  also  be 
caused  by  obstruction  and  rupture  of  the  duct  and  by  suppurative  or  gan- 
grenous processes. 

In  wounds  of  the  duct  the  ends  should  be  brought  as  near  together  as 
possible  by  catgut  sutures  which  do  not  enter  the  lumen  of  the  duct;  if  the 
mucous  membrane  is  not  already  opened  an  incision  should  be  made  through 
it  to  permit  drainage  of  saHva  into  the  mouth,  and  the  skin  should  be  sutured. 
In  some  cases  the  central  end  of  the  duct  may  be  carried  into  the  mouth  and 
sutured  to  the  mucous  membrane.  If,  after  an  injury  of  Steno's  duct,  saliva 
gathers  under  the  skin,  make  an  incision  through  the  mucous  membrane  to 
give  a  route  for  the  saliva  to  enter  the  mouth,  and  apply  pressure  externally. 
When  an  external  fistula  forms,  it  may  perhaps  be  cured  by  the  cautery  and 

pressure,  but,  if   the  peripheral 
\  V  portion  of  the  duct  is  obliterated 

(which  can  be  determined  by 
a  sound)  a  cutting  operation 
must  be  performed.  Tillmanns 
advocates  cutting  out  the  ex- 
ternal portion  of  the  fistula  by- 
two  elliptical  incisions.  A  trocar 
is  passed  through  the  bottom  of 
the  wound  in  two  places,  about 
I  cm.  apart;  a  piece  of  stout 
silk  is  drawn  through  the  holes 
and  tied  tightly  and  the  super- 
ficial incision  is  closed.  The 
silk  cuts  through  and  makes  an 
internal  fistula.  Another  method  is  to  make  an  incision,  find  and  isolate 
the  central  end  of  the  duct,  open  the  mucous  membrane,  suture  the  duct  to 
it,  and  close  the  superficial  wound. 

De  Guise's  operation  is  shown  in  Fig.  574.  He  threads  a  piece  of  silk 
through  two  needles  and  carries  the  needles  into  the  mouth  so  that  the  silk 
will  embrace  a  bit  of  tissue  |  cm.  in  length.  The  silk  is  tied  tightly  within  the 
mouth,  the  ends  are  cut  off,  and  the  margins  of  the  fistula  at  the  surface  are 
freshened  and  sutured.     I  prefer  silver  wire  to  silk. 

Parotitis.— Mumps,  or  epidemic  parotitis,  is  treated  by  the  physician. 
In  this  condition  the  submaxillary  and  sublingual  glands  are  usually  involved 
as  well  as  the  parotid.  In  pyemia,  metastatic  abscesses  may  form  in  the  par- 
otid gland.  Great  swelling  arises,  respiration  is  often  embarrassed,  and  early 
incision  is  necessary.  Parotid  inflammation  other  than  mumps  is  usually  due 
to  the  passage  of  bacteria  up  Steno's  duct,  the  source  of  the  microbes  being  a 
foul  condition  of  the  mouth,  particularly  noma  or  stomatitis.  Hence  such 
inflammation  is  most  common  during  the  existence  of  acute  infectious  diseases 
and  sepsis.     Suppuration  or  even  gangrene  may  occur.     As  a  rule,  only  one 


Fig.  574-- 


-De  Guise's  operation  for  salivary  fistula 
(Esmarch  and  Kowalzig). 


Lymphomata  of  the  Salivary  and  Lachrymal   Glands  915 

gland  is  attacked,  but  both  may  be.  It  is  a  well-known  fact  that  occasionally, 
though  very  rarely,  after  an  abdominal  operation  inflammation  of  the  parotid 
gland  occurs.  The  condition  is  more  common  in  adults  than  in  children. 
This  form  of  parotitis  may,  of  course,  be  due  to  septic  metastatis  and  may  be 
produced  by  trauma,  but  I  am  satisfied  that  most  cases  result  from  foul 
mouths,  the  infection  ascending  from  the  mouth  along  the  duct.  Oral  clean- 
liness tends  strongly  to  prevent  the  so-called  sympathetic  parotitis.  In  about 
one-third  of  the  cases  the  condition  is  not  to  be  distinguished  from  mumps  and 
is  recovered  from  in  seven  to  eight  days.  ]Mild  cases  seldom  suppurate,  and  if 
they  do,  the  pus  may  flow  down  the  duct  into  the  mouth.  In  nearly  one-half 
of  the  cases,  according  to  Marchetti  (''Epitome  of  Surger}-,"  in  ''Brit.  Med. 
Jour.,"  March  6,  1909),  there  is  plflegmonous  inflammation  with  necrosis  and 
suppuration  of  the  tissues  and  formation  of  a  salivary  fistula.  In  non-suppura- 
tive  parotitis  there  are  pain,  tenderness,  ob\ious  swelling,  and  h}-peremia  of  the 
skin,  and  it  is  difficult  to  open  the  mouth  or  swaUow.  \Mien  suppuration 
occurs,  all  of  the  above  symptoms  are  intensified,  the  discoloration  becomes 
dusky,  the  skin  becomes  shiny  and  edematous,  the  constitutional  s}Tnptoms 
of  pus  formation  exist,  and  there  is  usuaUy  dehrium. 

Treatment. — In  the  non-suppurative  form  apply  heat.  Wash  the  mouth 
out  frequently  with  an  antiseptic  wash  and  apply  ichthyol  and  lanolin  to 
the  swollen  region.  In  the  suppurati^•e  form  make  several  openings  by 
Hilton's  method,  seeking  for  points  of  softening;  apply  hot  antiseptic  fomenta- 
tions, w^ash  the  mouth  frequently  with  an  antiseptic  fluid,  and  combat  sepsis 
by  appropriate  constitutional  treatment. 

Salivary  Concretions. — The  saliva  contains  in  solution  certain  salts  which 
may  be  deposited.  Deposited  on  the  teeth  they  constitute  tartar.  Deposited 
in  a  salivar}'  duct  or  the  acini  of  a  gland  they  constitute  a  calciflus.  The 
salts  deposited  are  carbonate  and  phosphate  of  lime.  A  calculus  may  consist 
purely  of  these  two  salts  or  there  may  be  a  foreign-body  nucleus.  A  cal- 
culus is  a  possible  result  of  an  inflammation  which  blocks,  constricts,  or 
roughens  a  duct  or  acinus  and  decomposes  saliva.  Small  concretions  are  often 
passed.  Concretions  the  size  of  a  bean  are  retained.  A  concretion  may 
attain  the  size  of  an  English  walnut.  A  concretion  does  not  block  a  duct 
continuously,  but  does  so  now  and  then,  causing  swelling  and  tenderness  of  the 
gland.  A  retained  calculus  can  be  palpated  by  a  finger  in  the  mouth  and  a 
finger  extemalh". 

Treatment.— \  calculus  in  a  duct  is  extracted  by  making  an  incision  through 
the  mucous  membrane.  If  a  ver}'  large  calculus  forms  m  the  submaxillary 
gland,  the  gland  should  be  removed  through  an  external  incision. 

Lymphomata  of  the  Salivary  and  Lachrymal  Glands  (Miktilicz's Disease). — 
Mikiihcz,  of  Breslau,  described  this  condition  in  188S.  It  is  a  chronic,  brawny, 
and  non-inflammatoiy  sweUing,  painless  though  sometimes  tender,  and  un- 
connected \\-ith  any  knowm  systemic  condition.  In  jNIikuHcz's  earty  cases  the 
lachr}Tnal,  parotid,  and  submaxillar}-  salivar\^  glands  of  both  sides  were 
enlarged,  hence  he  regarded  it  as  s}Tnmetrical.  We  now  know  that  non-s}Tn- 
metrical  cases  occur,  in  fact,  only  one  gland  may  be  enlarged,  although,  of  course, 
such  cases  may  eventually  develop  growths  on  the  other  side.  In  some  cases 
the  sublinguals  have  been  involved,  in  some  the  accessory-  lachr\-mals,  in  some 
the  glands  of  Xuhn  and  Blandin.  In  a  case  of  Osier's  there  was  enlargement 
of  the  spleen,  tonsils,  and  cervical  hmiph-glands.  In  a  t}-pical  case  the  cheeks 
are  much  broader  than  natural,  and  the  eyelids  droop  on  the  temporal  side  like 
''those  of  a  bloodhound''  (Ziegler,  in  "Xew  York  Med.  Jour.,"  Dec.  11,  1909). 
The  mouth  is  \exy  &sy  because  of  deficiency  of  salivar\-  secretion.  The  con- 
junctiva is  dry  for  want  of  enough  tears.  Chronic  inflammation  in  the  naso- 
phar^'nx  is  not  unusual. 


9i6  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

The  condition  may  occur  at  practically  any  age  after  three  or  four.  A.  case 
four  years  of  age  has  been  reported.  The  glands  may  undergo  regression 
during  pneumonia,  appendicitis,  or  some  other  infection.  The  cause  is  doubt- 
ful. Some  think  it  is  due  to  bacteria,  but  the  tissue  is  not  inflammatory,  being 
merely  hyperplastic  lymph  tissue.  Others  regard  it  as  due  to  a  toxic  material 
in  the  blood.  Ziegler  beUeves  that  the  causal  toxic  material  comes  from  the 
nasal  sinuses. 

Treatment. — Arsenic,  internally  will  perhaps  produce  cure.  The  iodids  are 
used  by  some  and  pilocarpin  has  been  recommended.  The  x-rays  should  be 
applied.  Operative  removal  has  not  been  successful.  All  diseased  conditions 
of  the  nasopharynx  should  be  corrected,  if  possible.  (See  Ziegler's  thorough 
study,  in  "New  York  Med.  Jour.,"  Dec.  ii,  1909.) 

Harelip  and  Cleft-palate. —  Harelip  is  a  congenital  cleft  in  the  upper 
lip  due  to  defective  development.  Cleft-palate  is  a  congenital  fissure  in  the 
soft  palate  or  in  both  the  hard  and  soft  palates.  In  harelip  the  cleft  is  usually 
complete,  through  the  entire  lip  into  the  nostril,  but  in  rare  cases  it  may  show 
only  as  a  furrow  in  the  mucous  edge  or  as  a  split  from  the  nostril  partly  into  the 
lip.  It  is  most  common  on  the  left  side.  In  double  harelip  the  central  por- 
tion of  the  Up  is  often  adherent  to  the  tip  of  the  nose.  Double  harelip  may  be 
free  from  complication,  but  is  often  associated  with  a  malformation  of  the  alve- 
olus and  palate.  The  term  "harelip"  is  a  poor  one,  as  the  cleft  in  a  hare's  lip 
is  the  shape  of  the  letter  Y,  the  stem  of  the  Y  being  median  and  an  arm 
entering  each  nostril.  Median  harelip  is  exceedingly  rare.  Dupuytren  said 
it  never  occurred,  but  at  least  9  cases  have  been  reported  (Ransohoff,  in  "Lancet 
Clinic,"  Nov.  2,  1912).  Ordinary  or  lateral  harelip  is  due  to  failure  of  fusion  of 
the  lateral  maxillary  and  frontal  processes.  Median  harelip  is  due  to  "failure 
of  union  between  the  lateral  tubercles  of  the  frontonasal  process  which  is  placed 
on  each  side  of  the  middle  line"  (Ransohoff,  Ibid.).  We  recall  His's  teaching, 
that  the  central  portion  of  the  upper  lip  is  formed  from  the  lower  portion 
of  the  frontonasal  process  by  the  fusion  of  its  two  buds  (Ransohoff,  Ibid.). 
In  cleft-palate  the  septum  of  the  nose  is  usually  adherent  to  the  palatine  process 
opposite  the  side  upon  which  the  fissure  exists.  In  those  rare  cases  of  cleft- 
palate  double  in  front,  the  nasal  septum  is  attached  only  to  the  premaxillary 
bone,  and  the  premaxillary  bone  is  not  attached  at  all  to  the  superior  maxillary 
bone.  In  harelip  there  is  frequently  a  cleft  in  the  alveolus,  and  almost  always 
flattening  of  the  corresponding  side  of  the  nose.  Harelip  is  often  associated 
with  cleft-palate,  talipes,  and  other  deformities.  It  is  a  great  deformity,  and 
interferes  with  sucking,  swallowing,  and  articulation. 

Operation  for  harelip  uncompKcated  by  cleft-palate  should  be  performed 
between  the  third  and  sixth  months  of  life  in  a  child  in  good  health,  free  from 
stomach  trouble,  cough,  or  coryza,  but  operation  is  not  advisable  in  the  early 
weeks  of  life.  Always,  if  possible,  operate  before  dentition  begins  (seventh 
month).  If  the  child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.  While  waiting  for  opera- 
tion be  sure  the  child  is  getting  enough  food.  If  it  cannot  suck,  feed  it  with 
a  spoon.  If  a  cleft  exists  in  the  palate,  we  sometimes  operate  first  upon  the 
lip,  because  the  pressure  of  the  parts  after  the  edges  of  the  gap  are  approxi- 
mated aids  in  the  closure  of  the  bony  cleft.  In  other  cases  we  operate  first  on 
the  palate.  Cleft-palate  interferes  with  sucking,  deglutition,  mastication,  and 
articulation.  In  severe  cases  the  food  passes  into  the  nose  and  excites  inflam- 
mation. Loss  of  control  of  the  palate  muscles  always  exists,  and  liquids  and 
soHds  are  hable  to  pass  into  the  wind-pipe.  Clefts  in  the  hard  palate  should 
not  be  operated  on  until  the  second  year,  but  should  be  operated  upon  then, 
otherwise  speech  will  be  permanently  affected.  Some  surgeons  refuse  to  oper- 
are  until  the  tenth  or  twelfth  year,  but  operation  done  this  late  will  not  correct 


Harelip  and  Cleft-palate 


917 


speech-  defect.  The  patient  at  the  period  of  operation  should  be  well  and  free 
from  cough.  In  many  cases  the  passage  of  food  and  drink  into  the  nose  can 
largely  be  prevented  by  the  use  of  a  diaphragm. 

Operation  for  Harelip. — Wrap  the  child  in  a  sheet;  place  it  in  the  Tren- 
delenburg position,  and  rest  the  head  upon  a  sand-pillow.  The  surgeon 
stands  to  the  right  side  of  the  patient.  Ether  or  chloroform  is  given.  For 
single  harelip,  separate  with  the  scissors  the  upper  lip  from  the  bone  on 
each  side  of  the  cleft  until  approximation  of  the  edges  can  be  effected  with- 
out tension.  If  the  premaxillary  bone  of  one  side  projects  more  than  its 
fellow,  grasp  it  with  sequestrum  forceps  and  bend  it  back  (Jacobson  and 
Treves).  Clamp  the  upper  lip  at  each  angle  of  the  mouth  to  prevent  hem- 
orrhage. If  the  edges  are  of  equal  or  nearly  equal  length,  and  if  the  gap 
is  not  very  wide,  perform  Malgaigne's  operation.  This  is  performed  as  fol- 
lows :  A  flap  is  detached  on  each  side,  the  detachment  beginning  at  the  upper 
angle  of  the  gap;  each  flap  is  detached  above,  but  remains  attached  below. 
The  flaps  are  separated  from  the  bone,  and  are  drawn  downward  so  as  to  form 
a  prominence  at  the  vermilion  border  (Fig.  575).  If  the  edges  are  pared  so 
that  in  closure  the  vermilion  border  is  even,  when  the  parts  are  healed  a  gutter 
will  be  visible  at  the  line  of  union.  The  edges  are  approximated  by  an  assist- 
ant, and  silkworm-gut  sutures  or  silver  wires  are  passed  by  means  of  a  straight 
needle.  Each  suture  goes  down  to  the  mucous  membrane.  The  first  suture 
is  passed  through  the  middle  of  the  lip,  5  inch  from  the  cleft.     Three  or  four 


Fig-  575- — Malgaigne's  opera- 
tion for  harelip. 


Fig.  576. — Mirault's  operation 
for  single  harelip  (Esmarch). 


Fig-  577- — Incisions  for  double  hare- 
lip (Esmarch  and  Kowalzig). 


main  sutures  are  passed  through  the  thickness  of  the  lip,  and  are  tied  and  cut 
off.  Two  or  three  fine  silk  or  catgut  sutures  are  passed  by  a  curved  needle 
through  the  vermilion  border  of  the  lip  and  the  mucous  membrane  of  the 
mouth,  and  are  tied  and  cut  off.  A  small  piece  of  gauze  is  placed  over  the  lip 
and  is  held  in  place  by  straps  of  rubber  plaster.  After  operation  prevent  the 
child  crying  by  feeding  it  often  and  giving  it  small  doses  of  laudanum.  Heath 
orders  2  drops  of  laudanum  in  i  oz.  of  distilled  water,  a  teaspoonful  to  be 
given  every  two  or  three  hours.  About  the  sixth  day  one-half  the  sutures  are 
taken  out,  and  on  the  eighth  or  ninth  day  the  remaining  ones  are  removed. 
In  many  cases  no  further  procedure  is  necessary,  but  if  after  some  weeks  the 
prominence  at  the  lip  border  does  not  shrink,  it  can  be  readily  clippeSi  away. 
Harelip-pins  are  not  used  at  the  present  time,  and  are  not  needed  if  the  lip 
is  well  separated  from  the  bone.  If  the  edges  of  the  cleft  are  of  unequal 
length,  Edmund  Owen's  operation  can  be  performed  (see  below,  under  Double 
Harelip),  or  we  can  perform  Mirault's  operation,  as  shown  in  Fig.  576. 

In  double  harelip  the  operation  is  similar  to  that  for  single  harelip.  If  the 
intervening  piece  is  vertical  and  is  covered  with  healthy  skin,  complete  each 
operation  as  for  single  harelip,  closing  both  fissures  at  once  with  silver  wire  in  a 
strong,  healthy  child,  closing  them  at  intervals  of  three  weeks  in  one  not  so 
lusty  (Fig.  577).  Excise  the  septum  if  it  is  deformed.  The  premaxillary  bone 
shoiild  in  most  instances  be  removed,  the  skin  over  it  being  preserved.  Sir  Wil- 
liam Fergusson  was  accustomed  to  incise  the  mucous  membrane  and  shell  out 


9i8  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

this  bone.  The  premaxillary  bone  can  be  forced  back  into  Kne,  being  held,  if 
necessary,  by  catgut  suture  of  the  periosteum;  but  if  saved,  it  is  Hable  to  necrose 
and  its  teeth  soon  decay.  Heath  removes  this  bone  two  weeks  before  operat- 
ing on  the  Hp.  If  there  is  much  hemorrhage  after  removal  of  the  bone,  arrest 
it  with  a  hot  wire  or  with  Horsley's  wax.  Figure  577  shows  incisions  for  double 
harelip.  Edmund  Owen's  operation  is  very  useful  (Figs.  578,  579).  In 
this  operation  very  thick  flaps  are  cut.  The  prolabium  and  incisive  bone  are 
removed.  The  flaps  are  cut  as  shown  in  Fig.  578,  on  one  side  by  a  line  a-b, 
and  on  the  other  side  the  piece  c-d-e  is  removed ; 
a  is  brought  to  e,  b  is  brought  to  d,  /  is  brought 
to  c,  and  sutures  are  applied  (Fig.  579). 


Fig.   578.— Double  harelip,   the  prolabium  and        Fig.  579.— The  two  sides  of  the  lip  drawn  together 
incisive  bone  having  been  removed  (Owen).  and  secured  by  sutures  (Owen). 

Operation  for  Cleft-palate. — It  is  true  that  during  the  early  years  of  its 
growth  a  cleft  diminishes  in  size,  and  particularly  if  a  harelip  is  closed,  but 
to  wait  too  long  before  we  operate  means  permanent  speech  impairment. 
Bony  clefts  should  be  operated  upon  early  in  the  second  year.  Clefts  of  the 
soft  palate  only  may  be  operated  upon  during  the  first  six  months  of  life.  If 
both  the  hard  and  soft  palates  are  cleft,  close  both  at  one  operation.  In 
an  ill-nourished  child  in  which  the  covering  of  the  bone  is  obviously  thin 
it  is  best  to  postpone  any  operation  upon  a  bony  cleft  until  the  end  of  the 
third  year.  I  agree  with  Berry  that  operation  is  justifiable  up  to  the  age  of 
twenty,  but  early  operation  is  highly  desirable.  Edmund  Owen  put  forth 
a  convincing  plea  for  early  operation. ^  He  says  he  is  operating  earlier  and 
earlier,  and  quotes  Chilton  as  the  gentleman  who  led  him  to  do  so.  Owen 
maintains  that  if  speech  is  to  be  improved,  operation  must  be  done  early, 
and  he  formulates  some  very  valuable  rules  for  preparation  and  care.  I  have 
never  been  convinced  that  operation  in  early  infancy  is  sufficiently  safe  or 
has  any  notable  advantages.  When  one  comes  to  treat  congenital  clefts  of  the 
lip,  the  alveolar  process,  and  the  hard  and  soft  palate,  the  necessities  one  should 
seek  to  obtain  are  the  surgical  closure  of  the  clefts,  the  estabhshment  of  the 
function  of  the  involved  tissues,  the  correction  of  the  congenital  deformity, 
and  the  prevention  of  postoperative  or  acquired  deformity.  There  are  few 
if  any  cases  of  cleft-palate  that  cannot  be  successfully  treated  by  surgical 
means;  and  it  is  a  very  unusual  thing  for  a  case  really  to  need  any  mechanical 
appliance,  such  as  the  obturator  and  velum. 

In  deciding  upon  the  time  for  operating  and  the  nature  of  the  operation, 
the  safety  of  the  patient  should  be  the  first  consideration.  One  must  care- 
fully consider  the  physical  condition,  especially  in  respect  to  nutrition.  An 
operative  method  that  has  a  greater  mortality  than  is  incident  to  minor  sur- 
gery ought  not  to  be  selected,  and  no  operation  should  be  performed  until  the 
condition  of  the  patient  justifies  it.  Having  considered  the  physical  condi- 
tion of  the  patient  and  the  relative  safety  of  different  operative  plans,  a  care- 
ful study  of  the  individual  case  should  be  made,  and  in  this  study  each  of 
the  four  requirements  above  set  forth  must  be  attentively  regarded.  If  we 
succeed  in  closing  the  cleft  without  establishing  the  function  of  the  tissues, 
without  correcting  congenital  deformity  and  without  preventing  postoperative 

1 "  Lancet,"  Jan.  4,  i8g6. 


Harelip  and  Cleft-palate  919 

or  acquired  deformity,  we  leave  the  patient  worse  off  than  he  was  before,  and 
perhaps  render  subsequent  satisfactory  treatment  impossible. 

We  should  attempt  to  secure  closure  of  the  cleft  with  the  least  possible  for- 
mation of  cicatricial  tissue.  The  simplest  technic  is  the  best,  and  we  should 
endeavor  to  avoid  all  unnecessary  additional  traumatism.  One  should  refrain 
from  passing  additional  approximation  sutures,  from  bruising  the  tissues  by  . 
overtension  or  by  traction-forceps,  and  from  using  large  needles  and  coarse 
suture  materials,  which  make  large  suture-cicatrices.  The  amount  of  scar 
tissue  bears  directly  upon  the  functional  result.  In  addition,  when  dealing 
with  the  lip,  and  especially  with  the  soft  palate,  one  must  seek  to  avoid 
incisions  that  involve  muscles,  and  particularly  the  nerve-supply  of  muscles. 

The  periosteal-flap  operation  separates  portions  of  the  soft  palate  from  the 
palatine  bones.  A  large  amount  of  cicatricial  tissue  is  necessary  to  effect  re- 
pair, and  this  mass  of  new  tissue  lessens  the  good  functional  results.  In  the 
periosteal-flap  operation  the  repaired  soft  palate  is  anterior  and  inferior  to  the 
position  secured  by  the  osteoplastic  method  and,  to  that  extent,  interferes  with 
the  closure  of  the  nasopharynx.  Nevertheless,  in  my  opinion,  the  operation 
which  uses  the  soft  tissues  only  is  by  far  the  safest  and  is  the  one  I  usually 
employ.  In  cases  of  complete  cleft  associated  congenital  deformities  are 
especially  manifest  in  the  nose,  lips,  premaxilla,  and  maxillae. 

To  correct  congenital  deformities  and  to  prevent  postoperative  or  acquired 
deformities  is  the  most  neglected  and  the  least  understood  phase  of  the  sub- 
ject, and  it  is  a  very  complicated  question  to  hope  to  make  clear  in  a  brief 
statement.  The  key  to  the  difficulty  is  the  normal  contour  of  the  face  as 
estabHshed  by  the  proper  occlusion  of  the  permanent  teeth.  In  finding  this' 
out  there  is  no  better  guide  than  the  rules  laid  down  by  Dr.  Angle  in  the 
latest  edition  of  his  "Orthodontia."  He  maintains  that  every  tooth  must  be 
held  in  its  proper  relation  and  occlusion;  and  that  if  any  teeth  are  lost  they 
must  be  replaced  in  order  to  establish  or  restore  the  proper  expression  and 
contour  of  the  face.  To  comply  with  the  foregoing  requirements  one  should 
avoid  any  operation  that  would  not  maintain  or  would  fail  to  replace  the 
normal  position  of  the  premaxilla  and  the  maxillae  and  their  future  comple- 
ment of  teeth.  If  the  premaxilla  is  only  slightly  in  advance  of  its  normal 
position,  the  early  closure  of  the  cleft  of  the  lip  will  help  to  replace  it.  If, 
however,  the  premaxilla  is  far  in  advance  of  its  normal  position,  it  is  hopeless 
to  expect  the  pressure  of  a  reunited  lip  to  restore  it  to  position.  In  such  a 
case  sufficient  of  the  nasal  septum  posterior  to  the  premaxilla  must  be  re- 
sected, and  the  premaxilla  must  be  carried  back  and  sutured  in  position;  but 
this  operation  should  be  done  after  the  closure  of  the  cleft  soft  and  hard  palates, 
and  seldom  at  the  same  operation.  If  the  cleft  is  unilateral  in  relation  to  the 
premaxilla  and  that  bone  is  swung  to  the  opposite  side,  and  anterior  to  its 
normal  position,  the  pressure  exerted  by  an  early  repaired  lip  will  often  cor- 
rect the  condition.  Until  the  deciduous  incisors  have  erupted  it  is  difficult 
to  determine  how  far  the  intermaxillary  bone  really  protrudes;  and  it  is  often 
surprising  to  observe  how  Httle  correction  is  needed  in  w^hat  had  appeared  to 
be  marked  protrusion  of  the  premaxilla  in  a  unilateral  or  bilateral  cleft.  If 
in  doubt  about  this  point  it  is  better  to  wait  until  the  eruption  of  the  decidu- 
ous incisors,  when  one  may  decide  with  certainty  whether  there  is  enough 
anterior  protrusion  to  warrant  the  closure  of  the  lip  before  operation  on  the 
palate.  Early  closure  of  the  cleft  of  the  lip  brings  very  considerable  pressure 
to  bear,  especially  in  double  cleft  or  the  typical  hareHp,  as  the  lateral  portions 
are  comparatively  short  and  the  lip  is  usually  quite  tense.  Sometimes  this 
pressure  is  quite  efficient,  when  exerted  upon  these  cases  of  protrusion  of  the 
premaxilla,  which  are  frequent,  and  of  lateral  separation  of  the  maxillae,  which 
are  infrequent;  but  when  such  pressure  is  exerted  upon  cases  without  protru- 


920  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

sion  or  separation,  it  produces  an  unfortunate  postoperative  deformity,  and 
one  that  is  too  frequently  encountered.  It  causes  the  alveolar  arch  to  lose  its 
parabolic  curve,  and  what  should  be  an  arch  is  frequently  V  shaped  or  tri- 
angular, and  not  infrequently  the  cuspid  teeth  are  closely  approximated.  One 
thus  gets  marked  flattening  of  the  anterior  lateral  region  of  the  face  or  cheek, 
with  loss  of  contour  and  position  of  the  upper  lip  and  apparent  protrusion  of 
the  lower  lip  and  chin.  It  is  true  that  such  a  postoperative  deformity  can  be 
corrected  by  modern  orthodontic  methods,  but  it  is  better  to  prevent  it  than  to 
be  obliged  subsequently  to  correct  it. 

From  the  preceding  remarks  it  is  evident  that  it  is  to  be  regarded  as  ad- 
visable in  many  cases  to  close  the  cleft  in  the  soft  and  hard  palates  before 
operating  upon  the  lip.  The  best  time  for  operating  is  just  before  the  patient 
begins  to  employ  articulate  speech.  In  most  cases  the  cleft  in  the  alveolar 
process,  including  the  floor  of  one  or  both  nares,  should  be  repaired  separately, 
and  subsequently  to  the  repair  of  the  hard  and  soft  palates.  A  comparatively 
short  time  after  operating  upon  the  palate  the  lip  may  be  repaired,  and  the 
lip  also  should  be  repaired  before  the  establishment  of  articulate  speech. 
An  advantage  in  operating  with  the  harelip  still  unclosed  is  that  one  can  see 
better  and  work  better  during  the  operation  on  the  palate,  and  can  give  the 
palate  better  local  care  after  the  operation.  Unfortunately,  however,  many 
children  with  cleft  palates  are  never  brought  for  advice  until  they  have  cul- 
tivated articulate  speech.  It  is  always  very  difficult  and  often  impossible 
to  correct  the  manner  of  speaking  that  they  have  taught  themselves.  Only 
long  training  and  much  perseverance  is  of  any  avail.  The  earlier  the  opera- 
tion is  performed,  the  better  will  be  the  result — not  only  from  the  functional 
standpoint,  but  also  as  regards  the  correction  of  existing  deformity  and  the 
prevention  of  future  deformity.  So  far  as  obtaining  good  surgical  results  go 
there  is  practically  no  set  age  limit. 

If  operation  is  refused  for  cleft  of  the  hard  palate,  if  it  offers  no  real  hope, 
or  if  it  is  very  dangerous,  an  obturator  must  be  worn.  An  obturator  is  made 
by  a  dentist.  In  preparing  a  child  for  operation  I  follow  Edmund  Owen's 
rules,  viz. :  Have  the  child  in  the  best  condition,  free  from  cough  and  stomach 
disorder.  Operate  in  summer.  Place  the  child  under  the  charge  of  a  nurse 
several  days  before  the  operation. 

Operation  for  Suture  of  the  Soft  Palate  {Staphylorrhaphy) . — The  operation 
of  staphylorrhaphy,  which  is  applied  to  clefts  of  the  soft  palate  alone,  is  a 
comparatively  easy  procedure.  In  performing  this  operation  the  patient 
should  be  anesthetized  and  be  placed  in  the  Trendelenburg  position,  or  else 
with  the  head  hanging  over  the  end  of  the  operating  table.  The  mouth  is 
held  open  by  Whitehead's  gag,  and  an  assistant  holds  an  electric  light  and 
a  reflector  to  iUuminate  the  oral  cavity.  If  the  patient  is  not  a  young  child, 
the  operation  may  be  done  under  cocain,  with  the  subject  sitting  erect  in  a 
chair  and  the  surgeon  sitting  directly  in  front  of  him. 

The  surgeon  should  have  at  hand  several  knives  of  different  shapes.  The 
double-edged,  pointed  knife  is  an  excellent  one  for  freshening  the  margins 
of  the  palate.  Special  forms  of  needle-holders  have  been  devised  for  the 
purpose  of  carrying  the  needle.  The  heavy,  curved,  sharp-pointed  bis- 
toury is  the  best  instrument  for  dividing  the  muscles  of  the  palate;  and  a 
sharp  hook  should  be  at  hand,  in  order  to  catch  the  edge  of  the  cleft,  if  neces- 
sary. 

The  surgeon  first  of  aU  separates  the  soft  palate  from  the  posterior  edge 
of  the  palate  bones  and  from  the  nasal  mucous  membrane.  This  step  is 
necessary  in  order  that  the  edges  may  meet  in  the  middle  line  (Berry).  One 
edge  of  the  cleft  uvula  is  now  grasped  with  a  pair  of  forceps  or  a  sharp  hook, 
and  is  pulled  upon  to  make  it  tense.     This  edge  is  then  pared  from  below 


Harelip  and  Cleft-palate 


921 


upward,  the  piece  being  continuous  from  the  base  to  the  apex  of  the  cleft.  This 
piece  is  severed,  and  then  the  other  margin  of  the  cleft  is  pared  in  the  same  way. 
It  is  now  ad\'isable  to  free  the  margins  of  the  wound  from  tension.  These 
lateral  incisions  not  only  relieve  tension,  but  temporarily  paralyze  the  soft 
palate.  Figures  580  and  581  show  the  incisions  as  recommended  by  Berry. 
These  incisions  divide  the  tendons  of  the  levator  palati  and  the  palatophar- 
yngeus  muscles  and  temporarily  paralyze  the  palate.  The  impairment  of 
palate  function  is  not  permanent,  as  the  nerves  to  the  muscles  are  not  cut. 

The  sutures  are  inserted  by  means  of  a  special  needle-holder,  so  arranged 
that  the  needle  may  be  directed  in  many  ditierent  positions  when  grasped. 
The  sutures  are  introduced  from  below  upward,  silkworm-gut  being  used 
for  the  uvula  and  the  lower  part  of  the  velum,  and  silver  -^are  for  the  balance 
of  the  cleft.  Each  sutiu*e,  as  it  is  passed,  is  tied  or  twisted,  and  it  is  not 
cut  oft"  until  the  next  suture  is  inserted,  and  thus  serves  as  a  handle.  If  there 
is  too  much  tension  to  allow  of  the  su- 
tures being  tied  as  they  are  inserted,  all 
the  sutures  are  passed  and  lightly  twisted 
before  one  is  tied. 


Fig.  5S0. — Cleft  of  soft  and  part  of  hard 
palate.  Shows  exact  situation  in  which  the  lat- 
eral incisions  should  be  made  (Berry). 


Fig.  581. — Semidiagrammatic  view  of  complete 
left  cleft  palate.  The  septum  nasi  is  attached  to 
the  palate  on  the  (patient's)  right  side.  The  mu- 
cous membrane  on  the  left  side  of  the  septum  may 
be  detached  and  brought  down  if  necessary  to 
help  in  the  closure  of  the  anterior  half  of  the  cleft. 
Shows  exact  situation  in  which  the  lateral  incisions 
should  be  made  (Berry). 


Closure  of  Clefts  in  the  Hard  Palate  {Uranoplasty). — ^As  prcA^iously  stated, 
the  best  time  to  perform  these  operations  is  during  the  second  year  of  life. 
In  some  few  cases  we  postpone  the  operation  until  the  end  of  the  third  year. 
If  the  child  learns  to  talk  ^\-ith  the  palate  cleft,  articulation  will  never  be  very 
greatly  improved,  even  by  operation.  One  should,  therefore,  try  to  operate 
before  the  child  learns  to  talk.  Even  after  the  closure  of  the  cleft  the  speech 
does  not  become  entirely  normal;  in  fact,  as  Berr}'  says,  it  never  becomes 
even  very  good.  One  should  exercise  the  greatest  care  in  forming  the  soft 
palate,  because  good  articulation  is  largely  dependent  upon  a  well-formed  soft 
palate  (Berry,  in  "Brit.  Med.  Jour.,"  Oct.  7,  1905).  The  surgeon  may  be  able 
to  close  the  entire  gap  at  one  operation;  or,  0"v\ing  to  undue  tension,  he  may 
be  forced  to  close  it  but  partly,  completing  the  closure  at  some  subsequent 
period. 

The  operation  that  to  my  mind  is  the  best  is  one  that  uses  the  soft  tissues 
alone — such  a  one  as  is  advised  by  Berry.  I  have  entirely  abandoned  the 
operation  of  wedging  the  bone  over  with  a  chisel.       I  am  satisfied  that  it 


922  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


is  far  more  dangerous  than  is  the  other  method;  it  is  more  hable  to  fail;  and, 
if  it  fails  because  of  necrosis,  it  is  difficult  or  impossible  to  cure  the  defect 
by  a  second  operation.  The  essence  of  a  successful  operation,  using  the 
soft  tissues  alone,  is,  as  Berry  insists,  the  complete  detachment  of  the  soft 
palate  from  the  posterior  edge  of  the  palate-bone  (Fig.  582),  because,  if  one 
fails  to  secure  this,  the  edges  of  the  gap  will  not  approximate  in  the  median 
line.  One  should  also  separate  the  soft  palate  from  the  mucous  membrane 
of  the  nose  (Fig.  582). 

A  second  very  important  point  is  the  imperative  necessity  of  making  inci- 
sions to  the  sides  to  relieve  tension  and  to  paralyze  for  a  time  the  soft  palate. 
The  incisions,  as  recommended  by  Berry,  are  shown  in  Figs.  580,  581.     The 

cut  is  close  to  the  teeth,  and  is 
taken  as  far  posterior  as  the  middle 
of  the  soft  palate,  at  the  junction 
of  that  structure  with  the  lateral 
pharyngeal  wall.  In  this  cut  there 
is  some  risk  of  dividing  the  anterior 
palatine  artery,  but  hemorrhage 
from  this  vessel  can  be  arrested  by 
pressure.  Berry  insists  that  the 
incision  need  not  go  forward  more 
than  the  level  of  one  or  two  pre- 
molar teeth;  or,  in  older  children, 
to  the  first  or  second  molars.  The 
edges  of  the  fissure  are  pared  on 
each  side,  from  the  tip  of  the  uvula 
to  the  top  of  the  gap.  Strips  of  the 
mucoperiosteum  are  hfted  up  on 
each  side  of  the  gap  and  shifted  to- 
ward the  cleft,  and  at  this  stage  the 
posterior  border  of  the  soft  palate  is 
separated  from  the  posterior  border 
of  the  hard  palate  (Fig.  582). 
The  parts  are  sutured  with  silver  wire,  following  the  advice  of  Edmund 
Owen  to  twist  and  cut  each  wire,  leaving  an  end  ^  inch  in  length.  This  pro- 
cedure causes  the  child  to  keep  his  tongue  from  the  suture  line. 

For  the  first  twenty-four  hours  only  water  is  given.  After  this  period 
the  patient  is  fed  with  jelly  and  liquids.  Only  fluid  or  soft  food  is  used  for 
two  or  three  weeks.  Talking  is  forbidden.  A  day  or  two  after  the  operation 
the  child  should  be  taken  into  the  open  air  and  kept  in  it  all  day.  As  Owen 
shows,  this  greatly  stimulates  vital  resistance  and  lessens,  to  a  considerable 
extent,  the  danger  of  sloughing  of  the  suture  line.  The  mouth  is  washed  fre- 
quently, and  always  after  taking  food,  with  Condy's  fluid.  The  sutures  are 
allowed  to  remain  between  two  and  three  weeks. 

^^V  William  Fergusson's  Operation. — In  this  operation  the  mucous  edges  are 
pared,  the  bones  are  drilled  for  wires,  and  the  sutures  are  inserted,  but  not  tied. 
An  incision  is  made  on  each  side  of  the  cleft  down  to  the  bone,  each  incision 
being  midway  between  the  cleft  and  the  corresponding  alveolus.  The  bone  is 
divided  on  each  side,  by  means  of  a  chisel,  to  the  full  length  of  the  incision; 
and  the  chisel  is  used  as  a  lever  to  force  each  half  of  the  bone  toward  the  gap. 
The  sutures  are  tied,  and  each  lateral  incision  is  plugged  with  iodoform  gauze. 
Brophy^s  Operation. — This  operation  is  employed  particularly  for  children 
under  three  months  of  age,  and  cannot  be  used  when  the  child  is  over  six  months. 
In  this  operation  the  palate  is  closed  before  the  harelip  is  touched.  Operat- 
ing at  this  time  the  bones  are  soft,  and   by  leaving  the  harelip  untouched 


Fig.  582. — ^Longitudinal  vertical  section  through  the 
hard  and  soft  palates:  a,  Before  operation ;  b,  pal- 
atine mucoperiosteum  detached  and  brought  down, 
blades  of  scissors  introduced  to  cut  attachment  of  soft 
palate  to  the  bony  palate  and  to  the  nasal  mucous 
membrane;  c,  the  same  after  the  cut  has  been  made 
and  the  soft  palate  thus  brought  down  (Berry). 


Carcinoma  of  the  Lower  Lip  923 

the  surgeon  has  more  room  to  work.  The  author  of  the  operation  beUeves 
that  when  it  is  performed  at  this  early  age  the  palate  muscles  do  not  atrophy, 
but  develop,  and  that  the  patient  does  not  form  the  evil  habit  of  talking  through 
the  nose. 

In  performing  this  operation  the  very  strong-handled  needles  of  Brophy 
are  necessary.  The  patient  is  anesthetized  and  put  into  the  Trendelenburg 
position  and  a  strong  piece  of  silk  is  put  through  the  tip  of  the  tongue  as  a 
traction-suture.  The  edges  of  the  cleft  in  the  hard  palate  are  pared,  a  little 
of  the  bone  being  taken  away  with  the  paring.  Then  the  edges  of  the  cleft  in 
the  soft  palate  are  pared.  The  needle  is  threaded  with  strong  silk;  the  cheek 
is  lifted,  and  the  threaded  needle  is  forced  through  the  superior  maxillary 
bone  from  without  inward,  starting  just  back  of  the  malar  process  and  just 
above  the  palate.  As  the  needle  shows  in  the  cleft  the  thread  is  picked  up 
with  a  pair  of  forceps,  and  the  needle  is  pulled  out,  the  loop  of  thread  remain- 
ing in  the  cleft.  Through  a  part  of  the  opposite  superior  maxillary  cor- 
responding with  this  first  point  of  entrance  the  needle  is  entered  again  and 
another  loop  is  got  into  the  cleft.  The  second  loop  is  caught  into  the  first 
loop,  and  when  the  former  is  pulled  out  it  carries  the  latter  with  it.  This 
thread  now  passes  through  both  the  superior  maxillary  bones  and  usually 
through  the  nasal  septum  as  well.  This  thread  is  used  to  pull  a  piece  of  strong 
silver  wire  through.  One  other  silver  wire  is  introduced  in  the  same  manner 
more  to  the  front.  The  silver  wire  ends  are  threaded  through  perforated  lead 
plates,  which  fit  the  external  outline  of  the  bones  on  each  side.  The  wires  are 
tightened  and  twisted.  For  instance,  on  one  side  the  end  of  the  anterior 
wire  is  twisted  to  the  end  of  the  posterior  wire,  and  so  on.  The  thumbs  are 
used  to  jam  the  two  ends  of  the  maxillary  bones  forcibly  together,  thus  closing 
the  cleft,  and  then  the  wires  are  twisted  more  firmly  to  hold  the  edges  in  con- 
tact. The  cleft  in  the  soft  palate  is  then  sutured,  although  the  surgeon  may 
deem  it  advisable  to  wait  one  day  before  doing  so.  After  the  palate  heals  the 
harelip  is  closed. 

Carcinoma  of  the  Lower  Lip. — Cancer  frequently  arises  in  the  lower  lip, 
very  rarely  in  the  upper  lip.  Males  suffer  frequently,  but  females  are  not 
very  often  attacked.  In  some  cases  it  seems  to  arise  in  smokers  at  the  point 
on  the  lip  where  the  pipe  habitually  rests.  A  short-stemmed  clay  pipe, 
which  grows  hot  when  it  is  smoked,  is  particularly  apt  to  lead  to  the  causal 
irritation.  The  region  of  the  lip  which  is  most  liable  to  cancer  is  the  junc- 
tion of  the  skin  and  mucous  membrane.  The  growth  may  begin  in  a  fissure  or 
abrasion,  may  start  in  an  eczematous  area,  but  most  frequently  arises  as  an  in- 
durated area  which  quickly  ulcerates.  After  a  cancer  has  existed  for  a  variable 
time  the  submental,  submaxillary,  and  cervical  lymphatic  glands  become  dis- 
eased. These  glands  are  usually  involved  within  three  months  of  the  beginning 
of  the  cancer.  In  a  case  of  my  own  they  were  found  to  contain  carcinoma 
cells  in  less  than  three  months  after  the  origin  of  the  carcinoma  of  the  lip.  This 
involvement  cannot  be  detected  by  external  manipulation  in  the  earliest 
stages,  hence  it  is  not  proper  to  conclude  that  the  glandular  involvement 
is  absent  simply  because  it  cannot  be  palpated.  It  occasionally  happens 
that  glands  enlarge  because  of  septic  absorption,  and  this  enlargement  rnay 
even  precede  carcinomatous  involvement.  From  an  operative  point  of  view 
the  glands  should  always  be  regarded  as  carcinomatous.  If  cancer  is  not  oper- 
ated upon  it  destroys  the  lip,  extensively  involves  the  glands  of  the  neck,  the 
floor  of  the  mouth,  the  periosteum  and  the  lower  jaw,  and  produces  death  in 
from  three  to  five  years.  If  the  jaw  is  involved  the  prognosis  is  bad,  and  it  is 
almost  hopeless  if  the  floor  of  the  mouth  is  involved. 

The  treatment  consists  in  the  early  and  thorough  removal  of  the  growth 
by  the  knife,  and  also  in,  the  removal  of  the  fatty  tissue  and  glands  from  the 


924  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

submaxillary  triangles,  from  the  submental  region,  and  down  to  the  carotid  bi- 
furcation. The  growth  must  be  thoroughly  removed,  that  is,  the  incision  must 
be  at  least  |  inch  wide  of  the  disease.  For  many  years  a  favorite  operation  was 
the  V-shaped  incision,  the  skin  edges  being  sutured  by  silkworm-gut,  the  sutures 
being  passed  almost  to  the  mucous  membrane  and  being  inserted  so  as  to  com- 
press the  vessels  when  tied,  and  the  mucous  membrane  being  sutured  with  fine 
silk  or  catgut.  The  V-shaped  incision  should  be  used  only  for  a  very  small  and 
very  recent  growth.  After  the  removal  of  the  growth  from  the  lip  a  vertical  in- 
cision is  made  from  the  point  of  the  V  over  the  cricoid  cartilage,  and  from  the 
origin  of  this  incision  incisions  are  made  in  each  direction  along  the  under  surface 
of  the  body  of  the  jaw.  The  glandular  area  is  thus  exposed,  and  after  the  re- 
moval of  the  fat  and  glands  the  wound  is  sutured  with  silkworm-gut.  Far  better 
than  the  V-shaped  incision  is  the  operation  devised  by  W.  W.  Grant,  of  Den- 
ver.^ In  this  operation  the  growth  is  removed  and  cheiloplasty  is  performed. 
Granfs  Operation  for  Cancer  of  the  Lip. — This  operation  gives  a  useful 
mouth  and  a  more  natural-looking  lip  than  does  the  ordinary  operation,  and 
there  is  decidedly  less  tension  on  the  suture  Hne.  Furthermore,  the  suture 
line  in  a  man  is  apt  to  be  soon  covered  with  a  beard.    The  procedure  has 


Fig.  583. — Grant's  method  for  removal  of  car- 
cinoma of  the  lower  lip.    The  incision. 


Fig.  584. — Grant's  method  for  removal  of  car- 
cinoma of  the  lower  lip.  Second  step.  The  mass 
removed. 


great  advantages  over  the  ordinary  V-shaped  operation,  which  greatly  lessens 
the  size  of  the  mouth,  making  it  what  is  known  as  a  sucker-mouth,  and  the 
new  lip  is  rigid  and  ugly. 

In  Grant's  operation  two  vertical  incisions  are  made,  one  on  each  side 
of  the  growth,  and  these  are  connected  by  a  horizontal  incision  at  the  base 
(Figs.  583,  584).  Thus,  a  quadrangular  gap  is  formed,  which  must  be  filled 
by  flaps.  An  incision  is  made  on  each  side  from  each  inferior  angle  of  the 
woimd,  obliquely  downward  and  backward  beneath  the  maxilla,  on  a  line 
about  midway  between  the  angle  of  that  bone  and  the  apex  of  the  chin  (Fig. 
583).  Its  further  extension  is  determined  by  the  amount  of  lip  removed  and 
by  the  degree  of  glandular  involvement. 

The  submaxillary  lymph-glands  are  removed  through  these  incisions. 
The  glands  in  the  midline,  however,  beneath  the  chin  may  require  a  separate 
incision.  If  the  lip  is  extensively  involved,  the  cheek  ought  to  be  completely 
separated  from  the  inferior  maxillary  bone  to  the  middle  of  the  masseter  mus- 
cle (Fig.  585).  When  the  glands  have  been  removed,  the  triangular  flaps  are 
brought  together  and  united,  first  of  all,  in  the  middle  line  (Fig.  586).  If  the 
tension  is  marked,  owing  to  the  amount  of  tissue  excised,  it  is  wise  to  insert 
1"  Medical  Record,"  May  27,  1899. 


Tongue-tie 


925 


a  traction  suture,  f  inch  from  the  center  line,  and  tie  it  over  pads  of  gauze 
covered  with  mushn.  One  thus  prevents  undue  tension  upon  the  sutures  in 
the  center  of  the  flap.  The  stitches  that  unite  the  cheek  posteriorly  are 
inserted  and  tied,  and  the  entire  thickness  of  the  cheek  must  be  included. 
Silkworm-gut  sutures  are  used.  A  drainage-tube  is  inserted  in  the  posterior 
angle  of  the  wound  on  each  side.  It  is  very  useful  to  use  also  a  T-drainage- 
tube  as  advised  by  Grant.  This  tube  is  about  the  diameter  of  a  lead  pencil 
and  the  cross-piece  rests  behind  the  incisor  teeth  or  symphysis  and  beneath  the 
tip  of  the  tongue.  It  drains  away  all  of  the  mouth  secretions,  saves  the  lines 
of  incision  from  being  constantly  bathed  in  them,  and  renders  very  frequent 
changes  of  dressing  unnecessary. 

I  have  employed  this  operation  repeatedly,  and  regard  it  as  the  most  use- 
ful method  we  have  for  the  purpose.  Thorough  removal  of  the  carcinoma 
of  the  lip  and  of  the  related  glands  will  cure  from  60  to  70  per  cent,  of  cases. 

Carbuncle  of  the  Upper  Lip. — In  contrast  to  carbuncle  in  other  regions 
of  the  body,  facial  and  labial  carbuncles  are  most  common  in  young  persons. 
Carbuncle  of  the  lip  is  due  to  staphylococcus  infection  and  begins  as  a 
papule.    Numerous  pustules  appear,  and  sloughing  usually  takes  place.    There 

may  or  may  not  be  serious  constitu- 
tional involvement.     The  condition  is 


Fig.  585. — Grant's  method  for  removal  of 
carcinoma  of  the  lower  lip.  Dissection  pre- 
liminary to  suturing. 


Fig.  586. — Grant's  method  for  removal  of 
carcinoma  of  the  lower  hp.  The  wound  su- 
tured. 


very  dangerous,  as  thrombophlebitis  may  arise  and  track  up  into  the  cranium 
by  way  of  the  ophthalmic  vein  and  cavernous  sinus.  I  have  known  two 
persons  to  die  from  carbuncle  of  the  lip. 

Treatment. — Excise  if  possible.  If  excision  is  impossible,  make  a  crucial 
incision,  cutting  away  the  corners  and  edges  with  scissors.  Scrape  out  the 
carbuncle  with  a  sharp  and  strong  curet,  swab  with  pure  carboHc  acid,  pack 
with  iodoform  gauze,  and  dress  with  antiseptic  poultices. 

Tongue-tie  {congenital  ankyloglossia  or  adherent  tongue)  is  congenital 
shortness  of  the  frenum,  the  tip  of  the  tongue  adhering  to  the  floor  of  the 
mouth.  It  is  due  to  the  projecting  portion  of  the  tongue  being  incompletely 
developed  from  the  tuberculum  impar.  "In  many  of  the  slighter  cases  the 
development  has  merely  lagged  behind,  and  will  be  completed  as  the  child 
grows  after  birth"  ("Diseases  of  the  Tongue,"  by  Henry  T.  Butlin,  Second 
Edition).  The  tongue  cannot  be  protruded  beyond  the  incisor  teeth.  Swal- 
lowing is  interfered  with,  and  later  in  life  articulation  is  impeded.  It  is  not 
very  unusual  in  infants,  but  in  the  great  majority  of  cases  disappears  as  the 


926 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


child  grows  older.  Persisting  tongue-tie,  Butlin  says,  is  one  of  the  rarest 
of  conditions,  and  my  experience  is  in  absolute  accord  with  his — in  fact,  I 
have  never  seen  a  single  case.  Many  unnecessary  or  even  harmful  operations 
are  done  for  a  condition  which,  if  let  alone,  will  usually  correct  itself.  Im- 
proper operation  may  result  in  fatal  hemorrhage  or  in  ''swallowing  of  the 
tongue."  The  operation  usually  done  is  to  tear  up  the  frenum  with  a  thumb- 
nail. This  is  unsurgical  and  makes  a  lacerated  wound.  A  better  way  is  to 
raise  the  tip  of  the  tongue  to  make  the  bands  tense,  and  then  snip  with  the 
scissors  close  to  the  mucous  membrane  of  the  lower  jaw.  The  slit  in  the 
handle  of  the  grooved  director  was  placed  there  to  catch  the  frenum  in,  but  a 
short  frenum  will  not  enter  it  (Butlin). 

Ranula  is  a  retention-cyst  of  the  duct  of  the  submaxillary  or  the  duct  of 
the  subungual  gland.  A  ranula  when  first  formed  contains  saliva,  but  after  a 
time  the  saliva  undergoes  a  change,  and  in  appearance  comes  to  resemble 
mucus.  Mucous  cysts  occur  in  the  floor  of  the  mouth,  resulting  from  obstruc- 
tion of  the  ducts  of  the  mucous  glands  of  Nuhn  and  Blandin.  These  glands, 
lie  on  each  side  of  the  frenum  of  the  tongue.  Such  a  cyst  is  often  spoken  of  as 
a  ranula.     A  cyst  of  the  incisive  gland  forms  just  back  of  the  lower  jaw  and 

lifts  up  the  frenum.  A  true  ranula 
appears  upon  the  floor  of  the  mouth 
on  one  side  and  pushes  the  tongue 
toward  the  opposite  side  (Fig.  587). 
The  treatment  of  a  mucous  cyst  is 
by  excision  of  a  portion  of  the  cyst 
wall  and  cauterization  of  the  interior 
with  pure  carbolic  acid;  or  by  cut- 
ting a  flap  from  the  cyst  wall  and 
stitching  it  aside  so  as  to  keep  a  per- 
manent opening.  Such  an  opera- 
tion may  cure  a  genuine  ranula, 
but  will  often  fail.  In  true  ranula 
an  external  incision  should  be  made, 
and  through  this  both  the  cyst  and 
the  gland  should  be  removed.  This 
plan  is  recommended  by  Mintz.^ 
Thyrolingual  or  Thyroglossal  Cysts  and  Sinuses. — In  early  embryonal 
life  the  thyroid  gland  has  a  duct  which  passes  from  the  thyroid  isthmus  to 
the  foramen  caecum  of  the  dorsum  of  the  tongue.  The  duct  may  be  lined  witL 
one  layer,  two  layers,  or  several  layers  of  epithelium,  and  there  are  mucous 
glands  and  lymph-follicles  in  its  walls,  these  structures  being  derived  from 
the  mucous  membrane  of  the  tongue.  The  wall  of  the  duct  presents  numerous 
irregularly  placed  and  irregularly  shaped  diverticula.  It  is  known  as  the  thyro- 
glossal or  thyrolingual  duct.  The  duct  runs  from  the  base  of  the  tongue  down 
the  midline  of  the  neck.  It  is  connected  with  the  body  of  the  hyoid  bone,  with 
the  periosteum  in  front  of  the  bone,  and  with  the  thyrohyoid  bursa  behind  the 
bone.  It  passes  to  the  upper  portion  of  the  front  surface  of  the  trachea,  where  it 
bifurcates,  each  branch  passing  to  a  lateral  lobe  of  the  thyroid  gland.  This 
fetal  structure  under  normal  conditions  begins  to  atrophy  in  the  fifth  week  and 
closes  by  the  eighth  week,  the  foramen  caecimi  marking  its  old  orifice  on  the  dor- 
sum of  the  tongue.  When  the  duct  is  obliterated,  it  becomes  a  cord  of  epithe- 
lium. In  more  than  30  per  cent,  of  bodies  the  remains  of  this  primitive  passage 
can  be  found  (Weglowski,  in  "Zentralb.  f.  Chir.,"  1908,  xxxv,  289).  The  duct 
may  persist  between  the  foramen  caecum  and  the  hyoid  bone,  developing, 
it  may  be,  into  a  sublingual  dermoid.  The  portion  behind  and  below  the 
^  "  Zeitschrift  fiir  Chirurgie,"  March,  1899. 


Fig.  587. — Ranula. 


Carcinoma  of  the  Tongue  927 

hyoid  may  remain  and  develop  into  a  subhyoid  cyst.  The  part  inferior  to  the 
hyoid  may  persist,  give  origin  to  a  cyst  which  ruptures,  and  constitute  an  in- 
complete median  cervical  fistula.  The  duct  may  remain  open  from  the  mouth 
and  make,  by  bursting  an  opening  in  the  neck,  a  complete  median  cervical  fistula. 
A  patent  duct  may  exist  for  years  and  announce  its  existence  by  some  acute 
inflammatory  process.  The  small  diameter  of  a  cervical  fistula  renders  prob- 
ing to  any  depth  impossible.  Some  have  told  us  to  determine  if  a  fistula  is 
complete  by  injecting  quassia  solution  into  the  lower  end.  The  patient  will 
perhaps  experience  a  bitter  taste.  If  we  inject  a  colored  fluid  we  may  see  it  if 
it  runs  from  the  mouth.  I  have  never  succeeded  in  doing  either.  Tumors 
may  spring  from  the  duct. 

Treatment. — If  a  thyroglossal  cyst  or  tumor  arises  on  the  dorsum  of  the 
tongue,  and  if  it  is  increasing  in  size  and  interferes  with  swallowing  and  speech, 
it  must  be  removed  through  the  mouth.  A  general  anesthetic  should  be  given. 
In  some  cases  preliminary  tracheotomy  is  necessary. 

A  cyst,  timior,  or  fistula  about  the  hyoid  bone  requires  excision,  the  patient 
being  under  the  influence  of  a  general  anesthetic.  A  portion  of  the  cyst  wall 
adheres  strongly  to  the  posterior  surface  of  the  hyoid  bone  and  must  be  care- 
fully removed  even  if  it  is  necessary  to  split  the  bone  to  accomplish  it.  In 
treating  fistula  the  surgeon  makes  an  elliptical  incision  of  the  skin  about  its 
orifice  so  as  to  free  the  fistula  from  the  subcutaneous  tissue.  When  traction 
is  made  upon  the  cutaneous  end  of  the  duct  it  will  stand  out  clearly  and  can  be 
dissected  out  (M.  S.  Seelig,  in  "Surg.,  Gynecol,  and  Obstet.,"  May,  1907). 
It  is  useless  to  tr}^  to  cure  a  fistula  by  cauterization.  A  fistula  requires  the 
complete  removal  of  its  epithelial-lined  walls.  No  lesser  operation  will  cure. 
In  I  case  I  operated  four  times  before  securing  success.  In  another  case 
I  divided  the  hyoid  bone,  removed  the  fistula,  sutured  the  bone  by  chromic 
gut,  and  obtained  a  cure. 

Carcinoma  of  the  Tongue.— This  is  one  of  the  most  dreadful  forms  of  cancer. 
It  is  a  quite  common  disease.  In  most  of  the  cases  I  see  it  is  far  advanced 
when  first  brought  to  the  hospital.  The  only  form  of  cancer  which  attacks  the 
tongue  is  epithelioma.  It  is  much  more  common  in  men  than  in  women.  It  is 
a  disease  of  adult  life  and  is  very  rare  before  the  age  of  thirty-five.  It  begins, 
as  a  rule,  near  the  tip,  on  the  side  or  at  the  base  of  the  anterior  two-thirds  of 
the  tongue,  as  a  warty  growth,  as  an  ulcer  having  at  first  a  papillary  struc- 
ture, as  a  fissure  which  indurates,  or  as  an  indurated  area  which  ulcerates. 
The  cause  of  the  growth  may  sometimes  be  traced  to  the  irritation  of  a  jagged 
tooth  or  an  ill-fitting  plate,  or  to  the  smoking  of  a  pipe,  or  to  holding  nails  in 
the  mouth,  as  is  done  by  those  who  nail  laths.  Cancer  may  follow  a  chronic  in- 
flammation— leukoplakia,  for  instance.  Chronic  ulcers  are  liable  to  become  can- 
cerous and  any  indurated  ulcer  has  potentialities  of  deadly  peril  and  should  be 
promptly  removed.  Fournier  regards  s3TDhilis  as  an  influential  cause,  and  states 
that  in  184  cases  of  cancer  of  the  mouth  or  tongue  155  had  had  syphilis.  There 
has  been  no  such  proportion  of  syphilitics  in  my  personal  cases.  In  White- 
head's 104  cases  only  7  had  had  s>T3hilis.  As  in  cancer  of  the  lip,  men  are 
much  more  frequently  affected  than  women.  In  most  cases  the  disease 
spreads  rapidly;  produces  early  and  extensive  glandular  involvement;  disease 
of  the  floor  of  the  mouth;  dribbling  of  saliva;  difficulty  in  masticating, 
swaUowing,  and  talking;  foulness  of  the  breath;  severe  pain  which  usually 
radiates  toward  the  ear,  and  often  a  fatal  septic  trouble.  Cases  not  operated 
upon  usuaUy  die  decidedly  within  two  years.  There  is  a  very  rare  form  of  car- 
cinoma described  by  Wolfler,  which  grows  very  slowly  or  even  remains  latent 
for  years. 

One  reason  why  cancer  of  the  tongue  grows  so  rapidly  has  been  pointed  out 
by  Heidenhain,  of  Greifswald.     The  lingual  muscles  are  contracting  almost 


928  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

constantly,  and  as  a  result  cancer-cells  are  forced  along  the  lymph-spaces  to 
healthy  areas. 

Treatment. — A  cancer  of  the  tongue  should  be  removed  radically  at  the 
earhest  possible  moment.  Specific  treatment  for  diagnostic  purposes  should 
not  be  continued  beyond  a  very  few  weeks.  In  doubtful  cases  a  Wassermann 
test  is  made,  and  if  it  is  positive,  salvarsan  is  given  intravenously.  If  still  in 
doubt  as  to  the  nature  of  the  growth,  remove  it  and  have  a  pathologist  at  hand 
to  immediately  study  it  by  frozen  sections  (Warren,  in  "Annals  of  Surger}%" 
Oct.,  1908).  Have  permission  beforehand  to  proceed  at  once  to  radical  opera- 
tion if  conditions  demand  it.  The  study  of  a  small  piece  is  always  of  uncer- 
tain value,  hence,  take  out  the  growth.  Whatever  it  is,  it  should  be  removed. 
Before  any  operation  is  undertaken  all  stumps  of  teeth  should  be  extracted 
and  a  dentist  should  clean  tartar  from  the  teeth.  During  several  days  pre- 
ceding an  operation  the  teeth  should  be  scrubbed  twice  a  day  with  a  brush 
and  soap  and  the  mouth  rinsed  with  hydrogen  peroxid.  The  nares  and  naso- 
pharynx should  be  sprayed  with  peroxid  of  hydrogen  and  then  with  boric  acid 
solution  every  second  or  third  hour  when  the  patient  is  awake. 

In  some  cases  the  entire  tongue  is  removed;  in  some,  half  of  it;  in  some,  only 
a  piece  of  it.  Not  only  the  diseased  tongue,  but  also  the  adjacent  lymphatic 
glands  must  be  removed.  Cancer  of  the  tip  of  the  tongue,  as  a  rule,  involves  the 
submental  and  sublingual  group  of  glands  early.  Cancer  of  the  anterior  two- 
thirds  of  the  dorsum  of  the  tongue  first  involves  the  lingual  and  submaxillary 
lymph-nodes.  Cancer  of  the  under  surface  of  the  tip  of  the  tongue  first  in- 
volves the  submaxillary  glands.  Sooner  or  later  the  superior  deep  cervical 
glands  about  the  carotid  bifurcation  become  involved  as  a  result  of  cancer  of 
the  tip  or  edges  of  the  anterior  portion  of  the  tongue.  In  cancer  of  the  dorsum 
the  deep  cervical  glands  become  involved  as  well  as  the  superficial  nodes.  The 
l5anphatic  system  of  the  base  of  the  tongue  is  distinct  from  that  of  the  balance 
of  the  organ.     It  drains  into  the  deep  cer\dcal  groups. 

It  was  formerly  my  belief  that  in  a  very  recent  and  limited  case  only 
the  glands  on  the  diseased  side  require  removal,  but  that  in  an  advanced 
case  the  glands  must  be  removed  from  both  sides  of  the  neck.  Experience 
has  convinced  me  that  in  any  case  the  glands  on  both  sides  should  be  re- 
mioved.  Kuttner,  of  Tubingen,  has  demonstrated  that  lymph  from  one 
side  of  the  tongue  may  flow  to  glands  on  the  same  side  of  the  neck,  but  some 
also  may  flow  to  the  opposite  side  of  the  tongue.  Remove  the  obviously 
involved  glands  by  the  block  dissection  of  Crile.  In  a  bad  case  everything 
is  removed  but  the  carotid  arteries.  The  sternocleidomastoid  muscle,  the 
omohyoid,  the  jugular  vein,  even  the  pneumogastric  and  phrenic  nerves  of  one 
side  may  be  taken  away.  After  a  week  or  two  the  other  side  of.  the  neck  should 
be  operated  upon.  It  seldom  requires  a  wide  removal  of  structures.  If  the 
pneumogastric  or  phrenic  were  cut  on  one  side  it  must  be  preserved  on  the 
other.  The  jugular  vein  can  be  removed  after  a  collateral  circulation  has  been 
established  subsequent  to  remo\dng  the  jugular  of  one  side.  Two  operations 
are  to  be  considered:  partial  removal  and  complete  removal. 

Partial  Removal  of  the  Tongue. — This  operation  is  restricted  to  recent  cases 
in  which  one  side  only  of  the  anterior  portion  of  the  tongue  is  involved.  The 
operation  does  not  offer  as  good  a  chance  of  cure  as  complete  excision,  because 
lymph  containing  cancer-cells  may  have  reached  the  opposite  side  of  the 
tongue.  Even  in  partial  removal  the  glands  should  be  removed  from  both 
sides.     Intratracheal  anesthesia  is  employed. 

In  performing  the  operation  of  partial  excision  introduce  a  mouth-gag, 
pass  a  silk  ligature  through  each  half  of  the  tip  of  the  tongue,  and  draw  the 
organ  out  of  the  mouth.  Place  the  patient  recumbent  with  the  head  a  little 
raised.     Split  the  tongue  back  in  the  middle  fine  by  the  scissors,  and  loosen 


Carcinoma  of  the  Tongue 


929 


the  cancerous  side  from  the  floor  and  side  of  the  mouth.  Pass  a  stout  silk 
Ugature  through  the  base  of  the  tongue  posterior  to  the  cancer.  Draw  the 
organ  out  and  cut  off  the  diseased  side  in  front  of  the  ligature,  but  well  back 
of  the  disease.  Tie  the  vessels,  remove  the  traction  threads,  and  treat  sub- 
sequently as  in  cases  of  complete  removal. 

Complete  Removal  of  the  Tongue  {Kocker^s  Method). — Kocher  recom- 
mends a  preliminary  tracheotomy  in  tongue  excision,  but  the  Trendelenburg 
position  renders  this  procedure  unnecessary  so  far  as  fear  of  the  passage  of 
blood  into  the  larynx  and  trachea  is  concerned.  I  operated  many  times  wdth 
the  patient  in  that  position.  At  present  I  operate  mth  the  head  a  little 
raised  and  the  patient  taking  ether  by  intratracheal  insufflation.  Because  of 
the  insufilation  there  is  no  respirator}^  difficulty  and  the  stream  of  escaping 
air  and  ether  keeps  blood  out  of  the  bronchial  tubes.  The  method  is  most 
satisfactory-.  The  surgeon  stands  to  the  side.  Ether  is  given  by  intratracheal 
insufflation  (seepage  1199).  Ligate  the  lingual  artei}'  on  the  side  opposite  to 
the  one  where  the  main  incision  is  to  be  made.  Remove  the  glands  on 
that  side  and  suture  the  wound.  An  incision  is  then  made  on  the  side 
opposite  to  that  on  which  the  artery  was  ligated.  This  incision  passes 
from  behind  the  lobe  of  the  ear,  along  the  anterior  edge  of  the  sternocleido- 
mastoid to  about  the  middle  of  the  margin  of  this  muscle.  From  this 
point  the  incision  is  carried  to  the  level  of  the  hyoid  bone  and  then  to  the 
symphysis  menti,  along  the  anterior  belly  of  the  digastric  muscle  (Fig.  588). 
The  flap  is  dissected  and  turned  up;  the  facial  and  lingual  arteries  are  ligated; 
"the  submaxillary  fossa  is  evacuated"  (Treves);  the  sublingual  and  sub- 
maxillary glands  are  removed;  the  mylo- 
hyoid muscle  is  di\dded;  the  mucous  mem- 
brane is  incised  close  to  the  jaw,  and  the 
tongue,  caught  by  tenaciflum  forceps,  is 
drawn  through  the  opening.  The  tongue  is 
split  in  the  middle  by  scissors,  and  the  near 
half  is  removed,  bleeding  is  arrested,  the  re- 
maining hah  of  the  tongue  is  cut  through, 
and  the  vessels  are  tied.  Stitch  the  mucous 
membrane  of  the  stump  to  the  mucous  mem- 
brane of  the  floor  of  the  mouth  -with  catgut 
sutures.  Kocher  does  -not  suture  the  skin 
wound.  I  prefer  to  suture  it  and  employ 
drainage-tubes.  I  follow  the  suggestions  of 
Treves  as  to  after-treatment.  Some  hours 
after  the  operation,  when  oozing  has  ceased, 

dust  the  mouth  wound  -v^-ith  iodoform.  The  patient,  as  soon  as  possible,  is 
propped  up  in  bed,  and  he  must  not  swallow  the  discharges  if  it  can  be  avoided. 
The  mouth,  every  half-hour,  is  sprayed  -^ith  peroxid  of  hydrogen  and  washed 
with  a  carbolic  solution  (i  :  60).  Ever\^  three  hours,  after  washing  the  floor 
of  the  mouth  and  the  stump,  the  parts  should  be  dried  ■s\ith  absorbent  cotton 
and  dusted  Mith  iodoform.  For  twenty-four  hours  after  the  operation  nothing 
is  given  by  the  mouth  except  a  httle  cracked  ice,  the  patient  being  fed  by 
rectum.  At  the  end  of  twenty-four  or  forty-eight  hours  some  Hquid  food  is 
given  from  a  feeding-cup.  The  patient  will  soon  learn  to  swaUow;  but  if  he 
cannot  swaUow  easily,  he  is  fed  by  a  tube.  Treves,  in  his  clear  and  positive 
directions  for  after-treatment,  states  that  nutrient  enemata  are  to  be  continued 
until  sufficient  nourishment  is  taken  by  the  mouth ;  that  the  mouth  should  be 
flushed  by  irrigation,  and  must  be  washed  immediately  after  taking  food;  that 
morphin  is  to  be  avoided,  and  that  the  patient  can  usually  leave  the  hospital 
in  from  seven  to  ten  days. 

59 


Fig 


588. — Kocher's  excision  of  tongue 
(Esmarch  and  Kowalzig). 


930  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

Whitehead's  Operation. — Whitehead  removes  one-half  of  or  the  entire  tongue 
from  within  the  mouth  by  the  use  of  scissors.  He  passes  a  Ugature  through  the 
tip,  cuts  the  frenum,  draws  the  tongue  strongly  forward,  and  separates  by  a 
series  of  clips  with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "The 
stump  should  be  kept  under  control,  as  regards  hemorrhage,  by  a  stout  silk 
ligature  passed  through  the  remains  of  the  glosso-epiglottidean  fold  and  re- 
tained for  twenty-four  hours.  "^ 

Heath  has  shown  that  if  the  forefinger  be  passed  to  the  epiglottis  and  used 
to  "hook  forward"  the  hyoid  bone,  the  lingual  arteries  are  stretched  and 
portions  of  the  tongue  can  be  removed  almost  without  bleeding.  It  is  rarely 
desirable  in  WMtehead's  operation  to  remove  the  glands  and  the  tongue 
at  one  seance.  To  do  so  increases  shock  and  the  danger  of  death.  The  rule  of 
procedure  set  forth  by  W.  Watson  Cheyne-  is  eminently  wise.  This  rule  is  as 
follows:  If  glandular  involvement  is  trivial  or  not  detectable,  it  is  perfectly 
proper  to  remove  the  tongue  first,  and  after  a  week  or  so  remove  the  glands. 
If  the  glandular  involvement  is  marked,  growth  in  the  glands  will  be  much  more 
rapid  than  growth  in  the  tongue.  In  such  a  case  the  glands  should  be  removed 
before  the  tongue,  because,  if  the  tongue  is  removed  before  the  triangles  are 
cleared,  in  the  week  or  two  of  waiting  the  case  may  become  inoperable.  In  the 
majority  of  cases  clear  out  the  triangle  before  removing  the  tongue,  doing  the 
other  operation  in  one  or  two  weeks  when  the  wound  in  the  neck  is  healed.  If 
the  disease  in  the  mouth  is  far  advanced,  do  both  operations  at  one  seance. 

Examination  of  the  Esophagus. — The  .r-rays  are  of  great  value  not  only 
in  detecting  foreign  bodies,  but  in  finding  carcinoma,  pouches,  and  constric- 
tions. As  Waggett  ("Brit.  Med.  Jour.,"  Oct.  19,  1912)  says,  by  means  of  the 
a;-rays  we  may  learn  that  there  is  a  stricture  (or  are  strictures) ,  where  it  is  (or 
they  are),  how  narrow  it  is  (or  they  are),  and  whether  or  not  there  is  extrinsic 
pressure.  In  this  examination  the  patient  first  swallows  material  through 
which  the  rays  pass  with  difficulty.  A  salt  of  bismuth  is  generally  used. 
The  carbonate  of  bismuth  is  a  safe  and  satisfactory  salt.  It  is  given  in  glutoid 
capsules  (Kohler,  Ibid.). 

Esophageal  Sounds  and  Bougies. — These  instruments  were  long  our 
only  mechanical  means  of  diagnosis.  They  are  used  far  less  than  formerly. 
They  possess  certain  dangers.  For  instance,  if  an  aneurysm  exists  and  we 
are  misled  in  believing  that  the  condition  is  stricture,  the  rigid  sound  and 
even  the  flexible  bougie  may  penetrate  the  sac  of  the  aneurysm  and  cause 
death.  I  have  personal  knowledge  of  such  a  case.  If  a  person  has  ever  brought 
up  blood,  neither  a  sound  nor  bougie  should  be  used.  Again,  neither  the  bougie 
nor  sound  can  prove  the  existence  of  a  slight  stricture.  They  give  no  informa- 
tion at  all  as  to  the  nature  of  a  stricture.  I  find  their  greatest  diagnostic  use 
is  to  locate  the  situation  of  a  constriction  before  passing  the  esophagoscope.  In 
view  of  the  fact  that  such  an  examination  may  cause  bleeding,  and  that  blood 
interferes  with  an  examination  by  the  esophagoscope,  the  bougie  or  sound,  if  used 
at  all,  should  be  employed  the  day  before  the  introduction  of  the  esophagoscope. 

The  olive  tip  bougie  is  flexible,  and  is  made  from  elastic  web.  It  is  a  safer 
instrimient  than  the  bulbous  sound  (see  Fig.  597,  e).  The  latter  has  a  series  of 
removable  ivory  or  metal  tips  which  vary  in  size.  Used  diagnostically,  the 
olive  tip  bougie  is  to  impart  information  as  it  enters;  the  bulbous  sound,  as 
it  enters  and  as  it  is  within.  On  withdrawing  the  bulbous  sound  it  may 
catch  upon  the  lower  border  of  a  constriction  which  it  passed  on  entering. 

Before  being  passed  the  bougie  or  sound  should  be  warmed  and  greased  with 
glycerin.  The  patient  sits  in  a  chair  and  throws  the  head  well  back  against 
the  breast. of  an  assistant.     The  mouth  is  opened  widely  and  is  held  open  by  a 

1 "  American  Text-Book  of  Surgery." 
^"The  Practitioner,"  April,  1899. 


Examination  of  the  Esophagus 


931 


large  cork  or  by  a  gag.  The  patient  is  directed  to  breathe  deeply  and  regularly 
while  the  instrument  is  being  passed.  Depress  the  tongue  with  the  finger  and 
carry  the  instrument  beyond  the  glottis.  As  it  reaches  the  back  of  the  pharynx 
the  patient  will  gag  and  choke.  Tell  him  to  swallow  and  breathe  regularly. 
The  fact  that  he  can  breathe  regularly  shows  that  the  instrument  is  not  within 
the  larynx.  It  may  then  be  gently  urged  along  the  gullet.  All  maneuvers 
are  to  be  conducted  with  the  utmost  gentleness.     Force  means  danger. 

Remember  that  in  an  adult  the  esophageal  orifice  is  5  or  6  inches  from  the 
incisor  teeth,  that  the  esophagus  has  a  length  of  from  9  to  10  inches,  hence,  that 
the  cardiac  orifice  of  the  stomach  is  from  14  to  16  inches  from  the  incisor  teeth 
(Maylard's  "Surgery  of  the  Alimentary  Canal").  It  is  further  important  to 
remember  that  the  normal  esophagus  is  of  smaller  caliber  in  some  regions  than 


Fig.  589. — Von  Mikulicz's  set  of  iastruments  for  esophagoscopy. 

in  others.  There  are  four  points  of  physiological  narrowing,  viz. :  On  a  level 
with  the  cricoid  cartilage,  where  it  is  crossed  by  the  aorta,  where  it  is  crossed 
by  the  left  bronchus,  and  where  the  tube  passes  through  the  diaphragm.  _ 

Auscultation  may  enable  the  surgeon  to  hear  the  food  bolus  rub  against 
a  stenosis  and  to  note  delay  in  the  passage  of  liquid.  Fluid  normally  passes 
in  four  seconds. 

The  Esophagoscope. — This  instrument  is  of  the  highest  value,  a  value  just 
beginning  to  be  properly  appreciated.  It  is  not  altogether  free  from  danger. 
Deaths  have  occurred  from  it.  The  mandrel  does  the  harm,  and  should  not  be 
used  at  all  or  should  be  withdrawn  as  soon  as  the  tube  has  passed  the  cricoid 
constriction.  The  rest  of  the  way  the  instrument  is  carried  along  while  the  sur- 
geon is  looking  through  it  and  seeing  what  is  ahead.  It  is  not  carried  into  a 
constriction;  it  is  not  carried  by  an  ulcer  or  a  pulsating  lump.  It  enables  us  to 
make  diagnoses  otherwise  impossible,  to  diagnosticate  cancer  in  an  early  stage, 
to  treat  local  conditions,  and  to  remove  a  fragment  of  tissue  for  examination. 


932 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


I  prefer  to  pass  the  instrument  without  general  anesthesia  except  in  children, 
highly  nervous  people,  or  cases  of  very  severe  spasm.  Apply  cocain  to  the 
back  of  the  tongue,  pillars  of  the  fauces,  epiglottis,  and  pharynx.  Place  the 
patient  on  the  right  side  with  the  head  thrown  back.  This  is  known  as  Starch's 
position,  and,  as  Gottstein  shows,  it  relaxes  the  diaphragmatic  crura.  An 
assistant  supports  the  head  and  follows  every  movement  of  the  surgeon.  The 
patient  is  cautioned  to  breathe  tranquilly,  and  is  told  if  the  pain  or  annoyance 
becomes  intolerable  to  raise  his  left  arm,  when  the  surgeon  will  cease  for  a  time. 
The  surgeon  must,  of  course,  keep  his  word  on  this  point.  Artificial  teeth  are 
removed.  The  instrument  is  kept  in  the  midline  and  is  inserted  as  is  a  sound  or 
bougie.  As  soon  as  it  passes  the  cricoid  narrowing  the  mandrel  is  withdrawn, 
and  the  instrument  is  passed  slowly  and  gently  along  while  the  surgeon  is 
looking  through  and  ahead  of  it.  For  Chevalier  Jackson's  method  of  esoph- 
agoscopy  see  page  888. 


Fig.  590. — Position  of  patient  during  esophagoscopy  (after  von  Mikulicz). 


The  cervical  esophagus  is  closed  and  seems  to  unroll  before  the  instru- 
ment. The  thoracic  esophagus  is  open,  and  while  the  esophagoscope  enters 
into  the  upper  part  of  this  region,  if  the  gullet  is  normal,  the  surgeon  can  see 
all  the  way  down  to  the  diaphragm.  At  the  diaphragm  the  esophagus  bends 
forward  and  to  the  left  and  this  point  must  not  be  mistaken  for  the  cardia 
(Kohler,  in  ''Brit.  Med.  Jour.,"  Oct.  19,  191 2). 

The  cardia  may  be  found  closed  or  may  be  seen  to  open  and  close  w^th 
respiration.  This  instrument  is  of  great  value  in  the  extraction  of  foreign 
bodies,  in  the  diagnosis  and  treatment  of  many  esophageal  diseases,  and  in  the 
diagnosis  of  certain  peri-esophageal  conditions.  Every  surgeon  should  be 
able  to  use  the  esophagoscope.  (See  Gottstein,  in  "Keen's  Surgery,"  vols,  iii 
and  vi;  Waggett,  in  "Brit.  Med.  Jour.,"  Oct.  19,  191 2;  Kohler,  in  "Brit.  Med. 
Jour.,"  Oct.  19,  1912;  "Reports  of  Eightieth  Meeting  of  the  British  Medical 
Assoc,"  July,  1912;  Lewisohn,  in  "Annals  of  Surgery,"  Jan.,  1913.)  For 
Chevalier  Jackson's  directions  as  to  the  use  of  the  esophagoscope  see  page  888. 

Stricture  of  the  Esophagus. — Fibrous  or  cicatricial  stricture  or  scar  of  the 
esophagus  is  due  to  the  healing  of  an  ulcer,  and  results  from  traiunatism,  chronic 
inflammation,  scarlet  fever,  syphilis,  tuberculosis,  chronic  ulcer,  prolonged 
vomiting,  variola,  gout,  or  to  swallowing  a  corrosive  substance  or  a  boiling 


Stricture  of  the  Esophagus 


933 


liquid.  In  about  15  per  cent,  of  cases  of  scarlet  fever  there  is  inflammation  of 
the  esophagus  and  larynx  and  stricture  may  result.  Fibrous  stricture  is  com- 
monest in  the  young,  and  is  apt  to  be  situated  opposite  the  cricoid  cartilage, 
at  the  tracheal  bifurcation  or  near  the  cardiac  end.  Cicatricial  strictures, 
except  when  due  to  boiling  or  corrosive  liquid,  are  usually  single,  but  may  be 
multiple.  A  cicatrix  may  be  of  irregular  shape,  may  be  cylindrical,  may  be 
annular,  may  be  narrow,  or  may  be  broad.  Stricture  following  impaction  of 
a  foreign  body  is  located  at  the  seat  of  impaction  unless  the  tube  has  been  in- 
jured by  efforts  at  extraction,  in  which  case  multiple  strictures  may  exist  (May- 
lard).  Strictures  which  result  from  swallowing  boiling  fluid  or  corrosive  Hquid 
are  usually  ver\-  extensive,  may  be  multiple,  and  give  early  symptoms.     In 


Fig.  591. — Cicatricial  stricture  of  esophagus. 

some  cases  they  are  slight  and  may  not  give  s}-mptoms  for  years  after  the  injmy. 
Syphilitic  stenosis  is  due  to  the  healing  of  a  gimimatous  ulceration,  but  there 
is  nothing  characteristic  in  this  kind  of  stenosis.  Tuberculous  stenosis  is 
extremely  rare.     The  esophagus  above  an  extensi\-e  scar  is  usuaUy  dilated. 

Symptoms  of  Cicatricial  Stenosis. — The  condition  is  most  common  in  youth, 
but  may  begin  at  any  age.  The  chief  s\Tnptom  is  difliculty  in  swallo\\ing,  at 
first  slight,  but  becoming  more  and  more  pronounced  until  swallowing  is  almost 
or  quite  impossible.  The  dysphagia  is  flrst  manifested  to  dry  solids,  then  to 
all  solids,  and  finaUy  to  liquids.  In  some  cases  vomiting  occurs  after  swallow- 
ing. If  the  stricture  is  high  up,  the  vomiting  is  almost  immediate;  if  it  is  low 
down,  the  vomiting  is  delayed,  especially  if  the  canal  is  dilated  above  the  stric- 
ture. From  time  to  time  the  patient  vomits  independently  of  taking  food,  the 
ejected  matter  containing  no  gastric  juice,  only  saliva  and  mucus  which  gathered 
in  the  dilated  gtillet  about  the  scar.     The  vomited  matter  is  not  bloodv.     The 


934  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

patient  feels  weak,  hungry,  and  thirsty,  becomes  exhausted  and  emaciated,  and 
suffers  from  flatulence,  gastralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the  region  of  the 
stricture,  possibly  "about  the  epigastrium  or  between  the  shoulder-blades" 
("The  Surgery  of  the  Alimentary  Canal,"  by  Maylard).  If  there  is  cer- 
tainly no  aneurysm  and  if  blood  has  never  been  brought  up,  the  flexible 
bougie  may  be  used  first  and  then  the  soHd  tipped  sound,  in  order  to  find  a 
stricture.  The  stricture  may  be  located  by  auscultation  over  the  spine  on  a 
line  with  the  supposed  obstruction.  While  a  patient  is  swallowing  water, 
the  arrest  of  the  fluid  at  the  seat  of  stricture  may  be  audible.  Even  if  the 
fluid  passes,  it  will  be  delayed  for  a  time  and  the  duration  of  deglutition  is 
thus  prolonged.  In  order  to  determine  the  time  of  deglutition  put  the  ear 
just  below  the  angle  of  the  left  scapula,  or  else  between  the  left  sternocostal 
margin  and  the  xiphoid  cartilage,  place  a  finger  on  the  patient's  Adam's 
apple,  and  hold  a  watch  in  the  other  hand.  Have  the  patient  take  a  drink  of 
water.  Count  the  time  from  the  moment  the  Adam's  apple  begins  to  rise 
until  the  fluid  is  heard  to  gurgle  into  the  stomach  (Ogston's  method).  It 
ordinarily  requires  four  seconds  for  fluid  to  pass  from  the  mouth  into  the  stom- 
ach (Maylard,  Ibid.).  The  a'-rays  are  used  to  diagnosticate  stricture  and  to 
locate  it.  They  are  valuable  in  diagnosis.  An  emulsion  of  bismuth  is  swaUowed 
and  a  skiagraph  is  taken.  The  bismuth  is  seen  on  the  plate  as  a  black  mass  ex- 
tending above  the  seat  of  constriction  (Fig.  591).  A  bougie  can  be  passed  tmtil 
it  reaches  the  block  and  a  skiagraph  may  be  taken  with  the  bougie  in  position. 

In  a  case  reported  by  SeeHg  ("Surgery,  Gynecology,  and  Obstetrics,"  Sept., 
1908)  the  patient  was  directed  to  swallow  a  fine  gold  chain  as  thick  as  ordinary 
wrapping  twine.  The  chain  was  about  2  feet  long.  If  a  diverticulum  exists 
the  chain  will  fill  the  sac  and  a  skiagraph  will  show  the  position  of  the  diver- 
ticulum. If  no  diverticulum  exists  the  plate  will  show  the  chain  nearly  in  the 
middle  line  of  the  body.     The  esophagoscope  should  be  used  (see  page  931). 

The  history  of  the  case  is  of  much  importance  in  diagnosis.  The  surgeon 
must  inquire  about  impaction  of  a  foreign  body,  or  swallowing  of  acids,  alka- 
lis, or  boihng  fluids;  and  must  examine  for  e\ddence  of  syphilis.  If  there 
is  no  history  of  injury,  syphilis,  tuberculosis,  scarlatina,  variola,  or  prolonged 
vomiting,  and  the  patient  is  over  forty  years  of  age,  the  indications  point  to 
cancer  rather  than  cicatricial  stenosis.  The  easy  passage  of  a  bougie  when 
the  patient  is  anesthetized  shows  that  spasm  is  the  cause,  and  not  organic 
disease.  Narrowing  due  to  external  pressure  {compression  stenosis)  is  marked 
by  positive  symptoms  of  the  causative  disease.^  Compression  stenosis  may 
arise  in  goiter,  vertebral  growths,  enlargement  of  the  heart,  glandiflar  enlarge- 
ment, peri-esophageal  abscess,  aneurysm,  lordosis,  and  mediastinal  tumor 
(Kohler,  in  "Brit.  Med.  Jour.,"  Oct.  19,  191 2). 

Treattnent. — Thiosinamin  is  given  by  some  physicians,  but  I  have  never 
seen  it  accomplish  the  sHghtest  good.  Telleky-  recommends  it  in  old  scars 
without  inflammation.  He  makes  a  15  per  cent,  alcoholic  solution  and  in- 
jects from  I  to  I  syringeful  at  a  dose,  throwing  the  fluid  beneath  the  skin 
between  the  scapulae.  He  uses  twenty  doses  in  the  course  of  two  weeks. 
Gradual  dilatation  through  the  mouth  is  a  method  employed  for  at  least  a 
time  in  almost  every  case.  It  is  the  method  of  choice  when  it  can  be  carried 
out,  and  usually  it  can  be  carried  out.  Begin  with  the  largest  flexible  bougie 
which  will  easily  pass.  Warm  the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in 
position  for  several  minutes,  prolonging  the  time  of  retention  of  the  bougie  as 
treatment  progresses.  Pass  an  instrument  every  second  or  third  day,  gradually 
increasing  the  size.    Plummer  ("Northwestern  Lancet,"  Jan.  15, 191 2)  dwells  on 

1  See  the  valuable  article  in  Maylard's  "Surgery  of  the  Alimentary  Canal." 

2  "Wien.  klin.  Woch.,"  Feb.  20,  1902. 


Stricture  of  the  Esophagus 


935 


the  danger  of  using  bougies,  especially  in  cancerous  constriction,  and  advocates 
the  use  of  the  string  guide  of  MLxter  in  tight  or  tortuous  stenoses.  MLxter's  plan 
is  to  have  a  patient  put  a  piece  of  silk  on  the  back  of  the  tongue  and  swallow 
it  while  drinkmg  water.  The  string  may  thus  be  floated  through.  Plummer 
proceeds  as  follows:  He  takes  a  spool  of  buttonhole  twist  and  inserts  a  safety- 
pin  so  as  to  make  a  reel.  He  unwinds  the  thread,  marks  it  with  black  ink  at 
intervals  of  i  yard,  rewinds  it,  takes  a  few  inches  of  the  free  end  of  the  thread, 
moistens  it,  places  it  on  the  back  of  the  patient's  tongue,  and  gives  the  patient 
a  swallow  of  water.  The  patient  is  directed  to  swallow  2  or  3  yards  before 
bedtime,  "and  an  equal  amount  at  the  rate  of  a  foot  an  hour  the  following 
forenoon."  The  first  portion,  in  a  state  of  snarl,  enters  the  intestine  during 
the  night.  By  afternoon  the  thread  may  be  rendered  taut  by  pulling  upon  it, 
yet  it  will  not  be  pulled  out.  The  thread  may  remain  in  place  for  some  time, 
dilating  the  stricture.  It  may  be  used  as  a  guide  to  direct  a  bougie  through  a 
tight  or  tortuous  constriction,  the  eyed  bougie  being  threaded  upon  the  strand 
(Plummer,  in  "Collected  Papers  of  the  Mayo  StaS  m  Rochester,"  191 1) .  If  the 
stenosis  involves  a  considerable  portion  of  the  esophagus,  gradual  dilatation 
will  almost  certainly  fail  to  cure. 

S}Tnonds  advocates  the  insertion  of  a  tube  through  the  stricture  and 
leaving  it  in  place  until  there  is  decided  dilatation,  and  then  replacing  the 
tube  mth  a  larger  instrument.  The  patient  is  fed  through  the  tube  (Fig.  592). 
In  some  cases  in  which  it  is  impossible  to  pass  a  bougie  through  the  stricture 


Fig.  592. — Symonds's  short  tube  for  intubation  of  the  esophagus  (Morrow). 

by  the  ordinary  plan  it  is  possible  to  pass  one  when  \dewing  the  opening 
through  the  stricture  by  means  of  the  esophagoscope.  Whalebone  or  olive- 
tipped  instruments  may  be  passed  in  increasing  sizes.  Strands  of  sUkworm- 
gut  may  be  gotten  through.  If  they  are,  they  can  be  left  in  place  a  few  hours, 
when  a  larger  bundle  of  gut  or  perhaps  an  instrument  can  be  passed.  Surgeons 
have  divulsed  strictures  and  performed  internal  esophagostomy  through  an 
esophagoscope.  Either  of  these  plans  is  preferable  to  forcible  dilatation  or 
internal  esophagostomy  by  a  special  instrument,  but  without  the  esophagoscope. 
Electrolysis  has  been  advocated  by  Fort  and  others.  Gradual  dilatation 
from  below  has  been  practised  in  cases  in  which  a  bougie  could  not  be  passed 
from  the  mouth.  A  gastrostomy  is  performed,  and  after  the  fistula  has  become 
sound  the  patient  is  made  to  swallow  "a  shot  to  which  is  attached  a  silk 
thread"  (Maylard).  The  silk  thread  is  brought  out  through  the  fistulous 
orifice  and  is  attached  to  a  bougie,  and  the  dilating  instrument  is  pulled  up 
through  the  esophagus.  Forcible  dilatation  can  be  employed  through  a 
gastrotomy  opening,  by  means  of  bougies,  tents,  or  di\adsing  instruments. 
A  fibrous  stenosis  in  the  region  of  the  cricoid  cartilage  which  is  not  cured 
by  gradual  dilatation  should  be  treated  by  the  operation  of  external  esoph- 
agotomy.  In  this  operation  the  stricture  is  di\'ided  by  a  longitudinal  incision; 
"funnel-shaped  retraction  of  the  cut  portion  is  caused  by  adhesion  to  the 


936 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


external  tissues  divided,  and  it  lessens  future  contraction."^  If  dilatation  fails 
in  the  case  of  a  stenosis  anywhere  above  the  line  of  the  aortic  arch,  the  esoph- 
agus may  be  opened  above  the  stricture  (external  esophagotomy) .  If  the 
stricture  is  below  the  wound  a  tenotome  may  be  introduced  through  the 
wound,  the  stricture  is  cut  and  well  dilated  by  the  passage  of  instruments. 
This  operation  is  known  as  Gussenbauer's  combined  esophagotomy. 


Fig-  593- — Abbe's  method  of  cutting  esophageal  strictures. 

If  a  stricture  is  impassable  from  above,  the  stomach  should  be  opened 
and  retrograde  dilatation  be  carried  out.  Billroth  showed  years  ago  that  a  stric- 
ture impassable  from  above  may  be  passable  from  below.  This  is  because  the 
esophagus  above  the  stricture  is  basin  shaped  and  immediately  below  the 
stricture  is  fimnel  shaped  (Abbe).  If  a  fine  bougie  is  carried  from  the  stomach 
to  the  mouth  it  is  used  to  carry  a  piece  of  string  through  the  same  route,  and 
this  string  is  used  to  pull  bougie  after  bougie  through  the  strictm-e.  A  firm, 
non-dilatable  stricture  in  the  thoracic  portion  of  the  esophagus  can  be  treated 

by  Abbe's  method  (Figs. 
593;  594)-  He  performs 
a  gastrotomy,  sutures  the 
stomach  to  the  abdominal 
wound  to  prevent  contam- 
ination of  the  peritonetmi, 
and  seeks  for  the  esophageal 
opening  by  two  fingers  passed 
within  the  stomach.  Abbe 
points  out  that  finding  the 
orifice  would  seem  much 
more  easy  than  it  is.  In  a  recent  case  I  found  it  only  after  a  prolonged  search, 
the  entire  esophageal  region  feeling  smooth  to  the  touch.  Abbe  says  that  "this 
surface  is  maintained  by  the  circular  sphincter  muscle  layers,  and  it  is  not 
imtil  a  moment's  pressure  of  the  finger  at  the  right  place  causes  them  to  yield 
that  it  slips  upward  into  the  esophagus"  ("Med.  Record,"  Nov.  30,  1907). 
Abbe  then  passes  a  long  fiHform  whalebone  bougie  from  the  stomach  into  the 
mouth,  ties  a  piece  of  braided  silk  to  the  bougie,  withdraws  the  instrument, 
and  leaves  the  silk  in  place.  One  end  of  the  silk  emerges  from  the  mouth 
and  the  other  end  from  the  gastrotomy  wound.  In  some  cases  he  opens  the 
stomach  and  also  opens  the  esophagus  above  the  stricture;  one  end  of  the  string 
1  W.  J.  Mayo,  "Jour.  Amer.  Med.  Assoc,"  July  29,  1899. 


Fig.  594. — ^The  bougie  engaged  in  the  stricture  while  the  string- 
saw  is  being  used. 


Carcinoma  of  the  Esophagus  937 

comes  out  of  the  esophagotomy  wound  and  the  other  end  out  of  the  gastrotomy 
wound.  A  large  dilating  bougie  is  then  passed  from  the  stomach  into  the 
esophagus  and  pushed  as  forcibly  as  is  safe  into  the  lumen  of  the  stricture. 
The  string  is  used  as  a  string-  or  bow-saw,  and  the  stricture  is  divided,  the  di- 
lating bougie  being  pushed  firmly  upward  while  the  saw  is  being  used.  If 
this  is  not  done  the  saw  will  not  cut.  Only  stretched  tissue  will  be  divided. 
When  the  stricture  has  been  divided  the  silk  is  withdrawn,  full-sized  bougies 
are  passed,  a  temporary  gastrostomy  is  usually  made,  and  the  wound  or  wounds 
are  sutured. 

An  operation  devised  by  A.  J.  Ochsner  is  thus  described  by  Mayo^:  "The 
anterior  wall  of  the  stomach  is  drawn  out  of  a  left  oblique  incision  through  the 
abdominal  coverings ;  a  small  opening  is  made  into  the  stomach  sufi&cient  in  size 
to  introduce  the  finger.  A  whalebone  probe,  to  the  tip  of  which  a  silk  string 
guide  has  been  tied,  is  now  passed  through  the  esophagus  either  from  above 
or  retrograde,  as  in  the  Abbe  method.  With  this  guide  a  loop  of  silk  is  drawn 
out  of  the  gastric  incision  in  such  manner  as  to  leave  the  guide  as  a  third 
string.  Into  this  loop  a  small  soft-rubber  drainage-tube  3  feet  or  more  in 
length  is  caught  in  the  middle  by  traction  on  the  ends  of  the  doubled  thread 
through  the  mouth;  this  loop  of  rubber  tube  is  drawn  through  the  stomach  and 
made  to  engage  in  the  stricture. 

"The  greater  the  amount  of  traction,  the  smaller  the  stretched  rubber 
tube,  until  it  is  sufficiently  reduced  in  size  to  enter  the  stenosed  portion; 
by  alternating  the  direction  of  the  pull  the  tube  is  drawn  out  by  its  free  ends 
and  in  by  the  silk  loop.  Increasing  sizes  of  tubes  can  be  employed,  and 
if  necessary  the  third  string  can  be  used  as  a  string-saw,  after  the  Abbe  plan 
of  procedure."  In  a  very  severe  case  of  stenosis  gastrostomy  is  performed  to 
keep  the  patient  from  starving.  In  a  case  of  fibrous  stenosis  in  charge  of  the 
author  it  was  found  impossible  to  insert  any  instrument  from  above  or  from 
below.  Gastrostomy  was  performed  by  Kader's  method.  The  patient  was  fed 
through  the  artificial  opening  and  the  esophagus  was  thus  put  at  rest.  Two 
weeks  after  the  operation  it  became  possible  to  pass  a  bougie  from  the  mouth. 
The  gullet  was  gradually  dilated  to  its  normal  caliber  and  the  gastrostomy 
wound  was  closed.  This  case  demonstrates  that  a  stricture  of  the  esophagus, 
like  a  stricture  of  the  urethra,  may  become  temporarily  impassable  from 
inflammation,  edema,  and  spasm;  but,  after  the  part  is  put  at  rest,  may  again 
permit  the  passage  of  an  instrument. 

In  some  cases  of  incurable  stricture  cervical  esophagostomy  is  perforrned 
below  the  stenosis,  and  the  patient  is  fed  permanently  through  the  opening. 
The  operation  is  performed  like  esophagotomy,  except  that  the  mucous  mem- 
brane is  sutured  to  the  skin. 

Carcinoma  of  the  Esophagus. — Cancer  causes  obstruction  of  the  esoph- 
agus. It  arises  in  those  beyond  middle  life,  and  is  far  more  common  in  men 
than  in  women.  The  disease  may  begin  at  any  portion  of  the  gullet,  but  is 
least  often  met  with  in  the  central  portion  (Maylard,  ButHn).  Epithelioma 
is  the  usual  form,  but  scirrhus  or  encephaloid  may  occur.  Cancer  soon  ulcer- 
ates, involves  adjacent  parts,  and  affects  the  deep  cervical  and  posterior 
mediastinal  glands.  In  at  least  75  per  cent,  of  cases  of  chronic  obstruction  of 
the  esophagus  cancer  is  the  cause. 

Symptoms  of  Cancerous  Stenosis. — The  patient  is  over  forty  years  of  age, 
is  usually  a  male,  and  presents  the  same  difficulty  of  swallowing  met  with 
in  cicatricial  stenosis.  Regurgitation  is  common.  The  regurgitated  matter  is 
alkaline  and  is  apt  to  contain  blood.  There  is  generally  decided  pain  and  very 
rapid  and  great  .emaciation  occurs.  The  seat  of  obstruction  may  be  located  by 
the  very  gentle  use  of  a  soft  or  semisolid  bougie,  but  it  is  wiser  to  use  no  bougie 
1  "Jour.  Amer.  Med.  Assoc,"  July  29,  1899. 


938  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

and  to  rely  on  the  x-rays  and  the  esophagoscope.  In  a  very  recent  case  diag- 
nosis is  possible  only  by  esophagoscopy.  The  stomach  is  the  seat  of  pain;  the 
mouth  is  dry,  and  there  is  often  great  thirst.  As  the  disease  infiltrates,  the 
involvement  of  adjacent  regions  produces  other  symptoms.  Dyspnea  may  re- 
sult from  tracheal  pressure.  Pleuritis,  pericarditis,  or  pneumonia  may  arise. 
There  may  be  paralysis  of  the  sympathetic  or  recurrent  laryngeal  nerves. 

In  suspected  cases  of  cancer  never  try  to  pass  unguided  bougies  or  sounds 
through  the  constriction.  In  a  cancer  case  dilating  instruments  are  weapons 
rather  than  tools.  If  a  bougie  is  used  to  locate  the  constriction  it  will  prob- 
ably start  bleeding  and  be  bloody  when  withdrawn.  A  soHd  instrument  might 
perforate  the  esophagus.  If  it  does,  death  will  follow.  The  x-rays  should  first 
be  used  and  then  the  esophagoscope. 

Treatment. — The  disease  is,  of  necessity,  fatal,  and  treatment  is  only  pallia- 
tive. Complete  excision  of  the  cancer  is  scarcely  feasible  even  in  the  cervical 
region.  I  know  of  but  one  successful  resection  of  the  thoracic  esophagus, 
which  was  the  case  reported  by  Torek.  At  present  the  justifiability  of  such 
an  operation  has  not  yet  been  conclusively  demonstrated.  The  patient  should 
be  put  upon  a  soft,  bland  diet,  small  quantities  being  given  frequently.  When 
trouble  is  experienced  in  swallowing  the  bland  and  soft  food,  pass  a  soft  bougie 
every  third  or  fourth  day.  When  the  patient  becomes  entirely  unable  to  swal- 
low soft  food,  we  may  insert  a  Symonds  tube  (see  Fig.  592)  or  do  an  esophagos- 
tomy  (if  this  can  be  performed  below  the  stricture) ,  or  perform  gastrostomy. 
In  every  doubtful  case  of  esophageal  stricture  give  a  course  of  iodid  of  potas- 
sium before  performing  any  operation. 

Spasmodic  Stricture  of  the  Esophagus  {Esophagismus;  Hysterical  Stric- 
ture).— By  this  term  is  meant  a  spasm  of  the  circular  muscular  fibers  of  the 
gullet,  which  is  most  common  near  the  larynx  or  the  cardia.  This  condition 
not  unusually  arises  in  a  hysterical  individual,  in  which  case  it  will  be  associ- 
ated with  the  stigmata  of  hysteria,  especially  globus  hystericus.  In  some 
cases  evidences  of  hysteria  are  wanting,  although  the  patient  is  neurotic  and 
ill-nourished,  the  condition  being  due  to  a  reflex  irritation.  A  spasm  of  the 
muscular  fibers  of  the  esophagus  may  be  clonic  or  may  be  tonic.  A  clonic 
spasm  may  arise  during  vomiting  or  from  some  reflex  cause;  it  may  affect 
one  part  of  the  tube  for  a  time  and  then  shift  to  another,  or  may  develop 
only  in  one  particular  region.  Globus  is  a  spasm  which  moves  upward.  Tonic 
spasm  is  in  one  fixed  place.  Most  reflex  spasms  are  tonic  and  result  from  cancer 
of  the  liver,  cancer  of  the  stomach,  tonsillitis,  glossitis,  pharyngitis,  or  inflam- 
mation of  the  epiglottis  (A.  L.  Benedict,  in  "Am.  Jour.  Med.  Sci.,"  Aug.,  1904). 
It  occasionally  occurs  in  tetanus,  sometimes  in  epilepsy.  Spasmodic  stricture 
may  also  arise  during  pregnancy  and  as  a  result  of  laryngeal  ulceration.  I 
have  seen  several  instances  due  to  cancer  of  the  stomach.  In  i  of  these  cases  the 
esophageal  spasm  entirely  disappeared  after  the  performance  of  pylorectomy. 

Symptoms  of  Spasmodic  Stenosis. — It  arises  suddenly  in  a  hysterical  or 
neurotic  individual.  It  may  last  for  a  time  and  suddenly  pass  away,  or 
may  persist  for  a  considerable  time.  The  difficulty  in  swallowing  is  irregular, 
rarely  interfering  seriously  with  nourishment.  Usually  fluids  are  taken  more 
easily  than  solids,  but  sometimes  solids  are  taken  more  readily  than  fluids. 

There  may  be  regurgitation;  but  in  recent  cases,  if  it  occurs,  it  does  so  at  once 
on  swallowing  food.  Examination  with  a  bougie  detects  the  obstruction.  If 
the  bougie  is  held  firmly  against  it,  in  most  cases  the  spasm  wiU,  after  a  time, 
relax  suddenly  or  gradually  and  let  the  instrument  pass.  A  medium-sized  in- 
strument or  a  large  one  may  not  pass  until  the  patient  has  been  anesthetized, 
but  in  every  case  a  bougie  can  be  passed  after  an  anesthetic  has  been  given. 

Treatment  of  Spasmodic  Stenosis  Above  the  Cardia. — The  systematic  passage 
of  bougies.     Occasionally  the  passage  of  an  instrument  but  once  will  cure  a 


Diverticula  of  the  Esophagus  939 

case.  The  general  health  must  be  improved,  and  in  persistent  cases  it  may 
be  necessary  to  use  electricity  within  the  esophagus,  employ  cold  locally,  and 
administer  the  bromids. 

Cardiospasm. — When  the  cardiac  sphincter  contracts  the  condition  is 
known  as  cardiospasm.  It  may  or  may  not  be  associated  with  cancer,  ulcer,  or 
some  other  disease  of  the  stomach,  with  gall-bladder  disease  or  cancer  of  the 
liver.  The  attacks  are  periodic,  with  a  variable  time  between  them,  but 
sooner  or  later  diffuse  dilatation  occurs.  Before  dilatation  the  patient  has 
periodic  attacks  of  difficulty  in  swallowing,  being  perfectly  well  between  the 
attacks.  One  of  Plummer's  cases  had  periodical  attacks  of  dysphagia  lasting 
from  three  to  fourteen  days,  and  during  these  attacks  it  was  impossible  to 
swallow  either  solids  or  liquids.  In  many  cases  the  attacks  are  neither  so 
severe  nor  prolonged.  They  usually  begin  suddenly  while  swallowing,  but  may 
begin  at  a  time  when  no  food  is  being  taken.  The  attack  is  a  feeling  of  choking 
or  obstruction  felt  in  the  cardiac  region  and  the  back.  Soon  after  these  attacks 
originate  the  patient  begins  to  suffer  very  soon  after  eating  from  regurgitation 
into  the  mouth.  As  the  esophagus  dilates  the  regurgitation  is  postponed 
longer  and  longer  after  eating,  until  finally  the  gullet  is  never  completely  empty 
(Plummer,  "Northwestern  Lancet,"  Oct.  i,  1906).  The  matter  which  is  re- 
gurgitated is  not  sour,  because  it  contains  no  gastric  elements.  Plummer 
points  out  that  a  stomach-tube  cannot  be  passed,  but  a  large-sized  sound  can 
be  passed  easily.  The  fact  that  a  large  sound  can  be  passed  proves  that  there 
is  no  organic  stricture.  When  external  causes  of  pressure  are  excluded  the  diag- 
nosis rests  between  diverticulum  and  dilatation  of  the  esophagus  (Plummer, 
Ibid.).     The  x-rays  aid  in  diagnosis.     Plummer  gives  methods  in  detail  (Ibid.). 

Treatment. — Russell's  plan  is  to  dilate  the  cardia  with  a  silk-covered  balloon 
of  rubber.  Plummer  describes  how  to  construct  it  ("Collected  Papers  of  the 
StafT  of  St.  Mary's  Hospital,  Mayo  Clinic,  1905-1909").  The  distention  is  to 
be  gradual,  and  at  once  suspended  if  there  is  violent  pain  indicating  laceration. 
Mikulicz  and  others  have  performed  gastrotomy  and  dilated  the  cardia.  Willy 
Meyer  ("Am.  Jour.  Surg.,"  June,  191 2)  has  opened  the  thorax  under  positive 
pressure,  plicated  the  dilated  portion  of  the  esophagus  into  two  longitudinal 
double  folds,  and  separated  the  pneumogastric  nerves,  tearing  off  the  minute 
esophageal  branches  {esophagoplication  and  vagolysis) .  This  patient  was  cured. 
This  operation  was  attempted  on  2  other  patients.  One  was  improved.  The 
other  turned  out  to  have  organic  stricture.  In  another  case  Wendel  performed 
cardioplasty  in  the  same  manner  as  pyloroplasty  is  done.  He  did  it  by  the 
abdominal  route.     Meyer  suggests  that  it  may  be  done  transthoracically. 

Diverticula  of  the  Esophagus. — Rokitansky  in  1849  described  traction  di- 
verticula and  pressure  diverticula.  Maylard  tells  us  that  these  pouches  may 
be  due  to  one  of  four  causes:  they  may  be  congenital;  may  be  due  to  stricture; 
may  be  caused  by  pressure  from  within  upon  a  weak  spot  of  the  wall ;  may  be 
due  to  traction  from  without  by  the  healing  and  contraction  of  an  area  of 
inflammation.  To  these  another  cause  should  be  added,  muscular  weakness 
resulting  in  dilatation.  The  usual  situation  for  such  a  pouch  is  on  the  posterior 
wall  of  the  gullet  on  a  level  with  the  cricoid  cartilage.  At  this  point  there  is  a 
space  devoid  or  nearly  devoid  of  muscle,  called  the  Lannier-  Hacker  man  area 
(Charles  H.  Mayo,  "Jour.  Am.  Med.  Assoc,"  July  22,  191 2).  As  the  pouch 
enlarges  the  fundus  comes  toward  the  side,  usually  the  left  side.  Pouches  are 
rare  in  the  thoracic  esophagus. 

Symptoms. — In  spite  of  the  statement  that  a  diverticulum  may  be  con- 
genital, we  encounter  the  condition  clinically  only  in  adults.  The  first  symptom 
is  difficulty  in  swallowing,  like  that  in  cancer.  There  may  be  cough  from  nerve 
irritation  and  dyspnea  from  pressure  on  the  trachea  (Chas.  H.  Mayo,  "Annals  of 
Surgery,"  June,  1910).     Regurgitation  may  occur,  the  regurgitated  matter 


94°  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

being  free  from  gastric  juice.  As  the  opening  of  the  sac  is  usually  a  prolonga- 
tion of  the  esophageal  canal  a  sound  or  bougie  tends  to  enter  the  sac.  When 
the  diverticulum  is  in  the  neck  a  lump  forms  during  deglutition,  and  this  lump 
may  be  obliterated  by  pressure.  Food  will  pass  into  the  stomach  only  when 
the  diverticulum  is  full.  A  bougie  can  seldom  be  passed  unless  the  pouch  is  full 
of  food,  at  which  time  it  may  pass  or  may  not.  Sometimes  it  enters  the  pouch. 
This  striking  symptom,  the  variability  in  the  passage  of  the  bougie,  is  evidence 
suggesting  the  diagnosis  of  intrathoracic  diverticulum.  By  listening  through  a 
stethoscope  fluid  may  be  heard  to  pass  into  the  pouch.  The  diverticulum 
causes  obstruction.  "The  depth  of  the  obstruction  can  be  measured  with  a 
stomach-tube,  bougie,  or  acorn  probe,  but,  as  a  matter  of  fact,  these  pro- 
cedures do  not  differentiate  between  diverticula  and  strictures  which  are 
pervious  to  Hquids  and  yet  impassable  to  sounds"  (Charles  H.  Mayo,  "Annals 
of  Surgery,"  June,  1910).  After  a  patient  swallows  an  emulsion  of  bismuth 
or  food  mixed  with  a  salt  of  bismuth  a  diverticulum  may  be  skiagraphed. 
When  a  bougie  is  passed  as  far  as  it  will  go  a  skiagraph  should  be  taken  with 
the  bougie  in  position.  The  plate  may  show  that  the  instrument  is  so  much 
deviated  to  the  side  that  it  must  be  in  a  pouch.  If  a  fine  gold  chain  is  swal- 
lowed it  may  fill  up  the  pouch,  and  if  it  does,  a  skiagraph  will  indicate  the 
diverticulum.  The  opening  of  the  pouch  may  be  seen  by  means  of  an  esopha- 
goscope.  Plummer's  test  is  valuable.  He  has  the  patient  swallow  a  string 
guide,  as  described  on  page  935.  The  thread  is  passed  through  the  eye  of  an 
olive  tip  set  on  a  whalebone  stem.  The  instrument  is  passed  onward  until  it 
meets  an  obstruction.  "Should  the  trouble  be  due  to  stricture  the  tip  wdll  not 
change  its  level  when  the  thread  is  tightened,  but  if  there  is  a  diverticulum  the 
probe  will  be  elevated  to  the  level  of  the  opening  in  the  lower  esophagus,  prov- 
ing at  once  the  existence  of  a  pocket  and  also  its  depth  by  the  amount  of 
elevation  of  the  probe  upon  tightening  the  thread"  (Charles  H.  Mayo,  Ibid.). 

Treatment. — In  very  early  cases  dilatation  may  cure.  In  advanced  cases 
in  the  cervical  esophagus  we  must  perform  extirpation  and  suture,  as  done  by 
von  Bergmann,  Hearn,  the  author,  and  others.  For  five  days  after  operation 
no  food  is  given  by  the  mouth.  No  attempt  should  be  made  to  extirpate  a 
pouch  in  the  thoracic  esophagus.     In  such  a  case  gastrostomy  may  be  necessary. 

Injuries  of  the  Esophagus  from  Within. — Injuries  of  the  internal  sur- 
face are  more  common  than  injuries  from  "wdthout.  Burns  and  scalds  are 
among  these  injuries.  Wounds  may  be  inflicted  by  foreign  bodies.  Injuries 
of  the  gullet  cause  pain  on  swallowing,  and  a  wound  induces  bleeding,  the 
blood  being  both  coughed  up  and  vomited.  A  severe  w^ound  may  involve 
a  large  vessel  and  cause  violent  or  even  fatal  hemorrhage.  If  the  bronchus 
or  trachea  is  involved,  there  will  be  "cough  and  expectoration  of  blood,  mucus, 
and  food"  (Maylard).     The  pleural  or  pericardiac  sacs  may  be  perforated. 

Treatment. — Feed  only  by  the  rectum.  Give  morphin  hypodermatically. 
Do  not  feed  by  the  mouth  for  ten  days,  and  even  then  give  only  fluid  food 
and  jelly.  Symptoms  are  met  as  they  arise.  After  burns  by  caustic,  admin- 
ister the  antidote;  give  large  drafts  of  water  and  wash  out  the  stomach.  From 
two  to  foiu:  wxeks  after  a  caustic  has  been  swaUowed  and  after  a  burn  or  scald 
the  use  of  sounds  shoifld  be  begun  (provided  there  is  no  raw  surface),  and 
sounding  should  be  persisted  in  for  a  considerable  time  to  prevent  contraction. 

Injuries  of  the  Esophagus  from  Without,  Other  Structures  Not  Being 
Seriously  Involved. — Such  injuries  are  rare.  Esophageal  injuries,  as  a  rifle, 
are  associated  wdth  serious  damage  to  adjacent  structures.  Injuries  may 
be  due  to  stabs  or  to  buUets.  Besides  the  obvious  external  signs  of  the  injury 
there  wifl  be  difficulty  in  swaUowing,  cough,  bloody  expectoration,  or  vomiting; 
and  mucus  or  the  contents  of  the  stomach  may  run  out  of  the  wound. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for  ten  days. 


Foreign  Bodies  Lodged  in  the  Esophagus 


941 


Foreign  Bodies  Lodged  in  the  Esophagus. — These  accidents  occur  especially 
in  children  and  lunatics,  and  women  are  more  apt  to  suffer  from  them  than  men. 
A  list  of  various  bodies  which  have  been  swallowed  will  be  found  in  Poulet's 
elaborate  treatise.  There  are  three  regions  where  a  foreign  body  is  especially 
apt  to  lodge — viz.,  opposite  the  cricoid  cartilage,  at  the  level  of  the  diaphragm, 
and  at  the  point  where  the  left  bronchus  crosses  the  gullet.  Small  and  sharp 
bodies  may  lodge  anywhere. 


Fig.  595. — ^Author's  case  of  whistle  in  esophagus,  removed  by  external  esophagotoniy. 

The  symptoms  are  \'ariable;  if  the  body  is  large,  there  will  be  pain  and 
difficulty  in  swallo-^dng,  and,  in  many  cases,  dyspnea  from  pressure  upon 
the  trachea  or  bronchus.  Occasionally  the  dyspnea  is  such  a  prominent 
feature  that  it  misleads  the  physician  into  the  belief  that  the  foreign  body 
is  lodged  in  the  air-passages.  Death  may  actually  result  from  asphyxia.  In 
some  other  cases  the  symptoms  are  very  slight.  If  the  body  is  sharp,  there 
will  be  hemorrhage  and  severe  pain.     The  blood  may  be  haw^ked  up,  or  may 


Fig.  596. — Author's  case  of  jackstone  in  esophagus,  removed  by  external  esophagotomy. 

be  swallowed  and  vomited.  In  rare  cases  a  patient  grows  accustomed  to  a 
foreign  body  and  ceases  to  notice  it;  but,  more  often,  the  foreign  body  pro- 
duces inflammation.  It  may  even  ulcerate  into  the  wind-pipe,  the  pleura, 
the  pericardium,  or  the  aorta.  In  many  cases  of  impaction  a  patient  makes 
violent  efforts  to  hawk  up  the  foreign  body  and  so  produces  aphonia.  There 
may  be  violent  retching.  Even  after  a  foreign  body  has  been  removed  by  swal- 
lowing, by  vomiting,  or  by  surgical  extraction  a  sensation  is  apt  to  remain  as 


942 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


if  the  body  were  still  lodged.  The  diagnosis  is  made  by  the  history,  the  detec- 
tion of  the  body  by  external  manipulation,  by  feeling  it  with  an  esophageal 
bougie,  by  esophagoscopy,  and,  if  bone  or  metal,  seeing  it  with  the  fiuoroscope 
or  obtaining  a  skiagraph. 

Treatment. — The  surgeon  should  learn,  if  possible,  the  size,  shape,  weight, 
and  nature  of  the  foreign  body,  and  should  locate  its  point  of  impaction. 
The  exact  point  of  lodgment  of  bone  or  a  metallic  body  is  determined  by 
the  :K-rays.  An  anesthetic  is  given  before  manipulating  a  child,  a  nervous 
woman,  or  a  lunatic,  and  is  sometimes  necessary  for  a  man.  If  the  foreign 
body  is  soft,  external  manipulation  may  succeed  in  altering  its  shape,  so  that 
it  may  be  swallowed  or  ejected.  If  the  foreign  body  is  hard,  external  manipu- 
lation may  shift  its  position.  It  is  usually  impossible  to  reach  the  foreign 
body  through  the  mouth  by  means  of  the  fingers  (when  the  body  is  in  the 
rear  of  the  pharynx  it  may  be  pulled  forward  or  pushed  down) .  Sharp  foreign 
bodies  may  be  entangled  and  carried  down  when  the  patient  eats  mush,  bread, 
or  boiled  potatoes.  The  administration  of  emetics  is  an  old  plan  which  occa- 
sionally succeeds,  but  which  is  too  unsafe  to  be  employed.     The  esophagoscope 

is  of  immense  value  in  many  cases. 
By  its  aid  foreign  bodies  may  fre- 
quently be  removed  which  without 
it  could  only  be  removed  by  the  per- 
formance of  a  grave  operation  (see 
page  943).  Nevertheless  I  believe, 
with  E.  Fletcher  Ingalls,  that  the 
esophagoscope ' '  cannot  entirely  sup- 
plant the  older  methods"  ("Amer. 
Jour,  of  Surg.,"  Jan.,  1912).  The 
instrument  is  not  always  at  hand, 
and  to  use  it  successfully  and  safely 
one  must  be  well  trained  in  its 
management.  Maylard  says  that 
when  a  mass  of  food  is  impacted 
it  is  occasionally  possible  to  soften 
and  disintegrate  the  mass  by  ad- 
ministering a  mixture  containing 
pepsin.  The  bristle  probang  (Fig. 
597,  c)  is  a  very  useful  instru- 
ment for  the  removal  of  fish- 
bones, pins,  and  other  small  ob- 
jects. It  may  be  used  to  push 
a  body  downward  into  the  stom- 
ach, or  to  catch  the  body  and 
pull  it  up.  When  this  instru- 
ment is  withdrawn  it  opens  like  an  umbrella.  It  has  been  shown  that  in 
an  adult  the  cardiac  opening  is  from  14  to  16  inches  from  the  incisor  teeth, 
a  point  to  be  remembered  in  deciding  whether  to  push  down  or  pull  up  the 
impacted  article.  Esophageal  forceps  (Fig.  597  a,  b)  are  valuable  in  some 
cases.  The  coin-catcher  (Fig.  597,  d)  is  a  useful  instrument.  Crequy's  plan 
of  removal  is  to  take  a  tangled  mass  of  threads,  tie  a  stout  piece  of  string 
about  the  middle  of  it,  coat  it  with  sugar,  and  have  the  patient  swal- 
low it.  It  may  pass  the  foreign  body;  if  it  does  so,  on  withdrawal  it  may 
entangle  the  object  and  extract  it.  To  remove  a  fish-hook  with  line  attached 
the  following  plan  may  prove  successful;  stick  the  line  which  projects  from 
the  mouth  into  a  metal  catheter,  carry  the  catheter  down  to  the  hook,  and 
push  the  hook  out.     It  is  not  proper  to  allow  a  foreign  body  to  remain  in  the 


Fig.  597- — Esophageal  instruments:  a,  b,  Forceps; 
C,  Gross's  bristle  probang;  d,  coin-catcher;  e,  bulbous 
esophageal  sound. 


Diagnosis  of  Intra-abdominal  Emergencies  945 

esophagus  until  it  causes  ulceration.  Neither  is  it  proper  to  make  prolonged 
efforts  to  extract  it  through  the  mouth.  Such  efforts  may  do  great  harm,  and 
if  one  careful  and  consistent  effort  fails,  and  the  esophagoscope  is  not  suited  to 
the  case,  fails,  or  is  unobtainable,  or  if  there  is  no  skilled  man  to  use  it,  an  opera- 
tion should  be  performed.  If  the  body  is  lodged  anywhere  above  the  lower 
third  of  the  esophagus,  external  esophagotomy  is  performed,  and  usually  on  the 
left  side.  Through  this  wound  the  foreign  body  is  extracted.  The  cut  is  made 
on  the  left  side,  between  the  trachea  and  larynx  in  front  and  the  carotid  sheath 
behind,  the  center  of  the  incision  being  opposite  the  cricoid  cartilage.  After  the 
foreign  body  has  been  extracted  the  mucous  membrane  is  sutured  with  chromic- 
ized  catgut,  and  the  superficial  structures  are  closed  with  silkworm-gut  after  a 
drainage-tube  has  been  inserted.  The  patient  is  fed  by  the  rectum  for  eight  or 
ten  days.  When  a  foreign  body  is  lodged  in  the  lower  portion  of  the  tube  the 
stomach  is  opened  and  the  body  extracted  by  this  route.  In  White's  case 
of  jackstone  in  the  gullet  gastrotomy  was  performed.  A  string  was  tied 
about  some  rolls  of  gauze,  the  string  was  passed  by  means  of  a  whalebone 
from  the  stomach  into  the  mouth,  and  the  body  was  entangled  and  drawn  out. 

Surgical  Invasion  of  the  Mediastinum. — The  posterior  mediastinum 
has  been  entered  in  order  to  remove  a  foreign  body  from  the  bronchus  and 
to  extract  a  set  of  false  teeth  wedged  in  the  esophagus.  The  same  method 
can  be  followed  to  reach  suppurative  processes  in  the  mediastinum,  abscesses 
of  the  lung  otherwise  inaccessible,  and  diverticula  and  carcinomata  of  the  lower 
end  of  the  gullet.  Nassilov  resects  ribs  close  to  the  spine.  The  portion  of  the 
esophagus  above  the  aortic  arch  can  be  reached  after  partial  resection  of  the 
third,  fourth,  fifth,  and  sixth  ribs  of  the  left  side.  The  inferior  portion  of  the 
esophagus  can  be  reached  after  resecting  portions  of  the  lower  third  or  fourth 
ribs  on  the  right  side  (Binnie's  "Operative  Surgery").  Willy  Meyer  has  made 
four  heroic  attempts  to  resect  cancers  of  the  esophagus.  All  the  patients 
perished.  He  does  it  under  positive  pressure  ("Surg.,  Gynec,  and  Obstet.," 
Dec,  191 2).  Out  of  35  known  operations  i  recovered  and  i  lived  two  weeks 
after  operation.  The  anterior  mediastimmi  may  be  entered  to  remove  a  bullet,, 
to  drain  an  abscess,  to  reach  a  wound  of  the  heart  or  lung,  and  to  explore  for  the 
cause  of  symptoms.  I  explored  the  anterior  mediastinum  after  rib  resection, 
found  a  bullet  embedded  in  the  aorta,  and  allowed  it  to  remain.  The  patient 
recovered.     M.  H.  Milton^  splits  the  sternum  and  separates  the  two  pieces. 

Invasion  of  the  mediastinum  is  much  safer  if  the  operation  is  performed  in 
the  Sauerbruch  chamber  or  with  the  aid  of  positive  pressure  within  the  bronchi. 
Either  of  these  plans  will  prevent  pulmonary  collapse  if  the  pleura  is  opened. 


XXVIII.  DISEASES  AND    INJURIES  OF  THE  ABDOMEN 

Diagnosis  of  Intra=abdominaI  Emergencies. — ^The  exact  diag- 
nosis is  always  difficult  and  in  many  cases  is  impossible.  What  a  surgeon 
must  try  to  determine,  and  what  he  usually  can  determine,  is  whether  he 
is  dealing  with  a  trivial  and  temporary  derangement  for  the  relief  of  which 
an  operation  is  entirely  unnecessary,  or  whether  he  is  confronted  by  a 
grave  calamity  which  imperatively  demands  immediate  surgical  aid.  We 
can  decide  that  a  calamity  exists,  but  the  exact  nature  of  the  lesion  is  often 
doubtful  until  operation  is  performed.  Every  operation  in  such  a  case  is 
exploratory.  Before  the  diagnosis  of  a  calamity  is  made  morphin  should  not 
be  given,  because  it  allays  the  pain,  relieves  the  anxiety,  causes  the  disappear- 
ance of  rigidity,  lowers  the  pulse,  abates  mental  shock,  and  hence  veils  the 
real  situation,  so  that  the  most  discerning  surgeon  will  probably  be  misled.     If 

1  "Lancet,"  March  27,  1897. 


944  Diseases  and  Injuries  of  the  Abdomen 

shock  is  profound,  diagnosis  is  usually  impossible,  unless  shock  is  due  to  hemor- 
rhage, and  immediate  operation  during  shock  is  not  to  be  thought  of  except  for 
a  perforation  or  to  arrest  bleeding.  If  excessive  and  continued  hemorrhage 
is  suspected,  immediate  operation  is  indicated.  If  it  is  not  suspected,  the 
patient  should  be  covered  with  blankets  and  surrounded  with  hot-water 
bags,  atropin  should  be  given  hypodermatically,  and  hot  salt  solution  should 
be  administered  by  rectum,  subcutaneously,  or  intravenously.  When  the 
patient  reacts,  and  he  usually  wiU  react,  an  attempt  is  made  to  make  a  diag- 
nosis. If  a  patient  must  be  moved  to  a  hospital  it  is  perfectly  proper  to  give 
a  single  hypodermatic  injection  of  morphin  (J  gr.)  after  the  effort  has  been 
made  to  diagnosticate  the  condition.  The  danger  of  deluding  the  surgeon  is 
past,  and  the  drug  abates  pain,  lessens  peristalsis,  reHeves  mental  anxiety,  and 
is  distinctly  beneficial.  Before  the  morphin  was  given  the  surgeon  came  to  a 
conclusion  as  to  the  necessity  for  operation.  After  the  morphin  has  been 
given,  if  an  operation  is  indicated,  it  is  performed  as  promptly  as  circum- 
stances admit.  Whenever  it  is  consistent  with  safety,  the  patient  ought  to 
be  removed  to  a  hospital  for  operation. 

Foreign  Bodies  in  the  Abdomen. — Now  and  then  a  sponge,  a  pad,  or  an 
instrument  is  left  in  the  abdominal  cavity  during  an  operation— left,  not  because 
of  the  surgeon's  carelessness,  but  in  spite  of  the  most  painstaking  precautions. 
Instruments  and  sponges  are  counted  before  and  after  the  operation.  A  mis- 
count means  calamity.  The  surgeon  does  not  and  cannot  make  the  count 
himself.  He  has  not  time.  He  is  doing  a  more  difficult  thing  which  he  is 
trained  to  do  and  which  the  patient  expects  him  to  do,  that  is,  operating, 
closing  the  wound,  and  dressing  it.  The  surgeon  must  delegate  this  duty, 
and  he  delegates  it  to  assistants  or  nurses,  who  do  it  with  as  much  certainty  of 
accuracy  as  he  could  have  were  he  to  do  it.  At  least  two  people  count 
sponges,  pads,  and  instrimients  at  least  twice  before  and  twice  after  the  oper- 
ation. If  the  count  is  short,  and  the  missing  instnmient  or  material  is  not 
discovered  on  the  floor,  in  a  bucket,  on  or  under  the  table,  the  abdomen 
must  be  opened  and  the  lost  object  sought  for  and  found. 

A  great  safeguard  is  to  use  no  small  sponge  or  pad  unless  it  has  a  bit  of 
tape  sewed  to  it.  The  tapes  stick  out  of  the  wound  and  on  each  one  a  forceps 
is  clamped.  The  safest  way  of  all  is  to  use  rolls  of  gauze  (Halsted's  packs).  To 
do  so  means  a  long  broad  end  sticking  out  of  the  wound  so  that  it  cannot  be 
lost  in  the  belly. 

If  a  septic  body  of  any  sort  is  left  in  the  abdomen  it  at  once  produces  acute 
disturbances. 

If  an  aseptic  gauze  pad  or  sponge  is  left  it  may  become  encapsuled  and  cause 
no  trouble  for  months  or  years.  Sooner  or  later  it  will  be  apt  to  cause  trouble  or 
even  death.  The  sufferer  may  become  a  chronic  invalid.  The  object  may  make 
its  way  into  the  intestine  or  into  the  bladder.  It  may  even  pass  out  through  the 
rectum.  Usually  a  piece  of  retained  aseptic  gauze  or  an  aseptic  instrument 
produces  abdominal  pain  and  a  tendency  to  intestinal  obstruction.  Sooner  or 
later  an  abscess  forms  and  the  symptoms  of  an  acute  septic  condition  arise. 

Schachner  says  the  mortality  in  reported  cases  is  about  50  per  cent.  Many 
fatal  cases  have  not  been  reported.  If  we  suspect  the  presence  of  a  metal 
instrument  the  a;-rays  wiU  show  it. 

Treatment. — ^Laparotomy  (which  is  often  exploratory)  and  removal  of  the 
offending  material. 

Simple  Contusion  of  the  Abdominal  Wall  Without  Injury  of  Vis= 
cera. — In  some  cases  of  contusion  of  the  abdominal  waU  only  the  parietes  are 
damaged;  in  other  cases  the  viscera  or  the  abdominal  tissues  are  injured.  Con- 
tusion may  involve  the  skin  alone,  or  may  involve  the  skin,  muscles,  and 
peritoneum.    In  simple  contusion  there  is  considerable  shock  if  the  injury 


Injuries  With  Damage  to  the  Peritoneum  or  the  Viscera         945 

is  severe.  There  is  pain,  increased  by  respiration,  motion,  pressure,  and 
attempts  at  urination  or  defecation.  When  tenderness  appears  some  days 
after  the  accident  there  is  usually  deep-seated  injury.  Extensive  ecchymosis 
may  appear.  Even  after  a  severe  contusing  force  has  been  appUed  there 
may  be  no  discoloration,  and  it  may  happen  that  after  a  slight  force  there 
is  much  discoloration.  There  is  great  ecchymosis  in  anemic  persons,  victims 
of  hemiplegia,  obese  individuals,  opium-eaters,  and  drunkards.  In  severe 
cases  the  tissues  are  pulpified  and  sloughing  inevitably  ensues.  Abscess 
occasionally  follows  contusion.  The  prognosis  after  abdominal  contusion  is 
always  uncertain. 

Treatment  of  Simple  Contusion. — In  treating  simple  contusion  place  the 
patient  at  rest  in  a  supine  position,  with  the  thighs  flexed  over  a  pillow. 
Obtain  reaction  from  the  shock.  If  pain  is  severe,  and  we  are  certain  there 
is  no  visceral  injury  and  no  internal  hemorrhage,  give  morphin.  After  shock 
has  passed  off  it  is  advisable  to  place  an  ice-bag  over  the  seat  of  injury.  If 
much  blood  is  extravasated  into  the  abdominal  wall,  aspirate  and  apply  a 
binder.  After  twenty-four  hours  apply  local  heat  by  means  of  the  hot-water 
bag,  employ  an  ointment  of  ichthyol,  and  move  the  bowels,  if  necessary,  by 
saHnes.  Regard  every  contusion  as  serious,  and  watch  carefully  for  the  devel- 
opment of  signs  of  internal  hemorrhage  or  visceral  injury. 

Muscular  Rupture  from  Contusion. — In  this  injury  there  are  severe  shock, 
and  pain  (increased  by  respiration  and  movement).  Separation  between  the 
fibers  of  the  muscle  is  distinct  at  first,  but  it  is  soon  masked  by  effusion  of 
blood.  Such  injuries  may  cause  death  or  may  lead  to  hernia.  The  rectus 
is  the  muscle  most  apt  to  rupture.  The  rupture  is  due  to  sudden  contraction 
rather  than  to  the  direct  effect  of  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Always  apply  a  binder. 
If  a  hernia  exists  it  is  returned  and  a  compress  is  applied  over  the  opening 
through  which  it  emerged.  Later  operation  is  performed.  If  strangulation 
occurs,  operate  at  once. 

Injuries  With  Damage  to  the  Peritoneum  or  the  Viscera. — 
Rupture  of  the  Peritoneum.— The  peritoneum  may  be  involved  in  an  abdomi- 
nal contusion.  It  may  rupture  even  when  there  is  no  visceral  injury  or  mus- 
cular contusion.  The  uterine  peritoneum,  the  parietal  peritoneum,  the  visceral 
peritoneum,  or  the  mesentery  may  rupture.  Rupture  of  the  peritoneum 
causes  intra-abdominal  hemorrhage. 

The  treatment  consists  in  opening  the  abdomen,  arresting  the  hemorrhage, 
and  bringing  about  reaction. 

An  injury  to  the  peritoneum  creates  a  point  of  least  resistance,  and  at 
such  a  point  peritonitis  may  develop.  The  peritonitis  is  usually  local,  but 
may  become  general.  After  any  severe  intra-abdominal  injury  the  S3anp- 
toms  of  peritoneal  shock  appear  {peritonism),  and  the  patient  may  rapidly 
die.  In  the  condition  of  peritoneal  shock  the  temperature  is  subnormal;  the 
extremities  are  cold;  the  face  is  paUid  and  sunken;  the  pulse  is  small,  weak, 
and  very  frequent;  the  respiration  is  shallow  and  sighing;  there  is  great  thirst; 
the  patient  is  restless  and  turns  uneasily,  and  there  is  rigidity  and  disten- 
tion. Vomiting  almost  always  occurs.  In  some  cases  there  is  regurgitation 
rather  than  vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent  pain. 
The  patient  is  fearful  of  impending  death.  As  the  symptoms  develop  in  a 
grave  case  they  will  point  to  one  of  two  conditions — hemorrhage  or  peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature  and  other 
evidences  of  shock  persist.  Vomiting  ceases,  but  nausea  exists.  The  patient 
is  uncontrollably  restless  and  tosses  about  in  bed.  The  thirst  is  great.  The 
abdomen  is  rarely  rigid.  Fainting-spells  occur.  Blood  examination  shows  a 
marked  fall  in  the  percentage  of  hemoglobin.  Percussion  demonstrates  the 
60 


946  Diseases  and  Injuries  of  the  Abdon^ien 

existence  of  an  effusion  which  alters  its  position  as  the  patient's  position  is 
altered,  and  which  gradually  increases  in  amount.  Dulness  is  first  met  with 
in  the  loins.  Digital  examination  of  the  rectum  or  vagina  may  aid  in  diagnosis, 
because  in  hemorrhage  blood  gathers  in  the  rectovesical  pouch.  If  peri- 
tonitis develops,  the  vomiting  is  aggravated,  the  pain  is  intensified,  and  the 
abdomen  grows  rigid  and  distended. 

Rupture  of  the  Stomach  Without  External  Wound. — ^The  usual 
cause  of  rupture  is  a  violent  blow,  although  the  accident  may  happen  while 
washing  out  the  stomach.  Rupture  is  more  apt  to  occur  when  the  stomach 
is  distended  with  food  than  when  it  is  empty.  The  rupture  may  be  partial, 
the  peritoneal  coat  not  being  torn.  The  rupture  may  be  complete.  Either 
the  anterior  or  the  posterior  wall  may  suffer.  The  region  of  the  pylorus 
is  most  apt  to  be  lacerated.  The  symptoms  of  rupture  are  collapse,  severe 
pain  over  the  entire  abdomen,  great  thirst,  excessive  tenderness,  especially 
over  the  epigastric  region,  occasionally  vomiting,  the  vomited  matter  being 
usually,  but  not  invariably,  bloody;  tympanitic  distention  and  muscular 
rigidity  coming  on  after  a  few  hours.  Austin  Flint  pointed  out  years  ago 
that  after  complete  rupture  or  perforation  gas  may  enter  the  abdominal 
cavity  and  cause  the  diminution  or  disappearance  of  liver-dulness,  but  the 
area  of  liver-dulness  can  be  lessened  by  great  intestinal  distention,  and  I 
have  seen  cases  of  perforation  of  the  stomach  and  intestine  in  which  it  was 
not  lessened  at  all.  (See  article  on  Perforating  Ulcer  of  the  Stomach.) 
After  incomplete  rupture  local  peritonitis  is  frequent;  in  complete  rupture  the 
escape  of  stomach  contents  into  the  peritoneal  cavity  causes  general  peritonitis. 
The  contents  of  the  stomach  are  not  so  liable  to  escape  after  rupture  of  that 
viscus  as  are  the  contents  of  the  intestine  after  rupture  of  the  gut,  because 
of  the  thickness  of  the  stomach  wall  and  the  tendency  of  the  mucous  mem- 
brane to  evert  and  block  the  opening.  Perforations  of  the  anterior  wall 
are  most  apt  to  lead  to  extravasation  and  general  peritonitis.  Posterior 
laceration  may  cause  subphrenic  abscess.  To  diagnosticate  between  complete 
and  incomplete  rupture,  Senn  endeavors  to  distend  the  viscus  with  hydrogen 
gas;  in  incomplete  rupture  the  contour  of  the  dilated  stomach  can  be  made 
out  upon  the  surface;  in  complete  rupture  the  viscus  cannot  be  distended, 
and  the  gas  passes  into  the  peritoneal  cavity,  producing  the  physical  signs  of 
tympanites.  This  maneuver  is  open  to  the  objection  that  it  may  increase 
extravasation  in  a  complete  rupture. 

The  treatment  for  complete  rupture  is  immediate  operation.  Treatment  for 
shock  is  at  once  instituted  and  an  intravenous  infusion  of  salt  solution  is  given 
before  or  during  operation.  In  doubtful  cases  endeavor  to  bring  about  reac- 
tion and  explore.  Open  the  abdomen.  Note  if  gas  emerges  from  the  wound 
or  if  stomach  fluid  appears.  Search  for  the  rupture  in  the  same  manner  as 
we  would  search  for  the  opening  of  a  perforated  ulcer.  When  the  rupture  is 
discovered,  flush  out  the  stomach  and  the  peritoneal  cavity  with  hot  salt 
solution;  sew  up  the  stomach  wound  with  a  double  row  of  silk  sutures,  the 
first  row  being  buried  and  including  the  muscular  coat  and  mucous  coat, 
the  second  row  being  Halsted  sutures;  drain  the  abdomen;  close  the  wound 
in  the  parietes;  place  the  patient  in  Fowler's  position;  let  salt  water  at  low 
pressure  flow  continuously  into  the  rectum;  feed  by  the  rectum  for  four  days, 
and  then  begin  the  administration  of  a  very  little  food  by  the  mouth.  In 
incomplete  rupture  the  danger  is  perforation.  The  patient  is  put  to  bed,  and 
after  reaction  has  taken  place  is  fed  by  the  rectum  for  several  days.  Cases 
of  complete  rupture  not  operated  upon  occasionally  recover,  adhesions  arising 
and  perigastric  suppuration  taking  place.  The  mortality  is  extremely  large. 
In  1896  Petry  collected  23  cases  in  which  operation  was  not  performed. 
The  mortality  was  59  per  cent.     This  mortality  is  not  so  large  as  one  would 


Rupture  of  the  Intestine  Without  External  Wound  947 

anticipate.  It  is  quite  possible  that  some  of  the  cases  were  not  genuine 
instances  of  rupture.  Many  fatal  cases  have  not  been  reported.  Never- 
theless, the  lesion,  for  reasons  previously  stated,  is  not  nearly  so  dangerous 
as  rupture  of  the  intestine.  Another  reason  for  the  greater  danger  of  intes- 
tinal rupture  is  that  fecal  matter  is  much  more  poisonous  than  the  gastric 
contents.  Laparotomy  has  lessened  the  mortality  of  rupture  of  the  stomach. 
Petry  and  also  Eisendrath  mass  together  operations  for  rupture  of  the  stomach 
and  rupture  of  the  intestine.  Petry  finds  the  group  mortality  to  be  52.3 
p*er  cent.,  and  Eisendrath  finds  it  to  be  52.5  per  cent.  Statistics  referring 
to  the  stomach  alone  should  show  a  much  lower  death-rate. 

Rupture  of  the  Intestine  Without  External  Wound. — In  the  great 
majority  of  cases  the  damage  is  produced  by  direct  violence.  In  some  few 
cases  the  force  is  indirect  (falls  on  the  feet  or  buttocks,  blows  on  the  back 
or  loin).  The  injury  may  result  from  oscillation  or  from  compression  (the 
yoimger  Senn).  The  common  cause  is  undoubtedly  compression  of  the 
gut  against  the  pehds  or  vertebral  column,  but  it  is  certain  that  a  gut  con- 
taining fluid  may  be  ruptured  purely  by  violent  shaking  or  oscillation.  If 
oscillation  produces  the  damage,  the  rupture  is  on  the  portion  of  gut  fur- 
thest from  the  mesentery;  if  compression  is  the  cause,  any  part  of  the  bowel 
may  suffer.  Rupture  is  most  apt  to  occur  if  the  belly  is  relaxed.  It  is  pre- 
disposed to  by  adhesions,  disease  of  the  wall  of  the  bowel,  and  irreducible 
hernia.  Most  ruptiu^es  are  complete.  In  a  wary  few  cases  the  tear  ex- 
tends only  through  one  or  two  of  the  coats  and  the  rupture  is  incomplete. 
A  contusion  of  the  gut  may  be  followed  by  rupture  several  days  after  the 
injury.  A  complete  rupture  usually  permits  leaking  of  feces,  but  in  very 
rare  cases  a  small  opening  is  closely  plugged  by  pouting  mucous  membrane. 
Leaking  from  a  rupture  may  be  delayed  because  intra-abdominal  pres- 
sure may  for  a  time  keep  the  opening  pressed  against  a  section  of  sound 
gut  (the  younger  Senn).  The  amount  of  damage  to  the  belly  wall  does  not 
convey  any  notion  of  the  extent  of  visceral  injur}^  The  belly  wall  may  be 
severely  injured  and  the  \dscera  escape.  With  only  slight  contusion  of  the 
wall  there  may  be  extensive  ^dsceral  injury.  Homer  Gage^  collected  85  cases; 
in  75  the  injur}^  was  due  to  direct  force,  and  in  32  of  these  the  force  was  in- 
flicted by  the  kick  of  a  horse  or  of  a  man.  In  i  of  my  cases  it  was  due  to 
the  kick  of  a  horse,  in  i  to  the  kick  of  a  man,  and  in  i  to  a  crush  inflicted 
by  a  cart-wheel.  The  victims  in  the  majority  of  reported  cases  were  young 
men,  probably  because  young  men  are  most  apt  to  be  exposed  to  \dolence. 
In  78  collected  cases  (Gage)  the  situation  of  the  injury  was  specified:  The 
duodenum,  10;  jejunum,  20;  ileum,  42;  large  intestine,  6.  Curtis  foxmd 
the  large  intestine  injured  in  4  cases  out  of  113,  and  Poland,  in  5  cases  out  of 
64.  In  many  cases  there  is  more  than  one  tear,  and  sometimes  many  tears  exist. 
Both  the  large  and  small  intestines  may  suffer.  Chavasse  collected  106  cases 
in  which  the  ileum  or  jejumun  suffered,  19  in  which  the  large  intestine  did, 
7  in  which  the  duodenum  did,  7  in  which  both  the  large  and  small  intestine 
were  involved,  and  i  case  in  which  the  rectum  was  ruptured  (quoted  by  the 
younger  Senn,  in  "Am.  Jour.  Med.  Sciences,"  June,  1904).  As  Makins  points 
out,  the  portion  of  gut  most  apt  to  be  injured  is  a  portion  hanging  low  in 
the  pelvis,  because  a  loop  in  this  situation  is  most  easily  squeezed  against 
bone  by  a  blow  on  the  belly.  The  mesenterv^  may  be  lacerated  (it  is  in  7  per 
cent,  of  cases,  according  to  Gage;  in  16  per  cent.,  according  to  Curtis).  The 
symptoms  of  rupture  of  the  intestine  are  profound  shock,  t^onpanites,  abdom- 
inal pain,  and  rigidity,  rapidly  followed  by  peritonitis  if  the  patient  survives. 
In  some  cases  pain  is  referred  to  the  back.  Vomiting  comes  on  soon  after 
the  accident,  the  vomited  matter  being  possibly  at  first  bloody  and  later  ster- 
^  "Annals  of  Surgery,"  March,  1902. 


948  Diseases  and  Injuries  of  the  Abdomen 

coraceous.  The  respiration  is  thoracic,  the  tongue  is  dry,  and  great  thirst 
exists.  The  pulse,  which  may  be  slow  at  first,  soon  becomes  small,  rapid, 
and  of  high  tension.  Blood  in  the  stools  rarely  appears  early  enough  to  be  of 
diagnostic  value,  and  there  may  be  diarrhea  or  constipation.  The  respiration  is 
costal.  Dyspnea  exists.  There  may  be  no  marked  symptoms  for  an  hour  or 
two  or  for  many  hours.  Cases  are  on  record  of  people  with  ruptured  intestine 
returning  to  work  perhaps  for  hours.  Holland's  patient  had  no  symptoms 
for  twenty-four  hours,  although  the  jejunum  was  ruptured.  Poland's  patient 
ruptured  the  duodenum,  but  walked  one  mile  in  spite  of  it.  The  escape  of 
gas  into  the  peritoneal  cavity  may  cause  the  diminution  or  disappearance  of 
liver  dulness.  After  anesthetizing  the  patient,  hydrogen  gas  insuffiated  into 
the  rectum  will  come  from  the  mouth  if  there  is  no  perforation  in  the  stomach 
or  the  intestine;  if  a  perforation  exists,  tympanites  is  much  increased  and  the 
area  of  liver  dulness  may  disappear.  To  apply  rectal  insufflation  of  hydrogen, 
generate  the  gas  in  a  bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the 
gas  in  a  large  rubber  bag,  and  attach  the  tube  from  the  gas  reservoir  to  a 
tip  which  is  inserted  in  the  rectum.  Give  the  patient  ether  to  relax  the  abdomi- 
nal muscles,  direct  an  assistant  to  press  the  anal  margins  against  the  rectal 
tip,  and  when  the  patient  is  unconscious  turn  on  the  stopcock  and  press 
upon  the  reservoir  (the  elder  Senn). 

It  has  been  suggested  that  ether  vapor,  mixed  with  air,  can  be  used  instead 
of  hydrogen  gas.^  In  this  method  a  little  ether  is  poured  into  the  bottle  of 
an  aspirator,  the  valves  are  opened,  one  tube  is  carried  into  the  rectum,  the 
other  tube  is  attached  to  a  bicycle  pump,  and  by  working  the  pump  the  ether 
vapor  is  driven  into  the  bowel.  If  there  is  perforation,  tympanites  is  notably 
increased.  Most  surgeons  regard  the  rectal  insufflation  test  as  unsatisfactory 
and  often  dangerous.  Personally,  I  am  not  incUned  to  use  it.  Its  appUcation 
requires  considerable  time;  it  must,  of  necessity,  increase  fecal  extravasation. 
If  we  operate  after  insufflation  the  gaseous  distention  is  an  embarrassment  to 
the  surgeon;  as  Le  Conte"  says,  it  "so  distends  the  intestines  that  it  may  be 
impossible  to  return  them  to  the  abdominal  cavity  until  they  have  been 
emptied  of  gas." 

Treatment  for  Rupture  of  Intestine. — After  an  abdominal  injury,  if  symp- 
toms point  to  dangerous  hemorrhage,  and  in  any  case  in  which  the  patient 
does  not  seem  to  be  reacting,  but  is  rather  getting  worse,  operate  at  once. 
If  in  doubt  as  to  whether  or  not  rupture  exists,  make  every  endeavor  to  bring 
about  reaction  and  explore.  Reaction  is  brought  about  as  previously  directed. 
Asepticize  and  anesthetize.  Perform  a  laparotomy,  making  the  incision  in  the 
middle  line  and  below  the  umbilicus;  observe  if  gas  escapes  when  the  perito- 
neum is  opened  or  if  fecal  material  or  an  inflammatory  exudate  flows  out; 
check  hemorrhage;  start  at  a  fixed  point  and  conduct  a  careful  search  to  find 
the  rent.  When  the  rent  is  found,  it  should  be  closed  by  Halsted  sutures  if 
possible,  but  only  a  small  rupture  can  be  so  treated.  A  large  tear  makes 
resection  necessary.  Because  of  the  frequency  of  multiple  lesions  the  surgeon 
must  not  be  sure  he  has  finished  his  work  when  he  finds  and  closes  one 
tear,  but  he  must  determine  by  careful  search  that  no  other  tears  exist. 
The  surgeon  notes  if  there  is  injury  of  the  mesentery  and  if  the  cir- 
culation of  any  portion  of  the  bowel  is  interfered  with.  If  there  is  serious 
impairment  of  circulation  in  any  part  of  the  bowel  wall,  perform  intestinal 
resection,  followed  by  end-to-end  approximation  or  lateral  anastomosis.  In 
some  cases  of  rupture  the  patient  is  so  severely  shocked  that  it  is  impossible 
to  do  a  resection  with  any  hope  of  his  living.  In  such  a  case  stitch 
the  ruptured  portion  of  gut  to  the  belly  wall.     The  opening  in  the  gut  be- 

1  Emerson  M.  Sutton,  of  Geneva,  in  "Jour.  Am.  Med.  Assoc,"  July  23,  1898. 
^  "Jour.  Am.  Med.  Sciences,"  Dec,  1901. 


Identification  of  the  Small  Intestine  and  of  the  Large  Intestine    949 

comes  a  fecal  fistula,  and  if  the  patient  survives,  can  be  subsequently  closed. 
The  same  procedure  is  proper  if  the  bowel  is  distended  and  paralyzed. 
After  closing  the  opening  in  the  bowel  or  resecting,  flush  the  abdominal  cavity 
with  hot  saline  solution,  and  wipe  the  peritoneal  fossae  and  the  space  between 
the  liver  and  diaphragm  with  gauze.  Finney  eviscerates,  wipes  out  the 
abdominal  cavity,  and  wipes  the  intestines  as  he  restores  them.  This  is 
justifiable  if  the  operation  is  done  soon  after  the  rupture,  but  not  in  later  cases, 
in  which  the  lymph  has  gathered  on  the  bowel.  Whatever  method  is  used 
to  cleanse  the  abdomen,  remember  that  infectious  material  is  apt  to  accumu- 
late between  the  liver  and  diaphragm  and  in  Douglas's  pouch.  Drainage  is 
to  be  used.  Suprapubic  drainage  is  most  advantageous.  Place  the  patient 
semi-erect  and  employ  continuous  proctoclysis  of  normal  salt  solution  as  directed 
for  peritonitis.  The  value  of  operation  for  intestinal  rupture  is  conclusively 
demonstrated.  Curtis  collected  116  cases  which  occurred  before  1887.  Not 
a  case  was  operated  upon,  and  every  patient  died.  Homer  Gage  collected 
85  cases  since  1887:  45  were  not  operated  upon  and  every  one  died;  40  were 
operated  upon  and  17  recovered.  Eisendrath  collected  40  cases  operated 
upon:  19  recovered  and  21  died  (52.5  per  cent.).  The  mortality  of  cases 
not  operated  upon  is,  according  to  Eisendrath,  at  least  93  per  cent.  The 
sooner  after  the  injury  operation  is  performed,  the  greater  the  chance  for 
success.  The  younger  Senn  points  out  that  in  operations  done  within  four 
hours  the  mortahty  is  15.2  per  cent.;  in  those  done  between  five  and  eight 
hours  it  is  44,4  per  cent. ;  in  those  done  between  nine  and  twelve  hours  it  is 
63.6  per  cent.,  and  in  those  done  later  it  is  70  per  cent. 

Identification  of  the  Small  Intestine  and  of  the  Large  Intestine. — "In 
abdominal  operations  it  is  frequently  imperatively  necessary  that  the  large 
intestine  be  recognized  wuth  certainty  or  the  small  bowel  be  positively  identi- 
fied. The  size  of  the  tube  will  not  always  aid  in  this  recognition,  as  a  small 
intestine  may  be  distended  enormously,  and  a  large  intestine  may  be  con- 
tracted to  the  size  of  a  finger  because  of  obstruction  above.  The  longitudinal 
muscular  fibers  of  the  large  bowel  are  accentuated  in  three  portions;  these 
accentuations  constitute  the  three  longitudinal  bands  which  begin  at  the 
cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of  the  colon.  Each 
band  is  composed  of  a  number  of  shorter  bands,  the  shortness  of  these  con- 
stituent bands  permitting  the  sacculation  of  the  large  intestine.  Longitudinal 
bands  and  sacculation  are  not  met  with  in  the  small  gut,  their  presence  or 
absence  being  a  means  of  identification  in  many  cases;  but  when  the  colon 
is  much  distended  the  bands  cannot  be  seen  distinctly  and  the  sacculation 
disappears.  From  the  large  intestine  only  spring  the  appendices  epiploicae 
(small  overgrowths  of  fat  in  pouches  of  peritoneum),  but  they  are  sometimes 
not  well  marked  except  upon  the  transverse  colon,  and  when  emaciation  exists 
they  may  almost  entirely  disappear.  The  relatively  fixed  position  of  the 
large  intestine  and  the  free  mobility  of  the  small  bowel  are  important  points 
of  distinction.  The  foregoing  indicates  that  it  is  not  always  easy  to  distinguish 
between  colon  and  small  gut,  and  that,  according  to  old  rules,  it  may  be  often 
necessary  to  make  large  incisions,  to  see  as  well  as  feel,  and  to  handle  a  large 
extent  of  the  bowel.  Any  scrap  of  knowledge  that  wUl  shorten  an  abdominal 
operation,  that  will  permit  of  as  certain  work  through  a  smaller  incision,  and 
that  will  diminish  handling  of  intraperitoneal  structures  tends  to  increase  the 
chances  of  recovery.  For  these  reasons  the  writer  suggests  a  method  of  bowel 
identification  which  rests  upon  the  facts  that  each  bowel  has  a  posterior  attach- 
ment, that  the  origin  of  the  attachment  differs  according  to  the  bowel  it  sup- 
ports, that  a  single  finger  can  detect  the  origin  of  the  peritoneal  support  of  any 
section  of  the  bowel,  and,  this  origin  being  known,  the  portion  of  the  bowel  it 
supports  is  with  certainty  deducible.     In  an  exploratory  operation,  for  instance, 


9SO 


Diseases  and  Injuries   of  the  Abdomen 


the  finger  comes  in  contact  \\'ith  the  bowel:  to  determine  whether  it  is  a  large 
or  a  small  bowel,  note  first  if  the  structure  is  movable  or  is  firmly  fixed;  next, 


Fig.  598. — ^A  loop  of  intestine,  the  middle  of  which  is  exactly  3  feet  from  the  end  of  the  duodenum. 
The  gut  is  of  large  size.  The  mesenteric  loops  are  primary-,  and  the  vasa  recta  large,  long,  and  regular 
in  distribution.  The  translucent  spaces  Qunettesj  between  the  vessels  are  extensive.  Below,  the 
mesentery  is  streaked  with  fat.  The  veins,  which  had  a  distribution  similar  to  the  arteries,  are  for 
simplicity  omitted  from  this  and  from  the  subsequent  drawings.  The  subject  from  which  the  specimen 
was  taken  was  a  male  of  forty  years,  with  rather  less  than  the  usual  amount  of  fat.  The  entire  length 
of  the  intestine  was  23  feet  (Monks). 


yig_  59g.— A  loop  of  intestine  at  6  feet.  As  compared  with  Fig.  598  the  gut  is  somewhat  smaller. 
The  vascularitj'  of  the  intestine  and  mesentery  is  less.  Secondary  loops  are  a  prominent  feature. 
The  vasa  recta  are  smaller.  The  lunettes  are  also  present,  but  are  not  so  large  as  m  Fig.  598.  The 
subject  was  a  male  of  about  thirty-five  years,  with  an  average  amoimt  of  fat.     The  entire  length  of  the 

intestine  was  20  feet  (Monks) . 

pass  the  finger  over  the  bowel  and  let  it  find  its  way  posteriorly.  If  dealing 
with  a  small  bowel,  the  finger  will  reach  the  origin  of  the  mesentery  between  the 
left  side  of  the  second  lumbar  vertebra  and  the  right  sacro-iliac  joint:  if  deaHng 


Location  of  a  Loop  of  Small  Intestine 


951 


with  the  large  bowel,  the  finger  will  reach  the  origin  of  the  mesocolon,  or  the 
point  where  the  colon  is  fixed  posteriorly  and  to  the  side."^ 


Fig.  600. — A  loop  of  intestine  at  12  feet.  The  vessels  are  smaller.  The  primary  loops  are  lost  in 
the  fat,  but  secondarj-  and  even  tertiary  loops  are  visible.  The  vasa  recta  are  shorter,  more  irregular, 
and  branching.     The  specimen  came  from  the  same  subject  which  furnished  Figs.  59S  and  599  (Monks). 


Fig.  601. — A  loop  of  intestine  at  20  feet.  The  gut  appears  to  be  thick  and  large.  The  mesenterj' 
is  quite  fat  and  opaque,  and  large  and  numerous  fat  tabs  are  present.  The  vessels,  which  are  compli- 
cated, are  seen  with  difficulty,  and  are  represented  by  mere  grooves  in  the  fat.  The  subject  was  a 
stout  woman,  and  the  entire  length  of  the  gut  was  21  feet  (Monks). 

Location  of  a  Loop  of   Small  Intestine  (Figs.  598-601). — Monks   points 
out  a  plan  by  which,  in  most  instances,  we  can  learn  with  approximate  accu- 
racy what  portion  of  the  small  intestine  we  may  have  hold  of   (''Annals 
.^The  author,  in  "Medical  News,"  June  9,  1894. 


952  Diseases  and  Injuries  of  the  Abdomen 

of  Surg.,"  Oct.,  1903).  He  learns  first  by  observation  of  the  mesenteric 
vessels.  Opposite  the  upper  portion  of  the  bowel  there  are  primary  vascular 
loops  only  with  perhaps  an  occasional  small  secondary  loop.  As  we  descend 
"secondary  loops  become  more  numerous,  larger,  and  approach  nearer  to  the 
bowel  than  the  primary  loops  in  the  upper  part,"  and  about  the  fourth  foot 
these  secondary  loops  first  become  a  ''prominent  feature."  As  we  descend 
primary  loops  become  smaller,  secondary  loops  become  more  numerous  and 
nearer  the  bowel,  and  possibly  tertiary  loops  appear.  Opposite  the  lower  por- 
tion of  the  ileum  the  loops  are  not  definite  in  arrangement,  but  are  simply  a 
network.  Monks  points  out  that  opposite  the  upper  bowel  the  vasa  recta, 
when  put  gently  on  the  stretch,  "are  straight,  large,  and  regular,  and  rarely 
give  off  branches  to  the  mesentery,"  and  are  about  5  cm.  long.  In  the  lower 
third  they  are  usually  less  than  i  cm.  long,  are  smaller,  are  not  quite  so 
straight,  are  not  so  regular,  and  give  off  numerous  mesenteric  branches. 
Monks  further  shows  that  fat  impairs  the  translucency  of  the  mesentery.  The 
thinnest  mesentery  is  that  connected  with  the  upper  gut.  As  we  descend  the 
mesentery  becomes  thicker  and  thicker  because  of  fibrous  tissue,  unstriated 
muscle,  and  fat.  Translucency  varies  greatly.  If  a  loop  of  upper  intestine  is 
raised  against  the  light,  one  notices  close  to  the  gut  and  between  the  vasa  recta 
transparent  lunettes.  The  lunettes  become  smaller  and  fatty  as  we  descend, 
and  disappear  at  the  eighth  foot.  In  an  incision  in  the  median  line,  if  the  loop  of 
intestine  is  pulled  downward,  we  can  determine  if  "the  line  of  resistance  from 
above  is  from  the  median  line  of  the  body  or  from  the  left  or  right  of  it." 
This  resistance  of  the  mesentery  indicates  to  which  point  the  loop  is  attached, 
and  hence  what  portion  of  bowel  the  loop  comprises.  I  have  used  these 
observations  of  Monks  repeatedly  to  great  advantage. 

Rupture  of  the  Liver. — (See  page  1032.) 

Rupture  of  the  gall=bladder  and  the  bile=ducts  (see  page  1032)  is 
most  apt  to  happen  from  injury  when  gall-stones  exist.  Peritonitis,  general  or 
local,  is  almost  certain  to  follow  such  a  rupture.  Besides  those  symptoms 
common  to  all  severe  abdominal  injuries  there  may  be  intense  jaundice. 

Treatment. — Suture  the  laceration  or  make  a  biliary  fistula. 

Rupture  of  the  Pancreas. — (See  page  1054.) 

Rupture  of  the  Spleen. — (See  page  1063.) 

Rupture  of  Mesenteric  Arteries. — The  symptoms  are  those  of  hemor- 
rhage. The  superior  mesenteric  artery,  the  inferior  mesenteric  artery,  or 
branches  of  either  or  both  may  be  damaged.  If  branches  of  the  superior  mes- 
enteric artery  are  divided  near  the  bowel,  gangrene  of  the  bowel  will  result,  but 
wound  of  a  branch  far  from  the  intestine  does  not  cause  gangrene.  The  branches 
near  the  gut  are  terminal  arteries,  hence  the  gangrene.  The  branches  of  the 
artery  divide  and  form  arcades  arranged  concentrically  and  the  terminal  arteries 
come  from  the  peripheral  arcades.  In  w^ounds  of  the  vessels  far  removed  from 
the  gut  anastomosis  prevents  gangrene  (Labastie,  in  "Archives  Generales  de 
Chirurgie,"  Jan.  25,  1908).  In  most  cases  in  which  there  has  been  rupture  of 
mesenteric  arteries  death  from  hemorrhage  rapidly  occurs.  If  the  victim 
should  not  die  of  hemorrhage  he  is  in  danger  of  gangrene  and  peritonitis. 
Aldrich^  reported  a  case  in  which  death  was  deferred  until  the  seventh  day. 
The  treatment  is  immediate  laparotomy.  If  the  wound  is  found  close  to  the 
gut,  the  portion  of  gut  supplied  by  the  cut  vessel  should  be  resected.  If  well 
removed  from  the  gut,  simply  ligate  the  vessel  (Labastie,  Ibid.).  In  a  wound 
near  the  root  of  the  mesentery  perform  extensive  resection  of  the  gut  and 
remove  also  a  portion  of  the  mesentery. 

Rupture  of  the  Kidney. — (See  page  1280.) 

Rupture  of  the  Ureter. — (See  page  1282.) 

1  "Annals  of  Siirgery,"  March,  1902. 


Penetrating  Wounds  953 

Wounds  of  the  Abdominal  Wall. — Non-penetrating  wounds  are  to  be 

treated  on  general  principles.     They  are  sutured  with  great  care  and  are  firmly 
supported  externallv.     Ventral  hernia  may  follow  a  large  wound. 

Penetrating  Wounds. — The  symptoms  of  penetrating  wounds  of  the  ab- 
dominal wall  are  usually  those  of  shock  and  hemorrhage,  and  later  of  septic 
peritonitis.  Emphysema  is  apt  to  occur  and  viscera  may  protrude,  and  often 
do  in  the  case  of  a  large  incised  or  lacerated  wound.  Extravasation  of  con- 
tents of  intra-abdominal  viscera  is  very  apt  to  occur,  and  is  sure  to  occur  if  the 
\"iscus  was  distended  when  injured.  Normal  urine  and  normal  bile  may  do 
little  harm,  but  if  either  excretion  is  septic,  disastrous  consequences  are  certain 
to  ensue.  If  intestinal  contents  escape,  septic  peritonitis  is  sure  to  arise. 
Bleeding  is  usually  profuse  and  prolonged,  because  spontaneous  arrest  of  hemor- 
rhage from  any  vessel  of  considerable  size  will  seldom  take  place  within  an 
unopened  abdomen. 

Treatment. — The  surgeon  endeavors  to  promptly  discover  if  a  wound  of 
the  abdominal  wall  is  or  is  not  penetrating  in  character.  This  fact  may  be 
proved  b}-  protrusion  of  \'iscera,  by  the  appearance  of  stomach  contents 
in  the  wound,  or  by  a  flow  of  bile,  urine,  or  feces  from  the  wound.  If  none  of 
the  above  indications  exists,  and  if  there  are  no  signs  of  serious  hemorrhage, 
the  wound  should  be  irrigated  with  hot  salt  solution,  and  should  be  dressed 
with  gauze,  and  every  effort  should  be  made  to  bring  about  reaction;  otherwise 
operation  should  be  immediate. 

When  reaction  is  obtained,  the  wound  should  be  enlarged  layer  by  layer 
until  it  becomes  obvious  whether  or  not  the  peritoneum  is  open.  Madelung,^ 
of  Strassburg,  points  out  that  incision  layer  by  layer  will  be  of  no  use  in  settling 
the  question  of  penetration  if  the  wound  is  in  the  chest,  the  buttock,  the 
permeum,  or  the  back  of  a  fat  individual.  If  after  incision  layer  by  layer 
it  becomes  e\ddent  that  penetration  has  not  occurred,  the  wound  should  be 
closed  and  treated  on  general  principles.  If  it  becomes  evident  that  it  has 
occiu"red,  the  abdomen  should  be  opened  at  the  point  of  penetration,  and  a 
thorough  exploration  of  intra-abdominal  structures  should  be  made  in  order 
to  locate  injury  and  be  able  to  treat  it  properly. 

In  a  case  still  doubtful  after  incision  by  layers,  do  an  exploratory  lapa- 
rotomy in  the  middle  line.  It  is  impossible  from  the  appearance  of  the  wound 
and  it  may  be  impossible  from  the  s^inptoms  to  affirm  that  visceral  injury 
has  not  occurred;  hence  in  every  case  in  ci\'il  practice  in  which  it  is  evident 
that  penetration  has  occurred,  laparotomy  is  necessary  in  order  to  detect  and 
correct  intra-abdominal  injur\",  and  to  clean  the  peritoneum  by  flushing  with 
hot  salt  solution.  If  viscera  protrude,  they  must  be  washed  off  with  hot  salt 
solution  and  covered  with  hot  sterile  pads,  and  after  the  patient  has 
reacted  the  wound  should  be  enlarged,  the  condition  of  the  contents  of 
the  abdomen  investigated,  hemorrhage  arrested,  wounds  properly  treated,  and 
the  \dscera  returned. 

It  is  customarv'  to  flush  the  belly  with  hot  salt  solution,  some  of  the  fluid 
being  allowed  to  remain.  This  procedure  mechanically  cleanses  the  perito- 
nemn,  removes  blood-clots,  strongly  combats  shock,  and  antagonizes  infection. 
It  is  not  absolutely  necessary  to  flush  out  the  beUy  unless  a  considerable 
hemorrhage  has  occurred  or  feces  or  stomach  contents  have  been  extravasated. 
If  extravasation  of  stomach  contents  or  feces  has  occurred,  not  only  should 
flushing  be  practised,  but  evisceration  should  be  carried  out;  the  fouled 
intestine  should  be  wiped  off  with  gauze  pads  wet  with  hot  salt  solution,  and 
while  extruded  should  be  kept  wrapped  in  hot  moist  towels;  the  peritoneal 
fossae  shotdd  be  rubbed  with  gauze  pads  and  the  space  between  the  liver 
and  the  diaphragm  shovdd  be  carefully  wiped. 

1  ".\nnals  of  Surgery,"  Sept.,  1897. 


•954  Diseases  and  Injuries  of  the  Abdomen 

A  wound  of  the  stomach  should  be  sutured;  a  wound  of  the  bowel  may  be 
sutured,  or  resection  and  anastomosis  or  resection  and  end-to-end  suturing 
may  be  required.  Visceral  injuries  are  treated  by  appropriate  means.  In  a 
punctured  wound  or  a  gunshot-wound  of  the  intestine  rectal  insufflation  of 
hydrogen  gas  when  the  abdomen  is  open  may  disclose  the  situation  of  the 
injury,  but  evisceration  is  usually  practised  instead  and  is  preferable. 

After  the  completion  of  intra-abdominal  manipulations  the  surgeon  restores 
any  protruding  bowel. 

Drainage  is  required  if  the  contents  of  the  stomach  or  the  intestines  escaped, 
if  hemorrhage  was  severe,  or  if  the  liver,  pancreas,  kidney,  or  spleen  were 
found  to  have  been  damaged.  The  peritoneum  may  be  sutured  with  a  con- 
tinuous suture  of  catgut;  the  muscles  and  fascia,  with  continuous  or  inter- 
rupted sutures  of  catgut,  and  the  skin,  with  interrupted  sutures  of  fine  silk  or 
of  sikworm-gut.  If  there  is  need  of  haste,  through-and-through  sutures  of  sUk- 
worm-gut  may  be  used.  Active  stimulation  and  artificial  heat  are  needed 
immediately  after  the  operation  to  combat  shock.  In  many  cases  intravenous 
infusion  of  hot  normal  salt  solution  is  given.  It  is  of  great  value.  It  may  be 
given  both  during  and  after  operation.  Enteroclysis,  or  high  rectal  injection 
of  hot  saline  fluid,  is  useful.  So  is  hypodermoclysis,  or  the  subcutaneous 
injection  of  hot  salt  solution.  The  usual  after-treatment  consists  of  the 
semi-erect  position,  continuous  proctoclysis  of  salt  solution,  avoidance  of 
food  by  the  stomach  for  forty-eight  hours,  and  the  administration  of  brandy 
and  water  from  time  to  time.  For  two  days  the  patient  should  be 
fed  by  the  rectum.  On  the  appearance  of  flatulent  distention,  forty- 
eight  hours  or  more  after  the  operation,  give  a  saline  cathartic.  It  is  not 
Mdse  to  purge  during  the  first  forty-eight  hours  after  the  operation  unless  a 
Murphy  button  was  used.  When  there  is  no  sign  of  peritonitis  a  purge  should 
not  be  given  until  the  fourth  day.  After  forty-eight  hours  liquid  food  can  usu- 
ally be  given  by  the  stomach.  Solid  food  may  be  given  after  seven  or  eight 
•days,  but  the  patient  must  not  leave  his  bed  until  the  abdominal  wound  is 
firmly  united  because  of  the  danger  of  ventral  hernia.  A  support  should  be 
worn  for  a  long  time.  E.  D.  Fenner^  reports  39  stab- wounds  of  the  abdomen 
operated  upon  in  the  Charity  Hospital  of  New  Orleans.  There  were  9  deaths 
(23.07  per  cent.). 

Qunshot=wounds  of  the  Abdomen. — The  bullet  may  penetrate  from 
the  front,  the  side,  the  back,  the  chest,  or  the  perineum.  If  a  bullet  has  pene- 
trated, it  may  or  it  may  not  have  produced  xdsceral  damage;  a  pistol-bullet  or 
the  bullet  of  a  sporting-rifle  almost  invariably  does.  A  projectile  of  a  modern 
military  rifle  may  not  or  may  produce  wounds  which  can  be  recovered  from 
without  operation.  A  urinary  examination  should  be  made  promptly  to  see 
if  blood  is  present. 

In  gunshot-woimds  of  the  belly  shock  is  usually  greatly  added  to  by 
hemorrhage,  and  in  chnl  practice  prompt  operation  is  certainly  indicated. 
The  incision  is  made  through  the  belly  even  when  the  shot  entered  the 
■back.  In  some  cases  the  opening  is  made  through  the  wound;  in  others  it  is 
not;  but  in  every  case  the  wound  made  by  the  bullet  is  explored  and  dis- 
infected. The  incision  should  be  long  enough  to  permit  of  thorough  work. 
After  opening  the  abdomen  our  first  duty  is  to  arrest  hemorrhage,  our 
next  is  to  look  for  perforations  of  the  viscera  and  mesentery  and  close 
them.  If  the  anterior  wall  of  the  stomach  is  perforated,  close  the 
opening  and  examine  the  posterior  wall  through  an  opening  made  in 
the  gastrocoHc  omentum.  If  a  posterior  perforation  is  found,  close  it,  and 
insert  posterior  drainage  into  the  lesser  peritoneal  cavity.  As  a  rule,  an 
intestinal  perforation  can  be  closed,  but  occasionally  a  portion  of  the  intestine 
1  ".\nnals  of  Surgery,"  January,  1902. 


Omental  Cysts  955 

requires  resection.  If  the  bullet  is  encountered  it  is  removed,  but  a  prolonged 
search  for  it  should  never  be  made.  Finally,  the  abdominal  cavity  is  cleansed, 
drainage  is  provided  for,  and  the  abdominal  wound  is  closed.  In  one  of  my 
fatal  cases  the  bullet  entered  the  rectum  low  down  and  was  not  found.  In  a  case 
of  mine  with  6  perforations  of  the  small  intestine  recover)-  followed  operation. 

E.  D.  Fenner^  reports  113  gunshot-wounds  of  the  abdomen  operated 
upon  in  the  Charity  Hospital  of  New  Orleans;  there  were  78  deaths  (69  per 
cent.).  In  a  series  of  14  cases  operated  upon  by  Vaughan  the  mortality 
was  64  per  cent.  (''Am.  Jour.  Med.  Sciences,"  Feb.,  1906). 

iSIilitary  surgeons  have  shown  that  wounds  inflicted  by  the  modern  hard- 
jacketed  projectile  are  not  so  apt  to  involve  fatal  hemorrhage  and  disastrous 
complications;  in  fact,  such  wounds  are  often  recovered  from  without  opera- 
tion, and  sometimes  mth  an  entire  absence  of  serious  symptoms.  Again,  it  is 
difficult  or  impossible  to  treat  such  cases  as  in  ci\dl  practice,  even  were  it 
desirable.  In  fact,  in  military  practice  the  results  are  slightly  better  from 
expectant,  treatment,  whereas  in  ci\'il  practice  expectant  treatment  is  a 
ghastly  failure.  Still,  even  in  war,  if  conditions  permit,  operation  should  be 
performed  if  there  is  hemorrhage  or  obvious  visceral  injury,  or  if  septic 
peritonitis  develops.  Treves  says  that  in  the  Boer  War  only  40  per  cent,  of 
cases  of  gunshot-wounds  of  the  abdomen  not  operated  upon  died,  but,  as 
pointed  out  by  Hildebrandt,  many  cases  die  on  the  battlefield  and  while  being 
taken  to  the  hospital,  hence  the  real  mortality  of  these  injiiries  is  much  more 
than  40  per  cent.  In  the  war  between  China  and  Japan  the  mortahty  from 
gunshot- wounds  of  the  abdomen  is  said  to  have  been  about  77  per  cent. 

Qunshot=\vounds  of  the  Pregnant  Uterus. — It  is  rarely  that  both 
walls  are  perforated,  as  the  force  of  the  bullet  is  greatly  lessened  by  the  uterine 
contents.  There  are  severe  shock  and  hemorrhage,  and  occasionally  amniotic 
fluid  flows  from  the  wound  of  entrance.  The  intestine  may  also  be 
injured.  As  a  rule,  labor-pains  come  on  soon  after  the  injmy-.  The  proper 
treatment  early  in  pregnancy,  if  the  wound  is  small,  consists  in  emptying  the 
uterus  and  closing  the  wound.  In  Albarran's  case  the  fetus  was  expelled 
forty-eight  hours  after  operation.  A  large  wound,  or  any  wound  late  in  preg- 
nancy, demands  the  Porro  operation — removal  of  the  uterus,  ovaries,  and  tubes. 
Gellhorn-  has  collected  18  cases.  In  this  series  there  were  12  recoveries. 
Russell  Fowler  reports  a  case  of  a  patient  eight  months  pregnant  who  was  shot 
t^dce  in  the  abdomen.  There  were  two  wounds  in  the  uterus.  Fowler  did  a 
Cesarean  operation.  The  cut  in  the  uterus  was  carried  through  one  of  the 
bullet  woimds.  The  other  bullet  wound  was  sutured.  The  baby  was  wounded 
on  the  fingers  of  the  right  hand.  Both  mother  and  baby  recovered  ("New 
York  State  Jour,  of  Med.,"  Nov.,  1911).  In  Judge's  case  (''Jo^r-  Am.  Med. 
Assoc,"  vol.  i,  191 2),  a  girl  of  sixteen,  nearty  at  full  term,  was  shot  with  a 
Winchester  rifle.  The  child  was  in  the  abdominal  ca\ity  and  dead.  The 
mother  recovered.  Tucker,  of  Shanghai  (Ibid.),  did  a  Cesarean  operation  for 
gunshot-wound  of  the  uterus.     The  mother  died  and  the  child  sur^dved. 

Omental  Cysts. — Cysts  may  spring  from  the  outer  surface  of  the  omen- 
tum (escaped  ovarian  cysts,  lymphatic  cysts,  dermoids). 

True  omental  cysts  arise  wdthin  the  cavity  of  the  great  omentum.  In  50 
per  cent,  of  cases  the  patient  is  an  adult,  but  in  half  of  the  reported  cases  the 
patients  were  under  ten  years  of  age.  Some  of  the  cysts  are  probably  of 
embryonic  origin.  Dowd  is  inchned  to  think  that  the  cyst  he  removed  resulted 
from  omental  hematoma  ("Annals  of  Surgen,^,"  Nov.,  191 1).  In  this  case  there 
was  torsion  of  the  pedicle  of  the  cyst.  Dowd  (Ibid.)  reports  i  case  of  omental 
cyst  and  collected  37  from  literature.    Hasbrouck  ("Annals  of  Surgery,"  August, 

1  "Annals  of  Surgery,"  Januar>%  1902. 

^  "St.  Louis  Med.  Review,"  Dec.  2  and  9,  1901. 


9S6  Diseases  and  Injuries  of  the  Abdomen 

1908)  points  out  that  the  condition  is  much  more  common  in  females  than  in 
males,  that  there  are  no  characteristic  symptoms,  that  the  condition  begins  as 
omental  endothelioma  between  the  two  surfaces  of  omentum  which  fuse  because 
of  inflammation  and  form  a  closed  sac,  that  hemorrhages  are  apt  to  occur  into 
the  cyst,  and  that  operation  shows  a  mortality  of  6  per  cent.  The  operation 
performed  is  extirpation. 

Mesenteric  Cysts. — These  rare  cysts  are  divided  into  (i)  embryonic, 
(2)  hydatid,  (3)  cystic  malignant  disease  (Dowd,  "Annals  of  Surgery,"  1910). 
A  great  majority  of  mesenteric  cysts  are  embryonic.  Moynihan  believes  that 
embryonic  cysts  arise  in  "rests"  from  "the  Miillerian  or  Wolfiflan  organs  or 
ducts,  or  from  the  ovary,"  which  are  included  between  the  folds  of  mesentery. 
These  rests  undergo  cystic  degeneration.  Mesenteric  cysts  grow  and  pass  along 
between  the  layers  of  mesentery  until  they  reach  the  gut  and  then  compress 
the  gut  and  push  its  wall  ahead  of  them. 

Such  a  cyst  may  contain  embryonal  material,  bloody  fluid,  serous  fluid, 
chylous  fluid,  or  lymph.  In  Harry  C.  Deaver's  report  of  a  case  ("Annals  of 
Surgery,"  May,  1909)  it  is  shown  that  in  40  cases  there  were  25  females  and 
'  15  males;  that  the  size  varies  from  that  of  a  split  pea  to  enormous  dimensions; 
that  there  may  be  a  pedicle  form  in  front  of  the  vertebral  column  or  from  the 
intestinal  wall;  that  the  sac  wall  may  be  exceedingly  thin  or  as  much  as  i  cm.  in 
thickness;  that  in  some  cases  large  veins  are  present  on  the  surface  of  the  cyst; 
that  adhesions  to  the  abdominal  viscera  are  common;  that  intestinal  obstruc- 
tion may  occur  (kinks,  volvulus,  intussusception) ;  that  cysts  are  most  commonly 
found  in  relation  with  the  lower  end  of  the  ileum ;  and  that  there  are  no  charac- 
teristic symptoms  except  perhaps  the  rapid  body  wasting  mentioned  by 
Moynihan.  Moynihan  also  points  out  that  the  cyst  fluctuates  and  is  most 
prominent  toward  the  navel,  that  it  is  very  mobile,  especially  transversely 
(we  should  add  if  not  anchored  by  adhesions),  and  that  the  cyst  is  sur- 
rounded by  a  resonant  zone  and  crossed  by  a  resonant  band. 

Treatment. — Incision  and  drainage  if  there  are  numerous  and  firm  ad- 
hesions. Enucleation  whenever  possible.  Resection  of  the  involved  portion 
of  gut  with  the  cyst  in  some  cases  of  multiple  cyst  (Harry  C.  Deaver,  Ibid.). 

Torsion  of  the  great  omentum  is  usually  caused  by  a  fall  or  strain  or 
attempts  to  reduce  a  hernia.  In  nearly  all  cases  a  hernia  is  present.  Hedley 
("Brit.  Med.  Jour.,"  Nov.  11,  191 1)  studied  records  of  73  cases.  In  60  there 
was  or  had  been  a  hernia.  In  5  cases  without  a  hernia  there  were  adhesions. 
In  48  of  the  hernia  cases  the  omentum  was  attached  in  the  sac,  in  4  it  was 
anchored  near  the  sac,  in  3  to  the  bowel,  and  in  i  to  the  Fallopian  tube. 

Symptoms  are  like  those  of  a  strangulated  omental  hernia  or  of  appendi- 
citis. 

The  treatment  is  by  laparotomy. 

Stomach  and  Intestines 

Foreign  Bodies  in  the  Stomach  and  Intestines. — Foreign  bodies 
of  considerable  size  are  rarely  taken  into  the  alimentary  canal  except  by  chil- 
dren, insane  people,  or  drunkards.  Small  bodies  (bits  of  straw,  fragments 
of  bone,  etc.)  are  frequently  swallowed.  Most  foreign  bodies  swallowed 
are  passed  with  the  feces,  but  some  lodge.  Any  body  which  can  pass  the 
esophagus  is  not  too  large  to  pass  through  the  intestines.  Lodgment  is  an 
accident,  not  an  inevitable  consequence — an  accident  which  is  due  to  the 
shape  and  size  of  the  body.  A  foreign  body  may  lodge  in  the  stomach.  In 
some  cases  there  are  no  symptoms.  In  other  cases  symptoms  are  violent.  The 
severity  of  the  symptoms  depends  upon  the  shape  and  character  of  the 
body. 


Symptoms  of  Fibromatosis  of  the  Stomach  957 

In  some  cases  it  is  possible  to  feel  the  body  from  without.  A  metal  body 
in  the  stomach  will  deflect  a  magnetic  needle  held  over  the  viscus  (Polaillon). 
Many  foreign  materials  can  be  skiagraphed.  A  body  of  small  size  may  pass 
through  the  entire  canal  and  emerge  without  having  done  any  harm,  but  it  may 
lodge  and  may  cause  perforation.  If  perforation  occurs,  the  foreign  matter  may 
become  encysted,  for  instance,  in  the  mesentery ;  may  cause  an  abscess  or  may 
cause  general  peritonitis.  A  fish-bone  may  cause  an  anal  abscess.  An  epiploic 
appendix  may  cause  sacculation  of  the  bowel,  perforation  by  a  foreign  body 
may  take  place  in  this  sac,  an  epiploic  abscess  resulting,  which  may  attain 
considerable  size  and  may  be  mistaken  for  carcinoma  (Sir  J.  Bland-Sutton, 
in  "Lancet,"  Oct.  24,  1903).  It  is  not  wise  to  attempt  to  recover  a  foreign 
body  from  the  stomach  by  inducing  vomiting.  In  some  cases  gastrotomy 
is  necessary.  When  a  small  or  sharp  foreign  body  has  been  swallowed  and 
has  not  caused  perforation,  abscess,  or  obstruction,  the  usual  treatment  is 
as  follows:  a  purgative  should  never  be  given  to  expedite  the  passage  of  a 
foreign  body,  because  increased  peristalsis  increases  the  danger  of  impac- 
tion or  of  perforation.  Endeavor  to  encrust  the  foreign  body,  and  thus  lessen 
the  danger  of  perforation,  by  feeding  with  bread  and  milk  only  for  several 
days,  and  at  the  end  of  this  period  give  a  mild  laxative.  An  exclusive  diet  of 
mush  or  of  mashed  potatoes  has  been  suggested.  Suet  dumplings  may  be 
given.  Pain  is  relieved  by  opium.  A  foreign  body  rarely  lodges  in  the  duo- 
denum, but  may  lodge  lower  down,  and  may  cause  ulceration,  perforation,  ab- 
scess, or  intestinal  obstruction.     Operation  is  necessary  in  such  cases. 

Volvulus  of  the  Stomach. — This  condition  is  very  unusual.  Ten  cases 
are  on  record  (Streit,  in  '^Am.  Jour.  Med.  Sciences,"  June,  1906).  One-third 
of  the  cases  are  associated  with  diaphragmatic  hernia.  The  symptoms  come 
on  suddenly.  There  is  violent  abdominal  pain.  Distention  and  collapse  are 
early.  There  is  nausea,  but  the  patient  can  neither  vomit  nor  belch.  In  the 
upper  left  abdomen  there  is  a  tender,  tense,  and  tympanitic  area.  The  rotation 
of  the  stomach  may  be  on  its  vertical  or  on  its  longitudinal  axis.  An  hour- 
glass stomach  may  undergo  twisting  on  its  vertical  or  longitudinal  axis.  Berg 
operated  successfully  for  volvulus  of  the  stomach.  He  opened  the  abdomen, 
relieved  distention  by  tapping  the  stomach  with  a  trocar,  and  then  easily 
corrected  the  twist.  The  gastrohepatic  omentum  should  be  shortened  by 
Beyea's  operation  (see  page  1104). 

Fibromatosis  of  the  Stomach.— This  condition  was  long  ago  described 
by  Brinton  as  cirrhosis  of  the  stomach.  Alexis  Thomson  has  recently  published 
an  admirable  description  containing  many  new  things  ("Annals  of  Surgery," 
July,  1 913).  He  shows  that  ulceration  of  some  form  is  the  cause  (simple 
ulceration  or  cancerous  ulceration).  The  condition  may  be  and  commonly  is 
localized,  but  it  may  involve  the  entire  stomach  ("leather-bottle  stomach"). 
There  may  be  glandular  enlargement.  The  local  form  starts  at  the  pylorus 
and  resembles  cancer,  but  is  not  nodular.  There  may  or  may  not  be 
adhesions.  There  is  no  "cicatricial  stenosis  of  the  pylorus,"  but  the  canal 
of  the  pylorus  is  narrowed  by  submucous  thickening.  The  thickening  is 
not  scar- tissue,  but  is  more  like  a  fibroma  (Ibid.).  It  is  probably  a  reaction 
against  infection.  Thomson  proves  that  there  is  an  innocent  form  of  fibro- 
matosis, and  thinks  it  probable  that  there  may  even  be  an  innocent  form  of 
leather-bottle  stomach  (Ibid.). 

The  symptoms  suggest  ulcer,  cancer,  or  some  sequel  of  ulcer.  It  is  often 
possible  to  be  mistaken  as  to  the  nature  of  the  mass  even  when  it  is  exposed 
by  exploratory  incision.  The  cases  of  "pyloric  cancer"  which  have  recovered 
after  gastro-enterostomy  and  some  of  the  cures  of  gastric  cancer  by  gastrec- 
tomy are  explained  when  we  know  how  easy  it  is  to  mistake  innocent  fibro- 
matosis for  cancer. 


958  Diseases  and  Injuries  of  the  Abdomen 

Treatment. — Thomson  always  insists  on  an  immediate  microscopical 
examination  of  a  portion  of  the  tumor  or,  better,  of  an  enlarged  lymph-gland. 
He  advocates  resection  for  local  fibromatosis  because  he  believes  cancer  is 
liable  to  arise.  In  some  cases  gastro-enterostomy  is  performed;  in  some, 
jejunostomy. 

Carcinoma  of  the  Stomach. — Innocent  tumors  and  sarcomata  occa- 
sionally attack  the  stomach,  but  they  are  infinitely  rare  in  comparison  with 
primary  cancer.  This  disease  is  unusual  before  the  age  of  forty,  and  is  very 
seldom  seen  before  the  age  of  thirty.  I  operated  upon  a  man  of  twenty-three 
for  gastric  cancer.  It  is  more  common  in  men  than  in  women,  the  proportion 
being  as  5  to  4.  Beyond  question,  in  some  cases  cancer  arises  from  the  margins 
of  an  ulcer.  The  forms  of  cancer  which  may  arise  in  the  stomach  are  the  sphe- 
roidal cell  growth  (either  the  hard  form  known  as  scirrhus  or  the  soft  form  known 
as  medullary  or  encephaloid) ,  the  cylindrical  cell  growth  or  adenocarcinoma,  and 
colloid  (due  to  the  myxomatous  degeneration  of  either  a  spheroidal  cell  or  a 
cylindrical  cell  carcinoma).  Scirrhus  more  than  any  other  form  produces 
constriction  of  the  pylorus  and  more  seldom  than  any  other  form  produces 
hemorrhage.  It  may  spread  for  a  considerable  distance  along  the  submucous 
coat,  muscular  coat,  and  subserous  coat  without  apparent  involvement  of  the 
mucous  membrane  wide  of  the  primary  focus  of  disease.  Fibromatosis  may 
develop  about  it.  In  some  cases  scirrhus  is  limited  to  the  pyloric  region,  in 
others  it  is  a  limited  tumor  of  some  other  part  of  the  wall  of  the  stomach. 
In  the  condition  known  as  malignant  "leather-bottle  stomach"  a  scirrhus  has 
invaded  the  entire  stomach  wall,  or  fibromatosis  has  developed  with  the  cancer 
and  the  wall  of  the  viscus  is  thick  and  rigid. 

Medullary  cancer  and  adenocarcinoma  produce  hemorrhage.  Both  of 
these  forms  most  often  arise  in  the  pyloric  region.  Medullary  cancer  may 
remain  limited,  but,  as  a  rule,  a  cauliflower  growth  arises  and  eventually 
fills  the  stomach  and  portions  of  the  mass  may  slough  away. 

Adenocarcinoma  is  apt  to  spread  along  the  mucous  membrane  instead  of 
"infiltrating  the  deeper  layers,"  as  other  forms  are  prone  to  do  ("Cancer  and 
Tumors  of  the  Stomach,"  by  Samuel  Fenwick  and  W.  Soltau  Fenwick). 
Spheroidal  celled  carcinomata  are  twice  as  common  as  cylindrical  celled,  and 
medullary  cancer  is  about  as  common  as  scirrhus.  Any  cancer  may  be  accom- 
panied by  fibromatosis. 

Cancer  may  be  limited  to  the  body  of  the  stomach  (either  curvature  or 
either  wall),  the  pyloric  end  or  the  cardiac  end,  but  it  may  involve  two  of  these 
regions  or  almost  the  entire  stomach,  or,  being  multiple,  may  be  found  in 
many  parts.  Sometimes  there  is  a  primary  cancer  on  one  wall,  and  another 
growth,  due  to  contact,  on  a  corresponding  point  of  the  opposite  wall  {contact 
cancer).  All  forms  of  carcinoma  most  frequently  begin  in  the  region  of  the 
pylorus.  In  many  cases  of  gastric  carcinoma  adhesions  form  between  the 
stomach  and  the  liver,  colon,  or  diaphragm.  Even  in  cancer  of  the  pylorus 
the  duodenum  is  seldom  invaded.  Medullary  cancer  not  unusually  passes  into 
the  esophagus.  Gastric  cancer  is  usually  fatal  in  from  four  months  to  two  years, 
and  most  patients  die  within  one  year.  In  60  per  cent,  of  cases  the  pylorus  is 
involved.  In  over  half  of  the  cases  of  cancer  of  the  pylorus  there  is  no  im- 
portant lymphatic  involvement  (McArdle) .  In  investigating  any  gastric  dis- 
order follow  the  advice  of  the  Mayo  brothers  and  study  the  history  of  the  case, 
the  size  and  situation  of  the  stomach,  the  existence  and  situation  of  pain  and 
tenderness,  the  presence  of  a  tumor,  and  if  the  passage  of  food  is  interfered  with. 

S3nnptoms. — Examine  with  care  a  patient  in  whom  cancer  is  suspected.  In 
imusual  cases  it  produces  no  symptoms  until  it  has  lasted  for  some  time  and 
has  attained  a  large  size  (latent  cancer).  In  nearly  all  cases  it  does  produce 
symptoms.   The  disease  comes  on  gradually,  usually  with  indigestion  and  physi- 


Symptoms  of  Carcinoma  of  the  Stomach  959- 

cal  weakness.  The  patient  has  persistent  dragging  pain,  which  is  increased  by 
eating  and  pressure,  and  attacks  of  vomiting  are  frequent.  After  a  short  time 
he  becomes  very  weak  and  exceedingly  anemic,  and  it  is  often  possible  to  feel  a 
tumor  in  the  stomach.  Blood  examination  shows  diminution  of  red  corpuscles 
and  hemoglobin  and  perhaps  absence  of  any  increase  of  leukocytes  after  a  full 
meal.  The  vomiting  of  a  patient  with  gastric  cancer  is  at  first  only  occasional, 
but  as  the  case  progresses  it  becomes  more  and  more  frequent.  Vomiting  soon 
after  eating  occurs  when  the  cardiac  region  is  involved;  vomiting  an  hour  or  so 
after  eating  occurs  when  the  pyloric  end  is  involved.  When  the  body  of  the 
organ  is  the  seat  of  disease,  vomiting  may  be  absent.  The  vomited  matter  is 
often  mixed  with  a  small  amount  of  altered  blood  {cofee-groioid  vomit) .  In  most 
cases  occult  blood  is  found  in  the  feces,  especially  if  hydrochloric  acid  is  absent 
from  the  stomach  contents.  These  symptoms  above  cited  associated  with 
"coffee-ground  vomit"  and  lactic  acid  in  the  stomach  contents  are  strongly  in- 
dicative of  cancer  (Wm.  J.  Mayo,  in  "Surg.,  G^^nec,  and  Obstet.,"  May,  1908). 
A  test-meal  is  given,  and  important  conclusions  are  sometimes  derived  from  the 
presence  or  absence  of  hydrochloric  acid  and  lactic  acid.  It  is  my  custom  to 
have  the  stomach  washed  out  and  then  have  Ewald's  test-breakfast  given. 
This  consists  of  one  roll  of  white  bread  (35  gm.),  400  gm.  of  H2O,  and  400  gm. 
of  tea  -vxithout  milk  or  sugar.  In  one  hour  the  stomach  is  emptied  by  means 
of  a  tube  and  a  pump  or  a  tube  and  abdominal  compression,  and  the  material 
is  examined.  If  the  result  of  the  test  seems  out  of  accord  with  the  other 
symptoms,  repeat  the  process  (L.  Boas,  in  "Berlin.  kHn.  Woch.,"  No.  440, 
1905).  In  most  cases  free  hydrochloric  acid  is  not  found  in  the  stomach 
contents,  but  lactic  acid  is  found  and  Oppler's  bacillus  can  often  be  detected. 
There  may  be  red  blood-corpuscles  in  the  fluid.  If  the  cancer  is  not  ulcerated, 
free  hydrochloric  acid  will  probably  be  found;  if  it  is  ulcerated,  it  will  usually 
be  absent.^  Free  hydrochloric  acid  may  be  absent  from  the  stomach  because 
of  atrophy  of  glands,  cessation  of  secretion,  or  neutralization  by  the  products 
of  the  cancerous  area.  Free  hydrochloric  acid  may  be  absent  in  individuals 
in  whom  cancer  does  not  exist.  I  have  noted  its  absence  in  several  cases  of 
cicatricial  stenosis  of  the  pylorus. 

It  may  be  absent  in  cancer  of  the  esophagus,  advanced  Bright's  disease^ 
cancer  of  the  duodenum,  distant  cancer,  febrile  conditions,  and  amyloid  disease. 
The  constant  presence  of  considerable  quantities  of  hydrochloric  acid  is  strong 
evidence  against  the  existence  of  cancer  of  the  stomach.  If  cancer  arises  from 
ulcer,  free  hydrochloric  acid  is  apt  to  be  present  for  a  considerable  time  after 
the  cancer  has  begun. 

Distend  the  stomach  mth  gas  or  fluid  and  map  out  its  outlines.  Feel  for 
a  tumor.  A  tumor  can  usuaUy  be  felt  if  it  involves  the  greater  curvature  or 
anterior  w^aU,  and  a  large  timior  of  the  pylorus  can  be  palpated,  but  in  other 
regions  the  tumor  can  rarely  be  felt. 

Cancer  of  the  cardiac  end  interferes  \\dth  the  entrance  of  food  into  the 
stomach,  and  in  such  a  case  the  stomach  is  shrunken  and  the  esophagus  is 
dilated  immediately  above  the  growth.  In  cancer  of  the  pylorus  the  food  is 
partially  or  completely  arrested  as  it  passes  to  emerge  from  the  stomach,  and 
the  stomach  becomes  much  dilated.  The  vomited  matter  in  a  case  of  cancer 
rarely  contains  recognizable  fragments  of  the  growth,  but  fluid  with  which 
the  stomach  has  been  irrigated  may  contain  pieces  which  can  be  identified 
as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  temperature  is  normal, 

but  there  are  occasional  de\dations  to  below  or  above  normal.     In  many  cases 

the  urine  contains  albumin,  indican,  acetone,  and  casts.     Occasionally  cancer  of 

the  stomach  produces  spasm  of  the  esophagus.     I  have  seen  this  in  several  cases. 

1  Reissner,  in  "Miinchen.  med.  Woch.,"  Dec.  3,  1901. 


960  Diseases  and  Injuries  of  the  Abdomen 

Cancer  of  the  stomach  is  apt  to  involve  secondarily  adjacent  lymph-glands, 
or  organs  or  other  structures,  especially  the  liver;  in  fact,  the  liver  is  involved 
in  30  per  cent,  of  the  cases  (Welch) .  Occasionally  there  is  enlargement  of  the 
supraclavicular  glands  of  the  left  side.  Metastases  are  usual  and  early,  but 
in  cancer  of  the  pylorus  60  per  cent,  of  the  cases  show  no  distinct  l}miphatic 
involvement.  In  many  doubtful  cases  exploratory  incision  is  imperatively 
required. 

Treatment. — The  medical  treatment  consists  in  milk-diet,  the  use  of  mor- 
phin,  and  of  lavage  if  the  pylorus  or  body  of  the  stomach  is  diseased.  Per- 
form lavage  as  follows:  The  tube  for  lavage  should  be  long  enough  to  extend 
about  3  feet  out  of  the  mouth  when  the  other  end  is  in  the  stomach,  it  should 
be  flexible,  should  have  an  opening  in  the  stomach  end  and  another  opening 
on  the  side  about  i  inch  above  the  stomach  end.  The  tube  should  be  greased 
with  glycerin.  The  patient  sits  down,  throw^s  the  head  back,  opens  the  mouth 
widely,  and  is  directed  to  take  deep  breaths,  at  regular  intervals.  The  tube  is 
carried  into  the  pharynx,  the  patient  is  ordered  to  make  eiJorts  to  swallow  it, 
and  the  tube  is  thus  taken  into  the  stomach.  x\bout  i  quart  of  fluid  is  poured 
into  the  funnel-like  end  of  the  tube,  and  just  before  the  tube  empties  itself  of 
the  last  of  the  water  the  funnel  is  lowered  and  the  flmd  runs  out.  This  pro- 
ceeding is  repeated  until  the  fluid  becomes  clear.  The  best  fluid  to  use  is  a  solu- 
tion of  bicarbonate  of  sodium,  a  teaspoonful  of  the  salt  to  a  quart  of  warm  water. 
Lavage  should  be  practised  before  breakfast,  and  sometimes  also  at  bed-time. 

The  indications  for  operation  are  well  set  forth  by  Macdonald'^:  They  are 
progressive  aggravation  of  s\Tnptoms  in  spite  of  a  rigid  diet  and  medical  treat- 
ment, loss  of  gastric  mobility,  progressive  diminution  of  gastric  peristalsis, 
progressive  diminution  of  free  hydrochloric  acid,  emaciation  even  under 
forced  feeding,  progressive  reduction  of  hemoglobin  to  65  per  cent,  or  under, 
and  moderate  leukocytosis. 

Surgical  treatment  aims  to  remove  the  growth  or  to  obviate  the  effect 
of  obstruction  at  one  of  the  orifices  of  the  stomach. 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not  extensive, 
excision  of  the  growth  may  be  performed;  if  it  is  extensive,  it  is  useless 
to  attempt  it  unless  the  growth  is  absolutely  non-adherent.  Conner,  of 
Cincinnati,  attempted  total  excision  of  the  stomach  in  1883,  but  the 
patient  died  on  the  table.  In  1897  Schlatter,  of  Zurich,  successfiiUy 
removed  the  entire  stomach.  Brigham,  Richardson,  Macdonald,  Boeckel, 
De  Carvalho,  Bardeleben,  Haine,  Gallet,  DoUinger,  Ferr\',  Ribera,  and 
others  have  successfully  removed  the  entire  stomach  and  attached  the  esoph- 
agus to  the  small  intestine  {complete  or  total  gastrectomy).  In  the  successful 
cases  digestion  was  satisfactorily  performed  after  removal  of  the  stomach. 
Very  rarely  will  cases  be  found  suitable  for  such  a  radical  proceeding.  The 
case  suitable  for  this  treatment  is  one  in  which  the  entire  stomach  is  involved 
in  the  growth,  in  which  there  is  no  obvious  glandular  involvement,  and  in 
which  the  stomach  is  not  adherent,  but  is  freely  movable.  Herbert  J.  Paterson 
("The  Hunterian  Lectures  for  1906")  collected  27  cases  of  total  gastrectomy 
for  cancer:  10  died  and  17  recovered.  If  a  small  portion  of  the  fundus  is 
left  the  operation  is  called  subtotal  gastrectomy.  H.  J.  Paterson  (Ibid.) 
coUected  20  cases  of  subtotal  gastrectomy  for  cancer  with  6  deaths.  In 
limited  cancer  of  the  body  of  the  stomach  perform  partial  gastrectomy.  In 
cancer  of  the  cardiac  orifice  of  the  stomach  the  siu"geon  usuaUy  keeps  the 
passage  open  as  long  as  possible  by  the  frequent  passage  of  a  tube,  and  through 
this  tube  introduces  hquid  food.  Sometimes  a  smaU  tube  is  introduced  and  per- 
manently retained.  When  it  becomes  difi&cult  to  introduce  a  tube,  gastrostomy, 
duodena stomy ,  ox  jejun ostomy  may  be  performed.  As  a  matter  of  fact,  in  most 
1  John  B.  Murphy,  m  "Chicago  Med.  Recorder,"  June  15,  1902. 


Ulcer  of  the  Stomach  961 

cases  gastrostomy  is  done  as  a  last  resort,  and  it  is  scarcely  worth  doing  in  cancer 
of  the  cardiac  end  of  the  stomach.  It  is  far  more  useful  in  cancer  of  the  esoph- 
agus. In  cancer  of  the  pylorus,  limited  in  extent  and  ^nthout  lymphatic  involve- 
ment, pylorcdomy  may  be  performed;  but  in  cancer  which  has  widely  infiltrated 
the  coats  of  the  stomach  and  has  involved  the  hinphatic  glands,  gastro-enter- 
osiomy  is  performed  as  a  palliative  measure,  the  patient  during  the  rest  of 
his  life  subsisting  upon  liquid  or  semiliquid  foods  and  submitting  to  frequent 
irrigation  of  the  stomach  to  remove  food  residue.  In  cases  of  irremovable 
and  far-advanced  cancer  it  is  often  best  to  refuse  to  operate  and  to  deliber- 
ately create  the  opium-habit  in  the  patient,  although,  in  some  cases,  duodenos- 
tomy  or  jejunostomy  may  be  performed. 

The  most  successful  of  all  the  above  operations  are  pylorectomy  and  partial 
gastrectomy.  The  mortaHty  is  large.  In  H.  J.  Paterson's  series  of  cases  the 
mortality  was  28  per  cent.  There  are  in  literature  many  cases  which  have  sur- 
\-ived  three  years  or  over.  INIayo  reported  21  gastro-enterostomies  for  cancer, 
vnth.  4  deaths.  The  greatest  prolongation  of  life  was  nineteen  months.  His  expe- 
rience makes  him  question  if  the  operation  is  worth  doing  in  malignant  disease. 

Sarcoma  of  the  Stomach.— Of  recent  years  it  has  been  proved  that 
sarcoma  is  more  common  than  was  once  supposed.  There  are  over  60  cases 
on  record.  It  can  occur  at  any  age,  but  is  more  usual  in  early  Hfe  than  car- 
cinoma. It  has  been  estimated  by  Wm.  T.  Howard^  that  37.7  per  cent,  of 
cases  are  imder  the  age  of  forty,  and  11.44  per  cent,  are  under  the  age  of 
twent}*.  The  pylorus  is  involved  in  about  one-fourth  of  the  cases.  In  most 
cases  the  posterior  wall  and  greater  cur\"ature  are  involved.  Howard  says 
there  is  a  diffuse  growth  in  21.31  per  cent,  of  cases  and  that  the  cardiac  end  is 
involved  in  only  4.9  per  cent,  of  cases.  Sarcoma  arises  in  the  submucous  coat. 
Any  form  of  sarcoma  may  arise.  It  causes  stenosis  in  less  than  one-tenth  of 
the  cases.  There  is  no  sex  predisposition  in  sarcoma.  The  growth  may  attain 
a  great  size. 

Symptoms. — ^A  tumor  forms,  grows  rapidly,  and  often  attains  a  large  size, 
and  not  imusually  actually  causes  a  projection  of  the  abdominal  wall.  If  it 
iilcerates  there  "^'ill  be  hematemesis,  but  it  often  does  not  ulcerate,  and  bleed- 
ing is  much  rarer  than  in  carcinoma.  Not  imusually  this  growth  arises  in  a 
person  under  forty,  and  sometimes  in  one  of  less  than  twenty  years  of  age. 
Stenosis  is  uncommon.  The  Hver  is  involved  secondarily  in  only  11.47  P^r 
cent,  of  cases  (Howard),  metastases  are  more  rare  than  in  carcinoma,  free  hy- 
drochloric acid  is  usually  absent  from  the  gastric  contents,  and  microscopical 
examination  of  washings  from  the  stomach  may  detect  fragments  of  sarcoma. 
Certain  diagnosis  is  impossible  mthout  explorators*  incision.  Howard  esti- 
mates the  average  duration  of  Hfe  to  be  from  nine  to  ten  months. 

Treatment. — If  the  liver  is  free  and  if  there  are  no  metastases,  partial 
gastrectomy  or  complete  gastrectomy  may  be  ad^^sable.  If  pyloric  stenosis 
should  arise,  gastro-enterostomy  may  be  performed.  Scudder  (''Amials  of 
Surger}',"  August,  1913)  reports  a  case.  He  performed  jejimostomy.  Six 
weeks  later  he  removed  the  tumor  by  partial  gastrectomy,  closed  the  jejunal 
opening,  and  did  anterior  gastro-enterostomy.  A  year  later  the  man  remained 
well. 

Ulcer  of  the  Stomach  (Peptic  Ulcer  of  the  Stomach). — Ulcer  of 
the  stomach  is  a  condition  due  to  digestion  of  a  portion  of  the  stomach 
wall  by  very  acid  gastric  jmce,  the  destroyed  portion  ha^dng  been  the  seat 
of  lowered  vitality.  The  reason  for  the  lowered  \dtality  of  the  gastric  mucous 
membrane  is  uncertain.  Thrombosis  has  been  suggested  as  a  cause,  but  it  is 
rare  in  gastric  ulcer.  Embolism  is  assigned  by  some  as  a  cause,  but  emboli 
are  seldom  found  on  pathological  examination.  It  has  been  asserted  that 
^  "Jour.  .\in.  Med.  Assoc,"  Feb.  8,  1902. 
6i 


962  Diseases  and  Injuries  of  the  Abdomen 

menstrual  disorders  may  be  responsible  for  iilcer,  that  tight  lacing  may  be,  and 
that  habitually  bending  over  (as  in  making  shoes)  may  be  a  cause.  The  Mayos 
are  of  the  opinion  that  the  grinding  action  of  the  pyloric  portion  of  the  stomach 
may  be  a  traumatic  exciting  cause  of  ulcer  of  that  region.  Some  assert  that 
mental  anxiety,  alcoholism,  and  syphilis  may  be  causal  (Alderson).  Thirty- 
two  per  cent,  of  the  cases  in  the  Mayo  Clinic  used  alcohol.  Ulcers  due  to 
syphilis  and  tuberculosis  are  not  peptic  ulcers. 

Robson  believes  that  gastric  ulcer  is  septic  in  origin,  and  that  oral  sepsis 
is  responsible  for  its  origin  in  most  cases.  "Mild  sepsis  leads  to  gastritis  and 
hyperchlorhydria,  which  in  its  turn  provokes  and  keeps  up  ulceration"  (A.  W. 
Mayo  Robson,  in  "Keen's  Surgery,"  vol.  iii).  In  140  cases  studied  by  Smithies 
in  the  Mayo  clinic  ("Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital," 
Mayo  Clinic,  191 2)  26  had  had  enteric  fever,  6  pneiimonia,  5  syphilis,  8  malaria, 
and  27  some  other  general  infection.  Twelve  had  previously  been  operated 
upon  for  appendicitis  and  2  for  gall-stones.  Some  observers  blame  direct 
damage  to  the  mucous  membrane  by  traumatism  or  the  swallowing  of  corrosive 
liquid.  The  question  of  cause  is  involved  in  uncertainty.  What  does  seem  to 
be  certain  is  that  anemia  predisposes  to  the  formation  of  very  acid  gastric  juice 
{hyperchlorhydria)  and  to  ulceration.  In  some  cases  chlorosis  is  associated  with 
ulcer.  According  to  Wm.  J.  Mayo  there  are  three  known  causal  factors  of  the  first 
importance,  viz.,  anemia,  hyperchlorhydria,  and  traumatism  (April  16,  1904). 

It  used  to  be  stated  that  ulcers  are  far  more  common  in  females  than  in 
males.  This  statement  is  not  correct.  It  applies  to  acute  iilcers,  but  not  to 
chronic  ulcers.  Up  to  July  i,  191 2,  the  Mayos  had  operated  on  404  proved 
ulcers  of  the  stomach,  and  over  70  per  cent,  of  these  patients  were  males 
(Smithies,  in  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo 
Clinic,  191 2).  The  acute  round  ulcer  is  vastly  more  common  in  women,  and  in 
young  women  rather  than  in  those  of  middle  or  advanced  age.  The  chronic 
indurated  ulcer  is  most  frequent  in  men.  Men  about  forty,  and  women  between 
twenty  and  thirty  are  particularly  liable.  Between  thirty  and  forty  is  the 
period  of  greatest  liability.  I  have  only  once  found  ulcer  in  a  person  under 
twenty.  There  is  usually  a  single  ulcer,  but  in  one-fifth  of  all  cases  there 
are  two  or  more,  and  when  there  is  an  ulcer  on  the  anterior  wall,  it  is  not  un- 
common to  find  one  exactly  opposite  on  the  posterior  wall  {a  kissing  ulcer 
Moynihan  calls  it).  The  Mayos  divide  ulcers  into  two  clinical  forms — the 
indurated  and  the  non-indurated.  In  the  indurated  ulcer  all  the  coats  of  the 
stomach  are  involved,  and  the  mass  of  scar  tissue  indicates  an  effort  at  repair. 
The  most  common  situation  for  this  form  of  ulcer  is  the  region  of  the  pylorus 
(Wm.  J.  Mayo,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  21,  1905).  The  non-in- 
durated ulcer  involves  the  mucous  coat  only  and  may  be  of  microscopical  size, 
and  even  a  microscopical  ulcer  may  cause  death  from  hemorrhage.  These 
non-indurated  ulcers  exhibit  no  sign,  or  almost  no  sign,  on  the  outer 
surface  of  the  stomach,  and  may  not  be  detected  even  when  the  stomach 
is  opened  by  the  surgeon.  The  non-indurated  ulcers  are  divided  into  the  mucous 
erosions  of  Dieulafoy,  in  which  the  superficial  epithelium  only  is  involved, 
and  the  true  round  fissured  peptic  ulcers  (Wm.  J.  Mayo,  in  "Jour.  Am.  Med. 
Assoc,"  Oct.  21,  1905).  Both  conditions  are  rare.  Ulcers  are  also  divided 
into  acute  ulcers,  which  progress  rapidly  and  produce  definite  symptoms,  and 
chronic  ulcers,  which  are  usually  chrohic  from  the  beginning,  but  which  may 
exhibit  acute  exacerbations,  and  may  have  periods  of  great  relief  or  apparent 
cure  (Wm.  J.  Mayo,  in  "Med.  Record,"  August  6,  1904).  The  most  common 
seats  of  ulcers  are  the  posterior  wall  and  lesser  curvature,  especially  in  the 
pyloric  region;  in  fact,  80  per  cent,  occur  in  the  pyloric  region.  An  ulcer  may 
heal  or  may  perforate.  Only  i  or  2  per  cent,  of  ulcers  on  the  posterior  wall 
perforate,  as  they  tend  to  form  adhesions  to  adjacent  structures.     Ulcers  on 


Symptoms  of  Ulcer  of  the  Stomach  963 

the  anterior  wall  are  unusual,  do  not  tend  to  form  adhesions,  and  are  apt 
to  perforate.  It  is  not  uncommon  to  have  ulcer  of  the  first  portion  of  the  duo- 
denum associated  with  gastric  ulcer.  An  ulcer  may  be  accompanied  or 
followed  by  fibromatosis  which  gives  a  deceptive  likeness  of  cancer  (see  page 
957).  Gastric  ulcer  is  at  least  four  times  as  frequent  in  England  as  in  the 
United  States.  In  2S30  autopsies  made  in  the  Philadelphia  Hospital  there  were 
40  gastric  ulcers,  and  in  3763  autopsies  made  in  four  Philadelphia  institutions 
there  were  51  gastric  ulcers — a  percentage  of  1.35.  (See  A.  P.  Francine,  in 
"Proceedings  Phila.  Coimty  Med.  Soc,"  March  31,  1905.) 

Symptoms. — In  an  acute  ulcer  the  symptoms  are  often  typical;  there  are 
pain,  tenderness  on  pressure,  slight  or  distinct  unilateral  muscular  rigidity, 
vomiting,  hemorrhage,  and  hyperchlorhydria.  In  a  chronic  ulcer  the  symp- 
toms may  be  clear,  may  be  misleading,  may  be  variable,  and  in  some  cases  even 
absent  {latent  ulcer).  In  ulcer  dyspepsia  usually  exists.  It  is  usually  but  not 
always  acid  dyspepsia,  and  is  associated  with  much  flatulence.  In  most  cases, 
though  not  in  all,  food  promptly  causes  pain.  There  is  a  gnawing  sensation 
{hunger-pain)  when  the  stomach  is  empty,  and  may  be  actual  pain.  The 
taking  of  food  may  temporarily  reheve  pain,  but  as  gastric  peristalsis  arises 
and  perhaps  as  quantities  of  gastric  juice  are  poured  out  to  digest  the 
food  the  pain  increases.  If  hyperchlorhydria  disappears  (as  it  may  do 
from  chronic  gastritis  and  does  from  gastric  dilatation  following  pyloric 
obstruction),  pain  may  not  be  increased  during  digestion.  In  ulcers  of  the 
cardiac  end  and  lesser  curvature  gnawing  uneasiness  is  but  briefly  or  not  at 
aU  relieved  by  taking  food  and  pain  develops  immediately  or  almost  at  once 
after  eating.  In  ulcer  of  the  pyloric  region  the  gnawing  uneasiness  may 
be  distinctly  reheved  by  taking  food,  but  in  an  hour  or  two  hours  pain 
is  apt  to  become  severe.  The  time  after  eating  when  pain  occurs  may  not  be 
constant  in  a  case.  In  ulcer  the  pain  is  paroxysmal.  It  is  at  times  very 
violent  in  the  epigastric  region,  and  may  pass  to  the  back,  being  located  be- 
tween the  eighth  and  ninth  dorsal  vertebrae  to  one  side  of  the  back  (the  right 
most  often),  into  the  esophagus,  into  the  chest,  or  to  the  top  of  the  ensiform 
process. 

In  gastric  ulcer  it  is  usual  to  find  distinct  or  severe  tenderness  developed  by 
epigastric  pressure,  and  tenderness  is  associated  with  more  or  less  rigidity.  In 
ulcer  of  the  lesser  curvature  pain  and  tenderness  are  in  the  neighborhood  of  the 
left  costal  margin.  In  ulcer  of  the  pylorus  they  are  above  the  umbilicus  in  or 
to  the  right  of  the  midline.  Vomiting  usually  reheves  the  pain,  so  does  lavage, 
so  does  the  administration  of  an  alkali.  In  ulcers  of  the  anterior  wall 
tenderness  is  most  acute.  In  many  of  these  patients  vomiting  occurs 
about  two  hours  after  eating.  The  vomited  matter,  as  a  rule,  contains 
much  hydrochloric  acid  and  the  vomiting  usually  relieves  the  pain. 
Examination  of  the  gastric  contents  after  the  administration  of  a  test-meal 
shows  in  about  So  per  cent,  of  the  cases  hyperacidity.  Obvious  hemorrhage 
from  the  stomach  occurs  in  less  than  one-half  of  the  cases,  and  from  3  to  8  per 
cent,  of  cases  actually  die  of  hemorrhage.  Wm.  J.  Mayo  states  that  "more 
than  90  per  cent,  of  hemorrhages  from  the  stomach  are  from  chronic  ulcers  with 
a  well-marked  ulcer  history"  ("Surg.,  Gynec,  and  Obstet.,"  May,  1908). 
The  blood  may  be  brought  up  with  food,  and  is  then  black  and  clotted,  or  may 
be  vomited  clear  and  in  large  amount.  Blood  may  be  present  in  vomited  matter 
or  stools  in  such  small  amount  that  its  presence  is  observed  only  by  the  micro- 
scope. The  demonstration  in  the  feces  of  minute  quantities  of  blood  (occult 
blood)  is  important  diagnostically.  It  may  be  demonstrated  by  the  guaiacum 
test  or  the  aloin  test.  For  two  days  before  this  test  the  patient  must  not  eat  rare 
meat,  sausages,  or  fish.  Blood  in  the  stools  does  not  prove  the  existence  of  gas- 
tric ulcer.  The  blood  may  have  come  from  any  spot  from  the  mouth  to  the  anus. 


964  Diseases  and  Injuries  of  the  Abdomen 

As  Wm.  J.  Mayo  ("Surg.  Gynec,  and  Obstet.,"  May,  1908)  says:  "Visible  or 
occult  blood  in  the  stool  affords  proof  as  to  the  fact  that  there  is  blood,  but  it 
should  never  be  lost  sight  of  that  it  bears  with  it  no  evidence  as  to  its  exact 
gastro-intestinal  origin.  The  patient  may  have  bleeding  gums  or  hemorrhage 
from  some  slight  abrasion  in  any  part  of  the  many  feet  of  mucous  membrane 
which  exist  between  the  lips  and  the  anus.  If  occult  blood  is  found  by  one 
chemical  test,  it  must  be  corroborated  by  others,  as  some  unsuspected  food  or 
drug  may  give  rise  to  the  reaction. 

"As  a  matter  of  fact,  hemorrhage  from  ulcer  is  by  no  means  of  frequent 
occurrence.  The  base  of  the  ulcer  is  clean  and  free  from  granulation  tissue,  so 
that  bleeding  may  be  infrequent.  Careful  examination  of  the  stools  for  many 
days  may  be  necessary  to  detect  its  presence." 

In  hemorrhage  from  an  acute  ulcer  a  pint  or  two  may  be  ejected  in  a  few  min- 
utes, and  such  a  patient  presents  all  the  general  symptoms  of  dangerous  hemor- 
rhage. When  an  ulcer  bleeds  the  blood  is  far  more  apt  to  be  vomited  than 
passed  by  the  bowels,  but  in  some  cases  blood  from  the  stomach  is  passed  by 
the  bowels  in  part  or  wholly.  A  very  large  hemorrhage  may  occur,  and  yet  the 
bleeding  never  be  repeated,  or  a  large  hemorrhage  may  be  followed  by  another 
or  be  the  first  of  three  or  of  a  series.  In  a  great  many  cases  after  a  large 
hemorrhage  there  is  no  further  bleeding  or  there  are  subsequently  a  few  small 
hemorrhages.  Small  hemorrhages  may  occur  indefinitely,  and  may  after  a  time 
eventuate  in  a  large  hemorrhage.  In  chronic  ulcer  in  which  small  hemorrhages 
recur  over  a  long  period  the  condition  is  due  to  bleeding  from  congested  mucosa, 
dilated  veins,  or  to  the  erosion  of  small  vessels  which  cannot  contract  or  retract 
because  they  are  embedded  in  fibrous  tissue.  A  large  hemorrhage  may  be  due 
to  the  erosion  of  a  large  vessel,  but  is  often  produced  by  the  existence  of  [a 
great  number  of  erosions  of  the  mucous  membrane,  erosions  perhaps  so  numer- 
ous that  blood  seems  to  pour  from  every  portion  of  the  mucous  surface.  It 
is  usually  stated  that  in  a  sudden  acute  violent  hemorrhage  there  will  prob- 
ably be  no  history  of  antecedent  stomach  trouble,  but  Wm.  J.  Mayo  is  of  the 
opinion  that  "a  single  hemorrhage  from  a  patient  who  has  not  had  previous 
gastric  symptoms  is  probably  not  due  to  ulcer"  (Ibid.).  It  may  arise  from  rup- 
ture of  veins  about  the  cardia  or  from  blood  from  hemoptysis  being  swallowed. 

In  a  chronic  ulcer  it  is  sometimes,  though  seldom,  possible  to  palpate  the 
indurated  area. 

Constipation  exists  in  at  least  90  per  cent,  of  cases.  There  is  often  very 
marked  anemia,  aggravated  and,  some  think,  occasionally  caused  by  continued 
loss  of  blood.  Indigestion  aggravates  anemia  and  also  may  cause  it.  Most 
cases  complain  of  prolonged  indigestion.  There  is  often  a  tender  area  in  the  back 
a  little  to  the  side  of  the  eighth  and  ninth  dorsal  spines  (usually  the  right  side). 
A  triangular  area  of  hyperesthesia  may  be  found  in  the  left  epigastric  region 
(Head). 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing  pain  and  hemorrhage, 
the  patient  usually  becomes  thinner,  more  anemic,  weaker,  and  even  exhausted. 
In  140  cases  in  the  Mayo  clinic  studied  by  Smithies  ("Collected  Papers  by  the 
Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic,  1912)  107  showed  loss  of  weight. 
The  average  loss  of  weight  was  20  potmds.  The  maximum  loss  observed  was 
65  pounds  in  sLx  months.     The  average  hemoglobin  finding  was  72  per  cent. 

It  is  certain  that  many  cases  of  gastric  ulcer  are  unrecognized;  in  fact,  as 
Habershon  says,  diagnosis  is  rarely  made  unless  hemorrhage  exists,  and  in 
certain  latent  cases  both  vomiting  and  bleeding  are  absent.  It  is  believed  by 
some  that  latent  ulcers  are  even  more  common  than  are  ulcers  causing  symp- 
toms. Hall  ("Am.  Jour,  of  Med.  Sciences,"  May,  1909)  says:  "Rather  than 
look  too  narrowly  for  exactly  this  or  that  evidence,  we  should  take  the  broader 
ground  that  ulcer  probably  exists  in  most  patients  complaining  of  persistent 


Symptoms  of  Ulcer  of  the  Stomach  965 

indigestion,  even  though  not  of  an  acid  character,  if  pain,  tenderness,  vomiting 
and  rigidity,  or  two  or  three  of  these  phenomena  be  present,  and  even  though 
hyperacidity  be  not  proved."  A  bleeding  ulcer  with  palpable  thickening  of  the 
pylorus,  especially  if  there  is  anemia  and  loss  of  weight,  is  frequently  mistaken 
for  cancer.  Fibromatosis  of  the  stomach  with  or  without  ulcer  is  usually 
diagnosticated  as  cancer.  This  condition  was  fully  described  by  Alexis  Thom- 
son at  the  1913  meeting  of  the  American  Surgical  Association.  The  entire 
stomach  may  be  indurated.  It  is  cases  like  the  above  that  may  get  well  after 
gastro-enterostomy  and  thus  furnish  the  first  obtained  proof  that  the  condition 
was  not  cancerous  (see  page  957).  The  diagnosis  of  ulcer  is  far  less  difficult 
when  there  is  food  retention  than  when  there  is  not. 

The  fluoroscope  may  aid  in  the  diagnosis.  Skiagraphs  after  a  bismuth  meal 
give  highly  important  information  as  to  the  existence  of  scars,  contraction  of  the 
pylorus,  dilated  stomach,  and  hour-glass  stomach.  In  many  cases  it  is  im- 
possible to  make  a  differential  diagnosis  between  pyloric  ulcer  and  duodenal 
ulcer.  In  duodenal  ulcer  the  pain  and  tenderness  are  above  the  umbilicus  and 
in  the  midline  or  to  the  right,  and  if  the  duodenal  ulcer  bleeds  the  blood  is  most 
apt  to  pass  by  the  bowel,  but  vomiting  of  blood  is  not  unusual.  A  small  per- 
centage of  duodenal  ulcers  also  involve  the  pylorus. 

A  gastric  ulcer  may  cicatrize  and  thus  be  cured,  but  the  cure  of  the  ulcer 
may  prove  the  ruin  of  the  stomach  by  producing  stenosis  of  one  of  the  stomach 
orifices  or  hour-glass  contraction  of  the  body  of  the  stomach.  An  ulcer  may 
perforate.  Perforation  occurs  in  about  15  per  cent,  of  cases  (Robson).  A 
perforation  may  be  acute;  that  is,  the  ulcer  suddenly  breaks  open  when  the 
stomach  contains  food  or  liquid,  and  the  contents  of  the  stomach  are  poured 
into  the  free  peritoneal  cavity.  A  subacute  perforation  occurs  when  the  stomach 
is  empty  or  nearly  empty.  The  opening  is  small  in  size,  there  is  no  escape 
of  stomach  contents  or  the  escape  of  only  a  small  amount,  and  the  opening 
may  be  quickly  closed  by  adhesion  to  an  adjacent  surface  of  peritoneum  or  a 
piece  of  omentum.  If  a  certain  amount  of  stomach  contents  is  extravasated, 
it  is  usually  surrounded  by  adhesions  or  tracks  slowly  toward  the  pelvis. 
In  what  is  known  as  a  chronic  perforation  the  break  takes  place  usually  in 
the  posterior  wall  into  a  box  of  preformed  adhesions,  the  extruded  gastric 
contents  are  circmnscribed  by  these  adhesions,  the  general  peritoneal  cavity 
is  not  invaded,  but  circumscribed  suppuration  is  inaugurated.^  This  condi- 
tion is  known  as  perigastric  abscess,  and  the  subphrenic  form  is  the  commonest. 
In  such  a  case  the  abscess  may  break  into  the  pleural  cavity  or  even  into 
the  lung.  I  operated  on  a  girl  of  sixteen  and  found  a  perigastric  abscess  and 
a  perforation  of  the  anterior  wall  near  the  pylorus,  and  this  condition  was 
tuberculous.     A  fistula  persisted  for  months,  but  finally  healed. 

Perforation  is  generally  preceded  by  a  history  of  indigestion,  but  it  may  come 
on  without  a  suggestion  of  antecedent  stomach  trouble,  is  usually  brought  about 
by  muscular  effort,  and  is  most  common  after  a  full  meal,  but  it  may  occur  when 
the  patient  is  perfectly  quiet  and  has  not  eaten  for  some  time.  The  real  cause 
is  spasm  of  the  pylorus,  which  causes  tension  of  the  stomach  walls  and  keeps 
the  viscus  from  emptying.  Pyloric  spasm  is  very  common  in  sufferers  from 
ulcers.  In  acute  perforation  food  is  the  most  active  cause;  in  chronic  perfora- 
tion, muscular  effort.  "The  severity  of  the  symptoms  depends  upon  several 
conditions:  the  previous  state  of  health,  the  size  and  number  of  the  perfora- 
tions, the  condition  of  the  stomach,  whether  full  or  almost  empty,  the  bacterial 
virulence  of  its  contents,  and  the  occurrence  of  vomiting."-  The  situation  of 
the  ulcer  has  some  influence  on  the  symptoms.  "If  in  the  fundus,  at  the 
cardiac  end,  or  in  the  body  of  the  stomach,  an  acute  infection  of  the  whole 

1  See  paper  by  B.  G.  A.  Moynihan,  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 
^Moynihan,  in  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 


g66  Diseases  and  Injuries  of  the  Abdomen 

peritoneal  ca\aty  rapidly  follows;  if  the  ulcer  be  at  the  pylorus  or  in  the  first 
portion  of  the  duodenum,  the  fluid  is  directed  down  the  right  side  of  the  abdo- 
men, o^\-ing  to  the  hillock  formed  by  the  transverse  mesocolon  at  the  pyloric 
end  of  the  stomach". ^  In  such  a  case  the  fluid  may  gravitate  toward  the 
right  iliac  region  and  the  condition  may  be  mistaken  for  appendicitis.  In  a 
case  of  subacute  perforation  I  operated,  beliexing  that  appendicitis  existed. 
Alderson  caUs  attention  to  the  fact  that  the  sudden  perforation  of  an  ulcer 
may  be  mistaken  for  poisoning,  and  he  cites  the  death  of  Henrietta,  Duchess 
of  Orleans,  in  1670. 

Acute  perforation  can  be  certainly  diagnosticated  if  the  case  is  seen 
early.  Such  an  emergency  has  usually,  but  not  invariably,  been  preceded  by 
positive  and  prolonged  symptoms  of  gastric  disorder.  It  causes  sudden 
and  intensely  \dolent  epigastric  pain,  greatly  increased  by  sw^allomng  fluids, 
by  vomiting,  by  turning  the  body,  by  cough,  by  inspiration,  and  by  pressure. 
This  pain  may  radiate  throughout  the  abdomen,  but  the  chief  tenderness  is  in 
the  region  of  the  stomach.  The  seat  of  the  pain  after  perforation  does  not,  of 
necessity,  correspond  to  the  seat  of  perforation.  Vomiting  occurs  in  about  half 
the  cases  after  rupture.  When  it  does  occur  it  comes  on  soon  after  the  pain,  may 
recur  again  and  again,  and  does  much  harm  by  increasing  shock  and  by  ejecting 
gastric  contents  into  the  peritoneal  cavity.  Vomiting  of  blood  is  very  im- 
usual.  In  many  cases  there  is,  singularly,  little  shock.  Even  when  severe  shock 
exists  its  duration  is  usually  temporary.  This  important  fact  is  insisted  on  by 
EHot  ("Annals  of  Surgery,"  May,  191 2).  Board-like  rigidity  exists,  and  it  is 
most  marked  in  the  upper  portion  of  the  abdomen.  The  area  of  hver  dulness  is 
in  some  cases  diminished  and  in  exceptional  cases  obliterated.  This  SAonptom 
is  due  to  gas  passing  into  the  peritoneal  ca\dty  and  getting  between  the  liver 
and  the  parietal  peritoneum.  It  is  seldom  present  after  pyloric  perforation  or 
when  the  stomach  at  the  time  of  the  perforation  contained  very  Httle  food. 
It  is  when  perforation  is  far  from  the  pylorus  and  when  the  stomach  contains 
fermenting  food  that  enough  gas  escapes  to  diminish  liver  dulness  (Eliot,  Ibid.). 
There  may  be  dulness  in  one  flank  or  both  flanks  due  to  fluid.  EHot  (Ibid.) 
lauds  auscultation  as  an  aid  to  detecting  smaU  amounts  of  fluid,  and  calls 
attention  to  Shoemaker's  symptom,  that  is,  a  dull  note  on  light  percussion  gi^dng 
way  to  a  tympanitic  note  when  the  percussed  finger  is  pressed  firmh'  against 
the  abdominal  waU,  thus  coming  nearer  to  the  intestine  by  pushing  fluid  away. 
The  pulse  may  be  very  rapid,  but  often  shows  curiously  little  disturbance. 
Some  few  cases  die  rapidly  in  shock,  but,  as  a  rule,  reaction  occurs  and,  if  opera- 
tion is  delayed,  peritonitis  arises.  Acute  perforation  of  the  stomach  may  be 
in  certain  cases  mistaken  for  appendicitis,  cholecystitis,  or  hemorrhagic  pan- 
creatitis. If  a  patient  with  acute  perforation  is  not  promptly  operated  upon, 
he  will  soon  exhibit  the  s\Tnptoms  of  general  peritonitis.  Subacute  perforation 
causes  less  \'iolent  s\Tiiptoms  and  they  come  on  more  graduaUy.  There  is  in 
the  beginning  severe  but  not  agonizing  pain,  which  gradually  abates.  Moyni- 
han  points  out  that  there  is  gastric  uneasiness  for  several  days  before  the 
perforation.  Peritonitis  develops  slowly  and  the  chief  symptoms  are  often 
pelvic.     Chronic  perforation  gives  the  signs  and  s^miptoms  of  perigastric  abscess. 

Treatment. — Medical  Treatment  of  Non-perforated  Ulcer. — Rest  in  bed. 
It  is  necessar\'  to  abandon  stomach  feeding  for  a  time.  For  seven  to  ten  days 
give  nothing  whatever  by  the  mouth  and  give  an  enema  of  10  oz.  of  normal 
salt  solution  everv-  sixth  hour.  This  is  preferable  to  a  nutritive  enema  because 
every  time  a  nutritive  enema  is  given  a  flow  of  gastric  juice  takes  place  into  the 
stomach.  (SeeW.  Pasteur,  in  "Lancet,"  May  21,  1904;  Se^Tnour  J.  Sharkey, 
in  "Lancet,"  Nov.  10,  1906.)  During  this  treatment  the  patient  is  usually 
comfortable  and  is  not  unbearably  disturbed  by  hunger  and  thirst.  At  the 
1  See  paper  by  B.  G.  A.  Mojiiihan,  in  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 


Treatment  of  Ulcer  of  the  Stomach  967 

end  of  a  week  or  ten  days  pancreatinized  or  peptonized  milk  is  cautiously  given 
by  the  mouth.  According  to  some,  nutritive  enemata  should  now  be  substituted 
for  saline  enemata  and  be  given  for  a  few  days  before  stomach  feeding  is  insti- 
tuted. After  rectal  enemata  (sahne  and  nutritive)  have  been  abandoned  the 
patient  is  placed  on  a  vers-  bland  diet,  preferably  pancreatinized  milk,  and 
lavage  is  given  twice  a  day.  The  value  of  introducing  food  into  the  rectum  is, 
to  say  the  least,  doubtful.  Saline  fluid  and  certain  drugs  are  absorbed  from 
the  rectum,  but  Httle  if  any  protein  matter  is  absorbed.  Investigators  are 
now  seeking  for  some  form  of  digested  protein  matter  that  will  be  absorbed. 
Protein  material  when  in  the  rectum  is  not  acted  upon  by  the  enz\-mes  necessary' 
for  its  absorption,  it  undergoes  putrefaction,  causes  irritation,  and  sets  free 
toxic  alkaloids  which  are  absorbed.  It  is  suggested  that  digested  albumin  and 
fat  and  grape-sugar  may  be  absorbed.  In  some  cases  of  ulcer  Carlsbad  salts 
are  given  by  the  mouth  (Ziemssen) ;  in  others,  silver  m'trate  with  extract  of 
belladonna,  bismuth  subnitrate,  or  oxalate  of  cerium.  If  pain  is  severe,  opium 
may  be  required.  Many  cases  are  apparently  cured  by  medical  treatment. 
Russel's  statistics  show  that  40  per  cent,  of  cases  were  reported  cured  under 
medical  treatment,  but  no  one  knows  how  many  of  those  reported  cured  again 
gave  e\'idence  of  the  disease  or  later  perished  because  of  hemorrhage  or  per- 
foration. Further,  iS  per  cent,  of  the  500  London  Hospital  cases  under  med- 
ical treatment  died  and  42  per  cent,  were  not  cured  when  discharged.  Out  of 
the  supposed  40  per  cent,  of  cures  many  later  undoubtedly  developed  or  -odU 
develop  renewed  s^inptoms  and  perhaps  fatal  conditions. 

Surgical. — The  exact  curative  value  of  operation  is  not  settled.  Kron- 
lein's  cHnic  claims  85  per  cent,  cures,  Von  Eiselsberg's  clinic  but  52  per  cent,  of 
cures  and  15  per  cent,  of  improvements.  The  nearer  the  ulcer  is  to  the  pylorus, 
the  better  the  chance  of  cure.  FoUo^^ing  the  IMayos,  we  would  not  ad\-ise  sur- 
gical treatment  in  acute  ulcer  miless  complicated  by  hemorrhage,  perforation, 
or  obstruction;  or  in  chronic  ulcer,  mitil  careful  medical  treatment  has  failed. 
Operation  is  indicated  for  chronic  ulcer  when  a  mechanical  cause  is  responsible 
for  retention  and  stagnation  of  stomach  contents,  and  in  certain  cases  of 
hemorrhage.  Operation  is  also  indicated  in  chronic  ulcer  \rith.  frequent 
exacerbations,  but  the  surgeon  should  be  ver\'  char}-  of  operating  upon  neurotic 
women  with  gastroptosis  unless,  of  course,  there  is  a  positive  indication  (Wm, 
J.  Mayo,  in  ''Jour.  .Am.  Med.  Assoc,"  Oct.  21,  1905). 

In  a  chronic  ulcer  if  the  patient  grows  worse  in  spite  of  careful  dietetic 
and  medical  treatment,  if  hemorrhage  has  been  profuse  or  if  there  have  been 
frequent  distinct  hemorrhages,  if  the  pain  is  \dolent,  or  if  tenderness  is  marked, 
open  the  abdomen  and  inspect  the  stomach.  An  ulcer  with  indurated  edges  is 
easily  found.  The  form,  called  by  the  ^Nlayos  the  non-indurated  ulcer,  gives  no 
e\-idence  or  Httle  e\-idence  of  its  existence  when  the  outer  coat  of  the  stomach 
is  felt  and  inspected  (Wm.  J.  Mayo,  Ibid.).  Even  when  the  stomach  is 
opened,  no  ulcer  may  be  found.  According  to  ^Mikulicz,  in  some  mucous 
ulcers  there  is  a  ver\-  little  thickening,  and,  according  to  jMo^mihan,  the 
mucous  coat  may  be  a  little  adherent  to  the  muscular  coat,  so  that  it  does 
not  sHde  easily.  An  enlarged  gland  in  a  portion  of  the  omentum  may  be  a 
sign  of  ulcer  (Limd).  An  indurated  ulcer  may  be  removed  by  an  elliptical 
incision  in  the  long  axis  of  the  stomach,  the  coats  being  sutured  by  the  usual 
method,  and  gastro-enterostomy  being  also  performed.  In  ulcer  of  the  pylorus 
with  great  thickening  we  may  excise  the  pylorus,  close  both  the  duodenal  and 
stomach  openings,  and  perform  posterior  gastro-enterostomy.  In  some  cases 
gastro-enterostomy  alone  leads  to  the  cure  of  chronic  ulcer.  The  Heineke- 
Mikulicz  operation  is  not  satisfactory-  in  ulcer.  Finney's  gastroduodenostomy 
is  not  ad\"isable  if  there  is  an  unhealed  ulcer,  because  food  still  passes  over 
the  ulcer  after  its  performance. 


968  Diseases  and  Injuries  of  the  Abdomen 

Wm.  J.  Mayo  ("Annals  of  Surgery,"  1910)  has  described  a  transgastric 
method  for  excising  ulcers  of  the  posterior  wall  which  are  adherent  to  the 
pancreas.  The  excision  passes  through  pancreatic  tissue.  Bleeding  is  arrested 
by  suture-ligatures.  The  wound  in  the  pancreas  is  not  sutured,  but  is  closed 
by  a  mobilized  portion  of  gastrohepatic  or  of  gastrocolic  omentum. 

Operation  for  Gastrorrhagia  {Hemorrhage  from  the  Stomach). — Rydygier 
proposed  in  1882  to  operate  for  hemorrhage.  The  first  operation  was  done 
by  Mikulicz  in  1887,  and  the  first  successful  operation  was  reported  by  Roux 
in  1893. 

In  acute  and  violent  hemorrhage  threatening  life  the  proper  course  to 
pursue  is  somewhat  uncertain.  It  is  not  proper  to  operate  if  there  has  been 
but  one  hemorrhage,  because  the  chances  are  that  the  bleeding  will  not  be 
repeated.  Again,  the  chance  of  arresting  such  a  hemorrhage  by  operation  is, 
on  the  whole,  poor.  The  danger  of  waiting  after  one  hemorrhage  is  not  so 
great  as  the  danger  of  immediately  operating,  because  collapse  antagonizes 
renewed  hemorrhage,  but  adds  enormously  to  the  risk  of  an  operation.  In 
over  90  per  cent,  of  cases  the  hemorrhage  ceases  spontaneously.  In  over  18 
per  cent,  of  those  dying  of  hemorrhage  death  is  so  rapid  that  operation  is 
impossible  (Savariaud).  If  the  bleeding  is  from  a  distinct  ulcer,  we  may  suc- 
ceed in  excising  the  ulcer  or  in  ligating  the  bleeding-point.  Roux,  of  Lausanne, 
saved  a  patient  by  excising  an  ulcer  and  ligating  the  bleeding  coronary  artery 
on  each  side  of  it.  As  a  rule,  however,  the  bleeding  is  not  from  a  distinct  point, 
but  from  a  multitude  of  excoriations.  In  the  light  of  our  present  knowledge 
we  may  lay  down  the  following  rule:  Do  not  operate  for  one  acute  hemorrhage. 
Simply  bring  about  reaction  by  gentle  means,  let  the  patient  take  bits  of  ice,  and 
give  suprarenal  extract  by  the  stomach.  If  the  bleeding  recurs  once  or  twice 
in  comparatively  trivial  amounts,  do  not  operate ;  but  if  it  recurs  violently,  we 
should  advise  operation.  In  cases  of  ulcer  in  which  bleeding  in  small  amounts 
persists,  operation  is  indicated.  In  operating  for  a  severe  hemorrhage  the  sur- 
geon opens  the  abdomen  while  hot  salt  solution  is  being  thrown  into  a  vein. 
The  stomach  is  opened,  the  clots  washed  out,  and  a  search  made  for  the  source 
of  the  blood.  If  it  is  found  that  the  blood  comes  from  an  area  of  ulceration,  this 
area  may  be  extirpated,  ligated,  or  cauterized  with  the  thermocautery.  Some 
advise  surrounding  it  with  a  purse-string  suture.  Others,  notably  Moynihan, 
simply  perform  gastro-enterostomy,  which  is  of  service  by  draining  and  giving 
rest  to  the  dilated  stomach,  the  hemorrhage  being  perhaps  arrested  by  contrac- 
tion of  the  gastric  walls  and  the  rest  secured  preventing  the  detachment  of 
hemostatic  clot.  Gastro-enterostomy  is  of  most  service  in  ulcer  near  the 
pylorus  and  in  duodenal  ulcer.  If  the  ulcer  is  well  above  the  pylorus  it  should 
be  excised  if  possible.  As  a  rule,  it  wUl  be  found  that  the  vessels  entering 
the  ulcer  are  varicose.  Excision  is  indicated  because  of  this  varicosity.  If 
excision  is  impossible  "the  main  blood-vessels  leading  into  the  ulcer  should  be 
ligated  and  the  peritoneum  and  musciilar  coats  drawn  over  it"  (Wm.  J.  Mayo, 
in  "Surg.,  Gynec,  and  Obstet.,"  May,  1908).  If  it  is  found  that  the  bleed- 
ing comes  from  a  multitude  of  excoriations  and  that  the  stomach  is,  as  Moy- 
nihan expresses  it,  "weeping  blood,"  wx  can  do  nothing  but  gastro-enter- 
ostomy, which  in  such  a  condition  is  of  uncertain  value. 

Operation  for  Perforation. — In  acute  and  subacute  perforation  operate  at 
once,  having  all  proper  means  taken  to  bring  about  reaction  from  shock,  while 
the  abdomen  is  being  sterilized  and  whUe  ether  is  being  administered  (hot 
saline  enemata,  external  heat,  atropin  hypodermatically,  etc.).  As  a  matter  of 
fact,  shock  is  seldom  so  profound  as  to  cause  us  to  hesitate  about  operating. 
I  formerly  advised  to  wait  until  reaction  was  established  before  operating.  I 
now  believe  such  advice  erroneous.  To  delay  after  an  acute  perforation  is  to 
wait  for  what  may  never  come.     Open  the  abdomen  at  the  point  of  greatest 


Cicatricial  Stenosis  of  the  Orifices  of  the  Stomach  969 

tenderness,  or,  if  there  is  no  such  point,  open  it  in  the  epigastric  region,  a  little 
to  the  right  of  the  midline.  When  the  abdomen  is  opened  there  may  be 
an  escape  of  odorless  gas,  and  food  or  fluid  may  be  discovered  in  the  peri- 
toneal ca^•ity.  The  perforation  is  sought  for  and  is  usually  found  in  the 
anterior  wall.  When  found,  it  should  be  buried  and  overlaid  by  stomach 
wall,  a  portion  of  which  must  be  inverted  by  two  layers  of  Halsted  sutures. 
I  do  not  believe  that  excision  or  paring  the  edges  is  necessar\-  or  desirable 
in  a  case  of  pert'orated  ulcer.  If  it  is  too  large  to  close,  stitch  a  plug  of  omentum 
into  the  opening  or  insert  a  tube  and  create  a  temporar\-  gastrostomy.  If  no 
perforation  is  found  on  the  anterior  waU,  make  an  opening  into  the  lesser 
peritoneal  ca\-it\-  through  the  gastrocolic  omentum,  explore  the  posterior  waU, 
and  close  and  cover  any  perforation  foimd.  In  addition  to  closing  the  perfora- 
tion, gastro-enterostomy  is  theoretically  indicated  in  order  to  drain  the  ^•iscu3, 
give  it  rest,  and  lessen  the  tendency  to  recurrence  of  ulceration.  But.  as  a 
matter  of  fact,  such  ulcers  seldom  return.  By  the  time  the  perforation  has  been 
closed  the  patient  is  perhaps  too  severely  shocked  to  render  such  an  additional 
operation  justifiable,  and  I  agree  -^-ith  Gibbon  that  such  an  operation  should  be 
performed  only  when  there  are  multiple  ulcers  or  when  there  is  pyloric  con- 
striction (John  H.  Gibbon,  in  paper  before  the  Tri-State  Med.  Assoc,  of 
Virginia  and  the  Carolinas.  Feb.  23.  24,  1904).  After  closing  the  perforation 
the  abdominal  ca^•ity  is  irrigated  with  hot  salt  solution,  and  the  space  between 
the  Hver  and  diaphragm  is  sponged  out  with  a  gauze  pad  wet  with  hot  salt 
solution.  If  the  case  is  operated  on  many  hours  after  the  perforation,  or  if  the 
peritoneum  was  badly  soiled,  drainage  must  be  used,  but  even  in  other  cases 
it  is  safest  to  use  it.  Drainage  is  obtained  by  means  of  a  cigarette  drain  or  a 
piece  of  gau^e  passed  to  the  suture  line  in  the  stomach.  In  cases  with  much 
extravasation,  especially  if  the  extravasation  has  reached  the  pehis.  a  supra- 
pubic opening  is  made  and  a  tube  inserted.  After  the  patient  has  reacted 
from  the  shock  of  the  operation  he  should  be  placed  in  a  semi-erect  position  to 
direct  the  flow  of  infective  material  to  the  pehds,  and  continuous  proctoclysis 
shoifld  be  employed  as  in  peritonitis  (see  page  1024).  The  treatment  of  chronic 
perforation  is  the  treatment  of  perigastric  abscess,  and  consists  of  incision 
and  drainage.  Of  late,  a  number  of  cases  of  acute  and  subacute  perfora- 
tion have  been  successfully  operated  upon.  ^Mo^idhan  estimates  that  35-40 
per  cent,  of  acute  perforations  recover  after  operation.  T.  Crisp  English 
CLancet,"  Xov.  2^,  1903)  reported  42  consecutive  gastric  pert'orations  oper- 
ated on  in  St.  George's  Hospital;  22  recovered. 

Cicatricial  stenosis  of  the  orifices  of  the  stomach  resiflts  from 
the  healing  of  an  ulcer,  the  swallowing  of  a  corrosive  substance,  or  trauma- 
tism from  a  foreign  body.  Constriction  of  the  cardiac  orifice  is  indicated 
by  gradually  increasing  difficiflty  in  swallowing.  After  a  time  the  esophagus 
above  the  stricture  dilates  or  pouches;  the  fluid  food  passes  into  the  stomach, 
but  the  soUd  food  lodges  in  the  esophageal  pouch  and  is  soon  regurgitated. 
The  site  of  the  stricture  is  located  by  a  bougie,  and  by  ha^'ing  the  patient 
swaUow  while  auscultating  over  the  esophagus  and  cardiac  end  of  the  stomach. 
If  the  constriction  be  mahgnant,  the  patient  will  be  found  to  be  beyond  middle 
life,  the  vomit  is  occasionally  bloody,  emaciation  is  rapid  and  decided,  and  occa- 
sionally the  supracla\"icular  glands  are  enlarged.  A  tiunor  of  the  cardiac  end 
of  the  stomach  can  seldom  be  palpated.  If  the  constriction  be  cicatricial,  the 
histor\'  will  indicate  the  cause.  Constriction  of  the  pyloric  orifice  causes  reten- 
tion of  food  and  dilatation  of  the  stomach.  Dyspeptic  s^Tnptoms  wiU  be  found 
to  have  been  long  present.  A  tube  passed  into  the  stomach  permits  of  the 
injection  of  fluid  so  as  to  fiU  the  stomach.  When  the  fluid  nms  out  it  contains 
portions  of  undigested  food,  which  was  perhaps  eaten  days  before,  and  measure- 
ment of  the  Hquid  shows  that  the  capacity  of  the  stomach  is  enormously  in- 


97©  Diseases  and  Injuries  of  the  Abdomen 

creased.  If  hydrogen  be  forced  through  the  tube,  the  outHne  of  the  distended 
stomach  is  at  once  made  clear.  The  usual  method  of  distending  the  stomach  is 
by  a  Seidlitz  powder:  two  solutions  are  made;  the  bicarbonate  solution  is  swal- 
lowed at  once,  and  the  tartaric  solution  is  taken  afterward  in  small  amounts 
at  a  time.  Percussion  over  the  distended  stomach  indicates  the  size  of  the 
viscus.  It  is  weU  to  remember  that  when  gastric  ulcer  exists  dilatation  of  the 
stomach  can  occur  without  cicatricial  stenosis.  The  cause  in  such  a  case  is 
pyloric  spasm,  or  perhaps  the  atonic  condition  which  may  result  from  anemia 
and  neurasthenia. 

In  malignant  disease  of  the  pylorus  a  tumor  may  often  be  palpated;  there 
are  tenderness  and  considerable  persistent  pain,  great  cachexia  and  emacia- 
tion, absence  of  free  hydrochloric  acid  from  the  gastric  juice,  diminution  of  red 
corpuscles  and  hemoglobin,  and  perhaps  no  increase  of  white  corpuscles  after  a 
full  meal.  There  is  sometimes  enlargement  of  the  supraclavicular  glands.  Vom- 
iting of  bloody  fluid  occurs  in  40  per  cent,  of  the  malignant  cases.  The  use 
of  the  a;-rays  after  a  bismuth  meal  is  a  valuable  aid  in  diagnosticating  pyloric 
constriction.  The  diagnosis  of  cardiac  constriction  is  discussed  in  the  section 
on  Stricture  of  the  Esophagus.  In  cicatricial  stenosis  of  the  pylorus  there  may 
be  paroxysms  of  pain,  there  is  no  tenderness,  emaciation  is  not  so  early  in 
onset  or  so  rapid  in  progress,  and  the  supraclavicular  glands  are  never  enlarged. 
Vomiting  occurs,  but  the  ejected  matter  is  not  bloody. 

Treatment. — Cicatricial  cardiac  stenosis  requires  dilatation  with  bougies 
and  the  maintenance  of  the  restored  caliber.  If  dilatation  from  above  is 
unsatisfactory,  perform  gastrotomy,  push  a  small  bougie  from  the  mouth 
into  the  stomach,  tie  a  string  to  the  bougie,  draw  the  string  through  the 
stricture,  use  the  string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full-sized 
bougie,  close  the  wound  in  the  stomach,  and  maintain  the  caliber  of  the  car- 
diac orifice  by  the  repeated  passage  of  dilating  instruments.  If  no  instru- 
ment can  be  passed  through  the  stricture  from  above,  perform  a  gastrotomy, 
introduce  an  instrument  from  below  and  pass  it  into  the  mouth,  tie  a  string  to  it, 
draw  the  string  into  the  stomach,  and  use  Abbe's  string-saw  (see  page  936).  If 
no  instrument  can  be  passed  from  below,  convert  the  gastrotomy  into  a  gas- 
trostomy. In  malignant  stenosis  of  the  cardia,  gastrostomy,  if  performed  at 
all,  should  be  performed  early.  Jejunostomy  is  a  better  operation.  Cicatricial 
pyloric  stenosis  was  formerly  treated  by  gastrotomy  and  digital  di\ailsion  of  the 
stricture  {Loreta's  operation) ;  but  this  operation  is  obsolete,  experience  ha\dng 
shown  that  recontraction  is  inevitable.  Pyloroplasty  was  until  recently  advo- 
cated by  many  surgeons.  This  is  known  as  the  Heineke-Mikulicz  operation.. 
In  30  per  cent,  of  the  cases  the  symptoms  are  not  relieved  by  pyloroplasty,  a 
condition  which  renders  gastro- enterostomy  necessary.  Mayo  points  out  that 
in  such  cases  pyloroplasty  fails  because  the  pylorus  is  on  a  higher  level  than  the 
gastric  pouch,  the  degenerated  muscle  of  the  stomach  is  unable  to  lift  the  food 
from  the  pouch  to  the  pylorus,  and  the  symptoms  of  gastric  dilatation  and  re- 
tardation of  the  passage  of  food  into  the  duodenum  are  not  relieved.  The  opera- 
tion has  been  generally  abandoned.  Finney's  method  of  gastroduodenostomy 
(Figs.  645-648)  is  a  great  improvement  on  pyloroplasty.  The  opening  is  large 
and  in  a  proper  position  to  afford  satisfactory  drainage.  Gastro-enterostomy 
is  the  most  satisfactory  operation  in  most  cases  and  usually  effects  a  cure. 
Malignant  stenosis  is  treated  by  pylorectomy  or  gastro-enterostomy.  (See 
under  these  heads  respectively.) 

Congenital  or  Infantile  Hypertrophic  Stenosis  of  the  Pylorus. — 
Osier  tells  us  that  the  first  case  was  published  by  an  American,  Hezekiah  Beards- 
ley,  in  1778.  Hirschsprung,  of  Denmark,  in  1887  published  the  first  modern 
case  (Bimts,  "Am.  Jour.  Med.  Sciences,"  Jan.,  1912).  Stenosis  in  adults  is  al- 
most invariably  due  to  cancer  or  to  ulcer,  but  in  very  young  children  one  occa- 


Perigastric  Adhesions  971 

sionally  meets  wdth  a  form  that  is  congenital.  The  history  of  such  a  case  is  that 
during  the  first  two  or  three  days  after  birth  the  child  seems  in  every  way  normal, 
but  that  after  several  or  a  number  of  days  or  perhaps  weeks  vomiting  suddenly 
begins — vomiting  for  which  no  dietary  cause  seems  responsible,  and  which  per- 
sists irrespective  of  medication.  After  the  stomach  has  been  emptied  by  vomit- 
ing the  child  seems  much  relieved,  but  when,  after  a  time,  food  is  administered, 
vomiting  will  begin  again,  either  in  a  very  short  time  or  after  an  hour  or  so.  It 
has  been  noted  that  the  vomited  matter  in  congenital  stenosis  of  the  pylorus 
never  contains  any  bile  whatever,  for  ob\'ious  reasons — the  pylorus  is  shut  and 
the  bile  cannot  enter  the  stomach.  A  child  in  this  condition  receives  httle  or 
no  nourishment,  becomes  quickly  emaciated,  and  soon  dies.  Some  of  these 
children  die  in  a  month ;  others,  in  several  months,  and  a  few  may  live  for  five 
or  six  months.  It  may  be  possible,  in  these  cases,  to  palpate  a  thickened  py- 
lorus, and  the  outhnes  of  the  dilated  stomach  may  be  made  out.  Regurgitant 
vomiting  by  keeping  the  stomach  empty  may  prevent  dilatation.  The  most 
conamon  symptom  is  gastric  peristalsis.  In  Bunts's  table  gastric  peristalsis  was 
present  in  84  per  cent.,  and  tvunor  in  69  per  cent,  of  cases.  In  true  congenital 
stenosis  there  is  h^-pertrophy.  The  circular  muscular  fiber  undergoes  great  in- 
crease from  hypertrophy,  perhaps  with  some  fibrosis.  The  mucous  mmbrane  is 
hypertrophied  and  throwTi  into  folds.  The  opening  into  the  duodenum  may 
be  no  larger  in  diameter  than  a  pin  and  may  be  totally  blocked  by  folds  of 
mucous  membrane.  Even  when  there  is  comparatively  Uttle  or  no  hyper- 
trophy the  lumen  of  the  pylorus  may  be  closed  by  spasm.  It  is  these  latter 
cases  which  are  benefited  by  medical  treatment.  Such  cases  are  not  in- 
stances of  congenital  hypertrophy  and  should  be  classified  as  pyloric  spasm. 
In  congenital  hypertrophic  stenosis  the  intestines  are  very  much  collapsed, 
and  the  child  is,  of  course,  much  constipated.  Cases  of  pyloric  closure  have 
recovered  after  lavage  carried  out  daily  for  some  weeks  and  careful  breast 
feeding.  Such  cases  are  probably  instances  of  spasm.  This  plan  is  only 
permissible  if  there  is  no  palpable  thickening  at  the  pylorus.  A  trial  should 
be  given  this  method  unless  the  condition  of  the  patient  demands  immedi- 
ate reHef.  If  there  is  palpable  thickening  of  the  pylorus,  operation  is  called 
for  imperatively.  The  delay  in  emplo\dng  surgery  in  hopes  of  lavage  succeed- 
ing must  never  be  so  long  that  the  patient  emaciates.  If  the  condition  does 
not  soon  show  signs  of  improvement,  operation  is  indicated.  Cases  reported 
cured  by  medical  means  may  have  been  instances  of  pyloric  spasm.  The 
operation  for  this  condition  is  usually  gastro-enterostomy.  The  mortahty 
after  the  operation  is  apparently  over  50  per  cent.  It  is  superior  to  pyloro- 
plasty because  it  enables  us  to  at  once  feed  the  exhausted  child.  Bunts 
("Amer.  Jour.  Med.  Sci.,"  Jan.,  1912)  operated  on  7  cases  and  4  recovered. 
Gastro-enterostomy  saves  the  child  from  starvation  and  restores  the  function 
of  the  intestinal  canal,  but  the  pyloric  timior  remains  permanently  (Scudder, 
in  "Siu-g.,  Gynec,  and  Obstet.,"  Sept.,  1910). 

Perigastric  Adhesions. — That  perigastric  adhesions  are  frequently 
responsible  for  stomach  pain  and  digestive  difficulty  is  imdoubted.  Such 
adhesions  often  arise  in  cases  of  protracted  ulceration  of  the  stomach  or 
duodenum.  A  common  cause  of  perigastric  adhesions  is  gall-stone  disease. 
Tuberculous  peritonitis  causes  dense  adhesions.  In  some  cases  adhesions 
are  traumatic,  in  some  are  due  to  syphiHs,  in  many  the  cause  is  uncertain 
(Fred.  D.  Bird,  "Intercolonial  Med.  Jour,  of  Austraha,"  Dec.  20,  1900). 
Adhesions  may  cause  blocking  or  kinking  of  the  pylorus,  or  may  glue  the 
stomach  to  the  parietal  peritoneiun  or  to  some  adjacent  viscus.  In  Fen- 
wick's  table  of  123  cases  he  finds  that  the  adhesions  usually  cause  the 
stomach  to  adhere  to  the  pancreas  or  to  the  liver.  The  formation  of 
adhesions  in  cases  of  gastric  ulcer  is,  in  many  instances,  conservative,  serv- 


972  Diseases  and  Injuries  of  the  Abdomen 

ing  to  prevent  perforation  or  to  limit  extravasation  if  perforation  of  the 
stomach  wall  occurs. 

The  symptoms  are  variable.  In  some  cases  the  adhesions  produce  little 
or  no  trouble;  but  in  the  majority  of  cases  they  cause  definite  symptoms, 
and  sometimes  the  condition  becomes  one  of  absolute  disablement.  The 
symptoms  may  be  due  to  blocking  of  the  pylorus,  a  condition  that  is  fol- 
lowed by  gastric  dilatation.  They  may  be  due  to  dragging  upon  the  adhe- 
sions when  the  stomach  contracts  during  digestion,  or  when  peristalsis  occurs 
in  an  adherent  piece  of  intestine. 

The  usual  symptom  is  pain,  frequently  of  a  violent  character.  The  pain 
comes  on  in  paroxysms,  and  recurs  over  and  over  again,  it  may  be  during  years. 
H.  Hale  White^  points  out  that  in  these  cases  there  is  usually  some  pain  persist- 
ing, which  is  now  and  then  increased  into  violent  paroxysms;  and  that  the  only 
other  condition  that  produces  persistent  pain  with  violent  exacerbations  is 
cancer.  In  adhesion-dyspepsia,  however,  there  is  no  distinct  loss  of  weight; 
the  condition  may  exist  in  youth,  as  well  as  in  middle  age  or  old  age;  it  is 
not  always  increased  by  taking  food,  and  it  very  rarely  causes  death.  If  there 
is  a  history  of  antecedent  gall-stone  disease  or  of  ulcer  of  the  stomach,  it  is 
possible  to  make  the  diagnosis  without  exploratory  operation.  Even  in  other 
cases  the  condition  may  sometimes  be  diagnosticated,  because,  although 
there  are  these  attacks  of  violent  pain,  there  is  no  tenderness.  In  rare  cases 
the  adhering  and  matting  together  with  inflammatory  exudate  produces  a 
palpable  mass.  In  doubtful  cases  of  chronic  and  disabhng  stomach  disease 
an  exploratory  operation  should  be  performed;  if  adhesions  exist,  they  will 
then  become  manifest. 

Treatment. — In  some  cases  simply  dividing  an  adhesion  effects  a  cure; 
in  other  cases  it  is  necessary  to  make  extensive  separation  of  adherent  struc- 
tures, covering  the  raw  surfaces  with  omental  grafts.  In  serious  adhesions 
about  the  pylorus  gastro-enterostomy  is  usually  the  proper  operation. 

Bilocular  Stomach  (Hour=glass  Stomach). — It  is  usually  stated  that 
some  cases  are  congenital,  but  the  writings  of  Mayo  Robson,  Moynihan,  and  H. 
L.  Paterson  cause  us  to  doubt  if  the  condition  is  ever  congenital.  Even  in  the  so- 
called  congenital  cases  ulcers  are  found,  or  ulcer  scars  exist,  or  ulcer  adhesions 
are  demonstrable.  The  advocates  of  a  congenital  origin  say  that  the  ulcers 
are  secondary  to  the  narrowing,  and  that  ulceration  tends  to  occur,  particularly 
at  the  seat  of  constriction.  Beyond  doubt,  a  very  great  majority,  at  least,  of 
cases  of  bilocular  stomach  result  from  adhesions  produced  by  the  healing  of  an 
ulcer.  In  hour-glass  stomach  with  a  large  opening  between  the  two  sacs  there 
may  be  no  symptoms.  When  the  opening  is  small  the  symptoms  resemble 
those  of  pyloric  stenosis.  The  sac  toward  the  cardia  is  frequently  much 
dilated. 

Symptoms. — The  diagnosis  of  cancer  is  often  made.  The  protracted 
gastritis  may  have  caused  free  hydrochloric  acid  to  disappear  and  acids  of 
fermentation  are  usually  found.  The  patient  vomits  from  time  to  time, 
bringing  up  food  which  was  eaten  a  day  or  two  before,  proof  that  food  is 
retained  in  the  stomach  and  not  digested.  Occasionally,  perhaps,  blood  is 
vomited.  There  is  pain  and  the  patient  is  harassed  by  foul-smelling  eructa- 
tions. Emaciation  becomes  pronounced.  Cumstom"  points  out  that  in  a  thin 
belly  distention  of  the  stomach  may  make  the  condition  evident;  further,  that 
if  water  is  thrown  into  the  stomach,  only  a  part  returns,  and  when  the  stomach 
is  emptied  as  much  as  possible  by  a  tube,  a  splashing  sound  can  still  be  elicited 
in  the  stomach  because  the  pyloric  pouch  is  not  empty.  One  cause  of  death  is 
torsion  on  the  axis.  A  skiagraph  taken  after  a  bismuth  meal  gives  diagnostic 
information  of  the  first  importance. 

1  "Lancet,"  Nov.  30,  1901.  ^  "Med.  News,"  Dec,  1901. 


To  Test  the  Motor  Power  of  the  Stomach  973 

Treatment. — The  diagnosis  becomes  certain  after  exploratory  operation, 
and  exploration  also  enables  the  surgeon  to  decide  with  certainty  as  to  what 
operation  should  be  performed.     Cumstom^  gives  us  the  following  suggestions: 

1.  In  rare  cases  resect  the  stricture  and  suture  the  pouches. 

2.  If  there  is  trivial  ulceration  or  a  slight  scar,  do  gastroplasty,  an  operation 
upon  the  constriction  exactly  similar  to  pyloroplasty. 

3.  The  best  operation  in  most  cases  is  gastrogastrostomy — that  is,  anas- 
tomosis of  the  cardiac  pouch  to  the  pyloric  pouch;  but  this  cannot  be  done 
if  the  pyloric  pouch  is  small.     Then  do  gastro-enterostomy. 

Other  operations  are: 

4.  Gastroduodenostomy. 

5.  Gastrojejunostomy. 

6.  Gastrolysis. 

In  malignant  disease  resection  (partial  gastrectomy)  is  indicated.  After 
gastroplasty  recontraction  is  common,  and  I  do  not  believe  in  the  operation. 
Gastro-enterostomy  is  unsatisfactory.  The  ordinary  operation  drains  but  one 
pouch.  Weir  and  Foote  advised  a  double  gastro-enterostomy,  tapping  each 
sac.  In  most  cases  gastrogastrostomy  followed  by  gastro-enterostomy  is  the 
best  procedure. 

Chronic  Dilatation  of  the  Stomach. — ^A  dilated  stomach,  roughly 
speaking,  is  one  which  can  contain  more  than  1.5  quarts  (Ewald).  Some 
few  cases  of  dilatation  result  directly  from  atrophy  of  the  muscular  coat 
brought  about  by  drinking  quantities  of  liquid,  especially  beer;  chronic  catarrh 
of  the  stomach;  and  conditions  such  as  cancer,  tuberculosis,  diabetes,  etc. 
The  common  cause  of  dilatation  is  constriction  of  the  pylorus.  In  order 
to  force  food  through  the  pyloric  narrowing  more  force  is  necessary  than  is 
required  in  a  normal  state  of  affairs  to  cause  the  food  to  enter  the  duodenum, 
hence  the  stomach  muscle  hypertrophies.  This  muscular  hypertrophy  is 
compensatory,  and  dilatation  does  not  occur  so  long  as  the  muscle  is  efficient. 
But  finally  the  pyloric  opening  becomes  so  narrow  that  compensation  fails, 
the  stomach  contents  accumulate,  and  the  stomach  dilates. 

Symptoms  of  Dilated  Stomach. — There  is  annoying  hunger  unless  cancer 
exists.  Thirst  is  complained  of.  At  intervals  of  a  day  or  two  the  patient 
vomits  enormous  quantities,  and  portions  of  food  may  be  identified  which  were 
eaten  one  or  more  days  before.  The  vomited  matter  is  sour  and  foul  smelling, 
contains  numbers  of  yeasts,  and  much  fermentative  acid.  Free  hydrochloric 
acid  is  often  absent.  In  some  cases  vomiting  occurs  two  or  three  hours  after 
each  meal.  The  patient  suffers  from  foul  gaseous  eructations.  There  are  pro- 
gressive emaciation,  constipation,  scantiness  of  urine ;  sometimes  cramp  in  the 
legs,  belly,  and  arms;  tetany  may  occur  (see  Parathyroid  Tetany,  page  1244) 
insomnia  is  the  rule ;  cardiac  palpitation  occurs,  and  there  is  dyspnea,  particu- 
larly at  night. 

Physical  Signs  of  Dilated  Stomach. — The  epigastric  region  is  hollow 
and  the  left  side  of  the  abdomen  is  more  prominent  than  the  right.  The 
outUne  of  the  greater  curvature  of  the  stomach  can  be  distinguished.  If  the 
stomach  contains  air,  percussion  gives  a  tympanitic  note;  if  it  contains  fluid, 
a  dull  note.  When  it  is  partly  full  of  fluid,  by  altering  the  position  of  the 
patient  we  can  show  by  percussion  that  the  fluid  changes  its  position.  In  a 
doubtful  case  give  a  light  meal  in  the  evening,  and  in  the  morning,  before 
the  patient  has  eaten,  introduce  a  tube  and  remove  any  material  contained 
in  the  stomach.     The  presence  of  undigested  food  points  to  dilatation. 

To  Test  the  Motor  Power  of  the  Stomach. —  Klemperer's  Test. — Wash 
out  the  stomach.  Introduce  100  c.c.  of  olive  oil  by  means  of  the  tube.  After 
two  hours  withdraw  the  oil.     The  stomach  cannot  absorb  ofl,  and  if  the 

1  "Med.  News,"  Dec.  7,  1902. 


974  Diseases  and  Injuries  of  the  Abdomen 

amount  withdrawn  is  subtracted  from  the  amount  introduced  the  difference 
is  the  amount  which  passed  the  pylorus.  If  the  condition  is  normal,  not 
more  than  from  20  to  40  c.c.  should  be  found  in  the  stomach  after  two 
hours. 

The  Salol  Test  of  Ewald. — Salol  is  not  decomposed  in  the  stomach,  but 
in  the  intestine  is  broken  up  into  phenol  and  salicylic  acid.  Salicylic  acid  is 
absorbed  and  salicyluric  acid  soon  appears  in  the  urine.  If  salol  cannot  reach 
the  intestine,  salicyluric  acid  will  not  appear  in  the  urine.  If  salol  reaches 
the  intestine  more  slowly  than  normal,  salicyluric  acid  will  appear  after  a 
longer  interval  than  when  there  is  no  pyloric  block  to  retard  the  emptying 
of  the  stomach.  In  a  normal  person  salicyluric  acid  is  found  in  the  urine 
in  from  three-fourths  of  an  hour  to  an  hour  after  swallowing  a  dose  of  salol. 
In  stenosis  of  the  pylorus  it  appears  much  later.  The  test  is  made  as  follows: 
The  bladder  is  emptied  and  the  patient  is  given  three  capsules,  each  con- 
taining 5  gr.  of  salol.  The  patient  is  directed  to  pass  water  every  half-hour, 
until  he  has  done  so  four  times.  Each  sample  voided  is  examined  for  sali- 
cyluric acid  by  adding  neutral  chlorid  of  iron.  If  salicyluric  acid  is  present, 
a  violet  color  is  noted. 

To  Test  the  Absorptive  Power  of  the  Stomach. — The  absorptive  power 
of  the  stomach  can  be  tested  by  giving  the  patient  a  capsule  containing  i| 
gr.  of  iodid  of  potassium.  Normally  the  drug  should  be  found  in  the  saliva 
in  from  ten  to  fifteen  minutes.  When  absorption  is  deficient,  it  may  not 
appear  for  an  hour  or  longer.  In  order  to  test  for  it,  moisten  starch  paper  with 
the  saliva  and  touch  the  moist  paper  with  a  drop  of  fuming  nitric  acid.  If 
iodin  is  present,  a  blue  color  develops. 

While  the  diagnosis  of  dilatation  of  the  stomach  can  be  certainly  made, 
the  determination  of  the  cause  may  require  an  exploratory  operation. 

Treatment. — Cases  not  due  to  pyloric  obstruction  are  much  improved 
by  lavage,  regulated  diet,  use  of  an  abdominal  belt,  electricity,  aperients, 
and  other  agents  called  for  by  symptoms. 

In  all  cases  in  which  there  is  pyloric  obstruction,  in  many  doubtful  cases, 
and  in  cases  in  which  medical  treatment  fails,  exploratory  operation  is  indi- 
cated. In  dilatation  without  pyloric  obstruction  some  surgeons  advocate  gas- 
troplication.  If  pyloric  obstruction  exists,  the  surgeon  may  elect  to  do  pylo- 
rectomy,  pyloroplasty,  or  gastro-enterostomy,  the  method  selected  depending 
on  the  condition  discovered.  If  gastroptosis  exists,  gastropexy  or  Beyea's 
operation  may  be  performed. 

Acute  Dilatation  of  the  Stomach.^ — This  condition  may  suddenly  arise 
in  the  course  of  chronic  dilatation  or  when  no  previous  dilatation  existed. 
Its  clinical  features  were  described  by  Brinton  in  1859.  Hilton  Fagge  in  1875 
furnished  us  with  the  first  comprehensive  description  of  the  signs  and  symp- 
toms. The  cause  is  uncertain,  and  is  a  subject  of  active  investigation  at  the 
present  time.  It  is  said  to  be  due  to  degeneration  of  the  gastric  muscle  in 
the  course  of  specific  fevers,  to  paresis  arising  in  the  course  of  chronic  gastritis, 
and  to  the  drinking  of  a  quantity  of  effervescing  liquid.  If  is  occasionally  a 
fatal  sequence  of  abdominal  operations,  particularly  operations  upon  the  gall- 
bladder and  bile-ducts.  The  surgeon  sees  it  in  the  course  of  sepsis  and  during 
shock  from  operations  in  which  a  general  anesthetic  was  used,  and  occasionally 
in  cases  of  spinal  curvature. 

One  set  of  observers  maintains  that  the  condition  is  brought  about  by  actual 
constriction  of  the  duodenum,  the  constricting  cause  being  the  root  of  the 
mesentery  and  the  superior  mesenteric  artery  and  the  duodenum  being  squeezed 
against  the  vertebral  column  (Rokitansky,  Albrecht,  Robinson,  and  Kundrat). 

iSee  Kelling,  in  "Archiv.  f.  klin.  Chir.,"  1901,  Ixiv;  Albrecht,  in  "Virchow's  Archiv.," 
1899,  clvi;  Conner,  in  "Am.  Jour.  Med.  Sciences,"  March,  1907. 


Treatment   of  Acute   Dilatation  of   the   Stomach        .  975 

Codman  beheves  that  normally  in  man  there  is  more  or  less  tendency  to  such 
constriction  on  standing  erect  or  hing  down,  and  that  a  trixdal  increase  of  the 
constriction  which  may  be  brought  about  by  various  causes  may  completely 
obstruct  the  duodenum  (^""Boston  Med.  and  Surg.  Jour.."  igcS'.  Le'uis  A. 
Conner  collected  iS  fatal  cases  shown  by  necropsy  to  be  due  to  mesenteric 
obstruction  (""Am.  Jour.  Med.  Sciences,"  March.  1907  h 

Another  set  of  obsen,-ers  asserts  that  acute  dilatation  is  due  to  lesion  of  the 
ner\-e-trunks  or  ner.-e-centers,  resulting  in  paresis  of  the  muscle  of  the  stomach 
wall  and  spasm  of  the  pylorus.  The  cause  of  the  nerve  lesion  is  variously  held 
to  be  h\-peracidity  of  gastric  secretion,  the  absorption  of  the  toxins  of  fermenta- 
tion, the  secretion  of  chloroform  into  the  stomach,  the  overdistention  of  the 
\'iscus  with  ether  vapor,  or  an  enormously  great  secretion  of  fluid  into  the 
stomach. 

As  Conner  (Ibid.)  says,  the  theor\-  of  pyloric  spasm  being  causative  is 
untenable  because  in  most  cases  vomited  matter  contains  bile,  and  in  two- 
thirds  of  the  cases  the  duodenum  is  involved  in  dilatation. 

It  seems  certain  that  some  cases  of  gastric  dilatation  are  associated  with 
mesenteric  constriction  of  the  duodenum,  brought  about  by  the  intestines 
descending  into  the  pehis.  The  constriction  inaugurates  the  dilatation  and 
is  aggravated  by  the  dilatation.  Conner  points  out  that  the  intestines  enter 
the  pehis  as  a  result  of  dorsal  decubitus,  a  long  mesenter\',  and  a  gut  nearly 
empty  of  gas  and  feces,  and  is  favored  by  relaxation  of  the  belly  waU  ( ■"Jour. 
Am.  Med.  Assoc.,'"'  March,  1907^ 

Symptoms. — The  most  frequent  and  prominent  is  \-iolent  vomiting, 
usually  inaugurating  the  s^miptoms  and  continuing  throughout  the  illness, 
although  occasionally  it  ceases  for  some  time  before  death.  The  amounts 
vomited  are  always  large  and  often  enormous.  The  vomitus  is  thin  and  of 
a  green  or  black  hue,  usually  contains  bile  and  sometimes  a  little  blood, 
but  ver\-  seldom  feces. 

In  most  cases,  but  not  in  all.  there  is  epigastric  or  umbihcal  pain  and 
tenderness.  Distention  is  the  rule.  Rigidity  is  rare.  In  many  cases  there  is 
no  passage  of  gas  or  feces,  but  in  some  diarrhea  exists.  There  is  great  thirst, 
there  may  be  hiccup,  and  delirium  may  arise  before  death.  The  tempera- 
ture is  nearly  always  normal  or  below  normal.  There  is  seldom  \isible  gas- 
tric peristalsis  (Conner,  rbid.\,  and  splashing  sounds  are  obtainable  over  the 
stomach. 

CoUapse  arises  early  and  quickly  becomes  profound.  Tetany  occasionally 
occurs.  A  case  of  my  own  died  of  acute  gastric  dilatation  after  an  operation 
for  stone  in  the  kidney.  He  suddenly  developed  attacks  of  ^"iolent  and  pro- 
fuse vomiting,  rapidly  went  into  coUapse,  hA-idity  deA-eloped  and  hiccup  arose, 
and  he  died  in  fort\--eight  hours. 

A  case  may  die  in  less  than  twenty-four  hours  or  may  die  after  ten  days 
or  more.  Conner's  group  of  cases  shows  a  mortahty  of  72.5  per  cent.  Fluid 
cannot  reach  the  smaU  intestine,  and  as  none  is  absorbed  from  the  stomach 
and  little  from  the  duodenum,  the  tissues  starve  for  the  want  of  it  (Laffer,  in 
"Annals  of  Surger}-,"  April,  190S).  The  condition  is  frequently  diagnosticated 
acute  intestinal  obstruction  or  peritonitis  from  perforation. 

Treatment. — When  the  stomach  has  dilated  greatly  and  when  coUapse  is 
profound,  treatment  is  usually  of  no  avaU.  \Mien  an  early  diagnosis  is  made 
treatment  is  often  of  the  greatest  value.  The  stomach  must  be  at  once  emptied 
by  the  use  of  a  tube  and  the  treatment  be  repeated  at  inten,-al5  of  a  few  hours. 
Neither  food  nor  drink  should  be  given  by  the  mouth.  SaKne  enemata  and  per- 
haps nutritive  and  stimulating  enemata  should  be  given.  The  patient  should 
at  once  be  placed  upon  the  beUy  and  kept  there  imtil  the  condition  abates,  in 
the  hope  that  this  posture  will  reheve  duodenal  constriction. 


976 


Diseases  and  Injuries  of  the  Abdomen 


Gastro-enterostomy  has  been  employed,  and  is  advocated  by  Mayo  Robson. 
Byron  Robinson  had  a  successful  case.  I  would  be  disposed  to  employ  it 
in  spite  of  the  reported  failures.  In  a  number  of  cases  the  stomach  has  been 
opened  and  washed  out  without  benefit.  Petit  opened  the  abdomen  and  dis- 
covered a  kink  at  the  junction  of  the  duodenum  and  jejunum;  he  raised  the 
jejunum  and  sutured  it  to  the  transverse  colon  and  the  patient  recovered 
(Conner,  "Jo^r.  Amer.  Med.  Assoc,"  March,  1907). 

Not  until  we  know  definitely  the  cause  or  causes  of  acute  dilatation  of 
the  stomach  will  we  be  able  to  lay  down  with  precision  and  accuracy  the 
treatment  which  is  indicated.     There  is  much  difference  of  opinion  as  to  the 

causation  of  the  con- 
dition, and  widely  dif- 
ferent methods  of  treat- 
ment are  advocated  by 
various  surgeons. 

Qastroptosis  (Fig. 
602). — In  this  condi- 
tion the  stomach  has 
undergone  displacement 
downward,  the  greater 
curvature  in  many  cases 
being  but  little  above 
the  pubic  symphysis 
and  the  lesser  curvature 
being  between  the  ensi- 
form  cartilage  and  the 
umbilicus.  This  condi- 
tion is  far  more  common 
in  women  than  in  men, 
and  is  especially  com- 
mon in  women  who 
have  had  many  chil- 
dren. It  may  be  pro- 
duced by  tight  lacing 
and  may  follow  mov- 
ability  of  the  right  kid- 
ney, of  the  liver,  or  of 
the  spleen.  It  is  often 
associated  with  enterop- 
tosis,  mobile  cecum,  and 
prolapse  of  the  colon, 
and  is  particularly  prone 
to  arise  in  the  anemic 
and  tuberculous. 

Symptoms. — There  may  be  no  symptoms  for  a  long  time,  but  sooner 
or  later  dyspepsia  arises  because  the  stomach  cannot  empty  itself.  The 
stomach  becomes  atonic,  its  secretions  are  scanty  and  altered,  and  while 
the  viscus  may  be  normal  in  size  or  even  shrunken,  it  is  usually  dilated.  The 
malposition  can  be  made  out  by  percussion  when  the  stomach  is  distended 
with  air  or  with  fluid,  and  by  the  x-rays  after  the  patient  has  drunk  a  pint  of  a 
solution  of  mucilage  of  acacia  containing  subnitrate  of  bismuth.  The  bismuth 
lines  the  stomach  and  intercepts  the  x-rays  and  a  radiograph  shows  the  outHnes 
of  the  stomach  and  hence  its  size  and  position.  The  pylorus  descends  to  the 
imabiHcal  region,  which  it  does  not  do  in  plain  dilatation.  In  dilatation  the 
pylorus  is  but  slightly  lower  than  normal,  but  the  lower  border  of  the  stomach 


Fig.  602. — Gastroptosis  (shown  by  a  skiagraph). 


Intestinal  Obstruction  977 

is  notably  depressed.  In  gastroptosis  there  is  often  a  constriction  a  short 
distance  from  the  pylorus  due  to  a  kink  produced  by  the  sagging. 

When  a  patient  with  gastroptosis  stands  erect  the  bulging  is  most  promi- 
nent in  the  region  of  the  umbilicus  and  the  epigastrium  is  deepened. 

Gastroptosis  is  not  infrequently  associated  with  chlorosis  and  commonly 
with  neurasthenia. 

Treatment. — Lavage,  regulation  of  diet,  improvement  of  the  general 
health,  the  wearing  of  an  abdominal  binder,  and  placing  the  patient  supine 
for  a  time  after  each  meal.  If  medical  treatment  fails  and  the  condition  is 
producing  grave  impairment  of  the  general  health,  it  may  be  necessary  to 
perform  a  surgical  operation.  Gastro-enterostomy  is  advocated  by  some  on 
the  ground  that  the  unpleasant  symptoms  result  from  stagnation  of  gastric 
contents.  Good  results  have  been  reported  by  this  plan.  The  operation  of 
Depage  is  unphilosophical.  Buret's  operation  is  objectionable  (see  page  1 104), 
Beyea's  operation  or  Ransohoff's  method  are  preferred  (see  page  1104). 

Chronic  Intestinal  Stasis. — This  is  a  term  employed  by  Mr.  Arbuthnot 
Lane  to  designate  such  a  delay  in  the  passage  of  material  along  the  gastro- 
intestinal tract  as  to  permit  of  the  absorption  of  so  much  toxin  that  the  body 
cannot  successfully  deal  with  it  (Lane's  paper  before  the  Derby  Med.  Soc, 
Oct.  17,  1911).  Defective  drainage  permits  absorption  of  poison,  and  absorp- 
tion of  poison  is  responsible  for  ill  health  and  the  lowering  of  vital  resist- 
ance to  various  bacteria.  Lane  and  his  followers  are  of  the  opinion  that 
toxemia  so  induced  may  cause  chronic  mastitis,  rheumatoid  arthritis,  gastric 
ulcer,  duodenal  ulcer,  appendicitis,  and,  by  lowering  resistance,  may  be  re- 
sponsible for  progressive  tuberculous  disease.  They  believe  that  the  block 
to  drainage  is  brought  about  by  kinks,  and  that  the  kinks,  which  tend  to 
form  in  certain  situations,  are  due  to  bands;  in  other  words,  the  condition  is 
due  to  a  mechanical  cause  (Lane,  Ibid.).  Mayo  regards  such  bands  as  con- 
genital. Lane  holds  that  faulty  feeding  in  early  life  causes  abnormal  disten- 
tion and  pull  on  the  gut,  that  when  the  erect  posture  is  assumed  the  condition 
is  exaggerated  by  the  formation  of  new  peritoneal  bands  which  are  formed  to 
resist  the  dropping  of  the  intestine. 

In  1909  Jabez  Jackson  described  a  pseudomembrane  sometimes  seen  over  the 
peritoneum  of  the  lower  ileum  and  colon  and  loosely  attached  to  it.  Sometimes 
it  is  also  attached  to  parietal  peritoneum  and  thus  limits  movements  of  the  gut. 
This  thin  membrane  is  known  as  Jackson's  veil,  and  it  is  probably  identical  with 
Lane's  bands.  Some  observers  regard  Jackson's  veil  as  the  result  of  pericolitis, 
some  as  due  to  infantile  cohtis,  some  to  chronic  colitis,  some  to  appendititis. 
Isaacs  ("New  York  Med.  Jour.,"  Oct.  26,  191 2)  points  out  that  this  pseudo- 
membrane  may  be  found  in  other  regions  than  over  the  colon,  and  suggests 
calling  the  condition  membranous  perienteritis.  He  believes  the  membrane  is 
formed  because  of  ulceration  or  inflammation  of  the  gastro-intestinal  tract. 

The  large  intestine  plays  such  a  prominent  part  in  toxin  absorption  that 
Barclay  Smith  (quoted  in  "Brit.  Med.  Jour.,"  Dec.  7,  1912),  Metchnikoflf, 
Lane,  and  others  put  under  ban  that  portion  of  the  gut,  regard  it  as  a  useless 
and  dangerous  encumberance,  and  would  take  it  out  and  cast  it  away. 

Treatment. — If  a  band  or  membrane  exists,  remove  it,  and  if  a  raw  surface 
is  left,  cover  it  over  with  peritoneum. 

In  partial  blocking  of  the  beginning  of  the  large  intestine  or  of  the  lower 
ileum  some  perform  ileocolostomy.  Lane  extirpates  the  colon  and  fastens 
the  upper  end  of  the  divided  ileum  to  the  rectum.  He  does  the  same  operation 
for  rheumatoid  arthritis,  tuberculous  joints,  and  other  conditions — radical 
steps  on  a  road  where  so  far  few  have  gone  more  than  a  short  distance. 

Intestinal  obstruction  (ileus  or  enterostenosis)  is  a  condition  in 
which  fecal  movement  is  mechanically  impeded  or  prevented.  It  may  be 
62 


978  Diseases  and  Injuries  of  the  Abdomen 

either  partial  or  complete^  acute  or  gradual.  Acute  obstruction  is  due  to  a 
sudden  narrowing  or  occlusion  of  the  lumen  of  a  portion  of  the  intestine. 
Chronic  obstruction  is  due  to  a  gradual  narrowing  of  the  lumen  of  a  portion 
of  the  intestine,  and  it  may  at  any  time  become  acute.  If  there  is  not  only 
interference  with  the  passage  of  the  fecal  current,  but  is  also  obstruction 
to  the  blood-current  in  the  wall  of  the  bowel,  the  condition  becomes  strangula- 
tion. The  primal  cause  is  mechanical  in  nature,  in  most  cases  a  mechanical 
block.  In  paralysis  of  the  bowel  from  peritonitis  there  is  inability  of  the 
bowel  wall  to  contract  and  force  the  feces  onward.  In  all  cases  of  unrelieved 
obstruction  the  nerves  are  sooner  or  later  damaged  and  paralysis  occurs.  In 
acute  obstruction  the  stagnated  intestinal  contents  become  charged  with  power- 
ful poisons  which  act  most  harmfully  on  the  musculature  of  the  intestinal  wall, 
and,  after  absorption,  attack  the  heart  and  nervous  system.  The  inaugural 
shock  is  due  to  the  production  of  the  block;  later  the  increasing  depression  is  due 
to  absorption  of  poisons.  Gas  forms  in  great  amount  in  the  intestine  and  pro- 
duces distention.  Distention  impairs  the  circulation  in  the  wall  of  the  intes- 
tine and  embarrasses  respiration  by  pushing  up  the  diaphragm. 

Acute  Obstruction. — The  worst  forms  of  this  grave  condition  are  due 
to  sudden  and  absolute  blocking  of  the  bowel  with  strangulation,  as  when  a 
portion  of  bowel  is  caught  under  a  band  or  in  a  hernial  aperture. 

As  soon  as  strangulation  occurs  there  is  violent  peristalsis.  The  bowel 
above  the  strangulation  for  a  short  time  vainly  lashes  itself  into  effort  to 
force  intestinal  material  by  the  obstruction.  The  peristalsis  below  empties  the 
bowel  below  the  obstruction,  leaving  it  empty  and  contracted,  but  not  paralyzed. 
Peristalsis  above  the  obstruction  soon  ceases,  and  the  bowel  in  this  region 
becomes  greatly  distended  with  bloody  fecal  fluid  and  gas.  The  putrefaction 
of  the  intestinal  contents  forms  great  quantities  of  gas:  none  of  it  can  pass  the 
obstruction  and  none  of  it  can  be  absorbed  because  of  circulatory  disturbance 
in  the  bowel  wall.  It  is  only  early  in  an  acute  obstruction  that  the  distended 
bowel  above  the  block  is  thin.  It  soon  becomes  congested  and  edematous, 
bleeding  may  occur  from  the  mucous  membrane,  and  that  structure  desqua- 
mates and  may  be  eroded.  When  the  mucous  membrane  is  desquamated, 
bacteria  pass  through  the  bowel  wall  and  cause  peritonitis,  or  erosions  may 
perforate.  Miles  ("A  System  of  Surgery,"  edited  by  C.  C.  Choyce)  points  out 
that  swelling  of  the  gut  is  greatest  when  obstruction  is  in  the  small  intestine 
because  "secretion  of  a  considerable  amount  of  fluid  is  reflexly  stimulated." 
The  distention  may  ascend  all  the  way  to  the  stomach. 

In  most  cases  strangulation  at  first  blocks  veins;  later,  in  severe  cases,  it 
also  blocks  arteries.  In  a  very  sudden  and  complete  strangulation  both  arte- 
ries and  veins  are  shut  off  simultaneously.  Early  in  the  case,  when  the  veins 
only  are  obstructed,  the  coil  of  gut  is  purple,  edematous  and  distended,  and 
bloody  serum  may  pass  into  the  lumen  of  the  bowel  and  also  into  the  cavity 
of  the  peritoneum.  Later  the  arteries  are  blocked  and  then  gangrene  soon 
occurs.  In  very  acute  cases  when  the  arteries  and  veins  are  blocked  simulta- 
neously gangrene  arises  promptly.  In  such  a  case  the  strangulated  coil  is  not 
distended  and  is  gray  or  greenish  in  color.  When  strangulation  occurs  bacteria 
soon  begin  to  pass  through  the  walls  of  the  strangulated  coil  and  cause  peri- 
tonitis. Perforations  may  take  place  in  the  coil,  at  the  seat  of  constriction,  or 
even  in  the  gut  above  the  block. 

Chronic  Obstruction. — This  comes  on  gradually.  A  tumor  may  slowly 
fill  up  the  lumen  of  the  bowel  or  a  cicatrix  or  tumor  in  the  bowel  wall  may  con- 
strict more  and  more.  Pressure  outside  the  bowel  may  be  responsible.  In 
regions  where  the  feces  are  fluid  great  narrowing  can  occur  without  symptoms. 
When  fecal  passage  is  seriously  hindered  the  bowel  above  the  obstruction  be- 
comes distended  and  its  muscular  wall  undergoes  hypertrophy.     The  hyper- 


Intussusception  979 

trophy  depends  on  the  exercise  of  greater  and  greater  effort  to  overcome  the 
obstruction.  Miles  ("A  System  of  Surgery,"  edited  by  C.  C.  Choyce)  states 
that  above  the  obstruction  the  bowel  becomes  thick,  "elongated,  and  tortuous" ; 
that  in  the  small  intestine  hypertrophy  exceeds  dilatation,  and  in  the  large 
intestine  dilatation  exceeds  hypertrophy. 

The  mucous  membrane  is  inflamed  because  of  irritation  of  retained  decom- 
posed material  and  ulceration  may  occur.  Peri-intestinal  suppuration  may 
arise.  Gas  does  not  gather  above  the  obstruction  because  the  circulation  is 
still  active  in  the  bowel  wall  and  because  some  gas  can  still  pass  naturally. 
When  the  narrowed  channel  in  a  partially  obstructed  bowel  suddenly  and  com- 
pletely closes,  acute  obstruction  arises.  When  it  does  the  bowel  above  becomes 
congested  and  distended.  An  active  purgative  or  indigestible  food  may  be 
responsible  for  acute  obstruction. 

Various  Causes  of  Intestinal  Obstruction. — Obstruction  by  Adhe- 
sions (Fig.  603). — Adhesions  result  from  previous  peritonitis.  There  may  be 
a  few  adhesions  or  a  multitude  of  them.  A  portion  of  bowel  may  be  bent  or 
twisted  by  the  traction  of  adhesions  or  gaseous  movement  may  twist  a  coil  or 
bend  it  above  an  adhesion.  The  obstruction  may  be  acute  or  chronic.  Even 
when  acute,  strangulation  is  unusual. 

Volvulus  (Fig.  604). — By  this  term  we  mean  twisting  of  a  loop  of  bowel 
upon  its  mesenteric  axis.  It  is  true  that  under  peculiar  circumstances  the  bowel 
may  twist  on  its  own  long  axis  because  of  adhesions,  but  such  a  twist  is  not  a 
true  volvulus.  Volvulus  may  occur  in  a  hernial  sac.  In  rare  cases  two  coils 
of  intestine  twist  together.  Volvulus  is  not  limited  to  the  pelvic  colon,  but  in  a 
very  large  majority  of  cases  it  is  that  portion  of  bowel  which  suffers.  The 
twist  may  be  partial,  a  complete  turn,  or  even  two  or  three  complete  turns. 
This  very  dangerous  condition  occurs  particularly  in  adults.  A  colon  loaded 
with  feces  predisposes;  so  does  a  long  mesocolon  and  a  mesocolon  with  a  nar- 
row base,  and  so  may  adhesions.  Rotation  may  be  caused  by  straining  at 
stool,  by  a  sudden  shift  in  position,  by  lifting,  by  a  blow  upon  the  abdomen,  or 
by  peristalsis  induced  by  an  active  purgative.  In  most  cases  the  twist  is  tight 
enough  to  occlude  the  blood-supply  of  the  loop.  The  loop  becomes  plum  colored 
and  edematous,  bloody  serum  flows  into  the  bowel  and  into  the  peritoneal  cavity, 
and  immense  distention  of  the  loop  occrus.  The  colon  above  the  obstruction 
also  distends.  Peritonitis  occurs  early.  Perforation  may  occur  and  is  most 
apt  to  take  place  above  the  loop. 

Intussusception  (Figs.  605,  606). — By  this  term  we  mean  the  invagination  of 
a  portion  of  bowel  wall  into  the  lumen  of  an  adjacent  part  of  the  gut.  In  nearly 
all  cases  an  upper  segment  invaginates  into  the  lower.  One-third  of  all  cases  of 
obstruction  are  due  to  this  cause  (Treves).  In  young  children  it  usually  causes 
acute  obstruction;  in  an  adult,  chronic  obstruction,  ending  perhaps  in  an  acute 
attack.  Most  cases  of  obstruction  in  children  are  due  to  intussusception.  Pitt 
reports  that  in  St.  Thomas's  Hospital,  from  1875  to  1900  inclusive,  there  were 
115  cases  of  intussusception,  and  every  patient  was  under  fifty  years  of  age. 
Gibbon's  patient  was  fifty-eight.  Rutherford  Morrison  had  a  case  due  to 
polypus,  and  the  patient  was  sixty-two  years  of  age.  Males  are  twice  as  liable 
as  females.  During  the  performance  of  peristalsis  a  localized  circular  con- 
striction forms  and  the  invagination  takes  place  through  the  constricted  area. 
The  great  relative  frequency  of  intussusseption  in  childhood  is  due  to  the  greater 
mobility  and  irritability  of  the  child's  bowel  (Treves).  The  irregular  and  local- 
ized spasm  is  due  to  bulky  or  irritant  material  within  the  gut,  and,  according  to 
Rushmore  ("Annals  of  Surgery,"  August,  1907),  the  starting-point  of  invagina- 
tion is  obstruction.  Were  peristalsis  alone  the  cause  the  condition  would  be 
far  more  common  than  it  is  in  the  diarrhea  of  children.  There  are  four  chief 
varieties :  the  ileocecal,  in  which  the  ileum  and  the  ileocecal  valve  pass  into  the 


980 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  609.  Fig.  610. 

Figs.  603-610. — Forms  of  intestinal  obstruction. 

Fig.  603.— Stenosed  ulcerated  tumor  of  the  pylorus;  coils  of  intestine  agglutinated  by  numerous 
adhesions.     Resected  intestinal  coils  (Payr). 

Fig.  604. — Volvulus  of  the  sigmoid  ilexure  (Richardson's  case). 

Fig.  605. — a,  Invaginatio  iliaca;  b,  invaginatio  ilia-ileocolica  (H.  Lorenz). 

Fig.  606. — a,  Prolapsus  ilei;  6,  invaginatio  ileocolica  (H.  Lorenz). 

Fig.  607.— Obstruction  of  the  jejunum  due  to  gall-stone,  showing  the  contraction  of  the  muscular 
fibers  of  the  intestine  upon  the  stone,  which  is  smaller  in  diameter  than  the  lumen  of  the  gut  (Mixter  s  case). 

Fig.  608. — Meckel's  diverticulum  (Bunts). 

Fig.  609. — Hernia  into  the  fossa  duodenojejunaUs  (after  Cooper). 

Fig.  610. — Strangulation  by  a  band.     (Warren  Museum.) 


Internal  Herniae  981 

cecum  and  colon;  the  colic,  in  which  the  large  intestine  is  prolapsed  into  itself; 
the  ileal,  in  which  the  small  intestine  alone  is  involved;  and  the  ileocolic,  in 
which  the  ileum  prolapses  through  the  ileocecal  valve.  Other  forms  are 
diverticular  (with  a  diverticulum),  retrograde  (due  to  reversed  peristalsis),  of 
Meckel's  diverticulum,  ileo-appendiceal,  and  cecal.  The  first  variety  is  vastly 
the  most  common.  In  Rushmore's  table  ("Annals  of  Surgery,"  August,  1907) 
the  location  was  definitely  stated  in  237  cases:  140  of  these  were  ileocecal  and 
31  were  ileocoHc. 

The  intussusceptum  consists  of  the  entering  tube  and  the  returning  layer. 

The  intussuscipiens  is  the  sheath  or  receiving  tube.  As  the  intussusceptum 
grows  longer  and  longer  the  mesentery  is  drawn  between  the  entering  tube  and 
the  sheath.  The  mesentery  becomes  curved  and  draws  the  involved  intestine 
toward  the  back  and  left  side.  The  dragging,  twisting,  and  squeezing  of  the 
mesentery  impairs  the  blood-supply  of  the  intussusception.  The  invaginated 
portion,  especially  the  returning  tube  and  apex,  becomes  congested  and  swollen, 
the  mucous  membrane  secretes  profusely,  and  blood  passes  into  the  bowel. 
From  this  source  come  the  blood  and  mucus  passed  by  the  bowel.  An  intus- 
susception tends  to  become  irreducible  by  adhesion  of  its  walls  and  by  en- 
gorgement, particularly  of  the  apex.  Any  intussusception  may  eventually 
cause  complete  obstruction,  strangulation  may  take  place,  gangrene  may 
occur,  peritonitis  may  arise. 

Foreign  Bodies,  Gall-stones,  and  Enteroliths  (Fig.  607). — Foreign  bodies 
include,  besides  certain  substances  that  have  been  swallowed,  gall-stones  and 
enteroliths  or  intestinal  calculi.  Foreign  bodies  are  apt  to  lodge  in  the  lower 
portion  of  the  ileum  or  in  the  cecmn,  and  they  may  cause  ulceration  at  the  seat 
of  lodgment.  If  a  gall-stone  is  sufficiently  large  to  cause  obstruction,  it  can- 
not have  passed  the  duct,  but  must  have  ulcerated  into  the  bowel  from  the  gall- 
bladder. About  three-fourths  of  the  cases  of  gall-stone  intestinal  obstruction 
occur  in  women.  The  stone  is  arrested  at  some  point  because  either  local  spasm 
or  paralysis  of  the  bowel  has  developed.  It  may  be  arrested  high  up,  but  is 
most  apt  to  be  in  the  lower  ileum.  A  stone  under  i  inch  in  diameter  ought 
to  pass.  A.  W.  Mayo  Robson  ("Brit.  Med.  Jour.,"  May  i,  1909)  points  out 
that  all  cases  of  obstruction  due  to  gall-stones  are  not  the  result  of  mechanical 
obstruction  by  a  large  stone  which  entered  the  intestinal  canal  by  ulceration, 
but  that  there  are  three  other  possible  conditions,  viz. :  Local  peritonitis  in 
the  gall-bladder  region  causing  paralysis  of  the  bowel;  volvulus  of  the  small 
intestine  due  to  biliary  colic  or  to  ulceration  of  a  gall-stone  into  the  gut; 
obstruction  coming  on  "after  the  original  cause  has  disappeared"  and  due  to 
adhesions  without  or  obstruction  within  the  gut. 

Enteroliths  (fecal  concretions)  are  usually  deposits  of  salts  from  the  feces, 
especially  apt  to  be  formed  when  the  patient  has  long  suffered  from  catarrhal 
inflammation  of  the  bowel.  The  nucleus  may  be  a  hair-ball  in  woman  who 
swallows  hair,  or  the  stone  of  a  fruit.  A  gall-stone  may  have  a  concretion  form 
about  it.  Food  residues  mixed  with  salts  may  constitute  concretions.  So 
may  insoluble  materials  taken  frequently  as  medicine  or  from  habit  (chalk, 
bismuth,  magnesia).  An  enterolith  increases  in  size  up  to  a  certain  point,  but 
seldom  becomes  enornious. 

Internal  Herniae  (Fig.  609). — These  include:  (i)  retroperitoneal  hernia, 
(2)  diaphragmatic  hernia. 

A  hernia  may  pass  into  one  of  the  fossae  about  the  duodenum,  one  of  the 
fossae  about  the  ceciun,  the  intersigmoid  fossae,  or  through  the  foramen  of 
Winslow  into  the  lesser  peritoneal  cavity.  The  appendix  may  be  strangulated 
in  a  pericecal  fossa  and  cause  obstruction.  Diaphragmatic  hernia  is  described 
on  page  11 64.  An  internal  hernia  may  become  strangulated  just  as  does  an 
external  hernia. 


982  Diseases  and  Injuries  of  the  Abdomen 

Obstruction  by  Bands  and  Abnormal  Openings  (Fig.  610). — The  band 
may  be  a  portion  of  the  great  omentum  which  has  taken  on  an  unnatural  at- 
tachment, a  Meckel's  diverticulum,  an  appendix  attached  at  its  tip,  a  broad 
band  or  cord-like  peritoneal  adhesion.  The  obstruction  in  these  cases  is  apt 
to  be  acute  and  is  commonly  accompanied  by  strangulation.  It  usually 
involves  the  ileum,  sometimes  the  colon.  There  may  be  an  abnormal 
opening,  congenital  or  acquired,  in  the  omentum,  the  mesentery,  or  the  meso- 
colon. The  bowel  may  slip  through  such  an  opening  and  be  caught  and 
strangulated. 

Obstruction  may  take  place  by  Meckel's  diverticulum  (Fig  608)  (see  page 
988),  a  structure  due  to  persistence  of  the  vitelline  or  omphalomesenteric  duct, 
coming  off  from  the  ileum  from  12  to  36  inches  above  the  ileocecal  valve,  and 
present  in  about  2  per  cent,  of  persons.  The  vitelline  duct  should  be  ob- 
literated in  the  eighth  week  of  fetal  life.  If  it  persists  the  individual  pos- 
sessing it  is  in  constant  and  serious  danger.  The  mortality  of  a  series  of 
cases  of  obstruction  due  to  Meckel's  diverticulum  is  enormous.  A  Meckel's 
diverticulum  usually  has  no  mesentery,  is  from  3  to  10  inches  long,  and  arises 
from  the  convex  side  of  the  gut.  It  may  hang  free  or  may  be  attached  to  the 
umbilicus  hy  its  tip  or  by  a  fibrous  cord  formed  by  the  obliterated  tip. 
In  some  cases  it  remains  open  at  the  umbilicus  (see  page  402).  In  other 
cases  a  cord  runs  from  the  umbilicus  to  the  gut  or  the  tip  of  the  diverticu- 
lum or  is  adherent  to  another  portion  of  the  intestine.  The  diverticulum  may 
become  strangulated,  may  enter  a  hernial  sac,  may  ulcerate  or  perforate  like  an 
appendix.  (W.  Sheen,  in  "Bristol  Medico-Chir.  Jour.,"  Dec,  1901,  gives  an 
admirable  account  of  "Some  Surgical  Aspects  of  Meckel's  Diverticuliun";  see 
also  article  on  "Obstruction  of  the  Bowels  by  Meckel's  Diverticulxmi,"  by 
James  E.  Moore,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  4,  1902,  and  on 
^'Abdominal  Crises  Caused  by  Meckel's  Diverticulum,"  by  Miles  F.  Porter, 
in  "Jour.  Am.  Med.  Assoc,"  Sept.  23,  1905.)  Strangulation  of  the  diver- 
ticulum may  take  place  beneath  an  adherent  appendix,  a  Fallopian  tube,  a 
portion  of  mesentery,  or  the  pedicle  of  an  ovarian  tumor,  or  it  may  take  place 
in  an  omental  or  a  mesenteric  aperture.  Gangrene,  inflammation,  or  twist- 
ing may  occur.  Obstruction  may  be  due  to  invagination  of  the  diverticulum 
into  the  bowel.  H.  Tyrrell  Gray  collected  39  cases  of  invagination  and  added 
I  of  his  own,  40  in  all  ("Annals  of  Surgery,"  Dec,  1908). 

Cicatricial  Stricture. — This  is  not  a  common  cause.  I  have  operated  on  i 
case  due  to  the  scar  of  a  typhoid  ulcer.  The  obstruction  occurred  gradually 
and  became  acute  years  after  the  fever.  Any  healed  ulcer  may  be  responsible. 
Tuberculosis  is  the  most  common  cause.  Sj^hiHs  or  dysentery  may  be  re- 
sponsible.    A  contusion  or  wound  of  the  bowel  may  be  causal. 

Tumors  of  the  Bowel. — They  are  uncommon  in  the  small  intestine. 
Adenoma,  lipoma,  fibroma,  and  myoma  may  occur.  They  may  cause  obstruc- 
tion from  blocking  or  may  be  responsible  for  intussusception.  Sarcoma  is 
seldom  met  with,  but  more  often  in  the  small  bowel  than  in  the  large  gut. 
The  patient's  general  health  is  much  impaired,  and  a  tumor  can  be  palpated 
before  obstruction  occurs,  and  obstruction  may  never  occur.  Cancer  of  the 
small  bowel  is  more  conrimon  than  benign  tumors  and  sarcoma,  but  less  common 
than  cancer  of  the  large  bowel.  Cancer  of  the  small  intestine  is  most  common 
in  the  lower  ileum,  and  arises  from  columnar  cells.  It  causes  constriction  and 
stenosis  and  usually  ulcerates.  In  the  large  intestine  fibroma,  lipoma,  adenoma, 
or  myoma  may  arise.  I  removed  an  adenoma  from  the  sigmoid  which  had 
produced  ob.struction.  Apparently  it  has  not  recurred  after  four  years.  A 
great  number  of  adenomata  may  be  present  (multiple  adenoma  of  Virchow). 
Obstruction  is  rare  from  innocent  tumors.  The  colon  is  a  common  site  for 
cancer.     It  is  usually  primary,  but  may  be  secondary.     It  produces  chronic 


Pseudo-obstruction  or  Spasm  of  the  Intestine  983 

obstruction.  The  growth  is  columnar  celled,  and  may  be  scirrhus,  encephaloid, 
or  colloid. 

Obstruction  by  Tumors,  Etc.,  Outside  the  Bowel. — Among  the  causes  of 
such  obstruction  are  retroflexion  or  retroversion  of  the  womb,  especially  in 
pregnancy,  cysts  or  tumors  of  the  kidneys,  ovaries,  uterus,  etc.,  movable  kidney, 
and  enlarged  spleen.  Obstruction  from  any  of  the  above  causes  takes  place  in 
the  rectum,  the  sigmoid  flexure,  or  the  colon  above  the  sigmoid. 

Obstruction  from  Fecal  Accumulation. — Fecal  impaction  resulting  from 
prolonged  constipation  is  quite  common.  Obstruction  sometimes,  but  seldom, 
occurs.  When  obstruction  follows  upon  impaction  it  is  usually  brought  about 
by  rotation  of  a  loop  of  bowel  (volvulus)  or  angulation  of  a  segment,  but  may 
be  due  to  abolition  of  peristalsis  because  of  paralysis.  In  impaction  the  fecal 
mass  is  usually  soft,  but  may  be  hard.  There  may  be  one  large  mass  or  numer- 
ous smaller  ones.  The  mass  may  reach  from  the  rectum  even  into  the  trans- 
verse colon.  It  usually  begins  to  form  in  the  pelvic  colon  (Miles,  "A  System 
of  Surgery,"  edited  by  C.  C.  Choyce).  The  weight  of  such  a  quantity  of  feces 
may  cause  a  packed  loop  of  gut  to  sink  into  the  pelvis  and  may  stretch  and 
narrow  the  mesocolon.  Ulcerations  of  the  mucous  membrane  may  form 
{stercoral  ulcers). 

Postoperative  Obstruction. — Obstruction  may  come  on  a  day  or  two 
after,  several  or  many  days  after,  or  weeks  or  even  months  after  an  abdominal 
operation.     We  deal  here  with  early  obstruction. 

Obstruction  may  be  due  to  a  mechanical  cause  at  the  seat  of  operation 
(adhesion  of  the  bowel  to  a  raw  surface,  volvulus,  catching  of  the  gut  under  a 
band,  etc.).  It  may  be  due  to  a  mechanical  cause  distant  from  the  seat  of 
operation  (bands,  adhesions,  displacement  of  the  intestine,  etc.).  It  may  be 
due  to  thrombosis  of  the  mesenteric  vessels.  Although  any  one  of  the  above  con- 
ditions may  arise  after  an  operation,  there  is  nothing  special  and  peculiar  in  it 
when  it  does.  Such  conditions  are  considered  under  special  headings  (bands, 
adhesions,  etc.).  Again,  postoperative  obstruction  may  be  due  to  the  pressure 
upon  the  gut  of  gauze-packing  or  of  a  drainage-tube.  It  may  be  due  to  paralysis 
of  a  loop  of  gut  because  of  local  sepsis  (as  after  an  operation  for  appendicitis), 
or  paralysis  of  the  intestine  from  widespread  sepsis  (general  peritonitis) . 

What  we  really  mean  by  postoperative  obstruction  is  a  condition  arising 
from  gaseous  distention.  Gas  begins  to  accimiulate  soon  after  the  operation. 
The  patient  cannot  expel  it.  He  tries,  but  the  straining  efforts  fail  and  may 
burst  the  belly  wound.  More  and  more  gas  gathers  and  annoyance  becomes 
torture.  The  overdistended  bowel  finally  becomes  paralyzed  and  paralytic 
obstruction  occurs.  This  true  postoperative  obstruction  is  particularly  apt 
to  arise  if  evisceration  has  been  practised,  if  the  intestines  have  been  squeezed 
and  handled  and  not  protected  from  chill,  and  if  the  operation  were  prolonged. 

Embolism  or  Thrombosis  of  the  Mesenteric  Vessels. — The  arteries  may 
be  the  seat  of  embolism  or  thrombosis;  the  veins,  of  thrombosis.  The  section  of 
bowel,  large  or  small,  from  which  the  blood  is  kept  undergoes  paralysis.  Gan- 
grene and  peritonitis  soon  follow.  This  very  fatal  condition  is  one  of  suddenly 
arising  paralytic  obstruction  in  an  individual  who  has  cirrhosis  of  the  liver  or 
valvular  disease  of  the  heart,  or  who  has  had  ulcerative  endocarditis. 

Pseudo-obstruction  or  Spasm  of  the  Intestine. — In  this  condition  a  limited 
portion  of  the  bowel  undergoes  spasmodic  contraction,  which  lasts  for  several 
hours  or  even  for  a  day  and  then  passes  quickly  away.  This  contraction  is 
usually  in  the  pelvic  colon.  In  many  cases  a  swelling  can  be  made  out.  It  is 
due  to  a  loop  of  distended  gut  and  disappears  when  the  patient  is  under  ether. 
Such  a  swelling  is  known  as  a  phantom  tumor.  These  attacks  occur  in  neurotic 
women,  especially  those  with  catarrh  of  the  colon.  Besides  the  causes  of  ob- 
struction above  mentioned  we  should  refer  to  shrinking  of  the  mesentery. 


984  Diseases  and  Injuries  of  the  Abdomen 

Symptoms  of  Acute  Obstruction. — The  onset  is  marked  by  pain,  shock,  and 
vomiting.  The  tighter  the  constriction,  the  more  sudden  is  the  attack;  the  more 
bowel  there  is  involved,  the  greater  the  shock.  This  element  of  shock  often 
makes  the  diagnosis  uncertain,  and  "we  may  suspect  abdominal  hemorrhage  or 
perforation  when  the  real  lesion  is  strangulation.  The  pain  is  violent  and 
continuous,  with  fierce  exacerbations.  The  continuous  pain  is  due  to  the  con- 
striction; the  exacerbations,  to  the  coUc  of  peristalsis.  If  the  small  intes- 
tine is  involved  the  continuous  pain  is  about  the  umbiHcus.  If  the  large 
intestine  or  duodenum  is  the  seat  of  trouble  the  continuous  pain  is  located 
about  the  lesion.  The  pains  of  peristalsis  are  generalized  throughout  the 
abdomen.  The  higher  up  the  constriction,  the  tighter  it  is,  and  the  more  bowel 
there  is  caught,  the  greater  the  pain.  Later,  when  paralysis  of  the  gut  occurs 
or  perforation  takes  place,  the  pain  for  a  time  abates,  to  recur  again  with 
peritonitis.  Early  in  the  case  there  is  neither  rigidity  nor  tenderness;  as 
paralysis  begins  tenderness  develops.  Early  in  the  case  pressure  may 
actually  afford  some  relief.  When  tenderness  exists  tapping  is  more  apt 
to  cause  pain  than  is  pressure;  in  peritonitis  pressure  causes  more  pain  than 
tapping  (Battle).  When  peritonitis  arises,  of  course  tenderness  becomes  acute 
and  rigidity  develops. 

Vomiting  comes  on  soon  after  the  development  of  pain,  but  does  not  give 
any  relief.  It  is  accompanied  by  nausea  and  violent  retching,  continues  prac- 
tically without  cessation,  and  whether  food  and  drink  are  taken  or  not. 

The  vomited  matter  consists  first  of  the  contents  of  the  stomach,  next  of 
quantities  of  bilious  matter,  and  finally  of  brown  or  yellow  stinking  fluid,  which 
was  long  believed  to  be  feces.  Vomiting  of  this  character  is  called  stercora- 
ceous  vomiting.  Vomiting  of  genuine  feces  may  occur,  but  is  rare.  In  stercora- 
ceous  vomiting  the  fluid  gushes  up  in  quantity  and  by  regurgitation  rather 
than  efforts  of  vomiting.  This  sort  of  vomiting  can  occur  even  when  the 
obstruction  is  in  the  upper  jejunum  or  duodenum. 

A  notable  characteristic  of  obstruction  is  total  inability  to  pass  gas  or  feces. 
It  is  necessary  to  remember  that  in  the  very  beginning  of  the  case  there  may 
have  been  a  bowel  movement,  due  to  peristalsis  emptying  the  intestine  below 
the  seat  of  lesion.  A  single  movement  early  is  no  proof  that  the  condition  is 
not  obstruction.  It  is  only  in  cases  of  strangulation  in  the  pelvic  colon  that  the 
patient  has  a  strong  desire  and  makes  frequent  attempts  to  move  his  bowels. 
If  an  enema  is  given  it  is  usually  retained,  or  else  leaks  away  without  bringing 
fecal  matter  with  it.  Distention  from  gas  (tympanites)  is  always  soon  present. 
The  lower  the  obstruction,  the  more  widespread  is  the  distention.  Early  in 
the  case  the  abdomen  is  flat  and  relaxed,  but  this  condition  is  very  temporary. 
We  may  be  able  to  gain  information  by  studying  the  distention.  If  both 
flanks  bulge,  the  block  is  in  the  pelvic  colon.  If  the  left  flank  is  flat  and  the 
right  distended,  the  block  is  in  the  colon  well  above  the  pelvic  colon.  If  only 
the  smaU  intestine  is  distended,  the  block  is  on  the  proximal  side  of  the 
ileocecal  valve.  As  the  case  progresses  distention  increases  and  causes  great 
embarrassment  to  respiration  by  pushing  up  the  diaphragm.  In  thin 
patients,  early  in  the  case,  we  may  occasionally  see  waves  of  peristalsis 
above  the  obstruction.  We  can  sometimes  feel  them  even  when  they  are 
unrecognizable  by  the  eye.  In  many  cases  of  intussusception  and  in  a  number 
of  cases  of  chronic  obstruction  which  have  become  acute  they  can  be  felt. 

Cases  of  intestinal  obstruction  tend  to  pass  into  collapse.  This  condition 
is  due  to  the  absorption  of  poisons  from  the  decomposing  matter  above  the 
obstruction,  and  is  aggravated  by  vomiting  and  sweating  which  abstract  quan- 
tities of  fluid  from  the  blood.  When  collapse  has  come  on  the  temperature  is 
subnormal;  the  extremities  cold;  the  pulse  very  rapid  and  weak,  often  a  mere 
thread  or  trickle;  the  respirations  are  rapid  and  shallow,  and  the  face  Hippo- 


Diagnosis  of  Intestinal  Obstruction  985 

cratic  (eyes  and  temples  sunken,  nostrils  thin  and  drawn,  features  pinched,  lips 
blue,  skin  livid  or  deadly  pale).  The  amount  of  urine  passed  is  very  small. 
The  higher  the  obstruction,  the  less  the  amount  passed.  During  or  after  the 
second  day  indican  is  usually  present  in  the  urine.  It  results  from  putrefaction 
of  proteins  and  the  formation  of  indol  in  the  intestine.  There  is  leukocytosis, 
the  white  count  being  from  15,000  to  30,000  (Bloodgood,  in  "Johns  Hopkins 
Hospital  Reports,"  vol.  vii). 

The  mortahty  from  acute  obstruction  is  very  high.  According  to  Elsberg, 
gangrene  occurs  in  13  per  cent,  of  cases.  Seldom  can  a  mass  be  felt.  It  can 
often  be  felt  in  intussusception;  it  can  sometimes  be  palpated  when  there  is  a 
fecal  concretion  or  other  foreign  body. 

Symptoms  of  Chronic  Obstruction. — The  symptoms  come  on  gradually. 
There  are  periods  when  great  constipation  exists,  alternating  with  periods  of 
comfort  or  perhaps  with  seizures  of  fluid  diarrhea.  After  a  time  the  attacks  of 
constipation  become  painful  and  accompanied,  it  may  be,  by  vomiting  after 
eating.  The  patient  feels  abdominal  discomfort  most  of  the  time  and  is  much 
annoyed  by  gas  in  the  intestine.  It  is  very  difficult  to  expel  the  gas  from  be- 
low. All  the  time  the  constipation  is  growing  more  obstinate  and  the  patient 
is  resorting  to  stronger  and  stronger  purgatives  and  obtaining  less  and  less 
response.  Finally,  a  strong  purgative  may  fail  utterly,  only  serving  to  cause 
severe  colic  and  perhaps  vomiting.  It  may  also  cause  pain  at  the  seat  of  the 
lesion.  Patients  in  this  condition  may  develop  attacks  of  diarrhea,  small 
amounts  of  feces  mixed  with  mucus  being  passed.  This  condition  is  due  to 
colonic  catarrh,  is  called  the  "diarrhea  of  constipation,"  and  affords  no  mitiga- 
tion to  the  discomfort  and  pain. 

During  the  progress  of  the  case  the  bowel  above  the  block  distends.  Be- 
cause of  the  hypertrophy  of  the  musciilar  wall  of  the  gut  and  of  the  loss  of  flesh 
painful  peristalsis  (which  can  be  felt  and  seen)  is  often  noted  above  the  obstruc- 
tion. This  sign  is  detected  far  oftener  in  chronic  than  in  acute  obstruction. 
The  distended  intestine  showing  peristaltic  contraction  is  a  strong  suggestion 
of  chronic  obstruction.  The  painful  peristalsis  is  often  productive  of  rumbling 
and  gurgling  noises  (borborygmi).  By  noticing  the  portion  of  gut  distended 
we  may  be  able  to  locate  the  seat  of  stenosis  (see  page  984).  This  method 
is  more  valuable  in  chronic  than  in  acute  obstruction.  On  digital  examina- 
tion of  the  rectum  the  rugae  may  no  longer  be  felt  and  the  rectimi  is  greatly 
distended  because  of  paralysis.     This  is  known  as  rectal  ballooning. 

The  above-described  condition  may  cease  to  intermit  or  even  remit,  all  the 
symptoms  may  grow  progressively  worse,  constant  nausea  being  present, 
vomiting  ensuing  on  taking  food,  and  the  breath  being  horribly  foul.  Such  a 
patient  is  being  poisoned  to  death  by  putrefactive  toxins.  He  may  perish 
from  exhaustion,  from  perforation,  or  from  peritonitis.  At  any  time  during  the 
progress  of  chronic  obstruction  acute  obstruction  may  develop.  The  sudden 
complete  block  may  be  due  to  a  plug  of  hardened  feces  or  some  foreign  body.  It 
not  unusually  foUows  the  taking  of  a  strong  purgative.  It  may  be  due  to 
volvulus  or  to  bending. 

In  some  cases  of  chronic  obstruction  a  tumor  may  be  palpated,  in  some 
intussusception  can  be  made  out,  in  some  there  is  a  history  of  antecedent  peri- 
tonitis, in  many  there  are  evidences  of  malignant  disease. 

Diagnosis. — The  determination  of  the  seat  of  lesion  requires  abdominal 
and  rectal  examination.  An  intussusception  may  sometimes  be  felt  by  a  fin- 
ger in  the  rectum  and  can  often  be  felt  by  palpation  of  the  abdomen.  Vaginal 
examination  may  be  demanded.  Pain  is  apt  to  arise  at  the  seat  of  obstruction 
or  to  radiate  from  there.  Abdominal  palpation  may  detect  a  tumor.  Rec- 
tal insufflation  of  hydrogen  may  locate  the  obstruction  by  causing  great 
distention  below  it.     Entire  suppression  of  urine,  early  vomiting,  absence  of 


986  Diseases  and  Injuries  of  the  Abdomen 

abdominal  distention,  and  rapid  collapse  mean  obstruction  in  the  duodenum  or 
in  the  jejunum.  Early  vomiting,  a  rapidly  progressive  case,  with  great  dis- 
tention of  the  umbilical  region,  means  obstruction  of  the  ileum  or  the  cecum. 
Distention  of  the  entire  abdomen  and  of  the  flanks,  linked  with  tenesmus, 
with  less  violent  symptoms,  less  rapidity  of  progress,  and  less  diminution 
of  urine  than  in  the  above-cited  forms,  means  obstruction  low  down  in  the  colon 
or  in  the  rectum.  An  old  test  for  obstruction  in  the  adult  large  intestine  is 
an  injection  by  a  fountain-syringe:  if  6  quarts  can  be  introduced,  there  is  no 
obstruction  in  the  large  intestine;  if  less  than  4  quarts  can  be  introduced,  there 
is  probably  obstruction  in  the  large  intestine.  This  test  is  unreHable.  The 
passage  of  a  sound  in  the  rectimi  is  generally  useless  and  is  often  unsafe.  In 
many  cases  the  seat  of  the  lesion  and  the  cause  of  the  obstruction  can  be  de- ' 
termined  only  by  exploratory  laparotomy. 

The  determination  of  the  causative  condition  is  always  difficult  and  is  often 
impossible.  Intussusception  may  arise  in  child  or  adult.  It  is  the  common 
cause  in  children.  Intussusception  may  induce  acute  or  chronic  obstruction. 
In  the  child  acute  obstruction  is  far  more  common  than  chronic  obstruction. 
In  most  cases  the  child  was  previously  healthy  except  for  previous  constipation 
or  diarrhea.  The  attack  begins  with  a  violent  seizure  of  colicky  pain  and  vomit- 
ing, but  although  the  patient  is  pale,  there  is  seldom  shock  at  this  stage.  The 
vomiting  may  be  occasionally  repeated,  but  it  is  not  forcible  retching  and  very 
rarely  becomes  stercoraceous.  The  bowel  below  the  obstruction  is  often  emp- 
tied in  this  stage.  After  a  time  pain  abates  or  disappears,  to  recur  again  and 
again.  Between  the  seizures  of  pain  the  patient  often  appears  to  be  in  good 
condition,  with  a  normal  temperature  and  an  almost  normal  pulse.  Tenesmus 
soon  arises  in  most  cases,  bloody  mucus  in  small  quantities  being  passed  fre- 
quently. The  source  of  the  bloody  mucus  is  the  squeezed  and  congested  intus- 
susceptum.  A  sausage-shaped  mass  can  usually  soon  be  felt  somewhere 
over  the  large  intestine.  It  may  be  in  the  right  iliac  fossa  or  in  the  left  ihac 
fossa,  but  usually  over  the  region  of  the  transverse  colon.  Osier  reports  that 
a  mass  was  palpable  in  66  of  93  cases,  and  in  over  one-third  of  these  cases  it  was 
noted  the  first  day.  It  has  been  felt  as  early  as  three  hours  after  the  onset  of 
pain.  It  becomes  rigid  during  a  pain.  It  may  shift  its  position  hour  by 
hour,  and  it  may  disappear  after  having  been  obvious.  It  may  be  detected 
only  when  an  anesthetic  is  given.  Rectal  examination  gives  no  information  in 
early  cases  or  cases  involving  only  the  small  bowel.  In  late  cases  a  mass  may 
perhaps  be  felt  in  the  rectum.  The  abdomen  is  rarely  rigid,  distended,  or  tender 
until  late  in  the  case,  and  at  this  period  there  may  be  shock  or  sepsis.  In 
chronic  intussusception  in  a  child  the  condition  may  progress  very  slowly. 
The  stools  contain  bloody  mucus,  there  are  attacks  of  abdominal  pain,  a  lump 
may  be  felt  along  the  colon  or  by  the  rectum,  and  peristalsis  may  be  visible. 
If  an  abdominal  lump  is  detectable  it  will  harden  during  colic  and  will  change 
its  position  from  day  to  day. 

Acute  intussusception  in  the  adult  seldom  presents  characteristic  features 
unless  the  sausage-shaped  lump  can  be  detected. 

Chronic  intussusception  in  an  adult  causes  sudden  attacks  of  vomiting  and 
of  abdominal  colic  which  last  a  short  time  and  pass  away  as  suddenly  as  they 
arose.  Later  they  may  linger  longer.  A  lump  can  usually  be  made  out. 
There  may  be  constipation  or  mucous  diarrhea,  and  blood  may  be  passed  with 
the  mucus.     Acute  obstruction  usually  arises. 

Obstruction  from  adhesions  is  chronic  obstruction  which  may  become 
acute.  There  is  a  history  of  antecedent  peritonitis.  A  local  distention  of  the 
intestine  is  often  noted.  In  obstruction  from  bands  there  is  a  record  of  ante- 
cedent peritonitis,  of  a  traumatism,  of  a  violent  effort,  or  of  pelvic  pain.  The 
attack  is  sudden  in  onset,  is  fierce  in  character,  and  is  usually  excited  by  violent 


Diagnosis  of  Intestinal  Obstruction  987 

exercise  or  the  taking  of  food.  Vomiting  is  early  and  intractable,  and  it  soon 
becomes  stercoraceous ;  pain  is  violent;  peristalsis  above  the  obstruction  is  forci- 
ble for  a  time ;  tympanites  and  abdominal  tenderness  appear  after  the  attack  has 
lasted  for  some  little  time;  obstruction  is  complete,  not  even  gas  being  passed; 
collapse  soon  arises;  no  tumor  can  be  detected,  and  rectal  examination  is  nega- 
tive. Volvulus,  which  is  usually  located  in  the  pelvic  colon,  is  far  commoner 
in  men  than  in  women,  in  the  middle  aged  than  in  those  at  the  extremes  of 
life.  It  is  usually  preceded  by  constipation.  The  symptoms  come  on  with 
explosive  suddenness  and  rapidly  attain  great  severity.  Obstruction  is  abso- 
lute; vomiting  is  late  and  is  rarely  stercoraceous;  no  tumor  can  be  detected; 
rectal  examination  is  negative;  abdominal  distention  is  early  and  pronounced, 
and  may  become  enormous;  peristalsis  above  the  volvulus  is  seldom  discovered; 
collapse  is  not  so  rapid  nor  so  grave  as  in  obstruction  from  bands  and  internal 
hernia.  There  is  severe  continuous  pain  with  frequent  exacerbations.  The 
pain  is  about  the  umbilicus  and  in  the  left  iliac  region  and  left  loin.  Tenderness 
is  soon  manifest  and  is  ominous,  as  it  means  peritonitis.  If  unrelieved,  death 
will  occur  in  from  forty-eight  to  seventy-two  hours.  Cases  of  incomplete  ob- 
struction by  volvulus  are  rarities.  Obstruction  by  a  foreign  body  may  sometimes 
be  inferred  from  the  history  of  some  such  body  having  been  swallowed.  The 
obstructing  body  may  occasionally  be  felt  during  palpation  or  may  be  dis- 
covered by  the  x-rays.  Abdominal  distress  may  exist  for  days  or  weeks  before 
obstruction  occurs.  Vomiting  is  late  and  is  rarely  severe,  but  pain,  tenderness, 
and  distention  are  marked.  In  obstruction  from  gall-stones  the  victim  is  elderly 
and  usually  stout.  There  may  be  a  history  of  one  or  more  attacks  of  hepatic 
colic,  but  often  the  only  history  is  of  what  was  supposed  to  be  painful  chronic 
indigestion.  When  the  stone  is  ulcerating  into  the  bowel  it  causes  localized  pain 
and  tenderness.  As  it  slowly  descends  along  the  intestine  it  may  be  arrested 
again  and  again,  causing  attack  after  attack  of  blocking.  When  the  gut  becomes 
really  blocked  pain  is  early  and  acute,  and  vomiting  is  invariable  and  usually 
becomes  stercoraceous.  There  is  seldom  much  tenderness.  Rigidity  is  not 
common.  Shock  is  seldom  present  at  the  onset.  Distention  is  not  marked. 
In  rare  cases  the  stone  can  be  palpated. 

In  obstruction  by  an  enterolith  the  patient  may  give  a  history  of  many  attacks 
of  supposed  enteritis  or  colitis,  followed  after  some  time  by  temporary  attacks 
of  obstruction.  The  calculus  in  rare  cases  can  be  palpated.  The  x-rays  will 
^ow  it. 

In  obstruction  from  fecal  impaction  the  subject  is  usually  of  advanced  years, 
and  more  often  a  woman  than  a  man.  There  is  a  long  history  of  constipation, 
flatiilent  indigestion,  abdominal  annoyance,  painful  straining  at  stool,  and  of 
repeated  attacks  of  the  diarrhea  of  constipation  (small  fluid  movements,  which 
bring  no  relief  because  the  solid  masses  remain  agglutinated  to  the  wall  of  the 
bowel).  The  colon  is  distended  by  a  mass  of  feces,  usually  dough-like,  but 
sometimes  hard,  which  is  appreciable  by  palpation.  Sometimes  hardened  or 
putty-like  masses  can  be  touched  by  a  finger  in  the  rectum.  In  such  a  subject 
acute  obstruction  may  at  any  time  arise.  It  is  characterized  by  severe  colic, 
great  distention,  and  often  by  vomiting,  but  the  vomiting  is  not  violent  and  is 
seldom  stercoraceous.  Collapse  soon  begins.  Obstruction  from  stricture  or  from 
pressure  comes  on  acutely  after  a  prolonged  period  of  disturbance,  during 
which  period  attack  after  attack  of  temporary  obstruction,  complete  or  partial, 
took  place.  A  history  of  blood  or  pus  in  the  stools  suggests  tumor  of  the  bowel; 
a  history  of  blood  or  pus  having  been  absent  would  suggest  pressure  from  with- 
out. In  pseudo-obstruction  or  spasm  of  the  bowel  there  is  sudden  apparent  ob- 
struction occurring  in  a  neurotic  subject,  especially  a  female.  It  is  most  apt 
to  arise  in  a  victim  of  old  colitis,  or  in  one  who  has  very  recently  been  subjected 
to  an  abdominal  operation.    There  is  severe  pain,  vomiting,  distention,  and 


988  Diseases  and  Injuries  of  the  Abdomen 

inability  to  pass  gas  or  fecal  matter.  The  attack  is  transitory,  lasting  a  few 
hours  or,  at  most,  a  day  or  two,  and  ceasing  as  suddenly  as  it  began.  Some- 
times a  limited  swelling  can  be  detected.  It  is  due  to  a  loop  of  distended  bowel 
and  results  from  a  contracted  segment  of  gut.  It  disappears  under  ether,  and 
is  called  a  phantom  tumor. 

The  presence  of  an  internal  hernia  is  not  thought  of  until  strangulation  takes 
place  and  seldom  then.  In  duodenal  hernia  the  patient  has  long  suffered  from 
pain  of  a  colicky  character.  There  is  "a  circumscribed  globular  swelling,  re- 
sembHng  a  movable  cyst,  except  that  it  is  resonant  on  percussion  and  yields 
intestinal  sounds  on  auscultation.  Owing  to  the  compression  of  the  inferior 
mesenteric  vein  at  the  neck  of  the  fossa,  the  patient  usually  suffers  from  piles 
which  bleed  freely"  (Alexander  Miles,  in  "A  System  of  Surgery,"  edited  by  C. 
C.  Choyce).  When  strangulation  occurs  shock  is  early  and  overwhelming,  and 
vomiting  is  early,  violent,  and  persistent.  Obstruction  from  pericecal  or  in- 
tersigmoid  hernia  is  not  diagnosticated  as  to  cause. 

In  hernia  into  the  foramen  of  Winslow  the  pain  is  violent  and  epigastric,  and 
in  this  region  there  is  a  swelHng  which  gives  a  dull  note  on  light  and  a  tympanitic 
note  on  deep  percussion.     Diaphragmatic  hernia  is  considered  on  page  1164. 

Obstruction  due  to  embolism  or  thrombosis  of  the  mesenteric  vessels  is  announced 
by  colicky  abdominal  pain,  but  early  in  the  case  there  is  no  tenderness,  no 
rigidity,  and  no  distention.  Pain  in  the  loin  and  back  is  often  complained  of 
(McArthur,  "Annals  of  Surg.,"  vol.  xxxiii).  Moderate  vomiting  may  occur  and 
there  may  be  blood  in  the  vomitus.  There  is  great  restlessness,  usually  col- 
lapse; frequently  bloody  diarrhea  or,  at  least,  bowel  washings  may  be  bloody. 
Cardiac  disease  can  usually  be  demonstrated  and  albuminuria  is  common. 

In  true  postoperative  obstruction  (see  page  983)  as  the  pulse  mounts  the 
abdomen  distends,  usually  vomiting  comes  on,  and  there  is  an  almost  con- 
tinuous regurgitation  of  brownish  putrid  fluid.  It  may  cease  for  an  hour  or 
two,  when  there  will  be  a  great  gush  of  the  fluid.  The  regurgitated  matter 
may  contain  blood.  There  is  seldom  pain  or  rigidity,  the  temperature  is  sub- 
normal, the  extremities  are  cold,  and  the  face  is  Hippocratic  (see  page  985). 
The  condition  resembles  acute  gastric  dilatation.  The  cause  is  intestinal 
paralysis.  The  symptoms  of  postoperative  thrombosis  of  the  mesenteric  vessels, 
according  to  A.  E.  Maylard,^  are  as  follows:  Abdominal  pain,  perhaps  coHcky 
in  character,  gradual  or  acute  in  onset,  and,  as  a  rule,  constant.  Early  in 
the  case  there  is  no  abdominal  tenderness,  no  distention,  and  no  rigidity. 
The  pulse  is  rapid,  the  patient  is  extremely  restless,  there  may  be  vomiting, 
but  it  is  never  violent,  as  in  acute  obstruction;  often  there  is  diarrhea,  and  some- 
times bloody  diarrhea.  These  S5rmptoms  become  particularly  significant  if 
there  is  cardiac  or  vascular  disease. 

Obstruction  from  Meckel's  diverticulum  is  usually  acute,  but  is  sometimes 
chronic,  and  occurs  particiilarly  in  young  adults  and  children.  It  has  been 
stated  that  other  and  visible  deformities  are  usually  present,  but  in  a  study 
of  69  cases  by  A.  E.  Halstead^  this  was  true  of  but  i  case,  in  which  hareUp 
existed.  In  obstruction  from  Meckel's  diverticulimi  there  is  often  a  history 
of  former  mild  attacks  (Ibid.).  Halstead  sums  up  the  symptoms  as  foUows: 
As  the  obstruction  is  high  up,  the  abdomen  is  the  shape  of  an  inverted  cone; 
early  in  the  attack  there  is  often  local  meteorism,  especially  under  the  costal 
arch  of  the  right  side,  but  there  is  no  distention  in  the  flanks.  Early,  active 
peristalsis  may  be  \dsible.  The  tenderness  is  just  to  the  right  of  the  imi- 
bilicus,  on  a  level  with  it  or  below  it.  In  most  cases  there  is  early  fecal 
vomiting.  Gray  ("Annals  of  Surgery,"  Dec,  1908)  describes  invagination 
of  the  diverticulum  into  the  bowel.  The  average  age  for  those  attacked  is 
fifteen  years.     Such  cases  give  a  history  of  previous  abdominal  crises  due  to 

1  "Brit,  Med.  Jour.,"  Nov.  16,  1901.  ^  "Annals  of  Surgery,"  April,  1902. 


Treatment  of  Intestinal  Obstruction  989 

twisting,  inflammation,  or  slight  invagination.  The  acute  attack  is  apt  to 
begin  while  the  patient  is  active.  Gray  says  that  about  30  per  cent,  of  the 
patients  pass  blood;  that  the  pain  is  umbilical  and  usually  very  violent;  that 
tenderness  is  seldom  acute  unless  there  is  peritonitis;  that  there  may  be  an 
abnormal  mnbilical  cicatrix;  that  in  a  minority  of  cases  there  is  a  palpable 
abdominal  mass,  and  that  the  mortality  after  operation  in  acute  cases  is  nearly 
60  per  cent. 

Differentiation  of  Intestinal  Obstruction  from  Other  Diseases. — Always  ex- 
amine for  a  strangulated  hernia  at  every  hernial  outlet.  If  obstruction  is 
complicated  with  an  irreducible  hernia  above  the  seat  of  lesion,  the  hernia, 
if  it  contains  gut,  wiU  always  enlarge  and  become  tender  because  of  accumu- 
lation of  feces.  Functional  obstruction  may  attend  peritonitis  or  may  follow 
the  reduction  of  a  hernia.  In  this  condition,  if  peritonitis  is  absent,  there 
is  no  pain,  no  tenderness,  no  tumor,  no  tendency  to  collapse,  but  simply 
absolute  constipation,  distention,  and  perhaps  non-stercoraceous  vomiting. 
Appendicitis  with  peritonitis  may  cause  symptoms  similar  to  those  of  obstruc- 
tion; but  there  is  fever,  is  a  history  of  pain  in  the  right  iliac  fossa,  and  the 
vomiting  is  not  stercoraceous.  Acute  pancreatitis  produces  symptoms  so 
similar  to  those  of  intestinal  obstruction  that  a  diagnosis  cannot  always  be 
made  (see  page  1059).  We  must  consider  in  the  diagnosis  perforation  of  a 
gastric  or  duodenal  ulcer,  rupture  of  an  extra-uterine  pregnancy  or  a  pus 
tube,  strangulation  of  the  pedicle  of  an  ovarian  tumor,  renal  colic,  and 
hepatic  coHc.  Poisoning  by  arsenic  or  by  corrosive  sublimate  should  not 
be  confounded  with  intestinal  obstruction. 

Prognosis. — Without  surgical  interference  most  cases  of  acute  intestinal 
obstruction  die  within  ten  days — usually  within  seven  days.  In  volvulus 
death  may  occur  in  forty-eight  or  seventy-two  hours.  It  may  occur  as  early  in 
obstruction  by  a  band,  in  internal  hernia,  or  mesenteric  blocking.  Death  may 
be  due  to  shock,  to  exhaustion,  to  perforation,  to  peritonitis,  or  to  obstruc- 
tion of  respiration  and  circulation  by  t3Tiipanites.  Recovery  occasionally, 
but  very  rarely,  happens  by  the  formation  of  a  fistula  externally  or  into 
another  portion  of  the  bowel.  In  acute  obstruction  from  foreign  bodies  the 
obstructing  body  occasionally  passes.  Volvulus  and  strangulation  by  bands 
are  almost  invariably  fatal  unless  an  operation  is  performed.  In  intussus- 
ception recovery  occasionally  follows  the  sloughing  away  of  the  prolapsed 
gut,  but  stricture  almost  inevitably  results  from  this  rare  event.  Functional 
obstruction  gives  a  good  prognosis.  The  prognosis  of  chronic  obstruction 
depends  upon  the  causative  lesion.  It  does  not  threaten  life  immediately 
to  anything  like  the  degree  that  acute  obstruction  does. 

Treatment. — In  any  abdominal  case  in  which  the  diagnosis  is  uncertain 
and  the  patient  is  shocked  give  an  enema  of  brandy  and  hot  water,  wrap 
the  patient  in  blankets,  surround  him  with  hot-water  bottles,  and  study  the 
development  of  symptoms  and  signs.  In  half  an  hour,  as  a  rule,  reaction 
will  be  brought  about  and  a  probable  diagnosis  may  be  made  (Greig  Smith). 
In  acute  obstruction  it  is  usually  customary  to  empty  the  stomach  by  lavage 
and  to  evacuate  the  rectum  by  means  of  copious  injections  given  while  the 
patient  is  in  the  knee-chest  position.  The  emptying  of  the  stomach  is  imper- 
ative if  stercoraceous  vomiting  has  been  going  on,  for  vomiting  of  a  quantity 
of  such  material  while  a  patient  is  taking  ether  may  cause  death  by  drowning, 
the  fluid  flowing  in  enormous  quantity  into  the  bronchi.  In  very  severe  cases 
a  general  anesthetic  cannot  be  given  and  the  belly  must  be  opened  under 
cocain.  Hutchinson's  method  of  taxis  and  massage  is  uncertain,  and  is  as 
liable  to  inflict  harm  as  to  confer  benefit.  Some  surgeons  apply  constant 
compression  to  the  abdomen  by  means  of  straps  of  adhesive  plaster.  Punc- 
ture of  the  intestine  by  an  aseptic  hypodermatic  needle  (introduced  obliquely) 


99©  Diseases  and  Injuries  of  the  Abdomen 

to  relieve  gaseous  distention  is  a  decidedly  dangerous  proceeding.  The  passage 
of  a  small  tube  from  the  anus  as  high  as  possible  will  empty  the  colon 
of  gas  if  no  obstruction  intervenes.  In  intussusception  it  is  the  custom  of 
some  surgeons  to  give  no  food  by  the  stomach;  administer  opium  and  bella- 
donna to  arrest  peristalsis,  wash  out  the  rectum  with  copious  injections,  give 
an  anesthetic,  and  insufflate  hydrogen  gas  or  carbonic-acid  gas  in  order  to 
distend  the  bowel.  Other  surgeons  treat  intussusception  by  forcing  air  into 
the  rectum  by  means  of  an  ordinary  bellows,  and  others  inject  water  by  a 
fountain-syringe,  the  reservoir  being  at  a  height  of  3  feet.  D'Arcy  Power 
believes  in  the  value  of  hydrostatic  pressure  in  intussusception  in  children. 
He  states  that  the  child  should  be  anesthetized  and  the  large  intestine  filled 
gradually  with  hot  saline  fluid,  the  reservoir  not  being  raised  more  than  3 
feet  above  the  patient.  The  fluid  should  be  retained  for  ten  minutes.  My 
own  feeling  is  that  whereas  it  may  be  justifiable  to  try  to  reduce  by  gaseous 
or  hydrostatic  pressure  during  the  first  twenty-four  hours  of  the  attack,  early 
operation,  except  in  newborn  infants,  gives  a  better  prognosis  and  is  safer  and 
more  certain.  Without  opening  the  abdomen  it  is  impossible  to  know  the 
condition  of  the  intestine.  Gangrene  may  occur  early  (it  has  been  found  in  less 
than  four  hours  after  the  onset  of  symptoms),  and  if  gangrene  exists  gaseous 
distention  or  hydrostatic  pressure  will  cause  death.  Rushmore's  reported  case 
shows  that  there  may  be  "no  systemic  symptoms  to  indicate  the  presence  of 
gangrene"  ("Annals  of  Surgery,"  August,  1907).  Another  point  against  con- 
servative treatment  is  the  common  uncertainty  as  to  whether  complete  reduc- 
tion has  been  accomplished.  Vomiting  may  continue  for  hours  after  genuine 
reduction  and  the  bowels  may  not  move  for  some  time.  Waiting  to  be  sure  re- 
duction was  accomplished  will  probably  be  responsible  for  death  if  reduction 
was  not  obtained.  After  the  first  twenty-four  hours  it  is  never  justifiable  to  use 
gaseous  or  hydrostatic  pressure  because  of  the  great  risk  that  ulcer  or  gangrene 
may  exist.  Pressure  cannot  be  accurately  regulated,  and  if  the  bowel  is  much 
damaged,  may  lead  to  rupture.  If  the  case  is  not  seen  until  after  the  first  day, 
or  if  injections  have  been  used  and  have  fafled,  aU  surgeons  believe  that  lap- 
arotomy should  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported  cases  of  lap- 
arotomy for  infantfle  intussusception,  and  considers  that  operation  done 
within  the  first  forty-eight  hours  wfll  give  a  mortality  of  22.2  per  cent.^  (see 
Operation  for  Intussusception).  In  very  young  infants  the  mortality  of  lap- 
arotomy is  very  high,  and  it  is  a  fair  question  if  on  them  immediate  lap- 
arotomy should  be  advised  without  a  trial  of  conservative  methods  if  the  case 
is  seen  during  the  first  twelve  or  twenty-four  hours.  The  mortality  of  operation 
is  very  large  on  those  under  eighteen  months  of  age.  But  even  in  those  under 
six  months  of  age  Wiggin  thinks  the  mortality  after  operation  is  not  above 
22.2  per  cent,  if  operation  is  done  within  forty-eight  hours,  and  my  personal 
feeling  is  that  operation  should  be  the  method  of  treatment  even  in  the  case  of  a 
young  baby. 

I  agree  with  Rushmore  that  operation  done  during  the  first  twelve  hours 
would  greatly  reduce  the  mortality,  perhaps  to  the  figures  he  expects  would 
come  from  such  a  practice,  viz.,  12.5  per  cent. 

In  obstruction  of  the  main  mesenteric  vessels  operation  is  of  no  avail. 
In  obstruction  of  branches  it  may  be  possible  to  resect  the  involved  region 
of  bowel,  a  region  which  is  found  to  be  gangrenous  or  at  least  is  becoming  so. 

In  obstruction  from  fecal  impaction  use  large  rectal  injections  and  give 
small  repeated  doses  of  salines  or  of  castor  oil.  If  there  are  signs  of  inflam- 
mation, do  not  give  cathartics,  even  in  small  doses,  but  give  opium  and 
belladonna  to  arrest  vomiting  and  to  relax  spasm.  Impactions  in  the 
^  "Med.  Record,"  Jan.  18,  1896. 


Treatment  of  Intestinal  Obstruction  991 

rectum  can  be  remo\"ed  by  the  use  of  a  spoon.  In  acute  intestinal  ob- 
struction do  not  delay,  but  open  the  abdomen,  if  possible,  before  collapse 
comes  on,  and  find  the  cause  of  the  obstruction.  If  it  is  a  gall-stone  or  en- 
terohth,  tr>-  to  crush  it  w-ithout  opening  the  intestine;  if  this  fails,  push  it  up  a 
httle  distance,  incise  the  bowel,  remove  the  stone,  and  close  the  incision  with 
Halsted  sutures.  Pilcher^  collected  40  cases  operated  upon  for  gall-stone 
obstruction,  with  21  deaths.  If  there  is  fecal  obstruction,  break  up  the 
masses  by  pressure  and  push  the  fecal  plug  do"mi  -udthout  opening  the 
bowel.  If  there  is  intussusception,  reduce  the  prolapse  and  shorten  the 
mesentery;  but  if  reduction  is  impossible,  perform  a  resection  and  enter- 
orrhaphy,  or  make  an  artificial  anus.  In  voh-ulus  untwist  and  shorten  the 
mesentery- :  but  if  this  is  impossible,  treat  as  an  irreducible  invagination.  In 
obstruction  from  adhesions  try  to  separate  them  and  straighten  out  the  bowel, 
stitching  healthy  peritoneum  over  each  raw  spot  to  prevent  recurrence.  In 
obstruction  by  a  band,  free  the  loop  and,  if  it  is  gangrenous,  resect  or  follow  the 
plan  of  ^Mikulicz  (see  page  992).  Anastomosis  may  be  necessary-.  In  flexion 
separate  the  intestines,  remove  the  flexion  by  a  V-shaped  incision,  and  suture 
the  woimd  in  the  bowel.  In  chronic  obstruction  it  is  often  ad^•isable  to  per- 
form an  exploratory-  laparotomy,  discover  the  condition,  and  determine  what  is 
to  be  done  to  correct  it.  Some  tumors  external  to  the  bowel  may  be  remo^"ed. 
Growths  in  the  bowel  wall  may  be  removed  by  resection  of  the  involved  por- 
tion of  intestine,  or  an  anastomosis  may  be  performed,  or  it  may  be  necessar}' 
to  make  an  artificial  anus.  In  obstruction  from  ^Meckel's  diverticulum  that 
structure  may  be  found  twisted,  the  gut  near  it  may  be  kinked  or  twisted,  or  the 
diverticulimi  may  act  as  a  band,  the  bowel  being  caught  under  it  or  kinked  over 
it.  Intussusception  of  the  gut  below  it  sometimes  occurs :  so  does  invagination 
of  the  mucous  membrane  of  the  diverticulum:  so  does  chronic  inflammation 
and  cicatricial  narrowing  of  the  diverticulum  or  gut  (,Halstead\  The  diverticu- 
lum may  be  gangrenous,  perforated,  or  cystic.  In  internal  hernia  the  constric- 
tion must  be  di\-ided  and  the  bowel  removed  from  the  fossa.  Any  gangrenous 
gut  should  be  resected  if  the  patient's  condition  justifies  it,  or  Mikulicz's  plan 
should  be  followed  (see  page  992). 

After  opening  the  abdomen  the  surgeon  must  be  guided  by  conditions. 
The  diverticulimi  should  be  removed,  just  as  the  appendix  is  removed  in 
appendicitis,  and  complications  relating  to  the  gut  must  be  dealt  with. 

The  mortahtv  after  operations  for  acute  intestinal  obstruction  is  ver\-  high 
(from  60  to  75  per  cent.V  If  the  diagnosis  were  made  earlier,  operations  would 
be  done  earlier  and  the  mortality  would  be  much  less.  Xine  out  of  10  of  these 
cases  that  I  see  m  hospital  work  are  gravely  shocked  and  practically  d\ing  on 
admission.  If  a  patient  with  obstruction  is  ver\-  gravely  shocked.  I  usually 
foUow  ;Mo}-nihan's  plan,  of  simply  opening  the  bowel  and  draining  it  in  its 
most  distended  coil  -without  any  search  being  made  for  the  lesion.  The 
object  is  to  drain  the  poisons  from  the  intestine,  poisons  which  are  the  active 
agents  in  killing  the  patient.  The  abdomen  is  opened  under  cocain,  the 
incision  being  small.  A  distended  coil  of  intestine  is  sutured  to  the  peritoneum 
about  the  abdominal  incision,  every  care  being  taken  that  the  stitches  do  not 
penetrate  the  mucous  membrane  of  the  gut  i^Ioynihan) .  A  purse-string  suture 
is  now  inserted  so  as  to  enclose  an  area  of  the  exposed  gut:  an  incision  is  made 
into  the  gut  in  this  enclosed  area,  and  gas  and  feces  flow  out.  Paul's  glass  tube 
(see  Fig.  718)  is  passed  into  the  gut  and  the  purse-string  suture  is  tied.  In- 
stead of  Paul's  tube  we  may  use  a  rubber  tube  sutured  as  is  the  tube  in  Kader's 
gastrostomy  (Elsberg,  in  "Annals  of  Surgen,-."'  ^lay,  1908).  The  obstruction  is 
thus  temporarily  relieved,  and  if  the  patient  recovers,  the  causative  lesion  may 
be  subsequently  sought  for  and  attacked.     If  a  fecal  fistula  follows  the  enter- 

1  "Med.  Xews."  Feb.  8,  1902. 


gc)2  Diseases  and  Injuries  of  the  Abdomen 

ostomy  and  refuses  to  close,  it  may  be  closed  by  operation.  If  Elsberg's  plan  is 
followed  a  persisting  fecal  fistula  will  be  rare.  My  colleague,  Professor  Francis 
T.  Stewart,  has  devised  a  method  by  which  the  bowel  can  be  drained  without  any 
risk  of  infection  of  the  peritoneal  cavity,  a  risk  which  always  exists  in  using 
Paul's  tube.  Stewart  places  a  clamp  at  either  extremity  of  the  loop  of  bowel 
and  surrounds  it  with  gauze.  One  half  of  a  Murphy  button  is  inserted  into  the 
empty  loop  through  a  small  incision.  The  other  half  of  the  button  is  squeezed 
into  a  rubber  tube  the  diameter  of  which  is  somewhat  smaller  than  the  flange 
of  the  button.  The  two  parts  of  the  button  are  then  clamped,  and  the  clamps 
are  removed  from  the  loop  of  bowel.  The  intestine  is  sutured  to  the  wound 
margins  and  the  feces  drain  into  a  receptacle  on  the  floor.     Fig.  6ii  shows 

Stewart's  operation.   In 
any  case   of   intestinal 
obstruction  if  gangrene 
exists  the  temptation  to 
do  immediate  resection 
is  strong.     I  have  done 
it  a  number  of    times 
with  a  very  large  mor- 
tality.    Of  late  I  have 
been  foUowing  the  plan 
of  MikuHcz  and  resiflts 
have  been   far   better. 
The  gangrenous  loop  is 
brought  outside  of  the 
abdomen,    it    is    fixed 
parallel  to  the  wound, 
and  enterostomy  is  per- 
formed above  it.     The 
loop  is  dealt  with  later. 
If  a  fecal  fistula  forms  it 
is  subsequently   closed 
by  appropriate  methods . 
Postoperative   obstruc- 
tion   coming    on    soon 
after  a  surgical  opera- 
tion is  often  not  recog- 
nized for  a  time,  and 
the  surgeon  will  be  in 
doubt    as    to    whether 
he  is  deahng  with  peri- 
tonitis or  intestinal  pa- 
resis.    When  distention 
becomes  evident  after  an  opei:ation  we  should  wash  out  the  stomach  with 
warm  salt  solution,  administer  salines  in  smafl  doses  frequently  repeated,  and 
employ  enemata.     Many  surgeons  give  two  or  three  doses  of  atropin  hypo- 
dermatically  at  intervals  of  two  hours.     Each  dose  should  be  o-i  o  gr-     Atropin 
is  given  with  the  idea  that  it  increases  peristalsis  and  contracts  blood-vessels. 
It  is  probably  merely  sedative,  relaxes  spasm,  and  is  useless  if  strangulation 
exists.      Eserin  stimulates  the  muscular  coat  of  the  intestines.     There  seems 
no  doubt  that  eserin  given  soon  after  an  operation  tends  to  prevent  distention. 
A  better  plan  than  the  administration  of  atropin  is  to  give  hypodermaticaUy 
sV  gr.  of  eserin  and  4V  gr-  of  strychnin  every  hour  until  four  doses  have  been 
taken.     During  fifteen  minutes  of  this  period  carry  the  heated  Paquelin  cautery 
to  and  fro  over  the  abdomen,  not  touching  the  skin,  but  near  enough  to  it  to 


Fig.  611. — Stewart's  method  of  enterostomy. 


Ulcer  of  the  Bowel  993 

cause  distinct  reddening.  The  intestinal  tract  should  be  gone  over  systemat- 
ically with  the  cautery,  first,  the  stomach  and  small  intestine,  then  the  large 
intestine.  Pituitrin  is  an  extract  of  the  posterior  lobe  of  the  pituitary  gland. 
When  given  intravenously  or  subcutaneously  it  raises  blood-pressure,  is  a  diu- 
retic, and  stimulates  involuntary  muscular  filaer.  It  is  useful  in  cases  of  flatulent 
distention.  It  comes  in  ampoules  each  of  which  contains  i  c.c.  The  dose  is 
one  to  two  ampoules,  repeated  in  two  hours.  If  these  measures  are  not  soon 
followed  by  the  passage  of  flatus  or  feces,  open  the  abdomen;  never  wait  for 
the  advent  of  stercoraceous  vomiting. 

Fecal  Fistula  and  Artificial  Anus. — A  fecal  fistula  is  an  abnormal  open- 
ing in  the  intestine  through  which  gas  or  a  portion  of  the  feces  escape  (Fig. 
612).  If  all  the  intestinal  contents  escape  through  the  opening,  it  is  called 
an  artificial  anus  (Fig.  613,  Senn).  A  surgeon  may  make  a  fistula  deliberately 
{intentional  fistula).  A  fistula  may  be  the  product  of  disease  or  injury  {acci- 
dental fistula).  Senn  enumerates  the  following  causes  of  accidental  fistula: 
wounds,  injury  of  the  intestines,  intestinal  ulceration,  intestinal  strangulation, 
foreign  bodies  in  the  intestinal  canal,  malignant  tumors,  actinomycosis,  pelvic 
and  abdominal  abscess,  appendicitis,  injury  of  the  bowel  during  an  abdominal 
operation,  the  application  of  ligatures,  catching  by  sutures,  and  the  employ- 
ment of  drainage-tubes. 

Treatment. — Many  fistulse  close  spontaneously.  This  can  be  hoped  for 
only  if  the  opening  is  quite  small,  if  the  general  health  of  the  patient  is  good, 
if  the  cause  has  passed  away,  if  the  fistula  is  not  lined  with  mucous  mem- 
brane, and  if  there  is  no  spur  (spur  is  shown  at  a,  Fig.  613).     In  most  cases 


Fig.  612. — Fecal  fistula:  a,  Direction  of  fecal  flow;         Fig.  613. — Artificial  anus,  showing  spur:  a,  Spur; 
b,  b,  belly  wall.  b,  b,  belly  wall;  c,  direction  of  fecal  flow. 

of  fistula  not  high  up  it  is  well  to  give  Nature  a  chance  to  effect  a  cure,  and 
not  to  be  in  a  hurry  to  operate.  Most  fistulae  in  the  large  bowel  heal  sponta- 
neously. The  part  is  cleansed  frequently  with  peroxid  of  hydrogen,  the  patient 
is  kept  recumbent,  food  is  given  which  does  not  leave  much  residue,  pads  of 
gauze  are  applied  with  pressure,  and  the  bowels  are  kept  regular. 

If  the  track  is  lined  with  granulations,  it  may  be  touched  with  lunar  caustic; 
if  it  is  lined  with  mucous  membrane,  the  actual  cautery  should  be  applied. 
Any  collection  of  pus  which  exists  should  be  drained.  If  these  methods  fail, 
an  operation  must  be  performed.  The  fistula  may  be  sutured  by  extraperi- 
toneal manipulation  (Greig  Smith) ;  it  may  be  covered  with  skin  (Dieffenbach) ; 
the  spur  may  be  removed  by  means  of  a  clamp,  or  resection  may  be  performed. 
In  most  cases  it  is  best  to  incise  a  button  of  skin  around  the  opening,  tempo- 
rarily suture  the  fistula,  open  the  peritoneal  cavity,  deliver  the  bowel,  and 
suture  carefully  (Senn's  method).  In  some  cases  partial  exclusion  of  the 
fistulous  part  is  necessary,  the  bowel  being  divided  above  the  fistula,  the  end 
near  the  fistula  sutured,  and  the  other  end  anastomosed  to  the  bowel  below  the 
fistula.     In  other  cases  complete  exclusion  may  be  performed  (see  page  11 18). 

Ulcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery  ulceration 
occurs.  In  erysipelas,  septicemia,  pemphigus,  melena  neonatorum,  and  ure- 
mia ulceration  may  occur.  An  ulcer  may  be  due  to  tuberculosis  or  cancer. 
Most  ulcers  of  the  duodenum  (see  below)  are  due  to  the  same  causes  as  ulcer 
of  the  stomach.  In  rare  cases  ulcer  of  the  duodenum  results  from  a  sur- 
63 


994  Diseases  and  Injuries  of  the  Abdomen 

face  burn  (Curling's  ulcer,  page  162).  An  ulcer  of  the  jejunum  sometimes 
develops  after  the  performance  of  gastrojejunostomy  for  gastric  ulcer  (see  page 
1090).  An  ulcer  may  heal  and,  by  causing  thickening  and  constriction,  pro- 
duce chronic  intestinal  obstruction.  It  may  perforate,  causing  collapse  and 
subsequent  peritonitis. 

Ulcer  of  the  duodenum  may  be  due  to  tuberculosis.  It  may  exist  in 
septicemia,  erysipelas,  melena  neonatorum,  and  uremia.  It  may  be  caused  by 
burns.  The  last  named  and  very  rare  condition  is  called  Curling's  ulcer,  he 
having  described  it  in  1841.  Moynihan  shows  in  his  book  on  "Duodenal  Ulcer" 
that  James  Long,  of  Liverpool,  was  really  the  first  one  to  describe  duodenal 
ulceration  following  burns.  He  did  so  in  the  "London  Medical  Gazette,"  1840. 
A  duodenal  ulcer  following  a  burn  or  scald  is  "a  toxic  ulcer,  and,  therefore, 
analogous  to  the  ulcer  which  occurs  in  septicemia,  uremia,  typhoid  fever, 
erysipelas,  and  pemphigus"  (Moynihan,  Ibid.).  It  occurs  only  when  the 
burnt  or  scalded  area  has  become  septic,  and  septic  emboli  may  be  responsible 
for  ulceration.  Some  believe  that  the  irritant  cause  is  in  the  bile.  Ulcer  from  a 
burn  is  extremely  rare  to-day,  rarer  than  formerly,  if  older  reports  are  correct. 
This  is  probably  due  to  the  modern  cleanly  treatment  of  burns  and  scalds. 
When  we  use  without  qualification  the  term  "ulcer  of  the  duodenum"  we  mean 
an  ulcer  like  the  ordinary  stomach  ulcer  and  which  may  be  regarded  as  a  peptic 
ulcer  of  the  duodenimi. 

Septic  ulcers  are  acute.     The  peptic  ulcer  is  nearly  always  chronic. 

Peptic  Ulcer  of  the  Duodenum. — The  condition  was  first  described  by 
Travers  in  1817  ("Duodenal  Ulcer,"  by  Sir  Berkley  G.  A.  Moynihan).  It  occurs 
usually  in  that  portion  of  the  duodenum  which  is  above  the  opening  of  the  bUe- 
duct ;  in  other  words,  in  the  region  acted  on  by  the  acid  fluid  from  the  stomach. 
In  Perry  and  Shaw's  list  of  149  cases  the  first  portion  was  involved  in  123,  the 
second  portion  in  16,  and  the  third  and  fourth  portions  in  2;  in  8  the  ulcers 
were  scattered.  Moynihan  (Ibid.)  says  the  first  portion  is  involved  in  95  per 
cent,  of  the  cases.  The  most  common  seat  of  ulcer  is  on  the  anterior  wall  of 
the  duodenum,  |  inch  below  the  pylorus.  The  pylorus  is  definitely  marked  for 
the  surgeon  by  the  pyloric  vein  which  runs  upward  from  the  greater  curvature 
(Moynihan,  Ibid.).  The  ulcer  is  often  puckered  like  a  scar.  Any  old  ulcer  is 
much  indurated.  In  rare  cases  there  is  no  induration.  Sometimes  an  exten- 
sive area  of  the  duodenum  is  indurated,  sometimes  a  duodenal  pouch  or  diver- 
ticulum is  formed.  In  rare  cases  an  ulcer  completely  encircles  the  bowel. 
Duodenal  ulceration  is  much  more  common  in  males  than  in  females  in  the 
proportion  of  3  or  4  to  i.  It  may  occur  at  any  period  of  life,  from  early  youth 
to  extreme  old  age,  but  is  most  common  between  the  twenty-fifth  and  forty- 
fifth  years.  Duodenal  ulcers  are  usually  single,  but  may  be  multiple.  It 
was  long  taught  that  gastric  ulceration  is  vastly  more  common  than  duodenal 
ulceration.  Some  recent  observers  regard  duodenal  ulcer  as  likely  to  be  met 
with  one-seventh  as  often  as  gastric  ulcer.  In  this  connection  Codman's  sta- 
tistics should  cause  us  to  revise  our  estimates.  In  3000  autopsies  held  in  the 
Massachusetts  General  Hospital  an  open  duodenal  ulcer  was  found  in  i  per 
cent,  of  the  cases.  The  duodenal  ulcers  were  found  twice  as  often  as  gastric 
ulcers  (quoted  by  E.  R.  McGuire,  "Buffalo  Med.  Jour.,"  June,  1912).  A  gas- 
tric ulcer  may  exist  with  a  duodenal  ulcer.  Murphy  sums  up  the  supposed 
causes  into  hyperchlorhydria,  local  infection,  embolism  and  thrombosis,  and 
disturbances  of  t"he  organs  of  elimination.  An  indurated  chronic  ulcer  may 
exist,  and  this  may  heal  and  produce  cicatricial  stenosis.  The  scars  of  two 
ulcers  may  cause  double  constriction  or  hour-glass  duodemmi. 

An  ulcer  may  heal  and  break  down  many  times.  A  duodenal  carcinoma 
seldom  arises  from  ulcer.  What  Moynihan  calls  the  "tucked  back"  ulcer  be- 
comes adherent  to  the  liver  or  posterior  wall  of  the  abdomen.     An  ulcer  adhe- 


Peptic  Ulcer  of  the  Duodenum  995 

rent  to  the  pancreas  may  eat  into  that  organ.  An  ulcer  scar  may  clutch  the 
common  bile-duct  in  the  duodenal  wall  or  block  the  outlet  of  the  ducts  in  the 
ampulla  of  Vater.  Perforation  is  more  common,  but  walling  off  is  more  fre- 
quent than  in  gastric  ulceration  (Wm.  J.  Mayo,  "Med.  News,"  April  16, 1904). 
In  the  vast  majority  of  cases  the  patient  gives  a  history  of  having  suffered 
at  intervals  for  many  years  from  attacks  of  flatulent  or  acid  and  painful  indi- 
gestion. A  man  suffers  thus  for  days  or  weeks,  and  then  gets  apparently  per- 
fectly well,  but  after  a  variable  time  the  attack  returns.  The  attack  comes  on 
from  two  to  sLx  hours  after  a  heavy  meal.  If  he  eats  his  heavy  meal  at  7  p.  m. 
his  attack  may  usually  be  expected  about  10  o'clock  or  later.  These  seizures 
of  "indigestion"  may  be  brought  on  by  worry,  overwork,  wet  feet  or  chilling 
of  the  body,  or  by  eating  some  indigestible  article  of  diet.  They  may  be  caused 
to  disappear  by  rest,  ease  of  mind,  or  change  of  climate.  They  have  been  called 
"hunger-pains"  because  food  for  a  time  distinctly  reheves  them.  A  patient  learns 
this  and  is  apt  as  soon  as  the  annoyance  begins  to  eat  some  crackers  or  drink  a 
glass  of  milk.  It  was  long  beHeved  that  hunger  pain  was  due  to  an  open  pylorus 
allowing  acid  material  to  run  into  the  duodenum,  and  that  food  or  an  alkali 
caused  the  pylorus  to  close.  Moynihan,  Hertz,  and  others  now  reject  this 
explanation  because  a;-ray  studies  show  that  food  begins  to  leave  the  stomach 
at  once  and  that  pain  begins  when  about  half  the  food  has  left  the  stomach 
(Moynihan,  "Duodenal  Ulcer").  It  must  be  that  the  last  portion  of  food  in 
the  stomach  is  much  more  acid  than  the  portions  which  pass  out  earlier.  When 
the  stomach  is  entirely  empty  there  is  no  pain ;  when  half  empty  there  is  pain. 

Arbuthnot  Lane  would  explain  the  relief  of  pain  by  food  by  invoking  a 
reflex  contraction  of  the  duodemmi  caused  by  food  and  serving  to  empty  that 
portion  of  the  gut.  The  condition  above  described  may  go  on  for  many  years, 
periods  of  relief  alternating  with  periods  of  pain,  water  brash,  flatulence,  etc. 
Usually,  but  by  no  means  always,  there  is  hyperacidity.  In  some  cases  acid- 
ity is  normal;  in  some,  actuaUy  subnormal.  It  is  probable  that  during  painful 
attacks  there  is  hyperacidity.  We  have  stated  that  the  pain  occurs  from  two  to 
SLX  hours  after  a  meal.  If  it  occurs  very  late  the  ulcer  is  posterior;  if  it  occurs 
earlier  than  two  hours  stenosis  has  begun  or  the  ulcer  is  adherent  to  the  liver 
or  befly  wall  (Moynihan,  Ibid.). 

Hemorrhage  occurs  in  about  40  per  cent,  of  the  cases.  The  blood  may  be 
passed  by  bowel  only  or  it  may  be  passed  by  bowel  and  also  vomited.  In 
most  cases  it  is  passed  by  bowel  and  not  vomited.  When  there  is  a 
severe  hemorrhage  the  patient  fii"st  has  a  peculiarly  severe  attack  of  indi- 
gestion, he  then  grows  deathly  pale,  presents  the  symptoms  of  internal 
hemorrhage,  and  passes  a  quantity  of  blood  which  is  first  tarry  black  and 
later  red,  and  perhaps  he  also  vomits  blood.  Just  as  chronic  gastric  ulcer 
may  be  latent,  no  symptoms  ever  being  observed,  so  may  chronic  duodenal 
ulcer  be  latent.  The  pain  is  located  in  the  epigastric  or  right  h^-pochon- 
driac  region  and  may  last  until  the  next  meal.  If  the  digestion  of  the  eve- 
ning meal  is  delayed  the  pain  rouses  the  patient  from  sleep,  but  a  glass  of 
milk  will  quiet  it.  The  pain  is  less  severe  than  is  usual  in  gastric  ulcer  and 
in  many  cases  does  not  radiate  to  the  back,  although  in  others  it  does  radiate 
to  the  right  scapular  region.  There  may  be  tenderness  on  deep  pressure  in  the 
right  h^.'pochondriac  region.  Symptoms  of  indigestion  are  not  nearly  so  marked 
as  in  ulcer  of  the  stomach.  Vomiting  is  far  less  common  than  in  gastric  idcer 
and  it  does  not  reheve  pain.  The  hemorrhage  from  the  bowels  may  be  so 
profuse  as  to  kill  or  almost  kill  the  patient.  It  may  be  so  frequently  repeated 
as  to  make  him  profoundly  anemic.  Unlike  the  bleeding  from  gastric  ulcer, 
bleeding  from  duodenal  ulcer  is  often  fatal.  In  some  cases  the  man  bleeds  in- 
sidiously, perhaps  even  without  knowing  it,  losing  some  blood  daily,  and  finally 
becoming  extremely  anemic.     Probably  in  every  case  of  duodenal  iflcer  occult 


996  Diseases  and  Injuries  of  the  Abdomen 

blood  is  at  times  present  in  the  stools.  In  many  cases  there  is  no  visible  blood 
in  the  feces,  but  the  guaiac  or  aloin  tests  show  occult  blood.  Vomiting  of 
quantities  of  blood  is  much  rarer  than  in  gastric  ulcer.  In  very  rare  cases  of 
duodenal  ulcer  the  first  symptom  is  perforation.  I  have  operated  on  one  such 
case.  In  other  cases  the  first  symptom  is  hemorrhage,  or  is  due  to  stenosis  or 
some  other  complication.  Examination  by  a;-rays  after  the  taking  of  a  meal 
containing  bismuth  shows,  if  there  is  ulcer,  greatly  increased  activity  of  the 
stomach.  In  some  cases  stenosis  is  demonstrated,  in  some  a  pseudodiver- 
ticulum.  Moynihan^  mentions  the  following  compHcations :  severe  hemor- 
rhage; perforation;  periduodenitis;  cancer,  and  cicatricial  contraction  in- 
volving the  bile-duct. 

Acute  perforation  is  more  common  than  we  once  thought.  Perforation  is 
usually  on  the  anterior  wall.  It  is  much  less  common  on  the  posterior  wall. 
It  is  extremely  rare  on  the  superior  wall  and  practically  never  occiurs  on 
the  inferior  wall.  Moynihan  gathered  49  cases  from  literature  and  added  2 
of  his  own.  In  the  great  majority  of  cases  perforation  of  the  duodenum 
cannot  be  differentiated  from  perforation  of  the  stomach  by  a  study  of  the 
symptoms.  In  some  cases  the  symptoms  resemble  appendicitis.  In  most  cases 
there  is  a  sudden  onset  of  violent  abdominal  pain,  followed  by  vomiting,  shock, 
rapid  pulse,  tenderness  of  the  epigastric  or  right  hypochondriac  region,  and 
board-like  rigidity  of  the  upper  abdomen.  Profound  shock  is  rare.  Often  shock 
is  trivial.  Even  if  shock  is  severe  the  patient  usually  reacts  after  a  few  hours. 
Sheild's  case  got  better  in  four  hours  and  walked  some  distance  to  the  hospital." 
Lucy's  case  got  better  a  short  time  after  the  onset,  walked  home,  and  attended 
to  a  horse,  but  then  became  rapidly  worse.  The  improvement  is  apparent,  not 
real,  and  is  only  temporary.  The  symptoms  quickly  become  worse,  and  when 
they  become  worse,  besides  the  pain,  tenderness  and  rapid  pulse,  there  will  be 
occasional  vomiting,  rigidity  of  the  abdomen,  usually  an  elevated  or  normal 
temperature,  and  possibly  diminution  of  the  area  of  liver-dulness.  Just  as  in 
stomach  ulcer,  there  may  be  acute,  subacute,  or  chronic  perforation. 

Treatment. — In  duodenal  ulcer  the  risks  of  serious  hemorrhage  and  of 
perforation  are  much  greater  than  in  gastric  ulcer,  and  operation  should  always 
be  recommended  if  the  diagnosis  is  made.  We  used  to  say  operate  only  if 
the  symptoms  are  not  amended  by  rigid  diet  and  medication;  if  severe  hemor- 
rhage occurs  or  if  cicatricial  contraction  interferes  with  the  passage  of  food 
through  the  bowel  or  bile  into  the  duodenum.  Moynihan  refers  to  4  cases 
of  chronic  ulcer  operated  upon,  and  all  recovered.  In  some  cases  excision  is 
practised;  in  others,  excision  with  gastrojejunostomy;  in  still  others,  gastro- 
jejunostomy alone. 

If  grave  hemorrhage  occurs  and  is  repeated  the  surgeon  should  open  the 
abdomen,  ligate  the  bleeding  vessels,  bring  the  outer  coats  of  the  bowxl  together 
over  the  indurated  area,  and  perform  posterior  gastrojejunostomy  (Wm.  J. 
Mayo,  in  "Surg.,  Gynec,  and  Obstet.,"  May,  1908).  In  such  a  bleeding  ulcer 
the  vessels  entering  it  are  usually  varicose. 

In  perforation  operation  is  performed,  as  in  gastric  ulcer,  as  soon  as  pos- 
sible. In  these  cases,  as  in  perforated  gastric  ulcer,  I  believe  operation  should 
be  immediate  and  that  we  should  not  wait  for  a  possible  reaction  from  shock. 
Personally,  I  do  not  practise  excision  of  the  ulcer,  as  I  believe  that  closure  is 
just  as  permanently  useful  and  is  safer.  The  ulcer  is  inverted  by  two  rows 
of  silk  sutures  applied  in  a  vertical  line  or  as  purse-string  sutures.  If  the 
gap  of  the  perforation  is  huge  it  may  be  impossible  to  close  it  by  inversion. 
It  may  then  be  closed  by  the  gall-bladder  (as  was  done  by  Downes)  or  by  an 
omental  plug.  Failing  in  this,  a  gauze  tampon  may  be  used  or  a  duodenal 
fistula  can  be  formed,  a  rubber  catheter  being  inserted  in  the  duodenum  and 
^  "Lancet,"  Dec.  14,  1901.  ^  Ibid.,  March  29,  1902. 


Treatment  of  Perforated  Typhoid  Ulcer  997 

wrapped  about  with  a  plug  of  omentum  (Eliot,  Corscaden,  and  Jamieson,  in 
''Annals  of  Surger}-,"  ^lay,  1912).  Then  gastrojejunostomy  should  be  done. 
Gastrojejunostomy  is  imperative  if  the  suturing  has  narrowed  the  duodenum. 
It  is  valuable  in  any  case  because  it  remo\-es  irritants  from  the  scar,  allows  of 
early  administration  of  food,  favors  healing,  and  antagonizes  recurrence.  Some 
surgeons  do  not  drain,  but  I  feel  it  safer  to  drain.  Sir  Berkeley  G.  A.  ]Moy- 
nihan^  gathered  49  operations  for  perforated  ulcer,  with  S  reco\-eries.  Mr.  T. 
Crisp  Enghsh  reports  8  operations  for  perforation  of  duodenal  ulcers,  with  2 
recoveries  ("Lancet,"  Nov.  28,  1903).  During  1912  in  the  Mayo  clinic  6  cases 
of  acute  perforating  ulcer  were  treated  by  suture  and  gastro-enterostomy. 
There  was  i  death.  In  perforated  duodenal  ulcer  the  extra^•asated  fluid  is  apt 
to  flow  into  the  right  fliac  region.  If  an  erroneous  diagnosis  of  appendicitis 
was  made,  an  opening  in  the  right  iliac  region,  by  gi^■ing  vent  to  this  fluid, 
might  for  a  time  confirm  the  surgeon  in  error,  but  the  character  of  the  fluid 
should  make  evident  the  condition  of  affairs. 

In  subacute  perforation  we  may  separate  adhesions,  find  and  close  the  per- 
foration, and  perform  gastrojejunostomy,  or  follow  Lund's  ad\-ice  ("Boston 
Med.  and  Surg.  Jour.,"  1905)  and  do  gastrojejunostomy  alone.  Lund  main- 
tains that  as  the  perforation  is  waUed  off  it  is  not  necessar\-  to  open  it  up  in 
order  that  we  may  close  it.  The  treatment  for  chronic  perforation  is  that  for 
an  abscess  about  the  duodenum.  In  ever}^  operation  for  duodenal  ulcer 
Moynihan  examines  the  appendix  and  often  finds  it  diseased  ("Lancet,"  Jan. 
6,  1912). 

Ulcer  of  the  Jejunum  After  Qastro=enterostomy. — (See  page  1090.) 

Perforated  Typhoid  Ulcer. — Perforation  occurs  in  2  or  possibly  3  cases 
out  of  100.  About  70  per  cent,  of  perforations  occur  in  the  second,  third, 
or  fourth  week.  Perforation  in  a  t}-phoid  iflcer  is  usually  effected  rapidly, 
a  large  opening  is  formed,  and  a  considerable  quantity  of  fecal  matter  is 
passed  into  the  peritoneal  ca\-ity.  In  a  few  perforations  very  little  fluid  es- 
capes. Severe  pain  and  a  ner\-ous  chill  indicate  that  perforation  is  occurring 
or  has  occurred.  Some  maintain  that  the  two  above-named  s\Tnptoms  asso- 
ciated with  marked  leukocytosis  indicate  that  perforation  is  about  to  occur, 
and  they  call  this  stage  the  pre  perforative  stage.  That  distinct  S}Tnptoms  may 
in  some  cases  point  to  impending  perforation  is,  I  believe,  true,  and  in  i  case 
I  operated  on  the  con\'iction  and  found  two  areas  almost  perforated.  In 
most  cases,  however,  I  do  not  beheve  that  there  is  a  distinct  preperforative 
stage,  but  the  perforation  exists  when  the  s^inptoms  are  first  noted.  The  con- 
^■iction  that  perforation  was  occurring  would  be  strengthened  by  a  progressive 
increase  in  the  leukocyte  count.  It  is  to  be  remembered,  however,  that  the 
leukocyte  count  is  increased  by  sweating,  cold  bathing,  vomiting,  hemorrhage, 
severe  diarrhea,  or  some  positive  complication.  When  perforation  occurs,  vio- 
lent pain  develops.  As  a  rule,  there  are  tenderness,  rapid  pulse,  costal  respira- 
tion, abdominal  rigidity,  vomiting,  and  shock.  UsuaUy  there  is  temporary-  re- 
action from  shock,  the  subnormal  temperature  gi^'ing  way  to  a  normal  or  to  an 
elevated  temperature.  The  vomiting  in  some  cases  becomes  stercoraceous. 
There  is  constipation  and  sometimes  dulness  on  percussing  the  flanks.  The 
face  is  Hippocratic.  The  patient  may  die  of  the  preliminary^  shock  or  may 
react  and  die  subsequently  of  toxemia.  In  a  few  hours  after  perforation 
distinct  leifl£OC\'tosis  may  be  obser^"ed,  but  it  may  never  take  place  at  all. 
Even  when  leukocytosis  arises,  it  may  disappear  as  peritoneal  infection  spreads 
and  systemic  poisoning  deepens.  Le  Conte  points  out  that  rupture  of  a 
mesenteric  gland  simulates  intestinal  perforation. 

Treatment. — In  1SS4  Ley  den  suggested  operation,  and  in  the  same  year 
]SIikulicz  obtained  the  first  operative  success.     Before  IMikuKcz's  paper  was 

1  "Lancet."  Dec.  14.  1901. 


ggS  Diseases  and  Injuries  of  the  Abdomen 

published  my  colleague,  Dr.  James  C.  Wilson,  published  a  paper  in  which  he 
advocated  operation.  Death  is  practically  certain  without  operation.  Opera- 
tion should  save  at  least  one-fourth  of  the  cases.  It  should  be  done  at  once, 
proper  means  being  adopted  to  combat  shock.  In  many  cases  a  general 
anesthetic  should  not  be  given,  but  a  local  anesthetic  should  be  employed. 
The  incision  should  be  made  in  the  right  iliac  region  and  the  colon  should 
be  first  located  and  then  the  end  of  the  ileum.  By  locating  the  colon  we 
obtain  a  fixed  point  from  which  to  begin  our  search  for  perforations,  and 
by  opening  the  abdomen  in  the  right  iliac  region  we  come  down  at  once  on  to 
the  perforated  gut  in  the  vast  majority  of  cases.  When  a  perforation  is 
found,  it  should  be  inverted  by  two  layers  of  Halsted  sutures.  It  is  not 
wise  to  excise  the  ulcer.  If  the  bowel  is  very  badly  damaged,  resection  can 
be  considered,  but  it  is  usually  wiser  to  make  a  temporary  artificial  anus. 
In  some  cases  the  perforation  can  be  used  as  the  anus,  a  tube  being  inserted, 
or  the  bowel  being  stitched  to  the  skin.  After  finding  a  perforation  and 
closing  it,  examine  to  see  if  there  are  others.  Close  every  perforation,  and 
if  a  point  is  found  where  the  thinning  of  the  bowel  wall  indicates  that  per- 
foration is  liable  to  occur,  protect  this  point  by  inverting  the  area  of  ulcera- 
tion by  sutures.  Cleanse  the  peritoneum  by  flushing  with  hot  salt  solution. 
Leave  the  wound  open,  insert  strands  of  iodoform  gauze,  and  establish 
tubular  suprapubic  drainage.  Elevate  the  patient  a  little  in  bed  and  em- 
ploy continuous  proctoclysis  of  salt  solution.  I  have  operated  lo  times 
for  typhoid  perforation,  with  3  recoveries;  3  cases  died  of  shock.  In  i 
case  the  perforation  was  not  found,  but  was  discovered  postmortem  in  the 
hepatic  flexure  of  the  colon,  the  gaU-bladder  being  responsible  for  the  ulcer 
of  the  bowel.  One  case  improved  greatly,  lived  for  eight  days,  developed 
another  perforation,  and  died  of  shock.  The  necropsy  showed  that  the 
sutured  perforation  was  soundly  closed.  One  case,  a  young  man,  brought 
to  me  by  Dr.  Godfrey,  was  operated  upon  twenty-four  hours  after  perfora- 
tion. There  was  one  perforation  in  the  ileum  and  considerable  fecal  ex- 
travasation. The  opening  was  large  and  the  stitches  would  not  hold.  The 
6  inches  of  bowel  between  the  ulcer  and  the  ileocecal  valve  presented 
several  ulcers  almost  perforated.  The  patient  was  too  weak  for  a  resec- 
tion. After  cleansing  the  abdomen  an  artificial  anus  was  made  proximal 
to  the  perforation.  The  patient  recovered  and  subsequently  the  anus  was 
successfully  abolished  by  resection.  In  another  case,  that  of  a  young  woman, 
on  opening  the  abdomen  violent  appendicitis  was  found,  the  appendix  being 
swathed  in  lymph  and  gangrenous.  The  appendix  was  removed.'  Search 
showed  a  perforation  in  a  loop  of  gut  2  feet  from  the  ileocecal  valve.  There 
was  considerable  extravasation.  The  perforation  was  closed.  The  perito- 
neum was  cleansed,  drainage  was  inserted,  and  the  patient  recovered.  Cul- 
tures from  the  appendix  and  from  the  peritoneal  cavity  showed  only  the  colon 
bacillus.  In  a  third  case,  that  of  a  young  woman,  impending  perforation  was 
diagnosticated  by  Dr.  Kalteyer  because  of  pain,  tenderness,  some  rigidity,  and 
definite  and  increasing  leukocytosis.  Two  ulcers  almost  but  not  quite 
perforated  were  found.  They  were  covered  over  by  the  use  of  inversion 
sutures,  the  wound  was  closed  without  drainage,  and  recovery  followed. 
Culture  from  the  peritoneal  cavity  was  negative.  These  3  successful 
cases  were  operated  upon  in  the  Jefferson  College  Hospital.  Harte  and  Ash- 
hurst  collected  the  cases  operated  upon  up  to  January,  1903.  There  were  362 
cases,  with  a  mortality  of  74.03  per  cent.  Dr.  F.  D.  Patterson  ("Am.  Jour. 
Med.  Sciences,"  May,  1909)  coUected  369  cases  occurring  since  the  paper  of 
Harte  and  Ashhurst.  Of  these  cases  242  died,  a  mortality  of  65.58  per  cent. 
The  perforations  were  located  as  follows:  stomach,  i;  jejunum,  i;  Meckel's 
diverticulum,  2;  ileum,  279;  cecum,  5;  appendix,  15;  colon,  12;  not  stated,  54. 


Primary  Intestinal  Tuberculosis  999 

Primary  Intestinal  Tuberculosis. — Although  intestinal  tuberculosis  is 
common  in  patients  with  chronic  pulmonary  tuberculosis,  primary  intestinal 
tuberculosis  is  a  rare  condition.  The  exact  propriety  of  rigidly  regarding  such 
cases  as  primary  is  doubtful.  Kocher's  cases  (reported  before  the  Swiss  Medi- 
cal Congress  in  1892)  came  from  tuberculous  stock,  and  suffered  in  infancy 
from  enlarged  glands,  pleurisy,  or  bronchitis,  and  that  surgeon  says  that,  in  all 
probability,  there  had  for  some  time  been  somewhere  in  the  body  a  latent 
tuberculous  focus,  and  from  this  focus  came  the  bacteria  which  attacked  the 
intestine.  Intestinal  tuberculosis,  in  the  victims  of  phthisis,  begins  with  the 
formation  of  multiple  ulcers,  due  to  swallowing  tuberculous  sputum.  Primary 
intestinal  tuberculosis  usually  begins  as  one  ulcer  or  several,  or  even  many 
ulcers  in  the  ileum  or  perhaps  in  the  cecum.  These  ulcers  when  they  heal  tend 
to  form  strictures  of  the  small  bowel,  seldom  of  the  large.  Primary  tuberculosis 
is  most  common  in  the  ileocecal  region.  It  may  exist  as  an  ulcerative  process 
with  inflammation  and  abscess  about  the  cecum  or  as  enormous  tumor-like 
thickening  of  the  cecum.  The  first  form  is  called  by  Hartmann  enter 0 peritoneal 
tiiherculosis.  The  second  form  is  called  hyperplastic  tuberculosis.  The  cecum 
may  be  involved  alone,  but  usually  a  portion  of  the  ileum  also  suffers.  The 
ulcers  cause  extensive  sloughing.  The  appendix  may  be  involved.  All  about 
the  cecum  a  multitude  of  adhesions  form  containing  masses  of  tuberculous  mat- 
ter, which  may  break  into  the  intestine,  through  the  skin  of  the  abdomen,  or 
in  both  directions.  (See  Hartmann,  in  "Revue  de  Chirurgie,"  Feb.,  1907.) 
Tuberculous  areas  suppurate.  In  tuberculosis  of  the  small  intestine  there  are 
bloody  diarrhea,  colicky  pain,  emaciation,  and  weakness.  There  are  very 
active  peristalsis  and  gurgling.  The  abdomen  may  be  tender.  The  bacilli 
may  be  found  in  the  stools.  As  ulcers  heal  strictures  develop  and  produce 
the  usual  symptoms.  Peritonitis  may  arise  or  death  may  be  due  to  pulmonary 
tuberculosis.  In  primary  intestinal  tuberculosis  the  urine  is  apt  to  show  the 
diazo-reaction  (Kocher) . 

In  h3^erplastic  (conglomerate)  tuberculosis  the  cecum  and  lower  end  of  the 
ileum  suffer  as  a  rule.  In  some  cases  the  colon  participates  in  the  process. 
Great  fibromatosis  with  adiposis  occurs  simulating  tumor  and  due  to  reaction  of 
tissue  against  infection.  Tuberculosis  of  the  ileocecal  region  is  most  common 
between  the  ages  of  twenty  and  forty.     There  is  seldom  demonstrable  phthisis. 

The  enteroperitoneal  form  of  ileocecal  tuberculosis  simulates  appendicitis. 
At  first  there  may  be  diarrhea,  the  liquid  stools  containing  blood.  Pain  in 
the  right  iliac  fossa  may  be  the  first  symptom.  In  any  case  pain  becomes 
the  permanent  symptom.  A  lump  can  be  palpated.  After  acute  pain  sub- 
sides the  lump  persists  and  increases.  There  may  be  attack  after  attack 
of  pain.  The  symptoms  of  abscess  arise.  Spontaneous  opening  finally 
occurs,  usually  about  Poupart's  ligament.  Several  fistulae  may  form.  Each 
fistula  discharges  pus  with  fecal  matter.  An  abscess  may  open  into  the 
intestine.  When  it  does,  pus  appears  in  the  stools.  Bacilli  may  be  found 
in  the  stools.  In  enteroperitoneal  tuberculosis  death  occurs  because  of  the 
development  of  pulmonary  tuberculosis  or,  in  a  small  number  of  cases,  by 
peritonitis  due  to  rupture  of  an  abscess  into  the  peritoneal  cavity  (Hartmann, 
Ibid.).  The  hyperplastic  form  develops  slowly,  the  individual  complaining  of 
indigestion  and  annoying  feelings  in  the  right  iliac  fossa.  During  many  months 
the  patient  feels  at  times  better  and  at  times  worse.  Then  food  begins  to  dis- 
agree radically.  Several  hours  after  a  meal  the  patient  suffers  from  colicky 
pain  in  the  right  iliac  region  and  distention  of  the  abdomen.  Severe  pain 
simulating  appendicitis  may  occur  intermittently.  Constipation  may  be  severe 
or  may  alternate  with  diarrhea.  Gradually  a  tumor  mass  forms,  evidences  of 
obstruction  become  obvious,  the  patient  becomes  weak  and  emaciated.  The 
lungs  are  involved  very  late,  if  at  all.     In  some  cases  ulceration  occurs.     Con- 


looo  Diseases  and  Injuries  of  the  Abdomen 

rath's  study  of  77  cases  led  him  to  believe  that  death  occurs  in  from  two  and 
one-half  to  three  years. 

Treatment  of  Primary  Intestinal  Tuberculosis. — In  the  first  stage  the  proper 
treatment  is  excision  of  ulcerated  areas,  possibly  excision  of  the  cecum.  Later, 
if  stricture  is  causing  chronic  obstruction,  an  operation  may  be  performed  to 
give  relief.  Laparotomy,  careful  separation  of  adhesions  which  are  not  fused 
with  the  gut,  and  the  introduction  of  iodoform  into  the  peritoneal  cavity  may 
prove  of  value.  Hartmann  ("Revue  de  Chirurgie,"  Feb.,  1907)  has  collected 
229  operations  for  ileocecal  tuberculosis,  viz.,  partial  excisions  of  the  cecum, 
resections  (with  end-to-end  anastomosis,  side-to-side  anastomosis,  or  end-to- 
side  implantation),  resections  in  two  seances,  ileocolostomies,  unilateral  exclu- 
sions, bilateral  exclusions,  and  other  operations.  There  were  46  deaths  in  these 
229  operations.  He  comments  on  the  fact  that  there  were  58  operations  with 
7  deaths  since  1900,  a  mortality  of  12  per  cent. 

Perforation  in  Intestinal  Tuberculosis. — By  this  term  we  mean  per- 
foration into  the  peritoneal  cavity,  not  into  another  segment  of  gut  and  not 
into  a  mass  of  adhesions.  It  is  supposed  to  be  a  rare  accident.  Cruice  esti- 
mates that  it  occurs  in  from  i  to  5  per  cent,  of  phthisis  cases  ("Am.  Jour.  Med. 
Sciences,"  Nov.,  191 1).  It  may  occur  in  either  the  primary  or  secondary 
tuberculosis  of  the  gut.  It  is  very  rare  in  ileocecal  tuberculosis,  commoner  in 
tuberculosis  of  the  small  bowel.  It  causes  sudden  and  severe  pain,  shock,  and 
usually  nausea  and  vomiting.  The  abdomen  becomes  rigid.  Distention  soon 
occurs.  Death  may  be  due  to  shock  or  peritonitis.  Now  and  then  a  perfora- 
tion causes  no  characteristic  sjonptoms  at  all  (Cruice,  Ibid.). 

Tuberculosis  of  the  Mesenteric  Glands  in  Children. — This  condi- 
tion is  very  common.  Corner  ("Lancet,"  Feb.  17,  1912)  makes  a  statement 
exactly  in  accord  with  my  own  experience  when  he  says  that  "tuberculous 
mesenteric  glands  will  be  found  in  practically  every  child  patient  submitted 
to  an  abdominal  operation."  They  are  often  recovered  from  unrecognized. 
They  may  produce  the  well-known  symptoms  of  tahes  mesenterica,  viz., 
greatly  enlarged  abdomen,  constipation  or  constipation  alternating  with  diar- 
rhea, loss  of  flesh,  anorexia,  anemia,  and  perhaps  a  palpable  mass.  There  are 
abdominal  pains  about  the  umbilicus,  coming  on  after  taking  food  and  par- 
ticularly common  at  night. 

In  some  cases  vomiting  occurs  and  pain  is  in  the  right  iliac  region  and  the 
case  is  mistaken  for  appendicitis.  In  such  a  case  the  pvilse  and  temperature 
are  normal  or  only  slightly  elevated  and  there  is  no  leukocytosis.  In  mesen- 
teric tuberculosis  the  appendix  is  apt  to  be  dilated,  constricted,  or  kinked. 
Mesenteric  tuberculosis  may  undergo  cure,  the  glands  becoming  fibrosed  and 
calcified.  It  may  lead  to  tuberculosis  of  the  intestine,  tuberculous  peritonitis, 
or  tuberculosis  in  some  distant  part. 

I  agree  with  Corner  that  the  abdomen  should  be  opened,  the  appendix  re- 
moved, and  the  patient  placed  a  long  time  on  full  antituberculous  treatment. 

Tumors  of  the  Intestine. — Innocent  Tumors. — ^Adenoma,  lipoma,  fibro- 
ma, myoma,  fibromyoma,  papilloma,  angioma,  and  chylangioma  may  occur. 
Such  tumors  are  rare.  If  attached  by  a  pedicle  or  stem  the  growth  is  called  a 
polypus.  Adenoma  is  the  commonest  tumor.  It  may  or  may  not  be  a  polyp. 
It  arises  from  an  intestinal  gland.  There  may  be  one,  several,  or  many. 
Adenomata  may  produce  no  symptoms,  may  cause  hemorrhage,  may  produce 
blocking,  or  may  lead  to  intussusception. 

Malignant  Tumors. — Sarcoma  is  very  rare,  but  does  sometimes  arise,  par- 
ticularly in  young  persons,  and  it  enlarges  very  rapidly.  It  is  most  prone  to 
attack  the  large  intestine.  Jopson  and  White^  reported  i  case  and  collected 
22  others.  The  mesenteric  glands  frequently  enlarge.  Cancer  is  not  uncom- 
^  "Am.  Jour.  Med.  Sciences,"  Dec,  1901. 


Appendicitis  looi 

mon,  attacking  especially  the  middle  aged.  According  to  Rolleston,  the  aver- 
age age  in  duodenal  cancer  is  fifty- two  years;  in  jejunal  and  iliac  cancer,  forty- 
seven;  in  cancer  of  the  cecum,  nearly  forty-eight,  and  in  cancer  of  the  rest 
of  the  large  intestine,  about  forty-nine  years.  It  is  most  common  in  the 
neighborhood  of  the  ileocecal  valve  and  in  the  sigmoid  flexure.  Ewald  col- 
lected 1 148  cases  of  cancer  of  the  intestine.  In  64  cases  the  cecum  was  in- 
volved; in  24  cases  the  ileum  was  involved.  There  is  pain  at  the  seat  of  growth. 
After  a  time  constipation  is  noted,  or  constipation  alternating  with  diarrhea. 
Finally,  intestinal  obstruction  occurs.  In  some  cases  the  symptoms  appear 
suddenly,  acute  obstruction  taking  place  or  intussusception  occurring.  It  is 
usually  possible  to  palpate  the  tumor,  which  is  hard  and  immovable.  The 
patient  wastes  rapidly  and  is  apt  occasionally  to  pass  blood  at  stool.  The 
growth  does  not  enlarge  very  rapidly  and  glands  are  not  involved  early.  In 
some  cases  the  supraclavicular  glands  enlarge.  In  more  than  one-half  of  the 
cases  which  die  of  intestinal  cancer  there  is  no  lymphatic  infection.^ 

Treatment. — Early  in  the  case  exploratory  laparotomy  should  be  per- 
formed, followed,  if  possible,  by  excision  with  end-to-end  or  side-to-side  approxi- 
mation. This  is  done  for  either  cancer  or  sarcoma.  It  may  be  possible  to 
remove  enlarged  glands.  In  cancer  of  the  cecum  extirpate  the  cecum  and  im- 
plant the  end  of  the  ileum  into  the  side  of  the  colon  (Wm.  J.  Mayo).  If  ex- 
cision is  impossible,  the  growth  should  be  side-tracked  by  performing  lateral 
anastomosis.  In  advanced  cancer  of  the  large  bowel,  if  resection  is  impossible, 
make  an  artificial  anus  above  the  tumor.    (See  Cancer  of  Rectum,  page  1187.) 

Appendicitis. — The  vermiform  appendix  is  found  in  man  and  anthropo- 
morphous apes.  Chimpanzees  in  captivity  are  apt  to  die  of  appendicitis. 
Some  mammals  "closely  allied  to  the  anthropomorphous  apes  possess  very 
large  ceca;  and  in  some  of  these  the  terminal  segment  of  the  cecum  resembles 
the  vermiform  appendix  in  that  it  possesses  a  very  large  proportion  of  the  pecu- 
liar kind  of  tissue  known  as  adenoid  or  lymphatic"  ("Evolution  and  Disease," 
by  Sir  J.  Bland-Sutton).  The  appendix  is  usually  regarded  as  a  vestigial  struc- 
ture. Prof.  Berry,  Dr.  Arthur  Keith,  and  some  others  regard  the  appendix  as 
a  specialized  region  of  the  cecum.  The  fact  that  the  appendix  of  a  newborn 
child  is  as  long  absolutely  as  the  appendix  of  a  full-grown  man  is  regarded 
by  Bland-Sutton  as  proof  "that  the  part  was  of  great  importance  to  the 
ancestors  of  the  human  species"  (Ibid.).  Appendicitis,  which  is  an  inflam- 
mation of  the  vermiform  appendix  of  the  cecum,  is  almost  invariably  the 
primary  lesion  of  all  of  those  various  conditions  known  as  t)q3hlitis,  perityph- 
litis, paratyphlitis,  etc. — terms  which  seldom  imply  pathological  entities,  and 
are  in  most  instances  well  relegated  to  obscurity.  I  say  in  most  instances, 
not  in  all,  because  I  believe  there  is  such  a  condition  as  primary  inflammation 
of  the  ceciun,  although  it  is  extremely  rare.  This  rare  condition  may  cause 
perforation,  perityphlitic  abscess,  or  peritonitis  when  the  appendix  is  sound. 
It  is  not  to  be  distinguished  clinicaUy  from  appendicitis  (McWiUiams,  in  "An- 
nals of  Siurgery,"  June,  1907).  Involvement  of  the  cecimi  as  a  result  of  appen- 
dicitis is  common.  Such  a  condition  should  be  expected  because  the  mucous 
membrane  is  continuous.  It  was  recognized  by  some  observers  many  years  ago 
that  such  a  disease  as  inflammation  of  the  appendix  existed,  but  the  majority 
of  the  profession  did  not  grasp  the  fact.  In  1 759  Mestevier,  of  France,  reported 
a  case  of  perforation  of  the  appendix  by  a  pin.^  In  181 2  a  perforated  ap- 
pendix was  shown  to  the  Medico-Chirurgical  Society  of  London,^  and  in  1835 
Southam  reported  an  appendiceal  abscess  (Manley).  In  1848  Hancock  re- 
ported an  appendiceal  abscess  ("Lancet,"  1848,  p.  380).     It  is  interesting  to 

^  Wm.  J.  Mayo,  "Jour.  Am.  Med.  Assoc,"  Oct.  19,  1901. 
-  "Jour.  Med.  Chir.  and  Pharm.,"  vol.  x,  1759. 
^  "Med.  and  Chir.  Trans.,"  London,  181 2,  vol.  iii. 


I002  Diseases  and  Injuries  of  the  Abdomen 

note  that  this  was  a  case  of  appendicitis  in  pregnancy.  Ten  days  after  a  pre- 
mature delivery  an  abscess  was  opened.  About  two  weeks  after  operation  two 
fecal  concretions  came  out  of  the  wound.  In  1827  Dr.  L.  Melier  described 
appendicitis,  and  named  among  its  symptoms  fixed  pain  in  the  right  iliac  fossa 
and  colic.  This  brilliant  and  original  young  Frenchman  was  years  ahead  of  his 
contemporaries.  He  reported  cases  of  undoubted  appendicitis  verified  by  au- 
topsy, described  gangrene,  perforation,  associated  peritonitis,  and  appendiceal 
concretions.  His  original  article,  Manley^  tells  us,  is  in  the  "Journal  of  Medi- 
cine, Surgery,  and  Pharmacy"  for  1827,. second  series,  no.  Howard  KeUy 
quotes  it  from  "Jo^-  gen.  de  med./'  1827,  vol.  c,  p.  317.  Melier  said:  "If  it 
were  possible  to  estabhsh  with  certainty  the  diagnosis  of  this  affection,  we  could 
see  the  possibility  of  curing  the  patient  by  operation.  We  shall  perhaps  some 
day  arrive  at  this  result."-  In  spite  of  Melier's  writings,  the  profession  adhered 
for  half  a  century  to  the  view  of  Dupuytren,  put  forth  in  1833,  that  abscesses  in 
the  ihac  region  take  origin  from  the  cecum  and  not  from  the  appendix.  Dr. 
Reginald  Fitz,  of  Boston,  in  1886  persuaded  the  world  that  the  appendix  is 
the  real  seat  of  most  inflammations  in  the  right  iliac  fossa,  and  introduced 
the  term  "appendicitis"  ("Am.  Jour.  Med.  Sciences,"  1886,  vol.  xcii).  This 
structure  is  particularly  liable  to  infection  because  of  the  large  amount  of 
lymphoid  tissue  in  its  make-up,  because  it  is  in  a  dependent  position,  is  always 
fuU  of  bacteria,  has  a  poor  blood-supply,  and  is  readily  blocked  by  kinking  or 
by  swelling  of  its  mucous  membrane.  Further,  as  a  vestigial  structure,  it 
has  a  low  resisting  power.  A  functionless  part,  like  a  loafer  in  a  city,  is  a  dan- 
gerous element.  Each  is  a  menace.  The  loafer  is  apt  to  become  a  criminal; 
the  appendix  is  apt  to  inflame  and  kiU.  The  appendix  is  a  long  and  narrow 
diverticulum  (musculomembranous  in  structure),  which  comes  from  the  pos- 
terior and  internal  part  of  the  cecum,  and  which  probably  has  no  physio- 
logical function.  The  structure  of  the  appendix  is  similar  to  the  structure 
of  the  colon,  except  that  the  muscular  structure  is  ill  developed  and  tri\ial 
in  amount.  Lockwood^  points  out  that  there  is  an  extensive  l\Tnph  system  in 
the  appendix,  and  that  the  submucous  and  subperitoneal  tissues  communicate 
by  nimaerous  gaps  in  the  muscles.  This  structure  has  a  poor  blood-supply,  and 
in  consequence  gangrene  occurs  from  rather  tri\aal  causes.  It  is  supplied  by  a 
branch  from  the  superior  mesenteric  arter}^  In  women  there  is  sometimes  an 
additional  supply  by  a  vessel  running  in  the  appendiculo-ovarian  Kgament. 
The  nerves  are  derived  from  the  superior  mesenteric  plexus.  The  appendix 
averages  about  4I  inches  in  length,  but  varies  in  size  between  the  limits  of 
J  inch  and  a  little  over  9  inches.  In  641  autopsies  the  longest  appendix  was 
9 1  inches  and  the  shortest  was  J  inch  (IVIonks  and  Blake).  Its  diameter  is,  as 
a  rule,  about  equal  to  that  of  a  No.  9  English  bougie;  its  canal  is  narrow  and  is 
partly  closed  by  the  valve  of  Gerlach  (Talamon).  The  appendix  enters  the 
cecum  at  its  posterior  internal  part,  which  is  usually  the  seat  of  the  most  intense 
pain  in  inflammation,  and  corresponds  to  a  point  on  the  surface  2  inches  from  the 
anterior  superior  spine  of  the  ilium,  on  a  line  drawn  from  the  umbilicus  to  the 
fliac  spine,  which  is  known  as  McBurney's  point.  The  free  part  of  the  ap- 
pendix in  one-third  of  all  persons  is  in  relation  ^^-ith  the  posterior  surface  of 
the  cecum;  in  almost  one- third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that 
if  perforation  occurs  the  contents  will  be  voided  into  the  retroperitoneal  tissue 
(iliac  abscess).  In  some  cases  it  is  external  to  the  cecum;  in  some  it  passes 
downward,  and  in  some  inward.  It  is  important  to  remember  that  the  appen- 
dix may  be  met  with  in  the  most  unexpected  situations.  When  the  ascend- 
ing colon  is  displaced,  the  diverticulum  may  be  upon  the  left  side.     It  is  not 

1  "Med.  Record,"  July  19,  1902. 

2  See  R.  J.  Lee  Morrill's  article  in  the  "Amer.  Med.  Surg.  Bull.,"  Dec.  19,  1896. 
^  "Brit.  ]Med.  Jour.,"  Jan.  27,  1900. 


Etiology  and  Pathology  of  Appendicitis  1003 

unusual  to  find  its  tip  in  the  middle  line,  up  toward  or  adherent  to  the  gall- 
bladder, or  in  the  pelvis.  In  about  two-thirds  of  all  cases  the  appendix  is  com- 
pletely covered  by  peritoneum;  in  one- third  of  all  cases  it  is  in  contact,  in 
some  part  of  its  length,  with  cellular  tissue  (Talamon).  Byron  Robinson  has 
called  attention  to  the  fact  that  the  appendix  in  men  is  frequently  in  contact 
with  the  psoas  muscle,  and  may  be  bruised  by  this  muscle.  In  10,000  autopsies 
the  appendix  is  said  to  have  been  absent  five  times.  In  most  cases  in  which 
surgeons  have  been  unable  to  find  the  appendix  it  was  not  absent,  but  was  cov- 
ered by  peritoneum.     Occasionally  the  appendix  is  found  in  a  hernial  sac. 

Etiology  and  Pathology. — Appendicitis  is  very  rare  in  infants.  I  operated 
unsuccessfiilly  on  a  male  two  years  of  age  for  gangrenous  appendicitis.  Savage 
operated  unsuccessfully  on  a  baby  sLxty-one  days  old,  and  Weiss  operated  un- 
successfully on  a  child  twenty  months  old.^  J.  P.  Crozer  Griffith"  has  collected 
15  cases  in  children  under  two  years  of  age.  One  of  these  patients  was  three 
months  old.  Nine  of  the  1 5  were  operated  upon,  with  7  recoveries.  In  4  of  the 
cases  the  appendix  was  in  the  scrotum.  In  2  cases  a  diagnosis  of  intussuscep- 
tion was  made.  In  children  nine  or  ten  years  old  the  disease  is  by  no  means  in- 
frequent (see  page  1013),  Appendicitis  is  common  at  any  period  beyond  child- 
hood, being  more  frequent  in  young  and  middle-aged  people  than  in  the  aged. 
It  is  about  four  times  as  common  in  males  as  in  females.  It  is  more  common  in 
summer  than  in  other  seasons,  and  in  warm  countries  than  in  cold  or  temperate 
climes.  Appendicitis  is  a  bacterial  disease.  It  is  produced  occasionally  by 
pus  cocci,  but  most  commonly  by  the  action  of  the  Bacterium  coli  commune  of 
Escherich.  The  colon  bacilli,  which  normally  inhabit  the  appendLx,  are  harm- 
less when  the  appendix  is  healthy,  but  become  active  for  harm  when  the 
diverticulum  is  bruised,  obstructed,  irritated  by  the  presence  of  uric  acid,  con- 
gested because  of  chilling  of  the  cutaneous  surface  of  the  body,  or  distended  by 
the  ingress  of  colonic  fluid  (C.  Van  Zwulenburg,  in  "Annals  of  Surgery,"  March, 
1905).  It  seems  probable  that  flatulent  distention  of  the  colon  may  be  re- 
sponsible for  forcing  fecal  matter  in  quantity  into  the  appendix  and  may  lead 
to  plugging  of  the  opening  (Rubin,  in  "Jour.  Am.  Med.  Assoc,"  vol.  xliii,  No. 
18).  When  inflammation  occurs,  swelling  of  the  mucous  membrane  may  oc- 
clude the  opening  into  the  colon.  If  this  occurs,  the  lumen  of  the  appendix 
is  dilated,  filled  up,  and  becomes  distended  by  a  thick  mucopurulent  fluid. 
Ulcers  sometimes  form  which  may  only  involve  the  mucous  membrane,  may 
pass  deeply  into  the  coats,  or  may  even  perforate.  Dieulafoy^  maintains  force- 
fully that  appendicitis  is  due  always  to  the  conversion  of  the  appendLx  into  a 
closed  cavity,  but  cases  are  met  with  which  disprove  this  assertion.  Various 
conditions  may  bring  about  this  transformation.  Partial  obstruction  may  be 
caused  by  calculi,  which  are  composed  of  stercoral  material  and  hordes  of  bac- 
teria mixed  with  salts  of  lime  and  magnesia.  These  calculi  are  not  formed  in 
the  colon,  but  are  formed  in  the  appendix.  The  theory  that  concretions  form 
in  the  colon  and  are  forced  into  the  appendix  by  peristalsis  has  been  very 
largely  abandoned.  Dieulafoy  speaks  of  the  condition  as  appendicular  lithiasis, 
and  says  it  has  a  tendency  to  run  in  family  lines,  and  has  a  kinship  to  gout 
and  rheumatism.  Obstruction  may  be  caused  by  local  infection  of  a  catarrhal 
area,  by  the  formation  of  a  fibrous  stricture,  or  by  several  causes  acting  in 
unison.  The  presence  of  a  concretion  is  always  dangerous.  It  is  frequently 
associated  with  ulceration,  either  as  cause  or  effect.  It  is  a  mass  of  virulent 
bacteria.  It  may  lead  to  perforation  or  gangrene.  Talamon  taught  that  the 
appendix  resents  the  presence  of  the  concretion,  reflex  contraction  of  the 
muscular  coat  taking  place,  which  is  accompanied  by  violent  pain  {appendicular 
colic) .     The  muscular  structure  is  so  rudimentary^  that  it  does  not  seem  probable 

1  Manley,  in  "Med.  Record,"  July  9, 1902.         -  "University  of  Penna.  Med.  Bull.,"  Oct.,  1902. 
"  "Progres  medicale,"  No.  11,  1896. 


I004  Diseases  and  Injuries  of  the  Abdomen 

that  attempts  at  contraction,  even  should  they  arise,  would  produce  \aolent  pain 
and  distant  symptoms.  Pozzi^  believes  that  appendicular  colic  may  be  caused 
by  torsion  or  bending  of  the  appendix  or  malposition  of  the  diverticulum,  and 
holds  that  pain  may  arise  when  there  is  no  lesion  in  the  appendix  and  no  inflam- 
mation of  the  peritoneimi  or  pericecal  structures.  What  is  called  appen- 
dicular coUc  is  really  inflammation  of  the  appendix  without  involvement  of 
the  peritoneum.  The  term  "appendicular  colic"  has  led  to  much  injudicious 
conservatism,  and,  as  Lockwood  shows,  if  an  appendix  is  removed  from  an 
individual  who  suffers  from  attacks  of  appendicular  colic,  it  will  usually  be 
found  that  the  diverticulum  is  inflamed  or  the  lumen  contains  a  concretion.  For- 
eign bodies,  such  as  pins,  fish-bones,  nails,  buttons,  date-stones,  cherry-stones, 
and  grape-seeds,  may  enter  the  appendix,  but  they  do  so  far  less  often  than  is 
generally  supposed,  most  alleged  grape-seeds  from  the  appendix  being  fecal  con- 
cretions. Fitz  found  concretions  in  15  cases  out  of  300.  Ranvier  collected 
the  records  of  459  postmortems,  and  found  reported  179  fecal  concretions  and 
16  foreign  bodies.  In  Burgess's  500  cases  fecal  concretions  were  found  in  21 
per  cent.  ("Brit.  Med.  Jour.,"  Feb.  24,  1912).  Appendicitis  due  to  a  foreign 
body,  such  as  a  grape-seed  or  a  pin,  is  known  as  foreign-body  appendicitis;  ap- 
pendicitis in  which  a  concretion  is  the  assumed  cause  is  known  as  stercoral.  A 
foreign  body  may  produce  instant  perforation.  If  impaction  of  a  foreign  body 
or  concretion  occurs,  the  ori&ce  of  the  appendix  is  closed,  the  circulation  is  soon 
cut  off,  the  secretions  are  retained,  the  coats  become  congested,  the  diverticulum 
enlarges  enormously,  microbes  multiply  with  great  rapidity,  and  the  wall  of  the 
congested  appendix  inflames  and  may  become  gangrenous  or  ulcerated,  and  is 
finally  perforated.  Interference  with  the  blood-supply  of  the  appendix  wiU 
predispose  to  appendicitis.  This  may  be  brought  about  by  twists,  bruises, 
adhesions,  concretions,  pressure,  or  bands;  and  the  psoas  muscle  may  play  a 
part  in  the  production  of  these  conditions.  In  women  appendicitis  is  occa- 
sionally secondary  to  tubo-ovarian  disease.  Appendicitis  is  rarer  in  women 
than  in  men,  probably  because  in  many  females  the  appendix  has  a  better  blood- 
supply  than  in  males,  the  additional  supply  coming  through  the  folds  of  the 
appendiculo-ovarian  ligament.  In  women  disease  of  the  uterus  or  adnexa 
frequently  precedes  or  actually  causes  appendicitis.  Catarrhal  conditions  of 
the  intestine,  habitual  constipation,  and  indigestion  with  flatulence  predispose 
to  appendicitis.  In  fact,  in  a  great  many  cases  there  has  been  a  more  or  less 
prolonged  history  of  diarrhea  or  constipation  and  flatulent  indigestion  before  the 
development  of  acute  appendicitis.  An  acute  attack  of  appendicitis  may  arise 
after  the  eating  of  a  large  and  indigestible  meal,  especially  if  such  a  meal  was 
taken  late  at  night.  Bolting  the  food  and  eating  large  meals  at  irregular  hours 
predispose  to  an  attack.  It  seems  probable  that  catarrhal  appendicitis  may 
result  from  extension  of  catarrh  of  the  colon,  and  possible  that,  in  rare  cases, 
appendicitis  may  arise  from  external  traimiatism  (traumatic  appendicitis) .  In 
most  cases,  however,  in  which  appendicitis  seems  to  be  produced  by  a  blow, 
the  injury  at  most  simply  "awakened  a,  sleeping  dog"  and  stirred  into  acute 
inflammation  an  appendix  already  diseased.  It  is  weU  to  be  skeptical  as  to  ex- 
ternal force  causing  appendicitis.  Sprengel  ("Deut.  med.  Woch.,"  Dec.  14, 
191 1)  says  there  is  no  case  in  Hterature,  in  which  abdominal  trauma  is  alleged 
as  the  cause,  confirmed  by  scientific  evidence.  If  before  perforation  the  ap- 
pendix adheres  to  the  cellular  tissue  behind  the  cecimi,  cellulitis  or  abscess 
without  peritonitis  may  result.  When  appendicitis  goes  on  to  perforation,  there 
is  always  some  peritonitis;  but  if  the  steps  to  perforation  are  gradual,  and  if  the 
causative  organism  is  the  colon  bacillus,  the  peritonitis  may  be  local.  Some- 
times, by  formation  of  adhesions,  a  barrier  is  made  between  the  appendix  and  the 
peritoneal  ca\'ity  before  perforation  occurs.  When  perforation  takes  place  sud- 
1  "Progres  medicale,"  No.  ig,  1896. 


Forms  of  Appendicitis  1005 

denly  peritonitis  is  inevitable.  When  the  causative  organism  is  the  strepto- 
coccus, general  peritonitis  is  very  apt  to  arise.  Peritonitis  may  arise  without  per- 
foration by  contiguity  of  structure  or  by  migration  of  bacteria  through  the 
congested  walls  of  an  obstructed  appendix.  In  some  cases  perforation  takes 
place  into  the  peritoneal  ca\'ity,  but  pus  is  circumscribed  by  matting  together 
of  the  intestines  with  plastic  exudate.  The  appendix  may  become  gangrenous 
ver\-  rapidly  or  after  some  time.  A  case  of  appendicitis  in  which  gangrene  and 
perforation  come  on  very  quickly  is  spoken  of  as  jidminating  appendicitis. 
In  some  cases,  if  the  perforation  is  ven,'  small  and  the  appendix  is  swathed  in 
l>Tnph,  or  if  perforation  does  not  occur,  the  inflammation  may  subside.  Per- 
foration rarely  occurs  from  liquid  pressure  or  from  the  pressiure  of  a  concretion; 
it  is  generally  due  to  ulceration  produced  by  the  action  of  micro-organisms. 
Appendicitis  which  subsides  may  at  any  time  recur,  and  the  life  of  such  a 
patient  is  under  constant  menace.  An  enormous  number  of  people  have  had 
appendicitis.  Toft  recorded  500  autopsies,  and  in  36  per  cent,  of  them  there  were 
positive  signs  of  past  attacks.  The  disease  is  occasionally  unsuspected  during 
life.     These  facts  prove  that  the  disease  may  subside  without  the  aid  of  surgen,'. 

Forms  of  Appendicitis. — In  what  is  known  as  appeiidicidar  colic  the  ap- 
pendix is  temporarily  obstructed  because  of  transitory  inflammator}^  swelling 
of  the  mucous  membrane  of  the  outlet,  and  the  stercoral  contents  are  retained 
in  the  diverticulum.  The  peritoneal  covering  is  not  involved  in  the  inflamma- 
tion. This  condition  is  called  by  Fergusson  constipation  of  the  appendix.  If 
not  relieved,  it  will  eventuate  in  appendicitis  with  involvement  of  the  perito- 
neal coat.  It  is  an  ujifortunate  term,  sometimes  used  as  an  excuse  for  avoid- 
ing operation.     In  such  cases  a  concretion  is  frequently  or  usually  present. 

Simple  parietal  or  catarrhal  appendicitis  does  not  remain  limited  to  the 
mucous  membrane;  hence  the  term  catarrhal  is  not  strictly  correct.  The 
vessels  of  the  appendix  are  distended  with  blood,  the  lumen  at  the  intes- 
tinal end  becomes  partiaUy  or  completely  obstructed,  the  epithelium  des- 
quamates from  numerous  glands,  the  mucosa  ulcerates,  and  the  lumen  of 
the  appendix  becomes  fifled  -^-ith  a  mixture  of  mucus,  bacteria,  and  por- 
tions of  organic  matter.  Bacteria  enter  the  h-mph-spaces  of  the  wall  of  the 
appendix,  and  pass  rapidly  from  the  subm.ucous  to  the  subperitoneal  tissues. 
In  from  twelve  to  thirty-sLx  hours  after  the  mucous  coat  begins  to  inflame 
the  peritoneal  coat  will  probably  be  involved.  The  inflammation  may  undergo 
resolution  and  the  patient  get  weU,  or  a  wait  for  cure  may  result  disastrously. 
The  appendix  may  thicken,  ulceration  may  take  place,  and  peritonitis  may 
arise.  Suppuration  or  gangrene  may  occur,  perforation  may  take  place,  or 
pyemia,  with  abscess  of  the  Hver,  may  arise.  The  acute  condition  may  pass  into 
chronic  appendicitis  or  ulcerations  of  the  mucosa  may  remain:  the  mucous 
cn,-pts  may  be  filled  with  bacteria:  a  concretion  may  exist:  cicatricial  con- 
tractions may  occur.  In  any  of  these  conditions  the  patient  is  in  danger  of  a 
fresh  attack  at  any  time.  In  a  catarrhal  inflammation  secondary"  to  catarrh  of 
the  colon  the  case  may  be  chronic  from  the  beginning.  If  the  lumen  of  the 
appendix  is  gradually  and  completely  obliterated  the  condition  is  denominated 
obliterative  appendicitis  (Senn).  This  progressive  obHteration  may  result 
from  repeated  attacks  of  inflammation  or  may  simply  be  a  degenerative  change. 
Recurrent  appendicitis,  it  was  once  said,  may  be  due  to  inordinate  size  of  the 
mouth  of  the  appendix,  making  of  this  diverticulum  a  drag-net  for  foreign 
bodies;  but  we  now  know  that  it  is  more  probably  due  to  smaUness  of  the 
opening,  so  that  it  quickly  closes  from  shght  swelling  and  converts  the  appen- 
dix into  a  closed  vase  flUed  with  septic  material.  Suppurative  appendicitis 
is  due  to  purulent  infiltration  of  the  walls.  Pus  in  the  lumen  is  not  purulent 
appendicitis.  Pus  may  form  about  the  appendix,  a  condition  kno-^Ti  as  appen- 
diceal or  appendicidar  abscess.    Gangrenous  appendicitis  is  a  moist  or  septic 


ioo6  Diseases  and  Injuries  of  the  Abdomen 

gangrene,  due  to  interference  with  the  circulation  and  to  tissue  destruction  by 
the  action  of  micro-organisms.  Perforation  occurs  and  multiple  perforations 
are  common.  The  entire  appendix  may  slough  off.  Interference  with  circu- 
lation may  be  caused  by  an  obstruction,  by  a  bend  or  twist  or  bruise  of  the  ap- 
pendix, or  by  the  action  of  virulent  organisms  on  an  appendix  whose  tissue 
resistance  is  lowered  by  injury  or  disease.  In  gangrenous  cases  the  vessels  of 
the  meso-appendix  are  usually  obstructed  by  thrombi  of  the  veins  or  arteries. 
In  rare  instances  appendicitis  is  due  to  tuberculous  ulceration,  in  other  cases  to 
typhoid  ulceration,  and  genuine  appendicitis  may  arise  during  typhoid  fever. 
Fowler  suggests  the  following  classification  of  cases  of  appendicitis:  Endo- 
appendicitis;  parietal  appendicitis;  peri-appendicitis;  para-appendicitis. 

As  a  matter  of  fact,  appendicitis  is  always  one  disease  which  varies  in  inten- 
sity and  complication.  It  is  useless  to  divide  it  into  a  great  number  of  symp- 
tomatic groups. 

Symptoms  and  Signs. — In  what  is  known  as  appendicular  colic  the  pa- 
tient suffers  from  disorder  of  digestion  and  occasionally  has  a  brief  attack  of 
abdominal  pain  associated  with  trivial  and  temporary  tenderness  in  the  right 
iliac  fossa.     The  colicky  pain  is  about  the  umbilicus  and  right  iliac  fossa;  there 
is  often  nausea  and  usually  constipation.     This  condition,  if  not  soon  reUeved, 
is  followed  by  the  evidences  of  peritoneal  inflammation.     The  symptoms  of 
genuine  acute  appendicitis  are  as  follows:  In  some  cases  the  disease  seems  to 
begin  suddenly,  but  in  most  of  the  cases  there  are  noted  for  a  few  hours  or  even 
for  a  day  or  two  distinct  premonitory  symptoms,  among  which  are  constipation 
or  diarrhea,  flatulence,  nausea,   anorexia,    dyspepsia,    coated   tongue,  weak- 
ness, general  gastro-intestinal  uneasiness,  cohcky  pain  about  the  umbilicus, 
and,  perhaps  soon,  tenderness,  a  sense  of  weight,  soreness,  or  uneasiness  in 
the  right  iliac  fossa.     The  acute  symptoms  suddenly  appear  after  the  pre- 
monitory symptoms  have  lasted  a  variable  time,  and  the  acute  symptoms  very 
frequently  appear  in  the  early  hours  of  the  morning.     The  first  definite  symp- 
tom is  severe  coHcky  pain.     The  tongue  is  coated  and  usually  dry.     Great 
thirst  is  often  complained  of.     The  face  is  expressive  of  pain  or,  later,  in  a 
severe  case,  becomes  Hippocratic.      The  posture  assumed  for  greater  ease  is 
one  of  recimibency,  with  the  right  thigh  and  knee  or  both  thighs  and  knees 
partly  flexed.     Respirations  in  acute  appendicitis  are  shallow  and  thoracic. 
The  development  of  acute  pain  is  usually  the  most  prominent  s^^mptom. 
The  pain  is  at  first  colicky  and  located  about  the  umbilicus  or  through  the 
abdomen  in  general,  this  distant,  primary,  or  generalized  pain,  according  to 
Treves,  corresponding  to  the  distribution  of  the  superior  mesenteric  plexus. 
Mr.  Burgess  ("Brit.    Med.    Jour.,"  Feb.  24,  191 2)  states  the  present  view 
when  he  says  that  the  primary  pain  is  referred  to  "the  peripheral  distribution  of 
the  spinal  nerves  arising  from  those  segments  of  the  spinal  cord  with  which  the 
appendix  and  small  intestine  are  connected  through  their  sympathetic  nerve 
supply — eighth  to  eleventh  dorsal."     This  primary  pain  may  subside  if  the 
appendix  succeeds  in  emptying  its  contents  into  the  colon,  but  it  may  also 
subside  if  the  appendix  becomes  gangrenous  or  ruptures  (Murphy).     Usually 
in  from  twelve  to  thirty-six  hours  the  pain  becomes  localized  in  the  right  iliac 
fossa,  and  associated  with  tenderness  and  hyperesthesia  of  the  skin — in  other 
words,  true  inflammatory  pain  develops.     It  is  due  to  peritoneal  inflamma- 
tion.    "Thus,  the  closer  the  situation  of  the  appendix  to  the  parietal  peritoneum, 
the  earher  will  the  latter  be  irritated  and  the  sooner  will  the  pain  be  locaHzed" 
(Burgess,  Ibid.).     The  usual  location  of  the  pain  in  the  right  iliac  fossa  depends 
on  the  fact  that  the  appendix  is  usually  placed  in  that  region.     Occasionally, 
when  the  appendix  crosses  the  belly,  the  pain  is  located  on  the  left  side,  and 
occasionally,  for  like  reasons,  in  the  gall-bladder  region,  the  right  loin,^  or  the 
pelvis.     "If  the  appendix  lies  among  coils  of  small  intestine  or  in  the  pelvis  there 


APPENDICITIS. 


Plate  io. 


.X3**'" 


Various  forms  of  appendicitis  (from  drawings  by  Dr.  M.  H.  Richardson):  i.  Obstruction  from 
stenosis  of  appendix.  2.  Dilatation  of  distal  end  of  appendix  ;  perforation  by  a  fecal  concretion 
3.  Gangrene  of  nearly  the  whole  of  the  appendi.x  ;  fecal  concretion  in  lumen. 


Symptoms  and  Signs  of  Appendicitis  1007 

may  at  no  time  be  local  pain,  the  initial  umbilical  pain  becoming  steadily  general- 
ized" (Burgess,  "Brit.  Med.  Jour.,"  Feb.  24,  1912).  If  the  pain  of  appendicitis 
is  \'iolent  the  patient  presents  some  evidences  of  shock.  Nausea  is  the  rule  in 
appendicitis ;  vomiting  usually  occurs  early — about  three  or  four  hours  after  the 
beginning  of  pain.  In  children  vomiting  is  often  early,  violent,  and  persistent, 
but  in  adults,  after  the  early  hours  of  the  attack,  vomiting  occurs,  as  a  rule,  occa- 
sionally or  not  at  all,  although  nausea  is  complained  of.  Early  vomiting  is  a 
reflex  s\Tnptom  due  to  distention  of  the  appendix  (Murphy).  If  vomiting  per- 
sists, it  points  to  peritonitis,  to  pus  formation,  or  to  intestinal  obstruction  unless 
it  results  from  the  administration  of  morphin.  There  is  usually  constipation  in 
acute  appendicitis,  although  diarrhea  occasionally  occurs.  In  appendicitis 
there  is  always  some  elevation  of  temperature,  although  it  may  be  very^  slight 
and  of  brief  duration.  The  fever  is  not  ushered  in  by  a  chill,  but  the  tempera- 
tuie  mounts  in  the  course  of  a  few  hours  to  102°  or  103°  F.  or  even  higher. 
The  fever  does  not  begin  imtil  several  hours  or  a  niunber  of  hours  after  the 
onset  of  pain.  In  a  ver}^  mild  case  the  temperature  remains  elevated  for  a 
day  or  two  and  then  falls  to  normal.  In  severe  cases  it  is  apt  to  remain  ele- 
vated for  a  longer  period,  but  it  is  always  to  be  borne  in  mind  that  in  very 
grave  appendicitis  the  surgeon  may  find  very  little  elevation  of  temperature, 
no  elevation,  or  actually  a  subnormal  temperature.  In  gangrenous  cases,  and 
in  cases  in  which  a  large  perforation  suddenly  forms,  and  when  general  perito- 
nitis develops,  there  is  usually,  for  a  time  at  least,  a  subnormal  temperature. 
A  siidden  drop  of  temperature  indicates,  as  a  rule,  a  calamity,  particularly 
gangrene  of  the  mucosa  of  the  appendix,  which  prevents  absorption  (Murphy) , 
or  perforation  of  the  appendix.  Leukocytosis  is  usually  present  (see  Diagno- 
sis). The  pulse  in  appendicitis  is  in  most  cases  rapid.  A  ven,^  rapid  pulse 
(well  over  100)  is  significant  usually  of  a  severe  case,  and  the  auguries  are 
especially  ominous  if  the  pulse  is  rapid  but  the  temperatvire  is  normal  or  sub- 
normal.    Occasionally,  however,  a  slow  pulse  exists,  even  in  the  worst  cases. 

Examination  of  the  abdomen  may  discover,  early  in  the  case,  general 
abdominal  rigidity;  but  usually  in  the  course  of  twenty-four  hours  or  more  the 
general  rigidity  passes  away,  the  abdomen  distends  more  or  less,  and  rigidity  of 
the  lower  half  of  the  right  rectus  muscle  becomes  evident  and  persists.  If  gen- 
eral peritonitis  begins  early,  general  abdominal  rigidity  does  not  abate  or  pass 
away.  If  general  peritonitis  begins  later,  general  abdominal  rigidity,  which  was 
present  at  first  but  which  passed  away,  returns.  Rigidity  may  not  exist  in  the 
very  beginning  of  appendicitis,  in  a  case  in  which  the  appendix  is  retrocecal 
or  pehdc,  in  some  abscess  cases,  or  in  a  case  with  relaxed  belly  walls. 

A  s^onptom  almost  invariably  present  in  appendicitis  is  tenderness.  In 
some  cases  the  tenderness  is  diffuse;  in  most  it  is  locahzed,  or  at  least  most 
acute,  in  the  right  ihac  fossa.  The  point  where  tenderness  is  usually  most 
acute  is  a  spot  about  2  inches  internal  to  the  anterior  superior  spine  of  the  ilium, 
on  a  line  drawn  from  that  bony  point  to  the  imibihcus  {omphalospinoiis  line). 
This  is  known  as  McBiirney's  paint,  and  overhes  the  usual  point  of  origin 
of  the  appendix.  In  some  cases,  however,  the  greatest  point  of  tenderness  is 
nearer  the  gall-bladder;  in  others,  in  the  loin;  in  others,  toward  the  umbilicus, 
in  the  midline,  or  on  the  opposite  side;  in  others,  in  the  rectum.  The  seat  of 
greatest  tenderness  depends  on  the  situation  of  the  appendix,  and  it  is  usually 
at  McBurney's  point,  because  this  usually  overhes  the  origin  of  the  appendix. 
The  lesson  is  that  in  appendicitis  there  is  a  point  of  tenderness  or  of  greatest 
tenderness  in  a  region  which  the  appendix  could  occupy.  If  tenderness  exists 
on  the  right  side  and  then  develops  in  the  left  side,  severe  spreading  perito- 
nitis usually  exists  (W.  Meyer).  WTien  the  appendix  becomes  gangrenous, 
local  tenderness  may  for  a  time  disappear,  because  the  peritoneum  of  the 
involved  region  has  become  anesthetic;  later,  however,  it  returns,  spreads. 


ioo8  Diseases  and  Injuries  of  the  Abdomen 

and  may  become  general.  In  view  of  the  fact  that  tenderness  in  the  right 
iliac  fossa  is  often  demonstrable  in  tubal  and  ovarian  disease,  the  sign  in  males 
"is  of  greater  significance  than  in  females"  (A.  H.  Tubby,  on  "Appendici- 
tis," in  "Medical  Monograph  Series").  Pressure  upon  the  left  side  will,  in  some 
cases,  cause  pain  in  the  right  iliac  region.  When  rigidity  abates  or  disap- 
pears the  case  may  go  on  to  cure,  but  sometimes  a  mass  becomes  evident  in 
the  right  iliac  fossa.  The  mass,  of  variable  shape,  is  at  first  hard,  and  if  of 
any  considerable  size,  is  dull  on  percussion.  In  some  cases  when  no  mass  is 
palpable  through  the  abdominal  wall,  rectal  examination  detects  one.  This 
mass  may  be  agglutinated  bowel  and  omentum  or  a  collection  of  coagulated 
inflammatory  exudate.  It  may  gradually  disappear  or  an  abscess  may  form. 
The  evidences  of  general  peritonitis  are:  great  distention  because  of  intestinal 
paresis,  general  abdominal  tenderness,  rectal  tenderness,  very  rapid  pulse, 
hiccup,  persistent  vomiting  which  may  become  regurgitation,  and,  as  Meyer 
points  out,  percussion  dulness  over  the  right  iliac  region  or  entire  lower  abdomen. 

In  some  cases  the  symptoms,  at  first  trivial,  become  grave.  In  some  all 
the  symptoms  are  violent  from  the  beginning,  the  attack  tends  to  linger,  and 
is  followed  by  persistent  soreness  of  the  appendix  and  harassing  digestive  dis- 
turbances. Any  case  of  appendicitis  may  become  all  of  a  sudden  desperately 
grave  because  of  perforation  or  gangrene,  and  in  any  case  general  peritonitis 
may  develop.  After  sudden  perforation  or  rapid  gangrene  the  temperature 
falls,  hiccup  begins,  abdominal  distention,  pain,  and  tenderness  become 
marked  and  general,  and  the  pulse  becomes  very  rapid.  In  some  cases  these 
grave  symptoms  are  present  almost  from  the  start  (fulminating  cases).  A 
sudden  perforation  produces  collapse  and,  if  reaction  takes  place,  general 
peritonitis  arises.  Peritonitis,  be  it  remembered,  may  arise  without  either 
perforation  or  gangrene.  If  pus  forms,  it  may  be  unlimited  by  adhesions. 
In  such  cases  there  is  the  rapid  onset  of  fatal  peritonitis  and  septicemia. 
Pus  may  be  limited  by  adhesions  and  be  practically  extraperitoneal.  In 
such  a  case  a  lump  is  felt  in  the  right  iliac  region,  but  dusky  discoloration 
and  edema  of  skin  very  seldom  exist.  The  surgeon  does  not  wait  for  fluctua- 
tion before  he  makes  a  diagnosis.  In  an  abscess  case  there  are  usually  ir- 
regular fever  and  sweating,  but  rigors  do  not  occur.  Hawkins  says  we  should 
always  suspect  pus  if  the  symptoms  continue  after  the  sixth  day,  and  par- 
ticularly when  the  symptoms  abate  and  suddenly  increase  between  the  seventh 
and  tenth  days.  A  limited  collection  of  pus  may  be  liberated  into  the  peri- 
toneal cavity  by  rupture  of  the  abscess  wall.  Such  a  rupture  may  be  caused  by 
pressure  or  muscular  effort;  rupture  is  foUowed  at  once  by  shock  and  later  by 
diffused  peritonitis.  An  abscess  may  rupture  externally  or  into  the  vagina, 
intestinal  tract,  or  bladder.  It  is  desirable,  if  possible,  to  locate  the  situation 
of  the  appendix,  and  this  is  usually  determined  by  locating  the  seat  of  swelling 
and  of  greatest  tenderness.  The  surgeon  should  not  lose  sight  of  the  fact  that 
the  appendix  may  be  found  in  the  most  unexpected  situations.  In  every  case 
a  rectal  or  vaginal  examination  should  be  made  in  order  to  detect  swelling 
and  tenderness,  and  thus  determine  if  the  inflammation  took  origin  in  or  has 
come  to  involve  the  pelvic  region.  Pain  at  the  end  of  micturition  points  to 
involvement  of  the  vesical  peritoneum.^  In  cases  in  which  there  is  no  localized 
swelling  and  no  local  tenderness — for  instance,  in  gangrenous  or  perforative 
appendicitis  with  general  peritonitis — "diagnostic  localization"  is  impossible 
(Van  Hook). 

Terminations    and    Prognosis. — ^Acute    appendicitis    may    terminate    in 

death,  in  complete  recovery,  or  in  a  condition  of  lowered  vitality  during 

the  existence  of  which  acute  attacks  are  almost  certain  to  occur.     Sometimes 

after  and  sometimes  without  an  antecedent  acute  attack  the  patient  develops 

^  Van  Hook,  in  "Jour.  Am.  Med.  Assoc,"  Feb.  20,  1897. 


Terminations  and  Prognosis  of  Appendicitis  1009 

persistent  soreness  and  tenderness  in  the  right  ihac  region.  Between  the 
attacks  of  recurrent  appendicitis  there  may  be  soreness,  tenderness,  and 
gastro-intestinal  disturbance,  or  there  may  be  no  e\ddent  trouble  ^Yhatever; 
yet,  even  in  the  latter  case,  there  may  be  an  ulcer  or  ulcers  of  the  mucous 
lining.  If  a  patient  has  once  had  appendicitis  he  will  always  be  Hable  to 
sutler  from  another  attack  if  the  appendix  has  not  been  removed.  The 
liability  becomes  almost  a  certainty  if  the  intestinal  end  of  the  appendix 
is  narrowed  or  if  the  lumen  is  obstructed  at  any  point,  if  a  concretion  exists, 
or  if  there  is  an  area  of  ulceration  or  of  desquamating  epithelium.  After 
an  attack  the  appendix  may  remain  enlarged  and  tender;  exercise  or  indis- 
cretion in  diet  may  cause  it  to  become  tender,  or  the  patient  may  have  occa- 
sional attacks  of  coHcky  pain.  If  any  of  the  above  conditions  exist,  another 
attack  may  be  confidently  anticipated  if  operation  is  not  performed.  In 
such  cases  the  appendix  can  usually  be  palpated.  The  method  of  palpation 
proposed  by  Robert  T.  ]\Iorris^  is  ver\'  useful.     It  is  applied  as  follows: 

The  surgeon  stands  to  the  right  of  the  patient  and  uses  three  fingers  of 
the  right  hand  to  feel  "^dth  and  three  fingers  of  the  left  hand  to  press  with. 
Morris  insists  that  no  muscular  effort  should  be  used  by  the  hand  which 
feels.  The  feeling  fingers  are  pressed  by  the  other  fingers  beneath  the  margin 
of  the  right  rectus  muscle  on  a  level  ■v\ith  the  umbilicus,  and  are  drawn  toward 
the  patient's  right  side,  and  the  colon  wtU  be  felt  to  roll  imder  the  fingers. 
The  process  is  repeated  several  times  until  the  end  of  the  cecum  is  reached. 
The  appendix  is  sought  for  by  rolling  the  cecum  from  side  to  side  with  the 
finger-tips,  and  working  toward  the  proximal  end  of  the  appendix. 

Adhesions  may  form  as  a  result  of  appendicitis,  general  peritonitis  may 
arise,  the  appendix  may  slough  or  become  perforated,  or  abscess  may  ensue 
upon  local  peritonitis.  L}-mphangitis  of  the  appendix  may  accompany, 
and  septic  hTnphangitis  or  phlebitis  and  secondary'  hepatic  and  hnnphatic 
infections  may  follow,  appendicitis.  They  are  thought  to  be  most  common 
after  mild  attacks  of  appendicitis.  The  secondar\'  lymphatic  and  hepatic 
infections  are  of  the  greatest  importance.  There  ma}^  be  abscess  of  the  liver, 
subphrenic  abscess,  or  retroperitoneal  hTnphangitis. 

A  subphrenic  abscess  may  result  from  infection  carried  from  the  appendix 
by  the  h-mphatics,  from  pus  ascending  along  the  posterior  cellular  spaces, 
or  by  direct  invasion  from  the  peritoneal  ca\dty  (John  C.  Munro,  in  "Annals 
of  Surger}",'"  Nov.,  1905) ;  such  an  abscess  is  usually  on  the  right  side,  but  may 
be  upon  the  left. 

Lymphangitis  is  the  rule  in  appendicitis,  and  when  we  open  the  abdomen 
there  is  usually  e^ddence  of  it  in  the  honph-glands  of  the  mesenter}",  and  in 
children  particularly  these  glands  are  apt  to  be  enlarged.  One  hTuph  path 
from  the  appendix  is  through  the  ileocecal  glands,  another  is  posterior  to 
the  cecum  and  retroperitoneal,  and  the  latter  reaches  the  liver  and  diaphragm 
(]Munro).  In  h-mphatic  infection  an  abscess  may  form  an}'T\-here  in  the 
course  of  the  lymphatics.  Abscess  of  the  fiver  usually  results  from  portal 
invasion,  but  may  result  from  hinphatic  infection. 

Among  other  possible  consequences  of  appendicitis  may  be  mentioned 
pyemia,  empyema,  inflammation  of  the  parotid  gland,  and  thrombosis  of 
the  right  iliac  vein.  A  positive  prognosis  of  any  case  of  appendicitis  is  an 
absolute  impossibihty.  The  future  of  everj^  case  is  clouded  with  imcertainty, 
and  the  most  that  can  be  attained  in  the  field  of  prediction  is  a  scientific 
guess  of  more  or  less  probability.  All  surgeons  have  seen  apparently  hopeless 
cases  recover,  and  have  obser\'ed  cases  with  the  most  trivial  s}Tnptoms  grow 
progressively  worse  or  suddenly  develop  a  fatal  complication.  Further, 
after  one  attack  other  attacks  are  very  apt  to  arise.  The  medical  man  who 
^"Medical  Record,"  Sept.  17.  1S9S. 
64 


loio  Diseases  and  Injuries  of  the  Abdomen 

estimates  that  80  or  90  per  cent,  of  cases  get  well  without  operation  has  prob- 
ably dealt  with  many  catarrhal  cases,  and  he  certainly  is  optimistic  as  to 
freedom  from  future  attacks,  because,  as  stated  before,  recovery  from  an 
attack  does  not  of  necessity  mean  freedom  from  the  disease.  In  appendici- 
tis there  may  be  delusive  evidences  of  improvement;  for  instance,  the  abate- 
ment of  pain  and  the  lessening  of  fever,  being  regarded  by  the  patient  him- 
self as  indubitable  signs  of  improvement,  may,  in  reality,  be  indicative  of  gan- 
grene. In  spite  of  the  previously  mentioned  difficulties  and  obscurities  we 
can  in  the  majority  of  cases  decide  with  a  reasonable  probability  of  accuracy 
w^hether  or  not  the  patient  is  becoming  worse.  In  a  delusive  improvement 
some  signs  and  symptoms  improve,  but  all  do  not;  and  in  endeavoring  to 
form  a  prognosis,  all  the  signs  and  symptoms  must  be  noted  and  weighed: 
pain,  tenderness,  rigidity,  distention,  nausea  and  vomiting,  delirium,  intesti- 
nal obstruction,  shock,  the  temperature,  the  rapidity  of  the  pulse,  the  blood 
examination,  etc.  If  all  these  elements,  not  only  some  of  them,  point  to  im- 
provement, we  may  be  reasonably  confident  that  improvement  is  really  taking 
place.  If  only  some  of  them  point  to  improvement  we  will  in  many  cases 
be  altogether  uncertain  as  to  the  significance  of  the  change. 

The  diagnosis  is  not  invariably  so  easy,  as  many  light-hearted  operators 
seem  to  beheve.  It  is  frequently  far  from  easy  and  is  sometimes  altogether 
impossible  without  exploratory  operation.  Sonnenburg  maintains  that  we  can 
diagnosticate  the  pathological  condition  of  the  inflamed  appendix.  Personally, 
I  am  unable  to  do  this  with  any  certainty,  although  I  always  try,  and  am 
often  right  and  just  as  often  wrong. 

In  attempting  to  make  a  diagnosis,  besides  the  ordinary  examination 
of  the  abdomen  a  rectal  or  vaginal  examination  should  be  made,  associated 
in  many  cases  with  bimanual  palpation.  If  an  appendix  is  enlarged  and 
an  individual  has  a  thin  abdomen  which  is  not  rigid,  it  may  be  possible  to 
palpate  the  appendix.  Sometimes  it  can  be  felt  after  the  administration 
of  ether  when  it  could  not  be  detected  before.  In  an  acute  case  forcible 
or  prolonged  palpation  is  always  unjustifiable,  as  it  may  force  an  ulcer  to 
perforate,  or  may  rupture  an  abscess,  and  the  information  gained  is  not  of 
sufiicient  importance  to  justify  the  risk.  In  a  chronic  case  information 
of  great  value  may  be  obtained  and  there  is  no  real  risk  in  the  maneuver. 
I  am  persuaded  John  B.  Murphy  is  correct  in  attaching  the  greatest  possible 
importance  to  the  order  in  which  symptoms  appear  in  acute  appendicitis.  Pain 
precedes  nausea  and  vomiting,  elevated  temperature,  and  abdominal  tenderness. 
If  fever  precedes  pain  the  condition  is  not  appendicitis.  If  vomiting  precedes 
pain  the  condition  is  probably  not  appendicitis. 

The  disease  may  be  confused  with  a  number  of  different  conditions.  It 
sometimes  is  confused  with  typhoid  feyer;  in  fact,  early  typhoid  fever  asso- 
ciated with  marked  abdominal  pain  gives  a  picture  very  similar  to  that 
furnished  by  appendicitis. 

In  typhoid  fever  the  temperature  is  usually  distinctly  higher  than  that 
commonly  encountered  in  appendicitis.  Maurice  H.  Richardson^  tells  us 
that  in  every  case  in  which  typhoid  is  suspected,  operation  is  not  justifiable 
on  the  hypothesis  of  existing  appendicitis,  unless  there  are  local  pain  and 
localized  tenderness  in  the  appendix  region,  associated  with  definite  mus- 
cular resistance  or  distinct  rigidity;  and  that  operation' should  be  postponed 
in  a  case  in  which  the  constitutional  signs  are  severe  and  the  local  signs  are 
difficult  to  detect;  but  when  there  are  pain,  tenderness,  and  rigidity  with 
or  without  distention,  operation  must  be  performed,  even  when  one  recog- 
nizes the  possibility  of  the  existence  of  typhoid  fever.  Richardson  lays 
down  the  following  rule:  Soft  abdomen  plus  high  temperature  suggests  ty- 
1  "Boston  Med.  and  Surg.  Jour.,"  Jan.  9,  1902. 


Diagnosis  of  Appendicitis  loii 

phoid,  even  if  there  are  pain  and  tenderness.  In  appendicitis  there  is  usually 
leukocytosis;  in  typhoid,  leukocytosis  is  absent,  except  when  perforation  is 
imminent  or  has  occurred,  or  when  some  other  complication  exists.  I  have 
seen  the  operation  performed  twice  for  supposed  appendicitis  when  the  con- 
dition in  each  case  was  found  to  be  early  typhoid  fever. 

Acute  intestinal  obstruction  is  sometimes  confused  with  acute  appendi- 
citis, and  the  mistake  is  particularly  likely  to  occur  if  the  obstruction  is  due 
to  intussusception.  In  acute  obstruction,  as  in  appendicitis,  the  pain  is 
first  appreciated  about  the  umbilicus;  but  in  acute  obstruction  it  remains 
in  that  region,  does  not  pass  to  and  locahze  itself  in  the  right  iliac  fossa,  and 
is  not  associated  with  tenderness  of  the  right  iliac  fossa.  In  obstruction 
the  vomiting  is  persistent;  in  appendicitis,  except  in  the  beginning,  it  is  usu- 
ally trivial  and  often  absent,  although  in  children  it  may  be  violent  and  per- 
sistent. In  acute  obstruction  shock  is  much  more  pronounced  than  in  ap- 
pendicitis, and  early  and  great  distention  of  the  abdomen  is  noted.  The 
temperature  in  obstruction  is  seldom  elevated  and  is  usually  subnormal ;  while 
in  appendicitis,  at  least  in  the  majority  of  cases,  the  temperature  is  distinctly 
elevated.  Further,  in  acute  intestinal  obstruction  the  constipation  is  absolute, 
not  even  gas  passing.  In  children,  intussusception  is  capable  of  particularly 
confusing  the  diagnosis,  because,  after  the  first  day,  it  is  by  no  means  unusual 
to  have  distinct  fever  in  this  condition,  and  occasionally  a  tumor-like  mass  is 
found  in  the  right  iliac  fossa ;  but  in  intussusception  the  tumor  does  not  remain 
fixed,  but  alters  its  position;  it  is  movable;  and  the  patient  usually  suffers  from 
tenesmus  and  the  passage  of  bloody  mucus.  One  should  bear  in  mind  that  in 
acute  appendicitis  associated  with  septic  peritonitis  acute  obstruction  may 
exist;  and  that  the  diagnosis  of  obstruction  may  be  made  without  recognizing 
the  appendicitis. 

In  those  rare  cases  of  typhlitis  occasionally  encountered  the  symptoms  are 
much  milder  than  in  appendicitis:  the  temperature  is  not  much  elevated,  the 
pulse-rate  is  only  slightly  accelerated,  the  leukocytosis  is  not  marked,  there 
is  seldom  rigidity,  there  may  be  tenderness,  but  is  seldom  pain.  Pain  when 
present  is  colicky  rather  than  continuous.  There  may  be  a  doughy  mass  or 
a  mass  feeling  "like  an  air-cushion"  in  the  right  iliac  fossa  (Raymond  Russ,  in 
"Surg.,  Gynec,  and  Obstet.,"  Oct.,  1912).  Chronic  typhlitis  causes  muscular 
atony  and  intestinal  stasis  (Russ,  Ibid.). 

Lesions  of  the  kidney  are  sometimes  mistaken  for  appendicitis,  but  in 
renal  colic  the  pain  runs  into  the  groin  and  testicle  of  that  side,  and  occasion- 
ally passes  down  the  front  of  the  thigh  or  into  the  rectum;  and  if  any  tender- 
ness exists,  it  is  found  in  the  loin  or  in  the  groin,  rather  than  in  the  right 
iliac  fossa.  Besides,  there  are  other  symptoms  of  kidney  trouble.  The 
urine  may  contain  blood  or  pus,  and  there  may  be  a  history  of  difficult  or 
of  frequent  urination,  though  one  should  bear  in  mind  that  in  appendicitis 
with  inflammation  of  the  vesical  peritoneum  there  may  also  be  a  record  of 
urinary  difficulties.  An  a:-ray  picture  may  exhibit  a  calculus  in  the  ureter  or 
kidney,  and  a  movable  kidney  is  distinctly  palpable.  In  ordinary  renal  colic 
there  is  vomiting  in  the  beginning,  just  as  in  the  beginning  of  appendicitis.  In 
movable  kidney  and  renal  colic  the  vomiting  is  often  more  violent  and  pro- 
longed than  is  common  in  appendicitis.  Movable  kidney  and  appendicitis 
may  exist  coincidentally.  Very  confusing  cases  are  those  in  which  hematuria 
accompanies  appendicitis.  I  have  seen  it  twice  and  in  neither  case  was  there 
any  apparent  connection  between  the  appendix  and  the  kidney,  ureter,  or 
bladder.  The  hematuria  must  have  been  due  to  acute  nephritis  which  is 
known  to  occur  in  some  cases  of  appendicitis,  the  nephritis  resulting  from  the 
toxins  of  a  bacterial  disease.  This  form  of  nephritis  Dieulafoy  calls  "nephrite 
toxique  appendiculaire."    As  pointed  out  by  M.  G.  Seelig  ("Annals  of  Sur- 


IOI2  Diseases  and  Injuries  of  the  Abdomen 

gery,"  Sept.,  1908),  hematuria  may  also  be  due  to  direct  involvement  of  the 
kidney,  ureter,  or  bladder. 

Gall-bladder  difi&culties,  too,  may  be  confounded  with  appendicitis.  I  have 
operated  upon  2  cases  of  cholecystitis  under  the  supposition  that  they  were 
cases  of  appendicitis;  and  upon  several  cases  of  appendicitis  in  the  belief  that 
the  condition  in  each  case  was  cholecystitis.  In  an  inflammation  of  the  gall- 
bladder, with  a  distended  gall-bladder  hanging  low  down,  and  with  muscular 
rigidity,  the  distinction  between  appendicitis  and  cholecystitis  is  always  diffi- 
cult and  sometimes  impossible.  So  it  is  when  the  cecum  has  not  descended 
and  the  appendix  is  in  the  gall-bladder  region.  So  it  is  when  the  tip  of  the 
appendix  is  adherent  to  the  gall-bladder.  In  ordinary  gall-stone  colic  the  con- 
dition is  generally  sudden  in  onset;  it  is  characterized  by  pain  in  the  epigastric 
region,  passing  toward  the  shoulder-blade  and  the  shoulder,  the  pain  being  most 
acute  and  becoming  more  or  less  localized  in  the  region  of  the  gall-bladder; 
and  there  is  always  tenderness  over  the  gall-bladder  region.  In  gall-bladder 
colic  the  vomiting  is  usually  violent  and  often  almost  continuous. 

The  perforation  of  a  gastric  or  of  a  duodenal  ulcer  may  be  diagnosti- 
cated as  appendicitis.  In  perforation  of  a  gastric  ulcer  there  is  usually  a  his- 
tory of  previous  difficulty  with  the  stomach,  though  this  is  not  always  the 
case.  The  onset  of  acute  perforation  is  sudden,  with  greater  shock  than  is 
characteristic  of  the  onset  of  appendicitis.  The  pain  is  violent,  the  rigidity 
intense,  and  the  pain,  rigidity,  and  tenderness  are  in  the  epigastric  region. 

Among  other  conditions  that  may  be  confused  with  appendicitis  may  be 
mentioned  malignant  disease  of  the  cecum,  tuberculosis  of  the  cecum,  acute 
tuberculous  peritonitis,  twisting  of  the  pedicle  of  an  ovarian  tumor,  tubal  dis- 
ease, extra-uterine  pregnancy,  membranous  colitis,  perinephric  abscess,  tuber- 
culous abscess  of  the  loin  or  of  the  groin,  and  abscess  from  hip-joint  disease. 

Pneumonia  of  the  right  base  and  pleurisy  may  cause  abdominal  pain 
and  be  mistaken  for  appendicitis.  The  pain  may  be  due  to  inflammation  of  the 
diaphragmatic  pleura  or  may  be  reflected  along  the  lower  six  intercostal  nerves 
which  supply  the  lower  part  of  the  pleura  and  the  abdominal  wall.  Irritation 
of  the  eleventh  thoracic  nerve  causes  pain  in  the  iliac  region.  There  may  even 
be  superficial  tenderness  in  the  abdomen,  but  deep  pressure  is  well  tolerated 
(Donald  W.  Hood,  "Brit.  Med.  Jour.,"  Dec.  30,  1905).  There  may  be  abdom- 
inal rigidity.  The  abdominal  pain  seldom  persists  more  than  a  few  hours. 
It  is  intensified  by  deep  respiration  and  is  accompanied  by  high  fever.  As 
Hood  says,  whenever  a  patient  suffers  from  vomiting,  abdominal  pain,  and 
high  fever,  examine  the  chest.  Sir  Thomas  Oliver  has  described  what  he  calls 
"the  abdominal  type  of  pneumonia."  It  is  characterized  by  the  sudden  onset 
of  severe  abdominal  pain.  Vomiting  often  occurs.  There  is  then  a  chill, 
usually  a  rise  of  temperature,  and  in  some  cases  coUapse.  The  pain  is  accom- 
panied by  tenderness,  and  both  these  phenomena  may  be  in  the  right  iliac 
region.  Early  there  are  no  physical  signs  of  pneumonia.  In  a  few  hours  the 
collapse  passes  away,  the  abdominal  pain  and  tenderness  subside,  the  tempera- 
ture rises,  and  signs  of  pneumonia  become  evident.  In  young  children  pneu- 
monia is  particularly  apt  to  cause  abdominal  pain  and  rigidity.  Beyond  a 
doubt,  more  than  one  abdomen  has  been  opened  for  supposed  appendicitis  when 
the  real  condition  was  pneumonia. 

In  reaching  a  diagnosis  in  doubtful  cases  of  appendicitis  I  believe  that 
the  blood-count  is  often  of  service.  It  is,  of  course,  not  to  be  maintained 
that  the  diagnosis  of  appendicitis  may  be  made  by  counting  the  blood;  but 
the  blood-count  may  furnish  evidence  that,  when  added  to  the  other  signs 
and  symptoms,  may  be  of  great  importance.  In  nearly  every  case  of  acute 
appendicitis  the  hemoglobin  is  diminished  by  at  least  30  per  cent.  In  a  catarrhal 
appendicitis  or  in  an  interstitial  appendicitis  the  leukocytosis  is  trivial;  but 


Appendiceal  Dyspepsia  1013 

in  cases  of  abscess  or  of  gangrene  of  the  appendix  the  leukocytes,  as  a  rule, 
rise  from  15,000  to  20,000.  It  is  to  be  remembered,  however,  that  when 
the  patient  is  profoundly  septic  the  systemic  condition  is  so  depressed  that 
leukocytosis  is  impossible;  hence  leukocytosis  may  be  absent  in  trivial  catarrhal 
cases  or  in  grave  cases  with  overwhelming  general  sepsis.  This  latter  con- 
dition, however,  is  extremely  rare.  The  blood-count  will  not  help  one  in 
making  the  differentiation  between  appendicitis  and  an  inflammatory  disorder 
of  the  pelvis  or  abdomen,  but  will  aid  one  in  making  a  diagnosis  from  typhoid 
fever,  intra-abdominal  or  pelvic  neuralgia,  and  movable  kidney  (See  J.  C. 
DaCosta,  Jr.,  study  of  118  cases,  "Am.  Jour.  Med.  Sciences,"  Nov.,  1901.) 

Appendiceal  Dyspepsia. — Indigestion  may,  for  a  longer  or  shorter  time, 
precede  an  attack  of  acute  appendicitis.     A  like  condition  may  follow  an  attack. 

In  chronic  recurrent  appendicitis  dyspepsia  may  so  dominate  the  clinical 
picture  as  to  lead  the  physician  to  regard  the  case  as  one  of  gastric  disease. 
Such  a  patient  has  prolonged  attacks  of  epigaS'tric  pain.  There  may  or  may 
not  be  tenderness  in  the  appendix  region.  The  condition  may  be  due  to  hyper- 
secretion of  the  gastric  juice  resulting  reflexly  from  appendix  inflammation. 
Fenwick  regards  chronic  hypersecretion  as  a  direct  cause  of  this  form  of 
dyspepsia.  The  epigastric  pain  may  be  due  to  pyloric  spasm  or  gastritis 
(Eusterman,  "Jour.  Missouri  State  Med.  Assoc,"  May,  1913).  At  times, 
however,  during  some  of  the  attacks  appendiceal  tenderness  is  demonstrable 
and  perhaps  there  is  pain  in  the  right  iliac  fossa.  The  epigastric  or  abdominal 
uneasiness  may  be  constant.  Food  may  immediately  cause  pain.  Nausea 
and  flatulence  are  common.  "As  a  rule  there  is  not  the  regularity  of  onset  of 
pain  after  food — the  periodicity  of  attack — which  characterizes  gastric  ulcer" 
(Eusterman,  Ibid.) .  Food  does  not  relieve  pain  except  in  the  less  common  cases 
in  which  there  is  hyperacidity. 

Appendicitis  in  Children. — The  disease  is  much  more  common  than  was 
once  thought  (see  page  1003).  Russel  S.  Fowler  ("Am.  Jour.  Diseases  of  Chil- 
dren," August,  1912)  collected  183  cases  occurring  in  children  under  twelve 
years  of  age  and  brought  to  the  German  Hospital  of  Brooklyn.  During  the 
same  period  (1900-1912)  the  total  number  of  cases  was  11 15,  the  proportion  of 
children  being  16.41  per  cent.  The  youngest  patient  in  this  series  was  two 
years  and  nine  months  old.  There  is  usually  a  history  of  antecedent  attacks  of 
gastro-intestinal  disorder.  The  onset  is  apt  to  be  sudden,  but  may  be  insid- 
ious, the  symptoms  as  a  general  thing  are  violent,  and  the  progress  of  the  dis- 
ease is  rapid.  Vomiting  is  usually  more  violent  and  prolonged  than  in  adults. 
There  is  a  great  likelihood  of  pus  formation,  and  general  peritonitis  is  more 
common  than  in  adults.  Marked  leukocytosis  usually  exists.  Occasionally 
in  young  children  pneumonia  begins  with  so  much  pain  and  rigidity  in  the  lower 
abdomen  that  the  signs  seem  to  point  to  appendicitis,  and  an  attack  of  appendi- 
citis may  begin  coincidently  with  or  soon  after  a  pulmonary  inflammation. 
I  have  seen  4  cases  in  children  in  which  pneumonia  was  ushered  in  by  abdominal 
pain  and  rigidity.  The  surgeon  should  be  awake  as  to  the  possibility  of  ty- 
phoid fever,  indigestion,  fecal  impaction,  intussusception,  and  tuberculous 
peritonitis.  In  children  the  appendix  occupies  a  lower  position  than  in  adults, 
the  point  of  abdominal  tenderness  is  usually  lower  than  in  adults,  the  inflamma- 
tion usually  reaches  the  right  side  of  the  pelvis,  a  painfiil  point  can  generally  be 
discovered  by  a  finger  in  the  rectum,  hence  a  digital  rectal  examination  must 
always  be  made.  This  usual  involvement  of  the  pelvis  is  responsible  for  the 
frequent  and  painful  micturition  which  is  very  common  (Karewski).  Some- 
times when  the  bladder  symptoms  are  very  prominent  they  dominate  the  clinical 
picture  and  the  bladder  is  thought  to  be  the  real  seat  of  disease.  An  attack  of 
peritonitis  in  a  child  is  more  apt  to  result  in  general  peritonitis  than  is  the  same 
disease  in  an  adult  (Selter).     I  agree  with  Springer  ("Prag.  med.  Woch.,"  1909, 


IOI4 


Diseases  and  Injuries  of  the  Abdomen 


xxxiv,  Nos.  7  and  8)  that  operation  in  children  should  invariably  be  prompt 
and, that  purgatives  should  not  be  given.  In  Fowler's  series  of  cases  ("Am. 
Jour.  Dis.  of  Children,"  Aug.,  1912)  the  operative  mortality  was  3  per  cent. 

Appendicitis  in  Pregnant  "Women. — Appendicitis  is  a  very  dangerous,  but, 
fortunately,  a  very  rare  complication  of  pregnancy.  In  731  women  operated  on 
for  appendicitis  in  the  Mount  Sinai  Hospital,  of  New  York,  from  1898  to  1907, 
only  7  were  pregnant  (Cooke,  in  "New  York  Med.  Jour.,"  May  i,  1909). 
Lobenstine  states  that  in  30,000  cases  under  the  care  of  the  New  York  Lying-in 
Hospital  there  were  but  5  cases  of  acute  appendicitis  (Cooke,  Ibid.).  Most  of 
the  patients  who  develop  appendicitis  during  pregnancy  have  had  previous 
attacks. 

The  condition  may  arise  at  any  stage  of  pregnancy.  It  is  usually  violent, 
rapid  in  progress,  and  accompanied  by  vomiting.  Early  in  pregnancy  the 
pain  and  tenderness  are  significant  and  are  located  regionally,  as  when  preg- 
nancy is  absent.  Cooke  points  out  that  later  in  pregnancy  the  pains  may 
be  so  spasmodic  as  to  cause  them  to  be  attributed  to  beginning  labor,  and  they 
,-  ~-       .     -,    are  of  ten  located  in  the  region  of 

the  liver  or  even  on  the  left  side 
of  the  belly  (Ibid.).  Two  hun- 
dred and  fifty  cases  have  been 
reported  and  over  100  have  been 
operated  on  (Renvall). 

Appendicitis  in  the  pregnant  is 
far  more  dangerous  than  in  the 
non-pregnant.  In  about  40  per 
cent,  of  cases  abortion  occurs, 
and  usually  the  child  dies  from 
infection.  In  some  cases  of  suc- 
cessful operation  pregnancy  con- 
tinues to  term.  The  diagnosis  is 
often  very  difficult  because  of  the 
enlarged  uterus. 

Appendicitis  Following  Child- 
birth.— Hilton  collected  reports  of 
29  cases  and  added  i  of  his  own 
("Surg.,    Gynec,    and    Obstet.," 
Oct.,  1907).     Hilton  demonstrates 
that  childbirth  and  the  puerperium 
may   be    causal    of    appendicitis. 
The  signs  and  symptoms  are  apt 
to  be  masked  or  are  thought  to  be  due  to  the  puerperal  state.     The  prognosis 
is  grave.     In  cases  developing  within  ten  days  of  labor  45.5  per  cent,  died 
(HUton,  Ibid.). 

Tuberculous  Appendicitis  (Fig.  614). — ^Acute  symptoms  may  develop  re- 
sembling acute  appendicitis.  There  is  usually  a  history  pointing  to  intestinal 
stenosis,  the  stenosis  existing  at  the  ileocecal  valve. ^  There  is  always  great 
thickening,  and  an  abscess  of  large  size  is  apt  to  form.  The  cecum  usually, 
but  not  always,  is  involved  in  the  tuberculous  process.  Chronic  cases,  with 
palpable  enlargement,  are  sometimes  mistaken  for  cancer  of  the  cecum. 

Malignant  Disease  of  the  Appendix  (Fig.  615). — This  is  a  very  rare  condition 
(less  than  |  of  i  per  cent,  of  appendices  removed  for  supposed  inflammation) .  It 
is  impossible  of  recognition  clinically,  but  is  sometimes  discovered  postmortem 
or  during  operation  for  supposed  acute  or  chronic  appendicitis  or  pelvic  dis- 
ease. Inflammation  does  not  cause  the  malignant  disease,  but  the  malignant 
1  Andrews,  "Annals  of  Sxirgery,"  Dec,  1901. 


Fig.  614.- 


-Tuberculous  appendix  with  perforation  and 
abscess. 


Treatment  of  Appendicitis 


1015 


disease  is  apt  to  block  the  appendix  and  so  cause  inflammation.  The  condition 
may  be  carcinoma,  sarcoma,  or  endothehoma,  and  usually  there  are  distinct 
inflammatory  changes.  It  is  more  common  in  women  than  in  men.  Rolles- 
ton  and  Jones  collected  42  cases.  McWilliams  reported  3  cases  and  collected 
45  not  in  RoUeston's  table.  This  makes  90  reported  cases  ("Am.  Jour. 
Med.  Sciences,"  June,  1908).  Since  writing  his  article  McWilliams  has  found 
15  more  cases  reported.  No  case  is  counted  in  which  the  colon  is  diseased. 
The  combined  statistics  show  the  average  age  of  the  patients  to  be  only  twenty- 
nine  years.  Two  patients  were  only  eight.  In  most  cases  the  appendix  alone 
is  diseased;  in  some  the  colon  or  glands  of  the  mesentery  are  involved.  In 
three-fourths  of  the  cases  the  growth  is  distal  to  the  middle  of  the  appendix. 
Glands  are  involved  late.  Out  of  90  cases  in  McWilliams's  table  only  8  had 
enlarged  glands,  and  in  4  of  these  it  was  proved  that  the  glands  were  not 
cancerous.  In  about  5  per  cent,  of  cases  concretions  were  found.  The  chance 
for  permanent  cure  after  removal  of  an  appendix  the  seat  of  malignant  disease 
is  very  good  if  the  disease  is  limited  to  the  appendix,  and  is  particularly  good 
if  the  growth  is  spheroidal-celled  carcinoma  (Rolleston  and  Jones) .  Metastasis 
is  rarely  noted.     The  growth  is  seldom  larger  than  an  almond. 

Treatment. — If  the  diagnosis 
were  alw^ays  certain  from  the  be- 
ginning, and  if  the  case  were  seen 
at  the  very  start  by  a  surgeon,  im- 
mediate operation  in  every  case 
would  be  eminently  proper.  If 
this  plan  could  be  followed,  the 
mortality  from  appendicitis  would 
be  extremely  small.  At  this  early 
stage  the  peritoneum  is  free  from 
infection,  and  the  appendix  can  be 
rapidly  and  easily  removed  with- 
out risk  of  infecting  the  perito- 
neum. Whenever  I  see  a  case  early, 
that  is,  during  the  first  thirty-six 
hours  of  the  attack,  I  practically 
alw^ays  ad\dse  operation.  Unfortu- 
nately, this  plan  cannot  be  habitu- 
ally followed.  As  a  rule,  when  the 
physician  first  sees  the  case  the 
appendicular  peritoneum  is  in- 
flamed, and  the  surgeon  usually 
sees  the  case  at  even  a  later  period 
than  the  physician.  At  this  time 
the  barriers  of  leukocytes  are  be- 
ing heaped  up  to  limit  the  spread  of 
infection,  and  delicate  encompass- 
ing adhesions  are  usually  being  formed.  Even  in  these  later  cases  I  often,  in 
fact,  usually,  advise  operation.  Operation  at  this  stage  may  be  imperatively 
necessary  because  of  the  rapid  spread  and  dangerous  nature  of  the  process; 
but  when  operation  is  not  done,  in  some  cases  at  least,  a  temporary  limita- 
tion will  be  secured  and  the  case  will  go  on  to  an  interval.  Operation  in 
the  acute  period  is  always  dangerous;  operation  in  an  interval  is  safe.  In 
some  instances,  when  the  case  is  not  seen  early,  it  is  wiser  to  avoid  operating 
at  the  time,  and  it  is  proper  to  wait  for  an  interval.  The  period  in  which  the 
surgeon  usually  sees  the  case  for  the  first  time  was  said  by  Maurice  Richardson 
to  be  "too  late  for  an  early  operation  and  too  early  for  a  late  operation."   Those 


Fig.  615. — Carcinoma  of  bowel  and  belly  wall  after 
appendix  operation.  Appendix  removed  by  English 
Army  Surgeon  in  Burmah.  Portion  of  bowel  re- 
moved at  Heidelberg. 


ioi6  Diseases  and  Injuries  of  the  Abdomen 

who  say  "operate  as  soon  as  the  diagnosis  is  made,"  operate,  as  a  rule,  in  this 
dangerous  period,  and  in  this  period  I  do  not  beHeve  that  every  case  should  be 
promptly  cut.  Many  cases,  it  is  true,  must  be  operated  on  as  soon  as  seen, 
irrespective  of  the  duration  of  the  disease.  We  must  operate  promptly  if  the 
pulse  is  small,  tense,  and  well  above  loo;  if  there  is  persistent  vomiting;  if 
there  is  delirium;  if  intestinal  obstruction  exists;  if  a  chill  has  occurred;  if  the 
pain  and  rigidity  are  very  marked;  if  a  mass  can  be  felt  in  the  right  iliac  fossa 
or  by  rectal  examination ;  if  there  is  marked  abdominal  distention ;  if  there  are 
evidences  of  pus  formation;  if  the  patient  is  growing  worse;  if  there  is  or  has 
been  shock;  or  if  the  pain  suddenly  passes  away  without  the  use  of  opiates. 

In  an  ordinary  mild  case,  not  seen  early,  in  which  none  of  the  above- 
named  conditions  or  symptoms  exist,  it  is  best  to  defer  operation.  Those  who 
advocate  operating  upon  every  case  consider  such  delay  reprehensible  and 
dangerous,  point  out  that  even  in  apparently  mild  cases  gangrene  or  perfor- 
ation may  qmckly  occur,  and  cite  striking  cases  to  emphasize  their  belief. 
There  is  much  force  in  this  view,  and  it  must  not  be  hastily  rejected.  The 
choice,  however,  is  not  between  a  dangerous  delay  and  a  safe  operation, 
but  rather  between  a  dangerous  delay  and  a  dangerous  operation.  It  is  a 
question  of  two  dangers,  and  each  side  chooses  the  danger  which  seems  to  it 
the  least.  Richardson's  elaborate  study  of  750  cases,  showing  a  mortality  of 
18  per  cent,  in  operations  for  acute  appendicitis,  determined  us  in  the  prac- 
tice of  the  more  conservative  plan. 

In  an  ordinary  mild  case  of  appendicitis  in  which  operation  is  refused, 
it  is  a  common  custom  to  purge  by  means  of  Epsom  or  Rochelle  salt.  This 
practice  was  begun  because  of  the  belief  that  inflammation  of  the  appendix 
is  associated  with  fecal  impaction  in  the  head  of  the  colon.  This  belief  has 
been  exploded,  but  the  treatment  is  still  used  by  some  who  regard  it  as  bene- 
ficial. If  the  condition  of  the  stomach  prevents  the  administration  of  salines, 
high  enemata  are  often  given.  My  own  belief  is  that  if  operation  is  refused, 
or  if  the  surgeon  determines  to  wait  for  an  interval,  he  should  not  give  a  pur- 
gative, but  follow  the  plan  of  treatment  suggested  by  Ochsner  to  control  peris- 
talsis and  favor  limitation  of  infection.  The  patient  is  kept  perfectly  quiet,  is 
placed  in  the  Fowler  position,  no  cathartics  are  given,  no  food  or  drink  is 
administered  by  the  mouth,  and  thirst  is  allayed  by  enemata  of  salt  solution. 
Nutritive  enemata  may  be  given.  It  is  also  my  custom  to  place  a  hot-water 
bag  instead  of  an  ice-bag  over  the  appendix  region. 

To  permit  peristalsis  favors  diffusion  of  the  infection;  to  prevent  peris- 
talsis is  to  favor  the  formation  of  encompassing  and  defensive  adhesions.  A 
purgative  is  very  dangerous.  It  may  cause  rupture  of  the  appendix.  By 
causing  peristalsis  it  diffuses  the  infection. 

Many  surgeons  use  the  ice-bag,  but  I  do  not  believe  in  it  in  these  cases. 
We  have  already  shown  (see  page  97)  that  cold  as  a  remedy  for  inflammation 
is  useful  only  in  the  brief  stage  of  hyperemia,  and  when  a  surgeon  sees  a  case 
of  appendicitis  there  is  certainly  more  or  less  stasis.  Cold  adds  to  stasis  and 
does  harm,  and  I  am  persuaded  that  the  routine  use  of  the  ice-bag  is  responsible 
for  some  cases  of  gangrene.  Again,  cold  actually  antagonizes  the  migration 
of  leukocytes  and  the  formation  of  adhesions.  For  a  number  of  years  I  have 
believed  and  taught  that  the  ice-bag  weakened  resistance  in  appendicitis. 
These  views  seem  to  find  confirmation  in  the  article  of  Dr.  A.  M.  Fauntleroy, 
U.  S.  N.  ("The  Ice-bag  and  Appendicitis,"  "Med.  Record,"  August  3,  1912). 
The  study  of  a  number  of  cases  led  him  to  the  conclusion  that  the  ice-bag  is 
often  responsible  for  "a  noticeable  lack  of  effort  on  the  part  of  Nature  to  wall  off 
from  the  rest  of  the  abdominal  cavity  the  appendix."  Further:  "It  was  also 
noted  in  the  ice-bag  cases  that  there  was  a  surprisingly  low  white  count  when 
one  took  into  consideration  the  condition."    These  reports  are  most  significant. 


Treatment  of  Appendicitis  1017 

They  are  in  strict  accord  with  my  own  results.  It  is  my  belief  that  the  use 
of  the  ice-bag  antagonizes  the  limitation  of  the  infection  and  favors  dissemina- 
tion of  toxins  and  bacteria.     I  believe  that  its  employment  is  a  grave  mistake. 

Heat  is  a  remedy  which  favors  limitation  of  the  process.  It  relieves  stasis, 
draws  leukocytes  to  the  part  and  stimulates  their  activity,  favors  the  formation 
of  an  encompassing  barrier  of  phagocytic  cells,  and  aids  the  cellular  prohferation 
which  leads  to  the  formation  of  adhesions.     Hence  I  prefer  the  hot-water  bag. 

The  ice-bag,  when  applied  before  the  diagnosis  has  been  made,  that  is, 
in  the  earliest  hours  of  the  attack,  when  it  might  be  thought  to  be  most  ser- 
viceable, allays  pain  and  lessens  rigidity  in  some  cases  almost  like  a  full  dose 
of  opium,  and  hence  masks  the  symptoms  as  does  that  drug. 

Opium  should  never  be  given  until  the  diagnosis  is  made.  In  the  first 
place,  it  is  not  needed,  for  if  the  pain  is  so  violent  as  absolutely  to  demand  opium, 
operation  should  be  performed.  In  the  second  place,  opium  masks  the 
symptoms,  makes  the  patient  feel  comfortable,  and  gives  the  physician  an 
unfortunate  and  ill-founded  sense  of  security.  The  pain  about  the  umbil- 
icus, if  severe,  can  be  distinctly  and  safely  reheved  by  the  administration 
of  30  min.  of  spirits  of  choroform  every  half-hour  imtil  three  doses  have  been 
taken.  Opium  should  not  be  given  if  the  surgeon,  having  decided  not  to  operate 
at  once,  is  awaiting  an  interval,  because  it  may  prevent  or  delay  the  recognition 
of  some  disastrous  change.     If  a  patient  refuses  operation,  it  can  be  given. 

When  we  are  inclined  to  wait  for  an  interval,  the  case  should  be  seen  again 
within  SLx  hours.  We  are  accustomed  to  follow  McBurney's  rule,  which  is  as 
follows :  If  on  seeing  the  patient  again,  six  hours  after  the  first  visit,  the  patient 
is  worse,  operate  at  once.     If  he  is  no  worse  there  is  no  pressing  danger. 

If  in  twelve  hours  after  the  beginning  of  the  attack  the  symptoms  are 
not  intensified,  they  will  soon  begin  to  abate;  if  the  symptoms  have  become 
worse  during  this  time,  operate.  If  in  twenty-four  hours  after  the  beginning 
of  the  attack  the  severity  of  the  symptoms  lessens,  it  is  usually  possible  to 
wait  for  an  interval;  but  if  during  the  second  twenty-four  hours  the  abate- 
ment in  the  severity  of  symptoms  has  not  gone  on  and  there  is  doubt  as  to 
the  condition,  operate  at  once.^  When  the  attack  has  subsided,  and  about 
three  weeks  or  more  have  passed,  the  appendix  can  be  removed  with  remark- 
able safety.  After  a  patient  has  had  two  or  more  attacks  of  appendicitis 
all  surgeons  agree  that  the  appendix  should  be  removed. 

If  pus  is  present  some  surgeons  delay  operation  in  the  hope  that  firm 
adhesions  will  form  around  the  pus,  and  that  the  necessary  operation  will 
simply  be  the  opening  of  an  abscess.  I  do  not  believe  it  is  safe  to  delay  opera- 
tion in  a  pus  case.  The  pus  may  become  limited,  but  it  may  instead  pass 
up  toward  the  liver  or  down  into  the  pelvis.     Delay  is  fraught  with  perU. 

If  only  one  attack  has  occurred,  there  may  never  be  another,  and  the 
question  arises.  Should  the  appendix  be  removed  after  one  attack?  We 
do  not  know  that  a  man  has  really  recovered  after  purely  medical  treatment. 
Many  cases  reported  as  cured  by  medical  means  have  subsequently  required 
operation.  As  Lockwood"  puts  it,  "To  say  that  a  man  with  appendicitis 
has  been  cured  by  medical  means  is  in  many  cases  equivalent  to  saying  that 
a  man  with  a  stone  in  his  bladder  has  recovered  from  calculus  after  the  cure 
of  a  cystitis  by  rest  in  bed." 

Even  after  a  first  attack,  if  the  appendix  remains  tender  or  becomes  tender 
after  exercise,  or  if  attacks  of  colicky  pain  occur,  operate. 

In  some  cases  a  single  attack  of  appendicitis  is  followed  by  persistent 
dyspepsia  and  ill  health,  and  in  such  cases  operation  should  be  performed. 
In  the  majority  of  cases,  even  after  one  well-marked  attack,  operation  is 

1  For  McBurney's  views,  see  "New  York  Polyclinic,"  Jan.  15,  1897. 
^  "Brit.  Med.  Jour.,"  Jan.  27,  1900. 


ioi8  Diseases  and  Injuries  of  the  Abdomen 

necessary.  It  is  always  necessary  after  two  attacks.  (See  Operation  for 
Appendicitis.) 

Appendicitis  cases  which  are  far  advanced  in  general  peritonitis  when  seen 
by  the  surgeon  some  operators  decline  to  touch.  If  we  make  a  custom  of 
operating  on  such  cases  we  will  lose  very  many,  but  will  save  some  few,  and 
these  few  would  have  died  if  we  had  not  operated.  To  operate  spoils  statis- 
tics, but  occasionally  saves  lives.  The  operation  should  consist  of  a  simple 
incision  to  relieve  tension  and  afford  exit  to  infected  fluids — rapid  removal 
of  the "  appendix  if  it  is  easily  accessible,  otherwise  leaving  it  alone — and 
drainage  of  the  pelvis.  After  such  an  operation  the  patient  is  placed  in 
Fowler's  position  and  a  continuous  stream  of  salt  solution  at  low  pressure  is 
caused  to  trickle  into  the  rectum.  (See  Murphy's  Treatment  for  Peritonitis, 
page  1024.) 

Appendicitis  in  a  child  is  treated  exactly  as  in  an  adult.  Appendicitis 
in  the  pregnant  woman  is  treated  as  in  the  non-pregnant.  Early  operation  is 
particularly  indicated,  and  it  is  not  proper  to  induce  premature  labor  in  a 
patient  far  advanced  in  pregnancy  unless  there  is  general  peritonitis.  Then  it 
is  proper  to  empty  the  uterus — primarily,  to  obtain  drainage  and  to  give  the 
patient  a  chance  for  life,  and  secondarily,  to  obtain  a  living  child. 

When  operating  upon  a  woman  for  appendicitis,  bear  in  mind  that  ovarian, 
tubal,  or  uterine  disease  may  have  preceded,  actually  caused,  or  resulted  from 
the  appendicitis;  examine  the  adnexa  and  remove  them  if  necessary. 

An  operation  for  tuberculous  appendicitis  is  rather  apt  to  be  followed 
by  a  fecal  fistula.  An  ordinary  laparotomy  is  sometimes  followed  by  cure, 
but  the  rule  of  an  operator  should  be,  when  possible,  to  remove  the  appendix 
and  resect  the  diseased  bowel.  Andrews^  mentions  as  expedients  suited 
to  special  cases  of  tuberculous  disease:  total  exclusion;  partial  exclusion; 
lateral  anastomosis,  and  the  formation  of  an  artificial  anus. 

Intestinal  Diverticula. — Congenital  diverticula  sometimes  exist  in  the 
duodenum.  Pressure  diverticula  may  arise  in  the  small  intestine;  they  are,  as 
a  rule,  small  and  multiple.  The  descending  colon  and  the  pelvic  colon  are  the 
most  common  seats  of  diverticula.  They  occur  at  any  portion  of  the  circum- 
ference of  the  tube,  are  usually  multiple,  and  vary  much  in  size.  Occasionally 
a  diverticulum  becomes  enormous.  A  diverticulum  contains  fecal  matter  and, 
perhaps,  fecal  concretions.  When  free  from  acute  inflammation  and  when 
unobstructed  a  diverticulum  may  cause  no  symptoms  whatever.  A  diverticu- 
lum may  inflame,  suppurate,  cause  pericolonic  suppuration,  perforate,  or 
become  the  focus  of  a  great  fibrous  area  (fibromatosis),  which  is  usually  mis- 
taken for  cancer. 

Acute  diverticulitis  occurs  in  ''adults,  mostly  in  males  in  midlife  and  given 
to  obesity"  (Joseph  Ransohoff,  in  "Annals  of  Surgery,"  August,  1913).  There 
may  be  catarrhal  inflammation.  An  abscess  may  form  about  the  diverticulum. 
Perforation  may  occur,  followed  by  abscess  or  general  peritonitis.  As  most 
diverticula  are  in  the  lower  colon  the  symptoms  are  usually  left  sided  and 
strongly  resemble  appendicitis.  Suppuration  about  the  sigmoid  does  not  of 
necessity  arise  from  acute  diverticuHtis.  Acquired  diverticula  do  not  exist  in 
children,  and  yet  Ransohoff  (Ibid.)  reported  cases  of  acute  perforating  sig- 
moiditis in  children. 

Meckel's  Diverticulum. — (See  page  988.) 

Treatment  of  Acute  Diverticulitis  and  of  Perforating  Sigmoiditis. — As  for 
appendicitis. 

Fibromatosis  of  the  Colon. — This  condition  produces  symptoms  strongly 
resembling  those  caused  by  carcinoma,  and  many  cases  have  been  operated 
upon  under  this  conviction,  the  truth  having  been  discovered  by  microscopical 
^  "Annals  of  Surgery,"  Dec,  1901. 


Treatment  of  Congenital  Idiopathic  Dilatation  of  the  Colon     1019 

examination  of  the  specimen.  It  is  an  inflammatory  condition  most  often 
met  with  in  the  pelvic  colon.  A  large,  hard  mass  forms  and  constriction  occurs. 
The  mucous  membrane  is  thrown  into  deep  folds  and  ulceration  occurs  in  the 
hollows. 

The  fibromatosis  is  a  reaction  to  infection.  The  infecting  agent  gains 
entrance  through  a  desquamating  area,  a  wound  of  the  mucous  membrane,  an 
ulcer,  or  an  inflamed  diverticulum.  Even  when  cancer  exists  there  may  be  ex- 
tensive fibromatosis  about  it,  the  area  of  real  malignancy  being  much  less  than 
the  induration  suggests. 

Fibromatosis  may  arise  at  any  age,  but  is  most  common  during  and  beyond 
middle  age.  There  is  continuous  abdominal  uneasiness  now  and  then  rising  to 
pain.  The  general  health  deteriorates.  The  victim  suffers  from  habitual 
constipation,  but  occasional  attacks  of  diarrhea  occur.  Blood  and  mucus  are 
at  times  found  in  the  stools.  If  the  constricting  mass  is  within  reach  of  the 
finger,  it  will  be  found  that  the  induration  is  beneath  thick  and  soft  mucous 
membrane.  If  it  can  be  seen  by  the  sigmoidoscope,  the  folds  of  mucous  mem- 
brane will  be  obvious.  Abdominal  palpation  often  detects  the  mass,  which  is 
sausage  shaped.    (See  Miles,  in  "A  System  of  Surgery,"  edited  by  C.  C.  Choyce.) 

Treatment. — Resection  and  anastomosis  if  possible.  If  real  obstruction 
exists,  or  if  the  mass  seems  irremovable,  do  colostomy.  After  colostomy  the 
mass  usually  shrinks  greatly  and  may  actually  disappear. 

Congenital  Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's 
Disease;  True  Megacolon). — This  condition  is  of  prenatal  origin.  The 
large  intestine  is  chiefly  involved.  The  rectum  and  small  bowel  seldom  suffer, 
"and  in  more  than  one- third  of  all  the  cases  the  sigmoid  flexure  is  alone  in- 
volved" (Finney,  in  "Surg.,  Gynec,  andObstet.,"  June,  1908).  There  is  no  defi- 
nite mechanical  obstruction  demonstrable  at  autopsy  or  operation.  It  is  in  this 
that  Hirschsprung's  disease  (true  megacolon)  differs  from  pseudomegacolon 
(Finney,  Ibid.).  The  diameter  may  reach  6  or  8  inches,  and  the  colon  may 
seem  elongated  and  be  in  loops.  Dilatation  and  hypertrophy  produce  marked 
changes  in  the  wall  of  the  gut.  The  condition  may  be  obvious  in  early  life 
or  it  may  not  become  so  until  adult  years,  being  aggravated  and  developed, 
but  not  caused  by  habitual  atony  of  the  bowel.  The  supposed  cause  is  an 
anatomical  anomaly  (perhaps  elongation)  leading  to  looping  of  the  colon,  a 
muscular  aplasia  leading  to  dilatation  and  valve  formation.  Various  causes 
have  been  suggested. 

The  victim  of  this  condition  is  obstinately  constipated  and  has  a  distended 
abdomen,  usually  from  early  infancy,  although,  as  previously  stated,  the 
condition  may  not  manifest  itself  until  childhood,  youth,  or  even  adult  life. 
It  is  most  difficult  to  get  the  bowels  to  move  at  all.  Gay  reported  a  case  in 
which  there  was  no  bowel  movement  for  three  months.  Periods  of  several 
weeks  without  a  movement  are  by  no  means  uncommon.  Now  and  then  an 
attack  of  diarrhea  may  cause  the  emptying  out  of  great  quantities  of  feces. 
The  abdomen  is  enormously  distended  and  the  patient  is  emaciated. 

The  abdominal  veins  are  distended  and  the  rectus  muscles  may  be  separated. 
In  Finney's  cases  (as  in  some  other  reported  cases)  the  cords  of  distended  gut 
could  be  seen  or  felt  to  be  more  prominent  on  one  side  than  on  the  other. 
There  is  no  abdominal  tenderness  and  pain  is  absent  unless  there  is  diarrhea. 
Borborygmus  is  often  very  loud.  Vomiting  is  rare.  The  urine  shows  a  marked 
increase  of  indican. 

The  disease  does  not  directly  cause  death,  but  the  ill-nourished  condition 
lessens  the  chance  for  recovery  from  any  attack  of  illness. 

Treatment. — Medical  treatment  consists  of  the  ordinary  plans  for  com- 
bating constipation.  Some  surgeons  have  removed  almost  the  entire  large 
intestine;  others  have  performed  entero-anastomosis;  others,  colopexy;  others 


I020  Diseases  and  Injuries  of  the  Abdomen 

have  established  a  permanent  artificial  anus;  others  have  made  an  artificial 
anus  preliminary  to  entero-anastomosis.  Finney  beHeves  that  the  operation 
of  choice  is  resection  of  the  affected  gut  followed  by  entero-anastomosis. 

Splanchnoptosis  (Visceroptosis). — Coffey  ("Surg.,  Gynec,  and  Ob- 
stet.,"  Oct.,  191 2)  points  out  that  in  man  special  provisions  are  made  to  keep 
the  viscera  from  riding  down  because  of  the  upright  posture.  He  names  four 
forms  of  support;  (i)  Peritoneal  fusions  before  birth  to  the  parietal  peritoneum; 
(2)  a  shelf  above  each  psoas  muscle;  (3)  tone  of  the  abdominal  wall;  (4) 
packing  of  subperitoneal  fat  which  regulates  intra-abdominal  pressure.  Vis- 
ceroptosis is  generally  said  to  be  due  to  relaxation  of  the  abdominal  walls  and 
decrease  of  intra-abdominal  tension,  which  leads  to  gradual  stretching  of 
suspensory  ligaments  and  finally  to  movement  of  the  viscera  downward. 
The  prolapse  may  involve  all  the  abdominal  viscera,  one  viscus,  or  several  vis- 
cera. According  to  Coffey  (Ibid.),  when  the  intestine  descends  kinks  occur  at 
the  junctions  of  fixed  and  movable  parts,  and  general  ptosis  is  an  attempt  on 
the  part  of  Nature  to  prevent  intestinal  kinks.  Prolapse  of  the  stomach  is 
known  as  gastroptosis  (see  page  976) ;  prolapse  of  the  liver,  as  hepatoptosis  (see 
page  1039);  prolapse  of  the  spleen,  as  splenoptosis  (see  page  1065);  prolapse 
of  the  kidney,  as  nephroptosis  (see  page  1275);  and  prolapse  of  the  intestines, 
as  enteroptosis  or  Glenard's  disease  (see  below). 

The  causative  relaxation  of  the  abdominal  walls  is  most  common  in  women, 
but  is  by  no  means  confined  to  that  sex.  It  may  be  produced  by  ascites, 
pregnancy,  muscular  effort,  febrile  maladies,  or  w^asting  diseases.  In  some 
cases  no  cause  can  be  assigned.  Such  a  relaxed  abdomen  may  or  may  not  be 
thin.  The  fascial  strands  and  muscular  fibers  are  stretched,  and  usually  at- 
tenuated and  separated,  the  belly  bulges  downward  and  forward,  and  a  viscus 
or  the  viscera  follow  because  of  lack  of  support. 

Enteroptosis,  or  Ql^nard's  Disease. — This  disease  is  a  prolapse  of 
the  intestine.  It  may  be  but  a  part  of  ptosis  or  prolapse  of  all  the  abdom- 
inal viscera;  it  may  exist  alone;  it  may  be  associated  with  movable  kidney, 
prolapse  of  the  stomach,  of  the  Hver,  or  of  the  spleen. 

In  Glenard's  disease  the  intestines  occupy  the  lower  portion  of  the  abdo- 
men, and  the  belly  below  the  costal  margins  is  flat,  is  dull  on  percussion, 
and  the  pulsations  of  the  aorta  are  very  evident.  The  right  portion  of  the 
transverse  colon  begins  to  descend  first,  and  other  portions  of  the  intestine 
follow.  The  splenic  and  hepatic  flexures  are  elongated,  and  sometimes  there 
is  venous  engorgement  of  dependent  parts  of  the  mesentery  (Lambotte,  in 
"Presse  Med.  Beige,"  Nov.  24,  1901).  The  victims  of  this  disease  are  dys- 
peptic, anemic,  and  neurasthenic.  Normally  the  tenth  rib  is  firmly  attached 
by  fibrous  tissue  to  the  ninth  costal  cartilage.  In  enteroptosis  the  tip  of  the 
tenth  rib  is  freely  movable  and  obviously  separated  from  the  ninth  costal 
cartilage  {Stiller' s  sign).  The  x-rays  used  after  a  bismuth  meal  are  of  the 
greatest  help  in  diagnosis.  The  ptosis  may  arise  without  apparent  cause, 
but  may  follow  the  wearing  of  ill-fitting  corsets,  falls,  blows,  lifting  heavy 
weights,  or  prolonged  vomiting.  The  dyspepsia  is  due  to  dragging  on  the 
duodenum,  the  tube  becoming  flattened  out  (A.  K.  Stone).  The  flattening 
of  the  duodenum  may  be  followed  by  kinking  of  the  pylorus,  and  in  such  a 
case  the  stomach  dilates,  otherwise  it  does  not  dflate.  Where  a  movable  por- 
tion of  the  gut  has  a  junction  with  a  fixed  portion  a  kink  forms  and  intestinal 
stasis  ensues. 

Treatment  of  Visceroptosis. — In  many  cases  medical  treatment  is  of  benefit. 
The  following  is  the  usual  plan :  Employ  lavage,  abdominal  massage,  and  elec- 
tricity; order  a  proper  abdominal  corset;  insist  on  regular  exercise,  and  treat 
the  anemia  and  dyspepsia.  Surgery  is  resorted  to  if  intestinal  stasis  exists  and 
cannot  be  reheved  by  medical  and  dietary  treatment.     The  surgical  methods 


Acute  Peritonitis  102 1 

applicable  to  special  organs  are  discussed  under  those  headings.  When  the 
intestines  are  ptosed  and  there  is  stasis  there  are  two  commonly  employed  sur- 
gical plans,  and  each  has  its  advocates:  (i)  The  suture  of  the  prolapsed  intestine 
to  some  adjacent  structure  or  the  shortening  by  sutures  of  its  supporting  Hg- 
aments.  (2)  Plastic  operation  to  lessen  the  area  of  the  abdominal  wall  and  thus 
increase  intra-abdominal  tension.  Depage  makes  the  abdominal  wall  less  in 
both  directions.  Webster,  in  cases  with  separation  of  the  recti,  resects  and 
sutures  the  fascia  of  the  muscles.  I  believe  that  Depage's  method  of  shortening 
the  diameters  of  the  abdominal  wall  cannot  permanently  succeed,  because  the 
\'iscera,  hanging  to  relaxed  ligaments,  will  eventually  stretch  the  wall;  it  ^ill 
be  stretched  easily  because  of  damage  done  to  its  ner\-e-supply  by  operation, 
and  hernia  will  be  apt  to  occur,  and  if  it  should,  the  patient  will  be  worse  off 
than  before  operation.  Of  course,  whatever  operation  is  done,  diastased  rectus 
muscles  should  be  approximated  and  sutured.  For  ptosis  of  the  small  intestine 
the  mesentery  may  be  shortened,  as  suggested  and  performed  by  Da\ds,  of 
Omaha,  in  1897. 

In  prolapse  of  the  transverse  colon  good  results  are  said  to  have  been 
obtained  by  attaching  the  splenic  and  hepatic  flexures  to  the  abdominal  wall 
{Lamhotte's  operation).  The  surgical  treatment  of  ptosis  of  the  stomach  is 
considered  on  page  977;  of  the  Kver,  on  page  1040;  of  the  spleen,  on  page 
1065;  of  the  kidney,  on  page  1278. 

The  Peritoxelii 

Acute  Peritonitis. — Peritonitis,  or  inflammation  of  the  peritoneum, 
is  a  common  and  usually  a  very  dangerous  disease. 

Aseptic  irritation  by  a  traimaatism  or  a  chemical  irritant  produces  aseptic 
peritonitis,  a  condition  which  is  strictly  limited;  which  may  produce  local 
pain  and  tenderness;  which  may  cause  aseptic  fever  from  the  absorption  of 
fibrin-ferment  and  the  products  of  tissue  change;  which  leads  to  the  formation 
of  temporar\^  or  permanent  adhesions,  and  which  is,  in  reality,  a  process  of 
repair. 

"Peritonitis,"  as  the  term  is  used  by  the  surgeon,  is  always  due  to  bacteria. 
Bacteria  may  reach  the  peritoneal  ca^dty  by  means  of  an  abdominal  wound 
or  the  entrance  of  foreign  bodies;  by  extravasations  from  the  stomach,  bowel, 
vermiform  appendix,  gafl-bladder,  iirinarv-  bladder,  kidney,  Fallopian  tube 
or  uterus,  or  by  the  passage  of  micro-organisms  through  the  damaged  waHs 
of  any  of  these  ^•iscera  or  structures;  by  way  of  an  open  Fallopian  tube;  from 
the  breaking  of  an  abscess  into  the  peritoneal  ca\-ity;  from  areas  of  necrosis 
due  to  voh-ulus,  strangtflation,  or  intussusception  of  the  intestine;  twisting  of 
the  pedicle  of  an  ovarian  tiunor,  a  floating  kidney,  or  a  floating  spleen;  blocking 
of  a  mesenteric  vessel  by  a  thrombus  or  an  embolism;  gangrene  of  the  pancreas 
or  spleen,  and  fat-necrosis.^  In  some  cases  the  peritoneum  may  contain 
a  point  of  least  resistance,  and  bacteria  contained  in  the  blood  reach  this  point 
and  produce  infection.  It  was  once  taught  that  cold  coifld  produce  peritonitis, 
but  it  seems  probable  that  it  can  only  act  by  producing  an  area  of  least  resist- 
ance.    The  capacity  of  the  rheumatic  poison  to  produce  peritonitis  is  doubtful. 

The  peritoneum,  as  Byron  Robinson  pointed  out  and  Fowler  confirmed, 
is,  in  reaHty,  a  great  honph-sac,  and  peritonitis  is  hTuphangitis.  "WTien 
the  peritoneiun  is  infected  the  lymphatics  furnish  an  exudate  which  clots 
in  the  h-mph-channels,  blocks  them,  and  limits  or  prevents  absorption.  This 
blocking  of  the  hnnph-channels  serv'es  to  preserve  the  life  of  the  subject, 
on  the  one  hand,  while  a  fanxure  in  this  respect,  either  because  of  the  enor- 
mous and  overwhelmingly  rapid  increase  of  septic  material  and  the  large 
1  See  Park's  "Surger>-  by  American  Authors." 


I02  2  Diseases  and  Injuries  of  the  Abdomen 

size  and  number  of  channels  necessary  to  destroy  and  obstruct,  on  the  other 
hand,  permits  the  destruction  of  the  organism. "^  Absorption  takes  place 
most  actively  from  the  region  of  the  diaphragm,  hence  peritonitis  in  this 
region  is  peculiarly  fatal.  Absorption  takes  place  very  rapidly  from  the 
intestinal  region,  although  not  quite  so  quickly  as  from  the  diaphragmatic 
area.  Absorption  takes  place  slowly  from  the  pelvic  region,  hence  perito- 
nitis of  this  region  is  much  less  dangerous  than  is  the  disease  in  the  intes- 
tinal region,  and  vastly  less  dangerous  than  is  the  disease  in  the  diaphrag- 
matic region  (Fowler). 

When  severe  bacterial  infection  of  the  peritoneum  occurs,  exudation 
of  blood-liquor  takes  place,  luekocytes  migrate  from  the  blood-vessels  be- 
neath the  endothelial  layer,  particularly  into  the  peritoneal  cavity,  and  the 
causative  bacteria  rapidly  spread  about  the  cavity.  The  fibrinous  exudate, 
in  many  infections,  coagulates  in  masses  on  the  free  surface  of  the  peritoneum, 
and  thus  serves  a  useful  purpose  by  blocking  the  lymph-channels  and  hinder- 
ing the  absorption  of  toxins  and  bacteria.  The  fibrinous  exudate  may  break 
down  in  a  widespread  suppuration  or  may  be  organized  into  an  adhesion. 
In  very  virulent  streptococcic  infections  a  patient  may  die  and  there  may 
be  scarcely  any  coagulated  exudation  or  may  be  none  at  all.  Exudation  and 
migration  take  place  also  in  the  subserous  tissues  and  into  the  muscular  coat 
of  the  bowel,  and  the  segment  of  bowel  which  is  attacked  becomes  paralyzed 
and  distended  with  gas,  the  gas  within  causes  it  to  rise  up,  and,  as  peristalsis 
is  absent,  obstruction  occurs  (James  P.  Warbasse,  in  "Am.  Jour.  Med.  Sciences," 
July,  1905).  Absorption  of  poison  in  peritonitis  takes  place  in  part  from  the 
peritoneal  cavity  and  in  part  from  the  subserous  tissues.  Warbasse  believes 
that  the  inflamed  peritoneum  is  scarcely  an  absorbing  surface,  but  in  cases  in 
which  coagulated  exudate  has  not  formed  or  has  been  destroyed,  it  seems  prob- 
able that  it  is  an  active  absorbing  surface,  and  absorption  may  occur  from  some 
regions,  but  not  from  others. 

Various  bacteria  may  be  responsible  for  peritonitis,  especially  staphy- 
lococci, streptococci,  pneumococci,  and  colon  bacilli.  The  infections  which 
spread  most  rapidly  and  widely  are  due  to  streptococci.  In  streptococcus 
infection  the  protective  exudate  does  not  coagulate,  barriers  of  leukocytes 
are  not  heaped  up,  encompassing  adhesions  do  not  form,  there  is  rapid  ab- 
sorption of  toxins,  and  overwhelming  systemic  poisoning.  Colon  bacilli 
cause  a  very  grave  form  of  peritonitis,  but  less  rapid  and  diffuse  than  that 
caused  by  streptococci — in  fact,  the  process  is  often  encompassed  for  a  time 
by  coagulated  lymph,  leukocytes,  and  adhesions.  The  omentum  particularly 
is  thickened,  and  is  apt  to  apply  itself  about  the  area  of  infection.  Staphylo- 
cocci and  pneumococci  produce  peritonitis  which  is  more  apt  to  be  limited 
than  that  produced  by  colon  bacilli.  In  most  cases  of  peritonitis  a  mixed 
infection  exists;  for  instance,  colon  bacilli  and  staphylococci  or  colon  bacilli 
and  streptococci.  In  some  apparently  severe  cases  of  acute  peritonitis  cul- 
tures have  remained  sterile. 

Forms  of  Peritonitis. — An  accurate  bacteriological  classification  is  not 
as  yet  possible. 

Peritonitis  can  be  named,  according  to  regions,  pelvic,  subdiaphragmatic, 
etc.;  it  can  be  divided  pathologically  into  diffuse  septic,  putrid,  hemorrhagic, 
suppurative,  serous,  and  fibrinoplastic  (Senn);  it  can  be  classified,  etiologic- 
ally,  into  traumatic,  puerperal,  perforative,  metastatic,  scarlatinal,  etc. ;  and  it 
can  be  divided,  clinically,  into  circumscribed  suppurative,  diffuse  suppurative, 
and  diffuse  septic. 

Circumscribed  Suppurative  Peritonitis. — In  this  condition,  which  is 
frequently  met  with  in  appendicitis,  the  area  of  infection  is  circumscribed 
1  George  R.  Fowler,  "Diffuse  Septic  Peritonitis,"  in  "Medical  Record,"  April,  14,  1900. 


Diffuse  or  General  Suppurative  Peritonitis  1023 

by  coagulated  exudate,  leukocytes,  and  adhesions,  and  an  abscess  forms. 
After  a  time  distinct  localization  becomes  evident. 

The  symptoms  of  circumscribed  peritonitis  are  pain,  at  first  general  and 
then  local,  tenderness  in  a  particular  region,  muscular  rigidity,  distention^ 
vomiting,  rapid  and  often  wiry  pulse,  constipation,  fever,  great  weakness, 
and  dorsal  decubitus  with  the  thighs  flexed.  After  a  time  a  distinct  mass 
can  usually  be  detected  by  palpation,  and  there  may  be  dulness  on  percussion, 
local  rigidity,  irregular  temperature,  sweats,  and  possibly  edema  of  the  belly 
wall.  An  abscess,  though  limited  for  a  time,  is  always  liable  to  break  through 
its  walls  and  produce  general  peritonitis.  Such  an  accident  may  be  produced 
by  muscular  effort  on  the  part  of  the  patient  or  by  injudicious  palpation  on 
the  part  of  the  surgeon;  its  occurrence  is  announced  by  shock,  and  the  symp- 
toms of  general  peritonitis  quickly  arise. 

Dififuse  or  general  septic  peritonitis  is  apt  to  destroy  life  even  before  the 
peritoneum  presents  any  marked  change.  Death  ensues  from  the  absorption 
of  toxic  alkaloids.  Septic  peritonitis  may  arise  during  puerperality,  through 
lymphatic  infection;  it  may  be  due  to  infection  from  without  by  an  operation 
or  an  accident;  to  perforation  of  an  ulcer;  to  gangrene  of  a  portion  of  the 
intestine;  to  rupture  of  an  abscess  into  the  peritoneal  cavity;  or  to  migration 
of  micro-organisms  through  a  damaged  wall  of  the  bowel.  Peritonitis  due  to 
perforation  is  called  perforative  peritonitis.  Perforation  is  made  manifest  by  pain, 
a  chill,  shock,  or  perhaps  collapse.  Gas  may  pass  into  the  peritoneal  cavity, 
and  if  it  does  so,  the  area  of  liver  dulness  may  be  lessened  or  abolished.  Symp- 
toms and  signs  of  hemorrhage  may  arise.  Diffuse  septic  peritonitis  is  an- 
nounced by  a  very  rapid  pulse,  which  is  at  first  wiry  and  later  gaseous;  a 
temperature  which  may  at  times  be  febrile,  but  which  is  apt  to  be  subnor- 
mal or  which  soon  becomes  so;  general  abdominal  pain  and  tenderness, 
dry  tongue,  delirium,  persistent  vomiting,  constipation,  and  collapse.  Rigidity 
exists,  and  also  intestinal  obstruction  due  to  paralysis  of  the  gut.  Usually, 
but  not  invariably,  there  is  distention.  In  puerperal  peritonitis  or  septic  peri- 
tonitis from  operation  there  is  often  no  severe  pain.  In  perforative  peritonitis 
there  is  acute  pain.  Victims  of  general  septic  peritonitis  if  unoperated  upon 
usually  die  within  five  or  six  days. 

Diffuse  or  general  suppurative  peritonitis  differs  clinically  from  diffuse 
septic  peritonitis  in  the  fact  that  it  is  less  apt  to  be  fatal  and  widespread.  In 
fact,  adhesions  may  form  about  an  area  representing  a  considerable  portion  of 
the  peritoneal  cavity.  The  causes  of  both  are  identical.  In  septic  peritonitis 
death  occurs  from  absorption  of  toxins  before  obvious  pathological  changes 
occur  in  the  peritoneum;  in  suppurative  peritonitis  the  microbes  are  fewer, 
are  less  virulent,  or  vital  resistance  is  more  decided,  and  suppuration  follows 
marked  changes  in  the  peritoneum.  In  suppurative  peritonitis  the  pyogenic 
bacteria  are  always  present,  and  there  exists  in  the  peritoneum  a  wound 
or  damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by  fever,  the  tem- 
perature rising  to  102°  or  104°  F.;  pain  is  intense,  and  is  accentuated  by 
motion  and  pressure;  the  attitude  of  the  patient  is  assumed  to  relieve  pain 
(he  lies  upon  his  back,  with  the  shoulders  raised  and  the  thighs  drawn  up); 
there  are  vomiting,  obstinate  constipation,  and  rigidity  of  the  abdominal  walls, 
followed  by  distention  when  the  intestine  becomes  paretic  from  septic  poisoning. 
The  pulse  is  rapid;  is  at  first  wiry,  but  may  become  gaseous.  The  constipation 
may  be  due  either  to  tympanitic  distention  or  to  the  shock  and  toxemia  inhibit- 
ing intestinal  peristalsis.  Obstruction  arises.  Vomiting  is  frequent.  In  perfora- 
tion gas  often  passes  into  the  peritoneal  cavity,  and  it  may  obscure  the  liver 
dulness ;  in  tympanites  without  perforation  the  liver  is  apt  to  be  pushed  up  and 
its  dulness  remains,  but  on  a  higher  level.     Pus  unconfined  by  adhesions  will 


I024 


Diseases  and  Injuries  of  the  Abdomen 


gravitate  to  the  most  dependent  part  of  the  peritoneal  cavity.  In  some  cases 
of  suppurative  peritonitis  there  is  no  tympanitic  distention  or  rigidity ;  in  some 
cases  there  is  no  elevation  of  temperature,  in  fact,  the  temperature  may  be 
actually  subnormal. 

Treatment  of  Peritonitis. — ^After  an  abdominal  operation  the  patient 
may  have  pain,  slight  rigidity,  constipation,  nausea,  flatulence,  etc.,  and  the 
surgeon  is  in  doubt  if  peritonitis  is  beginning  or  about  to  begin.  Our  custom 
is  in  such  cases  to  give  a  saline  cathartic,  which  will  empty  the  peritoneal  cavity 
of  fluid,  will  favor  the  elimination  of  microbes,  and  will  combat  inflammation. 
The  old-time  remedy  was  opium,  but  Tait  denounced  it  as  inefficient,  and 
showed  that  it  masked  the  symptoms  and  often  created  a  false  sense  of  security 
in  the  very  midst  of  imminent  dangers.  The  usual  method  of  administering 
salines  is  to  give  i  dram  of  Rochelle  salt  and  i  dram  of  Epsom  salt  every  hour 
until  a  free  movement  occurs.  Administer  an  enema  of  turpentine  at  the  time 
the  first  dose  of  the  saline  is  given.  Atropin,  eserin,  and  pituitrin  may  be 
useful  (see  page  992).  This  treatment  will  often  abolish  pain  and  distention 
and  will  perhaps  prevent  peritonitis  after  an  abdominal  operation.  If,  how- 
ever, genuine  peritonitis  is  known  to  actually  exist  no  purgative  should  be 


Fig.  616. — Murphy  treatment  for  suppurative  peritonitis. 

given.  It  is  a  deadly  dangerous  thing  to  give  one,  as  it  diffuses  infection. 
Operation  is  required.  Prompt  operation  is  the  only  hope  in  genuine  post- 
operative peritonitis  and  any  delay  means  certain  death.  When  diffuse  septic 
or  suppurative  peritonitis  exists  from  any  cause  and  the  surgeon  sees  the  case 
early  (within  thirty-six  hours)  the  abdomen  should  be  opened.  In  a  perforative 
case  operate  even  if  the  case  is  first  seen  later  than  thirty-six  hours.  If  a  non- 
perforative  case  is  seen  later  it  may  be  wise  to  use  Ochsner's  treatment  and 
wait  for  localization  (Stanton,  in  "New  York  Med.  Jour.,"  Aug.  27,  1910). 
If  a  perforation  exists,  it  should  be  closed.  A  perforated  or  inflamed  appen- 
dix should  be  removed.  Until  recently  it  was  surgical  custom  to  break  up 
adhesions,  eviscerate,  wash  the  belly  with  gallons  of  very  warm  salt  solution, 
wipe  out  the  space  between  the  liver  and  diaphragm,  wipe  out  the  pelvis,  wipe 
off  the  intestines,  and  remove  masses  of  adherent  coagulated  exudate.  We  thus 
produced  dreadful  shock,  tried  to  cleanse  the  peritoneal  cavity  when  it  is  im- 
possible thoroughly  to  cleanse  it,  carefully  removed  the  exudate  which  was 
doing  good  by  plugging  the  lymph-spaces,  and  yet  we  did  not  reach  the  infec- 
tion inside  of  the  lymphatics,  which  is,  after  all,  the  greatest  source  of  danger. 
Then  we  drained  through  two  or  more  incisions  and  put  the  patient  recumbent 
in  bed,  and  thus  permitted  infected  material  to  flow  up  to  the  diaphragm,  where 


Treatment  of  Peritonitis 


1025 


it  is  quickly  absorbed.  The  mortality  from  this  procedure  was  dreadful. 
John  B.  Murphy  has  taught  us  wisdom  and  has  combined  some  of  the  conser- 
vative views  of  Ochsner  with  the  use  of  the  semi-erect  position  of  Fowler,  and 
with  the  continuous  rectal  irrigations  that  several  advocated.  Murphy's  plan 
is  founded  upon  the  following  principles: 

First,  that  the  initial  lesion  of  the  peritonitis  should  be  got  rid  of  as  quickly 
as  possible  and  with  the  slightest  possible  amount  of  handling.  For  instance, 
we  should  remove  a  gangrenous  appendix;  we  should  close  a  perforation  in 
the  bowel,  etc.  Flushing  of  the  peritoneal  cavity  with  gallons  of  salt  solu- 
tion is  inadvisable.  It  cannot  thoroughly  cleanse  the  peritoneum;  it  may 
diffuse  the  infection  to  regions  that  it  had  not  previously  reached,  and  it  may 
tear  up  adhesions.  Inflammatory  exudate  should  not  be  removed  from  the 
intraperitoneal  structures.  It  is  Nature's  method 
of  sealing  the  lymph-spaces,  and  if  we  remove  it 
we  open  thousands  of  channels,  previously  sealed, 
for  the  dissemination  of  the  infection.  A  drainage- 
tube  should  be  introduced  through  the  operation 
wound,  and  suprapubic  incision  should  also  be 
made  and  a  drainage-tube  be  carried  through  this 
into  the  pelvis.  When  the  operation  is  completed 
the  patient  should  be  placed  in  the  semi-erect 
position,  which  is  commonly  called  Fowler's  posi- 
tion. This  is  done  in  order  that  the  intraperi- 
toneal fluids  may  gravitate  away  from  the  dia- 
phragm, where  absorption  is  extremely  rapid,  and 
into  the  pelvis,  where  absorption  is  much  slower. 

When  the  patient  is  placed  in  the  bed  quantities 
of  warm  salt  solution  are  passed  slowly  into  the 
rectimi.  The  mucous  membrane  of  the  large  intes- 
tine absorbs  fluid  with  great  rapidity  when  that 
portion  of  the  gut  is  in  its  normal  condition  of 
moderate  distention.  Overdistention  leads  to 
spasm,  which  expels  the  fluid.  Hence  the  fluid 
must  be  given  at  low  pressure  and  administration 
should  be  continuous.  The  simplest  sort  of  appa- 
ratus is  shown  in  Fig.  617.  It  consists  of  a  foun- 
tain syringe,  a  large  rubber  tube,  and  a  rectal  tip 
of  hard  rubber.  The  nozzle  that  is  used  is  angled, 
has  one  opening  on  the  end  and  several  on  the  side, 
and  this  nozzle  is  passed  so  that  the  angle  fits  to  the  sphincter  (see  Fig.  619). 
The  tube  is  strapped  to  the  thighs  by  adhesive  plaster.  The  hose  that  comes 
from  the  nozzle  is  attached  to  a  reservoir,  the  base  of  which  is  hung  from  4  to  6 
inches  above  the  level  of  the  patient's  buttocks;  and  the  fluid,  therefore,  enters 
the  rectimi  only  about  as  fast  as  the  rectum  will  absorb  it.  The  reservoir  is 
kept  warm  by  bags  of  hot  water  hung  about  it.  The  fluid  is  allowed  to  enter 
continuously,  unless  it  should  run  out  from  the  side  of  the  tube;  if  this  happens, 
the  flow  may  be  cut  off  for  a  short  time  and  then  allowed  to  begin  again.  Gas 
from  the  bowel  passes  into  the  openings  of  the  tube,  and  every  now  and  then 
bubbles  up  through  the  reservoir.  By  this  continuous,  low-pressure  instilla- 
tion (proctoclysis)  an  enormous  quantity  of  fluid  is  absorbed  by  the  rectum. 
In  some  cases  a  number  of  quarts  are  taken  up  in  twenty-four  hours.  The 
absorption  of  this  fluid  greatly  increases  the  amount  of  urine  eliminated,  re- 
moves toxins,  and  stimulates  the  heart.  The  reservoir  must  not  be  high.  In- 
crease of  pressure  will  cause  expulsion  of  fluid  and  defeat  the  possibility  of  con- 
tinuous administration.     The  plan  so  often  followed  of  keeping  the  reservoir 

6_; 


Fig.  617. — Proctoclj'sis  appa- 
ratus consisting  of  fountain  syr- 
inge, large  rubber  tube,  and 
vaginal  hard-rubber  or  glass  tip 
(Murphy). 


I026 


Diseases  and  Injuries  of  the  Abdomen 


high  and  limiting  the  flow  by  a  clip  on  the  tube  is  a  mistake.  Murphy  says: 
"It  should  never  have  a  headway  of  more  than  15  inches  hydrostatic  pressure, 
and  it  gives  the  best  and  most  uniform  results  at  4  to  7  inches"  ("Jour.  Am.  Med. 
Assoc,"  April  17,  1909).  A  straight  tube  is  sometimes  responsible  for  ex- 
pulsion of  the  fluid,  because  it  touches  the  posterior  rectal  wall  of  a  patient 
in  Fowler's  position.  Fig.  618  shows  a  more  elaborate  apparatus  than  that 
just  described. 

After  the  water  has  been  entering  the  rectum  for  some  time  a  profuse 
discharge  of  sour-smelhng  material  comes  from  the  drainage-tube.  This 
discharge  may  be  profuse  for  one  day,  two  days,  or  longer,  when  its  sour 
smell  disappears  and  it  greatly  lessens  in  quantity.  The  outflow  of  this  fluid 
from  the  wound  means  that  saHne  flmd  from  the  rectum  has  entered  the  lymph- 
spaces  and  flowed  into  the  peritoneal  cavity.  Murphy  thinks  the  Ijnnph-cur- 
rent  has  been  reversed.  Whether  this  is  true  or  not  the  peritoneum  certainly 
seems  to  become  a  secreting  instead  of  an  absorbing  surface,  and  the  lymphatics 
are  washed  out.     During  the  time  that  this  treatment  is  pursued  the  patient 


Fig.  6i8.^Alcohol  or  gas  heater  in  operation,  showing  it  properly  connected.     A  short  glass  tube 
connects  catheter  to  rubber  tubing  (Murphy). 

has  no  food  or  w^ater  given  him  by  the  mouth.  Stomach  feeding  is  rigidly  for- 
bidden in  order  to  prevent  peristaltic  movements.  Small  amounts  of  opium 
may  be  given  to  prevent  peristalsis.  If  the  patient  is  in  a  weak  condition, 
stimtilants  or  food  can  be  given  by  the  rectum,  the  solution  in  the  reservoir 
being  aUowed  to  reach  a  low  level,  and  then  the  material  that  it  is  desired  to 
give  being  poured  into  the  receptacle.  Besides  the  above  method  of  treat- 
ment antistreptococcic  serum  is  usually  given. 

I  am  convinced  that  this  method  of  treatment  is  of  the  greatest  value,  and 
that  the  principles  upon  which  it  rests  are  entirely  sound,  and  I  have  had  a 
number  of  striking  successes  from  its  employment. 

If  a  case  of  diffuse  peritonitis  has  lasted  for  three  or  four  days  and  any  sign 
points  to  locaHzation,  do  not  operate  at  once.  Wash  out  the  stomach,  place 
the  patient  in  Fowler's  position,  give  salt  solution  by  the  rectum,  and  with- 
hold purgatives  and  food.      The  inflammation  may  subside  or  may  localize  into 


Tuberculous  Peritonitis  1027 

a  circumscribed  suppuration.  When  in  a  patient  with  peritonitis  the  skin  is 
blue,  cold,  and  moist,  the  pulse  very  rapid  and  weak,  the  abdomen  immensely 
distended,  and  the  temperature  subnormal  death  is  almost  certain,  and  the 
only  chance  is  the  conservative  plan  set  forth  above.  We  wait  in  hope  that 
the  infection  may  localize  in  an  abscess.  (See  Buchanan,  in  "Med.  Record," 
Jan.  28,  1911,  and  Stanton,  in  "*Xew  York  Med.  Jour.,''  Aug.  27,  1910.) 

A  circumscribed  suppuration  is  treated  as  follows:  Open  the  abscess.  It 
will  be  possible,  if  the  abscess  is  adherent  to  the  abdominal  wall,  to  open 
the  abscess  directly  -^-ithout  opening  the  peritoneal  ca\-ity.  If  this  is  not 
possible,  after  opening  the  abdominal  ca\-ity  pack  gauze  pads  in  such  a  man- 
ner about  the  abscess  as  to  prevent  the  dGlusion  of  pus  when  the  abscess 
is  evacuated.  After  opening  the  abscess  the  primary-  lesion  is  sought  for 
and,  if  possible,  removed.  The  surgeon  should  not,  in  most  cases,  tear  awav 
the  abscess  walls  in  an  attempt  to  find  the  primank'  lesion,  but  should  rather 
let  it  go  undiscovered.  Pack  iodoform  gauze  against  the  intestines  to  rein- 
force the  barrier  of  honph  and  insert  a  tube.  It  is  frequently  ad^'isable  to 
leave  the  wound  wide  open  and  drain  by  means  of  gauze. 

Ever\'  patient  "^-ith  peritonitis  requires  stimulants. 

Tuberculous  Peritonitis. — Tuberculosis  of  the  peritoneimi  is  not  very 
common.  In  11 70  autopsies  in  the  Boston  City  Hospital  tubercle  existed 
in  some  region  in  197,  and  in  14  of  these  the  peritoneum  was  involved.^  Pri- 
mary local  peritoneal  tuberculosis  is  occasionally,  though  rarely,  seen  by 
the  surgeon.     In  a  great 

majority  of  cases  of  peri-  ~1 

toneal  tuberculosis  other 
distant  structures  are  in- 
volved. In  about  hah' 
of  the  cases  the  lungs  are 
involved.  In  2S  cases 
reported  by  Bottoml\- 
not  one  was  primary.  In 
ever}^  one  of  these  cases 
the  diagnosis  was  con- 
firmed by  the  microscope, 
by    the    tubercuUn    test, 

or  by  autopsy.  In  most  pj^  619.— Tube  vdth  orifices  mied  with  chalk  in  order  to  show 
supposed    cases    of    pnm-  openings  better. 

ar\-  peritoneal  tubercu- 
losis another  focus  of  disease  exists,  but  is  not  demonstrable  by  clinical 
methods  or  has  been  overlooked.  The  disease  sometimes  exists  as  a  part 
of  general  tuberculosis.  Tuberculous  peritonitis  may  be  only  a  part  of 
acute  mihan.-  tuberculosis.  Bacteria  may  be  swallowed  with  tuberculous  food 
or  a  tuberculous  patient  may  swallow  tuberculous  sputtun  and  intestinal  tuber- 
culosis may  result,  the  peritoneum  being  involved  later.  Peritoneal  infection 
may  follow  a  tuberculous  lesion  of  the  intestine,  the  bacteria  may  enter  by 
way  of  the  Fallopian  tube,  the  initial  lesion  may  be  tuberculous  appendicitis 
or  tuberculosis  of  the  mesenteric  glands.  The  germ  may  lodge  from  the  blood 
or  h-mph.  The  h-mphatic  form  most  commonly  attacks  the  cecum.  Tubercu- 
lous peritonitis  is  four  times  as  common  among  women  as  among  men,  and  most 
frequently  attacks  those  between  twenty  and  forty  years  of  age,  but  I  have 
seen  it  in  a  child  of  five  and  in  a  colored  man  of  sixty.  There  are  two  groups 
of  cases — the  common  chronic  form  and  the  rarer  acute  condition.  The 
acute  form  begins  suddenly,  and  such  cases,  as  pointed  out  by  Lejars,  resemble 
acute  appendicitis.  In  either  the  acute  or  chronic  condition  it  is  frequently 
^  Bottomly,  in  ".-Vmer.  Med.,"  Feb.  15,  1902.        -  Ibid. 


I028  Diseases  and  Injuries  of  the  Abdomen 

the  case  that  pulmonary  phthisis  exists.  Cirrhosis  of  the  Hver  is  sometimes 
found  with  tuberculous  peritonitis.  There  are  three  forms  of  chronic  tuber- 
culous peritonitis:  the  ascitic,  the  fihrino plastic,  and  the  caseous,^  although, 
as  a  matter  of  fact,  these  so-called  forms  are  only  stages  of  the  same  disease. 
Tuberculous  infection  may  exist  for  some  time  without  causing  symptoms, 
acute  symptoms  may  suddenly  arise,  or  intestinal  obstruction  may  take  place. 
Symptoms  sometimes  develop  quickly  after  pregnancy.  In  other  cases  the 
symptoms  appear  gradually  and  progressively  grow  more  positive. 

Symptoms  of  the  Chronic  Form. — Usually  the  disease  begins  insidiously. 
The  digestion  is  found  to  be  disturbed,  there  is  nausea,  the  bowels  are  out  of 
order,  the  abdomen  is  distended  and  tender,  there  is  occasional  colicky  pain, 
and  the  patient  is  weak,  loses  flesh  rapidly,  and  becomes  very  anemic.  Fre- 
quently pain  is  the  symptom  which  leads  the  patient  to  seek  advice.  The 
pain  may  be  present  from  the  very  beginning,  it  may  arise  after  malaise  and 
gastro-intestinal  disorder  have  existed  for  some  time,  but  sooner  or  later  it 
will  develop. 

In  many  cases  there  is  ascites,  but  the  amount  of  fluid  is  rarely  very  great. 
In  some  cases  the  fluid  is  serous,  in  some  seropurulent,  in  some  purulent,  and 
in  some  bloody.  Chylous  fluid  occasionally  exists  because  of  fatty  degenera- 
tion of  tuberculous  masses.  Ascites  may  be  either  unconfined  or  sacculated  by 
adhesions.  In  some  cases,  and  especially  in  early  youth,  there  is  little  or  no 
ascites,  and  the  condition  is  characterized  by  the  production  of  a  quantity  of 
adhesions  which  bind  coils  of  intestine  to  each  other,  to  the  omentum,  to»  the 
stomach,  liver,  and  other  viscera.  In  this  condition,  which  develops  very 
slowly,  small  cavities  are  formed  between  adhesions  and  the  spaces  contain 
fluid  and  bacteria.  This  is  the  most  chronic  form  of  the  disease.  In  any  case 
of  tuberculous  peritonitis  the  mesenteric  glands  may  enlarge.  There  is  usually 
moderate  fever,  but  there  may  be  episodes  of  high  fever  and  protracted  periods 
of  subnormal  temperature,  or  the  temperature  may  be  slightly  elevated  in  the 
evening  and  subnormal  in  the  morning.  When  the  temperature  becomes 
markedly  elevated,  pain,  tenderness,  and  distention  notably  increase.  In 
some  cases  there  is  a  continued  fever  resembling  typhoid.  Tumor-like  forma- 
tions may  be  detected.  These  formations  may  consist  of  indurated  omentum, 
encysted  exudate,  or  enlarged  mesenteric  glands.  If  diarrhea  exists  for  a  long 
period  there  is  probably  tuberculous  ulceration  of  the  gut. 

In  every  suspected  case  a  bimanual  examination  should  be  made  under 
ether,  in  order  to  discover  if  there  are  any  matted  masses  of  intestine  (Thom- 
son). 

In  many  cases  a  careful  examination  will  detect  tuberculous  disease  of  other 
regions  of  the  body,  particularly  of  the  lungs.  If  tuberculous  disease  of  the 
lungs  or  pleura  is  detected,  if  tuberculous  glands  exist  or  have  been  present, 
if  a  nodule  not  due  to  gonorrheal  inflammation  is  palpable  in  an  epididymis, 
or  if  there  are  indurations  in  the  prostate,  the  probability  of  the  presence  of 
tuberculous  peritonitis  is  much  enhanced.  In  many  cases  there  is  dilatation 
of  the  superficial  abdominal  veins.  In  some  cases  tuberculous  peritonitis 
undergoes  spontaneous  cure.  In  the  majority  of  instances  death  ensues  from 
the  tuberculous  peritonitis  directly  or  from  associated  or  secondary  disease  in 
other  organs. 

If  an  intraperitoneal  tuberculous  area  caseates,  a  large  cold  abscess  may 
form,  and  such  an  abscess  may  break  into  the  intestine  or  may  be  opened  ex- 
ternally, and  may  be  responsible  for  the  formation  of  a  fecal  fistula. 

In  a  case  of  tuberculous  peritonitis  intestinal  obstruction  may  occur,  the 
gut  getting  caught  by  bands  or  adhesions,  or  becoming  a  rigid  tube  because  of 
the  formation  of  tubercles. 

1  Parker  Syms,  in  "Medical  Record,"  April  2,  1898. 


Tuberculous  Peritonitis  1029 

Symptoms  of  the  Acute  Form. — This  is  sometimes  mistaken  for  appen- 
dicitis. It  comes  on  rather  suddenly,  but  a  carefully  elicited  history  will 
usually  show  the  previous  existence  of  malaise,  gastro-intestinal  disturbance, 
loss  of  flesh,  and  anemia.  The  symptoms  are  not  so  strictly  localized  to  the 
right  iliac  fossa  as  in  appendicitis.  There  are  abdominal  distention,  a  cer- 
tain amount  of  rigidity,  nausea  and  vomiting,  colicky  pain  which  may  be 
very  severe,  general  abdominal  tenderness,  fever,  and  exhaustion.  It  may 
be  possible  to  palpate  masses  like  tumors,  or  to  feel  nodules  in  the  prostate 
or  epididymis,  or  to  detect  tuberculosis  in  some  other  part. 

Treatment. — In  some  cases  there  is  a  tendency  to  spontaneous  cure,  and  in 
them  medical  treatment  is  of  great  service.  The  patient  should  be  placed 
under  antituberculous  conditions,  nutritious  food  and  tonics  should  be  admin- 
istered (see  page  230),  the  abdomen  should  be  counterirritated  and  massaged, 
and  purgatives  should  be  given  frequently.  Guaiacol  applied  daily  to  the 
abdomen  is  thought  by  some  to  be  of  service,  but  I  doubt  it.  A  mixture  is  made 
of  I  part  of  guaiacol  and  5  parts  of  olive  oil ;  i  dram  of  this  mixture  is  rubbed  into 
the  abdomen,  and  the  part  is  covered  with  a  piece  of  flannel  held  in  place  by 
means  of  a  binder.  If  medical  treatment  is  not  soon  productive  of  benefit,  the 
advisabflity  of  operating  must  be  considered.  It  is  a  curious  fact,  but  one  con- 
firmed by  ample  evidence,  that  after  simple  abdominal  section,  without  the  in- 
trod,uction  of  germicides  and  without  drainage,  at  least  30  per  cent,  of  the  cases 
recover  from  the  disease  in  from  six  months  to  one  year.  Some  surgeons 
doubt  the  curative  effect  of  operation.  For  instance,  the  late  Professor 
Fenger  was  strongly  of  the  opinion  that  many  patients  recover  after  operation, 
but  not  as  a  result  of  operation.  In  his  opinion  they  recover  because  they 
are  strong,  free  from  fever,  and  well  nourished,  and  because  the  disease 
tends  to  spontaneous  cure.  He  further  believed  that  some  die  from  opera- 
tion because  the  traumatism  lessens  the  already  lowered  tissue  resistance. 
The  majority  of  surgeons,  however,  believe  that  operation  in  many  cases  tends 
to  cure.  Ochsner,  in  a  paper  before  the  American  Surgical  Association  in  1902, 
apparently  proved  that  simple  incision  and  evacuation  of  fluid  tends  to  cure. 
It  is  uncertain  how  an  operation  tends  to  cure.  It  has  been  thought  that 
the  ascitic  fluid  is  a  culture-medium  for  bacilli,  and  when  it  is  withdrawn  the 
bacilli  die,  but  opposed  to  this  view  is  the  fact  that  aspiration  is  rarely  curative. 
It  has  been  suggested  that  the  operation  brings  numerous  phagocytes  to  the 
peritoneimi;  that  it  stimulates  vital  resistance;  that  it  leads  to  the  exudation 
of  antitoxic  serum.  The  entrance  of  air  seems  to  play  a  definite  and  important 
part  in  effecting  a  cure. 

The  ascitic  cases  are  most  frequently  benefited  by  operation.  In  en- 
cysted fluid  operation  often  cures. 

In  cases  in  which  there  are  numerous  adhesions  operation  is  not  so  likely  to 
produce  a  cure.  Great  care  should  be  exercised  in  separating  adhesions, 
because  the  bowel  is  apt  to  be  torn  and  a  fecal  fistula  may  result.  It  may  be 
necessary  to  separate  adhesions  or  short-circuit  a  portion  of  gut  to  relieve 
obstruction.  Drainage  should  not  be  used  unless  a  cold  abscess  exists.  Not 
only  is  drainage  of  no  service,  but  it  is  dangerous ;  death  is  more  apt  to  ensue 
in  a  drained  case  and  a  fecal  fistula  will  arise  in  nearly  one-fourth  of  the  drained 
cases.  If  operation  is  performed  for  cold  abscess,  tube-drainage  must  be  used 
for  some  days.  In  a  woman  with  tuberculous  peritonitis  the  abdomen  shoidd 
be  opened  in  the  midline,  and  if  the  FaUopian  tubes  are  tuberculous  they  should 
be  removed.  In  a  man  the  incision  should  be  made  over  the  appendix,  and  if 
this  is  tuberculous  it  should  be  removed.  In  either  sex  it  may  be  necessary  to 
resect  tuberculous  intestine  or  perform  anatomosis  because  of  stricture. 
(In  confirmation  of  these  views  see  W.  J.  Mayo,  in  "Jo'i^r.  Am.  Med.  Assoc," 
April  15,   1905.)     The  Mayos  have  performed  26  radical  tubal  operations 


1030  Diseases  and  Injuries  of  the  Abdomen 

on  cases  of  tuberculous  peritonitis  and  25  recovered.  Of  these,  7  had  pre- 
viously been  operated  on  from  one  to  four  times  by  simple  laparotomy  ("Jour. 
Am.  Med.  Assoc,"  April  15,  1905).  In  a  very  advanced  case,  in  a  case  with 
notably  high  temperature,  or  in  a  case  with  marked  and  advancing  tuber- 
culosis in  another  region,  an  operation  should  not  be  performed  except  to  relieve 
obstruction  or  drain  an  abscess.  If  a  patient  does  not  die  within  a  few  months 
after  an  operation,  he  will  probably  recover,  and  in  m.ost  cases  operation 
secures  at  least  temporary  improvement  (Bottomly,  "Amer.  Med.,"  Feb.  15, 
1902).     The  mortality  from  operation  is  i  or  2  per  cent.  (Fenger). 

Pneumococcus  Peritonitis. — -This  condition  is  an  unusual  one.  It  is  most 
apt  to  arise  during  the  progress  or  after  the  termination  of  pneumonia  or  some 
other  pneumococcic  lesion,  but  is  sometimes  primary — is  far  commoner  in  fe- 
males than  in  males  and  in  children  than  in  adults.  Out  of  74  reported  cases, 
57  were  children  under  five  years  of  age  (Dr.  Max  von  Brunn,  in  "Beitrage  zur 
klinischen  Chirurgie,"  Bd.  xxxix,  Heft  i).  In  primary  cases  the  bacteria  may 
enter  by  way  of  the  blood-stream  or,  perhaps,  in  some  cases  through  the  bowel 
wall  or  Fallopian  tube.  In  secondary  cases  infection  may  arise  from  an  ad- 
jacent pneumococcic  area  (pleura)  or  be  carried  by  the  blood  from  a  distant 
point  {pneumococcic  septicemia) .  The  condition  may  appear  in  a  sufferer  from 
otitis  media.  The  symptoms  in  children  are  sudden  in  onset.  The  first 
symptoms  are  general  abdominal  pain,  usually  a  continuous  pain  with  colicky 
exacerbations,  tenderness,  rigidity,  vomiting,  elevated  temperature,  disten- 
tion, and  diarrhea.  In  a  few  days  the  symptoms  abate  and  some  of  them 
disappear,  although  pain,  tenderness,  and  rigidity  are  apt  to  localize  at  some 
point,  particularly  about  the  umbilicus,  and  may  remain  for  a  number  of 
weeks.  In  such  a  chronic  case  physical  signs  of  a  fluid  collection  are  usually 
demonstrable.  In  the  chronic  stage,  as  Brunn  points  out,  there  is  seldom  severe 
tenderness  and  there  may  be  no  fever  at  all,  and  a  septic  temperature  is  very 
rarely  observed.  Pus  may  form,  and  if  it  does,  it  contains  pneumococci. 
Adhesions  practically  always  form.  These  adhesions  glue  the  intestines  to- 
gether and  often  encompass  pus.  Rapid  emaciation  and  progressive  weak- 
ness are  always  noted.  In  adults  the  symptoms  are  irregular  and  less  char- 
acteristic than  in  children  (Brunn).     The  prognosis  is  excellent. 

Treatment. — Incision  and  drainage. 

A  subphrenic  abscess  is  a  collection  of  pus  beneath  the  diaphragm. 
It  is  a  rare  condition.  The  pus  may  occupy  a  part  of  the  lesser  peritoneal 
cavity;  it  may  be  extraperitoneal  (when  it  is  of  renal  origin);  in  some  cases  it 
is  contained  in  the  area  between  the  diaphragm,  cardiac  end  of  the  stomach, 
and  liver  or  spleen.  It  is  impossible  to  classify  accurately  these  abscesses  by 
anatomical  position.  George  A.  Ross  ("Jour.  Am.  Med.  Assoc,"  August  12, 
191 1)  classifies  them  as  right,  left,  anterior,  and  posterior.  Most  are  on  the 
right  side,  but  even  an  abscess  due  to  appendicitis  may  be  on  the  left  side. 
It  is  an  unusual  thing  for  such  an  abscess  to  break  into  the  general  cavity 
of  the  peritoneum,  but  it  may  break  into  the  pleural  sac  (Maydl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the  gall-bladder  or 
gall- ducts,  ulceration  of  the  duodenum,  disease  of  the  liver,  spleen,  pancreas, 
intestine,  appendix,  or  kidney,  hydatid  disease,  internal  injury,  metastasis, 
external  injury,  caries  of  rib,  disease  of  the  pleura,  general  peritonitis,  or  portal 
infection  may  be  responsible  for  a  subphrenic  abscess.  We  have  abandoned 
the  notion  that  the  infecting  source  must  be  in  the  upper  abdomen.  Appendi- 
citis is  the  most  common  cause.  Charles  A.  Elsberg^  has  collected  73  cases  of 
subphrenic  abscess  after  appendicitis.  He  points  out  that  the  condition  may 
arise  from  direct  extension  or  by  way  of  the  lymph-channels,  and  may  be 
either  intraperitoneal  or  extraperitoneal,  although  in  the  majority  of  cases  it  is 
1  "Annals  of  Surgery,"  Dec,  1901. 


Symptoms  of  Subphrenic  Abscess  103 1 

intraperitoneal.  In  rare  cases  extension  is  by  way  of  the  portal  vein.  Ross 
claims  that  in  most  cases  due  to  appendicitis  the  infection  extends  by  cellular 
tissue  directly  upward  from  the  lower  peritoneal  fossae.  In  some  cases  infection 
ascends  between  the  colon  and  the  parietal  peritoneum  (the  parietocolic  sinus 
of  our  French  colleagues).  In  all  but  7  of  Elsberg's  cases  there  was  sup- 
puration about  the  appendix.  The  pus  was  thick  and  foul  in  all  the  cases.  In 
15  per  cent,  of  them  gas  was  also  present,  and  in  25  per  cent,  of  these  cases  the 
diaphragm  was  perforated.  In  3391  consecutive  cases  of  appendicitis  operated 
on  in  the  German  Hospital  of  Philadelphia  there  were  30  cases  of  subphrenic 
abscess  (Ross,  ''Jour.  Am.  Med.  Assoc,"  Aug.  12,  1911).  Subphrenic  abscess 
may  develop  soon  after  an  appendicitis,  it  may  develop  extraordinarily  late. 
Ashhurst's  case  arose  four  years  after  appendicitis  ("Trans.  Phila.  Acad,  of 
Surg.,"  1910),  I  of  Ross's  cases,  one  year  after  (Loc.  cit.).  If  ascending  retro- 
peritoneal infection  exists  during  appendicitis,  removal  of  the  appendix  does 
not  arrest  it  (Lance,  in  "Gaz.  d.  Hop.,"  1909,  Ixxxvii).  In  2  cases  on  which 
I  operated  the  abscess  developed  after  cholecystitis;  in  2  others,  after  suppura- 
tive appendicitis. 

The  symptoms  usually  come  on  suddenly,  but  may  do  so  gradually.  There 
may  or  may  not  be  abdominal  symptoms.  A  patient  with  subphrenic  abscess 
usually  complains  of  pain  in  the  lower  part  of  the  chest  on  the  right  side.  Usu- 
ally there  is  high  temperature  and  often  delirium,  but,  as  Jopson  ("Annals  of  Sur- 
gery," July,  1910)  says,  the  temperature  may  be  only  moderately  elevated  and 
the  pulse  may  be  nearly  normal.  The  area  of  liver  dulness  is,  in  many  cases,  dis- 
tinctly enlarged,  and  there  is  tenderness  in  the  lower  part  of  the  right  chest  when 
pressure  is  made  through  one  or  through  several  intercostal  spaces.  Frequently 
friction  sounds  may  be  heard  about  the  region  of  the  dome  of  the  liver.  Breath 
sounds  and  vocal  fremitus  are  lessened.  The  signs  are  usually  best  heard  poste- 
rior, but  may  be  lateral  or  anterior.  There  is  cough  and  bulging  of  the  chest  wall. 
Jaundice  is  absent  in  uncomplicated  cases.  Sometimes  the  symptoms  are  obscure 
or  indefinite,  and  not  accompanied  by  particular  pain.  If  the  abscess  happens 
to  contain  not  only  fluid  but  also  a  considerable  amount  of  gas — and  about 
one-half  of  such  abscesses  do  contain  gas — not  only  will  there  be  no  increase 
in  the  area  of  liver  dulness,  but  the  normal  area  of  dulness  may  be  diminished 
or  obliterated.  The  presence  of  gas  may  be  due  to  some  connection  with  an 
organ  which  contains  gas  or  to  gas-forming  bacteria.  It  is  very  common  for 
a  pleural  effusion  to  be  associated  with  a  subphrenic  abscess.  A  pleural 
effusion  will  be  preceded  by  or  accompanied  by  symptoms  pointing  to  the 
lung  or  pleura;  and  it  is  to  be  remembered  that  the  area  of  percussion-dulness 
found  in  the  pleural  effusion  shifts  its  position  whenever  the  position  of  the 
patient  is  changed,  which  is  not  true  of  the  area  of  dulness  found  in  sub- 
phrenic abscess.  When  the  abscess  breaks  through  the  diaphragm  the  patient 
collapses,  cough  and  other  thoracic  symptoms  develop;  and  if  the  abscess 
breaks  into  a  bronchus  the  patient  will  expectorate  pus.  In  subphrenic 
abscess  the  diaphragm  of  the  diseased  side  is  paralyzed — a  condition  rarely 
met  with  in  liver  abscess.  There  are  general  symptoms  of  suppuration  and 
a  swelling  in  the  subdiaphragmatic  region  following  some  recognized  causa- 
tive condition.  The  history  of  chills  with  recurrent  fever  and  sweats  is  rather 
indicative  of  abscess  of  the  liver;  but  in  abscess  of  the  liver  there  is  usually 
pain  in  the  shoulder-blade  of  the  right  side,  and  this  is  rarely  encountered 
in  subphrenic  abscess.  The  a;-rays  show  that  the  diaphragm  is  elevated  on 
the  side  of  the  lesion.  The  proof  of  the  diagnosis  is  not,  however,  obtained 
until  an  exploratory  incision  has  been  made  and  the  purulent  matter  has  been 
found.  Empyema  and  subphrenic  abscess  resemble  each  other.  In  empyema 
the  upper  limit  of  the  fluid  is  concave;  in  subphrenic  abscess  it  is  convex.  In 
empyema  the  flow  of  pus  through  an  aspirating-needle  will  be  most  marked 


1032  Diseases  and  Injuries  of  the  Abdomen 

during  expiration;  in  abscess,  during  inspiration.  The  same  is  true  of  the 
rush  of  gas.  In  empyema  the  needle  does  not  oscillate;  in  abscess  it  does.^ 
If  an  abscess  contains  gas,  percussion  elicits  a  tympanitic  note  over  a  part  of 
the  cavity,  and  there  is  an  alteration  in  the  area  of  tympany  with  an  alteration 
in  the  position  of  the  patient.  An  abscess  of  the  liver  almost  never  contains  gas 
and  decidedly  changes  the  outlines  of  the  organ.^  Empyema  may  follow  sub- 
phrenic abscess. 

Treatment. — Incision  and  drainage.  The  incision  is  made  in  the  lumbar 
region  if  the  abscess  points  there.  In  some  cases  it  is  made  through  the  ab- 
dominal wall  (epigastric  region,  iliac  region,  hypochondrium) .  In  other  cases 
the  chest  wall  is  incised,  the  ninth  or  tenth  rib  is  resected,  and  the  abscess  is 
opened  below  the  pleura  or  the  pleura  is  opened,  the  parietal  and  diaphragmatic 
layers  are  sutured  together,  if  possible,  and  the  diaphragm  is  incised.  If  appendi- 
citis was  the  cause,  be  sure  the  appendicitis  is  well ;  and  if  it  was  not,  open  the  ap- 
pendix region  and  drain  freely  (Elsberg).  If  it  is  necessary  to  open  the  pleural 
sac,  first  try  to  stitch  the  parietal  to  the  diaphragmatic  layer  of  the  pleura,  or,  if 
this  is  impossible,  protect  the  cavity  with  iodoform  gauze  to  prevent  infection. 

The  Liver,  Gall-bladder,  and  Bile -ducts 

Rupture  and  Wounds  of  the  Liver. — Rupture  of  the  liver  is  due  to 
very  great  force,  and  is  usually  accompanied  by  injury  of  other  viscera.  It 
may  be  produced  by  a  blow,  by  a  fall,  or  by  the  end  of  a  broken  rib.  The 
superior  surface  or  margin  most  often  suffers.  It  is  a  very  fatal  accident.  Out 
of  543  reported  cases  over  one-half  died  of  hemorrhage  within  twenty-four 
hours  of  the  accident.^  At  least  80  per  cent,  will  die  if  not  operated  upon. 
Wilms*  collected  19  cases,  and  only  3  recovered  after  operation.  Eisen- 
drath^  has  collected  37  cases  of  suture  of  the  liver  for  rupture  and  22  of  them 
recovered  (59.5  per  cent.).  The  first  operation  was  performed  by  Willette  in 
1888.  Out  of  Kraussine's  13  stab-wounds  of  the  liver  7  died  (Murphy,  in  "Prac- 
tical Medicine  Series,''  1910,  vol.  ii).  An  attempt  should  certainly  be  made  to 
save  the  patient  by  opening  the  abdomen  and  arresting  hemorrhage,  and  in  a 
suspected  case  an  exploratory  operation  should  be  performed.  A  wound  of  the 
Uver  causes  violent  hemorrhage,  which  is  usually  rapidly  fatal.  Such  a  wound  is 
apt  to  divide  bile-ducts  and  allow  bile  to  escape  into  the  peritoneal  cavity,  and 
perhaps  externally.  Bile,  if  sterile,  will  do  little  harm  to  the  peritoneum,  but 
if  it  contains  bacteria  it  will  produce  diffuse  peritonitis.  Even  sterile  bile  is 
corrosive  and  may  cause  fibroplastic  peritonitis.  The  symptoms  of  a  rupture 
or  wound  of  the  liver  are  those  of  severe  intra-abdominal  hemorrhage,  with 
collapse,  accompanied  by  hepatic  tenderness  and  respiratory  embarrassment. 
Soon  after  the  injury  the  abdomen  is  soft  and  fiat,  but  it  quickly  becomes 
rigid  and  ultimately  distended.  The  diagnosis  becomes  more  probable  when 
it  is  known  that  violence  was  appHed  to  the  hepatic  region.  Usually  there 
is  abdominal  pain  and  often  pain  in  the  back.  Sugar  may  appear  in  the 
urine.  In  a  few  cases  after  several  days  jaundice  and  skin  itching  have  been 
noted.  The  area  of  liver  dulness  is  usually  increased.  Patients  do  not 
always  die  from  a  serious  traumatism  of  the  liver.  Some  recover  because 
operation  has  saved  them.  Some  few  recover  without  operation.  This  last 
fact  is  proved  by  reports  of  autopsies  in  which  scars  were  found  in  the 
liver  parenchyma  (Nussbaum).  The  fataUty  which  usually  ensues  on  a 
liver  injury  may  be  due  to  hemorrhage  or  peritonitis.     If  a  surgeon  is  called 

1  Wharton  and  Curtis,  "Practice  of  Surgery." 

2  In  a  case  of  abscess  of  the  liver  secondary  to  appendicitis  operated  upon  in  the  Jefferson 
Hospital  the  abscess  did  contain  gas  produced  by  gas-forming  bacteria. 

3  Mercade,  in  "Rev.  de  Chir.,"  Jan.  10,  1902. 

^  "Deut.  med.  Woch.,"  Nos.  34  and  35,  1901.       ^  "Jour.  Am.  Med.  Assoc,"  Nov.  i,  1902. 


Tumors  and  Cysts  of  the  Liver  1033 

to  a  patient  suffering  from  wound  of  the  Hver,  he  must  open  the  abdomen 
to  arrest  hemorrhage.  If  a  penetrating  woimd  is  suspected,  it  may  be 
desirable  to  enlarge  the  wound  in  the  abdominal  wall  layer  by  layer,  in 
order  to  determine  that  the  liver  is  wounded.  If  the  left  lobe  of  the  liver 
is  wounded,  or  if  it  is  uncertain  which  lobe  is  wounded,  the  incision  should 
be  median.  If  the  right  lobe  is  wounded,  a  curved  incision  is  made  along 
the  line  of  the  costal  cartilages.  In  some  cases  these  two  incisions  are  joined.^ 
The  convex  surface  of  the  liver  can  be  reached  by  Lannelongue's  plan.  Lan- 
nelongue  resects  the  eighth,  ninth,  tenth,  and  eleventh  costal  cartilages  and 
draws  the  ends  of  the  ribs  well  out.  It  can  also  be  reached  by  Langenbuch's 
plan,  that  is,  by  cutting  the  coronar\-  ligament  and  the  right  lateral  ligament. 
This  allows  the  liver  to  be  pulled  well  up  into  the  wound  in  the  belly  wall. 
The  site  of  the  wound  can  be  discovered  if  the  hepatic  vessels  are  grasped 
between  the  thumb  and  a  linger  (the  linger  in  the  foramen  of  Winslow  and  the 
thumb  in  front  on  the  gastrohepatic  omentum).  This  completely  arrests 
hemorrhage,  and  the  blood  that  has  gathered  may  be  sponged  out  and  the 
wound  sought  for  in  a  clear  field.  (See  Pringle,  of  Glascow,  in  "Annals  of  Sur- 
gery," Oct.,  1908.)  \Mien  the  wound  in  the  liver  is  discovered  and  well 
exposed,  deep  sutures  of  catgut  should  be  inserted  in  the  liver  and  the  cap- 
sule should  be  stitched  with  fine  silk  (Schlatter).  If  sutures  fail  to  arrest  hem- 
orrhage, the  organ  should  be  sutured  to  the  belly  wall  and  the  wound  in  the 
Hver  packed  with  iodoform  gauze.  It  is  useless  to  tr\^  packing  T\-ithout  first 
attaching  the  liver  to  the  abdominal  wall,  because  pressure  'vsill  simply  push 
the  Hver  away  and  will  not  arrest  the  bleeding.  The  cauten,-  is  a  ver\-  useful 
means  of  arresting  bleeding.  It  should  be  avoided  if  possible  in  a  large  wound, 
because,  even  if  it  arrests  primary-  hemorrhage,  secondary'  hemorrhage  may 
occur.  After  arresting  hemorrhage,  wash  out  the  abdomen  with  hot  saline 
fluid,  insert  drainage,  and  close  the  abdominal  wound.  In  a  case  of  the 
author's  in  the  Philadelphia  Hospital  the  liver  was  wounded  by  the  sharp  ends 
of  fractured  ribs.  The  abdomen  was  opened,  a  wound  was  found,  and  bleed- 
ing was  arrested  by  suturing  the  Uver  to  the  belly  wall  and  packing  the  wound. 
The  patient  died,  and  necropsy  showed  another  wound  on  the  posterior  portion 
of  the  organ.  The  possibility  of  such  an  occurrence  should  not  be  lost  sight  of. 
Tumors  and  Cysts  of  the  Li\'er. — ^The  hver  may  be  the  seat  of  pri- 
mary- carcinoma,  sarcoma,  endothelioma,  angioma,  hTnphangioma,  ade- 
noma, fibroma,  m}-xoma,  or  Hpoma.  ^lany  tmnors  called  adenomata 
are  reaUy  adenocarcinomata.  Secondar}'  malignant  growths  are  far  more 
common  than  priniar\-  neoplasms — in  fact,  96  per  cent,  of  Hver  tumors  are  sec- 
ondar\-.  Prunar}'  cancer  of  the  Hver  is  found  once  in  ever\-  2000  autopsies 
(Eggel).  The  commonest  variety  is  nodular,  but  the  diffuse  form,  known 
as  cancerous  cirrhosis,  may  occur.  The  nodular  form  is  most  often  encoun- 
tered in  the  right  lobe,  and  it  has  been  found  in  persons  imder  the  age  of  twenty. 
Metastases  occur  early.  "There  is  always  more  or  less  coexisting  cirrhosis 
of  the  Hver"  (Leonard  Freeman,  in  "Trans.  Am.  Surg.  Assoc,"  1904).  It 
takes  origin  from  the  hepatic  ceUs.  The  frequency  of  cancer  of  the  liver 
secondarv'  to  cancer  of  the  stomach  has  already  been  aUuded  to.  The  com- 
monest priman.-  tumor  of  the  liver  is  cavernous  hemangioma.  It  is  especially 
apt  to  take  origin  in  the  atroph}-ing  liver  of  an  elderly  indi^•idual.  Primary 
sarcoma  may  arise  at  any  age  and  may  even  be  congenital.  The  growth  is 
rapid  and  emaciation  is  soon  noted.  The  Hver  enlarges,  often  greatly.  Jaun- 
dice and  ascites  are  rather  rare.  The  patient  soon  becomes  ver\-  weak.  There 
is  always  pain.  As  Ejnott  ("Surg.,  Gynec,  and  Obstet.,"  Sept.,  190S)  points- 
out,  the  condition  may  simulate  abscess,  and  if  it  arises  in  a  middle-aged  or 
elderly  person  can  scarcely  be  differentiated  from  carcinoma. 

^  See  Schlatter,  "Beitrage  zur  klinischen  Chirurgie,"  Ed.  xv.  Heft  ii,  1896. 


I034  Diseases  and  Injuries  of  the  Abdomen 

Knott  ("Surg.,  Gynec,  and  Obstet.,"  Sept.,  1908)  has  collected  59  cases 
of  primary  sarcoma  "from  literature,  and  adds  14  reported  by  personal  com- 
munications and  I  of  his  own,  74  in  all. 

He  shows  that  28  cases  have  been  operated  upon.  In  9  the  operation  was 
exploratory  and  no  attempt  was  made  to  remove  the  growth.  In  19  the 
growth  was  extirpated,  with  10  recoveries  and  9  deaths.  One  of  these  patients 
was  well  after  nineteen  months,  i  after  two  years,  i  after  seven  months. 
Operation  is  indicated  for  a  circumscribed  growth. 

Among  the  cysts  occurring  in  the  liver  are  blood  cysts,  congenital  cysts, 
bile  cysts,  and  hydatid  cysts.  Terrier  and  Auvray  in  1901  collected  52  opera- 
tions for  hepatic  tumors. 

Angiomata  have  been  removed  successfully  by  hepatectomy,  a  cautery- 
knife  at  a  red  heat  being  used  to  cut  through  the  normal  liver  tissue  around  the 
base  of  the  tumor,  the  large  vessels  being  tied  with  catgut.  Enucleation 
is  not  feasible  because  of  excessive  hemorrhage.  If  a  tumor  is  pedunculated, 
the  base  may  be  encircled  by  an  elastic  ligature  held  in  place  by  a  steel  needle, 
and  five  or  six  days  later  the  tumor  may  be  cut  across  by  the  cautery.^  I 
assisted  Prof.  W.  W.  Keen  in  such  an  operation. 

Carcinoma  of  the  liver  has  been  extirpated,  but  it  is  seldom  that  a  growth 
is  recognized  early  enough  and  is  found  to  be  sufficiently  limited  to  justify 
such  a  procedure.  Operation  is  proper  only  when  there  is  a  limited  nodule  of 
primary  cancer.  In  1901  Terrier  and  Auvray  collected  9  operations  for  pri- 
mary cancer.  In  most  cases  there  has  been  rapid  recurrence  or  secondary 
growth,  but  Schrader's  case  was  well  at  the  end  of  seven  years  and  Leonard 
Freeman's  at  the  end  of  sixteen  months.  (For  operative  methods,  see  Leonard 
Freeman,  in  "Trans.  Am.  Surg.  Assoc,"  1904.)  Hunbald  has  collected  96 
cases  of  resection  of  the  liver,  with  a  mortality  rate  of  26  per  cent.  Probably 
the  best  method  of  arresting  hemorrhage  is  the  use  of  suture  ligatures  of  doubled 
catgut  passed  by  round,  blunt  needles,  as  advised  by  Mikuhcz. 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  productive  of 
no  signs  or  symptoms;  or  may  be  of  large  size  and  productive  of  the  signs  of 
tumor.  In  the  epigastrium  the  mass  may  be  prominent  and  fluctuate. 
In  cyst  of  the  right  lobe  the  dulness  is  found  in  the  axillary  line  and  the  growth 
encroaches  on  the  pleura.  In  a  large  cyst  fluctuation  and  hydatid  fremitus 
may  exist.  Hydatid  fremitus  is  a  vibration  imparted  to  the  palpating  fingers 
of  one  hand  when  the  fingers  of  the  other  hand"  knock  upon  the  cyst.  There 
may  be  no  discomfort  produced  by  even  a  large  cyst,  but,  as  a  rule,  the  patient 
suffers  from  a  dragging  sensation  in  the  epigastrium  and  pressure  symptoms. 
Suppuration  in  the  cyst  produces  the  symptoms  of  abscess  of  the  liver  and 
septicemia.  Rupture  of  the  cyst  produces  shock  and  even  death.  Rupture 
may  take  place  into  the  pleural  sac,  the  lung,  or  the  peritoneal  cavity.  If  the 
shock  is  recovered  from,  inflammation  arises,  the  area  of  which  depends  upon 
the  structures  damaged.  The  escape  of  even  a  small  quantity  of  hydatid  fluid 
into  the  peritoneal  cavity  produces  urticaria  {hydatid  toxemia).  Aspiration 
for  diagnostic  purposes  is  not  advisable. 

Treatment. — Exploratory  incision  may  be  necessary  to  confirm  the  diag- 
nosis, and  the  operation  is  completed  at  this  time.  After  exposing  the  cyst 
it  is  packed  around  with  gauze  and  a  trocar  is  introduced.  If  there  is  a  con- 
siderable thickness  of  liver  tissue  over  the  cyst,  incise  the  liver  by  the  cautery 
knife.  When  the  fluid  is  evacuated  the  sac  is  incised  and  is  drawn  partly 
through  the  wound  in  the  abdominal  wall,  and  is  attached  to  the  wound  mar- 
gins {marsupialization).  The  endocyst  can  then  be  removed  by  the  hand  or 
by  irrigation.     A  large  drainage-tube  is  introduced. 

Syphilis  of  the  liver  is  a  very  able  actor  and  often  impersonates  with 

^  Russell  S.  Fowler,  on  "Tumors  of  the  Liver,"  "Brooklyn  Med.  Jour.,"  Dec,  1900. 


Abscess  of  the  Liver  1035 

surprising  accuracy  various  other  diseases.  It  may  be  congenital  or  acquired. 
The  congenital  condition  may  cause  cirrhosis,  miliary  gummata,  spots  of  fibrosis, 
and  occasionally  large  gummata.  Sometimes  the  liver  manifestations  of  con- 
genital or  hereditary  s\^liilis  may  be  postponed  for  years  (ten,  fifteen,  or  more) 
and  then  appear  as  ordinary  tertiary  lesions.  Acquired  syphilis  may  cause 
hepatic  disease  in  the  secondary  and  in  the  tertiary  stage. 

In  secondary  syphilis  there  may  be  temporary  jaundice  due,  Rolleston 
thinks,  to  catarrh  of  the  smaller  bile-ducts  witMn  the  liver.  It  is  possible, 
according  to  Rolleston,  for  temporary  pericellular  cirrhosis  to  e.xist  in  the 
secondary  stage. 

The  tertiary  lesions  are  the  most  common  and  important.  Among  these 
lesions  are  gummata  and  scars.  They  are  most  common  ten  years  or  more 
after  the  primary  sore.  Tertiary'  s\-philis  may  appear  as  irregular  patches  of 
inflammation  in  Glisson's  capsule  (a  condition  apt  to  eventuate  in  hepatic 
sclerosis) — as  a  large  solitary  gumma  (only  one-eighth  of  cases  of  gumma 
present  a  soHtar}^  lesion) — or  as  multiple  and  usually-small  gummata.  Gimi- 
mata  are  most  usual  upon  the  anterior  surface  of  the  right  lobe.  A  gumma 
adjacent  to  the  common  duct  or  the  hepatic  duct  causes  jaundice.  A  large 
gumma  is  often  mistaken  for  cancer  of  the  liver,  and  it  is  a  curious  fact  that  in 
many  cases  of  hepatic  gummata  we  are  unable  to  obtain  any  history  of  s^-philis. 
S}Tphilis  may  be  mistaken  for  ordinan.-  cirrhosis,  but  in  the  latter  disease  the 
general  nutrition  is  more  impaired  than  in  the  former,  and  vomiting  of  blood, 
dilated  cutaneous  veins,  ascites,  and  indigestion  are  far  more  apt  to  be  present 
(Archibald  jMacLaren,  in  "Annals  of  Surgery,"  August,  igoS).  The  victims  of 
gumma  are  apt  sooner  or  later  to  develop  jaundice,  cohcky  pain,  moderate  fever, 
and  palpable  enlargement  of  the  liver.  The  spleen  may  enlarge.  The  fever  may 
be  continuous  or  may  occur  episodically.  .  In  some  cases  it  continues  for  weeks. 
It  may  be  intermittent,  preceded  by  a  chill  and  followed  by  a  sweat.  Such  a 
fever  may  be  due  to  Spirochaeta  cholangitis.  It  may  be  due  to  absorption  of 
toxic  material  from  a  breaking-down  gumma.  The  Wassermann  reaction  is  a 
valuable  aid  to  diagnosis.  A  gumma  sometimes  undergoes  secondary  infection 
and  an  abscess  forms.  A  gumma  may  rupture  into  the  pleural  or  peritoneal 
ca^dty  or  some  viscus. 

Treatment. — Mercurs'  and  iodid  wiH  cure  most  cases.  If  these  drugs  fail, 
it  is  proper  to  remove  the  tumor,  if  solitary,  by  resecting  the  involved  area  of  the 
liver.  MacLaren  (Ibid.)  collected  9  cases  of  resection  for  solitary  gumma 
and  added  i  of  his  own.  There  were  2  deaths  in  this  series.  MacLaren's  10 
cases  added  to  Keen's  12  ("Annals  of  Srugerv-,"  Sept.,  1899)  and  Cumston's  15 
(quoted  by  Rolleston  in  his  work  on  "Diseases  of  the  Liver")  make  37  cases. 

If  an  area  is  opened  for  exploration  and  a  solitary  gumma  is  discovered, 
the  abdomen  should  be  closed  and  specific  treatment  be  tried  before  resorting 
to  resection,  that  is,  if  specific  treatment  has  not  been  tried  before. 

Abscess  of  the  Liver. — An  abscess  of  the  liver  may  be  produced  by 
bacteria,  especially  staphylococci  and  streptococci.  These  organisms  reach 
the  liver  by  the  general  circulation  or,  what  is  more  frequent,  are  taken  up 
from  the  intestinal  tract  and  reach  the  liver  by  the  portal  circulation,  or  pass 
to  the  liver  by  the  honphatics.  Appendicitis  with  lymphatic  infection  may 
result  in  hepatic  abscess.  A  subphrenic  abscess  may  break  into  the  liver  and 
thus  induce  a  liver  abscess.  Liver  abscess  may  directly  result  from  peritoneal 
infection.  The  fact  that  abscess  of  the  liver  is  in  hot  countries  frequently 
preceded  by  amebic  dysentery  led  to  the  presumption  that  the  Amoeba  coH  pro- 
duces the  abscess,  and  in  a  large  majority  of  cases  of  tropical  abscess  amebae 
exist  in  the  pus  or  at  least  on  the  abscess  walls.  Habitual  intemperance  and 
constant  overeating  predispose  to  abscess  of  the  liver.  The  disease  may  follow 
traumatism,  dysentery,  diarrhea,  cholangitis,  suppuration  of  a  hydatid  cyst. 


1036  Diseases  and  Injuries  of  the  Abdomen 

gall-stones,  typhoid  fever,  appendicitis,  and  a  chill  to  the  surface  of  the  body.^ 
Abscess  of  the  liver  may  be  metastatic,  and  such  abscesses  are  multiple. 
It  may  be  caused  by  foreign  bodies  and  parasites.  A  tropical  abscess  is  an 
abscess  of  the  liver  in  an  inhabitant  of  a  hot  country. 

There  are  three  forms  of  abscess  of  the  liver:  traumatic,  pyemic,  and 
tropical. 

Traumatic  abscess  may  result  from  a  wound  of  the  liver  or  may  follow 
a  contusion  without  a  break  of  the  skin.  In  the  latter  case  bacteria  from  the 
blood  are  arrested  in  the  injured  liver  tissue.  Such  an  abscess  is  usually 
solitary.  Streptococci,  staphylococci,  or  colon  bacilli  may  be  found.  Trau- 
matic abscesses  are  more  common  in  children  than  in  adults,  are  situated 
superficially,  and  the  symptoms  are  usually  acute.  Recovery  is  usually  rapid 
and  permanent  after  incision  unless  the  causal  injury  brings  danger  or  fatality. 

Pyemic  Abscess. — Multiple  abscesses  exist,  but  they  may  fuse  into  one. 
It  is  frequently  due  to  suppurative  inflammation  of  radicles  of  the  portal  vein, 
infected  emboli  forming  and  reaching  the  liver;  it  may  follow  ulceration  of  the 
intestine,  hemorrhoids,  or  appendicitis. 

Occasionally  abscess  may  arise  from  the  extension  of  an  infective  proc- 
ess, such  as  pylephlebitis.  It  may  arise  from  cholecystitis  or  cholelithiasis 
with  obstruction.  In  these  latter  cases  both  the  BacUlus  typhosis  and  the 
pneumobacillus  of  Friedlander  have  been  found  as  the  direct  bacterial  agent. 
Colon  bacilli  are  a  common  cause.  Abscess  of  the  liver  following  appendicitis 
may  be  due  to  portal  infection  {portal  pyemia)  or  to  lymphatic  infection.  It 
is  usually  multiple,  but  in  a  case  of  mine  in  the  Jefferson  Hospital  it  was  soH- 
tary,  several  cavities  having  probably  joined  to  form  one.  Echinococcus  cyst 
of  the  liver  may  suppurate  and  form  abscess.  I  operated  unsuccessfully  on 
I  such  case  which  was  brought  to  me  by  Dr.  Hultsizer.  The  round- worm, 
the  liver  fluie,  and  the  Balantidium  coli  sometimes  cause  abscess,  and,  finally, 
it  has  been  observed  in  measles,  epidemic  influenza,  and  perforating  ulcer  of 
the  stomach.^ 

Tropical  abscess  of  the  liver  is  rare  in  temperate  climates,  but  is  extremely 
common  in  the  tropics.  Its  usual  antecedent  in  either  climate  is  dysentery. 
The  reason  for  the  great  frequency  of  the  disease  in  tropical  regions  is  that  the 
chief  causative  agent,  the  Amoeba  coli,  is  found  widely  distributed  in  hot  coun- 
tries; and  that  passive  congestion  of  the  liver  is  a  common  condition  among  the 
white  inhabitants  of  tropical  regions.  It  has  been  pointed  out  that  tropical 
abscess  is  particularly  common  among  white  persons  who  abuse  alcohol,  the 
condition  of  passive  congestion  of  the  liver  making  that  organ  a  nutritious  soil 
for  a  fruitful  infection.  Predisposing  factors  are  protracted  malaria  and 
chilling  of  the  surface  of  the  body. 

Major  Charles  F.  Kiefifer,  U.  S.  A.,^  in  a  lecture  on  tropical  abscess  of 
the  liver,  stated  that  in  his  own  experience  he  found,  in  a  series  of  33  abscess 
cases  in  soldiers,  that  dysentery  was  present  in  every  case;  and  that  in  a  second 
series  of  25  cases  in  natives  and  civilians  he  elicited  a  history  of  dysentery  in 
22  cases.  Some  observers — notably  McLeod — state  that  dysentery  is  the 
antecedent  factor  in  97.5  per  cent,  of  cases.  Kieffer  points  out  that  in  all  the 
figures  allowance  must  be  made  for  a  number  of  latent  dysenteries,  as  well  as 
for  cases  in  which  no  effort  was  made  to  elicit  a  history  of  dysentery  one  or  two 
years  previously.  It  is  also  to  be  remembered  that  a  case  of  amebic  infection 
of  the  colon  may  have  been  so  mild  in  the  beginning  as  to  have  caused  but  a 
transient  diarrhea,  which  the  patient  may  have  forgotten.  Amebae  occasionally 
exist  in  the  colon  without  producing  any  dysenteric  evidences.     From  20  to 

^  G.  B.  Johnston,  "Annals  of  Surgery,"  October,  1897. 

2  Major  Charles  F.  Kieffer,  U.  S.  A.,  in  "Phila.  Med.  Jour.,"  Feb.  21,  1903. 

3  Ibid. 


Tropical  Abscess  of  the  Liver  1037 

25  per  cent,  of  severe  amebic  dysenteries  lead  to  the  formation  of  abscess 
of  the  liver,  and  that  at  least  85  per  cent,  of  all  tropical  abscesses  are  due  to 
infection  with  the  Amoeba  coli.  Occasionally,  an  abscess  begins  very  soon 
after  the  dysentery;  but,  as  a  rule,  it  does  not  form  for  some  time  afterward 
— weeks,  months,  a  year,  or  even  two  years. 

When  an  abscess  of  this  sort  forms  in  the  liver  that  organ  becomes  en- 
larged and  congested,  and  an  area  or  areas  of  necrosis  exist  in  it.  But  one 
abscess  may  be  present;  there  may  be  an  abscess  with  satellite  abscesses  about 
it;  several  abscesses  may  coalesce,  making  a  very  large  cavity;  or  genuine 
multiple  abscesses  may  exist.  In  about  70  per  cent,  of  cases,  however,  the 
tropical  abscess  is  solitary. 

The  right  lobe  of  the  liver  is  the  region  most  frequently  involved.  The 
abscess  is  found  in  the  right  lobe  in  at  least  90  per  cent,  of  cases,  and  it  is  more 
often  toward  the  convexity  of  the  liver  than  toward  the  base. 

An  abscess  of  the  liver  contains  characteristic  and  peculiar  material; 
it  is  different  from  the  pus  found  in  other  abscesses,  and,  in  fact,  is  not  pus, 
but  is  necrotic  liver  substance.  Liver  abscesses  due  to  pyogenic  organisms 
contain  true  pus;  a  tropical  abscess,  free  from  pyogenic  infection,  does  not. 
Ordinary  pus  contains  hordes  of  leukocytes,  but  the  fluid  of  a  tropical  abscess 
contains  very  few.  Riesman  is  of  the  opinion  that  the  reason  there  are  so 
few  leukocytes  is  that  the  abscess  contains  a  substance  that,  by  chemotaxis, 
repels  leukocytes.  The  matter  is  of  a  reddish-brown  color,  is  thick,  and  fre- 
quently contains  some  blood.  Occasionally  it  is  offensive  in  odor.  Micro- 
scopic examination  shows  it  to  contain  portions  of  necrotic  liver  tissue,  some 
liver-cells  that  are  not  destroyed,  elastic  tissue,  blood,  pus-cells,  and  amebas. 
On  bacterial  examination  it  may  be  found  that  the  fluid  is  infected,  containing 
staphylococci,  streptococci,  or  pyogenic  bacteria.  In  about  20  per  cent,  of  the 
cases  the  matter  contains  neither  bacteria  nor  the  Amoeba  coli.  In  over  60  per 
cent,  of  the  cases  the  matter  of  a  recently  opened  abscess  is  free  from  bacteria. 
In  cases  in  which  the  fluid  is  sterile  it  is  possible  that  bacteria  were  originally 
present,  but  have  died.  The  reason  for  the  death  of  micro-organisms  in  this  mat- 
ter is  in  great  doubt,  because,  as  Riesman  points  out,  bile  cannot  kill  them  and 
organisms  may  be  grown  in  the  fluid.  In  the  large  majority  of  cases  amebcC  are 
readily  demonstrable  in  the  matter;  but  that  in  some  few  cases  it  is  necessary 
to  rub  a  piece  of  gauze  on  an  abscess  wall  in  order  to  obtain  amebae,  and  that 
in  others  they  can  be  demonstrated  only  after  the  abscess  has  been  discharging 
for  some  days.  The  causative  role  of  the  amebae  has  been  doubted  by  some 
observers,  but  most  surgeons  who  have  had  experience  in  the  tropics  believe 
it  to  be  a  fact. 

The  symptoms  may  be  very  definite  and  positive;  they  are  frequently  mis- 
leading and  obscure;  and  in  some  cases  nothing  whatever  directs  the  surgeon's 
attention  to  the  liver  until  the  patient  passes  a  huge  quantity  of  puriform 
fluid  at  stool  or  coughs  up  an  enormous  amount  of  the  characteristic  material. 
If  rupture  takes  place,  death  usually  ensues.  As  a  rule,  the  symptoms  of  a 
tropical  abscess  are  positive  and  marked. 

Kieffer  sums  up  the  chief  symptoms  under  four  heads:  fever,  sepsis,  en- 
largement of  the  liver,  and  pain.  In  about  three-fourths  of  the  patients  fever 
and  sweats  are  definitely  present;  in  about  one-fourth  they  are  absent  or  are 
very  trivial.  The  type  of  fever  met  with  is  what  has  been  previously  spoken 
of  as  hectic.  Usually  there  is  an  evening  rise,  preceded  by  a  chilly  sensa- 
tion or  by  a  chill;  and  as  the  temperature  begins  to  fall,  toward  morning, 
there  is  a  profuse  sweat.  It  is  seldom  that  there  is  any  violent  chiU,  though 
there  are  frequently  sHght  ones.  The  sweats  are  extremely  exhausting.  They 
may  occur  either  during  the  night  or  in  the  daytime,  according  to  the  time 
in  which  the  patient  sleeps.      Kieffer   says  that  they  should  not  be  called 


1038  Diseases  and  Injuries  of  the  Abdomen 

night-sweats,  but  rather  sleeping  sweats.  In  very  chronic  cases  there  may 
be  no  pyrexia.  As  a  rule,  the  temperature  resembles  that  of  malaria,  but 
it  is  not  controlled  by  quinin  and  the  blood  is  free  from  malarial  parasites. 
Sometimes  the  temperature  suggests  typhoid,  with  the  exception  that  from 
time  to  time  there  are  episodes  of  subnormal  temperature.  The  patient 
loses  flesh  and  strength,  the  appetite  fails  completely,  and  the  skin  becomes 
pasty  or  dirty  yellow. 

The  entire  liver  is  usually  enlarged,  and  the  enlargement  may  be  detected 
by  percussion,  and  in  some  cases  a  hard,  smooth  area  can  be  palpated.  Some- 
times the  liver  reaches  as  high  as  the  third  rib  anteriorly,  or  to  the  spine 
of  the  scapula  behind,  and  it  may  extend  downward  to  the  anterior  superior 
spine  of  the  ihum.  It  is  rarely,  however,  that  the  enlargement  takes  place 
in  a  downward  direction;  it  is  usually  upward.  In  many  cases  the  right  side 
of  the  chest  appears  to  be  rather  full,  and  sometimes  there  is  actual  obliteration 
of  several  intercostal  spaces.  If  an  abscess  becomes  adherent  to  the  surface, 
there  may  be  skin  edema  and  dusky  discoloration.  In  rare  instances,  if  a 
very  large  abscess  comes  near  the  surface,  fluctuation  may  be  obtained.  By 
auscultation  it  is  frequently  possible  to  obtain  friction  sounds  in  the  region  of 
the  diaphragm  and  the  superior  surface  of  the  liver. 

The  liver  becomes  tender.  This  tenderness  may  be  developed  particu- 
larly by  pressure  upon  the  lower  edge  of  the  organ,  and  sometimes  by  pressure 
through  the  intercostal  spaces.  There  is  not  always  pain,  but,  as  a  rule,  there 
is.  The  pain  may  be  dull  and  heavy,  but  as  the  abscess  nears  the  surface 
of  the  organ  the  pain  becomes  sharp  and  lancinating.  The  pain  is  persistent 
and  is  not  strictly  localized,  but  radiates  to  the  back,  the  right  shoulder-blade, 
and  the  point  of  the  shoulder.  Pain  is  increased  by  pressure,  coughing,  sudden 
or  violent  movement,  and  is  sometimes  felt  in  the  esophagus  when  food  is 
swallowed.  When  the  upper  surface  of  the  liver  is  involved  the  patient 
breathes  as  if  he  had  pleurisy;  and  pleurisy  frequently  does  develop,  with 
marked  effusion. 

Paralysis  of  the  diaphragm  rarely  occurs  in  abscess  of  the  liver,  and  the 
respiration  is  not  much  affected  unless  the  diaphragm  of  that  side  and  the 
pleura  become  involved,  though  the  patient  frequently  has  a  dry  cough. 
A  severe  cough  suggests  that  the  abscess  is  on  the  convex  surface  of  the 
organ.  Such  a  cough  is  aggravated  by  recumbency.  Kieffer  points  out  that 
the  patient  lies  on  his  right  side,  and  almost  on  the  right  front  aspect,  the 
shoulder  being  drawn  down  and  the  right  knee  drawn  up  to  relieve  the  ten- 
sion of  the  abdominal  muscles.  In  about  one-fourth  of  the  cases  of  tropical 
abscess  of  the  liver  jaundice  occurs.  It  is  most  apt  to  occur  when  the  abscess 
is  on  the  inferior  surface.  Jaundice  does  not  occur  unless  the  common  or 
hepatic  ducts  are  compressed  or  cholangitis  exists.  The  leukocyte  count  is  of 
no  particular  help  in  the  diagnosis,  as  there  may  or  may  not  be  leukocytosis. 
The  urine  is  usually  scanty.  Diarrhea  is  a  common  accompaniment,  but  con- 
stipation may  exist,  and  nausea  and  vomiting  are  by  no  means  unusual. 

Diagnosis. — With  an  antecedent  history  of  dysentery  the  diagnosis  is 
easy.  Without  such  a  history,  it  is  always  difficult  and  may  be  impossible. 
In  the  tropics  exploratory  aspiration  is  freely  used,  but  exploratory  incision, 
if  necessary,  with  subsequent  exploratory  aspiration  of  the  liver  after  the  organ 
is  exposed,  would  seem  to  be  safer  and  more  certain. 

Symptoms  of  Traumatic  Abscess. — Similar  to  those  of  tropical  abscess. 

Symptoms  of  Pyemic  Abscess. — The  liver  is  enlarged  and  tender,  there 
is  slight  jaundice,  and  the  general  symptoms  of  pyemia  are  present. 

Treatment  of  Tropical  Abscess. — If  in  doubt  as  to  the  diagnosis,  make  an 
exploratory  incision,  exposing  enough  liver  surface  to  permit  of  exploration  by 
finger  and  needle.     If  pus  is  not  found,  pack  the  wound  with  gauze  to  keep  it 


Hepatoptosis  io39 

open,  and  when  adhesions  form  explore  again.  The  operation  for  abscess  is 
incision  and  drainage.  The  abdominal  route  is  used  when  the  liver  bulges  front 
or  when  it  extends  well  below  the  costal  margin  (McGill,  in  "Surg.,  Gynec, 
and  Obstet.,  Nov.,  191 1).  If  the  abscess  is  adherent  to  the  parietal  peritoneum 
and  is  not  covered  by  liver  substance  open  it  at  once.  If  it  is  not  adherent,  or  is 
covered  by  a  considerable  layer  of  liver  substance,  make  a  ring  of  gauze  about 
the  periphery  of  the  abscess  cavity.  The  abscess  may  be  opened  at  once  within 
the  ring,  the  gauze  being  a  coffer-dam  to  protect  the  peritoneal  cavity.  It  is 
safer  to  catch  the  gauze  to  the  parietal  peritoneum  with  two  or  three  fine  catgut 
sutures  and  wait  for  forty-eight  hours  before  opening.  This  is  an  easier  plan 
and  just  as  safe  as  attempting  to  stitch  the  liver  to  the  visceral  peritoneum  or 
to  the  parietal  peritoneum.  The  operation  consists  in  evacuating  the  pus  by 
a  trocar  and  cannula,  incising  the  abscess,  stitching  its  edges  to  the  edges  of 
the  abdominal  wound,  irrigating,  and  inserting  a  drainage-tube.  If  the  abscess 
is  covered  by  a  layer  of  liver  tissue,  after  locating  it  by  an  aspirating  cannula 
open  into  it  by  a  cautery  knife  and  arrest  hemorrhage  by  packing.  When 
the  parietal  and  visceral  layers  of  peritoneum  are  adherent,  packing  will  arrest 
bleeding ;  if  they  are  not  adherent,  packing  will  only  push  away  the  movable 
liver  (John  O'Connor) .  The  transpleural  route  gives  the  best  access  to  the  right 
lobe,  which  is  far  and  away  the  commonest  region  for  liver  abscess.  The 
operation  devised  by  McGill  (Ibid.)  may  be  at  first  exploratory;  it  avoids 
pneumothorax  and  empyema.     It  is  performed  as  follows: 

The  ninth  and  tenth  ribs  are  exposed  by  a  curvilinear  incision;  the  flap 
(which  does  not  include  the  fascia  of  the  muscles)  is  raised;  4  inches  of  the 
tenth  rib  are  resected;  the  gutter  left  by  the  removal  of  the  bone  is  closed  by 
catgut  suture.  This  gutter  can  be  pushed  against  the  diaphragm  by  two  fingers 
of  an  assistant,  and  while  the  pressure  is  being  made  an  incision  is  carried  along 
near  to  the  upper  border  of  the  eleventh  rib.  The  incision  goes  directly  into  the 
peritoneal  cavity  through  the  layers  of  chest  wall  and  through  the  diaphragm, 
but,  as  the  parietal  pleura  is  being  pressed  directly  against  the  diaphragmatic 
pleura,  pnemnothorax  does  not  occur.  The  edges  of  the  chest  wall  and  dia- 
phragm are  clamped  together  and  sutured,  the  pleural  cavity  being  thus  closed. 
The  liver  is  exposed  and  may  be  needled  for  exploration,  or  an  abscess  can  be 
drained  at  once  or  after  causing  adhesions  by  gauze,  as  previously  described. 

Rogers  and  Wilson  ("Brit.  Med.  Jour.,"  June  16,  1906)  advocate  aspiration 
and  examination  of  the  pus.  If  amebs  only  are  present,  they  inject  a  solution 
of  quinin,  a  material  quickly  fatal  to  amebae.  The  dose  is  30  gr.  of  bihydro- 
chlorate  of  quinin  in  a  sterile  solution.  If  the  abscess  holds  less  than  10  oz. 
of  matter  the  quinin  is  given  in  2  oz.  of  fluid;  if  it  holds  more,  in  4  oz.  of  fluid. 
The  authors  report  2  cases  cured  by  this  method. 

Treatment  of  Traumatic  Abscess. — Same  as  for  tropical  abscess. 

Treatment  of  Pyemic  Abscess. — Surgery  is  usually  futile,  because  multiple 
abscesses  exist,  but  an  operation  should  be  performed  in  the  hope  that  it  may 
do  good.  In  a  case  in  the  Jefferson  Hospital  in  which  abscess  of  the  liver 
followed  appendicitis  the  patient  recovered  after  operation. 

Hepatoptosis  (Floating  or  Movable  Liver). — Hepatoptosis  may  be 
congenital,  but  is  usually  acquired.  In  a  congenital  case  certain  ligamen- 
tous supports  of  the  liver  are  absent.  In  the  following  discussion  the  acquired 
form  is  the  variety  referred  to.  This  condition  is  rare.  Ninety-eight  cases 
have  been  reported.^  It  is  a  form  of  splanchnoptosis  and  is  due  to  relaxation 
of  the  abdominal  wall  and  stretching  of  the  supports  of  the  liver.  It  may 
occur  alone,  but  it  is  more  often  a  part  of  a  general  abdominal  relaxation  or 
of  Glenard's  disease,  and  often  a  kidney  is  movable,  or  uterine  displacement 
or  hernia  may  exist.  The  liver  may  descend  into  the  lower  abdomen,  may 
^  J.  H.  Carstens,  "Jour.  Am.  Med.  Assoc,"  May  17,  1902. 


I040  Diseases  and  Injuries  of  the  Abdomen 

be  upside  down  (Demarquay),  may  rotate  on  its  transverse  axis  (Griffiths), 
the  anterior  surface  may  become  posterior,  or  the  organ  may  lie  with  the 
superior  surface  in  the  right  flank  and  the  inferior  surface  looking  to  the  left/ 
may  be  movable,  or  may  be  anchored  by  adhesions.  It  is  most  common  in 
women.  The  liver  is  supported  by  ligaments  and  also  by  the  inferior  vena 
cava  (which  vessel  is  firmly  adherent  to  the  central  tendon  of  the  diaphragm — 
Faure),  by  the  abdominal  wall,  and  by  the  intestines  (Glenard).  The  cause 
of  the  condition  is  in  dispute.  It  can  result  from  relaxation  of  the  belly  wall, 
relaxation  of  the  ligaments,  enteroptosis,  great  enlargement  of  the  gall-bladder, 
increase  in  weight  of  the  liver,  atrophy  of  the  connective  tissue  between  the 
liver  and  diaphragm,  pregnancy,  the  growth  of  a  liver  tumor,  and  tight  lacing. 
Either  a  strain,  cough,  or  the  dragging  of  an  adherent  tumor  may  be  the 
exciting  cause. 

Signs  and  Symptoms. — ^An  abdominal  mass  may  appear  suddenly  after 
a  blow  or  a  strain,  and  if  it  does  appear  suddenly  there  is  always  pain  in 
the  hepatic  region,  nausea,  and  weakness.  When  the  condition  comes  on 
gradually  there  may  be  no  symptoms  for  a  long  time,  but,  as  a  rule,  there 
is  some  pain  in  the  loin  which  becomes  worse  after  exercise  or  effort.  In 
rare  cases  jaundice  appears,  and  occasionally  there  is  ascites.  The  abdominal 
walls  are  relaxed  and  the  signs  of  splanchnoptosis  are  manifest.  When 
the  patient  stands,  a  transverse  furrow  of  skin  covers  the  lower  part  of  the 
umbilicus  {Glenard'' s  sign).  In  most  cases  the  shape,  the  movability,  and 
the  absence  of  the  liver  from  its  proper  position  are  diagnostic.  Even  when 
the  organ  is  dislocated  and  attached  in  its  new  situation,  it  is  missed  from 
its  proper  abode,  and  palpation  outlines  the  characteristic  shape.  When  the 
patient  lies  down  the  liver  usually  returns  to  place,  and  in  most  cases  it  can 
be  restored  by  manipulation.  In  some  cases,  however,  it  wiU  not  return 
to  place  and  cannot  be  restored  by  manipulation.  A  floating  liver  causes  a 
recognizable  enlargement  in  the  right  loin,  and  the  mass  usually  moves  on 
respiration. 

Treatment. — In  many  cases  the  patient  can  be  kept  comfortable  by 
wearing  an  abdominal  support,  and  can  be  distinctly  improved  by  the  use 
of  massage  and  electricity  to  the  abdominal  wafl,  the  administration  of  tonics, 
and  a  course  of  forced  feeding.  If  these  means  fail  and  the  patient  suffers, 
an  operation  should  be  performed.  The  operation  of  hepaiopexy  was  de- 
vised by  Marchant.  He  opens  the  abdomen  and  tries  to  restore  the  liver 
to  its  proper  position.  This  can  usually  be  accomphshed.  In  some  cases 
it  can  be  done  after  adhesions  have  been  separated.  In  other  cases  it  can 
be  only  partially  accomplished.  After  the  liver  has  been  restored,  he  sutures 
it  by  means  of  catgut  or  silk  to  the  abdominal  wall  or  costal  cartilages,  the 
stitches  passing  through  the  hepatic  parenchyma  and  being  carried  through 
the  liver  by  means  of  a  round  and  blunt  needle.  The  sutures  attaching  the 
liver  to  the  beUy  waU  are  tied  beneath  the  skin.  Marchant  scarified  the 
dome  of  the  liver  in  order  to  favor  adhesions.  Ramsay  rubs  the  upper  sur- 
face of  the  liver  with  gauze  to  promote  adhesion  and  transfixes  the  round 
ligament  with  a  suture  which  is  carried  around  the  cartflage  of  the  seventh 
rib.  In  a  severe  case  Depage  advises  us  to  associate  hepatopexy  with  an 
excision  of  a  portion  of  the  abdominal  wall  to  amend  relaxation  {laparec- 
tomy).  If,  in  operating  on  a  floating  liver,  it  is  found  impossible  to  get  the 
liver  back  into  its  normal  position,  fix  it  with  sutures  as  near  its  proper  abode 
as  is  possible.  Terrier  and  Auvray  report  ii  cases  of  hepatopexy.  One 
case  died  and  8  completely  recovered. 

Floating  Hepatic  Lobe  (Partial  Hepatoptosis). — This  condition 
is  not  uncommon  in  cases  of  chronic  disease  of  the  gall-bladder  and  is  most 
1  Terrier  and  Auvray,  "Rev.  de  Chir.,"  Aug.  and  Sept.,  1897. 


Bacteriolog}-  of  Cholecystitis  1041 

often  met  in  cholelithiasis.  It  is  believed  that  it  can  be  caused  bv  tight 
lacing.  A  tongue-like  projection  forms  upon  the  right  lobe  of  the  liver  \Ungui- 
Jorm  lobe  J  lacing  lobe).  It  can  be  palpated  below  the  costal  margin  and  the 
dulness  of  the  mass  on  percussion  is  contmuous  with  liver  dulness.  A  lingui- 
form  lobe  can  usually  be  moved  laterally  and  forward  and  backward;  it  is 
always  tender  and  is  sometimes  the  seat  of  pain. 

Treatment. — When  this  condition  is  associated  with  gaU-bladder  trouble, 
it  may  disappear,  or  at  least  cease  to  cause  pain,  when  the  gall-bladder  is 
drained  by  cholecystostomy.  Langenbuch  has  successfully  removed  a  hn- 
guiform  lobe. 

Cholecystitis  (Inflammation  of  the  Qall=bladder). — Inflammation 
of  the  gaU-bladder  is  produced  by  infection.  Healthy  bile  is  sterile;  and 
when  bacteria  are  found  in  the  bile,  the  condition  is  one  of  disease.  ]Micro- 
organisms  may  find  entrance  into  the  gall-bladder  by  way  of  the  blood,  the 
bile  becomuig  infected  secondarily  to  the  infection  of  the  gaU-bladder;  or 
they  may  enter  by  way  of  the  ducts,  from  the  intestine.  The  conditions  that 
foUow  infection  depend  upon  the  characteristic  tendency  and  the  \-irulence 
of  the  infecting  germs.  A  tri^-ial  infection  produces  mucous  catarrh;  a  more 
active  infection  causes  suppuration,  and  possibly  ulceration;  a  ver\-  \'iolent 
infection  leads  to  gangrene. 

In  most  cases  of  cholecystitis  an  inflammatory  swelling  blocks  the  cystic 
duct,  and  obstructs  it  so  that  the  bile  stagnates  m  the  gall-bladder.  In 
many  cases  this  condition  lasts  but  a  short  time;  and  when  the  obstruction 
is  reUeved,  bile  flows  down  the  duct.  Occasionally,  as  a  secondary'  conse- 
quence, cholangitis,  or  infection  of  the  hepatic  duct,  follows.^  Occasionally, 
also,  the  obstruction  of  the  duct  is  not  relieved,  and  a  quantity  of  clear,  thin 
m.ucus  gathers  in  the  gaU-bladder  and  overdistends  it — the  condition  known 
as  hydrops.  The  gall-bladder  may  likewise  become  distended  "^-ith  pus, 
constituting  an  empyema  of  the  gall-bladder;  and  any  overdistended  gaU- 
bladder  may  ruptm^e.  A  gall-bladder  may  distend  to  a  most  enormous  size. 
Terrier  reported  a  case  of  distended  gall-bladder  in  which  the  ^"iscus  con- 
tained 42  pints  of  fluid.  F.  \V.  Collinson  ("Brit.  Med.  Jour.,"  May  29, 
1909)  reports  the  case  of  a  woman  thirty-one  years  of  age  who  was  tapped 
twice  before  operation  and  at  each  tapping  25  pints  of  fluid  were  T^ithdrawn. 
At  the  operation  22  pints  were  obtained.  Collinson's  case  arose  from  blocking 
of  the  common  duct  as  a  result  of  traumatism,  f oUowed  by  kinking  of  the  cystic 
duct  and  subequent  opening  of  the  common  duct.  In  cases  of  ver\'  chronic 
inflammation  of  the  gaU-bladder  this  structure  becomes  fibrous  and  contracts, 
imtfl  it  may  become  no  larger  than  the  thumb,  in  which  condition  it  may 
contain  a  ver\'  smaU  amount  of  thickened  bfle.  In  some  inflammatory'  con- 
ditions due  to  infection  the  bile  mixes  with  thickened  mucus,  and  micro- 
organisms form  the  nucleus  upon  which  bile  salts  are  deposited  to  form  gall- 
stones. As  the  same  author  points  out,  cholelithiasis  may  result  from  chole- 
cystitis, and  may  cause  chronic  cholecystitis,  because  the  stones  existing  in  a 
gall-bladder  are  sources  of  irritation. 

Bacteriology  of  Cholecystitis. — It  has  been  proved  by  abundant  ob- 
ser^'ation  that  the  fact  that  bile  contains  micro-organisms  is  no  e^idence 
that  the  gaU-bladder  is  inflamed;  but  that  when  the  gaU-bladder  is  mflamed 
micro-organisms  are  demonstrable  in  the  bile.  We  know  that  the  bile  is 
infected  during  the  course  of  t}phoid  fever,  and  that  it  is  frequently  so  in 
pneumonia.  The  colon  baciUus  is  not  unusuaUy  demonstrable  in  chole- 
cystitis; and  pus  cocci,  either  in  pure  cultin^e  or  mixed  with  other  germs, 
constitute  the  most  common  cause  of  the  inflammation.  It  is  probable  that 
bacteria  entering  the  gall-bladder  and  not  being  particiflarly  \'irulent  produce 
1  Joseph  McFarlandj  "Proceedings  of  the  Phila.  County  ^led.  Soc,"  Sept.,  1902. 
66 


I042  Diseases  and  Injuries  of  the  Abdomen 

no  immediate  harm  when  the  flow  of  bile  is  unobstructed,  though  even  then 
they  may  become  the  nuclei  of  gall-stones;  but  if  the  bacteria  are  very  viru- 
lent they  may  actually  lead  to  obstruction.  Stagnation  of  the  bile  favors 
infection,  and  infection  may  be  the  cause  of  stagnation.  Each  influence 
reacts  upon  the  other  and  aggravates  the  other,  and  it  seems  more  than 
possible  that  infection  of  the  gall-bladder  is  to  be  regarded  as  serious  only 
when  there  is  obstruction  to  the  outflow  of  bile.  The  same  variety  of  germ 
may,  under  some  circumstances,  cause  catarrhal,  and  under  others  suppu- 
rative, inflammation;  that  is,  when  bacteria  are  virulent  and  tissue  resist- 
ance is  slight,  suppurative  cholecystitis  results;  but  when  the  bacteria  are  not 
virulent  and  the  tissue  resistance  is  powerful,  the  gall-bladder  is  not  infected 
at  all,  or  only  catarrhal  inflammation  is  produced.  I  operated  upon  a  case 
of  acute  suppurative  inflammation  of  the  gall-bladder  three  weeks  after  the 
termination  of  an  attack  of  typhoid  fever.  .  The  culture  taken  from  the 
gafl-bladder  showed  an  unidentified  baciUus,  which  was  not  the  colon  baciUus 
or  the  paracolon  baciUus,  and  which  was  not  identical  with  the  typhoid  bacillus 
or  the  paratyphoid  bacillus.  It  strongly  resembled  the  typhoid  bacillus,  but 
possessed  no  agglutinative  power  (the  author,  in  "New  York  Med.  Jour.," 
April  8,  1905). 

A  patient  in  the  medical  ward  of  the  Jefferson  Hospital  w^as  supposed 
to  be  developing  a  typhoid  relapse,  but  no  fresh  spots  appeared,  and  there 
were  pain,  tenderness,  and  rigidity  in  the  region  of  the  gall-bladder.  I  oper- 
ated and  found  the  gall-bladder  full,  dark  colored,  and  surrounded  by  numer- 
ous recent  adhesions.  It  could  be  emptied  slowly  by  pressure.  There  was 
no  pus.  It  was  drained  and  the  symptoms  promptly  passed  away  and  the 
man  recovered.  The  culture  was  reported  sterile.  I  cannot  understand 
this  finding,  as  inflammation  undoubtedly  existed.  It  may  have  been  peri- 
tonitis rather  than  cholecystitis,  but  from  what  cause  is  unknown.  No 
culture  was  taken  from  the  peritoneal  cavity.  The  finding  of  sterfle  bile 
at  the  end  of  an  attack  of  undoubted  t5Aphoid  is  of  interest. 

Catarrhal  Inflammation  of  the  Qall=bladder  and  Bile=ducts. 
— This  condition  is  known  as  catarrhal  jaundice,  acute  or  chronic,  and  is 
usually  treated  by  the  physician;  but,  as  A.  W.  Mayo  Robson  points  out, 
chronic  catarrhal  jaundice  sometimes  resembles  the  jaundice  of  organic  dis- 
ease, and  is  occasionally  associated  with  gall-stones,  malignant  disease,  or 
hydatid  cyst.  The  same  authority  asserts  his  belief  that  chronic  catarrhal 
jaundice  usually  results  from  interstitial  pancreatitis  and  duct  obstruction. 
This  condition  usually  comes  on  without  pain.  If  there  is  pain  it  means  some 
complication.  Robson  ("Surg.,  Gynec,  and  Obstet.,"  Jan.,  1908)  names 
among  such  complications  catarrhal  cholecystitis,  cholangitis,  gall-stone,  and 
duodenal  ulcer.  The  jaundice  is  striking.  There  is  loss  of  flesh  and  anemia, 
and  the  liver  is  enlarged  and  smooth.  Robson  tells  us  that  if  the  gall-bladder 
is  not  shrunken  from  stone,  and  if  there  is  great  duct  obstruction,  the  bladder 
will  be  distended.  Chills  and  fever  mean  infective  cholangitis.  In  a  case  of 
chronic  catarrhal  jaundice  in  which  medical  treatment  fails,  surgical  treatment 
must  be  considered  (cholecystostomy  or  cholecystenterostomy). 

Catarrhal  Cholecystitis. — This  is  a  catarrhal  inflammation  of  the  gall- 
bladder usually  without  jaundice.  The  gafl-bladder  becomes  thick  and  its 
mucous  membrane  is  frequently  pHcated.  Very  thick  mucus  is  secreted, 
which  gathers  in  masses,  and  the  descent  of  these  plugs  causes  pain  that 
is  sometimes  indistinguishable  from  that  produced  by  the  passage  of  a  gall- 
stone. Such  a  plug  may  temporarfly  block  the  cystic  duct.  In  catarrhal 
cholecystitis  the  gall-bladder  is  frequently  distended,  but  rarely  admits  of 
palpation;  and  there  are  no  adhesions  to  surrounding  structures,  unless  gall- 
stones have  been  present  (Robson).     Catarrhal  cholecystitis  may  lead  to  the 


Suppurative  Intiammation  of  the  Gall-bladder  and  Bile-ducts     1043 

formation  of  gall-stones;  may  result  from  the  presence  of  gall-stones;  or  may- 
be found  in-  cases  in  which  gall-stones  have  been  present,  but  have  passed. 
In  I  case  upon  which  I  operated  the  gall-bladder  was  enlarged,  thick,  and 
without  adhesions;  the  mucous  membrane  was  con^•oluted;  and  the  viscus  was 
filled  with  thick,  tenacious  mucus,  and  the  mucous  membrane  of  the  gall- 
bladder contained  many  minute  concretions.  In  this  case  stone  formation 
was  probably  beginning  to  follow  upon  catarrhal  cholecystitis.  In  another 
case  a  woman  had  presented  \'iolent  s>miptoms  of  gall-stone  cohc,  and  stones 
had  been  recovered  from  the  feces;  but  on  opening  the  gall-bladder  no  stones 
were  found — only  a  condition  of  catarrhal  cholecystitis.  Jaundice  is  rare  in 
catarrhal  cholecystitis  unless  gall-stones  are  present ;  it  is,  however,  occasionally 
noted.  Even  if  jaundice  does  occur,  it  is  sligljt  and  lasts  but  a  short  time. 
The  painful  attacks  that  occur  during  catarrhal  cholecystitis  are  similar  to 
gall-stone  attacks;  but  the  pain  is  less  A^olent  and  of  briefer  duration,  and 
jaundice  is  not  apt  to  follow  the  passage  of  a  plug  of  mucus  and  is  apt  to  follow 
the  passage  of  a  gall-stone.  Further,  as  Robson  has  shown,  in  catarrhal  chole- 
cystitis with  gall-stones  there  may  be  tenderness,  but  there  is  rarely  tender- 
ness in  uncompHcated  catarrhal  cholecystitis. 

Treatment. — The  majority  of  the  cases  recover  under  medical  treatment. 
If  a  case  fails  to  recover  under  medical  treatment,  one  cannot  be  sure  whether 
there  are  gall-stones  or  not;  but  an  operation  is  indicated  in  either  case.  Chole- 
cystostomy  should  be  performed  and  the  gall-bladder  should  be  drained 
for  a  week  or  two.     This  treatment  wiU  almost  always  produce  cure. 

Croupous  Inflammation  of  the  Qall=bladder  and  the  Bile=ducts. 
— This  is  an  extremely  rare  condition,  due  to  the  formation  of  a  thick 
membrane  in  the  bile-passages,  which  causes  obstruction  to  the  flow  of  bile 
and  spasmodic  contraction  of  the  gall-bladder.  The  S}Tnptoms  are  identical 
with  those  of  gall-stones.  Robson  points  out  that  a  study  of  the  evacuations 
ma}^  discover  membranous  intestinal  casts;  and  that,  as  membranous  enteri- 
tis is  usually  associated  with  croupous  inflammation  of  the  gall-bladder  and 
bile-ducts,  a  diagnosis  may  thus  be  reached.  The  same  author  says  that 
one  may,  in  some  cases,  even  find  a  cast  of  the  gall-bladder  in  the  evacuations. 

Treatment. — If  medical  treatment  fails,  cholecystostomy  should  be  per- 
formed and  drainage  should  be  employed  for  a  considerable  time. 

Suppurative  Inflammation  of  the  Qall=bladder  and  Bile=ducts. — 
Adopting  the  classification  of  ]Mr.  Robson,  we  di\dde  these  suppurative  in- 
flammations into  simple  suppurative  cholecystitis,  suppurative  and  infective 
cholangitis,  phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder, 
ulceration  of  the  gall-bladder  and  bile-ducts,  pericystic  abscess  with  adhesions, 
and  certain  consequences  of  these  conditions,  such  as  stricture  of  the  gall- 
bladder and  bile-ducts,  perforation  of  the  gall-bladder  and  bile-ducts,  and  fistula 
of  the  gall-bladder  and  bile-ducts.  Suppurati-\-e  inflammations  of  the  gall- 
bladder and  the  bile-passages  are  due  to  infection  by  \'irulent  organisms  or  to 
infection  when  the  tissue  resistance  is  at  a  low  ebb. 

One  fact  must  strike  the  physician  in  regard  to  these  cases;  that  is,  that 
there  is  a  strong  simflarity  between  the  possible  changes  of  acute  cholecystitis 
and  the  possible  changes  of  acute  appendicitis.  In  the  gall-bladder,  as  in 
the  appendix,  there  may  be  a  catarrhal  inflammation,  which  ma}'  not  advance 
beyond  this  stage,  or  which  may  advance  into  a  more  dangerous  form;  in 
each  structure  blocking  and  stagnation  favor  infection  and  aggravate  ex- 
isting infection;  in  each  there  ma}"  be  suppuration,  ulceration,  gangrene,  and 
perforation;  in  each  there  may  be  grave  complications  and  disastrous  and 
fatal  consequences;  and  in  each  prompt  surgical  operation  is  usually  life- 
saving.^ 

1  The  author,  "Proceedings  of  Phila.  County  Med.  See,"  Sept.,  1902. 


I044  Diseases  and  Injuries  of  the  Abdomen 

Simple  Suppurative  Cholecystitis. — This  condition  is  also  spoken 
of  as  suppurative  catarrh  of  the  gall-bladder  or  simple  empyema  of  the  gall- 
bladder. It  is  a  rare  condition  unless  gall-stones  exist  or  unless  some  infec- 
tious disease — especially  typhoid  fever — has  antedated  the  condition.  I 
operated  for  this  condition  upon  a  boy  eleven  years  of  age  three  weeks 
after  the  termination  of  an  attack  of  typhoid  fever.  It  is  not  only  typhoid 
fever  that  may  be  causative,  but  also  other  continued  fevers.  No  matter, 
however,  what  organism  is  primarily  responsible — be  it  colon  bacillus,  typhoid 
bacillus,  or  what  not — a  mixed  infection  with  pyogenic  cocci  usually  takes 
place.  Pyogenic  cocci  may  alone  be  causative.  In  simple  suppurative 
catarrh  of  the  gall-bladder,  when  the  duct  becomes  blocked,  the  condition 
known  as  simple  empyema  exists;  and  when  hydrops  of  the  gall-bladder 
undergoes  suppuration  simple  empyema  is  produced. 

In  an  ordinary  case  of  suppurative  catarrh  following  gall-stones  one 
usually  obtains  the  history  of  a  number  of  attacks  of  biliary  cohc,  the  pain 
finally  having  become  persistent  instead  of  intermittent,  and  a  definite  swell- 
ing being  palpable  in  the  gall-bladder  region.  This  swelling  is  tender  on 
pressure.     There   are   usually   constitutional    symptoms,    sometimes   trivial, 


Fig.  620.— Gall-bladder  filled  with  calculi.     Removed  by  cholecystectomy. 

often  severe.  The  trivial  symptoms  are  a  somewhat  rapid  pulse,  sweating 
at  night,  and  some  elevation  of  temperature.  The  more  severe  symptoms 
are  chills,  a  remittent  fever,  and  profuse  sweats.  The  development  of  severe 
symptoms  indicates  that  a  dangerous  change  is  taking  place — usually  iilcera- 
tion  of  the  gall-bladder,  occasionally  phlegmonous  cholecystitis.  Distinct 
jaundice  is  rare  in  simple  empyema,  though  the  patient  usually_  shows  loss 
of  flesh,  has  a  very  poor  appetite,  and  suffers  considerably  from  thirst. 

To  distinguish  an  enlarged  gall-bladder  from  any  other  intra-abdominal 
mass  is  sometimes  dif&cult.  Very  large  gall-bladders,  such  as  have  been  placed 
on  record  by  CoUinson,  Terrier,  Lawson  Tait,  Gersuny,  and  others,  may  be 
mistaken  for  ovarian  cysts.  Alban  Doran  discusses  such  cases  in  the  "Brit. 
Med.  Jour.,"  June  17,  1905.  An  enlarged  gall-bladder  moves  on  respiration 
unless  the  mass  becomes  adherent  to  the  abdominal  wall,  when  it  wiU  cease 
to  do  so.  An  enlarged  gall-bladder  is  sometimes  mistaken  for  a  movable 
kidney,  and  the  diagnosis  between  these  conditions  is  discussed  in  the  section 
on  Movable  Kidney  (see  page  1277). 

Treatment.— The  gall-bladder  should  be  opened  and  drained  by  the 
operation  of  cholecystostomv.     After  it  has  been  exposed,  it  is  packed  about 


Pericystic  Abscess  1045 

with  gauze  pads,  a  considerable  portion  of  the  contents  is  removed  through 
an  aspirator,  the  gall-bladder  is  opened  and  irrigated  with  salt  solution, 
and  a  search  is  made  for  any  cause  of  obstruction  in  the  cystic  duct.  This 
cause  should  be  removed,  and  any  gall-stones  that  are  present  should,  of 
course,  be  taken  away.  The  walls  of  the  gall-bladder  will  frequently  be 
found  diseased  and  softened,  so  that  it  is  impossible  to  apply  stitches.  In 
some  cases,  if  the  gall-bladder  is  badly  diseased,  it  should  be  removed,  but 
in  others  incision  with  drainage  is  sufficient. 

Recurrent  Simple  Empyema  of  the  Qall=bladder. — In  this  con- 
dition a  person  develops,  at  intervals,  pain,  fever,  tenderness,  and  enlarge- 
ment of  the  gall-bladder.  Then  the  symptoms  clear  up  and  he  is  well  for  a 
time,  but  they  again  become  manifest;  and  at  last  they  may  become  persist- 
ent or  violent  because  of  the  development  of  some  complication.  In  these 
cases  it  is  impossible,  after  a  number  of  attacks,  to  palpate  any  enlargement 
of  the  gall-bladder;  and  when  an  operation  is  performed  the  gall-bladder  is 
found  shrunken,  thickened,  and  deeply  placed,  containing  some  purulent 
matter,  and  strongly  fixed  to  the  surrounding  structures  by  adhesions. 

Treatment. — Cholecystectomy  is  usually  the  proper  operation. 

Acute  Phlegmonous  Cholecystitis. — Some  call  this  condition  acute 
empyema.  It  is  extremely  dangerous,  and  is  apt  to  cause  gangrene  of  the 
gall-bladder.  It  is  due  to  infection  by  extremely  virulent  organisms.  It 
may,  even  without  perforation,  produce  rapid  peritonitis  and  death.  As  a 
rule,  in  advanced  cases  perforation  takes  place.  It  is  generally  associated  with 
the  presence  of  calculi,  but  sometimes  none  are  found;  and  the  condition  some- 
times develops  during  typhoid  fever  or  septicemia. 

This  disease  begins  with  sudden  and  violent  pain  in  the  gall-bladder 
region.  This  pain  usually  radiates  toward  the  right  shoidder-blade,  and 
soon  becomes  general  throughout  the  abdomen.  There  are  tenderness  in  and 
great  rigidity  over  the  gall-bladder  region,  thoracic  respiration,  exhausting 
vomiting,  septic  fever,  and  in  some  cases  jaundice.  If  an  operation  is  not 
performed  promptly  general  peritonitis  quickly  takes  the  patient's  life.  In 
one  case  upon  which  I  operated  there  were  intense  jaundice,  tenderness, 
violent  pain,  abdominal  rigidity  and  distention,  chills,  and  septic  fever;  and 
when  the  abdomen  was  opened  it  was  found  that  a  portion  of  the  gall-bladder 
was  gangrenous  and  that  a  calculus  projected  through  the  gangrenous  opening. 

It  is  this  form  of  cholecystitis  that  is  especially  likely  to  be  mistaken 
for  appendicitis.  In  making  a  diagnosis  the  situation  of  the  primary  pain 
is  of  importance,  and  likewise  the  situation  of  the  tenderness;  but  a  displaced 
gall-bladder  or  an  abnormally  situated  appendix  may  lead  to  error.  Acute 
phlegmonous  cholecystitis  is  usually  accompanied  by  absolute  constipation, 
and  the  sudden  onset  and  the  abdominal  distention  may  lead  to  the  disease 
being  mistaken  for  intestinal  obstruction.  It  may  also  be  confused  with  per- 
forating ulcer  of  the  stomach  or  of  the  duodeniun. 

Treatment. — In  any  case  of  doubt  an  exploratory  incision  should  be 
made.  If  phlegmonous  cholecystitis  is  found  to  exist,  the  gall-bladder  should, 
whenever  possible,  be  extirpated;  but  if  the  desperate  condition  of  the  patient 
forbids  this  operation,  the  bladder  should  be  incised,  surrounded  with  iodoform 
gauze,  and  a  drainage-tube  should  be  carried  well  up  toward  the  cystic  duct. 

Pericystic  abscess  may  follow  infection  of  the  gall-bladder.  It  is  espe- 
cially common  in  the  condition  known  as  recurrent  simple  empyema.  When 
a  pericystic  abscess  exists  there  are  great  localized  abdominal  tenderness  and 
rigidity  and  the  temperature  is  usually  indicative  of  suppuration.  The  causa- 
tive micro-organisms  may  have  passed  through  a  diseased  gall-bladder  wall, 
rupture  not  existing ;  or  the  abscess  may  follow  ulceration  or  perforation  of 
the  gall-bladder  wall. 


1046  Diseases  and  Injuries  of  the  Abdomen 

Treatment. — Operation  should  invariably  be  performed,  though  it  is 
frequently  difficult.  After  a  pericystic  abscess  has  been  drained  it  will  be 
found  necessary  in  some  cases  to  extirpate  the  gall-bladder,  whereas  in  others 
incision  of  the  gall-bladder  and  drainage  will  prove  sufficient. 

Infective  Cholangitis. — Cholangitis  is  usually  inaugurated  by  infected 
bile,  but  when  it  arises  during  a  general  infection  the  bacteria  may  be 
brought  by  the  blood.  It  may  arise  in  a  case  of  hepatic  cirrhosis.  Naunyn 
("Deutsche  medizinische  Wochenschrift,"  Berlin,  Nov.  2,  191 1)  says  that 
most  germs  can  cause  cholangitis;  that  mixed  infection  may  occur,  and  that 
during  an  acute  general  infection  cholangitis  is  seldom  recognized.  The 
usual  cause  of  infective  cholangitis  is  gall-stones  lodged  in  the  common  duct. 
Some  maintain  that  duct-stones  are  causal,  particularly  in  those  cases  in  which 
a  gall-stone  acts  as  a  ball-valve.  A.  W.  Mayo  Robson,  though  he  beheves 
that  infective  cholangitis  does  occur  when  the  gall-stones  are  freely  movable 
in  the  common  duct,  sets  it  forth  as  his  experience  that  it  is  much  more  com- 
mon in  such  cases  to  find  gall-stones  impacted  in  the  common  duct. 

In  such  cases  the  patient  gives  a  history  of  attacks  of  gall-stone  colic 
without  jaundice  for  several  years,  and  then  of  attacks  followed  by  tempo- 
rary jaundice  (see  page  105 1).  Finally  comes  an  attack  that  is  followed  by  a 
chill  and  fever;  and  jaundice,  varying  in  intensity,  ensues  upon  this,  and  now, 
though  it  may  fade,  it  seldom  completely  disappears  between  the  attacks  of 
pain.  Robson  points  out  that  the  interval  between  the  attacks  may  be  short 
or  long,  and  that  the  rigors  may  be  repeated  daily  or  at  uncertain  intervals; 
that  the  gall-bladder  is  usually,  but  not  always,  contracted;  and  that  after  the 
condition  has  persisted  for  some  time  the  liver  becomes  distinctly  enlarged. 
There  are  tenderness  over  the  gall-bladder  or  in  the  epigastric  region,  loss  of 
flesh,  and  persistent  jaundice  which  may  vary  in  hue. 

Infective  cholangitis,  even  after  it  has  lasted  for  a  considerable  length 
of  time,  may  be  recovered  from;  but  it  may  pass  on  into  an  acute  condition 
in  which  poisoning  takes  place  from  the  biliary  elements,  suppurative  cho- 
langitis may  arise,  an  empyema  of  the  gall-bladder  may  develop,  and  there 
may  be  an  abscess  of  the  liver  or  some  other  dangerous  or  fatal  compHcation. 
The  ague-like  attacks  of  infective  cholangitis  have  been  called  by  Charcot 
intermittent  hepatic  fever  (see  page  105 1). 

Treatment. — After  an  incision  has  been  made  the  common  duct  is  opened, 
the  cause  removed,  and  the  duct  drained;  but,  as  Mr.  Robson  points  out; 
the  complication  should  be  anticipated.  When  one  finds  that  carefully  ap- 
plied medical  treatment  has  failed  to  free  the  patient  from  gall-stones,  they 
should  be  removed  surgically. 

Suppurative  cholangitis  is  usually  a  development  of  the  ordinary 
infective  cholangitis,  which  has  just  been  discussed.  Among  the  other  causes 
that  Robson  sums  up  are  acute  infectious  diseases,  particularly  typhoid  fever 
and  influenza,  cancer  of  the  bile-ducts,  and  hydatid  disease. 

In  this  condition  the  liver  enlarges  notably  and  becomes  tender.  In 
some  cases  there  is  an  empyema  of  the  gall-bladder,  but  this  is  rare;  in  fact, 
the  gall-bladder  is  usually  very  much  shrunken.  When,  in  a  chronic  case, 
there  are  enlargement  of  the  liver,  blocking  of  the  common  duct,  and  enlarge- 
ment of  the  gall-bladder  the  inference  is  in  favor  of  cancerous  obstruction 
of  the  common  duct.  If  the  obstruction  is  due  to  cancer  there  wfll  usually  be 
Httle  pain;  but  when  it  is  due  to  gaU-stones  there  will  be  violent  attacks 
of  pain,  accompanied  by  rigors  and  fever,  with  deepening  of  the  jaundice. 
In  this  disease  there  is  always  jaundice,  usually  unfading;  but  in  cases  of 
baU- valve  gall-stone  in  the  duct  it  will  be  mitigated  from  time  to  time  (see  page 
105 1).  The  patient  suffers  form  septic  fever  and  there  is  very  rapid  loss  of 
flesh. 


Treatment  of  Tj^hoid  Cholecystitis  1047 

The  condition  is  generally  fatal  unless  operation  is  performed  early. 
There  is  a  strong  tendency  for  abscess  of  the  liver  to  form,  and  in  i  case  upon 
which  I  operated  a  subphrenic  abscess  had  developed. 

Treatment. — Cholecystostomy  with  free  and  prolonged  drainage.  If  an 
abscess  of  the  liver  exists  it  should  also  be  drained.  If  gall-stones  are  gath- 
ered in  the  common  duct  they  should  be  removed. 

Typhoid  Cholecystitis. — T^-phoid  bacilh  were  first  found  in  the  bile 
by  Futterer  in  1SS8,  and  typhoid  cholecystitis  was  first  described  by  Giroche  in 
1S90.  As  previously  stated,  typhoid  bacilli  are  usually  present  in  the  bile 
during,  and  perhaps  are  present  months  or  years  after,  an  attack  of  t^-phoid 
fever.  They  are  not  always  present,  however,  for  in  a  case  of  cholecystitis 
folloT\dng  t>phoid  on  which  I  operated  an  unidentified  bacillus  was  found  ("New 
York  Med.  Jour.,"  April  8,  1905);  in  a  case  on  which  I  had  made  an  artificial 
anus  for  tjq^hoid  perforation  and  subsequently  performed  intestinal  resection 
I  drained  a  greatly  distended  gall-bladder  at  the  second  operation  and  cultures 
of  the  bile  remained  sterile;  and  in  a  case  of  typhoid  with  distended  and  appa- 
rently inflamed  gaU-bladder  on  which  I  operated  the  bile  was  reported  to  be 
sterile.  Because  t^-phoid  bacilli  are  usually  present  in  the  bile  during  typhoid 
does  not  mean  that  most  cases  of  typhoid  have  cholecystitis;  cholecystitis  is 
not  very  common,  and  arises  when  bacilli  are  very  munerous  or  very  virulent, 
when  \dtal  resistance  is  lowered,  when  there  is  antecedent  inflammation  of  the 
gall-bladder,  when  there  are  gaU-stones,  and  particularly  if  there  is  a  block  of 
the  duct  causing  stagnation  of  bfle.  Bacilli  in  bile  may  do  no  harm  at  all,  but 
they  may  cause  catarrh,  purulent  catarrh,  suppuration  of  the  gall-bladder 
walls,  suppuration  outside  of  the  gall-bladder,  or  perforation.  When  bile  or 
inflammatory  exudate  contains  typhoid  bacilli,  agglutinins  are  present  and 
may  precipitate  masses  which  become  nuclei  for  gall-stones. 

The  usual  period  for  cholecystitis  to  arise  is  during  the  third  week  of 
the  fever,  but  it  is  not  uncommonly  met  with  during  convalescence  and  is 
perhaps  mistaken  for  a  relapse. 

The  condition  may  arise  months  or  a  year  after  the  attack  of  typhoid,  and 
yet  a  pure  culture  of  typhoid  baciUi  may  be  obtained  from  the  gall-bladder. 
Strange  to  say,  cases  of  cholecystitis  have  been  operated  on  in  persons  giving 
no  history  of  ha\'ing  had  typhoid,  and  typhoid  bacilli  have  been  obtained 
from  the  gall-bladder.  Such  a  person  may  have  had  a  very  mfld  attack  of 
typhoid,  or  he  may  be  immune  to  typhoid  fever  and  yet  the  bacillus  may  be 
capable  of  causing  inflammation.  Many  cases  of  typhoid  cholecystitis  are 
probably  unrecognized  because  of  the  trivial  symptoms,  or  because  a  high 
position  of  the  Hver  renders  the  real  seat  of  pain  obscure,  because  the  general 
symptoms  are  uncertain,  because  toxemia  blurs  perception  of  pain,  or  because 
the  condition  is  confused  with  appendicitis.  It  is  rare  in  children,  more 
common  in  adults.  Most  infections  result  from  the  bacilli  ascending  the 
common  duct,  some  are  by  way  of  the  lymphatics  (Charles  H.  Mayo),  some 
by  an  adhesion  of  the  gall-bladder  to  the  bowel,  some  by  way  of  the  portal 
circulation  and  the  bile-ducts.  MLxed  infection  may  occur,  and  a  secondary 
staphylococcus  infection  may  be  followed  by  disappearance  of  the  typhoid 
bacilH.  The  symptoms  of  typhoid  cholecystitis  are  pain  and  tenderness  in 
the  gall-bladder  region,  rigidity  of  the  upper  half  of  the  right  rectus  muscle, 
perhaps  a  palpable  mass,  an  elevated  and  remittent  temperature,  sweats, 
perhaps  jaundice,  and  sometimes  leukocytosis.  In  some  cases  perforation 
occurs.  Erdmann  reported  i  case  and  coUected  from  literature  34  cases  of 
perforation  ("Annals  of  Surgery,"  June,  1903). 

Treatment. — In  an  ordinary  case  without  perforation  incise  and  drain  the 
gaU-bladder.  If  perforation  exists,  do  cholecystectomy  if  possible;  if  not, 
drain.     No  attempt  should  be  made  to  suture  the  perforation.     If  perforation 


1048  Diseases  and  Injuries  of  the  Abdomen 

exists  and  operation  is  not  done,  death  is  practically  certain.  Of  27  cases  not 
operated  upon,  all  died;  of  7  cases  operated  upon,  4  recovered  (Erdmann). 

Qall=stones  are  formed  during  life  in  the  gall-bladder  or  bile-ducts  by  the 
agglutination  of  materials  which  have  precipitated  from  bile.  The  nucleus  of 
a  gall-stone  may  be  a  mass  of  bacteria,  a  blood-clot,  epithelium,  crystals  of 
cholesterin  or  carbonate  of  lime,  or  a  cast  of  a  small  duct.^  A  condition  of 
the  body  thought  to  lead  to  the  formation  of  gall-stones  is  designated  by 
the  term  cholelithiasis  (Brockbank).  But  one  stone  may  be  present  or  great 
numbers  may  exist.  Solitary  stones  may  be  nearly  round  or  cylindrical. 
When  several  stones  or  many  stones  exist  the  mutual  pressure  often  leads  to 
the  formation  of  facets  (Naunyn).  In  color,  calculi  may  be  pale  yellow, 
green,  black,  or  brown.  Some  are  heavier  than  bile  and  some  are  lighter. 
Brockbank  gives  the  following  varieties  of  gall-stones:  pure  cholesterin  stones, 
stratified  cholesterin  stones,  common  or  gall-bladder  calculi,  mixed  bilirubin- 
calcium  calculi,  pure  bilirubin-calcium  calculi,  and  certain  rare  forms.^  Gall- 
stones usually  take  origin  in  the  gall-bladder,  but  may  arise  in  the  common 
duct,  the  cystic  duct,  the  hepatic  duct,  or  the  smaller  ducts  of  the  liver.  As 
a  rule,  however,  calculi  in  the  common  or  cystic  duct  were  not  formed  there, 
but  were  transported  from  the  gall-bladder  or  hepatic  ducts. 

Causes. — Gall-stones  are  very  commonly  found  postmortem.  In  Ger- 
many it  is  estimated  that  they  are  found  in  12  per  cent,  of  all  cases.  In  1655 
autopsies  in  the  Johns  Hopkins  Hospital  gall-stones  were  present  in  6.94 
per  cent,  of  all  cases.^  The  usual  estimate  is  5  per  cent,  of  autopsies.  The 
cause  is  a  catarrhal  condition  of  the  bile-ducts,  due  particularly  to  the  entrance 
of  bacteria  from  the  intestine  (colon  bacilli,  typhoid  bacilli,  pus  organisms, 
pneumococci) .  This  catarrhal  condition  causes  stagnation  of  bile.  Healthy 
bile  is  sterile,  but  not  germicidal,  and  bacteria  will  grow  in  it.  Bacteria  have 
been  found  in  bile  years  after  the  termination  of  an  attack  of  typhoid  fever. 
Experimental  infection  of  the  gall-bladder  producing  mild  cholecystitis  is 
almost  always  followed  by  gall-stone  formation.*  Welch  pointed  out  that 
recent  gall-stones  have  bacteria  in  their  center.  Gushing  tells  us  that  30  per 
cent,  of  gall-stone  cases  operated  upon  in  the  Johns  Hopkins  Hospital  had 
previously  suffered  from  t3q3hoid  fever,  but  the  experience  of  the  Mayos  is 
not  in  accord  with  this  opinion.  In  view  of  the  fact  that  bile  containing  typhoid 
bacilli  may  contain  agglutinins  we  can  understand  how  masses  could  be  pre- 
cipitated to  form  nuclei — 30  per  cent,  of  Ochsner's  cases  had  had  appendicitis. 

The  chief  predisposing  causes  are  advancing  years,  insufficient  exercise, 
the  daily  consumption  of  unnecessarily  large  quantities  of  food,  gouty  tenden- 
cies, and  conditions  which  interfere  with  the  emptying  of  the  gall-bladder. 
Cardiac  disease  and  cancer  of  the  liver  predispose.  Gall-stones  rarely  form 
before  the  age  of  thirty-five.  The  youngest  patient  from  whom  I  have 
removed  stones  was  a  girl  of  twenty.  The  disease  is  more  common  in  the 
insane  than  in  the  mentally  sound,  in  the  white  race  than  in  the  black, 
and  in  women  than  in  men.  In  25  per  cent,  of  all  females  beyond  sixty 
years  of  age  gall-stones  are  present  (Naunyn).  The  special  liability  of 
women  may  be  brought  about  by  tight  lacing,  pregnancy,  inactivity,  or 
movable  right  kidney.  Stout  and  lazy  women  are  particularly  liable  to 
gall-stone  formation,  and  women  who  have  borne  children  are  far  more 
liable  than  those  who  have  not.  Total  abstainers  seem  to  possess  a  greater 
predisposition  than  users  of  alcohol,  probably  because  they  are  more  apt  to 
be  large  eaters  (Herbert  F.  Waterhouse,  in  "Lancet,"  May  8,  1909).     There 

^  Bevan,  in  "Chicago  Med.  Recorder,"  April,  1898. 

^  Brockbank's  treatise  on  "Gall-stones." 

'  C.  D.  Mosher,  in  "Johns  Hopkins  Hosp.  Bull.,"  Aug.,  1901. 

*  Gilbert,  in  "Archives  generates  de  med.,"  Aug.  and  Sept.,  1898. 


Symptoms  of  Gall-stones  1049 

are  two  forms  of  the  condition  to  be  considered:  the  acute  type,  due  to  efforts 
made  by  the  gall-bladder  or  duct  to  expel  the  concretion ;  and  the  chronic  con- 
dition, in  which  a  calculus  is  lodged  for  a  long  time,  or  in  which,  as  soon  as  one 
calculus  is  passed  into  the  intestine,  "another  begins  its  journey"  (Brockbank's 
treatise  on  "  Gall-stones").  The  fact  that  bacteria  cause  the  condition  must 
not  lead  us  to  infer  that  pus  is  of  necessity  formed.  If  the  bacteria  are  present  in 
small  numbers,  or  if  their  virulence  is  greatly  mitigated,  they  produce  only  catar- 
rhal inflammation,  the  bile  stagnates,  and  a  stone  forms.  There  may  be  one 
stone,  two,  several,  or  many  stones.  I  have  removed  200  from  a  patient. 
Multiple  stones  are  usually  facetted.     Solitary  stones  are  not  facetted. 

Many  observers  believe  that  inflammation  of  the  mucous  membrane  causes 
the  secretion  of  quantities  of  cholesterin,  which  material  forms  a  large  part  of 
most  gall-stones.  Others  maintain  that  cholesterin  is  a  normal  constituent 
of  bfle  and  is  not  obtained  from  the  mucous  membrane. 

Bachmeister  ("Miinch.  Med.  Woch.,"  Feb.  18,  1908)  demonstrates  that 
if  pure  sterile  bile  is  permitted  to  stand  for  a  considerable  time  cholesterin 
will  be  precipitated,  and  that  if  epithelial  cells  are  added  to  this  the  cholesterin 
is  precipitated  much  more  rapidly.  The  catarrhal  inflammation  furnishes 
quantities  of  epithelial  cells  and  the  cells  precipitate  cholesterin,  and  in  this 
way  inflammation  causes  gall-stones.  It  is  probable  that  when  gall-stones 
exist  they  are  all  due  to  a  common  cause  and  all  began  to  form  at  the  same 
time.  It  is  not  likely  that  one  begins  and  then  another,  and  so  on.  After 
a  stone  once  begins  it  may  progressively  increase  in  size.  In  many  cases  the 
stone  or  stones  never  cause  trouble.  A  gall-stone  may  begin  to  descend 
because  of  violent  muscular  exertion,  external  pressure,  or  at  the  onset  of  a 
fresh  inflammation  which  leads  to  loosening  of  the  stone.  A  very  small  stone 
usually  passes  freely.  A  larger  stone  in  passing  causes  colic.  A  still  larger 
stone  remains  in  the  gall-bladder,  or  becomes  fixed  in  the  cystic  duct  or  in 
the  common  duct.  In  most  cases  gall-stones  form  in  the  gall-bladder.  In 
some  they  form  in  the  common  duct  if  stones  have  previously  existed  in  the 
gall-bladder.  When  the  common  duct  retains  a  stone  and  is  suffering  from 
some  degree  of  obstruction  and  from  infection,  stones  not  very  unusually 
form  in  the  hepatic  ducts  (Wm.  J.  and  Chas.  H.  Mayo,  in  "Am.  Jour.  Med. 
Sciences,"  March,  1905).  Stones  are  occasionally  found  at  necropsy  in  the 
radicles  of  the  hepatic  duct. 

Symptoms. — The  formation  of  a  stone  requires  several  months,  and 
during  the  antecedent  period  of  gastro-intestinal  catarrh,  the  prodromal 
state  of  Kraus,  certain  symptoms  may  exist,  viz.:  constipation,  flatulence, 
loss  of  appetitie,  migraine,  uneasy  sensations  in  the  epigastrium  or  right 
h)Apochondrium,  sallowness' of  the  skin,  slight  yellowness  of  the  conjunctivae, 
scantiness  of  urine,  which  excretion  is  saturated  with  uric  acid,  and  may  after 
a  time  contain  a  little  bile.  If  this  condition  is  not  arrested  by  treatment,  it 
grows  worse.  The  abdomen  becomes  decidedly  distended;  pressure  over  the 
stomach  or  liver  may  cause  distinct  uneasiness  or  even  pain;  acid  indigestion 
is  very  troublesome;  violent  attacks  of  migraine  occur;  constipation  becomes 
more  decided,  the  feces  become  clay  colored,  gastralgia  may  occur,  the  skin 
is  apt  to  be  slightly  jaundiced,  itching  is  complained  of,  the  patient  is  irritable 
and  sleeps  poorly.  The  liver  is  found  to  be  enlarged  and  the  urine  contains 
distinct  amounts  of  bfle.  When  the  patient  reaches  this  stage,  gall-stones  have 
formed  or  are  very  liable  to  form.  These  symptoms  may  pass  away  even  if  a 
concretion  forms.  It  is  quite  true  that  in  some  cases  a  stone  exists  for  years 
without  causing  trouble.  This  is  particularly  true  in  elderly  people.  A  stone 
seldom  fails  to  cause  symptoms,  but  often  the  symptoms  are  unrecognized.  In 
many  cases  the  symptoms  which  stones  cause  are  thought  to  be  due  to  dis- 
ease of  the  stomach  (indigestion,  flatulence,  pain  after  eating,  pyloric  spasm, 


1050  Diseases  and  Injuries  of  the  Abdomen 

etc.).  Most  of  the  cases  I  have  seen  long  thought  they  had  stomach  trouble,  and 
the  real  condition  was  recognized  only  when  there  was  a  seizure  of  colic  or  an 
attack  of  inflammation. 

As  Waterhouse  ("Lancet,"  May  8,  1909)  says,  the  symptoms  do  not  bear 
any  relation  to  the  size  or  the  number  of  the  stones.  In  fact,  gall-stones  give 
rise  to  active  symptoms  only  when  infection  occurs  or  when  the  ducts  become 
occluded  and  cease  to  drain,  or  when  a  stone  starts  to  pass.  If  infection  occurs, 
it  may  pass  away  spontaneously,  but  seldom  does  so.  When  a  stone  forms, 
pain  is  apt  to  become  a  marked  feature  of  the  case.  John  B.  Murphy  ("Med. 
News,"  Nov.  2, 1903)  points  out  that  in  a  person  with  stones  in  the  gall-bladder 
there  may  be: 

1.  The  pain  of  acute  inflammation,  the  result  of  a  severe  infection.  In 
this  condition  there  are  abdominal  rigidity  and  contracted  gall-bladder. 

2.  The  pain  of  tension.  In  this  there  is  not  persistent  abdominal  rigidity, 
but  pressure  always  causes  sudden  and  transient  tension  of  the  belly  muscles. 
Murphy's  method  of  demonstrating  tenderness  of  the  gall-gladder  is  most 
valuable,  and  I  always  use  it.  It  is  as  follows:  Hook  the  fingers  well  up  under 
the  liver  and  tell  the  patient  to  take  a  deep  inspiration.  On  inspiration  pain 
becomes  acute  and  respiration  suddenly  ceases. 

3.  Referred  pain,  which  may  exist  with  either  of  the  above  conditions. 
Colic  is  spasmodic  pain,  and  means  that  a  stone  has  left  or  is  trying  to  leave 
the  gall-bladder,  and  is  in  or  is  trying  to  enter  a  duct.  Many  persons  with  a 
stone  or  with  stones  in  the  gall-bladder  never  have  colic.  A  sense  of  pressure 
or  of  soreness  in  the  hepatic  region,  the  result  of  cholecystitis,  has  added  to  it 
sudden  and  transient  paroxysms  of  pain,  due  to  the  passage  of  thick  bUe  from 
the  gall-bladder  and  small  ducts,  or  of  gravel  from  the  small  ducts,  urged  on  by 
bile  pressure.  When  any  stone  but  the  very  smallest  begins  to  pass  from  the 
gall-bladder,  violent  colic  is  experienced.  Such  a  colic  usually  comes  on  very 
suddenly,  and  often  about  three  hours  after  a  meal.  It  may,  however,  come 
on  gradually,  the  patient  complaining  greatly  of  flatulence.  In  some  cases 
it  is  so  sudden  and  violent  as  to  simulate  perforation  of  the  stomach  or 
duodenum.  The  reason  colic  is  particularly  apt  to  come  several  hours  after 
a  heavy  meal  is  that  at  that  time  bile  is  passing  down  into  the  intestine. 
A  bladder  containing  calculi  often  tolerates  the  presence  of  the  foreign  bodies 
for  an  indefinite  length  of  time,  and  then  suddenly  resents  their  presence  and 
ejects  them  forcibly  or  tries  to  eject  them.  The  pains  are  violent,  spasmodic, 
and  paroxysmal,  and  over  the  hepatic  and  epigastric  regons,  "radiating 
upward  over  the  right  half  of  the  thorax"  (Kraus),  and  passing  particularly 
from  the  epigastriimi  to  the  right  shoulder-blade.  The  patient  is  profoundly 
nauseated  and  usually  vomits.  In  many  cases  the  vomiting  is  \dolent.  The 
abdomen  is  distended  and  a  condition  almost  of  collapse  is  soon  reached. 
The  temperature  is  usually  normal  or  subnormal,  but  is  occasionally  some- 
what elevated.  The  patient  may  shiver  and  sweating  may  follow,  but  rigors 
are  rare.  The  respirations  are  shallow,  the  patient  groans,  cries  out,  flings 
himself  about  in  the  bed,  and  often,  in  seeking  relief,  assumes  some  strange 
or  contorted  position.  He  frequently  holds  one  hand  over  the  liver  region. 
His  expression  is  indicative  of  intense  suffering  and  apprehension  and  some- 
times of  abject  terror.  The  pain  is  one  of  the  most  awful  a  human  being 
can  feel,  and  women  who  have  felt  it  assert  that  the  pains  of  parturition  are 
trivial  in  comparison.  The  attack  lasts  a  variable  time,  and  terminates  when 
the  stone  passes  into  the  intestine  or  drops  back  into  the  bladder.  The  usual 
duration  of  an  attack  is  from  four  to  twenty  hours.  I  have  seen  attacks 
that  lasted  three  days,  four  days,  or  even  five  days,  almost  without  intermis- 
sion. It  terminates  suddenly  if  the  stone  passes  or  falls  back  in  the  gall- 
bladder.    It  abates  very  gradually  if  the  stone  becomes  wedged  in  a  duct. 


S^inptoms  of  Gall-stones  105 1 

In  many  cases  at  the  termination  of  the  attack  an  enormous  amount  of  clear 
pale  urine  is  passed.  During  and  for  a  time  after  the  attack  the  gall-bladder 
may  be  ven.-  tender.  After  the  cessation  of  coHc,  if  the  feces  are  examined 
carefully  during  several  days,  the  stone  may  be  discovered.  The  fact  that 
no  stone  is  discovered  does  not  prove  that  one  was  not  passed,  because  a 
cholesterin  stone  may  be  destroyed  in  the  intestinal  canal.  If  the  stone  is 
passed,  jaundice  almost  invariabh'  follows  the  coHc  in  from  twenty  to  thirty- 
six  hours  and  lasts  several  days.  The  jaundice  results  from  the  stone  being 
in  or  ha\'ing  passed  through  the  common  duct.  If  stones  do  not  pass  from 
the  cystic  duct  so  as  to  enter  or  protrude  into  the  common  duct,  jaundice 
does  not  occur.  In  80  per  cent,  of  my  cases  of  gall-stones  (excluding 
common  duct  cases)  there  was  no  history  of  jaundice.  Even  when  a  stone 
is  lodged  in  the  common  duct  jaundice  may  be  slight  or  absent.  \Mien 
jaundice  arises  after  a  colic,  it  comes  on  gradually,  bile  appears  in  the 
urine,  and  often,  but  not  always,  the  stools  become  clay  colored  from 
absence  of  bile.  Jaundice  may  be  first  noticeable  in  the  urine  or  in  the 
conjunctiva.  The  skin  is  apt  to  itch  anno}ingly.  even  atrociously.  The 
patient  is  constipated  and  \-er}*  thirsty.  The  liver  is  enlarged  and  tender  and 
the  spleen  is  enlarged.  Some  writers  state  that  the  pulse  is  slow  in  jaundice. 
My  experience  is  in  agreement  \\ith  the  much  larger  experience  of  ^Nloynihan, 
who  says:  "1  have  not  found  any  reduction  in  the  pulse-rate  in  jaundice 
unless  a  degree  of  chronic  pancreatitis  is  present'"'"  ("GaU-stones  and  Their 
Surgical  Treatment""^.  If  the  stone  becomes  impacted,  after  a  time  the  pains 
become  gradually  less  ^dolent,  and  may  entirely  cease.  If  it  ceases  and  the 
stone  does  not  move,  pains  do  not  recur:  if  the  stone  moves  pains  recur,  and, 
usually,  again  and  again  the  patient  suffers  from  severe  pain.  An  indi- 
\-idual  may  get  about  when  a  stone  is  impacted,  but  again  and  again  fierce 
attacks  of  colic  occur,  and  if  the  stone  is  wedged  immovably  in  the  common 
duct,  producing  absolute  obstruction,  the  patient  becomes  and  remains  deeply 
jaimdiced.  Continued  deep  jaundice  is  seldom  seen  when  stones  are  lodged 
in  the  common  duct,  because  they  are  not  often  absolutely  fixed  and  hence 
rarely  produce  complete  obstruction.  Usually  the  stone  moves  from  time 
to  time  or  is  at  least  Lifted,  so  that  bile  gets  by  it  at  inter\'al5.  This  con- 
dition constitutes  the  hall-vahe  stone,  and  in  it  jaundice,  though  present 
more  or  less,  is  at  times  much  more  intense  than  at  other  times.  It  is  a 
jaundice  in  which  the  hue  is  yeUow,  not  deep  brown,  and  it  is  a  jaundice 
that  wanes  and  deepens.  It  deepens  after  each  coHc  and  later  wanes,  but 
seldom  entirely  disappears  while  the  stone  remains  in  the  duct. 

In  persistent  jaimdice  due  to  gall-stones  the  gaU-bladder  is  seldom  en- 
larged. Cour\-oisier  showed  that  when  persistent  jaimdice  is  associated  with 
enlargement  of  the  gaU-bladder  the  cause  is  usually  pressure  on  the  duct  from 
without  (malignant  disease  of  the  pancreas) . 

SUght  jaundice  is  not  always  easy  of  recognition.  Recognition  is  par- 
ticularly difficult  in  sallow  indi^■iduals  and  by  artificial  light.  !Mo}'nihan  praises 
Hamei's  test  for  slight  jaundice.  It  is  made  by  dravi-ing  a  httle  blood  from 
a  puncture  of  the  lobe  of  the  ear  into  a  capUlar}"  tube  and  permitting  the  tube 
to  stand  for  a  few  hours.  If  any  jaundice  is  present  the  serum,  which  collects 
in  the  upper  part  of  the  tube,  wiH  be  yellow  i_]Mo}Tiihan) . 

In  certain  cases  when  a  stone  is  in  the  common  duct  an  attack  of  coUc  is 
followed  by  or  accompanied  by  a  dull  or  chills,  which  may  be  ver\'  "violent, 
moderate,  or  slight,  and  by  a  febrile  seizure  resembling  malaria  and  called 
hepatic  fever  or  Charcot's  fever.  The  temperature  rises  rapidly,  and  in  an  hour 
becomes  104°  F.  or  more,  remains  high  for  several  hours,  and  then  drops  sud- 
denly to  normal.  It  may  remain  normal  for  a  few  hours,  a  day,  two  days,  sev- 
eral days,  or  weeks.     In  this  condition  there  are  jaundice  and  tenderness  of 


1052  Diseases  and  Injuries  of  the  Abdomen 

the  liver.  Charcot's  fever  is  brief  in  duration.  It  usually  means  stone  in  the 
common  duct.  If  stones  are  in  the  bladder,  we  are  more  apt  to  get  a  persist- 
ent slightly  elevated  temperature.  These  intermissions  distinguish  Charcot's 
fever  from  the  remittent  fever  of  sepsis,  and  the  absence  of  the  plasmodium 
in  the  blood  and  the  history  of  colic  distinguish  it  from  malaria.  The  fever 
is  due  to  intoxication  with  toxins  from  infected  bile  retained  in  the  ducts 
by  obstruction.  The  condition  is  ominous  because  it  is  due  to  infection, 
and  means  inflammation  of  the  large  ducts  (cholangitis). 

The  chart  of  Charcot's  fever  shows  sudden  elevations,  precipitate  descents, 
and  complete  intermissions.  Moynihan  calls  it  the  "steeple  chart"  ("Gall- 
stones and  Their  Surgical  Treatment").  When  infection  spreads  widely  in  the 
smaller  intrahepatic  ducts  the  temperature  is  high  and  does  not  remit.  Con- 
tinuous fever  of  this  type  has  usually  been  preceded  by  Charcot's  fever. 

If  a  stone  lodges  in  the  cystic  duct,  it  does  not  cause  jaimdice  imless  an 
end  of  the  stone  projects  into  the  common  duct.  It  grows  in  size  from  incrus- 
tation, prevents  the  entrance  of  bile  into  the  gall-bladder,  and  the  bladder 
may  shrivel  and  thicken  or  become  distended  and  fLUed  with  mucus,  the 
bile  being  absorbed  (hydrops  of  the  gall-bladder).  If  a  bladder  so  blocked 
becomes  infected,  pus  forms,  and  the  condition  known  as  empyema  of  the 
gall-bladder  arises.  An  empyema  of  the  gall-bladder  may  rupture  into  the 
bowel,  the  peritoneal  cavity,  or  even  through  the  skin. 

The  common  duct  is  involved  in  i  out  of  5  or  6  cases  of  gall-stone  disease.^ 
Brewer  points  out  that  in  67  per  cent,  of  common  duct  cases  the  stone  is  in  the 
duodenal  extremity,  in  15  per  cent,  in  the  hepatic  extremity,  and  in  18  per  cent, 
in  the  middle.  If  a  stone  blocks  the  common  duct,  jaundice  always  exists  and 
persists.  Blocking  may  be  complete  and  the  stone  may  ulcerate  into  the  bowel 
or  the  peritoneal  ca\'ity.  Blocking  may  be  incomplete,  the  stone  acting  as  a 
ball-valve  and  producing  intermiUent  colic  and  jaundice,  which  wanes  and 
deepens  (see  page  105 1).  Fenger  pointed  out  that  if  a  stone  remains  fixed  in  the 
common  duct  the  liver  becomes  tender  and  enlarged,  but  if  a  stone  floats 
about  in  the  common  duct  the  gall-bladder  undergoes  atrophy.  In  complete 
obstruction  the  stools  become  clay  colored  and  bilirubin  is  found  in  the  urine. 
Fluctuating  jaundice,  with  attacks  of  pain  and  fever,  and  a  shrunken  gall- 
bladder are  strongly  suggestive  of  a  "ball- valve"  stone  in  the  common  duct. 
Persistent  deepening,  painless  jaundice,  the  color  of  the  skin  becoming  brown 
or  even  of  a  mahogany  hue,  associated  with  a  distended  gall-bladder,  is  strongly 
suggestive  of  malignant  disease  compressing  the  common  duct.  The  above 
statements  constitute  Courvoisier^s  law.  It  is  found  true  in  90  per  cent,  of 
cases.  We  may  add  that  a  persistent  jaundice  of  yellow  hue,  varying  some- 
what, and  associated  with  pain  or  with  actual  colic,  suggests  blocking  of  the 
duct  by  an  immovable  stone. 

Gall-stones  may  lead  to  suppurative  inflammation  of  the  gaU-bladder 
or  bile-passages,  ulceration,  occlusion  of  the  neck  of  the  gall-bladder,  dilata- 
tion of  the  stomach  from  the  formation  of  adhesions  which  kink  the  pylorus, 
pericystic  abscess,  peritonitis,  empyema  of  the  gall-bladder,  and  cancer  of  the 
gall-bladder.  In  cancer  of  the  ducts  gall-stones  are  seldom  found,  at  least  are 
seldom  found  in  the  ducts.  Eddes  coUected  22  cases  of  cancer  of  the  papilla. 
In  3  of  these  cases  there  were  stones  in  the  gall-bladder,  in  i  there  was  a  stone 
in  the  common  duct  ("Boston  Med.  and  Surg.  Jour.,"  March  7,  1901).  If  the 
patient  develops  distinct  infection  of  the  gall-bladder  or  bile-ducts,  he  \\ill  suffer 
from  chills,  fever,  and  sweats. 

Gall-stones  may  lead  to  cirrhosis  of  the  liver.  A  stone  may  ulcerate 
into  the  bowel  and  cause  intestinal  obstruction.  It  may  be  difficult  to  make 
a  diagnosis  between  gall-stones  with  icterus  and  cirrhosis  of  the  liver  with 
1  Robson,  in  "Lancet,"  April  12,  1902. 


Treatment  of  Gall-stones  1053 

icterus.  In  the  former  case  the  urine  contains  biHrubin  and  in  the  latter 
case  urobilin. 

Treatment. — In  the  prodromal  stage  and  after  recovery  from  an  attack 
insist  on  the  patient  taking  considerable  outdoor  exercise.  Direct  him  to 
take  a  cold  sponge-bath  every  morning,  to  move  the  bowels  freely  every 
day,  and  to  employ  a  sim.ple  diet.  He  should  avoid  all  highly  seasoned  foods, 
pastry,  rich  soups,  fatty  food,  cheese,  alcohol,  and  sweets.  AlkaHs  internally 
are  of  value. 

During  coHc  give  a  purgative  enema,  apply  hot  turpentine  stupes  over  the 
hepatic  region,  and  administer  hypodermatic  injections  of  morphin  and  atro- 
pin.  If  vomiting  does  not  occur,  let  the  patient  drink  a  large  amount  of 
warm  water  to  favor  it.     After  the  attack  administer  a  saline  purgative. 

WTien  the  attack  has  terminated,  examine  carefully  for  any  evidence  of 
inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mr.  A.  W.  Mayo  Robson^ 
advises  operation  m  the  following  cases:  in  frequently  recurring  biliary  colic 
without  jaundice,  whether  the  gall-bladder  is  enlarged  or  not;  in  cases  of 
enlargement  of  the  gall-bladder  T\ithout  jaundice,  even  if  there  is  no  pain; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful  seizures  occur- 
ring, whether  or  not  febrile  attacks  occur;  in  empyema  of  the  gall-bladder; 
in  peritonitis  beginning  in  the  gall-bladder  region;  in  intrahepatic  abscess  and 
in  abscess  about  the  liver,  gall-bladder,  or  bUe-ducts;  in  some  patients  in 
W'hom  the  stones  have  been  passed,  but  adhesions  remain  and  produce  pain; 
in  fistula  cases;  in  some  cases  of  persistent  jaundice  due  to  obstruction  of  the 
common  duct,  although  there  may  be  a  possibility  of  cancer  existing;  in 
phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder.  Besides  these 
conditions,  w^hich  may  be  produced  by  gall-stones,  Robson  operates  for  wounds 
of  the  gall-bladder,  infective  and  suppurative  cholangitis,  and  for  some  con- 
ditions of  chronic  catarrh  of  the  bile-ducts  and  gall-bladder.-  The  tendency 
to  operate  early  for  gall-stones  is  growing.  It  is  true  that  stones  may  cause  no 
trouble,  but  sooner  or  later  they  are  apt  to  cause  it,  there  is  no  tendency  what- 
ever to  spontaneous  cure,  and  medicine  cannot  dissolve  them  in  the  bladder. 
Early  operations  are  easy  and  comparatively  safe;  late  operations  are  difficult 
and  dangerous,  and  by  early  operation  dangerous  complications  (infection, 
adhesions,  obstructive  jaundice)  are  avoided.  As  Maurice  H.  Richardson^ 
says:  An  early  operation  is  less  dangerous  than  the  passage  of  a  stone;  com- 
pHcations  are  avoided  or  lessened;  even  if  the  diagnosis  is  wrong,  the  real 
condition  may  be  foimd  and  removed.  If  obstructive  jaundice  exists  opera- 
tion is  dangerous  because  of  the  possibility  of  fatal  oozing  of  blood. 

The  common  operation  is  cholecystostomy ,  which  consists  in  opening  the 
gall-bladder,  removing  the  stones,  and  making  a  temporary  fistula  in  the  gaU- 
bladder.  The  drainage  cures  the  diseased  mucous  membrane.  The  fistula  is 
permitted  to  heal  after  a  time,  hence  man}'  call  the  operation  cholecystotomy 
rather  than  cholecystostomy.  Operation  should  be  done  promptly  and  should 
not  be  delayed.  Delay  permits  the  gall-bladder  to  thicken  and  shrink,  and  allows 
the  stone  to  enter  the  duct.  After  drainage  gall-stones  rarely  re-form.  Wm. 
J.  Mayo  collected  1000  operations  done  by  six  surgeons,  and  in  not  i  case 
did  stones  re-form.  Kocher  has  seen  stones  reciu:  in  3  out  of  31  cases  of 
cholehthiasis  after  ideal  cholecystotomy  (suturing  the  gall-bladder  after  remov- 
ing stones).  The  operation  of  incision,  removal  of  the  stone,  and  suture  of  the 
gall-bladder  is  known  as  ideal  cholecystotomy  or  cholecystendysis.     It  is  not  a 

1  On  the  "Gall-bladder  and  Bile-ducts." 

-  Robson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition  of  the  surgery 
of  the  gall-bladder  and  bile-ducts. 

^  "Boston  iled.  and  Surg.  Jour.,"  Sept.  5,  1901. 


I054  Diseases  and  Injuries  of  the  Abdomen 

proper  procedure,  as  it  does  not  cure  the  diseased  mucous  membrane  and 
stones  are  apt  to  re-form.  Cysticotomy  is  incision  of  the  cystic  duct.  If  calculi 
exist  in  the  common  duct,  it  may  be  possible,  after  celiotomy,  to  manipulate 
them  back  into  the  bladder  and  extract  them  from  that  viscus  by  a  scoop, 
but  this  maneuver  is  impossible  unless  the  cystic  duct  is  dilated.  In  some 
cases  the  gall-bladder  is  incised,  a  fistula  is  made,  and  the  duct  and  bladder 
are  frequently  irrigated.  In  other  cases  the  stone  may  be  crushed  by  the 
fingers  manipulating  the  duct  and  the  concretion  within  it  {choledocholithotrity) . 
Robson  points  out  that  crushing  of  the  stone  is  apt  to  leave  fragments 
which  may  cause  trouble,  and  it  should  be  done  only  when  the  stones  are 
soft.  It  is  wrong  to  endeavor  to  force  a  stone  from  the  common  duct  into 
the  duodeniun.  The  attempt  will  fail,  and  in  some  cases  the  patient  will 
be  placed  in  a  worse  condition  by  the  stone  lodging  in  Vater's  diverticu- 
lum.^ The  duct  may  be  opened,  and  after  the  removal  of  the  stone  closed 
by  sutures  {choledochotomy)  or  drained  for  a  time  (choledochostomy),  strands 
of  gauze  being  carried  down  to  the  opening  and  in  some  cases  a  tube  being 
carried  up  a  dilated  duct  toward  the  liver.  If  the  stone  is  impacted  near  the 
outlet  of  the  duct,  it  may  be  necessary  to  incise  the  duodenum  in  order  to  re- 
move the  stone  {diwdenocholedochoto?ny) .  A  dilated  common  bile-duct  may  be 
anastomosed  to  the  bowel  {choledocho-enter ostomy)  or  to  the  surface  {choledochos- 
tomy) .  The  obstruction  may  be  side-tracked  by  anastomosing  the  gall-bladder 
to  the  bowel  {cholecystenter ostomy)  (see  page  1127).  Cholecystenterostomy 
affords  drainage,  but  does  not  remove  the  cause  of  trouble,  and  infection  is  apt 
to  be  received  from  the  bowel.  In  some  rare  cases  of  common  duct  obstruc- 
tion, in  which  the  gall-bladder  is  distended  and  the  condition  of  the  patient  is 
desperate,  anastomose  the  gall-bladder  to  the  colon  (Robson).  In  some  cases 
of  diseased  gall-bladder  the  viscus  is  removed  {cholecystectomy) .  Wm.  J.  Mayo 
and  others  have  pointed  out  that  a  danger  in  operations  on  the  common  duct 
is  a  sudden  fall  in  blood-pressure  when  the  duct  is  being  manipulated.  AU 
operators  have  observed  it.  Ransohoff  maintains  that  it  arises  only  when  the 
portal  vein  is  compressed. 

Carcinoma  of  the  Qall=bladder. — In  405  operations  on  the  gaU-bladder 
and  biliary  passages  the  Mayo  brothers  found  malignant  disease  20  times 
(5  per  cent,  of  cases).  (See  Wm.  J.  Mayo,  in  "Med.  News,"  Dec.  13,  1902.) 
MaUgnant  disease  may  be  primary  or  secondary.  In  primary  carcinoma  cal- 
culi are  always  present,  and  are  apparently  the  cause  of  cancer  by  maintaining 
chronic  irritation.     Stones  are  seldom  present  in  secondary  mahgnant  disease. 

Carcinoma  of  the  gall-bladder  can  usually  be  palpated.  It  is  hard  and 
nodular,  and  seldom  accompanied  by  much  abdominal  rigidity.  There  will 
be  a  long  history  of  attacks  of  biliary  colic  and  of  recent  or  comparatively  re- 
cent grave  loss  of  flesh.     Sooner  or  later  jaundice  arises,  deepens,  and  persists. 

Cholecystectomy  has  been  employed  for  this  condition,  but  offers  but 
little  hope.  In  2  cases  in  which  I  opened  the  abdomen  without  suspecting 
mahgnant  disease  of  the  gall-bladder  the  liver  was  hopelessly  involved.  In 
I  case  in  which  I  operated  for  a  supposed  impacted  stone  in  the  common  duct 
an  inoperable  cancer  of  the  common  duct  was  found. 

Injuries  and  Diseases  of  the  Pancreas 

Injuries  of  the  Pancreas. — The  pancreas  is  very  rarely  ruptiired  alone, 
although  this  sometimes  occurs  as  the  result  of  blows  or  crushes.  In  the 
majority  of  cases  in  which  the  pancreas  is  damaged  other  organs  are  involved; 
for  instance,  the  stomach,  the  spleen,  and  the  liver.  A  gunshot-wound  of 
the  pancreas  is  almost  certain  to  injure  the  left  kidney,  the  stomach,  or  the 
^  See  A.  W.  Mayo  Robson,  in  "Lancet,"  April,  12,  1902. 


Treatment   of  Injuries  of  the  Pancreas  1055 

vertebral  column.  It  will  be  remembered  that  in  the  case  of  President  ]Mc- 
Kinley  the  bullet  passed  through  the  stomach,  damaged  the  left  kidney,  and 
injured  the  pancreas.  Becker  reported  an  isolated  gunshot-wound  of  the 
pancreas,  the  only  case  on  record  (^Stephen  H.  Watts).  Garre  ("Beitrage 
ztir  Klinische  Chirurgie."  >d\'i,  Xo.  i)  collected  30  cases  of  subcutaneous 
rupture  of  the  pancreas,  and  in  only  8  of  these  cases  was  the  pancreas  alone 
damaged. 

Symptoms. — When  the  pancreas  is  injured  alone,  hemorrhage  is  not 
usually  severe;  but  if  adjacent  organs  are  also  damaged,  it  is  sure  to  be 
profuse.  Hence  when  adjacent  organs  are  damaged  immediate  s^Tuptoms  of 
severe  intra-abdominal  hemorrhage  appear;  but  profound  collapse  is  not  often 
present  when  the  pancreas  alone  is  injured.  In  fact,  symptoms  may  not  arise 
for  a  considerable  length  of  time  after  injur}"  of  the  pancreas.  A  diagnosis  at 
this  stage  is  impossible  without  explorator}-  operation.  Wohlgemuth  and 
Xoguchi  claim  that  within  a  few  hours  of  a  pancreatic  injur}-  there  is  an  in- 
crease of  diastase  in  the  blood  and  lu^ine  ("Berlin,  klin.  Wochen.,"'  x1ix,  1912). 
If  this  obsen,'ation  is  correct  we  have  a  ver}-  valuable  diagnostic  test.  Severe 
injur}'  of  the  pancreas  is  usually,  but  not  invariably,  fatal.  After  slight  damage 
of  the  gland  the  patient  may  completely  recover;  but,  as  a  rule,  he  partly  re- 
covers, and,  after  a  mmiber  of  weeks,  a  smooth  enlargement,  palpable  in  the 
epigastric  region,  is  formed.  \Mien  operation  is  performed  this  mass  is  found 
to  be  back  of  the  stomach.  It  contains  a  quantity  of  fluid  blood,  clot,  and 
pancreatic  fluid.  Such  a  fluid  coUection  is  in  the  lesser  peritoneal  canity  and 
is  called  a  cyst,  though  it  is  not  a  true  cyst  of  the  pancreas.  It  is  a  pseudo- 
cyst. Robson  and  Moynihan,  in  their  valuable  treatise  on  "Diseases  of  the 
P'ancreas,"  explain  the  formation  of  this  collection  of  fluid  as  follows: 

The  injur}-  lacerates  the  posterior  layer  of  the  lesser  sac  of  the  peritoneum 
and  the  pancreas,  to  which  it  is  adherent.  Blood  and  pancreatic  fluid  enter 
the  lesser  peritoneal  sac.  Peritonitis  foUows.  The  foramen  of  Winslow  be- 
comes blocked  by  adhesions;  and  the  lesser  peritoneal  canity,  being  now  a 
closed  sac,  is  distended  by  a  serous  exudate  mixed  with  blood  and  pancreatic 
fluid.  Collections  of  this  character  form  xery  rapidly,  and  several  pints 
mav  gather  in  a  few  days.  Other  results  of  injur}-  to  the  pancreas  are  abscess, 
pancreatitis,  and  true  cyst  formation.  A  fistula  may  follow  operation  for 
ruptmre  of  the  pancreas.  Such  a  fistula  is  very  troublesome,  often  refuses 
obstinately  to  heal,  and  the  pancreatic  fluid  macerates  the  skin  severely. 

Treatriient. — Operation  is  imperatively  demanded,  although  the  pros- 
pects are  bad.  Garre  collected  S  cases,  3  were  operated  upon,  and  all  died. 
He  reported  a  successful  case  of  his  own  (Loc.  cit.).  The  pancreas  was  torn 
in  two  and  the  pieces  were  separated.  The  splenic  vessels  were  uninjured. 
The  two  portions  of  gland  were  sutured  together.  This  stopped  the  bleed- 
ing. Gauze-packing  was  introduced.  ^Mikulicz  ("Proceedings  of  Amer. 
Surg.  Soc.'")  in  1903  collected  21  wounds  and  24  crushes  of  the  pancreas. 
Twelve  of  the  wounds  were  due  to  bullets  and  9  were  stabs.  Five  of  the  12 
gunshot-wounds  were  operated  upon,  with  2  deaths.  All  unoperated  upon 
died.  The  9  patients  who  had  been  stabbed  were  all  operated  upon  and  only 
I  died.  In  a  gimshot-wound  of  the  abdomen,  when  exploration  leads  the 
surgeon  to  siumiise  that  the  pancreas  has  been  injmred,  this  organ  should 
be  approached  by  di^-iding  either  the  gastrocolic  omentum,  the  transverse 
mesocolon,  or  the  gastrohepatic  omentum.  Accessor}-  injiu^ies  must  be 
carefully  noted,  and  if  a  bullet  has  penetrated  the  posterior  wall  of  the 
stomach,  the  pancreas  is  almost  certain  to  be  damaged.  One  should  re- 
member that,  as  Park  says,  even  after  opening  the  abdomen  it  is  diflicult 
to  explore  the  pancreas,  especially  in  a  stout  person.  If  there  is  no  e\-i- 
dence  of  posterior  perforation  of  the  stomach  by  a  foreign  body,  one  may 


1056  Diseases  and  Injuries  of  the  Abdomen 

assume  that  the  pancreas  has  escaped.  When  the  pancreas  is  exposed,  if  it  is 
found  to  be  bleeding,  the  bleeding  vessels  should  be  ligated  and  the  tear  in  the 
gland  should  be  sutured  with  catgut,  care  being  taken  not  to  puncture  the  main 
duct  of  the  gland.  If  this  duct  has  been  cut,  it  should  be  carefully  sutured. 
In  some  cases  of  gunshot- wound  it  is  necessary  to  resect  a  portion  of  the  gland. 
At  the  termination  of  an  operation  upon  the  pancreas  posterior  drainage,  prefer- 
ably at  the  costovertebral  angle,  should  always  be  obtained.  It  is  necessary 
to  carefully  drain  away  all  escaping  pancreatic  fluid,  as  it  tends  to  cause  necro- 
sis of  tissue  with  which  it  comes  in  contact. 

In  cases  of  crush  with  pancreatic  injury  the  associated  injury  to  other 
structures  usually  proves  rapidly  fatal,  but  in  a  less  severe  case  the  abdomen 
may  be  opened  for  exploration,  and  if  this  is  done,  the  surgeon  should  pro- 
ceed as  previously  directed. 

The  question  of  excising  a  lacerated  portion  of  the  pancreas  is  one  of  great 
interest.  It  is  known  that  dogs  have  lived  for  some  time  after  complete  ex- 
cision of  the  pancreas.  Four-fifths  of  the  pancreas  can  be  removed  from  a 
dog  without  producing  permanent  glycosuria,  but  if  more  than  this  is  removed 
the  dog  develops  saccharine  diabetes  and  eventually  dies  of  it.  In  man,  quite 
large-sized  pieces  of  the  gland  have  been  removed  and  recovery  has  followed. 
Hence  it  is  justifiable  to  excise  a  hopelessly  damaged  portion,  bearing  in  mind 
Park's  caution  that  the  chief  danger  in  excising  a  portion  of  the  pancreas  is 
injury  to  the  splenic  artery. 

Wounds  of  the  Pancreas  During  Operations  on]  the  Stomach  and 
Spleen. — In  the  performance  of  gastrectomy,  partial  or  complete,  the  pancreas 
will  be  injured  if  the  growth  or  ulcer  is  adherent  to  it.  Such  an  accident  is  held 
by  most  operators  to  greatly  increase  mortality.  The  Mayos  report  448 
resections  of  the  stomach  for  benign  and  malignant  disease.  The  average  mor- 
tality was  10  per  cent.  In  8  per  cent,  of  these  cases  the  pancreas  was  injured, 
and  the  average  mortality  of  such  cases  was  only  1 1  per  cent.  (Wm.  J.  Mayo,  in 
"Annals  of  Surgery,"  August,  1913).  The  injuries  reported  by  the  Mayos 
were  superficial  at  the  point  the  stomach  adhered.  In  no  case  was  the  main 
duct  opened.  It  was  noticed  in  these  cases  that  local  peritonitis  had  caused  the 
formation  of  a  fibrous  capsule.  Bleeding  was  controlled  by  suture-ligatures  of 
catgut.  The  pancreatic  wound  was  not  sutured.  As  stated  on  page  1085,  if 
the  pancreas  is  wounded  during  pylorectomy,  the  closed  end  of  the  duodenum 
is  placed  in  the  pancreatic  wound  and  the  anterior  peritoneum  and  adventitious 
sheath  is  sutured  to  the  anterior  portion  of  the  duodenum.  If  an  ulcer  of  the 
posterior  wall  of  the  stomach  is  adherent  to  the  pancreas,  transgastric  excision 
removes  considerable  pancreatic  tissue.  Such  a  wound  is  not  sutured,  but  the 
gap  is  filled  by  a  mobilized  bit  of  gastrohepatic  or  gastrocolic  omentum  (Wm. 
J.  Mayo,  Ibid.),.  In  2  of  my  cases  of  splenectomy  I  damaged  the  pancreas, 
tying  off  a  bit  of  the  tail  with  the  splenic  vessels.  In  i  case  leakage  occurred 
and  death  followed  in  spite  of  anterior  drainage.  In  the  other  case  there  was 
profuse  drainage  for  several  days,  which  was  carried  off  by  a  posterior  drain. 
This  patient  recovered.     Both  were  cases  of  Banti's  disease. 

Pancreatic  Fistula. — A  fistula  may  follow  a  wound  of  the  pancreas. 
It  is  a  very  troublesome  condition,  often  refuses  most  obstinately  to  heal,  and 
the  pancreatic  secretion  causes  maceration  and  violent  irritation  of  the  adjacent 
skin.  The  usual  treatment  is  to  keep  the  way  open  for  easy  drainage.  Wohl- 
gemuth's  plan  is  promising  ("Berliner  klin.  Wochen.,"  1908,  No.  8).  He  re- 
ported 5  successful  cases.  I  have  had  i.  The  treatment  consists  in  feeding 
upon  strict  antidiabetic  diet  and  in  giving  large  doses  of  bicarbonate  of  soda 
before  and  after  meals.  By  cutting  off  carbohydrates  a  powerful  stimulus  to 
the  flow  of  pancreatic  juice  is  removed.  The  bicarbonate  of  sodium  lessens 
the  acidity  of  the  stomach  contents.     The  more  acid  the  contents  which  enter 


Pancreatitis  1057 

the  duodenum,  the  greater  the  flow  of  pancreatic  juice;  the  less  acid,  the  less 
the  flow. 

Displacement  of  the  Pancreas. — In  cases  of  splanchnoptosis  the 
pancreas  may  become  considerably  displaced,  though  this  condition  cannot 
be  recognized  without  opening  the  abdomen.  It  may  be  a  portion  of  the  pedicle 
of  a  movable  spleen.  So  far,  I  know  of  no  case  in  which  fixation  has  been 
attempted,  though,  of  course,  theoretically  it  could  be  done.  The  pancreas 
has  been  found  in  umbilical  herniae.  In  10  per  cent,  of  diaphragmatic  hernise 
the  pancreas  constitutes  part  of  the  contents.  Korte  collected  8  cases  in  which 
the  pancreas  prolapsed  through  an  abdominal  wound.  In  several  cases  in  which 
the  pancreas  prolapsed  into  an  abdominal  wound  the  protruding  part  has  been 
excised.     In  other  cases  it  has  been  restored. 

Pancreatitis  often  leads  to  the  production  of  jaundice;  always  to  very 
rapid  loss  of  weight;  occasionally  to  the  presence  of  fat  and  sugar  in  the  urine; 
sometimes  to  the  presence  of  fat  in  the  stools,  and  frequently  to  the  condition 
known  as  fat  necrosis.  Robson  and  Moynihan^  point  out  that  when  there  is 
no  diarrhea  and  the  stools  contain  undigested  muscle-fiber,  one  may  assume 
that  there  is  a  deficiency  in  pancreatic  juice.  When  there  is  a  blockage  to  the 
secretion  from  the  pancreas,  if  salol  is  given  by  mouth,  salicyluric  acid  does  not 
appear  in  the  urine.  The  test  is  made  by  putting  1 5  gr.  of  salol  into  gelatin 
capsules  hardened  with  formalin  (Sahli)  and  giving  them  with  a  roll  and  a  cup  of 
water.  If  pancreatic  ferment  is  in  the  intestine,  salicyluric  acid  appears  in  the 
urine  in  from  three-quarters  of  an  hour  to  one  hour;  if  the  ferment  is  absent  from 
the  intestine,  salicyluric  acid  is  not  found  in  the  urine  because  the  salol  is  not  split 
up  and  absorbed.  The  test  for  the  acid  is  ferric  chlorid,  which,  in  the  presence 
of  the  acid,  turns  the  urine  \nolet.  The  general  cause  of  pancreatitis  is  infection. 
Often  obstruction  of  the  common  duodenal  outlet  of  the  pancreatic  duct  and 
common  bile-duct  is  followed  by  infection  and  suppuration  of  the  pancreatic 
ducts  and  pancreatitis.  Besides  the  general  cause,  which  is  infection,  various 
exciting  causes  may  be  named,  among  which  are  gall-stones  in  the  common 
duct  and  calcifli  in  the  pancreatic  ducts,  traumatism,  cancer  of  the  stomach  or 
duodenum,  catarrh  of  the  stomach  or  duodeniun,  and  many  infectious  diseases. 
It  thus  becomes  evident  that  the  infection  may  be  by  way  of  the  blood;  but, 
undoubtedly,  in  the  vast  majority  of  cases,  the  infection  comes  by  way  of  the 
duct.  One  manner  in  which  the  disease  may  be  produced  was  suggested  by 
Halsted  and  Opie,  of  Baltimore:  A  stone  becomes  impacted  in  the  duodenal 
outlet  of  the  common  duct  and  pancreatic  duct,  the  pancreatic  duct,  where  it 
emerges  above  the  common  duct,  not  being  blocked.  The  bile  and  pancreatic 
juice  are  thus  prevented  from  entering  the  duodenum,  and  the  bile  flows  back 
into  the  pancreatic  ducts.  SweUing  of  the  papilla  could  act  in  the  same  way. 
So  coifld  a  plug  of  mucus.  It  is  thought  that  overacid  gastric  juice  may  enter 
the  duct  and  produce  pancreatitis.  Pancreatitis  is  predisposed  to  by  obesity 
and  arteriosclerosis  (Balch  and  Smith,  "Publications  of  the  Mass.  Gen.  Hosp.," 
Oct.,  191 1).  Deaver  is  of  the  opinion  that  some  infections  reach  the  pancreas 
through  the  lymphatics  ("x\nnals  of  Surgery,"  August,  1913). 

That  strange  condition  known  as  fat-necrosis  is  often  present  in  pan- 
creatitis. In  fat-necrosis  the  fat  is  decomposed  into  fatty  acids  and  glycerin. 
The  glycerin  is  absorbed,  but  the  fatty  acids  unite  with  calcium  salts  and 
remain  in  the  tissues,  forming  patches  of  yellowish- white  color  and  varying 
size.  These  patches  are  fomid  in  the  fat  beneath  the  peritoneima,  in  the 
omentum,  and  in  the  mesentery,  and  even  in  distant  parts  (for  instance, 
the  pericardium).^  It  is  an  undoubted  fact  that  fat-necrosis  is  not  uncom- 
monly found  after  diseases  and  injuries  of  the  pancreas;  and  many  assume 
that  it  is  produced  by  the  entrance  of  the  ferment  of  the  pancreas  into  the 

1  Robson  and  Moynihan,  on  "Diseases  of  the  Pancreas."  ^  Ibid. 

67 


1058  Diseases  and  Injuries  of  the  Abdomen 

fatty  tissue.  How  the  ferment  gets  there  is  a  matter  of  some  doubt.  In  the 
case  of  a  wound  of  the  pancreas  one  can  understand  the  flow  of  the  secretion 
and  its  imbibition  by  adjacent  parts;  but  in  other  cases  one  must  assume  that 
it  has  been  absorbed  by  the  lymphatics  and  distributed  to  more  distant  parts. 
When  one  reflects  that  in  some  conditions  of  the  pancreas  there  is  no  fat-necrosis, 
while  in  others  this  condition  arises,  it  is  presumable  that  the  pancreatic  condi- 
tions associated  with  it  are  such  as  to  permit  the  fat-splitting  ferment  to  diffuse 
into  neighboring  tissues. 

In  pancreatic  disease  hemorrhage  into  that  organ  is  common.  The  hemor- 
rhage is  not,  of  necessity,  fatal,  but  frequently  is  so.  Occasionally  death 
takes  place  as  the  result  of  sudden  pancreatic  hemorrhage  in  a  person  appa- 
rently in  excellent  health.  It  is  thought  by  Robson  and  Moynihan  that  during 
the  existence  of  cancer  of  the  pancreas  there  is  a  strong  tendency  to  excessive 
hemorrhage  after  any  operation.  In  i  case  of  my  own  the  patient  bled  to 
death  after  the  performance  of  cholecystostomy  for  obstructive  jaundice. 
The  oozing  of  blood  in  this  case  was  from  the  margins  of  the  gall-bladder 
and  the  adjacent  peritoneal  surfaces.  We,  therefore,  conclude  that  in  certain 
conditions  of  the  pancreas  there  is  a  tendency  to  local  hemorrhage  in  that 
organ;  and  that  there  may  also  be  a  tendency  to  the  development  of  a  general 
hemorrhagic  diathesis,  the  general  hemorrhagic  tendency  being  much  in- 
creased if  jaundice  exists.  During  acute  inflammation  of  the  pancreas 
hemorrhage  is  almost  certain  to  occur  into  that  gland;  in  other  varieties  of 
inflammation  hemorrhage  may  occur  or  may  be  absent.  In  degenerative 
lesions  of  the  pancreas  a  material  like  unfermented  pentose  is  frequently 
present  in  the  urine.  When  the  reaction  for  this  material  is  obtained  we 
speak  of  it  as  the  Cammidge  reaction,  after  its  discoverer.  (For  Cammidge's 
improved  method,  see  "Brit.  Med.  Jour.,"  May  19,  1906.)  Th-e  Cammidge 
reaction  is  not  by  any  means  conclusive  proof  of  organic  pancreatic  disease. 
It  may  be  found  in  a  great  variety  of  oth-er  conditions  (gall-stones,  cholecystitis, 
gastric  carcinoma,  burns,  etc.) .  In  most  patients  who  exhibit  it  there  is  arterio- 
sclerosis and,  of  course,  this  condition  might  effect  pancreatic  secretion  (Wat- 
son, "Brit.  Med.  Jour.,"  April  11,  1908).  My  own  views  coincide  with  those 
of  Swan  and  Gilbride  ("New  York  Med.  Jour.,"  April  23,  1910).  They  believe 
a  positive  reaction  indicates  disturbed  pancreatic  function,  but  not,  of  necessity, 
organic  disease. 

Forms  of  Pancreatitis.— This  disease  is  divided  by  Robson  and  Moyni- 
han into  the  acute,  the  subacute,  and  the  chronic  forms;  and  they  say  that 
recorded  cases  demonstrate  the  fact  that  three  distinct  classes  of  inflammation 
may  arise:  (i)  Cases  that  die  within  forty-eight  hours  of  the  beginning  of 
the  trouble.  In  this  group  hemorrhage  is  usually  found,  and  if  fat-necrosis 
is  present,  it  is  limited  in  area.  (2)  Those  that  live  for  some  weeks  after 
the  beginning  of  the  trouble.  In  these  cases  the  pancreas  may  become  necrotic 
or  suppuration  may  occur.  Fat-necrosis  is  usually  widespread.  (3)  In  the 
third  class  of  cases  long-continued  inflammation  or  repeated  attacks  produce 
sclerosis  of  the  pancreas. 

Acute  Pancreatitis. — In  this  condition  the  pancreatic  secretion  is  infected 
and  is  blocked  up  in  the  ducts.  It  digests  or  ruptures  the  walls  of  the  small 
ducts  and  diffuses  through  the  gland,  producing  necrosis  of  gland  tissue,  exu- 
dation into  gland  tissue,  necrosis  of  the  blood-vessels,  and,  in  consequence, 
hemorrhage  (Balch  and  Smith,  in  "Publication  of  Mass.  Gen.  Hosp.,"  Oct., 
19 11).  It  is  known  that  normal  pancreatic  juice  will  not  digest  living  pancreas. 
It  seems  probable  that  trypsin  is  activated  by  bacteria  and  material  from  the 
duodenum  (Polya,  in  "Pfliiger's  Archiv,"  cxxi,  Heft  9  and  10).  A  part  of  the 
gland  or  the  entire  gland  may  be  involved.  Fat-necrosis  occurs.  The  entire 
pancreas  may  become  gangrenous. 


Subacute  Pancreatitis  1059 

The  symptoms  of  this  condition  come  on  suddenly  and  consist  of  violent 
pain  in  the  epigastric  region,  but  seldom  marked  tenderness,  usually  vomiting, 
constipation,  weakness  of  the  circulation,  slow  or  moderate^  rapid  pulse,  cold 
extremities,  and  collapse,  with  a  great  fall  in  blood-pressure.  The  temper- 
ature is  normal  or  moderately  elevated.  Some  maintain  that  collapse  is 
due  to  trypsin;  others,  that  it  results  from  the  absorption  of  toxic  products 
from  the  gland.  The  pain  is  extremely  ^dolent  and  is  intensified  in  par- 
oxysms, and  there  is  rigidity  of  the  epigastrium.  In  some  cases  there  is 
appreciable  tenderness.  The  patient  vomits  the  contents  of  the  stomach  and 
then  bilious  matter.  Distention  soon  becomes  distinct  in  the  upper  portion 
of  the  abdomen.  The  patient  presents  the  appearance  of  one  suffering  from 
peritonitis.  This  condition  is  not  unusually  mistaken  for  intestinal  obstruction, 
but  in  acute  pancreatitis  the  constipation  is  not  absolute;  the  patient  passes 
gas,  and  may  even  have  a  bowel  movement  as  the  result  of  the  administration 
of  an  enema.  The  condition  is  usuaUy  fatal  within  a  few"  days,  but  in  very 
rare  instances  recovery  takes  place.  In  acute  pancreatitis  from  stone  in  the 
common  duct  there  is  no  leukocytosis  (Murphy).  In  some  cases  of  pancre- 
atitis from  other  causes  there  is  high  leukocytosis. 

The  diagnosis  cannot  be  made  "udth  certainty  and  is  merely  an  inference. 
Reginald  Fitz  told  us  that  the  existence  of  this  disease  should  be  suspected 
when  a  person  pre\dously  in  good  health,  or  who  has  complained  only  of 
occasional  attacks  of  digestive  disorder,  is  suddenly  seized  with  severe  pain 
in  the  epigastric  region,  followed  by  vomiting  and  coUapse;  and  when,  within 
twenty-four  hours  or  more,  there  appears  a  circumscribed  swelling  in  the 
epigastrium  which  is  resistant  or  tympanitic.  Visible  oil  in  the  stools,  a  Cam- 
midge  reaction,  or  sugar  in  the  urine  add  probability  to  a  diagnosis  of  pancrea- 
titis. When  an  exploratory  incision  is  made  in  the  abdomen,  if  fat-necrosis  is 
detected,  the  diagnosis  becomes  certain.  The  peritoneal  ca^dty  may  contain 
thin,  bloody  fluid. 

Treatment. — Operation  was  suggested  by  Naunyn  in  1903.  The  exploratory 
operation  is  carried  out  in  front,  and  the  earHer  it  is  made  the  better.  Robson 
operates  at  once,  even  in  shock.  It  is  quite  true  that  the  patient  might,  if  let 
alone,  pass  through  the  acute  stage,  and  that  a  local  abscess  might  then  form, 
the  treatment  of  which  woiild  be  obvious.  But  the  danger  of  waiting  is  too 
great  to  justify  delay,  and  if  suppuration  should  occur  it  might  not  remain  local, 
but  might  spread  mdely  in  the  retroperitoneal  tissues.  When  observation  after 
exploratory  incision  into  the  greater  ca\dty  of  the  peritoneum  suggests  the  ex- 
istence of  acute  pancreatitis,  the  infected  area  should  be  exposed,  preferably 
above  the  stomach,  through  the  gastrohepatic  hgament.  The  pancreas  should 
be  incised,  hemorrhage  should  be  arrested  by  ligation  or  packing,  the  gauze 
pack  emerges  above  the  lesser  curv^ature,  an  incision  should  be  made  at  the 
costovertebral  angle,  and  posterior  drainage  should  be  made  from  the  lesser 
peritoneal  cavity.  One  should  follow  the  rule  laid  down  by  Rosswell  Park, 
and  explore  in  every  case  in  which  the  disease  is  suspected  to  exist.  Of  Korte's 
16  cases  operated  on  during  the  first  week  11  recovered  ("Annals  of  Surgery," 
1911,  vol.  Iv).  Of  Balch  and  Smith's  cases  ("Publication  of  Mass.  Gen.  Hosp.," 
Oct.,  19 11),  1 1  were  operated  upon  within  three  days,  and  3  recovered.  The 
two  authors  just  quoted  state  that  the  Massachusetts  General  Hospital  records 
for  twenty-one  years  show  only  i  \dctim  who  recovered  wdthout  operation. 

Subacute  pancreatitis  comes  on  suddenl}^,  with  \dolent  pain,  vomiting,  and 
constipation,  but  there  is  far  less  exhaustion  and  weakness  than  in  the  acute 
form.  The  vomiting  is  less  marked  and  the  swelling  in  the  epigastric  region 
is  not  so  rapid.  The  s}Tnptoms  are  similar  to  those  of  the  acute  form,  but 
not  so  violent  nor  so  rapidly  progressive.  The  temperature  frequently  rises 
higher  than  in  the  acute  form,  and  it  may  become  irregular  or  chiUs  may  occur. 


io6o  Diseases  and  Injuries  of  the  Abdomen 

In  many  cases  the  patient  seems  to  grow  better  after  a  time,  the  violent  pain 
abating,  though  distinct  pain  may  remain;  but  he  does  not  gather  strength 
and  continues  to  lose  flesh,  and  there  is  usually  albumin  and  there  may  be 
sugar  in  the  urine.  In  rare  instances  fat  is  found  in  the  urine.  In  subacute 
pancreatitis  abscess  is  prone  to  form.  The  abscess  may  make  a  distinct  swell- 
ing in  front,  and  may  lead  to  the  development  of  a  subphrenic  or  of  a  periren^al 
abscess.  In  rare  cases  an  abscess  of  the  pancreas  tracks  its  way  for  a  long  dis- 
tance in  the  subperitoneal  tissue;  occasionally  it  opens  into  the  stomach  or 
bowel.  Cases  of  subacute  pancreatitis  usually  die,  but  occasionally  recover 
after  a  long  illness. 

Treatment. — Exploratory  incision.  Expose  the  pancreas,  preferably  by 
dividing  the  gastrohepatic  Hgament;  determine  its  condition;  remove  puru- 
lent matter  and  necrotic  areas;  arrest  hemorrhage  with  packing,  and  insert 
posterior  drainage  at  the  costovertebral  angle.  Leave  the  anterior  wound 
open  for  the  emergence  of  the  gauze  packing.^ 

Wm.  J.  Mayo^  reports  a  successful  operation  for  subacute  pancreatitis. 
The  patient  was  a  man  of  fifty-two  years,  who,  seven  days  before  Mayo  saw 
him,  had  developed  violent  pain  in  the  epigastrium,  collapse,  distention,  and 
other  signs  of  intestinal  obstruction;  but  some  slight  movements  had  taken 
place  from  the  bowels  as  the  result  of  medication.  On  admission,  the  abdo- 
men was  tympanitic.  An  ill-defined  mass  the  size  of  a  fist  could  be  palpated 
to  the  right  of  and  above  the  umbilicus.  The  pulse  was  120  and  very  weak; 
the  temperature  between  101°  and  102°  F.;  and  there  were  sHght  jaundice, 
restlessness,  and  hiccup.  A  diagnosis  of  gangrenous  cholecystitis  was  made. 
The  abdomen  was  opened,  and  the  omentum  was  found  to  be  studded  with 
thick,  adherent,  infiltrated  round  spots,  the  size  of  a  pea  or  larger.  There 
were  some  similar  spots  in  the  mesentery,  and  the  peritoneal  cavity  con- 
tained bloody  fluid.  On  palpation  the  pancreas  felt  like  a  pudding  in  a 
tight  sac,  and  on  aspiration  a  little  blood  was  obtained.  The  gall-bladder  was 
opened,  a  stone  was  removed,  and  some  pus  was  evacuated.  Drainage 
was  inserted  into  the  gall-bladder,  and  eighteen  days  later  there  was  an  enor- 
mous flow  of  bloody  fluid,  containing  bile  and  pancreatic  juice,  from  the 
drainage-tube.  The  patient  recovered.  This  plan  of  treatment^free  drain- 
age of  the  pancreas  by  the  performance  of  cholecystostomy — is  to  be  taken  into 
consideration. 

Chronic  Pancreatitis. — There  are  many  causes  of  chronic  pancreatitis, 
viz.,  syphilis,  alcohol,  bacteremia,  block  of  the  common  duct  (stenosis,  stone, 
etc.),  extension  of  inflammation  from  the  bile-ducts,  and  ascending  infection 
from  the  duodenum.  It  usually  results  from  disease  of  the  bile-passages 
and  is  often  associated  with  gall-stones.  In  2200  operations  performed  by  the 
Mayo  brothers  on  the  gall-bladder  and  bile-ducts,  the  pancreas  was  found 
diseased  141  times  (6.4  per  cent.). 

In  168  cases  of  pancreatic  disease  on  which  they  operated  81  per  cent,  were 
caused  by  or,  at  least,  associated  with  gall-stones.  In  operations  upon  the  com- 
mon or  hepatic  ducts  the  pancreas  was  diseased  in  1S.6  per  cent,  of  cases. 
It  was  diseased  in  4.45  per  cent,  of  cases  of  operation  upon  the  gall-bladder. 
Chronic  pancreatitis  produces  enlargement  of  the  organ,  and  the  enlarged  area 
is  hard  and  feels  like  a  malignant  growth.  This  condition  is  more  common 
than  the  acute  or  subacute  form.  Robson  and  Moynihan  have  operated  upon 
30  cases.  This  disease  is  frequently  associated  with  gall-stones  or  with  stones 
in  the  pancreatic  duct,  and  occasionally  with  ulcer  of  the  stomach  or  of  the 
duodenum.  In  some  cases  symptoms  of  the  condition  come  on  acutely.  Pain, 
nausea,  and  vomiting  occur,  and  jaundice  develops  rapidly,  as  it  does  after  the 

1  Roswell  Park,  "Annals  of  Surgery,"  December,  15,  1901. 

2  "Jour.  Am.  Med.  Assoc,"  Jan.  11,  1902. 


Pancreatic  Cysts  1061 

passage  of  a  gall-stone.  It  is  noted,  however,  that  the  pain  is  not  in  the  region 
of  the  gall-bladder,  but  is  in  the  middle  of  the  epigastrium,  and  it  passes  to 
the  left  rather  than  to  the  right.  The  tenderness,  too,  is  in  the  middle  of  the 
epigastrium  and  not  in  the  gall-bladder  region.  There  is  either  constipation 
or  diarrhea.  A  series  of  these  attacks  may  occur,  the  jaundice  growing  worse 
after  each  attack.  In  some  cases,  however,  the  condition  comes  on  gradually 
and  insidiously,  the  pain  slowly  developing,  but  no  violent  seizures  taking 
place.  There  are  rigidity  of  the  rectus  muscles,  rapid  loss  of  flesh,  anemia, 
sometimes  bronzed  skin,  usually  vomiting,  and  considerable  flatulence.  The 
gall-bladder  is  enlarged  and  commonly  palpable. 

In  some  cases  it  is  possible  to  palpate  the  inflammatory  mass.  There  may 
be  irregular  fever  and  chills  with  episodes  of  subnormal  temperature.  None 
of  the  above  indications  are  conclusive  signs  of  disturbed  pancreatic  function. 
Signs  of  disturbed  function  of  the  gland  are  of  great  importance  in  making  the 
diagnosis,  and  these  signs  are  glycosuria  and  impaired  power  of  digesting  fats 
and  proteins  (Walko,  in  "Arch.  f.  Veranungskrankheiten,"  1907,  xiii).  Fatty 
stools  containing  unsaponified  neutral  fat  are  very  significant. 

The  jaundice  in  chronic  pancreatitis  results  from  compression  of  the  duct  by 
the  h}q3erplastic  mass,  or  blocking  of  the  duct  by  a  stone.  Stenosis  of  the 
duodenum  may  occur.  In  jaundice  from  chronic  pancreatitis  capillar}-  hem- 
orrhage is  particularly  common  (Robson).  Mayo  Robson  attaches  much  im- 
portance to  the  Cammidge  reaction.  In  the  Jefferson  Hospital  we  regard  it  as 
often  of  decided  use,  but  we  do  not  as  yet  attach  as  much  importance  to  it  as 
do  some  other  clinicians.  This  reaction,  when  present,  indicates  degenerative 
disease  of  the  pancreas.  It  is  obtained  when  the  urine  contains  a  substance 
ha\dng  the  characteristics  of  unfermented  pentose. 

Treatment. — Exploratory  incision,  opening  and  draining  the  gall-bladder; 
or  the  performing  of  cholecystenterostomy. 

Pancreatic  Calculi. — When  the  pancreatic  secretion  is  blocked,  stones 
tend  to  form;  and  the  blocking  may  be  due  to  inflammation  of  the  duct  of 
Wirsung,  or  may  result  from  chronic  pancreatitis.  The  stones  may  be  single 
or  multiple. 

Symptoms. — There  is  pain  in  the  epigastric  region,  which  usually  comes 
on  in  paro.wsms  that  resemble  those  due  to  gall-stones,  though  they  are  not 
so  violent.  Pain  is  accompanied  by  vomiting,  exhaustion,  and  sometimes 
actual  coUapse,  and  may  be  followed  by  rigors.  Portions  of  stone  are  some- 
times recovered  from  the  feces,  and  sugar  is  occasionaUy  found  in  the  urine. 
Fat  has  also  been  noted  m  the  stools  in  some  cases.  Sometimes  jaundice 
develops  because  the  calculus  presses  upon  the  common  duct.  Pancreatic 
calculi  are  composed  of  lime  salts  and  can  be  skiagraphed. 

Treatment. — Pancreatic  calculi  have,  in  rare  instances,  been  removed 
by  operation;  and  this  is  the  proper  procedure  when  the  diagnosis  can  be 
made.  The  diagnosis  is,  however,  possible  only  after  exploratory  incision. 
As  a  rule,  no  operation  is  performed  untfl  a  cyst  results  or  an  abscess 
forms;  and  when  the  cyst  or  abscess  is  opened  fragments  of  stone  may 
be  found  in  the  fluid,  and  stones  may  subsequently  come  away  in  the  result- 
ing fistula.  My  colleague,  Prof.  Nassau,  removed  successfully  a  pancreatic 
calculus. 

Pancreatic  Cysts. — Many  forms  of  cyst  may  develop  in  the  pancreas; 
the  foUowing  are  set  forth  by  Robson  and  Mo3^nihan:  (i)  Retention  cysts; 
(2)  proliferation  cysts,  including  cystic  adenoma  and  cystic  epitheHoma;  (3) 
hydatid  cysts;  (4)'  congenital  cysts;  (5)  hemorrhagic  cysts;  (6)  pseudocysts. 
What  we  speak  of  as  pseudocysts  have  already  been  considered  in  discuss- 
ing effusions  into  the  lesser  peritoneal  cavity.  They  result  from  lacerations 
of  the  pancreas  (see  page  1055).     Retention  cysts  are  due  to  blocking  of  the 


io62  Diseases  and  Injuries  of  the  Abdomen 

pancreatic  duct.  Congenital  cystic  disease  is  extremely  rare.  Hemorrhagic 
cysts  result  from  hemorrhage  into  the  substance  of  the  pancreas  itself. 

Symptom.s. — -Cysts  are  somewhat  more  common  in  men  than  in  women. 
A  cyst  of  the  pancreas  proper  is  more  often  met  with  in  the  head  of  the  organ 
than  in  its  body  or  tail.  The  cyst  may  be  single  or  multiple.  In  its  growth 
it  either  destroys  the  substance  of  the  pancreas  or  it  grows  away  from  the 
pancreas  and  damages  it  but  Httle.  In  some  cases  the  cysts  grow  to  a  very 
large  size;  and  Robson  and  Moynihan  refer  to  a  case  in  which  the  cyst  at- 
tained the  size  of  a  man's  head,  and  to  another  in  which  it  was  the  size  of 
a  full-term  pregnancy.  A  pancreatic  cyst  is  smooth,  round,  elastic,  and 
rather  tense  (Robson  and  Moynihan).  The  contained  fluid  varies  greatly. 
As  a  rule,  it  is  brownish- red  in  color;  in  i  case  upon  which  I  operated  it  was 
clear  yellow;  in  some  cases  it  is  milky,  and  in  others  it  is  nearly  black.  The 
fluid  is  always  albuminous.  Urea  may  be  present,  and  in  many  cases  pan- 
creatic ferments  are  found.  In  most  cases  the  cyst  adheres  so  closely  to 
the  surrounding  structures  as  to  render  extirpation  practically  impossible. 
A  pancreatic  cyst  of  considerable  size  causes  epigastric  discomfort,  pain 
during  digestion,  and  frequently  vomiting.  In  some  cases  the  pain  is  triv- 
ial, in  others  it  is  very  violent.  As  a  general  rule,  the  patient  is  consti- 
pated, but  sometimes  diarrhea  occurs,  and  the  movements  may  even  con- 
tain blood.  If  the  tumor  presses  upon  the  common  bile-duct,  jaundice  will 
develop.  The  patient  loses  flesh  markedly  and  with  considerable  rapidity, 
and  he  becomes  very  weak.  In  rare  instances  fat  is  present  in  the  stools, 
and  in  other  unusual  cases  sugar  is  found  in  the  urine.  A  test  should  always 
be  made  with  salol,  to  see  whether  pancreatic  ferment  is  present  in  the  intes- 
tine (see  page  1057).  In  the  beginning  the  pancreatic  cyst  is  behind  the 
stomach;  but  it  enlarges  and,  as  a  rule,  pushes  the  stomach  upward  and  to  the 
right  side,  and  the  transverse  colon  downward.  The  cyst  approaches  the  sur- 
face of  the  abdomen  below  the  greater  curvature  of  the  stomach  (Robson  and 
Moynihan).  The  same  authors  tell  us  that  in  rare  cases  the  cyst  appears 
at  the  upper  border  of  the  stomach,  and  that  in  others  it  inserts  itself  between 
the  layers  of  the  transverse  mesocolon.  In  a  case  upon  which  I  operated 
it  had  worked  its  way  through  the  subperitoneal  tissue  into  the  right  loin, 
and  was  looked  upon  by  Professor  Montgomery  and  myself  as  a  hydro- 
nephrosis. As  a  rule,  the  pancreatic  cyst  is  immovable,  but  in  rare  instances 
it  is  movable.  When  a  hand  is  placed  in  the  loin  and  another  on  the  abdo- 
men, ballottement  may  be  appreciated.  If  the  distended  stomach  or  colon 
overlies  the  timior  there  will  be  a  tympanitic  percussion-note,  but  when 
the  timior  reaches  the  abdominal  wall  there  will  be  a  dull  percussion-note. 
On  inquiring  into  the  history  of  these  cases  it  will  be  found  frequently  that 
there  has  been  a  severe  injury  to  the  upper  abdomen. 

Treatment. — Exploratory  incision  makes  the  condition  clear.  In  the 
majority  of  cases  the  cyst  is  incised,  emptied,  and  stitched  to  the  wall  of 
the  abdomen.  This  operation  may  be  done  in  two  stages — first,  exposing 
the  cyst  and  fixing  it  to  the  abdominal  wall;  second,  when  adhesions  have 
formed,  opening  it.  As  a  rule,  however,  it  is  performed  in  one  stage,  the 
abdominal  cavity  being  carefully  protected  by  gauze.  Some  authors  advo- 
cate exposing  the  cyst,  opening  and  evacuating  it  through  the  abdominal 
wound,  and  draining  through  the  loin.  Complete  extirpation  is  usually  impos- 
sible because  of  the  adherence  of  the  cyst.  If  the  cyst  is  movable,  extirpation 
may  be  carried  out,  but  the  safest  operation  consists  of  incision  and  drainage. 

Tumors  and  Other  Growths  of  the  Pancreas. — The  pancreas  may 
be  affected  with  sarcoma,  carcinoma,  adenoma,  tuberculous  disease,  or  syphilis. 
Primary  tumors  are  very  rare.  Billroth  in  1884  removed  an  adenocarci- 
noma.    Finney  reported  i  case  and  collected  16  from  literature  which  came  to 


Rupture  of  the  Spleen  1063 

operation  ("Annals  of  Surgery,"  June,  1910).  He  says  the  diagnosis  can 
only  be  made  by  exclusion  and  that  in  25  per  cent,  of  cases  the  mass  is  not  fixed, 
but  is  movable.  In  Finney's  series  of  cases  there  were  9  recoveries  and  8 
deaths.  Wm.  J.  ]\Iayo  reports  the  successful  removal  of  a  cyst  with  sclerosed 
pancreatic  tissue  (Ibid.,  August,  1913). 

Treatment. — Attempts  have  been  made  to  remove  tumors  of  the  pan- 
creas. After  an  exploratory  incision  has  determined  the  condition  the 
pancreas  is  exposed  at  the  point  at  which  the  tumor  projects.  This  is  usually 
done  by  opening  through  the  gastrocolic  omentum.  If  the  tumor  is  in  the  tail 
of  the  pancreas,  however,  the  exposure  may  be  effected  in  the  flank.  When 
the  tumor  has  been  exposed  an  attempt  may  be  made  to  enucleate  or  resect  it. 
Coffey  ("Annals  of  Surgery,"  Jan.,  191 1)  shows  that  ligation  of  the  duct  does 
not  occlude  it  permanently.  Tmnors  of  the  splenic  portion  of  the  pancreas 
have  been  removed.  Total  pancreatectomy  or  complete  resection  of  the  head 
of  the  gland  should  not  be  attempted. 

In  a  large  timior  of  the  head  of  the  pancreas  palliate  the  condition  by 
cholecystenterostomy.  Villar  reports  13  cases  of  partial  resection  of  the  pan- 
creas for  tumors,  with  5  recoveries  from  operation  (French  Surgical  Congress 
of  1905).     Finney's  paper  deals  "with  17  cases  (see  above). 

Injuries  and  Diseases  of  the  Spleen 

Wounds  of  the  Spleen. — A  considerable  wound  of  the  spleen  causes 
great  hemorrhage  and,  if  surgical  aid  is  not  soon  at  hand,  will  almost  inevit- 
ably produce  death.  It  is  caused  by  a  bullet  or  a  stab  and,  as  a  rule,  other 
^dscera  are  also  damaged.     Immediate  operation  is  indicated. 

Rupture  of  the  spleen  (Fig.  621)  is  unusual  if  the  organ  be  healthy,  but 
does  occasionally  occur  from  crushes.  It  is  rarely  found  unassociated  with  other 
injuries.  The  spleen  may  be  dislocated  as  well  as  ruptured.  An  enlarged  spleen 
is  particularly  Hable  to  rupture  not  only  from  a  crush,  but  from  a  kick,  a  blow, 
or  a  faU.  Rupture  of  the  spleen  produces  pain  and  rigidity  in  the  left  hypo- 
chondriac region  and  the  signs  and  symptoms  of  intra-abdominal  hemorrhage. 
There  is  tenderness  over  the  spleen,  pain  over  the  heart,  and  great  shortness 
of  breath.  The  bleeding  is  profuse,  but  sometimes  slow.  The  splenic  blood 
contams  numerous  leukocytes  and  clots  rapidly,  hence  the  bleeding  may  be 
arrested  for  a  time,  and  if  it  should  be  the  patient  will  not  bleed  to  death  rapidly 
and  reaction  will  generally  occur  (Ballance).  The  blood  in  some  cases  clots  so 
rapidly  that  it  gathers  in  the  left  loin,  and  is  not  commonly  diffused  throughout 
the  abdomen.  It  gives  rise  to  an  increasing  area  of  dulness  on  percussion  in  the 
left  flank,  which,  Ballance  points  out,  seldom  shifts  when  the  position  of  the 
patient  is  shifted,  as  it  does  in  bleeding  from  other  intra-abdominal  structures. 
In  some  cases,  however,  the  blood  remains  fluid  and  spreads  throughout 
the  belly,  and  then  there  is  rising  dulness  in  each  flank.  The  cases  reported 
by  Le  Dentu  and  Mouchet  shows  that  the  blood  may  remain  fluid  ("Bull, 
de  I'Academie  de  Med.,"  June  16,  1903).  In  some  cases  the  signs  of  hem- 
orrhage are  late  and  they  may  even  be  deferred  until  the  fourth  day  (Eisen- 
drath,  "Annals  of  Surgery,"  Dec,  1902).  In  some  cases  there  is  violent  pain 
in  the  left  shoulder  {Kehr's  sign).  Exploratory  incision  will  be  required  to 
recognize  the  condition  positively.  In  Elder's  table  there  are  52  uncompH- 
cated  cases,  not  a  case  was  operated  upon  (operation  was  not  the  rule  until 
1890),  and  84.6  per  cent.  died.  Eisendrath^  has  collected  50  cases  operated 
upon:  56  per  cent,  recovered  and  44  per  cent.  died.  Fevrier  has  coUected  56 
ruptures  of  the  spleen.  In  46  cases  operation  was  performed  and  the  mortality 
was  50  per  cent.     E.  Berger  ("Archiv.  fiir  klinische  Chirurgie,"  Bd.  28,  Heft  3) 

1  "Jour.  Am.  Med.  Assoc,"  Oct.  25,  1902.  ^  "Rev.  de  Chir.,"  Nov.,  1901. 


1064 


Diseases  and  Injuries  of  the  Abdomen 


collected  168  fatal  cases  of  rupture  of  the  spleen:  145  died  during  the  first  day 
and  every  one  of  them  died  from  hemorrhage.  After  the  first  day  23  died. 
In  90  per  cent,  of  the  entire  series  hemorrhage  caused  death;  in  10  per  cent, 
infection  was  responsible  for  death.  Vedova  collected  194  cases  of  splenectomy 
for  traumatic  rupture,  with  65  deaths,  a  mortality  of  33.5  per  cent.  ("Practical 
Medicine  Series,"  vol.  ii,  1913).  Hemorrhage  is  the  great  danger  in  ruptured 
spleen — hemorrhage  from  the  parenchyma  rather  than  from  the  great  vessels. 
The  parenchyma  is  friable  and  contains  multitudes  of  capillaries  and  veins, 
there  is  no  muscular  tissue,  divided  vessels  do  not  tend  to  contract,  and  the 
capsule  is  thin  (the  elder  Senn,  in  "Jour.  Am.  Med.  Assoc,"  Nov.  21,  1903). 

Treatment  of  Wounds  and  Rupture. 
— The  treatment  is  evident  from  the 
previous  remarks.  It  is  as  follows:  Open 
the  abdomen  immediately,  the  patient 
being  surrounded  with  hot  bottles  and 
hot  salt  solution  flowing  into  a  vein. 
Explore  the  spleen  and  other  viscera.  If 
the  spleen  is  damaged,  we  may  do 
splenectomy  (total  or  partial),  may  use 
the  suture,  the  cautery,  or  the  tampon, 
and  any  other  visceral  injuries  are,  of 
course,  attended  to. 

The  usual  operation  has  been  total 
splenectomy.  In  partial  splenectomy 
only  the  injured  part  is  excised  and  the 
wound  margins  are  sutured. 

The  arrest  of  hemorrhage  by  suture 
is  known  as  splenorrhaphy.  Lamarchia, 
in  1896,  was  the  first  to  perform  this 
operation.  The  tear  or  wound  is  sutured 
with  catgut  and  the  suture  line  is  covered 
with  omentum.  Berger  collected  14  cases 
of  suturing,  with  2  deaths,  but  these  were 
injuries  of  less  severity  than  those  requir- 
ing splenectomy.  In  some  cases  the  tam- 
pon can  be  used.  Berger  collected  10 
cases,  with  i  death.  Another  method  is  to 
crush  the  splenic  structure  slowly  with  broad  forcipressure  forceps  and  suture 
the  crushed  margins  with  catgut.  Senn  followed  this  plan.  George  Ben 
Johnston  (paper  read  before  Johns  Hopkins  Med.  Soc,  March  2,  1908)  has 
collected  150  cases  of  splenectomy  for  wounds  or  ruptures,  with  99  recoveries 
and  51  deaths,  a  mortality  of  34  per  cent. 

Abscess  of  the  spleen  is  a  rare  condition  which  is  usually  metastatic 
in  origin.  It  may  follow  typhoid,  may  develop  during  pyemia,  or  may  result 
from  injury.  Chronic  suppuration  may  be  due  to  tuberculosis  or  actinomy- 
cosis. Pain  is  felt,  and  enlargement  is  noted  in  the  splenic  region,  and  the 
symptoms  of  pyemia  exist.  The  abscess  may  become  adherent  to  the  belly  wall, 
may  become  encapsulated,  or  may  rupture  into  a  viscus  or  the  peritoneal  cavity. 
Fluctuation  can  seldom  be  obtained.  What  is  known  as  a  tropical  abscess 
(Fontoynant  and  Jourdrau,  in  "Archiv.  Prov.  de  Chir.,"  No.  11,  1902)  may 
develop  during  a  malarial  attack  as  a  result  of  severe  exertion.  There  are  severe 
pain  in  the  left  hypochondrium,  dyspnea,  and  dry  tongue.  There  may  or  may 
not  be  fever.     The  pus  may  be  sterile. 

The  treatment  of  abscess  of  the  spleen  consists  in  incising  the  abdomen 
at  the  outer  edge  of  the  left  rectus  muscle,  suturing  the  spleen  to  the  abdominal 


Fig 


621. — Fauntleroy's    case    of     ruptured 
spleen.     External  surface. 


Treatment  of  Splenoptosis,  or  Wandering  Spleen  1065 

wall,  opening  the  abscess,  and  providing  for  drainage  (Tedenat^.  If  the 
abscess  is  adherent  to  the  abdominal  wall,  incise  it  directly.  Splenectomy  has 
been  performed  for  abscess.  In  9  recorded  cases  of  splenectomy  for  abscess 
there  was  i  death  (George  Ben  Johnston,  paper  read  before  Johns  Hopkins 
Med.  Soc,  ]Mar.  2,  1908). 

Enlargements  and  Tumors  of  the  Spleen. — (See  RoyaleH.  Fowler,  in 
"Long  Island  Med.  Jour.,"  July,  191 1.)  The  spleen  undergoes  hypertrophy 
in  the  course  of  infectious  disease,  from  amyloid  disease,  from  malaria,  from 
splenic  anemia,  from  tuberculosis,  from  leukemia,  and  from  Hodgkin's  disease. 
Secondary  cancer  is  seen  after  cancer  of  the  stomach.  Genuine  primary 
tumors  are  extremely  rare.  Fibroma,  enchondroma,  hemangioma,  lymphan- 
gioma, angioma,  and  sarcoma  occasionally  develop.  Jepson  and  Albert  re- 
ported a  case  of  primary  sarcoma  of  the  spleen  and  collected  31  others  from 
Hterature  ("Annals  of  Surger}^,"  July,  1904).  Primar}^  carcinoma  can  only 
arise  from  fetal  inclusion.  It  is  usually  medullar}^  and  is  sometimes  melanotic. 
Secondar}'  carcinoma  and  secondary  sarcoma  are  more  common.  Echinoccocus 
cysts,  dermoid  cysts,  lymph  cysts,  serous  cysts,  and  blood  cysts  occasionally 
develop.  The  spleen  alone  may  suffer  from  hydatid  disease.  The  Hver  is  apt 
to  be  also  involved.  "There  is  but  a  single  recorded  case  of  a  dermoid  cyst. 
It  was  reported  by  Andral  in  1830"  (Royale  Hamilton  Fowler,  in  "Surg.,, 
Gynec,  and  Obstet.,"  August,  1910). 

Xon-parasitic  cysts  may  be  miilocular  or  multilocular. 

A  blood  cyst  is  usually  preceded  by  injur}^  or  an  infectious  disease.  A 
serous  cyst  may  result  from  a  hemorrhagic  cyst,  and  a  blood  cyst  may  be  due 
to  hemorrhage  into  a  serous  cyst  (Fowler,  Ibid.).  There  are  on  record  12  cases 
of  splenectomy  for  sarcoma:  9  recovered  and  3  died  (George  Ben  Johnston, 
Loc.  cit.). 

Treatment. — The  condition  may  become  clear  only  after  exploratory 
laparotomy.  For  some  tumors  splenectomy  is  indicated.  A  hydatid  cyst  is 
treated  as  is  a  hydatid  cyst  of  the  liver  (see  page  1034) .  A  blood  cyst  is  sutured 
to  the  incision  in  the  abdominal  wall  and  is  drained. 

Splenoptosis,  or  Wandering  Spleen. — The  spleen  may  wander  into 
any  part  of  the  general  peritoneal  ca^-ity.  This  condition  is  seldom  met  with 
except  in  women.  It  is  most  common  in  women  who  have  borne  children. 
A  wandering  spleen  may  undergo  atrophy,  engorgement,  or  axial  rotation 
(Sir  J.  Bland-Sutton).  The  spleen  may  be  healthy  or  enlarged  from  malaria 
or  leukemia.  As  a  matter  of  fact,  it  is  usually  diseased.  The  organ  when 
displaced  drags  upon  the  stomach,  producing  dilated  stomach;  it  may  interfere 
with  the  bile-duct,  causing  jaundice;  it  may  cause  intestinal  obstruction  by 
forming  adhesions,  or  may  cause  uterine  retroflexion  or  prolapse  by  passing- 
into  the  pehds. 

Sir  J.  Bland-Sutton-  says  this  condition  may  endanger  life,  as  it  may  lead 
to  rupture  of  the  stomach,  intestinal  obstruction,  splenic  abscess,  or  splenic 
rupture.  A  wandering  spleen  can  be  identified  by  the  fact  that  it  has  a  notch 
upon  its  edge,  and  can  be  pushed  about  the  abdomen.  When  the  spleen 
wanders  it  may  be  missed  from  its  normal  situation.  Always  examine  the 
blood  in  order  to  determine  if  leukemia  or  malaria  exist. 

Treatment. — Greiffenhagen  advocates  suturing  the  organ  in  place  (spleno- 
pexy). Most  surgeons  prefer  to  perform  splenectomy.  In  a  case  without 
leukemia  the  operation  is  very  successful.  Splenectomy  for  wandering  spleen 
is  rarely  followed  by  serious  blood  changes  or  other  trouble.  The  reason  is 
that  a  wandering  spleen  is  usually  a  diseased  organ,  ha^dng  imdergone  hA^per- 
trophy  or  fibroid  change,  and  other  structures  have  taken  on  splenic  function. 

1  "Rev.  de  Gynec.  et  de  Chir.  Abd.,"  July,  August,  1901. 

2  "Brit.  Med.  Jour.,"  Jan.  16,  1897. 


io66  Diseases  and  Injuries  of  the  Abdomen 

Splenectomy  should  not  be  undertaken  if  leukemia  exists.  In  such  a  case  sur- 
geons usually  apply  a  support  and  employ  medical  treatment  for  the  existing 
disease,  but  some  endeavor  to  suture  the  organ  in  place.  If  the  wandering  spleen 
were  enlarged  by  malaria,  I  would  perform  splenectomy.  If  the  spleen  were 
healthy  I  would  surround  it  with  gauze  exactly  as  is  done  with  the  kidney  in 
a  case  of  movable  kidney.  If  the  spleen  were  enlarged  by  leukemia  I  would 
not  operate  at  all. 

Operations  Upon  the  Abdomen 

Abdominal  Section  {Celiotomy;  Laparotomy). — There  are  many  differ- 
ent methods  of  opening  the  abdomen.  The  plan  selected  depends  upon 
the  nature  and  the  situation  of  the  disease,  and  upon  the  inclinations  and 
the  custom  of  the  operator.  The  abdomen  may  be  opened  to  attack  a  recog- 
nized seat  of  disease  or  injury  or  to  determine  what  the  disease  or  injury  is  and 
where  it  is  situated.  Abdominal  section  performed  for  the  latter  purpose  is 
spoken  of  as  exploratory  section  or  exploratory  incision. 

An  incision  should  not  be  unnecessarily  lengthy,  but  it  should  be  long 
enough  to  permit  of  thorough  exploration  and  rapid  and  safe  work.  A  very 
lengthy  incision  favors  visceral  prolapse  and  renders  the  patient  liable  to  hernia. 
Again,  a  lengthy  incision  requires  longer  to  suture  than  a  short  one,  and  so  opera- 
tion is  prolonged.  James  E.  Moore  protests  against  too  small  incisions,  which 
are  often  made  as  a  matter  of  pride  ("Jour.  Am.  Med.  Assoc,"  Sept.  i6,  1911). 

Of  recent  years  exploratory  operations  have  become  extremely  common, 
and  many  abdominal  conditions  would  be  unrecognized  without  such  explora- 
tion, or  would  be  recognized  at  so  late  a  period  as  to  be  beyond  the  reach 
of  surgery  by  the  time  the  diagnosis  had  been  made.  This  is  notably  true 
of  the  surgical  diseases  of  the  stomach.  The  wise  surgeon  will  not  be  too 
radical  in  employing  exploratory  operations.  The  fact  that  he  can  explore 
with  such  comparative  impunity  does  not  release  him  from  the  obHgation 
to  endeavor  by  every  proper  method  to  make  a  diagnosis  before  resorting 
to  operation.  I  fancy  that  of  recent  years  the  beHef  that  it  is  almost 
waste  of  time  to  make  prolonged  efforts  to  diagnosticate  many  intra-abdom- 
inal troubles  because  the  solution  is  so  much  easier  by  section,  has  become 
so  common  as  to  have  led  young  and  unskilled  operators  to  perform  section 
in  cases  in  which  the  diagnosis  might  have  been  made  without  this  procedure. 

Before  opening  the  abdominal  cavity  for  exploratory  purposes  or  to  gain 
access  to  some  area  of  abdominal  or  pelvic  disease  the  patient  is  carefully 
prepared  as  for  any  other  operation.  In  an  appendicitis  case  the  patient 
is  moved  with  the  utmost  care  and  is  prepared  for  operation  most  gently, 
because  of  the  possible  danger  of  rupturing  an  abscess.  In  an  emergency 
case  no  prolonged  or  compHcated  method  of  cleansing  can  be  employed. 
The  abdomen  and  loins  are  scrubbed  carefully  with  soap  and  water,  special 
attention  being  given  to  the  umbilicus;  the  pubic  region  is  shaved,  the  soap- 
suds are  washed  away  with  sterile  water,  the  surface  is  gently  scrubbed  with 
alcohol  and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  1000),  and 
is  covered  with  gauze  wet  with  the  sublimate  solution.  In  emergencies  the 
iodin  method  can  be  used  after  dry  shaving  (see  page  68).  As  previously 
stated  (see  page  67),  we  no  longer  regard  it  as  necessary  to  "prepare"  the 
abdomen  the  day  before.  The  patient  can  be  prepared  antiseptically  the 
morning  of  the  operation,  or  can  be  shaved  just  before  etherization,  and  be 
cleaned  when  under  ether.  The  instrimients  reqiiired  depend  upon  the  natiu^e 
of  the  case.  Have  at  hand  an  electric  Hght  and  appUances  for  throwing  salt 
solution  into  a  vein.  Always  have  the  instruments,  sponges,  and  pads  counted 
twice  by  two  people,  write  down  the  number,  and  have  two  people  coiuit  them 
twice  after  operation.  This  rule  is  adopted  so  that  no  instrument,  sponge,  or  pad 


Operation  for  Abdominal  Section  1067 

will  be  left  in  the  abdomen.  Some  surgeons  do  not  use  abdominal  pads  and 
sponges  when  dry,  believing  that  dry  gauze  injures  the  peritoneum  and  favors 
the  subsequent  development  of  adhesions  (Sanger).  Believers  in  this  hold 
that  pads  and  sponges  should  be  wrung  out  in  hot  normal  salt  solution  before 
being  used.  I  find  moist  pads  and  sponges  satisfactory,  but  moist  packs  can- 
not be  satisfactorily  adjusted.  If  dry  packs  are  used,  dry  pads  and  sponges 
may  as  well  be. 

Operation. — An  anesthetic  is  given.  In  some  cases  the  patient  is  placed 
recumbent;  in  others,  is  put  in  the  position  of  Trendelenburg  (Fig.  622).  In 
the  Trendelenburg  position  the  pelvis  is  elevated,  the  intestines  fall  toward  the 
epigastrium,  are  removed  from  the  necessity  of  being  handled  and  from  the 
danger  of  being  bruised,  the  pelvis  is  thoroughly  exposed,  and  pelvic  work  be- 
comes easier  and  safer.  This  position  should  not  be  used  if  there  is  myocardial 
disease,  as  the  increased  pressure  in  and  flow  of  blood  from  the  inferior  cava  may 
cause  fatal  acute  dilatation  of  the  heart  (Kraske,  of  Freiburg,  in  ''Proceedings 
of  German  Surg.  Congress,"  1903).  The  position  is  of  little  use  in  very  fat 
people  (Trendelenburg),  and  in  such  subjects  may  cause  intestinal  obstruction 
(Kraske) .  When  this  position  is  employed,  the  table  should  be  lowered  as  soon 
as  possible,  because  gastric  hemorrhage  may  occur  (von  Eiselsberg).  The 
normal  position  should  not  be  suddenly  assumed,  as  this  may  cause  intestinal 
■obstruction,  the  omentum  being  mixed  with  coils  of  intestine,  pulling  the  colon 
down  (Pasteau,  in  "Bulletins  and  Mem.  de  la  Soc.  Anat.  de  Paris,"  July,  1905). 
The  position  should  not  be  used  in  a  pelvic  abscess  (K5nig),  as  it  may 
lead  to  a  flow  of  pus  from  the  pelvis  into  the  far  more  dangerous  regions  above. 

Volvulus  or  kinking  of  the  ileum  and  of  the  large  intestine  have  followed 
the   use   of    the   position.     If    the   Trendelen- 
iDurg  position  was  employed,  before  closing  the 
l)elly  return  the  omentum  to  its  proper  posi- 
tion   and    spread    it    out     (Lauenstein) .     In 
€very  abdominal  operation  the  patient  is  to  be 
carefiflly  protected  from  cold,  the  extremities 
and  the  chest  are  covered  with  blankets,  and      f".v'„Tir^ 
sterflized   sheets   are   placed   weU   around   the     pj^  ^^^^xhe  Trendelenburg  posi- 
fleld  of  operation.     The  skm  is  sterflized  anew  tion. 

immediately   before   operating.     The     surgeon 

steadies  the  skin  of  the  belly  with  the  fingers  of  his  left  hand,  and,  holding  the 
knife  free  in  the  right  hand,  makes  an  incision.  For  purposes  of  exploration  the 
incision  is  made  about  2  inches  in  length,  and  it  is  lengthened  if  it  is  found 
necessary.  The  abdomen  may  be  opened  in  the  median  line  above  or  below 
the  umbflicus.  This  incision  is  advantageous  for  operations  on  the  pelvis,  for 
general  exploration,  and  for  certain  procedures  upon  the  stomach,  the  in- 
testines, and  the  left  lobe  of  the  liver.  The  closure  of  such  an  incision,  how- 
ever, lacks  strength,  as  compared  with  the  closure  of  an  incision  where  strong 
muscles  wfll  overlie  the  scar  through  the  peritoneum  and  the  transversalis 
fascia.  Incision  through  the  semflunar  line  is  practised  by  a  number  of  oper- 
ators. A  favorite  incision  is  through  the  rectus  muscle.  The  fibers  of  this 
muscle  are  separated,  the  structures  beneath  it  are  divided,  and,  after  the  com- 
pletion of  the  operation,  the  deeper  structures  are  sutured  and  the  parts  of  the 
separated  muscle  are  allowed  to  fall  together.  The  scar  resulting  from  such 
an  incision  is  well  supported  and  solid,  hence  the  likelihood  of  hernia  develop- 
ing is  diminished.  A  favorite  method  with  some  is  to  open  the  sheath  of  the 
rectus  muscle,  retract  the  entire  muscle  aside,  incise  the  posterior  portion 
of  the  sheath  and  the  structures  back  of  it,  and,  when  the  operation  has  been 
completed,  allow  the  entire  muscle  to  come  back  into  place,  thus  strengthen- 
ing the  deep-seated  scar.     When  the  abdominal  trouble  is  in  a  region  that 


io68  Diseases  and  Injuries  of  the  Abdomen 

admits  of  it,  I  almost  invariably  go  through  the  rectus  muscle  or  retract  the 
entire  muscle.  Besides  these  methods,  there  are  special  incisions,  suitable 
for  particular  cases:  An  incision  along  the  costal  margin,  for  reaching  the 
gall-bladder;  an  incision  shaped  like  the  italic  letter  /,  for  the  same  pur- 
pose; special  incisions  for  certain  operations  upon  the  stomach,  for  abdomi- 
nal nephrectomy,  etc.  Some  operators  have  even  used  a  transverse  incision 
in  certain  pelvic  operations.  (A  full  discussion  of  abdominal  incisions  will  be 
found  in  an  article  by  R.  E.  Farr,  "The  Journal  Lancet,"  Nov.  i,  191 2). 

In  an  operation  through  the  median  line  the  first  cut  goes  to  the  aponeu- 
rosis of  the  external  oblique  muscle.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  between  the  recti 
muscles.  Above  the  umbilicus  the  linea  alba  is  very  distinct  and  the  sur- 
geon often  cuts  through  it.  Divide  the  transversalis  fascia,  beneath  which 
is  a  little  fat,  and  expose  the  peritoneum.  The  latter  structure  is  recognized 
by  its  glistening  appearance,  by  the  ease  with  which  it  can  be  pinched  up 
between  the  finger  and  thumb,  and  by  the  readiness  with  which  its  opposed 
surfaces  may  be  made  to  glide  over  each  other.  On  identifying  the  perito- 
neimi,  catch  it  at  each  side  of  the  incision  with  forceps,  raise  a  fold,  nick  it 
with  a  knife,  and  open  the  layer  by  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is  to  anchor  it  to  the 
belly  wall  with  a  stitch  on  each  side  of  the  incision.  Through  the  wound 
thus  made  the  abdomen  and  its  contents  are  explored,  the  trouble  located, 
and  determination  made  as  to  whether  or  not  further  operation  is  advisable, 
and,  if  it  is  advisable,  what  form  it  shall  take.  It  may  be  necessary  to  enlarge 
the  wound.  This  is  done  by  placing  the  index  and  middle  fingers  of  the 
left  hand  in  the  belly,  with  their  pulps  against  the  peritoneum,  in  the  line 
where  the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and  as  guards 
to  intraperitoneal  structures.  The  scissors  are  introduced  and  the  wound  is 
enlarged  upward  or  downward,  going  around  the  umbilicus  if  necessary.  As 
soon  as  the  incision  is  complete  for  work  in  the  lower  abdomen  or  pelvis  it  is 
a  good  plan  to  push  a  large  pad  into  Douglas's  pouch  and  leave  it  there  until 
the  operation  is  finished,  when  it  must  be  removed.  Slender  adhesions  are 
stripped  off  with  the  finger  or  are  pushed  off  with  gauze ;  firm  adhesions  are 
tied  in  two  places  and  cut  between  the  ligatures. 

The  toilet  of  the  peritoneum  is  important  after  the  operation  is  completed. 
Following  a  clean  laparotomy,  when  but  little  blood  has  flowed  into  the  cavity, 
flushing  is  not  required;  if  much  blood  has  flowed  or  if  septic  matter  has  passed 
into  the  peritoneal  cavity,  after  removing  the  pad  from  Douglas's  pouch  flush 
the  belly  thoroughly  with  hot  normal  salt  solution.  In  a  clean  case  empty  out 
most  of  the  fluid,  but  let  a  pint  or  more  remain  in  the  abdomen.  In  flushing  the 
abdomen  bear  in  mind  Monks's  observations  as  to  the  mesentery.  It  is  a  sort 
of  shelf.  If  we  follow  down  the  left  side  of  it  with  the  finger  the  finger  must 
enter  the  left  iliac  fossa;  if  we  follow  down  the  right  side  of  it  the  finger  must 
enter  the  right  iliac  fossa.  Hence  in  order  to  flush  the  right  cavity  carry  the 
nozzle  down  the  right  side  of  the  mesentery  to  its  root,  and  in  order  to  flush 
the  left  fossa  carry  it  down  the  left  side  of  the  mesentery  to  the  root  (Monks, 
"Annals  of  Surgery,"  Oct.,  1903).  The  retention  of  the  saline  fluid  in  the 
belly  minimizes  shock.  It  is  absorbed  with  great  rapidity  after  the  operation 
if  the  patient  is  placed  with  his  head  lower  than  his  feet,  because  in  this  posi- 
tion the  saline  fluid  gravitates  to  the  diaphragmatic  region,  where  absorption 
is  very  active;  in  fact,  in  one  hour  the  peritoneal  cavity  can  absorb  from  3  to  8 
per  cent,  of  the  body  weight.  If  there  is  widespread  infection  with  stomach 
contents  or  feces,  eviscerate,  wipe  out  the  peritoneum  with  pads  soaked  in  hot 
normal  salt  solution,  and  wipe  the  intestines  carefully,  slowly  returning  them 
as  they  are  wiped.     Extravasated  septic  matter  is  apt  to  coUect  in  the  peritoneal 


Operation  in  Abdominal  Section  1069 

fossae  and  between  the  li\-er  and  diaphragm,  and  these  regions  must  be  care- 
fully wiped  and  irrigated.  In  cases  of  septic  and  piurulent  peritonitis,  flushing, 
e\'isceration,  and  wiping  with  gauze  are  not  adWsable  (see  page  1024 ) .  In  some 
cases  it  is  desirable  to  drain  through  a  lumbar  incision.  Rutherford  !Morison 
has  pointed  out  that  a  lumbar  opening  into  the  right  kidney  pouch  will  drain  a 
fossa  which  holds  over. a  pint  of  fluid,  and  which,  when  the  patient  is  recumbent, 
is  the  most  dependent  portion  of  the  peritoneal  ca\"ity.  In  some  cases  a  drain- 
age-opening is  made  through  the  linea  alba,  through  one  side  or  on  each  side 
of  the  belly,  or  above  the  pubis  or  through  the  vagina.  In  septic  cases  it  may 
be  ad\isable  to  drain  with  several  pieces  of  iodoform  gauze  instead  of  inserting 
tubes.  After  most  laparotomies  drainage  is  not  needed,  but  it  should  be  used 
when  stomach  contents  were  extravasated.  and  it  must  be  used  if  feces  or 
urine  were  extravasated,  in  certain  recent  septic  cases,  and  when  hemorrhage 
has  been  severe.  We  may  drain  by  a  rubber  tube,  strands  of  gauze,  a  cigarette 
drain,  or  a  glass  tube.  If  a  glass  tube  is  used,  it  is  introduced  at  a  lower  angle 
of  the  woimd  and  reaches  the  bottom  of  the  pouch  of  Douglas.  The  tube  is  re- 
peatecUy  emptied  during  the  progress  of  the  case  by  means  of  a  S}-ringe.  Before 
closing  the  wound  arrest  hemorrhage  and  ask  for  the  count  of  the  instnunents 
and  pads  in  order  to  know  that  nothing  foreign  has  been  left  in  the  beUy. 

It  is  highly  important  that  an  abdominal  incision  shall  be  acciu^ately 
closed,  for  any  faflure  of  neat  approximation  will,  in  all  probability,  result 
in  the  formation  of  a  hernia  through  the  cicatrix.  \*arious  methods  have 
been  employed.  Probably  the  majority  of  operators  use  layer  sutures. 
sewing  up  the  peritoneum  with  a  continuous  suture  of  catgut,  and  the  apo- 
neurotic layers  with  the  same  material  or  vvdth  chromicized  catgut,  and  closing 
the  skin  with  either  interrupted  sutures  of  siLkworni-gut  or  a  subcuticular 
stitch  of  catgut,  silkworm-gut,  or  silver  wire.  Other  operators  close  the  peri- 
toneum with  a  continuous  suture  of  catgut,  then  pass  silkworm-gut  sutures 
through  aU  the  other  structiures,  lea^dng  them  for  the  time  untied;  put  in 
and  tie  layer  sutirres  of  catgut  or  of  chromicized  catgut,  and  then  tie  the 
silkworm-gut  sutures.  A  layer  suture  makes  a  beautifully  neat  approxima- 
tion, and  is  frequently  quite  satisfactory-:  but  I  have  become  persuaded  that 
the  dead  space,  so  often  left  imobliterated  when  this  method  of  suturing 
is  employed — a  space  in  which  blood  and  inflammatory-  exudate  may  gather — 
is  a  danger  to  the  future  integrity-  of  the  wound.  The  combination  of  a 
dead  space  with  catgut,  a  material  that  is  always  somewhat  uncertain,  is 
an  unfortimate  one  from  the  surgical  point  of  \iew.  I  have  returned  in 
many  cases  to  the  use  of  the  through-and-through  suture.  appHed  according 
to  the  method  of  the  late  Dr.  Joseph  Price.  This  suture  is  inserted  with 
the  straight  needle,  is  composed  of  silk  or  of  sflkworm-gut.  is  put  in  close  to 
the  margin  of  the  skin,  gathers  up  a  great  deal  more  muscle  than  skin,  and 
then  passes  close  to  the  margin  of  the  cut  peritoneum  and  transversalis 
fascia.  T\'lien  these  sutures  are  adjusted  the  peritoneal  edges  are  brought 
into  accurate  and  firm  apposition,  the  peritoneal  surface  is  overlaid  with 
abimdant  muscle,  the  skin  edges  are  brought  into  neat  approximation,  and 
the  formation  of  a  dead  space  is  rendered  impossible.  \^TLen  passing  the 
sutures  have  a  gauze  pad  under  the  wound  and  be  ver\-  careful  not  to  include 
bowel  or  omentimi  in  the  stitches.  It  is  necessary-  to  tighten  and  tie  most 
carefully  to  prevent  omentiun  being  caught  in  the  loop  of  the  stitch.  After 
closing  a  laparotomy  wound,  dress  with  aseptic  gauze  and  apply  a  flannel 
binder.     In  badly  infected  cases  the  wound  is  often  kept  open. 

If  a  2-inch  incision  has  been  closed  ^-ithout  drainage  and  primary-  imion 
has  taken  place,  the  patient  can  usually  get  out  of  bed  in  seven  or  eight  days. 
A  large  incision  offers  greater  danger  of  subsequent  hernia,  and  the  patient 
should  be  kept  in  bed  for  two  or  three  weeks.     If  the  wound  has  been  kept  open 


1070  Diseases  and  Injuries  of  the  Abdomen 

for  drainage,  a  prolonged  retention  in  bed  may  be  necessary.  I  get  patients  up 
at  an  earlier  period  than  used  to  be  my  custom,  but  I  do  not  get  them  up  as  do 
Kiimmell  and  others  in  from  one  to  three  days  (Kiimmell,  in  "Zentralblatt 
f.  Chirurgie,"  1908).  To  get  them  up  reasonably  early  lessens  constipation, 
favors  an  early  return  of  appetite  and  strength,  and  diminishes  the  risk  of 
postoperative  thrombosis  and  embolism  and  of  bronchitis.  We  must  bear 
in  mind  that  if  there  is  myocardial  degeneration  very  early  getting  up  may 
prove  disastrous  or  even  fatal,  and  that  in  septic  diseases  there  is  often  myo- 
cardial degeneration  (E.  W.  Foote,  in  "Progressive  Medicine,"  June,  1909). 
In  a  case  in  which  an  incision  of  considerable  length  has  been  made,  an  ab- 
dominal support  should  be  worn  for  a  variable  time.  It  limits  the  movements 
of  cough,  laughter,  etc.,  and  reminds  the  patient  of  the  necessity  of  caution  in 
lifting,  hurrying,  etc. 

The  after-treatment  depends  somewhat  on  the  case,  but  certain  general 
rules  can  be  laid  dow^n.  The  late  J.  Greig  Smith  said  many  wise  things,  and 
among  them  this:  "A  golden  rule  in  the  treatment  of  cases  of  celiotomy  is  to 
let  the  patient  alone.  Everything  approaching  to  meddlesomeness  is  to  be 
condemned.  The  patient  must  not  be  upset  by  fussy  applications  of  tentative 
therapeutics;  when  an  emergency  arises,  it  is  to  be  met,  promptly  and  decisively, 
by  a  method  which  has  been  approved  trustworthy"  ("Abdominal  Surgery"). 
In  many  cases  immediately  after  the  operation  the  patient  must  be  treated 
for  shock  by  methods  previously  set  forth.  The  treatment  of  vomiting  result- 
ing from  the  administration  of  an  anesthetic  is  discussed  on  page  1202.  If 
vomiting  persists  during  the  third  or  fourth  day  it  may  be  due  to  acidosis, 
but  is  probably  due  to  the  development  of  inflammation  which  has  caused 
intestinal  paresis;  and  if  it  is  so  produced,  medicine  is  practically  useless.  In 
this  condition  there  is  usually  marked  tympanitic  distention,  and  vomiting  is, 
in  a  sense,  a  relief.  Nothing  should  be  given  by  the  mouth  and  the  patient 
should  be  fed  entirely  by  enemata.  The  insertion  of  a  rectal  tube  and  its 
retention  for  a  considerable  time  may  afford  relief.  Lying  on  the  side  is  more 
comfortable  than  recumbency.  Washing  out  the  stomach  from  time  to  time 
gives  great  comfort  and  is  often  of  real  service. 

In  the  average  case  of  celiotomy,  in  which  persistent  vomiting  does  not 
occur,  the  question  of  feeding  is  of  much  importance.  Usually,  for  the  first 
twelve  or  twenty-four  hours,  nothing  is  given  by  the  mouth  but  small  quantities 
of  hot  water.  The  day  after  the  operation,  if  everything  is  satisfactory,  food 
is  given  to  the  patient.  In  many  cases,  however,  food  is  not  given  by  the 
stomach  for  forty-eight  hours  and  the  patient  is  fed  by  the  rectum  during  the 
wait.  He  should  not  be  given  milk  because  it  will  not  be  easily  digested,  may 
lead  to  nausea,  and  causes  flatulence.  Peptonized  milk,  if  the  patient  will  take 
it,  does  not  possess  these  hurtful  qualities.  At  first  albumin-water  or  liquid 
beef  peptonoids  should  be  given,  and  later  meat-juice,  beef-jelly,  broth,  etc. 
Food  is  given  every  third  or  fourth  hour,  and  stimulants  are  administered 
if  required.  After  the  first  twenty-four  or  forty-eight  hours  considerable 
quantities  of  plain  water  or  Poland  water  should,  if  possible,  be  taken,  to  favor 
elimination  by  the  kidneys.  Hot  coffee  is  not  only  a  stimulant,  but  is  an  ex- 
cellent diuretic.  The  urine  is  always  scanty  after  an  abdominal  operation, 
and  a  normal  daily  amount  is  not  voided  for  ten  days  or  more.  Solid  food 
is  not  given  for  seven  or  eight  days.  The  patient  is  apt  to  suffer  greatly 
from  thirst,  in  spite  of  the  hot  water  given  during  the  first  twelve  to  twenty- 
four  hours.  He  seldoms  takes  and  should  never  have  any  great  amount  of  hot 
water,  and  iced  water  and  ice  are  inadmissible  and  tend  to  induce  nausea  and 
vomiting.  Sucking  ice  or  sipping  water  draws  air  into  the  stomach  and  causes 
distention.  Thirst  can  be  much  mitigated  by  enemata  of  salt  solution. 
J.  Greig  Smith  recommended  an  enema  composed  of  from  4  to  20  oz.  of  tepid 


Operation  for  Appendicitis 


1071 


water  and  some  brandy.    Usually,  after  the  first  twenty-four  hours,  a  sufficient 
amount  of  Hquid  can  be  given  to  keep  the  patient  free  from  actual  distress. 

The  bladder  must  be  watched  to  see  that  retention  does  not  occur.  If 
retention  occurs,  a  clean  catheter  must  be  used  at  regular  intervals.  If 
tympanitic  distention  occurs  after  forty-eight  hours,  a  saline  purgative  should 
be  given  and  it  should  be  followed  by  an  enema  of  turpentine.  The  rectal  tube 
is  frequently  of  signal  service  in  such  cases.  If  obstruction  develops,  it  is 
treated  as  directed  on  page  989. 

In  any  ordinary  case  after  operation  the  bowels  should  be  moved  after 
forty-eight  hours  as  a  prophylactic  measure  against  distention,  peritonitis, 
and  obstruction.  From  four  to 
eight  I -dram  doses  of  Epsom 
salts  are  given,  in  hot  water,  the 
solution  having  been  filtered 
through  gauze.  The  saline  is  fol- 
lowed by  the  administration  of  an 
enema  consisting  of  soap,  water, 
and  ^  oz.  of  castor  oil.  Should 
opium  be  given?  Never  as  a 
routine,  and  not  to  secure  sleep; 
but  if  the  patient  is  in  pain  which 
not  only  harasses  him,  but  causes 
him  to  turn  and  shift  in  tortur- 
ing restlessness,  one  or  possibly 
two  hypodermatic  injections  each 
containing  j  gr.  of  morphin  can 
be  given  with  confidence  that  the 
good  will  overbalance  the  harm. 

Operation  for  Appendi= 
citis. — Before  operating  try  to 
locate  the  situation  of  the  ap- 
pendix, and  the  relation  the 
area  of  infection  bears  to  the 
ascending  colon.  The  incision 
should  be  over  the  seat  of  dis- 
ease. In  the  rare  left-sided 
cases  and  in  median  cases  the  in- 
cision is  median.  In  some  cases 
in  which  the  appendix  is  poste- 
rior the  cut  may  be  in  the  loin. 
In  I  case  I  opened  a  purulent 
collection  through  the  rectimi. 
In  the  vast  majority  of  cases 
the  incision  is  made  in  the  right 
ihac  region. 

In  acute  appendicitis,  when  there  is  not  thought  to  be  a  distinct  abscess, 
the  incision  usually  made  is  2  inches  internal  to  the  anterior  superior  iliac 
spine  and  perpendicular  to  a  line  drawn  from  the  spine  to  the  umbilicus  (Fig, 
623).  The  skin  incision  is  usually  3  inches  in  length,  the  upper  third  of  the 
incision  being  above  the  omphalospinous  line;  the  incision  in  the  peritoneum 
is  about  2  inches  in  length,  but  if  there  are  many  adhesions,  it  may  be  necessary 
to  make  it  much  longer.  The  oblique  incision  may  be  carried  out  as  advised 
by  McBurney,  the  muscles  being  separated  by  blunt  dissection.  By  this  method 
very  few  nerve-fibers  are  divided,  and  hence  the  operation  is  not  followed  by 
marked  musciilar  wasting,  a  condition  which  strongly  predisposes  to  hernia. 


Fig.  623. — Resection  of  the  vermiform  appendix,  inci- 
sion through  the  abdominal  wall:  a,  External  oblique  mus- 
cle; b,  internal  obUque  muscle;  c,  aponeurosis  of  external 
obhque;  d,  aponeurosis  of  internal  obhque;  e,  peritoneum; 
/,  outer  border  of  rectus  abdominis  muscle  (under  it  the 
deep  epigastric  vessels)  (Kocher). 


1072 


Diseases  and  Injuries  of  the  Abdomen 


Further,  as  Van  Hook^  points  out,  the  oblique  incision  enables  the  surgeon  to 
reach  freely  all  the  ordinary  areas  of  appendix  trouble,  the  wound  is  par- 
allel with  the  lines  of  traction  of  the  abdominal  muscles,  and  does  not  tend  to 
gape  widely.     In  an  acute  case  I  make  an  oblique  incision,  but  cut  the  muscles 


JJmhdicu^. 


Linea. 

^emilunarU. 


^External 
'Oblioue. . 

JtectuS- 

Jnternal 
Oblique. 


Fig.  624. — Davis's  small  transverse  incision  for  simple  cases. 


(Fig.  623).  In  an  interval  case  I  separate  the  muscular  fibers.  Battle's  incision 
at  the  outer  edge  of  the  rectus  muscle  is  preferred  by  many  surgeons.  The 
anterior  layer  of  the  rectus  sheath  is  opened  longitudinally,  the  rectus  is  drawn 


Fig.  625. — Davis's  large  transverse  incision  for  difficult  cases. 

inward,  and  any  existing  portion  of  the  posterior  rectus  sheath  with  the  trans- 
versahs  fascia  and  peritoneum  is  incised. 

I  have  used  Davis^s  transverse  incision  (Figs.  624  and  625)  in  many  interval 
■cases  with  entire  satisfaction  (Gwilym  G.  Davis,  in  "Annals  of  Surgery,"  Jan., 
1  "Jour.  Amer.  Med.  Assoc,"  Feb.  20,  1897. 


Operation  for  Appendicitis 


1073 


igo6).  This  incision  does  not  divide  arteries,  but  it  divides  the  deep  muscles 
in  the  direction  of  the  nerves,  hence  the  nerves  are  not  injured.  The  center  of 
this  incision  is  almost  over  the  base  of  the  appendix.  Davis  describes  his  in- 
cision as  follows: 

"For  easy  cases  the  incision  is  made  directly  transverse,  i^  inches  long.  Its 
center  is  to  be  on  the  semilunar  line  on  a  level  with  the  anterior  superior  spine. 
The  aponeurosis  of  the  external  oblique  is  divided  in  the  line  of  the  skin  incision, 
but  obliquely  to  the  direction  of  its  fibers.  The  fibers  of  the  internal  oblique  and 
transversalis  muscles  are  parted — not  cut — in  the  same  line  as  the  structures 
above.  The  peritoneum  is  then  opened  and  the  incision  is  carried  inward,  first 
through  the  anterior  layer  of  the  sheath  of  the  rectus.  A  blunt  retractor  f 
inch  wide  is  then  inserted  and  the  muscle  drawn  toward  the  median  line.  This 
exposes  the  transversalis  fascia  and  peritoneum  posteriorly,  which  are  then  also 
divided.  Thus  is  obtained  a  tri- 
angular opening  with  its  base  of  f 
inch  and  two  sides  of  about  i  inch 
long,  which  is  ample  for  simple  cases. 

"For  Difficult  Cases. — If  the  case 
is  a  difficult  one,  the  outer  end  of 
the  incision  is  prolonged  to  the 
anterior  spine  or  even  above  and 
inwardly  through  the  sheath  of  the 
rectus  to  within  i  inch  of  the 
median  line.  This  will  give  an 
opening  4  to  5  inches  long,  accord- 
ing to  the  size  of  the  patient,  sufii- 
ciently  large  to  insert  the  hand  if 
necessary  and  through  which  the 
appendix  can  be  extracted  under 
almost  all  circumstances." 

After  opening  the  peritoneum 
examine  very  gently  to  detect  the 
situation  of  the  appendix,  and  if 
there  are  or  are  not  adhesions.  In 
a  very  recent  case  and  in  a  very 
acute  case  there  will  probably  be 
no  adhesions  unless  there  have  been 
previous  attacks.  Surround  the 
region  of  infection  with  packs  of 

plain  gauze,  each  strip  being  2^  inches  wide,  15  inches  long,  and  four  layers 
in  thickness.  The  edges  of  the  wound  should  be  lifted  up  by  retractors  and 
the  strips  inserted  around  the  cut,  between  the  parietal  peritoneum  and  intes- 
tines and  to  a  distance  of  3  inches  from  the  wound.  Strips  of  gauze  are  passed, 
when  possible,  below  the  appendix  to  prevent  entrance  of  infected  material  into 
the  pelvis,  and  a  piece  is  pushed  upward  toward  the  liver  (Van  Hook).  Over 
the  packing  gauze,  which  it  may  be  necessary  to  leave  in  place  after  the  opera- 
tion, other  pads  are  packed.  The  appendix  is  sought  for  by  finding  the  colon. 
The  colon  is  found  by  following  the  parietal  peritoneum  with  the  finger.  The 
course  of  the  finger  is  first  outward,  next  backward,  and  finally  inward;  the  first 
obstruction  it  encounters  is  the  colon.  The  fact  that  it  is  the  colon  can  be 
confirmed  by  finding  the  longitudinal  bands.  The  anterior  longitudinal 
band  leads  directly  to  the  appendix.  Pass  the  finger  down  to  the  head  of  the 
colon,  find  the  appendix,  usually  posterior  and  internal,  and  lift  it  and  the  head 
of  the  colon  into  the  wound.  In  many  cases  it  will  be  advisable  to  deliver  the 
head  of  the  colon  from  the  belly  (Fig.  626);  in  other  cases  this  will  not  be 


Fig.  626.- 


-Radical    operation    for    appendicitis 
(Kocher) . 


I074 


Diseases  and  Injuries  of  the  Abdomen 


necessary,  in  some  it  will  not  be  possible.  If  adhesions  exist,  they  must  be 
gently  and  carefully  separated.  Barker's  method  (Fig.  627)  is  a  very  satisfac- 
tory mode  of  removing  the  appendix.  It  is  done  as  follows:  Turn  up  a  cuff  of 
peritoneum,  pull  down  the  other  coats,  ligate  at  the  base,  cut  through  the  tube, 
let  the  musculomucous  stump  retract,  and  tie  or  suture  the  peritoneal  cuff  over 
the  stump.  Another  method,  which  is  the  one  I  usually  employ,  is  as  follows: 
Pass  a  ligature  through  the  meso-appendix,  as  shown  in  Fig.  628,  A ,  tie  the  liga- 
ture, and  cut  off  the  meso-appendix  below  the  threads.  Crush  the  stump  of  the 
appendix  with  strong  straight  hemostatic  forceps.  This  divides  the  mucous 
membrane,  submucous  tissue  and  muscular  coat,  and  leaves  the  peritoneal  coat 
undivided.  Remove  the  forceps.  Surround  the  appendix  with  a  catgut  ligature 
and  tie  the  ligature  in  the  groove  produced  by  the  crushing.  When  the  ligature 
is  tied,  peritoneum  is  brought  against  peritoneum.  Cut  off  the  appendix  between 
the  ligature  and  a  clamp  by  the  cautery,  a  knife,  or  scissors.  Disinfect  the  stump 
of  the  appendLx  by  pure  carbolic  acid.  The  stump  beyond  the  ligature  contains 
mucous  membrane  and  muscle,  which  are  lifted  out  with  forceps  and  scissors. 
Suture  the  fringe  of  the  meso-appendix,  invert  the  stump  into  the  wall  of 
the  colon,  and  suture  a  portion  of  the  wall  over  it  by  inversion  stitches. 
Figure  628  shows  an  older  method  stUl  used  by  many.    The  meso-appendix  is 


Fig.  627. — Barker's  technic  of  operation 
for  removal  of  the  appendix. 


Fig.  628. — Ligation  of  appendix  and  meso-appendix. 


tied  off  by  one  ligature,  the  appendix  is  not  crushed,  but  is  tied  off  by  another 
ligature,  and  both  structures  are  cut  off  below  their  respective  ligatures.  The 
stump  is  disinfected  with  pure  carbolic  acid  or  the  cautery,  inverted,  and  the 
fringe  of  the  meso-appendix  is  sutured.  This  method  does  not  entirely  remove 
the  appendix,  but  inverts  glandular  tissue  into  the  wall  of  the  bowel.  The 
stump  may  not  be  completely  asepticized  by  the  carbolic  acid  and  hence  may 
lead  to  postoperative  abscess,  dense  adhesions  or  fecal  fistula,  or  the  unde- 
stroyed  lymphoid  structure  may  cause  further  trouble,  even  persistent  ill 
health  (Joseph  Price).  Some  remove  the  appendix  by  an  elliptical  incision 
around  its  base,  and  close  the  colon  wound  by  Lembert  sutures.  This  method, 
of  course,  removes  the  appendix  completely.  Dawbarn  surrounds  the  appen- 
dix with  a  continuous  Lembert  purse-string  suture  of  silk.  This  is  inserted  in 
the  superficial  layers  of  the  cecum,  ^  inch  from  the  appendix.  The  appendix 
is  divided  so  as  to  leave  a  stump  never  shorter  than  ^  inch.  The  lumen  of  the 
stump  is  gently  stretched  by  inserting  a  pair  of  mouse-toothed  forceps  and 
opening  the  blades.  The  stump  is  then  invaginated  into  the  cecum,  that  is,  it 
is  turned  ''outside  in."  The  sutures  are  tightened,  and  while  this  is  being 
done,  the  mouse-tooth  forceps  used  in  effecting  inversion  are  withdrawn. 
Finally,  the  sutures  are  tied  (Robt.  H.  M.  Dawbarn,  in  'Tnternat.  Jour,  of 


Operation  for  Appendicitis  1075 

Surg.,"  May,  1895).  In  this  method  the  stump  is  not  ligated  and  hemorrhage 
is  Uable  to  take  place  into  the  gut.  Deaths  from  such  hemorrhage  are  on 
record.  The  retained  bit  of  appendLx  drains  into  the  colon.  I  believe  it  is  a 
mistake  to  trust  to  simple  ligation  and  to  fail  to  bury  the  stump  left  after 
appendectomy.  If  a  surgeon  follows  this  plan  in  any  large  number  of  cases  he 
will  now  and  then  have  a  case  in  which  the  ligature  slips  and  feces  pass  into 
the  peritoneal  cavity,  or  cases  of  temporary  fecal  fistula,  or  cases  of  intestinal 
obstruction  from  adhesion  of  some  portion  of  the  bowel  to  the  exposed  stump 
(Murat  WilHs,  in  "Annals  of  Surgery,"  July,  1908).  I  do  not  believe  that  a 
a  buried  stump  increases  postoperative  pain. 

If  there  is  no  pus  and  no  extravasated  feces,  if  the  peritoneum  is  not  seriously 
affected,  if  the  appendix  is  not  gangrenous  or  perforated,  and  if  there  is  no  pus 
within  the  appendix,  remove  the  pads  which  were  inserted  last,  irrigate  with 
hot  salt  solution,  remove  the  strips  of  gauze  which  were  inserted  first,  and  close 
the  wound.  If  any  of  the  above  conditions  were  found,  remove  the  infected 
pads,  but  leave  in  place  the  strips  which  were  first  inserted  in  order  to  limit 
infection  and  secure  drainage.  Pass  sutures  through  wound  edges,  tie  some  of 
them  and  leave  some  untied  until  gauze  is  removed  at  a  later  period  (Van  Hook) . 

If  an  operation  is  performed  in  a  distinct  interval,  pus  is  absent  and  the 
surgeon  can  proceed  without  apprehension.  If  there  is  any  question  of  the 
presence  of  pus,  surround  the  region  with  gauze,  as  suggested  above,  before 
breaking  down  adhesions  -and  liberating  the  appendix.  An  interval  opera- 
tion should  not  be  performed  until  three  weeks  after  an  attack.  In  an  interval 
case  McBurney  proceeds  as  follows:  He  makes  the  skin  incision  in  the  direc- 
tion of  the  fibers  of  the  external  oblique  muscle,  separates  the  fibers  of  this 
muscle  by  blunt  dissection,,  retracts  them,  separates  the  fibers  of  the  internal 
oblique  and  the  transversalis  muscles  in  the  same  way  and  retracts  them,  and 
opens  the  transversalis  fascia  and  peritoneum.  No  muscle-fibers  are  cut  and 
hernia  is  not  apt  to  follow.  Such  a  wound  is  closed  as  follows:  a  continuous 
catgut  suture  for  the  peritoneum,  sutures  of  chromic  gut  for  the  transversalis 
fascia,  the  muscles  are  restored  to  place,  the  aponeurosis  of  the  external  oblique 
is  sutured  with  chromic  gut,  and  the  skin  is  closed  by  interrupted  sutures  of 
fine  silk  or  silk-worm  gut  or  by  a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel  with  Poupart's 
ligament  and  over  the  area  of  dulness  on  percussion  (Willard  Parker's  oblique 
incision).  If  the  abscess  is  adherent  to  the  anterior  abdominal  wall  such  an 
incision  will  not  enter  the  free  peritoneal  cavity.  If,  after  opening  the  abdo- 
men, an  abscess  is  thought  to  exist,  although  it  is  not  adherent  to  the  anterior 
abdominal  wall,  surround  the  abscess  with  gauze  before  opening  it,  as  directed 
under  acute  appendicitis.  The  gauze  is  placed  under  the  margins  of  the 
incision  in  the  peritoneum  all  around  the  appendix  area;  a  piece  is  carried 
toward  the  pelvis  and  another  piece  tow^ard  the  liver.  Overlay  this  gauze 
with  gauze  pads  (Van  Hook).  Adhesions  are  broken  through  with  the  finger, 
and  when  pus  appears  it  is  at  once  wiped  away.  Remove  the  appendix  in 
most  cases,  but  not  in  all.  If  the  appendix  lies  loose  in  the  abscess  cavity, 
if  it  is  sloughed  off  or  but  loosely  attached  to  the  abscess  wall,  remove  it.  If 
the  appendix  is  firmly  fixed  in  the  abscess  w^all  and  must  be  dug  out  of  a  mass 
of  inflammatory  material  do  not  remove  it.  To  remove  it  under  these  cir- 
cumstances may  rupture  the  wall  and  disseminate  the  pus  into  regions  not 
protected  by  pads  and  gauze.  Deaver  and  others  tell  us  always  to  remove 
the  appendix.  I  do  not  believe  this  to  be  a  safe  rule  to  follow.  To  insist 
on  removing  the  appendix  may  cause  death.  When  the  appendix  is  left  it 
usually  sloughs  away.  It  is  true,  a  fecal  fistula  may  result,  but  this  is  in  the 
large  bowel  and  usually  heals  spontaneously.  Even  if  a  fecal  fistula  forms  and 
does  not  heal,  the  surgeon  acted  properly  in  not  removing  the  appendix,  be- 


1076  Diseases  and  Injuries  of  the  Abdomen 

cause  a  fecal  fistula  may  be  remedied  by  another  operation.  It  is  rarely  that 
secondary  abscess  forms,  and  there  are  not  a  great  many  cases  recorded  in 
which  an  appendix  has  subsequently  given  serious  trouble  when  left  after  oper- 
ation. In  fact,  in  many  cases  the  appendix  is  destroyed  or  obliterated  by  in- 
flammation. In  some  cases,  however,  a  secondary  operation  will  be  required 
because  of  a  fecal  fistula,  a  persistent  sinus,  or  an  acute  inflammatory  attack. 
When  Deaver  decides  to  remove  such  an  appendix,  he  makes  an  incision 
in  the  median  line  of  the  abdomen,  packs  around  the  periphery  of  the  ab- 
scess -^nth  gauze,  opens  the  abdomen  by  another  incision,  removes  the  appen- 
dix, disinfects,  inserts  drainage,  and  then  removes  the  surrounding  gauze 
and  closes  the  median  incision.  In  every  abscess  case  search  for  fecal  concre- 
tions and  remove  them  if  found.  Irrigation  should  not  be  employed  in  appen- 
dicular abscess.  The  force  of  the  stream  may  break  down  barriers  of  lymph 
and  spread  infection.  After  the  evacuation  of  the  pus,  whether  the  appen- 
dix was  removed  or  not,  take  out  the  pads,  but  leave  the  long  strands  of 
gauze  first  placed  to  keep  the  woimd  open.  Introduce  iodoform  gauze  into 
the  abscess  cavity  and  insert  a  rubber  tube,  partially  suture  the  wound,  and 
dress  with  dry  gauze.  In  forty-eight  hours  aU  the  strands  of  gauze  are 
removed  and  fresh  pieces  are  inserted  for  drainage.  After  this  period  the 
gauze  drain  is  changed  daily.  Morris  maintains  and  proves  that  large  pieces 
of  gauze  sometimes  cause  intestinal  obstruction  and  iodoform  gauze  sometimes 
causes  iodoform-poisoning,  but  the  risk,  it  seems  to  me,  should  be  taken.  An 
interval  case  should  be  up  and  about  in  from  ten  days  to  two  weeks  after 
operation.  An  abscess  case  may  require  a  much  longer  time  for  complete 
recovery.  A  fecal  fistula  sometimes  results  in  cases  in  which  the  appendix 
was  not  removed,  and  occasionally  forms  when  it  was  removed. 

If  on  opening  the  abdomen  pus  is  found,  unlimited  by  adhesions  but 
widespread  in  the  peritoneal  cavity,  remove  the  appendix,  and  then  bear 
in  mind  Murphy's  wise  coimsel  as  to  how  to  treat  general  peritonitis  (see  page 
1025).  Put  a  drainage-tube  into  the  pelvis  and  one  in  the  appendix  region, 
place  the  patient  in  Fowler's  position,  and  administer  salt  solution  by  contin- 
uous proctoclysis  at  a  low  pressure.  The  after-treatment  of  an  ordinary  ap- 
pendix operation  is  that  advised  after  celiotomy  fsee  page  1070). 

Mortality  After  Operations  for  Appendicitis. — Theinter\"al  operation  is  prac- 
tically without  mortality.  In  over  1000  cases  Treves  had  2  deaths.  In  446 
cases  of  chronic  appendicitis  the  Mayos  had  i  death  ("Report  of  St.  Marv^'s 
Hospital  for  191 2").  In  grave  acute  cases  the  mortahty  is  large.  In  100 
consecutive  cases  of  this  character  coUected  by  Hearn  and  operated  upon  in  the 
Jefferson  Hospital  by  Keen,  Hearn,  and  DaCosta,  there  were  8  deaths.  As 
previously  stated,  Maurice  H.  Richardson  reported  a  death-rate  in  such  cases 
of  18  per  cent,  in  750  cases.  Deaver  reports  from  the  German  Hospital  144 
cases,  with  a  mortality  of  17.8  per  cent.  He  eliminates  i  death  from  diabetes, 
I  from  pneumonia,  and  i  from  phthisis,  and  estimates  his  personal  mortality 
at  15.9  per  cent.  (Deaver  and  Ross,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  5,  1901). 
In  124  cases  (including  all  chronic  cases  and  those  acute  cases  in  which  the 
inflammation  had  not  extended  beyond  the  peritoneal  coat)  there  was  i  death. 
In  347  cases  of  acute  and  suppurative  appendicitis  operated  upon  in  the  Mayo 
clinic  in  191 2  there  were  but  2  deaths  ("Report  of  St.  Mary's  Hospital  for 
1912").  I  fancy  most  of  these  cases  came  from  a  distance  and  hence  the  pro- 
portion of  violent  and  rapid  cases  must  have  been  less  than  is  usuaUy  the  rule 
in  a  great  city  In  Burgess's  500  consecutive  operations  there  were  40  deaths 
("Brit.  Med.  Jour.,"  Feb.  24,  191 2).  WTien  infection  was  limited  to  the 
appendix  the  mortahty  was  .74  per  cent  (135  cases);  when  there  was  circum- 
scribed abscess  it  was  4.64  per  cent  (213  cases) ;  when  there  was  difi"use  spreading 
peritonitis  it  was  19.07  per  cent.  (152  cases).     The  usual  causes  of  death  are 


Enterorrhaphy,  or  Suture  of  the  Intestine 


1077 


intestinal  obstruction,  septic  peritonitis,  septic  endocarditis,  pylophlebitis, 
hepatic  suppuration,  metastatic  abscesses,  endocarditis,  and  gangrene  of  the 
bowel.  In  a  further  report  from  September  i,  1902,  to  September  i,  1903, 
Deaver  reports  566  cases  in  the  German  Hospital,  with  an  aggregate  mortality 
of  5  per  cent.  In  cases  with  diti'use  peritonitis  the  mortahty  was  31  per  cent. 
In  abscess  about  a  necrotic  and  perforated  appendix;  it  was  12  per  cent.  In 
early  appendicitis  or  when  disease  was  confined  to  the  appendix  it  was  0.8  per 
cent.  In  107  cases  of  circumscribed  abscess  in  which  Burgess  removed  the 
appendix  the  mortality  was  1.S6  per  cent.  In  106  cases  in  which  he  did  not 
remove  the  appendix  it  was  7.54  per  cent.  ("Brit.  Med.  Jour.,"  Feb.  24,  191 2). 
Appendicostomy  (Weir's  Operation). — This  operation  w^as  devised  by 
Weir,  of  New  York,  in  1902.  It  consists  in  opening  the  abdomen,  finding 
the  appendix,  fastening  this  structure  to  the  skin,  closing  the  rest  of  the  wound, 
opening  the  appendix  to  see  that  it  is  patent,  and  applying  a  temporary  ligature 
to  prevent  leaking.  The  temporary  ligature  is  removed  in  a  day  or  two, 
and  a  few  days  later  the  adherent  and  open  appendix  is  used  as  a  route  for 
the  introduction  of  irrigating  fluids.  The  operation  is  of  the  greatest  value 
in  chronic  ulcerative  colitis,  as  it  enables  us  to  irrigate  thoroughly  the  large 
bowel.  Daily  a  large  tube  is  passed  into  the  rectum  and  a  small  tube  into 
the  appendix.  The  fecal  matter  is  washed  out  of  the  bowel  through  the 
rectal  tube  by  salt  solution,  and  then  a  i  :  5000  solution  of  silver  nitrate  or 


Fig.  629. — E3^e  of  the 
cal>'x-ej'ed  needle. 


Fig.    630. — Enterrorhaphy:   A,    Lambert   suture;   b,    Dupuytren's   suture. 


bismuth  and  starch  water  (i  dram  to  i  oz.)  is  used  to  irrigate  the  colon.  It  is 
injected  by  way  of  the  appendix  and  it  runs  out  of  the  rectal  tube.  It  is 
used  for  the  same  purpose  in  some  cases  of  tuberculous  rectal  or  anal  fistulae. 
A  most  extraordinary  suggestion  is  that  appendicostomy  be  performed  in  epi- 
leptics, so  that  the  opening  may  be  used  to  flush  the  bowel,  a  suggestion  which 
I  ^dll  not  act  upon.  When  the  fistula  exists,  it  does  not  leak  to  any  apprecia- 
ble degree.  When  we  wish  to  close  it  w^e  insert  within  the  lumen  of  the  tube 
the  Paquelin  cauten,^  at  a  red  heat.  This  destroys  the  mucous  membrane 
and  the  fistula  closes  (Robt.  Weir,  in  "Med.  Record,"  August  9,  1902). 

Enterorrhaphy,  or  Suture  of  the  Intestine. — Surgical  opinion  has 
greatly  altered  in  regard  to  this  operation  since  the  day  when  John  Bell  wrote 
his  famous  attack  on  Benjamin  Bell.  John  Bell  said:  "If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up  a  wounded  gut." 
To-day  we  know  that  if  in  all  surger}^  there  is  a  proceeding  of  imperative 
necessity,  it  is  the  sewing  up  of  a  wound  in  the  intestine.  To  perform  this 
operation  take  fine  sterile  silk  and  thread  a  thin,  roimd,  straight,  calyx-eyed 
needle  with  it  (Fig.  629).  The  needle  is  ver}^  useful,  as  it  can  be  threaded 
rapidly  by  pushing  the  calyx  eye  down  upon  the  silk  thread  while  the  latter  is 
kept  taut.  LemberVs  suture  (Figs.  630,  a,  631,  and  632)  was  devised  in  1823. 
Lembert  used  it  on  animals,  but  never  on  man.  It  is  inserted  at  right  angles 
to  the  wound.  It  goes  down  to,  but  not  through,  the  mucous  membrane. 
It  is  formed  by  picking  up  a  fold  of  the  intestine  {-Y2  to  ^  inch  wide)  ^  inch  from 


I078 


Diseases  and  Injuries  of  the  Abdomen 


the  edge  on  one  side  of  the  wound,  passing  the  needle  through,  picking  up  a  fold 
on  the  opposite  side  of  the  wound,  and  passing  the  needle  through.     On  tying 


Fig.  631. — Lembert's  suture. 


the  threads  the  serous  membrane  is  inverted  and  peritoneum  is  brought  into 
contact  with  peritoneum.     For  many  years  it  was  taught  that  this  suture 


Fig.  632. — Lembert's  suture  closed. 


Fig-  ^33- — Cushing's  right-angled  suture  (Senn). 


should  include  only  the  serous  coat,  but  Halsted,  in  1887,  showed  that  it  must 
include  the  tough  submucous  coat.  The  submucous  coat  is  strong  and  will 
hold  a  suture.     The  other  coats  are  thin,  tear  easily,  and  will  not  hold  a  suture. 


X  1  1^ 

)  ^ 

)  i 

)  ^ 


Fig.  635. — A,  Halsted  sutures  untied;  B, 
Halsted  sutures  tied  and  serous  surface  in- 
verted. 


Fig.  634. — Ford's  stitch,  showing  a  Lembert  in- 
sertion and  the  needle  passed  so  as  to  tie  a  single 
knot  by  drawing  it  on  through. 


So  thin  are  the  coats  that  a  surgeon  could  not  suture  the  serous  coat  alone  were 
he  to  try.  Sutures  which  include  only  the  muscular  and  serous  coats  tear  out 
easily.     Dupuytren' s  suture  (Fig.   630,  b)   is  simply  a  continuous  Lembert 


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EXPLANATION  OF  PLATE  11. 

intestinal  suture,  all  knots  inside  (Connell). 

a,  Suspending  loops  2,  3,  and  4  are  made  with  one  thread  inserted  at  a  point  two  thirds 
of  the  distance  from  mesenteric  to  convex  border.  The  needle  with  suture  is  passed 
through  the  four  walls  of  the  cut  ends,  and  that  portion  of  suture  within  each  lumen  is 
drawn  up  to  a  sufficient  length,  then  cut,  and  the  contiguous  threads  tied  at  the  points 
indicated  by  the  arrows;  thus  having  as  a  result  four  suspending  loops  dividing  the  cir- 
cumference of  each  cut  end  into  thirds.  Instead  of  employing  four  suspending  loops 
which  divide  the  circumference  of  the  bowel  into  thirds,  we  may  use  but  two  loops,  and 
thus  divide  the  circumference  into  halves;  or,  if  available,  the  "holder"  devised  by  Dr. 
E.  H.  Lee  can  be  recommended  highly,  and  will  be  found  a  most  efficient  aid  in  main- 
taining the  cut  edges  in  apposition.  (The  description  of  the  instrument  will  be  found  in 
the  "Annals  of  Surgerj',"  January,  1901.) 

h,  Loop  2  has  been  cut  away,  and  loop  i  takes  its  place  in  one  hand  of  the  assistant, 
with  loops  3  and  4  held  in  the  other  hand,  thereby  bringing  into  apposition  that  portion 
of  the  walls  to  be  included  in  the  second  third  of  the  suture.  The  operator  continues 
the  suture  to  the  points  of  insertion  of  loops  3  and  4,  where  again  a  back  stitch  is  taken, 
to  fix  the  suture  and  prevent  a  purse-string  contraction  of  the  same.  The  white  eleva- 
tion in  the  center  of  illustration,  representing  mesentery,  shows  that  that  portion  of  the 
intestinal  wall  not  covered  by  peritoneum,  at  the  mesenteric  border,  has  been  secured 
in  the  suture. 

c.  The  needle,  after  having  entered  the  lumen,  is  passed  out  again  on  the  same  side 
I  inch  distant;  then  over  to  the  opposite  cut  end,  where  it  is  inserted  from  vrithout  in, 
and  again  emerges  from  within  out,  on  the  same  side.  This  step — the  taking  of  a  bite 
— is  repeated  alternately  on  opposing  margins  until  the  necessary  number  of  stitches 
have  been  inserted.  It  will  be  observed  that  when  the  needle  enters  the  lumen  the  last 
time,  it  makes  what  might  be  termed  a  half-stitch,  as  it  does  not  return  again  through 
the  wall;  but  having  reached  the  point  where  the  suture  was  commenced,  the  free  end 
and  the  needle  end  will  complete  the  last  stitch,  when  tied,  on  the  mucosa.  The  needle 
at  this  point  is  then  brought  out  of  the  lumen  at  the  angle  of  wound  alongside  of  the  free 
end  of  the  suture.  The  cross-over  stitches  are  next  carefully  drawn  up,  thus  bringing 
into  contact  the  opposing  serous  surfaces  at  every  point  except  where  the  suture  ends 
still  protrude. 

d,  The  eye-end  of  threaded  needle  is  made  to  emerge  alongside  of  the  suture  ends, 
and  is  then  withdrawn  a  little,  which  causes  its  thread  to  form  a  loop,  through  which  the 
assistant  passes  the  ends  of  the  suture.  The  operator  next  withdraws  the  threaded 
needle,  at  the  same  time  bringing  vwth  it  the  suture  ends,  and  they  present  externally  at 
the  point  of  withdrawal  of  the  needle.  The  serous  coats  throughout  the  entire  circum- 
ference are  now  in  apposition,  and  the  suture  ends  can  be  tied. 

e.  By  slight  traction  on  the  suture  ends  the  opposing  mucous  surfaces  are  brought 
in  close  contact;  the  suture  ends  are  then  tied  firmly,  and  deep  between  the  serous  coats, 
thus  tying  the  knot  upon  the  mucous  coat,  and  the  ends  then  cut  off  short. 


.INTESTINAL   SUTURE. 


Plate  ii. 


Operations  Upon  the  Stomach 


1079 


suture  running  obliquely  across  the  wound.  Cushing's  right-angled  suture  (Fig. 
633)  is  a  continuous  suture  catching  up  the  submucous  coat  and  serving  to 
invert  the  serous  layer.  Ford,  of  San  Francisco,  employs  a  continuous  inversion 
suture,  which  is  tied  in  a  single  knot  each  time  it  is  drawn  through  (Fig.  634). 
Ualsted's  mattress  or  quilt  suture  is  shown  in  Fig.  635.  Each  stitch  picks  up 
the  submucous  coat.  Mattress  sutures  do  not  tear  out  easily,  they  appose 
evenly  considerable  surfaces,  and  do  not  constrict  the  tissue  as  much  as  Lem- 
bert  stitches.  The  Czerny-Lembert  suture  is  a  suture  passed  through  the  serous 
membrane  on  one  side  of  the  wound,  made  to  perforate  the  mucous  membrane, 
and  to  emerge  at  a  corresponding  point  of  the  serous  membrane.     A  Lembert 


Fig.  636. — Czemy-Lembert  suture. 


Fig.  637. 


-Czerny-Lembert  suture  as  at  present 
used. 


suture  is  added  (Fig.  636).  As  at  present  used,  the  Czerny  suture  is  carried  to, 
but  not  through,  the  mucous  membrane  (Fig.  637) .  Gussenbauer's  suture  is  simi- 
lar to  the  Czerny-Lembert  suture,  except  that  it  applies  the  Czerny  and  the  Lem- 
bert -uith  one  suture,  and  this  suture  does  not  pass  through  the  mucous  mem- 
brane (Fig.  638).  In  ConneWs  suture  (F.  Gregory  Connell,  in  "Phila.  Med. 
Jour.,"  Jan.,  1899)  the  knots  are  placed  within  the  lumen  of  the  bowel  (Plate 
11).  Connell's  very  useful  and  ingenious  stitch  seems  to  be  a  modification  of  a 
stitch  described  by  Frederick  Holme  Wiggin  ("Med.  Record,"  Nov.  19,  1898). 
Wolfler's  suture  unites  broad  layers  of  the  serous  coat,  the  knots  being  tied 
internally  (Fig.  639).     Senn  says  that  after  suturing  a  large  wound  of  the  stom- 


Fig.  638. — Gussenbauer's  suture. 


Fig.  639. — Woliier's  sutiure. 


ach  or  of  the  intestine  a  strip  of  omentum  ought  to  be  laid  over  the  wound  and 
fastened  by  catgut  sutures  (omental  graft) .  These  grafts  adhere  and  are  a  safe- 
guard against  leakage.  (For  other  methods  of  enterorrhaphy  see  Intestinal 
Resection  and  Anastomosis.) 

Operations  Upon  the  Stomacli. — A  patient  must  be  carefully  pre- 
pared for  an  operation  upon  the  stomach.  The  Johns  Hopkins  method, 
founded  on  the  researches  of  Harvey  Cushing  regarding  sterilization  of  the 
stomach,  is  to  be  used.  During  the  two  or  three  days  immediately  preceding 
operation  clean  the  mouth  and  teeth  several  times  dtiring  the  day  with  a  car- 
bolic solution.     Give  only  sterile  water  and  sterile  liquid  food  by  the  mouth. 


io8o  Diseases  and  Injuries  of  the  Abdomen 

and  for  twelve  hours  before  operation  give  no  food  whatever.  During  the  two 
or  three  days  before  operation  wash  out  the  stomach  with  boiled  water  night 
and  morning.  I  do  not  wash  immediately  before  operation,  as  it  sometimes 
leads  to  annoying  vomiting  and  thus  may  interfere  with  anesthetization. 
After  operation  give  no  food  whatever  for  thirty-six  hours.  Small  quantities 
of  hot  water  are  allowed  as  soon  as  the  patient  recovers  from  ether.  During 
the  first  twenty-four  hours  give  an  enema  of  hot  salt  solution  and  coffee  every 
five  hours  and  then  alternate  nutritive  enemata  with  salt  enemata.  After 
thirty-six  or  forty-eight  hours  usually  begin  to  give  food  by  the  mouth — at  first 
small  doses  of  albumin-water,  and,  if  this  is  tolerated,  broth  and  milk.  Sohd 
food  should  not  be  given  for  two  weeks. 

If  the  patient  is  advanced  in  emaciation  and  much  exhausted  we  should  not 
wait  for  thirty-six  hours  to  feed  him,  but  should  give  milk  and  broth  as  soon  as 
the  patient  recovers  from  ether.  The  bowels  should  be  moved  by  enema  the 
day  after  the  operation.     If  the  enema  fails,  calomel  is  given  (3  or  4  gr.). 

Digital  Dilatation  of  Pylorus  for  Cicatrical  Stenosis  (Loreta's 
Operation,  or  Pylorodiosis). — Place  the  patient  recumbent  and  admin- 
ister ether.  Make  a  vertical  incision  in  the  linea  alba  or  through  the  right 
rectus  muscle.  The  median  incision  begins  i  inch  below  the  ensiform  car- 
tilage. The  cut  in  either  case  should  be  5  inches  in  length.  When  the  peri- 
toneum has  been  opened  the  stomach  is  drawn  out  of  the  wound,  any  adherent 
omentum  is  separated,  and  the  pylorus  is  carefully  examined.  The  stomach, 
after  being  surrounded  with  gauze  pads,  is  opened  near  the  center  of  its  anterior 
surface,  "but  rather  nearer  to  its  pyloric  end"  (Jacobson). 

Insert  the  index-finger  through  the  stomach  wound  and  into  the  pylorus, 
and  follow  that  with  the  middle  finger.  The  pylorus  can  be  well  dilated  by 
separating  the  fingers.  If  the  stenosis  is  so  tight  as  to  prevent  the  entry  of  a 
finger,  first  introduce  a  pair  of  hemostatic  forceps  and  open  the  blades  a  little 
when  they  are  within  the  lumen  of  the  constricted  area.  The  wound  in  the 
stomach  is  closed  by  a  continuous  silk  suture  of  the  mucous  membrane  and 
two  layers  of  Halsted  sutures,  to  invert  and  approximate  the  peritoneal  sur- 
faces.    After  closure  of  the  stomach  wound  the  abdominal  wound  is  sutured. 

Divulsion  by  the  fingers  or  by  an  instrument  is  no  longer  practised,  because 
experience  has  shown  that  the  constriction  is  sure  to  return. 

Pyloroplasty  (Heineke=Mikulicz  Operation). — The  first  operation 
was  performed  by  Heineke  in  1886.  Early  in  1S87  Mikulicz,  not  knowing 
of  Heineke's  antecedent  operation,  did  the  same  thing.  Open  the  abdomen  in 
the  middle  line  or,  better,  through  the  right  rectus  muscle.  Draw  up  the 
pylorus  as  well  as  possible,  and  pack  warm  moist  gauze  pads  around  it ;  make 
an  incision  through  the  stricture  and  in  a  direction  corresponding  to  the  long 
axis  of  the  stomach  and  bowel  (Fig.  640).  Catch  an  aneurysm-needle  under 
the  upper  margin  of  the  incision  and  draw  it  up,  and  an  aneurysm-needle  under 
the  lower  margin  and  draw  it  down.  The  effect  of  traction  is  to  convert  the 
longitudinal  wound  into  a  transverse  wound.  The  sutures  are  applied  so  as  to 
maintain  the  wound  in  a  vertical  line  (Fig.  641).  The  mucous  membrane  is 
sutured  with  a  continuous  suture  of  silk,  and  interrupted  Lembert  or  Halsted 
sutures  of  silk  close  the  peritoneal  and  muscular  coats  (Figs.  641  and  642). 
Do  not  drain.  A.  W.  Mayo  Robson  inserts  a  bone  bobbin  and  then  applies 
the  sutures.  The  operation  of  pyloroplasty  shows  a  mortality  about  the  same 
as  or  slightly  less  than  gastro-enterostomy.  In  some  cases  it  is  a  very  satisfac- 
tory procedure,  but  there  are  objections  to  it,  and  in  30  per  cent,  of  cases  it 
fails  to  give  relief  (Wm.  J.  Mayo).  The  outlet  is  not  at  the  most  dependent 
part  of  the  stomach,  hence  the  stomach  may  not  empty  itself.  Further,  as 
Finney  points  out,  it  cannot  be  performed  if  there  are  firm  adhesions  or  active 
ulceration,  and  the  scar  may  contract  and  give  rise  to  stenosis.     Again,  it  is 


Gastroduodenostomy  by  Finney's  Method 


1081 


difficult  to  suture  the  wound  so  as  certainly  to  provide  against  leakage.     The 
Mayos  reported  21  pyloroplasties  without  a  death,  but  7  cases  required  sec- 


640.— Heineke-Mikulicz's  pyloroplasty:  The 
incision. 


Fig.  641. — Heineke-Mikulicz's  pyloroplasty: 
The  axis  of  the  incision  is  changed  by  traction 
from  horizontal  to  vertical;  sutures  in  position; 
only  one  of  the  two  rows  of  sutures  is  shown. 


ondary  operations  ("Annals  of  Surgery,"  Nov.,  1905).     Pyloroplasty  has  been 
abandoned  by  many  surgeons ;  J.  Rutherford  Morison  still  advocates  it.     Fin- 
ney has  devised  an  operation  to  correct 
the  objections  to  pyloroplasty. 

Gastroduodenostomy  by  Fin= 
ney's  Method.  —  This  operation  is 
usually  called  a  method  of  pyloroplasty, 
but  it  is  rather  a  gastroduodenostomy. 
The  operation  was  described  in  the 
''John's  Hopkins  Hospital  Bulletin," 
July,  1902,  and  was  then  called  pylo- 
roplasty. It  is  performed  as  follows: 
Thoroughly  free  the  first  portion  of 
the  duodenum  and  the  pyloric  end  of 
the  stomach  by  dividing  the  posterior 
layer  of  peritoneum  i  inch  to  the  right 

side  of  the  duodenum.     This  step  is  known  as  mobilization.     Insert  three 
retractor  sutures  (Fig.  643)  and  draw  upon  them.     Suture  together,  as  far 


Fig.     642. — Heineke-Mikulicz's     pyloroplasty: 
After  tying  the  sutures. 


Fig.  643.- 


-Finney's  pyloroplasty:  The  retractor 
sutures. 


Fig.     644. — Finney's    pyloroplasty:     Suture    of 
greater  curvature  of  stomach  to  duodenum. 


posterior  as  possible,  the  peritoneal  surface  of  the  duodenum  and  the  peri- 
toneal surface  of  the  stomach  along  its  greater  curvature  (Fig.  644).    Then 


io82 


Diseases  and  Injuries  of  the  Abdomen 


insert  an  anterior  row  of  mattress  sutures,  but  do  not  tie  them  as  yet  (Fig. 
645).  Make  a  horseshoe-shaped  incision  (Fig.  646);  arrest  bleeding;  excise  as 
much  scar-tissue  as  possible  on  either  side  of  the  incision,  and  trim  off  the  re- 
dundant mucous  membrane.  Insert  a  continuous  catgut  suture  on  the  posterior 
side  of  the  incision  and  carry  it  through  all  the  coats  (Fig.  647) .     Straighten  out 


Fig.  645. — Finney's  pyloroplasty:  Shows  the 
three  retractor  sutures,  the  posterior  hne  of  su- 
tures tied  and  the  anterior  line  of  sutures  untied. 


Fig.  646. — Finney's  pyloroplasty:  The  anterior 

sutures  gathered  and  lifted. 


the  anterior  sutures  and  tie  them  (Fig.  648).  The  Mayos  reported  58  Finney 
operations,  with  4  deaths  and  2  secondary  operations  (Wm.  J.  Mayo,  in  "Annals 
of  Surgery,"  Nov.,  1905). 

The  mortaHty  is  greater  than  after  gastro-enterostomy,  due  probably  to  the 
necessity  of  separating  adhesions  and  setting  the  duodenum  free.     The  opera- 


Fig.  647. — ^Finney's  pyloroplasty:  The  continu- 
ous posterior  catgut  suture. 


Fig.  648. — Finney's  pyloroplasty  completed  by 
tying  the  anterior  sutures. 


tion  should  be  restricted  to  cases  in  which  adhesions  are  not  widespread  and 
firm  and  in  which  the  gastrohepatic  omentum  is  of  fair  length.  In  properly 
selected  cases  it  is  a  very  valuable  operation. 

Pylorectomy  (Excision  of  the  Pylorus). — The  removal  of  a  portion  of 
the  stomach  is  a  partial  gastrectomy,  and  pylorectomy  is  a  partial  gastrectomy 
in  which  the  pylorus  and  also  a  portion  of  duodenum  are  removed. 


Method  of  the  Mayos  for  Pylorectomy 


1083 


The  experiments  of  Gussenbauer  and  von  Winiwarter  on  dogs  in  1876  led 
them  to  suggest  the  operation.  It  was  first  performed  by  Pean  in  1879.  It 
was  next  performed  by  Rydygier  in  1880.  Billroth  did  the  first  successful  pylo- 
rectomy in  1 88 1.  The  operation  is  seldom  performed  for  anything  but  cancer, 
but  sometimes  is  done  for  pyloric  ulcer  and  its  results.  In  many  cases  of  pyloric 
cancer  the  abdomen  is  opened  only  after  a  palpable  tumor  is  detected,  and  when 
a  palpable  tumor  is  detectable  it  is  usually  too  late  to  perform  pylorectomy.^ 
The  lesson  is  to  explore  suspected  cases  earlier  than  has  been  our  custom. 

I  agree  with  Hemmeter  that  stenotic  symptoms,  even  when  no  tumor  is 
palpable,  call  for  exploratory  laparotomy;  if  the  stomach  is  dilated,  if  there 
is  cachexia,  if  there  is  no  free  hydrochloric  acid  in  the  gastric  jmce,  if  there  is 
an  excess  of  lactic  acid  in  the  gastric  juice,  if  the  patient  is  at  or  beyond  forty 
years  of  age,  when  there  is  vomiting  of  blood,  when  the  Oppler  bacillus  is 
present,  when  blood  examination  shows  a  diminution  in  red  corpuscles  and 
hemoglobin,  and  also  shows  that  there  is  no  increase  in  white  corpuscles  after  a 
fuU  meal.  After  the  abdomen  has  been  opened  the  stomach  is  examined,  and 
if  a  tvimor  exists,  the  surgeon  must  decide  between  the  performance  of  pylo- 
rectomy and  gastro-enterostomy.  If  the  tumor  is  not  very  extensive,  if  there 
is  no  glandular  involvement  or  only  involvement  which  can  be  removed,  and  if 

adhesions  are  not  extensive,  pylorec- 
tomy is  chosen;  otherwise  gastro-enter- 
ostomy is  selected. 


Fig.  64g. — Billroth's  method  of  pylorectomy. 


Fig.  650. — Pylorectomy. 


UntU  very  lately  the  mortahty  from  pylorectomy  was  estimated  to  be  25 
per  cent.,  even  in  favorable  cases.  In  9  complete  pylorectomies,  with  closure 
of  both  the  stomach  and  duodenal  ends,  communication  being  reestabhshed 
by  the  performance  of  gastrojejunostomy,  Mayo  reported  i  death,  and  in  14 
pylorectomies  and  partial  gastrectomies  he  reported  2  deaths,  or  14  per  cent. 
(Wm.  J.  Mayo,  in  ''Annals  of  Surgery,"  Aug.,  1902)  (seepage  1085).  Prepare 
the  patient  for  pylorectomy  as  for  any  stomach  operation.  The  best  incision 
through  the  abdominal  wall  is  a  vertical  one  in  or  near  the  median  Hne.  A 
small  incision  is  first  made  to  permit  of  exploration,  and  if  the  growth  is  found 
to  be  removable,  the  incision  is  enlarged.  In  some  cases  it  will  be  found 
necessar}'  to  divide  the  rectus  muscle  by  a  transverse  cut. 

Method  of  the  Mayos. — This  is  the  best  operation.  The  Billroth  method, 
which  was  long  employed,  does  not  remove  enough  of  the  stomach  if  there  is 
malignant  disease,  the  opening  left  in  the  stomach  is  much  larger  than  the 
duodenal  opening,  and  in  suturing  so  as  to  make  the  two  openings  of  equal 
size  an  angle  is  left  which  is  apt  to  leak.  Billroth's  operation  is  shown  in 
Figs.  649  and  650.  In  the  Mayo  method,  after  the  stomach  has  been  exposed 
the  gastric  arten,^  is  ligated  close  to  the  stomach,  the  lesser  omenttmi  is  tied 
in  several  segments  close  to  the  liver  and  then  di\dded,  and  the  pyloric  artery 
is  tied.  Two  clamps  are  appHed  to  the  duodenum  i  inch  apart,  and  the  duo- 
denimi  is  divided  by  means  of  the  cautery  (Fig.  651). 

The  right  end  of  the  duodemmi  is  closed  by  means  of  a  continuous  catgut 
^  Keen's  "Cart-wTight  Lectures  for  1808." 


1084 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  651. — Pylorectomy  by  the  Mayo  method: 
Clamps  applied,  duodenum  divided,  and  continuous 
catgut  stitch  introduced  (Mayo) . 


suture,  the  clamp  is  removed,  and  the  closed  end  of  the  duodenum  is  inverted 
by  a  purse-string  suture  (Fig.  652).     A  hand  is  passed  from  above  back  of  the 

stomach  and  lifts  the  great  omen- 
tum forward.  The  right  gastro- 
epiploic artery  is  tied  close  to  the 
stomach.  The  left  gastro-epiploic 
artery  is  tied  distinctly  to  the  left 
of  any  enlarged  glands  in  the  great 
omentum.  The  great  omentum  is 
tied  in  several  segments.  The 
great  omentum  is  divided,  leaving 
any  enlarged  glands  attached  to 
the  portion  of  the  stomach  it  is 
the  intention  to  remove.  The 
stomach  is  to  be  divided  to  the 
left  of  all  lymphatic  glands  into 
which  the  cancerous  region  drains. 
The  clamps  are  applied  as  shown 
in  Fig.  651.  The  stomach  is 
divided  between  the  clamps  by 
a  cautery,  and  as  the  di\dsion  is 
being  carried  out  the  stump  is 
caught  here  and  there  by  hemo- 
static forceps  to  prevent  it  slip- 
ping through  the  clamps.  Slip- 
ping is  disastrous  and  will  cause 
leaking  and  entrance  of  air  into  the  stomach,  and  entrance  of  air  is  apt  to 
be  foUow^ed  by  pulmonary  difficulty.  A  row  of  locking  stitches  is  passed 
through  all  the  coats  of  the  stump. 
The  stitches  are  tied  and  a  second 
row  is  passed  and  tied  (Fig.  652). 
The  clamp  is  removed  and  the 
stump  is  buried  by  Cushing's 
right-angled  suture  or  Dupuy- 
tren's  suture.  A  gastrojejunos- 
tomy is  then  performed  to  the 
posterior  wall  of  the  portion  of 
stomach  which  remains. 

Such  a  patient  is  usually  much 
dehydrated,  and  if  he  is,  salt  solu- 
tion should  be  given  intraven- 
ously during  the  operation,  and 
an  enema  of  warm  salt  solution 
should  be  administered  every  six 
hours  for  several  days  after  the 
operation.  Active  stimulation  is 
usually  necessary  and  8  oz.  of 
coffee  should  be  given  by  rectimi 
at  the  completion  of  the  opera- 
tion. The  patient  must  be  placed 
erect  or  semi-erect  in  bed  as  soon 
as  the  effects  of  the  ether  pass 

away.  Twelve  hours  after  operation  begin  to  give  small  amounts  of  hot  water 
by  the  mouth.  Nourish  by  the  rectum  from  four  to  sLx  days,  when  fluid  food 
may  be  given  by  the  mouth,  starting  w^th  small  doses  of  albumin- water,  and, 


Fig.  652. — Pylorectomy  by  the  Mayo  method: 
End  of  divided  duodenum  buried  by  a  purse-string 
suture.  Row  of  lock  stitches  inserted  in  stomach 
stump  (Mayo). 


Gastrotomy  1085 

if  this  is  tolerated,  giving  dessertspoonful  doses  of  peptonized  milk  every 
hour.  During  191 2  the  Mayos  did  46  pylorectomies  for  cancer,  with  5 
deaths  ("Report  of  St.  Mary's  Hospital").  They  did  13  for  ulcers  and  benign 
tumors  without  a  death  (Ibid.).  If  during  the  operation  the  pancreas  is 
wounded  the  closed  end  of  the  duodenum  is  applied  chrectly  to  the  pancreatic 
wound,  as  Willy  Meyer  suggested  (^ 'Trans,  of  Am.  Surg.  Assoc,"  1910). 
"The  anterior  peritoneiun  and  adventitious  sheath  of  the  pancreas  is  then 
sutured  to  the  anterior  surface  of  the  duodenum."  This  plan  prevents  leakage 
from  the  duodenum  and  pancreas  (Wm.  J.  Mayo,  in  "Annals  of  Surgery," 
August,  1 91 3). 

Total  Gastrectomy. — The  entire  stomach  was  first  removed  by  Conner, 
of  Cincinnati,  in  1SS3.  The  first  successful  operation  was  performed  by 
Schlatter,  of  Zurich,  in  1897.  Total  gastrectomy  will  rarely  be  required,  but  in 
certain  unusual  cases  it  will  be  proper  to  perform  it.  In  some  cases  the  duo- 
denal end  can  be  sutured  to  the  divided  esophagus ;  in  others  it  will  be  necessary 
to  close  the  end  of  the  di\aded  first  portion  of  the  duodenum,  and  anastomose 
the  esophagus  to  the  jejunum. 

The  cases  suitable  for  total  gastrectomy  are  those  in  which  the  entire 
\'iscus,  or  almost  the  entire  viscus,  is  cancerous,  the  stomach  being  still  freely 
movable,  and  the  glands  not  so  much  imphcated  as  to  forbid  attempts  at 
removal.  It  is  a  remarkable  fact,  first  demonstrated  in  Schlatter's  case, 
that  an  indi\ddual  can  digest  food  very  well  without  a  stomach.  This  state- 
mient  is  true  only  if  the  stomach  function  has  been  gradually  abolished  by  dis- 
ease. Durmg  this  period  the  functions  of  the  stomach  have  been  assumed  to  a 
greater  or  less  degree  by  other  parts.  In  a  recent  injury  of  the  stomach  com- 
plete removal  would  almost  certainly  be  followed  by  death,  as  in  such  a  case 
other  parts  would  have  had  no  chance  to  learn  how  to  assmne  gastric  duties. 
The  reported  cases  of  total  gastrectomy  show  10  deaths  out  of  27  cases,  but, 
as  Robson  truly  says,  if  all  cases  were  reported,  the  mortality  would  probably 
be  found  to  be  50  per  cent.  Trinkler  ("Archiv.  fiir  klin.  Chir.,"  Berlin, 
xcvl,  No.  2)  reports  i  case  (which  died  on  the  eighth  day)  and  gathers  25 
from  literature;  13  recovered.  WTien  the  duodenimi  was  stitched  to  the 
esophagus  the  mortahty  was  57.1  per  cent.  When  the  jejunum  was  stitched 
to  the  esophagus  the  mortality  was  28.5  per  cent. 

I  have  done  the  operation  once.     The  patient  died  on  the  third  day. 

Gastrotomy. — This  term  is  used  to  designate  the  operation  of  opening 
the  stomach  for  the  accomplishment  of  some  purpose,  and  immediately  closing 
the  incision  in  the  gastric  wall  when  that  purpose  is  accomplished.  Gas- 
trotomy may  be  performed  to  permit  of  the  removal  of  foreign  bodies,  of  explo- 
ration of  the  stomach  and  its  extremities,  of  divulsion  of  the  pyloric  orifice, 
of  the  treatment  of  bleeding  of  an  esophageal  stricture  or  a  stricture  of 
the  cardiac  orifice  of  the  stomach,  or  of  the  removal  of  a  foreign  body  lodged 
in  the  esophagus.  The  first  case  on  record  was  in  1602,  when  Florian  Mathias, 
of  Brandenburg,  removed  from  the  stomach  of  a  juggler  a  knife  which  had 
been  accidentally  swallowed.  When  Evelyn  was  in  Leyden  in  1641  he  saw  a 
knife  which  had  been  removed  by  gastrotomy.  He  says  (Evelyn's  Diary) : 
"I  was  showed  the  knife  newly  taken  out  of  a  drunken  Dutchman's  guts  by 
an  incision  in  his  side,  after  it  had  slipped  from  his  fingers  into  his  stomach. 
The  picture  of  the  surgeon  and  his  patient,  both  living,  were  there." 

The  patient  is  prepared  as  for  pylorectomy.  The  incision  may  be  vertical 
in  the  middle  line  or  identical  with  the  incision  for  pylorectomy.  If  a  large 
foreign  body  can  be  felt,  the  incision  is  made  directly  over  it.  WTien  the 
peritoneal  ca\'ity  is  opened,  the  surgeon  decides  as  to  the  point  where  the 
stomach  is  to  be  incised,  and  draws  this  portion  out  through  the  wound, 
packing  gauze  pads  under  and  around  it.     The  stomach  is  opened  by  means 


io86 


Diseases  and  Injuries  of  the  Abdomen 


of  scissors,  the  cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus  (Jacob- 
son).  Bleeding  vessels  are  ligated  with  catgut.  The  purpose  for  which  the 
stomach  was  opened  is  now  to  be  carried  out,  the  interior  of  the  stomach 
and  the  surface  of  the  extruded  portion  are  irrigated  with  hot  salt  solution, 
the  mucous  membrane  is  sutured  with  a  continuous  suture  of  silk,  and  two 
rows  of  Halsted  sutures  are  inserted.  The  abdominal  wound  is  closed,  drain- 
age being  employed  for  twenty-four  hours. 

Gastrostomy  is  the  making  of  a  permanent  gastric  fistula,  through  which 
opening  the  patient  can  be  fed.  Gastrostomy  was  first  proposed  by  Egebert 
in  1837  and  was  first  performed  by  Sedillot  in  1849.  In  1875  Sydney 
Jones  operated  upon  the  twenty-ninth  case  and  obtained  the  first  recovery 
(Keen).  Up  to  1884  the  estimated  mortality  was  80  per  cent.  At  present 
the  mortality  in  maUgnant  cases  is  from  20  to  25  per  cent.,  and  in  non-malig- 


Fig.  653. — Witzel's  method  of  gastrostomy, 
showing  application  of  sutures  in  wall  of  stom- 
ach, embedding  tube  obliquely  therein. 


Fig    654 — Sutures  tied    completely  embedding- 
tube  obliquely  therein. 


nant  cases  from  8  to  10  per  cent.  Gastrostomy  is  employed  in  cases  of  esopha- 
geal obstruction  or  obstruction  of  the  cardiac  end  of  the  stomach.  In  many 
cases  of  malignant  disease  the  operation  is  performed  too  late,  and  if  performed 
when  the  patient  is  greatly  emaciated  and  exhausted  the  operation  has,  of 
course,  a  high  mortality.  An  early  operation  is  far  safer  and  confers  the  maxi- 
mum of  relief.  The  operation  should  be  performed,  as  Mikulicz  advises,  when 
the  patient  is  steadily  losing  weight  and  there  is  beginning  to  be  difficulty  in 
swallowing  semisolids  or  liquids.  The  surgeon  must  endeavor  to  perform 
an  operation  which  will  not  permit  of  leakage.  Prepare  the  patient  as  for  any 
stomach  operation,  except  as  to  washing  out  the  stomach,  which  is  usually 
impossible. 

Witzel's  Method. — This  operation  was  first  practised  in  1 89 1 .  Make  an  incis- 
ion 4  inches  in  length,  running  to  the  left  from  the  middle  line,  just  below 
the  border  of  the  ribs.     After  opening  the  peritoneal  cavity  seize  the  stomach. 


Gastrostomy 


1087 


bring  it  out  of  the  wound,  and  pack  gauze  around  it.  Introduce  a  rubber 
tube  into  the  stomach  and  enfold  it  by  a  double  row  of  Lembert  sutures 
(Figs.  653,  654).  This  tube  should  be  5  inches  long  and  of  the  same  diameter 
as  a  No.  25  French  bougie.     The  opening  is  made  in  the  stomach  toward  the 


Fig.  655. — Kader's  method  of  gastrostomy:  Tube 
in  place  and  first  row  of  sutures  inserted. 


Fig.  656. — Kader's  method  of  gastrostomy:  First 
row  of  sutures  tied  and  second  row  inserted. 


cardiac  extremity,  the  tube  is  placed  parallel  with  the  belly  wound,  and  the 

outer  end  of  the  tube  emerges  in  the  median  line.     The  tube  is  retained  in  place 

by  a  catgut  stitch  carried  through  the  tube  and  the  stomach  wall.     The 

stomach  is  returned  and  is  stitched  by  three 

sutures  to  the  abdominal  wall.     The  abdominal 

incision  is  sutured  and  a  clamp  is  placed  on  the 

tube.      When  the   patient  is  fed,   a  funnel   is 

slipped  into  the  tube,  the  clamp  is  removed, 

and   liquid   food    is   poured   into    the    funnel. 

After    the   wound    heals   it   is    not    necessary 

to  retain  the  tube  permanently.     It  is  passed 

when  the  patient  desires  food. 

Kader's  Method. — This  operation  was  devised 
in  1896.  It  is  a  modification  of  Witzel's  method. 
A  small  incision  is  made  in  the  stomach  and  a 
tube  is  introduced  and  fastened  to  the  stomach 
by  one  catgut  stitch.  Four  Lembert  sutures  are 
passed  so  as  to  form  a  fold  on  each  side  of  the 
tube  and  turn  the  stomach  wall  inward  around 
the  tube  (Fig.  655).  Lembert  sutures  are  in- 
serted in  the  furrow  on  each  side  of  the  tube. 
Two  more  folds  are  formed  over  the  first  two 
(Figs.  656  and  657).  The  stomach  wall  is 
stitched  to  the  parietal  peritoneum  and  sheath 
of  the  rectus  muscle  (Willy  Meyer). 

The  Ssabanajew-Frank  Method. — This  operation  is  preferred  by  many 
surgeons.  I  usually  employ  it  if  the  stomach  is  not  so  shrunken  as  to  ren- 
der the  pulling  out  of  a  sufficient  cone  impossible.  It  was  first  performed 
by  Ssabanajew  in  1890  and  was  performed  independently  by  Frank  in  1893. 
Fenger's  incision  is  made  (a  curved  incision  at  the  margin  of  the  costal  car- 
tilages of  the  left  side).  A  cone  of  the  stomach  is  pulled  out  of  the  wound 
and  is  passed  under  a  bridge  of  skin  which  has  been  prepared  for  it.  The 
stomach  is  fLxed  above  the  margin  of  the  ribs  and  opened  (Figs.  658,  659). 


Fig.  657. — Kader's  method  of  gas- 
trostomy: Second  row  of  sutures 
tied. 


io88 


Diseases  and  Injuries  of  the  Abdomen 


Von  Hacker  makes  the  gastric  fistula  through  the  left  rectus  muscles,  and  Hahn 
between  two  of  the  rib  cartilages  (Willy  Meyer). 

The  Younger  Semi's  Method. — Emanuel  Senn  devised  the  following 
method:  A  cone  of  the  stomach  is  pulled  out  of  the  abdominal  wound,  and 
this  cone  is  puckered  by  the  insertion  of  two  drawing-string  sutures  of  chromi- 
cized  catgut,  A  cuff  of  gastrocolic  omentum  is  sutured  by  silk  around  the 
neck  of  the  puckered  cone.  The  stomach  is  sutured  to  the  belly  wall  with  silk, 
the  sutures  including  the  omental  cuff,  the  serous  and  muscular  coats  of  the 

stomach,  and  the  structures  of  the 
belly  wall,  except  the  skin.  The  skin 
is  partly  sutured.  The  stomach  may 
be  opened  at  any  time. 


Fig.  658.  Fig.  659. 

Figs.  658,  659. — The  Ssabanajew-Frank  method  of  gastrostomy  in  carcinoma  of  the  esophagus. 

Qastro=enterostomy  or  gastrojejunostomy  is  the  estabhshment  of 
a  permanent  fistula  between  the  stomach  and  the  small  intestine,  in  order 
to  side-track  the  pylorus.  The  operation  is  performed  for  cancer  of  the 
pylorus,  for  non-cancerous  stenosis  of  the  pylorus,  in  some  cases  of  ulcer 
of  the  stomach,  and  for  tetany.  Anterior  gastro-enterostomy  was  proposed 
by  Nicoladoni  in  1881  and  was  first  performed  by  Wolfler  the  same  year. 
In  Wolfler's  early  operations  the  jejunimi  was  so  placed  that  the  proximal  end 
was  to  the  right  of  the  anastomosis  opening.  Hence  peristalsis  in  the  stomach 
was  from  left  to  right  and  in  the  jejunum  from  right  to  left,  and  this  was  sup- 
posed to  be  responsible  for  the  common  occurrence  of  regurgitant  vomiting. 
It  was  sought  to  prevent  this  by  altering  the  direction  of  the  loop  (Liicke), 
then  by  entero-anastomosis  (Braun),  and  finally  by  posterior  anastomosis. 
Posterior  gastro-enterostomy  was  first  proposed  by  Courvoisier  in  1883. 
His  suggestion  was  that  the  posterior  surface  of  the  stomach  be  reached 
through  the  transverse  mesocolon.  His  plan  necessitated  a  transverse  division 
of  the  mesocolon,  but  it  was  found  that  this  impaired  the  blood-supply  of  a 
part  of  the  colon  and  might  lead  to  gangrene.  Von  Hacker,  in  1885,  devised 
an  improved  posterior  operation.  As  a  matter  of  fact,  the  transverse  meso- 
colon has  a  marginal  artery,  unlike  other  parts  of  the  colon,  and  the  danger  of 
gangrene  from  a  transverse  incision  is  probably  not  very  great.  In  the  earlier 
operations  by  the  posterior  method  a  long  loop  was  used  and  results  were  not 
notably  better  than  after  the  anterior  operation.  In  1890  Czerny  and  Peter- 
son advised  the  making  of  the  jejunal  opening  close  to  the  duodenojejunal 
flexure.     The  results  from  this  operation  are  vastly  better  than  from  the 


Complications  Following  Gastro-enterostomy  10S9 

anterior  operation.  Posterior  gastro-enterostomy  has  been  signally  im- 
proved in  technic  by  the  Mayos,  JMoynihan,  and  others.  In  the  earUer  opera- 
tions of  anterior  gastro-enterostomy  the  mortaUty  was  40  per  cent.  In  non- 
malignant  conditions  the  mortality  after  gastro-enterostomy  is  now  very  low 
(mider  3  per  cent.),  the  hA-peracidity  of  the  gastric  juice  disappears,  and  the 
fmictions  of  the  stomach  are  restored.  In  malignant  cases  the  mortality  is 
about  20  per  cent.,  but  even  in  such  cases,  if  operation  is  done  early,  life  may 
be  prolonged  and  made  comfortable  for  months.  Wm.  J.  IMayo  makes  the 
following  report  upon  421  cases  of  gastrojejmiostomy:  "Benign,  307  cases, 
19  deaths  (6.1S  per  cent.).  In  the  last  140  there  were  4  deaths,  a  mortahty 
of  2.85  per  cent.;  the  last  80  gave  but  i  death.  jSIalignant,  114  cases,  T\ith 
21  deaths  (1S.5  per  cent.).  Of  these  114  cases,  63  were  in  connection  '^\ith 
pylorectomy  and  partial  gastrectomy,  with  8  deaths  (12.6  per  cent.).  The 
very  unfavorable  cases  of  cancer  obstruction  were  subjected  to  gastro-enter- 
ostomy, so  that  this  operation  gives  a  higher  mortahty  than  radical  excision. 
In  the  last  40  gastrojejunostomies  for  malignant  disease  the  mortahty  was  8 
per  cent.  In  the  421  gastrojejunostomies  there  were  21  reoperated  cases  (5 
per  cent.)"  (''Annals  of  Surgery,''  Xov.,  1905).  During  191 2  the  Mayos  did 
40  gastro-enterostomies  for  chronic  ulcer  of  the  stomach,  with  2  deaths,  and 
31  for  cancer  of  the  pylorus,  ■v^•ith  2  deaths.  They  did  the  operation  1S7  times 
for  chronic  and  subacute  ulcer  of  the  duodenum  T\ith  i  death  ("Report  of  St. 
Mar}-'s  Hospital  for  1912"),  In  about  5  per  cent,  of  cases  of  gastro-enterostomy 
for  benign  disease  secondary'  operation  has  been  required.  In  Kronlein's  clinic, 
51  cases  of  malignant  disease  subjected  to  gastro-enterostomy  showed  an  aver- 
age duration  of  life  of  192  days;  470  days  after  operation  17  cases  were  liWng. 
The  causes  of  death,  according  to  Wm.  J.  ]\Iayo,  are:  exhaustion,  exhaustion 
with  vomiting,  pneumonia,  and  detachment  of  the  anastomosed  intestine. 

Treatment  After  Gastro-enterostomy. — On  returning  the  patient  to  bed 
at  once  estabUsh  continuous  proctoclysis  "udth  one-half  strength  salt  solution, 
the  reservoir  bemg  onl}-  6  inches  above  the  level  of  the  bed.  As  soon  as 
the  patient  is  out  of  ether  place  him  semi-erect.  Mayo  begins  in  from  sixteen 
to  twenty  hours  to  administer  b}-  the  mouth  i  oz.  of  hot  water  even,"  hour,  and 
if  it  is  well  tolerated  the  amoimt  is  quickly  increased,  and  in  thirty-six  hours 
liquid  food  is  given,  and  if  tolerated,  is  continued. 

Complications  Following  Gastro-enterostomy. — Among  them  are  Jung  com- 
plications. These  are  not  due  to  the  anesthetic,  for  they  tend  to  occur  even 
when  local  anesthesia  has  been  employed.  They  are  not  due  to  the  epigastric 
incision  interfering  -^-ith  cough  and  expectoration,  for  they  are  not  nearly  so 
common  after  operations  upon  the  gall-bladder  (Wm.  J.  iSIayo).  ]Mayo  says 
that  the  latest  theor\'  is  that  some  of  the  venous  blood  returning  from  the 
stomach  does  not  pass  through  the  liver,  and  infected  emboH  are  deposited  in 
the  lungs.  The  suture  line  may  leak  after  gastro-enterostomy  because  of 
imperfect  suturing,  or  the  anastomosed  intestine  may  become  detached;  20 
per  cent,  of  the  deaths  among  Mayo's  cases  resulted  from  this  cause.  Con- 
traction of  the  anastomosis  opoiing  may  gradually  take  place.  This  has  been 
held  by  some  to  be  particularly  common  in  cases  of  dilated  stomach,  shrinking 
of  the  stomach  being  the  efficient  cause,  but  e\ddence  upon  this  point  is  not 
conclusive.  In  cases  in  which  the  pylorus  is  not  obstructed  shrinking  often 
occurs,  but  it  rarely  takes  place  when  the  pylorus  is  obstructed.  In  some  cases 
after  operation  a  spur  forms  in  the  jejunum  because  of  angulation;  in  other  cases 
adhesions  produce  obstruction;  and  in  rare  instances  ulceration  takes  place  in 
the  jejunum.  The  most  common  complication  after  gastro-enterostomy  is 
persistent  vomiting,  which  may  or  may  not  be  expressive  of  the  formation  of  a 
\dcious  circle. 

Peptic  Ulcer  of  the  Jejunum. — The  first  case  was  reported  by  Braun  in  1899. 
69 


lOQO  Diseases  and  Injuries  of  the  Abdomen 

The  first  English  case  was  reported  by  Mayo  Robson  in  1903.  Herbert  J.  Pat- 
erson  reported  a  case  and  collected  reports  of  61  other  cases  (A.  W.  Mayo 
Robson,  "Brit.  Med.  Jour.,"  Jan.  6,  191 2).  F.  Gregory  Connell  has  collected 
38  cases  and  reported  i  of  his  own,  39  in  all  ("Surg.,  Gynec,  and  Obstet.," 
Jan.,  1908).  He  points  out  that  in  many  of  the  reported  cases  acute  per- 
foration occurred.  Most  of  the  reported  cases  suffered  from  non-malignant 
trouble  and  had  hyperacid  gastric  juice.  It  very  seldom  occurs  after  opera- 
tions for  cancer.  Most  of  the  reported  cases  happened  after  the  anterior 
operation  and  when  the  anastomosis  was  very  near  to  the  pylorus.  It  has 
happened,  however,  in  9  cases  after  the  posterior  operation,  and  cases  have  been 
reported  following  both  the  anterior  and  posterior  methods  associated  with 
entero-anastomosis.  It  is  probable  that  more  cases  seem  to  follow  the  anterior 
method  because  until  late  years  it  has  been  the  operation  commonly  performed. 
In  most  of  the  reported  cases  the  ulcer  was  single;  in  3  out  of  24  cases  it  was 
multiple.  It  is  usually  in  the  distal  loop,  but  may  be  in  the  proximal  loop. 
It  may  be  situated  at  the  anastomosis  level,  a  little  way  below  it,  or  even  5  or 
6  inches  below  it.  The  ulcer  may  appear  a  few  days  after  the  operation, 
weeks  after,  months  after,  or  even  years  after.  The  condition  results  from  hy- 
peracid gastric  juice  passing  directly  into  the  jejunum  before  it  has  been  neutral- 
ized by  admixture  with  bile  and  pancreatic  juice.  It  is  possible  that  the  condi- 
tion is  predisposed  to  by  a  twist  in  the  jejunum  and  by  such  a  small  anastomosis 
opening  that  hyperacidity  was  not  corrected. 

There  may  be  no  symptoms  at  all  until  there  is  a  severe  hemorrhage  or 
perforation,  or  symptoms  similar  to  those  which  called  for  the  gastro-enter- 
ostomy  may  return.  Connell's  table  shows  that  acute  perforation  took  place 
in  14  of  the  39  reported  cases.  Pain  is  to  the  left  of  the  umbilicus,  comes  on 
two  or  three  hours  after  eating,  and  is  relieved  by  food.  There  may  be  tender- 
ness and  may  be  rigidity  of  left  rectus  muscle  (Robson,  Loc.  cit.) .  In  chronic 
cases  treatment  is  first  medical;  if  this  fails,  operation  is  indicated.  If  on 
opening  the  abdomen  it  is  found  that  the  original  pyloric  or  duodenal  ulcer 
has  healed,  but  there  is  an  ulcer  in  the  jejunum,  separate  the  bowel  from  the 
stomach,  close  the  stomach  opening,  excise  the  jejunal  ulcer,  and  close  the 
wound  in  the  bowel.  If  there  is  stenosis  of  the  pylorus  or  duodenum  we  must 
have  a  gastro-enterostomy,  so  we  make  another  after  closing  the  original  open- 
ing (Robson).  Very  extensive  ulceration  may  call  for  resection.  If  the  pa- 
tient is  greatly  weakened  or  if  the  ulceration  is  extensive,  jejunostomy  (see  page 
1 105)  may  be  done  (Robson).     In  perforation,  operation  must  be  immediate. 

The  Vicious  Circle  and  Regurgitation. — Vomiting  may  occur  after  the  per- 
formance of  gastro-enterostomy.  It  may  soon  cease,  may  be  productive  of  dis- 
astrous consequences,  and  may  be  expressive  of  an  existing  complication  of  great 
gravity.  In  some  cases  of  gastro-enterostomy  vomiting  arises  because  the  anas- 
tomosis has  been  made  high  up  on  the  anterior  gastric  wall  and  the  stomach 
is  not  drained.  In  other  cases  ether  induces  vomiting,  and  the  mechanical 
efforts  force  the  contents  of  the  duodenmn  and  even  of  the  jejunum  into 
the  stomach.  The  true  "vicious  circle"  is  a  condition  in  which  the  contents 
of  the  stomach  pass  through  the  anastomosis  opening  into  the  duodenal 
side  of  the  loop  of  intestine,  mix  with  the  duodenal  secretions,  and  return 
to  the  stomach  (Fowler,  in  "Annals  of  Surgery,"  Nov.,  1902).  The  following 
conditions  are  often  classified  under  the  same  head,  but  each  is  called  by 
Fowler  a  regurgitation  or  reflex:  (i)  When  the  duodenal  secretions  pass  back 
into  the  stomach  through  a  permeable  pylorus  (as  in  cases  of  gastroptosis, 
non-cancerous  pyloric  stenosis,  and  gastric  dilatation) ;  (2)  when  the  duodenal 
secretions  enter  the  stomach  through  the  anastomosis  opening;  (3)  when  the 
contents  of  the  jejunum  pass  into  the  stomach,  because  of  efforts  at  vomiting 
or  as  a  result  of  reversed  peristalsis.     In  some  cases  the  contents  of  the  jeju- 


Complications  Following  Gastro-enterostomy 


1091 


num  may  pass  into  the  atierent  loop  of  intestine  and  distend  it.  It  was  long 
thought  that  the  vicious  circle  was  due  purely  to  bile  passing  into  the  stomach 
from  the  proximal  (afferent)  loop  of  the  jejunimi.  Dastre's  experiments  on 
dogs  show  that  bile  in  the  stomach  does  not  impair  either  digestive  power  or 
the  general  health,  and  Moynihan  has  confirmed  these  experiments  by  chnical 
observation.  It  has  been  held  that  the  cause  of  this  condition  is  the  making 
of  an  anastomosis  with  a  long  loop  between  the  duodenojejunal  flexure  and 
the  anastomotic  opening  into  the  jejunum,  the  loop  being  unable  to  propel  its 
contents  downward  and  tending  by  its  weight  to  pro- 
duce a  bend  or  kink  at  the  seat  of  anastomosis. 
This  is  a  very  doubtful  theon.-. 

Persistent  vomiting  may  be  due  to  spur  formation, 
which  de\'iates  stomach  contents  into  the  duodenal 
side  of  the  loop.  It  is  in  some  cases  due  to  kinking 
or  twisting  of  the  distal  loop;  in  others,  to  failure  of 
peristalsis  in  the  proximal  loop;  in  still  others,  to 
contraction  of  the  opening  in  the  stomach  wall 
(Chlumsky  on  "Gastro-enterostomy"  in  the  Breslau 
Clinic;  article  by  Charles  L.  Gibson,  in  "Annals  of 
Surger\-,"  Aug.,  1908).  I  cordially  agree  with  the  statement  of  Herbert 
J.  Paterson,  xiz.:  "Most,  if  not  aU,  fatal  cases  of  regurgitant  vomiting  are 
due  to  mechanical  obstruction  at  the  afferent  opening"  ("The  Himterian 
Lectures,"  dehvered  before  the  Royal  College  of  Surgeons  of  England,  Feb. 
19,  21,  and  22,,  1906).  In  order  to  lessen  the  danger  of  vomiting  after  gastro- 
enterostomy, do  the  operation  under  a  local  anesthetic  whenever  possible:  and 
in  order  to  prevent  regurgitant  vomiting  take  ever\-  care  in  the  operation  to 
prevent  the  formation  of  a  spur  on  the  mesenteric  border  of  the  jejimum  1  Her- 
bert J.  Paterson,  Ibid.). 


Fig.    660. — Bi]lrotli"s  method 
of  gastro-enterostomy. 


Fig.  661. — Gastro-enterostomy  (after  Liicke). 


Fig.    662. — Wolder-Liicke    method    of 
enterostomy. 


After  BiUroth's  operation  (Fig.  660)  and  in  all  the  earlier  methods  the  con- 
tents of  the  duodenum  certainly  pass  into  the  stomach,  mix  with  the  stomach 
contents,  and  usually,  but  not  always,  pass  into  the  efferent  loop.  In  aU 
these  operations  there  is  great  danger  of  the  development  of  a  \dcious  circle. 

Liicke  de^'ised  an  operation  with  the  idea  of  preventing  such  a  complica- 
tion. In  the  Liicke  operation  the  direction  of  peristalsis  in  the  eff'erent 
loop  is  the  same  as  in  the  stomach  CFig.  662).  ]McGraw  points  out  that 
the  crossing  of  the  loop  which  is  eff'ected  is  dangerous.  The  Wolfler-Liicke 
operation  is  shown  in  Fig.  661.  Wolfler  also  de^-ised  the  operation  pictured  in 
Fig.  663.     \'on  Hacker's  posterior  operation  is  thought  by  some  to  be  less  apt 


1092 


Diseases  and  Injuries  of  the  Abdomen 


than  the  anterior  method  to  be  followed  by  the  vicious  circle  (Fig.  664). 
Kocher  devised  an  operation  in  which  a  valve  is  formed,  but,  as  Fowler  points 
out,  this  valve  does  not  prevent  filling  of  the  duodenum  and  imbibition  of 
the  material  by  the  stomach;  and,  further,  that  the  valve  does  not  work  when 
the  parts  become  cicatricial  (see  Fig.  668). 

The  combination  of  gastro-enterostomy  with  entero-anastomosis  does  tend 
to  prevent  the  vicious  circle.     This  operation  is  shown  in  Figs.  665  and  666. 


Fig.  664- 


-Von  Hacker's  posterior  gastro-enteros- 
tomy. 


Fig.  663. — ^Implantation  of  duodenum  into 
jejunum  and  jejunum  into  stomach  (after 
Wolfler). 

I  do  not  believe  it  should  ever  be  a  primary  operation.  It  permits  acid  gastric 
juice  to  flow  directly  into  the  jejunum  and  keeps  away  the  bile  which  would 
normally  protect  mucous  membrane.  Hence  such  an  operation  exposes  the 
patient  to  the  danger  of  jejunal  ulceration.  Another  defect  in  such  an  opera- 
tion is  that  there  is  still  a  communication  between  the  stomach  and  the  efferent 
loop.  Fowler's  operation  (see  Fig.  672)  closes  the  jejunum  and  corrects  the  de- 
fect inherent  in  Braun's  and  in  Jaboulay's  operation.     Other  operators  close 


Fig. 


665. — ^Jaboulay's   method   of  gastro-enter- 
ostomy. 


Fig.  666. — Braun's  method  of  gastro-enterostomy. 


the  pylorus.  McGraw's  operation  (see  Figs.  669  and  670,  which  show  entero- 
anastomosis)  tends  to  prevent  the  formation  of  a  vicious  circle.  It  seems  cer- 
tain that  the  danger  of  the  formation  of  a  vicious  circle  is  greatest  after  a  long- 
loop  anterior  operation  and  least  after  a  short-loop  posterior  operation.  The 
shorter  the  loop,  the  less  the  danger,  hence  the  latter  is  the  operation  of  choice. 
The  safest  operation  of  all  is  the  short-loop  operation  of  Moynihan  or  Scudder 
(see  page  1099)  or  the  "no-loop"  operation  of  the  Mayos  (see  page  iioi). 

Treatment  of  Persistent  Vomiting  After  Gastro-enterostomy. — If  vomiting 
persists  in  spite  of  gastric  lavage  and  rectal  feeding  following  the  operation 
of  gastro-enterostomy  with  a  long  loop  without  entero-anastomosis,  open  the 


Anterior  Gastro-enterostomy 


1093 


abdomen  again  and  perform  anastomosis  between  the  afferent  and  efferent 
loops  of  intestine.  This  was  suggested  by  Braun  in  1892,  and  both  he  and 
Jaboulay  performed  it  in  the  same  year.  The  operation  has  saved  lives.  In  a 
short-loop  operation  we  should  assmne  that  the  jejunum  has  been  twisted,  should 
open  the  abdomen,  and  endeavor  to  correct  the  condition.  Herbert  L.  Pater- 
son  ("Hunterian  Lectures,"  before  the  Royal  College  of  Surgeons  of  England, 
Feb.  19,  21,  22,  1906)  points  out  that  sUght  cases  of  regurgitant  vomiting  not 
immediately  following  an  operation  may  be  due  purely  to  constipation,  and 
may  be  recovered  from  if  care  is  taken  to  secure  daily  a  free  bowel  movement. 
In  Paterson's  opinion  constipation  causes  reversed  peristalsis,  and  as  both 
the  duodenal  "siphon-trap  and  the  pyloric  sphincter  are  put  out  of  service," 
regurgitation  takes  place  from  the  efferent  loop  into  the  stomach. 

Anterior  Gastro-enterostomy. 
—  Sennas  Method. — A  median 
incision  is  made  through  the 
abdominal  wall,  from  below  the 
xiphoid  cartilage  to  the  umbili- 
cus. An  opening  is  made  in  the 
lower  part  of  the  anterior  wall 
of  the  stomach  in  the  direction 


Fig.  667. — ^laj'o's  method  of  anterior  gastro-enter- 
ostonL}',  showing  proper  and  improper  locations  of  open- 
ings: a,  Proper  position,  lea\ing  no  pouch;  b,  usual  posi- 
tion, forming  intragastric  pouch  ("Annals  of  Surgery''). 


Fig.  668. — Kocher's  method  of  gastro- 
enterostomy: a.  Places  of  posterior  annular 
suture  through  entire  wall  of  stomach  and 
intestine;  b,  places  of  anterior  annular  suture 
through  the  entire  wall;  c,  valve  at  the  jeju- 
num bj'  arch-formed  incision;  d,  posterior 
annular  suture  of  the  serosa;  e,  thread  ends 
for  continuing  anterior  suture  of  the  serosa. 


of  the  long  axis  of  the  viscus,  and  its  edges  are  stitched  by  a  continuous 
catgut  suture.  The  contents  of  the  jejimimai  are  forced  along  to  below 
the  point  where  an  incision  is  to  be  made.  The  duodenal  loop  of  jejunum 
should  be  from  12  to  14  inches  in  length.  A  rubber  tube  is  fastened  around 
the  bowel  above  this  point,  and  another  below  it;  an  incision  is  made  in 
the  long  axis  of  the  bowel,  and  the  margins  of  the  wornid  are  sutured  in  the 
same  manner  as  the  stomach  wound.  Bone  plates  are  introduced  into  the 
stomach  and  intestine,  and  the  ligatures  are  tied  as  in  intestinal  anastomosis. 
Catgut  rings  or  rubber  rings  may  be  used. 

Mayo's  Anterior  Method  (Fig.  667). — Open  the  abdomen,  and  pick  up  the 
small  intestine  and  find  a  point  of  jejimima  about  14  inches  from  the  point  at 
which  it  emerges  from  under  the  mesocolon.      Effect  the  union  to  the  inferior 


1094 


Diseases  and  Injuries  of  the  Abdomen 


border  of  the  stomach  close  to  the  greater  curvature  and  at  the  lowest  portion 
of  the  stomach  pouch.  When  the  anastomosis  is  completed  the  stomach 
pouch  is  funnel  shaped.  The  usual  custom  has  been  to  place  the  opening  higher 
on  the  anterior  wall.  It  sometimes  led  to  the  formation  of  a  pouch  on  the  an- 
terior wall,  did  not  drain  the  stomach,  and  caused  vomiting.  After  the  perform- 
ance of  gastro-enterostomy  the  edges  of  the  omentum  are  caught  upon  each  side 
of  the  anastomosis  and  are  sutured  to  each  other  and  to  the  stomach  wall  i 
inch  above  the  opening.  The  edges  are  then  united  to  each  other  in  a  down- 
ward direction  for  about  3  inches  so  as  to  form  an  apron  over  the  anastomosis, 
yet  not  connected  with  it.  Catgut  is  used  for  suturing.  If  leakage  occurs,  the 
omentum  is  adjacent  and  "available."  If  it  does  not  occur,  the  omentum  soon 
returns  to  its  normal  position  (Wm,  J.  Mayo,  "Annals  of  Surg.,"  Aug.,  1902). 
Kocher's  Method  (Fig.  668). — After  opening  the  abdomen  lift  up  the 
omentum,  pull  up  a  loop  of  intestine,  and  find  the  point  where  the  jejunum 


Fig.  669. — McGraw's  method  of  lateral   anastomosis:  The  elastic  hgature  is  introduced  (Walker). 
Gastro-enterostomy  is  done  by  the  same  plan. 


appears  from  under  the  mesocolon.  Select  a  loop  16  inches  from  the  origin 
of  the  jejunum  and  prepare  to  attach  it  to  the  stomach.  Wolfler  believed  that 
the  intestine  should  be  appHed  to  the  stomach  in  such  a  manner  that  the  direc- 
tion of  peristalsis  in  the  bowel  would  correspond  to  the  direction  of  the  stomach- 
tide.  This  can  be  accomplished  by  having  the  proximal  portion  of  gut  to  the 
left,  and  the  distal  portion  to  the  right.  The  operation  is  to  be  so  performed 
that  after  its  completion  the  stomach  contents  pass  into  the  distal  portion  of 
the  gut,  and  intestinal  contents  do  not  tend  to  enter  the  stomach  (see  Fig.  662). 
In  order  to  accomplish  this  Kocher  hangs  the  intestine  to  the  stomach  wall  in 
such  a  manner  that  the  proximal  portion  of  the  loop  is  posterior  and  ascending, 
and  the  distal  portion  is  anterior  and  descending.  The  bowel  is  hung  to  the 
stomach  by  a  continuous  serous  suture  of  silk,  the  ends  of  which  are  left  long. 
The  intestine  is  opened  by  a  curved  incision,  the  convexity  of  which  is  down- 
ward. The  stomach  is  opened  so  that  the  convexity  of  the  cut  is  upward.  The 
valve-like  portion  of  the  bowel  wall  is  sutured  to  the  stomach  below  the  inci- 
sion in  that  viscus.     The  two  openings  are  well  approximated  by  sutures. 


Operation  by  IMcGraw's  Elastic  Ligature 


1095 


Operation  by  McGraw's  Elastic  Ligature  (Figs.  669-671). — The  elastic 
ligature  was  introduced  by  Silvestri  in  1S62,  and  was  first  used  in  intestinal 
anastomosis  by  the  same  surgeon.     ^NIcGraw  perfected  the  operation  m  1S91. 


Fig.  670. — !McGraw"s  method  of  lateral  anastomosis:  One  tie  of  the  elastic  ligature  with  a  strong 
silk  ligatxire  underneath  ready  to  fasten  the  elastic  ligature  where  it  is  drawn  taut  (W'alker). 

(See  Dudley  Tait,  in  ''Annals  of  Surger\^,"  Feb.,  1906.)    The  operation  may  be 
anterior  or  posterior.     The  intestine  and  stomach  are  sutured  together  by 


Fig.  671. — ^IcGraw's  method  of  lateral  anastomosis:  The  operation  completed  (IValker). 


Lembert  stitches.  The  elastic  cord,  which  is  3  to  5  mm.  in  diameter,  is  passed 
through  the  stomach  and  then  the  bowel,  in  the  long  axis  of  each,  and  is  tightly 
tied,  and  the  knot  is  fastened  with  a  silk  thread.     Another  row  of  Lembert 


1096  Diseases  and  Injuries  of  the  Abdomen 

sutures  buries  the  elastic  cord  from  sight.  The  cord  cuts  through  in  from  forty- 
eight  to  seventy-two  hours  and  makes  the  anastomosis.  Thus  the  danger 
of  infection  is  greatly  lessened,  for  when  the  anastomosis  opening  is  formed  it  is 
completely  encompassed  by  firm  adhesions.  Further,  the  danger  of  the  forma- 
tion of  a  vicious  circle  is  greatly  lessened,  because  there  is  no  communication 
between  the  stomach  and  bowel  for  between  forty-eight  and  seventy-two  hours, 
the  period  in  which  vomiting  of  the  type  previously  described  is  most  apt  to 
occur.  The  method  is  not  suitable  for  absolute  pyloric  occlusion.  In  this 
condition  it  is  imperative  to  give  nourishment  early,  and,  again,  an  ordinary 
gastro-enterostomy  allays  auto-intoxication  and  this  operation  cannot  until  the 
ligature  cuts  through.  It  is  particularly  valuable  in  the  performance  of  lateral 
intestinal  anastomosis.  The  cuts  show  the  operation  of  lateral  anastomosis 
of  intestine,  but  gastro-enterostomy  is  performed  in  the  same  manner, 

Jaboulay's  Gastroduodenostomy. — This  operation  was  devised  by  Jabou- 
lay  in  1892.  It  aims  to  obviate  some  of  the  objections  to  pyloroplasty  and  at 
the  same  time  to  retain  the  advantages  this  operation  possesses  over  gastro- 
jejunostomy. Jaboulay's  gastroduodenostomy  has  never  become  popular 
with  surgeons,  and  Finney's  method  is  much  more  satisfactory  (see  page  1081). 

Posterior  Gastro-enterostomy  (see  page  1088  and  Fig.  664). — In  a  thin 
subject  with  a  long  mesocolon  posterior  gastro-enterostomy  is  to  be  chosen,  but 
if  the  mesentery  is  short  or  contains  much  fat,  or  if  the  vascular  loop  coming 
from  the  superior  mesenteric  artery,  and  which  supplies  the  transverse  colon 
with  blood,  is  small,  so  that  on  opening  the  posterior  layer  of  the  gastrocolic 
omentum  it  would  be  close  to  the  artery,  the  anterior  operation  is  employed 
(Wm.  J,  Mayo,  in  "Annals  of  Surgery,"  Aug.,  1902).  If  a  Murphy  button  is 
used,  the  posterior  operation  is  selected.  Posterior  gastro-enterostomy  is  com- 
monly performed  as  follows:  After  the  abdomen  has  been  opened  the  stomach 
and  omentum  are  raised;  a  portion  of  the  upper  jejunum  is  seized,  emptied,  and 
a  site  selected  for  the  clamp.  This  site  must  be  within  5  inches  of  the  flexure. 
If  there  is  a  broad  mesocolic  band  preventing  a  near  approach  to  the  flexure 
the  band  must  be  divided.  A  clamp  is  applied  on  the  side  opposite  the  mesen- 
teric attachment.  A  spot  is  selected  on  the  transverse  mesocolon  where  there 
are  no  vessels,  and  an  opening  is  made  through  the  mesocolon  with  a  blunt 
instrument.  The  posterior  wall  of  the  stomach  is  pulled  into  the  opening  and 
sutured  to  its  edges.  This  prevents  downward  displacement  of  the  stomach 
and  obstruction  of  the  loop  of  gut.  A  portion  of  the  posterior  wall  of  the 
stomach  is  pulled  out  into  a  cone  and  clamped.  Openings  are  made  and  the 
sutures  applied  as  directed  on  page  1088.  Regurgitation  is  less  common  after 
posterior  than  after  anterior  gastro-enterostomy.  In  250  posterior  operations 
in  Czerny's  clinic  there  was  not  one  case  of  regurgitant  vomiting;  170  cases 
were  button  operations  and  45  were  by  sutures  alone  (Peterson).  Von  Hacker 
had  one  instance  of  regurgitation  in  60  posterior  operations. 

Operation  by  the  Murphy  Button, — Gastro-enterostomy  may  be  quickly 
performed  by  the  use  of  a  large-sized  Murphy  button.  Murphy  says  that  in 
some  reported  cases  the  button  has  slipped  back  into  the  stomach,  but  this  acci- 
dent can  be  prevented  by  the  use  of  an  oblong  button  and  by  making  the  anas- 
tomosis on  the  posterior  stomach  wall.  The  same  surgeon  advises  us  to  scarify 
the  peritonemn  in  order  to  hasten  union,  and  says  supporting  sutures  about  the 
button  are  not  required,  except  when  considerable  tension  exists.  There  is  no 
question  that  an  anastomosis  on  the  anterior  wall,  accomplished  by  a  Murphy 
button,  can  be  speedily  performed.  Anastomosis  on  the  posterior  wall  cannot 
be  performed  so  speedily,  and  it  sacrifices  to  some  extent  the  great  advantage 
of  the  button  operation — that  is,  speed.  In  spite  of  the  reported  cases  we  can 
positively  assert  that  the  danger  of  the  button  producing  grave  trouble  is  slight. 
In  some  cases  it  drops  into  the  stomach  and  remains  there,  but  seems  to  do  no 


Fowler's  Method  of  Gastro-enterostomy 


1097 


harm.  In  other  cases  it  takes  a  long  time  to  pass.  In  i  of  the  author's  cases 
it  did  not  pass  until  the  eighty-sLxth  day.  In  one  of  Keen's  cases  it  has  been 
retained  for  years.  If  it  does  not  pass  in  four  weeks,  the  rectum  should  be 
explored  by  the  finger  from  time  to  time  to  see  if  it  is  lodged  in  that  region. 
The  .v-rays  will  determine  whether  the  button  is  in  transit.  If  the  wall  of  the 
stomach  is  thick,  the  incision  should  be  made  in  the  stomach  waU  before  the 
suture  is  passed,  and  this  suture  should  pick  up  only  a  small  portion  of  the 
stomach  wall,  otherwise  the  button  may  be  retained  in  place  for  a  very  long 
time  (\Vm.  J.  Mayo).  ''In  many  cases  in  which  the  button  passes,  vomiting 
with  symptoms  of  obstruction  may  appear  during  the  second  or  third  week 
while  it  is  in  transit.  Gastric  la^■age  and  rectal  feeding  for  a  day  or  two  cause 
these  s}Tnptoms  to  subside"  (Wm.  J.  Mayo, 
in  "Annals  of  Surgery,"  Aug.,  1902).  Mayo 
long  ago  maintained  that  the  suture  opera- 
tion is  as  good  as  the  button  operation, 
and  that  the  results  are  about  the  same. 
MikuHcz  says  that  in  the  suture  operation 
entero-anastomosis  is  necessary,  but  not  in 
the  button  operation,  because  the  button, 
while  in  place,  prevents  angulation.  The 
last-named  surgeon  uses  the  button  in  malig- 
nant cases  and  the  suture  in  benign  cases. 
Czerny  is  an  advocate  of  the  button.  Every 
button  should  be  tested  before  it  is  used. 
JMayo  finds  nearly  20  per  cent,  of  buttons 
imperfect  and  dangerous. 


Fig.  672. — Fowler's  method  of  gastro-enterostomy. 


Fig.  673. — MojTiihan's  clamp  for  gas- 
tric and  intestinal  operations  (made  by 
Down  Brothers,  London). 


Fowler's  Method  (Fig.  672). — Anastomose  the  posterior  waU  of  the  stomach 
to  the  jejunum  and  do  an  entero-anastomosis  between  the  afferent  and  efferent 
loops  of  jejunum.  Pass  a  No.  20  silver  vnre  two  or  three  times  around  the 
afferent  loop  of  jejuniun  and  draw  it  sufi&ciently  tight  to  occlude  the  lumen 
without  strangulating  the  wall  of  the  gut.     The  ends  are  twisted,  cut  short, 


1098 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  674. — Moynihan's  method  of  gastro-enterostomy :  The  obhque  application  of  the  clamp  to  the 

stomach  (Moynihan). 

rolled  into  a  flat  coil,  the  cut  ends  being  in  the  coil.     (See  Geo.  Ryerson  Fowler 
on  the  "Circulus  Vitiosus"  following  gastro-enterostomy,  "Annals  of  Surgery," 


Fig.  675. — Moynihan's  method  of  gastro-en-  Fig.  676. — Moynihan's  method  of  gastro-en- 

terostomy-'    The    strip    of    gauze   between    the        terostomy:   The    first    layer    of    serous    suture 
clamps  (Moynihan).  (Moynihan). 


Moynihan's  Method  of  Gastro-enterostomy 


1099 


Nov.,   1902).     This  operation  positively  prevents  the  entrance  of  material 
from  the  duodenal  loop  into  the  stomach  and  also  drains  that  loop. 

Moynihan's  Method. — This  plan  I  have  employed  repeatedly.  It  is  easy, 
rapid,  and  clean:  jSIake  a  4-inch  incision  i  inch  to  the  right  of  the  middle 
line  and  above  the  umbilicus.  Open  the  anterior  sheath  of  the  rectus  and 
separate  it  from  the  front  of  the  muscle  as  far  as  the  middle  Hne.  Draw  the 
entire  muscle  outward,  open  the  posterior  portion  of  the  sheath,  and  then 
open  the  belly.  Inspect  and  feel  the  entire  stomach.  Lift  the  omentum 
and  transverse  colon  out  of  the  abdomen  and  make  the  mesocolon  taut  by 
raising  the  stomach  and  colon  with  the  left  hand.  Find  "a  bloodless  spot  in 
the  arch  of  the  middle  colic  artery,"  pick  up  a  bit  of  the  under  surface  of  the 
mesocolon  by  a  pair  of  hemostatic  forceps,  lift  it  from  the  posterior  stomach 


Fig.  677. — ^lojTiihan's  method  of  gastro-en- 
terostomy: Removal  of  the  ellipse  of  mucous 
membrane  (Moj^nihan). 


Fig.  678. — IMoynihan's  method  of  gastro-en- 
terostomj-;  The  inner  suture  continued  (Moy- 
nihan). 


wall,  and  open  the  lesser  sac  of  peritoneum  by  the  scissors.  Enlarge  the 
opening  by  dilatation  or  tearing  until  it  admits  three  fingers.  Inspect  and 
feel  the  posterior  stomach  wall.  Place  the  stomach  in  its  natural  position, 
mark  -^ith  the  thumb  the  lowest  part  of  the  posterior  stomach  wall,  and 
again  turn  the  ^^scus  over.  From  the  spot  marked  by  the  thimib  a  fold  is 
raised.  The  fold  is  oblique  and  its  upper  end  is  to  approach  the  cardia  and 
lesser  cur\^ature.  A  stomach  clamp  (Fig.  673)  ha\ang  a  rubber  tube  bent  over 
each  blade  is  applied  obUquely  so  as  to  grasp  the  base  of  this  fold.  In  apply- 
ing the  clamp  the  tip  should  point  to  the  right  shoulder  and  the  handle  of  the 
outer  side  of  the  left  hip,  and  the  lowest  portion  of  the  stomach  is  grasped 
in  the  tip  of  the  blade  of  the  clamp  (Fig.  674).  The  clamp  is  now  put  in  a  hori- 
zontal position.  The  duodenojejunal  flexure  is  found  by  the  finger,  the  jeju- 
num is  identified  and  its  natural  position  is  noted.     The  jejunum  is  picked  up 


IIOO 


Diseases  and  Injuries  of  the  Abdomen 


and  "drawn  tight"  and  a  spot  is  noted  which  reaches  the  greater  curvature  of 

the  stomach  when  the  jejunum  is  in  its  natural 
position.  The  point  noted  is  5  inches  from  the 
flexure  and  the  anastomosis  is  made  to  the  jeju- 
nimi  above  the  spot.  The  clamp  is  applied  in  the 
side  of  the  gut  opposite  the  mesentery.  The  sur- 
geon must  be  sure  that  the  jejuniun  is  not  twisted 
around  its  longitudinal  axis.  If  it  is,  the  clamps 
are  not  rightly  applied,  and  they  must  be  placed 
so  that  after  the  anastomosis  the  jejunum  hes  in 
its  natural  position  without  a  twist.  The  clamped 
gut  is  placed  by  the  side  of  the  clamped  stomach,  a 
bit  of  gauze  being  put  between  them  (Fig.  675). 
The  stomach  (except  the  clamped  portion),  the 
omentimi,  and  transverse  colon  are  returned  to 
the  abdomen  and  the  clamps  are  surrounded  by 
gauze.  Each  clamp  holds  a  fold  3I  to  4  inches  in 
length.  Pagenstecher's  celluloid  thread  is  used  for 
suturing.  The  first  line  of  sutures  is  passed  as 
shown  in  Fig.  676.  In  front  of  these  sutures  an 
incision  is  made  into  the  stomach  and  another  into 
the  jejunum,  the  serous  and  muscular  coats  being 
first  divided,  and  an  ellipse  of  mucous  membrane 
being  removed  (Fig.  677).  The  next  row  of  sutures 
is  inserted  as  shown  in  Fig.  678.  When  this  row  is 
completed  the  clamps  are  removed  and  the  long 
suture  of  the  first  row  is  picked  up  again  and  the 
operation  is  completed  (Fig.  679).  Finally,  the  edges  of  the  mesocolic  open- 
ing are  sutured  to  the  jejunum.     The  parts  are  cleansed  with  salt  solution, 


j  . 

/ 

/ 

/  ■ 

/ 

\ 

}  i 

\ 
\ 

\ 

\ 
\ 

\ 

/    ■ 

1 

""-''      --_. 

/    , 

Fig.  679. — Moynihan's  method 
of  gastro-enterostomy:  The  ser- 
ous suture  resumed  (Mo3Tiihan). 


Fig.  680. — Mayo's  method  of  gastro-enterostomy:  Showing  posterior  wall  of  the  stomach  drawn- 
through  a  rent  in  the  transverse  mesocolon.  Note  slight  separation  of  gastrocoHc  omentum  from  its 
attachment  to  the  stomach,  permitting  anterior  wall  of  stomach  to  appear,  and  insuring  drainage  at 
lowermost  level.     Black  lines  mark  site  of  proposed  anastomosis;  the  jejunimi  shows  at  its  origin. 

the  suture  line  is  inspected,  the  parts  are  returned  to  the  belly,  and  the 
abdomen  is  closed.     (See  Moynihan's  "Abdominal  Operations.") 


The  No-loop  Operation  of  the  Mayos  for  Gastro-enterostomy     iioi 

The  No-loop  Operation  of  the  Mayos. — (Figs.  6S0-6S2). — It  is  this 
operation  I  usually  perform.  By  it  the  gastric  opening,  which  is  placed 
in  the  line  advised  by  JMoynihan,  extends  i  or  |  inch  into  the  anterior  wall 


Fig.  681. — Ma3-o's  method  of  gastro-enterostomy:  Forceps  in  place  and  anastomosis  half  completed 

by  suture. 

of  the  stomach,  and  thus  the  lowest  part  of  the  opening  will  be  the  lowest 
part  of  the  stomach  (Fig.  680).  The  incision  in  the  intestine  begins  from  i 
to  3  inches  from  the  origin  of  the  jejunum,  the  measure  being  made  on  the 
anterior  surface  (Fig.  680). 


Fig.  682. — Mayo's  method  of  gastro-enterostomy:  Completed  operation  from  behind.     Margin  of  torn 
mesocolon  attached  bj'  several  interrupted  sutures  to  Hue  of  union. 


The  object  is  to  get  as  short  a  piece  of  jejunimi  as  can  be  attached  with- 
out tension.  The  operation  is  described  as  follows  (Wm.  J.  Mayo,  in  "Annals 
of  Surger}',"  Nov.,  1905) : 


1 102  Diseases  and  Injuries  of  the  Abdomen 

"(a)  The  abdominal  incision  is  made  4  inches  in  length,  f  inch  to  the 
right  of  the  middle  line,  the  fibers  of  the  rectus  muscle  being  separated.  The 
lower  end  of  the  external  wound  lies  opposite  the  umbilicus.  This  opening 
also  enables  inspection  of  the  duodenum  and  gall-bladder  and  is  reliable 
against  hernia  when  closed. 

"(b)  The  transverse  colon  is  pulled  out  and  the  mesocolon  made  taut  by 
traction  upward  and  to  the  right,  in  this  manner  bringing  the  jejunum  into  view 
at  its  origin. 

"(c)  About  3  to  4  inches  of  the  jejunum  opposite  the  mesentery  are  drawn 
into  a  slightly  curved  clamp.  The  handles  of  the  clamps  should  be  to  the  right, 
to  enable  a  short  grasp  on  the  intestine.  Three-fourths  of  the  circumference  of 
the  bowel  is  pulled  through;  the  posterior  border  is  not  included,  to  prevent 
entanglement  of  the  suture  with  the  redundant  posterior  mucous  membrane. 
The  holding  clamps  are  applied  suificiently  tight  to  check  hemorrhage  and 
prevent  extravasation  of  intestinal  contents. 

"(d)  The  ligament  of  Treitz  is  a  short  muscular  mesentery  covered  by  a 
variable  peritoneal  fold  (too  variable  for  a  reliable  landmark)  extending  upward 
from  the  origin  of  the  jejunum  on  to  the  mesocolon.  This  peritoneal  fold  lies 
at  the  base  of  the  arterial  loop  of  the  middle  colic  artery  which  supplies  the 
transverse  colon.  The  mesocolon  is  opened  within  the  vascular  loop  and  the 
posterior  inferior  border  of  the  stomach  pushed  through.  A  small  separation 
of  the  greater  omental  attachment  to  the  stomach  enables  the  anterior  gas- 
tric wall  to  be  drawn  out  posteriorly.  The  posterior  gastric  wall  is  drawn 
into  a  clamp,  with  the  handles  to  the  right,  in  such  a  manner  as  to  just 
expose  the  anterior  wall  at  the  base. 

"(e)  The  two  clamps  are  laid  side  by  side  and  the  field  carefully  protected 
by  moist  gauze  pads.  With  fine  celluloidal  linen  thread  on  a  straight  needle 
the  intestine  is  sutured  to  the  stomach  from  left  to  right  by  a  Gushing  suture 
at  least  2|  inches. 

"(/)  The  stomach  and  intestine  are  incised  |  inch  in  front  of  the  suture 
line  and  the  redundant  mucous  membrane  excised  flush  with  the  retracted 
peritoneal  and  muscular  coats.  With  a  No.  i  chromic  catgut  on  a  straight 
needle  the  posterior  cut  margins  of  the  entire  thickness  of  the  gastric  and 
jejunal  wall  are  united  by  a  buttonhole  suture  from  right  to  left;  at  the 
extreme  left  the  suture  changes  to  one  which  passes  through  all  the  coats, 
of  each  side  alternately,  from  the  peritoneal  to  the  mucous,  then  directly  back 
on  the  same  side  from  the  mucous  to  the  peritoneal.  This  acts  as  a  hemo- 
static suture,  and  also  turns  the  peritoneal  coats  into  apposition.  It  passes 
around  the  anterior  surface  and  is  tied  to  the  original  end,  which  has  been 
left  long  for  the  purpose.  If  silk  or  linen  is  used  for  this  suture  it  may  hang 
in  situ,  suppurating  for  months. 

"(g)  The  clamps  are  now  removed  and  the  linen  thread  continued  around 
until  it  is  tied  to  the  original  end,  firmly  catching  the  blood-vessels  in  sight 
along  the  suture  line.  The  parts  are  carefully  cleansed  and  inspected.  If 
necessary,  a  suture  or  two  is  applied  to  accurately  coapt  or  to  check  the  oozing. 

"(A)  The  margins  of  the  incised  mesocolon  are  now  united  to  the  suture 
line  by  3  or  4  interrupted  sutures,  and  the  parts  returned  into  the  abdomen." 
In  this  operation  the  greatest  care  must  be  taken  to  avoid  twisting  the  gut 
around  its  longitudinal  axis. 

Qastro=anastomosis  or  gastrogastrostomy  is  an  operation  per- 
formed for  hour-glass  contraction  of  the  stomach,  a  condition  which  occa- 
sionally ensues  on  the  healing  of  an  ulcer.  In  this  operation  an  anastomosis 
is  effected  between  the  pyloric  and  cardiac  pouches.  It  was  devised  and 
practised  by  Wolfler  in  1894.  I  have  performed  it  twice  with  success.  Watson 
folds  the  two  stomachs  over  each  other,  using  the  narrow  isthmus  as  a  hinge; 


Gastroplication 


1 103 


sutures  the  pouches  together  and  leaves  the  ends  of  the  sutures  long.  He  in- 
cises the  anterior  wall  of  the  anterior  stomach  in  order  to  obtain  access  to  the 
double  septum  between 
the  two  pouches.  He 
makes  an  anastomosis 
opening  through  the 
double  septum,  sutures 
the  edges,  and  closes 
the  wound  in  the  an- 
terior wall  of  the  an- 
terior stomach.  Wolfier 
made  a  vertical  cut  in 
each  pouch  and  united 
these  openings  to  make 
an  anastomosis.  The 
best  plan  is  to  apply 
clamps  on  each  side  of 
the  isthmus  and  operate 
as  we  would  for  gastro- 
enterostomy (Fig.  684). 

Gastroplication  (Brandt's  Operation  of  Stomach-reefing  for  Dilated 
Stomach). — Apply  sutures  in  the  anterior  wall  so  as  to  form  reefs,  then 
tear  through  the  great  omentum  and  apply  sutures  in  the  posterior  walL 


Fig.  683. — Bircher's  method  of  gastroplication. 


Fig.  684. — Hour-glass  stomach.     The  application  of  clamps  and  the  method  of  suture  m  gastrogastros- 
tomy.     The  details  are  the  same  as  in  the  operation  of  gastro-enterostomy  (Moynihan) . 


The  sutures  pass  through  the  serous  and  muscular  coats.  A  continuous 
suture  may  be  used  on  the  anterior  wall  and  another  on  the  posterior  wall,, 
or  numerous  interrupted  sutures  may  be  inserted.     This  operation  is  of  ques- 


1 104 


Diseases  and  Injuries  of  the  Abdomen 


tionable  value,  and  must  never  be  used  if  stenosis  of  the  pylorus  exists,  and 
stenosis  of  the  pylorus  is  the  most  common  cause  of  gastric  dilatation. 

Bircher's  method  of  gastroplication  is  shown  in  Fig.  683. 

Gastropexy  (Buret's  Operation  for  Gastroptosis). — It  has  been  shown 
by  Duret  that  dyspepsia  of  a  peculiarly  severe  type  may  be  produced  by 
prolapse  or  downward  displacement  of  the  stomach.  In  this  condition  he 
advised  the  following  operation:  Perform  a  median  laparotomy,  but  do  not 
incise  the  peritoneum  in  the  upper  portion  of  the  wound.  Expose  the  stomach 
and  fix  it  by  means  of  a  silk  suture  to  the  undivided  but  exposed  peritoneum. 
The  suture  should  be  parallel  to  the  lesser  curvature  and  near  the  pylorus 
should  be  horizontal.^  Rovsing,  too,  fixes  the  stomach  to  the  abdominal  wall. 
So  do  Hartmann  and  Eve.  The  operations  of  Duret,  Rovsing,  Hartmann, 
and  Eve,  of  London,  fix  and  distort  the  stomach.  This  seems  to  me  an  objec- 
tional  procedure  and  liable  to  be  followed  by  pain.     To  fix  an  organ  which 


a;  Z 


Fig.  685. — Beyea's  operation  for  gastroptosis:  i,  Position  of  one  suture  of  first  row;  2,  one  suture 
of  second  row;  3,  one  suture  of  third  row.  Others  of  each  row  introduced  at  intervals  to  and  including 
the  gastrophrenic  ligament. 

undergoes  active  peristalsis  must  surely  be  productive  of  difficulty.  Byron 
Davis  advises  the  suturing  of  the  gastrohepatic  omentum  near  its  attachment 
to  the  lesser  curvature  to  the  stomach  wall  as  high  as  possible.  Beyea  has 
devised  an  operation  which  is  free  from  the  objections  which  may  be  urged 
against  Duret's  operation.     Sometimes  gastro-enterostomy  is  also  performed. 

Beyea's  Operation  for  Gastroptosis. — Insert  three  rows  of  interrupted 
silk  sutures  through  the  gastrohepatic  omentum  and  the  gastrophrenic  liga- 
ment. Each  suture  is  passed  from  above  downward  and  the  row  begins  at 
the  right  and  passes  to  the  left  (Fig.  685).  When  the  sutures  are  tied,  a  fold 
or  plication  is  formed  in  the  ligaments,  the  supports  of  the  stomach  are  short- 
ened, and  the  viscus  is  elevated  to  a  normal  position  without  any  disturbance 
of  its  physiological  mobility  ("Univ.  of  Penna.  Med.  Bull.,"  Feb.,  1903). 

Ransohoff's  Omentopexy  for  Gastroptosis. — Ransohoff  ("Medical  Com- 
munications of   the  Mass.   Med.   Soc,"   191 2,   vol.  xxiii)    points   out   that 

1  "Rev.  de  Chir.,"  June,  1896. 


Enterectomy  1105 

Beyea's  operation  is  insufficient  because  only  the  right  and  left  borders  of  the 
gastrohepatic  omentum  act  as  supports.  He  uses  the  omentum  to  raise  and 
fix  the  stomach,  and  at  the  same  time  raises  and  fixes  the  transverse  colon. 
He  makes  spaces  between  the  fascia  and  peritoneum  as  advised  by  Coffey 
and  sutures  the  omentum  into  these  spaces.  If  necessary  he  also  does  gastro- 
plication,  or  coloplication,  or  reefs  the  mesocolon  or  separates  bands  and 
adhesions,  or  shortens  the  round  ligament  of  the  liver. 

Duodenostomy  and  Jejunostomy. — It  has  been  suggested  that  one  of 
the  above  operations  should  be  performed  in  a  case  of  pyloric  obstruction  in 
which  neither  pylorectomy  nor  gastro-enterostomy  is  feasible.  Duodenostomy 
is  said  by  some  to  be  an  easy  operation  because  of  the  mobility  of  the  pylorus 
and  first  part  of  the  duodenum,  and  to  be  not  only  easier,  but  safer,  than 
jejunostomy,  because  it  makes  the  fistula  above  the  opening  of  the  common 
biJe-duct  ("Bull,  et  Mem,  de  la  Soc.  de  Chir.  de  Paris,"  No.  39,  1901).  Cackove 
advocates  the  operation  in  some  cases  of  gastric  ulcer  with  repeated  hemor- 
rhages and  some  cases  of  gastric  cancer.  In  the  latter  cases  he  asserts  that  the 
mortality  is  about  the  same  as  from  gastro-enterostomy  and  the  prolongation 
of  life  is  greater  ("Arch.  f.  klin.  Chir.,"  Bd.  Ixv,  Heft  2).  Hartmann's  case  of 
duodenostomy  lived  two  months.  The  operation  was  performed  for  extreme 
cicatricial  stenosis  of  the  pylorus  due  to  swallowing  hydrochloric  acid. 

Jacobson  disapproves  of  both  procedures,  and  objects  particularly  to 
duodenostomy,  because  it  involves  a  portion  of  the  intestine  which  is  difficult 
to  deal  with,  and  because  important  fluids  escape  constantly  from  the  fistula. '^ 

If  duodenostomy  is  performed,  it  should  be  done  in  the  same  manner  as 
gastrostomy  by  Witzel's  method.  I  regard  jejunostomy  as  an  operation 
which  is  occasionally  justffiable  and  as  preferable  to  duodenostomy.  As  per- 
formed to-day  there  is  little  danger  of  leakage,  even  if  the  tube  slips  out.  This 
operation  puts  the  stomach  at  absolute  rest.  It  is  employed  in  very  extensive 
ulceration,  in  multiple  ulcers,  and  in  some  cases  of  cancer  in  which  gastro-en- 
terostomy is  impossible  or  is  contra-indicated,  because  the  fistula  would  be  in 
or  too  near  the  malignant  growth.  Wm.  J.  Mayo  ("Am.  Jour.  Med.  Sciences," 
April,  191 2)  regards  the  operation  "as  an  active  competitor  of  gastrostomy  in 
cases  of  esophageal  and  cardiac  obstruction."  Mayo-Robson  ("Brit.  Med. 
Jour.,"  Jan.  6,  191 2)  advocates  the  operation.  Mayo  makes  an  epigastric 
incision,  picks  up  the  jejuniun,  makes  a  little  opening  at  a  point  from  12  to 
16  inches  from  the  jejunal  origin,  introduces  a  rubber  catheter  (No.  9  English) 
"down  stream"  for  about  3  inches,  catches  it  to  the  wall  of  the  bowel  by  one 
suture  of  chromic  gut,  infolds  it  for  i  inch  or  more  as  in  Witzel's  gastrostomy, 
using  mattress  sutures  of  linen,  anchors  the  gut  to  the  peritoneum  by  two  or 
three  lines  of  linen  sutures  at  the  lower  angle  of  the  incision,  and  closes  the 
abdominal  wound  (Wm.  J.  Mayo,  Loc.  cit.).     Food  can  be  given  at  any  time. 

If  the  tube  slips  out  it  must  be  put  back  at  once,  as  the  tract  might  close  in  a 
few  hours.  When  the  operation  has  been  done  for  cancer  the  fistula  is  per- 
manently maintained.  If  for  ulcer,  it  can  be  allowed  to  close  or  can  be  closed 
surgically,  if  it  persists,  as  soon  as  the  ulceration  heals.  Billon  ("Archiv.  prov. 
de  Chir.")  has  collected  127  cases.  The  direct  mortality  was  29  per  cent. 
Sixty-four  of  the  patients  lived  but  three  months  or  less.  A  single  case  lived 
beyond  a  year.     This  is  not  a  very  gratifying  showing. 

Maydl  does  a  much  more  formidable  operation  (divides  the  jejunum,  at- 
taches the  upper  end  to  a  far-away  portion  of  gut,  and  attaches  the  lower  end 
in  the  abdominal  wound).     He  has  operated  on  25  cases,  with  4  deaths. 

Enterectomy,  or  Resection  of  the  Intestine  with  Approximation 
by  Circular  Enterorrhaphy. — How  much  of  the  intestine  can  be  removed 
without  the  patient  dying  from  lack  of  nutrition?     The  question  is  not  settled. 
1  Jacobson's  "Operations  of  Surgery." 
70 


iio6 


Diseases  and  Injuries  of  the  Abdomen 


It  has  been  stated  that  the  removal  from  an  adult  of  more  than  6§  feet  produces 
nutritional  disturbance,  and  that  a  child  tolerates  the  removal  of  a  piece  rela- 
tively larger  better  than  does  an  adult.  Senn  was  of  the  opinion  that  excision 
of  more  than  one-third  of  the  intestine  makes  inanition  inevitable.  Certain 
it  is  that  great  lengths  have  been  successfully  removed,  and  the  patients  have 
not  only  lived,  but  have  been  well  nourished.  Ruggi  removed  ii  feet,  Witall 
removed  lo  feet  "8  inches,  Von  Eiselsberg,  ii  feet  8  inches,  and  Obulinski,  12 
feet  2  inches.  Brougham  removed  11  feet  2  inches  for  mesenteric  thrombosis 
and  the  patient  recovered.  Childe  successfiilly  removed  9  feet  6  inches  of 
small  intestine  for  embolism  of  the  mesenteric  artery.  Hayes  removed  8  feet 
4I  inches  from  a  boy  ten  years  of  age,  and  the  patient  was  well  eight  months 
later.  Dressman  reported  26  cases  in  each  of  which  more  than  3  feet  3  inches 
had  been  removed  (Alexander  Blaney,  in  "Brit.  Med.  Jour.,"  Nov.  16,  1901). 
Blaney  adds  7  cases  from  literature,  and  tells  us  that  in  9  of  the  ^T)  cases  death 
occurred  soon  after  operation. 

Alexander  Blaney,  in  the  previously  quoted  article,  reviews  the  subject 
of  the  resection  of  great  lengths  of  intestine.  He  tells  us  that  how  much  re- 
mains after  a  resection  is  important,  but  uncertain.  It  is  uncertain  because,  as 
Treves  has  shown,  the  length  of  the  intestine  varies  from  15  feet  6  inches  to 
31  feet  10  inches. 


Fig.  686. — Excision  of  bowel :  first  step  (Esmarch 
and  Kowalzig). 


Fig.  687  — Excision  of  bowel  with  enteror- 
rhaphy  and  stitching  of  the  redundant  mesen- 
tery: second  step  (Esmarch  and  Kowalzig). 


Could  end-to-end  anastomosis  be  done  as  safely  as  lateral  anastomosis  it 
would  usually  be  the  preferred  method.  The  great  danger  is  infection  from 
soiling.  "Occasionally,  the  circular  suture  is  the  only  feasible  one"  (Halsted, 
"Jour,  of  Exper.  Med.,"  No.  3,  191 2). 

Resection  of  the  jejunum  is  much  more  dangerous  than  resection  of  an 
equal  length  of  ileum.  Resection  of  the  ileum  is  more  dangerous  than  resection 
of  the  colon.  If  resection  is  employed,  all  diseased  or  injured  bowel  must  be 
removed  irrespective  of  ultimate  bad  consequences  (Blaney).  The  operation  is 
performed  as  follows:  After  opening  the  abdomen  isolate  the  loop  of  intestine 
we  intend  to  resect.  Push  a  rubber  tube  through  the  mesentery  close  to  the 
bowel,  above  the  seat  of  operation,  and  pass  a  rubber  tube  through  the  mesen- 
tery below  the  seat  of  operation.  Instead  of  tubes,  strips  of  iodoform  gauze  may 
be  used  to  encircle  the  bowel.  Empty  this  segment  of  bowel  by  squeezing 
and  stroking,  tighten  the  rubber  tubes,  and  clamp  them  to  keep  the  bowel 
empty  (Fig.  686).  The  diseased  intestine  is  resected,  each  incision  being  car- 
ried through  a  healthy  segment,  and  care  being  taken  that  the  cuts  are  so 
arranged  that  at  each  end  a  blood-vessel  from  the  mesentery  reaches  the  edge 
of  the  cut  bowel.  Otherwise  repair  can  scarcely  occur.  The  lumen  of  each 
end  of  the  divided  gut  is  irrigated  with  salt  solution.  The  divided  surfaces  are 
approximated  by  a  double  row  of  sutures — a  continuous  suture  for  the  mucous 
membrane,  and  Lembert's,  Dupuytren's,  Cushing's  suture,  or  Halsted's  sutures 


Enterectomy 


1107 


— to  effect  inversion.  Thoroughly  satisfactory  approximation  can  be  effected  by 
one  row  of  Halsted  mattress  sutures  (Fig.  688) .  If  a  redundant  fold  of  mesentery 
is  left,  it  can  be  stitched  at  its  raw  edge  (Fig.  687).  Many  surgeons  remove  a 
V-shaped  piece  of  mesentery,  tie  the  divided  mesenteric  vessels  (Fig.  686),  and 
introduce  sutures  so  that  no  mesenteric  vessel  will  be  constricted  (Fig.  688). 
The  tubes  are  removed,  and  the  wound  is  cleansed,  closed,  and  dressed. 

Senn  effects  invagination  by  means  of  a  bone  ring  (Fig.  689) . 

If  the  two  segments  of  bowel  are  unequal  in  size,  it  was  formerly  the  custom 
to  cut  the  narrow  part  of  the  bowel  obliquely  and  the  larger  part  transversely. 
To  meet  this  complication  Billroth  devised  lateral  implantation  (see  Fig.  717). 
Suppose  the  cecum  has  been  resected:  its  lower  end  is  closed  by  Lembert 
sutures,  an  opening  is  made  in  the  long  axis  of  the  periphery  of  the  colon 
opposite  the  attachment  of  the  mesocolon,  and  the  end  of  the  ileum  is  sutured 
into  this  incision.  This  is  called  end-to-side  approximation,  or  implantation. 
It  is  used  in  the  sigmoid,  in  the  cecum,  and  in  any  intestinal  segment  in  which 
the  circulation  is  deficient.  Eugene  A.  Smith  (''Amer.  Med.,"  May  10,  1902) 
sums  up  the  advantages  of  end- to-side  approximation  as  follows:  The  strain 
of  peristalsis  is  less  than  in  end-to-end  union ;  the  circulation  of  each  end  of  the 


Fig.  688. — Suture  of  the  mesentery  after  circular 
enterorrhaphy  (Halsted). 


Fig.  68g. — Senn's  modification  of  Jobert's  in- 
vagination method:  A,  Upper  end  lined  with  ring; 
B,  invagination  sutures  in  place;  C,  lower  end. 


bowel  and  the  parts  of  bowel  adjacent  is  better;  each  cut  edge  of  mesentery 
is  free  to  recover  its  circulation,  and  there  is  no  dead  space  at  the  mesenteric 
border  to  lead  to  leakage. 

Senn  advised  the  insertion  of  an  anastomosis  ring  in  the  ileimi,  the  in- 
vagination of  the  colon  as  the  ring  is  pulled  into  place,  and  firm  suturing  of  the 
Hne  of  junction.  By  Senn's  method  the  ileum  may  be  implanted  into  the  end 
of  the  colon  or  into  a  slit  in  the  wall  of  the  large  bowel  after  the  end  of  the 
colon  has  been  closed.  In  some  cases,  in  which  one  portion  of  bowel  is  larger 
than  the  other,  lateral  anastomosis  is  the  preferable  method.  For  a  full  week 
after  an  intestinal  resection  the  patient  is  fed  chiefly  by  nutrient  enemata. 
During  the  first  twenty-four  hours  nothing  is  given  by  the  stomach  but  small 
amounts  of  hot  water,  and  for  the  next  six  days  only  water  and  a  little  liquid 
food  is  allowed  to  be  swallowed. 

The  use  of  Murphy's  button  (Fig.  691)  permits  of  rapid  approximation  after 
resection  (Fig.  690).  This  button  closely  approximates  the  portions  of  the 
intestine  within  its  bite,  rapid  adhesion  taking  place.  The  diaphragm  of  tissue 
undergoes  pressure-atrophy  and  liberates  the  button,  which  is  passed  per  anum. 
It  is  claimed  that  the  button-opening  contracts  but  slightly.  For  end-to-end 
or  side-to-side  approximation  of  the  small  intestine  a  No.  3  button  is  used. 


iio8 


Diseases  and  Injuries  of  the  Abdomen 


\\\)   w      w  I 


Fig.  690. — Resection  of  intestine:  a,  b,  The  two  halves  of  the  button;  c,  the  two  portions  clamped 
together;  d,  introduction  of  the  sutures  for  holding  each  half  of  the  button  in  place.  The  lower  figure 
shows  the  completed  union  of  the  intestine  by  the  Murphy  button;  the  slit  in  the  mesentery  has  been 
closed  by  linear  union  (after  Zuckerkandl) . 


For  similar  operations  on  the  large  intestine  a  No.  4  button  is  employed 
(Murphy).  After  the  resection  one-half  of  a  button  is  inserted  into  each  seg- 
ment, and  is  held  in  place  by  a  purse-string  suture  of  silk  which  passes  through 

all  the  coats  (Fig.  690).  The 
redundant  mucous  membrane 
is  tucked  in  or  clipped  off,  so 
that  it  will  not  be  interposed 
between  the  serous  surfaces. 
The  serous  surfaces  are 
scratched  with  a  needle  and 
the  halves  of  the  button  are 
locked  (Fig.  690).  It  is  not 
necessary  to  surround  the 
margin  of  junction  with  su- 
tures. Murphy  says  that 
liquid  nourishment  should  be 
given  as  soon  as  the  patient 
has  recovered  from  the  effect  of  the  ether,  and  that  the  bowels  should  be  moved 
at  an  early  period,  and  frequent  evacuations  should  be  maintained.     If  the 


Fig.  691. — Comparison  of  old  (a)  and  new  ih)  Murphy 
buttons. 


Enterectomv 


1 109 


button  does  not  pass  in  four  weeks,  examine  the  rectum  for  it.'  The  situa- 
tion of  the  button  can  be  ascertained  by  the  x--rays.  An  objection  to  the  but- 
ton is  that  it  introduces  a  foreign  body  which  must  pass  per  rectum  to  complete 
the  operation  successfully.  It  may  not  pass,  but  trouble  does  not  of  necessity 
follow.     In  some  cases  its  retention  does  lead  to  trouble,  and  intestinal  obstruc- 


Fig.  692. — ^The  segmented  ring  of  Harrington  and  Gould. 

tion  ensues.  If  the  caliber  of  the  button  blocks  before  dislodgment,  obstruction 
follows,  hence  the  rule  to  give  saline  purgatives  the  day  after  the  operation. 
Some  surgeons  have  sought  to  make  a  button  which  would  come  apart 
and  be  absorbed  after  it  had  accomplished  its  purpose.  One  of  these  appli- 
ances is  Frank's  coupler,  which  is  made  of  bone,  the  compression  being 


■7,f"^ 


\ym^ 


Fig.  693. — ^End-to-end  union  with  aid  of  seg- 
mented ring.  Continuous  stitch  beginning  at  one 
side  of  the  handle  rHarrington  and  Gould). 


Fig.  694. — End-to-end  union  with  aid  of  seg- 
mented ring.  Handle  unscrewed,  suture  completed 
(Harrington  and  Gould). 


furnished  by  rubber.     In  this  apparatus,  however,  the  amount  of  pressure 
obtained  is  always  uncertain  and  the  rubber  is  apt  to  wear  out.     The  button 
gives  a  lower  mortality  than  the  suture  operation,  and  some  surgeons  now  use 
it  who  once  condemned  it.     Czemy  is  a  strong  advocate  of  the  button. 
1  John  B.  Murphy,  in  "Med.  Xews,"  Feb.  9,  1895. 


mo 


Diseases  and  Injuries  of  the  Abdomen 


Harrington  and  Gould  use  a  segmented  aluminum  ring.     This  ring  collapses 
into  small  segments  after  the  anastomosis  has  been  effected.     By  its  use  the 

authors  believe  that  the 
operation  is  made  more 
rapidly  and  safely  ("Annals 
of  Surgery,"  Nov.,  1904). 
During  the  suturing  the 
ring  is  held  by  means  of  a 
handle,  which,  after  the  an- 
astomosis has  been  effected, 
is  removed.  The  ring  in  the 
handle  is  shown  in  Fig.  692 
and  the  operation  in  Figs. 
693,  694. 

Maunsell  has  devised  a 
most  ingenious  method  of 
circular  enterorrhaphy.  The 
two  portions  of  bowel  are 
attached  by  two  fixation  su- 
tures which  penetrate  all  the 
coats  (Fig.  695).  An  inci- 
sion 1 1  inches  in  length  is 
made  through  the  wall  of 
the  proximal  segment  of  gut, 
about  I  inch  from  its  edge. 
The  fLxation  sutures  are 
brought  through  this  open- 
ing, traction  is  made  upon 
them,  the  distal  portion  of 
the  bowel  is  invaginated 
into  the  proximal  portion, 
and  the  ends  emerge  from 
the  opening,  their  peritoneal  surface  being  in  contact  (Fig.  695).  Sutures  of 
silk  are  passed  through  both  sides  of  the  area  of  invagination,  the  threads 
are  caught  up  in  the  center,  cut,  and  tied  on  each  side.  The  fixation  sutures 
are  cut  off.  The  invagination  is  reduced  by  traction.  The  longitudinal  cut  is 
closed  by  Lembert  sutures. 


Fig.  695. — Maunsell's  method  of  anastomosis  (after  Wiggin). 


Fig.  696. — Robson's  decalcified  bone  bobbin. 


Fig. 


697. — Allingham's    decalcified    bone 
bobbin. 


A.  W.  Mayo-Robson  performs  circular  enterorrhaphy  and  brings  the 
ends  of  the  gut  together  over  a  bobbin  of  decalcified  bone  (Fig.  696).  Ailing- 
ham  uses  a  bone  bobbin  the  shape  of  two  cones  joined  at  their  apices.  The 
bobbin  is  decalcified,  except  an  area  at  the  center  (Fig.  697,  a).  Kocher  per- 
forms circular  enterorrhaphy  as  follows:    A  fixation  suture  is  introduced 


Enterectomy 


mi 


through  the  bowel  at  the  mesenteric  attachment  and  another  is  inserted 
at  an  opposite  point.  The  intestinal  ends  are  approximated  by  a  continuous 
silk  suture,  which  passes  through  all  of  the  coats,  but  which  includes  more  of 
the  serous  than  of  the  mucous  coat.  The  suture-line  is  overlaid  by  a  continu- 
ous Lembert  suture  which  includes  the  serous  and  a  portion  of  the  muscular 
coat. 

In  doing  an  end-to-end  approximation  I  prefer  to  use  the  clamp  of  Moyni- 
han  (see  Fig.  673),  as  shown  in  Figs.  698-700.  We  thus  are  able  to  hold  the 
parts  and  keep  them  clean,  rapidly  make  an  even  and  secure  stitch  line,  and 
have  no  free-edged  septum. 

Some  surgeons  have  used  inflatable  rubber  cylinders  in  making  an  end-to- 
end  anastomosis  (Halsted,  Downes,  and  others).  The  method  was  devised  by 
Treves,  but  was  subsequently  abandoned  by  him.    Halsted  no  longer  uses  the 

inflatable  cyhnders.  Professor  Halsted  is  at  present 
developing  a  method  which  seems  to  be  aseptic 
and  to  offer  other  advantages.       He  calls  it   "A 


Fig.  698.— Moynihan's  meth- 
od of  end-to-end  anastomosis 
(Moynihan) . 


Fig.  699. — Moynihan's  meth- 
od of  end-to-end  anastomosis 
continued. 


Fig.  700. — Moynihan's  meth- 
od of  end-to-end  anastomosis 
continued. 


Bulkhead  Suture  of  the  Intestine"  ("Jour,  of  Exper.  Med.,"  No.  3,  191 2). 
He  reduces  the  wall  of  the  bowel  by  crushing  its  submucous  coat  on  each  side 
of  the  loop  to  be  excised;  he  then  finally  ligates  and  cuts  through  by  a  cautery. 
There  is  now  a  diaphragm  on  each  end  of  the  divided  gut.  He  invaginates  the 
gut  by  paper  cylinders  held  in  wooden  mandrels,  redivides  it  (thus  cutting  loose 
the  diaphragm),  and  sutures  it. 

Connell  has  devised  a  method  which  places  the  knots  in  the  lumen  of  the 
bowxl  (F.  Gregory  Connell,  "Medicine,"  April,  1901).  He  maintains  that 
the  placing  of  the  knots  within  the  lumen  of  the  gut  has  the  following  advan- 
tages: there  is  no  foreign  body;  the  suture  passes  away  early;  adhesions  to 
neighboring  organs  are  few;  the  serous  approximation  is  perfect;  the  suture 
line  is  more  secure;  the  septum  is  smaller  and  the  danger  of  necrosis  is  less. 
The  suture  is  shown  in  Plate  1 1 . 


III2 


Diseases  and  Injuries  of  the  Abdomen 


Laplace  has  devised  forceps  which  greatly  facilitate  suturing,  which  make 
it  easy  to  obtain  an  even  suture  line,  and  which  can  be  withdrawn  after  the 
suturing  is  finished,  the  small  opening  through  which  the  instrument  emerged 


Fig.  701. — Laplace's  forceps  for  intestinal  anastomosis.    Fig.  702. — End-to-end  anastomosis  with  the 

aid  of  Laplace's  forceps. 


being  closed  by  a  stitch  (Figs.  701,  702).  By  aid  of  Laplace's  forceps  the 
operation  can  be  neatly  and  rapidly  performed,  but  a  large  diaphragm  is 
formed,  a  considerable  area  is  exposed  to  infection,  the  tissues  of  the  dia- 
phragm are  bruised  and  may  slough,  the  raw  ends  may 
grow  together  and  cause  obstruction,  and  it  seems  prob- 
able that  considerable  contraction  will  follow.  Another 
objection  is  that  an  infected  instrument  is  withdrawn 
from  the  bowel  and  may  contaminate  the  peritoneum. 


Fig.  703. — O'Hara's  an- 
astomosis forceps  (about 
one-third  original  size). 


Fig.  704. 


—Showing  the  manner  of  placing  forceps  in  resection  of  bowel; 
dotted  lines  show  the  incision  to  be  made  (O'Hara). 


O'Hara's  forceps  (Fig.  703)  permit  of  rapid  and  accurate  suturing,  but  possess 
the  same  disadvantages  as  the  Laplace  forceps.  In  i  case  within  my  knowl- 
edge absolute  obstruction  from  adhesion  of  the  raw  edges  of  the  septum 


Operation  with  Rings  for  Lateral  Intestinal  Anastomosis        1113 


followed  its  employment.  Figures  704  and  705  show  the  use  of  O'Hara's  for- 
ceps. Of  the  operations  pre\dously  set  forth,  I  prefer  the  clamp  and  suture  as 
employed  by  Moynihan,  the  operation  of  Halsted  by  mattress  sutures  and 
without  mechanical  aids,  and  in  some  cases  the  operation  with  the  Murphy 
button. 


H 


III'! 


.^ 


lliil 


Fig-  705- 


-End-to-end  anastomosis.    Forceps  brought  together  and  held  by  serre-fine  (not  shown); 
sutures  introduced,  some  of  which  are  tied  (O'Hara). 


operation  than  end-to-end   anas- 
an  opening  as  we  desire.     Again. 


Lateral  Intestinal  Anastomosis. — Approximation  may  be  effected  by 
other  methods  than  by  end-to-end  junction  or  by  implantation.  In  fact,  I  pre- 
fer in  most  cases  of  resection  to  close  each  end  of  the  di\dded  gut  and  per- 
form lateral  anastomosis.  It  is  a  safer 
tomosis  and  by  it  we  can  obtain  as  large 
after  lateral  anastomosis  the  parts  ob- 
tain a  better  blood-supply  than  after 
end-to-end  suturing,  because  in  the 
former  operation  the  mesenteric  vessels 
are  not  interfered  with.  Further,  in 
lateral  anastomosis  there  is  Httle  tend- 
ency to  cicatricial  contraction.  Lateral 
anastomosis  may  be  performed  in  some 


Fig. 


707.— Alethod  of  passing  the  silk  sutures 
in  inserting  the  rings  of  Abbe. 


Fig.  706. — Senn's  entero-anastomosis:  A, 
Senn's  bone  plate;  B,  intestinal  anastomosis;  C, 
operation  complete. 

cases  without  a  preliminary^  resection  for  the  purpose  of  short-circmting  the  fecal 
current,  throwing  a  diseased  portion  of  the  bowel  out  of  action,  and  thus  avoid- 
ing obstruction  (Fig.  706).  This  operation  has  the  disadvantage  that  the 
diseased  structure  is  not  removed. 

Operation  with  Rings. — In  this  operation  a  portion  of  bowel  above  the 
obstruction  and  a  loop  below  the  obstruction  are  brought  into  the  wound. 


III4 


Diseases  and  Injuries  of  the  Abdomen 


These  segments  are  emptied,  and  are  kept  empty  by  fastening  around  them 
rubber  tubes  or  iodoform  strips.  Two  tubes  are  needed  for  each  loop  of  bowel. 
Pack  in  gauze  pads.  Alake  an  incision  in  one  loop,  in  the  long  axis  of  the  bowel, 
on  the  surface  away  from  the  mesentery ;  permit  the  contents  to  escape  exter- 
nally; irrigate  this  segment  with  saHne  solution,  and  introduce  the  bone  plate 
of  Senn  (Fig.  706,  a)  or  Abbe's  catgut  ring  (Fig.  707).  Calyx-eyed  needles 
are  used  to  pass  the  silk,  and  the  threads  of  the  ring  are  carried  through  the 

coats  of  the  bowel  and  are 
gathered  together  in  the  bite 
of  a  pair  of  forceps.  The 
other  loop  of  intestine  is 
treated  in  a  similar  manner. 
The  two  segments  of  intes- 
tine are  so  brought  together 
that  the  two  wounds  are 
opposite  each  other,  the  pos- 
terior sutures  being  tied 
first,  the  upper  next,  then 
the  lower,  and  finally  the 
anterior  threads.  The  ends 
of  the  threads  are  cut  off, 
and  the  entire  anastomosis 
is  surrounded  by  a  layer  of 
Lembert  or  Halsted  sutures 
or  is  encircled  by  Cushing's 
suture.  Figm"e  706,  b,  shows 
an  intestinal  anastomosis 
partly  finished,  and  Fig.  706,  c,  shows  an  anastomosis  complete.  Figure  707 
shows  the  passing  of  the  sutures  when  the  catgut  rings  of  Abbe  are  employed. 
After  an  intestinal  resection  each  end  can  be  closed  and  anastomosis  effected 
as  described  above.  Lateral  anastomosis  can  be  accompHshed  with  a  Murphy 
button,  the  intestine  being  prepared  for  the  button  as  is  shown  in  Fig.  708. 
Abbe's  method  of  anastomosis  without  mechanical  aid  is  as  follows:  After 
resecting  the  bowel  and  mesentery  and  closing  the  ends  of  the  bowel  he  places 


Fig.  708. — Showing  relative  size  of  incision  and  method  of 
introducing  sutures  in  lateral  approximation  with  Murphy's 
button. 


Fig.  709. — Suturing  intestines  in  apposition  be-     Fig.  710. — Showing  the  4-inch  incision  and  sewing 
fore  incision  (Abbe).  of  the  edges  (.\bbe). 


the  extremities  side  by  side  and  applies  two  rows  of  a  Dupuytren  suture,  J  inch 
apart.  These  rows  of  sutures  are  i  inch  longer  than  the  slit  in  the  bowel  will 
be  (Fig.  709),  the  thread  at  the  end  of  each  row  being  left  long.  An  incision  is 
made  in  the  bowel,  J  inch  from  the  sutures,  both  rows  of  threads  being  on  the 
same  side  of  the  cut.  This  incision  is  4  inches  long.  The  other  portion  of  the 
bowel  is  then  incised  in  the  same  way.  The  adjacent  cut  edges  are  united  by 
a  whip-stitch  which  goes  through  all  the  coats,  and  the  free  cut  edges  are 


Operation  with  Rings  for  Lateral  Intestinal  Anastomosis       1115 


stitched  in  the  same  manner  (Fig.  710).  The  surgeon  now  utilizes  the  long 
threads  of  the  first  sutures,  and  brings  the  serous  surfaces  of  the  opposite 
sides  together  by  means  of  Dupuytren's  suture.  Halsted  performs  anastomo- 
sis as  follows:  He  places  the  two  portions  of  bowel  with  their  mesenteric  borders 
in  contact.  Six  quilted  sutures  of  silk  are  introduced,  tied,  and  cut  off  (Fig. 
711,  a).     At  each  end  of  this  row  of  sutures  two  quilted  sutures  are  introduced, 


WiMlMMiSSi.^  ^^ii:^iiisissa<^^^  V\\TO\m»MAV\^ 

Fig.  711. — Halsted's  operation  for  lateral  anastomosis,  showing  four  steps  of  same   (Jessett,   from 

Halsted). 


tied,  and  cut  (Fig.  711,  6).  A  number  of  quilted  sutures  are  introduced,  as  is 
shown  in  Fig.  711,  c.  The  intestinal  openings  are  made  with  scissors,  and  the 
sutures  last  introduced  are  tied  and  cut  off  (Fig.  711,  d). 

J.  Shelton  Horsley  has  suggested  an  ingenious  method  of  intestinal  anasto- 
mosis which  secures  for  the  sutured  portion  a  greater  diameter  than  that  nor- 
mal to  the  intestine.^    After  resection  of  the  intestine  and  a  V-shaped  piece  of 


Fig.  712. — Represents  the  ends  of  the  intestine  in 
position  and  grasped  by  the  artery  forceps.  The  first 
row  of  sutures  has  been  partially  applied,  the  septum 
partly  cut  away,  and  the  second  row  of  overhand  su- 
tures begun:  a,  b,  are  the  two  ends  of  the  intestine; 
c,  cf ,  the  first  row  of  sutures  (Gushing) ;  d,  the  second 
row  of  sutures  (overhand);  e,  the  septum;  /  and  g, 
the  mesentery  (J.  Shelton  Horsley). 


Fig.  713. — Operation  nearly  completed. 
The  septum  has  been  cut  away,  and  the  row 
of  overhand  sutures  has  been  brought  almost 
to  its  point  of  commencement.  The  cut  also 
shows  the  first  row  of  sutures  (Gushing)  as  it 
should  be  continued  after  the  overhand  sutures 
are  finished  (J.  Shelton  Horsley). 


mesentery,  the  ends  of  the  bowel  are  placed  side  by  side,  the  openings  being 
in  the  same  direction,  and  are  clamped  in  place  (Fig.  712).  The  first  stitch 
approximates  the  two  limbs  of  the  bowel  near  the  mesenteric  attachment,  is 
carried  obliquely  for  about  2  inches  to  the  border  opposite  the  mesenteric 

1  "Nevsr  York  Polyclinic." 


iii6 


Diseases  and  Injuries  of  the  Abdomen 


attachment,  and  continued  over  the  other  side  (Fig.  712).  The  septum  is 
cut  away,  a  margin  being  left  ^  inch  wide.  The  edge  of  the  shelf  made  by- 
cutting  the  septum  is  sutured.  When  the  suture  reaches  the  end  of  the  shelf, 
it  is  continued  by  invaginating  about  the  rest  of  the  resected  ends  (Fig.  713). 


Fig.  714. — Lateral  anastomosis  with  the  aid  of  Laplace's  forceps. 

Bodine's  method  of  intestinal  anastomosis  is  referred  to  on  page  1122. 
Laplace,  of  Philadelphia,  has  de\ised  an  operation  in  which  temporary  ap- 
proximation is  effected  by  means  of  forceps,  the  instrument  being  withdrawn 
before  the  abdomen  is  closed.     Junction  of  two  segments  of  intestine  can  be 

quickly  and  neatly  effected  by  this 
method  and  the  suture  line  is  even 
and  secure.  The  objections  are 
that  an  infected  instrument  is 
withdrawn  from  the  bowel  and 
may  contaminate  the  surface ;  that 
the  septum  is  tightly  squeezed 
and  this  septum  may  slough  or 
may  become  infected,  conditions 
which  will  be  followed  by  infec- 
tion of  the  suture  line;  and  that 
contraction  of  the  collar  may  en- 
sue. The  operation  is  more  Hable 
to  be  followed  by  leakage  or  by 
partial  or  complete  obstruction 
than  is  the  operation  without  for- 
ceps. Figures  714  and  715  illus- 
trate the  use  of  Laplace's  forceps 
in  lateral  anastomosis.  I  usually 
perform  lateral  anastomosis  with 
the  assistance  of  Moynihan's 
clamps,  the  method  being  identical  with  the  operation  of  gastro-enterostomy. 
Moynihan's  operation  is  shown  in  Fig.  716. 

Consideration  of  Methods  of  Intestinal  Approximation. — At  least  250 
methods  of  uniting  a  divided  intestine  have  been  devised  and  the  best  method  is 
a  matter  of  dispute.     The  essentials  of  a  good  method  are:  rapidity  of  execu- 


Fig.  715. — Withdrawal  of  Laplace's  forceps. 


Consideration  of  Methods  of  Intestinal  Approximation  iii; 


tion,  the  formation  of  an  even  and  rehable  line  of  junction,  and  the  absence  of 
any  considerable  permanent  septum.  The  Murphy  button  can  be  applied 
with  great  rapidity,  and  rapid  operation  is  of  immense  importance  in  intestinal 
work.  The  opening  left  by  the  Murphy  button  is  small  (too  small,  some  sur- 
geons think),  but  it  does  not  strongly  tend  in  most  instances  to  contract  because 
the  tissue-diaphragm  is  separated  by  tissue-atrophy  and  not  by  inflammatory 
gangrene.  The  separation  of  the  diaphragm  is  a  most  valuable  feature.  No 
other  instnmient  thus  cuts  away  the  objectionable  septum.  Occasionally  the 
opening  made  by  the  button  contracts  and  gives  trouble;  occasionally  the 
Ivmien  of  the  button  blocks  with  feces;  occasionally  the  button  is  retained,  this 
latter  complication  being  especially  frequent  after  anterior  gastro-enterostomy. 
If  the  button  is  used,  liquid  food 
should  be  given  soon  after  the 
effect  of  the  anesthetic  has 
passed  off,  and  movement  of  the 
bowels  should  be  obtained  at  an 
early  period  after  operation  and 
frequent  evacuations  should  be 
maintained.  The  button  gives 
better  results  in  end-to-end  ap- 
proximation than  in  lateral  an- 
astomosis. Moynihan's  forceps, 
Laplace's  forceps,  O'Hara's  for- 
ceps, the  decalcified  bone  plates 
of  Senn,  the  catgut  rings  of 
Abbe,  the  segmented  ring  of 
Harrington,  the  catgut  strands 
inside  of  rubber  tubing  of 
Brokaw,  Chapuf's  button,  AI- 
lingham's  bone  bobbin,  Robson's 
bone  bobbin,  Frank's  coupler, 
Clark's  bobbin,  tubes  or  plates 
of  potato  or  carrot,  and  rings 
or  plates  of  leather,  all  have 
their  adherents.  Of  mechan- 
ical appliances,  the  best  are 
Miu^hy's  button,  the  bone  ring, 
and  ]\Io}Tiihan's  forceps.  Of 
recent  years  many  surgeons  have 
abandoned  all  mechanical  aids, 
and  have  returned  to  closure 
by  simple  sutures.  The  ideal 
operation  is  without  mechanical 
contrivances.  But  such  de\-ices 
operation  vn]l  often  save  life. 


Fig.  716. — Moynihan's  inner  surfure  in  lateral  anasto- 
mosis to  show  the  infolding  of  the  mucosa  which  results. 
A  loop  of  the  suture  lies  on  the  mucous  surface  (Mojiii- 
han) . 


are  time-savers,  and  to  lessen  the  time  of 
Further,  Moynihan's  forceps  prevent  fecal 
extravasation  and  consequent  infection.  WTiat  method  to  follow  must  be 
determined  in  each  particular  case  by  a  study  of  the  necessities  of  the  situation. 
Nevertheless,  it  may  be  possible  to  formulate  a  few  general  rules:  If  the  condi- 
tion of  the  patient  is  excellent  and  the  bowel  is  in  a  fairly  healthy  condition,  well 
above  and  well  below  the  seat  of  trouble,  end-to-end  approximation  should 
be  performed  by  circular  enterorrhaphy  "^-ith  the  aid  of  ]\Ioynihan''s  clamp, 
or  each  end  can  be  closed  after  resection  and  a  lateral  anastomosis  be  effected 
with  the  aid  of  the  clamp.  If  the  condition  of  the  patient  is  such  as  to  make 
haste  necessarv-,  use  a  Murphy  button.  If  the  bowel  below  the  seat  of  trouble 
is  much  contracted  and  haste  is  necessar}',  do  not  use  a  Murphy  button,  but 


iii8 


Diseases  and  Injuries  of  the  Abdomen 


use  Senn's  bone  plate  or  Robson's  bobbin.  If  haste  is  not  imperatively  neces- 
sary, do  simple  enterorrhaphy.  If  the  surgeon  is  obliged  to  join  a  very  much 
distended  bowel  to  a  very  much  contracted  bowel,  perform  end-to-side  ap- 
proximation (implantation)  with  the  bone  plate  of  Senn  or  by  simple  suturing, 
or  else  effect  side-to-side  junction  by  the  method  of  Abbe  or  of  Moynihan.^ 

Local  Intestinal  Exclusion. — This  operation  was  introduced  by  Salzer 
in  1 89 1.  It  excludes  the  fecal  current  from  a  portion  of  the  intestine.  In 
complete  exclusion  the  intestine  is  cut  through  above  and  belo^v  the  diseased 
portion,  and  the  ends  of  the  healthy  gut  are  united  to  each  other  or  the  end 
of  one  portion  of  gut  is  implanted  into  the  side  of  the  other.  Both  ends 
of  the  excluded  portion  may  be  fastened  to  the  skin,  making  a  double  fistula 
(Von  Eiselsberg) ;  the  distal  end  or  the  proximal  end  alone  may  be  fastened  to 
the  skin,  the  other  end  being  closed  by  sutures  and  replaced  within  the  abdo- 
men. Sometimes  each  end  is  closed  and  dropped  back,  and  a  fistula  is  made 
in  the  middle  of  the  excluded  portion  to  permit  of  drainage.  Some  operators 
close  each  end  by  suture  and  drop  them  back,  and  do  not  drain  the  excluded 
portion;  and  others  aim  at  the  same  end  by  suturing  together  the  two  ends 


Fig.  717. — Operation  of  complete  exclusion  of  the  cecum:  a  and  h,  Lines  of  incision;  /  is  implanted 
into  c;  e  and  d  are  sutured  to  the  abdominal  wall. 


of  the  excluded  part.  It  seems  wisest  to  suture  both  ends,  or  at  least  one  end 
to  the  skin  (LeDentu,  in  "Rev.  de  Gyn.  et  de  Chir.,"  Jan.  and  Feb.,  1899). 
It  is  true  this  makes  a  permanent  fistula,  but  if  it  is  not  done,  the  loop  may 
become  distended  with  secretion  containing  virulent  bacteria,  a  condition 
which  may  lead  to  perforation  and  death.  Exclusion  is  rarely  performed  upon 
the  small  intestine.  It  is  best  suited  to  the  large  intestine.  If  it  is  done  at 
all,  complete  exclusion  is  the  best  operation  (Fig.  717).  Partial  exclusion  is 
rarely  satisfactory.  Exclusion  has  been  performed  instead  of  colostomy  in 
cases  of  intestinal  obstruction,  but  it  is  best  suited  to  inflammatory  areas  or 
tumors,  irremovable  because  of  adhesions  or  some  other  cause.  After  the 
operation  the  diseased  area  may  improve  because  of  drainage  and  freedom  from 
irritant  fecal  matter.  In  many  cases  it  can  be  irrigated  through  the  fistula. 
Sometimes  the  diseased  part  improves  sufficiently  after  a  time  to  permit  of 
extirpation. 

Surgical  Treatment  of  Ascites  Resulting  from  Hepatic  Cirrho= 
sis  (Epiplopexy;  Talma's  Operation). — The  portal  system  communicates 
with  the  vena  cava  by  means  of  a  number  of  small  vessels.  Normally,  only  an 
^  See  the  discussion  of  this  subject  by  the  late  J.  Greig  Smith,  in  his  "Abdominal  Surgery." 


Surgical  Treatment  of  Ascites  Resulting  from  Hepatic  Cirrhosis     1119 

insignificant  amount  of  portal  blood  passes  by  this  route  to  the  general  circula- 
tion. When  cirrhosis  obstructs  the  flow  of  blood  through  the  liver,  the  radicles 
of  communication  between  the  portal  system  and  the  vena  cava  enlarge  and  an 
increased  amount  of  blood  is  thus  sent  direct  to  the  systemic  circulation. 
Adhesions  develop  between  the  parietal  peritoneum  and  some  of  the  viscera 
and  the  collateral  circulation  is  further  increased.  Thus,  Nature  seeks  to 
prevent  ascites.  If,  however,  the  obstruction  to  the  passage  of  portal  blood 
becomes  so  great  that  "the  collateral  circulation  is  no  longer  able  to  maintain 
an  equilibrium  in  the  blood-pressure  in  the  portal  radicles,  the  pressure  thus 
rises  to  a  point  at  which  transudation  takes  place  and  ascites  develops"  (M.  L. 
Harris,  paper  read  before  Chicago  Medical  Society,  Feb.,  1902).  The  theory 
above  set  forth  is  the  "mechanical  theory" ;  but,  as  Harris  points  out,  increased 
portal  tension  is  not  the  only  factor  concerned  in  the  production  of  ascites, 
chronic  inflammatory  changes  in  the  peritoneum  being  "materially  instru- 
mental" in  maintaining  ascites  by  lessening  the  absorbing  power  of  the  peri- 
toneum. Influenced  by  the  mechanical  theory  of  causation.  Talma,  of  Utrecht, 
devised  an  operation  to  cure  ascites  by  establishing  more  free  communication 
between  the  portal  system  and  the  systemic  circulation.  Drummond  and 
Morison  about  the  same  time  independently  devised  a  like  procedure.^  This 
operation  is  called  epiplopexy.  In  some  cases  the  abdomen  has  been  opened 
and  the  omentum  sutured  into  the  abdominal  wound;  in  others,  between  the 
layers  of  the  anterior  abdominal  wall.  The  results  are  slightly  better  when 
the  omentum  is  sutured  between  the  layers  of  the  abdominal  wall.  The  gall- 
bladder may  be  sutured  to  the  abdominal  wall  as  well  as  the  omentum.  The 
liver  and  spleen,  under  surface  of  the  diaphragm,  and  parietal  peritoneum 
about  the  liver  and  spleen  are  usually  rubbed  harshly  with  a  piece  of  gauze. 
Drainage  is  not  used  by  most  operators.  It  does  not  appear  to  contribute 
any  favorable  chances  and  it  exposes  the  patient  to  the  danger  of  infection. 
Morison,  however,  advocates  it,  and  makes  suprapubic  drainage,  a  glass  tube 
being  carried  into  the  rectovesical  or  recto-uterine  pouch  ("Brit.  Med.  Jour.," 
Jan.  20,  1912). 

The  operation  ought  to  be  performed  early,  before  the  onset  of  chronic 
inflammation  of  the  peritoneum.  In  a  great  majority  of  cases  the  operation 
proves  futile,  and  not  uncommonly  death  soon  follows  from  complications  or 
because  the  disease  is  very  far  advanced.  In  exceptional  cases  the  operation 
proves  of  distinct  benefit.  The  operation  shows  the  least  mortality  and  the 
greatest  number  of  apparent  cures  when  the  liver  is  large;  the  greatest  mor- 
tality and  the  few^est  cures  when  the  liver  is  contracted.  The  greatly  lowered 
vital  resistance  of  these  patients  is  the  imminent  danger.  Renal  disease,  car- 
diac disease,  other  grave  complications,  and  the  absence  of  sufficient  function- 
ating liver  substance  to  maintain  life  contra-indicate  operation  (Greenough,  in 
"Am.  Jour.  Med.  Sciences,"  Dec,  1902). 

Harris,  in  the  paper  previously  quoted,  collected  46  cases;  23  of  these  were 
instances  of  alcoholic  cirrhosis;  30  per  cent,  were  dead  within  fourteen  days; 
52  per  cent,  were  dead  within  two  months;  56  per  cent,  were  dead  within  six 
months.  Ascites  had  returned  in  all  of  those  who  died  late.  At  the  end  of 
one  year  or  longer  13  per  cent,  had  recovered  from  ascites.  The  remaining 
30  per  cent,  were  either  unimproved  or  were  said  to  be  improved  with  some 
ascites. 

Of  the  group  of  mixed  cases  constituting  the  remainder  of  those  Harris 
collected,  10  per  cent,  were  dead  in  four  days,  25  per  cent,  were  dead  in  four 
months.  In  40  per  cent,  no  improvement  took  place.  In  10  per  cent,  the 
report  was  too  early  to  give  any  information.  About  15  per  cent,  were  free 
of  ascites  after  one  year  or  longer,  and  5  per  cent,  were  cured  of  intestinal 
1  "Brit.  Med.  Jour.,"  Sept.  19,  1896. 


I120  Diseases  and  Injuries  of  the  Abdomen 

hemorrhage,  ascites  never  having  been  present.  Greenough  collected  105 
operations:  42  per  cent,  were  improved;  58  per  cent,  were  not  improved; 
29.5  per  cent,  died  within  thirty  days.  Two  years  after  operation  9  cases 
were  apparently  in  good  health  ("Am.  Jour.  Med.  Sciences,"  Dec,  1902). 
One  of  Morison's  cases  was  alive  and  well  eleven  years  after  operation;  another 
was  well  for  six  years,  when  an  attack  of  pneumonia  lead  to  death;  another 
patient  remained  well  for  two  years,  but  died  after  an  operation  for  ventral 
hernia  (Morison,  in  "Brit.  Med.  Jour.,"  Jan.  20,  1912). 

Operation  for  Intussusception. — Air  distention  and  hydrostatic  pres- 
sure are  uncertain;  in  an  advanced  case  may  rupture  the  gut;  even  in  a  re- 
cent case  may  fail  or  may  reduce  the  bulk  of  the  intussusception,  but  not  its 
apex.  Russell  ("Intercolonial  Med.  Jour,  of  Australasia,"  March  20,  1902) 
alludes  to  the  uncertainty  of  the  method.  He  used  hydrostatic  pressure 
in  5  cases.  Two  died  and  2  recovered.  In  i  case  the  method  failed  and 
operation  was  then  performed.  It  is  safer  and  better  to  operate  early,  but 
if  the  conservative  plan  is  tried  and  fails,  operation  should  certainly  be  done 
at  once,  because  an  early  operation  enables  the  surgeon  easily  to  effect  reduc- 
tion, and  also  because  early  complications  are  unusual.  The  incision  is  made 
in  the  midline  above  the  umbilicus.  The  surgeon  endeavors  by  manipulation 
to  reduce  the  intussusception  by  pushing  it  back,  not  by  pulling  it  out.  If  the 
intussusception  is  gangrenous,  perform  intestinal  resection  and  circular  enter- 
orrhaphy.  The  same  rule  maintains  when  malignant  disease  of  the  gut  exists 
(D'Arcy  Power).  It  is  inadvisable  to  make  an  artificial  anus.  MaunselVs 
operation  is  suited  to  cases  of  irreducible  intussusception.  It  is  performed 
as  follows:  A  longitudinal  incision  is  made  in  the  intussuscipiens.  The  intus- 
susception is  gently  pulled  upon  and  is  caused  to  protrude  from  this  opening. 
Two  straight  needles  threaded  with  horse-hair  are  passed  so  as  to  transfix  the 
base,  and  \  inch  above  the  needles  the  intussusception  is  cut  off.  The  needles 
are  carried  completely  through,  the  sutures  are  hooked  up  in  the  middle  and  cut, 
and  the  two  ends  are  tied  on  each  side.  These  sutures  unite  the  intussusception 
to  the  intussuscipiens.  The  two  surfaces  are  now  carefully  approximated 
by  sutures.  The  sutures  are  cut.  The  stump  is  replaced.  The  longitudinal 
incision  is  closed  with  Lembert  sutures.^ 

Russell  (Ibid.)  reports  16  cases  operated  upon:  12  recovered  and  4  died. 
In  every  one  of  the  4  fatal  cases  the  diagnosis  was  not  made  until  the  disease 
had  lasted  several  days.  In  only  2  of  the  successful  cases  the  diagnosis  was 
made  late.  If  operation  is  done  in  the  first  twelve  hours  the  mortality,  even 
in  infants,  will  probably  be  comparatively  small.  If  gangrene  exists  the  mor- 
taHty  is  enormous  (at  least  90  per  cent.). 

Senn's  Operation  for  Fecal  Fistula. — Suture  the  opening  trans- 
versely with  Czerny  sutures  of  silk  in  order  to  prevent  infection.  Cleanse 
the  surface  thoroughly.  Open  the  abdomen  and  separate  the  edges  of  the 
bowel  from  the  parietes.  DeHver  the  portion  of  bowel  which  contains  the 
fistula  and  apply  Lembert  sutures  over  the  Czerny  sutures.  Another  method 
is  to  open  the  abdomen  above  the  fistula,  insert  the  fingers,  cut  out  the  skin 
and  tissues  around  the  fistula  in  an  elliptical  course,  leaving  them  attached 
'to  the  bowel,  draw  the  bowel  from  the  abdomen,  pack  gauze  around,  remove 
the  tissues  adherent  to  it,  and  suture  the  fistula  transversely. 

Enterostomy  is  the  making  of  an  artificial  anus.  If  performed  in  the 
large  bowel,  it  is  called  colostomy.  In  some  cases  of  intestinal  obstruction 
it  is  necessary  to  open  the  small  intestine,  and  if  this  is  required,  the  artificial 
anus  should  be  made  as  near  as  possible  to  the  cecum.  The  higher  above 
the  cecum  it  is  made,  the  more  apt  is  the  patient  to  die  of  lack  of  nourish- 
ment. A  small  intestinal  anus  may  be  made  in  the  middle  fine  or  in  the 
^T.  Pickering  Pick,  "Quarterly  Med.  Jour.,"  Jan.,  1897. 


Inguinal  Colostomv 


right  iliac  region.  The  bowel  is  fixed  and  opened  as  directed  under  Colos- 
tomy. In  acute  intestinal  obstruction  it  may  be  necessar}'  to  open  the  bowel 
at  once.  In  such  a  case  Paul's  tube  (Fig.  718)  is  ver>'  useful.  It  is  made  of 
glass,  is  bent  to  a  right  angle,  and  has  a  rim  near  each  end.  The  large  tube 
is  used  in  the  colon,  the  small  tube  in  the  small  intestine.  A  small  opening 
is  made  in  the  intestine,  the  tube  is  introduced,  and  is  tied  in  place  by  a  silk 
suture  which  surrounds  all  the  coats  of  the  bowel,  a  gush  of  feces  is  caught  in 
a  basin,  a  rubber  tube  is  fastened  to  the  glass  tube,  and  fluid  feces  are  collected 
in  a  bottle  and  beneath  an  antiseptic  liuid.^  In  from  three  or  four  days  to  a 
week  the  tube  becomes  loose  and  can  be  removed.  Stewart's  method  of 
enterostomy  was  outhned  on  page  992. 

Valvular  Cecostomy  (Gibson's  Operation) . — This  operation  was  de\-ised 
in  1900  by  Charles  L.  Gibson,  of  Xew  York.  It  is  used  in  chronic  dysenter\-. 
It  allows  us  to  flush  the  large  intestine  and  to  apply  remedies  to  it.  The  incision 
is  made  over  the  caput  coli,  a  small  puncture  is  made  in  it,  a  soft  catheter 
(Xo.  30  Fr.)  is  introduced  well  into  the  bowel,  and  is  fixed  there  as  is  the  tube 
in  Kader's  gastrostomy  (seepage  10S7).  After  ten  or  twelve  days  the  tube  is 
not  kept  in  place,  but  is  introduced  when  needed.  The  fistula  closes  spon- 
taneously on  the  discontinuance  of  introducing  the  catheter  daily.  Appendi- 
costomy  has,  to  a  great  extent,  replaced  cecostomy,  because,  as  a  rule,  it  is  easier 
and  safer.  "The  appendix  may,  however,  not  be  of  a  suitable  size  or  position 
(retrocecal)  to  lend  itself  properly  to 
the  procedure"  (Gibson,  paper  read 
before  the  Intemat.  Surg.  Assoc,  at 
Brussels,  Sept.,  191 1). 


Fig.  71S. — Paul's  tube. 


Fig.  719. — Inguinal  colostomy  (after  Zuckerkandl) . 


Inguinal  Colostomy  (Maydl's  Operation)  (Fig.  719). — In  this  opera- 
tion a  vertical  or  oblique  incision  4  inches  in  length  is  made  over  the  portion  of 
colon  to  be  incised.  In  all  cases  when  possible  do  a  left  inguinal  colostomy. 
In  right  inguinal  colostomy  it  is  more  difficult  to  deliver  the  bowel  than  in  a  left 
inguinal  colostomy,  because  of  shortness  or  absence  of  mesocolon  at  this  point  of 
the  colon.  Right  inguinal  colostomy  has  been  performed  for  chronic  amebic 
dysentery-.  It  puts  the  colon  at  rest  and  permits  of  free  irrigation.  It  is  kept 
open  until  the  dysentery-  is  well.  Appendicostomy  and  vahTilar  cecostomy 
have  replaced  it  for  dysenter}-.  It  has  also  been  employed  for  the  treatment 
of  ulceration  of  the  colon.  After  the  incision  on  the  left  side  the  colon  usu- 
ally bulges  into  the  wound,  but  if  it  does  not,  it  may  easily  be  found  by 
following  with  the  finger  the  parietal  peritoneum  outward,  backward,  and  in- 
ward, the  first  obstruction  it  encounters  being  the  mesocolon.  Draw  the 
colon  out  of  the  woimd  imtil  its  mesenteric  attachment  is  level  with  the  ab- 
dominal incision.  Push  a  glass  bar  through  a  slit  in  the  mesocolon  near  the 
bowel,  and  wTap  the  ends  of  the  bar  -nith  iodoform  gauze  to  prevent  slipping. 
Instead  of  the  bar,  a  piece  of  gauze  can  be  employed  (Fig.  719),  or  a  bridge 
^  Paul,  in  '"Liverpool  ]\Ied.-Chir.  Jour.,"  Jul}",  1892. 


II22 


Diseases  and  Injuries  of  the  Abdomen 


of  skin  can  be  made  under  the  bowel  by  sutiiring  the  two  skin  edges.  In  order 
to  make  a  spur  the  two  parts  of  the  flexure  are  stitched  together  by  sutures 
which  penetrate  to  and  catch  the  submucous  coat.  Stitch  the  serous  coat  of  the 
bowel  to  the  parietal  peritoneum  (Fig.  719).     Whenever  possible,  wait  from 


Fig.  720. — Stevenson's  bag  for  inguinal  colostomy. 

twenty-four  to  forty-eight  hours  before  opening  the  gut.  The  colon  is  opened 
by  the  cautery  or  by  scissors.  If  the  artificial  anus  is  to  be  permanent,  make 
a  transverse  incision  through  the  bowel.  Cut  one-fourth  way  across  the 
colon  when  it  is  first  opened,  and  entirely  across  at  a  later  period.  If  the  arti- 
ficial anus  is  to  be  temporary,  the 
incision  should  be  longitudinal. 
Maydl's  operation  has  great  advan- 
tages :  it  is  quick,  certain,  reasonably 
safe,  satisfactorily  prevents  fecal  ac- 
cumulation below  the  opening,  and 
is  rarely  followed  by  absolute  fecal 
incontinence.  In  many  cases  the 
bowels  move  but  two  or  three  times 
a  day.  The  movements,  however, 
come  quickly  with  but  Httle  warning. 
Sometimes  there  is  no  warning.  If 
diarrhea  develops,  there  will  be  fecal 
incontinence  as  long  as  it  lasts.  An 
air-pad  covered  with  gauze  may  be 
held  in  place  by  a  firm  belt,  or  the 
appliance  shown  in  Figs.  720  and  721 
may  be  worn. 

Bodine's  Operation  (Figs.  722, 
723) . — Bodine's  method  of  colostomy 
permits  of  a  future  restoration  of  the 
fecal  current  by  an  easily  performed 
anastomosis.  This  surgeon  main- 
tains that  the  spur  after  colostomy 
should  reach  to  and  remain  at  the 
level  of  the  skin,  a  condition  impos- 
sible of  attainment  by  hanging  the 
bowel  over  a  rod  or  piece  of  gauze,  be- 
cause a  spur  thus  formed  is  not  thick 
and  rigid  and  is  inevitably  dragged 
below  the  skin  level,  and  when  this 
dragging  has  taken  place,  some  fecal  matter  will  pass  into  the  bowel  below 
the  artificial  anus.  Bodine  opens  the  abdomen,  sutures  the  parietal  perito- 
neimi  to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  6  inches  of  healthy 
bowel  out  of  the  incision.  He  lays  the  limbs  of  the  loop  side  by  side.  He 
inserts  a  silk  stitch,  beginning  at  the  point  where  exsection  is  to  be  made,  and 


Fig.  721. — Stevenson's  bag  applied. 


The  Incision  for  Operations  Upon  the  Gall-bladder  and  Bile-ducts     1123 


for  6  inches  unites  the  two  segments  close  to  their  mesenteric  borders.  The 
loop  is  dropped  into  the  abdomen  until  the  beginning  of  the  suture  is  on  a 
level  with  the  skin,  and  at  this  point  it  is  fastened  to  the  abdominal  wound 
with  a  continuous  catgut  suture.  The  protruding  lesion  is  cut  off  along  the 
dotted  line  (Fig.  ^22).  The  artincial  anus  is  thus  established.  \Mien  it  is 
desired  to  close  the  artificial  anus,  di\ide  the  septimi  •uith  scissors  or  a  Grant 
clamp  I  Fig.  723)  and  close  the  abdominal  woimd.^ 

Lumbar  colostomy  is  a  most  uiisatisfactor\-  operation.  It  does  not  com- 
pletely intercept  the  fecal  current,  and  it  leaves  the  patient  in  a  condition  of 
wretched  discomfort  because  fecal  incontinence  is  ine^-itable.  A  patient  who 
has  had  lumbar  colostomy  performed  upon  him  either  obtains  little  benefit, 
because  the  feces  pass  into  the  bowel  below  the  opening  which  was  made  to 
intercept  them  or  else  they  pour  out  of  the  opening  uncontrolled,  making  the 
poor  imfortunate  a  h\-ing  horror  to  himself  and  others.  It  is  rarely  performed 
at  the  present  day. 


Fig.  722. — ^Bodine's  method  of  colostomy, 
showing  one  side  of  the  loop  after  it  has  been  su- 
tured, passed  back  into  the  ca%-it}-  and  stitched 
into  the  abdominal  woimd.  The  lesion  is  left  pro- 
truding, and  the  dotted  line  indicates  where  the 
protrusion  is  to  be  clipped  off. 


Fig.  723. — ^Bodine's  method  of  colostomy, 
showing  the  septum  to  be  di%'ided  in  restoring 
the  feral  current;  Grant's  clamp  in  position 
for  the  diAision.  (La  permanent  colostomy 
thig  septum  remains  as  a  rigid  and  effective 
spur.) 


The  health}-  gall=bladder  has  a  capacity-  of  about  i  oz.,  and  its  hue  is 

bluish.  If  a  ga'U-bladder  contains  calculi  or  has  contained  them,  its  hue  is 
gra^-ish-white  or  veUowish  ( ^Mo^-nihan') . 

Congenital  Absence  of  the  Qall=bladder. — \Mien  the  gaU-bladder  is 
shnmken  and  buried  in  adhesions,  it  is  ver\-  difficult  to  find  it  at  operation. 
Sometimes  it  is  not  found  and  one  may  jump  to  the  conclusion  that  it  is  con- 
genitallv  absent.  This  is  occasionally,  but  ver\-  seldom,  the  case.  Gray  col- 
lected 19  instances  of  congenital  absence  of  the  gaU-bladder  ("Trans,  of  Chicago 
Path.  Soc,"  1902).  \\T3en  it  is  absent  the  subject  seems  to  have  gotten  along 
perfectly  well  without  it. 

The  Incision  tor  Operations  Upon  the  Qall=bladder  and  Bile=ducts. 

— ^I  have   employed  several  methods,    and   have   frequently    used  Bevan's 

incision  (Fig.  724,  b).     The  primar\-  portion  of  the  incision  is  shaped  like  the 

italic  letter  /.     It  is  by  the  side 'of  or  through  the  right  rectus  muscle, 

1  "New  York  Polvclinic,"  Feb.  15,  1897. 


II24 


Diseases  and  Injuries  of  the  Abdomen 


and  is  shown  by  the  double  line  in  Fig.  724,  b.  The  primary  incision  is  iised 
for  exploration  and  cholecystotomy.  The  primary  incision  is  from  3  to  4 
inches  long,  and  the  extended  portions,  shown  by  heavy  lines  in  Fig.  724,  b, 
are  added  if  required  (Arthur  Dean  Bevan,  "Annals  of  Surgery,"  July,  1899), 
This  incision  gives  most  satisfactory  exposure,  its  edges  can  be  separated 
without  tension,  and  it  injures  but  few  of  the  nerv^es  of  the  abdominal  walls. 
Kocher's  incision  (Fig.  724,  a)  gives  a  very  satisfactory  exposure.  It  cuts 
the  two  obhques  and  the  transversaHs  muscle  and  divides  intercostal  nerves, 
but  can  be  sewed  up  evenly  and  is  seldom  followed  by  hernia.  Mayo-Robson's 
incision  (Fig.  724,  d)  gives  an  admirable  exposure  of  the  common  duct,  although 
it  damages  the  right  rectus  muscle  and  the  nerv^e-supply  of  the  inner  part  of  the 
muscle.  None  of  these  incisions  are  entirely  satisfactory.  Collins's  incision 
(Figs.  724,  c,  725)    ("Surg.,  Gynec,  and  Obstet.,"  March,  1909)  seems  to 


Fig.  724. — Incisions  for  the     .,.-  ...    jf  the  bile-tracts:  A,  Kocher's  ir-J-iMii:  B,  Bevan's  incision;  C, 
Colhns  3  incision;  D,  Mayo-Robson's  incision  (.Collins j. 

largely  correct  the  defects  of  the  pre\dous  operations.  Collins  thus  describes 
his  incision: 

"The  incision  for  the  bile-tracts  begins  at  the  inner  edge  of  the  right  mus- 
cle, I  or  2  inches  from  the  ensiform  cartilage,  and  extends  diagonally  down- 
ward and  outward  to  the  outer  edge  of  the  right  rectus,  close  to  the  level 
of  the  umbiHcus.  It  cuts  through  the  skin,  fat,  and  anterior  wall  of  the  sheath 
of  the  rectus  (Fig.  725).  A  short  transverse  incision  about  i  inch  in  length 
may  be  made  inward  from  the  upper  end  of  the  diagonal  incision  through  the 
skin,  fat,  and  linea  alba;  and  a  similar  one  through  the  linea  semilunaris  at 
the  lower  end.  In  case  more  room  is  required  the  upper  transverse  incision 
may  be  extended  further  into  the  anterior  and  posterior  walls  of  the  sheath  of 
the  left  rectus. 

"The  rectus  muscle  is  then  separated  from  its  sheath.  It  is  easily  sepa- 
rated from  the  posterior  portion  of  its  sheath  by  blunt  dissection,  but  the 
anterior  portion  presents  some  difficulty  at  the  insertion  of  the  linea  transversae, 
one  of  which  is  found  about  midway  between  the  ensiform  cartilage  and 
umbihcus  and  is  crossed  by  this  incision.     The  attachment  of  the  muscle  to 


Cholecvstostomv 


112: 


the  anterior  wall  of  its  sheath  is  very  close  at  this  linea  transversa,  and  requires 
sharp  dissection  vrith  knife  or  scissors. 

''\Mien  the  muscle  is  thoroughly  freed  from  its  sheath  except  at  its  outer 
border,  it  is  easily  retracted  outward  and  allows  the  posterior  wall  of  its  sheath 
and  the  peritoneum  to  be  incised  in  the  same  direction  as  the  skin  and  ante- 
rior wall.  The  upper  end  of  this  diagonal  incision  through  the  posterior 
wall  extends  into  the  short,  transverse  incision  across  the  Knea  alba,  ^^^len 
this  last  cut  is  made  the  incision  pulls  open  and  gives  ready  access  to  the 
right  upper  abdomen."  This  incision  does  not  damage  the  intercostal  ner\^es, 
hence  muscular  atrophy  is  avoided.  The  opening  through  the  different 
planes  of  the  abdominal  wall  are  not  continuous,  hence  closure  will  be  more 


Fig.  725. — A,  Anterior  wall  of  sheath  of  rectus  muscle;  B.  posterior  wall  of  sheath:  C,  rectus  muscle; 
D,  intercostal  ner\-es.  The  direction  of  the  incision  through  the  skin,  fat,  and  anterior  wall  of  the 
sheath  of  the  rectus  muscle  (Collins). 

solid.     The  opening  in  the  posterior  portion  of  the  rectus  sheath  is  protected 
by  iminjured  muscle. 

Cholecystostomy  or,  as  many  call  it.  cholecystotomy,^  is  the  oper- 
ation of  opening  and  draining  the  gall-bladder  in  order  to  extract  gall-stones 
or  secure  the  removal  of  infectious  material.  In  the  hands  of  the  Mayos 
operations  for  stone  exhibit  a  mortaht}'  of  less  than  i  per  cent. ;  Kocher's  mor- 
tality is  2  per  cent.  WTien  death  follows  an  operation  on  the  gall-bladder  or 
ducts,  in  about  one-half  the  cases  it  is  due  to  duct  infection  and  is  preceded 
b^'  grave  nen'ous  s}Tnptoms  (]\Iayo).  Cholecystostomy  is  performed  in  cases 
of  acute  cholecystitis,  in  hydrops,  and  in  empyema  of  the  gall-bladder:  in  gall- 
stone cases  in  which  jaundice  has  lasted  for  four  weeks  or  more,  and  in  colic  of 
the  gall-bladder  with  fever,  the  coHc  ha\iag  recurred  a  second  or  third  tune 
1  First  performed  by  Bobbs,  of  Indianapolis,  in  1867. 


1 1 26  Diseases  and  Injuries  of  the  Abdomen 

(Carl  Beck).  The  operation  completed  in  one  stage  is  performed  as  follows: 
The  patient  is  placed  recumbent  with  a  sand-pillow  beneath  the  liver  and 
the  incision  is  made.  The  peritoneum  is  opened.  If  the  gall-bladder  is  dis- 
tended, it  is  surrounded  with  pads  and  aspirated,  and  is  then  opened.  Gall- 
stones are  removed  by  forceps,  the  scoop,  or  irrigation.  The  gall-ducts  are 
examined  by  the  fingers  external  to  them  before  opening  the  gall-bladder,  and 
are  sounded,  if  possible.  If  a  stone  is  wedged  in  the  duct,  try  to  manipulate  it 
back  into  the  gall-bladder.  If  this  fails,  introduce  an  instrument  from  the  gall- 
bladder and  break  up  the  stone;  if  this  fails,  open  the  duct,  remove  the  stone, 
and  close  the  incision  in  the  duct  (A.  W.  Mayo  Robson).  The  only  way  to  be 
certain  that  stones  have  been  removed  entirely  from  the  cystic  duct  is  to  insert  a 
finger  and  dilate.  Sounds  are  unrehable.  After  the  removal  of  all  stones  and 
fragments  pass  a  rubber  tube  which  has  no  side  perforations  into  the  gall- 
bladder, purse  up  the  cut  in  the  gall-bladder  around  the  tube  by  means  of  a 
catgut  suture,  and  suture  the  gall-bladder  to  the  abdominal  aponeurosis.  If 
sutured  to  the  skin,  a  permanent  biliary  fistula  is  apt  to  follow.  It  will  seldom 
follow  if  the  gall-bladder  is  sutured  to  the  aponeurosis.  A  small  piece  of  gauze 
is  retained  under  the  gall-bladder  in  case  there  should  be  a  leak  into  the  perito- 
neum and  in  case  the  peritoneum  may  have  been  soiled.  If  gauze  causes  no 
trouble  it  is  retained  in  place  from  five  to  eight  days.  It  can  then  be  removed 
easily  and  without  breaking  encompassing  adhesions.  The  drainage-tube, 
which  drains  into  a  bottle  outside  of  the  dressings  and  below  the  level  of  the 
bed,  can  usually  be  dispensed  with  in  from  one  week  to  ten  days.  It  should 
not  be  dispensed  with  until  the  bile  becomes  sterile. 

Some  surgeons  have  advocated  immediate  suture  of  the  gall-bladder  after 
removing  a  stone  {ideal  cholecystotomy).  I  believe  this  is  never  advisable 
when  the  stones  are  active  for  harm,  because  small  calculi  may  be  in  the  ducts 
and  minute  fragments  of  stone  are  often  left  in  the  bladder,  and  the  drainage 
will  remove  them.  Drainage  also  relieves  the  diseased  condition  of  the  gaU- 
ducts  and  bladder.  In  Kocher's  31  operations  by  this  method,  gall-stones 
re-formed  in  3  cases.  Further,  the  operation  with  inunediate  suture  is  decid- 
edly more  dangerous  when  infection  exists.  The  Mayos  only  employ  it  in 
latent  cases  of  gall-stone  disease  when  the  existence  of  stones  is  discovered 
during  the  performance  of  an  abdominal  operation. 

It  is  advised  by  some  that  the  operation  of  cholecystostomy  be  performed 
in  two  stages.  First,  the  bladder  is  exposed  and  sutured  to  the  parietal  peri- 
toneum. When  adhesion  takes  place,  the  gall-bladder  can  be  opened  without 
risk  of  infecting  the  general  peritoneal  surface.  Riedel  advocates  operation 
in  two  stages,  and  so  did  Christian  Fenger  in  certain  cases.  The  two-stage 
operation  is  objectionable  because  it  does  not  permit  of  satisfactory  explora- 
tion of  the  ducts.  The  biliary  fistula  which  is  left  by  cholecystostomy  usually 
closes  spontaneously,  but  may  not.  If  it  does  not  close  and  the  secretion  is 
pure  mucus,  it  is  evident  that  the  cystic  duct  is  absolutely  blocked  and  chole- 
cystectomy should  be  performed. 

If  the  secretion  from  a  persistent  fistula  is  bile  and  if  the  common  duct  is  not 
obstructed,  separate  the  edges  of  the  gall-bladder  opening  from  the  parietal 
peritoneum,  endeavoring  to  avoid  entering  the  abdominal  cavity,  and  close 
the  fistula  with  Lembert  or  Halsted  sutures.  If  the  secretion  is  bile  and  the 
common  duct  is  obstructed  permanently,  perform  cholecystenter ostomy.  If  the 
,  secretion  does  not  contain  bile  and  the  cystic  duct  is  blocked,  remove  the  gall- 
bladder. At  the  end  of  1907  Hans  Kehr  placed  his  mortality  at  2  per  cent. 
("Jour,  de  Chir.,"  Oct.,  1908).  The  report  of  St.  Mary's  Hospital,  Rochester 
(the  Mayo  clinic),  for  191 2  shows  426  cholecystostomies,  with  3  deaths. 

The  Mc Arthur  Drip. — In  1909  Lewis  L.  McArthur  suggested  using  a 
biliary  fistula  as  a  means  for  introducing  fluid  or  food  into  the  duodenum.     He 


Cholecystenterostomy 


1127 


proved  that  if  a  tube  draining  bile  from  the  gall-bladder  is  connected  to  an 
irrigator  containing  salt  solution  (elevated  not  more  than  20  inches  and  giving 
a  rate  of  flow  not  over  5  or  6  drops  a  second) ,  there  will  be  a  continuous  flow  of 
fluid  into  the  duodenum  without  any  discomfort  to  the  patient  (McArthur,  in 
"New  York  Med.  Jour.,"  Jan,  27,  1912).  Matas  has  improved  the  method  by 
introducing  into  the  duodenum  at  the  time  of  operation  and  by  way  of  the 
conmion  duct  a  ureteral  catheter,  through  which  food,  fluid,  or  medicine  can 
be  at  any  time  carried  into  the  duodenum.  (Rudolph  Matas,  in  "New  Orleans 
Med.  and  Surg.  Jour.,"  Oct.,  191 1).  The  method  is  used  in  many  cases  of 
obstructive  jaundice  (after  removal  of  the  obstruction).  The  salt  solution 
reheves  thirst,  removes  toxins,  and  stimulates  the  kidneys.  It  relieves  post- 
operative vomiting,  favors  intestinal  peristalsis,  combats  flatulent  distention, 
and  causes  movements  of  the  bowels,     Matas  points  out  that  liquid  food 


Fig.  726. — Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in  cholecj'stenter- 

ostomy. 

and  medicines  (strychnin,  castor  oil,  Hunyadi  water,  etc.)  can  be  given  by 
the  biliary  route.  McArthur  believes  that  the  method  can  be  used  instead  of 
jejunostomy  in  certain  cases  of  pyloric  obstruction  and  stomach  ulceration. 

Cholecystenterostomy^  consists  in  making  an  anastomosis  between  the 
gall-bladder  and  intestine,  preferably  the  duodenum,  or,  if  this  cannot  be 
done,  the  jejuniun.  It  is  employed  in  cases  of  irremovable  obstruction  of 
the  common  duct.  It  is  done  chiefly  in  cases  of  malignant"  obstruction. 
It  is  not  a  suitable  operation  for  gall-stones  impacted  in  the  common  duct, 
because  it  does  not  remove  the  cause  of  trouble,  infection  of  the  bile- 
passages  may  follow,  and  the  fistula  is  liable  to  contract.  In  those  rare  cases 
of  common  duct  obstruction  from  gall-stones,  in  which  the  gall-bladder  is 
distended  and  the  patient  is  desperately  ill,  it  may  be  done  (Robson).  In 
such  a  case  Robson  attaches  the  gall-bladder  to  the  colon  because  the  operation 
is  easier  and  because  he  considers  it  as  useful  as  the  attachment  to  the  duo- 

1  The  operation  was  suggested  by  Nussbaum,  but  was  first  performed  by  Winiwarter  in 
1882  ("A  Manual  of  Operative  Siurgery,"  by  Sir  Frederick  Treves). 


II2S  Diseases  and  Injuries  of  the  Abdomen 

deniim.  Cholecystenterostomy  can  be  done  most  rapidly  and  successfully 
by  means  of  a  small  Murphy  button.  Before  the  gall-bladder  is  incised  it  is 
aspirated.  Murphy's  operation  is  shown  in  Fig.  726,  and  is  similar  in  per- 
formance to  intestinal  anastomosis.  I  believe  that  Brentano  is  right  and 
that  it  is  best  to  do  posterior  cholecystenterostomy,  bringing  the  jejummi 
through  an  opening  made  in  the  transverse  mesocolon. 

Cholecystectomy  is  the  extirpation  of  the  gall-bladder.  It  was  first 
performed  by  Langenbuch  in  1882.  Sometimes  primary  extirpation  is  per- 
formed; at  other  times  cholecystectomy  is  performed  as  a  secondary  opera- 
tion, cholecystostomy  for  drainage  having  been  first  performed.  Its  per- 
formance may  be  demanded  by  the  existence  of  phlegmonous  inflammation 
or  gangrene,  ulceration,  "in  chronic  cholecystitis  from  gall-stones  where  the 
gall-bladder  is  shrunken  and  too  small  to  safely  drain,  and  where  the  common 
duct  is  free  from  obstruction"  (A.  W.  Mayo  Robson),  in  empyema  with  greatly 
damaged  walls,  in  fistula  associated  with  irremediable  obstruction  of  the  cystic 
duct,  the  common  duct  being  free,  in  cancer,  and  in  some  wounds  of  the  gall- 
bladder. Objections  to  the  operation  are  that  drainage  can  only  be  obtained 
by  putting  a  tube  into  the  hepatic  or  the  common  duct,  and  that,  should  renewed 
drainage  be  subsequently  required,  the  necessary  operation  will  prove  difficult 
and  dangerous  (Maurice  H.  Richardson,  "Medical  News,"  May  2,  1903). 

After  opening  the  abdomen  the  gall-bladder  is  found  and  is  drawn  into 
the  wound.  If  it  is  distended  and  tense  or  if  it  is  thought  "to  contain  infec- 
tious fluid"  (Liiienthal) ,  it  is  packed  about  with  iodoform  gauze  and  emptied 
by  an  aspirating  trocar.  "When  the  walls  are  very  friable,  it  is  even  wise 
to  incise  and  empty  the  viscus,  closing  the  opening  by  ligature  or  clamp 
before  proceeding  with  the  extirpation.  The  gall-bladder  is  usually  quite  a 
tough  organ,  and  in  the  majority  of  cases  it  may  be  grasped  with  an  ovarian 
ring-clamp  applied  near  its  fundus,  which  at  the  same  time  closes  the  aspi- 
ration puncture"  (Liiienthal,  "Annals  of  Surgery,"  July,  1904).  The  peri- 
toneum which  covers  the  gall-bladder  must  be  divided  just  below  the  liver, 
the  gall-bladder  is  dissected  from  the  liver  until  the  cystic  duct  is  reached, 
the  cystic  artery  is  tied  and  divided,  and  if  the  liver  ducts  are  healthy,  the 
cystic  duct  is  ligated  with  silk  and  divided,  the  stump  is  touched  with  pure  car- 
bolic acid  and  is  covered  with  a  layer  of  peritoneum  fastened  by  sutures  of 
fine  silk.  In  cases  free  from  infection  it  is  not  necessary  to  drain  the  bile- 
ducts.  In  cases  with  cholangitis  external  drainage  is  necessary,  and  it  is 
obtained  by  incising  the  hepatic  duct  and  inserting  a  drainage-tube,  or,  better, 
by  leaving  the  stimip  of  the  cystic  duct  open.  The  report  of  St.  Mary's  Hos- 
pital, Rochester,  Minnesota  (the  Mayo  clinic),  shows  255  cases  of  cholecystec- 
tomy with  5  deaths.  Howard  Liiienthal  (Ibid.)  reported  42  cases  with  i  death. 
Hans  Kehr's  mortality  at  the  end  of  1907  was  3.6  per  cent.  ("Jour,  de  Chir.," 
Oct.,  1908). 

Removal  of  the  Mucous  Membrane  of  the  Qall=bladder. — Mayo 
has  suggested  the  removal  of  the  fundus  and  of  all  the  mucous  membrane 
of  the  gall-bladder  as  an  occasional  substitute  for  cholecystectomy.  By 
this  operation  we  are  enabled  to  drain  the  cystic  duct  and  through  it  the  hepatic 
ducts.  A  serious  objection  to  the  operation  is  that,  as  glands  pass  from  the 
mucous  coat  to  and  through  the  musciilar  coat,  it  is  impossible  absolutely  to 
remove  the  mucous  membrane  of  the  gall-bladder  alone  (Emil  Reis) . 

Drainage  of  the  H'epatic  Duct. — This  operation  is  employed  for 
certain  hepatic  infections.  It  was  first  performed  by  Cabot  in  1892.  If  the 
cystic  duct  is  dilated  throughout,  it  may  be  carried  out  through  that.  After 
opening  the  gall-bladder  a  tube  is  passed  through  the  cystic  and  into  the 
hepatic  duct.  It  is  often  done  after  opening  the  common  duct,  a  tube  being 
carried  up  into  the  hepatic  duct.     The  hepatic  duct  may  be  exposed  and 


Supraduodenal  Choledochotomy  1129 

opened  directly,  a  tube  being  carried  into  it  for  a  short  distance  and  stitched 
to  the  edges  of  the  incision  in  the  duct  by  catgut.  The  tube  should  be  sur- 
rounded by  iodoform  gauze. 

Supraduodenal  choledochotomy  is  the  operation  of  incising  the  com- 
mon bile-duct  above  the  duodenum  for  the  removal  of  a  stone.  It  is  also  called 
choledocholithotomy.  If  drainage  is  used  it  is  choledochostomy.  It  was  first 
performed  by  Kiimmel  in  1889.     Courvoisier  did  his  first  operation  in  1890. 

Cases  upon  which  this  operation  is  done  are  often  deeply  jaundiced  and 
there  is  grave  danger  of  infection  and  perhaps  of  fatal  oozing  of  blood.  In  i  of 
my  cases  this  happened.  The  patient  was  laboring  under  stones  in  the  com- 
mon duct,  associated  with  cancer  of  the  head  of  the  pancreas.  In  everv^  case 
in  which  operation  is  contemplated  for  obstruction  of  the  bile-ducts  take  the 
coagulation  time  of  the  blood.  Normal  coagulation  time  (taken  by  Wright's 
coagulometer)  is  from  three  to  sbc  minutes.  Prolongation  to  seven  or  eight 
minutes  calls  for  pre-operative  treatment  to  hasten  coagulability.  If  jaundice 
exists,  it  is  customary  to  endeavor  to  prevent  hemorrhage  by  employing  Rob- 
son's  plan:  Give  by  the  mouth  from  30  to  60  gr.  of  chlorid  of  calcium  three 
times  a  day  during  the  twenty-four  or  forty-eight  hours  preceding  operation, 
and  60  gr.  by  enema  three  times  a  day  for  the  forty-eight  hours  following 
operation.  I  have  followed  this  course  in  a  number  of  cases,  but  am  not  con- 
vinced of  its  value.  Instead  of  this  method  we  may  follow  the  plan  of  giving 
thyroid  extract  (5  gr.  three  times  a  day)  for  several  days  preceding  operation. 

The  plan  I  now  pursue  I  am  certain  does  reduce  the  coagulation  time  dis- 
tinctly. I  give  an  injection  of  horse  serum  the  day  before  operation  and 
another  the  morning  of  the  operation. 

When  ready  to  operate,  a  sand-bag  should  be  placed  under  the  lower  ribs. 
This  will  bring  the  liver  at  least  2  inches  nearer  to  the  abdominal  wound. 
The  abdominal  incision  must  be  longer  than  that  employed  for  cholecys- 
tostomy.  The  pylorus  and  stomach  are  drawn  to  the  left,  the  colon  and  omen- 
tum are  drawn  downward,  and  the  Kver  and  ribs  are  lifted  strongly  upward. 
Gauze  packs  are  inserted. 

"The  operator  should  now,  after  having  separated  adhesions,  have  a 
good  view  of  the  common  duct  within  the  free  border  of  the  lesser  omentum, 
and  on  inserting  his  left  index-finger  into  the  foramen  of  Winslow,  or  on  grasp- 
ing the  duct  between  the  index-finger  and  thumb,  he  can,  without  difficulty, 
bring  the  duct  well  within  reach,  the  concretion  making  a  distinct  projec- 
tion."^ A  longitudinal  incision  is  made,  the  stone  is  removed,  and  a  probe 
is  introduced  into  the  duct  to  determine  whether  other  stones  are  present. 

Stones  in  the  second  and  third  portions  of  the  duct  are  often  missed  and  the 
second  portion  of  the  duodenum  should  always  be  palpated  with  the  utmost 
care.  If  the  lowermost  stone  removed  from  the  common  duct  is  faceted,  we 
should  always  search  most  carefully  to  find  a  concretion  which  is  lower  still 
(F.  Gregory  Connell,  "Annals  of  Surgery,"  April,  1908). 

If  a  calculus  is  found  in  the  lower  part  of  the  common  duct,  the  surgeon 
tries  to  push  it  up  so  that  he  may  reach  it.  This  can  usually  be  accomplished. 
Failing  to  push  the  stone  up  into  reach,  some  try  and  force  it  into  the  duode- 
num. This  attempt  w^ill  sometimes,  but  seldom,  succeed.  If  it  does  not  suc- 
ceed, the  surgeon  must  perform  a  transduodenal,  or  a  retroduodenal  operation. 
Only  in  cases  so  shocked  that  prolonged  operation  is  impossible  is  it  proper 
to  do  cholecystostomy  or  cholecystenterostomy.  If  either  of  these  palliative 
operations  is  performed  a  radical  operation  must  be  done  later. 

Many  surgeons  suture  the  incision  in  the  duct.  This  procedure  is  ren- 
dered easier  by  the  use  of  Halsted's  hammer,  which  draws  the  duct  toward 
the  surface  and  keeps  it  imder  control  (Fig.  727). 

^  A.  W.  Mayo-Robson's  "Treatise  on  Diseases  of  the  Gall-bladder  and  Bile-ducts." 


II30 


Diseases  and  Injuries  of  the  Abdomen 


Interrupted  sutures  of  fine  catgut  are  used.  The  muscular  and  serous 
coats  may  be  included  in  each  suture,  and  over  this  layer  Lembert  or  Halsted 
sutures  are  applied.  A  drainage-tube  is  inserted  and  a  piece  of  iodoform 
gauze  is  placed  upon  the  suture  line,  the  other  end  being  brought  out  of  the 
abdominal  wound.  This  precaution  is  taken  because  leakage  may  occur. 
If  it  is  found  impossible  to  suture  the  wound  in  the  duct,  the  operation  then 
becomes  a  choledochostomy  (although  this  term  is  usually  used  only  when 
the  incised  duct  is  stitched  to  the  abdominal  wall).  The  surgeon  carries 
a  glass  tube  down  to  the  opening  and  surrounds  it  with  iodoform  gauze, 
or  inserts  a  rubber  drainage-tube  into  the  opening  and  carries  it  up  toward 
the  hepatic  duct,  or  makes  an  incision  into  the  right  loin  after  the  plan  of 
Rutherford  Morison,  and  carries  a  tube  into  the  right  kidney  pouch,  which  is 
the  most  dependent  part  of  the  peritoneal  cavity  when  the  patient  is  recumbent. 
Personally  I  always  drain  the  duct,  when  I  have  opened  it  for  stone,  carrying 
the  tube  up  toward  the  hepatic  duct.  The  same  reasons  which  cause  us  to 
drain  the  gall-bladder  after  removing  stones  should  influence  us  in  this  case. 

Robson  ("Lancet,"  April 
22, 1902)  has  performed  the 
operation  of  choledochot- 
omy  60  times.  In  10  cases 
of  stone  in  the  common 
duct  he  manipulated  the 
stone  back  into  the  gall- 
bladder and  removed  it 
through  an  incision  in  that 
viscus  by  means  of  a  scoop. 
The  above  maneuver  is  im- 
possible unless  the  cystic 
duct  is  dilated.  In  30  cases 
he  crushed  the  stones  be- 
tween his  finger  and  thumb, 
but  this  is  only  possible 
when  the  stones  are  soft, 
and  it  has  the  objection  that 
it  may  leave  fragments.  If 
a  stone  is  lodged  in  the  com- 
mon duct  and  cannot  be 
manipulated  back  into  the 
gall-bladder,  choledochot- 
omy  should  be  performed.  Robson's  mortality  in  60  cases  of  choledochotomy 
was  16.6  per  cent.  Since  1900  his  mortality  has  been  7.1  per  cent.  Before 
that  it  was  23.8  per  cent.  Kehr's  mortality  is  4.1  per  cent.  During  1912  the 
Mayos  performed  choledochotomy  96  times,  with  5  deaths  ("Report  of  St. 
Mary's  Hospital  for  191 2"). 

Hepaticotomy. — By  this  term  we  mean  the  opening  of  the  hepatic  duct. 
If  the  opening  is  drained  the  procedure  is,  in  reality,  hepaticostomy,  although 
this  term  is  seldom  used  to  designate  it.  Hepaticotomy  is  performed  for 
stone  in  the  hepatic  duct.  The  operation  was  first  performed  by  Kocher 
in  1889.  There  were  7  cases  on  record  in  1903  (Delageniere,  in  "Bull,  et 
Mem.  de  Chir.  de  Paris,"  No.  10,  1903). 

Duodenocholedochotomy  (McBumey's  Operation;  the  Transduodenal 
Route). — This  operation  is  seldom  necessary.  In  the  more  than  2000  opera- 
tions performed  by  the  Mayos  on  the  gall-bladder  and  ducts,  it  was  only 
required  in  4  cases.  I  have  never  performed  it.  In  1891  McBin-ney  pro- 
posed the  method  for  the  removal  of  gall-stones  impacted  near  the  papilla 


Fig.  727. — Suture  of  duct  over  Halsted's  hammer. 


Total  Splenectomy  1131 

("Annals  of  Surgen-,"  Oct.,  1S98).  McBurney's  original  suggestion  was  to 
open  the  duodenum,  dilate  or  incise  the  papilla,  remove  the  stone,  and  suture 
the  duodenum.  The  duodenum  must  be  mobilized  so  that  it  may  be  lifted 
into  the  wound.  If  the  stone  is  located  in  the  diverticulum  of  Vater,  it  may, 
in  some  few  cases,  be  removed  by  simply  stretching  the  opening  of  the  duct  with 
forceps  (Collins's  method).  If  this  is  not  possible,  the  opening  in  the  papilla 
may  be  enlarged  by  cutting  or  the  duodenal  mucous  membrane  over  the  stone 
may  be  incised  (]SicBurney's  plan).  When  the  stone  is  not  impacted  at  the 
outlet,  but  is  lodged  a  httle  higher  up,  and  when  dense  adhesions  render 
access  by  the  ordinary'  supraduodenal  route  difficult  or  impossible,  the  anterior 
wall  of  the  duodenum  may  be  opened  longitudinally,  the  posterior  wall  of  the 
duodenum  and  the  common  duct  incised  over  the  stone,  the  stone  removed, 
the  duodenum  and  common  duct  sutured  together  (Kocher's  method,  or 
internal  choledoclwduodenostomy),  and  the  anterior  wall  of  the  duodenimi 
closed.  (See  Charles  Otto  Thienhaus,  in  "Annals  of  Surger}-,"  Dec,  1902.) 
After  finding  and  remo\ing  a  stone  by  the  transduodenal  route  we  must  make 
a  careful  search  to  see  that  no  stones  are  left  before  closing  the  duodenal  incision. 
Robson  opposes  the  transduodenal  route  and  says  he  has  abandoned  it  because 
of  the  danger  of  sepsis.  Thienhaus  (Ibid.)  opposes  this  ^iew  of  Robson  and 
shows  that  in  29  operations  by  the  transduodenal  route  there  were  but  2  deaths. 

Connell  ("Annals  of  Surger}-,'"  Jan.,  1908)  has  collected  77  cases  in  which 
stones  were  removed  by  the  transduodenal  route.  There  were  10  deaths.  In 
2  of  these  cases  duodenal  fistula  preceded  death. 

Retroduodenal  Choledochotomy. — In  this  operation  the  second  por- 
tion of  the  common  duct  is  incised  back  of  the  duodenum  T\-ithout  opening  the 
gut.  That  this  may  be  done  the  duodenum  must  first  be  drawn  toward  the 
midline  of  the  body,  and  this  can  be  done  only  by  "mobilizing"  the  duodemmi, 
incising  the  posterior  layer  of  the  parietal  peritoneum  i  inch  to  the  right  of  the 
descending  portion  of  the  duodemmi.  After  freeing  the  gut  and  retroperitoneal, 
structures  the  duodenimi  becomes  sufficiently  free  to  Hft  toward  the  left  with  a 
rotation.  We  thus  expose  the  posterior  aspect  of  the  duodenum,  the  head  of 
the  pancreas,  and  the  common  duct. 

The  duct  is  opened,  the  stone  removed,  the  duct  sutured,  and  a  drain  in- 
serted. 

This  operation  has  been  successfully  performed  by  a  number  of  surgeons, 
but  there  is  a  great  objection  to  it.  In  nearly  aU  cases  the  common  bile-duct 
passes  through  the  pancreas  rather  than  back  of  it.  Biingner  foimd  this  to  be 
the  case  in  55  out  of  58  dissections  ("Gray's  Anatomy,"  Seventeenth  xA-merican 
edition,  p.  1352).  Hence,  incision  of  the  common  duct  in  this  situation  means 
in  nearly  all  cases  incision  of  the  pancreas  and  aU  the  grave  dangers  of  leaking 
of  pancreatic  fluid.     The  transduodenal  operation  is  a  much  better  procedure. 

Total  Splenectomy. — This  operation  is  performed  for  wounds  and 
rupture  of  the  spleen,  tumors,  cysts,  floating  spleen,  and  non-leukemic  splenic 
h}T3ertrophy.  Twisting  of  the  pedicle  of  an  ectopic  or  wandering  spleen  caUs 
imperatively  for  operation.  It  should  not  be  performed  for  hjpertrophy  in 
leukemia. 

\'edova  (quoted  in  "Practical  Medicine  Series,"  1913,  vol.  ii)  collected  134 
cases  of  splenectomy  for  traumatic  rupture  of  the  spleen.  There  were  40  deaths. 
He  adds  these  to  Berger's  60  cases,  with  25  deaths.  This  makes  a  total  of  194 
cases,  with  65  deaths  (33.5  per  cent.). 

In  ^'iew  of  the  bone-marrow  changes  in  splenomyelogenous  leukemia,  we 
caimot  hope  to  cure  a  patient  by  remoAing  the  spleen.  In  a  leukemic  patient 
the  operation  has  a  very  high  mortahty  from  shock  and  hemorrhage.  Geo. 
Ben  Johnston  ("Annals  of  Surgen,^,"  Jan.,  1908)  has  coUected  49  splenectomies 
in  leukemia  with  only  6  operative  recoveries  (a  mortahty  of  87. 7  per  cent.). 


1 132  Diseases  and  Injuries  of  the  Abdomen 

One  of  the  6  cases  lived  eight  months,  i  lived  four  years,  and  it  is  claimed  that 
I  was  cured. 

Splenectomy  has  been  performed  for  malarial  h^q^ertrophy  (ague-cake). 
The  operation  has  been  advocated  on  the  theory  that  by  removing  the 
spleen  we  get  rid  of  the  lurking  place  of  the  malarial  parasites,  but  they  also 
lurk  in  the  bone-marrow  and  in  the  capillaries  of  the  Uver.  The  operation 
should  not  be  performed  for  malarial  spleen  unless  the  organ  is  movable, 
unless  it  greatly  interferes  with  the  patient's  comfort  or  occupation,  or  unless  we 
fear  rupture,  and  then,  if  it  is  done,  it  is  for  the  movability,  the  discomfort,  or  the 
danger  of  rupture,  and  not  for  the  malaria.  It  is  to  be  noted  that  the  opera- 
tion does  not  cure  the  malaria.  Johnston  ("Annals  of  Surgery,"  Jan.,  1908) 
collected  58  splenectomies  performed  for  malarial  hypertrophy  since  1900. 
There  were  50  recoveries  and  8  deaths.  To  these  he  adds  3  successful  ones  of 
his  own,  making  61  cases,  wdth  8  deaths  (a  mortality  of  13. i  per  cent.). 

A  nimiber  of  operations  have  been  done  for  splenic  anemia  or  its  terminal 
stage,  which  is  known  as  Banti's  disease.  Those  who  believe  that  the  splenic 
enlargement  and  anemia  result  from  some  underlying  condition  common  to 
both  do  not  operate.  The  theory  of  the  operation  is  that  removal  of  the  spleen 
stops  the  production  of  some  toxic  material  which  causes  anemia  and  cirrhosis 
of  the  Hver,  in  other  words,  that  the  splenic  disease  causes  the  anemia.  There 
seems  ample  evidence  that  splenectomy,  if  done  early,  may  save  the  patient. 
It  is  useless  and  highly  dangerous  to  do  it  after  the  development  of  the  second 
stage  of  Banti's  disease.  Cushing's  case  was  alive  and  well  eight  years  after 
the  operation. 

Johnston  (Ibid.)  has  collected  61  splenectomies  for  splenic  anemia  or  Ban- 
ti's disease.  There  were  49  recoveries  and  12  deaths,  a  mortality  of  19.5  per 
cent.  I  have  performed  splenectomy  twice  for  Banti's  disease,  with  one  re- 
covery and  one  death. 

Johnston  (Ibid.)  notes  12  splenectomies  for  sarcoma  of  the  spleen,  with  9 
recoveries.  One  lived  eight  and  one-half  years  and  died  of  heart  disease; 
3  are  known  to  have  died  from  recurrent  sarcoma. 

It  is  stated  that  there  are  on  record  4  splenectomies  for  cancer.  Moynihan 
doubts  the  diagnostic  accuracy  of  the  three  earUer  reports.  Mary  A.  Smith 
records  a  case  of  colloid  cancer  occurring  in  a  woman  who  had  been  operated 
on  ten  years  before  for  ovarian  cyst  associated  with  pseudomyxoma  of  the 
peritoneum.  The  pathologist  reported  that  the  growth  in  the  spleen  was 
a  metastasis  of  colloid  carcinoma.  This  patient  died  seven  rnonths  after  the 
splenectomy  from  peritoneal  and  omental  cancer  ("Annals  of  Surg.,"  Jan.,  1908). 

In  Johnston's  table  of  708  splenectomies  for  various  causes  (Loc.  cit.)  the 
mortality  is  27.4  per  cent.  In  the  cases  operated  upon  from  1900  to  1907 
inclusive  the  mortality  is  18.5  per  cent. 

In  order  to  remove  the  spleen  most  operators  make  an  incision  from  the 
anterosuperior  spine  of  the  ilium  to  the  ribs.  I  prefer  to  make  an  incision  below 
the  left  costal  margin  like  Kocher's  incision  on  the  right  side  to  reach  the  gall- 
bladder. This  incision  can  be  extended  to  any  necessary  degree,  and  posterior 
drainage  of  the  pancreas  region  can  emerge  from  its  outer  end.  Open  the 
peritoneum  and  di\dde  adhesions  between  ligatures.  If  the  spleen  is  adherent 
to  the  pancreas,  it  may  be  necessary  to  remove  a  fragment  of  the  last-named 
organ.  It  is  a  very  undesirable  thing  to  have  to  do,  and  I  lost  a  case  from 
pancreatic  leakage  after  having  done  it.  Ligate  the  suspensory  ligament  and 
di\ade  it.  Bring  the  spleen  well  out  of  the  wound.  Surround  it  with  gauze 
pads.  Transfix  the  pedicle  with  stout  silk.  Tie  it  firmly,  lea^dng  the  ends  of 
the  ligature  long  for  a  time,  and  cut  through  the  pedicle  beyond  the  ligature. 
Ligate  the  vessels  separately  with  catgut.  Cut  off  the  long  ends  of  the  silk 
ligature  and  drop  the  pedicle  back,  unless  apprehensive  of  bleeding,  when  it  may 


Abdominal  Hernia  or  Rupture 


1133 


be  fastened  to  the  surface.  The  wound  is  closed  without  drainage,  unless 
the  pancreas  has  been  injured,  in  which  case  posterior  drainage  is  employed. 
Traction  upon  and  ligation  of  the  vessels  in  the  pedicle  may  cause  profound 
shock  by  injuring  the  splenic  plexus,  which  is  in  close  relation  with  the  solar 
plexus  (Jordan,  in  "Lancet,"  Jan.  22,  1S99). 

Changes  After  Splenectomy. — About  two  weeks  after  the  removal  of  a 
normal  spleen  certain  deiinite  changes  happen  in  adults,  but  not  in  children. 
These  changes  last  for  several  weeks,  and  are  manifested  by  enlargement  of  the 
l>Tiiph-glands,  pain  in  and  tenderness  of  bones,  blood  changes,  loss  of  weight, 
weakness,  thirst,  polyuria,  abdominal  pain,  elevation  of  temperature,  and  rapid 
pulse.i  Tizzoni  says  that  these  changes  are  not  obvious  in  children,  because 
in  them  compensatory  organs  act  at  once,  whereas  in  adults  compensatory 
organs  act  slowly  and  with  painful  effort.  Such  symptoms  are  noticed  when 
the  spleen  is  removed  because  of  a  wound  or  a  rupture,  but  rarely  after  removal 
of  a  diseased  spleen.  It  is  likely  that  compensating  organs  become  active  when 
the  spleen  is  diseased,  and  consequently  are 
in  full  operation  when  such  a  spleen  is  re- 
moved. After  partial  splenectomy  these 
changes  are  not  noted  (Jordan).  Changes 
can  be  prevented  after  splenectomy  by  the 
administration  of  tablets  of  extract  of 
spleen,  and  red  bone-marrow  (Ballance), 
and  iron  (especially  in  foods)  is  of  value. 

The  blood  changes  after  splenectomy 
consist  of  diminution  in  hemoglobin  and 
red  blood-cells.  The  coloring-matter  and 
cells  do  not  become  normal  for  two  or 
three  months. 

Splenopexy. — This  is  the  operation 
of  anchoring  a  movable  spleen.  It  should 
only  be  used  when  the  spleen  is  not  en- 
larged and  is  not  diseased.  Rydygier  in 
1895  published  the  first  case,  although 
both  TuiSer  and  Kouwer  operated  before 
this  date.  Sutures  should  not  be  passed 
through  the  spleen:  the  structure  is  so 
soft  that  stitches  are  bound  to  loosen  and 
the  insertion  will  cause  bleeding.  A  prom- 
ising method  is  to  create  adhesions  by  the 
use  of  iodoform  gauze,  as  is  done  for  mov- 
able kidney,  and  as  was  done  by  Kouwer. 
Some  advocate  making  a  pocket  outside  of  the  peritoneum  and  bringing  the 
spleen  into  this  pocket,  thus  placing  it  extraperitoneal. 

Abdominal  Hernia  or  Rupture. — A  hernia  is  a  protrusion  of  peri- 
toneum liable  to  contain,  containing  at  times,  or  permanently  containing  any 
viscus  or  part  of  a  viscus  from  the  abdominal  cavity.  MacCormac  says  the 
term  implies  that  the  protruded  viscus  is  covered  with  integiunent;  hence 
a  protrusion  of  \dscera  through  a  wound  does  not  constitute  a  hernia.  A 
hernia  has  three  parts — the  sac,  the  sac-contents,  and  the  sac-coverings 
(Fig.  728).  The  sac  is  formed  of  peritoneum.  A  congenital  sac  is  due  to 
developmental  defect,  and  may  be  in  the  inguinal  region,  the  femoral 
region,  the  umbiHcal  region,  the  lumbar  region,  or  in  the  epigastric  region. 
In  the  epigastric  region  it  is  a  result  of  a  congenital  sUt  in  the  transversahs 
fascia.  It  used  to  be  stated  that  femoral  hernia  was  never  congenital,  but 
1  Ballance,  in  "Practitioner,"  April,  1898;  H.  Martyn  Jordan,  in  "Lancet,"  Jan.  22,  1898. 


Fig.  728. — A  diagrammatic  representa- 
tion of  the  coverings  of  a  hernia:  a.  The 
skin;  h,  the  superficial  fascia;  c,  the  muscu- 
lar layer — e.  g.,  the  cremaster  muscle  in  an 
inguinal  hernia;  d,  the  transversalis  fascia; 
c,  d,  have  also  been  called  the  fascia  propria 
hernije;  e,  the  peritoneum — i.  e.,  the  sac  of 
the  hernia  (Sultan) . 


1 134  Diseases  and  Injuries  of  the  Abdomen 

Russell  and  Coley  both  say  that  a  femoral  hernia  may  have  a  congenital 
sac.  In  ICO  necropsies  Murray  found  20  potential  femoral  sacs  (sacs  into  which 
a  hernia  had  not  entered).  An  acquired  sac  is  due  to  intra-abdominal  pres- 
sure bulging  the  peritoneal  covering  of  an  abdominal  ring  and  converting 
it  into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a  mouth.  A  sac  once 
formed  is  almost  certain  to  persist,  because  it  adheres  by  its  outer  surface 
to  surrounding  parts,  and  hence  the  sac  of  a  hernia  is  usually  irreducible 
even  when  the  contents  are  reducible.  The  neck  of  the  sac  is  due  to  the  con- 
striction through  which  the  sac  passes;  it  becomes  furrowed  and  folded, 
and  the  adhesion  of  these  folds  causes  thickening  and  rigidity.  Hernia  of  the 
bladder  or  of  the  cecum  may  have  no  sac  or  but  a  partial  sac.  A  ventral  hernia 
following  an  abdominal  operation  may  be  without  a  sac.  The  contents  of  the 
sac  depend  chiefly  on  the  situation,  a  portion  of  the  ileum  being  the  usual 
contents.  The  colon,  the  stomach,  the  great  omentum,  the  bladder,  and  other 
structures  may  enter  the  hernial  sac.  An  enter ocele  contains  only  intestine;  an 
epiplocele  contains  only  omentum;  a.n  entero-epiplocele  contains  both  omentum 
and  intestine;  a  cystocele  contains  a  portion  of  the  bladder.  The  coverings  of 
the  sac,  which  vary  with  its  situation,  will  be  set  forth  during  the  consideration 
of  special  forms  of  hernia.  In  old  hernia  the  layers  are  never  distinct,  fat  and 
muscle  waste,  tissues  adhere,  and  the  skin  stretches  and  atrophies.  The  sac 
of  an  old  hernia  occasionally  becomes  tuberculous,  and  the  disease  may  remain 
local  in  the  hernial  sac  or  spread  to  the  general  peritoneum.  Renault  tells  us 
that  tuberculosis  of  a  hernia  is  made  manifest  by  increase  in  size,  pain  on 
pressure,  and  loss  of  body  weight. 

Causes  of  Hernia. — Hernia  is  a  common  trouble.  According  to  Berger, 
in  1000  people  4.4  per  cent,  suffer  from  hernia.  It  occurs  at  all  periods  of 
life,  and  hereditary  predisposition  sometimes  seems  to  exist.  The  male  sex  is 
three  times  as  liable  to  hernia  as  the  female  sex.  That  increase  of  intra- 
abdominal tension  is  a  common  cause  in  children  has  been  amply  demon- 
strated. (See  Hernia  in  Childhood,  page  11 58.)  Excessive  length  of  the 
mesentery  has  been  assigned  as  a  cause.  In  some  instances  a  mass  of  fat 
forms  {fat  hernia)  and  advances  before  the  hernia,  and  seems  to  bear  a  causa- 
tive relation  to  it.  Lucas-Championniere  explains  this  as  follows :  When  a  person 
begins  to  take  on  fat,  it  is  deposited  not  only  under  the  skin,  but  also  in  the 
omentum,  mesentery,  and  subperitoneal  tissues.  The  semifluid  fat  is  easily 
influenced  by  pressure.  The  deposit  of  fat  within  the  abdomen  lessens  the  size 
of  that  cavity,  intra-abdominal  pressure  is  increased,  and  subperitoneal  fat  pro- 
trudes at  any  weak  spot  in  the  wall.  The  protruding  mass  of  fat  adheres  to 
and  makes  traction  upon  the  peritoneimi,  and  this  membrane  is  drawn  upon 
to  form  a  sac,  and  the  sac  is  surrounded  by  fat.  This  method  of  formation 
is  frequently  noticed  in  imibilical  hemiae,  and  occasionally  in  inguinal  herniae. 
Any  laborious  occupation  predisposes  to  rupture.  Any  condition  which 
weakens  the  abdominal  wall  predisposes  to  rupture  (muscular  relaxation  from 
ill-health,  relaxation  of  abdominal  walls  following  the  termination  of  pregnancy, 
the  removal  of  a  large  tumor  or  tapping  for  ascites,  and  wounds  or  abscesses 
of  the  abdominal  wall).  The  commonly  assigned  cause  is  repeated  muscular 
effort  which  increases  intra-abdominal  tension  (straining  at  stool,  coughing, 
lifting  weights,  jumping,  the  sexual  act,  and  straining  during  micturition) .  In 
25  per  cent,  of  cases  the  cause  is  supposed  to  have  been  lifting  or  carrying  a 
weight  (Coley).  I  am  satisfied  that  in  some  cases  at  least  the  external  abdom- 
inal ring  enlarges  before  it  has  been  stretched  by  a  descending  hernia.  Such 
a  condition  predisposes  to  hernia  by  weakening  muscular  support  of  the 
abdomen.  A  hernia  may  appear  gradually  or  suddenly.  Berger  and  Coley 
state  that  nearly  70  per  cent,  of  herniae  in  adult  males  appear  gradually.  The 
sac  of  an  acquired  hernia  exists  for  a  longer  or  shorter  time  before  the  hernia 


Reducible  Hernia  113  5 

enters  it.  The  sac  of  a  congenital  hernia  is  present  at  birth.  The  sac  of  an 
acquired  hernia  forms  gradually.  A  sac  may  exist  for  years  and  yet  remain 
empty.  When  bowel  or  omentum  enters  it  from  some  strain  or  effort,  the 
parts  were  long  prepared  to  receive  the  extruded  mass.  This  extrusion  may 
occvir  gradually  or  it  may  occur  suddenly.  If  it  occurs  suddenly,  the  sufferer 
beheves  that  his  hernia  was  formed  then  and  there,  but,  as  a  matter  of  fact, 
the  extrusion  of  bowel  or  omentum  and  its  entrance  into  the  sac  were  but  the 
last  of  a  long  series  of  antecedent  and  preparator}-  changes.  Fiaallv,  a  hernia 
appears,  and  often  does  so  during  effort.  In  rare  cases  traimiatism  may 
cause  a  hernia  immediately,  no  sac  existing  before  the  accident.  It  does  so 
in  the  inguinal  region  by  stretching  or  tearing  the  internal  ring,  the  inguinal 
canal  at  once  enlarging.  Such  a  condition  is  a  true  traumatic  hernia,  trau- 
matism being  the  sole  cause  and  not  simply  the  exciting  cause. 

The  old  and  erroneous  idea  was  that  a  hernia  was  always  formed  by  tearing 
of  the  peritoneimi;  hence  the  term  rupture.  This  mode  of  formation  is  ex- 
tremely unusual,  but  occasionally  does  occur.  Coley  saw  such  a  case.  An 
ordinary-  non-traimiatic  hernia,  when  the  bowel  suddenly  and  for  the  first  time 
enters  the  sac,  is  the  seat  of  some  pain,  but  the  pain  is  not  disabling  and  the 
limip  disappears  on  recimibency.  In  many  cases  the  bowel  Or  omentum  grad- 
ually finds  a  way  into  the  sac,  and  in  such  cases  pain  is  usually  trivial  and  may 
even  be  absent.  In  true  traumatic  hernia  there  are  \-iolent  pain,  coUapse,  vomit- 
ing, inability  to  walk  and  stand,  and  the  mass  does  not  return  to  the  belly  on 
recumbency,  but  must  be  reduced  by  taxis  or  operation.  True  traumatic 
hemiae  may  occur  am-where  in  the  abdomen,  but  are  most  common  in  the 
inguinal  region,  where  they  are  direct  herniae.  (The  relation  bom  by  accidents 
to  the  development  of  hernia  is  discussed  by  Paul  Berger,  in  ''Rev.  de  Chir.," 
April  and  ^lay,  1906,  andby  Wm.  B.  Coley,  in  'Tnternat.  Joiu:.  of  Surg.,"  Feb., 
igoS) .  AH  congenital  hemiae  are  due  to  stm ctural  defects.  Hemis  are  di\-ided 
clinically  into  reducible,  irreducible,  incarcerated,  inflamed,  and  strangulated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents  of  the  sac  can 
be  reduced  into  the  abdominal  ca\ity.  At  a  known  hernial  opening  the 
patient  has  a  smooth  enlargement  (^narrower  above  than  below),  which  began 
to  grow  above  and  extended  downward.  A  distinct  neck  can  often  be  felt. 
In  enterocele.  straining,  lifting,  or  standing  enlarges  the  mass;  the  protrusion 
becomes  smaller  and  may  disappear  on  hing  down;  cough  causes  impulse  or 
succussion,  the  protrusion  is  elastic,  and  may  be  t^Tnpanitic  on  percussion, 
and  on  reduction  the  mass  suddenly  disappears  and  there  is  a  gxirgling  sound. 
In  epiplocele  the  mass  is  often  irregiilar  and  compressible,  and  feels  bogg}-  rather 
than  elastic;  muscular  effort  does  not  have  much  influence  in  enlarging  it; 
impulse  on  coughing  is  shght;  percussion  gives  a  dull  note,  and  reduction  is 
accomplished  gradually  and  produces  no  gurgling  soimd.  In  entero-epiplocele 
some  parts  of  the  mass  are  smooth,  elastic,  and  perhaps  tjTapanitic;  others  are 
dull  pn  percussion,  irregular,  and  flabby,  but  the  diagnosis  of  this  especial  form 
from  the  other  forms  is  often  uncertain.  The  \-ictims  of  reducible  hernia  com- 
plain of  some  pain  on  exertion,  of  dyspepsia,  and  often  of  constipation. 

WTien  a  hernia  is  beginning  to  form  there  is  often  premonotory  uneasiness; 
the  patient  complains  of  musciflar  pain  in  the  lower  abdomen,  and  this  condition 
may  exist  for  weeks  or  months  before  it  is  recognized  that  a  hernia  is  present. 
An  inguinal  hernia  can  be  recognized  before  it  protrudes  from  the  external 
ring.  The  tip  of  the  finger  is  inserted  in  the  ring  and  the  patient  is  asked  to 
cough.  If  a  hernia  has  entered  the  canal,  succussion  wifl  be  detected  on 
coughing.  In  a  healthy  man  the  external  ring  should  admit  the  tip  of  the  httle 
finger,  but  not  the  end  of  the  index-finger.  If  the  end  of  the  index-finger  can 
be  made  to  enter  the  ring  that  apertiure  is  dilated,  and  even  if  there  is  no 
hernia  in  the  canal,  in  future  a  hernia  wiU  probably  descend.      In  a  man,  if  the 


1 136  Diseases  and  Injuries  of  the  Abdomen 

surgeon  desires  to  examine  the  ring,  he  inverts  the  skin  of  the  scrotum  over  the 
finger  and  carries  the  finger  to  or  in  the  ring.  When  the  hernia  first  appears 
there  may  be  pain,  faintness,  and  some  sick  stomach,  but  often  there  is  no  pain 
or  any  discomfort. 

Treatment  of  Reducible  Hernia. — Palliative  Treatment. — Prevent  con- 
stipation and  forbid  sudden  strains  and  violent  exercise.  If  operation 
is  refused  or  inadvisable,  order  a  truss.  The  continued  employment 
of  a  truss  in  young  persons  may  bring  about  a  cure.  The  day  truss 
should  be  applied  before  rising  in  the  morning  and  be  removed  after  lying 
down  at  night,  when  a  light  truss  should  be  substituted.  A  special  truss 
is  applied  before  bathing.  In  very  fat  people  there  is  always  trouble 
in  adjusting  a  truss.  A  femoral  hernia  is  more  difficult  to  keep  reduced 
than  an  inguinal  hernia.  In  a  hernia  in  which  the  gut  is  replaceable,  but 
a  portion  of  omentum  is  irreducible,  it  is  difficult  to  maintain  reduction  of 
the  gut  with  a  truss,  and  an  operation  should  be  performed.  In  an  oblique 
inguinal  hernia  the  pad  of  the  truss  fits  over  the  internal  abdominal  ring; 
in  a  direct  inguinal  hernia,  over  the  external  abdominal  ring;  in  a  femoral 
hernia,  over  the  femoral  ring  at  the  level  of  Gimbernat's  ligament.  Mac- 
Cormac's  method  of  measuring  for  a  truss  is  as  follows:  In  either  inguinal 
or  femoral  hernia  start  the  tape  from  the  lower  part  of  the  hernial  opening, 
carry  it  up  to  the  anterior  superior  iliac  spine  of  the  same  side,  then  take  it 
around  the  body,  i  inch  below  the  crest  of  the  ilium,  to  the  other  anterior 
superior  iliac  spine,  and  then  to  the  upper  part  of  the  hernial  opening.^  A 
well-fitting  truss  will  keep  the  hernia  up  even  when  the  patient  sits  in  a  posi- 
tion to  relax  the  abdominal  walls  and  coughs  and  strains.  A  truss  is  always 
uncomfortable  at  first,  but  a  person  usually  becomes  accustomed  to  it.  It 
should  be  kept  scrupulously  clean,  and  borated  talc  powder  should  be  dusted 
upon  the  skin  under  the  pad  at  least  once  a  day.  A  truss  which  does  not 
keep  the  hernia  up  or  which  causes  pain  does  harm.  Too  strong  a  spring 
tends  to  enlarge  the  hernial  orifice,  and  thus  aggravates  the  case.  Even  after 
an  apparent  cure  with  a  truss  the  instrument  must  be  worn  for  a  long  time. 

Radical  treatment  of  reducible  and  of  non- strangulated  hernia  seeks  to  ob- 
tain cure  by  plugging  the  mouth  of  the  sac  or  by  obliterating  the  canal  of 
descent.  Radical  operations  should  be  performed  when  a  strangulated  hernia 
is  operated  upon,  in  ordinary  cases  of  reducible  hernia,  particularly  if  a  truss 
is  very  painful  or  does  not  keep  the  bowel  up,  in  most  cases  of  irreducible 
hernia,  and  in  any  case  of  hernia  in  which  there  are  occasional  attacks  of 
obstruction.  It  was  formerly  believed  that  a  cure  would  fail  if  the  subject 
was  under  three  years  of  age,  but  Coley  and  others  have  proved  that  it  is  a 
very  successful  operation  in  childhood.  It  is  rarely  recommended  under  the 
age  of  four,  because  in  two-thirds  of  the  cases  a  truss  will  cure  very  young 
subjects.  It  is  strongly  advised  in  children  after  the  age  of  four  when  a  truss 
has  failed,  when  there  is  irreducible  omentum,  or  when  there  is  a  reducible 
hydrocele  which  prevents  the  truss  from  holding  (Wm.  B.  Coley,  in  "Annals  of 
Surgery,"  June,  1903).  The  radical  operation  is  almost  without  danger  in 
properly  selected  cases,  and  is  one  of  the  most  successful  of  surgical  procedures. 
We  are  justified  in  doing  the  operation  upon  an  individual  under  fifty  years  of 
age  and  free  from  complications,  purely  to  relieve  him  or  her  from  the  annoy- 
ance of  wearing  a  truss.  If,  however,  a  patient  is  sixty  years  of  age  or  over  and 
a  truss  keeps  the  hernia  up  satisfactorily,  the  operation  should  not  be  performed 
unless  it  is  demanded  by  some  complication.  Organic  diseases  of  the  heart, 
lungs,  and  kidneys  are  contra- indications.  Enormous  hernije  (Figs.  729  and 
730)  are  unfavorable  for  operation.  Restoration  is  difficult  or  impossible,  the 
forcible  handling  produces  much  shock,  and  recurrence  is  to  be  expected. 
1  Treves's  "Manual  of  Surgery,"  "Hernia." 


Treatment  of  Reducible  Hernia 


1137 


Restoration  is  difficult  or  impossible  because  the  abdominal  cavity  has  con- 
tracted and  holds  with  difficulty  or  cannot  hold  the  huge  hernia.  As  J.  L.  Petit 
said,  the  hernia  ha.s  forfeited  the  right  of  domicile  (Fig.  729).  In  an  operation  for 
an  enormous  hernia  a  great  quantity  of  omentum  will  require  removal,  and  it 
may  be  necessary  to  resect  a  considerable  piece  of  intestine.  If  we  decide  to 
operate  upon  an  enormous  hernia,  treat  the  patient  some  time  before  with  the 
object  of  making  him  lose  flesh.  The  absorption  of  mesenteric  fat  lessens 
intra-abdominal  pressure.  That  operation  may  succeed  in  such  cases  is  shown 
by  Figs.  730  and  731.  In  any  operation  for  the  radical  cure  of  inguinal  her- 
nia always  remember  that  the  bladder  may  be  part  of  the  hernia,  and  be  on 
the  lookout  for  it.  Eggenberger's 
table  of  6778  hernial  operations 
shows  75  bladder  herniae  (i  per 
cent.).  As  a  rule,  it  is  covered 
with  cellular  fat,  which  differs  in 
color  and  consistence  from  omen- 
tal fat  and  from  other  fat  which 
may  be  found  about  a  hernia. 
The  presence  of  a  quantity  of  ex- 
traperitoneal fat  outside  of  the 
sac  suggests  the  adjacency  of 
the  bladder  and  warns  us  not  to 
tie  off  the  sac  very  high  up.  It 
was  the  author's  misfortune  on 
two  occasions  to  open  a  bladder  in 
operating  for  inguinal  hernia.  In 
each  case  the  bladder  was  sutured 
and  both  patients  recovered.  It 
has  been  estimated  that  the  mor- 
tality after  this  accident,  even 
when  the  bladder  is  sutured,  is 
from  6  to  16  per  cent.  Among 
other  possible  accidents  which 
may  occur  during  hernia  opera- 
tions are:  injury  of  an  iliac  ves- 
sel, of  a  femoral  vessel,  or  of  an 
epigastric  vessel. 

The  success  of  an  operation 
for  the  radical  cure  of  a  hernia 
depends  upon  the  attainment  of 
primary  union.  Primary  union  is 
favored  by  thorough  cleanliness; 
by  wearing  gloves  while  operat- 
ing; by  cutting  the  parts  with  a 

sharp  knife  instead  of  tearing  them  with  a  dissector;  by  removing  some  fat  and 
any  superfluous  tissue  fragments;  by  tying  the  stitches  firmly,  but  not  tightly 
(a  tight  stitch  causes  necrosis  and  creates  a  point  of  least  resistance) ;  by  careful 
closure;  by  dressing  with  pressure;  and  by  keeping  the  patient  recumbent  for 
from  fifteen  days  to  three  weeks. 

A  truss  is  not  to  be  used  after  operation.  Ten  years  ago  Wm.  B.  Coley 
("Annals  of  Surgery,"  June,  1903)  had  operated  upon  1075  cases  of  inguinal 
and  femoral  hernia.  In  his  report  he  did  not  consider  operations  performed 
within  the  preceding  six  months,  and  so  presented  a  study  of  1003  cases.  Of 
these,  937  cases  were  inguinal,  66  cases  were  femoral.  In  the  1003  cases,  647 
were  traced  and  were  found  well  from  one  to  eleven  years  after  operation;  705 
72 


Fig.  rag- 


Hernia   which  has   "forfeited  the  right  of 
domicile." 


1 138 


Diseases  and  Injuries  of  the  Abdomen 


were  well  from  six  months  to  eleven  years ;  460  were  well  from  two  to  eleven  years. 
If  the  patient  is  well  one  year  after  operation,  he  will  probably  remain  well. 
This  is  proved  by  Coley's  study  of  relapses,  an  investigation  which  shows  that 


Fig.  730. — Oblique  inguinal  hernia  of  large  size  (dxiration,  sixteen  years). 

65  per  cent,  of  relapses  occur  within  six  months  of  operation  and  80  per  cent, 
within  the  first  year.     Only  13!  per  cent,  occur  from  one  to  two  years,  and  only 


Fig.  731. — The  case  shown  in  Fig.  730  six  months  after  operation. 

6§  per  cent,  after  two  years.  Coley  had  2  deaths  in  1075  cases  (less  than 
i  of  I  per  cent.).  After  Bassini's  operation  there  are  about  i  per  cent,  of 
relapses.     Coley  reports  that  from  Dec,  1891,  to  Jan..  1909,  there  were  per- 


Treatment  of  Reducible  Hernia 


"39 


formed  by  Drs.  Bull,  Walker,  and  himself,  in  the  Hospital  for  Ruptured 
and  Crippled,  2384  operations  for  the  radical  cure  of  hernia.  Of  these,  2218 
were  inguinal  (only  445  in  females).  In  the  1773  male  cases  the  typical  or 
modified  Bassini  operation  was  done  with  12  relapses,  or  .68  per  cent.  ("Pro- 
gressive Medicine,"  June,  1909). 

Lannelongue's  Method. — Lannelongue  has 
for  certain  cases  returned  to  the  old  injection 
plan,  using  a  10  per  cent,  solution  of  chlorid  of 
zinc  instead  of  white  oak  bark.  The  hernia  is 
first  reduced  and  is  held  up  by  an  assistant, 
who  closes  the  internal  ring  with  a  finger  and 
also  holds  the  cord  aside.  Several  injections  of 
10  min.  each  are  thrown  in  the  region  of  the 
internal  pillar,  the  region  of  the  external  pillar, 
and  into  the  canal  behind  and  outside  of  the 
cord.     The  surgeon  must  be  careful  that  no 

zinc  solution  escapes  into  the  subcutaneous  tissue.  The  effect  of  the  chlorid 
of  zinc  is  to  cause  the  formation  of  quantities  of  fibrous  tissue.  It  is  scarcely 
to  be  expected  that  a  cure  so  produced  will  be  permanent  in  an  adult,  though 
it  may  be  in  a  child. 

Macewen's  Operation  for  Inguinal  Hernia-  A.  hernia  director  (Fig.  732,  a) 
and  special  hernia  needles  (Fig.  732,  b)  are  required  for  this  operation.     The 


Fig.  732. — A,  Hinged  hernia  director; 
B,  hernia  needles. 


Fig.  733. — Macewen's  operation  for  radical  cure  of  inguinal  hernia:  A,  Stripping  of  the  sac:  B, 
purse-string  suture;  c,  fastening  the  purse-string  suture;  D,  passing,  and  E,  tjdng,  the  sutures  for  the 
internal  ring. 

patient  lies  recimibent,  the  thigh  being  abducted  and  partly  flexed  and  rest- 
ing on  a  pillow  beneath  the  knee.  The  bowel  is  reduced,  and  an  incision  3 
inches  long  is  made  in  the  direction  of  the  inguinal  canal,  the  center  of  the 
incision  corresponding  to  the  external  ring.  The  sac  is  freed  from  its  attach- 
ments below  and  is  lifted  up.     The  surgeon  introduces  a  finger  into  the  inguinal 


1 140  Diseases  and  Injuries'  of  the  Abdomen 

canal  and  separates  the  sac  from  the  cord  and  from  the  walls  of  the  canal,  and 
then  carries  the  finger  through  the  internal  ring  and  separates  the  peritoneimi 
for  I  inch  about  the  periphery  of  this  aperture  (Fig.  733,  a).  A  chromicized 
catgut  stitch  is  fastened  to  the  lowest  portion  of  the  sac,  and  is  passed  through 
the  sac  several  times,  so  that  pulling  on  the  stitch  will  purse  the  sac  (Fig.  733, 
b).  The  free  end  of  this  stitch  is  carried  through  the  internal  ring  into  the 
belly,  and  is  pushed  out  through  the  abdominal  muscles  i  inch  above  the 
internal  ring,  the  skin  being  pushed  aside  so  as  to  escape  perforation  by  the 
needle.  The  thread  is  tightened  so  as  to  fold  up  the  sac  and  pull  it  into  the 
belly.  This  plugs  the  ring.  The  thread  is  handed  to  an  assistant  to  keep 
tight  until  the  sutures  are  introduced  into  the  ring,  when  the  sac  is  perma- 
nently anchored  by  taking  several  stitches  in  the  external  oblique  muscle. 
A  strong  catgut  suture  is  passed  with  a  Macewen  needle  through  the  conjoined 
tendon  from  below  upward,  the  ends  of  this  suture  be- 
ing carried  through  Poupart's  ligament  and  the  outer 
border  of  the  internal  ring  from  within  outward.  This 
suture  is  tightened  and  closes  the  internal  ring.  The 
external  ring  is  sutured  and  the  skin  is  stitched  (Fig. 
733>  c,  D,  and  e). 

In  congenital  hernia  the  sac  is  divided  in  its  middle, 
and  the  lower  part  is  closed  by  stitches  of  chromicized 
catgut,  forming  a  tunica  vaginalis.  The  upper  part  of 
the  sac  is  slit  posteriorly  to  permit  the  escape  of  the 
cord,  and  is  closed  by  stitches  of  chromicized  catgut 
_  ,      (Fig.  734).     The  operation  is  finished  as  in  the  acquired 

operatioiflor  the'^raScal  form.  After  Macewen's  operation  the  patient  should 
cure  of  congenital  hernia,  stay  in  bed  for  at  least  three  weeks,  and  must  not  work 
for  eight  or  nine  weeks.  Workmen  after  this  operation 
should  always  wear  for  a  time  a  pad  and  a  spica  bandage.  Children  require 
no  pad.  Never  apply  a  truss,  as  strong  pressure  will  produce  atrophy  of  the 
curative  scar. 

Bassini's  Operation  for  Oblique  Inguinal  Hernia. — (See  E.  Wyllys  An- 
drews, in  "Med.  Record,"  Oct.  28,  1899,  who  describes  from  personal  ob- 
servation how  Bassini  does  his  operation.  I  have  drawn  upon  his  descrip- 
tion in  the  following  section.)  Bassini's  operation  displaces  the  spermatic 
cord  from  the  old  canal  and  places  it  in  a  new  canal,  and  this  new  canal 
is  oblique.  Curved  and  rounded  needles  are  employed  to  insert  the 
stitches.  The  suture  material  is  kangaroo-tendon  or  chromicized  catgut. 
Silk  or  silver  wire  is  apt  to  make  trouble — it  may  be  long  after  the 
operation.  The  patient  is  placed  supine  with  the  thighs  extended.  An 
incision  is  made  parallel  to  Poupart's  ligament  and  extending  from  the 
external  ring  to  a  point  external  to  the  internal  ring.  The  incision  is  about 
i|  inches  above  the  ligament  and  is  from  5  to  7  inches  in  length.  By 
this  incision  the  aponeurosis  of  the  external  oblique  and  the  pillars  of  the 
external  ring  are  exposed.  All  bleeding  is  arrested,  the  aponeurosis  is  incised 
in  the  direction  of  its  fibers  and  from  above  downward,  and  the  inguinal  canal 
is  opened.  The  aponeurosis  of  the  external  oblique  is  dissected  up  with  a  blunt 
instrument  until  Poupart's  ligament  is  exposed.  We  speak  of  this  ligament 
as  the  shelf.  A  mass  containing  the  sac  of  the  hernia,  the  cord,  the  cremaster 
muscle,  and  considerable  fat  is  lifted  up.  Bassini  employs  blunt  dissection. 
Coley  advocates  the  use  of  the  knife.  Masses  of  fat  and  usually  the  cremaster 
muscle  are  removed.  The  sac  is  isolated  first  at  its  neck  and  the  neck  is 
stripped  from  the  inner  aspect  of  the  internal  ring  for  the  distance  of  A  inch. 
The  object  of  this  stripping  is  to  permit  the  removal  of  the  sac  at  a  high  level. 
High  removal  obviates  the  leaving  of  a  funnel-shaped  depression  of  peri- 


Treatment  of  Reducible  Hernia 


1141 


toneum.  Such  a  depression  would  predispose  to  relapse.  The  sac  is  opened 
at  the  fundus,  the  interior  is  investigated,  and  if  the  contents  are  reducible, 
they  are  restored  to  the  abdominal  cavity  and  the  neck  of  the  sac  is  clamped 
high  up.  If  adherent  masses  of  omentum  are  found,  the  adhesions  are  sepa- 
rated, bleeding  is  arrested,  and  the  omentum  is  restored  to  the  abdomen  unless 
it  is  in  a  hard  and  thick  mass,  when  it  is  tied  off  and  removed.  Bassini  ties 
off  the  neck  of  the  sac  above  the  clamp  with  a  strong  ligature  of  silkworm-gut. 
If  the  sac  is  large  and  thick,  he  also  threads  both  ends  of  a  ligature  upon  a 
needle,  passes  the  strand  through  the  stump,  and  ties  around  over  the  first 
loop.  (See  E.  Wyllys  Andrews,  "Med.  Record,"  Oct.  28,  1899.)  Coley  and 
many  other  operators  prefer  to  tie  off  the  sac  with  a  catgut  suture  rather 
than  with  silkworm-gut  or  silk.  It  is  my  usual  custom  to  employ  fine  black 
silk,  catching  it  to  prevent  slipping  by  running  a  stitch  through  the  w^all  of  the 
neck  of  the  sac.  After  Hgating  the  neck  of  the  sac  the  sac  is  cut  across  and  re- 
moved. The  cord  is  now  lifted  out  of  the  way  (Fig.  735,  a),  the  inner  surface 
of  Poupart's  ligament  is  exposed  by  retraction,  and  the  deep  sutures  are  passed 
(Fig.  735,  a).     Bassini  uses  silk  which  has  been  boiled  in  glycerin.     Most 


Fig-  735- — A-c,  Bassini's  operation  for  the  cure 
of  inguinal  hernia  (Esmarch  and  Kowalzig). 


Fig.  736. — Bassini's  operation  (deep  sutures), 
showing  extra  suture  above  the  cord,  as  advised 
by  Coley. 


American  operators  use  kangaroo-tendon  or  chromicized  catgut.  Bassini 
inserts  first  the  sutures  nearest  to  the  pubes.  The  first  suture — and  sometimes 
also  the  second — includes  part  of  the  rectus  sheath  and  rectus  muscle.  Each 
stitch  includes  the  internal  oblique  and  transversalis  muscle  in  the  upper  edge 
and  the  shelf  of  Poupart's  ligament  below  the  lower  margin,  and  from  four 
to  six  stitches  are  passed  behind  the  cord  (Fig.  735,  b).  The  last  stitch 
narrows  the  internal  ring  so  that  it  fits  tightly  around  the  cord  (E.  Wyllys 
Andrews,  Ibid.).  Coley's  rule  for  passing  this  suture  is  to  insert  it  so  "that 
it  just  touches  the  lower  border  of  the  cord  when  the  latter  is  brought  ver- 
tically to  the  plane  of  the  abdomen"  ("Annals  of  Surgery,"  June,  1903).  He 
always  places  a  suture  above  the  cord,  and  believes  it  tends  to  prevent  relapse 
(Fig.  736).  The  sutures  are  tied  from  above  downward.  The  cord  is  laid  upon 
this  new  floor  and  the  aponeurosis  of  the  external  oblique  is  sutured  over  it  (Fig. 
735,  c).  I  close  the  aponeurosis  by  a  continuous  suture  of  chromic  catgut  and 
the  skin  with  interrupted  sutures  of  silkworm-gut  or  fine  silk.  Drainage  is  not 
used.  The  wound  is  covered  with  a  roll  of  iodoform  gauze  and  some  pieces  of 
sterile  gauze,  and  compression  is  made  by  strips  of  adhesive  plaster,  and  a  piece 


II42 


Diseases  and  Injuries  of  the  Abdomen 


of  adhesive  plaster  run  from  one  thigh  to  the  other  acts  as  a  shelf  for  the  testicles 
to  rest  upon.  The  adhesive  plaster  is  overlaid  with  dry  gauze,  and  this  is 
covered  AAdth  absorbent  cotton  and  the  dressing  is  retained  in  place  by  a  firm 
spica  of  the  groin  (Coley's  dressing).  The  wound  is  dressed  on  the  seventh 
or  eighth  day,  and  the  patient  is  kept  in  bed  for  two  weeks  and  is  allowed  to  get 
about  in  two  and  one-half  to  three  weeks,  wearing  a  bandage  until  four  weeks 
after  operation. 

In  Bassini's  operation  some  surgeons  treat  the  sac  as  in  Macewen's  opera- 
tion, carrying  out  the  rest  of  the  procedure  as  directed  above.  In  a  pure  Bas- 
sini  operation  the  funnel-shaped  depression  in  the  peritoneum  at  the  point  of 
emergence  of  the  cord  may  remain  and  predispose  to  hernia,  but  the  use  of 
Macewen's  plan  for  treating  the  sac  obviates  this. 

H aisled' s  Old  Operation  (as  described  by  J.  C.  Bloodgood,  in  "Jotms  Hop- 
kins Hosp.  Report,"  vol.  vii). — The  skin  incision  is  not  parallel  to  Poupart's 
ligament,  but  at  an  angle  of  25  degrees  to  it  (Fig.  737).     Poupart's  ligament  is 


Fig.  737. — The  skin  incision,  retractors  in  the 
lower  angle  of  the  wound  dislocating  the  opening 
in  the  skin  and  subcutaneous  fat  downward,  ex- 
posing the  aponeurosis  of  the  external  oblique 
and  external  ring.  The  dotted  hne  within  the 
wound  represents  the  direction  of  the  division  of 
apKineurosis  of  external  oblique  (Bloodgood) . 


Fig.  738. — The  aponeurosis  of  external  oblique 
has  been  divided  and  retracted,  uncovering  the 
internal  obHque  muscle  and  inguinal  canal.  The 
lines  on  the  muscle  represent  the  direction  and 
extent  of  the  division.  The  dotted  hne  in  the 
inguinal  canal  is  the  direction  and  extent  of  the 
division  of  the  coverings  of  sac  (Bloodgood). 


well  exposed  to  within  2  cm.  of  the  pubic  spine.  The  aponeurosis  of  the  exter- 
nal oblique  muscle  is  divided.  Free  the  lower  border  of  the  internal  oblique 
muscle  and  divide  the  edge  of  the  muscle  at  a  right  angle  to  its  fibers  (Fig.  738), 
and  as  far  as  possible  from  the  linea  semilunaris.  The  coverings  of  the  sac 
near  the  neck  are  picked  up  ^nth  mouse-toothed  forceps  and  are  divided.  The 
division  of  the  fasciae  is  continued  from  the  neck  of  the  sac  downward  toward 
the  pubes.  The  sac  is  then  lifted  from  the  inguinal  canal  and  it  brings  'wdth  it 
"the  larger  bundle  of  veins  and  the  vas  deferens"  (Fig.  739).  The  sac  is  sepa- 
rated from  the  veins  and  the  vas  with  a  knife  or  scissors,  and  the  separation  is 
carried  to  and  beyond  the  neck  of  the  sac.  In  "certain  cases  the  larger  bundle 
of  veins  is  separated  from  the  vas  deferens,  ligated,  and  excised"  (Fig.  740). 
Whether  the  veins  are  excised  or  not,  the  sac  is  opened,  its  contents  reduced, 
the  opening  into  the  peritoneal  ca\dty  closed  with  a  continuous  sUk  suture, 
and  the  excess  of  sac  excised.  During  the  entire  operation  the  vas  and  its 
vessels  "should  be  handled  very  little,  and  should  not  be  torn  from  their  bed 


Treatment  of  Reducible  Hernia 


1 143 


in  the  inguinal  canal."     Even-  point  of  bleeding  should  be  ligated.     At  this 
stage  the  vas  is  gently  picked  up  and  a  blunt-pointed  hook  is  used  to  tear  the 
mesocord.     The  freed  vas  is  lifted  into 
the  upper  angle  of  the  di\-ided  internal 
obhque  muscle,  and  is  held  there  until 
the   sutures   are   inserted.     The   deep 


Fig-  739- — ^The  internal  oblique  muscle  and  the 
coverings  of  the  sac  have  been  (ii\'ided,  the  sac 
with  the  veins  and  vas  deferens  are  drawn  out  of 
the  wound  preparatorj-  to  the  excision  of  the  sac 
and  the  ligation  and  excision  of  the  veins  (Blood- 
good). 


Fig.  740. — ^The  method  of  excision  of  veins 
in  operations  for  hernia  and  variocele.  The  vas 
deferens  and  its  "immediate'"  vessels  and  the 
mesocord  have  not  been  disturbed  (.Bloodgood) . 


sutures  of  silver  -v^Tre  are  next  inserted.     Usually  five  are  needed.     The  upper 
one  is  passed  first.     These  sutures  are  shown  in  Fig.  741.     The  cord  emerges 


Fig.  741. — The  insertion  of  the  deep  silver 
wire  sutures,  one  above  and  four  below  the 
cord.  The  veins  have  been  hgated  and  ex- 
cised. The  mesocord  has  been  torn  gently 
in  its  center  onlj'  (Bloodgood) . 


£ifoil 


Fig.  742. 


-Exposure  of  the  sac,  the  vas,  and  the 
spermatic  veins  (Halsted) . 


from  the  cut  in  the  internal  obhque  muscle  between  the  first  and  second  sutures. 
Sutures  No.  i  and  No.  2  pierce  the  mesocord,  but  care  is  taken  to  see  that  thev 


1 144 


Diseases  and  Injuries  of  the  Abdomen 


do  not  injure  the  vas  or  its  vessels.  Each  suture  is  drawn  upon  and  twisted 
about  six  times.  The  cut  and  twisted  ends  are  caught  by  forceps  and  turned  in. 
The  skin  wound  is  closed  with  a  subcuticular  stitch  of  silver  wire.  It  is  covered 
with  silver-foil  and  dry  gauze,  and  often  a  plaster-of-Paris  bandage  and  splints 
are  used,  "the  splints  extending  from  just  above  the  knee  to  near  the  costal 
margins." 

The  Modified  Halsted  Operation. — The  operation  at  present  performed 
by  Professor  Halsted  and  his  assistants  has  been  evolved  from  the  former 
operation  so  long  associated  with  his  name,  and  has  been  greatly  modified 
by  him  and  by  Dr.  Bloodgood.  In  this  operation  the  skin  and  the  aponeu- 
rosis of  the  external  oblique  are  incised  exactly  as  in  performing  Bassini's 
operation,  and  flaps  of  aponeurosis  are  raised.  Next,  the  cremaster  muscle  and 
the  cremaster  fascia  are  incised  in  a  line  slightly  above  the  center  of  the  sper- 
matic cord.  The  internal  oblique  muscle  is  then  brought  into  distinct  view  at 
the  side  of  the  inguinal  canal  and  the  hernia  is  carefully  inspected  (Fig.  742). 
If  the  veins  are  found  to  be  large  they  should  be  excised;  but  the  surgeon  does 
not  lift  the  vas  from  its  bed,  and  even  avoids  touching  it,  if  he  possibly  can,  for 
fear  that  thrombosis  may  occur  in  its  veins.  The  veins  are  tied  above,  well  up 
in  the  abdomen;  and  below,  well  above  the  testicle,  and  excised  between  the 
ligatures.  The  sac  is  then  ligated  or  sutured  with  a  purse-string  suture.  One 
end  of  the  thread  that  ties  or  sutures  the  sac  is  carried,  by  means  of  a  long, 
curved  needle,  in  an  outward  direction  under  the  internal  oblique  muscle, 
through  which  it  is  then  pulled.  The  other  end  of  the  thread  is  also  pulled 
through  the  muscle  |  inch  from  the  first  end,  and  these  two  ends  are  tied  to- 
gether. It  will  be  observed  that 
this  treatment  of  the  neck  of  the 
sac  is  somewhat  similar  to  the 
method  practised  by  Kocher. 


■\V"¥ 


Fig.  743- 


-Suture  of  the  cremaster  to  the  mtemal 
oblique  (Halsted). 


Cremastkn- 


Fig.  744. — Suture  of  the  lower  edge  of  the  internal 
oblique  to  Poupart's  Ugament  (Halsted). 


The  next  step  is  to  carry  the  inferior  flap,  composed  of  cremaster  muscle  and 
fascia,  under  the  internal  oblique  muscle,  and  suture  it  there  (Fig.  743).  We 
next  suture  the  internal  oblique  muscle  and  the  conjoined  tendon  to  Pou- 
part's ligament,  the  lower  edge  of  the  internal  obhque  being  tucked  under 
the  edge  of  the  ligament  (Fig.  744).  In  order  to  accomplish  this,  it  may 
be  necessary  to  release  the  muscle  by  incising  the  anterior  rectal  sheath.  The 
incision  in  the  external  oblique  is  now  closed  with  sutures  that  overlap  the 
margins  (Figs.  745  and  746),  and  the  skin  wound  is  also  closed. 

Halsted's  Operation  Plus  Bloodgood' s  Method  of  Transplanting  the  Rectus 
Muscle. — (See  Jos.  C.  Bloodgood,  in  "Johns  Hopkins  Hosp.  Reports,"  voL 


Treatment  of  Reducible  Hernia 


1145 


vii.)  WTien  the  conjoined  tendon  is  ven-  thin  or  obUterated,  the  ordinary' 
operation  is  not  enough.  Insufficiency  of  the  conjoined  tendon  is  known  to 
exist  when  a  linger  does  not  meet  any  obstruction  after  passing  through  the 


-tl 


Fig.  745. — Suture  of  the  aponeurosis  of  the  ex- 
ternal obhque  (^Halsted) . 


Fig.  746. — Suture  of  the  margin  of  aponeurosis  to 
Poupart's  hgament  (Halsted). 


external  abdominal  ring,  but  can  be  introduced  for  some  distance  into  the 
abdominal  ca%-ity  (Bloodgood).  To  meet  this  condition  of  affairs,  Bloodgood 
de\-ised  '"'a  plastic  operation  on  the  rectus  muscle,  brin.ging  this  muscle  down 


Fig.  747. — ^The  method  of  transplanting  the  rectus 
muscle.  The  sac  has  been  excised  and  the  peritoneal 
ca%'ity  closed;  internal  obhque  muscle  has  been  di- 
vided, the  rectus  exposed  and  transplanted;  at  this 
stage  the  wound  is  readj^  for  the  deep  sutures.  This 
illustration  shows  how  perfectlj"  the  transplanted 
rectvis  muscle  lines  the  lower  half  of  the  wound 
(Bloodgood). 


Fig.  74S.— The  transplanted  rectus  included 
by  the  deep  sutures.  In  this  illustration  the 
cord  has  been  excised  in  order  to  demonstrate 
the  operation  more  dearly  (Bloodgood). 


and  suturing  it  vrith  the  other  available  tissue  to  Poupart's  hgament  and  to 
the  aponeurosis  of  the  external  oblique  from  the  arch  of  the  pubis  up  to  the 
position  of  the  transplanted  cord"  (Bloodgood),  in  pre\-iously  mentioned  re- 


1 146  Diseases  and  Injuries  of  the  Abdomen 

port).  The  first  steps  of  the  operation  are  identical  with  those  previously 
described,  but  before  the  insertion  of  the  deep  stitches  the  rectus  sheath  is 
exposed  and  divided  in  the  direction  of  the  muscle-fibers,  from  the  pubic  inser- 
tion upward  for  5  cm.  The  muscle  bulges  from  the  cut  and  is  caught  with 
silk  sutures  (Fig.  747).  Deep  sutures  are  now  introduced  as  in  Halsted's 
operation,  except  that  they  include  the  rectus  and  its  sheath  (Fig.  748).  The 
operation  is  completed  as  is  Halsted's.  I  have  performed  this  operation  a 
niimber  of  times  with  entire  satisfaction. 

Kocher's  Operation. — Kocher  exposes  the  aponeurosis  of  the  external 
oblique,  makes  a  small  incision  through  the  aponeurosis  above  and  external 
to  the  internal  ring,  and  draws  the  sac  through  this  incision  and  sutures  it  in 
place. 

Fowler's  operation  is  as  follows:  An  incision  is  made  parallel  with  Poupart's 
ligament  from  the  spine  of  the  pubis  to  the  level  of  the  internal  ring,  and  a  flap 
is  turned  up.  The  inguinal  canal  is  opened  and  the  sac  and  cord  are  isolated. 
The  sac  is  opened,  its  contents  reduced,  it  is  cut  off,  and  its  edges  grasped  with 
forceps.  The  deep  epigastric  artery  and  vein  are  sought  for,  each  is  tied  in  two 
places  and  divided  between  the  ligatures.  The  index-finger  is  introduced 
into  the  belly,  and  on  this  as  a  guide  the  floor  of  the  canal  is  divided  (transver- 
salis  fascia,  subserous  tissue,  and  peritoneum).  The  cord  is  placed  in  the 
peritoneal  cavity.  The  edges  of  the  opening  are  sutured  so  that  broad  serous 
siirfaces  are  approximated,  through-and-through  sutures  being  passed  from 
side  to  side.  The  cord  is  brought  out  at  the  inner  end  of  the  incision,  the  lower 
angle  of  the  cut  being  at  such  a  level  that  the  cord  curves  upward  and  forward 
as  it  leaves  the  abdomen.  The  inguinal  canal,  the  gap  in  the  aponeurosis,  and 
the  skin  wound  are  closed.^ 

Ferguson's  Operation. — In  studying  a  nimiber  of  recurrences  after  opera- 
tion A.  H.  Ferguson  observed  that  a  hernial  protrusion  is  apt  to  return  at  the 
upper  and  outer  portion  of  the  scar,  above  the  cord  and  near  Poupart's  ligament. 
When  he  operated  upon  relapsed  cases,  he  discovered  a  slit  of  the  aponeurosis 
of  the  external  abdominal  wall,  through  which  the  sac  and  some  fat  protruded. 
In  order  to  determine  the  cause  of  the  failure  of  these  operations,  he  thought  it 
proper  to  make  a  semilunar  incision  and  raise  a  flap  of  skin,  fascia,  and  aponeu- 
rosis of  the  external  oblique.  On  doing  this,  he  was  surprised  to  find  an  angle 
between  the  lower  border  of  the  internal  oblique  muscle  and  the  inner  aspect 
of  Poupart's  ligament  absolutely  unprotected  by  the  internal  oblique  or  the 
transversalis  muscle.  In  some  cases  this  angle  extended  upward  and  outward 
to  the  anterior  superior  iliac  spine.  He,  therefore,  concluded  positively  that 
the  cause  of  a  rupture  returning  in  this  angle  after  an  operation  for  radical 
cure  is  deficient  origin  of  the  internal  oblique  muscle  and  of  the  transversalis 
muscle  at  Poupart's  ligament.  He  is  now  persuaded  that  in  all  cases  of  hernia 
there  is  a  deficient  origin  of  these  muscles,  and  he  has  demonstrated  the  same 
thing  in  a  series  of  dissections  in  the  inguinal  region.  Ferguson  describes  his 
operation  as  follows  ("Jour.  Am.  Med.  Assoc,"  July  i,  1899):  He  begins  his 
incision  over  Poupart's  ligament,  i^  inches  below  the  anterior  superior  iliac 
spine,  carries  it  inward  and  downward  in  a  semilunar  curve,  and  terminates  it 
over  the  conjoined  tendon,  near  the  pubic  bone.  The  incision  goes  down  to  the 
aponeurosis  of  the  external  oblique,  and  the  flap,  with  its  fat  and  fascia,  is 
turned  downward  and  outward  (Figs.  749  and  750).  The  next  step  is  to  incise 
the  external  abdominal  ring  to  the  intercolumnar  fascia  and  separate  the 
longitudinal  fibers  of  the  external  oblique  over  the  inguinal  canal  to  beyond  the 
internal  ring,  at  a  point  nearly  opposite  the  anterior  superior  spine  of  the  ilium. 
Any  transverse  fibers  that  may  be  encountered  are  severed.  The  separated 
aponeurosis  of  the  external  oblique  muscle  is  then  retracted.  One  has  then 
1  "Annals  of  Surgery,"  Nov.,  1897. 


Treatment  of  Reducible  Hernia  1147 

brought  into  view  the  contents  of  the  inguinal  canal,  the  hernial  sac  and  its 
adhesions,  the  spermatic  cord,  the  ilio-inguinal  nerve,  the  internal  abdominal 
ring,  the  subserous  fat,  the  cremaster  muscle,  the  conjoined  tendon,  the  internal 
obhque  and  its  deficient  origin  at  Poupart's  ligament,  the  transversahs  fascia 
and  the  internal  surface  of  Poupart's  ligament.     The  sac  is  now  dissected  from 


Fig.    749— Ferguson  s  operation:  The   semilunar        Fig.  750.— Ferguson's  operation:  Flap  turned 
skm  incision  (  Jour.  Am.  Med.  Assoc").  back  exposing  the  aponeurosis  and  the  sac  of  the 

hernia  ("Jour.  Am.  Med.  Assoc"). 

the  cord  and  the  internal  ring.  It  is  opened  and  its  contents  are  inspected  and 
properly  dealt  with.  It  is  tied  high  up  and  cut  off,  and  the  stump  is  dropped 
into  the  abdomen  (Fig.  751).  If  the  sac  is  congenital  it  is  divided  into  two 
parts:  the  distal  portion  is  used  to  make  a  tunic  for  the  testicle  and  the  proximal 


Fig.  751. — Ferguson's  operation:  Dealing  with 
the  sac  and  its  contents  ("Jour.  Am.  Med. 
Assoc"). 


Fig.  752. — Ferguson's  operation:  Suture  of  the 
slack  in  the  transversalis  fascia  ("Jour.  Am 
Med.  Assoc"). 


portion  is  treated  as  above  directed.  The  cord  is  not  disturbed,  and  it  is  be- 
yond doubt  that  Ferguson  is  right  in  saymg  that  the  testicle  frequently  comes 
to  harm  after  operations  that  disturb  the  cord.  The  vems  in  the  cord  should 
not  be  touched  unless  a  varicocele  also  exists.  Any  excessive  quantity  of 
subserous  adipose  tissue  should  be  removed.    The  next  step  in  the  operation  is 


1 148 


Diseases  and  Injuries  of  the  Abdomen 


to  restore  the  structures  to  their  normal  position ;  and  one  should  remember  that 
in  the  transversalis  fascia  is  the  internal  ring.  In  hernia  the  internal  ring  is 
large  and  the  transversalis  fascia  bulges  outward;  one  must,  therefore,  take  up 
the  slack  in  this  fascia  and  make  a  well-fitting  ring  for  the  cord  by  means  of  a 
catgut  suture,  either  interrupted  or  continuous  (Fig.  752).  After  this  has  been 
accomplished  the  internal  oblique  and  transversalis  muscle  are  sutured  to  the 
internal  aspect  of  Poupart's  Hgament,  after  the  lower  borders  of  the  muscles 
have  been  freshened  and  Poupart's  ligament  has  been  scarified.  The  sutures 
must  be  carried  two-thirds  of  the  way  down  Poupart's  ligament,  which  is  about 
the  normal  origin  of  this  muscle  in  the  female  (Fig.  753).     The  next  step  is  to 

suture  the  edges  of  the  divided  aponeu- 
rosis of  the  external  oblique;  this  re- 
stores the  external  abdominal  ring. 
The  skin-flap  is  then  carefully  sutured. 
Radical  Cure  of  Direct  Inguinal 
Hernia. — If  the  hernia  goes  through, 
the  conjoined  tendon  or  pushes  that 
structure  before  it,  the  operation 
should  consist  in  transplanting  the 
rectus  muscle  as  practised  by  Blood- 
good  (see  page  1145)  and  suturing 
the  arched  fibers  of  the  internal  ob- 
lique and  conjoined  tendon  to  Pou- 
part's ligament  and  beneath  the  cord. 
If  the  hernia  passes  aroimd  the 
outer  edge  of  the  conjoined  tendon 
an  overlapping  operation,  like  the 
Mayo  operation  for  umbilical  hernia, 
should  be  performed  (G.  G.  Davis,  in 
"Annals  of  Surgery,"  Jan.,  1906). 
Radical  Cure  of  Umbilical  Hernia. — The  results  of  operations  for  lunbilicaL 
hernige  have  not  been  satisfactory.  Recurrences  are  frequent.  This  is  prob- 
ably due  to  the  fact  that  most  of  the  subjects  are  fat,  and  that  the  muscles 
are  thin  and  flabby.  The  usual  operation  may  be  thus  described:  Make  a 
longitudinally  elliptical  incision  through  the  skin  around  the  mass.  En- 
deavor to  separate  the  sac  from  the  superficial  tissue.  If  this  cannot  be  done, 
open  the  sac  and  separate  it  from  the  contents.  Even  if  the  sac  can  be  stripped 
from  the  skin,  always  open  it  and  separate  the  contents.  Return  any  bowel 
which  may  be  present,  and  do  not  forget  that  there  may  be  a  small  portion  of 
bowel  completely  encased  in  omentum.  Tie  into  segments  and  cut  off  the  su- 
perfluous omentum  and  return  the  stiunp  into  the  belly.  Excise  the  umbilicus 
{omphalectomy).  Suture  the  peritoneum  with  a  continuous  catgut  suture. 
Close  the  musculofascial  waU  with  two  layers  of  interrupted  sutures  of  kanga- 
roo-tendon or  chromic  catgut,  or  one  layer  of  silver  wire  mattress  sutures. 
Close  the  skin  by  interrupted  sutures  of  silkworm-gut  or  a  subcuticular  stitch. 
Mayors  Operation. — This  is  a  vast  improvement  on  the  older  operation. 
It  gives  a  firm  cicatrix  free  from  disastrous  traction.  Mayo  believes  that  the 
defect  in  the  old  operation  is  that  the  recti  muscles  are  naturally  separated  at 
the  level  of  the  umbilicus,  and  in  bringing  the  recti  together  we  have  virtually 
performed  muscle  transplantation,  and  these  thin  muscles  are  of  no  great  value 
in  preventing  relapse,  and  in  a  large  hernia  it  is  not  even  possible  to  cover  the 
gap  by  muscle.  Mayo  now  operates  as  follows :  Transverse  elliptical  incisions 
are  made  aroimd  the  lunbilicus  and  hernia  and  the  base  of  the  protrusion  is 
exposed  (Fig.  754).  The  surface  of  the  aponeurosis  is  cleared  for  i|  inches 
around  the  neck  of  the  sac.    The  fibrous  and  peritoneal  coverings  of  the  hernia 


Fig.  753— Ferguson's  operation:  Suture  of  the 
internal  oblique  and  of  the  transversalis  muscle 
to  the  internal  aspect  of  Poupart's  ligament 
("Jour.  Am.  Med.  Assoc"). 


Treatment  of  Reducible  Hernia 


"49 


are  divided  by  a  circular  incision  around  the  neck  of  the  sac.  Intestine  is 
freed  from  adhesions  and  placed  within  the  abdomen.  Omentum  is  ligated  and 
removed  with  the  sac.     The  margins  of  the  ring  are  grasped  and  overlapped 

in  order  to  indicate  in  which  way 
it  can  be  most  easily  done;  thus 
is  the  direction  of  the  closure 
indicated.  An  incision  is  made 
through  the  fibrous  and  peritoneal 
coverings  of  the  ring  i  inch  or 
more  transversely  on  each  side,  and 


Fig-  754- — Mayo's  operation  for  the  radical  cure 
of  umbilical  hernia:  Exposure  of  hernia  and  lateral 
incision. 


Fig-  755- — Mayo's  operation  for  the  radical 
cure  of  umbihcal  hernia:  Peritoneum  su- 
tured. 


the  peritoneum  is  stripped  from  the  under  surface  of  the  upper  flap.  Several 
mattress  sutures  of  silver  wire  are  introduced  i  inch  above  the  edge  of  the 
upper  flap  and  are  carried  through  the  margin  of  the  lower  flap ;  suJB&cient  trac- 
tion is  made  to  permit  of  the  closing  of  the  peritoneum  with  a  continuous  catgut 


Fig.  7s6. — Mayo's  operation  for  the  radical  cure 
of  umbilical  hernia:  Aponeurosis  sutured. 


Fig.  757. — Mayo's  operation  for  the  radical 
cure  of  lunbilical  hernia:  Aponeurosis  sutured 
second  time  with  gut  sutures. 


suture  (Fig.  755).  When  this  has  been  accomplished,  the  silver  wire  sutures 
are  drawn  so  as  to  slide  the  lower  flap  into  the  pocket  between  the  peritoneum 
and  the  under  surface  of  the  upper  flap  (Fig.  756).     The  free  margin  of  the 


iiSo 


Diseases  and  Injuries  of  the  Abdomen 


upper  flap  is  fixed  by  catgut  sutures  to  the  aponeurosis  (Fig.  757),  and  the 
superficial  incision  is  closed  as  usual.  Wm.  J.  Mayo  ("Jo^r-  Am.  Med.  Assoc," 
June  I,  1907)  reported  upon  88  operations  for  umbilical  hernia  by  this  method 
between  1894  and  1905;  75  were  traced;  i  had  a  partial  relapse;  i  was  sup- 
posed to  have  a  relapse,  but  operation  disclosed  a  second  opening  above  and 
outside  of  the  closed  umbilical  opening. 

Radical  Cure  of  Femoral  Hernia. — Cheyne  ligates  the  neck  of  the  sac, 
stitches  the  stump  to  the  abdominal  wall,  dissects  out  a  flap  from  the  pec- 
tineus  muscle,  stitches  this  flap  to  Poupart's  ligament  and  to  the  abdominal 
wall,  and  thus  fills  up  the  crural  canal.  Bassini  makes  an  incision  parallel  to 
Poupart's  ligament,  ties  the  neck  of  the  sac,  cuts  off  the  sac  below  the  ligature, 
and  returns  the  stump  into  the  belly.  He  attaches  by  deep  sutures  Poupart's 
ligament  to  the  pectineal  aponeurosis  as  high  up  as  the  pectineal  eminence, 
the  cord  or  round  ligament  being  drawn  out  of  the  way.  Superficial  sutures 
are  passed  between  the  pubic  portion  and  the  iliac  portion  of  the  fascia  lata. 


Fig.  758. — Fabriciub's  operation   for   the  radical  cure  of  femoral  hernia:  Neck  of  sac  shown.     Sac 
cut  away.    Dotted  line  shows  line  of  separation  of  Poupart's  ligament  and  fascia  lata  (Fowler) . 

The  operation  of  Fabricius  is  very  satisfactory.  It  is  performed  as  fol- 
lows: An  incision  is  begun  over  the  pubic  spine  and  is  carried  outward  for 
5  inches  parallel  with  Poupart's  ligament.  The  sac  is  exposed,  isolated,  and 
opened,  its  contents  are  reduced,  its  neck  is  ligated,  the  sac  is  cut  off,  and 
the  stimap  is  dropped  back  (Fig.  758).  An  incision  is  now  made  below 
Poupart's  ligament  so  as  to  separate  this  structure  and  the  fascia  lata,  and 
the  flap  of  fascia  is  turned  down  (Fig.  759).  The  crural  sheath  and  the 
vessels  are  retracted  outward.  The  surgeon  is  careful  not  to  injure  the 
obturator  artery  and  vein.  The  origin  of  the  pectineus  muscle  is  sutured  to 
Poupart's  ligament.  The  lower  stitches  include  the  periosteum  of  the  hori- 
zontal ramus  of  the  pubes  as  well  as  the  beginning  of  the  muscle  (Fig.  760). 
Care  must  be  taken  in  passing  certain  of  them  to  avoid  injuring  the  deep  epi- 
gastric vessels.  When  these  stitches  are  tied,  the  femoral  canal  is  obliterated. . 
The  flap  of  fascia  lata  is  sutured  to  the  aponeurosis  of  the  external  oblique, 
and  the  skin  is  sutured. 

Operative  Treatment  of  Adherent  {Sliding)    Hernia  of  the  Ascending  and 
Descending  Colon. — My  personal  experience  consists  of  8  cases  of  right  and  2 


Treatment  of  Reducible  Hernia 


1151 


cases  of  left  inguinal  hernia.     The  sac  is  deficient  posteriorly  and  externally 
(see  page  1161).     In  order  to  restore  the  bowel  into  the  abdomen  many  opera- 


Fig.  759. — Fabricius's  operation  for  femoral  hernia;  Fascia  lata  turned  back,  exposing  crural  sheath 
and  origin  of  pectineus  muscle  (Fowler). 

tors  have  sought  to  force  up  the  adherent  intestine  to  the  external  ring,  and 
others  have  stripped  the  gut  from  the  subperitoneal  tissues  in  order  to  per- 


Fig.  760. — Fabricius's  operation  for  femoral  hernia:  Crural  sheath  and  vessels  retracted  and  kan- 
garoo-tendon sutures  applied  to  Poupart"s  ligament  and  origin  of  pectineus,  ready  for  tying.  Twc^ 
sutures  are  placed  in  position  to  approximate  the  pillars  of  the  external  ring  (Fowler). 

mit  of  reduction.  The  first  plan  should  never  be  followed.  If  it  should  be 
employed,  sutm-es  wall  fail  to  hold  the  bowel  up.  The  second  plan  is  risky 
and  may  be  followed  by  gangrene  of  the  bowel.     In  my  cases  I  followed 


II52 


Diseases  and  Injuries  of  the  Abdomen 


Weir's  plan  ("Med.  Record,"  Feb.  24,  1900),  and,  after  dissecting  up  the 
peritoneum  on  each  side  to  a  little  above  the  internal  ring,  freed  the  bowel 
from  its  bed  and  covered  the  new  surface  with  the  peritoneal  flaps  (Fig.  761). 
The  bowel  was  then  restored  and  a  radical  cure  was  made. 

Irreducible  Hernia. — ^The  swelling  in  irreducible  rupture  presents  the 
usual  evidences  of  hernia,  imparts  an  impulse  on  coughing,  but  cannot  be  re- 
placed in  the  abdomen.  Sometimes  a  portion  is  reducible  and  a  portion  is 
irreducible.  A  hernia  may  become  irreducible  because  of  the  size  of  the  mass, 
because  of  adhesions,  or  because  of  excessive  growth  of  omental  fat.  An  irre- 
ducible hernia  is  liable  to  be  bruised  and  to  cause  much  distress  and  pain, 
and  is  always  a  menace  to  life  because  of  the  danger  of  obstruction  and  strangu- 
lation. It  was  formerly  the  custom  to  support  a  small  irreducible  hernia  by  a 
hollow,  padded  truss,  but  now  operation  should  be  advised.  A  large  hernia  of 
this  variety,  if  operation  is  refused,  must  be  carried  in  a  bag  truss.     The  patient 

must  not  take  very  active  exercise,  must  keep 
the  bowels  regular,  and  must  live  upon  a  plain 
diet.  Most  cases  of  irreducible  hernia  should 
be  treated  by  operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruc- 
tion takes  place  by  the  damming  up  of  feces  or 
of  undigested  food,  the  fecal  current  being  ar- 
rested, but  the  blood-current  in  the  wall  of  the 
bowel  not  being  cut  off.  Incarceration  is  com- 
monest in  irreducible  hernia,  especially  umbilical 
hernia,  and  during  the  existence  of  constipation. 
The  hernia  enlarges  and  becomes  tender,  painful, 
and  dull  on  percussion;  pressure  may  diminish  it 
somewhat  in  size.  It  remains  irreducible,  but  still 
presents  impulse  on  coughing.  The  abdomen  is 
somewhat  distended  and  painful ;  there  are  nausea, 
constipation,  and  not  unusually  slight  vomiting.  Constitutional  disturbance 
is  trivial  and  constipation  is  not  absolute,  gas  at  least  usually  passing.  Vomit- 
ing is  not  fecal. 

The  treatment  is  rest  in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over 
the  hernia  for  a  very  few  hours,  and  a  little  opiimi  for  pain.  Do  not  give  a 
particle  of  food  for  twenty-four  hours ;  when  the  active  symptoms  subside  give 
an  enema,  and,  after  this  acts,  a  dose  of  castor  oil.  Do  not  employ  taxis,  as 
bruising  the  bowel  may  produce  strangulation.  If  improvement  does  not 
rapidly  occur,  operate.  Prompt  operation  saves  the  patient  from  the  danger 
of  strangulation  and  cures  the  hernia. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peritonitis  due  to 
injury  of  an  irreducible  hernia.  The  mass  becomes  tender  and  painful,  and 
perhaps  heat  is  noted.  In  enterocele  much  fluid  forms;  in  epiplocele  the 
mass  becomes  hard.  The  hernia  cannot  be  reduced;  there  is  constipation, 
often  vomiting,  usually  elevated  temperature,  but  the  mass  still  shows  impulse 
on  coughing.  Vomiting  is  not  fecal.  Some  gas  is  usually  passed  through 
the  bowels.     Constitutional  symptoms  are  slight. 

The  treatment  usually  recommended  is  rest  in  bed  with  abdominal  relaxa- 
tion, an  ice-bag  to  the  tumor  for  a  few  hours,  a  small  amount  of  opium  by  the 
mouth  if  pain  is  severe,  an  enema,  and,  after  this  acts,  a  saline.  In  an  in- 
flamed hernia  there  is  great  danger  of  strangulation,  and  operation  should  be 
performed  in  preference  to  relying  upon  the  conservative  plan. 

Strangulated  hernia  is  a  condition  in  which,  if  the  hernia  contains  bowel, 
not  only  is  the  fecal  circulation  arrested  and  gas  prevented  from  passing, 
but  the  circulation  of  blood  in  the  bowel  wall  is  also  arrested.     The  bowel  is 


Fig.  761. — Outline  of  peritoneal 
lining  of  sac  utilized  as  a  flap  to 
cover  posterior  surface  after  it  has 
been  freed  by  dissection  (Weir). 


Strangulated  Hernia 


1153 


irreducible  and  obstructed,  and  the  blood  ceases  to  circulate.  If  the  hernia 
contains  omentum,  the  omental  vessels  are  tightly  constricted.  In  both 
bowel  and  omentum  gangrene  soon  occurs,  but  sooner  in  bowel  than  in  omen- 
tum. Strangulation  is  commonest  in  old  inguinal  ruptures  in  active,  middle- 
aged  men,  and  is  more  frequent  in  enteroceles  than  in  epiploceles.  It  is  most 
common  when  the  hernial  orifice  is  small  and  is  seldom  seen  in  large  ruptures.^ 
Strangulation  is  rare  in  childhood.  Strangulation  is  much  more  dangerous 
if  bowel  is  present  in  the  sac  than  if  only  omentum  is  present.  If  in  a  sub- 
ject of  hernia  the  abdominal  pressure  is  suddenly  increased,  as  by  a  violent 
cough  or  a  muscular  effort,  the  hernial  orifice  is  dilated  for  a  moment,  more 
intestine  or  omentum  may  enter  the  sac,  and  if  it  does,  it  may  be  caught 
and  constricted  by  the  now  constricted  hernial  orifice  and  strangulation  begins. 
Strangulation  so  caused  is  called  elastic  strangulation.  A  sudden  increase  of 
intra-abdominal  pressure  may  force  a  quantity  of  fecal  matter  into  the  her- 
niated intestine.  The  sudden  entry  of  a  quantity  of  fluid  and  gas  into  the 
herniated  coil  causes  fecal 
strangulation,  the  mechan- 
ism of  which  is  obscure. 
By  retrograde  strangulation 
we  mean  a  condition  in 
which  the  end  of  a  loop  of 
bowel  or  a  piece  of  omen- 
tum in  a  hernia  re-enters 
the  abdomen  and  then  be- 
comes strangulated,  the  bal- 
ance of  the  hernia  not  being 
strangulated.  Strangulation 
may  be  due  to  active  peris- 
talsis or  to  congestion,  and  it 
may  arise  from  inflammation 
or  from  incarceration.  The 
constriction  may  be  at  the 
neck  of  the  sac,  in  the  outside 
tissues,  or  even  in  the  sac  it- 
self. In  an  hour-glass  hernia 
the  constriction  may  be  in 
the  body  of  the  sac.  In 
inguinal  hernia  a  tight  ex- 
ternal ring  is  a  common  cause  of  strangulation  and  is  the  commonest  cause  in  chil- 
dren. As  Coley  shows,  the  neck  of  the  sac  is  very  seldom  the  cause  in  children. 
Adhesions  within  the  sac  may  cause  strangulation.  Spasmodic  contraction  of 
the  tissues  about  the  neck  of  the  sack  is  an  exploded  hypothesis.  The  obstructed 
veins  dilate  and  the  blood  in  them  ceases  to  move,  the  bowel  becomes  deep 
bluish  and  finally  black,  effusions  of  blood  occur  beneath  the  peritoneum,  and 
the  intestinal  wall  becomes  edematous.  Fluid  transudes  into  the  sac,  and  the 
fluid,  at  first  clear,  assumes  a  bloody  hue,  and  finally  becomes  dry  and  foul. 
The  peritoneimi  ceases  to  glisten,  becomes  dry  and  rough,  and  coated  here 
and  there  with  lymph.  Strangulated  omentum  undergoes  edema  and  hemor- 
rhagic infarction  and  thrombosis  occurs.  When  strangulation  once  begins 
the  hernia  swells,  a  furrow  forms  on  the  bowel  at  the  seat  of  constriction,  the 
bowel  and  omentimi  below  the  constriction  become  deeply  congested  and  edem- 
atous, and,  finally,  the  hernia  passes  into  a  state  of  moist  gangrene  (Fig. 
763).  The  gangrene  may  be  in  spots  or  the  entire  mass  may  be  gangrenous. 
The  mucous  membrane  may  be  gangrenous  when  the  serous  coat  looks  fairly 

^  Strangulation  developed  in  the  large  herniae  shown  in  Figs.  730  and  762. 

73 


Fig.  762. — Strangulated  umbilical  hernia  containing  nearly- 
all  the  intestines  and  part  of  the  stomach.  Strangulation 
under  bands  within  the  sac. 


1 1 54  Diseases  and  Injuries  of  the  Abdomen 

sound.  When  gangrene  is  once  estabHshed,  the  bowel  is  in  danger  of  rupturing. 
At  the  point  of  constriction  there  may  be  a  hne  of  ulceration  or  of  gangrene 
even  when  the  balance  of  the  gut  looks  fairly  safe.  A  strangulated  femoral 
hernia  becomes  gangrenous  more  rapidly  than  a  strangulated  inguinal  hernia. 
Symptoms. — This  condition  is  sometimes  preceded  by  diarrhea  and  un- 
easiness or  pain  about  the  hernial  orifice.  When  strangulation  begins  the 
victim  is  seized  with  pain  in  and  about  the  hernia  and  with  violent  colicky 
pain  about  the  umbilicus,  and  the  paroxysms  of  colic  become  more  and  more 
frequent,  until  finally  the  pain  may  become  continuous.  The  hernia  is  found 
to  be  irreducible;  larger  than  usual,  tender,  painful,  dull  on  percussion,  without 
impulse  on  coughing,  and  the  skin  above  it  may  be  reddened.  Eructations  of 
gas  are  frequent,  and  generally  uncontrollable  vomiting  and  prostration  come  on. 
Vomiting,  as  a  rule,  is  an  early  symptom,  and  one  which  increases  in  severity. 
Occasionally  it  only  follows  the  swallowing  of  Hquids.  Not  unusually  there  is 
retching  rather  than  vomiting.  In  rare  cases  vomiting  does  not  begin  for 
twenty-four  to  forty-eight  hoiu^s.  Vomiting  is  earlier  and  more  violent 
when  bowel  is  present  in  the  sac  than  when  the  hernia  is  piirely  omental. 

^__^^^         During  the  course  of  a  strangu- 
'.'9^>°^^!,^'7^^^  lation  vomiting  may  cease  for  a 

day  or  more,  and  it  not  unusu- 
ally ceases  toward  the  end,  when 
prostration  is  profound.  The 
early  vomiting  is  due  to  reflex 
causes;  the  later  vomiting  is  due 
to  waves  of  peristalsis  which  pro- 
duce regurgitation  (Macready's 
"Treatise  on  Ruptures")-  The 
vomiting  is  first  of  the  aHmentary 
contents  of  the  stomach,  next  of 

Fig.  763.— A  strangulated  coil  of  intestine  after  the  ™,,p„e  anH  hilinnc  mnttpr  anri 
strangulation  existed  for  a  considerable  period  of  time.  mucus  dnu  UUlOUb  matter,  ana 
The  color  has  become  almost  black  and  the  peritoneal      finally     of    the     Contents     of     the 

^!^ftrlr  '^'^•^'''^  '"""''"h^  ^\^  ^^^T  °^  ^}^-    ^\^     small  bowel  {fecal  or  stercoraceous 

constriction   rings    are    deeply   sunken,    their    walls               .  .      ^  };•' 

markedly  thinned,  relaxed,  and  dirty  gray  in  color.  VOmiting).  SterCOraceOUS   VOmit- 

Both   constriction  rings   are  gangrenous   and   hemor-  jng   rarely  arises    until    strangula- 

rhages  are  observed  m  the  mesentery  (Sultan).  ..         ,        ■^,  ^     -.    .     ^        •   ^  ^   ^ 

tion  has  lasted  forty-eight  hours, 
and  may  not  appear  imtil  much  later.  "It  is  seldom  met  with  in  inguinal, 
more  often  in  femoral,  and  more  often  stiU  in  obturator,  hernia"  (Macready, 
Ibid.).  Prostration  is  a  marked  symptom  of  a  strangulated  hernia,  and  it 
increases  hour  by  hour  and  goes  on  to  coUapse.  Early  in  the  case  there 
may  be  some  elevation  of  temperature,  but  later  it  becomes  normal  or  sub- 
normal. The  pulse  is  small,  irregular,  rapid,  and  very  weak;  the  extremi- 
ties cold;  the  face  becomes  Hippocratic.  Constipation  is  absolute,  no  gas 
even  being  passed,  though  in  the  very  beginning  there  may  be  some  diarrheal 
passages  from  below  the  constriction.  The  urine  is  scanty  and  high  colored, 
and  contains  only  a  small  amount  of  the  chlorids;  the  tongue  becomes  dry 
and  brown;  the  thirst  is  torturing,  and  the  patient  often  has  an  imperative 
desire  to  go  to  stool.  Pains  in  the  abdomen  and  in  the  hernia  become  more 
and  more  violent,  and  collapse  rapidly  increases.  When  gangrene  begins 
the  symptoms  apparently  lessen  in  violence:  there  is  a  delusive  calm.  Vomit- 
ing usually  ceases,  though  regurgitation  may  take  its  place;  hiccup  begins; 
the  pain  abates  or  disappears;  the  pulse  becomes  very  frequent,  feeble,  and 
intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is  a  safe  clinical 
rule  that  in  strangulated  hernia  sudden  cessation  of  pain  without  the  relief  of 
constriction,  the  disappearance  of  the  lump,  or  the  use  of  opiates  means  that 
gangrene  has  begun.     In  some  cases  of  strangulation  there  are  muscular 


Strangulated  Hernia 


1155 


cramps  in  the  legs  (Berger).  In  children  convulsions  are  not  unusual.  In 
a  piu^e  omental  hernia  strangulation  produces  similar  but  less  decided  symp- 
toms. It  may  be  that  only  a  portion  of  the  circumference  of  the  bowel  is 
caught  and  constricted  in  a  hernial  orifice  (see  Fig.  770,  a).  Such  a  condition 
is  encountered  occasionally  in  the  femoral  ring,  and  is  called  partial  enterocele 
or  Richter's  hernia.  The  name  Littre's  hernia  is  often  wrongly  given  to  this 
condition.  What  Littre  described  was  a  hernia  of  Meckel's  diverticulum 
(see  Fig.  770,  b).  In  a  strangulated  Richter's  hernia  constipation  is  rarely 
absolute  and  often  no  protrusion  is  discovered. 

Treatment. — In  treating  strangulated  hernia  place  the  patient  upon  his 
back,  bend  the  knees  over  a  piUow,  and  rigidly  interdict  the  administration  of 
food.  An  attempt  may  usually  be  made  to  effect  reduction  by  gentle  manipu- 
lation or  taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex  and 
adduct  the  thigh  of  the  affected  side.  In  applying  taxis  to  an  umbilical  hernia 
both  thighs  should  be  flexed  upon  the  abdomen.  Always  lower  the  shoulders 
and  head  and  raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot  of  the 
bed  and  placing  pillows  under  the  pelvis.  In  some  cases  raise  the  entire 
body  and  lower  the  head.  Grasp  the  neck  of  the  sac  with  the  fingers  and 
thumb  of  one  hand,  and  employ  the  other  hand  to  squeeze  the  hernia  and 
urge  it  toward  the  belly.  In  direct  inguinal  hernia  the  pressure  should  be 
backward  and  a  httle  upward;  in  lunbflical  hernia  it  should  be  backward; 
in  oblique  inguinal  hernia  it  should  be  upward,  outw^ard,  and  backward; 
in  femoral  hernia  it  should  be  downward  until  the  hernia  enters  the  saphenous 
opening,  and  then  "backward  tow^ard  the  pubic  spine"  (MacCormac,  in 
Treves's  "Manual  of  Surgery").  If  the  bowel  should  be  reduced,  it  will  pass 
from  the  hand  with  a  sudden  slip  and  enter  the  belly  with  an  audible  gurgle; 
omentimi,  when  reduced,  slowly  glides  back  without  gurgling.  Taxis  is  never 
to  be  continued  long,  and  it  is  not  even  to  be  attempted  in  cases  of  great 
acuteness,  in  cases  in  which  strangulation  has  lasted  for  several  days,  in  cases 
known  to  have  been  previously  irreducible,  in  cases  associated  with  stercora- 
ceous  vomiting,  or  in  inflamed  or  gangrenous  herniae. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate.  Anesthetize; 
in  some  cases  try  taxis  again  upon  the  unconscious  patient  and  while  ether 
is  being  dropped  upon  the  hernia  to  cause  cold;  if  reduction  fails,  at  once 
perform  herniotomy.  Taxis  possesses  certain  dangers:  It  may  rupture  the 
bowel;  it  may  rupture  the  neck  of  the  sac  and  force  the  bowel  through  the 
rent  into  the  tissues  of  the  abdominal  wall;  it  may  strip  the  peritoneum 
from  around  the  hernial  orifice  and  force  the  bowel  between  the  detached 
peritoneum  and  the  abdominal  wall;  it  may  reduce  a  hernia  into  the 
beUy  when  the  bowel  is  still  strangulated  by  adhesions;  it  may  reduce  the 
hernia  en  masse  or  en  bloc.  By  the  term  "reduction  en  masse"  we  mean  that 
the  sac  has  been  separated  and  dislocated  and  with  the  constricted  bowel 
within  it  has  been  forced  through  the  internal  ring.  By  "reduction  en  bissac" 
is  meant  the  forcing  of  a  congenital  hernia  into  a  congenital  pouch  or  diver- 
ticulum. Reduction  en  masse  is  a  rare  accident.  Corner  and  Howitt  ("Annals 
of  Surgery,"  vol.  xlvii)  collected  137  cases  of  reduction  en  masse  of  strangu- 
lated hernia.  Of  these,  no  were  males,  113  wxre  inguinal,  22  femoral,  and  2 
obturator  herniae.  No  ventral  or  lunbilical  cases  are  recorded.  The  accident  is 
a  very  dangerous  one.  According  to  Corner  and  Howitt  (Ibid.),  the  mortality 
after  inguinal  reductions  en  masse  is  48  per  cent.,  and  after  femoral  reductions, 
72  per  cent.  Strange  to  say,  reduction  en  masse  can  occur  spontaneously. 
The  subject  most  hable  to  reduction  en  masse  is  an  elderly  person  with  an  old 
hernia.  In  acute  cases  the  small  bowel  is  the  viscus  which  was  reduced.  In 
subacute  and  chronic  reductions  en  masse  the  omentum,  large  bowel,  or  bladder 
was  reduced  (Corner  and  Howitt,  Ibid.).     Subacute  and  chronic  cases  may 


II56 


Diseases  and  Injuries  of  the  Abdomen 


happen  in  non-strangulated  hernia.  In  any  of  the  above  accidents  obstruction 
may  persist  after  apparent  reduction  by  taxis.  Persisting  obstruction  means 
strangulation  or  peritonitis  and  calls  for  instant  laparotomy — in  most  instances 
through  the  hernial  aperture.  If  taxis  is  successful,  put  the  patient  to  bed, 
apply  a  pad  and  bandage,  allow  no  food  until  vomiting  ceases,  merely  permit 
hirri  to  take  a  little  hot  water  during  the  first  twenty-four  hours,  and  keep  him 
on  a  liquid  diet  for  several  days.  At  the  end  of  the  first  week  give  solid  food. 
Do.  not  disturb  the  bowels  for  a  few  days,  but  if  they  have  not  acted  when 
four  or  five  days  have  elapsed  since  the  operation,  give  a  saline  cathartic  fol- 
lowed in  a  few  hours  by  a  purgative  enema.  There  is  usually  a  spontaneous 
movement  within  twenty-four  hours  after  reduction  by  taxis. 

Herniotomy. — If  there  has  been  stercoraceous  vomiting  the  stomach  must 
be  washed  out  before  giving  the  anesthetic,  and  during  the  administration  of 
the  anesthetic  the  head  should  be  turned  upon  its  side.  In  most  cases  a  gen- 
eral anesthetic  can  be  given,  but  in  desperate  cases  it  is  not 
justifiable  to  give  ether  or  chloroform,  and  a  local  anesthetic 
must  be  used  (infiltration  anesthesia) .  Wrap  the  patient  up 
in  blankets.  In  most  cases  try  gentle  taxis  for  a  brief  time 
after  the  patient  has  been  anesthetized  and  while  ether  is 
being  dropped  upon  the  hernia  to  cause  cold.  Never  try 
taxis  if  stercoraceous  vomiting  has  occurred.  If  taxis  fails, 
at  once  sterilize  the  parts  and  operate.  Always  lay  out 
a  hernia  knife  (Fig.  764),  a  director  (see  Fig.  732,  a),  and 
Murphy  buttons.     During  the  operation  the  patient  lies 


Fig.    764. — Cooper's       Fig.  765. — The  di\asion  of  the  constriction  from  within  outward  (Sultan), 
curved  hemiotome. 


upon  his  back  wdth  the  shoulders  raised,  the  surgeon  standing  to  the  pa- 
tient's right  side.  In  oblique  inguinal  hernia  it  has  been  the  custom  since 
the  days  of  Scultetus  to  raise  a  fold  of  skin  at  a  right  angle  to  the  axis  of 
the  external  ring  and  transfLx  it,  the  wound  which  results  being  extended  until 
it  becomes  3  inches  in  length.  This  incision  possesses  no  special  merit.  It  is 
better  to  cut  from  without  inward,  and  to  make  the  same  incision  as  for  the  per- 
formance of  a  radical  cure  in  a  non-strangulated  case.  The  superficial  tis- 
sues are  divided,  the  aponeurosis  is  opened  as  in  Bassini's  operation,  and  the  sac 
is  reached.  In  most  cases  the  constriction  is  relieved  as  soon  as  the  external 
ring  is  nicked,  and  in  many  cases  fibrous  adhesions  will  be  found  in  that  region, 
gluing  the  sac  to  the  ring.  The  sac  must  be  identified;  and  it  is  known  by  the 
fat  which  usually  covers  it,  by  the  fluid  within  the  sac,  by  the  arborescent 


Herniotomy  1157 

arrangement  of  its  vessels,  and  by  the  fact  that  it  can  be  pinched  up  between 
the  finger  and  thumb  and  the  layers  rolled  over  each  other.  Should  the  sac  be 
opened?  It  may  not  be  actually  necessary  in  every  recent  case,  but  if  there  is 
any  doubt  as  to  the  condition  of  the  bowel  or  if  a  radical  cure  is  to  be  attempted, 
open  the  sac  and  be  certain  as  to  the  condition  of  its  contents.  As  there  is 
always  some  doubt  as  to  the  condition  of  the  contents,  and  as  a  radical  cure  is 
to  be  made,  make  it  a  rule  to  always  open  the  sac.  The  sac  is  opened  and  the 
contents  examined  for  fecal  odor  (which  is  not  unusual)  and  for  gangrenous 
smell;  the  thickness  of  the  bowel  is  estimated  and  the  color  and  luster  are 
determined.  If  a  constriction  exists  at  the  neck,  it  is  nicked  with  a  hernia 
knife.  If  the  hernia  is  oblique  inguinal  and  is  caught  at  the  internal  ring,  nick 
the  constriction  upward  and  outward  or  directly  upward,  as  shown  in  Fig.  765. 
In  direct  inguinal  hernia  and  in  an  oblique  inguinal  hernia  caught  at  the  external 
ring  the  cut  is  made  upward  and  inward.  Always  pull  the  bowel  down  and 
examine  the  seat  of  constriction  to  see  what  damage  has  been  inflicted  at  that 
point.  If  the  serous  coat  glistens;  if  the  proper  color  comes  back  to  the  bowel 
wall  after  irrigation  with  very  hot  water;  and  if  there  are  no  spots  of  gangrene, 
restore  the  bowel  to  the  abdomen  and  do  a  radical  cure.  If  the  bowel  is  in  a 
doubtful  condition,  fasten  it  to  the  incision,  apply  a  dressing,  and  watch  the 
development  of  events.  If  the  bowel  is  gangrenous,  our  action  depends  upon 
the  condition  of  the  patient.  If  the  patient  is  in  good  condition,  resect  the 
gangrenous  portion  and  perform  end-to-end  approximation.  If  the  patient's 
condition  is  bad,  draw  the  gangrenous  portion  well  out,  anchor  it  to  prevent 
leakage  and  retraction,  make  an  artificial  anus,  and  at  a  later  period  perform 
anastomosis.  An  artificial  anus  can  be  made  by  the  method  of  Bodine  (see 
page  1 1 22).  Unfortunately  in  these  cases  the  artificial  anus  must  usually  be 
made  in  the  small  intestine.  In  many  cases  in  which  there  is  some  uncertainty 
as  to  the  need  for  an  artificial  anus  prepare  the  bowel  for  the  opening,  but  do  not 
open  at  once,  because  the  bowel  may  recover  in  a  day  or  two,  when  it  can 
be  restored  to  the  belly,  or  it  may  slough  and  form  an  artificial  anus.  In  such 
doubtful  cases  fasten  the  bowel  to  the  belly  wall  with  sutures,  dust  it  with  iodo- 
form, dress  it  with  hot  antiseptic  fomentations,  and  await  future  developments. 
Gangrenous  omentum  requires  ligation  and  resection.  If  the  bowel  is  fit  to 
reduce,  push  it  just  inside  the  ring,  irrigate  the  parts,  suture,  and  perform  a 
radical  cure.  In  femoral  hernia  we  can  make  the  incision  i  inch  internal  to  and 
parallel  with  the  femoral  vessels  and  crossing  the  timior  and  ligament  (Barker) ; 
but  it  is  better  to  make  the  incision  of  Fabricius  for  radical  cure.  Divide  the 
constriction  by  cutting  upward  and  a  little  inward.  If  the  gut  is  found  gan- 
grenous or  in  a  doubtful  condition,  follow  Blake's  advice  ("Surg.,  Gynec,  and 
Obstet.,"  May,  1906),  make  an  incision  at  the  edge  of  the  rectus,  draw  the 
affected  portion  of  gut  into  the  abdomen  and  ouLof  the  incision,  and  either  resect, 
fix  it  under  or  out  of  the  incision,  or  wait  for  return  of  circulation,  as  may  be 
indicated  in  the  case.  To  draw  the  gut  out  of  the  femoral  ring  makes  so  much 
traction  that  return  of  circulation  may  be  prevented,  and  any  intestinal  opera- 
tion is  difficult  in  this  region  without  splitting  Poupart's  ligament.  In  umbilical 
hernia  make  a  slightly  curved  incision  a  little  to  one  side  of  the  middle  of  the 
tumor,  open  the  sac,  separate  adhesions,  and  divide  the  constriction  by  cutting 
upward  or  downward,  and  sometimes  also  laterally,  or,  better,  operate  as  for 
radical  qure  (see  page  1148). 

After  an  operation  for  strangulated  hernia  put  the  patient  to  bed;  bend 
the  knees  over  a  pillow;  give  no  food  by  the  mouth  for  thirty-six  hours  (Mac- 
Cormac),  only  allowing  hot  water,  and  every  sixth  hour  give  an  enema  of  salt 
solution  containing  brandy.  Abdominal  pain  and  tenderness  call  for  the 
administration  of  saline  cathartics  and  enemata  containing  turpentine  or  oil 
of  rue.     The  enema  rutae  is  a  favorite  preparation  in  St.  George's  Hospital, 


II58 


Diseases  and  Injuries  of  the  Abdomen 


London.  It  is  made  as  follows:  Take  i6  oz.  of  an  infusion  of  camomile,  warm 
it,  and  pour  it  upon  3  dr.  of  confection  of  senna  (Sheild).  If  there  is  no 
abdominal  pain  and  no  tenderness  the  bowels  need  not  be  disturbed  for  a  few 
days;  but  if  at  the  end  of  four  or  five  days  they  have  not  acted,  give  a  saline 
cathartic  and  a  few  hours  later  a  purgative  enema.  At  the  end  of  about  three 
weeks  get  the  patient  up.  If  a  radical  cure  has  not  been  attempted,  apply  a 
pad  and  a  spica  bandage  to  the  groin,  and  later  a  truss.  A  truss  should  not 
be  worn  if  a  radical  cure  has  been  made. 

Mortality. — Cases  of  strangulated  hernia  irreducible  by  taxis  wUl  prac- 
tically all  die  without  operation.  The  mortahty  following  operation  is  large; 
it  is  not  due  to  operation,  but  is  due  to  the  condition,  and  is  due  particularly  to 

delay  in  operating  or  to 
forcible  antecedent  taxis. 
Sultan,  from  a  total  of 
1429  herniotomies,  esti- 
mates the  mortality  at 
20.7  per  cent.  Estimating 
the  mortality  according  to 
the  time  of  strangulation, 
Henggeler  reaches  the  fol- 
lowing conclusions :  The 
mortality  of  cases  oper- 
ated upon  "the  first  day 
after  the  strangulation  is 
8.09  per  cent.;  during  the 
second  day,  22.2  per  cent.; 
during  the  third  day,  45.5 
per  cent. ;  during  the  fourth 
day,  60  per  cent."  ("Atlas 
and  Epitome  of  Abdomianl 
Hernias,"  by  Dr.  George 
Sultan.  Translated  and 
edited  by  Wm.  B.  Coley, 
M .  D . ) .  The  mortality  in 
cases  of  children  under  two 


Fig.  766. — Double  inguinal  rupture. 


children  is  smaller  than  in  adults.     In  Coley's  12 
years  of  age  there  was  not  a  death. 

Hernia  in  Childhood. — Hernia  is  extremely  common  in  children,  but 
it  is  an  interesting  fact  that  if  one  conducts  a  careful  investigation  of  hernia 
in  adults,  it  will  be  found  that  but  5  or  6  per  cent,  of  them  have  suffered 
from  the  hernia  in  childhood.  This  fact  seems  to  demonstrate  positively 
that  the  majority  of  cases  of  hernia  in  childhood  are  recovered  from.  A.  J. 
Ochsner  ("Jour.  Am.  Med.  Assoc,"  Dec.  22,  1900),  in  commenting  upon  the 
frequency  of  hernia  in  childhood,  alludes  to  Malgaigne's  statistics.  Malgaigne 
estimated  that  during  the  first  year  of  life  i  child  in  every  21  has  hernia,  and 
that  this  proportion  is  maintained  until  the  age  of  six.  Then  it  diminishes 
rapidly  until  the  age  of  thirteen,  at  which  age  there  is  i  hernia  in  every  77 
children.  It  is,  therefore,  obvious  that  75  per  cent,  of  all  herniae  in  children  of 
six  years  will  heal  spontaneously  before  the  age  of  thirteen.  Ochsner  states 
that  95  per  cent,  of  herniae  in  children  will  be  cured  without  operation.  He 
points  out  that  between  the  ages  of  thirteen  and  twenty  hernia  is  fairly  common 
among  boys,  but  very  rare  among  girls.  The  reason  for  the  tendency  to  cure 
is  somewhat  uncertain.  The  view  advocated  by  Thomas  C.  Martin  is  that,  as 
the  pelvis  broadens,  the  parietal  peritoneum  enlarges.  It  does  this  at  the 
expense  of  the  mesentery,  which  is  shortened,  and  the  internal  abdominal  ring 
is  displaced.     In  a  very  instructive  analysis  of  this  condition  Ochsner  shows  that 


Varieties  of  Hernia  ii59 

in  25  per  cent,  of  cases  of  hernia  in  childhood  hereditary  weakness  exists;  that 
the  condition  is  commoner  among  the  poorer  classes  than  among  the  rich; 
that  in  many  cases  there  is  an  undescended  testicle;  and  that  the  chief  cause 
is  an  excess  of  intra-abdominal  pressure.  This  excess  of  intra-abdominal 
pressure  may  result  from  flatulent  distention  of  the  stomach  and  intestines, 
the  product  of  bad  feeding;  constipation  and  straining;  straining  on  urinating, 
due  to  the  existence  of  phimosis;  vomiting,  or  cough.  He  thinks  that,  as 
a  rule,  indigestion  causes  flatulence  and  pain;  that  the  child  cries;  that  this 
increases  the  pressure;  that  the  mother  then  feeds  it  in  order  to  keep  it  quiet, 
and  that  this  makes  it  worse.     Strangulation  is  rare  in  childhood. 

Treatment. — Strangulated  herniae,  irreducible  herniae,  herniae  mth  very 
large  rings,  cases  in  which  trusses  fail,  and  cases  associated  with  reducible 
hydrocele  require  operation  (Ochsner).  Most  cases  are  curable  without 
operation,  the  ring  being  guarded  by  a  truss  of  rubber  or  a  pad  of  lamb's  wool. 
Ochsner  believes  that  many  cases  can  be  cured  by  keeping  the  child  recum- 
bent, with  the  foot  of  the  bed  raised,  from  four  to  six  weeks.  If  phimosis 
exists,  it  should  be  operated  upon,  and  any  other  causative  condition  should 
be  treated  (cough,  vomiting,  constipation,  flatulent  indigestion,  etc.).  An 
umbilical  hernia  can  usually  be  cured  by  the  use  of  a  cork.  The  cork  should 
be  I  inch  in  diameter  and  i^  inches  in  length,  and  shaped  like  a  cone.  The 
smaller  end  is  pushed  into  the  ring  and  the  cork  is  held  in  place  by  adhesive 
plaster.  In  two  weeks  a  smaller  cork  must  be  used,  and  in  six  or  eight  weeks 
it  can  usually  be  dispensed  with.  Radical  cure  operations  are  seldom  done 
before  the  age  of  four  (see  page  1136). 

Varieties  of  Hernia. — Direct  inguinal  hernia  comprise  less  than  2  per 
cent,  of  cases  of  inguinal  herniae.  In  direct  hernia  the  contents  pass  out 
through  Hesselbach's  triangle  internal  to  the  deep  epigastric  artery.  They 
enter  the  inguinal  canal  low  down,  and  pass  outside  the  conjoined  tendon  or 
force  the  conjoined  tendon  before  them  or  split  through  the  tendon.  They 
do  not  enter  the  scrotum.  The  neck  of  the  sac  is  internal  to  the  deep  epi- 
gastric artery.  The  protrusion  is  globular  in  shape,  imless  it  emerges  around 
the_  edge  of  the  tendon,  in  which  case  it  is  pear  shaped.  The  coverings  of 
this  hernia,  when  it  passes  external  to  the  conjoined  tendon,  are  the  same  as 
those  of  an  indirect  inguinal  hernia,  except  that  the  transversalis  fascia  instead 
of  the  infundibuliform  process  of  the  transversalis  fascia  is  one  of  the  layers. 
When  a  direct  hernia  pushes  before  it  the  conjoined  tendon,  its  coverings  are 
skin,  superficial  fascia,  intercoliunnar  fascia,  conjoined  tendon,  transversalis 
fascia,  subserous  tissue,  and  peritoneum. 

In  indirect  inguinal  hernia  the  contents  pass  through  the  internal  abdominal 
ring  external  to  Hesselbach's  triangle  and  external  to  the  deep  epigastric  artery. 
They  pass  do\\Ti  the  inguinal  canal  and  emerge  from  the  external  ring ;  and  may 
or  may  not  enter  the  scrotum  or  labium  {scrotal  or  lahial  hernia).  The  pro- 
trusion is  pear  shaped.  The  neck  of  the  sac  is  external  to  the  deep  epigastric 
artery.  Its  coverings  are  skin,  superficial  fascia,  intercolumnar  fascia,  cre- 
master  muscle,  infundibuliform  fascia,  subserous  tissue,  and  peritoneum. 

Congenital  inguinal  hernia  is  a  portion  of  bowel  Tvdthin  an  imclosed  vaginal 
process.  The  bowel  in  congenital  hernia  has  one  layer  of  peritoneum  in  front 
of  it.  The  testicle  is  posterior  and  below  (Fig.  767,  h).  Always  remember  that 
boiwel  may  not  enter  the  sac  of  a  congenital  hernia  for  several  months  or  longer 
after  birth.  Congenital  hernia  conceals  or  buries  the  testicle;  acquired  hernia 
does  not.  If  a  vaginal  process,  open  above  and  closed  below,  contains  a 
hernia,  the  condition  is  called  hernia  into  the  funicular  process  (Fig.  767,  c). 

If  the  fimicular  process  is  closed  at  the  abdominal  end,  but  not  below,  a 
hernia  in  a  special  sac  may  descend  back  of  the  vaginal  tunic.  This  condi- 
tion is  known  as  infantile  hernia.     In  infaitile  hernia  there  are  three  layers 


ii6o 


Diseases  and  Injuries  of  the  Abdomen 


of  peritoneum  in  front  of  the  bowel — the  two  layers  of  the  vaginal  tunic  and 
the  one  layer  of  sac.     The  testicle  is  in  front  (Fig.  767,  d). 

If  the  tunica  vaginalis  is  closed  above  and  not  below,  and  a  hernia  pushes 
down  the  vaginal  process  and  causes  it  to  double  on  itself,  the  condition  is 
known  as  encysted  infantile  hernia  (Fig.  767,  e). 

In  femoral  hernia  the  contents  descend  along  the  femoral  canal  to  the 
inner  side  of  the  vein,  and  the  neck  of  the  sac  is  at  the  femoral  ring.  The  neck 
of  a  femoral  rupture  is  always  external  to  the  pubic  spine;  the  neck  of  an 
inguinal  rupture  is  always  internal  to  the  pubic  spine.  Femoral  hernia  con- 
tains omentimi,  but  seldom  intestine,  except  in  strangulated  cases.  It  used 
to  be  said  that  femoral  hernia  is  never  congenital.     Russell  and  Coley  show 

that  it  may  be  (see  page  1133). 
The  coverings  of  a  femoral  hernia 
are  skin,  superficial  fascia,  cribri- 
form fascia,  crural  sheath,  septimi 
crurale,  subserous  tissue,  and  peri- 
toneimi. 

Occasionally  a  femoral  hernia 
may  pass  in  front  of  the  vessels  {pre- 
vasadar  femoral  hernia).  Mosch- 
chowitz  operated  upon  such  a  case 
(''Annals  of  Surgery,"  June,  191 2). 
A  hernia  may  be  external  to  the 
femoral  artery  (Eesselbach's  hernia) ; 
may  pass  through  an  opening  in 
Gimbernat's  ligament  {Laugier's 
hernia)]  may  come  down  alongside 
of  the  femoral  vein,  but  instead  of 
emerging  from  the  saphenous  open- 
ing spread  into  the  pectineus  mus- 
cle {Cloquefs  hernia). 

Umbilical  hernia  may  be  con- 
genital (the  ventral  plates  having 
closed  incompletely),  infantile  (the 
cicatrix  of  the  imibilicus  having 
stretched),  or  acquired. 

Ventral  hernia  is  a  protrusion 
through  any  part  of  the  anterior 
abdominal  wall  except  at  the  wxa- 
bilical  or  inguinal  regions.  A  ven- 
tral hernia  may  be  median  {hernia 
of  the  linea  alba)  or  lateral.  The 
treatment  is  radical  operation. 
Epigastric  hernia  is  a  form  of  ventral  hernia.  In  this  condition  there  is 
a  protrusion  of  the  peritoneum  in  the  space  bounded  by  the  ensiform  cartilage, 
the  ribs,  and  the  umbilicus.  The  sac  of  peritoneum  may  be  empty,  may 
contain  omentimi,  or  omentum  and  bowel.  The  stomach  very  rarely  passes 
into  the  sac.  The  protrusion  is  usually,  but  not  invariably,  through  the  linea 
alba.  The  condition  may  be  due  to  a  congenital  gap  in  the  transversalis 
fascia  or  to  the  growth  of  a  fat  hernia.  This  condition  may  cause  abdominal 
pain,  epigastric  pain,  nausea  and  vomiting  after  eating  or  eft"ort,  and,  according 
to  Farrar  Cobb  ("Annals  of  Surgery,"  Jan.,  191 2),  chronic  diarrhea. 

Cecal  hernia  is  very  uncommon  in  w^omen.  It  may  be  either  congenital, 
infantile,  or  acquired.  If  a  vaginal  process  is  open  the  cecum  may  readily 
enter  it,  it  may  be  drawn  in  by  the  plica  vascularis  as  the  testicle  descends 


Fig.  767. — a,  Scrotal  hernia;  h,  congenital  her- 
nia; c,  funicular  hernia;  d,  infantile  hernia;  e,  encysted 
hernia. 


Varieties  of  Hernia 


1161 


(Wrisberg),  it  may  be  drawn  in  by  a  descending  testicle  the  posterior  perito- 
neum over  which  has  formed  adliesions  to  the  cecum.  Most  acquired  cecal 
herniffi  are  preceded  and  caused  by  hernia  of  the  small  gut,  but  they  may 
occur  alone.  In  the  simple  form  the  cecum  is  completely  covered  by  a  coat  of 
peritoneum  and  Hes  within  the  sac.  Usually  there  is  a  complete  surrounding 
sac,  but  sometimes  the  sac  only  partially  covers  the  cecum  hing  in  front  and  to 
the  inner  side.  In  these  cases  the  cecum  is  on  the  posterior  and  external  aspect 
of  the  wall  of  the  sac.  The  appendix  may  be  in  the  sac,  outside  of  the  sac,  or 
part  may  be  within  and  part  without.  If  the  sac  is  incomplete,  it  means  that 
we  have  one  of  the  iS  per  cent,  of  cases  m  which  the  cecum  is  not  completely 
covered  with  peritoneum.  A  cecal  hernia  may  be  and  usuallv  is  right  inguinal, 
but  may  be  right  femoral,  left  inguinal,  or  left  femoral.  It  is  most  common 
in  advanced  life  and  is  frequently  irreducible. 

Hernia  of  the  appendix  may  occur  alone,  and  ^Merigot  de  Treigney  collected 
22  cases  of  it  ("These  de  Paris,"  1887).     In  17,  the  hernia  was  inguinal;  in 

5  it  was  femoral.  I  operated  upon  a  case  of 
appendicitis  in  which  the  uiflamed  appendLx 
was  the  sole  occupant  of  an  mcomplete  right 
inguinal  hernia  sac.  In  some  cases  the  ap- 
pendix accompanies  the  cecum  into  a  hernia. 


Fig.  76S. — The  large  intestine  behind  the  peri- 
toneum i^W'eir). 


Ccnnectue  t/ssae 


Fig.  769. — ^The  retroperitoneal  large  intes- 
tine in  a  cross-section  of  the  hernia  with  its  in- 
complete sac  (Weir). 


Adherent  hernia  of  the  large  intestine  (sliding  hernia)  is  a  condition  first 
described  by  Scarpa,  in  which  the  sac  of  a  right-sided  hernia  contains  ascending 
colon;  of  a  left-sided  hernia,  descending  colon.  The  sac  is  complete  on  the  ante- 
rior, but  apparently  absent  on  the  posterolateral  aspect,  where  the  bowel  seems 
as  though  fused  to  it.  This  condition  has  often  been  called  "hernia  vi-ith  m- 
complete  sac.""  A  commonly  accepted  theory-  is  that  because  of  looseness  of 
the  peritoneum  of  the  ihac  region  a  portion  of  the  large  bowel  slides  into  the 
hernia.  In  such  a  case  the  posterolateral  aspect  of  the  sac  is  absent  (Figs. 
768  and  769).  In  a  right-sided  condition  the  descending  bowel  carries  with  it 
into  the  scrotum  a  fold  of  loosened  peritoneum,  just  as  in  the  descent  of 
the  testis  (Weir,  in  '']Med.  Record,"'  Feb.  24,  1900).  SHding  hernia  of  the 
ascending  colon  is  wTongly  called  sliding  hernia  of  the  cecum.  In  most  cases 
of  shding  hernia  of  the  left  side  the  descending  colon  is  dragged  into  a  preexisting 
hernia  sac  containing  small  bowel,  omentum,  or  both.  The  large  bowel  is 
covered  "nith  peritoneum  except  posteriorly,  where  the  mesocolon  is  attached. 
This  form  is  nearly  always  irreducible  and  occurs  particularly  in  elderly  men. 
In  another  group  of  cases  the  large  bowel  makes  a  direct  inguinal  hernia  and 
the  sac  is  limited  to  the  anterior  surface  of  the  protruded  gut. 

In  this  edition  I  have  adopted  the  name  "adherent  hernia""  mstead  of 
"sliding  hernia."    L.  J.  Ransohoti  ("Annals  of  Surger}^,"  August,  1912)  seems  to 


1 1 62  Diseases  and  Injuries  of  the  Abdomen 

demonstrate  that  the  condition  is  not  due  to  sliding  of  the  peritoneum,  and 
hence  is  not  a  sliding  hernia;  that  an  incomplete  sac  is  a  secondary  process,  the 
sac  having  been  complete  in  its  incipiency,  but  obliterated  posteriorly  "by 
secondary  adhesions  of  the  embryonic  type."  The  immobile  loop  of  intestine 
in  the  sac  was  originally  mobile;  "the  hernia  is  primary,  the  adhesions  second- 
ary" (Ransohoff,  "Annals  of  Surgery,"  Aug.,  191 2). 

In  pro  peritoneal  hernia  the  sac  is  between  the  peritoneum  and  trans- 
versalis  fascia.  The  form  of  hernia  is  sometimes  produced  by  making  taxis 
on  an  inguinal  hernia,  when  the  internal  ring  is  small  or  is  blocked  by  an 
undescended  testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most 
common  form,  there  are  two  sacs,  one  in  the  scrotum,  the  other  parallel  with 
Poupart's  ligament,  and  as  one  sac  is  emptied,  the  other  distends  (Breiter,  of 
Zurich) . 

In  interstitial  or  interparietal  inguinal  hernia  the  hernia  sac  is  between  the 
transversalis  muscle  and  fascia,  or  between  the  external  and  internal  oblique 
muscles,  or  in  the  midst  of  the  fibers  of  the  internal  oblique  muscle,  or  be- 
tween the  external  oblique  muscle  and  the  transversalis  fascia,  the  internal 
oblique  and  transversalis  muscles  being  pushed  aside  (Sultan's  "Atlas  of  Ab- 
dominal Hernias"). 

In  superficial  inguinal  hernia  the  sac  is  between  the  aponeurosis  of  the 
external  oblique  muscle  and  the  superficial  fascia.  This  variety  of  hernia 
is  always  congenital  and  the  testicle  is  invariably  misplaced. 

Obturator  hernia  passes  through  the  obturator  membrane  or  the  obturator 
canal,  and  is  felt  below  the  horizontal  ramus  of  the  pubes,  internal  to  the 
femoral  vessels.  The  obturator  nerve  is  pressed  upon  and  pain  arises  in  its 
trajectory. 

Lumbar  hernia  is  a  very  rare  condition.  It  may  be  congenital,  traimiatic, 
or  spontaneous,  and  may  follow  a  lumbar  abscess.  Braacz  collected  68  cases. 
It  occurs  through  the  triangle  of  Petit,  or  just  below  the  twelfth  rib  through 
the  superior  lumbar  triangle,  or  through  a  congenital  defect  in  the  aponeurosis 
of  the  latissimus  dorsi  muscle,  or  through  a  defect  near  the  triangle  of  Petit 
(Dowd,  in  "Annals  of  Surgery,"  Feb.,  1907).  A  lumbar  hernia  may  be  present 
at  the  edge  of  or  through  the  quadratus  lumborum  muscles. 

The  triangle  of  Petit  is  bounded  in  front  by  the  external  oblique,  behind  by 
the  latissimus  dorsi,  below  by  the  iliac  crest,  and  its  floor  is  formed  by  the 
internal  oblique.  The  superior  lumbar  triangle  (of  Grynfelt  and  Lesshaft)  is 
bounded  anteriorly  by  the  external  oblique,  posteriorly  by  the  iliocostal  muscle, 
above  by  the  serratus  posticus  inferior  and  the  end  of  the  twelfth  rib,  and  below 
by  the  internal  oblique.     The  latissimus  dorsi  overHes  it. 

Sciatic  or  gluteal  hernia  passes  through  the  great  sacrosciatic  foramen,  above 
or  below  the  pyriformis  muscle,  or  through  the  lesser  sacrosciatic  foramen. 

Pudendal  hernia  protrudes  into  the  lower  part  of  the  labium,  the  bowel  hav- 
ing descended  between  the  ischial  ramus  and  the  vagina. 

Perineal  hernia  presents  in  the  perineum,  between  the  rectum  and  the 
prostate  gland  or  between  the  rectum  and  the  vagina. 

Internal,  retroperitoneal,  or  intra-abdominal  hernice  include  hernia  into  the 
foramen  of  Winslow,  hernia  into  the  retroduodenal  fossce,  the  retrocecal  fossa, 
and  the  intersigmoid  fossa  (see  page  981). 

Vaginal  hernia  is  associated  with  uterine  prolapse  or  ensues  upon  destruc- 
tion of  the  vaginal  wall. 

Richter's  hernia  (partial  enterocele  or  hernia  of  the  intestinal  wall.  Fig.  770, 
a)  was  described  by  Richter  in  1778.  He  called  it  "the  small  rupture."  It 
occurs  only  in  adults  and  is  most  common  in  women.  It  is  the  catching  of  a  por- 
tion of  the  circumference  of  the  bowel,  usually  a  portion  of  the  lower  part  of 
the  ileum.     It  is  usually  femoral,  but  may  be  inguinal,  and  even  epigastric  or 


Hernia  of  the  Bladder 


1 163 


obturator.  It  arises  usually  in  an  old,  reducible  hernia  (Royal  Hamilton 
Fowler,  "Am.  Jour.  Surg.,"  Jan.,  1912).  Some  cases  are  due  to  adhesions.  It 
may  be  due  to  truss  pressure  on  an  incompletely  reduced  hernia  (Fowler,  Ibid.) . 
Strangulation  of  a  partial  enterocele  may  not  completely  close  the  lumen  of  the 
gut.  There  may  not  be  stercoraceous  vomiting  or  absolute  constipation,  and 
the  protrusion  is  barely  perceptible  or  cannot  be  palpated. 

Littre's  hernia  is  hernia  of  Meckel's  diverticulum  (Fig.  770,  b).  It  was 
described  by  Littre  in  1700.  This  diverticulum  is  the  persistent  vitelline  duct 
and  comes  off  from  the  ileum  from  12  to  36  inches  above  the  ileocecal  valve. 
It  arises  from  the  convex  ..^ 

side  of  the  gut  and  rarely  -wft, 

has  a  mesentery  (see  pages 
982  and  988). 

Rokitansky's  divertic- 
xxlar  herniae  are  due  to 
separation  of  the  muscu- 
lar fibers  of  the  bowel, 
permitting  the  sacculation 
of  mucous  membrane  and 
peritoneum.  These  false 
diverticula  may  be  no 
larger  than  peas  or  may 
be  larger  than  walnuts, 
and  there  may  be  scores 
of  them  in  one  patient. 
They  may  produce  no 
symptoms  or  may  lead  to 
peritonitis,  abscess  about 
the  bowel,  perforation,  or 
to  symptoms  of  intestinal 
obstruction. 

Hernia  of  the  Bladder. 
— ^This  is  a  protrusion  of 
a  portion  of  the  bladder 
wall  through  a  hernial 
opening.  Eggenberger 

adds  no  cases  to  B run- 
ner's 182  cases,  a  total 
of  292  cases  ("Deutsch. 
Zeitschr.  f.  Chir.,"  Oct., 
1908).  Most  cases  are  in- 
stances of  false  hernia, 
there  being  no  sac  of  peri- 
toneum.    The  protrusion 

may  or  may  not  be  covered  with  peritoneimi,  and  in  most  cases  it  is  not  so 
covered,  but  lies  by  the  side  of  a  hernial  sac  and  not  inside  of  it.  Brunner's 
table  shows  only  5  cases  of  true  bladder  hernia,  that  is,  of  intraperitoneal 
hernia.  It  is  most  frequently  met  with  in  the  inguinal  region.  Brunner 
describes  three  forms:  (i)  Entirely  without  a  peritoneal  covering  (extraperi- 
toneal); (2)  partly  covered  with  peritoneum  (paraperitoneal — the  commonest 
form);  (3)  completely  covered  with  peritoneum  (intraperitoneal).  The  blad- 
der may  constitute  the  hernia,  or  there  may  be  an  ordinary  hernia  and  also  a 
cystocele.  In  an  inguinal  hernia  the  bladder  will  be  internal  and  somewhat 
behind  the  other  constituent  parts  of  the  protrusion.  Hernia  of  the  bladder 
is  much  more  common  in  men  than  in  women. 


Fig.  770. — A,  Diagrammatic  representation  of  Rickter's  her- 
nia of  intestinal  wall.  B,  Diagrammatic  representation  of  Littre's 
hernia,  which  is  a  hernia  of  Meckel's  diverticulum  (Sultan). 


1 1 64  Diseases  and  Injuries  of  the  Abdomen 

A  hernia  of  the  bladder  may  become  strangulated.  In  some  cases  a 
diagnosis  of  hernia  of  the  bladder  can  be  made  by  the  fact  that  the  protrusion 
lessens  in  size  when  the  patient  micturates,  and  increases  in  size  as  urine 
gathers  or  when  the  bladder  is  injected  with  fluid.  The  treatment  should 
be  operative.  When  the  bladder  is  exposed  it  is  replaced  if  possible  without 
resection  of  a  portion. 

Diaphragmatic  Hernia. — The  majority  of  cases  are  congenital  and  in 
90  per  cent,  of  them  there  is  no  sac.  The  hernia  may  pass  through  a  natural 
opening  or  through  a  gap  due  to  congenital  defect.  The  hernia  is  most  com- 
mon on  the  left  side,  and  the  stomach  is  the  organ  which  is  most  often  found  in 
the  hernia,  but  the  colon,  the  omentiun,  the  small  intestine,  the  spleen,  liver, 
duodenum,  cecum,  pancreas,  or  kidney  may  be  found  (Cranwell,  "Rev.  de 
Chir.,"  1908,  No.  i).  Violent  traumatism  may  be  the  cause.  When  the 
stomach  passes  suddenly  through  the  left  side  of  the  diaphragm  there  will 
be  dyspnea,  cyanosis,  displacement  of  the  heart  to  the  right,  pain  in  the  upper 
abdomen,  thirst,  and  in  most  cases  rapid  death.  When  the  stomach  or  in- 
testine has  entered  the  left  side  of  the  thorax,  there  is  a  tympanitic  note  on 
percussing  over  that  area  of  the  thorax,  the  heart  is  displaced  to  the  right,  and 
the  side  of  the  chest  is  unduly  prominent.  The  upper  border  of  the  tympanitic 
area  does  not  move  with  respiration.  There  are  no  breath  sounds  audible  over 
the  tympanitic  area,  but  gurghng  is  heard.  In  250  cases  of  traumatic  dia- 
phragmatic hernia  collected  by  Leichtenstern  the  diagnosis  was  made  before 
death  in  but  5  cases.  The  a:-rays  are  of  value  in  diagnosis,  especially  if  the 
stomach  is  in  the  hernia.  Strangulation  of  a  diaphragmatic  herjiia  produces 
severe  pain  in  the  upper  abdomen,  violent  vomiting,  constipation,  boat-shaped 
abdomen,  great  thirst,  rapid  wasting,  and  the  excretion  of  a  very  small  amount 
of  urea  (Mackenzie  and  Battle,  "Lancet,"  Dec.  7,  1901).  Diaphragmatic 
hernia  may  be  confused  with  eventration  of  the  diaphragm,  an  unnaturally 
high  position  of  the  left  half  of  the  diaphragm,  with  ascent  of  the  viscera  of  the 
abdomen,  especially  the  stomach.  It  was  first  described  by  Petit  in  1790. 
Sailer  and  Rhein  reported  a  case  and  collected  12  others  ("Am.  Jour.  Med. 
Sciences,"  April,  1905).  The  physical  signs  of  eventration  are  practically 
identical  with  those  of  diaphragmatic  hernia,  except  that  in  the  former  the 
upper  border  of  the  tympany  moves  on  respiration. 

Treatment. — Open  the  belly  for  exploration.  If  a  hernia  is  found,  return  it 
to  the  abdomen;  open  the  chest  and  suture  the  diaphragm  from  above  (trans- 
pleural suturing).  Mackenzie  and  Battle,  Mikulicz,  Hiunbert,  and  others 
have  operated  for  this  condition. 

Hernia  of  the  Ovary. — The  ovary,  because  of  failure  of  descent,  may 
remain  in  the  lumbar  region.  It  may  pass  into  the  inguinal  canal  or  labium 
majus  (inguinal  hernia);  to  the  gluteal  region  (gluteal  hernia);  to  the  region 
of  the  obturator  foramen  (obturator  hernia);  or  to  the  front  of  the  abdo- 
men (ventral  hernia).  In  congenital  inguinal  hernia  there  may  be  ovary 
alone,  or  ovary,  tube,  omentmn,  and  even  part  of  a  bicornate  uterus  (Gar- 
rigues) .  It  is  impossible  to  restore  a  congenital  hernia.  Acquired  hernia  may 
follow  a  fall  and  sometimes  it  can  be  restored.  A  femoral  or  crural  ovarian 
hernia,  a  condition  in  which  the  ovary  passes  to  the  front  of  the  thigh  below 
Poupart's  ligament,  is  never  congenital.  In  some  cases  a  herniated  ovary 
can  be  returned  within  the  abdomen.     Any  herniated  ovary  may  inflame. 

Treatment. — If  the  ovary  can  be  restored,  a  truss  will  probably  retain  it, 
but  even  in  such  a  case  operative  cure  is  better.  If  it  cannot  be  restored  or 
if  it  is  painful  or  undesirable  to  wear  a  truss,  operation  must  be  done.  Ex- 
pose the  ovary,  return  it  to  the  belly  if  healthy,  and  do  a  radical  cure  of  the 
hernia.     In  some  conditions  of  disease  remove  the  ovary. 

Hernia  of  the  Uterus. — This  condition  is  a  surgical  curiosity,  but  a  few 


Teratoids  and  Dermoids  Associated  with  the  Sacrococcygeal  Region    1165 

cases  have  been  reported  (John  Howard  Jopson's  case  in  "Annals  of  Sur- 
gery," July,  1904).  The  hernia  may  be  umbilical,  ventral,  inguinal,  or  fem- 
oral. Hernia  of  the  unimpregnated  womb  may  be  congenital  or  acquired; 
impregnation  may  occur  when  the  uterus  is  herniated,  or  an  impregnated 
uterus  may  pass  into  a  preexisting  hernia  sac.  If  a  herniated  uterus  becomes 
impregnated  or  if  an  impregnated  uterus  becomes  herniated,  pregnancy  may 
go  on  to  term.  IMultiple  pregnancies  predispose  to  uterine  hernia.  Ovarian 
hernia  may  precede  uterine  hernia,  or  hernia  of  omentum  adherent  to  the 
uterus  ma}"  pull  that  organ  into  the  sac.  In  many  cases  congenital  anom- 
alies have  been  found  to  exist  (bicornate  uterus,  rudimentary  uterus,  shortness 
of  the  round  ligament,  imperforate  vagina,  etc.).  A  hernia  of  the  uterus  en- 
larges and  becomes  painful  during  menstruation,  and  a  vaginal  examination 
shows  that  the  uterus  is  absent  from  its  normal  position  and  that  the  direction 
of  the  cervix  and  vagina  are  abnormal  (Jopson,  Ibid.) .  A  uterine  sound  can- 
not be  passed  at  all  or  can  be  passed  with  great  difficulty.  The  hernia  is  hard 
and  probably  p\T-iform.  If  impregnation  occurs,  there  are  the  ordinary  signs 
of  pregnancy  and  progressive  enlargement  of  the  hernia. 

Treatment. — Expose  the  mass  by  incision.  If  conditions  justify  such  a 
course,  return  the  uterus  and  adnexa,  if  they  are  present  (one  or  both  ovaries 
and  tubes  may  be  present),  to  the  abdomen  and  do  a  radical  cure.  If  the 
uterus  is  infected,  remove  it.  Jopson  in  his  case  removed  the  uterus  and 
right  ovar\'  and  fastened  the  uterine  stump  into  the  wound. 


XXIX.  DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS 

Teratoids  and  Dermoids  Associated  with  the  Sacrococcygeal 
Region. — In  the  sacrococcygeal  region  there  are  many  opportunities  for  de- 
velopmental error.  In  this  region  the  caudal  end  of  the  primitive  streak  must 
undergo  evolution  and  involution,  the  neurenteric  canal  must  form  and  dis- 
appear, the  anus  must  be  formed,  the  posterior  fissure  must  close,  the  sacriun 
and  coccyx  must  develop,  and  various  other  processes  must  go  on  correctly 
and  imiformly  if  complete  development  is  to  be  obtained.  As  CopHn  puts 
it:  "Perfect  evolution  of  the  tissues  embraced  in  this  part  of  the  body  is  beset  by 
many  narrow  escapes"  ("Publications  from  the  Laboratories  of  Jefferson  Med. 
College  Hospital,"  1906,  vol.  iii).  Fissures  and  clefts  may  fail  to  close,  frag- 
ments from  one  blastodermic  layer  may  be  lodged  in  another  layer,  groups  of 
cells  may  be  sequestered,  closing  clefts  may  include  tissue  elements,  and  parts 
that  should  normally  atrophy  may  do  so  late  or  not  at  all. 

In  order  to  understand  teratomata  and  dermoids  arising  in  the  rectal  region 
we  must  recall  some  facts  of  development. 

Early  in  embr\'onic  life  the  central  canal  of  the  spinal  cord  and  the  aU- 
mentarv'  canal  are  continuous  around  the  caudal  end  of  the  notochord  by 
a  communicating  path  called  the  neurenteric  canal. 

\\Tien  the  anal  pit  undergoes  invagination  it  meets  the  gut  considerably 
in  front  of  the  region  where  the  neurenteric  canal  joins  the  gut.  The  portion  of 
intestine  between  the  anus  and  the  opening  of  the  neurenteric  canal  is  called 
the  postanal  gut.  The  postanal  gut  disappears  during  normal  development. 
If  it  persists  it  causes  tumor  formation. 

The  congenital  tumors  of  the  sacrococcygeal  region  are:  (i)  Tumors  of  the 
postanal  gut;  (2)  dermoids  back  of  the  rectiun;  (3)  rectal  dermoids. 

According  to  Bland-Sutton,  timaors  of  the  postanal  gut  "are  composed  of 
closed  vesicles  lined  with  glandular  epithelium  and  contain  glue-like  fluid" 
("Tumors,  Innocent  and  Malignant,"  by  Sir  J.  Bland-Sutton).  These  tumors 
grow  to  a  large  size. 


ii66 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Dermoids  back  of  the  rectum  often  contain  teeth,  may  attain  large  size, 
are  apt  to  mount  up  behind  the  peritoneum,  and  may  rupture  and  form  a  fistula. 
I  helped  Prof.  Keen  operate  on  such  a  case.  The  skin  over  the  mass  showed 
a  growth  of  hair,  there  was  a  gap  or  cleft  in  the  sacrum,  and  through  this  there 
was  a  clear  passage  from  the  rectum  to  the  skin.  This  sinus  closely  resembled 
the  trachea  in  structure. 

Dermoids  occasionally  grow  from  the  mucous  membrane  of  the  rectum  and 
are  apt  to  contain  an  abundant  growth  of  hair. 

Examination  of  the  Anus  and  Rectum. — ^There  are  four  positions  in 
which  we  may  place  the  patient  for  rectal  examination,  the  one  to  be  selected 
depending  upon  the  probable  local  difficulty.  These  positions  are  the  left 
lateral  prone,  the  knee-chest,  the  exaggerated  lithotomy,  and  the  squatting 
position.  The  knee-chest  position  is  desirable  if  the  sigmoidoscope  is  to  be 
used.  A  commonly  employed  position  is  the  left  lateral  prone  position  of  Sims, 
in  which  the  patient  lies  on  the  left  side,  the  chest  on  the  table,  the  left  arm  be- 
hind the  back,  the  knees  drawn  up,  and  the  pelvis  elevated  on  a  hard  pillow. 
Very  stout  people  should  be  placed  in  the  knee-chest  position  or  exaggerated 
lithotomy  position,  as  the  rectum  cannot  be  seen  when  they  lie  on  the  side. 

A  squatting  position,  when  the  patient  is  placed  as  though  on  a  commode, 
is  best  adapted  to  cases  of  prolapse  and  hemorrhoids.     It  is  also  used  to  bring 

within  the  range  of  the 
finger  strictures  or  new 
growths  that  in  the  other 
attitudes  would  be  beyond 
digital  reach. 

Sometimes  the  surgeon 
is  able  to  pass  a  sigmoido- 
scope upon  a  patient  in 
the  exaggerated  lithotomy 
position  when  it  has  been 
found  impossible  to  carry 
the  instrimient  high  enough 
with  the  patient  in  any 
other  position. 

While  making  a  rectal 
examination  the  patient 
should  have  no  -constric- 
tion about  the  abdomen, 
such  as  corsets,  bandages, 
or  tight  clothing. 
It  is  important  that  the  first  examination  be  made  when  no  cathartics  or 
enemata  have  been  administered,  so  that  the  condition  of  the  excretions  and 
secretions  may  be  noted.  By  such  first  examination  pus,  blood,  mucus,  or 
inspissated  fecal  matter  if  present  may  be  seen,  and  from  their  varying  char- 
acteristics, quantities,  and  locations  inferences  as  to  causation  may  be  drawn. 
After  these  observations  have  been  made  an  enema  should  be  given  and  the  anus 
and  rectum  be  well  cleansed.  When  the  parts  have  been  cleaned  and  the  bowel 
washed  out  the  anus  is  carefully  inspected,  the  anal  folds  being  opened  during 
the  process.  By  inspection  the  surgeon  can  notice  the  external  opening  of  a 
fistula,  external  piles,  protruding  internal  piles,  mLxed  piles,  pruritus,  discharge 
from  the  rectiun,  eczema,  fissure,  tumor,  ulcer,  condylomata,  abscess,  whether 
or  not  the  anus  is  retracted  and  funnel-shaped  or  protruding,  or  if  there  be 
parasites  on  the  anal  hairs. 

Next  the  thiunbs  should  be  placed  on  either  side  of  the  anus  and  gently 
separated;  this  maneuver,  aided  by  a  bearing  down  effort  on  the  part  of  the 


Fig.  771. — Mathews's  self-retaining  rectal  speculum. 


Examination  of  the  Anus  and  Rectum 


1167 


patient,  will  often  cause  piles  to  protrude,  exhibit  fissures  and  polypi,  and  reveal 
the  condition  of  the  mucocutaneous  border. 

Next,  a  digital  examination  of  the  rectum  is  made.  The  nail  of  the  index- 
finger  is  filled  with  soap  and  the  finger  is  oiled  or,  better,  is  covered  with  a 
rubber  finger-tip  which  is  oiled.  The  digit  is  gently  inserted  through  the 
sphincter,  the  patient  being  asked  to  strain  lightly  while  it  is  passing.  The 
finger  is  inserted  with  a  gentle  boring  motion  and  is  pointed  toward  the  urn- 


Fig.  772. — Brinkerhoff's  speculum. 


bilicus  until  the  sphincter  is  passed.  A  digital  examination  enables  the  sur- 
geon to  detect  an  ulcer,  a  polypus,  a  timior,  a  stricture,  and  to  determine 
certain  points  regarding  the  condition  of  the  prostate  in  the  male  and  the 
uterus  in  the  female.  Non-indurated  piles  cannot  be  detected  by  the  finger. 
A  speculum  will  be  needed  to  discover  them  if  they  are  not  protruding. 

Next,  in  some  cases,  the  rectum  must  be  examined  by  means  of  a  specu- 
lum. It  is  not  often  necessary  to  give  ether.  Mathews's  speculum  (Fig.  771) 
is  very  serviceable.  Sims's  duck-bill  speculum  is  a  valuable  instrument  for 
certain  cases.     The  speculum  is  warmed,  oiled,  and  slowly  introduced.     It  is 


Fig.  773. — Martin's  speculum. 

first  directed  toward  the  umbilicus,  and  when  it  passes  the  sphincter  its  direc- 
tion is  gradually  altered  until  it  is  toward  the  promontory  of  the  sacrum. 
Illumination  is  obtained  by  direct  sunlight  or  by  a  forehead  mirror  and  an 
electric  light.  This  examination  will  extend,  confirm,  or  disprove  the  findings 
of  the  digital  examination;  ulcers,  hemorrhoids,  and  malignant  growths  can  be 
carefiilly  examined,  and  the  condition  of  the  rectal  mucous  membrane  can  be 
thoroughly  investigated. 


ri68 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Marion  Sims  in  1845  demonstrated  the  ballooning  of  the  vagina  by  atmo- 
spheric pressure,  and  in  1870  Van  Buren  applied  this  method  to  the  rectum, 
Kelly  in  1895  put  forth  his  straight  tubes  and  described  in  detail  the  methods 


Fig.  774. — Cook's  operating  speculum. 

and  advantages  of  examination  by  them,  and  the  great  diagnostic  value  of 
ballooning  the  rectum.  Kelly's  method  of  examination  is  shown  in  Fig.  775. 
The  tubes  are  shown  in  Fig.  776.     It  is  not  necessary  to  give  ether.     The 


Fig-  775- — Examination  of  the  rectimi  by  reflected  light  (Kelly). 

patient  is  placed  in  the  knee-chest  position.  A  tube  containing  an  obtu- 
rator is  well  greased  with  vaselin.  "The  buttocks  are  drawn  apart,  and 
the  blunt  end  of  the  obturator  is  laid  on  the  anus,  which  is  als^  coated  with 


Examination  of  the  Anus  and  Rectum 


1169 


vaselin.     The   direction   of   the  instrument  should  be  first  downward  and 
forward,  and,  when  the  sphincter  is  well  passed,  up  under  the  sacral  promon- 


Fig.  776. — ^Kelly's  rectal  specula. 


tory.  The  moment  the  speculimi  clears  the  sphincter  ani  and  the  obturator 
is  withdrawn,  air  rushes  in  audibly  and  distends  the  bowel."  When  the  enter- 
ing instrument  is  pressed 
gently  against  the  sphincter 
a  sharp  muscular  contraction 
ensues.  If  the  instrument  is 
gently  and  sHghtly  with- 
drawn, relaxation  occurs,  and 
the  moment  of  relaxation 
may  be  seized  to  make  an 
entry.  An  entry  so  made  is 
rapid  and  unresisted.  The 
bowxl  being  distended  with 
air,  the  mucous  membrane 
is  plainly  seen  as  the  tube 
is  slowly  withdrawn  and  the 
electric  light  is  reflected  into 
the  speculimi  by  a  forehead 
mirror.  The  normal  mucous 
membrane  is  dull  red,  like 
the  nasal  mucosa,  and  the 
blood-vessels  are  plainly  dis- 
tinguishable. The  Kelly  tube 
must  be  used  with  great 
care,  as  harm  may  be  done 
by  it,  and  the  longest  tube 
should  be  used  only  in  excep- 
tional cases. 

I  use  ^\'ith  the  greatest  satisfaction  James  P.  Tuttle's  pneumatic  proc- 
toscope (Fig.  777).     Dr.  Tuttle  describes  it  as  follows  ("Diseases  of  the 
74 


Fig.  777. — Tuttle's  pneumatic  proctoscope:  a,  Obturator; 
b,  plug  with  glass  window  closing  end  of  tube;  c,  handle;  d, 
cords  connecting  instrument  with  battery;  e,  inflating  appara- 
tus; /,  main  tube  of  proctoscope. 


II70 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Anus,  Rectum,  and  Colon"):  "This  instrument  is  composed  of  a  large  cyl- 
inder (/),  into  one  part  of  the  circumference  of  which  is  fitted  a  small  metallic 
tube  closed  by  a  flint-glass  bulb  at  its  distal  end.  The  electric  lamp  (d)  is 
fitted  upon  a  long  metallic  stem,  and  carried  through  the  small  cylinder  to  the 
end  of  the  instrument,  as  shown  in  the  illustration.  The  proctoscope  is  intro- 
duced through  the  anus  with  the  obturator  (o)  in  position.  As  soon  as  the 
internal  sphincter  is  passed  this  obturator  is  withdrawn  and  the  bayonet- 
fitting  plug  (b) ,  which  contains  either  a  plain  glass  window  or  a  lens  focused  to 
the  length  of  the  instrument  to  be  used,  is  inserted  in  the  proximal  end  of  the 
instrument.  This  plug  is  ground  to  fit  air-tight  and  thus  closes  the  instru- 
ment perfectly.  The  plug  being  inserted  in  the  tube,  a  very  slight  pressure 
upon  the  hand-bulb  will  cause  inflation  of  the  rectal  ampulla  to  such  an  extent 
that  the  whole  rectum  can  be  observed  and  the  instrument  can  be  carried  up 
to  the  promontory  of  the  sacrum  without  coming  in  contact  with  the  rectal 
Avail.  Further  dilatation  will  show  the  direction  of  the  canal  leading  into 
the  sigmoid,  and,  by  a  little  care  in  manipulating  the  instrument  and  keeping 


Fig.  778.  Fig.  77g. 

Figs.  778,  77Q. — A  new  and  simple  method  of  proctoscopy  (Thomas  C.  Martin). 


the  gut  well  dilated  in  advance,  it  can  be  carried  up  into  this  portion  of  the 
intestine  without  the  least  traumatism  of  the  parts.  If  any  fecal  matter  ob- 
scures the  light  by  being  massed  or  smeared  over  the  glass  bulb,  the  plug  can 
be  removed,  and  a  pledget  of  cotton,  introduced  with  a  long  dressing  forceps, 
will  wipe  this  off,  so  that  the  plug  can  be  reintroduced  and  the  examination 
continued  with  very  slight  delay  or  inconvenience.  The  adjustable  handle 
(c)  fits  on  the  rim  of  the  instrument  and  thus  converts  it  into  a  Kelly  tube. 
This  instrument  is  operated  with  an  ordinary  dry  battery  of  four  cells.  It  is 
better,  however,  to  have  a  battery  with  six  cells,  as  it  will  not  require  being 
recharged  so  frequently."  All  the  air  must  be  allowed  to  escape  before  the 
instrument  is  withdrawn,  otherwise  colic  may  develop. 

If  an  anesthetized  patient  is  placed  in  the  knee-chest  position,  the  sphincter 
can  be  stretched  by  the  fingers,  and  the  rectum  will  distend  with  air  and 
can  be  easily  examined.  The  fingers  are  introduced  as  suggested  by  Mar- 
tin (Fig.  778)  and  the  rectum  becomes  visible  when  they  are  separated  (Fig. 
779)- 


Wounds  and  Injuries  of  the  Rectum  1171 

Passage  of  Rectal  Tubes. — Some  have  asserted  that  soft  tubes  can  be 
passed  from  the  anus  through  the  sigmoid.  I  do  not  beheve  this  can  be  done 
in  a  normal  rectum,  it  matters  not  in  what  position  the  patient  is  placed,  and 
whether  or  not  fluid  flows  from  the  tube  during  its  introduction.  A  soft  tube 
always  coils  up  after  it  has  ascended  6  or  7  inches.  In  a  number  of  laparot- 
omies, desiring  to  locate  the  rectum,  I  have  had  an  assistant  pass  a  rubber  tube. 
It  would  never  ascend  above  the  rectal  dome  unless  I  aided  it  with  a  hand  in 
the  belly,  when  it  could  be  gotten  through  the  sigmoid.  Fortunately  it  is  not 
necessary  to  give  high  enemas,  as  fluid  introduced  into  the  rectum  is  carried 
back  to  the  sigmoid.  If  we  wish  fluid  retained,  attempts  to  pass  the  tube  high 
up  will  cause  irritation,  and  irritation  will  lead  to  expulsion. 

Foreign  Bodies  in  the  Rectum. — It  is  not  at  all  unusual  for  hard, 
imdigested  articles  taken  with  the  food  to  lodge  in  the  rectiun.  They  can 
usually  be  removed  through  a  speculum  by  means  of  forceps.  In  some  cases 
ether  must  be  given  and  the  sphincter  stretched;  in  others,  the  sphincter  must 
be  di\'ided.  Sometimes  large  bodies  are  voluntarily  inserted  and  the  indi- 
vidual is  unable  to  remove  them.  Lewis  H.  Adler  ("Am.  ]\Ied.,"  July  20, 
1901)  removed  the  valve  of  a  steam  radiator  pipe  from  the  rectum.  The 
small  end  was  ik  inches  in  diameter;  the  large  end  was  2^  inches  in  diameter. 
The  patient  had  been  in  the  habit  of  introducing  it  frequently  and  remo\ing  it 
with  a  hook  of  galvanized  iron  -^ire.  A.  Marmaduke  Sheild  ("Lancet,"  Oct. 
12,  1901)  reports  the  case  of  a  man  sixty  years  of  age  who  forced  a  gallipot  into 
the  rectum.  The  pot  was  2k  inches  in  diameter  and  2f  inches  in  height.  The 
patient  broke  it  tr}-ing  to  get  it  out.  Sheild  incised  the  sphincter  from  behind 
and  removed  the  article  by  means  of  obstetric  forceps. 

If  the  foreign  body  is  soft,  as  an  apple  or  a  potato,  a  hole  should  be  bored 
through  to  allow  the  air  to  pass  and  thus  relieve  the  suction.  It  can  then  be 
lifted  out.  If  the  body  is  of  wood,  screw  in  a  gimlet;  if  of  metal,  cut  with  strong 
forceps;  if  of  glass,  remove  as  Sheild  did  the  gallipot.  If  the  article  is  rough  or 
has  sharp  edges,  pack  gauze  all  around  it  as  a  first  step  to  protect  the  rectal  walls. 
In  a  case  in  which  a  boar's  tail  had  been  introduced,  large  end  first,  the  holding 
back  of  the  bristles  was  overcome  by  sliding  over  it  a  large-sized  rubber  catheter. 

Foreign  bodies  may  escape  into  the  sigmoid  and  necessitate  a  laparotomy. 
They  may  also  cause  periproctic  inflammation. 

A  remarkable  series  of  cases  of  foreign  bodies  in  the  rectum  may  be  found 
in  "Anomalies  and  Curiosities  of  Medicine,"  by  George  M.  Gould  and  Wal- 
ter L.  Pyle. 

Wounds  and  Injuries  of  the  Rectum. — These  accidents  may  result 
from  fractures  of  the  peh-is,  most  often  from  fractm-es  of  the  sacrum,  from  the 
improper  use  of  enema  s^Tinge  nozzles  or  tips,  from  gimshot-wounds,  stab- 
wounds,  foreign  bodies  introduced  by  the  patient,  and,  rarely,  from  digital 
examinations.  The  important  points  to  consider  in  these  wounds  are  whether 
or  not  there  is  penetration  of  the  entire  rectal  wall,  involvement  of  the  perirectal 
tissues,  or  peritoneum.  •  Slight  woimds  invoMng  only  the  mucous  membrane 
are  frequently  ver\'  grave  from  the  fact  that  the  hemorrhage  is  constant  into  the 
rectum,  filling  back  into  the  sigmoid,  often  followed  by  collapse  before  or  when 
the  blood  is  voided.  The  investigations  in  these  cases  should  always  be 
thorough  and  by  both  digital  and  visual  examination,  for  exact  diagnosis  is 
of  the  utmost  importance. 

If  the  peritoneum  has  been  lacerated,  laparotomy  should  be  performed  at 
once,  the  wound  in  the  bowel  repaired,  the  peritoneal  ca\'ity  cleansed  and 
drained,  and  the  Murphy  treatment  for  general  peritonitis  instituted  (see 
page  1025).  If  the  laceration  involves  the  perirectal  tissues  but  not  the  peri- 
toneimi,  cut  do'v\Ti  on  the  side  of  the  bowel  that  is  injiu-ed  and  make  free 
drainage.     In  the  event  of  xer\-  extensive  injuries  to  the  perirectal  tissues  the 


1 172  Diseases  and  Injuries  of  the  Rectum  and  Anus 

question  of  inguinal  colostomy  should  be  considered.  If  the  wound  involves 
only  the  mucous  or  submucous  coats,  dilate  the  sphincter,  arrest  hemorrhage 
by  suture  or  ligature,  and  follow  by  irrigation. 

Inflammation  of  the  Rectum  and  Sigmoid  (Proctitis  and  Sig= 
moiditis).— These  conditions  may  be  acute  or  chronic,  simple  or  specific. 
The  simple  forms  are  acute  catarrhal,  atrophic  catarrhal,  and  hypertrophic 
catarrhal.  The  specific  forms  are  gonorrheal  catarrhal,  diphtheritic  catarrhal, 
erysipelatous  catarrhal,  dysenteric  catarrhal,  and  syphilitic  catarrhal  (Tuttle, 
"Diseases  of  the  Anus,  Rectum,  and  Colon"). 

Acute  Inflammation. — Acute  catarrhal  inflammation  may  be  caused  by  that 
class  of  incidents  which  are  apt  to  be  followed  by  ordinary  catarrh  of  the  respi- 
ratory passages  and,  in  addition,  errors  of  diet  or  sudden  change  of  temperature, 
as  sitting  on  a  cold  seat  when  overheated.  The  onset  is  sudden,  with  chill, 
general  malaise,  pain  and  discomfort  locally,  and  slight  fever.  There  is  a  sense 
of  fulness  and  weight,  with  often  a  burning  sensation  referred  to  the  rectum,  and 
at  times  tenesmus  with  frequent  desire  to  go  to  stool.  Pain  radiates  to  adjacent 
parts  and  there  is  bladder  irritability.  Patients  usually  prefer  to  be  in  the  re- 
ciunbent  posture. 

There  will  be  at  first  a  thin  fecal  discharge  followed  by  mucus  tinged  with 
blood.  Ulceration  soon  supervenes.  The  parts  are  hot,  dry,  and  swollen  in 
the  first  stages  and  digital  examination  is  very  painful.  Later  the  parts  are 
slimy  and  the  mucous  membrane  is  covered  with  tenacious  mucus  and  pus. 

Treatment. — First  remove  irritating  intestinal  contents  and  reduce  en- 
gorgement by  lavage  and  saline  cathartics,  followed,  if  early  in  the  case,  by  irri- 
gations of  cold  water;  if  later,  by  hot  water.  A  useful  medicated  irrigation  is 
a  5  to  ID  per  cent,  solution  of  the  aqueous  extract  of  krameria. 

Chronic  Inflammation. — In  chronic  proctitis  and  sigmoiditis  the  symp- 
toms are  similar  to  those  present  in  the  acute  forms  of  the  inflammation,  but 
less  severe  in  character.  In  addition  there  is  increased  secretion  of  mucus, 
flatulence,  and  marked  general  intestinal  disturbance. 

The  mucous  membrane  is  soft,  doughy,  and  thickened,  which  condition 
palpably  reduces  the  caliber  of  the  gut.  Through  the  speculum  the  membrane 
is  seen  to  be  edematous,  pale,  and  covered  with  secretion.  It  bulges  into  the 
aperture  of  the  speculum  and  does  not  bleed  easily. 

Treatment  is  hygienic  and  dietetic,  with  antiseptic  and  astringent  irrigations. 

Atrophic  Inflammation. — The  atrophic  variety  of  inflammation  is  char- 
acterized by  long-continued  constipation,  dry  stools  covered  with  blood  and 
mucus.  There  is  such  pain  on  expulsion  of  feces  as  to  simulate  in  many 
cases  fissure  of  the  anus.  The  mucous  membrane  of  the  anus  ruptures  easily 
when  stretched  during  examination.  It  is  bright  red  and  shiny,  does  not  fill 
the  aperture  of  the  speculum,  and  bleeds  readily.  Ulceration  is  common  and 
hemorrhoids  are  a  frequent  complication. 

Treatment  is  local  and  general.  Locally,  use  a  dilute  solution  of  nitrate 
of  silver  (1:2000),  hydrastis  (2  per  cent,  solution),  or  ichthyol,  applied  after 
the  rectiun  is  emptied.     General  treatment  is  hygienic  and  dietetic. 

Peri=anal  and  Perirectal  Inflammations. — ^These  are  of  two  classes 
— circumscribed  inflammations  or  abscesses  and  diffuse  inflammations  that 
always  develop  pus.  The  circimiscribed  variety  may  be  either  superficial 
or  deep.  The  superficial  variety  again  may  be  tegmentary,  subtegmentary, 
or  ischiorectal.  The  deep  variety  may  be  of  two  forms — retrorectal  or  superior 
pelvirectal.  It  is  important  to  note  that  right-sided  superior  pelvirectal  abscess 
may  be  confounded  with  appendicitis. 

The  diffuse  perirectal  inflammations  are  variously  classified,  but  the  par- 
ticular names  refer  only  to  the  degree  of  the  inflammatory  process,  which  may 
vary  from  ordinary  suppuration  to  gangrene. 


Fistula  in  Ano  ii73 

These  inflammations  travel  in  the  hne  of  least  resistance,  which  is  upward, 
and  more  often  burst  into  the  bowel  than  externally.  They  may  follow  chiJling 
of  the  region  or  external  traumatisms,  may  be  caused  by  perforation  of  the 
rectum  by  hard  fecal  masses,  or  by  the  direct  passage  of  bacteria  into  the  fossa 
through  a  fissure,  an  ulcer,  or  an  ulcerated  pile.  They  may  be  either  acute  or 
tuberculous.  In  many  cases  the  process  is  at  first  tuberculous,  and  secondary 
infection  with  pyogenic  bacteria  takes  place. 

The  symptoms  are  nearly  identical  with  those  of  abscess  elsewhere,  the  swell- 
ing, however,  being  brawny,  and  it  being  difficult  or  impossible  to  detect  fluctua- 
tion. Pain  in  the  groins  is  often  complained  of,  and  there  may  be  enlarged 
glands  in  these  regions.  Abscesses  commonly  result  in  fistula,  and  a  patient 
should  be  warned  of  this  tendency  before  operation  is  performed.  Superior 
pehdrectal  abscesses  generally  follow  inflammation  of  some  pehdc  organ,  \dz.: 
tubes,  urethra,  prostate,  and  the  s}Tnptoms  are  mainly  those  of  such  an  inflam- 
matory condition.  The  usual  tendency  of  the  pus  is  to  burrow  upward.  The 
presence  of  pus  is  indicated  by  the  symptoms  of  suppurative  toxemia,  which 
sometimes  simulate  t}-phoid  fever. 

The  treatment  is  instant  incision.  The  patient,  after  ha\'ing  been  anesthe- 
tized, is  placed  in  the  lithotomy  position.  The  cut  should  be  parallel  to  the 
fibers  of  the  external  sphincter  and  weU  outside  of  the  muscle  and  longer  than 
the  inflamed  area.  \\Tien  this  incision  is  made,  the  finger  should  be  introduced 
to  break  down  the  necrotic  septa  of  ceUular  tissue.  Then  an  incision  should 
be  made  from  the  middle  of  the  first  cut  radiating  outward  and  opening  any 
pockets  external  to  the  original  focus.  Then  the  free  edges  of  the  cuts  are 
pared  away,  sacrificing  all  involved  tissue.  The  wound  is  irrigated,  the 
sphincter  dilated,  and  the  canity  packed  -^dth  iodoform  gauze.  If  a  fistula  is 
found  opening  into  the  rectum,  it  is  not  to  be  operated  on  until  after  the  wound 
is  nearly  healed,  only  a  smaU  fistulous  tract  remaining. 

In  cases  of  superior  pehdrectal  abscess  the  incision  should  be  made  at 
right  angles  to  the  fibers  of  the  levator  ani  muscle  to  facilitate  drainage.  In 
these  cases  tubal  dramage  is  used. 

Imperforate  Anus. — There  are  two  forms  of  this  condition.  In  one  form 
the  rectimi  empties  into  the  bladder,  vagina,  or  urethra.  In  the  other  form 
there  is  no  rectal  opening  either  upon  the  surface  of  the  body  or  in  the  genito- 
lU'inarv'  organs.  The  diagnosis  is  usuaUy  at  once  apparent,  except  in  cases  in 
which  the  anus  looks  normal,  when  the  diagnosis  ^\"ill  often  not  be  made  untfl 
s}Tnptoms  of  obstruction  arise. 

Treatment. — If  the  rectum  bulges  when  the  chfld  cries,  open  into  it  with 
a  knife  and  keep  the  opening  patent  by  inserting  a  plug  of  iodoform  gauze. 
In  cases  in  which  the  rectum  is  more  deepty  seated,  a  catheter  is  introduced 
into  the  bladder,  an  incision  is  made  from  the  anus  to  the  cocc}^,  the  rectum 
is  sought  for,  and  when  found  is  sewed  to  the  anus  and  is  incised.  Keen, 
the  author,  and  others  have  performed  Kraske's  sacral  resection,  pulling  down 
the  rectum  to  the  anal  margin,  sewing  it  there,  and  incising  the  occluded  anus. 
If  the  rectum  cannot  be  found  or  cannot  be  pulled  down,  an  artificial  anus 
must  be  made. 

Fistula  in  ano  is  the  track  of  an  uifliealed  abscess.  An  abscess  in  the 
anal  region  is  apt  to  refuse  to  heal  because  of  the  constant  movement  of  the 
parts  (produced  by  respiration,  coughing,  the  passage  of  gas,  defecation,  etc.). 
The  passage  of  feces  along  the  tract  will  keep  a  fistula  open.  If  a  tuberculous 
ulcer  perforates  a  tuberculous  sinus  forms,  and  a  tuberculous  sinus  is  also  apt  to 
foUow  a  cold  abscess  of  the  ischiorectal  fossa.  Fistula  is  often  associated  with 
phthisis  piflmonalis,  and  is  not  unusuall}^  linked  with  piles,  cancer,  or  stricture. 

There  are  three  varieties  of  fistula — the  blind  external  (Fig.  780,  a),  the 
blind  internal  (Fig.  7S0,  b),  and  the  complete  (Fig.  780,  c).     The  external 


II74 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


opening  is  usually  near  the  anus,  but  may  be  far  away,  and  there  may  be  only 
one  pathway  or  there  may  be  several  sinuses  and  openings.  In  a  healthy 
individual  the  external  orifice  is  small  and  a  mass  of  granulations  sprouts 
from  it.  In  a  tuberculous  fistula  the  external  orifice  is  large  and  irregular, 
with  thin  and  midermined  edges,  shows  no  granulations,  extrudes  small 
quantities  of  sanious  pus,  and  the  skin  about  it  is  purple  and  congested.  In  a 
fistula  following  an  anal  abscess  the  internal  opening  is  just  above  the  anus, 
between  the  two  sphincters.  In  fistula  following  an  ischiorectal  abscess  the 
internal  opening  is  usually  near  the  anus,  but  may  in  rare  cases  be  above  the 
internal  sphincter.  A  sinus  may  run  up  under  the  mucous  membrane  from  the 
internal  opening.  In  a  horseshoe  fistula  the  internal  opening  is  usually  upon  the 
posterior  wall  of  the  bowel,  "and  from  this  a  tract  leads  into  the  ischiorectal 
fossa,  not  on  one  side  only,  but  upon  both.  Therefore  we  have  one  opening  into 
the  bowel  and  one  through  the  skin  on  either  side."^  In  some  cases  of  horse- 
shoe fistula  there  is  no  internal  opening;  in  other  cases  there  are  two  openings. 
In  an  old  fistula  the  track  becomes  fibrous  and  cannot  collapse.  Two  or  more 
fistulae  may  exist  in  the  same  patient.  In  dealing  with  a  fistula  always  deter- 
mine if  the  condition  is  stationary  or  progressive. 

The  symptoms  of  a  complete  fistula  are  the  passage  of  feces  and  gas  through 
the  opening  and  the  flow  of  a  discharge  which  stains  the  clothing.  In  a  com- 
plete fistula  a  probe  can  be  carried  from  the  external  opening  into  the  bowel. 
After  a  time  incontinence  of  feces  is  apt  to  come  on,  repeated  attacks  of  inflam- 
mation thickening  the  rectum  and  destroying  its  sensibility.     From  time  to 


Fig.  780. — Fistula  in  ano:  a,  Blind  external;  b,  blind  internal;  C,  complete  (Esmarch  and  Kowalzig), 

time  the  opening  will  block  and  new  abscesses  form.  In  examining  a  fistula 
use  Brodie's  probe,  as  its  flat  handle  enables  one  to  locate  the  direction  the 
bent  instrument  has  taken,  and  its  slender  shaft  will  find  its  way  through  a 
very  small  channel. 

Treatment. — In  treating  a  fistula  cleanse  the  parts,  as  cleanly  work, 
though  it  will  not  prevent  pus,  will  limit  suppuration.  The  external  parts 
are  washed  with  soap  and  water.  The  rectum,  which  must  be  empty,  is  irri- 
gated with  warm  saline  solution.  Corrosive  sublimate  should  not  be  used  in 
the  rectum  because  it  is  irritant,  causes  a  flow  of  serum,  and  hence  lessens 
tissue  resistance,  and  is  rendered  inert  as  an  antiseptic  by  being  converted 
into  sulphid  of  mercury.  Anesthetize  the  patient  with  ether  unless  the  fistula 
is  tuberculous,  in  which  case  use  local  anesthesia,  spinal  anesthesia,  or 
nitrous  oxid.  Ether  is  avoided  in  such  cases  by  many  surgeons  for  fear  of 
the  existence  of  a  pulmonary  focus.  A  tuberculous  focus  in  the  lung  may 
disseminate  after  inhalation  anesthesia.  Place  the  patient  in  the  lithotomy 
position.  If  operating  upon  a  complete  fistula  the  usual  method  is  as  fol- 
lows: Pass  a  grooved  director  into  the  external  opening,  carry  it  through 
the  sinus,  make  it  enter  the  bowel,  bring  its  point  out  externally,  and  lift 
the  tissue  between  the  sinus  and  the  surface.  If  the  director  ascends  above 
the  internal  opening,  the  opening  must  be  made  into  the  bowel  from  the 
summit  of  the  sinus.  If  there  is  no  internal  opening,  make  one.  Incise 
the  bridge  of  tissue  which  is  held  up  on  the  director  (Fig.  781).  Cut 
1  "Diseases  of  the  Rectum,  Anus,  and  Sigmoid  Flexure,"  by  Joseph  M.  Mathews. 


Treatment  of  Fistula  in  Ano  ii75 

the  sphincter  at  a  right  angle  to  its  fibers,  and  do  not  cut  it  more  than 
once  at  one  operation.  If  a  fistula  is  non-tuberculous,  cut  with  a  knife.  If 
it  is  tuberculous,  di\-ide  the  tissues  with  a  PaqueUn  cautery  in  order  to  lessen 
the  danger  of  dissemination  of  the  infection.  Push  the  finger  to  the  depth 
of  the  wound,  to  determine  that  the  sinus  does  not  ascend  above  the  internal 
opening.  Search  with  a  small  probe  for  branching  sinuses, 
and  if  any  are  found,  slit  them  open.  Examine  carefully 
to  see  if  there  is  a  sinus  beneath  the  mucous  membrane 
of  the  bowel,  and  if  such  a  smus  is  found,  slit  it  up. 
Curet  all  sinuses,  and  if  they  are  very  fibrous,  clip  away  the 
fibrous  wall  by  scissors.  Cut  away  diseased  skin,  irrigate 
the  wound  with  salt  solution,  pack  firmly  with  iodoform 
gauze  to  prevent  oozing,  and  dress  with  gauze  and  a  T- 
bandage.  The  packing  is  removed  in  twenty-four  hours 
unless  it  is  soiled  earlier,  in  which  case  it  is  promptly  re- 
moved. After  twenty-four  hours  the  wound  is  irrigated  Fig.  7S1.  —  Opera- 
and  packed  lightly  \\ith  gauze  to  its  full  depth.  This  Jl^maTch  aS^  K^wal° 
dressing  should  be  repeated  every  da}^  and  any  bridging  zig). 
of  the  tissues  should  be  broken  down  by  a  probe.  If 
the  wound  becomes  sluggish,  it  is  stimulated  with  nitrate  of  silver  and 
sodimn  iodid  is  gi\-en  in  small  doses  three  times  daily. 

The  bowels  should  be  moved  after  forty-eight  hours  by  enema.  The  diet 
should  be  hght  and  fluid  for  the  first  few  days  after  operation,  and  the  bowels 
should  not  be  restrained  by  drugs.  Get  a  tuberculous  patient  out  of  bed  as 
soon  as  possible.  If  there  are  two  fistulae,  cut  one  through,  and  when  one 
wound  has  healed,  cut  the  other.  Some  straight  sinuses  can  be  extirpated 
and  the  parts  sutured,  primary  imion  occasionally  resulting. 

If  a  blind  external  fistula  does  not  heal,  ever>'  sinus  must  be  incised,  and 
thickened  walls  must  be  cut  away  or  scraped  away. 

In  a  blind  internal  fistula  an  external  incision  is  made  to  convert  the  case 
into  a  complete  fistula,  which  is  then  treated  as  directed  above. 

In  horsehsoe  fistula  more  than  one  operation  may  be  necessary  in  order 
to  avoid  cutting  the  sphincter  muscle  twice  in  one  operation,  a  proceeding 
which  would  probably  lead  to  fecal  incontinence.  One  side  alone  is  operated 
on  at  one  seance.  Sinuses  are  opened  and  scraped,  the  sphincter  is  divided, 
the  angles  and  edges  of  skin  are  trimmed  away,  and  the  woimd  is  packed. 
When  the  wound  is  healed,  or  nearly  healed,  the  other  side  should  be  operated 
upon. 

Any  operation  v^-Hl  fail  if  it  is  not  done  thoroughly.  Operative  failure  is 
common  after  fistula  operations.  The  operation  described  above  usually  gives 
excellent  results  in  simple  fistula.  It  gives  reasonably  good  results  even  when 
the  internal  opening  is  between  the  sphincters,  although  in  that  case  it  may  leave 
distinct  impairment  of  fecal  control.  If  the  internal  opening  is  in  and  above  the 
internal  sphincter,  the  operation  just  outlined  leaves  as  a  legacy  definite  loss 
of  sphincter  control  and  great  consequent  discomfort  (jVIackenzie,  "Treatment 
of  Fistula  in  Ano").  For  such  cases,  and  particular^  for  horseshoe  fistulae, 
Mackenzie  (Ibid.)  does  an  operation  which  does  not  mutilate  the  sphincter. 
He  dilates  the  sphincter;  finds  and  dilates  the  internal  orifice  of  the  fistula; 
Hfts  the  mucous  membrane  around  it;  pares  it  in  the  direction  of  the  long  axis 
of  the  bowel;  trims  the  muscle  in  the  direction  of  the  circumference  of  the 
sphincter;  sutures  the  muscle  -^-ith  catgut,  the  stitches  passing  at  right  angles 
to  the  fibers;  sutures  the  mucous  membrane  with  chromic  gut;  makes  a  flap 
on  the  side  involved,  the  flap  including  the  fistulous  tract  and  all  of  its  branches 
(in  a  horseshoe  fistula  he  makes  a  flap  on  each  side) ;  removes  all  scar  from  the 
rectal  wall  and  enfolds  the  wall  by  catgut  over  the  stitches  ^^ithin ;  removes  all 


1 176  Diseases  and  Injuries  of  the  Rectum  and  Anus 

of  the  fistulous  tracts  from  the  flap,  sutures  the  fat  with  buried  sutures  of  cat- 
gut, inserts  a  small  drain,  and  closes  the  skin. 

If  fecal  incontinence  results  from  an  operation  for  fistula,  remove  the 
scar  tissue  and  endeavor  to  suture  the  separated  muscular  fibers.  A.  W. 
Mayo  Robson  (''The  Practitioner,"  Feb.,  1903)  performs  the  following  opera- 
tion for  incontinence:  A  crescentic  incision,  from  |  to  f  inch  in  depth  and 
taking  in  about  one-half  of  the  circumference  of  the  bowel,  is  made  at  the 
anterior  border  of  the  anus.  The  middle  borders  of  the  incision  are  then 
pulled  apart  until  the  ends  of  the  cut  approximate  in  the  middle  line,  when 
they  are  stitched  with  deep  catgut  sutures  and  the  skin  is  sewed  with  silk- 
worm gut,  the  immediate  result  being  an  incision  apparently  radiating  from 
the  anus.  Should  an  operation  be  undertaken  for  fistula  if  phthisis  exists? 
Many  of  the  old  masters  said  no.  Mathews  sums  up  the  modern  view:  In 
incipient  phthisis  operate;  in  rapidly  progressive  fistula  operate  whether  cough 
exists  or  not;  if  much  cough  exists  do  not  operate  unless  the  fistula  is  rapidly 
progressive;  in  the  last  stages  of  phthisis  do  not  operate. 

Pruritus  of  the  anus  is  a  symptom  and  not  a  disease.  It  may  be 
due  to  piles,  fissure,  seat-worms,  eczema,  nerve  disturbance,  kidney  disease, 
gout,  jaundice,  constipation,  inebriety,  the  opiimi-habit,  torpid  liver,  dyspepsia, 
alcohol,  tea-drinking,  vesical  calculus,  tobacco-smoking,  urethral  stricture, 
uterine  disease,  diabetes,  ovarian  trouble,  and  mental  disorder.  In  some 
cases  it  seems  to  be  a  pure  neurosis  and  no  special  causative  factor  can  be 
recognized.  It  is  vastly  more  frequent  in  males  than  in  females,  and  is  espe- 
cially common  in  fat  men  who  sweat  profusely.  It  is  seldom  seen  before  the 
age  of  thirty,  except  in  children  suffering  from  thread-worms.  The  itching 
comes  on  gradually  and  usually  intermittently,  but  grows  progressively  worse 
and  worse  until  it  becomes  torturing.  In  many  cases  it  is  at  first  noticed  only 
when  warm  in  bed;  in  other  cases  it  exists  day  and  night.  A  violent  exacer- 
bation may  be  excited  by  worry,  anxiety,  overwork,  dietary  indiscretion,  a 
sudden  change  of  temperature,  and  many  other  things.  The  itching  finally 
becomes  an  unbearable  agony,  sleep,  except  in  snatches,  is  impossible,  the 
appetite  disappears,  the  strength  fails,  and  the  sufferer  may  become  a  nervous 
wreck.  In  some  cases  of  pruritus  the  anal  folds  are  edematous,  there  are 
abrasions  here  and  there  from  scratching,  the  area  is  white  and  moist  and 
gives  origin  to  a  fine  secretion;  in  other  cases  the  mucous  membrane  is  dry 
and  fissured. 

Treatment. — In  every  case  first  of  all  make  a  careful  examination  to 
find  a  probable  or  a  possible  cause,  local,  reflex,  or  constitutional,  and  en- 
deavor to  remove  this  supposed  cause.  Then  undertake  treatment  for  the 
pruritus.  It  is  very  important  to  prevent  constipation.  Kelsey  directs 
that  the  parts  be  cleansed  twice  a  day,  and  after  each  cleansing  the  follow- 
ing ointment  be  applied:  Menthol,  i  dr.;  cerat.  simp.,  2  oz. ;  oil  of  sweet 
almonds,  i  fl.oz.;  acid,  carbolic,  i  dr.;  pulvis  zinc,  oxid.,  2  oz.  Mathews  com- 
mends the  following  mixture:  Chloral,  i  dr.;  gum-camphor,  |  dr.;  glycerin 
and  water,  each,  i  oz.^  In  this  disease  a  "scarf  skin"  forms,  which  must  be 
made  to  peel  off  by  the  application  of  iodin,  pure  carbolic  acid,  corrosive  subli- 
mate (4  gr.  to  I  oz.  of  cosmolin),  or  calomel  (2  dr.  to  i  oz.  of  cosmolin). 
In  obstinate  cases  paint  the  parts,  night  and  morning,  with  a  mixture  of  60 
gr.  of  alum,  30  gr.  of  calomel,  and  300  gr.  of  glycerin;  or  smear  with  an  oint- 
ment compossed  of  |  part  of  oleate  of  cocain,  3  parts  of  lanolin,  2  parts  of 
vaselin,  and  2  parts  of  olive  oil  (Morain).  In  very  severe  cases,  in  which  the 
skin  is  dry  and  cracked,  apply  a  5  per  cent,  solution  of  eucain  to  the  abraded 
portions  and  paint  the  entire  surface  with  a  concentrated  solution  of  silver 
nitrate.     It  may  be  necessary  to  repeat  this  treatment  several  times  at  inter- 

^  "Diseases  of  the  Rectum." 


Hemorrhoids,  or  Piles  1177 

vals  of  four  or  five  days.  Adler  advised  us  to  apply  to  the  parts  the  day  after 
the  silver  has  been  used  unguentum  hydrargyri  nitratis  in  full  strength,  only  dis- 
continuing on  the  day  a  fresh  application  of  silver  is  made,  and  the  next  day 
resimiing  the  applications  of  ointment.  If  during  treatment  the  skin  becomes 
sore,  use  calomel  ointment  until  soreness  disappears.  Violent  attacks  of 
itching  are  met  by  applying  hot  water  and  black  wash  or  calomel  ointment. 
This  plan  of  treatment  must  be  pursued  for  some  months  (Lewis  H.  Adler,  Jr., 
"New  York  and  Phila.  Med.  Jour.,"  July  29,  1905).  I  have  used  this  plan 
with  some  satisfaction.  In  severe  and  protracted  cases  we  may  employ  the 
x-Ta,ys  twice  a  week  (J.  R.  Pennington).  I  have  seen  their  application  pro- 
ductive of  great  benefit.  In  some  cases  we  employ  the  Paquelin  cautery,  in 
others  we  resect  the  mucous  membrane,  as  in  Whitehead's  operation  for  hem- 
orrhoids. Ball  divides  the  sensory  nerves  going  to  the  implicated  skin  and  has 
obtained  excellent  results. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  orifice  producing 
spasm  of  the  sphincter.  Pain  exists  because  twigs  of  nerves  are  exposed  upon 
the  floor  of  the  ulcer.  Fissure  is  caused  by  constipation  or  traumatism.  It  is 
usually  posterior. 

The  symptom  is  violent,  burning  pain,  sometimes  beginning  during  defeca- 
tion, but  usually  at  the  end  of  the  act,  and  lasting  for  some  hours.  Consti- 
pation exists,  and  often  pruritus.  Examination  discloses  a  fissure,  usually  at 
the  posterior  margin,  running  up  the  bowel  j  to  ^  inch.  Piles  often  exist  with 
fissure. 

Treatment. — The  palliative  treatment  is  to  prevent  constipation,  to  wash 
out  the  rectimi  with  cold  water,  and  apply  an  ointment  made  by  evaporating 
2  oz.  of  the  juice  of  coniimi  down  to  2  dr.,  and  adding  it  to  i  oz.  of  lanolin  and 
12  gr.  of  persulphate  of  iron.  Pure  ichthyol  frequently  promotes  healing  unless 
the  edges  are  thick  or  the  base  indurated,  when  operation  must  be  done. 
Many  cases  are  so  sensitive  and  painful  to  the  touch  that  medication  and 
examination  are  almost  impossible.  These  may  be  made  bearable  by  in- 
sufiiations  of  orthoform. 

Operative  Treatment. — Anesthetize  the  patient.  Thoroughly  cleanse  the 
parts.  Some  surgeons  advocate  operation  without  stretching  the  sphincter. 
It  has  always  been  my  custom  to  stretch  the  sphincter  for  fissure.  Stretching 
gives  us  room  in  which  to  work,  and  by  thus  paralyzing  the  muscular  fibers 
the  raw  surface  is  put  at  rest  and  paroxysms  of  pain  cease  to  occur.  In  order 
to  stretch  the  sphincter  the  patient  is  anesthetized,  the  surgeon's  thumbs  are 
inserted  into  the  rectvun,  and  the  parts  are  stretched  slowly  until  the  thimibs 
touch  the  ischia.  After  stretching  the  sphincter  the  fissure  is  incised  through 
its  base  \  inch  deeper  than  the  deepest  part  of  the  ulcer,  extending  \  inch  above 
and  below  the  diseased  tissues,  so  that  the  healthy  muscular  fibers  at  either 
end  are  divided.  In  cases  in  which  the  ulcer  is  at  either  the  anterior  or  pos- 
terior commissure  a  V-shaped  incision  is  made,  the  apex  of  which  should 
begin  \  inch  above  the  highest  point  of  the  ulcer  and  the  diverging  Ime  run- 
ning close  to  the  sides  of  the  fissure,  but  in  healthy  tissue. 

A  search  is  made  by  a  probe  to  be  sure  no  pockets  exist.  Any  pocket 
must  be  opened  and  scraped.  The  floor  should  be  curetted  and  touched  with 
the  solid  stick  of  nitrate  of  sflver.  If  there  are  redundant  edges,  exuberant 
granulations,  a  sentinel  pile,  or  a  polypus,  they  should  be  curetted  or  excised. 
The  wound  is  then  packed  lightly  with  gauze  and  the  patient  kept  in  bed  for 
twenty-fom:  hours. 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of  varicose  tiunors 
of  the  rectum,  namely:  external,  which  take  origin  without  the  external  sphinc- 
ter; internal,  which  take  origin  within  the  external  sphincter;  and  mixed 
hemorrhoids,  which  are  a  combination  of  the  two. 


1 1 78  Diseases  and  Injuries  of  the  Rectum  and  Anus 

External  hemorrhoids  are  covered  with  skin.  Internal  hemorrhoids  are 
covered  with  mucous  membrane.  The  term  "external  hemorrhoids"  is  not 
strictly  accurate,  as  hemorrhage  does  not  occur  in  external  piles,  and  all  ex- 
ternal piles  are  not  related  to  the  external  hemorrhoidal  veins.  An  external 
pile  may  involve  the  veins  or  the  skin. 

External  hemorrhoids  are  classified  as  thrombotic,  varicose,  inflammatory, 
and  connective- tissue  external  hemorrhoids  (Tuttle). 

Thrombotic  External  Hemorrhoids. — These  are  external  hemorrhoidal 
veins  filled  with  clot.  When  an  external  hemorrhoidal  vein  inflames  the 
parts  become  itchy,  painful,  and  swollen,  and  defecation  increases  the  pain. 
The  blood  clots  in  the  inflamed  vein  and  sometimes  the  vessel  ruptures. 

Symptoms  and  Treatment. — External  piles  of  this  variety  are  usually,  but 
not  always,  multiple.  Small  oval  tumors  appear  beneath  the  skin  or  the 
junction  of  the  skin  and  mucous  membrane.  They  appear  suddenly.  The 
parts  itch  and  pain,  defecation  increases  the  pain,  and  each  pile  increases 
rapidly  in  size.  When  the  vein  ruptures,  a  livid,  soft  enlargement  rapidly 
forms.  External  pfles  of  this  variety  may  be  absorbed,  may  become  organ- 
ized into  a  scar,  or  may  suppurate.  These  piles  do  not  bleed.  In  treating 
external  hemorrhoids  some  surgeons  merely  use  remedies  to  combat  the 
inflammation.  An  old  plan  of  treatment  is  to  incise  the  blood-tumor,  turn 
out  the  clot,  and  pack  with  a  bit  of  iodoform  gauze.  Mathews  freezes  the 
part  or  injects  cocain,  catches  up  the  blood-tumor  with  a  volsellum,  excises 
the  tumor  and  the  tabs  of  inflamed  skin,  dusts  the  part  with  iodoform,  and 
dresses  it  with  antiseptic  gauze.  The  bowels  should  not  be  allowed  to  move 
for  two  days.  Never  inject  external  piles  with  carbolic  acid;  it  causes  great 
inflammation,  violent  pain,  sloughing,  and  is  not  free  from  danger.  If  the 
patient  declines  operation,  order  rest,  a  non-stimulating  diet,  avoidance  of 
tobacco  (Mathews),  the  use  of  saline  purgatives,  injections  into  the  rectum 
of  cold  water  several  times  a  day,  sponging  of  the  anus  frequently  with  hot 
water,  and  the  application  of  hot  poultices.  As  the  acute  symptoms  begin  to 
disappear  use  extract  of  hamamelis  locally;  when  they  have  nearly  subsided, 
apply  zinc  ointment. 

Varicose  External  Hemorrhoids. — They  are  varicose  external  hemor- 
rhoidal veins  and  are  visible  at  the  anal  margin  when  the  patient  strains. 
They  rarely  produce  pain  or  discomfort,  and  it  is  seldom  that  operation  is 
necessary.  The  bowels  should  be  moved  dafly,  but  not  with  violent  purga- 
tives, and  after  each  movement  cold  should  be  applied  to  the  anus,  while  the 
patient  is  recumbent.  Tuttle  advocates  the  use  at  night  of  an  ointment 
containing  2  dr.  of  suprarenal  extract  and  6  dr.  of  lanolin;  this  is  spread  on 
cotton- wool,  which  is  applied  to  the  anus  and  held  in  place  by  a  T-bandage. 

Inflammatory  Piles. — -By  this  term  we  mean  edematous  inflammation 
of  the  anal  folds.  The  inflammation  may  be  due  to  a  traumatism,  the  pres- 
ence of  an  ulcer  or  fissure,  etc.  There  are  burning,  itching,  and  sweUing  of 
the  anus,  which  are  all  greatly  increased  by  defecation.  One  or  more  pear- 
shaped  swellings  can  be  seen  at  the  anal  margin. 

In  some  cases  medical  treatment  produces  cure.  This  treatment  consists, 
during  the  first  twenty-four  hours,  in  the  use  of  cold  and  of  rest  in  bed.  After 
this  period  heat  should  be  employed.  Tuttle  applies  gauze  soaked  in  a  25 
per  cent,  solution  of  boroglycerid  and  places  a  hot-water  bag  over  this.  He 
also  reconamends  the  following  ointment,  to  be  applied  two  or  three  times  a 
day: 

I^.     Morphinae  sulph gr.  v-x; 

Ichthyol 3  iv; 

Ung.  belladonnse  )  --   "K' 

Ung.  stramonii     J    ^^  ^^' 

Sig. — Apply  two  or  three  times  a  day. 


Internal  Hemorrhoids  1179 

If  these  means  fail,  ether  is  given,  the  sphincter  is  stretched,  and  the 
tumors  are  cut  away. 

Connective-tissue  External  Hemorrhoids  (Skin  Tabs). — They  are  due 
to  hypertrophy  of  mucocutaneous  tissue  at  the  anal  margin.  Usually  they  re- 
sult from  acute  inflammatory  external  piles;  sometimes  they  arise  gradually  as 
a  result  of  chronic  anal  or  rectal  inflammation  or  irritation,  and  they  may 
be  due  to  varicose  or  thrombotic  external  piles  (Tuttle).  They  produce  no 
trouble  when  not  inflamed.  If  they  cause  serious  annoyance  the  treatment  is 
extirpation. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal  hemorrhoidal 
plexus,  and  are  found  internal  to  the  external  sphincter,  just  within  the  anus, 
and  they  prolapse  easily.  They  are  not  simply  varicosities,  but  new  tissue 
has  been  formed,  and  they  are,  in  reality,  vascular  tumors.  They  are  covered 
with  mucous  membrane.  Capillary  piles  are  small,  sessile,  with  a  surface 
like  a  mulberry,  and  bleed  freely.  Children  are  not  very  liable  to  develop 
piles,  excepting  the  capillary  form.  Venous  piles  are  the  most  common  va- 
riety. They  extend  from  just  above  the  anal  margin  of  the  rectum  for  an 
inch  or  more.  They  are  purple  in  color,  soft,  irregular  in  outline,  and  are 
usually  multiple.  They  bleed  when  irritated  by  hard  fecal  masses,  but 
not  so  easily  as  the  capillary  piles.  Each  pile  is  composed  of  a  varicose  vein, 
some  fibrous  tissue,  and  a  few  arterial  twigs.  Arterial  piles  are  very  unusual. 
They  are  large,  smooth,  pedunculated,  bleed  easily  and  freely,  and  contain, 
besides  a  distended  vein,  arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum — constipation,  dis- 
eases of  the  rectum,  enlargement  of  the  prostate,  pregnancy,  tiunors  of  the 
womb,  congestion  of  the  liver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart 
and  lungs,  sedentary  occupations,  relaxing  climate,  and  stricture  of  the  urethra 
— may  cause  hemorrhoids. 

Symptoms  and  Treatment. — If  there  is  neither  bleeding  nor  protrusion  the 
piles  give  no  trouble.  The  first  symptom  is  usually  hemorrhage,  and  rectal 
examination  by  the  speculum  will  make  clear  the  condition.  After  a  time, 
during  defecation,  the  piles  protrude;  they  may  reduce  themselves  when  the 
patient  stands  up,  or  it  may  be  necessary  to  push  them  in.  Pain  does  not 
exist  in  uncomplicated  cases,  and  pain  during  or  after  protrusion  means  "abra- 
sion, fissure,  or  ulceration"  (Mathews). 

Palliative  Treatment. — This  ■will  not  cure,  but  it  will  give  great  comfort. 
Some  people  only  suffer  at  rare  times  when  the  liver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible,  the  cause  (alcohol, 
irritating  foods,  want  of  exercise,  etc.);  restrict  the  diet;  insist  on  regular  ex- 
ercise; give  a  course  of  Carlsbad  salt,  and  follow  this  by  the  administration  of 
bichlorid  of  mercury  (2^  gr.  after  each  meal).  Prevent  constipation  by  a 
nightly  dose  of  extract  of  cascara.  After  each  bowel  movement  wash  the  parts 
with  a  soft  sponge  soaked  in  cold  water,  and  syringe  out  the  rectum  with  cold 
water  and  dry  outwardly  with  a  soft  rag.  If  the  hemorrhoids  pi'olapse 
after  restoring  them  and  injecting  cold  water,  insert  a  suppository'  containing 
10  gr.  of  the  extract  of  hamamelis  and  use  another  suppository  at  bedtime. 
A  useful  suppository  for  prolapse  is  that  employed  by  Tuttle:  it  contains 
5  gr.  of  ichthyol,  5  gr.  of  tannic  acid,  |  gr.  of  ext.  of  stramonium,  \  gr.  of  ext.  of 
belladonna,  and  10  gr.  of  ext.  of  hamamelis.  Bleeding  may  be  arrested  by 
suppositories,  each  containing  5  gr.  of  suprarenal  extract.  When  the  piles 
prolapse  and  inflame,  rub  AUingham's  ointment  on  the  parts  (2  dr.  each 
of  ext.  of  conium  and  ext.  of  hyoscyamus,  i  dr.  of  ext.  of  belladonna,  and  i  oz. 
of  cosmolin).  Mathews  uses  12  gr.  of  cocain,  i  dr.  of  iodoform,  |  dr.  of  ext. 
of  opium,  and  i  oz.  of  cosmolin.  Grant  uses  an  ointment  containing  8  gr.  of 
morphin,  1 2  gr.  of  calomel,  and  i  oz.  of  vaselin.     This  is  applied  after  bathing 


ii8o 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


the  part  with  hot  water.  If  the  piles  are  protruding  and  reduction  cannot  be 
effected,  put  the  patient  to  bed,  give  a  hypodermatic  injection  of  morphin,  and 
apply  hot  poultices.  If  reduction  cannot  soon  be  effected,  divulsion  of  the 
sphincter  must  be  practised  or  radical  operation  must  be  resorted  to. 

Operative  Treatment. — Give  a  saline  the  morning  before  and  an  enema 
the  evening  before  the  operation,  and  wash  out  the  rectum  well  the  morning 
of  the  operation.  In  treating  by  injection  of  carbolic  acid  the  sphincter  should 
be  divulsed  while  the  patient  is  under  the  influence  of  nitrous  oxid  gas  unless  the 
pile  is  thrombotic.  "Under  gas  muscular  relaxation  does  not  obtain  as  in  the 
use  of  ether.  Hence  dilatation  under  gas  can  be  more  rapidly  induced,  as  we 
have  the  sphincteric  rigidity  as  a  guide  in  knowing  exactly  how  much  force  may 
be  employed  in  the  individual  case"  (Lewis  H.  Adler,  Jr.,  in  "Jour.  Am.  Med. 
Assoc,"  Jan.  21,  1905).  The  surgeon  must  be  careful  not  to  tear  the  parts. 
The  tumors  are  drawn  out  or,  if  gas  was  not  given,  the  patient  strains  them  out. 
An  injection  is  given  by  a  hypodermatic  syringe  into  the  center  of  the  pile, 
and  as  each  pile  is  injected  it  is  pushed  into  the  rectum.  Only  one  or  two  piles 
are  injected  at  each  seance,  and  the  operation  is  not  repeated  for  one  week  (Geo. 
W.  Gay,  in  "Boston  Med.  and  Surg.  Jour.,"  Dec.  5,  1901).  The  dose  for  each 
pile  is  I  or  2  min.  of  a  10  per  cent,  solution  of  carbolic  acid.  The  injections 
relieve  the  condition,  but  are  rarely  absolutely  curative  and  are  not  without 


Fig.  782. — Brick's  pile  clamp. 

danger,  and  may  produce  abscess,  sloughing,  hemorrhage,  phlebitis,  pyemia, 
stricture,  and  even  death  (W.  T.  Bull-Kelsey).  Dr.  Collier  F.  Martin  ("Ameri- 
can Medicine,"  August  27,  1904)  maintains  that  the  method  is  safe  and  satis- 
factory. He  injects  equal  parts  of  a  French  preparation  of  phenol  and  distilled 
water,  freshly  mixed  and  filtered.  From  7  to  15  min.  are  injected  into  a  pile 
and  only  one  pile  is  injected  at  a  seance.  In  from  live  days  to  one  week 
another  injection  may  be  given.  Before  beginning  a  course  of  injections  the 
sphincter  is  stretched  while  the  patient  is  under  nitrous  oxid  and  oxygen.  It 
is  not  necessary  to  repeat  this  for  future  injections.  During  injection  a  special 
speculum  is  used.  The  pile  protrudes  into  the  speculum,  is  cleansed  with  a  i 
per  cent,  solution  of  creolin,  and  the  injection  is  thrown  into  the  most  promi- 
nent part  of  the  pile.  The  speculum  is  withdrawn  before  pulling  out  the 
needle.  This  maneuver  prevents  escape  of  injection  and  arrests  bleeding.  I 
seldom  employ  the  injection  treatment.  I  never  use  it  if  the  patient  consents 
to  the  clamp  and  cautery  operation  or  to  ligation.  The  clamp  and  cautery  is, 
in  the  great  majority  of  cases,  the  operation  of  choice.  It  requires  but  a  few 
minutes  to  do  it;  after  it  is  done  there  is  little  or  no  postoperative  pain,  in 
very  many  cases  retention  of  urine  does  not  occur,  and  the  patient  usually  is 
about  again  within  ten  days.  The  patient  is  anesthetized  and  the  sphincter 
is  carefully  and  thoroughly  stretched.  The  stretching  of  the  sphincter  is  very 
important.  It  gives  free  access  to  the  parts,  prevents  subsequent  spasm 
and  pain,  and  lessens  the  likelihood  of  venous  bleeding  after  operation.     The 


Internal  Hemorrhoids 


iiSi 


Fig.  7S3.  ^  Extirpa 
tion  of  hemorrhoids  (Es 
march  and  Kowalzig). 


pile  is  caught  by  forceps  and  drawn  outside  of  the  sphincter.  Many  use 
Smith's  clamp.  It  is  applied  with  the  ivory  surface  against  the  mucous  mem- 
brane of  the  bowel.  I  use  the  clamp  de\ised  by  Dr.  J.  Coles  Brick  (Fig.  782). 
From  the  bite  of  Brick's  clamp  the  pile  cannot  sHp,  as  the  blades  come  evenly 
and  firmly  together.  The  pile  is  cut  ofE  and  the  stump  is  seared  with  the 
Paquelin  cautery  at  a  dull-red  heat.  Pile  after  pile  may  be  thus  treated,  care 
being  taken  to  leave  some  mucous  membrane  at  each  side  of  every  pile. 
If  this  precaution  is  not  taken,  healing  will  be  slow  and  stricture  vnR 
result.  After  cauterization  is  complete  a  speculum  is  inserted  and  the 
blades  are  widely  opened.  Any  bleeding-points  are  at  once  ligated.  This 
is  a  most  important  precaution.  Packing  is  never  inserted.  I  formerly 
used  it,  but  have  given  it  up.  It  is  of  no  service  and  produces  severe  pain 
and  edema.  The  treatment  from  this  point  is  identical  with  that  ad\-ised 
below  after  the  use  of  the  Kgature.     Excision  is  preferred  by  Allingham.     He 

stretches  the  sphincter,  holds 

it    open    ■^^■ith    a    retractor, 

catches  up  the  pile,  cuts  it 

off,  and  twists  the  bleeding 

vessels.     Some  prefer  to  pass 

a  silk  or  catgut  suture,  cut 

off  the  timior,  and  tie   the 

thread   (Fig.    783).      White- 
head's operation  (Fig.  784)  is 

only    to    be    performed    in 

severe  cases,  when  the  piles 

are  extremely  large  and  form 

a  protruding  circular  mass. 

Primary  union  is  rarely  se- 
cured. When  first  introduced  the  operation  was 
viewed  vAth.  favor,  but  experience  shows  it  is 
sometimes  followed  by  disastrous  consequences.^ 
Stricture  not  infrequenth'  arises  after  its  per- 
formance; fecal  incontinence  occasionally  results, 
and  anal  anesthesia  with  inability  to  restrain  the 
passage  of  gas  is  common.  After  this  operation 
the  anus  is  permanently  more  or  less  moist.  The 
entire  pile-bearing  area  of  mucous  membrane  is 

dissected  out  and  the  cut  margin  of  mucous  membrane  is  pulled  down  and 
stitched  to  the  surface.  The  sphincter  may  be  dilated  as  a  preliminary 
measiu:e. 

The  application  of  the  ligature  is  an  easy  and  useful  method.  It  is  not  so 
rapid  as  the  canters'-,  is  followed  by  more  pain,  healing  requires  a  longer 
time,  and  stricture  is  more  common.  In  this  operation,  after  anesthetizing, 
stretch  the  sphincter  and  treat  each  hemorrhoid  separately.  Catch  a  pile 
with  a  pair  of  forceps  or  a  volselliun,  pull  it  do-nn,  and  cut  a  gutter  through 
the  skin-margin  if  the  pile  is  of  the  mixed  variety;  tie  the  small  piles  without 
transfixing,  but  transfix  the  large  piles;  tie  with  silk  (coarse  silk  for  the  large 
piles,  finer  silk  for  the  small  piles) ;  cut  off  each  tumor  beyond  the  thread  and 
cut  the  ligatures  short.  Treat  the  other  piles  in  the  same  manner.  Irrigate 
with  hot  normal  salt  solution.  Do  not  insert  packing.  Place  a  2-gr.  opium 
suppository^  in  the  rectmn.  Apply  a  gauze  pad  and  a  T-bandage  over  the 
anus.  The  opium  locks  up  the  bowels.  The  patient  is  kept  on  a  Hght  diet 
for  three  days,  at  the  end  of  which  time  a  saline  may  be  given.  Just  before 
the  bowels  act  remove  the  dressings  and  give  an  enema  of  warm  water  or  of 
1  Andrews,  in  '"Mathew's  Medical  Quarterly."  Oct.,  1S95. 


Fig.  784. — S,  S,  The  lower  circu- 
lar incision  along  Hilton's  white 
Une:  M,  tube  of  mucous  membrane 
dissected  from  the  sphincter;  B,  B, 
dotted  Une  showing  the  place  for 
the  upper  circular  incision  (Ed- 
mund Andrews). 


1 1 82  Diseases  and  Injuries  of  the  Rectum  and  Anus 

glycerin.  After  the  movement  wash  the  parts  first  with  dilute  peroxid  of 
hydrogen  and  next  with  hot  salt  solution,  dust  with  iodoform,  and  apply  a 
gauze  pad  over  the  anus.  Irrigate  daily  until  healing  is  complete.  After 
the  tenth  day  examine  with  a  speculum  to  see  that  the  ligatures  have  come 
away;  if  any  are  found  in  place,  remove  them. 

Prolapse  of  the  Rectum. — If  the  mucous  membrane  is  prolapsed  the 
condition  is  commonly  called  prolapsus  ani;  if  the  entire  thickness  of  the 
rectal  wall  is  prolapsed,  it  is  commonly  called  prolapsus  recti  (Fig.  785). 
The  term  "prolapse  of  the  anus"  is  an  incorrect  and  objectionable  one,  and 
we  should  designate  such  cases  prolapse  of  the  rectal  mucous  membrane,  in- 
complete or  partial  prolapse.  If  all  the  coats  of  the  bowel  descend  the  con- 
dition should  be  called  complete  prolapse  or  procidentia. 

Incomplete  Prolapse  (Partial  Prolapse). — In  this  condition  the  mucous 
membrane  of  the  rectum  protrudes  from  the  anus.     In  normal  conditions  the 


1 


^■-^'i'?!J?Sf5^SS5^'" 


\    I 


■&        :. 


m?^. 


Fig.  785. — Rectal  prolapse. 

membrane  protrudes  during  defecation  and  at  once  retracts  when  the  act  of 
defecation  terminates.  In  the  condition  under  discussion  the  mucous  mem- 
brane remains  protruded  because  the  submucous  tissues  being  stretched  and  re- 
laxed find  it  difl&cult  or  are  unable  to  draw  the  mucous  membrane  in  again.  In 
this  condition  a  ring  of  mucous  membrane  or  only  a  portion  of  its  circtunference 
may  protrude.  It  is  particularly  common  in  early  youth  and  in  old  age.  Pro- 
lapse is  apt  to  occur  from  excessive  straining  at  stool  and  is  commonest  in  feeble, 
ill-nourished  children.  A  polypus  may  be  the  cause.  Piles  and  worms  may  lead 
to  prolapse.  Straining  from  phimosis,  stone  in  the  bladder,  or  urethral  stric- 
ture may  be  causative.  Its  development  is  favored  by  the  use  of  articles  of  food 
which  cause  frequent  movements  of  the  bowels.  If  an  individual  sits  a  long 
time  on  the  seat  of  the  closet  or  on  the  chamber  the  development  of  prolapse 
is  favored.  The  condition  comes  on  gradually  and  is  at  first  painless.  Fdr 
some  time  it  reduces  itself  spontaneously  after  defecation,  but  reduction  be- 
comes more  and  more  dif&cult.     A  common  custom  of  sufferers  is  to  push  it 


Complete  Prolapse  of  the  Rectum  1183 

by  the  fingers  above  the  grasp  of  the  sphincter.  Sometimes,  but  seldom,  it 
becomes  strangulated.  A  recent  prolapse  is  pink,  an  older  one  is  angry  red, 
one  which  is  tightly  caught  is  purple,  a  strangulated  one  is  deep  purple  and  soon 
becomes  black  from  gangrene.  If  the  prolapse  is  of  the  entire  circumference 
it  shows  radial  folds  of  mucous  membrane.  It  frequently  bleeds.  Prolapse, 
be  it  large  or  small,  tends  to  recur  again  and  again,  and  eventually  the  mucous 
membrane  inflames,  ulcerates,  or  sloughs.  Prolapse  of  all  the  coats  may  ensue 
(see  below).  The  condition  is  sometimes  confused  with  hemorrhoids,  but  in 
prolapse  the  protruding  mass  is  circular  and  has  a  depression  in  the  center, 
whereas  hemorrhoids  are  distinct  masses.  Further,  hemorrhoids  are  very 
rare  in  children.  Hemorrhoids  often  exist  with  prolapse  of  the  mucous  mem- 
brane and  frequently  cause  it.  In  prolapse  of  the  mucous  membrane  there 
is  no  sulcus  between  the  sphincter  muscle  and  the  anterior  portion  of  the  pro- 
trusion, in  complete  prolapse  there  is. 

Treatment. — Palliative  treatment  forbids  straining  at  stool  and  amends 
an  improper  diet.  Phimosis  must  be  corrected;  stone  in  the  bladder  must 
be  crushed  or  cut  for  and  removed;  stricture  must  be  dilated;  hemorrhoids  and 
polypi  are  to  be  removed.  Give  an  enema  of  cold  water  just  before  going  to 
stool  in  order  to  hurry  the  emptying  of  the  rectum.  If  prolapse  occurs,  the 
protrusion  must  be  bathed  with  cold  water  and  restored.  Constipation  must 
be  prevented  (enemata  of  water  or  glycerin  may  be  used),  and  after  each  move- 
ment several  ounces  of  an  infusion  of  white  oak  bark  (i  ounce  of  quercus  to 
a  pint  of  water)  should  be  injected.  If  a  prolapse  is  caught  firmly,  paint  it 
with  cocain  and  adrenalin,  place  the  patient  in  the  knee-chest  position,  apply 
hot  compresses,  grease  it  with  cosmolin,  insert  a  finger  into  the  rectum,  and 
apply  taxis  around  the  finger  (Mathews) .  If  this  fails,  cover  a  finger  with  a 
handkerchief  and  insert  the  wrapped  digit  into  the  rectum;  if  this  proves 
futile,  invert  the  patient  before  manipulation.  Do  not  give  a  general  anes- 
thetic imless  it  is  imperatively  necessary;  the  vomiting  so  often  caused  by 
ether  and  chloroform  might  reproduce  the  prolapse.  After  reduction  apply  a 
compress  upon  the  anus,  direct  that  it  be  worn  when  at  stool,  and  before  each 
act  of  defecation  give  an  injection  of  cold  water  containing  an  astringent  (tannin 
or  fluidextract  of  hydrastis).  Most  cases  in  children  can  be  cured  without 
operation.  Some  cases  in  adults  and  obstinate  cases  in  children  may  be  treated 
by  painting  the  prolapse  with  fuming  nitric  acid,  greasing  it  with  olive  oU, 
and  restoring  it.  Some  cases  require  excision  of  the  mucous  membrane,  the 
di\aded  edge  of  this  membrane  being  stitched  to  the  skin.  In  other  cases  the 
protrusion  is  stroked  longitudinally  with  the  actual  cautery  and  restored. 
When  the  surgeon  comes  to  operate  for  recurring  prolapse,  it  will  often  be 
found  to  have  modestly  withdrawn  and  he  may  be  obliged  to  stretch  the 
sphincter  to  bring  it  into  \'iew. 

Complete  Prolapse  (Procidentia). — In  this  condition  all  of  the  rectal  coats 
protrude.  There  are  said  to  be  three  degrees  of  this  condition.  In  the  first 
degree  the  prolapse  begins  at  the  anal  margin  and  its  outer  surface  is  continuous 
with  the  peri-anal  skin,  there  being  no  sulcus  between.  It  is  usually  a  conse- 
quence of  prolapse  of  the  mucous  membrane.  In  the  second  degree  (genuine 
procidentia)  the  prolapse  begins  on  a  level  or  above  the  level  of  the  lower  margin 
of  the  peritoneum  and  projects  out  of  the  anus.  In  the  third  degree  the  pro- 
lapse begins  at  the  origin  of  the  rectum  or  in  the  sigmoid,  and  is,  in  reality,  a 
protruding  intussusception.  Some  cases  come  on  suddenly.  The  prolapse  of 
the  first  degree  has  no  f m-row  between  it  and  the  perianal  skin,  and  the  folds  are 
circular  instead  of  longitudinal.  It  is  usually  treated  as  is  prolapse  of  the 
mucous  membrane.  If  simple  methods  fail,  it  will  be  necessary  to  do  an  opera- 
tion to  lessen  the  size  of  the  anal  orifice.  In  prolapse  of  the  third  degree  the 
treatment  is  as  for  intussusception.     It  is  prolapse  of  the  second  degree  we 


1 1 84  Diseases  and  Injuries  of  the  Rectum  and  Anus 

consider  here.  It  is  more  common  in  adults  than  in  children.  There  are  many 
theories  as  to  its  causation.  Esmarch  regards  it  as  due  to  inflammation  of  the 
rectima,  which  spreads  to  all  the  coats  and  also  to  the  perirectal  structures.  An- 
other theory  (Jeannei's)  is  that  the  small  intestine  is  in  a  state  of  ptosis,  and  by 
falling  into  Douglas's  culdesac  presses  upon  and  causes  atrophy  of  the  levator 
ani  muscle.  The  most  probable  theory  is  that  the  condition  is,  in  reality,  her- 
nia (Waldeyer,  Zuckerkandl,  Moschchowitz) .  Moschchowitz  ("Surg.,  Gynec, 
and  Obstet.,"  July,  191 2)  makes  a  powerful  argument  to  prove  that  the  intes- 
tine in  Douglas's  culdesac  causes  a  bulge  of  the  anterior  rectal  wall,  that  this 
bulging  part  of  the  wall  grows  larger  and  descends,  and  that  finally  the  entire 
circumference  of  the  rectum  is  dragged  down. 

Complete  prolapse  is  usually  preceded  by  chronic  constipation,  great  strain- 
ing being  necessary  to  effect  defecation.  Chronic  rectal  catarrh  is  also  a  com- 
mon antecedent. 

A  mass  sticks  out  of  the  rectum  and  there  is  a  purulent  discharge  which 
often  contains  blood.  The  protruding  mass  (which  is  seldom  over  6  inches  in 
length)  is  covered  externally  with  mucous  membrane  (which  may  be  normal, 
inflamed,  ulcerated,  or  bleeding)  and  is  lined  by  normal  mucous  membrane 
(Moschchowitz,  Ibid.).  The  opening  is  at  the  apex  of  a  canal  directed  back- 
ward. The  anterior  part  of  the  protrusion  is  greatly  larger  than  the  pos- 
terior part,  the  anterior  part  is  usually  tympanitic,  and  the  posterior  part 
dull  on  percussion  (Moschchowitz,  Ibid.).  There  is  a  deep  furrow  between 
the  anterior  portion  of  the  sulcus  and  the  anal  margin.  The  furrow,  as  a  rule, 
is  about  I  inch  deep. 

Early  in  the  case  the  prolapse  is  reduced  spontaneously,  later  it  must  be 
reduced  by  the  hand.  It  may  become  incarcerated  or  strangulated.  The 
protrusion  when  strangulated  becomes  gangrenous. 

Treatment. — In  children  the  condition  may  often  be  cured  by  the  methods 
used  for  prolapse  of  the  mucous  membrane.  If  a  prolapse  is  caught  tightly, 
apply  hot  compresses  to  reduce  swelling,  paint  it  with  cocain  and  adrenalin,  put 
the  patient  in  the  knee-chest  position,  and  reduce  as  described  under  partial  pro- 
lapse. General  anesthesia  is  undesirable  because  of  the  probability  of  vomiting 
with  consequent  straining.  After  reduction  apply  a  support.  Electricity  is 
used  by  some,  injections  of  astringents  under  the  mucous  membrane  by  others. 
Operation  is  necessary  for  prolapse  in  most  adults  and  in  some  children.  As  a 
preliminary,  hemorrhoids,  ulcerations,  etc.,  must  be  cured.  A  multitude  of 
operations  have  been  recommended.  Some  try  to  constrict  the  anal  opening 
(cauterization  by  the  actual  cautery,  nitric  acid  or  chlorid  of  zinc,  removing 
a  wedge-shaped  piece  from  posterior  rectal  wall  followed  by  suturing,  twisting 
the  rectum,  injections  of  parafi&n  about  the  sphincter,  and  various  other  plans). 
Such  operations  are  entirely  inefflcient.  Some  operate  on  the  bowel  higher  up, 
striving  to  increase  support.  Moschchowitz  also  mentions  ''methods  which 
pay  particular  attention  to  the  fLxation  apparatus  of  the  rectum."  One  plan 
is  to  operate  through  an  abdominal  incision,  fixing  the  sigmoid  to  the  abdominal 
wall — an  unphilosophical  operation  "because  the  distal  end  of  the  sigmoid  is 
fixed  to  the  sacrum,  and  pulling  can  have  very  little,  if  any,  effect  upon  the 
prolapse  of  the  rectum"  (Moschchowitz,  Ibid.). 

I  have  abandoned  the  operation  of  stitching  the  sigmoid  to  the  abdominal 
wall  {colopexy)  because  it  is  dangerous  to  thus  anchor  the  gut  and  because,  I 
believe,  it  always  fails  to  cure.  Mikulicz's  operation  of  excision  of  the  pro- 
lapse has  elements  of  decided  danger,  but  may  cure  the  case.  I  apparently 
cured  i  case  this  way,  but  in  another  case  the  condition  reciu^red. 

Moschchowitz's  operation  is  the  most  reasonable  one.  The  abdomen  is 
opened,  the  rectum  is  held  taut,  and  the  culdesac  of  Douglas  is  obliterated  by 
sUk  or  linen  sutures.     The  pelvic  fascia  is  included  in  the  sutures. 


Benign  Tumors  of  the  Rectum  and  Anus  1185 

Ulcers  of  the  rectum  are  dudded  into  the  simple  traumatic,  the  s>'philitic, 
the  tuberculous,  the  dysenteric,  the  gonorrheal,  and  the  malignant.  Simple 
ulceration  is  due  to  abrasion  with  fecal  masses  or  a  foreign  body,  the  abraded 
area  ulcerating.  It  may  follow  an  operation  for  piles  and  also  protracted  labor 
("Diseases  of  the  Rectum,"  by  AUingham),  and  is  apt  to  be  single.  The  base 
and  edges  of  a  simple  ulcer  are  neither  prominent  nor  hard  and  stricture  rarely 
forms.  Syphilitic  ulceration  is  a  tertiary  lesion  commonest  in  women.  There 
are  numerous  small  ulcers  of  the  mucous  coat  or  submucous  tissue,  but  little 
indurated,  with  sharp-cut  edges  which  are  not  undermined.  These  ulcers  fuse 
and  constitute  one  large  irregular  ulcer;  fibrous  tissue  forms  in  the  wall  of  the 
bowel,  induration  becomes  noticeable,  and  stricture  follows.  There  is  profuse 
discharge  and  fistulae  are  apt  to  form.  Such  ulcers  may  be  surroimded  by 
nodules  of  a  bluish  color.  In  many  cases  the  first  condition  is  stricture  due 
to  the  formation  of  masses  of  fibrous  tissue  in  the  rectal  walls,  and  ulceration 
occurs  secondarily.  In  s}'philis  there  may  be  a  breaking  down  of  a  huge  gummy 
mass  or  of  multiple  gummata.  It  has  been  proved  by  the  microscope  that 
tuberculous  ulceration  may  arise  in  the  rectum.  Tuheradoiis  ulceration  pre- 
sents a  conical  ulcer  with  overhanging  edges  and  a  pale-red  base.  There  is 
some  mucous  discharge,  some  tenesmus,  and  a  little  pain.  Tuberculosis  is 
seldom  directly  responsible  for  stricture  (see  page  11 86).  Dysentery,  catarrh, 
diabetes,  Bright's  disease,  neoplasms,  and  foreign  bodies  may  produce  ulcera- 
tion of  the  rectum. 

Symptoms. — There  may  be  merely  uneasiness  about  the  rectum,  but 
sometimes  there  is  severe  burning  pain  on  defecation,  and  perhaps  for  some 
time  after  the  act.  There  may  be  constipation  or  diarrhea,  the  patient  strains 
at  stool,  and  the  stools  may  contain  blood,  mucus,  or  pus.  As  a  rule,  there  is 
diarrhea  on  rising  in  the  morning,  the  first  movement  consisting  of  blood  and 
mucus,  and  the  next  movement  being  fecal.  The  history-  should  be  carefully 
inquired  into;  tuberculosis  should  be  sought  for;  the  question  of  s^-phiHs 
should  be  investigated.  A  digital  examination  enables  the  surgeon  to  feel  the 
ulcer,  and  an  examination  by  means  of  an  ordinary  speculiun  or  an  electric 
proctoscope  brings  it  into  \-iew. 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  administration  of 
a  sahne  cathartic,  wash  out  the  rectum  -v^dth  hot  water  after  the  saline  has 
acted,  introduce  a  speculima,  touch  the  ulcer  T\ith  pure  carboHc  acid  or  silver 
nitrate  (40  gr.  to  i  oz.),  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  (10  per  cent.)  or  insnfflate  iodoform 
into  the  rectum.  If  this  fails,  give  ether,  stretch  the  sphincter,  incise  the  ulcer 
through  its  entire  thickness,  and  cauterize  T\-ith  fuming  nitric  acid,  caring  for 
the  case  subsequently  as  we  would  a  patient  who  had  had  piles  ligated.  In 
tuberculous  ulcer  improve  the  general  health,  send  the  patient  to  a  genial 
climate,  or  at  least  into  the  sunhght  and  fresh  air,  prevent  constipation,  give 
nutritious  food,  especially  fats,  wash  out  the  rectimi  every  day  -^itli  hot  water, 
and  insufflate  iodoform  or  inject  iodoform  emulsion.  Touch  the  ulcer  once  a 
week  with  silver  nitrate  (10  gr.  to  i  oz.).  In  syphilitic  ulcer  give  antis>-philitic 
treatment  and  treat  the  ulcer  locally,  as  is  done  in  tuberculous  ulcer.  Dys- 
enteric ulcer  requires  injections  of  hot  water,  the  touching  of  the  ulcer  with  pure 
carbohc  acid,  insufflations  of  iodoform,  and  special  treatment  of  the  dysenter^^ 

Benign  Tumors  of  the  Rectum  and  Anus. — These  tumors  may  be  of 
the  connective,  epithehal,  or  muscular  tissue  type.  Of  the  first  there  are 
fibroma,  enchondroma,  hTnphadenoma,  lipoma,  and  myxoma;  of  the  second, 
adenoma  and  papilloma;  of  the  third,  myoma  and  fibromyoma.  Many 
benign  tumors  appear  in  pohpoid  form.  A  pohp  is  a  timior  vnXh.  a  pedicle. 
A  pol}^  may  be  a  fibroma,  myxoma,  myoma,  papilloma,  or  adenoma.  Papil- 
loma is  a  rare  growth,  usually  has  a  broad  pedicle,  but  may  have  no  pedicle. 

75 


ii86  Diseases  and  Injuries  of  the  Rectum  and  Anus 

It  does  not  occur  in  childhood.  A  papilloma  bleeds  profusely  and  causes  a 
discharge  of  mucus.  A  polyp  causes  no  pain  unless  ulceration  occurs.  It 
causes  bleeding  and  mucous  discharge.  On  coming  from  stool  the  patient 
feels  as  though  the  rectimi  still  contains  feces.  A  polyp  may  protrude  during 
defecation.  It  can  be  detected  by  digital  examination  and  can  be  readily  seen 
through  a  proctoscope.  There  may  be  one  polyp;  two,  several,  or  many 
polypi.  Polj^i  are  most  common  in  children.  (See  Adler,  in  "Annals  of  Sur- 
gery," Dec,  1909.)  The  most  common  forms  of  tumor  are  the  myxoma, 
hypertrophied  solitary  follicles,  adenoma,  fibroma,  and  Hpoma.  Myxoma  is 
most  common  in  children.  Fibroma  originates  in  the  connective  tissue  or  the 
submucosa  and  is  very  rare.  It  may  arise  at  the  upper  end  of  a  fissure.  It 
has  a  long  pedicle  and  may  become  very  large. 

Symptoms  of  tumor  are  dull,  aching  pain,  tenesmus,  frequent  defecation, 
and  sometimes  ulceration  of  the  mucous  membrane.  In  a  non-polypoid  benign 
tumor  there  is  absence  of  hemorrhages  and  of  mucous  discharges. 

Treatment. — Remove  the  tumor  after  dilating  the  sphincter.  In  tying  or 
snaring  off  polypi  it  should  be  borne  in  mind  that  the  peritoneum  may  be  in- 
vaginated  in  the  pedicle  and,  therefore,  no  traction  on  it  should  be  made  when 
operating.  Sessile  growths  are  dissected  out.  The  postoperative  treatment  is 
practically  the  same  as  for  hemorrhoids. 

Cryptitis  {Inflammation  of  the  Crypts  of  Morgagni). — These  crypts,  five  to 
ten  in  mmiber,  are  situated  in  the  mucous  membrane  of  the  rectum,  about 
3  cm.  from  the  anus.  They  occasionally  become  packed  with  mucus  or  feces. 
There  is  quite  severe  pain  referred  to  the  site,  especially  after  defecation.  In 
this  condition  the  examination  of  the  anus  by  the  finger  is  extremely  painful. 
The  inflamed  crypts  may  be  detected  by  examination  through  the  speculum. 

Treatment. — Divide  the  affected  crypts,  curet  away  any  granulations,  and 
allow  the  parts  to  heal. 

Non=cancerous  stricture  of  the  rectum  may  be  congenital  or  ac- 
quired. There  are  two  forms  of  acquired  stricture:  first,  stricture  due  to  ex- 
ternal pressure;  second,  stricture  due  to  primary  narrowing  of  the  rectal  lu- 
men.^ Stricture  due  to  external  pressure  is  very  rarely  complete,  and  may  be 
caused  by  bands  of  adhesions  or  a  tumor  growth.  The  second  form  may  be 
produced  by  syphilitic  tissue,  ordinary  inflammatory  tissue,  cicatrices  after 
operations,  sloughing,  tuberculous,  syphilitic  or  dysenteric  ulceration,  rectal 
gonorrhea,  and  traumatism.  The  usual  seat  of  simple  stricture  is  from 
I  inch  to  i|  inches  above  the  anus.  The  deposit  may  be  limited  to  the  sub- 
mucous coat  or  all  the  coats  may  be  involved.  It  is  very  seldom  that  stricture 
arises  as  a  result  of  abrasion  from  fecal  masses  or  foreign  bodies.  It  may 
follow  an  operation  for  piles  if  considerable  tissue  is  removed,  and  is  an  occa- 
sional sequence  of  Whitehead's  operation.  Stricture  due  to  dysentery  is  ex- 
tremely rare,  and  no  case  has  ever  been  reported  to  the  United  States  Pension 
OfiQce  (Peterson).  The  existence  of  stricture  as  a  result  of  rectal  gonorrhea 
has  not  been  positively  proved.  A  majority  of  sufferers  from  rectal  stricture 
have  labored  under  syphilis,  but  it  is  not  probable  that  the  lesion  is  syphilitic 
in  all  or  even  in  most  of  them.  The  stricture  may  be  due  to  the  formation  of 
fibrous  tissue  and  iilceration  may  or  may  not  occur.  It  may  be  caused  by  the 
contraction  and  healing  of  a  large  ulcer.  Some  maintain  that  tuberculous 
stricture  does  occur.  Mathews  dissents  from  this  view  and  points  out  that  the 
disposition  of  tuberculous  matter  is  to  break  down,  and  before  the  rectum  can 
be  strictured  from  tuberculosis  it  breaks  down  from  ulceration.  Peterson^ 
says  a  large  proportion  of  the  victims  of  rectal  stricture  die  of  phthisis,  and  that 
one-third  of  so-called  syphilitic  cases  are  tuberculous.  It  may  begin  as  an  ulcer 
or  as  an  infiltration  of  submucous  tissue.    Although  a  syphilitic  or  a  tuberculous 

1  Reuben  Peterson,  in  "Jour.  Am.  Med.  Assoc,"  Feb.  3,  1900.  ^  Ibid. 


Symptoms  of  Cancer  of  the  Rectum  11S7 

lesion  may  cause  rectal  stricture,  in  most  cases  such  lesions  simply  expose  the 
tissues  to  infection,  and  benign  rectal  stenosis  results  from  the  infection. 
Tuberculosis  may  cause  stricture,  but  does  so  indirectly  rather  than  directly. 

The  symptoms  of  rectal  stricture  are  constipation,  pain  on  defecation,  strain- 
ing at  stool,  perhaps  the  presence  of  blood  and  mucus  in  the  stools,  an  open 
anus,  and  the  passage  of  stools  flattened  out  into  ribbons  if  the  stricture  is  low 
down.  In  some  cases  there  is  fluid  diarrhea,  solid  fecal  matter  being  retained 
above  the  stricture.  The  stricture  is  found  by  the  finger  or  by  the  soft-rubber 
bougie,  used  with  the  utmost  gentleness  and  care.  A  stiff  instrument  or  the 
rough  use  of  any  instrument  would  be  dangerous  and  might  rupture  the  rectum. 
In  s}-philitic  cases,  in  tuberculous  cases,  and  in  benign  cases  the  fibrous  thick- 
ening is  usually  in  the  submucous  coat,  and  in  SA^philitic  and  tuberculous  cases 
the  mucous  membrane  is  apt  to  ulcerate.  It  is  said  that  complete  obstruction 
may  arise.  I  have  seen  obstructive  symptoms,  but  never  complete  obstruction 
in  rectal  stricture.     Distention  of  the  abdomen  and  colic  are  ver>"  usual. 

The  treatment  of  non-cancerous  and  primary  narrowing  of  the  rectal  canal 
is  rest,  non-stimulating  diet,  warm-water  injections,  mild  laxatives,  and  hot 
hip-baths.  Cocain  suppositories  may  be  needed.  Any  existing  disease  is 
treated.  Bougies  are  passed  every  other  day.  Use  a  soft-rubber  bougie, 
warmed  and  oiled,  and  introduce  it  gently.  If  only  the  method  of  gradual 
dilatation  is  employed  the  patient  must  for  the  remainder  of  his  life  pass  a 
bougie  from  time  to  time.  For  fibrous  strictures  forcible  dilatation  {divulsion) 
by  a  special  instrument  is  employed  or  incision  is  practised.  Incision  {proc- 
totomy) may  be  either  external  or  internal.  In  internal  proctotomy  one  or 
more  incisions  are  made  from  the  rectum  through  the  stricture  down  to  healthy 
tissue,  the  first  cut  being  in  the  middle  line  posteriorly.  External  proctotomy, 
which  di\'ides  the  sphincters,  is  apt  to  leave  incontinence  as  a  legacy.  Electro- 
lysis finds  some  advocates,  but  on  what  grounds  it  is  difficult  to  see.  In  some 
cases  the  rectiim  should  be  removed.  In  incurable  cases  perform .  inguinal 
colostomy. 

Cancer  of  the  rectum  is  the  cancer  of  the  bowel  most  often  met  with. 
According  to  Abbe  ("Keen's  Surgerv^")  rectal  carcinomata  constitute  three- 
fourths  of  aU  intestinal  tumors.  Its  growth  may  be  primarily  malignant  or 
may  arise  from  an  adenoma.  The  commonest  growths  are  composed  of  cylin- 
drical cells,  and  may  be  either  soft  or  scirrhous.  In  cases  secondary  to  epithe- 
lioma of  the  anus  ordinar\-  epithelioma  arises. 

In  most  rectal  carcinomata  the  cells  present  a  tubular  arrangement  sur- 
rounded by  a  more  or  less  plentiful  stroma  of  connective  tissue.  In  soft 
tumors  the  connective  tissue  is  scanty;  in  hard  tumors  it  is  plentiful. 

Cancer  is  most  common  after  the  age  of  forty,  but  it  not  imusually  occurs 
before  the  thirty-fifth  year,  and  is  sometimes  seen  as  early  as  the  twenty-fourth 
year  or  even  earlier.  "Of  115  cases  of  cancer  of  the  rectmn  at  the  Rostock 
Clinic,  4  occurred  in  patients  between  fourteen  and  seventeen  years  of  age" 
(Miles  Porter,  in  "New  York  Med.  Jour.,"  Feb.  10,  1912).  Extensive  ulcera- 
tion occurs.  If  a  hard  ring  encircles  the  rectum  the  lumen  of  the  tube  is 
greatly  and  progressively  diminished.  In  cases  of  diffuse  infiltration  the  lumen 
is  not  greatly  lessened.  In  growths  involving  the  anus  the  inguinal  glands  are 
involved  and  also  the  glands  in  the  hollow  of  the  sacrum.  In  growths  limited 
to  the  rectum  proper  the  glands  back  of  the  peritoneum  in  the  sacral  hollow  are 
involved,  and  the  inguinal  glands  are  involved  late  or  not  at  all. 

Symptoms. — In  the  beginning  and  for  a  considerable  time  after  there  are 
no  s\Tnptoms.  There  may  be  none  for  a  year  or  more.  S\Tnptoms  begin  with 
iflceration  or  constriction.  The  s\Tnptoms  of  rectal  cancer  are  like  those  of  non- 
malignant  stricture,  except  that  the  pain  is  usually  greater  and  the  hemorrhage 
more  severe.     Constipation  is  apt  to  alternate  with  diarrhea.     The  diarrhea 


ii88  Diseases  and  Injuries  of  the  Rectum  and  Anus 

is  usually  in  the  morning.  Unfortunately,  in  many  cases  symptoms  are  long 
trivial;  in  fact,  pain  may  be  absent  until  the  disease  is  far  advanced.  Muco- 
purulent or  bloody  stools  are  often  thought  to  result  from  dysentery  or  hemor- 
rhoids, which  latter  condition,  however,  may  be  only  an  accompanying  con- 
dition of  rectal  cancer.  The  above  symptoms  may,  on  the  patient's  say-so, 
have  been  accepted  by  the  physician,  without  any  local  examination,  as  caused 
by  hemorrhoids.  The  patient,  again,  may  have  only  imagined  the  presence  of 
hemorrhoids,  since,  according  to  his  notion,  the  above  symptoms  must  result 
from  hemorrhoids,  with  which  condition  so  many  of  his  friends  with  like  com- 
plaints are  afflicted.  Loss  of  strength,  emaciation,  and  cachexia  are  generally 
noticeable  only  in  the  late  stages  of  rectal  cancer.  Only  in  the  very  latest  stages 
the  characteristic  odor  is  perceptible,  the  patient  becomes  septic,  and  abscesses 
attended  by  gangrene  may  form  (Ernest  Jonas,  in  "Interstate  Med.  Jour.," 
No.  4,  1906).  The  finger  and  the  speculum  make  the  diagnosis.  In  rectal 
cancer  metastasis  occurs  late.  The  most  favorable  cases  for  operation  are  those 
in  which  the  growth  is  small  and  movable.  Accurately  define  the  extent  of 
the  growth,  and  endeavor  to  make  out  if  it  has  invaded  the  cellular  tissue 
outside  of  the  rectum,  the  prostate,  the  bladder,  the  sacrum,  the  uterus,  etc. 

Treatment. — In  every  case  of  cancer  of  the  rectum  the  following  questions 
must  be  considered:  Shall  we  perform  a  radical  operation  in  hope  of  producing 
cure  or  at  least  greatly  prolonging  life?  In  what  cases  should  a  radical 
operation  be  attempted?  It  is  the  proper  procedure  if  there  are  no  metas- 
tatic deposits,  if  the  patient  is  in  fair  general  condition  and  free  from  serious 
organic  disease,  and  if  the  cancerous  bowel  is  movable  and  not  fixed  by  dis- 
semination to  adjacent  structures.  As  W.  Watson  Cheyne  ("Brit.  Med. 
Jour.,"  June  13,  1903)  says,  a  slight  adhesion  to  the  vagina  is  not  a  contra- 
indication, because  this  portion  of  the  vagina  can  be  readily  removed  with  the 
diseased  rectum.  Some  surgeons  will  not  attempt  radical  operation  if  they 
cannot  pass  a  finger  through  the  growth.  I  do  not  regard  high  position  as 
forbidding  operation,  although,  of  course,  it  makes  it  more  dangerous  to  life 
and  less  promising  as  to  cure.  Cheyne  is  of  the  same  opinion.  When  the 
surgeon  is  first  called  to  a  case  of  cancer  of  the  rectum  it  is  usually  found  to 
be  so  far  advanced  as  to  be  inoperable.  In  at  least  75  per  cent,  of  my  cases 
radical  extirpation  was  impossible  when  I  first  saw  the  case. 

If  a  radical  operation  is  determined  on,  the  next  question  to  answer  is, 
Shall  we,  or  shall  we  not,  perform  preliminary  colostomy?  If  the  cancer  is  very 
low  down,  involves  the  anal  canal,  and  is  to  be  removed  from  the  perineum, 
preliminary  colostomy  is  rejected  by  many.  I  believe  that  even  in  such  cases 
it  should  be  done.  If  the  cancer  is  high  up  and  we  propose  to  attack  it  by 
Weir's  method  or  the  Quenu-Mayo  method,  preliminary  colostomy  should 
not  be  done.  If  Kraske's  operation  is  to  be  performed,  I  believe  prelimi- 
nary colostomy  is  usually  indicated.  It  enables  us  to  cleanse  the  area  upon 
which  operation  is  to  be  performed,  and  to  keep  the  wound  clean,  and  gives 
us  a  much  better  chance  of  obtaining  primary  union.  In  cases  in  which  the 
sphincter  is  retained  and  it  is  possible  to  anastomose  the  divided  ends  of  the 
rectiun  together,  colostomy  is  not  necessary;  and  if  an  artificial  anus  has  been 
made  in  such  a  case,  another  operation  will  be  required  to  close  it.  As  a  matter 
of  fact,  I  have  found  it  always  diificiilt  and  usually  impossible  to  suture  the 
divided  ends  of  the  gut  together  after  Kraske's  operation,  and  I  now  foUow 
the  advice  of  Keen,  and  always  precede  Kraske's  operation  by  colostoiny. 
The  abdominal  incision  necessary  to  reach  the  bowel  to  do  colostomy  may 
be  used  to  permit  of  exploration,  but  it  is  wiser  to  have  a  median  incision 
for  this  purpose.  I  consider  exploration  as  of  the  first  importance.  It  en- 
ables the  surgeon  to  examine  the  outer  surface  of  the  rectum,  to  detect  gland- 
ular involvement,  to  find  out  if  there  has  been  metastasis  to  the  liver,  and  to 


Treatment  of  Cancer  of  the  Rectum 


1189 


determine  Tvnth  certainty  whether  or  not  the  cancer  is  operable.  Several  times 
in  cases  of  small  and  apparently  operable  cancer  of  the  rectum  I  have  found 
on  opening  the  abdomen  extensive  glandular  involvement  or  unsuspected 
metastasis  to  the  liver,  and  once  I  found  another  cancer  4  inches  above  the  one 
to  which  attention  had  been  directed.  It  is  my  custom  to  make  a  median 
incision  for  exploration  and  then  a  small  incision  through  which  to  bring  out 
the  gut  for  colostomy.  A  large  abdominal  incision  for  colostomy  is  objection- 
able. I  strongly  object  to  operating  at  all  on  rectal  cancer  without  a  prelim- 
inary exploratory  operation.  If  radical  operation  is  rejected  (and  about  three- 
foiurths  of  the  cases,  when  first  seen  by  the  surgeon,  are  obviously  beyond  such 
aid),  palliative  treatment  is  desirable.  The  best  palliative  treatment  is  the 
operation  of  inguinal  colostomy.  If  this  is  refused,  what  shall  be  done?  One 
plan  is  to  introduce  a  tube  through  the  stricture  daily,  wash  out  the  rectum 
with  warm  water,  and  after  washing  inject  emulsion  of  iodoform  (10  gr.  to  i  oz. 
of  sweet  oil).  Injections  of  chlorid  of  zinc  (i  gr.  to  i  oz.  of  water)  lessen  the 
foulness  of  the  discharge.  The  bowels  are  opened  regularly  by  laxatives,  and 
if  the  growth  causes  obstructive  symptoms  it  is  scraped  away  with  a  sharp 
spoon.  Opium  is  given  to  relieve  pain.  The  advantage  of  this  plan  is  that  the 
patient  does  not  suffer  from  the  unpleasantness  of  an  artificial  anus.  Sooner 
or  later,  however,  the  growth  gets  outside  of  the  bowel,  and  terrible  pain  will 
arise  from  involvement  of  the  sacral  plexus.  W.  Watson  Cheyne  ("Brit.  Med. 
Jour.,"  June  13,  1903)  would  restrict  palliative  treatment  of  this  character  to 
cases  in  which  fungating  masses  grow  from  one  side  of  the  bowel. 

If  a  growth  encircles  the 
bowel  and  produces  symp- 
toms of  obstruction,  pallia- 
tive colostomy  should  be 
performed.  This  operation 
gives  great  comfort  to  the 
patient  and  allays  pain  by 
intercepting  the  feces  be- 
fore they  reach  the  cancer. 
I  am  not  convinced  that 
it  distinctly  retards  the 
growth  of  the  cancer  or 
notably  prolongs  life.  Un- 
fortunately, colostomy  does 
not  do  away  with  pain  if  the 
sacral  plexus  is  involved. 
I  have  had  no  experience 
with  radium  in  inoperable 
cancer  of  the  rectum  and 
have  never  seen  the  .r-rays 

produce  any  marked  or  lasting  improvement.  Operative  treatment  includes  one 
of  several  procedures.  Excision  of  the  rectum  from  below  (Cripps's  operation) 
is  practised  by  some  if  not  more  than  3  inches  require  removal,  if  the  peritoneum 
is  not  invaded,  and  if  the  adjacent  organs  are  free  from  disease.  The  peri- 
toneimi  must  not  be  opened  in  Cripps's  operation.  After  the  growth  is  re- 
moved the  divided  rectum  is  pulled  down  and  sutured  to  the  skin.  As  the 
sphincter  is  sacrificed  the  condition  would  be  dreadful  without  an  artificial 
anus.  A  perineal  anus  without  a  sphincter  is  vastly  more  distressing  than  an 
ingmnal  anus.  I  seldom  do  perineal  excision  (it  does  not  permit  any  consider- 
able removal  of  lymph-glands).  When  of  recent  years  I  have  done  it  I  have 
preceded  it  by  exploratory  laparotomy  and  the  formation  of  an  ingmnal  anus. 
In  some  cases  in  women  it  may  be  possible  to  remove  a  low  growth  without 


Fig.  7S6. — ^Different  levels  of  resection  of  the  sacrxim: 
K-0,  Kodier's  line:  B-0,  Kraske's;  B-H,  Hochenegg's;  B-D, 
Bardenheuer's;  R-S,  Rose's  (Mass.). 


1 190 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


damage  to  the  sphincter  through  an  incision  in  the  posterior  vaginal  wall. 
Excision  of  the  rectum  after  excising  the  coccyx  and  a  portion  of  the  sacrum 
( Kraske's  operation,  that  is,  excision  of  the  rectum  after  sacral  resection,  Fig. 
786,  B-0)  is  a  procedure  which  permits  removal  of  the  entire  tube,  portions  of 
the  colon,  and  even  of  adjacent  parts.  The  peritoneum  is  opened  deliberately 
in  this  operation,  and  is  subsequently  closed  with  sutures  before  the  gut  is 
opened.  The  glands  from  the  mesocolon  are  always  removed.  The  lower  end 
of  the  upper  segment  of  bowel  is  fastened  in  the  wound,  or,  if  colostomy  has 
been  previously  performed,  may  be  closed.  In  some  few  cases  in  which  it  is 
not  necessary  to  remove  the  lower  end  of  the  rectum,  the  two  portions  may 
be  anastomosed  after  resection  of  a  part  of  the  tube.  Kraske's  operation  may 
be  done  by  an  osteoplastic  method,  the  bone  not  being  removed.  It  is  well  to 
precede  a  Kraske  operation  two  weeks  by  an  inguinal  colostomy,  which  per- 
mits of  cleansing  the  lower  bowel  of  feces  and  lessens  the  chance  of  severe 
wound  infection  and  delayed  healing  after  the  removal  of  the  rectum:  Pre- 
liminary colostomy  may  make  the  operation  of  extirpation  more  difficult  by 
fixing  the  intestine,  and  thus  interfering  with  the  necessary  drawing  down  of 
the  gut  (E.  H.  Taylor).  If  the  growth  is  extensive  and  the  mesocolon  short,  it 
may  be  best  to  perform  right  inguinal  colostomy,  but  in  most  cases  left  ingmnal 
colostomy  is  preferred  (Gerster).  The  colostomy  remains  open  during  the  pa- 
tient's life,  except  in  those  rare  cases  of  Kraske's  operation  in  which  the  con- 


Fig.  787. — Tying  off  the  tumor  through  an 
abdominal  incision  after  separating  peritoneum 
from  sacrum  and  bladder  (Weir). 


Fig.  788. — Lower  end  of  rectum  everted 
through  the  anus  and  the  upper  end  of  bowel 
drawn  out  of  the  abdominal  cavity  (Weir). 


tinuity  of  the  rectum  can  be  reestablished  after  excision  of  the  growth.  In  such 
cases  the  artificial  anus  may  be  closed  some  time  after  resection  of  the  rectum. 
Robt.  F.  Weir  ("Med.  News,"  July  27,  1901)  has  been  so  much  impressed 
with  the  difficulties  and  dangers  of  Kraske's  operation  in  a  case  of  high  car- 
cinoma that  he  now  employs  it  solely  in  cases  in  which  there  is  freedom  from 
disease  for  2  inches  immediately  above  the  anus  and  in  which  the  cancer 
does  not  extend  more  than  5  inches  above  the  anus.  In  high  cases  he  does 
the  following  operation:  Open  the  abdomen  above  the  pubes,  separate  the  peri- 
toneum so  that  the  bowel  and  "contents  of  the  sacral  curve"  are  liberated 
behind  nearly  "to  the  tip  of  the  coccyx  and  in  front  of  the  edge  of  the  pros- 
tate." The  tumor  is  then  tied  off  with  tapes  (Fig.  787).  The  portion  of  the 
rectimi  bearing  the  tumor  is  removed,  the  lower  end  of  the  bowel  is  everted 
through  the  anus,  and  the  upper  end  is  drawn  out  of  the  abdominal  incision 
(Fig.  788).  The  upper  end  is  then  caught  with  forceps  and  drawn  through  the 
everted  lower  end  of  the  rectum  (Fig.  789,  a).  The  ends  of  the  two  everted 
portions  (Fig.  789,  b)  are  sewn  together,  the  everted  bowel  is  replaced,  the 
divided  peritoneum  is  sutured  to  shut  off  the  peritoneal  cavity,  and  posterior 
drainage  is  inserted  (Fig.  790).      In  the  Quenu-Mayo  operation  the  object  is 


Anesthesia 


1191 


to  remove  all  of  the  diseased  glands  as  well  as  the  cancer  (Wm.  J.  Mayo,  in 
"St.  Paul  Med.  Jour.,"  April,  1906).  The  patient  is  placed  in  an  exaggerated 
Trendelenburg  position  and  the  belly  is  opened  by  a  median  incision.  The 
growth  is  studied  to  see  if  it  is  removable,  and  a  search  is  made  for  enlarged 
glands  which  might  cause  us,  and  for  secondary  growths  which  would  cause  us, 
to  abandon  the  operation.  If  we  conclude  to  attack  the  growth,  pack  away  all 
the  intestine  except  the  sigmoid,  catch  two  clamps  across  the  sigmoid,  one  of 
them  being  on  the  level  of  the  sacral  promontory.  Divide  the  gut  between  them. 
Free  the  mesosigmoid  by  lateral  cuts  and  bring  the  proximal  stump  out  of  the 
belly,  ligate  it,  and  apply  a  purse-string  suture  to  invert  it.  A  gridiron  incision 
is  then  made  on  the  left  side  and  the  proximal  stump  is  pulled  through  it  and  is 
sutured  there.  Incisions  are  now  made  in  the  sides  and  in  front  to  liberate  the 
rectum,  the  mferior  mesenteric  artery  is  tied  above  and  to  the  left  of  the  promon- 
tory, the  fat  and  glands  are  thoroughly  removed  from  the  sacral  hollow, 
vessels  being  tied  as  cut,  except  the  middle  sacral  and  middle  hemorrhoidal 
vessels,  which  are  tied  before  di\asion.  The  area  is  now  packed  with  gauze 
and  the  patient  is  put  in  the  lithotomy  position.  The  rectimi  is  packed 
with  gauze,  the  anus  is  sutured,  and  the  rectum  is  separated  from  the  prostate 
and  urethra  or  from  the  vagina  from  below  upward  to  just  above  the  levator 


a--  h 

Fig.  78g. — a,  The  upper  bowel  drawn  out 
through  the  everted  lower  end  of  rectum;  h, 
the  ends  of  the  two  portions  of  the  rectum  sewn 
together  (Weir). 


Fig.  7go. — The  united  bowel  replaced  with 
posterior  drainage  and  the  divided  peritoneum 
so  sewn  together  as  to  shut  oS  the  general 
peritoneal  cavity  from  the  pelvis  (Weir). 


ani  muscle.  An  assistant  presses  the  cancer-bearing  fragment  carrying  glands 
doTvm  from  the  abdomen  and  the  surgeon  removes  it  from  the  perineum.  The 
peritoneimi  is  sutured  within  the  abdomen,  room  being  left  for  a  small  drain 
which  protrudes  from  the  perineum.  The  perineal  wound  is  narrowed  by 
sutures  and  the  wound  in  the  belly  is  closed.  In  twenty-four  hours  the  pro- 
truding end  of  the  sigmoid  is  opened  and  an  artificial  anus  is  thus  made. 

(See  Joseph  A.  Blake's  views  as  to  "The  Operation  of  Choice  in  Carcinoma 
of  the  Rectum,"  "New  York  Med.  Jour.,"  Jtily  i,  1911.) 

The  mortaHty  of  Kraske's  operation  is  from  12  to  15  per  cent.  Twenty- 
eight  per  cent,  of  Kocher's  cases  of  extirpation  of  cancer  of  the  rectum  remain 
well  from  three  to  sixteen  years  after  operation  (W.  W.  Cheyne,  "Brit.  Med. 
Jour.,"  June  13,  1903). 


XXX.  ANESTHESIA   AND   ANESTHETICS 

Anesthesia  is  a  condition  of  insensibihty  or  loss  of  feeling  artificially 
produced.  An  anesthetic  is  an  agent  which  produces  insensibility  or  loss 
of  feehng.  Anesthetics  are  divided  into — (i)  general  anesthetics,  as  amylene, 
chloroform,  chlorid  of  ethyl,  ether,  bromid  of  ethyl,  nitrous  oxid,  and  bichlorid 


1 192  Anesthesia  and  Anesthetics 

of  methylene;  (2)  local  anesthetics,  as  alcohol,  bisulphicl  of  carbon,  carbolic 
acid,  ether  spray,  cocain,  eucain,  stovain,  ice  and  salt,  rhigolene  spray,  and 
ethyl  chlorid  spray. 

Anesthesia  may  be  induced  by  a  general  anesthetic  to  abolish  the  usual 
pain  of  labor  and  of  surgical  procedures;  to  produce  muscular  relaxation 
in  tetanus,  herniae,  dislocations,  and  fractures;  and  to  aid  in  diagnosticating 
abdominal  timiors,  joint -diseases,  fractures,  and  malingering. 

Ether  was  first  used  as  a  surgical  anesthetic  by  Cra^v'ford  W.  Long,  of 
Georgia,  in  1842,  but  he  did  not  publish  his  cases  until  after  William  T.  G. 
Morton,  of  Hartford,  had  given  ether  in  public  in  1846.  Horace  Wells  gave 
nitrous  oxid  in  1S44.     Sir  James  Y.  Simpson  introduced  chloroform  in  1847. 

Death=rate  from  Anesthetic  Agents. — Sir  Frederic  W.  Hewitt  ("Anes- 
thetics and  Their  Administration")  combines  the  statistics  of  JuUiard  and 
Ormsb}^,  with  the  following  result: 


Anesthetic. 

ToTAi.  Number  or 
Administeations. 

TOTAl  XUMBER  OF 

Deaths. 

Death-rate. 

Chloroform 

Ether 

676,767 
407,553 

214 
25 

I  in    3,162 
I  in  16,302 

Hewitt  regards  the  St.  Bartholomew  Hospital  records  as  furnishing  the 
most  reliable  statistics  accessible.  He  takes  them  from  187 5-1 900.  The 
fatahty  from  chloroform  was  i  in  1300;  from  ether  (andgas  and  ether),  i  in  9319. 
It  is  to  be  noted  that  statistics  coA^ering  many  coimtries  would  indicate  that 
chloroform  becomes  relatively  safer  in  warm  regions.  In  temperate  regions 
it  is  relatively  safer  (compared  with  ether)  in  summer  than  in  "winter.  Hewitt 
is  of  the  opinion  that  ether  is  six  times  as  safe  as  chloroform.  Gwathmey 
("Jour.  Am.  Med.  Assoc,"  Nov.  23,  191 2)  collects  statistics  from  American 
sources.  In  157,453  administrations  of  ether  there  were  28  deaths  (about  i 
death  in  5623  administrations).  In  16,390  administrations  of  chloroform  there 
were  8  deaths  (about  i  death  in  2049  administrations). 

Hemtt  finds  that  during  the  last  forty  years  only  30  fatalities  are  recorded 
as  produced  by  nitrous  oxid,  and  he  thinks  several  of  these  should  be  excluded. 
It  is  practically  certain,  however,  that  many  deaths,  or  at  least  some  deaths, 
have  not  been  recorded. 

Seitz  collected  16,000  instances  of  anesthesia  by  chlorid  of  ethyl,  "n-ith  i 
death.  During  a  hospital  experience  of  twenty-eight  years  I  have  seen  anes- 
thetics (particularly  ether)  giA'en  many  thousand  times.  For  five  years  I  gave 
ether  and  chloroform  for  Prof.  Keen.  I  have  mtnessed  3  deaths,  each  of  which 
at  the  time  was  thought  to  be  directly  due  to  the  anesthetic,  and  i  of  them 
was  so  caused.  One  death  resulted  from  pouring  a  quantity  of  chloroform 
upon  an  AUis  inhaler,  the  bandage  of  which  was  saturated  with  ether.  At 
the  time  the  chloroform  was  poiired  in  the  inhaler  the  patient  had  just  been 
struggling  and  consequently  was  breathing  deeply.  One  death  resulted  from 
gi\ing  ether  on  a  thick  cone  made  of  several  towels  A\ith  paper  between  the 
folds.  The  towels  were  saturated  with  ether,  the  patient  got  no  air  at  all,  and 
was  asphyxiated,  as  she  might  have  been  had  the  cone  only  been  wet  udth 
water.  The  third  case  was  a  man  who  had  an  impacted  hip  fracture.  He  be- 
came cyanotic  under  ether  while  the  impaction  was  being  pulled  apart  and 
died.  The  death  was  supposed  to  be  due  to  ether,  but  necropsy  discovered 
fat  emboU  in  the  brain  and  lungs. 

Preparation  of  the  Patient. — Whenever  possible  prepare  a  patient 
before  administering  a  general  anesthetic,  and  prepare  him,  if  the  case  admits 
of  it,  during  two  or  more  days.     Heart  disease  is  not  a  positive  contra-indica- 


Preparation  of  the  Patient  1193 

tion  to  surgical  anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
to  people  with  fatty  hearts,  but  shock  is  also  dangerous,  and  the  surgeon 
stands  between  the  Scylla  of  anesthesia  and  the  Charybdis  of  shock.  Gallant 
truly  says  that  not  enough  attention  is  paid  to  the  "character  of  the  pulse 
and  action  of  the  heart  before  operation,  by  which  to  compare  its  work  during 
anesthesia,  and  after  the  operation  is  over,  and  this  neglect  leads  to  unneces- 
•sary  stimulation  and  overdriving  a  heart  which  is  doing  its  average  best."^ 
Always  examine  the  urine  if  the  nature  of  the  case  allows  time.  If  albumin 
is  found,  operation  is  not  contra-indicated,  but  the  peril  of  anesthesia  is  greater, 
and  certain  dangers  are  to  be  watched  for  and  guarded  against.  If  much 
albumin  is  present,  postpone  operation  except  in  emergency  cases.  If  sugar 
is  found,  the  danger  is  considerable,  as  diabetic  coma  occasionally  develops. 
The  percentage  of  sugar  does  not  determine  the  amount  of  danger.  Coma 
may  arise  w^hen  only  a  little  sugar  is  present,  and  may  not  arise  when  there 
is  a  considerable  amount.  The  presence  of  aceto-acetic  acid  is  more  ominous 
than  is  the  presence  of  sugar.  Empty  the  intestinal  canal  by  purgation  a 
mmiber  of  hours  before  anesthetization.  It  is  well  to  give  the  bowel  six  to 
twelve  hours'  rest  before  operation.  The  usual  custom  is  to  give  a  saline 
cathartic  the  evening  before  operation  and  an  enema  early  on  the  morning  of 
the  operation.  Frequently  the  nature  of  the  case  or  the  necessity  for  haste 
does  not  permit  of  preliminary  emptying  of  the  intestine  by  the  administration 
of  cathartics.  During  the  twenty-four  hours  preceding  operation  food  should 
be  taken  in  small  amounts  and  in  forms  easily  digestible.  During  the  day 
or  so  before  operation  there  is  usually  impaired  digestion,  and  no  undue  strain 
should  be  put  upon  the  stomach.  In  the  morning  allow  no  breakfast  if  the 
operation  is  to  be  performed  at  an  early  hour,  but  if  the  patient  is  very  weak, 
order  a  little  brandy  and  beef -tea.  If  the  operation  is  to  be  about  noon,  give 
a  breakfast  of  beef-tea  and  toast  or  a  little  consomme;  never  give  any  food 
within  three  hours  of  the  operation,  but  brandy  is  admissible  if  stimulation  is 
required.  If  the  stomach  is  not  empty  at  the  time  of  operation,  vomiting  is  al- 
most inevitable,  and  portions  of  food  may  enter  the  windpipe;  if  the  stomach 
contains  no  food,  vomiting  is  far  less  likely  to  happen;  and  even  if  it  occurs  and 
vomited  matter  should  enter  the  windpipe,  it  may  do  little  harm,  as  it  consists 
chiefly  of  liquid  mucus.  In  cases  of  intestinal  obstruction  in  which  there  has 
been  stercoraceous  vomiting  there  is  much  danger  that  vomiting  will  occur  dur- 
ing anesthetization.  In  some  cases  of  intestinal  obstruction,  during  the  admin- 
istration of  the  anesthetic  and  during  the  anesthetic  state,  a  stream  of  stinking 
brown  fluid  may  flow  without  effort  from  the  mouth.  Vomiting  or  regurgi- 
tation of  stercoraceous  material  is  profuse,  sudden,  and  dangerous.  It  may 
flood  the  bronchial  tubes  during  inspiration  and  cause  death  by  suffocation. 
In  a  case  in  which  stercoraceous  vomiting  has  occurred  wash  out  the  stomach 
before  administering  the  anesthetic.  If  a  patient  with  intestinal  obstruction 
is  too  weak  to  permit  lavage,  a  local  anesthetic  should  be  used  instead  of 
a  general  anesthetic.  Vomiting  while  the  patient  is  under  the  influence  of 
an  anesthetic  is  dangerous  in  any  case,  because  of  the  great  cardiac  weakness 
which  precedes  and  follows  it.  If  a  patient  sleeps  well  the  night  before  an 
operation,  he  will  probably  take  the  anesthetic  better  than  if  he  sleeps  poorly. 
Effort  should  be  made  to  obtain  a  night's  sleep.  An  excellent  expedient  is 
a  hot  ammonia  bath,  followed  by  a  rub-down  with  weak  alcohol."  It  may  be 
necessary  to  administer  trional  or  bromid.  About  fifteen  minutes  before 
giving  the  anesthetic  let  the  patient  drink  a  glass  of  hot  water.  Water 
protects  the  stomach  from  the  irritant  effects  of  any  anesthetic  which  may 
be  swallowed.  Before  giving  the  anesthetic  see  that  artificial  teeth  are  re- 
moved and  that  the  patient  does  not  have  a  piece  of  candy  or  a  chew  of  tobacco 
1  "Medical  Record,"  Feb.  2,  1899.  ^  a.  Ernest  Gallant,  "Med.  Record,"  Dec.  30,  1899. 


1 1 94  Anesthesia  and  Anesthetics 

in  the  mouth.  Always  have  a  third  party  present  as  a  witness,  because 
in  an  anesthetic  sleep  vivid  dreams  often  occur,  and  erotic  dreams  in  women 
may  lead  to  damaging  accusations  against  the  surgeon.  Place  the  patient  re- 
cimabent.  The  effort  should  be  to  place  him  in  as  comfortable  a  position  as  pos- 
sible if  this  position  is  consistent  with  operative  necessities.  Put  a  small  pillow 
under  him,  so  as  to  support  the  normal  limibar  curve  and  prevent  postopera- 
tive backache.  See  that  the  clothing  is  loose,  particularly  that  there  is  no 
constriction  about  the  neck  and  abdomen.  Do  not  have  the  head  high  unless 
this  position  is  demanded  by  the  exigencies  of  the  operation.  The  anesthetist 
must  have  a  mouth-gag  and  a  pair  of  tongue  forceps  at  hand.  It  is  very 
wrong  to  say  that  a  mouth-gag  and  tongue  forceps  are  never  necessary.  It 
is  quite  true  they  are  often  used  when  not  needed,  but  this  does  not  justify 
us  in  being  without  them  when  they  are  needed,  and  they  may  be  needed  very 
badly.  The  anesthetist  should  also  have  a  pair  of  artery  forceps  and  some 
small  gauze  sponges  to  swab  out  the  mouth  and  throat.  A  hypodermatic 
syringe  in  working  order,  and  solutions  of  strychnin,  atropin,  and  brandy  are 
to  be  in  an  accessible  place,  oxygen  must  be  ready  for  administration,  and 
it  is  well  to  have  an  electric  battery  adjacent.  Accidents,  it  is  true,  are  rare, 
but  they  may  happen  at  any  time,  and  hence  the  surgeon  should  always  be 
prepared  for  them.  Any  danger  which  arises  must  be  met  promptly  and 
decisively,  or  action  will  be  of  no  avail.  Many  surgeons  give  a  hypodermatic 
injection  of  morphin  a  short  time  before  operation  to  steady  the  heart,  to  pre- 
vent vomiting  during  anesthetization,  to  shorten  the  stage  of  excitement,  to 
prevent  rigidity,  and  to  aid  the  bringing  about  of  insensibility  with  very  httle  of 
the  anesthetic.  This  method  has  been  tried  by  many  during  the  last  forty 
odd  years.  It  is  used  in  drunkards  (as  their  muscles  tend  to  remain  rigid  in  the 
anesthetic  state),  in  those  whom  it  is  difficult  to  make  completely  unconscious, 
in  neurotic  individuals,  and  in  badly  frightened  subjects.  Its  greatest  use  has 
been  in  operations  about  the  mouth  and  face,  for  in  these  procedures  an  anes- 
thetic was  given  on  a  towel  or  inhaler,  was  of  necessity  given  intermittently, 
and  a  preliminary  dose  of  morphin  was  found  to  keep  the  patients  from  rousing 
during  the  intervals.  At  present  intratracheal  anesthesia  does  away  with  the 
need  of  morphin  in  operations  about  the  mouth  and  face.  There  are  objec- 
tions to  giving  morphin  before  anesthesia,  and  its  use  should  be  the  exception 
and  not  the  rule.  It  should  not  be  used  in  children,  in  cases  of  stupor,  or  in 
cases  in  which  the  respiratory  center  is  disordered.  It  depresses  the  respira- 
tion, lowers  temperature,  and  thus  perhaps  increases  operative  shock,  interferes 
with  the  pupillary  phenomena  of  anesthesia,  delays  awakening  from  the  anes- 
thetic sleep,  adds  to  subsequent  abdominal  distention  and  headache,  and  actu- 
ally favors  postanesthetic  vomiting.  Hewdtt  ("Anesthetics  and  Their  Admin- 
istration") says  that  several  recorded  fatalities  were  due  to  the  combination. 
If  the  surgeon  determines  to  give  morphin,  he  gives  e  to  |  gr.  twenty  minutes 
before  the  anesthetist  begins  to  give  the  anesthetic.  Hewitt  (Ibid.)  says:  "The 
anesthetic  should  be  given  until  the  usual  signs  of  anesthesia  commence  to  ap- 
pear. .  It  should  then  be  discontinued  for  a  few  moments  and  only  reappHed 
as  occasion  may  require.  As  little  as  possible  of  the  ether  or  chloroform  should 
be  subsequently  administered;  the  conjunctival  reflex  should  be  retained."  In 
the  clinic  of  the  Jefferson  Hospital  the  elder  Gross  long  used  as  a  routine  the 
preliminary  administration  of  opium,  but  during  his  later  years  he  used  it  ex- 
ceptionally. His  successor,  the  younger  Gross,  used  morphin  hypodermatically 
exceptionally.  In  some  cases  we  may  anticipate  trouble  from  the  anesthetic. 
Cyanosis  may  occur  in  drunkards;  in  fat,  thick- necked  individuals  of  the  Major 
Bagstock  type,  who  are  short  of  breath  and  congested  in  appearance;  in  indi- 
viduals with  some  disease  of  the  lungs,  bronchi,  pharynx,  larynx,  or  trachea 
(empyema,  emphysema,  chronic  bronchitis,  croup,  cancer  of  the  larynx,  etc).; 


Ether  and  Chloroform  1195 

in  in di\-i duals  suffering  from  fatty  heart  or  vahoilar  incompetence.  Buxton 
points  out  that  an  indi\-idual  without  teeth  and  with  stenosis  of  the  nares  is  apt 
to  become  cyanotic  under  an  anesthetic,  because  the  Hps  and  pillars  of  the 
fauces  are  drawn  in  like  valves  during  inspiration. 

Ether  and  Chloroform. — The  two  favorite  anesthetics  are  ether  and 
chloroform.  Only  the  verv'  best  ether  or  chloroform  should  be  used.  It 
is  a  good  plan,  in  order  to  lessen  bronchitis,  to  mix  with  ether  turpentine 
of  Pinus  pumilio  in  the  proportion  of  20  drops  to  6|  oz.  (Becker,  in  '"Cen- 
tralbl.  f.  Chir.,"  June  i,  1901).  Chloroform  is  more  dangerous  than  ether 
in  general  cases,  though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Chloroform,  compared  to  ether,  is  relatively 
safer  in  warm  than  in  cold  countries.  In  fact,  in  the  tropics  it  is  a  matter  of 
considerable  difficulty  to  use  ether  because  of  its  great  volatility.  It  should, 
however,  be  noted  that  Squire  used  ether  successfully  when  the  temperature 
was  120^ F.  in  the  shade  ("Lancet,"  vol.  i,  1913).  Chloroform  is  preferred  in 
campaigns,  because  less  is  required  and  transportation  is  easier.  Recovery 
from  chloroform  is  quicker  and  quieter  than  that  from  ether,  but  chloroform 
vomiting  lasts  longer  than  ether  vomiting.  Chloroform  may  induce  sudden 
and  even  fatal  s^mcope.  Hare's  experiments  on  animals  indicate  that  chloro- 
form may  kill  by  respirator}-  failure  occurring  secondarily  to  failure  of  the 
vasomotor  center:  but  certain  it  is  that  clinically  a  danger  of  chloroform 
is  paralysis  of  the  heart,  and  this  condition  may  come  on  so  rapidly  that 
death  may  occur  almost  before  an  attempt  can  be  made  to  save  life.  Leonard 
Hill  has  proved  that  most  chloroform  deaths  that  take  place  after  considerable 
of  the  anesthetic  has  been  taken  arise  from  paralytic  distention  of  the  heart. 
Sudden  death,  when  inhalations  of  chloroform  have  just  commenced,  may 
be  due  to  the  irritant  vapor  acting  on  the  nasal  mucous  membrane,  exciting  a 
nasal  reflex,  and  powerfully  stimulating  cardiac  inhibition.  If  ether  produces 
danger  it  does  so  usually  through  the  respiration,  and  not  the  heart,  and  there 
is  generally  time  to  undertake  means  of  resuscitation,  which  means  are  apt 
to  be  successful.  Chloroform  is  preferred  to  ether  by  many  surgeons  for 
children  under  ten  years  of  age,  in  whom  ether  causes  a  great  outflow  of 
bronchial  mucus,  which  may  asphyxiate;  for  people  over  sLxty,  entirely  free 
from  myocardial  disease,  at  which  age  most  persons  have  some  bronchitis, 
and  ether  chokes  them  up  with  mucus.  Ether  also  irritates  the  kidneys, 
which  at  the  latter  age  are  apt  to  be  weak  or  diseased.  Personally,  I  give  ether 
even  to  infants  (if  they  are  free  from  bronchitis)  and  to  old  subjects  "^dthout 
marked  respirator}-  trouble.  Chloroform  is  given  if  the  actual  cauter}-  is  to 
be  used  about  the  face,  neck,  or  mouth,  because  ether  vapor  may  take  fire 
and  chloroform  vapor  will  not.  Chloroform  is  preferred  for  labor  cases, 
when  moderate  anesthesia  only  is  required,  and  was  preferred  for  operations 
on  the  mouth  and  nose  before  the  advent  of  intratracheal  anesthesia.  In  cleft- 
palate_[operation3  chloroform  is  usually  preferred,  because  it  causes  but  little 
cough  and  salivar}-  flow.  In  Hgation  of  a  large  artery  which  is  overlaid  by  a 
vein  ether  greatly  enlarges  the  vein,  but  this  is  no  real  embarrassment  to 
an  experienced  surgeon.  In  goiter  operations  ether  will  decidedly  enlarge 
the  veins.  Most  goiters  may  be,  and  many  should  be,  removed  T\-ith  the 
aid  of  local  anesthesia  only.  Chloroform  is  particiflarly  dangerous  when 
there  is  myocardial  disease,  and  is  apt  to  produce  cyanosis  and  embarrassed 
respiration.  In  vah-ular  heart  disease  chloroform  is  more  dangerous  than 
ether,  and  even  in  fimctional  heart  trouble  it  is  an  imdesirable  anesthetic.  It 
should  not  be  used  in  those  who  smoke  or  chew  tobacco  to  excess,  or  who 
overindulge  in  coffee  or  alcohol.  Chloroform  is  more  dangerous  in  shock  than 
ether.  A  patient  in  dangerous  shock  requiring  operation  should,  if  possible, 
have  the  nerves  coming  from  the  part  injected  with  cocain  so  as  to  prevent 


1 196  Anesthesia  and  Anesthetics 

further  shock  by  introducing  a  "physiological  block" — Crile  (see  page  262). 
Chloroform  is  preferred  for  patients  with  difficult  respiration  from  any  cause- 
other  than  heart  disease  (in  emphysema,  bronchitis,  or  pulmonary  tubercu- 
losis), and  for  patients  with  kidney  disease.  I  am  convinced  that  etheriza- 
tion is  sometimes  responsible  for  a  latent  area  of  pulmonary  tuberculosis 
becoming  active.  Some  surgeons  do  not  use  ether  in  abdominal  operations 
because  they  believe  it  may  cause  persistent  oozing  of  blood,  but  this  view 
is  not  in  accord  with  the  author's  experience.  Ether  is  the  best  and  safest 
anesthetic  for  general  use.  It  is  much  safer  than  chloroform  in  valvular 
disease  and  functional  heart  trouble.  It  is  dangerous  in  myocardial  disease, 
but  not  nearly  so  dangerous  as  chloroform.  In  valvular  disease  without 
heightened  arterial  tension  it  is  reasonably  safe,  but  in  valvular  disease  with 
heightened  arterial  tension  it  is  dangerous.  Ether  is  dangerous  when  athe- 
roma exists.  Both  ether  and  chloroform  may  induce  changes  in  the  blood.^ 
In  practically  all  cases  they  produce  a  diminution  of  hemoglobin  and  leuko- 
cytosis. In  some  cases  they  produce  alteration  in  the  shape  of  the  corpuscles. 
These  changes  are  especially  marked  in  anemic  blood.  Ether  produces 
distinct  leukocytosis,  probably  toxic  in  origin.  Both  ether  and  chloroform 
seem  to  lessen  the  phagocytic  activity  of  leukocytes,  and  hence  to  lower  vital 
resistance  (Ferguson,  in  "New  York  Med.  Jour.,"  May  11,  191 2).  These 
blood  changes  indicate  that  prolonged  anesthesia  must  miHtate  against  recovery 
from  a  severe  operation.  If  a  patient's  hemoglobin  is  below  30  per  cent.,  a 
general  anesthetic  should  not  be  given.  During  the  state  of  anesthesia  the 
temperature  drops  from  i  to  3  degrees  or  more,  hence  the  patient  should  be 
carefully  covered  during  the  operation.  The  question  as  to  the  effect  of  ether 
on  the  kidneys  is  much  disputed.  Most  surgeons  believe  that  it  tends  to 
cause  albuminuria  or  increase  existing  albuminuria.  Nitrous  oxid  is  very 
dangerous  when  there  is  vascular  degeneration,  and  it  may  induce  apoplexy. 
It  is  also  dangerous  if  the  air-passages  are  narrowed  as  by  a  goiter.  In  giving 
ether  or  chloroform  the  administrator  must  devote  his  undivided  attention  to 
the  task.  He  must  note  every  symptom,  must  order  or  carry  out  proper 
treatment  for  complications,  and  must  keep  the  operator  informed  as  to  the 
necessity  for  haste.  The  anesthetist  must  be  a  man  who  has  a  wholesome 
respect  for  ether  and  chloroform,  although  not  afraid  of  them. 

Can  an  anesthetic  be  administered  to  a  sleeping  person  without  waking 
him?  I  know  that  chloroform  can  be  so  given,  for  I  have  succeeded  in  giving 
it  to  a  child  without  breaking  the  slimiber.  Probably,  in  most  cases,  an 
attempt  will  fail,  but  in  some  it  will  succeed.  Stone  ("Cleveland  Med.  Jour.," 
Jan.,  1902)  reports  successful  administration  to  sleeping  children  and  also 
the  chloroforming  of  a  resident  physician  while  asleep.  Paugh  ("Jour.  Am. 
Med.  Assoc,"  May  18,  1901)  reports  three  successes  with  children.  Ether,  be- 
cause of  the  irritant  nature  of  its  vapor,  would  be  more  apt  to  arouse  a  sleeper 
than  chloroform. 

Administration  of  Chloroform. — Chloroform  should  be  given  only  by 
a  highly  trained  man.  In  fact,  safety  in  giving  chloroform  is  dependent  upon 
skill  and  experience  more  than  in  giving  ether.  No  one  should  think  of 
allowing  anyone  but  a  physician  to  give  chloroform.  The  most  dangerous 
period  is  when  the  patient  is  incompletely  anesthetized,  but  is  going  under. 
Most  deaths  happen  at  this  time.  In  administering  chloroform  have  at  hand 
a  mouth-gag,  tongue  forceps,  artery  forceps,  small  gauze  sponges,  a  clean 
towel,  a  hj^odermatic  syringe,  solutions  of  strychnin,  atropin  and  brandy, 
an  electric  battery,  and  a  can  of  oxygen.     Use  only  pure  chloroform.     The 

^  See  the  author  on  the  "Blood-alterations  of  Ether-anesthesia,"  "Medical  News," 
March  2,  1895,  and  also  the  author  and  Kalteyer  in  "The  Proceedings  of  the  Americaa 
Surgical  Association  for  1901." 


Administration  of  Chloroform 


1197 


patient  must  be  recumbent.  No  special  inhaler  is  required,  but  the  drug 
may  be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint.  The  mask 
of  Skinner  (Fig.  791)  is  very  useful.  Junker's  inhaler  (Fig.  792)  is  used  by 
many  anesthetists.  In  operations  about  the  face  Souchon's  instrument 
is  serviceable.  Souchon's  apparatus  is  so  arranged  that  chloroform  may 
be  given  through  a  tube  which  is  introduced  through  the  nose,  the  instrument 
being  well  out  of  the  way  of  the  operator.  Some  surgeons  cocainize  the  nares 
before  giving  chloroform,  so  as  to  prevent  the  supposedly  dangerous  nasal  reflex 
(Rosenberg).  It  is  advisable  to  smear  the  lips  and  face  with  cosmolin  to 
prevent  blistering.  The  chloroform  vapor  must  be  well  mixed  with  air. 
The  chloroform  is  sprinkled  on  the  fabric  from  a  drop-bottle.  Raise  the 
napkin  well  above  the  mouth,  add  5  drops  of  chloroform,  and  tell  the  patient 
to  take  deep  and  regular  breaths,  but  do  not  tell  him  to  breathe  forcibly. 
Forcible  respiration  may  lead  to  cessation  of  respiration.  Add  a  few  more 
drops  of  chloroform,  and  when  the  patient  grows  so  accustomed  to  it  that 
it  does  not  choke,  turn  the  wet  part  of  the  fabric  toward  the  face  and  place 
it  near  the  mouth;  do  not  touch  the  mouth  with  the  wet  lint,  because  it  will 
blister.  If  the  drug  is  given  gradually,  struggling  is  not  usually  violent  or 
prolonged.  Never  pour  on  a  large  amount  at  one  time.  Keep  the  lower 
jaw  pushed  forward  during  the  time  the  chloroform  is  being  given.     Cough 


Fig.  791. — Skinner's  mask. 


Fig.  792. — Junker's  inhaler. 


and  vomiting  at  this  time  mean  that  the  vapor  is  too  strong.  During  the 
stage  of  excitement  do  not  suspend  the  administration  of  chloroform  unless 
respiration  becomes  difficult,  in  which  case  suspend  it  until  the  patient  takes 
one  or  two  respirations.  If  the  patient  struggles,  do  not  hold  him,  and  push 
the  administration  of  the  drug.  He  holds  his  breath  while  struggling,  and 
as  struggling  ceases  takes  full,  deep  breaths.  If  the  inhaler  is  saturated  with 
chloroform,  he  may  inhale  a  dangerous  amount  during  the  deep  respiration 
after  struggling.  Chloroform  given  in  considerable  amount  when  the  patient 
is  breathing  deeply  from  the  effects  of  ether  is  unsafe.  If  chloroform  is 
given  subsequent  to  anesthetization  by  ether,  it  should  be  given  gradually 
and  well  mixed  with  air.  When  the  patient  becomes  anesthetized,  give 
just  enough  of  the  drug  to  keep  him  so.  While  a  patient  is  taking  chloro- 
form hiccup  usually  means  that  vomiting  is  going  to  occur.  If  vomiting 
occurs  at  this  time  more  chloroform  must  be  given  to  abolish  the  reflexes. 
Deep  and  sighing  respiration  and  repeated  swallowing  indicate  that  more 
of  the  anesthetic  is  required.  Stop  the  administration  or  give  very  little 
when  shock  becomes  evident  or  when  there  is  profuse  hemorrhage.  Chloro- 
form vapor  is  not  inflammable,  hence  it  is  safer  than  ether  when  a  hot  iron 
is  to  be  used  about  the  face  and  when  there  is  a  lighted  lamp  or  a  stove  in 
a  small  room;  but  the  presence  of  a  naked  gas-flame  decomposes  chloroform 


IK 


Anesthesia  and  Anesthetics 


into  irritant  products  of  chlorin  (COCI3),  which  cause  the  patient  and  the 
surgeon  to  cough. 

Chloroform  and  Oxygen. — The  use  of  this  mixture  was  suggested  by 
Neudorf er.  Some  anesthetists  advocate  the  mixture  of  chloroform  and  oxygen, 
asserting  that  it  does  not  produce  spasm  of  the  glottis  or  muscles  of  respiration, 
that  it  does  not  produce  cyanosis  or  weakness  of  circulation,  that  it  does 
not  irritate  the  kidneys,  is  safer  to  life  than  pure  chloroform,  and  is  less  often 
productive  of  severe  and  prolonged  vomiting.  These  alleged  advantages 
are  probably  stated  with  rather  undue  emphasis,  although  I  do  believe  the  mix- 
ture has  less  tendency  to  produce  cyanosis  than  has  the  pure  drug,  does  not  so 
often  induce  vomiting,  and  is  somewhat  safer.  Hewitt  does  not  think  that  the 
method  offers  any  "special  advantages"  ("Anesthetics  and  their  Administra- 
tion," by  Sir  Frederic  W.  Hewitt).  If  this  method  is  used,  a  bag  containing 
oxygen  is  attached  to  the  hand-bellows  attachment  of  a  Junker  inhaler,  and 
oxygen  is  forced  through  the  chloroform  and  flows  to  the  face-piece. 

Administration  of  Ether. — The  administration  should  not  be  intrusted 
to  a  novice.  The  anesthetist  should  be  one  of  your  most  trusted  men.  I  do 
not  believe  in  allowing  a  nurse  to  give  ether.  She  cannot  have  sufficient 
knowledge  to  observe  incipient  trouble,  to  antic'  "d  effects,  and  to 


Fig-  793- 


ether  inhaler. 


Fig.  794. — Clover's  portable  regulating  ether  inhaler. 


at  once  do  the  correct  thing  when  difficulty  arises  or  calamity  impends.  The 
moral  responsibility  and  the  legal  responsibility  demand  that  a  physician  give 
the  ether.  Ether  is  best  given  from  a  partially  open  inhaler.  The  most  satis- 
factory appliance  is  AUis's  inhaler  (Fig.  793).  This  inhaler  secures  a  plentiful 
supply  of  air.  Before  being  used  the  metal  frame  is  scalded,  dried,  and  threaded 
with  a  clean  gauze  bandage.  The  end  of  the  frame  which  is  to  be  toward  the 
mouth  is  covered  with  one  layer  of  gauze.  The  frame  is  then  inserted  in  a 
clean  metal  case  and  the  case  is  wrapped  in  a  clean  towel.  The  drug  is  given 
drop  by  drop,  the  drops  following  each  other  in  regular  sequence.  This  is  known 
as  the  drop  method.  The  drop  method  is  the  safest  plan  and  the  most  com- 
fortable to  the  patient.  Instead  of  AUis's  inhaler  a  piece  of  gauze  or  an  Esmarch 
inhaler  may  be  used.  Some  surgeons  prefer  closed  inhalers.  The  Clover 
inhaler  (Fig.  794)  is  popular  in  England.  F  is  the  face-piece;  C,  a  reservoir  of 
ether  through  which  the  air-current  passes;  B  is  an  India-rubber  bag.  In  this 
apparatus  there  is  no  provision  for  the  entrance  of  fresh  air.  By  turning  the 
reservoir  C  on  the  tube  /  the  amount  of  current  passing  over  the  ether  can 


Intratracheal  InsufBation  Anesthesia  1199 

be  regulated.  When  this  apparatus  is  used,  the  ether  vapor  breathed  into  the 
limgs  is  expired  into  the  bag  and  is  rebreathed.  This  inhaler,  if  used  by  a 
skilful  man,  is  very  useful;  but  any  lack  of  watchfulness  or  skill  will  permit  of 
cyanosis,  and  the  very  young,  the  senile,  the  anemic,  and  feeble  are  best 
anesthetized  by  the  drop  method  described  above. 

An  admirable  detailed  account  of  anesthetization  by  the  closed  method 
will  be  found  in  Sir.  Frederic  W.  Hewitt's  treatise  on  "Anesthetics  and  Their 
Administration,"  and  in  Mr.  Dudley  W.  Buxton's  treatise  on  "Anesthetics, 
Their  Uses  and  Administration."  When  giving  ether,  have  at  hand  the 
same  drugs  and  appliances  as  when  chloroform  is  given,  and  keep  the  lower 
jaw  pushed  forward  during  the  administration.  When  using  AUis's  in- 
haler, take  every  care  that  none  of  the  ether  runs  through  on  to  the  face 
and  into  the  eyes.  If  it  does  it  wUl  irritate  and  perhaps  blister.  Even  the 
vapor  irritates  the  eyes,  and  boric  acid  solution  should  be  used  now  and  then 
during  the  administration  to  flush  out  the  conjunctival  sacs.  It  is  wise 
to  grease  the  face  and  lips  with  cosmolin.  Place  the  dry  inhaler  over  the 
mouth  and  nose,  let  the  patient  take  several  breaths,  that  he  may  gain  confi- 
dence, begin  to  drop  ether  into  the  inhaler,  let  the  patient  take  several  more 
breaths,  and  so  on,  gradually  increasing  the  rapidity  with  which  the  drops  of 
ether  are  given.  If  he  tends  to  struggle,  diminish  the  amoimt  of  ether  for 
a  time,  but  do  not  hold  him.  Do  not  tell  him  to  breathe  forcibly.  Forcible 
breathing  is  liable  to  cause  a  cessation  of  respiration.  Never  suddenly  add 
a  large  amount  of  the  anesthetic:  it  causes  coughing  and  often  vomiting. 
When  the  patient  becomes  thoroughly  anesthetized,  give  a  very  little  ether 
as  often  as  is  required  to  maintain  unconsciousness.  When  bleeding  is 
profuse  or  shock  is  marked,  suspend  the  administration  of  ether  or  give 
very  little  of  it.  If  he  rolls  his  eyes  from  side  to  side,  if  the  respirations  are 
deep  and  sighing,  if  there  are  repeated  movements  of  swallowing,  more  anes- 
thetic should  be  given  (Tarnowsky).  Hiccup  is  often  preliminary  to  vomit- 
ing, and  always  means  that  the  reflexes  are  returning.  If  a  hot  iron  is  to  be 
used  about  the  face,  remove  the  inhaler  and  fan  awa}^  the  ether  before  bring- 
ing the  cautery  near.  Have  any  light  set  high  up,  as  ether  vapor  is  heavier 
than  air,  and  no  explosion  is  possible  until  it  reaches  the  level  of  the  flame.  If 
the  vapor  takes  fire,  cover  the  patient's  mouth  and  nose  with  a  towel. 

The  patient  shoifld  be  kept  in  a  condition  in  which  he  feels  no  pain,  makes 
no  movement,  and  is  not  rigid.  In  this  condition  the  cutaneous  reflexes  are 
abohshed,  the  breathing  is  regular  and  quiet,  the  color  is  good,  and  the  pupfls 
react  to  light,  though  slowly.  Just  enough  anesthetic  must  be  given  to  cause 
the  patient  to  pass  into  this  condition  and  remain  in  it.  To  give  any  more 
is  to  poison  him.  The  amount  necessary  varies  with  the  individual  and  the 
operation,  and  requires  skill,  experience,  and  attention  on  the  part  of  the  anes- 
thetist. 

The  old  idea  that  we  must  poison  a  man  into  dangerous  coma  has  been 
abandoned.  When  the  breathing  becomes  louder,  more  rapid,  or  spasmodic, 
it  means  that  reflexes  are  returning,  and  a  little  more  anesthetic  should  be 
given. 

Ether  and  Oxygen. — This  mixture  is  useful  in  certain  cases  in  which 
respiratory  difficulty  exists,  particularly  in  empyema.  If  during  the  adminis- 
tration of  ether  cyanosis  tends  to  occur,  it  is  often  advantageous  to  give  oxygen 
mth  the  ether.  The  process  of  anesthetization  by  ether  and  oxygen  is  some- 
what slower  than  by  ether  vapor  mixed  with  air.  It  can  be  given  by  insert- 
ing beneath  the  Allis  inhaler  or  pushing  deep  down  into  it,  from  above,  a  tube 
attached  to  a  reservoir  of  oxygen  and  from  which  a  stream  of  ox^^gen  emerges. 

Intratracheal  Insufflation  Anesthesia  (Method  of  Meltzer  and 
Auer). — A  flexible  elastic  tube  much  smaller  in  diameter  than  the  trachea  is 


I200  Anesthesia  and  Anesthetics 

carried  down  almost  to  the  tracheal  bifurcation.  When  air  is  forced  in  it 
emerges  between  the  tube  and  the  trachea.  The  addition  of  ether  vapor  to  the 
air  makes  the  maintenance  of  anesthesia  easy.  Ether  can  thus  be  administered 
by  means  of  a  tracheal  tube,  a  Wolff  bottle  to  contain  the  ether,  and  a  foot- 
bellows.  I  have  had  it  given  in  this  way  a  number  of  times.  Elsberg's 
apparatus  (see  Fig.  570)  permits  of  the  most  desirable  method. 

The  patient  is  iirst  anesthetized  by  the  ordinary  method.  When  uncon- 
scious the  head  is  dropped  back  over  the  end  of  the  table,  and  the  tube  is  passed 
into  the  trachea  "under  the  guidance  of  the  eye  by  means  of  a  Jackson  direct 
laryngoscope"  (see  Fig.  562).  (See  Brewer,  in  "Keen's  Surgery,"  vol.  vi.) 
In  this  form  of  anesthesia  the  stream  of  air  carries  off  ether  vapor  and  pre- 
vents accumulation  in  the  tubes. 

A  degree  of  anesthesia  necessary  to  maintain  muscular  relaxation  will  not  ap- 
parently cause  dangerous  symptoms.  If  the  ether  is  given  for  a  long  time  in  un- 
necessarily large  amounts  danger  may  be  reached,  but  it  is  attained  gradually 
and  not  suddenly  and  gives  warning.  If  there  should  be  an  ominous  fall  in 
blood-pressure  and  respiratory  failure,  cut  out  the  ether  vapor  and  use  the  ap- 
paratus for  artificial  respiration.  A  patient  remains  very  still  under  this 
method  of  anesthesia,  awakes  rapidly  from  it,  and  suffers  little  from  shock  and 
postoperative  vomiting.  Nitrous  oxid  and  oxygen  have  been  given  by  this 
method.  Meltzer  is  studying  chloroform  so  used  ("Keen's  Surgery,"  vol.  vi). 
In  operations  about  the  head,  mouth,  and  neck  insufflation  anesthesia  keeps  the 
anesthetist  out  of  the  operator's  way.  In  operations  about  the  mouth  the 
method  prevents  the  inhalation  of  blood  or  vomit.  In  goiter  operations  it  is  a 
safeguard  against  sudden  suffocation.  In  intrathoracic  operations  it  serves 
to  prevent  collapse  of  the  lung.  After  the  operation  all  ether  vapor  is  driven 
out  of  the  lungs  by  a  stream  of  fresh  air.  Peck  ("Annals  of  Surgery,"  July, 
191 2)  maintains  that  the  insufflation  method  is  safe  if  certain  rules  are  carefully 
followed.  These  rules  are  to  avoid  excessive  pressure  (which  might  rupture 
air-cells),  be  sure  not  to  spray  liquid  ether  into  the  tracheal  tube,  do  not  carry 
the  tube  into  the  gullet  or  beyond  the  tracheal  bifurcation,  and  do  no  damage 
by  rough  introduction.     Meltzer  (Loc.  cit.)  refers  to  3  deaths. 

Rectal  Etherization. — Pirogoff  suggested  this  method  in  1847  ^-nd 
Roux  employed  it  the  same  year.  The  method  is  only  used  in  operations  about 
the  face,  tongue,  nasopharynx,  pharynx,  mouth,  and  larynx;  in  other  words,  in 
cases  in  which,  were  the  ether  given  by  inhalation,  the  operator  and  anes- 
thetist would  interfere  with  each  other.  The  rectum  should  be  emptied 
by  a  purgative  enema  the  day  before  the  operation,  and  again  the  morning  of 
the  operation,  and  a  short  time  before  giving  the  ether  the  rectum  should  be 
irrigated  with  warm  salt  solution.  A  dose  of  laudanum  is  given  a  few  hours 
before,  or  'an  injection  of  morphin  and  atropin  twenty  minutes  before  the  admin- 
istration of  the  ether.  We  should  employ  an  apparatus  of  the  type  of  Buxton's, 
which  prevents  liquid  ether  from  passing  into  the  rectum. 

A  tube  containing  ether  is  set  in  a  vessel  containing  water  at  a  temperatiu*e 
of  122°  F.  The  ether  tube  is  joined  by  a  glass  tube  and  rubber  pipe  to  a  glass 
globe,  and  the  globe  is  connected  by  a  rubber  pipe  to  the  tip,  which  is  inserted 
into  the  rectum.  If  ether  vapor  condenses  into  liquid  in  the  glass  globe  the 
globe  should  be  at  once  emptied.  During  the  administration  abdominal  dis- 
tention occurs  from  iinabsorbed  ether,  and  from  time  to  time  the  administra- 
tion should  be  suspended  temporarily  to  permit  the  gas  to  escape,  otherwise 
too  much  will  be  given  and  prolonged  stupor  and  postoperative  colic  may 
result.  It  takes  much  longer  to  obtain  unconsciousness  by  rectal  administra- 
tion than  by  inhalation.  The  method  must  never  be  used  if  the  intestines  are 
irritated  or  inflamed  (Dimiont,  in  "Corr-Bl.  f.  Schweizer  Aerzte,"  Dec.  15, 
1908).     The  method  has  never  come  into  general  use.     It  irritates  the  large 


Anesthetic  State  from  Ether  or  Chloroform  1201 

intestine,  often  produces  cohc.  and  sometimes  is  said  to  lead  to  protracted  stupor 
(''Anesthetics  and  Their  Administration,"  by  Sir  Frederic  \V.  He\s-itt) .  In  some 
cases  we  can  begin  the  ether  by  inhalation  and  shift  to  the  rectal  administration 
when  ready  to  operate.  I  agree  with  Baum  that  the  method  is  more  dangerous 
than  the  inhalation  method.  After  one  of  Baum's  cases  intestinal  hemorrhage 
occurred;  in  another,  gangrene  and  perforation  (''Zentral.  flir.  Chir.,"'  ^larch 
13,  1909).  Dudley  W.  Buxton,  however,  has  employed  it  in  many  operations 
about  the  face,  mouth,  and  lar^-nx,  and  in  some  operations  for  empyema,  and 
commends  it.  Rectal  etherization  does  not  produce  a  sense  of  suffocation,  the 
stage  of  excitement  is  short,  and  struggling  is  tri\'ial  or  absent.  Intratracheal 
insufflation  anesthesia  seems  to  have  practically  done  away  "^-ith  all  need  for 
rectal  anesthesia. 

Intravenous  Etherization  (Infusion  Anesthesia). — This  method  was 
de\'ised  by  Burkhardt,  of  Wiirzburg,  and  is  stiU  on  trial.  A  7I  per  cent, 
solution  of  ether  in  normal  salt  solution  is  employed  by  Rood  ("Lancet," 
March  2-^,  1912).  He  found  that  a  10  per  cent,  solution  causes  hemolysis  and 
a  5  per  cent,  solution  is  inadequate.  About  three-quarters  of  an  hour  before 
operation  he  gives  a  h\podermatic  mjection  of  \  gr.  of  morphin,  y^  gr.  of 
scopolamin,  and  y^  gr.  of  atropm.  WTien  read}'  to  operate,  a  vein  is  selected. 
exposed  and  opened,  and  the  cannula  is  introduced.  The  solution  is  warm. 
From  ^  to  I  pint  of  the  fluid  is  run  in  and  anesthesia  should  be  secured 
in  from  three  to  five  minutes.  Anesthesia  is  maintained  by  running  in  a 
constant  succession  of  drops.  If  anesthesia  becomes  too  deep  the  rate  of 
flow  is  lessened,  and  ^"ice  versa.  This  method  of  anesthesia  keeps  the  anes- 
thetist out  of  the  way  in  operations  on  the  head,  neck,  and  mouth.  It  is  claimed 
that  it  enables  us  to  measure  the  dose  of  anesthetic  much  more  accurately 
than  does  the  respiratory  plan,  and  that  by  it  we  avoid  irritation  of  the 
mucous  membrane  of  the  respiratory  tract.  The  respiration  must  be  watched 
just  as  carefully  as  in  respirator}'  anesthesia.  Rood  ("'Brit.  Med.  Jour.,"' 
Oct.  21,  1911)  has  had  136  cases  and  no  bad  results. 

Hedonal  has  been  used  for  infusion  anesthesia.  It  was  suggested  by 
Federoff,  of  St.  Petersburg.  ]SIr.  Page,  of  London,  has  reported  75  cases  ("Lan- 
cet," March  2-1,^  1912).  He  uses  a  .75  per  cent,  solution  in  normal  salt  solution 
and  gives  it  continuously.  Ward  ("Lancet,"  IMarch  2^,  191 2)  has  reported  a 
death  from  it. 

Anesthetic  State  from  Ether  or  Chloroform. — The  inhalation  of 
an  anesthetic  produces  irritation  of  the  fauces,  often  some  cough,  a  profuse 
secretion  of  mucus,  acts  of  swallo-ning,  dilatation  of  the  pupils,  flushed  face, 
and  sometimes  strugglmg  (especially  in  children  and  in  drunkards) .  If  at  the 
start  the  vapor  is  given  in  concentrated  form,  cough  will  be  ^-iolent  and  -^-iU 
cause  c}-anosis.  If  the  anesthetic  is  given  gradually  the  cough  soon  ceases, 
the  respirations  become  rapid  and  often  con^'ulsive,  the  pulse  becomes  fre- 
quent, and  the  patient  passes  into  a  condition  of  active  intoxication  with 
preser\-ation  of  sight  and  touch,  loss  of  hearing  and  smeU,  diminution  of 
pain  and  sensibility,  and  often  -^"ith  illusions  or  hallucinations.  In  this 
stage  the  patient  may  struggle,  and  while  efl'orts  are  being  made  to  hold 
him,  cyanosis  may  occur.  From  the  stage  of  excitement  just  aUuded  to, 
many  subjects  (strong  men  and  drunkards)  pass  into  a  stage  of  rigidity  in 
which  the  muscles  become  firmly  fixed,  the  breathing  is  impeded,  the  respira- 
tions are  stertorous,  and  the  face  is  bluish  and  congested.  Too  rapid  forcing 
of  the  anesthetic  tends  to  cause  rigidity,  and  a  skilled  anesthetist  endeavors 
to  avoid  its  production,  because  it  is  dangerous.  The  next  stage  is  one  of 
insensibility;  the  pupils  are  contracted  and  react  sluggishly  to  Hght.  If  anes- 
thesia is  deep  the  contracted  pupils  -ttiU  not  react  to  light:  if  anesthesia  is  pro- 
found the  pupils  dilate,  but  wiU  not  react  to  hght.  The  conjunctival  reflex 
76 


I202  Anesthesia  and  Anesthetics 

is  gone;  the  lids  are  closed;  if  the  arm  is  lifted  and  allowed  to  fall,  it  drops 
as  a  dead  weight;  the  skin  is  cool  and  moist  and  often  wet  with  sweat;  the 
respirations  are  easy  and  shallow;  the  pulse  is  slow,  and  there  is  complete 
unconsciousness  to  pain.  The  loss  of  conjunctival  reflex  is  the  usually  ac- 
cepted sign  that  the  patient  is  unconscious.  In  a  young  child  this  reflex 
is  soon  exhausted  by  touching  the  eye,  and  the  sign  is  unreliable.  If  a  baby 
is  to  be  anesthetized,  the  administrator  places  bis  finger  in  the  infant's  hand. 
The  child  grasps  the  finger,  and  relaxes  its  grasp  when  unconscious. 

Always  bear  in  mind  that  dilated  pupils  reacting  to  light  and  associated 
with  preserved  conjunctival  reflex  mean  that  anesthesia  is  not  complete; 
that  contracted  pupils  reacting  to  light  and  without  conjunctival  reflex  mean 
moderate  anesthesia;  that  contracted  pupils  not  reacting  to  light  and  without 
conjunctival  reflex  mean  deep  anesthesia;  that  dflated  pupfls  not  reacting 
to  light  and  associated  with  lost  conjunctival  reflex  mean  dangerously  pro- 
found anesthesia.  Sudden  dilatation  with  fixation  is  always  very  ominous. 
The  pupillary  phenomena  are  very  valuable  when  present,  but  unfortunately 
they  are  absent  at  some  stage  of  the  anesthesia  in  many  cases.  InequaHty  of 
the  pupils  is  not  unusual  and  fixation  of  one  pupil  or  of  both  may  occur.  A 
preliminary  dose  of  morphin  or  atropin  interferes  with  the  pupillary  phenomena. 
Weak  pulse  and  paUor  may  be  due  to  nausea,  but  always  require  instant  at- 
tention. Vomiting  may  be  due  to  forcing  strong  vapor  upon  the  patient,  but 
may  also  be  due  to  his  partially  emerging  from  a  state  of  insensibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak,  irregular,  ab- 
normally slow,  abnormally  fast,  or  if  it  suggests  a  fall  of  blood-pressure. 
Syncope  may  be  due  to  nausea,  shock,  hemorrhage,  or  the  giving  of  too 
much  of  the  drug.  Watch  the  respiration,  and  do  not  forget  that  the  chest 
waUs  and  belly  may  move  when  no  air  is  entering  the  lungs;  hence  always 
listen  to  the  breathing.  Cyanosis  is  a  dusky  or  bluish  discoloration  of  the  skin. 
This  condition  indicates  want  of  oxygen  in  the  blood.  The  individual  may 
have  been  cyanotic  or  predisposed  to  cyanosis  to  start  with;  cyanosis  may  be 
due  to  pressure;  to  cough  early  in  the  administration;  to  struggling  during  the 
stage  of  excitement ;  to  gathering  of  mucus  in  the  respiratory  tract ;  or  to  rigid 
fixation  of  the  respiratory  muscles.  It  may  also  be  due  to  obstruction  of  the 
air-passages  by  some  foreign  matter,  as  blood  or  vomit,  lodging  in  the  bronchial 
tubes,  windpipe,  larynx,  or  pharynx;  falling  back  of  the  tongue  {swallowing 
of  the  tongue);  closure  of  the  epiglottis;  or  to  the  glottis  being  pushed  against 
the  pharyngeal  wall  by  bending  the  head  forward.  Some  patients  with 
occluded  nostrils  may  fail  to  get  enough  air  because  of  closure  of  the  Hps. 
A  patient  may,  whfle  taking  an  anesthetic,  lie  perfectly  quiet  and  appear  to 
"forget  to  breathe."  Ether  and  chloroform  mitigate  the  causal  mental  phases 
of  shock,  but  neither  drug  keeps  nerves  from  conveying  stimuli  and  each  pro- 
duces a  fall  of  blood-pressure,  chloroform  directly  by  its  action  on  the  vaso- 
motor center,  ether  by  overstimulation  of  the  vasomotor  center  (Buxton,  in 
"Proceedings  of  the  Royal  Soc.  of  Med.,"  April,  1909).  Each  produces  a 
fall  of  temperature.  Buxton  heartily  condemns  the  once  common  belief  "that 
evidences  of  shock  during  a  surgical  operation  are  a  proof  that  an  insufficient 
quantity  of  the  anesthetic  has  been  given  and  that  the  symptoms  of  shock 
can  be  abrogated  by  increasing  the  depth  of  the  narcosis"  (Ibid.).  Heavy 
anesthesia  by  ether  or  chloroform  produces  or  adds  to  shock.  Shock  is  mani- 
fested by  deathly  pallor,  weak,  rapid,  and  irregtdar  pulse,  slow  respiration, 
cold  extremities,  and  a  drenching  sweat.  Edema  of  the  lungs  occasionally 
arises  during  or  after  anesthesia. 

Treatment  of  Complications. — Vomiting  due  to  too  much  anesthetic  is 
corrected  by  giving  a  few  breaths  of  air ;  vomiting  due  to  incomplete  anesthesia  is 
amended  by  giving  more  of  the  vapor.     While  the  patient  vomits  hold  the  head 


Treatment  of  Complications  1203 

over  the  edge  of  the  bed,  and  when  vomiting  ceases  separate  the  jaws  with  the 
gag,  and  wipe  out  the  vomited  matter,  mucus,  and  saliva.  Shock  is  treated  by 
diminishing  the  amount  of  the  anesthetic  that  is  being  given,  by  the  hypoder- 
matic injection  of  atropin  (atropin  is  particularly  useful  when  there  is  a  profuse 
sweat),  by  the  administration  of  hot  saline  fluid  by  the  rectum,  by  surrounding 
the  patient  with  hot-water  bottles,  or  by  wrapping  him  in  hot  blankets,  and  by 
lowering  the  head  of  the  bed.  Syncope  is  sudden  cerebral  anemia  and  is  usually 
due  to  a  reflex  cause.  A  tendency  to  syncope  requires  lowering  of  the  head 
of  the  bed,  suspension  of  the  anesthetic,  and  hypodermatic  injection  of  strych- 
nin. In  extreme  syncope,  which  is  most  apt  to  occur  from  chloroform,  do 
not  wait  for  breathing  to  cease,  but  suspend  the  anesthetic,  lower  the  head 
of  the  bed,  open  the  mouth  with  the  gag,  catch  the  tongue,  and  make  rhyth- 
mical traction  while  an  assistant  is  making  slow  artificial  respiration.  If  the 
patient  does  not  at  once  improve,  invert  him  completely,  holding  him  by  the 
legs  and  continuing  artificial  respiration  by  compressing  the  stermmi  (Ne- 
laton).  By  continuing  artificial  respiration  the  blood  is  urged  on  through 
the  heart.  Give  hypodermatic  injections  of  atropin,  ether,  or  even  of  am- 
monia. Put  mustard  over  the  heart  and  spine.  Employ  faradism  to  the 
phrenic  nerve  (one  pole  to  the  epigastric  region,  the  other  to  the  right  side 
of  the  root  of  the  neck).  Let  fresh  air  into  the  room,  put  hot- water  bottles 
around  the  legs,  apply  friction  to  the  extremities,  wrap  the  patient  in  hot 
blankets,  give  an  enema  of  hot  salt  solution,  and  hold  ammonia  to  the  nose. 
In  some  cases  of  anesthetic  poisoning  direct  heart  massage  has  been  successfully 
employed.  The  method  was  suggested  by  Schliff  in  1874.  Frazier  was  oper- 
ating for  hydrocele  when  the  patient's  respiration  ceased  and  his  pulse  disap- 
peared. Frazier  at  once  opened  the  abdomen  and,  with  one  hand  on  the 
chest  wall  and  the  other  against  the  diaphragm,  "massaged  the  heart  at 
the  rate  of  15  to  20  movements  a  minute."  In  about  two  minutes  car- 
diac contractions  were  perceptible.  In  about  eight  minutes  resuscitation 
was  complete  ("Jour.  Am.  Med.  Assoc,"  May  20,  191 1).  In  Conkling's 
case  there  was  a  chest  wound  exposing  the  lung.  The  heart  ceased  to 
beat.  The  surgeon  grasped  the  heart  between  the  fingers  and  made  com- 
pressions. In  less  than  a  minute  he  detected  a  thrill,  and  in  a  few  seconds 
more  regular  pulsation  began  ("New  York  Med.  Jour.,"  Sept.  2,  1905).  In 
Sencert's  successful  case  an  operation  was  being  done  for  gall-stones  when 
collapse  occurred,  and  the  surgeon  stroked  and  kneaded  the  heart  through  the 
diaphragm.  In  a  case  recorded  in  the  "Brit.  Med.  Jour.,"  Nov.  18,  1905, 
respiration  and  pulse  had  ceased  three  minutes  when  the  abdomen  was  opened 
and  the  heart  was  kneaded.  Recovery  ensued.  Miiller,  of  Hamburg,  advo- 
cates exposing  and  opening  the  pericardium  to  perform  massage,  introducing 
oxygenated  salt  solution  into  a  vein,  opening  the  trachea,  and  performing  arti- 
ficial respiration.  Frazier  ("Progressive  Medicine,"  March,  191 1)  publishes 
statistics  of  50  collected  cases.  These  figures  indicate  that  the  subdiaphrag- 
matic method  is  more  successful  than  either  the  direct  method  or  the  trans- 
diaphragmatic method.     The  table  is  as  follows: 

Successful.                 ^P-S.  F^^""^^^-  Total. 

Direct 2                           8  18  28 

Transdiaphragmatic  ..01  2  3 

Subdiaphragmatic. ...                8                            5  6  i£ 

10                          14  26  50 

Leonard  Hill  holds  that  in  the  failure  which  arises  soon  after  administration  of 
chloroform  is  begun  the  trouble  is  due  to  vasomotor  paralysis  with  starvation 
of  the  nerve-centers.     In  such  a  case  he  applies  abdominal  compression  and 


I204  Anesthesia  and  Anesthetics. 

inverts  the  patient,  making  artificial  respiration  at  the  same  time.  In  the 
failure  which  occurs  after  considerable  chloroform  has  been  taken  there  are 
paralytic  distention  of  the  heart,  fulness  of  the  venous  system,  and  loss  of 
the  compensations  for  the  hydrostatic  effects  of  gravity.  In  such  a  con- 
dition empty  the  distended  heart  of  venous  blood  by  raising  the  patient 
into  an  erect  position,  and  after  a  moment  place  him  recumbent  and  make 
artificial  respiration. 

Forgetting  to  breathe  is  met  by  removing  the  inhaler  and  waiting  a  moment; 
a  breath  will  usually  be  taken  soon;  but  if  it  is  not  taken,  somewhat  forcibly 
knead  the  structures  in  the  arm-pit.  If  this  fails,  open  the  mouth  and  pull 
forward  the  tongue;  this  causes  a  reflex  inspiration.  Cyanosis  is  practi- 
cally not  encountered  when  oxygen  is  given  with  ether  or  chloroform.  Cyano- 
sis, if  slight  and  due  to  cough  or  struggling,  is  met  by  removing  the  inhaler 
while  the  patient  takes  a  breath  or  two  of  air.  If  position  is  responsible  for 
cyanosis,  correct  it.  In  empyema,  lying  upon  the  sound  side  may  produce  it. 
Obstruction  to  breathing  may  be  due  to  bending  down  the  head.  If  due 
to  stenosis  of  the  nares  in  a  person  without  teeth,  hold  the  lips  apart  with  a 
finger.  If  due  to  collection  of  mucus,  wipe  the  mucus  out  of  the  mouth  by 
means  of  bits  of  gauze  firmly  clamped  in  forceps;  raise  the  shoulders,  extend  the 
head  and  place  it  on  its  side  in  order  that  mucus  may  run  out  of  the  angle  of 
the  mouth;  and  give  a  dose  of  atropin  hypodermatically.  If  the  amount  of 
mucus  is  large  and  the  secretion  is  persistent,  it  may  be  necessary,  especially 
in  children,  to  empty  the  respiratory  passages  by  inverting  the  patient.  In 
cases  of  excessive  bronchial  secretion  we  fear  the  development  of  pulmonary 
edema  or  postoperative  bronchopneumonia. 

Dudley  W.  Buxton  points  out  that  duskiness  will  often  pass  away  if 
ether  is  removed,  one  or  two  inhalations  of  chloroform  given,  and  ether  then 
continued.  If  in  any  case  cyanosis  is  severe  or  grows  worse,  suspend  the 
drug,  dash  cold  water  in  the  face,  force  open  the  jaws,  pull  forward  the  tongue, 
make  artificial  respiration  until  a  breath  is  taken,  and  then  give  oxygen  for 
a  time.  If  these  means  fail,  stretch  the  sphincter  ani  and  bleed  from  the 
external  jugular  vein.  If  a  breath  is  not  now  taken,  do  tracheotomy.  In 
respiratory  or  heart  failure  forced  artificial  respiration  by  Fell's  method  is 
of  great  value  (see  page  896).  The  pulmotor,  if  at  hand,  enables  the  sur- 
geon to  maintain  regular  artificial  respiration  for  an  indefinite  time  (see  page 
867).  Swallowing  the  tongue  is  corrected  by  pulling  the  tongue  forward.  If 
it  tends  to  recur,  lay  the  head  upon  its  side  or  keep  the  tongue  anchored  with 
forceps.  Closure  of  the  epiglottis  is  corrected  by  pulling  the  patient's  head 
over. the  edge  of  the  table  and  pushing  strongly  back  upon  his  forehead.  This 
maneuver  lifts  the  hyoid  bone,  and  with  it  the  epiglottis.  The  epiglottis  can 
be  lifted  by  passing  a  spoon-handle  or  the  index-finger  over  the  dorsum  to  the 
base  of  the  tongue  and  pressing  forward.  If,  in  obstruction  to  respiration,  the 
above  means  fail,  make  artificial  respiration  at  once  (see  page  864);  if  ob- 
struction continues,  perform  tracheotomy. 

Edema  of  the  lungs  is  treated  by  instant  venesection,  the  inhalation  of 
nitrite  of  amyl,  and  the  administration  of  stimulants  and  nitroglycerin  hypo- 
dermatically. Sometimes  during  the  anesthetic  state  the  muscles  of  the  belly 
become  very  rigid,  a  condition  which  greatly  interferes  with  an  abdominal 
operation.  It  may  arise  during  cyanosis,  and  if  so  caused  is  amended,  as 
cyanosis  abates  under  proper  treatment.  In  some  cases  it  is  due  to  the 
fact  that  sufficient  anesthetic  has  not  been  given.  If  the  air-passages  are 
obstructed  before  operation,  abdominal  rigidity  is  apt  to  arise.  In  some 
cases  it  seems  impossible  to  overcome  it  with  ether.  In  such  a  case,  if 
the  anesthetist  is  a  trusted  man,  anesthetize  the  patient  with  gas  and  ether 
and  then  give  chloroform  (Blumfield,  in  ''Lancet,"  May  31,  1902). 


After-effects  of  Anesthetics  1205 

The  Reaction  from  Anesthesia. — When  ether  or  chloroform  is  given, 
a  considerable  quantity  is  swallowed  and  either  drug  irritates  the  stomach 
and  creates  nausea  and  often  vomiting.  The  longer  the  operation,  the  more 
of  the  anesthetic  enters  the  stomach,  and  the  greater  the  liability  to  subse- 
quent vomiting.  At  the  termination  of  a  prolonged  operation  upon  an 
adult,  if  the  patient's  condition  admits  of  it,  and  if  the  nature  of  the  operation 
does  not  forbid  it,  I  like  to  have  a  stomach-tube  passed  and  the  stomach 
well  washed  out  with  warm  water.  The  washings  smell  strongly  of  the 
anesthetic,  and  the  procedure  greatly  lessens  the  severity  and  frequency  of 
postoperative  vomiting  (Geo.  S.  Brown,  in  "Surg.,  Gynec,  and  Obstet., 
August,  1905).  After  the  administration  of  the  anesthetic  has  been  sus- 
pended and  the  operation  has  been  completed  the  temperature  is  usually 
subnormal.  The  patient  must  be  watched  until  consciousness  returns.  If 
he  is  left  alone,  a  change  of  posture  may  lead  to  arrest  of  feeble  respiration, 
the  assmnption  of  the  erect  position  may  cause  fatal  syncope,  and  mucus  or 
vomited  matter  may  block  the  air-passages  and  cause  suffocation.  The  best 
position  to  place  him  m  is  the  recumbent,  the  head  being  level  with  the  bodv 
or  somewhat  lower  and  the  side  of  the  face  resting  on  the  pillow.  Shock  is 
treated  by  ordinary  methods  (see  page  262).  The  inhalation  of  oxygen  is 
of  great  value  in  rousing  a  patient  from  the  state  of  anesthesia,  and  will 
often  prevent  vomiting.  If  vomiting  occmrs,  the  head  should  be  upon  its 
side  or  should  be  held  over  the  edge  of  the  bed,  and  after  the  spell  of  vomit- 
ing the  mouth  must  be  wiped  clean.  The  face  should  be  washed  with  cold 
water  and  be  fanned  rather  actively.  It  is  the  routine  practice  of  some 
surgeons  to  administer  vinegar  by  inhalation  during  the  reaction  from  an 
anesthetic.  This  proceeding  sometimes  seems  to  prevent  vomiting.  Some 
patients  awake  from  anesthesia  as  from  a  quiet  sleep;  others  are  noisy,  tur- 
bulent, and  \iolent.  The  duration  of  the  period  of  reaction  varies  with  the 
anesthetic  used,  the  amoimt  given,  and  the  personal  tendencies  of  the  patient. 
The  patient  must  not  be  allowed  to  sit  up  for  several  hours  at  least.  No  food 
is  to  be  allowed  for  at  least  six  hours.  Unless  the  operation  was  upon  the 
stomach,  I  do  not  forbid  water,  but  allow  the  patient  to  drink  freely  of  hot 
water.  This  dilutes  any  irritant  material  in  the  stomach  and  dissolves  mucus, 
and  if  vomiting  does  occur  it  serves  to  wash  the  stomach  out.  All  fat  patients, 
all  patients  with  respiratory  difi&culties,  or  in  whom  we  apprehend  respiratory 
compHcations  should,  if  there  is  no  contra-indication,  be  placed  in  a  sitting  or, 
at  least,  a  semi-erect  posture  as  soon  as  reaction  from  anesthesia  is  obtained. 
If  this  plan  is  followed,  ether-pnetmionia  and  other  respiratory  troubles  will 
verv^  seldom  develop. 

After=effects  of  Anesthetics. — Vomiting, — I  am  convinced  that  in 
many  cases  postanesthetic  vomiting  is  due  or  is  largely  due  to  irritation  of  the 
stomach  caused  by  swallowing  considerable  quantities  of  an  irritant  anes- 
thetic. The  liability  to  it  is  greatly  lessened  by  washing  out  the  stomach 
before  the  patient  leaves  the  operating  table,  and  allowing  the  patient  (in 
suitable  cases)  to  drink  freely  of  hot  water  as  soon  as  he  returns  to  conscious- 
ness. Most  patients  vomit  more  or  less,  but  if  the  man  has  been  drinking  hot 
water  an  act  of  vomiting  washes  out  his  stomach  and  he  may  not  vomit  again. 
Violent  vomiting  may  occuj  in  spite  of  all  our  efforts,  and  may  persist  for  hours, 
greatly  exhausting  the  patient  and  doing  infinite  harm,  it  may  be,  especially 
if  the  operation  were  upon  the  brain  or  an  intra-abdominal  structure.  If  vomit- 
ing continues,  forbid  food  absolutely.  Verv^  hot  water  in  doses  of  a  teaspoonful 
should  be  given  at  frequent  intervals.  Drafts  of  hot  water  may  relieve  the 
condition  by  washing  out  the  mucus  from  the  stomach.  Other  remedies  which 
may  succeed  are:  inhalations  of  vinegar,  hot  black  coffee  by  the  mouth,  a  mus- 
tard plaster  over  the  stomach,  fresh  air  in  the  room,  small  pieces  of  ice  placed 


i2o6  Anesthesia  and  Anesthetics 

in  the  mouth  and  sucked,  small  doses  of  iced  champagne,  and  drop  doses  of  a 
3  per  cent,  solution  of  cocain  or  3-drop  doses  of  a  5  per  cent,  solution  of  eucain. 
The  best  remedy  for  persistent  vomiting  is  lavage  of  the  stomach.  Some 
persons,  as  Dudley  W.  Buxton  points  out,  suffer  greatly  from  nausea,  although 
there  is  little  or  no  vomiting.  In  such  cases  Buxton  uses  i  min.  of  tincture  of 
mix  vomica  in  a  teaspoonful  of  hot  water  every  ten  minutes  until  six  doses  have 
been  taken.  If  this  plan  fails,  he  gives  drop  doses  of  wine  of  ipecac  or  minim 
doses  of  dilute  hydrocyanic  acid.^ 

Vomiting  from  chloroform  is  usually  more  difficult  to  check  than  vomiting 
from  ether.  In  any  case  of  persistent  vomiting  examine  for  acidosis  (see  page 
1207). 

Backache. — This  is  a  very  common  and  often  a  very  distressing  consequence 
of  anesthesia.  It  is  complained  of  soon  after  consciousness  is  regained,  it  may 
persist  for  several  days,  and  it  is  a  not  uncommon  cause  of  wakefulness. 
It  is  usually  greatly  aggravated  by  turning  and  twisting,  and  by  attempting 
to  rise  up  from  the  bed.  The  pain  is  located  in  the  lumbar  and  sacral  regions 
and  is  often  accompanied  by  rigidity  of  the  lumbar  muscles.  Various  ex- 
planations have  been  given  of  it.  One  \dew  is  that  it  is  due  to  renal  congestion. 
Another,  that  it  results  from  congestion  of  the  spinal  cord.  I  believe  that  the 
explanation  of  most  cases  is  that  given  by  John  Dunlop  f'Xew  York  Med. 
Jour.,"  July  10,  1909),  viz.:  "The  patient  during  the  operation  lay  upon  a  flat 
table  without  support  to  the  lumbar  curve,  consequently  the  sacro-iliac  syn- 
chondroses were  strained.  The  backache  may  be  largely  prevented  by  placing 
a  small  pillow  so  that  it  wall  support  the  lumbar  curve  during  anesthesia." 

Respiratory  disorders  are  more  often  noted  after  ether  than  after  chloro- 
form. Bronchitis  may  follow  or  bronchopneumonia  (ether-pneumonia). 
Respiratory  difficulties  may  be  due  to  chilling  the  patient  by  bringing  him 
from  a  warm  operating  room  through  a  cold  hall  and  into  a  cool  bedroom. 
Bronchopneumonia  is  especially  common  in  septic  patients,  and  may  be 
due  in  some  cases  to  septic  emboli  and  in  others  to  aspiration  of  septic  material 
into  the  bronchi  (cases  of  cancer  of  the  tongue  and  pharynx,  and  cases  with 
stercoraceous  vomiting).  They  are  treated  by  ordinary  methods.  If  chloro- 
form is  given  when  a  gas-light  is  in  the  room  the  vapor  is  decomposed  and 
certain  highly  irritant  products  are  formed,  which,  when  inhaled,  produce 
laryngeal  spasm  and  possibly  bronchitis.  The  irritant  material  is  probably 
COCI3.  The  treatment  is  to  admit  fresh  air  freely  into  the  room,  and  to  have 
the  patient  inhale  ^dnegar  and,  later,  oxygen.  Ether-pneumonia  must  not  be 
confounded  with  postoperative  pneiunonia,  described  by  Wm.  H.  Bennett.^ 
This  latter  condition  may  arise  from  seven  to  fourteen  days  after  operation  in 
robust,  gouty  people,  and  is  usually  unilateral.  Some  cases  of  respiratory 
disorder  result  from  chilling  while  in  the  operating  room,  or  while  coming  from 
it,  rather  than  from  the  anesthetic.  If  the  patient  is  placed  in  a  sitting  posi- 
tion or,  at  least,  semi-erect  in  bed,  as  soon  as  he  reacts  from  the  anesthetic 
the  danger  of  serious  respiratory  disorder  -will  be  at  a  minimum. 

Renal  Complications. — After  the  administration  of  an  anesthetic,  blood,  albu- 
min, sugar,  acetone,  or  diacetic  acid  may  appear  in  the  urine,  and  the  secretion 
may  become  scanty  or  even  be  suppressed.  It  is  usually  maintained  that  chloro- 
form is  less  apt  to  irritate  the  kidney  epithelium  than  ether,  but  there  has  been 
much  dispute  on  this  point.  If  casts  and  albumin  are  present  before  anestheti- 
zation, the  condition  may  be  rendered  worse  if  ether  or  chloroform  is  given. 
If  neither  casts  nor  albumin  are  present,  they  will  not  be  so  apt  to  appear 
after  taking  chloroform  as  after  taking  ether,  but  if  they  do  appear  after 
chloroform,  they  remain  longer  than  after  ether  (Legrain).     The  truth  of 

1  "Anesthetics,"  by  Dudley  W.  Buxton. 

2  "Practitioner,"  December,  1896. 


Acid  Intoxication 


1207 


the  matter  probably  is,  that  if  the  kidneys  are  healthy  a  small  or  moderate 
amount  of  either  drug  is  not  particularly  irritant;  but  if  the  kidneys  are  dis- 
eased, a  small  amount,  and  even  if  they  are  healthy,  a  large  amount,  of  either 
drug  produces  decided  renal  irritation.  Chloroform  is  less  irritant  because 
less  chloroform  than  ether  is  given  to  secure  and  maintain  anesthesia.  Scanti- 
ness or  suppression  of  urine  may  be  due  to  operative  shock  rather  than  to 
ether  or  chloroform.  If  the  urine  becomes  somewhat  scanty  or  if  albumin 
appears  in  it,  give  non-irritant  diuretics,  diaphoretics  and  cathartics,  and 
employ  proctoclysis.  The  treatment  of  acidosis  is  set  forth  below.  If  the 
urine  becomes  very  scanty,  use  h}-podermoclysis.  If  postoperative  suppres- 
sion arises,  it  is  the  usual  custom  to  give  intravenous  infusion  of  hot  saline 
fluid,  but  I  am  doubtful  of  its  value.  Exposure  of  each  kidney  in  the  loin 
and  incision  of  its  capsule  to  reheve  tension  is  justifiable  and  may  do  good. 

Acid  Intoxication. — This  condition  has  been  called  delayed  poisoning, 
acetonuria,  and  acidosis.  Diabetic  coma  is  due  to  acid  intoxication.  It  is 
knowTi  that  even  in  healthy  urine  there  may  be  a  trace,  but  a  bare  trace,  of 
acetone.  A  diabetic  indi\'idual  deprived  absolutely  of  carbohydrates  is  apt  to 
get  acetone  and  diacetic  acid  in  the  urine.  In  such  cases  carbohydrates  cause 
the  prompt  disappearance  of  the  acetone  and  diacetic  acid.  In  a  case  which 
shows  acetonuria  before  operation  Bonn  gives  glucose  as  a  prophylactic 
("Brit.  Med.  Jour.,"  Feb.  25,  191 1).  Even  people  who  do  not  suffer  from 
diabetes  may  develop  acetonuria  after  anesthesia.  In  certain  cases  in  which 
dangerous  s}Tnptoms  arise  after  anesthesia  the  urine  shows  increased  acidity, 
may  contain  albimiin  or  casts,  and  contains  acetone  bodies  (particularly  ,5-oxy- 
but\Tic  acid),  diacetic  acid,  or  both  of  these  substances.  The  blood  contains 
an  excess  of  free  fat  and  shows  diminution  of  alkalinity.  Acid  intoxication  is 
ver}'  much  commoner  after  the  administration  of  chloroform  than  of  ether,  but 
may  follow  the  gi^ing  of  any  general  anesthetic.  It  may  occin  in  indi^-iduals 
whose  tissues  contain  areas  of  fatty  degeneration,  but  it  also  occurs  in  those 
entirely  free  from  degeneration;  in  fact,  chiLdren  particularly  sufi'er  in  this  way 
after  the  use  of  chloroform.  The  actual  operation  has  nothing  to  do  with  the 
trouble,  and  sepsis  is  not  causative.  The  drug  used  as  an  anesthetic  causes 
acute  fattv  degeneration  of  the  liver  and  other  organs,  quantities  of  toxins  are 
formed,  and  these  toxins  cause  the  s}Tnptoms.  Diacetic  acid  and  /^-ox^'butyric 
acid  are  by-products  of  the  process  and  are  antecedents  or  precursors  of  acetone. 
The  s}Tnptoms  arise  after  the  patient  has  emerged  from  anesthesia  and  reacted 
from  shock.  There  is  persistent  vomiting  of  thin  and  foul  fluid,  the  patient  is 
extremely  restless  and  much  excited,  there  may  be  delirium,  but  dulness  and 
heaA-iness  may  take  the  place  of  restlessness  and  excitement  and  coma  may  arise 
(J.  A.  Kelly,  in  "Annals  of  Surg.,"  Feb.,  1905) .  Usually  the  temperature  is  sub- 
normal, but  sometimes  there  is  elevated  temperature.  In  many  cases  jaundice 
arises.  There  is  an  odor  of  acetone  on  the  breath.  Latent  cases  free  from  s}Tnp- 
toms  usuaU}^  get  weU.  Slight  cases  and  even  some  grave  cases  recover,  but  most 
of  the  grave  cases  die  in  from  one  to  five  days.  A  knowledge  of  this  condition  ex- 
plains some  othern-ise  inexpHcable  deaths,  and  also  some  cases  of  persistent  post- 
operative vomiting  and  of  retarded  convalescence.  In  acid  intoxication  there  is 
fatty  degeneration  of  the  kidneys,  of  the  fiver,  of  the  suprarenal  glands,  and  of 
the  gastric  mucosa.  The  occurrence  of  such  a  condition  is  anjmpressive  admoni- 
tion that  a  surgeon  should  operate  quickly,  that  as  fittle  of  the  anesthetic  should 
be  given  as  possible,  that  the  urine  should  be  carefuUy  examined  each  day  after 
operation  for  certainly  several  days,  and  that  chloroform  should  not  be  used  for 
prolonged  administration.  The  indication  for  treatment  is  to  saturate  the 
patient  with  alkafis.  Sodium  carbonate  is  usually  selected.  It  may  be  given 
by  the  rectum,  by  the  mouth,  by  h^-podermoch-sis,  or  intravenously.  Rectal 
-administration  produces  irritation  and  diarrhea.     In  acetonuria  without  clinical 


i2o8  Anesthesia  and  Anesthetics 

symptoms  alkalinize  the  urine  by  4  or  5  dr.  of  sodium  bicarbonate  daily,  given 
by  the  mouth.  When  the  urine  becomes  alkahne  it  is  to  be  kept  so.  When 
symptoms  appear  give  from  10  to  20  teaspoonfuls  a  day  by  the  mouth.  If 
symptoms  do  not  soon  disappear  give  the  drug  intravenously.  Severe  acid 
intoxication  is  treated  as  follows:  Encourage  skin  activity  by  wrapping  the 
patient  in  blankets  and  surrounding  him  with  hot-water  bags.  Give  carbon- 
ate or  bicarbonate  of  sodium  intravenously.  A  solution  of  bicarbonate  of  a 
strength  of  from  3  to  5  per  cent,  is  used.  Labbe  gives  from  i  to  2  liters.  If 
the  patient  improves,  the  sodium  bicarbonate  is  again  given  by  mouth.  Some 
surgeons  give  citrate  of  sodiiun.  Drennan  gives  a  salt  of  calcium.  Bevan  and 
Farill  ("Jour.  Am.  Med.  Assoc,"  Sept.  20,  1905)  reported  i  case  and  collected 
27  from  literature.  In  this  series  there  were  2  recoveries.  (On  this  subject  see 
Lewis  Beesly,  in  "Brit.  Med.  Jour.,"  May  19,  1906;  J.  A.  Kelly,  in  "Annals  of 
Surgery,"  Feb.,  1905;  A.  D.  Bevan  and  H.  B.  Farill,  in  "Jour.  Am.  Med. 
Assoc,"  Sept.  20,  1905;  Geo.  E.  Brewer,  in  "Transactions  Am.  Surg.  Assoc," 
vol.  XX,  1902;  Labbe,  in  "Arch.  gen.  demed.,"Dec.,  1911,  and  in  "Pressemed.," 
Feb.  5,  1910;  Braun,  in  "Brit.  Med.  Joiu.,"  Feb.  25,  1911.) 

Postanesthetic  Paralysis  or  Narcosis  Palsy. — Paralysis  may  arise  during 
anesthesia  as  a  result  of  cerebral  hemorrhage  or  embolism. 

It  sometimes  happens  that  w^hen  a  person  has  come  out  of  the  anesthetic 
sleep  a  palsy  of  some  part  is  found  to  exist,  the  condition  being  peripheral  and 
not  central  in  origin.  Peripheral  narcosis  palsies  are  pressure  palsies,  although 
it  is  held  by  some  that  the  anesthetic  has  a  toxic  influence  which  distinctly  lowers 
•the  capacity  of  the  nerves  to  sustain  pressure.  Certain  it  is  that  palsy  some- 
times follows  what  seems  a  degree  of  pressure  inadequate  to  cause  such  a 
result.  Narcosis  palsies  may  be  due  to  pressure  of  an  extremity  upon  a  table 
edge  or  to  pressure  upon  nerves  by  placing  the  patient  in  certain  positions.^ 
When  the  Trendelenburg  position  has  been  employed,  the  flexures  of  the  knees 
are  in  contact  with  the  edge  of  the  table,  and  paralysis  of  one  or  both  external 
popliteal  nerves  may  be  induced.  When  the  patient  lies  upon  the  side  any 
nerve  of  the  arm  or  forearm  may  suffer,  but  the  circumflex  and  radial  are  most 
liable  to  be  damaged.  When  the  arm  is  elevated  to  the  side  of  the  head,  or  when 
it  is  drawn  out  strongly  from  the  body,  the  brachial  plexus  may  be  compressed 
by  the  head  of  the  humerus  (Braun,  in  "Deutsche  Med.  Woch.,"  1894).  When 
the  arm  is  in  external  rotation  and  is  drawn  backward  and  outw^ard  the  median 
nerve  is  stretched,  and  when  the  forearm  is  flexed  and  supinated  the  ulnar 
nerve  is  stretched  (Braun,  Ibid.).  In  most  cases  the  paralysis  involves  muscles 
supplied  by  the  brachial  plexus  and  is  due  to  drawing  the  arm  upward  and 
backward  over  the  head,  a  position  which  may  squeeze  the  cords  of  the  plexus 
between  the  collar-bone  and  the  first  rib.  Garrigues  shows  that  the  plexus 
is  particularly  apt  to  be  squeezed  when  it  is  stretched  by  the  head  being 
drawn  to  the  opposite  side  or  being  aUowed  to  fall  back.'  According  to 
Biidinger  the  mounting  up  of  the  clavicle  squeezes  the  plexus  as  its  cords 
cross  the  first  rib.  This  surgeon  thinks  that  extreme  abduction  of  the  arm 
may  squeeze  the  cords. 

Postanesthetic  peripheral  paralysis  is  most  common  in  the  arm,  but  may 
occur  in  the  leg  or  face.  The  prognosis  is  good,  as  a  rule.  Slight  cases  are  soon 
recovered  from;  more  serious  cases,  in  which  degeneration  occurs,  may  not  be 
recovered  from  for  months.     The  treatment  is  that  of  any  pressure  palsy. 

Primary  Anesthesia. — Instruct  the  patient  to  count  aloud  and  hold 
one  arm  above  his  head.  Give  the  ether  rapidly.  In  a  short  time  he  be- 
comes mixed  in  his  count  and  his  arm  sways  or  drops  to  the  side.  There 
is  now  a  period  of  insensibility  to  pain  lasting  only  about  half  a  minute,  and 

1  H.  J.  Garrigues,  in  "Am.  Jour.  Med.  Sciences,"  Jan.,  1897. 

2  Ibid. 


Ethyl  Bromid  1209 

during  this  period  a  minor  operation  can  be  performed.  The  patient  quickly 
reacts  from  primary  anesthesia  without  vomiting  (Packard). 

Mixtures  are  used  by  some  because  of  the  belief  that  a  mixture  might 
eliminate  some  unpleasant  feature  or  some  danger  from  a  particular  anesthetic. 

Mixture  of  Ether  and  Chloroform. — This  may  be  used  in  varying  propor- 
tions.    Hewitt  at  times  employs  2  parts  of  chloroform  to  3  parts  of  ether. 

Vienna  mixture  contains  i  part  of  chloroform  and  3  parts  of  ether. 

Mixtxire  of  Alcohol  and  Chloroform. — All  the  chloroform  mixtures  pro- 
duce the  effects  of  chloroform,  but  we  are  gi^'ing  the  drug  in  an  unknown  amount. 
It  was  believed  by  Sansom,  who  devised  this  mixture,  that  the  alcohol  prevents 
concentration  of  chloroform  vapor  by  retarding  evaporation.  When  used, 
I  part  of  alcohol  is  added  to  4  parts  of  chloroform. 

Nitrous  Oxid  and  Oxygen. — (See  page  1211.) 

A.  C.  E.  Mixture. — This  mixture  was  originally  used  by  Harley  in  1864.  It 
is  often  valuable  in  cases  in  which  ether  cannot  be  given.  It  is  composed  of  i 
part  of  alcohol,  2  parts  of  chloroform,  and  3  parts  of  ether.  Its  action  is 
supposed  to  be  between  that  of  chloroform  and  ether.  The  objection  to  the 
A.  C.  E.  mixture,  as  to  any  mixture,  is  that  the  materials  do  not  evaporate  in 
the  ratio  in  which  they  are  mixed,  hence  an  uncertain  amount  of  chloroform 
vapor  is  being  inhaled  (Buxton).  This  mixture  is  given  by  some  from  a 
Jimker  and  by  others  from  an  open  inhaler.  Plenty  of  air  should  be  given 
with  it.     The  anesthetic  acts  similarly  to  chloroform. 

Billroth' s  mixture  contains  i  part  of  alcohol,  3  parts  of  chloroform,  and  i 
part  of  ether. 

Schleich's  Mixture  for  General  Anesthesia. — Schleich,  in  1895,  introduced 
a  nrd.'  anesthetic  agent  W'hich  he  claims  is  safer  than  chloroform.  This  sur- 
geon maintains  that  a  material  is  safe  as  an  anesthetic  only  when  almost  all 
of  the  amoimt  taken  in  at  an  inspiration  is  expelled  on  expiration.  The 
anesthetic  is  unsafe  in  direct  proportion  to  the  amount  absorbed;  and  the 
lower  the  boiling-point  of  an  anesthetic,  the  less  is  absorbed,  hence  an  anes- 
thetic agent,  to  be  safe,  should  have  a  low  boiling-point.  Schleich  makes 
three  solutions.  The  first  contains  (by  volume)  i|  oz.  of  chloroform,  |  oz. 
of  petroleiun  ether,  and  6  oz.  of  sulphuric  ether.  The  second  contains  i|  oz. 
of  chloroform,  ^  oz.  of  petroleum  ether,  and  5  oz.  of  sulphuric  ether.  The 
third  contains  i  oz.  of  chloroform,  |  oz.  of  petroleum  ether,  and  2§  oz.  of 
sulphuric  ether.  No.  i  is  used  for  light  anesthesia,  No  2  for  medium  anesthe- 
sia, and  No.  3  for  deep  anesthesia.  The  anesthetic  can  be  given  from  an  open 
inhaler  or  a  towel.  The  anesthetic  state  is  quiet,  reaction  is  rapid,  and  vomiting 
occurs  in  but  half  the  cases.  The  superiority  of  this  new  anesthetic  has  not 
been  proved.  It  sometimes  causes  dangerous  symptoms,  and  has  produced 
death.  Some  surgeons,  who  formerly  approved  of  it,  have  abandoned  it.  It  will 
certainly  not  displace  ether  or  chloroform.  Schleich's  mixtures  are  now  seldom 
or  never  used  in  the  United  States.  Petroleiun  ether  has  no  anesthetic  power, 
and  Meltzer  shows  that  it  is  dangerous  and  tends  to  paralyze  the  respira- 
tory muscles.  Willy  Meyer  ("Med.  Record,"  August  15,  1908)  believes 
in  the  Schleich  principle,  but  substitutes  ethyl  chlorid  with  a  boiling-point  of 
59°  F.  for  the  petroleum  ether.  He  uses  17  per  cent,  volume  of  ethyl  chlorid 
with  83  per  cent,  volume  of  the  molecular  mixture  of  ether  and  chloroform. 

Ethyl  bromid  was  first  used  by  Nunneley,  of  Leeds,  in  1S49.  It  was  re- 
introduced in  1S82  and  again  in  1896.  It  is  still  sometimes  used  for  short  opera- 
tions. It  is  given  while  the  patient  is  recumbent.  The  unconsciousness  is 
obtained  in  from  one  to  three  minutes  and  is  rapidly  recovered  from,  and  there 
is  no  after-sickness.  The  unconsciousness  lasts  about  three  minutes.  Three 
dr.  are  given  to  a  child,  and  6  dr.  to  an  adult.  A  towel  is  put  over  the  face 
and  the  entire  amount  is  poured  on  at  once,  and  as  soon  as  the  patient  is  uncon- 


I2IO  Anesthesia  and  Anesthetics 

scious  the  towel  is  taken  away  and  no  more  of  the  drug  is  given  (Cumston). 
Even  if  consciousness  is  regained  too  quickly  to  suit  the  purposes  of  the  surgeon, 
it  is  not  safe  to  give  more  of  the  drug,  a  notable  objection  which  chlorid  of 
ethyl  does  not  possess.  Cases  have  been  reported  in  which  sudden  death 
has  followed  the  administration  of  this  drug,  and  it  should  not  be  given  if 
there  is  disease  of  the  heart,  lungs,  or  kidneys.^  Twenty-four  deaths  from 
bromid  of  ethyl  are  on  record  (Guadiana).  If  it  kills,  it  acts  like  chloroform. 
It  may  be  given  before  ether  to  prevent  unpleasant  effects,  but  it  is  usually  not 
considered  proper  to  give  before  chloroform.  Zematski,  however,  has  used 
it  before  chloroform  in  2000  cases  ("Vratch,"  August  25,  1901J.  I  know  of  2 
unpubHshed  deaths  from  it  in  Philadelphia.  I  never  use  it  and  regard  it  as 
imsafe.  The  drug  rapidly  deteriorates,  and  the  deteriorated  drug  is  very  dan- 
gerous. 

Chlorid  of  ethyl  is  a  rapid  anesthetic  and  statistics  imply  that  it  is  a 
safe  one.  My  faith  in  it  has  been  greatly  shaken  by  knowledge  of  3  un- 
published deaths  in  Philadelphia.  It  was  first  used  by  Heyfelder  in  1848. 
A  committee  of  the  British  Medical  Association  condemned  it  in  1880.  Carlson 
and  Thiesing  reintroduced  it  in  1895  (McCardie,  in  "Lancet,"  xA.pril  4,  1903). 
It  may  be  sprayed  upon  a  mask  covered  by  six  to  eight  layers  of  gauze,  so  that 
the  drug  T\nll  not  evaporate  too  quickly  in  the  air.  Many  anesthetists  give  it 
in  a  closed  apparatus,  the  patient  respiring  into  and  from  a  rubber  bag.  I 
beHeve  it  should  be  mixed  ^nth  air  and  that  concentrated  vapor  is  a  danger  to 
the  heart.  The  odor  of  the  drug  is  agreeable.  From  5  to  10  gm.  of  ethyl 
chlorid  are  given  for  a  short  operation  if  the  mask  is  used.  The  patient  must 
always  be  recumbent  when  taking  it.  Early  in  the  inspiration  the  pulse  and 
respiration  become  rapid.  When  unconsciousness  comes  they  should  be  nor- 
mal. The  anesthetic  state  is  induced,  when  the  mask  is  used,  in  from  two  to 
three  minutes,  and  as  soon  as  it  is  obtained  the  patient  is  allowed  to  get  air. 
If  the  closed  inhaler  is  used  unconsciousness  is  obtained  more  rapidly.  Excite- 
ment does  not  precede  unconsciousness.  The  anesthetic  condition  lasts  from 
one  to  three  minutes,  and  it  is  recovered  from  rapidly,  usually  without  vomiting 
or  unpleasant  after-effects.  If  the  patient  recovers  too  rapidly  for  the  surgeon's 
purpose,  more  ethyl  chlorid  can  be  given.  It  is  to  be  noted  that  complete  mus- 
cular relaxation  does  not  occur,  in  many  cases  the  conjunctival  reflex  is  not 
completely  abolished,  and  often  the  pupils  do  not  dilate.  It  has  no  superiority 
over  nitrous  oxid,  except  as  to  cost  and  portability,  and  sometimes  it  fails  to 
produce  complete  imconsciousness.  K  large  dose  rapidly  given  is  dangerous, 
as  it  may  cause  cessation  of  respiration  and  spasm  of  the  diaphragm.  A  contra- 
indication to  its  use  is  any  respiratory  obstruction.  In  many  cases  there  is 
spasm  of  the  masseters.  Concentrated  vapor  administered  for  a  considerable 
time  lowers  the  blood-pressure,  induces  cyanosis  and  asphyxia,  and  would  even- 
tually cause  death  by  respiratory  failure  (McCardie,  Ibid.).  Lotheisser,  in  a 
study  of  2500  cases  of  anesthesia  by  this  agent,  reports  i  death.  Ware  col- 
lected 12,436  cases,  with  i  death  ("Jour.  Am.  Med.  Assoc,"  Nov.  8,  1902), 
Seitz,  of  Konstanz,  collected  16,000  cases,  -odth  i  death.  Miller  ("Jour.  Am. 
Med.  Assoc,"  Nov.  23,  1912)  estimates  that  there  is  i  death  in  13,365  ad- 
ministrations. It  is  perhaps  safer  than  chloroform,  not  nearly  so  safe  as 
nitrous  oxid,  and  not  so  safe  as  ether.  The  drug  is  used  for  a  brief  opera- 
tion or  examination.  It  can  be  given  to  infants  a  few  days  old  with  reasonable 
safety,  and  it  has  been  administered  many  times  to  the  aged.  WTien  it  kills,  it 
acts  in  a  similar  manner  to  chloroform.  I  have  often  given  it  before  ether  to 
prevent  unpleasant  symptoms  and  to  hasten  the  advent  of  anesthesia,  but  it 
must  never  be  given  before  chloroform.  Recently  I  have  practically  ceased 
to  administer  ethyl  chlorid. 

1  See  Cumston,  in  "Boston  Med.  and  Surg.  Jour.,"  Dec.  20,  1894. 


Nitrous  Oxid  Gas 


I2II 


Nitrous  oxid  gas  may  be  used  to  obtain  anesthesia  for  brief  operations. 
It  is  contra-indicated  when  high  blood-pressure  indicates  vascular  degeneration, 
because  apoplexy  may  follow  its  administration.  It  should  never  be  given 
when  the  air-channel  is  narrowed,  as 
in  Ludwig's  angina,  abscess  in  or  be- 
low the  tongue,  and  thyroid  enlarge- 
ment (F.  W.  Hewitt,  in  "Lancet,"  July 
20,  27,  and  August  10,  1907).  This 
gas  is  stored  in  steel  cylinders,  in 
which  it  is  liquefied.  The  gas  is 
passed  into  a  rubber  bag  (Fig.  795), 
and  is  given  to  the  patient  by  means 
of  a  tube  and  a  mouth-mask,  a  wedge 
being  placed  between  the  patient's 
molar  teeth,  and  the  nostrils  being 
closed  by  the  anesthetist's  fingers. 
The  wedge  must  be  held  by  a  string, 
so  that  it  cannot  be  swallowed.  The 
patient  becomes  unconscious  in  about 
one  minute,  and  we  know  the  patient 
is  anesthetized  by  the  stertor  and 
cyanosis  and  the  insensitiveness  of 
the  conjunctivae.  The  pulse  should 
be  watched,  and  if  it  flags  the  ad- 
ministration must  be  suspended  at 
once.  The  striking  phenomena  are 
asphyxial,  stertorous  respiration, 
cyanosis,  and  even  convulsions,  dila- 
tation of  the  pupils,  rapidity  of  the 
heart,  and  swelling  of  the  tongue.^ 
Muscular  relaxation  is  not  as  com- 
plete as  in  ether-anesthesia.  Slow- 
ing of  the  heart  is  a  danger  sign. 
If  nitrous  oxid  causes  death,  it  does 
so  by  asphyxia  or  by  asphyxia  and 
cardiac  inhibition.  A  person  rouses 
very  rapidly  when  the  administration 
of  nitrous  oxid  is  suspended.  It  is  a 
useful  plan  to  give  nitrous  oxid  first 
and  follow  this  with  ether  (see  page 
1 2 14).  By  this  method  the  patient  is  anesthetized  rapidly  and  pleasantly 
with  the  nitrous  oxid,  and  the  anesthesia  is  maintained  by  the  ether. 

It  was  formerly  taught  that  nitrous  oxid  necessarily  produces  cyanosis,  be- 
cause the  gas  can  only  cause  anesthesia  by  partially  asphyxiating  the  patient. 
We  know  this  is  untrue,  because  if  nitrous  oxid  is  mixed  with  oxygen  or  atmo- 
spheric air  anesthesia  is  obtained  without  cyanosis.  Nitrous  oxid  is  a  genuine 
anesthetic  agent.  If  a  prolonged  administration  of  nitrous  oxid  is  desired,  pure 
nitrous  oxid  can  be  given,  a  breath  of  fresh  air  being  allowed,  from  time  to  time. 
By  this  method  Preston  has  anesthetized  many  patients,  the  duration  of  the 
anesthesia  being  from  ten  to  fifty  minutes.  A  better  plan  is  to  give  nitrous  oxid 
and  oxygen.  I  am  satisfied  that  this  combination  does  not  occupy  the  place  in 
surgery  its  merits  entitle  it  to.  One  reason  is  the  absolute  necessity  of  having  a 
specially  skilled  administrator.  A  trouble  frequently  encountered  is  persistent 
rigidity.  This  can  often  be  prevented  by  a  preliminary  dose  of  morphin. 
1  See  Hewitt,  "Brit.  Med.  Jour.,"  Feb.  18,  1899. 


Fig.  795. — Hewitt's  nitrous  oxid  apparatus. 


I2I2 


Anesthesia  and  Anesthetics 


Postanesthetic  vomiting  is  rare  (Teter,  on  "Thirteen  Thousand  Administrations 
of  Nitrous  Oxid  with  Oxygen,"  "Jour.  Am.  Med.  Assoc,"  August  7,  1909). 
Hewitt^  formulates  the  following  views  as  to  the  use  of  oxygen  and  nitrous  oxid: 
"In  order  to  obtain  the  best  form  of  ^.nesthesia  oxygen  should  be  admin- 
istered with  nitrous  oxid  by  means  of  a  regulating  apparatus  (Fig.  796), 
the  percentage  of  the  former  gas  being  progressively  increased  from  2  to 
3  per  cent,  at  the  commencement  of  the  administration  to  7,  8,  9,  or  10  per 
cent.,  according  to  the  circumstances  of  the  case.  The  longer  the  adminis- 
tration lasts,  the  greater  may  be  the  percentage  of  oxygen  admitted. 


Fig.  796. — Hewitt's  nitrous  oxid  and  oxygen  apparatus. 


"The  next  best  results  to  those  obtainable  by  means  of  a  regulating  appa- 
ratus for  nitrous  oxid  and  oxygen  are  to  be  secured  by  administering  certain 
constant  mixtures  of  these  two  gases.  Mixtures  containing  5,  6,  or  7  per 
cent,  of  oxygen  are  best  for  adult  males,  and  mixtures  containing  7,  8,  or  9 
per  cent,  are  best  for  females  and  children.  The  next  best  resiilts  to  those  last 
mentioned  are  to  be  obtained  by  means  of  mixtures  of  nitrous  oxid  and  air, 
from  14  to  18  per  cent,  of  the  latter  being  advisable  in  anesthetizing  men  and 
from  18  to  22  per  cent,  in  anesthetizing  women  and  children." 
1  "Brit.  Med.  Jour.,"  Feb.  18,  1899. 


Ether  Followed  by  Chloroform 


1213 


Crile  uses  nitrous  oxid  and  oxygen  as  the  anesthetic  of  choice  for  many 
operations,  even  major  operations.  He  believes  it  produces  less  shock,  less 
nausea,  and  less  lowering  of  vital  resistance  to  infection  than  does  ether.  He 
insists  on  the  necessity  of  having  a  highly  trained  administrator  and  of  keep- 
ing the  patient  pink  during  the  administration.  Respiratory  failure  is  met  at 
once  by  turning  off  the  nitrous  oxid  and  substituting  pure  oxygen.  If  relax- 
ation is  impossible  (and  it  may  be  in  a  very  muscular  subject),  ether  is  given 
until  relaxation  is  attained  and  then  a  return  is  made  to  nitrous  oxid  ("Trans- 
actions of  Southern  Surg,  and  Gynec.  Assoc,"  1909).  Crile  gives  a  small  dose 
of  morphia  and  scopolamin  before  operation  to  prevent  too  early  postopera- 
tive appreciation  of  the  ''operative  trauma." 

The  Gwathmey-Woolsey  ap- 
paratus is  a  very  useful  one  for 
nitrous  oxid  and  oxygen  admin- 
istration (Fig.  797). 

Bichlorid  of  Methylene. 
— The  composition  of  the  so- 
called  bichlorid  of  methylene  is 
a  matter  of  dispute.  Some  high 
authorities  believe  it  to  be  a 
mixture  of  methyl  alcohol  and 
chloroform.  It  rapidly  produces 
unconsciousness,  and  the  patient 
returns  quickly  to  consciousness 
when  the  administration  is  sus- 
pended. Some  surgeons  have 
thought  highly  of  it,  and  claimed 
that  it  is  pleasant,  safe,  and  is 
not  followed  by  vomiting  as 
often  as  chloroform.  The  weight 
of  opinion  is  that  it  is  dangerous, 
death  being  similar  to  death  from 
chloroform.  It  is  given  by  means 
of  a  Junker  apparatus. 

Anesthetic  Successions. — 
Bromid  of  Ethyl  Followed  by 
Chloroform  or  Ether. — (See  page 
1210.) 

Chlorid  of  Ethyl  Followed  by 
Ether, — (See  page  12 10.) 

Chloroform  Followed  by 
Ether. — Chloroform  is  sometimes  given  until  the  sensation  becomes  more  or  less 
obtunded,  when  ether  is  substituted.     This  is  done  to  save  the  patient  from  the 
unpleasant  sensations  of  etherization.     It  is  a  practice  not  to  be  commended, 
because  it  is  precisely  in  the  beginning  that  chloroformization  is  most  dangerous. 

Ether  Followed  by  Chloroform. — When  the  patient  cannot  be  relaxed 
or  rendered  unconscious  by  ether,  or  when  some  other  complication  develops, 
it  is  common  practice  to  suspend  ether  and  substitute  chloroform.  If  the 
change  is  made,  chloroform  should  be  given  cautiously.  A  large  quantity 
should  never  be  poured  upon  the  inhaler  at  one  time.  The  change  should 
never  be  made  when  the  patient  is  struggling,  because  the  deep  respirations 
which  attend  or  follow  struggling  may  lead  to  the  rapid  inhalation  of  a  dan- 
gerous dose  of  chloroform  vapor.  Further,  as  Hewitt  points  out,  when  the 
patient  is  deeply  under  the  influence  of  ether  the  change  should  not  be  made 
unless  it  is  imperatively  necessary. 


Fig.  797. — Gwathmey-Woolsey  nitrous  oxid  oxygen 
apparatus  with  tanks  in  place:  0,  Regulating  valve  for 
oxygen;  O3,  oxygen  tank;  N-iO,  nitrous  oxid  tank. 


1 2 14  Anesthesia  and  Anesthetics 

Nitrous  Oxid  Gas  Followed  by  Ether  fGas  and  Ether). — This  very  valu- 
able method  was  suggested  by  Clover.  I  have  used  it  repeatedly  with  great 
satisfaction.  The  patient  is  made  unconscious  by  nitrous  oxid  and  is  kept 
unconscious  by  ether.  Thus  are  avoided  excitement,  struggling,  choking, 
and  the  very  unpleasant  sensations  induced  by  ether.  It  lessens  the  amoimt 
of  time  requisite  to  obtain  anesthesia  and  lessens  the  amount  of  ether  used. 
More  important  even  than  this,  the  method  is  safe.  It  is  more  satisfactory 
in  women  and  children  than  in  men.  In  very  muscular  men  and  in  very 
stout  elderly  men  it  should  not  be  used.  In  many  cases  nitrous  oxid  causes  a 
flow  of  mucus  from  the  respiratory  tract.  Because  of  the  frequency  of  this 
happening  it  is  wise  to  precede  gas  and  ether  anesthesia  twenty  minutes  by  a 
hypodermatic  injection  of  morphin  and  atropin  (Van  Kaathoven,  in  "Annals 
of  Surgery,"  Sept.,  1908),  or  of  atropin  alone.  Many  operators  first  anes- 
thetize mth  nitrous  oxid,  using  an  ordinary  dental  apparatus,  and  then  give 
ether  on  an  ordinary  inhaler.  The  anesthetist  must  bear  in  mind  that  ether 
must  be  given  gradually,  not  suddenly,  poured  on  in  large  amount.  Others 
prefer  to  use  a  combined  gas-and-ether  inhaler.  I  use  the  Gwathmey-Woolsey 
apparatus  (Fig.  797). 

He-^dtt  ("Anesthetics  and  Their  Administration")  thus  describes  the  ad- 
ministration by  means  of  Clover's  portable  ether-inhaler  fitted  with  a  stop-cock 
and  a  detachable  gas  bag: 

"If  the  patient  be  lying  upon  his  back,  his  head  should  be  turned  to  one 
side.  The  face-piece  with  the  charged  ether  chamber  is  then  applied  during 
an  expiration.  Air  will  be  breathed  backward  and  forward.  When  the  res- 
piration is  seen  to  be  proceeding  freely,  and  the  face-piece  fits  well,  the  charged 
gas  bag  is  attached  to  the  ether  chamber.  Air  ^atII  still  be  breathed,  but  not 
through  the  valves  of  the  special  stop-cock.  When  the  valves  are  heard  to 
be  w^orking  properly  'gas'  is  turned  on,  and  is  likewise  breathed  through  the 
valves.  Three  or  four  respirations  (or  about  one-half  of  the  contents  of 
the  bag)  are  allowed  to  escape.  The  valve  action  is  now  stopped  by  turning 
the  tap  at  the  upper  part  of  the  stop-cock.  At  the  same  moment  at  which  the 
patient  begins  to  breathe  'gas'  backward  and  foru^ard,  the  rotation  of  the  ether 
chambers  for  the  addition  of  ether  vapor  should  be  commenced.  The  admin- 
istrator wiU,  in  fact,  find  that  he  can,  in  a  few  seconds  from  the  commencement 
of  the  administration,  rotate  the  ether  chamber  as  far  as  'i'  or  'i|.'  Should 
swallowing  or  coughing  arise,  he  must  rotate  more  slowly.  Respiration  soon 
becomes  deep  and  regular,  and  more  and  more  ether  may  be  admitted.  At 
about  this  juncture,  if  the  apparatus  has  been  fitting  the  face  well,  signs  of 
nitrous  oxid  narcosis  may  appear,  especially  in  those  who  are  quickly  affected 
by  this  gas.  Should  jerky  breathing  or  'jactitation'  arise,  one  full  inspiration 
of  air  may  be  admitted  at  the  air-tap.  It  should  be  remembered,  however, 
that  in  giving  'gas  and  ether'  by  this  method,  the  object  is  to  just  steer  clear  of 
the  clonus  and  'stertor'  of  nitrous  oxid  narcosis  and  to  gradually  but  increas- 
ingly mix  ether  with  the  gas. 

"In  muscular  and  vigorous  subjects  the  quantity  of  gas  above  mentioned 
will  be  found  to  be,  as  a  general  rule,  insuSicient  to  lead  to  the  usual  signs  of 
deep  nitrous  oxid  anesthesia.  The  rotation  of  the  ether  chamber  should  be 
continued  till  the  indicator  points  to  '2',  '3,'  or  'F.' 

"The  mistake  that  is  most  commonly  made  is  that  of  admitting  air  too  soon. 
Should  air  be  given  during  the  first  half  or  three-quarters  of  a  minute,  the 
patient  will  partially  come  round,  hold  his  breath,  set  his  teeth,  and  give  a  good 
deal  of  trouble.  Duskiness  of  the  features  must  be  expected.  Speaking  gen- 
erally, air  should  not  be  allowed  imtil  the  patient  is  stertorous,  when  one  breath 
may  be  given.  In  this  manner  the  patient  will  continue  breathing  a  mixtiire 
of  nitrous  oxid,  ether,  and  air  till  the  usual  signs  of  deep  ether-anesthesia  appear. 


Local  Anesthesia  1215 

when  the  gas  bag  may  be  detached,  and  the  little  bag  ordinarily  used  ^vith 
Clover's  inhaler  substituted." 

Hewitt  prefers  to  use  a  moditied  Clover  inhaler,  which  permits  of  the 
introduction  of  ether  after  the  inhalation  of  nitrous  oxid  has  begun. 

Hypnotic  Anesthesia. — It  is  well  known  that  Esdaile  in  India  did  numbers 
of  operations  upcn  patients  in  hypnotic  anesthesia.  Cloquet,  as  long  ago 
as  1829,  amputated  a  breast  of  a  woman  who  was  held  free  from  pain  by  hyp- 
nosis. In  1S51  Guerineau  amputated  the  thigh  of  a  h\-pnotized  person  and 
there  was  no  sign  of  pain.  But  all  subjects  are  not  susceptible.  Even  sus- 
ceptible subjects  require  to  be  hypnotized  again  and  again  for  days  before  the 
operation.     The  method  has  its  own  dangers  and  has  been  entirely  abandoned. 

Scopolamin-morphin  Anesthesia. — This  method  has  been  enthusiastically 
praised  and  I  have  used  it  with  satisfaction  in  a  number  of  cases,  but  I  have 
grown  afraid  of  it.  In  a  patient  in  the  Jefferson  Hospital  dangerous  s^-mptoms 
arose  after  a  dose  of  y^  gr.  of  scopolamin.  Ely  records  a  death  from  respira- 
tor}- failure  two  hours  after  the  administration  of  j  gr.  of  morphin  and  j^  gr.  of 
scopolamin  (''Xew  York  Med.  Jour.,"  Oct.  20,  igo6).  A  number  of  deaths  have 
been  reported  following  its  use  and  there  are,  beyond  doubt,  unreported  cases. 
Four  deaths  in  2400  cases  were  certainly  directly  due  to  it  (H.  J.  Whitacre, 
in  "New  York  ]\Ied.  Jour.,"  March  31,  1906).  It  has  even  been  stated  that 
the  death-rate  is  i  in  100  ("Semaine  Medicale,"  Jan.  11,  1905).  Scopolamin 
is  chemically  identical  with  hyoscin  and  must  never  be  used  imless  fresh,  as 
it  decomposes  in  air  and  Hght.  If  given  -^-ithout  morphin,  it  is  inefficient. 
Large  doses  are  certainly  dangerous,  and  the  combination  should  never  be 
given  in  sufficient  amount  to  induce  anesthesia  unaided.  If  used  at  all,  it 
should  only  be  as  an  aid  to  local  anesthesia  or  to  general  anesthesia  by  ether  or 
chloroform.  I  have  used  it  as  an  aid  to  local  anesthesia  in  6  goiter  operations 
and  in  2  cases  of  removal  of  the  Gasserian  ganglion.  It  should  not  be  used 
in  heart  disease  (Hayem) :  in  persons  under  sixteen  or  over  sixty  (Korft") ; 
in  any  one  -uith  a  tendency  to  pulmonan.-  edema  or  with  any  acute  condition 
of  the  throat  which  interferes  with  respiration  (A.  C.  Wood,  in  "American 
Medicine,"  Xov.  11,  1905). 

It  produces  a  drowsy,  hea^y  state  or  actual  sleep,  and  the  patient  can  be 
kept  unconscious  with  an  extremely  small  quantit}'  of  ether  or  chloroform. 
For  five  or  sLx  hours  after  the  operation  the  sleep  continues,  and  in  most  cases 
there  is  no  postoperative  vomiting. 

If  it  is  used,  a  mixture  is  freshly  made  containing  y^  gr.  of  scopolamin 
and  J  gr.  of  morphin,  and  this  is  given  h\podermaticaUy  one-half  an  hour 
before  the  operation.  During  the  operation  the  sleep  may  be  maintained 
by  small  amounts  of  ether  or  chloroform.  If  s\-mptoms  of  poisoning  occur, 
artificial  respiration  and  oxygen  inhalations  may  be  required,  external  heat  is 
needed,  and  nitroglycerin,  str\-chnin,  or  caff'ein  should  be  given. 

I  agree  with  Kochmann  that  we  are  not  as  yet  justffied  in  recommending 
this  method  of  anesthesia  ("Miinchener  medizinische  Wochenschrift,"  1905, 
No.  17). 

Local  Anesthesia. — In  ever\-  case  requiring  operation  we  should  in- 
quire whether  local  anesthesia  should  be  used  instead  of  general  anesthesia. 
Many  reaUy  extensive  operations  can  be  done  under  it,  and  its  field  has  been 
greatly  broadened  by  the  knowledge  that  \'iscera  inner\-ated  by  purely  \-isceral 
ner\-es  are  insensitive  and  sensation  exists  onl}^  in  those  which  receive  branches 
from  the  somatic  ner\-es  (K.  G.  Lennander,  in  "Mittheilungen  aus  dem  Grenz- 
gebeiten  der  Medicin  und  Chirurgie,"  1902,  Bd.  x,  Heft  i  and  2).  Len- 
nander shows  that  the  parietal  peritoneum  is  sensitive  to  pain,  but  not  to 
touch — that  the  intestine,  stomach,  edge  of  the  liver,  mesenter\',  gaU-bladder, 
urinary  bladder,  kidney  parenchyma,  lung,  anterior  wall  of  the  trachea^  tes- 


I2l6 


Anesthesia  and  Anesthetics 


tide,  and  epididymis  are  insensitive,  though  the  coverings  of  the  testicle  and 
epididymis  are  sensitive.  My  experience  is  that  the  viscera  may  be  cut, 
sutured,  and  handled  without  any  severe  pain  if  they  are  not  pulled  upon.  In 
removing  an  appendix  the  only  pain  felt  will  be  when  the  meso-appendix 
is  pulled  upon  or  adhesions  to  the  parietal  peritoneum  are  separated.  The 
advantages  of  operation  under  local  anesthesia  are  freedom  from  the  danger 
of  anesthetic  accidents,  blood  changes,  and  postanesthetic  discomforts  and 
dangers.  The  disadvantage  is  the  knowledge  of  the  patient  as  to  what  is 
taking  place.  He  may  become  alarmed  and  turbulent,  and  may  thus  interfere 
with  a  necessary  procediire  at  a  vital  moment.  I  have 
operated  under  infiltration  anesthesia  with  satisfaction 
in  the  following  cases:  Gastrostomy,  tracheotomy,  rib  re- 
section, goiter,  inguinal  colostomy,  typhoid  perforation, 
abscess  of  the  limg,  gangrenous  appendicitis,  appendi- 
citis in  the  interval,  radical  cure  of  hernia,  strangu- 
lated hernia,  suprapubic  cystotomy,  extirpation  of  the 
external  carotid  artery  (Dawbarn's  operation),  ampu- 
tation through  the  thigh,  ligation  of  the  thyroid  arter- 
ies, varicocele,  hydrocele,  circumcision,  and  ligation  of 
the  femoral  artery.  There  are  many  methods  of  local 
anesthesia. 

Freezing. — Ice  and  salt  may  be  used .  Take  \  pound 
of  ice,  wrap  it  in  a  towel,  and  break  it  into  fine  bits; 
add  i  pound  of  salt;  then  place  the  mixture  in  a  gauze 
bag  and  lay  it  upon  the  part.  The  surface  becomes 
pallid  and  numb,  and  in  about  fifteen  minutes  decidedly 
analgesic.  A  spray  of  rhigolene  freezes  a  part  in  about 
ten  seconds.  It  is  highly  inflammable.  Ether-spray 
anesthesia  was  suggested  by  Benjamin  Ward  Richard- 
son. Chlorid  of  ethyl  comes  in  glass  or  metal  tubes 
(Fig.  798).  Remove  the  cap  from  the  tip  of  the  tube 
and  hold  the  bulb  in  the  palm:  the  warmth  of  the  hand 
causes  the  fluid  to  spray  out.  Hold  the  tube  some 
little  distance  from  the  part,  and  let  the  fine  spray 
strike  the  surface.  The  skin  blanches  and  whitens,  and  is  ready  for  the 
operation  in  about  thirty  seconds.  Freezing  is  only  of  value  in  a  trivial 
operation  and  when  only  a  single  cut  or  stick  is  required. 

Hypodermatic  Injection  of  Cocain  Hydrochlorate. — Cocain  was  discovered 
by  Gaedeke  in  1855.  In  1884  Koller,  of  Vienna,  demonstrated  the  value  of 
cocain  as  an  analgesic  in  ophthalmic  practice.  In  1885  J.  Leonard  Corning,  of 
New  York,  showed  that  cocain  when  applied  to  a  mLxed  nerve  in  man  abolishes 
nerve  conduction,  as  it  was  already  known  to  do  in  the  lower  animals.  In  1885 
Halsted  and  Raymond  induced  anesthesia  in  the  nerve  distribution  by  inject- 
ing cocain  about  the  inferior  dental  and  lingual  nerves  (perineural  injection). 
This  was  done  before  pulling  a  tooth.  Schleich  introduced  infiltration  anes- 
thesia. Braun,  Van  Hook,  and  Matas  did  much  to  develop  local  anesthesia. 
A  tremendous  impetus  was  given  to  infiltration  anesthesia  by  Harvey  Cushing's 
report  on  herniotomy  under  local  anesthesia  ("Annals  of  Surgery,"  1900,  vol. 
xxxi).  He  used  a  very  weak  solution  of  cocain  (i  :  1000).  Cocain  hydrochlo- 
rate is  soluble  in  water,  but  should  not  be  boiled  in  water.  To  boil  it  impairs 
its  anesthetic  power.  A  tablet  of  the  drug  should  be  sterilized  by  dry  heat 
and  dissolved  in  sterile  water.  Always  bear  in  mind  that  cocain  is  sometimes 
a  decidedly  dangerous  agent.  There  are  a  number  of  deaths  from  cocain  on 
record.  The  urethra  is  a  particularly  dangerous  region,  and  so  is  the  face. 
It  is  undesirable  to  use  more  than  §  gr.  upon  a  mucous  surface,  and  to  inject 


Fig.  798. — Gebauer's  ethyl- 
chlorid  tube. 


Cocainization  of  a  Nerve- trunk  12 17 

hypodermatically  more  than  J  gr.  The  drug  must  never  be  injected  into  a 
vein.  Moderately  severe  cases  of  cocain-poisoning  are  characterized  by  great 
tremor,  restlessness,  pallor,  dry  mouth,  talkativeness,  and  weak  pulse.  In 
dangerous  cases  there  is  syncope  or  delirium.'  Death  may  arise  from  paraly- 
sis or  from  fixation  of  the  respiratory  muscles.  Cases  with  a  tendency  to 
respirator},'  failure  require  the  h>^odermatic  injection  of  strychnin.  In 
cases  with  tetanic  rigidity  of  muscles  hj'podermatic  injections  of  nitrogly- 
cerin or  inhalations  of  the  nitrite  of  amyl  should  be  given.  In  cases 
marked  by  delirium,  if  the  circulation  is  good,  hyoscin  is  given.  In  any  case 
stimulants  are  given,  a  catheter  is  used,  and  diuresis  encouraged.  Cocain- 
poisoning  is  always  followed  by  a  wakeful  night.  Cocain  should  not  be  used  in 
any  considerable  amount  if  the  kidneys  are  inefficient.  In  using  cocain  try  to 
prevent  poisoning.  Because  of  the  dangers  inherent  in  cocain,  have  the  patient 
recumbent.  One  minute  before  giving  the  cocain  administer  hA-podermatically 
I  drop  of  a  I  per  cent,  solution  of  nitroglycerin  and  repeat  the  dose  once  during 
the  operation.  In  operating  on  a  finger,  after  making  the  part  anemic,  tie  a  tube 
around  the  root  of  the  digit  before  injecting  cocain,  and  after  the  operation 
gradually  loosen  the  tube.  A  hot  solution  of  cocain  is  more  efi&cient  than  a 
cold  solution,  hence  hot  solutions  can  be  used  in  much  less  strength  and  are 
safer.  The  method  of  injection  is  as  follows:  A  sharp  needle  is  held  at  an 
angle  of  45  degrees  to  the  surface  and  is  pushed  into  the  Alalpighian  layer. 
One  or  2  min.  of  a  2  per  cent,  solution  are  forced  into  the  Malpighian  layer, 
and  a  whitened  elevation  forms.  The  needle  is  withdrawn,  at  the  margin  of' the 
wheal  is  reinserted,  and  more  fluid  is  introduced,  and  so  on  until  the  region  to 
be  operated  upon  has  been  injected.  After  waiting  five  minutes  the  operation 
is  begun.  If,  after  cutting  the  skin,  it  is  necessary  to  cut  the  subcutaneous 
tissue,  inject  a  few  drops  of  a  i  per  cent,  solution  into  the  tissue.  After  the 
completion  of  the  operation,  if  a  rubber  band  was  used,  it  is  loosened  for  a  few 
seconds,  tightened  for  a  few  minutes,  again  loosened  and  readjusted,  and  so 
on  several  times  (Wyeth).  In  this  way  only  a  small  quantity  of  cocain  is 
admitted  into  the  circulation  at  one  time  and  toxic  symptoms  are  prevented. 
For  operations  upon  the  eye  a  i  to  4  per  cent,  solution  is  employed;  i  drop  of 
fluid  is  instiUed  every  ten  minutes  until  3  drops  have  been  given.  Rarely 
use  over  a  10  per  cent,  solution  on  mucous  membrane,  although  in  lar\^ngeal 
operations  a  20  per  cent,  solution  may  be  required.  For  the  nasal  mucous  mem- 
brane a  bit  of  wool  soaked  in  a  5  per  cent,  solution  is  inserted  or  a  spray  of  4 
per  cent,  solution  is  thrown  from  an  atomizer  into  the  nostrils.  In  the  rectiun, 
vulva,  vagina,  and  uterus  use  a  5  per  cent,  solution;  in  the  urethra,  a  4  per  cent, 
solution,  and  in  the  bladder,  a  2  per  cent,  solution. 

Cocainization  of  a  Nerve-trunk. — Kjrogius,  Halsted,  and  Ra\Tnond  pointed 
out  that  if  cocain  is  injected  into  the  tissue  about  a  ner\-e- trunk  (perineural 
injection),  anesthesia  -^-ill  follow  in  the  area  supplied  by  the  nen,^e.  The  anes- 
thesia '^"ill  be  produced  in  five  minutes,  and  will  last  fifteen  minutes.  If  cocain 
is  injected  about  the  root  of  the  finger,  all  of  the  tissues  of  the  digit  will  become 
insensitive.  Injection  over  both  supra-orbital  notches  renders  the  middle  of 
the  forehead  insensitive.  Injection  over  the  ulnar  ner^^e  causes  complete  anes- 
thesia of  its  trajector\^     This  plan  is  extensively  used  in  Helsingfors. 

It  has  been  demonstrated  by  Crile  ("Jour.  Am.  Med.  Assoc,"  Feb.  22, 
1902)  that  the  injection  of  cocain  into  a  nen.'e-trunk  (endoneural  injection) 
Interposes  an  absolute  block  to  the  transmission  of  afl'erent  and  efferent  im- 
pulses and  greatly  lessens  operative  shock.  In  3  cases  I  employed  this  method 
to  secure  anesthesia  for  amputation  of  the  leg.  None  of  the  patients  felt  pain 
and  shock  was  tri^dal. 

In  two  amputations  of  the  entire  upper  extremity,  although  the  patient 
was  under  ether,  the  brachial  plexus  was  cocainized  to  minimize  shock  and 
n 


I2i8  Anesthesia  and  Anesthetics 

shock  was  very  slight.  The  cocain  was  injected  directly  into  the  trunks 
(endoneural  injection).  The  combination  of  local  anesthesia  and  general 
anesthesia  is  part  of  Crile's  anoci=association  operation,  a  plan  to  rule 
out  all  noxious  or  noci  influences  ("Jour.  Am.  Med.  Assoc,  July  13,  1912). 
He  points  out  that  though  a  person  under  ether  is  without  feeling,  the  greater 
part  of  the  brain  is  still  awake,  nerve  impulses  still  reach  the  brain  and  cause 
functional  depression  and  morphological  alterations  in  the  brain  cells  (Crile's 
"Ether  Day  Address,"  1910).  He  would  prepare  a  patient  by  filling  him  with 
calm  confidence,  giving  him  morphin  and  scopolamin  previous  to  operation, 
administering  nitrous  oxid,  and  isolating  the  brain  from  the  field  of  operation 
by  infiltrating  the  region  with  i  :  400  solution  of  novocain.  At  the  conclusion 
of  the  operation  the  region  may  be  injected  with  the  hydrochlorid  of  quinin 
and  urea. 

,  Eucain  hydrochlorate  (/9-eucain)  is  far  safer  than  cocain  used  in  full  doses, 
and  in  many  cases  is  to  be  preferred  to  it.  It  is  injected  in  the  strength  of 
from  2  to  5  per  cent.  It  is  soluble  in  water  and  can  be  boiled  without  destroy- 
ing its  properties,  and  hence  can  be  readily  rendered  sterile.  It  occasionally, 
though  rarely,  happens  that  the  injection  of  eucain  causes  sloughing,  especially 
at  the  extremities,  in  fatty  tissue,  in  tendon-sheaths,  and  in  bursae.  It  can  be 
used  on  mucous  membranes. 

Stovain. — This  agent  is  a  local  anesthetic  introduced  by  Fourneau.  It 
is  as  powerfully  analgesic  as  cocain,  is  only  one-third  as  toxic,  and  is  slightly 
germicidal.  It  is  dissolved  in  cold  water  or  salt  solution,  and  a  solution  used 
of  the  strength  of  0.5  per  cent.  Adrenalin  can  be  given  with  it.  (See  Son- 
nenburg,  in  "Deutsche  medicinische  Wochenschrift,"  March,  1905.) 

Quinin-urea  hydrochlorid  in  from  j  to  i  per  cent,  solution  causes  pro- 
longed local  anesthesia.  A  solution  of  i  per  cent,  is  too  strong — it  causes  the 
wound  to  heal  slowly  and  produces  induration.  The  drug  has  no  toxic  effect  and 
can  be  used  in  considerable  quantity;  it  lessens  bleeding,  and,  by  producing  an 
effect  for  many  hours,  lessens  postoperative  pain.  Quinin-urea  hydrochlorid  is 
used  by  infiltration  (see  below) .    It  is  dissolved  in  water  or  normal  salt  solution. 

Novocain  of  a  strength  in  solution  of  from  i  :  200  to  i  :  400  is  preferred 
by  some  surgeons.  It  may  be  given  alone  or  mixed  with  stovain.  It  is  given 
by  infiltration.  The  drug  is  soluble  in  water  and  the  solution  can  be  boiled 
without  being  impaired  in  anesthetic  power.     It  is  one-sixth  as  toxic  as  cocain. 

Infiltration  anesthesia  is  in  most  instances  the  preferred  method  of  local  an- 
esthesia. It  is  a  term  used  to  indicate  a  form  of  local  anesthesia  in  which  the 
tissues  are  not  only  injected,  but  are  distended  decidedly  with  a  fluid  anes- 
thetic indifferent  in  nature.  It  is  called  terminal  anesthesia  because  the  anes- 
thetic acts  upon  the  terminal  branches  of  sensory  nerves.  It  is  CdXl&d  regional 
anesthesia  because  the  fluid  injected  affects  a  particular  part  of  a  sensory  nerve  in 
its  course.  Infiltration  anesthesia  was  devised  by  Schleich,  of  Leipsic,  who  was 
dissatisfied  with  cocain,  because  it  is  not  safe  and  sometimes  fails  to  produce 
complete  local  anesthesia,  owing  to  want  of  thorough  diffusion.  He  found  that 
salt  solution  (0.2  per  cent.),  if  injected  into  uninflamed  parts,  produced  anesthe- 
sia. To  obtain  this  anesthesia  the  part  must  be  distended  by  wide  infiltration. 
If  minute  quantities  of  cocain,  morphin,  and  carbolic  acid  are  added  to  the 
solution,  the  anesthesia  becomes  more  thorough  and  more  prolonged,  and  can 
be  obtained  even  in  inflamed  areas.     Schleich  uses  three  solutions: 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas:  cocain  hydrochlo- 
rate, 3  gr. ;  morphin  hydrochlorate,  f  gr. ;  sodium  chlorid,  3  gr. ;  distilled  sterile 
water,  3!  oz.;  phenol  (5  per  cent.),  2  drops. 

No.  2,  medium  solution,  which  is  employed  in  most  cases:  cocain  hydro- 
chlorate, i|  gr.;  morphin  hydrochlorate,  |  gr.;  sodium  chlorid,  3  gr.;  dis- 
tilled sterile  water,  3!  oz.;  phenol  (5  per  cent.),  2  drops. 


Infiltration  Anesthesia  12 19 

No.  3  is  the  weak  solution  used  to  infiltrate  extensive  areas:  cocain  hvdro- 
chlorate,  I  gr. ;  moq3hin  hydrochlorate,  |  gr. ;  sodium  chlorid,  3  gr. ;  distilled 
sterile  water,  3^  oz. ;  phenol  (5  per  cent.),  2  drops. 

The  addition  of  adrenalin  chlorid  to  the  cocain  solution  is  an  advantage,  as 
it  retards  the  circulation  and  hence  favors  analgesia  and  lessens  bleeding  during 
the  operation.  A  satisfactory  tiuid  for  infiltration  is  i  part  of  a  i  :  1000  solu- 
tion of  adrenalin  chlorid  and  9  parts  of  a  0.5  per  cent,  solution  of  cocain  (Gan- 
gitans,  in  "Riforma  Medica,"  Sept.  9,  1903).  Eucain  and  adrenalin  are  pre- 
ferred by  some.  Barker  uses  distilled  water,  100  gm. ;  pure  sodium  chlorid,  0.8 
gm. ;  ,5-eucain,  0.2  gm. ;  chlorid  of  adrenalin,  o.ooi  gm.  iVfter  injecting  Barker's 
fluid  the  surgeon  waits  for  twenty  minutes  before  operating. 

The  injections  are  begun  in  the  skin,  not  under  it  (Fig.  799),  and  are  made 
one  after  another  until  the  area  to  be  operated  upon  is  surrounded  above,  below, 
and  on  all  sides  ^\-ith  Schleich's  solution.  At  each  infiltrated  area  a  wheal 
forms  in  the  skin.  This  infiltration  can  be  made  painlessly  by  touching  with 
pure  carbolic  acid  the  point  where  the  needle  is  to  be  inserted,  or  by  freezing 
this  spot  with  ethyl  chlorid.  After  infiltration  of  the  skin  with  the  cocain  solu- 
tion the  surgeon  waits  for  a  minute  or  two  and  then  operates;  incision  is  made, 
and  when  deeper  tissues  are  reached  they  are  infiltrated  before  incising  them. 
If  a  nerve  comes  in  sight,  touch  it  -^ith  a  drop  of  pure  carbolic  acid.  Van 
Hook  says  that  the  anesthesia  obtained  by  this  method  is  due  to  artificial 


^-^sSi- 


II  \^ 


-■sp^^^tiir  ;| 


Fig.  790. — The  s\Tiiige-point  stops  at  the  papiUan-  layer,  and  the  fluid  lodges  in  the  skin  itself  (Van. 

Hook). 

ischemia,  pressiire  upon  the  tissues,  the  direct  action  of  the  drugs,  and  the 
lowered  temperature.^  The  method  is  very  efficient,  and  can  be  used  for 
operations  of  considerable  magnitude.  IMatas  uses  a  special  apparatus  to 
infiltrate  the  tissues.  The  fluid  is  driven  by  compressed  air,  and  widespread 
or  massive  infiltration  is  produced. 

An  ideal  fluid  to  be  injected  should  be  isotonic  with  the  blood,  and 
should  contain  the  smallest  percentage  of  chemical  agent  necessary  to  render 
the  part  anesthetic.  The  solution  recommended  by  Dr.  James  jNIitchell, 
of  Washington,  D.  C,  seems  to  meet  these  requirements  as  closely  as  prac- 
tically possible.  ^Mitchell  uses  a  tablet  containing  f  gr.  of  cocain  and 
4¥o  gr.  of  adrenalin.  The  tablets  are  dxy  sterilized,  and  just  before  opera- 
tion are  dropped  into  cups  containing  normal  salt  solution.  Two  strengths 
of  solution  are  prepared:  one  tablet  is  dissolved  in  a  cup  containing  50  c.c. 
of  the  saline  solution,  one  in  a  cup  containing  100  c.c.  The  stronger  solu- 
tion is  used  for  infiltrating  the  skin,  blocking  nerves,  or  for  any  particularly 
sensitive  area ;  the  weaker  solution  is  employed  for  general  infiltration  of  tissue. 
As  Karl  G.  Lennander  ("Local  and  Subarachnoid  (Spinal)  Anesthesia,"  in 
''Keen's  Surgery,"  vol.  v,  page  1054)  has  pointed  out,  "Cocain  has  a  greater 
affinity  for  the  sensory  than  for  the  motor  nerv^es.  The  effect  of  cocain  in  a 
certain  proper  concentration  upon  peripheral  mixed  ner\^es  is  to  abolish,  first, 
1  "Med.  News,"  Nov.  16,  1895. 


I220  Anesthesia  and  Anesthetics 

the  sense  of  tickling,  then  the  sense  of  temperature,  thereafter  the  sense  of  pain, 
and,  lastly,  the  sense  of  touch  (pressure) ,  and  only  thereafter  the  motor  faculty, 
which  may  remain  unaffected,  although  all  the  modalities  of  sensation  have  been 
paralyzed.  During  the  retrogression  of  poisoning  the  faculty  of  motion  is  the 
first  to  return,  then  the  sense  of  pressure,  next  the  sense  of  pain,  and  lastly  the 
sense  of  temperature."  The  addition  of  the  adrenahn  to  the  cocain  solution  is 
an  advantage,  in  that  it  retards  the  circulation  by  contracting  non-striped 
muscle-fibers  in  arteries  and  capillaries.  The  cocain  is  thus  localized,  its  anes- 
thetic action  prolonged,  and  bleeding  diminished  during  the  operation.  I  do 
not  believe  that  adrenalin  in  any  way  modifies  the  toxic  action  of  cocain;  indeed, 
Berry  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1905)  seems  to  prove  that  it  actually 
increases  it.  With  the  extremely  weak  solution  recommended  by  Mitchell 
I  have  never  seen  the  sHghtest  physiological  action  of  cocain.  The  total  dosage 
of  cocain  given  by  infiltration  should  not  exceed  i|  gr.  In  i  case  I  observed 
superficial  sloughing  of  the  skin  when,  by  an  operating-room  error,  three  tablets 
had  been  dissolved  in  50  c.c.  of  saline.  I  believe  the  slough  was  due  to  the 
high  percentage  of  adrenalin. 

The  field  of  operative  achievement  under  infiltration  anesthesia  has  broad- 
ened to  such  an  extent  that  it  is  difficult  to  definitely  hmit  its  possibilities  when 
it  is  in  the  hands  of  one  skilled  in  its  use.  It  is  necessary  for  the  surgeon  oper- 
ating by  this  method  to  use  an  essentially  different  technic  from  that  com- 
monly employed  in  operations  under  a  general  anesthetic.  He  should  be 
calm,  equable,  content  to  wait,  and  patient  in  spite  of  delay.  He  must  be 
skilled  in  clean  operative  dissections,  and  accustomed  to  refrain  from  handling 
tissues  unnecessarily.  Failure  is  certain  if  the  operator  is  not  constantly  en- 
gaged in  this  kind  of  work,  for  he  must  have  learned,  above  all  things,  gentle- 
ness and  willingness  to  spend  plenty  of  time,  and  must  have  acquainted  him- 
self accurately  with  the  sensibilities  of  the  various  tissues  encountered  in  dif- 
ferent operative  fields.  For  the  occasional  operator  to  attempt  major  opera- 
tions under  infiltration  anesthesia  is  to  court  failure.  The  patient  should  be 
informed  that  operation  is  to  be  a  matter  of  intelligent  co-operation,  and  in 
major  operations  it  is  wise  to  give  a  hypodermatic  injection  of  morphin  (J  gr.) 
a  half-hour  before  beginning.  This  is  usually  sufficient  to  allay  the  apprehen- 
sion natural  in  one  about  to  undergo  an  operation.  A  tactful  assistant  should 
be  detailed  to  sit  by  the  patient's  head  and  engage  him  in  conversation,  sponge 
his  face,  administer  small  sips  of  water,  and,  in  other  words,  be  what  may  be 
called  the  "psychic"  anesthetist.  The  patient  should  not  see  any  of  the  pre- 
operative preparations;  instruments  should  be  carefully  excluded  from  the  range 
of  his  vision.     Needless  conversation  and  other  noise  should  be  avoided. 

The  special  instruments  required  are:  two  Record  syringes  of  2  c.c.  capacity 
and  one  of  5  c.c. ;  two  fairly  fine  needles  i|  inches  in  length  and  two  coarser 
needles  2  inches  in  length;  a  pair  of  Mayo's  5|-inch  straight  dissecting  scissors 
with  keen  edges;  dissecting  forceps  with  teeth,  and  fine-pointed  artery  clamps. 
For  example,  let  us  take  an  appendectomy  in  a  patient  with  a  frank  tuberculosis 
of  the  lung ;  a  case  in  which  general  narcosis  would  cause  damage  and  might 
prove  fatal.  The  patient,  having  been  prepared  for  operation  (care  having  been 
taken  to  administer  morphin  a  half -hour  previously),  is  placed  upon  the  oper- 
ating table  and  made  as  comfortable  as  possible.  The  head  is  arranged  upon  a 
pillow,  the  arms  are  disposed  comfortably  at  the  sides,  and  a  folded  blanket  is 
placed  under  the  liimbar  spine.  The  patient's  wishes  may  be  consulted  as  to 
whether  he  desires  a  piece  of  gauze  placed  over  his  eyes  or  not.  Usually  the 
patient,  unless  addressed,  keeps  his  eyes  closed.  The  psychic  anesthetist  en- 
gages the  patient  in  conversation,  the  surgeon  must  show  full  confidence,  be 
cheerful,  and  endeavor  to  communicate  this  frame  of  mind  to  his  subject. 

The  easiest  method  of  approach  to  the  appendix  imder  infiltration  anesthe- 


Infiltration  Anesthesia  1221 

sia  is  McBiirney's  muscle-splitting  incision.  Begin  infiltration  by  taking  the  2 
c.c  syringe  filled  with  the  stronger  cocain  and  adrenalin  solution.  Use  a  fine 
needle.  Pinch  up  a  small  piece  of  skin,  informing  the  patient  that  you  are  going 
to  stick  him  slightly  with  a  fine  needle.  Holding  the  needle  almost  parallel  with 
the  skin,  barely  insert  the  point  under  the  epidermis  and,  at  the  same  time, 
press  on  the  piston  of  the  syringe  so  as  to  obtain  an  infiltrated  spot  simultane- 
ously with  the  introduction  of  the  needle.  The  pain  caused  by  the  first  intro- 
duction of  the  needle  is  tri\'ial  and  even  that  degree  is  absent  during  subsequent 
insertions.  A  small  wheal  is  produced,  the  integument  assimiing  a  blanched, 
pig-skin  appearance.  From  the  center  of  this  infiltrated  circle  the  needle 
may  now  be  inserted  painlessly  to  its  full  length  in  the  skin  (not  under  the 
skin),  parallel  with  the  surface.  Do  not  insert  the  needle  too  deeply  at  this 
time.  As  the  point  of  the  needle  travels  the  solution  should  be  fed  from  the 
syringe.  Ordinarily  2  c.c.  of  solution  wUl  infiltrate  i|  to  2  inches  of  skin. 
After  the  superficial  infiltration  a  coarser  and  longer  needle  should  be  used  to 
infiltrate  subcutaneous  tissues.  The  incision  may  now  be  carried  down  to 
the  aponeurosis  of  the  external  obHque.  Infiltrate  the  muscular  and  aponeu- 
rotic portion  of  the  external  oblique.  IMake  a  split  in  the  aponeurosis  by  a 
knife  and  continue  by  Mayo's  scissors.  Gentle  clips  with  the  scissors  cause 
less  pain  than  knife  dissection.  Retract  carefully  the  aponeurotic  layer.  In- 
filtrate the  internal  obHque  and  split  it.  The  transversahs  and  peritonetmi 
are  infiltrated  with  the  stronger  solution,  which  we  employ  at  this  point  for 
the  first  time  since  the  infiltration  of  the  skin.  These  layers  are  then  incised. 
Incisions  in  all  layers  of  the  abdominal  wall  must  be  of  ample  size  to  avoid 
unduly  strong  retraction.  Up  to  this  stage  the  patient  should  experience 
no  pain  imless  one  has  thoughtlessly  clamped  a  vein  without  previous  infil- 
tration with  the  stronger  solution.  The  \-isceral  peritoneimi  may  be  cut, 
clamped,  burned,  and  stitched  -^ith  impiuiity,  but  imdue  traction  upon  the 
mesentery-  immediately  causes  general  cramp-like  abdominal  pain  with  con- 
sequent rigidity  of  the  abdominal  w^all.  The  appendix,  therefore,  is  sought 
for  by  gently  following  the  anterior  longitudinal  band  intra-abdominaily 
rather  than  by  attempting  to  pull  the  ceciun  out  of  the  abdominal  incision. 
Once  the  base  of  the  appendix  is  found,  the  rest  is  easy.  Traction  on  the 
meso-appendLx  must  be  gentle,  and  before  tying  it  infiltrate  it  with  the 
stronger  solution.  The  crushing  ligation  and  inversion  of  the  appendix  is  not 
accompanied  by  pain.  Occasionally  the  necessary  traction  on  the  mesocolon 
will  cause  the  patient  to  have  nausea,  which  is  relieved  as  soon  as  the  traction 
ceases.  Suture  of  the  abdominal  wall  now  follows  without  special  incident, 
except  that  very  small  gutta-percha  tissue  drains  should  be  inserted  just  under 
the  skin  at  one  or  both  ends  of  the  incision  when  infiltration  anesthesia  has 
been  used.  These  drains  take  care  of  any  possible  oozing  that  may  occiu:  after 
the  effect  of  the  adrenalin  has  worn  off. 

By  the  use  of  infiltration  anesthesia  I  have  operated  -v^ith  satisfaction  in  the 
following  cases:  Tracheotomy,  tuberculous  glands  of  the  neck,  rib  resection, 
goiter,  drainage  of  a  cerebral  cyst,  ligation  of  the  thyroid  arteries,  gastrostomy, 
inguinal  colostomy,  t\phoid  perforation,  abscess  of  the  lung,  chronic  and  acute 
appendicitis,  appendiceal  abscess,  jejunostomy,  radical  cure  of  inguinal,  femo- 
ral, and  imibilical  hernia,  strangulated  hernia,  incisional  hernia,  resection  of  the 
bowel,  suprapubic  cystostomy,  extirpation  of  the  external  carotid  arter\-  (Daw- 
barn's  operation),  ligation  of  the  femoral  arter\-,  cholecystostomy,  suture  of 
fractured  patella,  amputation  of  the  arm,  amputation  of  the  thigh,  amputation 
of  the  leg,  removal  of  stone  from  the  pehis  of  the  kidney,  posterior  gastro- 
enterostomy, hysteropexy,  kidney  abscess,  psoas  abscess,  and  large  nmnbers  of 
minor  conditions. 

Patients  after  abdominal  section  under  infiltration  anesthesia  verv^  rarely 


1222  Anesthesia  and  Anesthetics 

vomit  at  all,  never  have  as  much  postoperative  pain  as  those  who  were  under 
a  general  anesthetic,  and  seldom  have  backache.  Distention  of  the  bowel  is 
uncommon.  The  catheter  is  rarely  required,  and,  of  course,  the  blood  changes, 
renal  difl&culties,  and  postoperative  pneumonias  are  much  less  frequent  than 
after  general  narcosis.  Infiltration  anesthesia  cannot  be  ignored  in  such  cases 
as  diabetes,  Addison's  disease,  sepsis,  advanced  Basedow's  disease,  diseases  of 
the  cardiac  muscle,  liver,  both  kidneys,  etc.  In  children  and  high-strung  in- 
dividuals infiltration  is  usually  impossible ;  in  operations  for  extensive  malignant 
growths,  or  during  which  complete  muscular  relaxation  must  be  obtained,  this 
form  of  anesthesia  is  absolutely  contra-indicated. 

To  those  interested  in  infiltration  anesthesia  I  would  suggest  a  careful 
study  of  Spalteholz's  admirable  illustrations  of  nerves  (especially  those  of  the 
extremities),^  together  with  the  perusal  of  the  following  writings: 

H.  Braun:  "Die  Lokalanasthesie,  ihre  wissenschaftlichen  Grundlagen  und  praktische 
Anwendung,"  Leipzig,  1907.     (A  very  full  bibliography  accompanies  this  excellent  work.) 

Harvey  Gushing:  "Observations  Upon  the  Neural  Anatomy  of  the  Ingviinal  Region  Rela- 
tive to  the  Performance  of  Herniotomy  Under  Local  Anesthesia,"  in  "Annals  of  Surgery," 
1900,  vol.  xxxl. 

Theodor  Kocher:  "Text-Book  of  Operative  Surgery,"  third  English  edition,  by  Harold 
J.  Stiles  and  C.  Balfour  Paul,  vol.  1,  page  16. 

Karl  G.  Lennander:  "Local  and  Subarachnoid  (Spinal)  Anesthesia,"  in  "Keen's  Surgery," 
vol.  v,  page  1045. 

James  F.  Mitchell:  "The  Production  of  Local  Anesthesia  for  Surgical  Purposes,"  in 
"American  Practice  of  Surgery,"  by  Bryant  and  Buck,  vol.  iv,  page  231. 

Bier's  Intravenous  Method  of  Local  Anesthesia. — This  plan  was  described 
by  Bier  at  the  German  Surgical  Congress  of  1908."  It  permits  of  serious  opera- 
tions upon  the  limbs,  operations  for  which  ordinary  methods  of  local  anes- 
thesia would  prove  quite  inefficient.  Suppose  the  surgeon  intends  to  resect 
an  elbow- joint:  Mark  the  position  of  the  veins  on  the  asepticized  extremity. 
Apply  an  Esmarch  bandage  from  the  tips  of  the  fingers  to  well  above  the  elbow- 
joint.  This  is  the  expulsion  bandage.  A  thin  soft-rubber  band  is  appHed  around 
the  arm  above  the  Esmarch  bandage,  the  bandage  is  removed,  and  a  like  band 
is  applied  below  the  elbow.  The  anesthetic  is  injected  into  a  superficial  vein 
of  this  bloodless  area  (the  basilic  or  cephalic).  The  tissues  above  and  about 
the  vein  are  infiltrated.  The  vein  is  exposed,  the  syringe  of  the  cannula  is  in- 
troduced, and  ligatures  are  used  as  though  we  were  going  to  give  an  ordinary 
intravenous  injection  of  salt  solution,  except  that  the  cannula  is  pointed  to 
the  periphery.  The  fluid  used  is  a  0.25  or  0.5  per  cent,  solution  of  novocain. 
The  syringe,  containing  50  c.c.  of  fluid,  forces  the  solution  downward  into  the 
veins  and  the  limb  swells. 

If  the  stronger  solution  is  used,  50  c.c.  are  enough;  if  the  weaker  solution  is 
used,  100  c.c.  will  be  required.  If  resecting  the  knee,  the  injection  should  be 
made  into  the  internal  saphenous  vein  and  twice  the  amount  would  be  necessary 
as  advised  for  the  elbow. 

After  injecting  the  strong  solution  operation  may  be  begun  at  once.  After 
injecting  the  weak  solution  we  should  wait  ten  minutes.  The  bloodless  area 
between  the  bands  becomes  anesthetic  very  promptly  after  the  injection,  the 
bones  as  well  as  the  soft  parts.  The  peripheral  portion  of  the  limb  beyond 
the  area  between  the  bands  becomes  anesthetic  after  a  short  time  and  motor 
paralysis  may  foUow.  Such  paralysis  is  eventuaUy  recovered  from.  If  anes- 
thesia between  the  bands  is  not  attained  within  five  minutes  there  has  been 
some  failure  in  technic  (Bier,  ''Edinburgh  Med.  Jour.,"  1910,  v.  No.  2).     The 

^  "Hand  Atlas  of  Human  Anatomy,"  by  Werner  Spalteholz.  Edited  and  translated  by 
Lewellys  F.  Barker. 

2  Bier:  "Ueber  einen  neuen  Weg  Lokalanasthesia  au  den  Gliedmaassen  zu  erzeugen," 
"Arch.  f.  klin.  Chir.,"  1908,  Ixxxvi,  No.  4. 


Spinal  Analgesia  1223 

analgesia  is  entirely  satisfacton'  and  passes  away  as  soon  as  the  band  is  re- 
moved. When  the  operation  has  been  completed,  wash  out  the  vein  with  salt 
solution  in  order  to  prevent  toxic  effects. 

By  this  method  the  anesthetic  passes  through  the  vein  walls  and  becomes 
fixed  in  the  tissues,  and  when  the  bands  are  removed  it  returns  vers-  gradually  to 
the  circulation,  hence  greatly  larger  doses  may  be  given  than  should  be  admis- 
sible by  any  other  method.  Adrenalin  should  not  be  given  with  the  novocain. 
Toxic  s\Tnptoms  are  rare.  The  method  is  contra-indicated  if  there  is  arterio- 
sclerosis. (See  Carroll  Smith,  in  "Jour.  Am.  INIed.  Assoc,"  March  23,  191 2; 
Page  and  McDonald,  in  "Lancet,''  Oct.  16,  1909;  Hitzrot,  in  "Annals  of  Sur- 
gery," 1909,  vol.  i.) 

Anesthesia  by  Infiltration  with  Sterile  Water. — WTien  the  tissues  are  well  in- 
filtrated \\"ith  warm  or  cold  sterile  water,  anesthesia  ensues  promptly.  I  have 
not  found  it  as  complete  as  when  cocain  or  eucain  is  employed,  even  when  a 
considerable  amount  of  fluid  is  introduced.  Gant  uses  it  in  rectal  operations 
and  commends  it  strongly  (''New  York  and  Phila.  Med.  Jour.,"  Jan.  28,  1904). 

Spinal  Analgesia. — J.  Leonard  Corning  in  1S85  discovered  that  cocain 
injected  between  the  spines  of  the  eleventh  and  twelfth  dorsal  vertebrae  pro- 
duces analgesia  of  the  lower  limbs  (''New  York  Med.  Jour.,"  Oct.  31,  1SS5). 
From  this  observation  spinal  anesthesia  springs.  Bier  produced  complete 
anesthesia  of  the  entire  body  except  the  head  by  the  injection  of  a  small 
amoimt  of  cocain  into  the  subarachnoid  space  of  the  spinal  cord.  A  solution  of 
cocain  of  a  strength  of  from  0.5  per  cent,  to  i  per  cent,  is  used  by  some,  but 
cocain  cannot  be  boiled  without  impairment  of  its  anesthetic  power,  and 
carbolic  acid  must  be  added  to  it  in  small  amoimt.  Hence  cocain  so  pre- 
pared is  not  certainly  sterile,  and  the  carbolic  acid  added  may  induce  harmful 
S}Tnptoms.  (See  Neugebauer,  in  "Wien.  klin.  Woch.,"  1901,  Nos.  50,  51, 
52.)  Some  surgeons  use  a  solution  of  eucain  which  can  be  boUed,  but  it 
is  not  so  rapid  and  certain  as  cocain.  Some  use  tropacocain  (Illwicz).  A 
solution  of  this  drug  can  be  boiled,  is  less  poisonous  than  cocain,  and  some- 
what slower  in  action.  Experimenters  tell  us  that  ^  to  i|  gr.  of  cocain  may 
be  given,  but  it  is  not  wise  to  give  o-\'er  0.5  gr.  I  have  used  stovain  in  a  num- 
ber of  cases.  Some  combine  it  with  adrenalin,  but  the  combination  is  not  de- 
sirable in  the  subarachnoid  space.  The  dose  is  i  c.c.  of  a  5  per  cent,  solution. 
The  analgesia  lasts  from  one-half  an  hour  to  an  hour  or  more,  and  was  followed 
in  my  cases  by  retention  of  urine.  Some  have  used  novocain  alone  or  combined 
with  adrenalin. 

A.  W.  Morton  ("Jour.  Am.  Med.  Assoc,"  Nov.  8, 1902)  takes  chemically  pure 
cr^^stalline  hydrochlorate  of  cocain,  places  it  for  fifteen  minutes  in  a  dr\'  temper- 
ature of  300°  F.,  and  puts  it  in  sterile  tubes  until  wanted.  The  dose  depends 
upon  the  locality  in  which  he  wishes  to  induce  analgesia,  and  varies  between  0.3 
and  0.5  gr.  The  required  dose  is  placed  in  the  barrel  of  the  sterile  syringe 
and  is  dissolved  in  cerebrospinal  fliu'd  drawm  into  the  syringe  for  that  purpose. 
I  now  follow  the  plan  of  Mr.  Arthm:  E.  Barker.  He  believes  that  the  spe- 
cific gra\'ity  of  the  fluid  containing  the  drug  plays  an  important  part  in  its 
localization  within  the  canal  ("Brit.  Med.  Jour.,"  March  16,  1912).  He  uses 
a  fluid  as  nearly  as  possible  isotonic  with  the  blood.  It  consists  by  weight  of 
5  parts  of  stovain,  5  parts  of  glucose,  and  90  parts  of  distilled  water.  Adrena- 
lin is  never  added.  It  may  do  harm,  it  can  do  no  good.  This  fluid  seeks  the 
lowest  level  it  can  find  and  mixes  but  Httle  with  the  cerebrospinal  fluid.  The 
average  dose  is  i  c.c.  of  the  5  per  cent,  solution. 

The  s\T:inge  used  is  of  glass  and  of  a  capacity  of  2  c.c.  The  needle  is  the 
hollow  one  of  Bier.  The  needle  must  be  sharp,  else  it  w^ould  not  go  through 
the  diu-a.     Barker's  fine  blunt  cannula  goes  through  the  lumen  of  the  needle. 

The  fluid  to  be  injected  is  kept  in  sealed  Jena  glass  ampoules,  and -should  not 


12  24  Anesthesia  and  Anesthetics 

be  more  than  a  week  or  two  old.  The  fluid  is  drawn  into  the  syringe  from  the 
ampoule.  The  patient  lies  upon  his  side  with  the  head  and  shoulders  well 
raised  and  with  the  back  curved.  The  back  has  been  previously  sterilized. 
The  dressings  are  removed  and  the  region  to  be  punctured  is  resterilized.  The 
spines  of  the  third  and  fourth  lumbar  vertebrae  are  located,  and  the  needle  is 
entered  in  the  midline  beneath  the  spine  of  the  third  or  fourth  lumbar  vertebra 
and  is  pointed  upward  and  forward.  The  surgeon  determines  that  he  has 
punctured  the  subarachnoid  space  by  lessened  resistance  and  the  appearance 
of  fluid  at  the  needle-opening.  The  injection  is  made  slowly,  the  needle  is 
withdrawn,  and  the  puncture  sealed  by  collodion.  In  performing  the  operation 
care  must  be  taken  to  prevent  the  escape  of  the  cerebrospinal  fluid. 

If  the  patient  remains  upon  the  side  the  nerve-roots  of  the  dependent  side 
are  rendered  analgesic  some  time  before  those  of  the  uppermost  side.  If  he  is 
turned  for  a  time  upon  the  other  side  the  nerve-roots  of  that  side  will  quickly 
become  anesthetized.  To  turn  him  upon  the  back  will  do  the  same  thing,  but 
less  rapidly.  If  he  is  placed  in  a  sitting  position  the  rectum  and  anus  are 
quickly  rendered  anesthetic. 

The  usual  position  for  operation  is  on  the  back,  but  he  may  perhaps  be  upon 
his  side.  When  the  patient  is  placed  upon  his  back  promptly  after  injection  the 
anal  region  becomes  anesthetic  in  from  one  to  two  minutes,  the  lower  extremi- 
ties in  from  three  to  six  minutes,  and  the  upper  extremities  in  from  fifteen  to 
thirty  minutes.  The  anesthetic  condition  lasts  from  one  to  three  hours  or 
even  longer,  and  is  due  to  the  contact  of  cocain  with  the  nerve-roots  (A.  W. 
Morton,  "Jo^r.  Am.  Med.  Assoc,"  Nov.  8,  1902). 

After  cocainization  of  the  spinal  cord  surgical  operations  can  be  performed 
on  many  regions  without  causing  pain.  Among  the  operations  which  have 
been  performed  are  resection  of  the  knee,  resection  of  the  ankle,  osteotomy, 
amputation  of  the  leg,  amputation  of  the  thigh,  hysterectomy,  perforation  of 
gastric  ulcer,  intestinal  obstruction,  strangulated  hernia,  excision  of  bowel, 
acute  appendicitis,  gastro-enterostomy,  oophorectomy,  removal  of  ovarian 
cyst,  and  removal  of  rectum. 

Spinal  analgesia  is  not  growing  in  popularity.  It  is  regarded  by  most 
surgeons  as  a  method  to  be  used  in  exceptional  cases.  It  should  never  be 
used  as  a  routine  procedure,  and  it  will  not  displace  ether  or  chloroform. 
By  it  analgesia  can  usually  be  secured.  A.  W.  Morton  (Ibid.)  used  it  673  times 
without  a  failure,  and  60  of  these  operations  were  above  the  diaphragm.  If  we 
desire  to  obtain  analgesia  of  the  upper  portion  of  the  body  the  patient  must  be 
placed  in  the  Trendelenburg  position  after  the  fluid  has  been  injected.  Most 
operators  have  had  failures,  especially  above  the  diaphragm.  In  Sonnenburg's 
1117  cases  there  were  78  utter  failures  ("Jour,  de  Chir.,".Oct.,  1908).  Bier  says 
that  failures  occur  in  4  per  cent,  of  cases;  Moynihan  says  in  14  per  cent. ;  Legueu 
says  in  one-seventh  of  the  cases.  In  Barker's  last  100  cases  there  were  3  fail- 
ures. No  one  should  attempt  it  who  is  not  well  trained  in  aseptic  methods, 
because  infection  of  the  cord  or  its  membranes  will  prove  fatal.  Untoward 
effects  are  common,  and  they  may  arise  during  or  after  the  operation. 

Sonnenburg  had  them  in  193  out  of  11 17  cases.  Among  the  untoward 
effects  reported  are  grave  collapse,  temporary  paralysis  of  the  abducens  nerve, 
of  the  facial  nerve,  of  the  hypoglossal  nerve,  meningitis,  retention  of  urine, 
chills,  elevation  of  temperature,  incontinence  of  urine,  persistent  paraplegia, 
pain  in  the  back  and  legs,  perhaps  lasting  for  weeks  or  even  for  months,  nau- 
sea and  vomiting  during  and  after  the  operation,  sweating,  overaction  of  the 
heart,  dimness  of  vision,  cramps  in  the  limbs,  dyspnea,  violent  headache,  invol- 
untary evacuation  of  feces,  and  cardiac  overaction.  Many  of  the  immediate 
S3anptoms  are  probably  due  to  the  absorption  of  the  drug  injected.  The  head- 
ache is  due  to  tension  and  is  relieved  when  some  cerebrospinal  fluid  is  with- 


Spinal  Analgesia  1225 

drawn  by  lumbar  puncture.  In  20  per  cent,  of  Barker's  cases  ("Brit.  Med. 
Jour.,"  March  16,  191 2)  there  was  more  or  less  transient  headache.  In  16.3 
per  cent,  there  were  nausea  and  vomiting. 

Headache,  vertigo,  weakness,  paresthesia,  neuralgia  may,  in  a  few  cases,, 
persist  for  months  or  even  vears  (Hohmeier  and  Konig,  in  ''Archiv.  flir  klin. 
Chir.,"  Oct.  S,  1910). 

Whether  or  not  permanent  harm  ever  comes  to  the  cord  is  not  certain.. 
Bristow  (''Brooklyn  Med.  Jour.,"  1902,  xvi,  page  410)  reported  the  case  of  a 
man,  fifty-five  years  of  age,  on  whom  he  operated  for  hemorrhoids  after  spinal 
cocainization.  An  examination  one  month  later  indicated  degeneration 
of  the  posterior  and  lateral  columns  of  the  cord  (spastic  lower  extremities, 
ataxic  gait,  increased  knee-jerk,  ankle-clonus,  and  inabihty  to  retain  urine). 
Marx  ("Xew  York  Med.  Record,"  Dec.  22,  1900)  states  that  i  case  in  his 
experience,  after  cocainization  of  the  spinal  cord,  developed  t^-pical  loco- 
motor ataxia.  Dandois  ("Jour,  de  Chir.  Brux.,"  April-May,  1901)  reports 
a  case  upon  which  he  had  operated  for  traumatic  rupture  of  the  urethra. 
Spinal  cocainization  was  employed.  Paraplegia  developed  and  lasted  two 
months.  Several  cases  of  hemorrhage  into  the  subarachnoid  space  are  on 
record.  Legueu  states  that  persistent  paraplegia  and  persistent  incontinence 
of  urine  may  arise  ("Rev.  de  Chir.,"  Oct.,  1908). 

Is  there  any  danger  of  death  from  spinal  analgesia?  If  the  operation 
is  not  performed  ■^ith  scrupulous  aseptic  care  it  is  ver}^  dangerous.  Even 
when  performed  by  the  best  surgeons  death  may  occur.  Tuifier  places  the 
mortality  at  3  in  2000,  but  excludes  from  consideration  3  deaths  ("La  Presse 
Medicale,"  vol.  Iv,  1901,  page  190).  Reclus  finds  6  deaths  in  less  than  2000 
cases  (Address  before  the  Paris  Academic  de  ^Medicine,  ]\Iarch  19,  1901). 
Hahn,  in  1708  cases  collected  from  Hterature,  found  8  deaths  ("Mitt.  a.  d. 
Grenzgeb.  d.  Med.  u.  Chir.,"  1900,  iii,  337).  The  mortahty  is  usually  supposed 
to  be  about  3  in  evey  1000  cases.  Wm.  N.  Perkins  ("New  Orleans  Aled.  Jour.," 
Jan.-Sept.,  1902)  collected  2345  cases  with  16  deaths  or  i  death  in  146  adminis- 
trations. Strauss's  table  shows  46  deaths  in  22,717  cases  (quoted  by  Hardonin 
in  "Archiv.  Generale  de  Chir.,"  August,  1908).  In  Barker's  2354  cases  there 
were  only  3  deaths  "which  could  be  in  any  way  put  down  to  the  spinal  method 
of  anesthesia"  ("Brit.  ]\Ied.  Jour.,"  March  16,  1912).  Hohmeier  and  Konig 
("Archiv.  flir  klin.  Chir.,"  Oct.  8,  1910)  collected  2400  cases  of  spinal  anes- 
thesia: 12  deaths  were  due  to  it  directly;  4  of  them  died  of  paralysis  of  respira- 
tion; 7  of  the  fatal  cases  were  over  seventy  years  of  age.  One  \ictim  was  only 
thirty-two. 

Cocain  seems  to  act  like  a  toxin  on  the  pia  and  arachnoid.  Examination 
of  fluid  -uithdrawn  after  the  performance  of  cocainization  shows  that  it  con- 
tains pohmorphic  leukocytes  (Ravant  and  Aubourg,  in  "Gaz.  Hebd.  de  Med. 
et  de  Chir.,"  June  27,  1901). 

jMy  behef  is  strong  that  the  method  should  only  be  used  for  operations  below 
the  diaphragm,  and  I  hold  this  behef  in  spite  of  the  claim  of  Jonnesco  that  he 
operates  vdih.  the  aid  of  spinal  anesthesia  on  any  part  of  the  body.  It  is  most 
successful  in  operations  below  the  umbilicus.  I  ver\'  seldom  use  it  for  opera- 
tions above  that  level. 

In  a  case  in  which,  because  of  heart  disease,  pulmonary  disease,  kidney 
disease,  or  some  other  condition  in  which  a  general  anesthetic  is  inadmissible, 
spinal  cocainization  is  justifiable.  It  should  be  reser^-ed  exclusively  for  cases 
in  which  other  forms  of  anesthesia  are  positively  contra-indicated.  The  method 
should  not  be  employed  on  those  under  fifteen  years  of  age  or  on  the  subjects 
of  central  nerv'ous  disease.  Barker  disapproves  of  spinal  anesthesia  in  "cases 
of  extreme  asthenia  due  to  carcinoma,  and  of  advanced  toxemia  depending 
upon  septic  peritonitis  or  obstruction,  especially  in  later  hfe"  ("Brit.  ^led. 


1226  Diseases  of  the  Skin  and  Nails 

Jour.,"  March  i6,  191 2),  although  some  surgeons  regard  such  conditions  as 
particularly  demanding  spinal  in  preference  to  general  anesthesia. 

A  solution  of  Epsom  salts  has  been  used  by  Blake,  Haubold,  and  Willy 
Meyer.  It  was  discovered  (Meltzer  and  Auer,  "Am.  Med.,"  Nov.  25,  1905) 
that  subcutaneous  injections  of  salts  of  magnesium  produce  local  anesthesia. 
The  same  investigators  later  pointed  out  ("Med,  Record,"  Dec.  16,  1905) 
that  subarachnoid  spinal  injections  of  Epsom  salts  produce  widespread  and 
complete  anesthesia.  A  25  per  cent,  solution  is  used  and  i  c.c.  of  this  is 
given  for  every  25  poimds  of  body  weight.  After  a  wait  of  three  or  four  hours 
the  drug  causes  paralysis  and  analgesia  of  the  legs  and  pelvic  region.  Sensa- 
tion and  motion  do  not  return  for  from  eight  to  fourteen  hours.  Retention  of 
urine  may  last  two  days.  The  pulse  and  blood-pressure  are  unaffected,  but  the 
respiration  is  slowed.  Large  doses  would  endanger  life  by  respiratory  arrest. 
In  view  of  the  fact  that  in  some  cases  the  effect  of  the  drug  is  inordinately  pro- 
longed, it  is  wise,  when  the  operation  is  completed,  to  puncture  the  theca  of 
the  cord  again  and  wash  it  out  with  salt  solution.  Guthrie  and  Ryan  ("Amer. 
Jour,  of  Phys.,"  August  i,  1910)  deny  that  magnesium  salts  have  specL&c 
anesthetic  properties  and  claim  that  anesthesia  following  their  injection  is  due 
chiefly  to  asphyxia. 


XXXI.  DISEASES  OF  THE   SKIN   AND   NAILS 

Dermatitis  venenata  is  a  dermatitis  resulting  from  irritants.  It  may 
be  caused  by  wearing  garments  containing  arsenic.  A  common  cause  is  rhus- 
poisoning.  Rhus-poisoning  arises  from  the  poison-oak,  the  poison-ash,  the 
poison-ivy,  and  some  other  species  of  sumach.  Actual  touching  of  the  plants 
is  usually,  but  not  always,  necessary.  Some  suffer  if  they  simply  come  near 
them.  Some  people  are  immune  to  rhus-poisoning,  some  are  slightly  suscep- 
tible, some  are  strongly  predisposed.  It  is  believed  that  toxicodendric  acid 
is  the  irritant  agent.  The  condition  is  most  apt  to  arise  when  the  skin  is 
moist  from  perspiration. 

The  symptoms  are  burning,  itching,  redness,  and  edema  of  the  affected 
parts.  The  hands  and  forearms  are  most  apt  to  siiffer,  but  any  part  may  be 
attacked.  If  the  penis  and  scrotum  suffer  from  rhus-poisoning  there  is  great 
swelling  from  edema.  An  eruption  on  the  hands  may  inoculate  the  penis 
when  that  organ  is  handled.  A  vesicular  eruption  begins  between  the  fingers. 
The  eruption  becomes  violently  inflammatory,  and  in  the  form  of  fierce  red 
edematous  inflammation  spreads  widely  over  the  body.  There  may  be  slight 
fever.  The  condition  usually  begins  to  abate  in  two  or  three  days  and  desqua- 
mation follows. 

When  one,  knowing  from  experience  that  he  is  predisposed,  feels  the 
inaugural  itching,  he  should  at  once  apply  to  the  parts  a  i  per  cent,  solution  of 
lactic  acid  in  95  per  cent,  alcohol  (R.  F.  Ward,  in  "New  York  Med.  Jour.," 
Dec.  26,  1908). 

The  treatment,  when  a  moderate  area  is  involved,  comprises  the  applica- 
tion of  cloths  wet  with  a  wash  of  lead-water  and  laudanum,  or  a  saturated 
solution  of  acetate  of  aluminum  (R.  F.  Ward,  Ibid.).  If  an  extensive  area 
is  involved,  apply  grindelia  robusta  (4  dr.  to  i  pint  of  water)  or  moisten  the 
surface  frequently  with  sweet  spirits  of  niter.  Oxid  of  zinc  ointment,  contain- 
ing 10  gr.  of  carbolic  acid  to  i  oz.,  gives  great  relief. 

Furuncle  (Boil). — (See  page  137.) 

Aleppo  Boil  {Endemic  Boil  of  the  Tropics,  Delhi  Boil,  Oriental  Sore,  etc.). — 
Papules  appear  upon  the  exposed  parts  of  the  body.  These  papules,  which 
ulcerate,  do  not  cicatrize  for  at  least  a  year,  and  leave  ineradicable  scars.     The 


Ingrowing  Toe-nail  1227 

condition  is  due  to  a  protozoan.  Man  is  infected  by  means  of  flies,  lice,  or 
other  insects.  The  Aleppo  boil  was  once  apparantly  confined  to  India,  Arabia, 
Persia,  Egypt,  Algeria,  etc.  Of  late  it  is  said  to  have  appeared  in  Panama, 
the  Philippine  Islands,  and  Hawaii. 

Erysipelas. — (See  page  199.) 

Erysipeloid. — (See  page  198.) 

Clavus,  or  Corn. — A  corn  is  a  tender  painful,  and  circumscribed  thickening 
of  the  epidermis,  and  is  commonest  over  one  of  the  joints  of  the  toes.  Hard 
corns  are  situated  on  exposed  parts  of  the  digits ;  soft  corns  appear  between  the 
digits,  where  the  parts  are  kept  constantly  moist.    Corns  are  caused  by  pressure. 

Treatment. — The  wearing  of  well-fitting  boots  will  usually  cause  a  com 
upon  the  toe  to  disappear.  Soak  the  feet  often  in  water  containing  bicarbonate 
of  sodiimi,  dry  them,  and  apply  a  circular  corn-plaster  to  the  corn  to  take  off 
the  pressure  of  the  boot.  Another  method  is  to  touch  the  corn  with  iodin 
every  night  and  pare  away  the  hard  tissue  ever\-  morning.  An  old  and  valu- 
able plan  is  to  paint  the  corn  even,'-  night  and  morning  with  a  mixture  com- 
posed of  salicylic  acid,  40  gr. ;  extract  of  cannabis  indica,  10  gr. ;  and  collodion 
and  flexible  collodion,  of  each,  2  dr.  After  several  days  of  the  treatment  soak 
the  parts  in  hot  w^ater  and  scrape  aw^ay  the  mass.  Soft  corns  are  treated  by 
washing  the  feet  often  with  ethereal  soap,  drying,  gently  removing  the  sodden 
epithehum,  dusting  the  toes  and  between  them  with  borated  talc,  and  placing 
absorbent  cotton  between  the  digits.  Incurable  soft  corns  require  the  removal 
of  the  skin  from  the  adjacent  sides  of  the  two  toes  and  suturing  the  toes  together 
(thus  converting  two  toes  into  one).  In  inflamed  corns  employ  rest  and  lead- 
water  and  laudanum,  and  let  out  pus  w^hen  it  forms.  Remember  that  in  old 
persons  the  cutting  of  a  corn  may  cause  senile  gangrene.  In  the  inflamed  and 
painful  feet  of  a  person  who  has  corns  nothing  gives  so  much  relief  as  washing 
the  feet  ^dth  ethereal  soap,  soaking  in  hot  water,  and  wrapping  the  feet  for  half 
an  hour  in  cloths  wet  wdth  a  mixture  composed  of  linseed  oil  and  Ltme-water, 
each,  2  oz.,  and  spirits  of  camphor,  i  dr. 

Warts. — (See  page  379.) 

Onychia  is  inflammation  of  the  matrix  of  the  nail.  S^-phiKs  often  causes 
severe  onychia  which  requires  specific  treatment  (see  page  326).  A  rim- 
around,  or  paronychia,  is  suppuration  of  the  matrix  at  the  root  of  the  nail, 
and  of  the  skin  about  it,  of  traumatic  origin.  It  requires  incision,  trimming 
away  of  the  buried  edge  of  the  nail,  and  packing  with  iodoform  gauze  (see 
page  724). 

Malignant  onychia,  which  is  inflammation  and  ulceration  of  the  entire 
matrix,  occurs  only  in  a  person  of  dilapidated  constitution.  This  condition 
requires  removal  of  the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics,  and  nourishing  diet. 

Ingrowing  toe=na{l  (see  page  157)  is  sometimes  due  to  lateral  h^qaertrophy 
of  the  edge  of  the  nail,  but  usually  to  forcing  of  the  soft  tissues  over  the  margin 
of  the  nail.  An  irritable  ulcer  arises.  The  condition  is  treated  by  splitting  the 
nan,  remo\ing  the  ingrown  piece,  the  soft  tissue  at  the  margin  and  the  adjacent 
matrix,  and  dressing  antiseptically. 


XXXII.  DISEASES  AND  INJURIES  OF  THE  THYROID  GLAND 

The  thyroid  gland  is  an  essential  organ.  It  possesses  functions  of  the  first 
importance.  It  has  a  great  influence  upon  nutrition.  It  acts  by  means  of  its 
secretion,  which  is  an  iodothyroglobulin. 

An  excess  of  this  secretion  if  imneutralized  in  the  body  causes  hj-perthy- 
roidism  (see  page  1236).     A  diminution  of  this  secretion  causes  h^-pothyroidism 


1228  Diseases  and  Injuries  of  the  Thyroid  Gland 

(see  below).  If  there  is  no  thyroid  or  a  functionally  inactive  thyroid  from  birth^ 
the  child  is  a  cretin  (see  below).  A  great  deal  of  the  gland  can  be  parted  with 
without  harm.  Charles  H.  Mayo  estimates  that  one-sixth  of  the  gland  can 
furnish  enough  secretion  for  the  body  needs  ("Illinois  Med.  Jour.,"  Feb.,  1913). 
The  older  a  person  is,  the  less  thyroid  is  apparently  needed  or,  perhaps,  the  less 
thyroid,  the  older  a  person  actually  is.  "According  to  Lorand,  the  deferring  of 
old  age  requires  the  continued  presence  of  some  of  the  thyroid  throughout  life" 
(Charles  H.  Mayo,  Ibid.).  The  thyroid  of  a  woman  is  apt  to  enlarge  at  puberty 
and  to  become  swollen  from  congestion  before  a  period  of  menstruation. 
During  pregnancy  or  at  the  menopause  women  are  apt  to  exhibit  symptoms  of 
h^-po-  or  hyperthyroidism.  Charles  H.  Mayo  (Ibid.)  points  out  that  increased 
secretion  does  not,  of  necessity,  cause  sjonptoms.  A  considerable  excess  may  be 
neutralized  in  the  body.  In  such  a  condition  a  shock  may  at  once  mduce  symp- 
toms. Entire  loss  of  the  thyroid  in  an  adult  causes  myxedema.  Kocher 
pointed  out  that  its  complete  removal  in  a  young  or  middle-aged  person  usually 
causes  operative  myxedema  {cachexia  striimipriva)  and  perhaps  tetany.  Re- 
moval of  the  gland  in  an  elderly  person  does  not  cause  these  curious  conditions. 
Later  knowledge  indicates  that  removal  of  the  thyroid  with  the  parathyroids 
certainly  produces  myxedema  or  tetany,  unless  aberrant  thyroids  exist  and  com- 
pensate. Removal  of  the  thyroid  without  the  parathyroids  does  not  induce 
tetany,  even  when  there  are  no  aberrant  thyroids.  The  thyroid  probably 
furnishes  an  internal  secretion  which  destroys  certain  toxic  products  of  met- 
abolism. It  is  thought  that  the  parathyroids  furnish  an  antitoxin  to  poisons 
formed  during  digestion. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to  arrest.  Ligatures 
may  cut  out  and  forceps  will  not  hold.  The  hemorrhage  is  arrested  by  suture- 
ligatures,  purse-string  sutures,  the  actual  cautery,  or  removal  of  the  bulk  of 
the  gland. 

The  thyroid  gland  may  be  absent  at  birth.  Congenital  atrophy  or 
congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  hypothyroidism  and  myxedema.  Hypothyroid- 
ism may  arise  during  any  process  destructive  of  the  cellular  activity  of  the  thy- 
roid gland.  It  is  seen  not  unusually  in  women  of  from  twenty-five  to  forty  who 
have  borne  children.  It  sometimes  occurs  in  men.  The  patient  usually  grows 
fat,  is  sterile,  and  neurasthenic.  The  temperature  is  subnormal.  Complaint 
is  made  of  headache,  backache,  shortness  of  breath,  and  indigestion.  In  women 
amenorrhea  is  the  rule.  In  severe  cases  there  is  myxedema.  (See  Robert  L. 
Pitfield,  in  "New  York  Med.  Jour.,"  August  27,  1910.)  Myxedema  is  a  condi- 
tion characterized  by  the  presence  of  a  firm  subcutaneous  swelling  in  the  face, 
neck,  and  limbs;  slow  speech;  mental  dulness,  and  subnormal  temperature. 
The  condition  is  identical  with  that  produced  by  removal  of  the  entire  gland. 

Cretinism  is  a  result  of  hypothyroidism.  It  is  a  form  of  infantilism  and 
idiocy  due  to  absence  of  the  gland  or  atrophy  of  glandular  elements  in  the 
thyroid.  When  atrophy  of  the  parenchyma  alone  exists  the  size  of  the  gland 
may  be  actually  increased.  The  body  is  dwarfed;  bone  development  is  very- 
defective,  the  face,  neck,  and  extremities  resemble  those  parts  in  myxedema, 
and  a  low  grade  of  idiocy  exists.  Myxedema  and  cretinism  are  treated  by 
the  internal  administration  of  thyroid  extract. 

Thyroid  Feeding  and  Grafting.- — Hypothyroidism,  with  or  without 
myxedema,  is  greatly  benefited  by  thyroid  feeding  or  the  administration  of 
thyroid  extract.  Some  experimenters  have  transplanted  thyroids  into  thyroid- 
ectomized  animals.  The  results  show  striking  but  temporary  improvement. 
Such  transplanted  material  eventually  disappears.  Experiments  have  been 
made  and  are  being  made  on  thyroid  grafting  in  the  treatment  of  cretinism  and 
myxedema.     Grafts  have  been  placed  imder  the  skin,  in  bone  at  the  jimction  of 


Tumors  of  the  Thyroid  Gland 


1229 


the  epiphysis  with,  the  diaphysis,  in  the  spleen,  and  in  other  regions.  Encourag- 
ing cases  have  been  reported,  but  the  results  are  temporary\ 

Congestion  of  the  thvroid  may  be  caused  by  \-iolent  exertion,  prolonged 
effort,  febrile  maladies,  and  venous  obstruction.  It  is  treated  by  removing 
the  cause  and  apphing  heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  {acute  or  inflammatory  goiter)  may  be  in- 
"duced  by  a  septic  or  febrile  malady,  rheiunatism,  muscular  strain  causing  vas- 
cular rupture,  a  woimd,  or  contusion  of  the  thyroid.  Usually  but  one  lobe  is 
affected.  The  ordinary-  s\"Tnptoms  of  inflammation  are  present.  In  addition 
there  are  dysphagia,  dyspnea,  venous  congestion  of  the  face,  epistaxis,  nausea 
and  vomiting,  and  possibly  delirium.  It  may  terminate  in  resolution,  suppu- 
ration, or  fibrous  induration. 

Tuberculosis  of  the  thyroid  is  usually  a  part  of  general  miliary  tuber- 
culosis. It  is  ver\'  seldom  that  a  local  caseating  focus  occurs,  but  such  cases 
have  been  reported. 

Syphilis  of  the  Thyroid. — Early  in  the  secondar\^  stage  there  is  apt 
to  be  slight  and  painless  th\Toid  enlargement.  In  the  tertiary  stage  gummata 
may  form. 

Tumors  of  the  thyroid  are  of  various  sorts.  Among  them  are  adenomata, 
cystic  adenomata,  sarcomata,  and  carcinomata.  Eight  cases  of  teratoma  are 
on  record  (Isabella  C.  Herb,  "Am.  Jour.  Med.  Sciences,"  June,  1906).  Malig- 
nant disease  is  imusual.  I  have  operated  on  but  2  cases :  i  of  cystic  carcinoma 
in  which  operation  was  rapidly  fatal,  and  i  of  round-ceUed  sarcoma.  The 
latter  patient  was  Hving  and 
apparently  well  four  years  after 
lobectomy.  Malignant  disease 
may  arise  in  the  normal,  but  is 
more  apt  to  arise  in  a  goitrous 
th}Toid.  In  over  50  per  cent, 
of  the  reported  cases  there  is  a 
history-  of  antecedent  goiter. 
Malignant  disease  is  more  com- 
mon in  women  than  in  men  and 
is  very  seldom  met  with,  before 
the  age  of  thirty*.  It  is  most 
common  between  forty  and  sixty. 
One  should  always  suspect  malig- 
nant disease  of  the  th\Toid  gland 
when  the  growth  appears  rather 
suddenly  in  a  patient  over  forty 
years  of  age.  If  the  growth 
is  irregular  m  outhne  and  is 
accompanied  by  pain  and  diffi- 
culty ia  swallowing,  the  diag- 
nosis becomes  reasonably  cer- 
tain. Later  in  the  case  there 
are  s3n3iptoms  due  to  pressiure 
upon    and    infiltration    of     the 

nerves;  the  growth  becomes  firmly  anchored  and  the  honph-glands  adjacent 
to  the  th\Toid  become  involved:  there  may  be  tracheal  bleeding,  and  perhaps 
fever,  and  eventually  cachexia  develops.  Sarcoma  or  carcinoma  may  occur 
and  it  is  seldom  possible  to  determine  clinically  vnth  which  we  are  dealing.  The 
cancer  may  be  a  scirrhus  or  an  epithelioma,  but  is  usually  an  adenocarcinoma. 
A  sarcoma  may  be  either  of  the  round  cell  or  spindle  cell  type.  In  mahgnant 
disease  of  the  th\Toid,  metastasis  occurs  early  in  a  great  majority  of  cases,  the 


Fie.  80c 


:vroid  gland. 


I230 


Diseases  and  Injuries  of  the  Thyroid  Gland 


lungs  being  first  involved,  and  then  the  bones  and  other  structures;  though 
it  has  been  stated  that  in  adenocarcinoma  the  lungs  are  likely  to  escape  and 
that  solitary  bone-metastasis  is  not  infrequently  noted.  Sarcoma  (Fig.  800) 
may  involve  one  lobe,  but  carcinoma  (Fig.  801),  even  at  an  early  stage,  is  apt 
to  involve  both  lobes  (Berry,  "Diseases  of  the  Thyroid  Gland")-  These 
growths  soon  penetrate  the  gland  capsule,  become  anchored  to  surrounding 

parts,  and  involve  the  vocal 
cords,  trachea,  and  even  the 
great  vessels  of  the  neck. 
Malignant  growths  if  not  cys- 
tic are  apt  to  be  hard  and 
nodular  and  they  grow  rapidly. 
At  first  the  gland  moves  with 
deglutition,  but  later  becomes 
anchored  to  surrounding  parts. 
In  malignant  disease  of  the 
thyroid  it  is  usual  to  find  diffi- 
culty of  swallowing  and  paral- 
ysis of  the  vocal  cord  on  the 
side  of  the  growth.  Malignant 
disease  is  rapidly  fatal.  Many 
die  within  six  months  and  few 
survive  over  eighteen  months. 
Radical  operation  is  proper 
only  before  the  growth  breaks 
through  the  capsule,  although 
at  any  stage  it  may  be  neces- 
sary to  operate  in  order  to 
prevent  suffocation. 

A  goiter^  is  an  enlarge- 
ment of  the  thyroid  gland  not  due  to  a  malignant  tumor  or  to  inflanmiation. 
The  enlargement  may  affect  a  small  portion  of  the  gland,  one  lobe,  both  lobes, 
or  both  lobes  and  the  isthmus,  and  it  may  occur  either  sporadically  or 
endemically. 

There  are  a  number  of  forms  of  ordinary  goiter.  The  most  common  is 
what  is  called  simple  or  parenchymatous  goiter  (Fig.  802).  In  this  condition  all 
portions  of  the  gland  enlarge,  and  the  goiter  is  consequently  bilateral.  It  does 
not  appear  first  in  one  lobe  and  at  a  considerably  later  period  in  the  other, 
but  each  lobe  is  enlarged  equally  or  nearly  equally.  Parenchymatous  goiter 
is  often  spoken  of  as  simple  goiter,  and  is  sometimes,  though  not  with  entire 
accuracy,  designated  hypertrophy  of  the  thyroid  gland. 

The  common  goiter  of  adolescence  is  "an  edematous  condition  of  the  gland 
due  to  watery  colloid"  (C.  H.  Mayo,  "Illinois  Med.  Jour.,"  Feb.,  1913). 

Adenomatous  goiter  (Fig.  803)  is  a  condition  due  to  the  growth  of  encapsuled 
adenomata  in  the  thyroid  gland.  There  may  be  a  single  adenoma,  but  fre- 
quently there  are  multiple  growths.  One  or  both  lobes  may  be  involved.  The 
goiter,  however,  usually  seems  to  begin  in  one  lobe;  and  if  both  lobes  enlarge, 
one  generally  does  so  at  a  period  distinctly  subsequent  to  the  enlargement  of 
the  other.  In  some  cases  growth  seems  to  originate  simultaneously  in  both 
lobes,  but  even  then  the  growths  seldom  increase  equally.  Adenoma  may 
develop  in  a  healthy  thyroid  gland,  but  adenomatous  growth  is  usually  asso- 
ciated with  some  parenchymatous  growth. 

1  For  a  study  of  the  "Pathological  Anatomy  of  Goiter"  see  W.  C.  MacCarty,  in  "New- 
York  State  Jour,  of  Med.,"  Oct.,  191 2.  This  study  is  founded  on  2500  cases  from  the 
Mayo  Clinic. 


Fig.  801. — Cystic  carcinoma  of  thyroid  gland. 


Goiter 


1231 


Cystic  goiter,  or  hronchocele,  is  a  condition  in  which  the  chief  mass  of  the 
enlargement  is  composed  of  a  cyst  or  of  multiple  cysts.  When  cysts  form, 
the  thyroid  gland  is  usually  hypertrophied  or  adenomatous;  occasionally,  how- 
ever, cysts  form  in  a  non-hypertrophied  thyroid.  The  great  majority  of  cysts 
are  due  to  cystic  degeneration  of  adenomata;  some  are  formed  by  the  running 
together  of  overdistended  thyroid  vesicles,  and  some  few  follow  blood-extrava- 
sation into  the  thyroid  tissue.  The  liquefaction  is  due  to  mucoid  or  colloid 
degeneration,  and  the  fluid  of  the  cyst  is  sometimes  clear  and  thin,  sometimes 
viscid,  and  often  coffee-ground  in  appearance. 

A  fibrous  goiter  is  a  fibrous  induration.  It  is  likely  to  arise  in  old  broncho- 
celes,  which  may  actually  pass  into  a  calcareous  condition.  By  the  term 
malignant  goiter  is  meant  malignant  disease  of  the  thyroid  gland,  either  carci- 
noma or  sarcoma.  As  stated  above,  such  cases  are  not  really  goiters.  When 
hemorrhage  takes  place  into  a  goiter  the  condition  is  often  spoken  of  as  a 
hemorrhagic  goiter.  A  colloid  goiter  is  a  form  of  parenchymatous  goiter  in  which 
there  is  an  extremely  large  amount  of  colloid  material.     Exophthalmic  goiter  is 


Fig.  802 . — Parenchymatous  goiter. 


Fig.  803. — Adenomatous  goiter. 


discussed  on  page  1235.  Occasionally  a  simple  or  an  adenomatous  goiter 
because  of  degenerative  changes  or  overstimulation  forms  toxic  material  or 
an  excess  of  secretion  and  causes  symptoms  of  toxemia.  "These  cases  may 
have  all  the  nervous  symptoms  and  heart  complications  of  a  bad  case  of 
Basedow's  disease  without  the  protruding  eyes"  (C.  H.  Mayo,  "Illinois  Med. 
Jour.,"  Feb.,  1913).  This  evolution  gives  rise  to  what  the  French  call  a 
Basedowified  goiter  (Morestin,  in  "Rev.  de  Chir.,"  Nov.  10,  1899).  A  goiter 
that  develops  with  great  rapidity  is  sometimes  called  an  acute  goiter,  and 
one  that  induces  marked  dyspnea  is  designated  a  suffocating  goiter.  Syphi- 
litic, tuberculous,  and  amyloid  enlargements  are  extremely  rare,  but  occasion- 
ally occur.  Further,  a  goiter  may  be  back  of  the  sternum,  that  is,  substernal 
or  retrosternal.  A  very  movable  goiter,  which  is  now  above  and  now  below  the 
sternal  notch,  is  called  a  wandering  or  diver  goiter.  A  goiter  within  the  thorax 
is  called  intrathoracic;  and  such  a  goiter  may  be  retrosternal,  retrotracheal,  or 
retro-esophageal.  When  a  number  of  persons  in  the  same  region  are  attacked 
with  goiter  the  condition  is  frequently  referred  to  as  epidemic  goiter.  When 
the  condition  is  common  in  a  certain  district  it  is  called  endemic  goiter.  When 
a  person  living  in  a  district  in  which  the  disease  is  rare  develops  goiter,  we  speak 


1232  Diseases  and  Injuries  of  the  Thyroid  Gland 

of  the  condition  as  sporadic  goiter.  It  has  long  been  known  that  accessory  or 
aberrant  thyroids  exist.  The  term  "aberrant"  is  better  than  "accessory"  because 
in  some  reported  cases  the  thyroid  proper  was  absent  (V.  L.  Schrager,  in  "Surg., 
Gynec,  and  Obstet./'  Oct.,  1906).  Aberrant  thyroids  are  masses  of  tissue 
composed  of  structure  identical  with  the  thyroid  gland,  and  distinct  and  separ- 
ate from  the  th3a-oid  gland  proper.  Median  aberrant  thyroids  are  found  about 
the  hyoid  bone  and  are  formed  from  remnants  of  the  thyroglossal  duct.  Lateral 
aberrant  thyroids  are  found  and  develop  from  the  remains  of  the  lateral  anlages 
of  the  thyroid  (Ibid.).  Aberrant  thyroids  vary  in  number:  there  may  be 
none,  one,  several,  or  chains  of  them.  An  aberrant  thyroid  may  enlarge  with 
the  thyroid,  may  not  enlarge  even  though  the  thyroid  does,  or  may  enlarge 
when  the  thyroid  proper  remains  normal.  When  cachexia  strumipriva  does 
not  develop  after  complete  thyroidectomy,  including  the  parathyroids,  the  pa- 
tient has  been  saved  by  enlargement  and  functionation  of  accessory  thyroids. 

Causes  of  Goiter. — It  is  known  that  goiter  is  extremely  common  in  the 
valleys  at  the  foot  of  certain  mountain  ranges  in  Switzerland,  southeastern 
France,  northern  Italy,  the  Austrian  Tyrol,  and  in  the  Himalayas  and  the 
Andes.  In  a  portion  of  England  it  is  so  common  that  it  is  referred  to  as 
the  Derbyshire  neck.  It  seems  evident  that  the  disease  is  due  to  the  intro- 
duction of  some  poisonous  element  into  the  system;  but  what  this  element 
is,  is  not  known.  Some  writers  maintain  that  individual  Hability  is  developed 
by  habits  of  life;  others  think  that  susceptibility  depends  upon  hygienic  sur- 
roundings; and  some  attach  great  importance  to  hereditary  influence.  The 
probability  is,  however,  that  the  disease  is  due  to  the  existence  of  some  poison- 
ous substance  in  the  drinking-water.  Some  observers  have  blamed  snow-water; 
many  have  laid  the  cause  of  the  trouble  at  the  door  of  water  impregnated  with 
salts  of  lime;  but  the  real  cause  has  not  been  demonstrated. 

Some  observers  believe  that  simple  goiter  is  due  to  bacteria  in  the  intestinal 
canal,  an  important  function  of  the  gland  being  to  save  the  body  from  poisons 
which  reach  the  blood  from  the  intestines,  an  excess  of  poison  or  certain  power- 
ful toxins  causing  the  gland  to  enlarge. 

An  ordinary  parenchymatous  goiter  seems  to  be  a  species  of  hypertrophy. 
A  number  of  years  ago  I  suggested  the  view  that  the  gland  has  undergone 
such  an  enlargement  and  has  become  distended  with  colloid  material  because 
the  human  body  has  demanded  more  of  the  secretion  of  the  gland  than  the 
normal  gland  has  been  able  to  supply;  as  a  consequence,  the  normal  gland  has 
enlarged  its  capacity  and  increased  its  output. 

Signs  and  Symptoms  of  Goiter. — One  may  determine  that  a  growth  is  in  the 
thyroid  gland  or  is  connected  with  it  by  studying  a  number  of  facts.  A  goiter, 
as  a  rule,  follows  the  movements  of  the  larynx  and  the  trachea  during  deglutition, 
and  this  sign  may  be  obtained  in  the  great  majority  of  instances.  There  are, 
however,  rare  conditions,  such  as  hyoid  cyst,  in  which  a  movement  of  the  mass 
takes  place  during  the  act  of  swallowing,  although  the  thyroid  gland  is  not 
involved.  Then,  again,  a  malignant  or  an  inflammatory  growth  of  the  thyroid 
usually  becomes  anchored  to  the  surrounding  tissues  and  does  not  show  this 
mobility.  Certainly,  however,  in  the  great  nimiber  of  cases  an  enlarged  thy- 
roid moves  with  the  larynx  and  the  trachea  during  swallowing. 

Goiters  vary  greatly  in  size.  Cases  in  which  the  goiter  was  as  large  as 
an  adult's  head,  and  some  cases  in  which  the  goiter  hung  in  front  of  the  breast- 
bone, and  reached  to  below  the  level  of  the  ensiform  cartilage,  have  been 
described.     A  very  large  goiter  may  have  a  stalk. 

When  the  entire  gland,  as  well  as  the  isthmus,  is  enlarged,  or  when  the 
isthmus  alone  is  involved,  the  swelling  may  appear  to  be  in  the  median  hne 
of  the  neck.  If  the  condition  begins  in  one  lobe,  the  growth  will,  for  a  time 
at  least,  be  distinctly  one  sided;  though  when  such  a  growth  has  attained  a 


Signs  and  Symptoms  of  Goiter  1233 

large  size,  it  may  displace  the  windpipe  and  come  itself  to  the  middle  line  of 
the  neck. 

A  goiter  of  any  considerable  size  pushes  the  sternocleidomastoid  muscle 
externally  and  anteriorly,  and  the  muscles  that  run  from  the  sternum  to  the 
hyoid  bone  and  to  the  thyroid  cartilage  overlie  the  front  of  the  growth.  The 
carotid  artery  is  displaced  externally  and  posteriorly.  The  relation  of  the 
jugular  vein  to  the  carotid  artery  is  usually  profoundly  altered.  The  artery, 
as  already  stated,  goes  externally  and  posteriorly,  while  the  vein  is  actually 
pulled  anteriorly  and  is  flattened  out  upon  the  side  or  the  anterior  surface 
of  the  goiter;  hence  the  vein  comes  to  lie  to  the  inner  side  of  the  artery.  This 
curious  alteration  in  relationship  is  due  to  the  fact  that  the  common  carotid 
arter}'  has  no  branches,  and  therefore  is  pushed  externally  with  ease;  but 
the  internal  jugular  vein  receives  branches  that  he  in  the  tumor,  pull  upon 
the  vem,  and  prevent  its  displacement  with  the  artery  (Liicke). 

Berr}^  alludes  to  the  fact  that  the  tumor,  unless  it  is  very  small,  usually 
reaches  the  upper  level  of  the  sternum,  and  frequently  passes  below  this 
level;  and  that  only  extremely  large  goiters  hang  in  front  of  the  sternum,  but 
that  it  is  not  at  all  unusual  for  prolongations  from  a  goiter  to  extend  for  quite 
a  distance  into  the  mediastinimi.  A  substernal  goiter  is  productive  of  very 
dangerous  s\Tnptoms  and  offers  many  difficulties  in  diagnosis.  A  goiter  will 
occasionally  wander,  now  appearing  in  the  neck  and  again  disappearing  behind 
the  sternimi. 

Some  goiters  are  said  to  pulsate.  This  takes  place  in  exophthalmic  goiter, 
the  vessels  of  the  goiter  pulsating  as  do  the  other  vessels  of  the  body;  but  in 
the  ordinary  simple  goiter  what  is  called  pulsation  of  the  goiter  is  usually  the 
transmitted  pulsation  from  the  carotid  artery. 

Some  of  the  most  important  symptoms  of  goiter  are  due  to  pressure  and 
to  the  displacement  of  anatomical  structures.  Pressiu"e  upon  the  veins  at  the 
root  of  the  neck  causes  great  enlargement  of  the  veins  above  the  goiter  and 
in  it.  Pressure  upon  the  recurrent  larwgeal  nerve  may  induce  characteristic 
S}Tnptoms  (spasm  of  the  glottis  or  paralysis  of  a  vocal  cord),  but  the  dyspnea 
of  goiter  is  due  to  pressure  upon  the  trachea  and  not  to  interference  with  the 
recurrent  lar^Tigeal.  Paralysis  of  a  vocal  cord  is  rare  in  non-malignant,  com- 
mon in  mahgnant,  goiter.  Pressure  upon  the  cervdcal  s>Tnpathetic  may  cause 
contraction  of  the  pupil  and  narro'U'ing  of  the  palpebral  fissure  (Berry).  Pres- 
sure upon  the  cervical  plexus  or  the  brachial  plexus  causes  paresthesia,  anesthe- 
sia, or  paralysis  in  the  parts  supplied  by  ner^-es  from  the  compressed  plexus. 
Pressure  upon  the  lar^oix  and  the  trachea  may  cause  very  great  displacement, 
and  any  such  displacement  is  productive  of  marked  dyspnea.  This  displace- 
ment is  usually  to  the  side;  and  it  may  cause  such  a  flattening  out  of  the  tra- 
cheal rings  that  when  the  tumor  is  removed  the  trachea  collapses  and  the 
patient  perishes  of  suffocation. 

A  parench\Tnatous  goiter  usually  begins  insidiously  and  grows  slowly. 
It  occasionally  ceases  to  grow  for  a  considerable  period  of  time,  and  may 
even  shrink.  It  frequently  enlarges  temporarily  during  menstruation  or 
pregnancy,  and  occasionally  attains  an  enormous  size  by  changing  into  the 
cystic  form.  Alterations  in  its  consistency  and  outline  may  be  due  to  the 
developing  of  adenomatous  masses. 

In  making  a  diagnosis  between  the  different  forms  of  goiter,  one  should 
remember  that  a  fairly  symmetrical,  bilateral  growth  is  probably  parenchy- 
matous; if  it  was  s\Tnmetrical  from  the  start  the  probabiHty  of  its  being  paren- 
chymatous is  enhanced;  that  sudden  enlargements  are  produced  by  hemorrhage; 
that  cyst  formation  may  lead  to  very  great  enlargement,  and  possibly  to  fluc- 
tuation; that  if  a  non-mahgnant  goiter  induces  dyspnea,  it  almost  invariably 
does  so  by  pressing  upon  the  larynx  and  the  trachea,  whereas  a  mahgnant 
78 


1234  Diseases  and  Injuries  of  the  Thyroid  Gland 

goiter  may  do  so  by  interfering  with  the  nerves  of  the  part  or  by  infiltration 
of  the  trachea;  that  a  non-malignant  goiter  very  rarely  produces  difficulty  in 
swallowing,  but  that  a  malignant  goiter  frequently  does  so;  and  that  cough 
often  exists  if  there  is  pressure  upon  the  larj^nx  or  the  trachea,  such  a  cough 
being  metallic  in  nature  and  unassociated  with  impairment  of  the  voice. 

In  any  goiter  there  may  be  cerebral  symptoms,  such  as  anemia,  syncope, 
or  even  convulsions.  Rapidly  growing  goiters  are  often  fatal,  and  slowly 
growing  goiters  are  very  rarely  so.  A  malignant  goiter  grows  with  great 
rapidity,  becomes  adherent,  infiltrates,  and  quickly  produces  metastases,  and 
both  sarcoma  and  carcinoma  produce  metastases  by  way  of  the  venous  system. 

Metastasis  of  Non-malignant  Goiter. — ^An  ordinary  goiter  which  presents 
no  sign  of  being  malignant  may  suddenly  be  disseminated.  The  deposits 
are  apt  to  take  place  in  the  bones  and  in  the  lungs.  Tumors  have  been  re- 
moved without  any  thought  of  thyroid  trouble  being  responsible,  and  examina- 
tion has  shown  thyroid  structure.  Patel  collected  i8  cases  of  thyroid  metas- 
tasis ("Timieurs  benignes  du  corps  thyroide  donnant  des  metastases,"  "Rev.  de 
Chir."  No.  29,  1904).  The  bones  most  apt  to  receive  metastases  are  the  bones 
of  the  cranium,  the  lower  jaw,  the  vertebrae,  the  pelvis,  and  the  long  bones.  In 
4  of  these  18  cases  the  spine  was  affected.  Dercum  has  reported  a  case  of  thy- 
roid metastasis  to  the  spine  ("Jour,  of  Nervous  and  Mental  Dis.,"  Mar.,  1906). 
Colloid  goiters  are  particularly  prone  to  metastasis.  Some  surgeons  maintain 
that  if  a  metastatic  deposit  grows  and  destroys  bone,  the  primary  tumor  should 
be  regarded  as  malignant,  no  matter  what  histological  studies  indicate. 

Treatment  of  Goiter. — lodid  of  potassium  and  arsenic  internally  have  been 
advised.  An  ointment  of  red  iodid  of  mercury^  locally  is  advocated  by  some 
writers.  It  should  be  rubbed  in  while  the  goiter  is  exposed  to  the  direct  rays 
of  the  sun.  The  administration  of  thyroid  extract  may  do  much  good  in  a  case 
of  parenchymatous  goiter,  but  it  is  useless  in  other  forms  of  the  disease.  It 
should  be  associated  with  the  local  use  of  tincture  of  iodin  or  ointment  of  red 
iodid  of  mercury.  McCarrison  ("Proceedings  of  the  Royal  Society  of  Medi- 
cine," Feb.,  191 2)  grew  cultures  from  the  feces  of  individuals  with  goiter.  He 
prepared  a  mixed  vaccine.  He  also  isolated  certain  bacteria  and  prepared 
vaccines  from  them.  Cases  of  goiter  were  treated  with  the  vaccines.  It  is 
claimed  the  vaccines,  especially  the  mixed  vaccine,  ^vill  cure  recent  parenchy- 
matous goiter.  The  vaccine  is  said  to  act  more  promptly  than  thyroid  extract. 
In  times  past  it  was  customary  to  treat  cystic  goiters  by  aspiration  and  injection 
with  a  solution  of  iodin.  Electrolysis  has  been  used  for  soft  goiter,  the  nega- 
tive pole  being  pushed  into  the  growth,  the  positive  pole  being  applied  to  its  sur- 
face. In  many  cases  the  .x-rays  prove  of  benefit.  In  considering  the  propriety 
of  operation  remember  that  a  goiter  which  begins  at  puberty  may  pass  away. 
We  should  operate  on  every  non-malignant  goiter  w^hich  is  increasing  in  size 
steadily  or  rapidly.  Operation  is  justifiable  even  if  there  is  not  pressure  because 
the  mortality  is  very  small,  and  it  saves  the  patient  from  the  possibility  of 
malignant  change,  of  hemorrhage,  and  of  inflammation.  I  always  used  to 
operate  under  local  anesthesia.  There  is  less  bleeding  under  local  anesthesia 
than  under  ether.  It  is  a  great  advantage  to  have  the  patient  conscious,  be- 
cause by  asking  him  to  speak  during  the  operation  the  surgeon  can  teU  if  the 
recurrent  laryngeal  nerve  is  being  approached  or  touched.  Two  cases  of  violent 
hemorrhage  in  conscious  patients  taught  me  a  lesson.  Each  patient  was  conscious 
that  something  was  wrong,  became  terrified  and  uncontrollable,  and  greatly  in- 
creased the  danger  and  difficulty.  I  now  give  ether  (by  intratracheal  insuffla- 
tion) unless  there  is  very  high  blood-pressure,  serious  tracheal  obstruction,  or 
disease  of  the  heart,  lungs,  or  kidneys  (C.  H.  Mayo,  "Illinois  Med.  Jour.,"  Feb., 

^This  ointment  consists  of  i  part  of  red  iodid  of  mercury  to  28  parts  of  vehicle  (white 
wa.x  and  almond  oil). 


Exophthalmic   Goiter  1235 

1913).  When  ether  is  to  be  given  I  precede  its  administration  twenty  or  thirty 
minutes  by  I  gr.  of  morphin  and  y.Vyf  gr.  of  atropin,  given  h^podermatically. 
In  some  cases  I  follow  Charles  H.  Mayo's  plan  and  combine  local  anesthesia 
with  Hght  general  anesthesia.  In  some  cases  intraglandular  enudeation  is  per- 
formed, in  other  cases  extirpation.  Occasionally  these  two  methods  are  com- 
bined (Bergeat).  Some  surgeons  ad\'ise  simple  di\ision  of  the  isthmus. 
Ligation  of  the  th}'Toid  arteries  has  been  recommended.  Exothyropexy  is  the 
operation  of  exposing  the  th\Toid  gland,  dislocating  it  through  the  woimd,  and 
lea\ing  it  in  this  situation.  Exoth\Topex}'  is  now  almost  never  performed,  on 
account  of  the  safety  of  the  operation  of  th\Toidectomy.  Atrophy  of  the 
gland  follows  exoth^Topex}-.  Enucleation,  if  possible,  is  the  desirable  opera- 
tion. It  may  easily  be  employed  for  the  removal  of  a  single  adenomatous, 
colloidal,  or  cystic  area.  Thyroidectomy  (extirpation)  is  employed  when 
enucleation  is  impossible.  The  entire  th^Toid  is  not  removed  for  an  innocent 
growth:  at  least  a  portion  of  a  lobe  is  left  behind,  otherwise  operative  myxedema 
will  probably  arise.  Unilateral  extirpation  {lobectomy)  is  the  method  usually 
chosen.  In  cancer  and  in  some  cases  of  sarcoma  complete  extirpation  may 
be  attempted.  The  operation  in  malignant  disease  will  occasionally  prolong 
life,  but  it  ^dU  rarely  effect  a  cure.  In  malignant  disease  tracheotom}'  may 
be  rendered  necessary-  by  ur- 
gent dyspnea.  The  operation 
is  often  ver\-  difficult  because 
the  growth  may  cover  the 
trachea,  the  trachea  may  be 
deviated  a  considerable  dis- 
tance from  its  proper  position, 
and  the  veins  are  ver\'  large.  Fig.  804.— Konig^s  tracheotomy  tube. 

After  the  performance  of  the 

operation  it  is  usually  impossible  to  use  an  ordinary-  tracheotomy  tube,  and 
in  such  a  case  Konig's  long,  flexible  tube  (Fig.  S04)  is  employed. 

Endotracheal  Goiter. — Such  a  goiter  may  be  due  to  misplaced  thyroid 
tissue,  or  may  be  a  prolongation  from  the  th\Toid  gland.  Occasionally  the 
growth  is  situated  in  front;  but,  as  a  rule,  it  is  attached  to  the  posterior  sur- 
face of  the  lan.mx  or  trachea.  The  first  s}Tnptom  is  dyspnea,  which  increases 
and  becomes  ver}-  severe.  An  examination  with  a  lar\Tigoscope  makes  the 
condition  e\-ident.  Endotracheal  goiter  is  much  more  common  in  the  female 
than  in  the  male.  It  is  beheved  to  begin  usually  at  about  the  age  of  puberty, 
though  it  may  exist  for  a  long  time  unnoticed.  In  some  reported  cases  the 
patients  were  forty  years  of  age  before  being  seen.  The  proper  treatment  for 
an  endotracheal  goiter  is  the  performance  of  a  preliminan.-  tracheotomy  and 
then  extirpation. 

Exophthalmic  Goiter  (Graves's  Disease;  Basedow's  disease;  Pulsating 
Goiter). — This  condition  was  first  described  by  Graves,  of  Dublin,  in  1835. 
It  is  a  condition  of  chronic  overacti^■ity  of  the  gland  (h}-perth}Toidism)  in  which 
the  secreting  structiu-e  of  the  gland  is  increased  in  amoimt.  The  increase  of 
parenchyma  may  perhaps  be  general,  may  perhaps  be  in  separated  areas  (C.  H. 
Mayo,  ''Illinois  ^led.  Jour.,''  Feb.,  iqis").  The  s}Tnptoms  are  ver\-  variable, 
depending  upon  the  amount  and  nature  of  the  th}Toid  secretion  and  also  upon 
the  ner\'Ous  tendencies  of  the  \-ictim.  It  is  vastly  more  common  in  women  than 
in  men,  and  is  most  common  between  the  ages  of  twenty  and  forty.  It  may 
arise  at  puberty.  It  has  been  stated  that  child-bearing  has  Little  influence  in  its 
causation,  but  I  have  seen  the  development  of  it  in  a  woman  three  times  in  three 
different  pregnancies.  There  is  no  proof  of  heredity,  but  it  is  not  unusual  to 
find  more  than  one  member  of  a  family  with  it.  It  is  not  particularly  prone  to 
appear  in  ordinar\-  goitrous  families,  although  a  person  \\-ith  an  ordinary-  goiter 


1236 


Diseases  and  Injuries  of  the  Thyroid  Gland 


sometimes  develops  all  the  nervous  symptoms  and  heart  symptoms  of  Graves's 
disease  (see  page  1231,  Basedowified  Goiter).  It  may  arise  after  emotional  ex- 
citement or  depression,  fright,  shock,  hemorrhage,  or  an  acute  illness.  It  may 
develop  during  the  existence  of  locomotor  ataxia,  paresis,  epilepsy,  neurasthenia, 
hysteria  and  other  nervous  troubles,  and  abdominal  and  pelvic  diseases.  A  shock 
or  fright  does  not  cause  hypersecretion.  That  existed  before,  but  there  were  no 
symptoms  because  the  body  was  neutralizing  the  poison.  Shock  develops  symp- 
toms by  abolishing  neutralization  (C.  H.  Mayo,  "Illinois  Med.  Jour.,"  Feb., 
1913).  Crile  ("Am.  Jour.  Med.  Sci.,"  Jan.,  1913)  believes  that  "Graves's 
disease  is  not  a  disease  of  a  single  organ  or  the  result  of  some  fleeting  cause," 
that  it  originates  in  fear,  and  is  excited  by  "some  stimulating  emotion  intensely 

or  repeatedly  given,  or  some 
lowering  of  the  threshold  of  the 
nerve  receptors,  thus  establish- 
ing a  pathological  interaction 
between  the  brain  and  thy- 
roid." Digestive  toxemia  is 
thought  by  many  to  be  the  un- 
derlying cause.  It  is  frequently 
associated  with  marked  ane- 
mia the  result  of  excessive 
vomiting.  The  disease  is  a 
toxemia  and  the  real  cause  of 
the  symptoms  is  hypertrophy 
of  the  thyroid  and  excessive 
secretion  of  the  gland  {hyper- 
thyroidism). This  view  is  ren- 
dered more  probable  when  we 
recall  that  a  condition  known 
as  myxedema  possesses  many 
symptoms  directly  opposite  to 
those  of  Graves's  disease  and 
that  myxedema  is  due  to  de- 
terioration, great  diminution 
or  absence  of  thyroid  secre- 
tion, and  the  unopposed  action 
of  adrenal  secretion.  The  ad- 
ministration of  thyroid  extract 
to  an  individual  may  produce  some  symptoms  observed  in  exophthalmic  goiter 
and  partial  thyroidectomy  may  improve  or  cure  Graves's  disease.  lodothyro- 
globulin  is,  perhaps,  the  poisonous  element. 

An  apparent  objection  to  this  view  is  that  Graves's  disease  may  exist  with- 
out detectable  thyroid  enlargement,  but  this  objection  loses  force  when  we 
recall  that  the  thyroid  may  be  somewhat  enlarged,  though  we  cannot  detect 
the  increase.  It  is  probable  in  exophthalmic  goiter  that  whether  or  not  there 
is  an  excess  of  thyroid  products  passing  into  the  circulation,  toxic  materials 
of  some  sort  are  formed  in  the  gland  and  are  taken  into  the  lymph  and  blood. 
The  real  cause  of  exophthalmic  goiter  is  not  positively  proved,  but  it  seems 
probable  that  the  disease  is  due  to  the  action  on  the  sympathetic  system  of 
large  amounts  of  thyroid  material,  of  some  poisonous  product  of  thyroid 
activity,  or  of  some  toxin  the  thyroid  fails  to  destroy. 

In  exophthalmic  goiter  the  vessels  of  the  gland  are  not  dilated — in  fact, 
they  are  "usually  smaller  and  less  numerous  than  in  a  parenchymatous  goiter 
of  the  corresponding  size"  (Berry,  on  "Diseases  of  the  Thyroid  Gland").  The 
surface  of  the  gland  is  smooth.     On  section,  the  cut  surfaces  seem  solid  and 


Fig.  805.- 


-Exophthalmic  goiter  and  total  blindness  from 
protrusion  of  eyes  (Hansell) . 


Exophthalmic  Goiter  1237 

very  little  colloid  is  visible.  The  enlargement  is  due  to  growth  of  the  glandu- 
lar epithelium,  either  general  or  in  localized  areas,  and  this  epithelial  prolifera- 
tion may  be  induced  by  different  exciting  causes. 

In  exophthalmic  goiter  the  lymphatics  within  the  lobules  are  usually  ob- 
literated, but  the  lymphatics  around  the  lobules  are  present  in  increased 
number  and  are  of  exaggerated  size.  Sometimes  the  thyroid  becomes  fibrous, 
and  in  such  cases  myxedema  is  apt  to  arise.  In  a  typical  case  there  are  rapid 
pulse  or  tachycardia,  protrusion  of  the  eyeballs  or  exophthahnus  (due  to  a  col- 
lection of  fat  back  of  each  eye),  and  enlargement  of  the  thyroid  gland  or  goiter. 
Either  thyroid  enlargement  or  exophthalmus  may  be  absent — in  fact,  in  some 
rare  cases  both  are  absent.  The  pulse-rate  in  most  cases  is  from  90  to  140. 
Exophthalmus  is  present  in  at  least  80  per  cent,  of  cases.  The  enlargement  of 
the  thyroid  is  bilateral.  Unilateral  enlargements  are  instances  of  Basedowified 
goiter — that  is,  are  cases  in  which  toxemia  arises  in  the  course  of  an  ordinary 
goiter  (see  page  1231).  A  systolic  bruit  is  usually  audible  over  the  thyroid 
region,  and  the  large  vessels  at  the  root  of  the  neck  pulsate  strongly  because  of- 
arterial  dilatation.  The  cardiac  symptoms  are  of  great  importance.  Acute 
cardiac  dilatation  occurs  during  tachycardia,  and  for  a  time,  at  least,  disappears 
as  tachycardia  abates.  Even  trivial  fatigue  brings  on  temporary  dilatation. 
Dilatation  may  become  permanent  (and  does  after  one  year),  valvular  in- 
sufficiency may  arise,  or  cardiac  hypertrophy  may  occur  (Grocco,  in  "Riv. 
Grit,  di  Clin.  Med.,"  Jan.  2,  1904).  Von  Graefe's  sign  may  be  present;  this  is 
inability  of  the  lids  to  follow  the  eyes  in  looking  down.  Stellwag's  sign  is  retrac- 
tion of  the  upper  lids.  The  lids  in  some  cases  cannot  be  completely  closed,  and 
when  the  eyeball  is  suddenly  turned  up,  the  lid  and  brow  may  fail  to  act  to- 
gether. Moebius's  sign  is  inability  to  maintain  the  eyes  in  convergence.  In 
some  cases  ocular  palsies  exist,  in  others  there  is  photophobia  or  nystagmus. 
Patients  may  suffer  from  neuralgia,  colic,  choreic  movements,  tremor,  flushes 
of  heat,  and  gastric  crises.  Tremor  is  practically  always  present  when  the 
arms  and  forearms  are  extended,  the  palms  of  the  hands  are  turned  down,  and  the 
fingers  are  spread  apart.  Widespread  tremor  is  apt  to  arise  from  any  excite- 
ment, shock,  or  surprise.  Dyspnea  often  exists  and  albuminuria  and  polyuria 
are  not  uncommon.  Hemoptysis,  hematemesis,  or  mental  disturbance  is  some- 
times noted.  The  patient  is  usually  greatly  depressed  mentally,  sometimes  is  ex- 
cited, and  may  have  outbreaks  of  violent  hysterical  excitement  or  even  of  mania. 
The  usual  expression  is  one  of  fright.  There  may  be  insomnia,  elevated  tem- 
perature, excessive  sweating,  or  sudden  attacks  of  diarrhea.  All  symptoms  are 
increased  by  fear  or  fright.  Exophthalmic  goiter  is  sometimes  associated 
with  osteomalacia.  This  fact  is  important  in  connection  with  MacGallum's 
observations  on  the  action  of  the  parathyroids  in  controlling  calcium  meta- 
bolism. Kocher  emphasizes  the  importance  of  the  blood-picture.  In  nearly 
all  cases  there  is  lymphocytosis.  Halsted  ("Annals  of  Surgery,"  August,  1913) 
says  of  his  cases:  "Almost  invariably  the  proportion  of  lymphocytes  was  in- 
creased, once  being  as  high  as  65  per  cent.  But  in  i  case,  the  most  serious  of 
all,  the  total  percentage  of  lymphocytes  was  only  9."  Halsted  regards  enlarge- 
ment of  the  thymus  as  probably  responsible  for  the  lymphocytosis,  and  the 
thymus  is  enlarged  in  at  least  75  per  cent,  of  marked  cases.  After  operation 
lymphocytosis  gradually  diminishes  (Halsted,  Ibid.).  The  duration  of  a  case 
is  entirely  uncertain.  It  is  usually  very  chronic,  with  remissions  or  actual  inter- 
missions. Sometimes  the  patient  gets  entirely  well,  but  this  result  is  rare. 
There  is  often  a  partial  cure,  which  may  at  any  time  be  followed  by  a  renewed 
outbreak.  Sometimes  the  condition  passes  away  rapidly,  but  abatement  is 
usually  gradual.  Some  cases  get  progressively  worse  and  die.  Certain  cases 
are  acute  and  these  are  apt  to  result  fatally.  A  man  in  the  Jefferson  Hos- 
pital died  in  five  weeks  after  the  first  symptoms  were  noted.     He  was  de- 


1238  Diseases  and  Injuries  of  the  Thyroid  Gland 

Hrious  for  several  weeks.  Another  died  in  four  weeks  in  spite  of  ligation 
of  the  two  superior  thyroids.  Very  grave  cases  of  exophthalmic  goiter  are 
probably  often  associated  with  disease  of  the  thymus  (Rehn).  C.  H.  Mayo 
("Illinois  Med.  Jour.,"  Feb.,  1913)  says:  "While  the  large  majority  of  cases 
can  be  easUy  diagnosed  from  the  nervous  symptoms,  tachycardia,  goiter,  and 
eye  symptoms,  there  are  a  few  cases  in  which  it  is  difficult  to  diagnose  true 
hyperthyroidism  from  pure  neurasthenia,  myocarditis,  or  Bright's  disease,  as 
well  as  a  few  cases  in  which  there  may  be  a  complication  by  affection  of  the 
hypophysis,  thymus,  or  adrenals." 

Treatment. — Thyroid  extract  does  harm.  Medical  treatment  in  a  severe 
case  should  comprise  rest  in  bed,  the  use  of  an  ice-bag  over  the  heart,  and  the 
administration  of  adrenalin.  When  the  patient  gets  about  again,  he  must 
avoid  alcohol  and  all  forms  of  excitement.  Gentle  exercise  is  desirable,  but 
never  violent  exercise.  Diet  is  to  be  nutritious,  but  non-stimulating.  Elec- 
tricity is  said  to  be  of  benefit.  Experiments  in  organotherapy  are  being  tried 
in  this  disease.  Thymus  extract  has  been  used.  Ballet  and  Enriquez  assumed 
that  the  thyroid  gland  furnishes  an  antitoxin  to  certain  body  poisons,  that  an 
excess  of  thyroid  secretion  over  the  amount  required  to  neutralize  toxin  causes 
the  condition  known  as  Graves's  disease,  and  that  the  symptoms  of  Graves's 
disease  should  disappear  if  sufficient  toxin  is  administered  to  antidote  the  excess 
of  thyroid  secretion  (Hubert  Richardson,  in  "Am.  Medicine,"  August,  1906). 
The  two  observers  mentioned  above  obtained  blood-serum  from  th3Toidecto- 
mized  dogs  and  injected  it  into  individuals  suffering  from  Graves's  disease  and 
claim  that  they  noted  improvement.  In  2  of  their  patients,  however,  tetany 
developed.  Lanz  has  used  the  milk  of  thyroidectomized  goats  instead  of  the 
serum  of  thyroidectomized  dogs.  The  serum  of  thyroidectomized  sheep,  pow- 
der made  from  the  dried  goiter  of  a  cretin,  and  the  powdered  flesh  of  thyroid- 
ectomized sheep  have  been  used  (Hubert  Richardson,  Ibid.).  What  is  known 
as  thyroidectin  is  the  dried  serum  of  an  animal  from  which  the  thyroid  gland 
has  been  removed.  John  W.  Rogers  and  S.  P.  Beebe  have  made  some  ex- 
tremely interesting  studies  on  the  production  and  application  of  a  serum. 
Rogers  makes  two  sera,  using  one  or  the  other,  according  to  the  needs  of  the 
case.  One  serum,  called  the  normal  serum,  is  obtained  from  sheep  or  rabbits 
after  injecting  them  with  the  combined  nucleoproteins  and  thyroglobulin  of 
healthy  thyroids;  the  other,  called  the  pathological  serum,  is  obtained  from 
the  animals  after  injecting  them  with  combined  nucleoproteins  and  thyro- 
globulin obtained  from  the  thyroids  of  Graves's  disease.  In  i  severe  case  I 
have  seen  rapid  improvement  and  apparent  cure  follow  the  use  of  Rogers's 
serum.  The  value  of  serum  treatment  is  as  yet  undetermined.  It  is  certainly 
not  free  from  danger  and  some  deaths  have  followed  its  use  One  cause  of 
diverse  results  after  the  use  of  goat  serum  may  be  found  in  the  fact  that  some 
of  the  animals  were  probably  incompletely  thyroidectomized.  The  goat  pos- 
sesses aberrant  thyroids  and  these  must  be  removed  as  well  as  the  gland  proper. 

There  are  upon  the  market  three  preparations  to  combat  hyperthyroidism: 

1 .  Thyroidectin  (or  thyreoidectin)  is  a  powder  made  from  the  dried  blood- 
serum  of  thyroidectomized  animals.  It  is  given  in  5-gr.  capsules.  The  dose  is 
I  or  2  capsules  three  times  a  day. 

2.  Beebe's  serum  is  the  serum  of  thyroidectomized  animals. 

3.  The  antithyroidin  of  Moebius  is  the  serum  of  sheep's  blood,  the  animal 
having  had  its  thyroid  gland  removed  at  least  six  weeks  before  the  serum  was 
obtained. 

Bilateral  extirpation  of  the  cervical  ganglia  of  the  sympathetic  and  division 
of  each  nerve  below^  the  ganglion  has  been  employed,  it  is  alleged,  with  bene- 
fit (Jaboulay).  I  have  not  employed  the  operation  for  this  disease.  Liga- 
tion of  the  thyroid  arteries  may  do  good.     Its  chief  use  is  preliminary  to  thy- 


Operations  on  the  Thyroid  Gland 


1239 


roidectomy.  Partial  thyroidectomy  is  the  operation  commonly  employed  in 
severe  cases;  it  cures  within  six  months  from  50  to  75  per  cent,  of  the  cases  oper- 
ated upon.  One  lobe,  the  isthmus,  and  a  portion  of  the  other  lobe  are  removed. 
Some  cases  do  not  improve;  others  improve  slowly  and  relief  is  only  partial. 
It  is  the  operation  which  I  prefer.  The  Mayos  have  obtained  a  splendid  series 
of  results  from  this  operation.  It  is  their  custom  to  apply  the  x-rays  daily  for 
several  weeks  and  then  to  operate.  The  rays  produce  decided  but  temporary 
improvement.  The  operation  is  intracapsular  extirpation  of  one  lobe.  Ether 
is  given  to  most  cases  (by  mtra tracheal  insufflation).  In  some  cases  thyroid 
intoxication  follows  operation.  In  other  cases  very  rapid  growth  follows  in- 
complete removal,  and  the  operation 
seems  actually  to  have  done  harm. 
Sudden  death  occasionally  follows 
the  operation.  The  removal  of  an 
exophthalmic  goiter  is  difficult;  the 
capsule  and  blood-vessels  rupture 
from  slight  force.  All  cases  should 
not  be  operated  upon.  (See  Opera- 
tion for  Exophthalmic  Goiter  on 
page  1243.)  The  ;v-rays  frequently 
have  a  very  beneficial  effect  upon 
the  s}-mptoms  of  exophthalmic  goiter. 
They  probably  destroy  some  of  the 
secreting  glandular  epithelium,  and 
thus  diminish  the  amount  of  the 
thyroid  secretion  and  alter  its  char- 
acter. They  also  induce  fibroid 
changes,  and  80  per  cent,  of  cases 
are  relieved.  Frequently  the}'  cause 
great  improvement,  occasionally  they 
will  produce  a  cure.  It  is  my  cus- 
tom to  use  the  rays  preliminary  to  operation  in  order  to  decrease  the  vascu- 
larity of  the  part,  to  lessen  the  amount  and  diminish  the  toxic  quality  of  the 
thyroid  secretion,  and  to  modify  the  various  s\Tnptoms. 

Operations  on  the  Thyroid  Gland. — The  removal  of  a  goiter  is  a  major 
operation  and  one  beset  ^^ith  difficulties  and  dangers.  Nevertheless  it  is  a  very 
successful  operation.  I  lost  a  case  of  supposed  adenomatous  goiter  which  turned 
out  to  be  a  metastatic  hypernephroma.  The  patient  died  from  secondary  hem- 
orrhage. I  lost  a  case  of  carcinoma  of  the  thyroid  and  a  case  of  simple  ade- 
noma. My  mortality  in  ordinary  goiter  has  been  under  2  per  cent.  In  1 200  cases 
of  ordinary-  goiter  the  Mayos  had  a  mortality  of  i  per  cent.  foUoA^ing  extirpation. 
Kocher's  mortahty  is  0.4  per  cent.  Certain  anatomical  points  are  to  be  borne 
in  mind.  The  internal  jugular  vein  is  frequently  found  to  the  inner  side  of 
the  carotid  artery  and  lying  on  the  goiter  (because  the  vein  has  branches 
which  run  to  the  goiter  and  hold  the  vessel  against  the  thyroid).  The  recur- 
rent laryngeal  nerve  ascends  along  the  side  of  the  trachea  back  of  the  gland, 
and  is  against  the  esophagus  before  it  passes  through  the  cricothyroid  mem- 
brane. On  the  right  side  the  nerve  is  very  close  to  the  inferior  thyroid  arter\', 
sometimes  passing  over  it,  sometimes  under  it.  On  the  left  side  it  is  deeper 
and  not  so  near  the  artery.  The  parathyroids  are  behind  the  thyroid  and 
usually  behind  the  capsule. 

In  view  of  the  fact  that  one  or  both  recurrent  laryngeal  nerves  may  be 
paretic  from  pressure,  all  cases  should  be  examined  with  the  laryngeal  mirror 
before  the  operation  to  determine  this  point.  If  the  paresis  is  on  one  side 
only,  the  sound  vocal  cord  may  possibly  compensate  by  advancing  across  the 


Fig.  S06. — Enucleation  of   cystic  goiter;   capsule 
opened  (C.  H.  Mayo). 


1240 


Diseases  and  Injuries  of  the  Thyroid  Gland 


midline.  In  such  conditions  the  paresis  may  be  first  observed  following 
operation,  leading  the  operator  to  think  that  he  has  injured  a  nerve  (C.  H. 
Mayo,  in  "Surg.,  Gyn.,  and  Obst.,"  July,  1907). 

Intraglandular  Enucleation  (Socin's  Operation). — By  this  operation  an 
adenoma  or  cyst  of  the  thyroid  gland  is  removed,  the  encompassing  glandular 
tissue  being  left  in  place.  The  capsule  of  such  a  growth  is  glandular  tissue. 
The  operation  of  enucleation  is  not  suited  to  the  removal  of  multiple  tumors 
and  it  cannot  be  performed  for  parenchymatous  goiter  or  exophthalmic  goiter. 
Intraglandular  enucleation  is  performed  as  follows:  The  thyroid  is  exposed 
by  an  oblique  or  by  a  transverse  incision.  An  incision  is  made  through  the 
capsule  of  the  thyroid  gland  and  through  the  glandular  tissue  until  the  cyst 
or  solid  tumor  is  reached.  As  a  rule,  the  tumor  can  be  recognized  by  the 
fact  that  its  color  differs  from  the  color  of  the  thyroid  tissue.  The  tumor  is 
turned  out  by  the  fingers,  a  special  scoop,  the  knife  handle,  or  a  dry  dissector. 
In  some  cases  a  cyst  can  be  most  easily  removed  if,  after  exposure,  it  is  in- 
cised and  emptied  and  its  wall  is  then  grasped  by  strong  forceps.  A  sohd 
tumor  should,  if  possible,  be  removed  intact.  The  wound  is  packed  tempo- 
rarily with  gauze,  the  edges  of  the  cavity  are  grasped  by  forceps,  the  gauze  is 


Fig.  807.— Kocher's  transverse  incision  ex- 
posing the  muscles  and  median  veins  of  the  neck 
(Kocher) . 


. — Isolating  the  accessory  veins  (Kocher) . 


removed,  and  every  bleeding  point  is  carefully  ligated.  The  wound  is  closed 
by  three  layers  of  sutures — "one  in  the  gland,  one  in  the  muscles,  and  a  third 
in  the  skin"  (James  Berry,  on  "Diseases  of  the  Thyroid  Gland").  If  the  tumor 
is  large,  drain  for  twenty-four  hours;  otherwise,  do  not  drain. 

Enucleation  is  a  very  successful  operation  if  performed  upon  properly 
selected  cases,  and  can  be  performed  rapidly,  but  the  arrest  of  bleeding  is 
often  tedious  and  troublesome. 

Extracapsular  Extirpation. — ^This  term  means  removal  of  the  entire  gland 
(complete  thyroidectomy)  or  a  portion  of  the  gland  (partial  thyroidectomy)  with 
the  glandular  capsule,  the  operation  being  an  extracapsular  procedure.  Usu- 
ally but  one  lobe  is  extirpated  (lobectomy),  or  one  lobe,  the  isthmus,  and  a  por- 
tion of  the  other  lobe.  This  method  enables  the  operator  to  tie  the  chief  ves- 
sels before  he  cuts  them;  as  his  vision  is  not  obscured  by  bleeding,  he  can 
avoid  cutting  the  glandular  capsule  (which  would  provoke  copious  bleeding), 
and  he  keeps  a  safe  distance  away  from  the  recurrent  laryngeal  nerve. 

If  the  patient  suffers  from  grave  respiratory  trouble  with  myocardial  disease, 
a  general  anesthetic  is  contra-indicated.  If  ether  is  used,  after  unconscious- 
ness is  obtained  the  ether  is  given  by  intratracheal  insufflation.     The  patient 


The  Operation  for  Goiter 


1241 


is  placed  recumbent,  with  the  shoulders  a  little  raised  and  the  neck  laid  upon  a 
sand-pillow  so  as  to  throw  the  head  back  as  far  as  is  consistent  with  comfort- 
able respiration. 

An  obHciue  incision,  a  horseshoe-shaped  incision,  or  a  transverse  collar  in- 
cision (Fig.  807)  may  be  made.  I  usuaUy  employ  an  incision  shaped  like  an  in- 
complete horseshoe,  the  convexity  being  downward.  Layer  by  layer  the  tissues 
are  divided.  Vessels  are  carefiilly  tied  as  divided  or  before  division.  The 
muscles  which  run  from  the  sternum  to  the  hyoid  bone  may  in  some  cases  be 
separated,  but  the  extirpation  of  a  large  goiter  requires  transverse  division 


J^ 


Fig.  809. — Exposure  of  veins  at  lower  end  before 
ligation  (Kocher). 


Fig.  8io.- 


-Dislocation  of  the  goiter  toward  the 
right  (Kocher). 


of  the  muscles  high  up.  The  capsule  of  the  lobe  is  exposed,  and  is  separated 
from  external  parts  (Figs.  808,  809,  and  810).  The  upper  portion  of  the 
gland  is  cleared.  The  superior  thyroid  vessels  are  found,  tied  with  two  liga- 
tures each,  and  di\'ided  between  the  ligatures  (Fig.  811).  The  clearing  of  the 
gland  is  carried  on  toward  the  median  Hne  and  some  rather  large  veins  are 
encountered  and  tied  (Fig.  813).  The  lower  portion  of  the  lobe  is  cleared  and 
the  inferior  thyroid  vessels  are  found.     Near  this  point  the  recurrent  laryngeal 


A  carotis 


_^ M  sternocleiio 


Fig.  811. 


-Isolation  of  the  superior  thyroid  artery 
and  vein  (Kocher) . 


Fig.  812. — Ligation  of  the  inferior  thyroid  artery 
(Kocher). 


nerv'e  Hes  and  may  be  located.  If  the  operation  is  being  done  under  a  local 
anesthetic  adjacency  to  the  nerve  is  readily  determined,  because  if  the  nerve 
is  pulled  upon,  or  if  it  is  pressed  upon  or  touched  by  a  blunt  instrimient,  the 
patient's  voice  becomes  metaUic.  A  deliberate  attempt  is  made  to  locate  the 
nerve,  and  the  patient  is  engaged  in  a  conversation  requiring  answers  while  the 
surgeon  is  investigating.  The  lobe  is  lifted  from  its  bed  and  dislocated  from  the 
wound  and  the  inferior  thyroid  vessels  are  tied  close  to  the  border  of  the  gland  in 
order  to  avoid  the  recurrent  laryngeal  nerve  (Fig.  812).    The  vessels  are  tied  and 


1242 


Diseases  and  Injuries  of  the  Thyroid  Gland 


cut  across  as  were  the  superior  thyroid  vessels.  The  isthmus  is  next  exposed, 
clamped,  ligated,  and  cut  across,  every  care  being  taken  to  prevent  colloid  from 
being  squeezed  into  the  wound  (Fig.  814).  After  dividing  the  isthmus,  any 
bleeding  point  is  ligated  and  the  stump  is  cauterized.  The  divided  muscles  are 
sutured  with  catgut,  a  drainage-tube  is  inserted,  and  the  superficial  wound  is 
closed  with  sutures  of  silkworm-gut. 

Intracapsular  Extirpation. — This  operation  is  warmly  advocated  by  the 
Mayos.  The  preservation  of  the  posterior  portion  of  the  capsule  protects  the 
recurrent  laryngeal  nerve  and  greatly  lessens  the  risk  of  injuring  the  parathy- 
roids. Ether  is  given  unless  there  is  grave  respiratory  difficulty  with  myocardial 
degeneration,  and  half  an  hour  before  administering  the  ether  the  patient  is 
given  a  hypodermatic  injection  of  \  gr.  of  morphin  and  y-^^  gr.  of  atropin.  The 
ether  is  continued  by  intratracheal  insuffiation.  When  anesthetized,  the  patient 
is  placed  in  the  reversed  Trendelenburg  position  and  the  shoulders  are  elevated 
(C.  H.  Mayo,  in  "Surg.,  Gyn.,  and  Obst.,"  June,  1907).  Kocher's  transverse  col- 
lar incision  is  made.  Muscles  are  separated  or  divided  as  in  ordinary  extraglan- 
dular  extirpation.  If  the  ribbon  muscles  are  divided  the  cut  is  made  near  their 
upper  insertion  to  save  their  nerve  supply  and  prevent  the  muscle  scar  from 


Fig.  813. — Isolation   of   the  venae   thyreoideas 
imas  (Kocher). 


Fig.  814. — Isolation  and  clamping  of  the  isthmus 
(Kocher) . 


being  in  line  with  the  skin  scar.  The  gland  is  elevated.  The  vessels  entering 
and  leaving  the  raised  lobe  are  double  clamped  and  tied.  The  capsule  is  incised 
along  the  outer  side  of  the  gland,  is  pushed  back  with  gauze,  and  the  lobe  is 
drawn  toward  the  midline,  and  vessels  are  caught  by  forceps,  the  tissues  being 
grasped  in  line  with  the  midline  of  the  body  (C.  H.  Mayo,  Ibid.). 

Every  structure  bearing  any  resemblance  to  a  parathyroid  is  allowed  to 
remain.  The  isthmus  is  clamped,  divided,  and  closed  by  suture.  The  muscles 
and  skin  are  sutured.  Drainage  is  required  after  removal  of  large  growths,  a 
separate  incision  being  made  to  permit  of  it. 

Dangers  in  Goiter  Operations. — During  any  operation  for  goiter  sudden 
death  may  occur.  In  some  cases  a  general  anesthetic  is  responsible.  In 
others  suffocation  arises  from  pressure  upon  or  bending  of  the  trachea  or 
collapse  of  the  trachea  as  the  goiter  is  lifted  from  its  bed.  In  rare  cases  dan- 
gerous dyspnea  arises  from  irritation  of  the  laryngeal  nerves,  and  cardiac 
inhibition  may  be  induced  in  the  same  manner.  The  parathyroids  may 
be  injured  or  removed  and  tetany  may  result.  Rough  handling  and  flood- 
ing the  wound  with  colloid  may  be  followed  by  great  and  even  fatal  h3^er- 
thyroidism.  The  trachea  or  esophagus  may  be  opened.  The  recurrent  laryn- 
geal nerve  may  be  injured.  Air  embolism  seldom  occurs.  Reactionary  or 
secondary  hemorrhage  is  usually  due  to  slipping  of  the  ligature  on  the  superior 


The  Operation  for  Exophthalmic  Goiter  1243 

th\Toid  arter\'  "caused  by  including  a  piece  of  muscle"  (C.  H.  Mayo,  in  "Surg., 
G)^!..  and  Obstet.."  June.  1907). 

Acute  Thyroidism  (Hyperthyroidism!. — When  colloid  from  the  th\Toid 
is  squeezed  into  the  wound  during  the  operation  or  leaks  into  it  later,  it  is 
absorbed  and  may  produce  serious  5>Tnptoms  or  even  death.  This  is  most 
apt  to  happen  in  exophthalmic  goiter.  The  s\Tnptoms  always  appear  within 
forty-eight  hours  and  usually  within  twenty-four.  Sometimes  thev  arise 
quickly  after  operation.  In  some  cases  in  which  this  happens  the  patient 
never  reacts  from  the  operative  shock,  but  develops  a  ver>-  rapid  pulse  and 
intense  dyspnea,  and  dies  in  a  few  hours.  In  less  severe  cases  there  is  a  period 
of  circulator}-  excitement,  dyspnea,  and  elevated  temperature  {thyroid  fever). 
The  surgeon  seeks  to  prevent  acute  th\Toidism  by  lirniring  leaking  of  colloid, 
by  cauterizing  the  stump,  by  washing  the  wound  with  adrenalin  solution, 
suturing  the  capsule  over  the  raw  stmnp  of  the  gland,  and  inserting  drainage. 
The  Operation  for  Exophthalmic  Goiter. — The  operation  of  th^Toidectomv 
is  not  to  be  performed  during  an  acute  exacerbation.  To  do  it  then  wiU  xqtv 
probably  cause  death.  DeKrium  is  a  contra-indication.  So  are  gastric  crises. 
The  operation  is  ver\-  dangerous  when  there  is  great  cardiac  dilatation.  After 
the  disease  has  existed  one  year  it  is  highly  probable  that  marked  dilatation 
exists.^  Hence,  early  operations  are  much  safer  than  late  ones.  If  a  case  is 
seen  early,  and  if  the  .v-rays  (and  perhaps  senuns)  fail  to  cure,  operation  should 
be  recommended.  In  any  case  with  serious  s}Tnptoms  the  surgeon  seeks  to 
modif>-  those  s\Tnptom5  before  th\Toidectomv  bv  means  of  rest,  the  ice-bag 
over  the  heart,  drugs,  the  .v-rays,  and  perhaps  serums.  If  imder  this  treatment 
the  dangerous  s\-mptoms  disappear  or  greatly  abate.  th}Toidectomy  may  be 
performed. 

If  the  dangerous  SAinptoms  are  little  modified  or  not  modified  at  all  by 
medical  treatment,  preliminar}'  ligation  of  one  of  the  th}Toid  arteries  is  indi- 
cated. Ligation  of  an  arter\-  will  not  cure  a  case,  but  will  probably  greatly 
improve  it.  The  operation  is  strictly  palliative  and  preliminary-.  Tie  the 
right  superior  tmToid.  Wait  one  week.  If  the  s\-mptoms  are  not  greath" 
improved,  tie  the  left  superior  th}Toid  and  wait  a  while.  In  severe  cases 
tie  both  superior  th}Toids  at  one  sitting.  The  operation  is  done  tmder 
infiltration  anesthesia.  It  is  not  entirely  free  from  damage  and  may  cause 
death.  Halsted  ("Annals  of  Surger}-.''  August,  1913)  ties  one  im'erior  thy- 
roid or  both  inferior  th^Toids.  He  says  that  by  the  inferior  operation  we 
obtain  a  better  cosmetic  effect,  leave  a  scar  largely  beyond  the  incision  which 
will  subsequently  be  used  for  lobectomy,  and  tie  vessels  which  are  larger 
than  the  superior  arteries.  In  i  of  his  cases  four  arteries  were  tied  in  4 
operations  before  lobectomy.  C.  H.  ^layo"  points  out  that  the  hgatiu-eof  the 
superior  th\Toid  should  be  applied  ver\'  close  to  the  pole  or  should  actually 
include  some  of  the  th}-roid  tissue,  "'so  that  a  reversed  circulation  in  anasto- 
motic branches  ^-ith  the  inferior  th^Toid  arter\-  may  not  occur." 

WTien  it  is  esteemed  safe  the  surgeon  prepares  to  perform  partial  th^Toidec- 
tomy.  In  most  cases  ether  is  given,  preceded  by  a  hypodermatic  injection  of 
morphin  and  atropin.  After  the  patient  is  anesthetized  by  ether  the  tracheal 
tube  should  be  introduced  and  the  unconsciousness  be  maintakied  by  insufiia- 
tion  anesthesia.  If  there  is  grave  cardiac  dilatation  and  we  determine  to  op- 
erate, infiltration  anesthesia  is  relied  upon. 

At  the  operation  an  entire  lobe  (except  a  thin  sHce),  the  isthmus,  and  a  por- 
tion of  the  other  lobe  should  be  removed.  The  more  of  the  gland  removed, 
the  better  the  prospect  of  cure  (Halsted.  "Annals  of  Surgery."  August,  1913). 

1  C.  H.  Mayo,  in  "Collected  Papers  by  the  Staft  of  St.  Mar>-"5  Hospital."  Mayo  Clinic, 
1912;  Halsted.  "Annals  of  Surgen,-,"  August,  1913. 

-  "Collected  Papers  bj-  the  Staff  of  St.  ilaiy's  Hospital,"  Mayo  Clinic.  August.  191 2. 


1244  Diseases  and  Injuries  of  the  Thyroid  Gland 

At  least  one-half  of  one  lobe  must  be  left  in  order  to  prevent  myxedema.  The 
parathyroids  are  protected  by  leaving  a  small  slice  of  the  posterior  portion  of 
each  lobe  (Halsted,  "Annals  of  Surg.,"  Aug.,  1913).  After  the  removal  of  one 
lobe  the  other  usually  undergoes  considerable  atrophy.  After  thyroidectomy, 
lymphocytosis  gradually  decreases,  and  an  enlarged  thymus  generally  disap- 
pears (Ibid.).  Thyroidectomy  may  cure  the  case;  it  may  greatly  improve  it; 
may  fail  or  nearly  fail,  or  may  cause  death.  Cure  is  gradual  and  may  be  at- 
tained only  after  several  months.  From  50  to  75  per  cent,  of  patients  are 
cured  by  the  operation.  Many  others  are  vastly  and  permanently  improved. 
Some  are  improved,  but  are  subject  to  temporary  relapses.  In  Halsted's  39 
cases  there  was  not  a  death  from  operation. 

In  the  first  16  cases  operated  upon  by  the  Mayos  the  mortality  was  25  per 
cent.  At  present  the  factors  which  forbid  operation  are  recognized.  In  1355 
operations  for  exophthalmic  goiter  their  mortality  was  under  4  per  cent.  They 
have  had  278  consecutive  cases  without  a  death,  a  truly  wonderful  record.^ 

The  elder  Kocher  ("Jour.  Am.  Med.  Assoc,"  April,  1910)  reports  upon  535 
partial  thyroidectomies  for  exophthalmic  goiter.  The  mortality  was  3.1  per 
cent:  3  died  from  the  anesthetic,  and  now  he  uses  local  anesthesia  pre- 
ceded by  Crile's  plan  of  psychic  narcosis;  3  others  died  from  kidney  dis- 
ease which  existed  at  the  time  of  operation.  Now  he  will  not  operate  if  kidney 
disease  exists.  There  were  3  thymus  deaths;  5  with  status  lymphaticus  died 
suddenly  while  being  prepared  for  operation.  Such  patients  should  not  be 
operated  upon  unless  they  are  greatly  improved  by  medical  treatment.  Kocher, 
like  Halsted,  says  that  the  degree  of  improvement  depends  upon  the  amount  of 
gland  removed.  In  such  cases  use  medical  treatment  and  the  x-rays  first. 
If  this  plan  fails,  tie  one  or  more  of  the  thyroid  arteries  before  doing  thyroid- 
ectomy. 

My  personal  experience  in  exophthalmic  goiter  is  small;  in  fact,  I  know  of 
no  one  in  Philadelphia  who  has  performed  any  great  number  of  operations  for  it. 
I  have  performed  thyroidectomy  for  exophthalmic  goiter  14  times,  with  2  deaths. 

The  Parathyroid  Glands  and  Tetany. — These  glands  were  discovered 
by  Sandstrom  in  1880,  and  their  vital  functions  were  pointed  out  by  Gley.  He 
showed  that  removal  of  the  parathyroids  causes  tetany. 

The  parathyroids  are  brownish  red  and  are  larger  in  adults  than  in  infants. 
They  are  constant  in  man,  never  being  congenitally  absent. 

They  are  usually  four  in  number  and  are  ordinarily  placed  external  to  the 
thyroid  capsule.  In  some  cases,  however,  one  or  more  of  them  may  be  found 
embedded  in  the  thyroid  gland,  but  even  when  they  appear  to  he  within  the 
thyroid  they  are  always  separated  from  it  by  a  capsule  of  connective  tissue. 

While  there  are  usually  four  parathyroids,  there  may  be  only  three,  or 
there  may  be  six,  seven,  or  eight.  Accessory  parathyroids  may  be  found  over 
wide  areas.  One  was  discovered  by  Rogers  and  Ferguson  in  the  middle 
of  the  posterior  portion  of  the  pharynx;  and  there  was  found  in  the  thorax  by 
Ogle  a  gland  that  was  partly  parathyroid. 

From  their  situation  the  parathyroids  are  divided  into  superior,  or  external, 
and  inferior,  or  internal.  Walsh  describes  these  glands  in  adults  as  being 
each  from  6  to  7  mm.  in  length,  3  to  4  mm.  in  breadth,  and  i|  to  i  mm.  in 
thickness.  Each  of  these  glands  is  supplied  by  a  terminal  artery,  and  the  arte- 
rial supply  is  very  largely  obtained  from  the  inferior  thyroid  artery  or  from  the 
branch  of  anastomosis  between  the  superior  and  inferior  thyroid  vessels. 

If  the  parathyroid  glands  are  extirpated  from  an  animal,  tetany  usually 
develops  {experimental  tetany).  This  is  positively  the  case  in  dogs.  These 
glands  certainly  have  most  important  functions  in  the  metabolism  of  the  body. 

1  C.  H.  Mayo,  in  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic^ 
1912. 


The  Parathyroid  Glands  and  Tetany  1245 

They  are  essential  for  normal  metabolism  (Mayo  and  McGrath,  in  ''Annals  of 
Surgery,"  Feb.,  191 2).  MacCallum  and  Voegtlin  ("Johns  Hopkins  Hosp. 
Bull.,"  March,  190S)  believe  that  damage  or  removal  of  them  causes  great 
changes  in  calcium  metabolism. 

Very  little  is  known  of  diseases  of  the  parathyroid  glands.  A  few  cases  of 
tumor  have  been  reported,  each  being  an  example  of  either  work-h}^ertrophy 
or  adenoma.  One  of  these  cases  was  reported  by  the  author  in  "Surg.,  Gyn., 
and  Obst.,"  Jan.,  1909.  In  this  case  the  tumor  was  removed  under  the 
impression  that  it  was  an  adenoma  of  the  right  lobe  of  the  thyroid  gland. 
The  pathological  report,  however,  showed  it  to  be  a  parathyroid.  No  trouble 
of  any  kind  followed  the  operation,  though  at  a  later  period  enlargement  of  the 
opposite  side  of  the  neck  occurred.  This  has  been  let  alone  through  fear  that 
it  may  be  a  left  parathyroid.  In  spontaneous  tetany  histological  changes  have 
been  fomid  in  the  parathyroids  and  there  is  some  e\d(lence  that  traumatism  may 
produce  functional  insufficiency. 

Some  persons  have  maintained  that  deficiency  of  parathyroid  secretion 
is  the  cause  of  paralysis  agitans,  but  this  idea  has  been  warmly  combated  and 
lacks  evidence.  Some  obser\xrs  believe  that  there  is  a  deficiency  of  parathy- 
roid secretion  in  exophthalmic  goiter. 

In  view  of  the  well-known  fact  that  removal  of  or  damage  to  the  para- 
thyroids may  result  in  tetany  (Jiypoparathyroidism),  provided  that  several  of 
these  glands  or  all  of  them  are  damaged  or  removed,  it  becomes  the  duty  of  the 
surgeon,  when  operating  for  goiter,  to  exercise  the  utmost  care  that  he  does  not 
remove  any  of  these  bodies.  The  safest  way  to  avoid  them  is  to  retain  the  pos- 
terior portion  of  the  capsule  of  the  thyroid  gland.  If,  during  an  operation,  any 
small  body  that  resembles  a  parathyroid  is  detected,  it  shotdd  be  let  alone;  or 
if  such  a  body  has  been  accidentalty  removed,  it  should  immediately  be  im- 
planted into  the  capsule  of  the  lobe  of  the  thyroid  gland  that  has  been  left  un- 
disturbed. It  is  highly  improbable  that  the  removal  of  even  both  parathyroids 
on  one  side  will  cause  tetany  if  there  are  two  normal  parathj^roids  on  the 
opposite  side. 

On  account  of  the  possibility  of  the  development  of  tetany  the  question  of 
the  transplantation  of  parathyroids  from  animals  becomes  extremely  important. 
Halsted  has  made  some  very  valuable  experiments  upon  the  auto-  and  iso- 
transplantation  of  the  parathyroid  glands  in  dogs  ("Annals  of  Surgery," 
Oct.,  1907;  "Jour,  of  Experimental  Med.,"  vol.  xi,  No.  i,  1909).  He  has 
shown  that  if  the  parathyroid  be  transplanted  into  an  animal  with  normal 
parathyroids  failure  will  follow,  and  the  transplanted  glandule  will  disappear. 
If,  however,  there  is  parathyroid  deficiency  in  the  animal  into  which  the  trans- 
plantation is  made,  the  glandule  will  attach  itself  and  grow.  He  obtained  the 
best  results  by  placing  the  parathyroid  beneath  the  posterior  sheath  of  the 
rectus  muscle  of  the  abdomen.  Some  observers  have  placed  it  in  the  spleen; 
others,  within  the  peritoneum  and  in  various  other  regions. 

One  of  the  dogs  experimented  upon  by  Halsted  and  reported  upon  in  "Jour, 
of  Exper.  Med.,"  vol.  xi,  No.  i,  1909,  lived  in  perfect  health  "for  fifteen  months 
and  was  in  good  health  until  the  performance  of  the  final  operation,  at  which 
a  parathyroid  autograft"  was  removed.  The  dog  died  in  three  months  from 
hypoparathyroidism  (Ibid.,  No.  3,  1912). 

If  tetany  follows  thyroidectomy,  it  may  be  treated  by  the  intravenous, 
rectal,  or  stomach  administration  of  a  5  per  cent,  solution  of  lactate  of  calcium 
(MacCallum  and  Voegtlin,  Loc.  cit.).  Beebe  and  Berkeley  have  prepared  a 
parathyroid  serum  which  they  claim  is  efficient.  Charles  H.  Mayo  maintains 
that  in  tetany  either  the  serum  or  the  calcium  lactate  should  be  used,  in  the 
hope  of  tiding  the  patient  over  until  parathyroid  glands  can  be  secured  and 
implanted  ("Annals  of  Surgery,"  July,  1909).     The  calcium  salt  may  be  given 


1246  The  Carotid  Gland;  the  Thymus  Gland 

intravenously,  subcutaneously,  by  the  stomach,  or  by  the  rectum.  Joseph  H. 
Branham  ("Annals  of  Surg.,"  August,  1908)  has  reported  tetany  following 
thyroidectomy  cured  by  the  subcutaneous  injection  of  parathyroid  emulsion. 
The  emulsion  was  made  by  grinding  up  fresh  glands  of  beeves  in  a  mortar, 
and  then  pouring  400  c.c.  of  sterile  salt  solution  into  the  mortar.  The  prepa- 
ration was  filtered  through  sterile  gauze  and  was  administered  beneath  the 
patient's  breast. 

When  tetany  begins  to  develop  in  a  patient  there  are  usually  headache, 
dizziness,  and  pain  in  the  extremities.  The  muscles  in  one  or  both  forearms 
and  hands  are  liable  to  be  affected.  The  hand  flexes  at  the  wrist,  while  the 
fingers  are  extended,  and  in  some  cases  the  forearm  flexes  at  the  elbow.  Now 
and  then  the  fingers  will  flex  at  the  metacarpophalangeal  joints,  but  the  distal 
phalanges  will  remain  extended.  These  spasms  are  painful.  Similar  spasms 
may  occur  in  the  feet  and  toes.  In  most  severe  cases  the  trunk  muscles  and 
those  of  the  chest,  throat,  and  eye  may  be  involved. 

Trousseau,  years  ago,  showed  that  a  spasm  may  be  brought  on  in  the 
affected  limb  by  pressing  upon  the  nerve- trunks  and  blood-vessels;  this  is 
called  the  Trousseau  sign.  Pressure  upon  the  facial  nerve  may  induce  the 
spasms,  and  it  is  called  Chvostek's  sign.  Erb's  sign  is  a  great  increase  in  the 
galvanic  irritability  of  the  motor  nerves.  Hoffmann's  sign  is  excessives  sensi- 
tiveness of  the  sensory  nerves.  SchuUze's  tongue  sign  ("Miinch.  med.  Woch.," 
Oct.  31,  1911)  is  said  to  be  invariably  present  in  adults  with  tetany.  If  the 
side  of  the  tongue  is  tapped  the  organ  responds  by  grooving  itself  on  that  side. 
If  the  tongue  is  lifted  by  a  spatula  and  the  dorsum  is  tapped  a  constriction  like 
a  waist  forms. 

Tetany  due  to  absence  of  the  parathyroids  will  inevitably  prove  fatal  if  not 
treated  actively. 

Before  we  understood  the  necessity  of  guarding  the  parathyroids  tetany  after 
goiter  operations  was  not  uncommon.  The  preservation  of  the  posterior  portion 
of  the  capsule  has  almost  abolished  this  peril.  In  3203  operations  on  the  thy- 
roid performed  at  the  Mayo  Clinic  in  St.  Mary's  Hospital,  Rochester  (up  to 
Dec.  I,  191 1),  there  was  but  i  case  of  tetany  and  the  symptoms  in  that  were 
slight  and  transitory. 


XXXIII.  THE  CAROTID   GLAND;  THE  THYMUS  GLAND 

The  Carotid  Body  or  Gland. — This  structure  was  discovered  by  Haller 
in  1743.  It  has  no  known  function.  It  is  about  the  size  of  a  grain  of  rice  and 
lies  in  or  very  near  the  carotid  bif\ircation,  being  adherent  usually  to  the  com- 
mon carotid,  occasionally  to  the  external  carotid.  Tumors  may  form  in  this 
little  body.  The  type  found  is  the  perithelioma.  Such  a  tumor  grows  slowly, 
is  hard,  is  movable  from  side  to  side,  but  not  up  and  down,  and  is  lifted  with  each 
beat  of  the  carotid  artery.  In  the  long  run  it  tends  to  become  malignant. 
As  the  tumor  grows  it  comes  to  surround  the  common  carotid  artery. 

Treatment. — Operation  on  an  advanced  case  is  very  difficult,  will  probably 
require  ligation  of  the  common  carotid,  and  cause  grave  injury  to  important 
nerves.  In  one  of  the  author's  patients  the  common  carotid  was  tied  and  the 
patient  developed  laryngeal  palsy  and  hemiplegia.  Early  operation  may  per- 
mit of  removal  of  the  tumor  without  tying  the  common  carotid  artery.  In  a 
second  case  the  author  was  able  to  accomplish  this.  My  first  case  led  me  to 
agree  with  Reclus  that  these  tumors  should  be  let  alone  unless  they  are  pro- 
ductive of  dangerous  symptoms.  I  have  come  to  the  conclusion  that  the  time 
to  operate  is  early,  long  before  there  are  dangerous  symptoms.  To  wait  for 
obvious  malignancy  is  to  court  failure  or  disaster. 


The  Thymus  Gland  1247 

The  Thymus  Gland. — This  bilobed  ductless  gland  becomes  fully  developed 
toward  the  end  of  the  second  year  of  life.  From  that  period  it  remains  station- 
ary for  a  time  and  then  undergoes  retrogression.  At  puberty  retrogression 
becomes  rapid.  Finally,  the  gland  almost  entirely  disappears,  although  a  small 
vestige  of  it  usually  remains  through  life.  Studied  m  the  very  young  child,  it  is 
found  to  consist  of  a  thoracic  portion  and  a  cervical  portion.  The  chief  part  of 
the  gland  lies  directly  back  of  the  sternum  and  upper  four  costal  cartilages  of 
each  side  m  the  superior  and  anterior  mediastinal  spaces.  On  each  side  are  the 
pleura  and  lung.  Posteriorly  it  lies  upon  the  pericardium,  superior  vena  cava, 
innominate  vein,  and  pulmonary  artery.  The  two  lobes  from  the  gland  rise 
into  the  neck  in  front  of  the  trachea.  The  left  lobe  overlaps  the  common  caro- 
tid; the  right  lobe,  the  innominate  artery.  A  strand  of  fibrous  tissue  usually 
passes  from  the  lobe  which  ascends  highest  to  the  corresponding  lobe  of  the 
thyroid  gland.  The  lobes  of  the  thymus  receive  numerous  A^eins  from  the 
thyrbids.  The  inferior  thyroid  artery  is  the  chief  source  of  arterial  blood.  The 
thymus  is  composed  of  many  lobules  separated  by  septa.  The  undegenerated 
thymus  contains  both  honphoid  and  epithelial  structure. 

The  cells  of  the  reticulum  are  epithelial.  In  the  medulla  of  the  lobules  are 
the  concentric  corpuscles  of  Hassall  which  are  derived  from  the  epithelium 
of  the  reticulum.  The  small  thymic  cells  are  probably  lymphocytes.  In 
Hammar's  words:  "The  thymus  is  an  epithelial  organ  which  is  permeated  with 
lymphocytes"  (quoted  by  Charles  H.  Mayo  and  Bernard  F.  McGrath  in  their 
thorough  and  impressive  study  of  "The  Surgical  Importance  of  the  Thymus." 
See  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic, 
1912). 

The  function  of  the  thymus  is  as  yet  undetermined.  Some  believe  it  is 
merely  a  lymphatic  structure  and  furnishes  no  internal  secretion.  Others 
believe  that  it  furnishes  an  internal  secretion  of  great,  perhaps  of  essential, 
importance  in  development.  Some  observers  believe  that  the  thymus  de- 
stroys toxins,  and  that  deficiency  of  thymus  permits  the  accumulation  of  toxic 
matter  in  the  system.  Theses  studies  of  h}^othymization  were  made  on  thy- 
mectomized  animals. 

Experiments  to  determine  the  result  of  excessive  thymus  function  (hj^^er- 
thymization)  are  peculiarly  contradictory,  unsatisfactory,  and  inconclusive. 
In  these  experiments  thymus  glands  have  been  implanted,  thymus  juice  has 
been  injected,  and  thymus  feeding  has  been  practised. 

Mayo  and  McGrath  (Ibid.)  conclude  "that  the  thymic  function  is  concerned 
in  the  general  process  of  nutrition,  particularly  with  the  ossification  of  bone"; 
further,  it  is  probable  "that  the  thymus  and  the  chromaffin  portion  of  the 
adrenals  act  antagonistically  on  the  sympathetic." 

Althooigh  the  thymus  should  have  practically  disappeared  between  the 
twelfth  and  twentieth  3'ear,  there  are  cases  in  which  it  fails  to  disappear  at  all. 
There  may  never  have  been  any  symptoms  to  suggest  persistence  and  the  gland 
may  be  discovered  at  a  necropsy. 

The  thymus  gland  may  enlarge.  The  enlargement  is  most  usual  in  child- 
hood, but  if  the  thymus  is  persistent,  may  occur  much  later  in  life.  The  condi- 
tion is  hypertrophy  or  h^-perplasia.  Enlargement  of  the  gland  may  be  met  with 
in  exophthalmic  goiter,  leukemia,  Hodgkin's  disease,  and  status  lymphaticus. 
It  may  produce  no  symptoms  whatever.  It  may  be  responsible  for  asthma  and 
for  sudden  death  (thymic  asthma  and  th}anic  death).  Enlargement  is  recog- 
nized by  the  x-rays. 

Infectious  and  wasting  diseases  in  children  may  cause  atrophy  of  the  thy- 
mus. The  gland  may  be  the  seat  of  hemorrhages,  inflammation,  tuberculosis, 
calculi  formation,  and  necrosis  (in  diphtheria).  In  congenital  syphilis  the 
thymus  may  be  the  seat  of  gummata  or  fibrosis. 


1248  Diseases  and  Injuries  of  the  Lymphatics 

Dubois's  abscesses  occur  in  syphilis  of  the  thymus.  Many  spaces  form  and 
the  spaces  are  full  of  a  fluid  resembling  pus  or  actually  being  pus. 

Enlargement  by  tumors  may  occur.  Innocent  tumors  (fibroma,  myxoma, 
and  adenoma)  are  rare.  Malignant  tumors  (carcinoma  and  sarcoma)  are 
more  common.     The  most  common  growths  are  small-celled  sarcomata. 

Tumors  of  the  thymus  cause  the  symptoms  of  mediastinal  tumor  (cyanosis, 
dyspnea,  exophthalmus,  cough,  alterations  in  voice,  circulatory  disturbance). 

Status  Lymphaticus  {Status  Thymicus;  Lymphatism) . — This  condition  is 
associated  with  enlargement  of  the  thymus.     (See  page  225.) 

Operations  for  Thymus  Enlargement  or  Tumor, — (See  Oliver,  in  "Archiv. 
gen.  d.  Chir.,"  vi,  138,  1912.) 

To  perform  exothymopexy  expose  the  thymus  by  an  incision  above  the 
sternum,  catch  the  gland  and  capsule  with  forceps,  draw  them  up  as  far  as 
possible,  and  suture  to  the  fascia.  This  operation  is  without  much  value.  A 
decompression  operation  can  be  done  by  resecting  the  manubrium.  It  does 
not  cure,  but  may  give  relief. 

Thymectomy  has  been  performed  a  number  of  times.  It  may  be  extracapsu- 
lar or  intracapsular,  partial  or  complete.  In  42  reported  cases  there  were  15 
deaths. 

XXXIV.  DISEASES  AND   INJURIES  OF  THE   LYMPHATICS 

Wounds,  Ruptures,  and  Occlusions  of  the  Left  Thoracic  Duct. 

— It  was  long  believed  that  wounds  of  any  part  of  the  thoracic  duct  were 
almost  certainly  fatal.  It  is  now  known  that  wounds  of  the  duct  at  the 
root  of  the  neck  are  rarely  very  dangerous  unless  the  duct  is  divided  close 
to  the  vein.  A  wound  of  the  duct  is  rarely  seen  as  the  result  of  an  accident 
because  the  adjacent  vital  structures  are  apt  to  be  injured  at  the  same  time 
and  death  rapidly  ensues.  Wounds  of  the  duct  or  of  its  large  branches  occa- 
sionally, but  very  rarely,  are  inflicted  during  surgical  operations.  Benetau 
speaks  of  12  cases  thus  inflicted;  in  8  cases  the  operation  was  for  tubercu- 
lous glands,  in  3  for  malignant  glands,  and  in  i  for  ligation  of  the  subclavian 
artery.  One  alleged  danger  of  wound  of  the  duct  is  entrance  of  air  into  the 
adjacent  vein.  This  is  said  to  have  happened  in  i  case.  As  a  rule,  the  short 
end  of  the  cut  duct  does  not  bleed,  the  duct  valves  preventing  hemorrhage. 
In  Fullerton's  case,  when  a  grooved  director  was  passed  along  the  stump  of  the 
duct  by  way  of  a  terminal  into  the  vein,  blood  at  once  appeared.  In  most 
cases  the  injury  is  not  recognized  at  the  time,  but  later,  when  white  fluid  escapes 
from  the  wound.  The  discharge  may  continue  or  may  cease  spontaneously. 
If  it  continues,  there  is  rapid  loss  of  flesh  and  strength.  I  assisted  Dr.  Keen 
in  the  case  in  which  he  did  recognize  the  wound  at  the  time  it  was  inflicted.  A 
thin  fluid  was  observed  flowing  rhythmically  from  a  tear  in  the  duct.  It  is  to 
be  remembered  that  the  course  of  the  cervical  part  of  the  duct  is  very  variable 
and  sometimes  the  duct  lies  very  high  above  the  clavicle.  There  was  i  death 
in  17  recorded  cases  (Dudley  P.  Allen  and  C.  E.  Briggs,  in  "Amer.  Med.," 
Sept.  21,  1901). 

The  discharge  from  a  cut  duct  may  continue  to  leak — perhaps  a  pint  or 
more  flowing  out  during  twenty-four  hours.  If  leakage  continues,  constitu- 
tional effects  will  sooner  or  later  become  evident.  In  Schoff's  case  ("Wien. 
klin  Woch.,"  Nov.  28,  1901)  it  was  not  known  that  the  duct  had  been  injured 
until  the  stitches  were  removed  from  the  wound  in  the  neck.  The  wound  was 
found  distended  with  chyle  and  Schoff  packed  it  with  iodoform  gauze.  Fifteen 
days  later  the  patient  died  from  chylothorax  and  pulmonary  compression. 

Rupture  of  the  thoracic  duct  or  of  the  receptaculum  chyli  may  occur  from 
traumatism  or  be  a  secondary  consequence  of  tuberculosis  or  carcinoma. 


Septic  or  Infective  Lymphadenitis  1249 

Rupture  leads  to  death  by  starvation,  or  to  fatal  compression  by  the  exuded 
fluid  (Harvey  W.  Gushing,  in  "Annals  of  Surgery,"  June,  1898).  Occlusion 
of  the  main  duct  may  be  followed  by  rupture  of  the  receptaculum  chyli. 
Gradual  occlusion  by  a  tuberculous  or  inflammatory  growth  may  not  produce 
any  serious  symptoms.  Gushing  assumes  that  in  such  a  case  the  lymph- 
current  is  reversed  and  is  taken  up  by  the  right  thoracic  duct.  In  gradual 
obstruction  masses  of  dilated  lymph-vessels  may  be  found,  particularly  in 
the  thorax  and  abdomen.  If  lymph-vessels  rupture,  chyle  flows  out  and, 
according  to  the  situation,  there  arises  "chylous  ascites,  chylothorax,  chyluria, 
or  chylous  diarrhea"  (Ibid.). 

Treatment  of  Wounds,— If  the  wound  in  the  neck  does  not  completely 
divide  the  duct,  and  if  the  duct  wound  is  discovered  at  the  time  of  operation, 
suture  the  duct.  AUen  sutured  the  duct  and  had  no  further  leakage.  Keen 
sutured  the  duct  and  recovery  followed.  If  the  duct  is  completely  divided,  fol- 
low Gushing's  advice:  "It  would  seem  advisable  to  place  a  provisional  ligature 
about  the  duct  on  the  proximal  side  of  the  wound,  and  to  control  the  leakage, 
if  possible,  by  a  gauze  tampon.  This  would  act  as  a  safety-valve,  and  allow 
chyle  to  escape,  if  the  pressure  in  the  duct  became  too  great  and  there  was 
difficulty  in  establishing  a  collateral  lymphatic  circulation.  The  patient 
meanwhile  should  be  given  a  meager  diet.  If  the  leakage  should  become 
uncontrollable  and  threaten  starvation,  the  provisional  ligature  should  be  tied, 
with  the  hope  of  a  final  readjustment  of  collateral  circulation  or  trusting  in  the 
presence  of  some  anomalous  anastomotic  branch  which  might  suffice  to  carry 
the  lymph  into  the  venous  circulation"  (Ibid.).  FuUerton  tied  both  ends  of 
a  divided  duct  and  the  patient  recovered  ("Brit.  Med.  Jour.,"  June  16,  1906). 
Deanesley  ("Lancet,"  Dec.  26,  1903)  inserted  the  divided  duct  into  the  in- 
ternal jugular  vein  and  sutured  it  in  place.  There  was  some  leakage,  but 
recovery  ensued.  After  ligation  the  duct  on  the  proximal  side  of  the  ligature 
may  distend  greatly  and  may  actuaUy  rupture.  When  a  woimded  duct  is 
leaking  the  patient  should  be  fed  exclusively  on  proteins.  The  diet  should 
be  scanty  and  the  patient  must  be  kept  absolutely  quiet  in  order  to  keep 
pressure  in  the  duct  at  as  low  a  level  as  possible  during  the  establishment  of 
a  coUateral  lymphatic  circulation  (FuUerton,  Loc.  cit.). 

Lymphangitis  is  inflammation  of  Ijonphatic  vessels.  Reticular  or  capil- 
lary lymphangitis  (erysipeloid),  which  is  inflammation  of  lymphatic  radicles, 
is  seen  in  some  circumscribed  inflammation  of  the  skin.  It  is  apt  to  attack 
the  hands,  causing  redness  and  sweUing,  fading  at  the  point  of  initial  trouble 
while  it  spreads  at  the  periphery;  it  is  caused  by  micro-organisms  derived 
from  decomposing  animal  matter  (see  page  198).  Erysipelas  also  causes  it 
(see  page  199).  Tubular  lymphangitis,  which  is  due  to  the  entry  into  the 
lymphatic  ducts  of  virulent  micro-organisms  or  toxic  materials,  is  seen  after 
the  infliction  of  dissecting  wounds,  septic  wounds,  snake-bites,  etc.  It  is 
announced  by  edema  and  by  minute,  hard,  red  streaks  running  from  the 
wound  up  the  extremity.     Suppuration  may  occur. 

Septic  or  infective  lymphadenitis,  or  inflammation  of  the  glands, 
may  follow  lymphangitis  or  may  be  due  to  the  deposition  of  infective  material, 
the  lymph-vessels  not  being  inflamed.  In  this  form  of  lymphadenitis  there 
are  pain,  tenderness,  and  swelling;  in  severe  cases  there  are  a  chill  and  a  septic 
fever.     Suppuration  may  arise. 

The  treatment  is  to  drain  and  asepticize  the  wound,  to  apply  iodin,  blue 
ointment,  or  ichthyol  over  the  glands  and  vessels,  and  to  employ  rest,  heat, 
and  compression.  Internally,  milk-punch,  quinin,  and  nourishing  diet  are 
required.  If  the  glands  do  not  rapidly  diminish  in  size  after  disinfection  of  a 
wound,  and  if  they  are  in  an  accessible  region,  extirpate  them.  If  suppuration 
of  the  glands  occurs,  incise  and  drain. 
79 


1250  Diseases  and  Injuries  of  the  Lymphatics 

Acute  lymphadenitis,  or  acute  inflammation  of  the  lymphatic  glands, 
may  be  due  to  tubercle,  syphilis,  glanders,  cold,  or  traumatism.  Suppura- 
tion may  or  may  not  occur.  In  inflammatory  lymphadenitis  there  are  pain, 
heat,  and  nodular  swelling.     In  severe  cases  there  is  fever. 

The  treatment  is  to  asepticize  any  area  of  infection,  place  the  glands  at 
rest,  apply  heat  and  ichthyol  ointment,  or  inject  into  the  gland  every  day  5 
minims  of  a  3  per  cent,  solution  of  carbolic  acid  to  prevent  suppuration.  If 
the  glands  do  not  rapidly  shrink,  extirpate  them.  If  pus  forms,  evacuate 
it,  drain,  and  asepticize. 

Chronic  lymphadenitis  is  almost  invariably  syphilitic  or  tuberculous.  It 
requires  constitutional  treatment  and  the  local  use  of  ichthyol,  iodin,  or  blue 
ointment.  If  these  remedies  are  not  rapidly  successful,  tuberculous  glands 
should  be  removed,  but  syphilitic  glands  rarely  require  such  radical  treatment. 

Lymphangiectasis  {varicose  lymphatics),  or  dilatation  of  the  lymphatic 
vessels,  is  due  to  obstruction.  It  maybe  congenital  (macroglossia;  lymphatic 
nevus,  see  page  368).  It  may  be  acquired.  Many  external  causes  may 
produce  obstruction;  for  instance,  the  removal  or  suppurative  annihilation  of 
a  considerable  group  of  lymphatics;  pressure  of  a  scar  or  of  a  new  growth  upon 
ly mph- vessels ;  tuberculosis  or  neoplasm  of  a  group  of  glands.  In  many  cases  of 
external  pressure  upon  lymphatics  there  is  no  lymphangiectasis  because  the 
lymph  finds  other  channels.  In  fact,  it  has  been  proved  that  ligation  of  a  large 
lymphatic  trunk  is  not  of  necessity  followed  by  lymphangiectasis.  Even  when 
the  condition  arises  from  external  pressure,  it  is  usually  temporary,  although, 
particularly  if  glandular  tumors  exist,  it  may  be  permanent. 

The  persistent  cases  are  usually  due  to  obstruction  within  the  ducts,  for 
instance,  endothelial  proliferation  as  a  result  of  chronic  lymphangitis,  or  re- 
current attacks  of  acute  capillary  lymphangitis  (erysipelas)  or  ordinary 
acute  lymphangitis;  or  tuberculosis  and  other  chronic  infections.  There 
may  be  such  a  condition  as  primary  intralymphatic  endothelial  prolifera- 
tion ("Med.  Record,"  Sept.  6,  1902).  Blocking  with  filarial  worms  may 
occur,  and  if  it  does,  the  lymphangiectasis  is  usually  situated  in  the  pubic, 
the  inguinal,  or  the  scrotal  region,  or  on  the  inner  side  of  the  thigh.  There 
are  two  forms  of  Ijonphangiectasis :  the  varicose,  in  which  the  vessels  have  a 
tortuous  outline,  like  varicose  veins,  but  are  covered  only  with  surface  epithe- 
liimi;  and  lymphatic  warts  {lymphangioma  circumscriptum) ,  in  which  wart-like 
masses  spring  up,  these  masses  being  covered  with  epithelium  and  filled  with 
lymph.  In  most  cases  of  lymphangiectasis  there  is  considerable  hard  edema 
{lymphedema) .  Lymphangiectasis  sometimes  develops  in  an  upper  extremity  , 
after  removing  the  axillary  glands,  and  in  the  lower  extremity  after  removing 
the  inguinal  glands.  Periodic  attacks  of  pain  and  redness  occur  in  the  area  of 
lymphangiectasis,  and  usually  at  such  times  fever  develops.  Rupture  of  the 
dilated  vessels  causes  a  flow  of  lymph  {lymphorrhea) .  Infection  and  erysipelas 
are  apt  to  occur;  it  may  be  over  and  over  again.  It  is  uncertain  whether  these 
repeated  attacks  of  erysipelas  cause  and  maintain  or  are  predisposed  to  by 
lymphangiectasis. 

Treatment.— If  the  entire  area  can  be  removed,  it  should  be  extirpated. 
Maitland  ("Brit.  Med.  Jour.,"  Jan.  25,  1902)  shows  that  many  varices  are 
local  and  can  be  removed.  If  the  varices  are  only  partially  removed,  lymphor- 
rhea will  probably  develop. 

Lymphangioma  is  an  advanced  stage  of  lymphangiectasis  (see  page  368). 

The  treatment  in  mild  cases  is  to  pierce  each  vesicle  with  the  negative 
pole  of  a  galvanic  battery  and  pass  a  current.  In  severe  cases  destroy  the 
mass  with  the  Paquelin  cautery  or  excise  it  with  a  knife  or  with  scissors. 

Elephantiasis. — True  elephantiasis  (elephantiasis  Arabum)  is  chronic 
hypertrophy  of  the  skin  and  subcutaneous  tissues  following  upon  a  lymphangi- 


Lymphadenoma 


1251 


ectasia  produced  by  a  nematode  worm  (the  Filaria  sanguinis  hominis).  The 
disease  is  only  encountered  in  the  tropics.  Elephantiasis  of  the  scrotum  is 
called  lymph-scrotum.     Elephantiasis  of  the  leg  is  called  Barbadoes  leg. 

Spurious  or  ^5eMfi?o-elephantiasis  (Fig.  815)  is  hypertrophy  of  the  skin  and 
subcutaneous  tissue  due  to  chronic  inflammation  (for  instance,  in  a  leg  which 
possesses  an  ancient  ulcer,  or  in  the  scrotum  of  a  man  with  urinary  fistula). 

The  treatment  of  true  elephantiasis  is  massage  and  bandaging,  sometimes 
ligation  of  the  artery  of  supply,  extirpation,  or  amputation. 

Tuberculous  Glands. — (See  page  250.) 

Lymphadenoma  {Malignant  Lymphoma;  Hodgkin's  Disease;  Pseudo- 
leukemia).— The  term  "lymphoma"  is  used  loosely  to  designate  any  persistent 
swelling  of  a  lymphatic  gland  or  glands.  Lymphadenoma  means  a  swelling 
of  lymph-glands  or  lymphadenoid  tissue,  which  swelling  is  progressive  in 
character,  involves  group  after  group  of  glands,  is  associated  with  anemia, 
and  often  accompanied  by  secondary  growths  in  the  abdominal  viscera. 

This  disease  is  most  com- 
mon in  those  under  forty,  and 
affects  males  far  more  fre- 
quently than  females.  In  many 
cases  the  disease  arises  slowly 
in  apparently  healthy  glands, 
and  exists  for  some  time  before 
it  takes  on  signs  of  malignancy 
and  invades  distant  glands. 
In  some  cases  the  disease  has 
a  tendency  to  generalization 
from  the  start;  in  others  it  ap- 
pears to  remain  localized  for 
many  months.  A  gland  en- 
larged from  irritation  or  from 
tuberculous  disease  may  be- 
come lymphadenomatous,  and 
tubercle  bacilli  can  sometimes 
be  found  in  lymphadenomatous 
glands.  Lazarus  asserts  that 
the  disease  is  lymphosarcoma 
and  the  tuberculosis  accidental. 
Musser,  Sternberg,  and  others 
believe  that  tuberculosis  is  the 
disease.  Some  few  believe  that 
l3anphadenoma  is  really  tuber- 
culosis, but  this  view  seems  to 
have  been  definitely  disproved. 

That  the  disease  is  at  least  similar  to  sarcoma  seems  certain.  That  it  is 
a  variety  of  sarcoma  is  highly  probable.  In  Hodgkin's  disease  Coley's  fluid 
(the  mixed  toxins  of  erysipelas  and  Bacillus  prodigiosus)  causes  reaction  as  in 
sarcoma.  There  is  a  form  of  tuberculosis  strongly  resembling  Hodgkin's  dis- 
ease, but  I  do  not  believe  that  the  two  processes  are  identical.  The  glandular 
and  splenic  enlargements  are  neoplastic  and  not  hyperplastic.  The  new  tissue 
formed  is'called  lymphadenoid  tissue  and,  according  to  Banti,  it  is  often  atypical, 
tends  to  invade  glandular  trabeculae  and  capsules,  sometimes  adjacent  tissue, 
and  gives  origin  to  metastases. 

'  Leukemia  and  pseudoleukemia  are  closely  related,  and  both,  according 
to  Banti,  are  sarcoma.  In  leukemia  the  influence  that  stimulates  proliferation 
falls  chiefly  upon  the  bone-marrow;  in  Hodgkin's  disease,  upon  the  lymph- 


Fig. 


815. — ^Spurious    elephantiasis.     No    filariae    found. 
Born  and  lived  in  Philadelphia. 


1252  Diseases  and  Injuries  of  the  Lymphatics 

nodes  (Neumann,  quoted  by  Coley,  in  a  forceful  article  maintaining  that  Hodg- 
kin's  disease  is  a  type  of  sarcoma,  "Trans.  Am.  Surg.  Assoc,"  1908). 

Symptoms.— The  glands  in  the  neck  are  usually  involved  first,  but  the 
disease  may  begin  in  the  axillary  glands,  the  thoracic  glands,  or  the  intra- 
abdominal glands. 

Two  or  more  regions  are  sometimes  involved  simultaneously  or  almost 
simultaneously. 

When  the  disease  begins  in  the  neck  it  affects  at  first  one  side,  and  after 
many  weeks  or  months  the  other  side  becomes  involved.  The  glands  are  at 
first  hard,  separated  from  each  other,  movable,  and  the  skin  moves  freely  over 
them.  Later  the  large  glands  weld  together  and  form  great  masses  upon  both 
sides  of  the  neck  and  in  the  axillae,  which  may  obstruct  respiration. 

After  a  time  a  very  large  mass  may  break  through  its  capsule  and  infiltrate 
adjacent  structures,  and  in  very  rare  cases  the  skin  becomes  adherent  and 
finally  breaks.  Intrathoracic  symptoms  point  to  involvement  of  the  thoracic 
glands.     It  may  be  possible  to  palpate  enlarged  abdominal  glands. 

The  leukocytes  may  be  increased  to  20,000  or  more,  but  in  many  cases  the 
count  is  normal  and  the  relative  proportion  of  the  varieties  remains  normal. 
In  a  certain  percentage  of  cases,  without  any  increase  in  the  number  of  leuko- 
cytes, there  is  great  relative  lymphocytosis.  Early  in  the  case  the  nimaber 
of  red  cells  may  be  unaffected,  but  after  a  time  anemia  develops.  A  fall  in 
hemoglobin  is  noted  early  and  this  fall  is  somewhat  more  rapid  than  the  de- 
crease of  erythrocytes  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.). 

The  spleen  is  enlarged;  the  thyroid  may  be  enlarged.  When  anemia 
becomes  marked  there  are  the  ordinary  symptoms  which  go  with  it,  viz.,  pal- 
pitation, breathlessness,  indigestion,' vertigo,  headache,  pallor,  and  sometimes 
epistaxis.  Occasionally,  without  obvious  reason,  the  glands  suddenly  increase 
in  size  or  rapidly  undergo  a  notable  but  temporary  diminution. 

Slight  fever  exists  at  times  in  many  cases,  and  ague-like  paroxysms  may 
occur.    During  the  existence  of  fever  the  glands  usually  increase  rapidly  in  size. 

Diagnosis. — In  a  widespread  case  the  diagnosis  is  easy;  in  a  localized 
case  it  is  difficult.  True  tuberculous  glands  are  most  apt  to  first  appear  in 
the  submaxillary  triangle;  lymphadenomatous  glands,  in  the  root  of  the 
neck  or  in  the  occipital  triangle.  Tuberculous  adenitis  is  most  common  in 
children.  As  a  rule,  tuberculous  glands  caseate,  but  they  may  remain  localized 
for  years  if  caseation  does  not  occur.  The  tuberculous  glands  usually  soon 
become  adherent  and  immovable.  Lymphadenoma  is  most  common  after 
twenty,  rarely  remains  localized  for  more  than  a  few  months,  rarely  softens 
unless  very  large,  and  the  glands  are  separated  and  movable  until  a  huge  mass 
forms.  Early  softening,  prolonged  limitation  to  one  region,  and  absence  of 
pronounced  anemia  in  a  person  under  twenty  point  to  tubercle.  In  doubtful 
cases  a  gland  should  be  removed  for  microscopical  and  bacteriological  study. 

In  widespread  tuberculous  lymphatic  involvement,  simvilating  Hodgkin's 
disease,  fever  is  far  more  hkely  to  be  present  than  in  Hodgkin's  disease.  La- 
Roy  ("Archives  Internat.  de  Chir.,"  1907,  vol.  iii)  says  that  tuberculous  glands 
are  but  little  improved  by  the  a;-rays  (a  statement  I  do  not  altogether 
endorse),  whereas,  enlargements  in  Hodgkin's  disease  may  be  greatly  benefited, 
and  that  in  tuberculous  conditions  there  is  no  particular  tendency  to  hemor- 
rhage and  there  often  is  in  Hodgkin's  disease.  Coley  ("Trans.  Am.  Surg. 
Assoc,"  1908)  shows  that  the  patients  with  Hodgkin's  disease  react  strongly 
to  the  toxins  of  erysipelas. 

Prognosis. — The  disease  is  almost  always,  if  not  invariably,  fatal.  Most 
cases  die  within  three  years,  some  die  within  six  months,  some  few  live  four 
or  five  years  or  more. 

Treatment. — If  the  glands  are  localized  to  one  side  of  the  neck,  or  even 


Spiral  Reversed  Bandage  of  the  Upper  Extremity  1253 

to  both  sides  of  the  neck,  remove  them.  Early  removal  before  dissemination 
has  occurred  may  possibly  save  the  patient.  If  early  or  radical  removal  is 
not  possible,  do  not  operate,  but  treat  the  patient  wdth  nutritious  food,  tonics, 
coturse  of  arsenic,  the  mixed  toxins  of  erysipelas  and  the  Bacillus  prodigiosus, 
and  applications  of  the  .v-rays.  Coley  treated  2  cases  by  the  mixed  toxins. 
In  both  cases  the  lymphatic,  hepatic,  and  splenic  enlargements  entirely  disap- 
peared ("Surg.,  Gynec,  and  Obst.,"  August,  191 1).  Efforts  are  now  being 
made  to  obtain  a  curative  serum.  Beck  makes  nucleoprotein  senim  from  the 
glands  of  cases  of  Hodgkin's  disease. 


XXXV.  BANDAGES 

A  bandage  is  a  fibrous  material  which  is  roUed  up  and  is  then  employed 
to  retain  dressings,  applications,  or  appliances  to  a  part,  to  make  pressure, 
or  to  correct  deformity.  It  may  be  composed  of  flannel,  of  calico,  of  un- 
bleached muslin,  of  plain  gauze,  of  gauze  infiltrated  with  plaster  of  Paris  or 
soaked  in  silicate  of  sodivun,  or  of  gauze  wet  with  corrosive  sublimate  solu- 
tion. Unbleached  muslin,  which  is  the  best  material  for  general  use,  is  washed 
to  remove  the  sizing,  is  torn  into  strips,  and  the  edges  are  stripped  of  selvage. 
One  end  is  folded  to  the  extent  of  6  inches,  this  is  folded  upon  itself  again  and 
again  until  a  firm  center  is  formed,  and  over  this  center  the  bandage  is  rolled. 
In  a  well-rolled  bandage  the  center  cannot  be  pushed  out  of  the  roll.  A  roller 
bandage  is  divided  iato  the  initial  end,  which  is  -^dthin  the  roll,  the  body  or 
rolled  part,  and  the  terminal  end,  which  is  free.  In  applying  a  bandage  the 
outer  surface  of  the  terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may.  be  covered  by  a  circular  bandage, 
each  turn  exactly  covering  the  pre\'ious  turns.  A  conical  part  may  be  covered 
by  a  spiral  bandage,  each  turn  ascending  a  little  higher  than  the  previous 
turn.  As  each  turn  of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at 
its  lower  edge,  the  reverse  was  de\'ised  to  correct  this  inequality;  hence  a 
conical  part  should  be  covered  by  a  spiral  reversed  bandage.  To  make  a 
reverse,  hold  the  roller  in  the  right  hand,  start  the  bandage  obliquely  upward 
(do  not  have  more  than  6  inches  of  slack),  place  the  thumb  across  the  fresh 
turn,  fold  the  bandage  down  without  traction,  and  do  not  make  traction 
until  the  tiurn  has  been  carried  weU  aroimd  the  limb.  A  projecting  point 
is  covered  with  figure-of-8  turns.  The  groin,  shoulder,  breast,  or  axilla 
can  be  covered  by  figure-of-8  turns,  each  succeeding  turn  ascending  and 
covering  two- thirds  of  the  previous  turn  and  forming  a  figure  like  "the  leaves 
of  an  ear  of  corn,"  Such  a  figure  is  called  a  "spica."  In  bandaging  an  ex- 
tremity the  peripheral  tinrns  should  be  tighter  than  the  turns  nearer  the  body. 
Never  apply  a  tight  bandage  to  the  leg  or  the  arm  without  including  the  foot  or 
the  hand.  In  firm  dressings  of  the  forearm  and  arm  it  is  well  to  leave  the  ends  of 
the  fingers  exposed,  and  use  them  as  an  index  of  the  condition  of  the  circula- 
tion in  the  part.     In  firm  dressings  of  the  leg  and  thigh  leave  the  toes  exposed. 

Spiral  Reversed  Bandage  of 
the  Upper  Extremity. — To  apply 
this  form  of  bandage  use  a  roller  2I 
inches  wide  and  8  yards  long.  Take 
a  circular  turn  about  the  wrist,  and 

a    second    turn    to    hold    the    first;     Fig.  S 16. —Spiral  reversed  bandage  of  the  upper  ex- 
pass  obliquely  across  the  back  of  t^emit:^^ 
the  hand  to  the  extremities  of  the 

fingers;  ascend  the  hand  to  the  root  of  the  thumb  by  several  spiral  turns; 
cover  the  wrist  by  ascending  figm-e-of-8  turns;  ascend  the  forearm  by 
spiral  reversed  turns;  cover  the   elbow  by  a  figure-of-8,  and  the  arm  by 


1254 


Bandages 


spiral  reversed  turns;  end  the  bandage  by  two  circular  turns,  and  pin  them 
together  (Fig.  8i6). 

Spiral  Bandage  of  All  the  Fingers  {Gauntlet). — The  gauntlet  bandage 
requires  a  roller  i  inch  wide  and  3  yards  long.  Take  two  circular  turns  around 
the  wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the  thumb,  and  descend 
to  its  tip  by  spiral  turns ;  cover  in  the  thumb  by  ascending  spiral  turns,  and  re- 
turn to  the  wrist.  Cover  successively  each  finger  in  the  same  manner,  and 
terminate  by  two  circular  turns  around  the  wrist  (Fig.  817). 


Fig.  817. — Gauntlet  bandage. 


Fig.  818. — Demigauntlet  bandage. 


Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand  {Demigaunt- 
let).— The  demigauntlet  requires  a  roller  i  inch  wide  and  3  yards  long.  This 
bandage  has  only  a  limited  value;  it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but  leaves  the  fingers  free.  If  it  is  desired  to 
-cover  the  palm,  supinate  the  hand;  if  to  cover  the  dorsum,  pronate  the  hand. 
Take  two  circular  turns  aroimd  the  wrist,  sweep  around  the  root  of  the  thumb, 
and  return  to  the  point  of  origin.  Treat  each  finger  in  the  same  way.  End 
by  circular  turns  around  the  wrist  (Fig.  818). 

Spica  of  the  Thumb. — For  this  bandage  use  a  roller  i  inch  wide  and  3 
yards  long.     Start  at  the  wrist,  and  reach  the  tip  of  the  thumb  as  in  apphing 


Fig.  819. — Spica  of  the  thumb. 


Fig.  820. — Selva's  thumb  bandage  applied. 


a  spiral  bandage  of  a  finger.  Make  a  series  of  ascending  figure-of-8  turns 
between  thumb  and  wrist,  each  ascending  turn  overlying  two-thirds  of  the 
previous  turn;  terminate  with  a  circular  of  the  wrist  (Fig.  819). 

Selva's  Thumb  Bandage  (Fig.  820). — ^Lay  the  terminal  end  of  the  bandage 
on  the  outer  side  of  the  second  phalanx  of  the  thumb,  near  the  base  of  the  pha- 
larLx.  Carry  it  over  the  palmar  side  of  the  pulp  of  the  last  phalanx  to  the  inner 
side  of  the  second  phalanx.  The  surgeon  holds  this  turn  in  place  with  his  left 
thumb  and  index-finger.  The  roller  is  returned  in  a  recurrent  manner  to  its 
place  of  origin,  overlaps  the  preceding  turn,  and  is  placed  as  much  as  possible 
on  the  dorsum.  The  roller  is  carried  over  the  dorsum  of  the  terminal  phalanx 
and  is  turned  around  the  tip,  the  loop  crossing  over  the  center  of  the  nail. 


Spiral  Bandage  of  the  Foot  Covering  the  Heel 


12: 


Figure-of-S  turns  are  now  made  over  the  dorsum  of  the  hand,  over  the  pahn, 
and  returning  to  the  terminal  phalanx,  and  an  ascending  spica  is  made.- 

Spiral  Reversed  Bandage  of  the  Lower  Extremity.— Take  a  roller 
25  inches  wide  and  7  yards  long,  and  make  two  circular  turns  just  above  the 
malleoli,  and  an  oblique  turn  across  the  dorsum  of  the  foot  to  the  metatarso- 
phalangeal articulation:  make  a  circular 
turn,  and  cover  the  foot  with  ascending 
spiral  reversed  turns:  return  to  the  ankle 
by  a  figure-of-8;  ascend  the  leg  by  spiral 
reverses:  cover  the  knee  by  a  figure-of-8, 
and  the  thigh  by  spiral  reverses ;  terminate 
by  two  circiilar  turns  yFig.  S21). 


Yis.  Si  I. — SDiraJ  reversed  bandaae  of  the  lower 


Fig.  i::2. — Method  of  covering  the  heel. 


Bandage  of  the  Foot  Co^  ering  the  Heel  American  Bandage  of  the  Foot). 
— ^Take  a  roller  2^  inches  wide  and  7  yards  long.  The  bandage  is  begun  as  a 
spiral  reversed  bandage  of  the  lower  extremity-.  After  the  foot  is  well  covered 
by  ascending  spiral  reversed  turns,  earn.-  the  bandage  directly  aroimd  the  point 
of  the  heel  and  return  to  the  instep :  from  this  point  carr\-  it  around  the  back  of 
the  ankle,  down  the  side  of  the  heel,  under  the  heel,  up  to  the  instep,  around  the 
ankle  in  tie  opposite  direction,  down  the  opposite  side  of  the  heel,  and  under  the 
heel  and  up  to  the  instep :  take  the  roller  to  above  the  malleoli,  and  end  b}'  a 
circular  turn  (Fig.  822). 


Fig.  S23. — FigTire-of-S  bandage  of  the  aakle. 


Fis.  izs.—S-lzj. 


Bandage  of  the  Foot  Not  Co\  ering  the  Heel  (French  Meikc'd  . — Take 
a  roller  2^  inches  wide  and  6  yards  long.  ^lake  a  spiral  reversed  bandage  of 
the  foot  and  a  ngure-of-8  of  the  ankle-joint    Fig.  $23'. 

Spiral  Bandage  of  the  Foot  Covering  the  Heel  (Ribbail's  Bandage; 

Spica  of  the  Insteps — Take  a  roller  2n  inches  wide  and  6  yards  long.     Apply 

as  a  spiral  reversed  bandage  of  the  lower  extremity"  until  the  metatarsus  is  well 

covered.     Carr\-  the  bandage,  parallel  with  the  margin  of  the  foot  (the  inner 

1  "Medical  Xews,"'  Sept.  2S,  1895. 


1256 


Bandages 


or  outer  margin,  according  as  to  whether  it  is  the  left  foot  or  the  right),  around 
the  posterior  aspect  of  the  heel,  along  the  opposite  margin  of  the  foot  to  cross 
the  original  turn  at  the  median  line  of  the  dorsum.  Make  a  number  of  these 
ascending  turns,  each  turn  covering  in  three-fourths  of  the  previous  turn; 
terminate  by  circular  turns  above  the  ankle  (Fig.  824). 

Crossed  Bandage  of  Both  Eyes  (Figure-of-8  of  Both  Eyes). — Take  a 
roller  2  inches  wide  and  6  yards  long.  Make  a  circular  turn  around  the  fore- 
head from  right  to  left,  a  second  turn  to  hold  the  first,  a  turn  downward  over 
the  left  eye,  under  the  left  ear,  around  the  back  of  the  neck,  and  upward  under 
the  right  ear  and  over  the  right  eye;  repeat  these  turns,  and  terminate  by  a  cir- 
cular turn  of  the  forehead  (Fig.  825). 

Borsch's  eye=bandage  is  convenient  and  useful  (Fig.  827).  A  narrow 
bandage  is  laid  along  the  head  and  permitted  to  hang  down  the  face  in  front 
of  the  sound  eye.  A  circular  bandage  is  applied  around  both  eyes,  and  over 
the  narrow  bandage  (a).  The  narrow  strip  is  lifted  and  pinned,  and  the 
sound  eye  is  thus  uncovered.  Of  course,  the  posterior  end  of  a  should  first 
be  pinned  to  the  circular  turn. 

Barton's  Bandage  (Figure-of-8  of  the  Jaw  and  Occiput). — Take  a  roller 
2  inches  wide  and  5  yards  long.  Place  the  initial  extremity  of  the  bandage  be- 
hind the  inion;  pass  over  the  right  parietal  bone,  across  the  vertex,  down  the  left 


Fig.  82s.- 


-Crossed  figure-of-8  bandage  of  both 

eyes. 


Fig.  826.- 


-Barton's  bandage  or  figure-of-8  of  the 

jaw. 


side  in  front  of  the  ear,  under  the  chin,  up  the  right  side  in  front  of  the  ear, 
across  the  vertex,  and  across  the  left  parietal  bone  to  the  point  of  origin.  A 
turn  is  now  taken  forward  along  the  right  side  of  the  jaw  to  the  chin,  and  back- 
ward along  the  left  side  of  the  jaw  from  the  chin  to  the  nape  of  the  neck;  repeat 
these  turns,  and  pin  the  points  of  junction  (Fig.  826).  In  Barton's  bandage  the 
ear  lies  in  an  uncovered  triangle.  The  bandage  may  be  finished  by  circular 
turns  around  the  forehead.  Barton's  bandage  is  used  for  fracture  of  the  lower 
jaw. 

Gibson's  Bandage. — Take  a  roller  2  inches  wide  and  6  yards  long. 
Make  three  vertical  turns  around  the  head  and  the  jaw  in  front  of  the  ear; 
reverse  the  bandage  above  the  level  of  the  ear,  and  carry  it  horizontally  around 
the  forehead  and  head  three  times;  drop  the  bandage  to  the  nape  of  the  neck, 
and  take  three  turns  around  the  neck  and  jaw;  terminate  by  taking  from  the 
nape  of  the  neck  a  half-turn  upward,  carrying  the  bandage  forward  to  the 
forehead,  and  pinning  it  over  the  neck  and  over  the  forehead.  Pin  each  point 
of  junction  (Fig.  828).     Gibson's  bandage  is  used  for  fracture  of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Oblique  Baiulage  of  the 
Jaw). — Take  a  roller  2  inches  wide  and  6  yards  long.     Make  a  circular  tiirn 


Spica  of  the  Shoulder 


1257 


around  the  forehead  toward  the  affected  side;  and  a  second  turn  to  hold  the 
first;  take  the  turn  to  the  back  of  the  neck;  cam-  it  forward  on  the  sound  side, 
under  the  ear  and  chin;  now  make  a  series  of  turns  around  the  head  and  jaw, 
in  front  of  the  ear  on  the  injured  side,  but  back  of  the  ear  on  the  sound  side: 
these  turns  successively  advance  on  the  injured  side  only;  terminate  bv  going 
backward  imder  the  ear  of  the  sound  side  to  the  nape  of  the  neck,  and  then  by 


Fig.  827. — Borsch's  eye-bandage:  a,  First  step;  b,  second  step. 

taking  two  circular  turns  around  the  forehead  (Fig.  S29).  This  bandage  is 
used  for  fractures  of  the  ramus  of  the  jaw  and  for  holding  dressings  upon  the 
face  and  the  cranium. 

Spica  of  the  Groin  {Figure-of-8  of  tlie  Thigh  and  Pelvis). — For  one  groin 
the  roller  is  3  inches  wide  and  7  yards  long;  for  both  groins,  3  inches  wide  and 
10  yards  long.  Take  two  circular  turns,  from  right  to  left,  around  the  waist, 
then  down  over  the  front  of  the  right  groin,  aroimd  the  back  of  the  thigh,  up 
over  the  front  of  the  right  groin,  around  the  waist,  down  over  the  front  of  the 
left  groin,  round  the  back  of  the  thigh,  up  over  the  left  groin,  and  around  the 


Fig.  S28. — Gibson's  bandage. 


Fig.  829. — Oblique  or  crossed  bandage  of  the 
angle  of  the  jaw. 


waist.  The  map  being  thus  laid  out,  the  turns  are  continued  and  ascended. 
each  turn  overl\-ing  one-third  of  the  pre\-ious  tiun,  and  the  bandage  is  completed 
by  a  circular  turn  around  the  waist  (Fig.  830^     Pin  the  crossed  pieces. 

Spica  of  the  Shoulder. — Take  a  roUer  2§  inches  wide  and  7  yards  long. 
Make  a  circ\ilar  tiim  and  several  spiral  reversed  turns  around  the  upper  arm; 
then,  coming  from  behind  forward,  carr\-  the  bandage«over  the  shoulder,  across 
the  front  of  the  chest,  through  the  opposite  arm-pit,  and  return  across  the  back 
to  the  shoulder.     Make  successive  and  advancing  turns  (Fig.  831). 


1258 


Bandages 


Figure-of-8  bandages  of  the  elbow,  both  shoulders  (posterior  figure-of-8), 

the  neck  and  axilla  are  shown  m  Figs.  832,  833,  and  834. 

A  figure-of-8  bandage  of  the  breast  is  shown  in  Fig.  839. 

Velpeau's  Bandage. — Take  a  roUer  2^  inches  wide  and  10  yards  long. 

Place  the  palm  of  the  hand  of  the  injured  side  upon  the  shoulder  of  the  sound 

side,  interposing  cotton  between  the  arm  and  the  side.     Start  the  bandage  at 

the  axilla  of  the  sound  side  posteriorly, 
carr^^  it  across  the  back  to  the  shoulder 


Fig.  830. — Spica  of  the  groin. 


Fig.  831. — Spica  of  the  shoulder. 


■of  the  injured  side,  down  the  front  of  the  arm  and  under  the  arm  just  above  the 
elbow,  returning  to  the  point  of  origin;  repeat  this  turn,  but,  on  reaching  the 
axilla  the  second  time,  cross  the  back  and  pass  around  the  chest,  including  the 
arm;  keep  on  with  these  turns,  each  alternate  turn  going  over  the  injured 
cla\"icle,  each  alternate  turn  encircling  the  arm  and  the  body,  the  first  turns 
advancing  and  the  second  turns  ascend- 
ing (Fig.  835).  Pin  the  crossed  pieces. 
This  bandage  is  used  for  fracture  of  the 
cla\dcle. 


Fig.  832. — Figure-of-8  bandage  of  the  elbow. 


Fig.  833- 


-Posterior  figure-of-8  of  both 

shoulders. 


Desault's  Apparatus. — This  apparatus  consists  of  three  rollers,  a  pad, 
and  a  sling.  Each  roUer  is  2^  inches  wide  and  7  yards  long.  The  pad,  which  is 
wedge  shaped,  is  inserted  into  the  axilla  with  the  base  up.  The  first  roller  is 
used  to  hold  the  pad  (Fig.  836).  The  secoid  roller  binds  the  arm  to  the  side 
over  the  pad.  This  pad  is  a  fulcrum,  the  shoulder  is  the  weight,  the  arm  is  the 
lever,  and  the  second  roller  of  Desault  corrects  the  inward  deformity  of  a 
fractured  cla\dcle  (Fig.  837).  The  third  roller  corrects  the  downward  and  for- 
ward displacement.  It  starts  in  the  axilla  of  the  sound  side  anteriorly,  crosses 
the  chest  to  the  shoulder  of  the  injured  side,  runs  down  the  back  of  the  arm, 
around  the  elbow",  and  crosses  the  chest  to  the  point  of  origin,  forming  the 
anterior  triangle;  it  is  now  carried  through  the  axilla  of  the  sound  side  to  the 


Desault's  Apparatus  1259 

back,  crosses  the  back  to  the  shoulder  of  the  injured  side,  runs  dawn  the  front 
of  the  arm,  around  the  elbow,  and  across  the  back  to  the  axilla  of  the  sound 


Fig.  834. — Figure-of-8  of  neck  and  axilla. 


Fig.  835. — Velpeau's  bandage. 


side,  forming  the  posterior  triangle  (Fig.  87,8).     The  formula  for  the  Desault 
bandage  is:  start  in  the  axilla  of  the  sound  side  anteriorly,  run  from  the  axilla 


Fig.  836. — Desault's  bandage,  first  roller. 


Fig.  837. — Desault's  bandage,  second  roller. 


to  the  shoulder,  from  the  shoulder  to  the  elbow,  from  the  elbow  to  the  axilla, 
and  pass  to  the  back;  from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 


Fig.  838. — ^Desault's  bandage,  third  roller. 


Fig.  839. — Figure-of-8  bandage  of  the  breast. 


elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  front.    Pin  the  crossed  pieces 
and  hang  the  hand  in  a  sling  (Fig.  838). 


I26o 


Bandages 


Recurrent  Bandage  of  the  Head. — Take  a  roller  2  inches  wide  and  6 
yards  long.  Make  two  circular  turns  horizontally  around  the  forehead  and 
head;  when  the  middle  of  the  forehead  is  reached,  catch  the  bandage,  take  a  half- 
turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch  it,  take  a  half -turn, 
bring  the  roller  forward  to  the  forehead,  covering  a  portion  of  the  preceding 
turn;  continue  this  process  until  the  scalp  is  well  covered;  terminate  with  two 
circular  turns  around  the  forehead  and  head  (Fig.  840).  It  is  often  advisable 
to  take  a  turn  around  the  head  and  chin.     Pin  the  crossed  pieces. 

Recurrent  Bandage  of  a  Stump. — Take  a  roller  2  inches  wide  and 
6  yards  long.  Make  two  light  circular  turns  around  the  root  of  the  stump; 
make  recurrent  turns  covering  the  stump  as  is  done  in  covering  the  head; 
take  a  circular  turn  around  the  root  of  the  stump,  oblique  turns  to  the  top 
of  the  stump,  circular  turns  around  the  tip,  and  apply  an  ascending  spiral 
reversed  bandage  (Fig.  841) 

T=Bandage  of  the  Perineum. — Pass  the  transverse  part  aroimd  the 
body  above  the  iliac  crests,  and  pin  it  in  front;  bring  one  of  the  tails  over 
the  dressing  and  up  between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and  the  genitals  of 
the  opposite  side;  secure  these  tails  to  the  horizontal  band. 


Fig.  840.— Recurrent  bandage  of  the  head. 


Fig  841. — Recurrent  bandage  of  a  stump. 


Handkerchief  Bandages. — Take  unbleached  muslin  i  yard  square. 
The  muslin  folded  once  makes  an  oblong  bandage;  bringing  its  diagonal  angles 
together  makes  a  triangle  bandage;  a  cravat  is  formed  by  folding  a  triangle 
bandage  from  summit  to  base;  a  cord  is  a  twisted  cravat.  The  triangle  makes 
an  admirable  sling. 

Fixed  Dressings. — Plaster-of-Paris  Bandage. — Cover  the  extremity 
with  a  cotton  or  flannel  bandage  or  with  a  woolen  stocking.  Take  a  gauze 
roller  infiltrated  with  plaster  and  place  it  endwise  in  a  basin  of  tepid  water, 
the  water  covering  the  plaster.  When  biubbles  cease  to  arise,  squeeze  the 
bandage  and  apply  it  without  much  tension,  smoothing  out  each  turn  with 
a  moistened  hand.  As  each  bandage  is  taken  from  the  basin  drop  a  fresh 
one  into  the  water.  Apply  four  thicknesses  of  bandage,  and  finish  the  dress- 
ing by  sprinkling  dry  plaster  over  the  bandage  and  smoothing  it  with  wet 
hands.  The  ordinary  plaster  will  set  in  from  fifteen  to  thirty  minutes.  If 
it  is  desired  to  have  it  set  more  rapidly,  put  a  tablespoonful  of  salt  in  each 
pint  of  water  used;  if  to  have  it  set  more  slowly,  pour  stale  beer  into  the  water. 
The  plaster  bandage  is  removed  by  sawing  it  down  the  front  or  by  moisten- 
ing with  dilute  hydrochloric  acid  and  then  cutting  through  the  moistened 
line  with  a  strong  knife.  Gigli  has  devised  a  mode  of  application  which 
enables  us  to  remove  the  dressing  with  ease.     A  layer  of  cotton  is  placed 


Plastic  Surgery  1261 

around  the  limb.  A  piece  of  parchment  paper  which  has  been  wet  and  shaken 
out  is  placed  over  the  cotton.  A  cord  greased  with  vaselin  is  laid  upon  the 
paper  in  a  position  corresponding  to  the  line  we  will  wish  to  saw  through  the 
plaster.  Apply  the  plaster  bandage  and  see  that  the  ends  of  the  cord  project 
beyond  the  bandage.  When  desiring  to  remove  the  bandage  take  a  steel  wire, 
make  nicks  on  one  side  of  it  by  means  of  a  file,  and  attach  the  string  to  the 
wire.  Pull  the  wire  under  the  bandage.  Attach  each  end  of  the  wire  to  a 
wooden  handle  and  saw  through  the  plaster.^ 

Silicate  of  Sodium  Dressing. — Protect  the  part  as  is  done  for  a  plaster 
bandage.  Bandage  the  limb  loosely  with  an  ordinan,'  gauze  bandage,  paint 
this  bandage  with  sHicate  of  sodium,  apply  another  bandage  and  paint  it, 
and  so  on  until  sLx  layers  are  applied.  Gauze  bandages  are  better  than  or- 
dinar\'  bandages  to  take  up  silicate  of  sodium.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dr}',  and  they  are  removed  by  softening 
with  warm  water  and  then  cutting. 


XXXVI.  PLASTIC  SURGERY 

Plastic  surgery  includes  operations  for  the  repair  of  deficiencies,  for 
the  replacement  of  lost  parts,  for  the  restoration  of  function  in  parts  tied 
down  by  scars,  and  for  the  correction  of  disfiguring  projections.  Many 
reparative  operations  have  been  de\ased.  Among  them  are:  cheiloplasty, 
or  the  construction  of  a  new  lip;  the  closure  of  a  cleft  in  the  palate,  the  lip, 
or  the  penis;  the  making  of  a  new  nose;  skin-grafting;  grafting  of  muscle 
or  tendon;  nerve-grafting;  the  introduction  of  celluloid  or  metal  into  the  tissues 
to  act  as  a  support;  the  injection  of  parafifin  into  the  tissues  to  amend  a  de- 
pression; the  diminution  in  the  size  of  a  lip  or  a  nose;  the  amendment  of  pro- 
tuberant ears;  the  correction  of  distortion  due  to  cicatrices;  excision  of  scars; 
closure  of  congenital  sinuses  and  of  fistulse ;  and  removal  of  disfiguring  growths. 

The  subject  of  plastic  surgery  is  very  extensive,  and  a  treatise  upon  it 
should  be  consulted  if  one  wishes  to  obtain  detailed  and  comprehensive  in- 
formation. 

A  plastic  operation  can  be  successful  after  lupus  only  when  the  disease 
has  been  cured.  It  is  useless  to  do  a  plastic  operation  during  active  s\^hilis, 
and  a  plastic  operation  for  a  syphilitic  loss  of  substance  is  to  be  performed 
only  after  the  patient  has  been  thoroughly  treated  and  the  disease  has  been 
apparently  cured.  The  first  step  of  a  plastic  operation  consists  in  making 
the  surfaces  which  are  to  be  brought  together  raw;  the  second  step  is  the 
complete  arrest  of  bleeding ;  the  third  step  is  the  approximation  of  the  surfaces 
without  tension;  the  fourth  step  is  to  close  any  gap  from  which  tissue  may 
have  been  transplanted;  and  the  final  step  is  the  application  of  the  dressings.- 
The  following  are  the  methods  used  ■? 

Displacement  is  the  method  of  stretching  or  of  sliding:  (i)  Approximation 
after  freshening  the  edges  (as  in  harelip);  (2)  sliding  into  position  after  trans- 
ferring tension  to  other  localities  (linear  incisions  to  allow  of  stretching  of  the 
skin  over  large  wounds).  Interpolation  is  the  method  of  borrowing  material 
from  an  adjacent  or  a  distant  region  or  from  another  person:  (i)  Transferring  a 
flap  with  a  pedicle,  which  flap  is  put  in  place  at  once  or  is  gradually  gotten  into 
place  by  a  series  of  partial  operations  (as  in  rhinoplasty,  when  a  flap  is  taken 
from  the  forehead);  (2)  transplanting  without  a  pedicle,  which  is  performed  by 
placing  in  position  and  by  fixing  there  portions  of  tissue  recently  removed  from 
the  part,  from  another  part  of  the  same  individual,  or  from  a  lower  animal  (as 

1  "La  Semaine  Med.,"  Nov.  3,  1895.  ^  "American  Text-Book  of  Surgerj-." 

3  Ibid. 


1262 


Plastic  Surgery 


replacement  of  the  button  of  bone  after  trephining,  transplanting  a  piece  of 
bone  from  a  lower  animal  to  remedy  a  bone  defect  in  a  human  being,  or  the 
grafting  of  a  piece  of  nerve  from  a  lower  animal  or  from  an  amputated  human 
limb  to  remedy  a  loss  of  nerve  in  a  human  being).  Retrenchment  is  the  re- 
moval of  redundant  material  and  the  production  of  cicatricial  contraction. 

Ski n=graf ting. — As  long  ago  as  1847  Dr.  Frank  Hamilton  partly  covered 
an  ulcer  with  a  pediculated  flap,  and  trusted  that  the  uncovered  portion  would 
be  healed  by  new  skin  from  the  flap.  We  may  graft  small  pieces  of  epithelium 
taken  from  the  patient,  another  person,  or  one  of  the  lower  animals,  or 
may  graft  large  pieces  of  epithelium.     The  grafts  should,  if  possible,  come 

from  the  person  to  be 
^^H^j^^K.  v^  .  '''*<|^^^EHnWi""*>i^^HH  grafted.  The  epidermic 
^^HpBl^^  ,^1^  ^^^^^^^^^^^m     scales    may    be    scraped 

W^^^^  dm      -  ^^     °^  ^^^    sound   skin  and 

grafted.  Lusk  has  blis- 
tered the  skin  with  can- 
tharides  and  grafted  por- 
tions of  the  epidermis. 
The  shavings  of  a  corn 
and  fragments  of  hair 
roots  have  been  used. 
The  best  plan  is  to  cut 
off  and  transplant  small 
bits  of  epidermis. 

Grafts  may  come  from 
another  person  or  from  a 
lower  animal,  but  such 
grafts  are  not  so  apt  to 
grow  as  those  obtained 
from  the  individual,  and 
even  when  they  do  grow, 
fail  to  furnish  a  se- 
cure cicatrix.  Frog-skin 
furnishes  unsatisfactory 
grafts.  Some  surgeons 
have  used  bits  of  sponge; 
others,  the  skin  of  rab- 
bits, guinea-pigs,  or  pups. 
Arnot  has  employed  the 
lining  membrane  of  a 
hen's  egg,  cut  in  strips 
and  applied  upon  the 
wound  with  the  shell- 
surface  uppermost.  Small  bits  of  epidermis  taken  from  a  recently  amputated 
foreskin  or  leg  may  be  used. 

Reverdin's  Method. — This  operation  was  devised  by  Reverdin  in  i86g. 
Small  bits  of  epithelium  are  used,  and  they  are  taken,  preferably,  from  the 
person  himself.  The  surface  to  be  grafted  should  possess  healthy  granula- 
tions level  with  the  skin.  Cleanse  the  skin  from  which  the  grafts  are  to 
come,  the  ulcer,  and  the  skin  about  it,  and,  if  corrosive  sublimate  is  used, 
wash  it  away  with  a  stream  of  warm  normal  salt  solution.  Thrust  a  sewing- 
needle  under  the  epidermis  to  raise  it,  cut  off  the  graft  by  a  pair  of  scissors, 
and  place  the  raw  surface  of  the  graft  upon  the  ulcer.  After  applying  a 
number  of  grafts,  place  thin  pieces  of  gutta-percha  tissue  over  them  and 
extending  on  each  side  of  the  ulcer,  and  so  placed  as  to  have  distinct  in- 


Fig.  842. — Injury  caused  by  crush  and  bum.  Healed  by  gran- 
ulation in  eight  months.  Showing  a  condition  after  removal  of 
scar  of  the  palm,  which  has  been  repaired  by  stitching  in  an  auto- 
plastic graft  (free  flap)  from  the  thigh  (George  S.  Brown). 


The  Ollier-Thiersch  Method  of  Skin-grafting 


1263 


ter\^als  between  them,  the  gaps  permitting  drainage.  Rubber  tissue  must 
be  aseptic  and  moist  with  warm  normal  salt  solution.  Dress  with  a 
pad  of  aseptic  gauze  moistened  with  salt  solution;  place  over  this  gauze  a 
rubber-dam,  and  over  the  latter  absorbent  cotton  and  a  bandage.  In  the 
case  of  a  child  apply  a  light  silicate  bandage.  If  the  grafted  area  is  very 
extensive  or  if  it  is  in  the  lower  extremity,  put  the  patient  in  bed.  In  forty- 
eight  hours  remove  all  the  dressings  except  the  gutta-percha  tissue,  irrigate 
with  normal  salt  solution,  and  reapply  the  dressings.  All  signs  of  the  grafts 
will  often  have  disappeared.  In  a  day  or  two  more,  at  the  site  of  grafting, 
bluish-white  spots  should  appear,  which  are  islands  of  epidermis.  Each  graft 
is  capable  of  forming  about  ^  inch  of  cicatrix.  Grafting  also  stimulates  the 
edges  of  the  ulcer  to  cicatrize  and  contract.  At  the  end  of  seven  days 
the  special  dressings  can  be 
dispensed  with.  The  spot 
from  which  the  grafts  were 
taken  is  dressed  antiseptic- 
aUy.  Reverdin's  method 
does  not  limit  cicatricial  con- 
traction to  any  great  degree, 
and  the  new  skin  is  apt  to 
break  down. 

The  Ollier-Thiersch 
Method. — Oilier,  of  Lyons, 
in  1872  succeeded  in  trans- 
ferring large  pieces  of  epi- 
dermis. In  1886  Thiersch,  of 
Leipzig,  set  forth  the  technic 
practically  as  it  is  employed 
to-day.  The  Ollier-Thiersch 
method  is  performed  as  fol- 
lows :  Thoroughly  asepticize 
the  ulcer,  the  surrounding 
skin,  and  the  site  from  which 
the  graft  is  to  come  (the  inner 
side  of  the  arm  or  the  thigh), 
and  wash  away  the  mercurial 
preparation  -vvdth  normal  salt 
solution.  Apply  dressings  wet 
with  salt  solution.  On  bring- 
ing the  patient  into  the  oper- 
ating room  remove  the  dress- 
ings  from   the   ulcer,   scrape 

the  ulcer  and  its  edges,  irrigate  with  salt  solution,  and  compress  to  arrest 
hemorrhage.  Grafts  are  then  obtained  by  putting  the  prepared  skin  upon 
the  stretch  and  cutting  strips  with  a  razor.  While  the  razor  is  being  used 
the  part  is  constantly  irrigated  with  salt  solution.  Mkter's  apparatus  enables 
one  to  perform  this  operation  with  great  neatness  and  speed.  This  apparatus 
consists  of  a  knife  and  an  open  square  with  sharp  points  on  the  under  surface. 
The  square  is  forced  down  upon  the  front  of  the  thigh,  the  epidermis  mounts 
up  in  the  opening  to  above  the  level  of  the  metal  sides,  and  the  grafts  may 
be  cut  with  ease.  The  graft  contains  the  epidermis,  the  rete,  and  part  of 
the  true  skin.  In  Halsted's  clinic  the  skin  of  the  thigh  is  made  tense  by 
pressing  and  drawing  upon  it  with  a  piece  of  asepticized  wood,  the  wood  is 
drawn  slowly  along,  and  is  followed  closely  by  the  sharp  catlin,  by  which  the 
surgeon  cuts  long  grafts.     The  grafts  are  pressed  into  place  upon  the  raw  sur- 


Fig.  843. — Claw-hand  from  burn.     A  flap  with  a  pedicle  was. 
taken  from  the  chest.     The  pedicle  was  cut  on  ninth  day. 


1264  Plastic  Surgery 

face,  and  each  graft  overlaps  a  little  the  edges  of  the  wound  and  the  adjacent 
grafts.  The  skin  wound  is  dressed  antiseptically,  and  the  grafted  area  may 
be  dressed  as  in  Reverdin's  method.  If  a  ring  of  aseptic  gauze  be  made  to 
encircle  the  limb  below  the  grafted  area,  and  another  ring  above  the  grafted 
area,  and  if  on  these  pads  little  strips  of  wood  wrapped  in  aseptic  gauze  be 
laid,  a  cage  is  made,  and  around  this  cage  the  dressings  may  be  applied 
(moist  chamber  plan)  (Fig.  844). 

Wolfe's  Method. — It  was  pointed  out  by  Wolfe  that  a  piece  of  skin,  com- 
prising the  entire  thickness  of  that  structure,  can  be  successfully  transplanted 
without  a  pedicle.  The  ulcer  is  extirpated  and  asepticized  and  bleeding  is 
arrested.  The  flap  is  cut  one-sixth  larger  than  the  surface  to  be  covered. 
Fat  is  kept  out  of  the  graft.  The  bit  of  tissue  is  laid  upon  the  wound,  the 
edges  of  the  graft  being  brought  against  the  edges  of  the  raw  area.  It  is  not 
necessary  to  employ  sutures.  The  part  is  dressed  in  a  moist  chamber.  If  the 
graft  perishes,  remove  it. 

Subcutaneous  Injection  of  Paraffin  for  Prosthetic  Purposes. — 
The  principle  of  injecting  solidifying  oils  into  tissues  to  mechanically  obtain 
effects  was  first  laid  down  by  J.  Leonard  Corning  in  1891.  The  use  of  paraffin 
was  introduced  by  Gersuny  to  amend  the  deformity  of  a  saddle-nose.  It  has 
been  used  to  limit  incontinence  of  feces,  incontinence  of  urine  in  women,  to 
prevent  reunion  of  nerves  after  division,  as  a  counterfeit  testicle,  to  obliterate 
small-pox  marks,  to  narrow  a  hernial  ring,  to  correct  sinking  of  the  cheek  after 
removal  of  the  upper  jaw,  and  for  other  purposes  (Moszkowicz,  in  "Wien.  klin. 


Fig.  844. — Mayer's  dressing  for  Thiersch's  method  of  skin-grafting  ("Amer.  Text-Book  of  Surg.").' 

Woch.,"  June  20,  igoi).  Paraffin,  is  not  toxic.  Its  injection  may  produce  some 
swelling  and  redness,  but  applications  of  cold  usually  control  inflammation. 
In  two  or  three  months  the  paraffin  becomes  hard  like  cartilage  and  encapsuled. 
It  is  questionable  whether  or  not  it  is  subsequently  destroyed  and  replaced  by 
granulation  tissue.     Sometimes  sloughing  takes  place  in  the  skin  above  it. 

Prepare  the  paraffin  as  follows:  In  Gersuny's  clinic  solid  paraffin  is  mixed 
with  liquid  paraffin.  The  melting-point  of  the  mixture  should  be  about  104° 
F.  It  is  rendered  sterile  by  boiling,  is  injected  by  a  warm  syringe,  and  as 
a  semisolid,  the  skin  having  been  first  warmed  by  a  hot  sponge.  After  in- 
jection it  is  molded  into  proper  shape.  It  sets  in  half  a  minute.  It  is  not 
wise  to  use  a  mLxture  with  a  much  higher  melting-point,  because  it  would 
possibly  cause  thrombosis  in  veins.  There  are  difficulties  and  even  dangers 
in  the  use  of  paraffin  for  saddle-nose.  It  should  only  be  used  when  the  skin  is 
loose  and  elastic.  It  should  never  be  used  if  there  is  great  deformity,  because 
then  the  amount  required  woiild  siirely  cause  dangerous  tension.  It  is  difficult 
to  prevent  the  injected  material  from  passing  down  the  sides  of  the  nose  and 
up  into  the  forehead.  Cases  of  embolism  causing  blindness  have  been  re- 
ported. The  skin  may  slough  if  the  injection  is  too  hot  or  if  it  produces  much 
tension. 

Paraffinoma. — This  term,  suggested  by  Delangre,  means  an  inflammatory 
new  formation  which  may  arise  in  the  submucous  or  subcutaneous  tissue 
about  a  depot  of  injected  paraffin.  It  may  or  may  not  ulcerate.  It  is  particu- 
larly apt  to  form  in  a  tuberculous  person.     The  sweUing  is  marked  and  the 


Rhinoplasty 


1265 


disfigurement  great.  The  possibility  of  the  formation  of  a  parafl&noma  is  par- 
ticularly great  if  parafiin  is  used  in  the  subcutaneous  tissue. 

The  only  treatment  is  excision. 

Correction  of  Saddle=nose  By  the  Insertion  of  a  Plate. — Saddle- 
nose  is  a  condition  in  which  the  bones  and  cartilages  have  been  destroyed 
by  ulceration  or  collapsed  by  injury.  It  is  useless  to  attempt  correction  by 
skin-flaps  alone.  Parafiin  injections  (see  page  1264)  may  be  used  in  the  less 
severe  cases.  In  a  bad  case  we  must  transplant  bone-fiaps  or  insert  a  plate 
for  support.  The  bone-fiap  operation  is  seldom  satisfactory  and,  of  necessity, 
creates  a  hideous  scar.  The  insertion  of  a  plate  may  give  an  excellent  result, 
although  the  future  is  always  uncertain.  In  2  cases  I  have  seen  sloughing 
occur  over  the  plate  months  after  the  operation.  In  i  of  these  cases  the 
sloughing  was  due  to  a  blow  from  a  cow's  tail. 

The  plate  used  may  be  of  silver,  gold,  or  celluloid.  An  incision  is  made  to 
permit  the  insertion  of  the  plate.  I  agree  with  Leonard  Freeman  ("Annals 
of  Surgery,"  August,  1907)  that  the  incision  along  the  bridge  and  the  incision 


Fig.  845. — Indian  method  of  rhinoplasty. 


Fig.  846. — Italian  method  of  rhinoplasty. 


in  the  septum  below  the  tip  are  both  objectionable.  The  first  leaves  an  im- 
sightly  scar  and  does  not  allow  for  stretching  of  the  skin.  The  incision  at  the 
tip  gives  imsatisfactory  access  to  the  tissues  requiring  separation  and  is  liable 
to  infection  from  the  nostril. 

The  best  incision  is  Freeman's.  This  is  a  short  incision  across  the  root  of 
the  nose  between  the  eyes.  The  skin  is  tmdermined  along  the  bridge  to  the 
tip  and  along  the  sides.     The  imdermined  skin  can  be  stretched  if  necessary. 

Rhinoplasty. — The  complete  operation  may  be  performed  by  trans- 
ferring a  flap  from  the  forehead.  This  is  known  as  the  Indian  operation. 
It  was  employed  for  centuries  in  India,  and  interest  in  it  was  awakened  in 
England  about  1820  by  Mr.  Carpue.  The  edges  of  the  defect  are  made 
raw.  A  model  of  the  desired  nose,  made  out  of  gutta-percha,  has  its  out- 
lines marked  upon  the  forehead,  and  the  cut  is  made  I  inch  outside  of  the 
outline,  so  as  to  allow  room  for  retraction.  The  flap  is  turned  down  and 
sutured  in  place  (Fig.  845),  care  being  taken  not  to  cut  off  the  blood-supply 
in  the  pedicle.     Plugs  of  gauze  or  tubes  are  inserted  to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian  method  (Taglia- 
cotian  method).  This  method  was  first  described  in  Tagliacozzi's  book, 
which  was  published  in  1597.  In  this  operation  the  flap  is  marked  out  on 
80 


1266  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  arm,  is  made  twice  the  size  of  the  desired  nose,  and  is  left  attached  by  a 
broad  pedicle.  The  nasal  surface  is  rendered  raw  at  proper  regions,  and  the 
flap  is  sutured  in  place,  the  hand  being  held  upon  the  head  by  a  special  appa- 
ratus (Fig.  846) .  The  raw  surface  upon  the  arm  is  dressed.  In  about  three 
weeks  the  flap  is  cut  loose  from  the  arm,  and  is  pared  and  corrected  as  may  be 
necessary. 

The  operations  for  hareHp  and  cleft  palate,  and  plastic  operations  on  mus- 
cles, nerves,  tendons,  and  bones  are  considered  in  other  portions  of  this  work. 


XXXVII.    DISEASES  AND   INJURIES  OF  THE   QENITO= 
URINARY   ORGANS 

Hematuria. — By  this  term  is  meant  the  voiding  of  bloody  urine  or  of 
pure  blood,  the  blood  arising  from  any  portion  of  the  urinary  apparatus, 
and  the  condition  being  a  sjonptom  and  not  a  disease.  In  hematuria  the 
urine  contains  more  than  blood  coloring-matter,  it  also  contains  blood-corpus- 
cles. The  condition  in  which  there  is  coloring- matter  only  is  called  hemoglo- 
binuria. Hemoglobinuria  may  arise  after  burns,  etherization,  and  taking  uro- 
tropin,  and  during  various  fevers,  especially  in  malaria  (see  page  1267). 
Hematuria  may  be  a  symptom  of  disease  or  of  injury  of  some  part  of  the  uri- 
nary system  (calculus,  acute  nephritis,  pyelitis,  renal  tuberculosis,  prostatic 
enlargement,  morbid  growth,  wounds  or  contusions  of  the  genito-urinary  tract), 
of  blood  disorganizations  (purpura,  scurvy,  variola,  leukemia,  or  anemia),  or 
of  metallic  poisoning  (mercury,  lead,  or  arsenic) .  It  may  arise  during  typhoid 
fever,  in  the  beginning  of  an  acute  fever  (especially  variola) ,  in  hemophilia,  in 
nephralgia,  in  malarial  fever,  and  in  kidney  infarction  resulting  from  endocar- 
ditis. It  may  be  caused  by  parasites  (Filaria  sanguinis-hominis  and  Bilharzia 
haematobia).  Some  drugs  are  renal  irritants  and  may  cause  hematuria  (can- 
tharides,  oil  of  turpentine) .  Oxaluria  is  an  occasional  cause.  The  most  usual 
cause  of  renal  hematuria  is  stone.  The  color  of  the  urine  in  hematuria  may 
be  anything  between  a  light  pink  and  a  decided  black,  but  these  colors  may 
be  produced  by  agents  other  than  blood.  (See  Solhnann's  "Text-Book  of 
Pharmacology.")  Carbolic  and  salicylic  acids  make  urine  brown  or  greenish 
black;  beet-root  and  sorrel,  the  color  of  blood;  methylene-blue,  green  or  blue. 
In  melanosis  and  splenic  fever  the  urine  becomes  brown.  Senna  and  rhubarb 
make  an  acid  urine  yellowish  brown  and  an  alkaline  urine  purple.  In  jaun- 
dice the  urine  is  yellow  or  green.  Coal-tar  products  may  make  it  blackish 
brown.  Picric  acid  makes  it  yellow.  Santonin  makes  an  acid  urine  yellow 
and  an  alkahne  urine  pink.  Logwood  imparts  no  color  to  acid  urine,  but  colors 
alkaline  urine  violet  or  reddish.  Trional,  sulfonal,  tar,  tannic  acid,  and  galUc 
acid  make  urine  brown. 

Tests  for  Blood. — Spectroscopal  Test. — Bloody  urine,  if  fresh  and 
diluted  with  water,  shows  the  two  absorption  bands  of  oxyhemoglobin.  The 
addition  of  ammoniimi  sulphid  causes  the  two  bands  to  give  place  to  the  band 
of  reduced  hemoglobin.  If  bloody  urine  stands  for  some  time  the  four  bands 
of  methemoglobin  are  discovered  (von  Jaksch) . 

Heller's  Test. — Add  potassium  hydrate  to  the  urine  and  boil;  a  red  pre- 
cipitate of  earthy  phosphates  and  hematin  forms.  Throw  the  precipitate  upon 
a  filter  and  treat  it  with  acetic  acid ;  a  red  solution  is  produced,  which  soon  fades. 

Rosenthal's  Test. — ^Take  the  precipitate  from  caustic  potash,  dry  it, 
and  test  it  for  hematin;  put  some  of  the  dry  sediment  on  a  slide,  add  a  crystal 
of  common  salt,  apply  a  cover-glass,  and  cause  a  few  drops  of  glacial  acetic 
acid  to  flow  under  the  glass;  warm,  but  do  not  boil.  Teichmann's  crystals 
YnR  appear  on  cooling. 


Bleeding  from  the  Kidney-substance  1267 

Struve's  Test. — Test  the  urine  with  hydrate  of  potassium,  and  add  acetic 
acid  in  excess;  a  dark  precipitate  forms,  which  will  yield  crystals  of  hematin 
when  treated  with  sal  ammoniac  and  glacial  acetic  acid. 

Almen's  Test  (Guaiac  Test). — Take  10  c.c.  of  urine  and  pour  upon  its 
surface  a  mixture  of  equal  parts  of  tincture  of  guaiac  and  old  oil  of  turpentine; 
at  the  point  of  junction  of  this  fluid  with  the  urine  there  forms  a  white  ring 
which  turns  to  a  striking  blue.  If  a  man  is  taking  iodid  of  potash  his  u^'ne 
shows  blue  in  the  guaiac  test. 

The  Benzidin  Test. — This  is  very  delicate.  If  the  reaction  cannot  be 
obtained  the  urine  is  certainly  free  of  blood.  Add  i  c.c.  of  glacial  acetic  acid 
to  10  c.c.  of  urine.  Add  to  the  mixture  one-third  of  its  volume  of  ether  con- 
taining a  few  drops  of  alcohol,  shake,  and  allow  to  stand.  The  ether  rises  to 
the  top,  is  taken  off  by  a  pipet,  and  is  put  in  a  test-tube  in  which  is  the  ben- 
zidin mixture  (0.5  c.c.  of  a  solution  of  a  little  benzidin  in  2  c.c.  of  glacial 
acetic  acid  and  2  c.c.  of  hydrogen  dioxid).  Blood  turns  the  reagent  green  or 
blue  within  two  minutes.  Later  the  color  changes  to  purple.  (See  Holland's 
"Medical  Chemistry  and  Toxicology.") 

Microscopical  Test. — The  microscope  shows  numerous  corpuscles  except 
in  a  very  alkaline  urine,  when  but  few  corpuscles  may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  after  burns,  as  a  result 
of  large  doses  of  urotropin,  and  during  malaria,  acute  febrile  maladies,  metallic 
poisoning,  acute  alcoholism,  poisoning  by  mushrooms,  chlorate  of  potash,  coal- 
tar  products,  pyrogallic  acid,  and  naphthol— there  is  present  blood  coloring- 
matter,  which  is  shown  by  Heller's  test  and  by  Almen's  test.  The  spectro- 
scope shows  methemoglobin.  The  microscope  shows  no  corpuscles  or  only  a 
few,  but  discloses  masses  of  pigment.  Hemoglobinuria  does  not  occur  in  dis- 
eases limited  to  the  genito-urinary  tract. 

Determination  of  the  Source  of  the  Blood. — In  a  woman,  be  sure  that  the 
bloody  urine  is  not  due  to  a  mixture  with  menstrual  blood.  If  menstruation 
does  exist,  obtain  the  urine  for  examination  by  a  catheter.  The  three-glass 
test  may  be  of  service.  Blood  may  be  thoroughly  mixed  with  urine.  Renal 
blood  is  sure  to  be  mixed.  Bladder  blood  may  or  may  not  be.  Blood  from 
the  urethra  comes  out  with  the  first  urine.  The  source  of  blood  may  be 
determined  certainly  only  by  the  urethroscope,  cystoscope,  or  urethral 
catheter. 

Bleeding  from  the  Kidney=substance. — Bleeding  from  the  pelvis  of 
the  kidney  and  from  the  ureter  may  be  due  to  inflammation,  congestion, 
contusion,  stone,  vicarious  menstruation,  hemorrhagic  diathesis,  powerful 
diuretics,  fevers,  purpura,  tumors,  catheterization  of  the  ureter,  etc.  Blood 
is  thoroughly  mixed  with  the  urine  and  no  sediment  forms  (smoky  urine). 
The  corpuscles  are  profoundly  altered,  are  devoid  of  coloring-matter,  and 
show  pale-yellow  rings.  The  severity  of  the  hemorrhage  is  measured  by 
thje  number  of  the  corpuscles.  Von  Jaksch  states  that  the  diagnosis  between 
renal  and  ureteral  hemorrhage  rests  on  the  nature  of  the  casts  and  epithe- 
liimi  present.  From  the  pelvis  of  the  kidney  and  from  the  ureter  comes 
small  epithelium,  the  cells  from  the  superficial  layers  being  polygonal  or 
elliptical,  those  from  the  deeper  layers  being  oval  or  irregular.  In  hemorrhage 
from  the  ureter  the  cells  are  few;  in  hemorrhage  from  the  pelvis  they  are 
plentiful  and  rest  upon  one  another  like  "tiles  on  a  roof"  (von  Jaksch).  Cells 
from  the  tubules  of  the  kidney  are  small,  granular,  and  polyhedral,  have 
large  nuclei,  and  are  often  so  arranged  as  to  form  cylinders  (epithelial  casts). 
The  urine  during  and  immediately  after  a  renal  hemorrhage  is  apt  to  be  acid 
unless  alkalis  have  been  administered,  unless  the  bleeding  has  been  severe, 
or  unless  pus  is  present  in  the  urine.  A  very  large  renal  hemorrhage  may 
cause  the  passage  of  almost  pure  blood.     In  renal  hematuria  there  are  aching 


1268  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

in  the  loin,  numbness  of  the  corresponding  leg,  and  often  renal  colic.  The 
use  of  the  cystoscope  enables  the  surgeon  to  determine  if  the  hemorrhage  is 
vesical  or  renal,  and  if  it  comes  from  one  or  both  kidneys.  If  the  bladder 
fluid  is  kept  clear,  the  blood  can  be  seen  flowing  out  of  the  ureter  of  the  damaged 
organ,  or  if  both  ureters  are  catheterized  a  sample  of  urine  can  be  obtained  from 
each  kidney.  Even  when  skilfully  used  the  ureteral  catheter  is  apt  to  cause 
slight  hemorrhage.  Hence,  after  catheterization,  microscopical  hemorrhage 
does  not  count  in  diagnosis. 

Spontaneous  Hemorrhage  Into  the  Elidney. — This  may  or  may  not  cause 
hematuria.  It  may  arise  during  nephritis  or  may  depend  on  arterial  disease. 
No  lesion  may  be  discoverable.  If  accompanied  by  hematuria  it  is  classed 
as  essential  hematuria  (see  below) .  The  bleeding  may  take  place  beneath  the 
capsule  or  through  a  tear  in  the  capsule  into  the  perirenal  tissue.  In  some 
cases  bleeding  begins  in  the  perirenal  tissue.  A  possible  cause  is  aneurysm  of 
the  renal  artery.  There  are  26  cases  of  this  condition  on  record  ("Lancet," 
Jan.  27,  191 2).  Spontaneous  hemorrhage  comes  on  suddenly  with  shock  and 
pain  in  the  loin.  There  may  or  may  not  be  hematuria.  A  mass  can  be  pal- 
pated. In  some  cases  the  skin  becomes  discolored.  Always  operate.  If 
hemorrhage  comes  from  perirenal  tissue,  excise  the  bleeding  tissue.  If  blood 
comes  from  the  kidney  it  is  usually  necessary  to  perform  nephrectomy.  In 
spontaneous  hemorrhage  blood  may  tear  its  way  into  the  peritoneal  cavity. 
(See  article  by  Russell  S.  Fowler,  in  "Annals  of  Surgery,"  Dec,  191 1.) 

Essential  Hematuria. — In  this  condition  the  ureteral  catheter  reveals 
blood  from  one  kidney  only,  there  being  no  demonstrable  lesion  to  account  for 
the  condition.  Randall,  in  a  very  comprehensive  article,  draws  the  following 
conclusions  regarding  this  condition  ("Jour.  Am.  Med.  Assoc,"  Jan.  4,  1913). 

He  divides  essential  hematurias  into  three  groups:  (i)  Nephritis  with  con- 
gestion plays  the  leading  role.  (2)  Varicosities  of  vessels  of  renal  pelvis  result- 
ing from  some  extrinsic  condition  aft'ecting  the  kidney  circulation.  (3)  Hemor- 
rhage due  to  rupture  of  capillaries  or  to  diapedesis  of  red  blood-corpuscles. 
In  either  of  these  conditions  congestion  probably  exists. 

I  believe  that  some  cases  are  due  to  unrecognized  papilloma.  Essential 
hematuria  is  sometimes  called  unilateral  hematuria,  an  unfortunate  name, 
as  many  cases  of  hematuria  which  do  not  belong  to  this  group  are  unilateral. 

Ureteral  Catheterism. — Catheterization  of  the  ureters  may  give  in- 
formation of  the  greatest  value.  It  enables  the  surgeon  to  obtain  the  urine 
from  one  kidney  unmixed  with  urine  from  the  other  kidney  and  uncontaminated 
by  material  from  the  bladder  or  urethra.  By  this  method  we  can  determine 
if  pus,  blood,  bacilli,  etc.,  come  from  the  ureter  or  kidney,  and  from  which 
ureter  or  kidney.  A  stricture  of  or  a  calculus  in  a  ureter  can  be  located;  hydro- 
nephrosis and  pyonephrosis  can  be  diagnosticated;  the  presence  of  both  kid- 
neys, if  either  kidney  is  diseased  or  if  both  are  diseased,  and  the  secretory 
capacity  of  each  kidney  in  a  given  time,  can  be  ascertained.  The  method 
is  also  employed  to  treat  various  conditions  of  the  ureter  and  kidney. 

Kelly  impressed  upon  the  profession  that  the  ureters  in  women  can  be 
catheterized  when  the  patient  by  the  knee-chest  posture  permits  the  atmo- 
spherical distention  of  the  bladder,  so  that  the  ureteral  orifices  can  be  inspected 
through  a  speculum.  Light  is  reflected  into  the  speculum,  a  forehead  mirror 
and  an  electric  light  being  employed.  It  may  be  necessary  to  dilate  the 
urethra  before  inserting  the  speculum.  It  is  rarely  necessary  to  give  a  general 
anesthetic.  Kelly  moistens  a  bit  of  cotton  wrapped  on  a  metal  rod  in  a 
10  per  cent,  solution  of  cocain,  introduces  it  just  within  the  external  urethral 
orifice,  and  holds  it  there  for  five  minutes  before  beginning  the  operation. 
When  the  ureteral  orifice  of  one  side  is  found  by  inspection  through  the  specu- 
lum, he  introduces  a  sterile  flexible  silk  catheter  lubricated  with  boroglycerid 


Segregation  of  Urine 


1269 


and  it  is  pushed  up  from  4  to  6  inches  in  the  ureter.  A  similar  tube  is  intro- 
duced into  the  other  ureter  and  the  separated  urines  are  collected  in  test-tubes. 
(See  Kelly's  "Operative  Gynecology.")  The  catheterization  of  the  ureters 
by  this  method  can  be  performed  only  by  a  dextrous  and  experienced  man; 
but  such  an  individual  can  do  it  with  ease  and  celerity;  as  practised  by  Kelly 
himself  it  seems,  until  one  tries  it,  the  perfection  of  easy  simpUcity. 

Kelly  has  catheterized  the  ureter  in  man  by  inserting  a  straight  speculum, 
placing  the  patient  in  the  knee-chest  position  to  inflate  the  bladder  with  air, 
and  introducing  a  metallic  catheter.  (For  a  discussion  of  the  technic  of  cath- 
eterizing  the  ureters  see  Cystoscopy,  page  1301.) 

Segregation  of  urine  is  the  method  of  obtaining  urine  separately  from  each 
ureter  by  segregating  each  ureter's  supply  into  an  artificial  trough,  from  which 
it  is  drawn.  The  method  is  seldom  used  in  the  United  States  at  the  present 
time.  It  is  painful,  unreliable,  and  has  been  replaced  by  ureteral  catheteriza- 
tion. In  cases  in  which  the  ureters  cannot  be  found,  segregation  may  be 
employed.  The  three  most  practical  segregators  are  Harris's,  Luys's,  and 
Catheiin's.  Professor  Harris,  of  Chicago,  has  devised  an  instrument  (Fig. 
84  7)  which  in  some  cases  simplifies  the  problem  of  obtaining  unmixed  urine 


Fig.  S47. — Harris's  segregator  fitted  for  use. 


from  each  ureter.  The  double  catheter  is  passed  into  the  bladder.  The  lever 
is  inserted  in  the  rectum  of  the  male  and  the  vagina  of  the  female.  The  lever 
is  fastened  to  the  perforated  frame  from  the  double  catheter.  The  double 
catheter  is  now  opened  in  the  bladder,  and  the  blades  of  the  instrument  are 
held  in  position  by  a  spring.  The  end  of  the  lever  in  the  vagina  or  rectimi 
humps  up  the  floor  of  the  bladder  between  the  separated  ends  of  the  divided 
catheter,  and  forms  a  longtitudinal  septtmi  or  watershed  between  the  ureteral 
orifices.  The  end  of  each  catheter  Hes  in  the  bottom  of  a  pocket  to  the  side 
of  the  watershed.  ''By  producing  a  very  slight  exhaustion  of  the  air  in  the 
vials  by  means  of  the  bulb  the  urine,  as  fast  as  it  escapes  from  the  ureters,  drops 
directly  into  the  ends  of  the  catheters  and  flows  at  once  into  the  \dals,  right  and 
left  respectively."^ 

In  using  this  instrument  place  the  patient  flat  on  his  back  upon  a  table, 
the  thighs  and  legs  being  flexed,  and  the  feet,  hips,  and  head  being  on  the 
same  level.  Irrigate  the  bladder  thoroughly  with  sterile  water  and  have 
150  c.c.  of  fluid  in  the  bladder  when  the  blades  are  opened.  Leave  the  instru- 
ment in  place  for  thirty  minutes.  It  is  rarely  necessary  to  give  an  anesthetic. 
In  some  cases  cocain  must  be  used,  and  in  some  cases  of  painfiil  cystitis  ether 
i"Jour.  Cutan.  and  Gen.-Urin.  Dis.,"  May,  1899. 


1270  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


should  be  given.  Harris  says  the  instrument  should  not  be  used  if  there 
is  a  growth  of  the  bladder  that  bleeds  easily,  if  the  bladder  is  contracted,  if 
there  is  a  very  large  prostate  or  a  vesical  stone.  ^ 

In  catheterization  of  the  iireters  there  is  always  some  danger  of  carrying 
infection  upward  from  the  bladder,  and  sometimes  catheterization  is  impossible. 
It  is  impossible  if  great  quantities  of  blood  or  pus  make  the  urine  opaque,  or 
if  inflammation  of  the  bladder  wall  hides  one  or  both  ureteral  orifices.  The 
Harris  method  of  segregation  produces  considerable  pain,  but  is  free  from 

this  danger.  As  a  matter  of  fact,  how- 
ever, Harris's  method  often  possesses  ele- 
ments of  uncertainty,  because  the  septum 
may  not  be  perfect  and  the  urine  from  one 
side  sometimes  contaminates  the  urine  from 
the  other.  The  separator  devised  by  Luys 
in  1901  finds  some  warm  advocates  (Fig. 
848).  It  causes  less  pain  and  accompHshes 
more  certain  results  than  the  instruments 
of  Harris  or  Cathelin.  Barringer  ("Am. 
Jour.  Med.  Sciences,"  March,  1907)  points 
out  that  "there  are  certain  classes  of  cases 
in  which  the  separator  cannot  be  used. 
They  are  the  following:  (A)  Those  in  which 
the  bladder  capacity  is  less  than  20  c.c; 
(B)  those  in  which  the  urethra  is  not  pene- 
trable by  the  instrument;  and  (C)  those  in 
which  the  base  or  neck  of  the  bladder  is 
distorted  by  (a)  marked  prostatic  hyper- 
trophy; (b)  extreme  anteversion  or  ante- 
flexion of  the  uterus;  (c)  certain  uterine 
tumors;  and  (d)  marked  cystocele."  Cath- 
eterization of  the  ureters  is  not  so  safe  as 
separation,  is  far  more  difficult,  but  gives 
more  certain  results. 

Urethral  Hemorrhage. — In  urethral 
bleeding  blood  appears  independently  of 
micturition,  or  blood  comes  out  first  and 
is  followed  by  clear  urine.  Urethral  hemor- 
rhage may  arise  from  acute  urethritis,  from 
an  inflamed  stricture,  from  the  passage  of 
an  instrument,  or  from  some  other  traimiatism.  It  may  be  due  to  a  polypus, 
to  a  stone  in  the  prostatic  urethra,  to  violent  or  prolonged  sexual  effort. 

The  source  of  urethral  hemorrhage  can  be  ascertained  by  the  use  of  the 
endoscope  or,  better,  by  means  of  the  cysto-urethroscope. 

Vesical  hemorrhage,  including  hemorrhage  from  the  prostate, 
may  follow  the  relief  or  retention  of  urine  (hence  do  not  draw  off  all  the  urine 
at  once  when  a  bladder  is  distended),  may  be  due  to  stone,  inflammation, 
tumors,  etc.,  or  may  arise  from  traimiatisms,  instrimiental  or  otherwise.  The 
color  of  the  urine  is  usually  bright  red,  but  if  long  retained  in  the  bladder 
it  becomes  black  and  often  tarry.  The  reaction  is  alkaline.  The  clots,  when 
floated  out,  are  large  and  without  definite  shape.  In  micturition  the  urine 
is  clear  or  only  a  little  colored  at  the  beginning,  but  becomes  darker  and 
darker  as  micturition  continues,  and  as  it  ends  the  flow  may  consist  of  almost 
pure  blood.  In  very  small  vesical  hemorrhages  the  urine  may  be  smoky. 
Crystals  of  triple  phosphate  indicate  bladder  disorder.  The  microscope  shows 
iM.  I.  Harris,  in  "Medicine,"  April,  1898. 


Fig.  848. — Luys's  separator:  a,  The 
composite  instrument  ready  for  intro- 
duction; i  and  k,  discharge  tubes;  h, 
screw  to  regulate  the  tension  of  the 
membrane;  b,  flat  middle  piece;  c  and  d, 
grooved  lateral  portions;  e,  tip  uniting 
the  parts;  g-f,  rubber  membrane,  tense. 
The  chain  is  not  visible  in  the  figure 
(Sahli). 


Frequency  of  Micturition  1271 

colorless  and  swollen  corpuscles  and  many  polygonal  cells.  Symptoms  of 
bladder  mischief  usually  exist,  but  cystoscopical  examination  or  exploratory 
suprapubic  cystotomy  may  be  required  for  the  diagnosis. 

Pain  in  Qenito=urinary  Diseases. — Pain  as  a  symptom  of  genito- 
urinary disease  may  be  found  at  some  point  distant  from  the  seat  of  lesion. 
A  stone  in  the  bladder  causes  pain  in  the  head  of  the  penis  just  back  of  the 
meatus;  stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the  thigh, 
and  the  testicle;  inflammation  of  the  testicle  causes  pain  in  the  line  of  the 
cord  in  the  groin.  In  other  cases  of  genito-urinary  disease  pain  is  felt  at 
the  seat  of  lesion,  as  in  urethritis  and  prostatitis.  Pain  felt  before  micturi- 
tion, and  being  relieved  by  the  act,  is  found  in  cystitis  and  in  retention  of 
urine.  Pain  is  felt  during  micturition  in  inflammation  of  the  bladder,  pros- 
tate and  urethra,  and  in  the  passage  of  gravel  or  stone.  Pain  which  is  acute 
at  the  end  of  micturition  is  noted  in  stone  in  the  bladder,  in  trigonitis  or  urethro- 
cystitis (inflammation  of  the  neck  of  the  bladder) ,  and  in  inflammation  of  the 
prostate  gland.  The  pain  caused  by  stone  in  the  bladder,  it  may  be  observed, 
is  amehorated  by  rest  and  is  aggravated  by  exercise  unless  the  stone  is  en- 
cysted. The  pain  caused  by  acute  prostatitis  is  intensified  by  defecation  and 
the  act  is  accompanied  by  the  appearance  at  the  meatus  of  a  few  drops  of 
starch-like  mucus. 

Frequency  of  Micturition. — Frequent  micturition  arises  from  irritation 
of  the  sensory  nerves,  from  phimosis,  contracted  meatus,  inflammations, 
very  acid  urine,  calculi,  urethral  stricture,  and  hyperesthesia  of  the  urethra, 
Frequency  of  micturition  may  be  due  to  spinal  irritability  from  concussion 
or  from  sexual  excess,  from  contraction  of  the  bladder  rendering  the  viscus 
imable  to  hold  much,  from  worry,  anxiety,  fear,  or  from  excessive  urinary 
secretion,  as  in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Frequent 
micturition  exists  in  obstruction  by  enlarged  prostate  and  in  atony  of  the 
bladder  walls.  Hypersecretion  of  urine  plus  bladder  intolerance  is  known  as 
''nervousness  of  the  bladder,"  and  is  found  in  hysteria.  Frequency  of  mictu- 
rition increased  by  movement  is  observed  in  stone  and  tumor  of  the  bladder. 
Nocturnal  frequency  of  micturition  is  present  in  cases  of  enlarged  prostate 
and  atony  of  the  muscular  walls  of  the  bladder.  Frequency  of  micturition 
with  diminution  of  the  diameter  of  the  stream  suggests  a  constriction  of  the 
urethral  canal;  frequency  of  micturition  with  diminished  projectile  force  sug- 
gests a  posterior  stricture,  enlarged  prostate,  or  bladder  atony.  Slowness  of 
micturition  hints  at  enlarged  prostate,  atony,  or  urethral  stricture. 

Sir  Henry  Thompson'' s  diagnostic  questions  are  as  follows: 

"i.  Have  you  any,  and,  if  so,  what,  frequency  in  passing  water?  Is  fre- 
quency more  manifest  during  the  night  or  the  day?  Is  frequency  more 
manifest  during  motion  or  rest?     Does  any  other  circumstance  affect  it? 

"2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before,  during,  or  after 
the  act?  What  is  its  character — -acute,  smarting,  dull,  transitory,  or  con- 
tinuous? What  is  its  seat?  Is  it  felt  at  other  times,  and  is  it  produced  or 
intensified  by  sudden  movements? 

"3.  What  is  the  character  of  the  stream?  Is  it  small  or  large;  twisted  or 
irregular;  strong  or  weak;  continuous,  remitting,  or  intermitting?  Does  it 
come  by  the  meatus,  or  partly  or  entirely  through  fistulae? 

"4.  Is  the  character  of  the  urine  altered?  What  is  its  appearance,  color, 
odor,  reaction,  and  specific  gravity?  Is  it  clear  or  turbid,  and,  if  turbid, 
is  it  so  at  the  time  of  passing?  Does  it  vary  in  quantity?  Are  the  normal 
constituents  increased  or  diminished?  Does  it  contain  abnormal  elements, 
as  albumin  or  sugar?  What  inorganic  deposits  are  found?  What  organic 
materials  are  met  with? 

"5.  Has  the  urine  ever  contained  blood?     If  so,  was  the  color  brown  or 


1272  Diseases  and  Injuries  of  the  Genito- urinary  Organs 

bright  red;  were  the  blood  and  urine  thoroughly  mixed;  was  the  blood  passed 
at  the  end  or  at  the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine ;  or  was  it  passed  independently  of  micturition? 

"6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  permanent  or  transitory, 
and  for  the  occurrence  of  severe  paroxysms  of  pain  in  these  regions." 

The  Determination  of  the  Excretory  Capacity  of  the  Kidneys  in 
Health  and  in  Disease. — The  Phloridzin  Test. — This  test  is  made  with 
comparative  ease  and  may  aid  the  surgeon  in  determining  whether  he  is 
justified  in  performing  some  operation  of  convenience.  It  enables  him  to  esti- 
mate with  a  fair  amount  of  acciuracy  the  capacity  for  elimination  possessed  by 
the  kidneys.  The  test  depends  on  the  fact  that  the  healthy  epitheliimi  of  the 
glomeruli  and  tubes,  when  stimulated  to  activity  by  phloridzin,  forms  sugar 
from  that  drug  and  thus  produces  temporary  glycosuria.  When  the  epithelium 
is  diseased,  little  or  no  glycosuria  occurs.  The  test  is  applied  as  follows:  The 
dose  is  about  5  to  10  mg.  of  phloridzin,  according  to  the  body- weight  of  the 
patient.  It  is  administered  hypodermatically,  the  bladder  having  been  emptied 
beforehand.  If  the  eliminating  powers  of  the  kidney  are  at  a  healthy  level, 
sugar  should  appear  in  the  urine  within  half  an  hour  of  the  injection.  If  at  the 
end  of  this  time  only  a  small  amount  of  sugar  can  be  detected,  one  may  assume 
that  the  kidneys  are  affected;  and  if  no  sugar  can  be  found,  a  serious  renal  dis- 
ease may  be  assumed  to  exist. 

The  actual  standard  that  is  to  be  considered  as  the  normal  amoimt  of  sugar 
which  should  be  eliminated  after  the  administration  of  phloridzin  is  a  matter 
of  some  uncertainty.  It  is  usuaUy  estimated  at  0.3  per  cent.,  a  less  amoimt 
of  sugar  than  this  being  taken  as  an  evidence  of  renal  difficulty  (Watson 
and  Bailey,  in  "Report  of  Boston  City  Hospital  for  1902").  The  sugar  is 
separated  from  the  phloridzin  in  the  epitheliiun  of  the  glomeruli  and  tubules 
of  the  cortex  of  the  kidney.     The  drug  seems  to  be  entirely  harmless. 

It  is  because  phloridzin  is  acted  upon  by  the  kidney  epithelium  that  this 
test  is  better  than  the  methylene-blue  test.  The  latter  does  not  really  measure 
the  excretory  power  of  the  kidney  epithelium ;  it  merely  shows  to  what  degree 
the  kidney  is  permeable  in  the  mechanical  sense.  Personally,  I  should  not 
be  disposed  to  set  aside  older  and  more  thorough  methods  of  urinary  analysis 
for  the  phloridzin  test,  although  I  believe  that  it  has  a  range  of  distinct  use- 
fulness. 

The  Methylene-blue  Test  {The  Method  of  Achard  and  Castaign). — When 
methylene-blue  is  injected  hypodermatically  it  normally  is  changed  into  a 
chromogen,  appears  in  the  urine  within  half  an  hour,  and  disappears  in  from 
thirty-six  to  forty-eight  hours.  If  the  blue  color  is  not  manifest  in  the  urine 
for  an  hour  or  more,  there  is  impairment  of  renal  permeability.  Only  50  per 
cent,  of  the  amount  ingested  is  removed  by  the  kidneys.  Accuracy  in  the 
test  is  not  possible  unless  the  amoimt  of  the  methylene-blue  actually  passing 
into  the  urine  in  a  given  time  is  determined.  The  dose  given  hypodermat- 
ically is  0.05  gm.  in  i  c.c.  of  sterile  water.  The  test  is  unreliable  and  the 
blue  color  may  appear  in  the  urine  in  half  an  hour  in  some  cases  of  marked 
kidney  disease.  At  its  best  the  test  only  indicates  the  freedom  of  mechanical 
renal  permeability. 

The  Indigo-cannin  Test. — This  drug  should  be  largely  excreted  in  a  few 
minutes.  It  colors  the  urine.  It  is  an  unreliable  method.  It  will  show 
functional  failure,  but  there  may  be  no  functional  failure  even  in  organic  dis- 
ease. In  many  cases  the  color  appears  as  quickly  in  urine  from  a  diseased 
kidney  as  in  urine  from  the  soxmd  organ. 

This  method  enables  us  to  recognize  functional  incapacity.  By  it  we  may 
forecast  uremia.  If  the  urine  is  collected  from  each  ureter  separately  we  can 
tell  the  capacity  of  each  kidney.    In  this  test,  if  color  does  not  appear  until 


Tumors  of  the  Kidney  1273 

after  twenty-five  minutes,  and  if  during  the  first  hour  less  than  30  per  cent,  of 
the  amount  introduced  is  excreted,  a  contemplated  surgical  operation  should 
be  postponed  or  abandoned. 

The  Phenolsulphonephthalein  Test. — This  is  the  most  reliable  one.  The 
drug  is  not  toxic.  It  is  given  in  an  alkaline  solution.  A  hypodermatic  injec- 
tion of  6  mg.  is  administered.  It  appears  in  the  urine  when  the  kidneys  are 
normal  in  from  six  to  twelve  minutes,  and  from  40  to  60  per  cent,  of  the  amount 
given  is  excreted  during  the  first  hour.  It  colors  urine  red  and  a  quantitative 
estimation  can  be  made  by  means  of  a  colorimeter.  When  the  color  first 
appears,  and  hov/  much  of  the  drug  is  excreted  in  the  first  hour,  must  be  noted. 

Cryoscopy  {Kordnyi's  Method). — Cryoscopy  is  the  determination  of 
the  freezing-point  of  a  liquid  and  the  comparison  of  this  with  the  freezing- 
point  of  distilled  water.  It  is  applied  particularly  to  blood  and  urine.  This 
method  is  complex  and  difficult  of  application,  requires  a  considerable  amount 
of  fluid,  and  is  not  regarded  as  very  valuable.  The  freezing-point  of  a  fluid 
depends  upon  the  number  of  molecules  it  contains.  The  freezing-point  goes 
hand  in  hand  with  molecular  concentration — great  concentration  gives  a  low 
freezing-point;  little  concentration,  a  high  freezing-point.  Cryoscopy  of  the 
blood  and  urine  is  used  to  determine  the  adequacy  of  renal  activity.  Normal 
blood  freezes  at  about  — 0.56°  or  — 0.57°  C.  Healthy  urine  freezes  between 
— 0.9°  and  — 2°  C.  In  renal  inadequacy  the  freezing-point  of  the  blood  is 
lower  than  normal  and  the  freezing-point  of  the  urine  is  higher.  It  is  held 
that  surgical  operation  is  contra-indicated  if  there  is  such  a  degree  of  renal 
inactivity  that  the  freezing-point  of  the  blood  is  at  or  below  — 0.6°  C.  and  if 
the  freezing-point  of  the  urine  is  at  or  above  1°  C.  The  urine  is  obtained  from 
each  kidney  separately  and  is  compared  with  the  blood's  molecular  composition. 

Diseases  and  Injuries  of  the  Kidney  and  Ureter 

Tumors  of  the  Kidney. — Timiors,  innocent  or  malignant,  may  arise  in 
the  kidney.  Among  the  innocent  tumors  are  fibroma,  lipoma,  angioma,  and 
adenoma.  Hypernephroma  of  the  kidney  arises  from  fragments  of  adrenal  tissue 
included  in  the  kidney.  Hypernephromata  were  thought  to  be  renal  lipomata 
imtil  1883,  when  Grawitz  showed  they  contained  adrenal  elements  ("Virchow's 
Archiv.,"  xciii).  The  name  "hypernephroma"  was  suggested  by  Birch-Hirsch- 
feld  in  1896.  A  hypernephroma  may  arise  directly  from  the  suprarenal  gland 
or  it  may  arise  from  an  adrenal  "rest"  or  aberrant  gland.  Such  rests  may  be 
met  with  in  the  substance  of  the  kidney,  under  the  renal  capsule,  in  the  peri- 
renal tissue,  in  the  testicle,  the  ovary,  the  liver,  the  inguinal  canal,  the  mesen- 
tery, among  the  spermatic  vessels,  in  the  broad  ligament,  in  the  renal  plexus, 
or  in  the  solar  plexus  (W.  W.  Keen).  The  term  hypernephroma  is  applied  to 
any  growth  which  arises  from  adrenal  cells  "whether  the  growth  be  adenoma, 
carcinoma,  or  sarcoma  in  type"  (Duffield,  in  "N.  Y.  Med.  Jour.,"  May  i,  1909). 
The  tissue  of  a  hypernephroma  is  identical  with  the  adrenal  gland,  and  it 
contains  fat  and  glycogen.  The  exact  nature  of  such  a  timior  is  imsettled. 
It  is  probably  an  adenoma,  but  some  consider  it  to  be  a  sarcoma  and  others 
a  carcinoma.  Some  tumors  give  no  evidence  of  malignancy;  some  are  very 
malignant.  A  malignant  hypernephroma  grows  rather  rapidly,  eventually 
attains  a  large  size,  and  is  sometimes  painful.  A  patient  in  the  Philadelphia 
Hospital  from  whom  I  removed  a  hypernephroma  complained  of  tenderness 
in  the  left  side  and  occasional  attacks  like  renal  colic  during  which  he  passed 
bloody  iirine.  The  ttmior  could  be  easily  palpated  in  the  left  loin.  The 
kidney  was  removed  and  resembled  a  huge  kidney  of  nearly  normal  shape,  but 
nodiflar  in  outline.  Dr.  Coplin  found  it  to  be  hypernephroma.  In  this  case 
there  was  no  increase  of  arterial  tension.    The  patient  died.    Another  case 


1274  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

was  a  woman  of  forty-five  who  was  brought  to  the  Jefferson  Hospital.  She 
had  suffered  from  pain  in  the  loin  for  months.  It  was  paroxysmal,  but  lacked 
the  radiation  of  renal  colic.  Hematuria  appeared  long  after  the  pain  had 
begun.  It  was  persistent,  but  small  in  amount.  Palpation  detected  a  tumor 
and  the  x-rays  showed  enlarged  kidney.  There  was  no  increase  of  arterial 
tension.  Recovery  followed  nephrectomy.  In  a  man,  aged  thirty-four,  in  the 
Philadelphia  Hospital  there  were  attacks  of  severe  pain  referred  to  the  groin, 
testicle,  and  loin.  The  bleeding  was  profuse.  A  mass  was  palpable  in  the  right 
upper  abdomen  and  loin.  Examination  of  blood  showed  hemolysis,  but  there 
was  no  hypertension.  The  growth  was  exposed  in  the  loin.  Hemorrhage  was 
so  violent  that  it  became  necessary  to  open  the  abdomen  and  ligate  the  renal 
pedicle.    The  kidney  was  removed  and  the  patient  recovered. 


. — Sarcoma  of  kidney  with  metastasis  (Horwitz) . 


Very  malignant  cases  have  proved  fatal  within  six  weeks  after  symptoms 
were  observed.  Some  patients  have  lived  three  years.  A  hypernephroma  of 
malignant  nature  involves  adjacent  structures,  and  gives  rise,  after  a  time,  to 
metastases,  particularly  by  way  of  the  blood.  The  bones  are  most  liable  to 
metastatic  deposit,  but  such  deposits  may  occur  in  the  limgs,  liver,  and  other 
regions.  In  a  case  upon  which  I  operated  for  a  supposed  adenomatous  goiter 
the  condition  was  really  metastatic  hypernephroma.  Hypernephromata  are 
infinitely  more  common  in  the  kidney  than  anywhere  else.  They  tend  par- 
ticularly to  occur  in  middle  life.  Sarcoma  or  carcinoma  may  arise  in  the  kidney. 
Sarcoma  is  most  common  in  the  young,  and  may  reach  an  enormous  size 
(Fig.  849).  A  malignant  tumor  of  the  kidney  produces  hematuria,  the  urine 
often  containing  blood-casts  of  the  ureter,  kidney,  and  pelvis,  and  sometimes, 
though  rarely,  characteristic  cells.    Pain  is  often  present  in  the  loin  and  thigh, 


Nephroptosis.   Prolapse  of  the  Kidney,   or  Mobile   Kidney       1275 

and  there  may  be  colic-like  attacks  when  clots  are  passing  through  the  iireter. 
Emaciation  is  rapid  and  pronounced.  A  tumor  can  usually  be  palpated. 
Pyelography  with  a  10  per  cent,  solution  of  collargol  may  aid  in  the  diagnosis 
(see  page  1309).  The  only  possible  treatment  for  a  maUgnant  growth  is  early 
nephrectomy.  In  some  few  cases  an  innocent  tumor  can  be  removed  by  a  par- 
tial nephrectomy.  A  mahgnant  tumor  requires  a  complete  nephrectomy. 
In  making  a  diagnosis  of  renal  tmnor  use  the  cystoscope.  If  blood  is  coming 
from  above  the  bladder,  note  if  it  is  from  one  or  from  both  ureters.  Blood 
from  both  would  contra-indicate  nephrectomy.  Before  remo^"ing  a  kidney  it 
is  necessary  to  be  sure  that  the  patient  is  possessed  of  two  kidneys.  Xote  if 
urine  flows  from  each  ureter,  or.  if  uncertain,  catheterize  the  ureters. 

Nephroptosis,  Prolapse  of  the  Kidney,  or  .Mobile  Kidney. — 
There  are  two  forms  of  this  condition:  11  >  Moiable  kidney,  which  is  an  organ 
freely  mo^Tng  back  of  the  peritoneum,  either  within  the  caA'ity  of  its  nbro- 
fatt\^  capsule  or  entirely  without  its  capsule  ithis  condition  is  acquired) :  and 
(2)  Hoating  or  wandering  kidney,  an  organ  ha\'ing  a  mesonephron  and  h'ing 
within  the  peritoneal  ca\-ity  (this  rare  condition  is  always  congenital).  Keen 
states  that  there  may  be  drawn  a  clear  theoretical  distinction  between  mov- 
able and  floating  kidney,  but  practically  there  is  no  rigid  line  of  demarca- 
tion, as  a  movable  kidney  may  have  as  large  a  range  of  movement  as  a  floating 
kidnev.  The  kidney  is  normally  somewhat  mobfle.  and  nephroptosis  is  con- 
sidered to  exist  oifly  when  the  range  of  movement  exceeds  distinctly  what 
is  normal.  XormaUy,  on  inspiration  the  kidney  descends  about  h  inch.  It 
is  seldom  that  a  normal  kidney  can  be  palpated  in  men.  but  in  most  women 
the  right  kidney  can  be  palpated,  and  in  some  women  the  left  organ  can  also 
be  felt.  Harris  ("Jour.  Amer.  Med.  Assoc.,'"  June  i.  1901)  describes  three 
degrees  of  movable  kidney.  In  cases  of  the  first  degree,  one-half  of  the  organ 
can  be  distinctly  grasped  and  the  kidney  can  be  made  to  recede.  In  cases 
of  the  second  degree  both  hands  can  be  brought  together  above  the  kidney. 
In  cases  of  the  third  degree  the  kidney  has  descended  as  low  as  the  pehic 
brim  or  has  moved  to  or  beyond  the  imibilicus.  The  organ  may  drop  below 
the  brim  of  the  peMs,  may  cross  the  vertebral  column,  or  may  reach  the 
anterior  abdominal  wall.  \\Tien  a  movable  kidney  becomes  iLxed  in  an  ab- 
normal situation,  the  organ  is  spoken  of  as  dislocated. 

Women  suffer  from  movable  kidney  more  often  than  do  men.  Kiister 
estimates  that  4.41  per  cent,  of  women  examined  in  general  surgical  practice 
have  movable  kidney.  Edebohls  finds  it  in  20  per  cent.,  and  Harris  in  56 
per  cent.,  of  cases  in  ,e}-necologlcal  practice.  In  about  one-half  of  the  cases 
it  gives  rise  to  Kttle  or  no  trouble.  A  movable  kidney  is  found  in  the  great 
majority  of  cases  upon  the  right  side.  In  many  cases  it  is  bilateral,  the  right 
kidney  being  usually  the  most  mobile.  Splanchnoptosis  may  be  associated  with 
acquired  nephroptosis.  Floating  kidney  is  always  congenital.  Movabiht}-  of 
the  kidney  is  occasionally,  but  rarely,  found  in  children,  though  congenital 
cases  occasionally  occur.  In  a  congenital  case  there  is  not  splanchnoptosis. 
Tuffier  has  reported  3  cases  in  children  six.  nine,  and  ten  years  of  age  re- 
spectively, and  J.  Cromby  reported  iS  cases  of  floating  kidney  in  children, 
the  youngest  patient  being  three  months  of  age  (quoted  by  Harris.  Ibid.). 
Among  the  assigned  causes  of  the  movable  condition  are  to  be  named  trau- 
matism: strains:  abdominal -wall  laxit\-  from  pregnane}-,  removal  of  a  tumor, 
or  tapping  for  ascites:  absorption  of  peritoneal  fat  from  wasting  disease 
(Edebohls):  tight  lacing:  uterine  displacements:  and  enteroptosis  leading  to 
traction  on  the  transverse  mesocolon.  The  condition  is  certainly  often  asso- 
ciated with  ptosis  of  the  other  abdominal  \nscera  fenteroptosis.  gastroptosis. 
etc.). 

Traumatism  is  rarelv  the  immediate  and  essential  cause  of  a  true  movable 


1276  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

kidney.  In  some  cases  people  assert  that  pain  began  immediately  after  a 
blow,  an  attack  of  coughing,  violent  vomiting,  lifting,  straining  at  stool,  a 
fall,  or  in  parturition.  In  such  cases  the  kidney  may  have  been  mobile 
before  the  accident.  Again,  pain  is  not  proof  of  the  inauguration  of  mova- 
bility.  It  is  probable,  however,  that  traumatism  may  loosen  the  kidney 
and  that  mobility  may  subsequently  develop.  Gutterbock  says  that  a  kidney 
in  normal  relations  cannot  be  rendered  mobile  by  a  simple  fall  or  a  trivial 
force.  Loosening  can  be  induced  only  by  rupturing  surrounding  tissues; 
and  if  this  happens,  symptoms  of  a  distinct  nature  will  indicate  the  seat  of 
injury.  Becher  and  Lennhoff  claimed  that  there  is  a  connection  between 
movability  of  the  kidney  and  the  length  and  breadth  of  the  body.  They  have 
laid  down  a  formula,  viz. :  Measure  the  distance  from  the  suprasternal  notch 
to  the  crest  of  the  pubes.  Divide  this  by  the  smallest  circumference  of  the 
abdomen.  Multiply  the  product  by  100.  The  result  is  the  abdominal  index. 
If  the  index  is  greater  than  75  there  is  a  tendency  to  movable  kidney.  If  it 
is  less  than  75  there  is  no  such  tendency.  Harris  makes  out  a  strong  case  for 
the  view  that  the  condition  is  due  to  the  relation  existing  between  the  location 
of  the  kidney  and  the  body  form.  He  divides  the  body  into  three  zones:  The 
upper  zone  contains  the  lungs  and  heart.  The  middle  contains  the  liver, 
stomach,  spleen,  pancreas,  and  the  greater  part  of  each  kidney.  The  lower 
contains  the  intestinal  canal  and  the  lesser  part  of  each  kidney.  When  there 
is  a  naturally  small  or  a  diminished  capacity  of  the  middle  zone,  the  kidney  is 
displaced  downward.  The  right  kidney  is  pressed  upon  by  the  heavy  liver, 
which  drives  it  down;  the  left  kidney  is  pressed  upon  by  the  comparatively 
small  spleen.  Hence  movable  kidney  is  more  common  on  the  right  side  than 
on  the  left.  The  upper  pole  of  the  kidney  is  first  pushed  forward  and  then  the 
entire  organ  descends  (M.  L.  Harris,  in  "Jour.  Amer.  Med.  Assoc,"  June  i, 
1 901).  Harris  maintains  that  the  amount  of  mobility  depends  upon  the  degree 
of  contraction  of  the  middle  zone  and  upon  internal  traumatisms  (lifting,  strain- 
ing, coughing,  etc.). 

Symptoms  of  Both  Forms. — ^There  may  be  no  discomfort  whatever,  or 
the  patient  may  be  a  confirmed  invalid.  The  usual  symptoms  are  epigastric 
pain  (just  to  the  left  of  the  middle  line),  which  disappears  when  the  kidney 
is  replaced,  dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
Sudden  attacks  of  violent  pain  in  the  kidney  or  stomach  may  occur — attacks 
which  are  accompanied  by  nausea,  vomiting,  great  weakness  or  collapse, 
vertigo,  chills,  and  subsequently  elevated  temperature  (Dietl's  crises).  Dietl's 
crises  are  due  to  kinking  or  twisting  of  the  ureter  or  renal  vessels  or  to  inflam- 
mation of  the  kidney.  They  may  be  caused  by  physical  exertion  or  indis- 
cretion in  diet  and  may  be  followed  by  hydronephrosis  or  strangulation  of 
the  renal  vessels.  A  few  years  ago  I  operated  upon  a  man  suffering  from  a 
violent  and  prolonged  crisis  and  found  a  twist  of  the  vessels  and  ureter.  In 
a  Dietl's  crisis  there  is  congestion  or  strangulation  or  both.  An  incomplete 
or  temporary  twist  of  the  renal  pedicle  may  induce  simply  pain  in  the  abdo- 
men and  loin,  hematuria,  albimiinuria,  and  cylindruria. 

The  question  as  to  whether  or  not  abdominal  pain  is  due  to  movable 
kidney  is  sometimes  in  doubt.  The  localization  of  the  pain  may  lead  us  to 
suspect  appendicitis.  Some  surgeons  think  that  catarrhal  appendicitis  is 
often  associated  with  movable  kidney,  but  I  do  not  think  the  association  is 
common.  "Dr.  Kelly  has  shown  us  how  to  solve  this  doubtful  question 
between  appendicular  pain  and  the  pain  of  movable  kidney.  He  catheter- 
izes  each  ureter  separately,  and  introduces  into  each  catheter  as  much  fluid  as 
the  renal  pelvis  will  hold  without  causing  pain.  He  then  measures  this  fluid 
from  each  side,  and  determines  whether  it  is  in  excess  of  an  estimated  average. 
If  it  is  in  excess,  he  is  sure  that  dilatation  has  begun.     He  then  injects  the 


S}'mptom5  of  Xephroptosis 


1277 


kidney  again,  with  the  deliberate  purpose  of  producing  pain;  and  if  the  patient 
recognizes  this  pain  due  to  the  distention  as  of  the  same  character  and  in  the 
same  position  as  that  which  he  has  pre\-iously  felt,  Dr.  Kelly  assumes  that 
the  pain  has  been  due  to  the  kidney,  and  not  to  the  appendix,  and  recommends 
an  operation  to  fix  the  kidney''  (the  author,  in  ""Xew  York  ^led.  Jour.,""  August 
4,  1906).  Usually  in  a  case  of  movable  kidney  there  is  a  sense  of  a  mo\'ing 
body  in  the  abdomen,  and  the  patient  has  aggravated  indigestion,  often  accom- 
panied by  vomiting.  Constipation  is  the  rule,  and  \'iolent  attacks  of  cardiac 
palpitation  are  common.  Most  subjects  of  kidney  mobiht}*  are  extremely 
ner\'ous — many  of  them  hysterical  or  h^-pochondriacal.  Persistent  vasomotor 
paresis  causes  cold  hands  and  feet  and  often  albimiinuria.  Temporary-  j aim- 
dice  is  not  imcommon.  There  is  frequently  irritability  of  the  bladder.  Vertigo 
and  insomnia  are  present  in  many  cases.  The  patient  cannot  sleep  when  hing 
on  the  sound  side  i  Goelet\  In  women  the  sexual  organs  are  almost  invariably 
deranged,  and  menstruation  aggravates 
the  pain  and  discomfort.  All  the  s^-mpn 
toms  are  intensified  by  exertion  and  are 
modified  by  rest.  The  urine  is  normal 
except  after  \-iolent  exercise,  when  it  may 
contain  blood.  Splanchnoptosis  may  also 
exist,  and  if  it  does,  the  pulsations  of  the 
abdominal  aorta  are  strongly  noticeable 
because  that  structure  is  bared  by  gas- 
troptosis.  The  proof  of  the  existence  of 
movable  kidney  is  the  finding  of  a  mass, 
movable  on  respiration,  change  of  posi- 
tion, and  palpation,  shaped  like  that 
organ,  pressure  upon  which  occasions  no 
sensation  or  causes  pain  or  a  sickening 
feeling.  A  "lumbar  recess"  (IM orris)  may 
sometimes  be  foimd,  and  percussion  over 
the  loin  gives  resonance.  In  some  cases  a 
movable  kidney  can  be  readily  detected 
when  the  patient  stands  up,  but  is  diffi- 
cult  to  find  when  he  is  recumbent. 
Franks"5  method  of  examination  is  ver\- 
satisfactory-  inmost  cases  (Fig.  850).  The 
patient  is  placed  reciunbent.  If  dealing 
^-ith  a  right  kidney,  the  surgeon  stands  to 
the  right  side  and  pushes  four  fingers  of 
his  left  hand  in  the  loin  below  the  twelfth 

rib,  and  rests  the  thumb  lightly  in  front  just  below  the  ribs.  The  patient  takes 
a  fuU  breath  and  holds  it  a  moment,  and  just  before  he  empties  his  lungs  the 
surgeon  presses-  his  thumb  up  deeply  below  the  ribs.  During  expiration  the 
thimab  foUows  the  hver,  and  the  fingers  press  toward  the  front.  If  with  the 
right  hand  the  kidney  can  be  felt  entirely  below  the  left  hand,  the  case  is  one 
of  movable  kidney.  If  such  a  condition  is  detected,  press  hard  vriih  the  right 
hand,  and  gradually  loosen  the  grasp  of  the  left  hand,  and  the  kidney  will 
sHp  between  the  fingers  and  ascend.  A  normally  mobile  kidney  descends 
so  that  its  lower  end  can  be  felt,  but  it  moves  back  during  expiration.-  Goe- 
let  uses  Kendal  Franks's  method  of  palpation,  but  has  the  patient  stand, 
with  the  weight  resting  on  the  leg  oi  the  soimd  side  and  with  the  leg  of  the 
impaired  side  slightly  flexed  and  resting  on  the  toes.  The  body  leans  a  Kttle 
forward.  A  movable  kidney  must  not  be  mistaken  for  a  distended  gaU-blad- 
i-Brit.  Med.  Jour.."  Oct.  12.  1805. 


Fig.  S50. — A.  H.  Goelet's  method  of  pal- 
pation for  the  detection  of  a  prolapsed  kid- 
nev. 


1278  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

der,  a  tumor  of  the  mesentery,  stomach,  or  omentum,  a  phantom  tumor,  an  ova- 
rian tiunor,  or  a  cancer  of  the  pancreas.  A  distended  gall-bladder  can  be  pushed 
upward,  but  not  backward,  and  not  downward  unless  the  liver  is  movable; 
it  is  extremely  tender,  and  cannot  be  pushed  out  of  reach.  A  kidney  can  be 
pushed  upward  and  backward — in  fact,  in  all  directions.  An  enlarged  gall- 
bladder can  always  be  palpated.  A  movable  kidney  which  is  not  enlarged 
can  be  felt  at  times  and  not  at  others  (Henry  Morris).  A  movable  kidney 
may  pass  between  the  examiner's  fingers,  and  if  pushed  into  the  loin,  it  tends 
to  remain;  but  if  a  distended  gall-bladder  is  pushed  into  the  loin,  it  springs 
out  as  soon  as  pressure  is  relaxed  (Henry  Morris) .  The  x-ray  study  of  the  kidney 
pelvis  after  injection  with  coUargol  is  known  as  pyelography  (see  page  13 10). 
The  x-ray  picture  of  a  kidney  so  injected  is  a  pyelogram.  This  method  is  of 
the  highest  diagnostic  value.  It  will  always  show  a  displaced  kidney,  and  it 
indicates  hydronephrosis.  One  picture  should  be  taken  with  the  patient 
standing,  another  with  the  patient  recumbent.  It  is  important  to  remember 
that  in  about  one-half  of  the  cases  of  movable  right  kidney  the  left  kidney  is 
also  movable,  but  to  a  less  degree.  Appendicitis  is  thought  by  some  to  be 
more  frequent  in  individuals  with  movable  right  kidney  than  in  those  free  from 
renal  mobility.  Sometimes  a  movable  kidney  endangers  life,  rupture  of  the 
kidney,  twisting  or  rupture  of  the  ureter,  or  strangulation  of  the  renal  vessels 
occurring,  the  ultimate  cause  of  death  being  albuminuria,  uremia,  or  hydro- 
nephrosis. 

Treatment. — Mobile  kidney  is  treated  as  follows:  If  the  kidney  is  but 
slightly  mobile  and  there  are  no  local  symptoms,  the  treatment  should  be 
non-operative:  (i)  The  rest  treatment  of  S.  Weir  Mitchell  may  be  tried;  it 
often  markedly  mitigates  the  symptoms,  but  does  not  seem  to  cure.  (2) 
Mechanical  support  should  always  be  tried.  The  most  satisfactory  mode  of 
applying  it  is  by  the  corset  recommended  by  Gallant  ("Am.  Jour.  Obstet.," 
July,  1901).  This  corset  is  long  and  straight  in  front,  and  when  applied,  fits 
firmly  over  the  hips  and  lower  abdomen,  less  firmly  at  the  waist,  and  least 
firmly  above. 

The  patient  lies  down,  a  pillow  being  under  the  buttocks  and  the  knees 
being  drawn  up.  While  in  this  attitude  the  corset  is  put  on  and  it  is  laced 
from  below  up.  If  the  attempt  to  apply  the  corset  develops  tenderness,  keep 
the  patient  at  rest  in  bed  imtil  it  can  be  applied  without  pain.  In  some  cases 
conservative  treatment  is  not  indicated;  in  others  it  fails. 

In  every  case  of  very  movable  kidney  and  in  some  cases  in  which  mova- 
bility  is  not  great  operation  is  indicated. 

"In  a  case  in  which  the  kidney  exhibits  trivial  movability,  but  in  which 
the  range  of  mobility  is  found  to  be  gradually  and  certainly  increasing,  or 
in  any  case  of  kidney  movability  in  which  there  are  distinct  local  symptoms, 
operation  is  indicated.  The  distinct  local  symptoms  mean  the  beginning  of 
actual  harm  to  the  kidney,  and  the  progressive  increase  of  movabiHty  means 
the  ultimate  attainment  of  a  wide  range  of  movement.  A  kidney  which  is 
widely  movable  may  at  any  time  twist  upon  the  ureter  and  the  renal  vessels; 
and  it  is  certain  to  suffer  from  partial  or  slight  twists,  probably  many  times 
repeated  in  the  twenty-four  hours,  even  if  a  severe  twist  does  not  occiu".  A 
deduction  from  the  foregoing  statements  is  that  a  patient  suffering  with  neph- 
roptosis, even  when  the  mobility  is  slight,  should  be  examined  at  regular 
intervals,  to  note  whether  the  area  of  movement  is  extending,  or  whether 
local  symptoms  have  arisen.  Three  local  symptoms  that  should  be  regarded 
as  indications  for  operation  are  severe  pain  in  the  renal  region,  distinct  ten- 
derness of  the  kidney,  and  enlargement  of  the  kidney"  (the  author,  in  "New 
York  Med.  Jour.,"  August  4,  1906).  Billington  ("Brit.  Med.  Jour.,"  May  i, 
1909)  formulates  the  following  indications  for  operation: 


Treatment  of  Nephroptosis  1279 

1.  When  renal  pain  is  so  severe  or  persistent  as  to  cause  serious  incon- 
venience. The  ordinary  dragging  pain  in  the  loin  is  not  an  indication.  Bil- 
lington  refers  to  severe  pain  due  to  perirenal  inflammation,  ureteral  obstruc- 
tion, or  impeded  venous  return. 

2.  When  there  are  harassing  and  depressing  gastric  and  colonic  troubles 
(gross  lesions  being  absent). 

3.  Cases  of  spinal  and  cerebral  neurasthenia. 

4.  Cases  of  lunacy.  Personally  I  do  not  operate  on  groups  3  and  4  unless 
there  are  signs  of  grave  renal  disaster. 

The  usual  operation  chosen  will  be  nephropexy,  very  seldom  nephrectomy, 
(i)  Nephropexy  is  the  operation  employed  in  most  instances  (see  page  1296). 
It  is  the  author's  experience  that  if  the  patient  has  had  marked  nervous  symp- 
toms for  a  long  time,  nephropexy  will  rarely  cause  them  to  pass  away  perma- 
nently, even  though  the  kidney  remains  firmly  anchored.  (2)  Nephrec- 
tomy is  necessary"  only  in  very  rare  cases;  it  may  be  done  for  dislocated  kidney, 
when  grave  kidney  disease  exists,  or  when  nephropexy  has  failed  in  a  case  of 
great  severity. 

In  many  cases  of  this  trouble  no  operation  should  be  performed,  the  use 
of  Gallant's  corset  securing,  perhaps,  decided  or  complete  relief.  I  do  not 
operate  if  the  kidney  is  only  slightly  movable  and  if  there  are  no  local  symp- 
toms or  if  there  are  merely  the  general  s\Tnptoms  of  hysteria.  If  the  mobility 
is  slight  and  the  hysterical  and  neurotic  condition  is  pronounced,  anchoring 
the  kidney  wall  not  cure  the  nervous  condition.  In  these  nervous  cases,  asso- 
ciated with  prolapse  of  the  kidney,  there  is  usuall}^  also  prolapse  of  the  other 
abdominal  viscera;  and  both  kidneys  are,  as  a  rule,  movable,  the  right,  how- 
ever, in  most  cases  being  decidedly  more  movable  than  the  left. 

If  there  is  but  slight  mobility  of  the  kidney,  but  the  range  of  movement 
is,  week  by  week  and  month  by  month,  increasing,  or  if  we  find  a  case  of 
movable  kidney  in  which  there  are  distinct  symptoms,  an  operation  should 
be  performed.  The  existence  of  definite  local  s\Tnptoms  means  beginning 
harm  to  the  kidney;  and  if  we  find  the  area  of  movement  gradually  increas- 
ing, we  know  that  eventually  it  will  become  extensive.  Any  widely  movable 
kidney  may  twist  the  ureter  and  the  renal  vessels,  producing  serious  trouble  or 
even  disaster,  and  consequently  should  be  fixed  by  operation.  Even  if  a  severe 
twist  does  not  take  place,  the  kidney  is  bound  to  suffer  from  partial  or  slight 
twists.  Such  kidneys  will  eventually  become  hydronephrotic.  The  meaning 
of  the  term  "slight  mobility"  is  indicated  on  a  previous  page  (see  page  1275). 

One  is  not  unusually  in  doubt  in  cases  of  movable  kidney  whether  a  pain 
indicates  local  trouble  with  the  kidney  or  catarrhal  appendicitis,  because 
the  pain  may  be  located  in  the  appendix  region.  Kelly,  of  Johns  Hopkins 
Hospital,  has  sho-wn  how  to  solve  this  problem  (see  page  1276). 

There  are  many  operations  for  movable  kidney.  In  all  of  them  the  kidney 
is  exposed  in  the  loin.  Some  make  a  vertical  and  some  an  obhque  incision. 
Edebohls  makes  a  vertical  incision,  forces  the  kidney  out  of  the  wound,  incises 
the  fibrous  capsule  longitudinally,  turns  a  cuff  down  on  each  side,  and  applies 
sutures.  These  sutures  traverse  the  kidney  substance  and  the  fold  of  capsule 
on  each  side.  The  upper  suture  catches  the  periosteum  of  the  last  rib;  the 
other  sutinres  catch  the  lumbar  fascia.  Drainage  is  not  required,  and  the 
suture  material  employed  is  kangaroo-tendon  or  chromicized  catgut. 

Some  surgeons  simply  pass  sutures  through  the  uncut  capsule  and  the 
kidney  substance  and  thus  fasten  the  kidney  to  the  lumbar  fascia.  Others 
split  the  capsule  and  pass  sutures  through  the  edge  of  the  capsule  and  the 
wound  edges,  but  not  through  the  kidney  substance. 

To  promise  success,  an  operation  ought  to  restore  the  kidney  nearly  to 
its  normal  position  and  fix  it  permanently  in  place.     It  is  undesirable  to  inflict 


i28o  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

damage  on  the  kidney  itself,  and  I  do  not  beUeve  in  any  operation  that  seeks 
to  obtain  fixation  by  passing  sutures  through  the  kidney  substance.  In  cases 
in  which  decapsulation  is  performed  the  kidney  will  grow  fast  without  any 
special  method  of  suturing. 

Most  of  the  operations  suggested  do  not  place  the  kidney  sufi&ciently  high 
up  to  get  it  into  a  fair  position.  Kelly's  operation  gets  it  higher  than  most 
of  them,  and  Goelet's  operation  gets  it  well  into  place.  In  many  of  the  suture 
operations  the  sutiures  are  placed  in  the  convex  surface  of  the  kidney  or  the 
kidney  capsule,  and  on  fixing  the  kidney  by  tying  the  sutures  there  is  a  per- 
manent quarter  twist  of  the  ureter — a  condition  that  may  be  responsible  for 
great  pain.  This  may  be  ob\dated  entirely  by  the  ingenious  method  of  Goelet 
("Annals  of  Surgery,"  Dec,  1903).  I  believe,  however,  that  the  suture  opera- 
tions which  do  lift  the  kidney  well  up  toward  its  proper  place  and  in  which 
the  sutures  are  applied  on  the  posterior  surface  and  not  the  convexity,  tilt  the 
upper  pole  forward  into  a  permanent  and  perhaps  disastrous  position.  Such 
operations  lift  the  kidney  from  below  its  midline  and  thus  fix  the  lower  half 
of  the  organ,  but  leave  the  upper  half  unfixed.  I  believe,  too,  that  in  many 
cases  in  which  kidneys  have  been  sutured  they  get  loose  again  and  that  the 
best  operation,  after  all,  is  that  by  the  use  of  slings  of  iodoform  gauze  (see 
page  1296). 

Injuries  of  the  Kidney. — Laceration  or  rupture  is  caused  by  falls  and 
by  blows  upon  the  back  or  the  belly. 

Symptoms. — In  some  cases  the  parenchymatous  structure  is  torn,  but 
the  capsule  is  not  torn,  and  in  consequence  urine  and  blood  are  not  extrava- 
sated  into  the  perirenal  connective  tissue  or  into  the  peritoneal  cavity.  In 
other  cases  the  parenchyma  and  capsule  are  both  torn  and  urine  and  blood 
are  extravasated  into  the  perirenal  tissues,  the  peritoneal  cavity,  or  both 
of  these  regions.  The  laceration  may  be  trivial,  may  be  considerable,  or 
may  tear  the  kidney  apart.  The  symptoms  depend  on  the  gravity  of  the 
injury.  A  slight  tear  without  involvement  of  the  capsule  may  produce  prac- 
tically no  symptoms  at  all.  A  more  severe  injury  produces  shock,  and,  if 
profuse  bleeding  occurs,  the  general  symptoms  of  hemorrhage.  In  intraperi- 
toneal rupture  there  is  profuse  and  usually  fatal  hemorrhage.  In  laceration 
of  the  kidney  there  are  severe  pain  in  the  loin,  which  shoots  into  the  testicle, 
and  limibar  tenderness.  If  there  is  considerable  perirenal  bleeding  the  loin 
will  be  full  and  dull  on  percussion,  and  if  the  hemorrhage  is  large,  a  palpable 
mass  will  form  after  a  time  and  after  some  days  the  skin  will  become  discolored. 
There  is  usually  frequent  and  painful  micturition,  and  in  some  cases  suppres- 
sion of  urine.  Hematuria  occurs  in  renal  laceration  unless  the  rupture  was 
intraperitoneal  or  the  ureter  was  torn.  If  the  rupture  was  intraperitoneal 
there  are  evidences  of  profuse  internal  hemorrhage,  abdominal  rigidity,  etc. 
(Daniel  N.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25,  1902).  It  is 
important  to  remember  that  hematuria  can  arise  from  simple  renal  contusion, 
and  that  even  severe  kidney  damage  does  not  of  necessity  cause  bloody  urine. 
If  there  is  hematuria,  the  use  of  the  cystoscope,  catheterization  of  the  ureters, 
or  the  employment  of  Harris's  segregator  will  demonstrate  from  which  kid- 
ney the  blood  comes.  A  kidney  laceration  may  be  followed  by  secondary 
hemorrhage,  perirenal  suppuration,  hydronephrosis,  or  pyonephrosis.  The 
force  of  the  injury  may  have  caused  kidney  displacement. 

Treatment. — In  an  intraperitoneal  rupture  laparotomy  should  be  performed. 
As  a  rule,  nephrectomy  is  necessary,  but  it  may  be  possible  to  arrest  hem- 
orrhage by  packing.  If  the  shock  is  pronounced  and  if  there  is  increasing 
fulness  in  the  loin,  whether  hematuria  exists  or  not,  or  if  blood  comes 
profusely  from  the  ureter,  whether  or  not  there  is  much  shock  or  lumbar 
fulness,  make   an   exploratory   lumbar   incision  and  stop   the  bleeding  by 


Perforating  Wounds  of  the  Kidney 


1281 


packing  or  by  a  purse-string  suture  (Figs.  851,  852),  or,  if  necessary, 
perform  partial,  or  even  complete,  nephrectomy.  Ordinarily,  after  a  kid- 
ney injury,  when  there  is  not  great  shock,  increasing  lumbar  swelling,  or 
severe  hematuria,  treat  by  rest  in  bed  and  by  feeding  with  Kquid  food  or 
by  nutritive  enemata  to  prevent 
vomiting.  Opium,  tannic  acid,  or 
gallic  acid  may  be  used.  Apply 
ice-bags  to  the  loin  and  the  side 
of  the  abdomen,  and  after  bleed- 
ing ceases  strap  the  loin  and 
apply  a  binder.  If  large  blood- 
clots  in  the  bladder  cause  pain 
or  retention  of  urine,  introduce 
a  catheter  and  inject  the  bladder 
Mith  boric  acid,  or  use  the  tube 
and  evacuator  of  a  Bigelow  ap- 
paratus. If  this  procedure  fails, 
open  the  bladder  by  a  suprapubic 
incision  and  drain. 

Results  of  Operation. — Up  to  1894  there  had  never  been  a  case  of  intra- 
peritoneal rupture  operated  upon.  During  the  follomng  seven  years  6  were 
operated  upon  and  all  recovered  (Daniel  N.  Eisendrath,  "Jour.  Amer.  Med. 
Assoc,"  Oct.  25,  1902).  Kiister  collected  47  cases  of  nephrectomy,  and 
^T,  per  cent,  recovered.  Keen  estimates  the  mortality  of  primary  neph- 
rectomy for  rupture  at  20  per  cent.,  and  of  secondan,^  nephrectomy  at 
38.5  per  cent.  Without  operation  intraperitoneal  rupture  is  inevitably 
fatal.  Of  extraperitoneal  ruptures,  70  per  cent,  recover  without  opera- 
tion (Eisendrath).     Francis  S.  Watson   ("Boston  Med.  and  Surg.  Jour.," 


Fig.  851. 


Purse-string  suture  applied  to  a  perfora- 
tion (after  Schacher). 


Fig.  852. — Showing  the  application  of  a  double  purse-string  suture  for  the  arrest  of   hemorrhage  in 

large  wound  (after  Schacher). 


July  16,  1903)  has  collected  660  cases  of  subparietal  injur}'  of  the  kidney. 
The  following  statistics  are  of  interest:  Treated  expectantly:  273  cases  wdth 
81  deaths,  a  mortality  of  29.6  per  cent.  Treated  by  operations  other  than 
nephrectomy:  99  cases  with  7  deaths,  a  mortality  of  7.7  per  cent.  Treated  by 
nephrectomy:    115  cases  ^\ith  25  deaths,  a  mortality  of  21.7  per  cent. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do  not  involve 
the  peritonetmi;  if  anterior,  they  do.  The  symptoms  are  escape  of  blood  and 
urine  by  the  wound;  hematuria  is  usual,  but  not  invariable;  pain  as  in  rup- 
ttire;  the  patient  may  be  unable  to  micturate;  and  nausea,  vomiting,  and  con- 
stitutional signs  of  hemorrhage  exist.  Traumatic  peritonitis,  perinephric 
abscess,  or  general  sepsis  may  ensue.    Confirm  the  diagnosis  by  exploration 


1282 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


with  the  finger  after  operative  exposure.     Extraperitoneal  injuries  give  a  good, 
and  intraperitoneal  a  bad,  prognosis. 

Treatment. — If  the  wound  of  the  kidney  is  extraperitoneal,  enlarge  the 
lumbar  wound  to  permit  of  drainage,  and  arrest  hemorrhage  by  packing  and 
hot  water  or  by  a  purse-string  suture  (Figs.  851,  852). 

Suture  of  the  Kidney. — The  tendency  of  any  suture  material  to  cut  through 
the  kidney  structure  is  great.  The  following  simple  procedure  greatly  lessens 
this  danger:  Cut  the  ordinary  catgut  roll  into  three  or  four  parts,  as  shown  in 
Fig.  853.  Slip  beneath  the  exposed  loops  of  the  purse-string  suture,  as  shown 
in  Fig.  854,  a  section  of  the  catgut  roll  consisting  of  a  series  of  short  stiff  strands. 
These  permit  fairly  firm  tying  of  the  suture-ligature  without  cutting  of  the  kid- 
ney structure  by  the  suture.  In  nephrotomy  the  same  procedure  can  be  used 
to  hold  the  kidney  wound  together. 

Asepticize  the  wound,  insert  a  drainage-tube  down  to  the  kidney,  dress  with 
bichlorid  gauze  and  make  frequent  changes  of  dressings,  keep  the  patient  in 
bed  and  on  a  low  diet,  and  give  gallic  acid  and  opium.     In  some  cases  neph- 
rectomy, partal  or  complete,  will  be 
required.     In  intraperitoneal  wounds 
perform  an  abdominal  section   and, 
as  a  rule,  remove  the  damaged  organ 
(see  Nephrectomy). 


Fig.  853. — Catgut  ring  cut  into  quarters  to  be 
inserted  under  the  suture  as  shown  in  Fig.  854. 


Fig.  854. — Stellwagen's  suture  of  kidney  to  pre- 
vent cutting  after  tying. 


Wounds  of  the  Ureters. — Rupture  from  external  violence  is  an  ex- 
tremely rare  accident.  Eisendrath  ("Jour.  Amer.  Med.  Assoc,"  Oct.  25, 
1902)  found  only  3  undoubted  cases  on  record.  A  rupture  or  wound 
from  accidental  violence  is  almost  invariably  associated  with  other  serious 
injuries.  The  ureter  may  be  wounded  accidentally  by  the  sturgeon  during  the 
performance  of  an  abdominal  operation,  or  it  may  be  wounded  intentionally, 
as  in  Morris's  case,  in  which  a  malignant  growth  was  incorporated  with  the  ure- 
ter. There  is  particular  danger  of  injuring  the  ureter  in  operations  upon 
intraligamentary  growths,  because  the  lU'eter  is  displaced  and  often  resembles 
an  adhesion.  The  rule  of  surgery  is  that  when  working  about  the  ureter  the 
surgeon  neither  clamps  nor  cuts  any  structure  without  a  careful  preliminary 
examination.  Rupture  causes  severe  shock  and  extravasation  of  urine  around 
the  kidney  or  into  the  peritoneal  cavity.  In  extraperitoneal  rupture  a  pal- 
pable mass  forms  in  the  loin.  When  the  ureter  is  divided  in  an  operation,  a 
flow  of  urine  is  seen. 

Treatment. — The  upper  three-fotirths  of  the  ureter  can  be  reached  by  an 
extraperitoneal  incision,  which  is  a  prolongation  of  the  incision  for  lumbar 
nephrectomy,  running  from  the  twelfth  rib  downward,  and  forward  to  i  inch 


S\inptoms  of  Renal  Calculus.  1283 

anterior  to  the  anterior  superior  spine  of  the  ilium,  and  then  parallel  to  Pou- 
part's  ligament  until  a  point  is  reached  above  its  middle  (Fenger).  Israel's 
incision  begins  at  the  anterior  edge  of  the  erector  spinas  mass,  one  finger's 
length  below  the  twelfth  rib,  is  taken  forward  parallel  with  the  rib  until  it 
reaches  the  line  of  the  rib's  tip,  and  is  then  carried  toward  the  middle  of 
Poupart's  hgament  ujitil  the  line  for  ligation  of  the  common  iliac  artery'  is 
reached,  and  is  then  taken  toward  the  middle  line  as  far  as  the  outer  border 
of  the  rectus  muscle.  The  lower  one-fourth  of  the  ureter  can  be  reached  by 
abdominal  section,  by  sacral  resection,  or  by  an  incision  like  that  for  extra- 
peritoneal Hgation  of  the  iliac  vessels.  The  best  operation  to  reach  the 
lower  ureter  is  Gibson's  (see  page  1299).  If  it  seems  probable  that  the 
ureter  is  wounded  or  ruptured,  explore,  and  if  this  is  foimd  to  be  the  case, 
endeavor  to  restore  the  continuity  of  the  tube.  A  longitudinal  cut  can  be 
sutiured  with  fine  catgut.  If  the  ureter  is  cut  across  near  the  bladder,  im- 
plant the  proximal  end  into  the  bladder  and  ligate  the  distal  end  (Van  Hook, 
Penrose,  Kelly).  If  it  is  cut  above  the  bladder  portion,  perform  lateral  im- 
plantation by  Van  Hook's  method  (see  page  1300). 

A  longitudinal  wound  of  the  ureter  inflicted  during  an  abdominal  operation 
should  be  sutured,  but  if  the  duct  cannot  be  readily  reached,  simply  make  a 
posterior  incision  and  drain  with  rubber  tissue,  as  the  longitudinal  wound 
will  heal  by  granulation  if  no  sutvires  are  inserted  (Van  Hook).  In  a  case 
of  transverse  di\'ision  perform  uretero-vireterostomy  or  vesical  implantation; 
or,  if  neither  of  these  methods  is  feasible,  make  a  iirinary  fistula  in  the  loin 
or  perform  nephrectomy. 

Renal  Calculus. — ^A  stone  in  the  kidney  is  formed  by  the  precipitation 
of  urinary  salts  into  the  renal  epithelial  cells  and  the  gluing  together  of  these 
salts  and  cells  by  material  from  mucus  or  blood-clot,  this  mass  ser\dng  as  a 
nucleus  on  which  accretion  takes  place.  Most  calculi  escape  when  small, 
as  gravel.  The  cause  is  a  highly  acid  urine,  which  induces  catarrh  of  the 
renal  tubes.  Such  high  concentration  of  urine  is  favored  by  a  sedentary  life, 
by  the  ingestion  of  much  alcohol  or  nitrogenous  food,  by  constipation,  by 
an  inactive  skin,  and  by  a  torpid  fiver.  The  slaves  of  poverty  are  particularly 
Hable  to  calcuH  because  of  the  use  of  imsmtable  foods  and  the  formation  of  great 
amounts  of  nitrogenous  waste.  Males  suffer  more  often  than  do  females; 
certain  locations  favor  the  development  of  the  malady,  and  a  family  tendency 
sometimes  exists. 

The  sjmiptoms  of  stone  in  the  kidney  may  not  appear  for  years  after  the 
stone  forms,  but  generally  they  are  manifested  early.  There  may  be  no 
pain.  There  had  been  none  in  13  cases  out  of  23  which  came  to  autopsy 
and  were  reported  by  Clark.  Usually  there  is  pain;  the  severity  of  the 
pain  depending  upon  the  roughness  and  movability  rather  than  upon  the 
size  of  the  stone.  K  fixed  stone  in  the  kidney  and  a  smooth  stone  in 
the  peh-is  may  cause  fittle  or  no  pain.  A  rough  stone  in  the  peMs  causes 
severe  pain.  The  patient  usually  complains  of  pain  ia  the  loin,  and  some- 
times of  pain  in  the  iHac  region.  Deep  percussion  over  the  kidney  causes 
pain  in  the  loin,  even  when  pressure  is  painless  (Jordan  Lloyd's  symptom). 
Pain  is  aggravated  by  exercise  and  pressure,  and  the  kidney  is  usually  en- 
larged. The  urine  is  often  somewhat  albuminous,  and  may  from  time  to 
time  contain  blood.  Frequency  of  micturition  is  noted  during  the  day,  but 
seldom  when  at  rest  at  night.  The  urine  may  be  purulent.  Nephritic  colic 
is  due  to  the  washing  of  a  calculus  into  the  orifice  of  the  ureter,  which  it 
blocks,  tears,  or  distends.  The  pain  is  either  sudden  or  gradual  in  onset,  is 
fearful  in  intensity,  and  rims  from  the  lumbar  region  down  the  corresponding 
thigh  and  spermatic  cord  (the  testicle  being  retracted),  and  into  the  abdomen 
and  back.    There  are  nausea,  vomiting,  collapse,  sometimes  unconsciousness 


1284 


Diseases  and  Injuries  of  the  Genito-urinars'  Organs 


or  convulsions.  Frequent  attempts  at  micturition  are  productive  of  pain,  but 
of  little  urine.  Rectal  tenesmus  is  common.  The  urine  is  often,  but  by  no 
means  always,  smoky  from  blood.  Blood  may  be  found  by  the  microscope 
when  it  cannot  be  detected  by  the  naked  eye.  In  rare  cases  fatal  hemorrhage 
occurs.  Blood  is  present  in  about  one-half  the  cases.  After  a  time  the  pain 
vanishes,  the  stone  having  passed  into  the  bladder  or  having  fallen  back  into 
the  pelvis  of  the  kidney.  Slight  attacks  of  colic  occur  from  the  passage  of  small 
stones  or  plugs  of  mucus.  A  calculus  retained  in  the  kidney  eventually  ex- 
cites pyeHtis,  pus  appears  in  the  urine,  and  soreness  or  pain  in  the  loin  exists. 
Kelly  says:  Even  if  pus  is  found,  we  are  not  always  sure  from  which  kidney  it 
came.    Pain  or  swelhng  may  point  to  one  side,  but  we  are  not  sure  that  the  outer 


Fig.  855. — Stone  in  kidney. 


organ  is  not  also  affected.  The  cystoscope  must  be  used.  Bloody  or  purulent 
urine  may  be  seen  coming  from  one  ureter.  If  able  to  pass  the  renal  catheter 
into  one  ureter,  attach  a  syringe,  and  by  making  suction  draw  out  any  pus 
which  may  be  present.  In  renal  calcuh  cases  this  fluid  is  apt  to  contain  frag- 
ments of  uric  acid.  By  using  a  renal  bougie  coated  with  dental  wax  it  may  be 
possible  to  make  scratches  on  the  instrimaent  when  it  comes  in  contact  mth  a 
concretion.^  WTien  a  stone  is  impacted  in  the  renal  pehds  the  point  of  greatest 
tenderness  on  pressure  is  below  the  last  rib,  by  the  edge  of  the  erector  spinee 
muscle.  In  septic  cases  there  may  be  chills  and  irregular  fever,  and  often 
there  is  leukocytosis.  In  most  cases  a  stone  in  the  kidney  or  ureter  can  be 
1  Howard  Kelly,  in  "Med.  Xews,"  Nov.  30,  1895. 


Symptoms  of  Calculus  Impacted  in  the  Ureter  1285 

skiagraphed.  Nephrolithiasis  may  cause  death  by  exhaustion,  by  sepsis,  by 
rupture  of  a  hydronephrosis,  or  by  amyloid  degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use  alkalis,  espe- 
cially the  Hquor  potassii  citratis,  and  reduce  the  amoimt  of  nitrogen  in  the 
diet  to  a  minimum,  at  the  same  time  washing  out  the  organs  by  copious 
drafts  of  water.  Citrate  of  lithia,  given  in  the  water,  is  supposed  to  add  to 
the  therapeutic  effect.  Some  surgeons  prescribe  natural  lithia  water.  Piper- 
azin,  in  doses  of  5  to  8  gr.  three  times  a  day,  is  highly  commended  by  some. 
Exercise  is  to  be  insisted  on.  WTien  gravel  is  phosphatic.  order  str\xhnin, 
the  mineral  acids,  and  rest  at  the  seaside.  When  oxalate  of  lime  is  found, 
restrict  the  diet,  use  the  mineral  acids,  recommend  travel  or  rest  amid  new 
surroundings,  and  give  an  occasional  course  of  sodii  phosphas,  h  dram  three 
times  a  day,  taken  in  a  natural  lithia  water.  Nephritic  colic  is  reUeved  by 
hypodermatic  injection  of  morphin  and  atropin,  a  hot  bath,  diluent  drinks, 
and  possibly  the  inhalation  of  ether.  After  an  attack  watch  aU  the  urine 
passed  to  see  if  a  stone  appears.  If  one  does  not  soon  appear,  use  the 
c\"stoscope,  and  if  a  stone  is  foimd  in  the  bladder,  wash  out  that  viscus 
"vsith  an  evacuator.  This  is  ver}'  important,  as  the  vesical  stone  may  fail 
to  pass,  and  if  it  remains  in  the  bladder  it  "^ill  progressivety  enlarge.  Fur- 
ther, finding  it  proves  the  diagnosis  of  renal  colic.  If  a  stone  impacts  in 
the  ureter,  perform  the  operation  of  ureterolithotomy.  The  diagnosis  of  this 
impaction  is  in  many  cases  aided  by  the  .T-rays,  but  is  sometimes  possible 
only  after  exploratory  laparotomy.  If  the  symptoms  point  to  stone  in 
the  kidney,  always  take  a  skiagraph.  If  this  shows  a  stone,  if  medi- 
cal treatment  fails,  or  has  faUed,  and  if  the  other  kidney  is  not  organically 
diseased,  operate.  If  in  doubt  in  spite  of  the  skiagraph,  make  an  explor- 
atory' lumbar  incision;  feel  the  surface  of  the  kidney  with  the  finger,  sound 
the  inside  of  the  organ  with  a  needle,  or  open  the  organ  for  exploration,  and  if  a 
stone  is  detected,  incise  the  kidney  and  remove  the  stone.  Keen  is  of  the 
opinion  that  operation  should  not  be  performed  if  the  urea  is  below  i  per  cent. 
If,  after  nephrolithotomy,  suppression  of  urine  occurs,  cut  into  the  other 
kidney,  as  in  one-half  of  aU  cases  a  stone  will  be  found  lodged  there.  I  agree 
with  Brewer  ("Med.  Record,"  March  20,  1909)  that  "a  kidney  containing  one 
or  more  calciili,  and  also  the  seat  of  an  advanced  septic  process,  should  be 
removed  if  the  opposite  organ  is  healthy.  To  leave  such  a  kidney  is  to  invite 
subsequent  trouble  from  recurrence  of  stone,  pyonephrosis,  or  long-continued 
sepsis."  I  agree  with  him  when  he  says:  "It  is  also  often  safer  to  remove  a 
kidney  with  multiple  calculi  embedded  in  its  substance  than  to  inflict  the 
trauma  necessary  to  remove  them,  as  alarming  primary'  or  secondary  hemor- 
rhage is  apt  to  occur."  In  a  case  of  my  o"^ti  a  most  persistent  postoperative 
hemorrhage  forced  me  to  perform  nephrectomy  to  save  life. 

Calculus  Impacted  in  the  Ureter. — A  ureteral  calculus  comes  from  the 
kidney,  sometimes  dropping,  but  more  often  being  forced,  into  the  tube.  A 
stone  may  be  arrested  at  any  one  of  the  points  of  constriction.  There  are  three 
points  of  constriction  in  the  ureter:  one  point  is  about  2  inches  below  the  renal 
peMs,  another  is  at  the  peMc  brim,  another  is  about  h  inch  from  the  bladder 
ori&ce  of  the  ureter.  The  highest  point  has  a  diameter  of  about  i  inch,  the 
middle  point  a  diameter  of  about  j  inch,  the  lower  point  a  diameter  of  about 
•iV  inch.  A  smaU  stone  may  completely  block  the  vureter.  A  large  stone  may 
fail  to  completely  block  it  because  the  ureter  dilates  above,  the  stone  acts  as 
a  ball-valve,  and  urine  trickles  by. 

Sjmiptoms. — Attacks  of  \'iolent  pain  of  the  nature  of  renal  colic  occur,  and 
not  unusually  there  is  a  rigor  ^\-ith  the  attack  and  fever  after  it.  Such  an  attack 
may  be  followed  by  hematuria.  The  urine  should  be  examined  microscopically 
during  several  davs  after  a  colic  to  see  if  it  contains  blood-cells.     Tenderness 


1286  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

can  be  developed  at  the  point  of  impaction,  the  point  of  greatest  tenderness 
being  in  the  loin  below  the  level  of  the  kidney  or  in  the  iliac  region  (Perkins). 
In  stone  in  the  ureter  pain  is  not  developed  by  pressure  in  the  loin  at  the  level 
of  the  kidney.  If  a  stone  partly  obstructs  the  ureter,  the  urine  is  pale,  of  low 
specific  gravity,  and  free  from  albimiin.  Impaction  near  the  bladder  causes 
symptoms  similar  to  stone  in  the  bladder  (Jordan  Lloyd) .  These  symptoms  are 
frequent  micturition,  pain  at  the  seat  of  impaction,  pain  in  the  head  of  the 
penis,  and  bloody  urine.  If  a  stone  is  impacted  in  the  lower  end  of  the  ureter 
a  finger  in  the  vagina  or  rectum  will  find  tenderness  and  perhaps  will  feel  the 
stone.  In  a  woman,  a  stone  lodged  in  front  of  the  broad  ligament  may  be 
felt  by  a  finger  in  the  vagina.  Back  of  this  region  and  up  to  the  pelvic  brim 
a  stone  may  be  felt  by  a  finger  in  the  rectum.  A  cystoscopic  examination,  in 
unusual  cases,  may  show  a  portion  of  stone  projecting  from  a  ureter  (Kelly). 
Impaction  near  the  kidney  is  accompanied  by  hematuria  and  pyuria,  lumbar 
pain,  pain  radiating  into  the  groin,  thigh,  or  testicle,  and  retraction  of  the  tes- 
ticle. These  symptoms  are  identical  in  character  with  the  symptoms  caused 
by  stone  in  the  renal  pelvis.  Complete  obstruction  of  the  ureter  causes  hydro- 
nephrosis. Pyonephrosis  results  from  infection  of  a  hydronephrosis.  In  some 
cases  a  stone  acts  as  a  ball-valve,  plugs  the  ureter  for  a  time,  during  which  a 
lumbar  mass  develops,  and  then  allows  the  urine  to  flow.  A  copious  flow  of 
urine  is  accompanied  by  disappearance  of  the  lumbar  mass.  Complete  urinary 
suppression  may  follow  blocking  of  a  ureter  by  a  calculus.  If  a  ureteral  catheter 
tipped  with  wax  is  introduced,  a  calciilus  will  make  distinct  scratches  upon  it 
(Kelly).  The  Cunningham  catheter  (see  Fig.  866,  e)  may  assist  in  detecting  a 
stone.  It  has  not  been  successfiil  in  our  hands  when  the  stone  was  impacted 
more  than  6  c.c.  above  the  ureteral  outlet.  This  catheter  may  also  be  of 
assistance  in  dislodging  the  stone. 

The  a;-rays  are  very  valuable  in  diagnosis.  A  pyelographic  study  of  the 
ureter  and  pelvis  may  give  material  assistance. 

Treatment. — During  a  painful  paroxysm  give  morphin  and  use  hot  packs. 
Belladonna  is  useful  by  inducing  relaxation  of  spasm.  The  ozonized  oil  of 
turpentine,  given  in  capsules  in  lo-min.  doses,  is  often  valuable.  It  was  em- 
ployed by  the  elder  Gross.  For  the  pain  Bransford  Lewis  ("Jour.  Am.  Med. 
Assoc,"  Jan.  29,  1910)  catheterizes  the  ureter  and  injects  into  the  renal  pelvis 
20  min.  of  a  I  per  cent,  solution  of  alypin  (monohydrochlorid  of  benzoyl). 
Alypin  is  a  powder.  It  is  soluble  in  water  and  is  to  be  steriHzed  by  boiling 
for  not  over  five  minutes.  The  attack  may  terminate  and  not  return,  because 
the  calciflus  passes.  If  such  an  attack  does  pass  away,  the  urine  should  be 
examined  after  every  act  of  micturition  to  see  if  the  stone  is  voided  from  the 
bladder.  After  a  day  or  two,  if  the  stone  does  not  appear,  use  the  cysto- 
scope,  perhaps  catheterize  the  ureter,  and  thus  discover  if  the  stone  is  in  the 
bladder  or  if  it  is  impacted.  If  the  stone  is  in  the  bladder,  use  the  Bige- 
low  evacuator  to  effect  removal,  or  crush  the  stone  by  the  small  forceps  of 
Bransford  Lewis  or  by  the  forceps  of  Leo  Buerger.  The  stone  must  never  be 
aUowed  to  remain,  as  it  will  surely  enlarge  and  cause  subsequent  trouble.  If 
a  stone  is  found  impacted  in  the  ureter  have  the  patient  drink  water  freely. 
Sterile  olive  oil  may  be  injected  into  the  ureter  through  a  ureteral  catheter,  or 
the  ureteral  orifice  may  be  dilated  by  a  suitable  bougie.  If  the  impacted 
stone  is  very  near  the  bladder  the  ureteral  orifice  may  be  slit.  Simple  cath- 
eterization of  the  ureter  may  be  followed  by  expulsion  of  the  stone.  If  in  spite 
of  these  procedures  the  stone  remains  impacted  in  the  ureter,  the  question  of 
operation  presents  itself.  An  impacted  stone  is  certainly  a  peril,  but  how  im- 
mediate the  danger  it  is  often  impossible  to  say.  In  some  cases  stones  have  re- 
mained impacted  for  many  years  without  doing  obvious  harm.  In  other  cases 
the  kidney  is  rapidly  destroyed.     The  stone  may  pass  after  having  been  retained 


Treatment  of  Pyelitis  and  Pyelonephritis  1287 

for  a  long  time,  and  drinking  freely  of  water  favors  its  expulsion.  One  of  my 
cases  had  long  had  a  retained  stone,  came  to  the  hospital  for  operation,  and 
passed  the  stone.  Sooner  or  later  a  retained  stone  will  lead  to  disaster  and  it 
ought  to  be  removed  by  operation.  It  will  cause,  if  retained,  thickening  or 
ulceration  of  the  ureter,  dilatation  of  the  ureter  above  it,  and  kidney  trouble. 
A  lodged  stone  increases  graduaUy  in  size  and  other  stones  may  form  above  it. 
The  extraperitoneal  operation  is  to  be  chosen  in  most  cases.  Even  when  the 
stone  is  impacted  below  the  pelvic  brim,  it  is  usually  better  to  do  the  extra- 
peritoneal operation.     (See  Ureterolithotomy.) 

Abscess  of  the  kidney  may  be  caused  by  traumatism,  by  calculus,  by 
stricture  of  the  ureter,  by  disease  of  the  bladder,  by  the  union  of  miliary 
abscesses  (tuberculosis) ,  by  pyemia,  and  by  certain  parasites. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but  not  invariable), 
hematuria  in  traumatic  cases,  and  pain  running  into  the  groin.  The  urine 
in  most  cases  is  alkaline.  Constitutional  symptoms  of  suppuration  exist,  the 
fever  being  far  higher  than  that  generally  met  with  in  renal  tuberculosis.  The 
bladder  should  be  examined  with  a  cystoscope  to  determine  that  the  turbid 
urine  flows  from  the  ureter  and  to  identify  the  diseased  side.  It  is  well,  if 
possible,  to  catheterize  the  ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purgation,  anodynes, 
and  hot  fomentations.  In  some  cases  repeated  lavage  through  the  ureter 
may  cure.  \Vhen  the  diagnosis  is  clear,  and  lavage  fails  or  is  not  thought 
desirable,  incise  the  loin,  open  the  kidney  and  stitch  it  to  the  abdominal  wall, 
oj,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  usually  affect  only  one  gland, 
are  caused  by  urethral  stricture,  by  stopping  of  the  ureter  by  blood-clot,  by 
vesical  paralysis,  by  stone  in  the  bladder  or  in  the  kidney,  by  enlargement  of 
the  prostate  gland,  by  ascending  tuberculous  or  gonococcic  infection,  by  growths 
in  the  calices,  and  by  certain  drugs.  It  is  said  to  occasionally  arise  from  large 
doses  of  oil  of  sandalwood  or  urotropin.  Such  drugs  could  not  furnish  pus 
cells  and,  at  most,  could  only  irritate  and  thus  predispose  by  lowering  resist- 
ance. Rare  cases  are  due  to  hematogenous  infection  by  tubercle  bacilli.  The 
colon  bacillus  is  the  organism  most  often  responsible. 

Symptoms. — A  patient  who  has,  or  who  has  had,  retention  of  urine  de- 
velops high  fever,  often  preceded  by  a  chill,  and  headache,  stupor,  and  dry 
tongue  are  noted.  Unlike  acute  Bright's  disease,  there  is  neither  edema  nor 
dry  skin,  convulsions  do  not  occur,  the  urine  is  plentiful  and  contains  pus,  but 
rarely  blood.    The  prognosis  is  very  bad. 

The  treatment  is  to  remove  the  obstruction  if  possible.  If  the  urine  be 
acid,  give  liquor  potassii  citratis;  if  alklaine,  give  benzoic  acid.  Gallic  acid, 
eucalyptol,  and  small  doses  of  copaiba  or  cubebs  are  recommended.  Venice 
turpentine,  camphor,  and  opium  may  be  given  in  pill  form.  Quinin  is  used 
to  stimulate  the  patient.  The  bladder  is  to  be  washed  out  every  day  with 
boric  acid  solution  (3  gr.  to  i  oz.  of  water).  Cups,  dry  or  moist,  and  hot 
sand-bags  or  bran-bags  are  to  be  applied  to  the  loin.  Alcohol  may  be  spar- 
ingly administered.  Urotropin  is  a  useful  drug.  Lavage  of  the  pelvis  by  means 
of  the  hydrostatic  apparatus  shown  in  Fig.  874  maybe  practised  and  is  often 
most  useful.  For  lavage,  use  a  retiirn  flow  catheter ;  first  wash  the  pelvis  gently 
with  normal  salt  solution  or  sterile  distilled  water.  Silver  nitrate  in  solution, 
of  a  strength  of  to"¥oT)  rna-y  be  used. 

S.  B.  Dudgeon  and  A.  Ross,  of  London  ("Annals  of  Surgery,"  March,  1910), 
recommend  in  colon  infections  the  use  of  autogenous  vaccine,  and  report  a 
series  of  cures.  A  sterile  urine  was  exceptional  in  chronic  cases.  Small  doses 
of  100,000,000  to  200,000,000,  administered  every  five  days,  were  best.  Relapses 
are  apt  to  occur. 


J 


1288  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty  tissue  pro- 
duced by  cold,  febrile  disease,  slight  traumatism,  or  the  spread  of  inflamma- 
tion from  another  part. 

The  symptoms  of  this  condition  are  rigidity  of  the  spine,  the  inclination 
being  toward  the  affected  side,  flexion  of  the  thigh,  pain  in  the  loin  and  iliac 
region,  and  often  pain  in  the  knee.  The  symptoms  resemble  those  of  hip- 
joint  disease  in  the  second  stage.  Suppuration  may  or  may  not  take  place. 
In  some  suppurative  cases  the  condition  strongly  suggests  woody  phlegmon  (see 
page  136). 

The  treatment  is  wet  cups  to  the  loin,  heat  to  the  loin,  rest,  purgation  by 
salines,  morphin  for  pain,  and,  after  the  acute  stage,  potassiimi  iodid  internally. 
In  a  lingering  case  an  incision  should  be  made.  It  will  frequently  be  followed 
by  cure.  Decapsulation  has  advocates.  If  suppuration  occurs  it  is  necessary 
to  incise  and  drain. 

Perinephric  or  Perirenal  Abscesses. — An  abscess  in  the  perinephric 
fat  is  known  as  a  perinephric  or  perirenal  abscess.  Primary  abscess  may 
follow  a  chill,  may  develop  during  or  after  an  acute  febrile  disturbance, 
or  may  be  caused  by  pus  flowing  from  some  other  part,  as  the  spine. 
Slight  traimiatisms,  by  producing  hemorrhage,  make  the  perinephric  region 
a  point  of  least  resistance  and  lead  to  abscess.  The  causative  injury  may  be 
produced  by  digging,  stamping,  coughing,  falling,  carrying  a  burden,  lifting  a 
weight,  or  riding  on  a  horse  or  on  a  jolting  wagon.  Consecutive  abscess  is  sec- 
ondary to  kidney  inflammation,  suppuration,  calculus,  tuberculosis,  or  cyst. 
In  the  consecutive  form  the  symptoms  may  be  masked  by  the  malady  to  which 
perinephric  abscess  is  secondary.  As  a  rule,  in  a  case  of  perinephric  abscess 
there  are  found  the  constitutional  symptoms  of  suppuration.  There  is  high 
leukocytosis.  The  local  symptoms  are  a  deep  aching  and  paroxysmal  pain  in. 
the  loin,  intensified  by  lumbar  pressure.  There  may  be  pain  in  the  iliac  region 
and  pain  in  the  knee.  Edema  of  the  corresponding  foot  and  lameness  are  not 
unusual.  The  thigh  is  often  drawn  up.  The  spine  is  rigid  and  inclined  toward 
the  diseased  side.  Edema  of  the  skin  is  usual,  but  fluctuation  is  not.  An 
exploratory  incision  will  settle  a  doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out,  and  drain. 

Stricture  of  the  Ureter. — This  is  usually  at  or  near  the  termination 
of  the  ureter.  It  is  due  to  gonococcic  inflammation,  pyogenic  inflamma- 
tion, or  tuberculosis.  The  symptoms,  as  Howard  Kelly  says,  are  at  first 
those  of  a  vesical  or  renal  inflammation.  The  diagnosis  is  made  by  the  ureteral 
catheter.  We  may  be  unable  to  introduce  it ;  we  may  introduce  it  with  diffi- 
culty and  find  that  the  pelvis  of  the  kidney  is  distended  and  that  the  urine 
obtained  is  slightly  acid  or  even  alkaline,  much  lower  in  urea  than  the  urine 
from  the  other  kidney,  and  perhaps  contains  pus.  Stricture  of  the  ureter 
causes  hydronephrosis  or  pyonephrosis.  Great  care  must  be  exercised  in 
the  examination  of  the  ureter  for  stricture,  and  we  know  of  cases  diagnos- 
ticated as  stricture  that  were  simply  spastic  contractions  or  deviations  in  the 
course  of  the  tube  resembling  stricture.  Some  urologists  have  regarded  the 
condition  as  quite  common,  but  we  do  not  believe  it  is  so;  in  several  of  the 
cases  so  diagnosticated  a  pyelographic  study  of  the  ureter  has  revealed  tortuos- 
ities due  to  a  descended  kidney.  These  cases  will  often  have  greatly  enlarged 
pelves  and  many  of  them  suffer  from  mild  attacks  of  kidney  colic.  Before 
arriving  at  a  diagnosis  the  Blasucci  catheter  should  be  used  and  a  pyelographic 
study  be  made. 

Treatment. — Dilatation  with  bougies,  resection  of  the  diseased  portion 
and  anastomosis,  resection  of  the  diseased  portion  and  implantation  of  the 
sound  end  into  the  bladder,  or  division  of  the  stricture  and  suture.  In  tuber- 
culosis the  diseased  kidney  and  ureter  may  be  removed. 


Symptoms  of  Pyonephrosis  or  Surgical  Kidney  1289 

Hydronephrosis  is  a  condition  of  the  kidney  resulting  from  an  imped- 
iment to  the  outflow  of  urine  by  obstruction  in  the  ureter,  the  bladder,  or  the 
urethra,  the  calices  of  the  kidney  becoming  overdistended  with  urine  and  the 
glandular  tissue  being  absorbed  by  pressure.  It  has  been  asserted  by  Albarran 
that  secretion  of  urine  ceases  in  a  kidney  whose  ureter  is  completely  blocked, 
distention  being  due  purely  to  congestion.  Hydronephrosis  may  be  con- 
genital, due  usually  to  twisting  of  the  ureter  or  to  valve-formation  obstructing 
the  ureter  at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the  valve 
being  produced  because  the  ureter  passes  into  the  kidney  pelvis  at  an  unnatural 
angle.  Occasionally  imperforate  urinary  meatus  produces  hydronephrosis 
of  both  kidneys. 

The  causes  of  the  acquired  form  are  the  pressure  of  pelvic  growths  or 
pregnancy,  inflammation  or  tumor  of  the  bladder,  stone  in  the  bladder,  kid- 
ney, or  ureter,  twisting  or  kinking  of  the  ureter  of  a  movable  kidney,  enlarge- 
ment of  the  prostate  gland,  and  stricture  of  the  urethra.  Acquired  hydro- 
nephrosis may  involve  both  kidneys,  all  of  one  kidney,  or  only  a  part  of  a 
single  gland. 

Symptoms. — Hydronephrosis  is  most  frequent  in  females.  When  a  limi- 
bar  tumor  is  absent  there  may  be  no  symptoms,  or  there  may  be  pain  in  the 
back  and  abdomen,  frequent  micturition,  a  persistent  or  intermittent  diminu- 
tion in  urine,  or  even  occasional  anuria.  A  mass  may  be  found  in  the  loin, 
which  growth  is  dull  on  percussion  and  may  come  and  go,  a  large  urinary  flow 
occasionally  occurring  as  it  disappears.  Hydronephrosis  may  last  a  long 
while  if  only  one  kidney  be  involved,  but  death  is  not  far  distant  if  both  glands 
suffer.  Death  occurs  from  uremia,  from  pressure  on  adjacent  organs,  or  from 
rupture  into  the  peritoneal  cavity.  The  diagnosis  is  aided  by  the  use  of  the 
cystoscope,  by  catheterizing  the  ureters,  and  by  pyelographic  study. 

Treatment  by  aspiration  may  possibly  cure,  but  the  operation  will  have  to 
be  done  repeatedly.  Tapping  on  the  left  side  is  performed  just  below  the  last 
intercostal  space;  on  the  right  side  the  tap  is  made  midway  between  the 
last  rib  and  the  crest  of  the  ilium.  Some  few  cases  have  been  cured  by  cathe- 
terizing the  ureter  (Pawlik).  The  proper  operation  in  most  cases  is  neph- 
rotomy, stitching  the  edges  of  the  cut  kidney  to  the  surface.  After  the  kid- 
ney has  been  opened,  explore  the  ureter  by  means  of  a  uterine  sound  or  an 
elastic  bougie.  A  healthy  ureter  will  permit  the  passage  of  an  instrument 
of  the  size  of  from  No.  9  to  No.  1 2  of  the  French  scale  (Fenger) .  If  the  open- 
ing of  the  ureter  into  the  pelvis  cannot  be  found,  open  the  pelvis  or  open  the 
ureter.  A  valve  should  be  slit  longitudinally  and  sutured  transversely  (Fenger) . 
If  a  permanent  suppurating  fistula  ensues  or  if  the  organ  is  found  extensively 
damaged,  nephrectomy  is  to  be  performed,  provided  the  other  kidney  is  in 
reasonably  good  condition. 

Pyonephrosis  or  surgical  kidney  is  a  condition  in  which  the  pelvis 
and  the  calices  of  the  kidney  are  distended  with  pus  or  with  pus  and  urine. 
The  whole  kidney  may  be  destroyed.  This  condition  has  the  same  causes 
as  hydronephrosis,  for  it  is,  in  reality,  usually  an  infected  hydronephrosis. 
In  some  cases  the  inaugural  malady  is_  pyelitis,  which  causes  blocking  of 
a  ureter.  Watson,  of  Boston,  has  reported  2  cases  associated  with  obHtera- 
tion  of  the  ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the  ureter). 

The  symptoms  are  those  due  to  the  obstructing  cause  plus  pyelitis. 
Pus  may  appear  in  the  urine  in  incomplete  obstruction,  or  it  may  inter- 
mittently come  and  go.  Bacilluria  and  especially  colon  bacillus  infection 
of  the  urine  has  a  strong  tendency,  unless  speedily  controlled,  to  cause 
pyonephrosis.  Constitutional  symptoms  of  suppuration  are  soon  manifest. 
A  mass  like  the  tumor  of  hydronephrosis  may  appear  in  the  loin.  If  only 
one  kidney  is  involved,  and  if  the  disease  is  due  to  blocking  of  a  ureter, 


1290  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

recovery  is  to  be  expected.  The  diagnosis  is  rendered  more  certain  by  the  use 
of  the  cystoscope  and  by  catheterizing  the  ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if  possible,  of  the 
cause  of  obstruction,  and  the  employment  of  measures  directed  to  the  cure 
of  the  pyelitis.  If  obstruction  is  not  complete,  palliative  measures  may  be 
employed  for  the  tumor.  If  fever  continues;  if  there  is  great  visceral  derange- 
ment; if  pain  is  severe  and  constant,  and  if  the  mass  continually  enlarges, 
perform  nephrotomy,  stitching  the  organ  to  the  sm^face  if  possible,  or  remov- 
ing it  if  it  is  hopelessly  disorganized  and  the  other  kidney  is  in  a  good  or  a 
fairly  good  condition. 

Chronic  Tuberculosis  of  the  Kidney. — This  condition  may  begin  in 
one  kidney,  no  other  area  of  infection  existing  in  the  body.  In  such  cases 
the  bacteria  were  deposited  from  the  blood.  Even  when  the  bacteria  are 
deposited  from  the  blood  there  is,  in  most  cases,  an  initial  focus  of  tubercu- 
losis somewhere  else  in  the  body.  Primary  renal  tuberculosis  remains  for  a 
long  time  a  local  disease,  but,  unfortunately,  the  other  kidney,  sooner  or  later, 
is  very  apt  to  become  involved,  the  process  in  the  first  kidney  affecting  the 
bladder  and  secondarily  the  other  kidney.  The  important  point  is  that 
tuberculosis  of  the  kidney  arising  in  this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  is  seldom  a  primary  disease  and  usually  arises 
secondarily  to  tuberculosis  of  the  prostate,  bladder,  or  epididymis.  In  such 
a  condition  the  kidney  disease  is  always  bilateral.  Renal  tuberculosis  is  par- 
ticularly common  in  the  third  and  fourth  decades  of  life,  and  is  more  fre- 
quent in  males  than  in  females. 

Symptoms. — Renal  tuberculosis  of  arterial  origin  may  exhibit  no  symp- 
toms until  the  disease  is  far  advanced.  Renal  tuberculosis  secondary  to 
disease  of  the  bladder  or  prostate  always  presents  symptoms.^  A  very  com- 
mon symptom  of  renal  tuberculosis  is  the  sudden  onset  of  polyuria  and  fre- 
quent micturition.  The  patient  is  annoyed  day  and  night,  and  in  some  cases 
micturition  is  distinctly  painful.  Paroxysms  of  renal  pain  are  not  unusual. 
The  urine  is  acid  and  may  contain  pus  or  blood.  Tubercle  bacilli  may  be  found 
in  the  urine  or  in  the  sediment  of  centrifuged  urine,  but  they  may  be  absent. 
Repeated  examination  should  be  made  before  it  can  be  stated  certainly  that 
bacilli  are  absent.  The  presence  of  bacilli  proves  the  diagnosis,  but  their  ab- 
sence does  not  negative  it  (Willy  Meyer) .  If  bacilli  are  not  found,  inject  some 
of  the  urinary  sediment  into  a  guinea-pig,  and  note  if  tuberculosis  arises  in 
the  animal.  Czerny  has  shown  that  in  cases  of  tuberculous  kidney  in  which 
bacilli  are  not  found  in  the  urine  the  administration  of  tuberculin  will  cause 
great  numbers  to  appear.  This  agent  will  also  cause  a  marked  febrile  reac- 
tion if  tuberculosis  exists.     The  urine  may  or  may  not  be  albuminous. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  the  renal  area  is  fre- 
quently tender  and  occasionally  painful  The  patient  loses  flesh,  and  there  is 
nocturnal  fever  followed  by  sweating.  The  use  of  the  cystoscope  furnishes 
important  information.  It  shows  from  which  ureter  turbid  urine  is  coming. 
Catheterization  of  the  ureters  should  be  practised  by  some  one  who  is  expert. 
Always  examine  carefully  to  determine  if  one  or  both  kidneys  are  involved,  if 
the  bladder  is  diseased,  and  if  the  prostate  gland  or  seminal  vesicles  are  tuber- 
culous. 

Treatment. — Lumbar  nephrectomy  is  not  justifiable  in  the  very  begin- 
ning of  a  case,  because  such  a  patient  may  be  cured  by  a  combination  of 
medical  and  hygienic  treatment,  and  the  weakening  effect  of  the  operation  of 
nephrectomy  may  cause  the  other  kidney  to  develop  tuberculosis  rapidly. 
Tell  such  a  patient  to  lead  an  outdoor  life.  Brown  recommends  camp-life 
in  the  Adirondacks  during  the  summer,  and  sends  such  patients  south  during 
^F.  Tilden  Brown,  "New  York  Med.  Jour.,"  April  10,  1897. 


Operation  for  Chronic  Nephritis  1291 

the  winter.  If  a  patient  cannot  go  to  another  climate,  urge  upon  him  the 
necessity  of  practically  living  out-of-doors  (see  page  230).  Insist  upon  the 
taking  of  plenty  of  nutritious  food.  Full  antituberculous  treatment  is  indi- 
cated (see  page  230). 

If  the  kidney  is  markedly  enlarged;  if  there  is  profuse  hematuria;  if  the 
fever  is  high  and  persistent ;  if  only  one  kidney  is  involved,  and  if  the  bladder 
and  prostate  are  free  from  disease,  perform  nephrectomy.  In  cases  "^-ith 
involvement  of  the  other  kidney  or  of  the  genito-urinary  tract  lower  down, 
nephrectomy  is  not  justifiable,  although  nephrotomy  for  drainage  mav,  for  a 
time,  greatly  benefit  the  patient. 

Operations  On  the  Kidney  and  Ureter. — Operation  for  Chronic  Neph- 
ritis.— In  1S97  ]Mr.  Reginald  Harrison  advocated  puncture  of  the  kidney 
to  relieve  tension  in  cases  of  albuminuria,  and  in  1901  advocated  incision  of 
the  true  capsule  of  the  kidney  and  pimcture  of  the  gland  to  accomplish  the 
same  purpose  ("Brit.  Med.  Jour.,''  Oct.  19,  1901).  Alexander  Hugh  Ferguson 
in  ]\Iarch,  1S99,  reported  2  cases  of  interstitial  nephritis  cin^ed  s^mptomaticaUy 
b}'  decapsulation  and  multiple  punctures  ("Jour.  Am.  Med.  Assoc.,""  March  11, 
1899).  Dr.  Geo.  ]M.  Edebohls  obsen,-ed.  between  1S92  and  1S97,  that  in  certain 
cases  of  movable  kidney  -^-ith  albuminuria  the  albumin  and  casts  disappeared 
after  nephropex}-.  Rose,  Wolff,  and  Ferguson  have  observed  the  same  fact. 
Harrison  believes  that  renipimcture  removes  the  symptoms  by  abating  ten- 
sion, but  Edebohls  concludes  that  nephropexy-  relieves  the  condition  and 
possibly  cures  it  by  establishing  vascular  adhesions  which  carr\-  on  additional 
supply  of  blood.  He  proposed  to  operate  for  Bright"s  disease  in  1899  ("]SIed. 
News,"  AprU  22,  1899).  Edebohls  deliberately  operated  for  chronic  nephritis 
and  claimed  8  complete  recoveries  from  chronic  Bright's  disease  ("]Med.  Record," 
Dec.  21,  1901).  There  can  be  no  doubt  whatever  that  operation  is  sometimes 
followed  by  pohniria,  disappearance  of  edema  and  other  s}'mptoms,  and 
apparent  cure.  But  in  some  cases  the  disappearance  of  s^inptoms  has  been  too 
rapid  to  permit  of  the  assumption  that  new  vessels  have  caused  it.  In  such 
cases  it  seems  much  more  probable  that  relief  of  tension  is  the  real  curative 
factor.  The  capsule  of  the  kidney  is  only  sHghtly  elastic,  and  tension  ma}'  be 
brought  about  by  an  increase  in  the  blood-supply,  by  edema,  and  by  cell  pro- 
liferation. Increased  tension  causes  pain  and  perhaps  hematuria,  and  tension 
is  relieved  by  Harrison's  plan  of  incising  the  capsule.  Simple  incision  is  easier, 
safer,  and  probably  just  as  useful  as  stripping  the  capsule  oft"  of  the  kidney. 
Edebohls  advocates  decapsulation  and  says  that  the  polyuria  begins  about  the 
tenth  day  after  operation;  that  improvement  begins  in  one  month  and  is  grad- 
ual; that  the  cure  is  due  to  vascular  adhesions:  that  the  adhesions  contain  more 
arteries  than  veins;  that  the  free  blood-supply  absorbs  exudate  and  products 
of  inflammation,  frees  the  tubes  and  glomeruli  from  pressure  and  constriction, 
causes  the  reestabHshment  of  a  normal  circulation  and  the  regeneration  of 
epithelium  (Ibid.). 

The  exact  status  of  the  operation  is  not  as  yet  determined.  It  does, 
however,  seem  to  be  proved  that  operation  is  in  some  cases  followed  by  ap- 
parent cure  or  great  amelioration  of  the  condition,  ^^llether  permanent 
cure  is  ever  thus  obtained  is  doubtful,  and  the  part  played  by  rest  in  bed 
and  drugs  in  effecting  an  improvement  must  not  be  lost  sight  of.  I  have  seen 
no  case  of  genuine  cure.  Albumin  has  always  continued  present  in  the  urine. 
It  is  certain  that  the  operation  is  unjustifiable  imless  medical  treatment  has 
been  tried  and  failed,  unless  the  s}Tnptoms  are  gro^^-ing  worse,  and  unless 
they  indicate  danger.  James  Tyson  ("Med.  Record,"  July  8,  1911)  sets 
forth  dangerous  sATnptoms  as  follows:  Persistent  dropsy,  uremia  (^-iolent 
headache,  con\'ulsions,  or  coma),  excessive  amount  of  albumin  causing  anemia 
and  weakness,  anuria.     The  best  results  are  obtained  in  chronic  parenchy- 


1292  Diseases  and  Injuries  of  the   Genito-urinary  Organs 

matous  nephritis  associated  with  marked  anasarca.  Pain  and  bloody  urine 
are  often  much  improved  by  incising  the  capsule.  Postoperative  suppression 
and  the  anuria  of  acute  infectious  diseases  may  be  favorably  influenced  by  the 
operation.  In  perinephritis  it  may  prove  curative.  An  important  fact  which 
Rovsing  maintains  and  Edebohls  proves  is  that  chronic  nephritis  may  be  for 
some  time  a  unilateral  disease.  (Read  the  views  of  Schmidt,  in  "Med.  Rec- 
ord," Sept.  13,  1902;  of  Rovsing,  of  Copenhagen,  in  "Mittheilungen  aus  den 
Grenzegebieten  der  Medicin  und  Chirurgie,"  vol.  x,  1902,  and  editorial  in 
"Jour.  Am.  Med.  Assoc,"  Jan.  11,  1902;  James  Tyson,  in  "Trans,  of  Amer. 
Physicians,"  1911,  and  "Med.  Record,"  July  8,  1911.)  Personally,  I  would 
not  operate  in  the  presence  of  grave  and  advanced  cardiovascular  disease. 
Tyson  believes  that  albuminuric  retinitis,  very  irregular  heart,  and  valvular 
disease  forbid  operation,  and  that  in  patients  over  fifty  the  operation  is  of 
slight  value. 

The  operation  as  practised  by  Edebohls  may  be  done  on  both  kidneys  either 
at  one  sitting  or  in  two  seances.  In  some  cases  only  one  kidney  is  subjected 
to  operation,  Edebohls  takes  a  very  radical  view  and  would  operate  on  any 
case  free  from  incurable  complications,  if  an  anesthetic  can  be  given  and  if 
the  Hfe- expectancy  without  operation  is  not  less  than  one  month  ("Med.  Rec- 
ord," Dec.  21,  1901).  Ether  is  given  or  nitrous  oxid  and  oxygen.  Lay  the 
patient  prone  with  an  air-cushion  under  the  belly  and  expose  the  kidney  by  a 
vertical  incision  at  the  edge  of  the  erector  spinae  mass,  which  cut  does  not  open 
the  sheath  of  the  muscle.  Remove  the  fatty  capsule  from  the  true  capsule, 
continuing  the  dissection  around  each  pole  until  the  pelvis  of  the  kidney  is 
reached.  The  kidney  is  extruded  from  the  wound,  the  true  capsule  is  incised 
along  the  convex  border  and  around  each  pole,  is  separated  from  the  kidney, 
and  is  cut  away  close  to  its  junction  with  the  kidney  pelvis.  The  kidney  is 
then  returned  to  its  bed  of  fat  and  the  wound  is  closed  (Ibid.).  Edebohls 
does  not  drain  unless  there  is  considerable  edema.  He  reported  18  operations 
without  a  death.  In  9  of  the  cases  the  operation  was  done  more  than  one 
year  ago,  and  8  of  them  are  said  to  be  cured.  Personally,  I  do  not  believe 
that  the  operation  can  really  cure  Bright's  disease.  It  cannot  restore  altered 
connective  tissue  and  epithelial  cells.  The  new  blood-supply  must  be  through 
scar  tissue,  and  we  have  yet  to  learn  that  such  a  blood-supply  can  be  efi&cient. 
The  operation  shoiild  be  restricted  to  acute  nephritis,  to  acute  exacerbations 
in  chronic  cases,  to  conditions  with  severe  renal  pain,  hematuria,  anasarca, 
very  high  albimiin  percentage,  or  persistent  and  notable  diminution  in  the 
amoimt  of  urine  voided  (Ertzbischoff,  in  "Archiv.  generales  de  Chirurgie," 
April,  1908). 

Nephrotomy  means  incision  of  a  kidney,  but  the  term  is  sometimes,  though 
wrongly,  applied  to  the  exploratory  exposure  of  the  kidney  A^dthout  incision 
of  the  organ.  When  the  kidney  wound  is  left  open,  as  it  almost  invariably 
is,  the  operation  should  be  called  nephrostomy.  The  operation  is  employed  to 
evacuate  infectious  material,  relieve  tension,  permit  of  the  removal  of  a  calculus 
or  exploration  of  the  ureter,  and  for  diagnosis  of  renal  disease.  The  patient  lies 
upon  the  sound  side,  a  sand-pillow  or  a  cylindrical  air-bag  being  placed  imder 
the  flank.  The  incision  is  made  \  inch  below  the  last  rib  and  close  to  the 
outer  border  of  the  erector  spinte  mass,  and  runs  obliquely  downward  and  for- 
ward toward  the  iliac  crest  for  3  inches,  the  incision  being  enlarged  later  if 
required.  Divide  the  skin,  the  superficial  fascia,  the  fat,  the  external  oblique, 
the  posterior  border  of  the  internal  oblique,  and  the  outer  edge  of  the  latissimus 
dorsi.  This  incision  exposes  the  lumbar  fascia.  Push  aside  the  last  dorsal  nerve 
and  incise  the  lumbar  fascia,  w^hen  the  perirenal  fat  will  bulge  into  the  wound. 
Two  distinct  layers  of  fat  exist.  Tear  through  this  fat  with  dissecting  forceps 
to  expose  the  kidney,  which  can  now  be  opened  while  it  is  forced  into  the  wound 


Nephrotomy  1293 

by  the  hand  of  an  assistant  making  abdominal  pressure.  In  some  cases  the 
kidney  can  be  brought  out  of  the  wound  for  exploration  and  operation.  In 
others  it  cannot.  When  it  cannot  be  drawn  out  it  is  brought  into  the  wound 
and  supported  by  means  of  a  pad  of  gauze  under  each  pole. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle  between  the  sacro- 
lumbalis  muscle  and  the  twelfth  rib,  and  is  carried  downward,  forward,  and 
outward  to  the  axillar}-  line  (see  Fig.  248).  This  incision  divides  the  skin,  sub- 
cutaneous tissues,  lumbar  fascia,  the  latissimus  dorsi,  and  the  serratus  posticus 
inferior  muscles.     If  possible,  the  kidney  is  brought  out  of  the  wound. 

Edebohls's  method  enables  the  surgeon  to  explore  the  kidney  thoroughly 
because  this  organ  is  brought  outside  of  the  body.  It  is  not  suited  to  cases  in 
which  the  organ  is  much  enlarged  or  when  it  has  a  short  pedicle.  Its  best 
field  is  in  operations  for  movable  kidney.  The  patient  lies  prone,  -v^dth  a  large 
cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A  vertical  incision  is 
made  close  to  the  border  of  the  erector  spinae  muscle,  from  just  below  the  last 
rib  to  just  above  the  iliac  crest.  The  sheath  of  the  muscle  is  not  opened.  The 
fibers  of  the  latissimus  dorsi  are  separated  by  blunt  dissection.  The  nioh^-po- 
gastric  nerve  is  found  and  retracted.  The  transversalis  fascia  is  incised  and 
the  fatty  capsule  reached.  The  two  layers  of  the  fatty  capsule  are  torn  through 
and  the  kidney  exposed.  The  fatty  capsule  is  well  separated  from  the  kidney 
front  and  back.  The  patient  is  pulled  by  the  legs  toward  the  foot  of  the  table, 
the  pad  remaining  stationar>\  This  change  of  position  brings  the  pad  beneath 
the  chest,  abdominal  respiration  takes  place,  the  kidney  is  forced  into  the  wound, 
and  can  be  easily  withdrawn  and  thoroughly  examined.  In  many  cases  the 
lumbar  incision  does  not  expose  the  kidney  pedicle  completely  enough  to  make 
the  surgeon  feel  that  he  can  readily  clamp  it  sho.uld  nephrectomy  become  neces- 
sary, and  in  any  operation  upon  the  kidney  nephrectomy^  may  at  any  minute 
become  necessary.  Cutting  the  twelfth  rib  adds  to  the  exposure,  but  in  cutting 
it  the  pleura  may  be  opened.  Wm.  J.  jNIayo  (''Annals  of  Surger}',"  Jan.,  191 2) 
in  203  Imnbar  operations  di\'ided  the  twelfth  rib  51  times,  and  in  13  of  the 
operations  accidentally  opened  the  pleural  ca\'ity.  In  not  a  case  did  the  lung 
collapse  (probably  because  the  patients  lay  upon  the  abdomen  -^^ith  the  hips 
somewhat  elevated,  the  chest  being  fixed  by  the  position).  In  each  case  the 
torn  pleura  w^as  sutured,  the  stitches  including  tissue  of  the  diaphragm. 

Mavo  discovered  that  after  di^'ision  of  the  quadratus  lumborum  muscle 
and  the  lateral  arcuate  ligament  (which  binds  the  twelfth  rib  to  the  transverse 
process  of  the  first  lumbar  vertebra)  the  rib  can  be  lifted  out  of  the  way 
and  does  not  need  to  be  divided.  Mayo  now  operates  as  follows:  Beginning 
over  the  eleventh  rib  2^  inches  external  to  the  spines  of  the  dorsal  vertebrse 
make  a  longitudinal  incision  3  inches  in  length.  From  this  point  carr\'  the 
incision  do^ATiward  and  forward  along  the  anterior  margin  of  the  quadratus 
Ixmibormn  to  i  inch  above  the  crest  of  the  ihum;  it  is  then  carried  forward 
parallel  to  the  crest.  The  twelfth  rib  is  cleared  nearly  to  its  articulation;  the 
pleura  is  pushed  up  out  of  the  way.  The  erector  spinae  mass  is  retracted  toward 
the  spine.  The  costal  margin  is  raised  by  retraction.  A  wide  area  for  opera- 
tion is  exposed,  the  kidney  can  be  brought  out  of  the  wound,  and  the  pedicle 
can  be  seen  and  reached. 

A  common  method  of  opening  the  kidney  is  to  make  a  longitudinal  incision 
through  its  convexity  sufficiently  large  to  admit  the  finger  into  the  renal  peMs. 
This  incision  may  be  enlarged  if  necessars^  until  the  kidney  is  split  in  half.  WTien 
the  operation  is  completed  close  the  kidney  wound  completely  by  means  of  a 
round  needle  and  catgut,  unless  drainage  is  necessan,^  or  packing  is  required. 
Another  popular  incision  is  placed  longitudinally  a  little  posterior  to  the  con- 
vex border.  This  goes  through  the  bloodless  zone  of  Hyrtl,  and  causes  less 
hemorrhage  than  the  incision  along  the  convexity.     ^Marrs-edel's  incision  is  a 


1294  Diseases  and  Injuries  of  the   Genito-urinary  Organs 

transverse  cut  at  the  middle  of  the  convex  border  of  the  kidney  into  the  renal 
pelvis.  It  is  doubtful  if  this  incision  is  accompanied  by  less  bleeding  than 
longitudinal  incision  of  the  convexity.  After  the  completion  of  our  work  on 
the  kidney  the  lumbar  wound  is  closed  completely  or  is  partially  closed  to  permit 
of  drainage. 

Operation  for  Stone  in  the  Kidney  By  Pyelotomy  or  Nephrotomy  (Pyelo- 
lithotomy,  Nephrolithotomy). — It  used  to  be  held  that  incision  of  the  pelvis  of 
the  kidney  is  far  more  apt  to  be  followed  by  fistula  than  incision  of  the  sub- 
stance of  the  kidney.  The  Mayos,  Bevan,  and  others  have  proved  that  this 
conviction  is  untrue.  In  many  cases  of  stone  pyelotomy  is  preferred  to 
nephrotomy.  It  is  used  for  single  stones  of  moderate  size  in  the  pelvis  and 
unaccompanied  by  suppuration.  When  we  have  a  large  branched  stone,  coral- 
shaped  stones,  multiple  stones,  and  stones  accompanied  by  distinct  and  gross 
evidences  of  infection,  then  nephrotomy  should  be  preferred  to  pyelotomy 
(Bevan  and  Smith,  in  paper  read  before  the  American  Surg.  Assoc,  in  1908). 
In  both  operations  the  patient  is  placed  on  the  sound  side  with  a  sand-pillow 
or  cylindrical  air-bag  under  the  flank.  In  both  cases  the  incision  recommended 
for  nephrotomy  is  used.  In  both  cases  the  kidney  is  lifted  into  the  wound  or 
brought  out  of  the  wound  so  that  it  may  be  satisfactorily  palpated.  In  both 
cases  bleeding  is  controlled  by  having  an  assistant,  if  possible,  grasp  the  pedi- 
cle with  his  fingers  or  with  a  pair  of  forceps,  each  blade  of  which  is  covered 
with  a  bit  of  rubber  tube,  while  the  surgeon  opens  the  pelvis  or  the  kidney 
tissue,  removes  the  stone,  and  explores  with  the  finger. 

Pyelolithotomy. — Remove  the  fat  from  the  posterior  surface  of  the  pelvis  of 
the  kidney.  We  may  then  be  sure  that  no  aberrant  vessel  is  in  our  way.  The 
normal  vessels  are  all  in  front  of  the  pelvis.  The  posterior  wall  of  the  pelvis 
is  now  opened,  the  stone  is  extracted,  the  pelvis  explored,  the  cut  in  the  pelvis 
is  sutured  with  fine  catgut  sutures,  the  kidney  is  restored  to  place,  a  cigarette 
drain  is  introduced,  and  the  wound  in  the  loin  is  closed. 

Nephrolithotomy. — The  methods  of  incision,  exposure,  and  opening  the 
kidney  are  described  on  page  1292,  under  Nephrotomy.  When  the  kidney 
has  been  opened,  loosen  the  calculus  with  the  nail,  and  remove  it  with  the 
finger,  with  a  scoop,  or  with  forceps.  After  removing  the  stone,  suture  the 
incision  with  catgut,  and  release  the  pressure  on  the  pedicle.  Hemorrhage 
will  usually  be  controlled,  but  sometimes  violent  bleeding  occurs.  If  in  spite 
of  this  plan  bleeding  occurs,  take  out  the  stitches  and  apply  pressure  and  hot 
water,  compress  the  bleeding  points  by  suture-ligatures,  and  close  again  by 
Stellwagen's  stitches  (see  Figs.  853,  854).  In  some  cases  plug  with  iodoform 
gauze,  suturing  the  gauze  in  place  within  the  kidney  by  fine  catgut  and  leav- 
ing it  until  it  loosens.  When  hemorrhage  ceases,  put  a  large  drainage-tube 
down  to  the  kidney.  Close  the  wound  in  the  muscles  and  integument  and 
dress  antiseptically.  The  dressings  must  be  changed  frequently  and  the  tube 
should  be  shortened  daily.  In  some  cases  nephrectomy  is  necessary  (see  page 
1285).  Formerly  in  these  cases  I  always  drained  for  a  time  and  removed  the 
kidney  secondarily,  believing  that  the  patient  would  gain  strength  in  the  in- 
terval and  stand  the  severe  operation  of  nephrectomy  better.  I  am  satisfied 
that  in  most  cases  this  view  is  wrong,  because  removal  of  a  kidney  bound  down 
by  adhesions  is  one  of  the  most  perilous  and  difficult  operations  of  surgery. 

Nephrectomy  is  the  removal  of  a  kidney.  There  are  two  methods  of 
nephrectomy — the  lumbar  and  the  abdominal.  The  first  nephrectomy  (ac- 
cording to  Watson)  was  performed  in  1861  by  an  American,  Walcott.  The 
operation  was  transperitoneal  and  was  for  the  removal  of  a  cancerous  kidney. 
Simon,  in  1869,  performed  the  first  lumbar  nephrectomy  and  the  first  successful 
nephrectomy.  Before  performing  nephrectomy  ascertain  the  competence  of 
the  kidneys.    If  at  least  i  per  cent,  of  urea  is  not  being  excreted,  it  is  very  un- 


Abdominal  Nephrectomy  1295 

safe  to  operate.  Be  sure  the  patient  possesses  two  kidneys.  Examination  of 
the  bladder  by  the  cystoscope  will  show  the  ureteral  orifices,  a  strong  indication 
that  both  kidneys  are  present.  Nevertheless,  when  we  reflect  that  a  horsehoe 
kidney  has  two  ureters,  the  proof  is  not  absolute.  Catheterization  of  the 
ureters  is  advisable  if  it  can  be  performed,  but  it  will  probably  require  a  special- 
ist to  perform  it.  Proof  absolute  of  the  presence  of  two  kidneys  consists  in 
feeling  both  of  them.  If  in  doubt  as  to  the  question,  and  if  uncertain  as  to  the 
ability  of  the  organ  which  is  to  be  left,  feel  each  kidney  during  the  operation 
and  before  removing  either,  or  perform  a  preliminary  exploratory  laparotomy. 

Lumbar  Nephrectomy. — The  patient  is  placed  on  the  sound  side  and  a 
pillow  is  placed  under  the  loin.  Several  incisions  have  been  proposed.  In 
many  cases  the  oblique  incision  is  first  made  to  permit  of  exploration.  This 
incision  is  begun  |  inch  below  the  last  rib  and  by  the  edge  of  the  erector 
spin£e  muscle,  and  is  carried  downward  and  forward  toward  the  iliac  crest. 
In  some  cases  a  kidney  can  be  removed  through  this  cut.  In  other  cases 
the  cut  must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut  down- 
ward. Morris  enlarges  it  by  adding  to  it  a  vertical  incision,  which  begins  i 
inch  below  the  origin  of  the  oblique  cut.  Konig's  incision  for  nephrectomy 
consists  of  a  vertical  cut  by  the  edge  of  the  erector  spinas,  carried  almost  to 
the  ihac  crest,  from  which  point  it  is  curved  forward  toward  the  umbilicus, 
and  is  carried  to  or  even  through  the  rectus  muscle.  After  thorough  exposure 
lift  the  kidney  and  separate  it  from  the  peritoneum,  if  possible,  with  the 
finger;  clamp  the  pedicle;  pass  an  armed  aneurysm  needle  between  the  vessels 
of  the  pedicle;  ligate  in  two  places;  cut  between  the  threads,  and  arrest  hemor- 
rhage permanently  by  ligation  of  each  vessel.  If  the  ureter  be  healthy,  ligate 
it  with  silk  and  drop  it  back;  if  it  be  foul  and  purulent,  scrape  it  with  a  sharp 
spoon,  wash  it  with  corrosive  sublimate,  and  touch  it  with  pure  carbolic  acid, 
and  then  either  ligate  it  with  catgut  and  drop  it  back  or  sew  it  into  the  wound. 
If  hemorrhage  persists  from  the  wound,  plug  with  gauze.  Insert  a  drainage- 
tube  and  close  the  wound.  If  the  peritoneum  be  accidentally  opened,  close  it 
with  Lembert  sutures.  Kocher's  method  is  excellent,  and  enables  the  surgeon 
to  feel  the  opposite  kidney  before  removing  the  one  which  is  known  to  be  dis- 
eased. The  incision  is  begun  as  described  on  page  1293,  and  is  carried  for- 
ward so  as  to  expose  the  reflection  of  the  peritoneum  on  to  the  colon  in  the 
posterior  axillary  line  (see  Fig.  248) }  At  this  point  the  peritoneum  is  opened, 
and  the  surgeon's  hand  is  inserted  into  the  abdominal  cavity  and  feels  the 
other  kidney.  If  another  kidney  exists  and  it  is  found  to  be  healthy,  the  dis- 
eased organ  may  be  removed.  Brewer's  personal  statistics  show  53  cases  of 
nephrectomy  with  2  deaths,  a  mortality  of  3.8  per  cent.  ("Med.  Record," 
March  20,  1909). 

Abdominal  nephrectomy  is  more  dangerous  than  the  limibar  operation.  The 
position  is  supine.  The  incision  is  that  of  Langenbeck — 4  inches  in  length 
in  the  linea  semilunaris,  its  center  corresponding  to  the  umbilicus.  Open 
the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and  if  both  show  serious 
disease,  do  not  perform  nephrectomy.  If  we  decide  to  remove  one  kidney, 
keep  the  small  intestine  away  by  pads,  push  the  colon  toward  the  umbilicus, 
incise  the  outer  layer  of  the  mesocolon,  and  bare  the  kidney.  Strip  off  the 
peritooieum  from  the  kidney  and  its  vessels,  and  ligate  the  vessels  by  passing 
strong  silk  through  the  center  of  the  pedicle  with  an  aneurysm  needle.  Ligate 
the  ureter  if  healthy,  and  divide  it.  If  the  ureter  is  septic,  fasten  it  to  an  open- 
ing made  in  the  loin  by  cutting  on  to  forceps  pushed  to  the  outer  edge  of  the 
quadratus  lumborum.  Stop  bleeding,  irrigate  the  belly  cavity,  and  dress  as 
usual,  employing  drainage  only  when  septic  matter  has  passed  into  the  peritoneal 
cavity  or  when  oozing  of  blood  is  persistent. 

1  Kocher's  "Text-Book  of  Operative  Surgery." 


1296 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Nephrectomy  in  Children.— The  operation  is  proper  in  certain  non-mahg- 
nant  troubles.  Jepson  did  a  successful  nephrectomy  for  a  congenital  cystic 
kidney  on  a  patient  four  months  and  fourteen  days  of  age.  Rovsing  did  it 
successfully  for  congenital  hydronephrosis,  the  patient  being  nine  months 
old.  Roswell  Park  did  a  successful  nephrectomy  for  congenital  cystic  kidney 
on  a  child  twenty-three  months  of  age.  The  value  of  nephrectomy  for  sarcoma 
is  certainly  doubtful.  The  operation  never  really  cures,  and  if  an  operative 
recovery  is  obtained  the  disease  appears  after  a  time  in  the  other  kidney. 
Jessup  performed  nephrectomy  in  11  children  and  every  case  died  within 
two  and  one-half  years  of  the  operation.  The  operation  often  prolongs  life 
and  relieves  discomfort,  but  does  not  cure. 

Partial  Nephrectomy. — This  operation  may  be  performed  in  some  cases 
for  wounds,  cysts,  and  innocent  tumors.  After  removing  the  damaged  or 
diseased  part,  bleeding  points  are  ligated  with  catgut.  The  wound  surfaces 
are  approximated  as  well  as  possible  by  catgut  sutures.     Drainage  is  intro- 


Fig.  856. — Gauze  slings,  each  composed  of  two  pieces  sutured  together  with  fine  plain  catgut. 


duced.  The  value  of  partial  nephrectomy  in  some  cases  seems  certain,  and 
we  should  apply  it  when  possible  instead  of  the  complete  operation/  except 
in  cases  of  malignant  disease. 

Renipuncture. — ^This  is  an  operation  devised  by  Reginald  Harrison  for 
the  relief  of  albuminuria  due  to  elevated  tension.  The  kidney  is  exposed  in 
the  loin,  the  capsule  is  incised,  and  punctures  are  made  in  the  kidney.  Simple 
incision  of  the  capsule  will  usually  relieve  nephralgia.  (See  Operation  for 
Chronic  Nephritis,  page  1291). 

Nephropexy  is  fixation  of  a  movable  kidney.  The  term  "nephrorrhaphy," 
so  long  used  for  the  operation,  really  means  suturing  a  w^ound  in  the  kidney. 

The  Author's  Modification  of  the  Elder  Senn's  Operation. — Many  sur- 
geons feel  that  it  is  not  desirable  to  pass  sutures  through  the  kidney  substance, 
and  I  have  entirely  abandoned  the  use  of  them  in  operations  for  movable  kid- 
ney.   Urinary  fistula  has  followed  suturing.    Again,  the  value  of  such  sutures 


1  See  Oscar  Bloch,  in  "  Brit.  Med.  Jour.,"  Oct.  17,  li 
heuer,  Tuffier,  and  Klimmell. 


);  also  reports  of  Czerny,  Barden- 


The  Author's  Modification  of  the  Elder  Senn's  Operation       1297 


is  very  doubtful.  The  kidney  is  a  very  soft  organ,  and  if  it  is  suspended  by 
sutures,  they  are  certain  to  cut  out.  In  most  suture  operations  the  kidney 
when  restored  to  place  is  not  placed  sufficiently  high  and  has  its  ureter  and 
vessels  looking  forward;  in  other  words,  there  is  a  one-fourth  twist  in  the 
ureter.  In  operations  like  Goelet's  and  Kelly's,  which  raise  the  kidney  much 
nearer  its  proper  level  and  which  do  not  twist  the  ureter  and  renal  vessels,  the 
upper  pole  is  not  anchored  and  tends  to  tilt  forward  (see  page  1279).  The 
operation  herein  described  fixes  the  kidney  without  using  sutures. 

The  patient  lies  upon  his  abdomen,  Edebohls's  bag  being  placed  directly 
beneath  the  lower  abdomen.  A  vertical  or  slightly  oblique  lumbar  incision  is 
made,  the  perirenal  fat  is  exposed,  and  its  two  layers  are  torn  through  until  the 
kidney  is  reached.  The  fatty  capsule  is  thoroughly  stripped  from  the  entire 
organ.  The  kidney  is  brought  out  of  the  wound.  This  is  accomplished  by 
pulling  the  patient  toward  the  foot  of  the  bed,  so  that  the  pad  gets  under 
the  ribs,  when  traction  on  the  fibrofatty  capsule  will  cause  the  kidney 
to  emerge  from  the  wound.  The  posterior  fatty 
capsule  is  cut  away,  and  also  the  anterior  fatty 
capsule  up  to  the  hilum.    The  true  capsule  of 


Fig.  857. — Right  kidney  projecting  from  wound.  Ob- 
server standing  on  riglit  side  of  patient:  i  and  2,  Slings  in  place, 
with  sutures  external;  3,  skin  of  the  back;  4,  upper  renal  pole; 
S,  lower  renal  pole;  6,  convex  border  of  kidney;  7,  external  sur- 
face of  kindey.  (Slings  should  be  broader  than  those  shown  in 
illustration.) 


Fig.  858. — Right  kidney  re- 
stored to  place,  seen  from  in  front: 
I  and  2,  SUngs  in  place,  sutures  ante- 
rior; 4,  upper  renal  pole;  5,  lower 
renal  pole;  7,  anterior  surface  of 
kidney.  (Shngs  should  be  broader 
than  those  shown  in  illustration.) 


the  kidney  is  scarified.  I  always  have  packing  prepared  by  suturing 
together  with  the  finest  plain  catgut  the  ends  of  two  pieces  of  iodoform 
gauze.  Two  such  strands  are  prepared  (Fig.  856).  One  piece  of  iodoform 
gauze  is  placed  under  the  upper  end  of  the  kidney,  and  another  piece  under  the 
lower  end,  the  sling  in  each  instance  being  directly  under  the  kidney  with  the 
suture  line  external  and  not  in  front,  as  the  kidney  protrudes  from  the  wound  in 
the  back  (Fig.  857).  When  the  kidney  is  replaced  the  suture  line  will  lie  in 
front  (Fig.  858) .  The  kidney  is  replaced  and  will  then  lie  in  a  sling  composed  of 
two  pieces  of  gauze,  the  ends  of  which  protrude  from  the  wound.  Another 
piece  is  placed  below  the  lower  renal  pole  to  fill  up  the  space  which  always 
exists  there  and  to  stimulate  granulation.  This  space  below  the  kidney  is  a 
frequent  cause  of  subsequent  loosening  in  most  suture  operations,  because 
the  kidney  hangs  in  it  unsupported,  as  a  bucket  hangs  in  a  well.  Harris 
recognizes  this,  and  in  his  operation  closes  the  space  by  sutures.  Gauze 
is  packed  in  over  and  about  the  kidney,  and  over  this  the  two  long  slings 
82 


1298 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


are  tied.  Several  sutures  of  silkworm-gut  are  inserted  to  close  the  super- 
ficial parts  and  the  lumbar  aponeurosis;  some  are  tied  and  some  are  left 
imtied.  A  large  gauze  pad  is  placed  upon  the  abdomen  over  the  anterior  sur- 
face of  the  kidney,  and  the  lumbar  wound  is  dressed  with  gauze.  The  dress- 
ing and  gauze  pad  are  held  in  place  by  a  binder.  In  about  eight  or  ten  days 
the  gauze  should  be  soaked  with  dripping  salt  solution  during  half  an  hour  and 
the  packing  removed.  At  this  time  the  catgut  is  destroyed  and  the  gauze  can 
be  easily  pulled  out.  The  tied  sutmres  are  cut  and  removed,  the  sutures  left 
unfastened  are  tied,  and  a  small  piece  of  gauze  is  inserted  as  a  drain  between 
the  granulating  surfaces.  If  a  continuous  piece  of  gauze  was  used,  ether  must 
be  given  before  removal  is  attempted.  Further,  in  the  old  operation,  a  large 
wound  was  left  to  granulate  and  weeks  were  often  required  to  obtain  heahng. 
In  this  operation  the  wound  is  usually  entirely  healed  in  from  eighteen  to 
twenty-one  days.    After  the  performance  of  nephropexy  the  patient  remains 


Fig.  85g. — Gibson's  incision  for  operations  on  Fig.  860. — Gibson's  incision  for  operations 

the  lower  ureter.  The  superficial  incision  (C.  L.  on  the  lower  ureter.  The  upper  flap,  consisting 
Gibson).  of  skin,  external  and  internal  obhque  muscles,  is 

retracted.  The  dotted  line  represents  the  line 
of  incision  in  the  transversalis  fascia  (C.  L. 
Gibson) . 

in  bed  for  three  weeks.  By  this  operation  the  kidney  is  placed  in  a  proper 
situation,  is  surrounded  with  granulations  w^hich  are  converted  into  scar- 
tissue,  and  the  organ  becomes  encased  in  a  box  of  fibrous  tissue.  I  beheve  that 
a  kidney  so  treated  will  probably  remain  fixed. 

If  a  kidney  has  been  decapsulated,  gauze  slings  should  not  be  placed 
around  it,  because  removal  of  them  might  lacerate  the  kidney.  After  decap- 
sulation the  surgeon  rests  content  when  he  has  filled  the  space  below  the  kid- 
ney with  a  support  of  gauze. 

Ureterolithotomy. — If  the  stone  is  impacted  in  the  upper  two-thirds  or 
three-fourths  of  the  tube  it  may  be  reached  by  an  incision  from  the  twelfth 
rib  downward  and  forward  to  just  anterior  to  the  anterosuperior  spine  of 
the  ilium  and  then  parallel  to  Poupart's  ligament  imtil  above  its  middle. 
The  peritonetim  is  stripped  up  as  in  extraperitoneal  ligation  of  the  iliac  vessels. 
The  ureter  adheres  to  the  peritoneum.    The  operation  is  strictly  extraperitoneal. 


Gibson's  Incision  for  Operations  on  the  Lower  Ureter  1299 


Gibson's  incision  for  operations  on  the  lower  ureter  ("Amer.  Jour.  Med. 
Sciences,"  Jan.,  iqio)  is  the  most  useful  for  reaching  and  amply  exposing  the 
lower  ureter.  Further,  it  enables  us  to  feel  and  accurately  operate  upon  the 
tube,  the  entire  operation  being  extraperitoneal.  Gibson  thus  describes  his 
operation : 

"The  skin  incision  runs  from  the  midline  about  a  finger's  breadth  above 
the  pubes,  horizontally  outward  nearly  parallel  to  Poupart's  ligament  at  first 
(Fig.  859),  and  curves  rather  sharply  upward  at  its  midpoint  to  end  about 
opposite  the  anterior  superior  spine  of  the  ilium.  This  incision  is  deepened 
in  the  same  line  through  the  aponeurosis  of  the  external  oblique  and  the 
internal  obHque  muscle — the  latter  is  the  only  structure  which  suffers  any  real 
damage,  and  only  to  a  sUght  degree,  for  the  lower  part  of  the  incision  runs 
about  parallel  to  its  fibers,  only  the  ascending  leg  cuts  across  a  small  part 
of  these  fibers.    The  incision  stops  short  of  the  transversalis,  which  is  not  dis- 


Fig.  861. — Gibson's  indsion  for  operations  on 
the  lower  ureter.  The  edge  of  the  rectus  muscle 
is  strongly  retracted  inward;  between  it  and  the 
cut  edge  of  the  transversalis  fascia  the  peritoneum 
is  exposed  (C.  L.  Gibson). 


Fig.  S62.— Gibson's  incision  for  operations 
on  the  lower  ureter.  The  peritoneum  has  been 
pushed  upward.  The  ureter  is  hfted  out  of  the 
pelvis  and  brought  to  the  level  of  the  external 
wound  (C.  L.  Gibson). 


turbed  at  all.  With  efi&cient  retraction  of  the  upper  flap  the  external  border 
of  the  rectus  muscle  is  identified  (Fig.  S60)  and  the  fascia  of  the  transversalis 
is  now  di\'ided  by  a  vertical  incision  close  to  and  parallel  to  the  rectus — that  is, 
at  right  angles  to  the  original  incision.  Two  retractors  are  now  inserted,  the 
outer  one  retracts  the  cut  edge  of  the  transversalis  outward,  the  other  (Fig. 
861)  pulls  the  rectus  muscle  well  tow^ard  the  midline.  A  generous  space 
is  thus  obtained,  situated  well  toward  the  midline  (the  low^er  part  of  the 
ureter  is  practically  in  the  midline  and  difficult  of  access  by  other  extra- 
peritoneal exposures).  The  floor  of  this  space  is  occupied  by  the  peritoneum. 
The  patient  being  in  a  complete  Trendelenburg  position,  the  peritoneum  is 
easily  and  gently  pushed  away,  and  a  free  access  to  the  pelvis  is  secured.  So 
ample  is  the  space  and  \'iew"  that  the  whole  hand  can  be  introduced  under  the 
control  of  the  eye.  The  ureter  is  released  from  its  surroundings  and  easily 
brought  to  the  level  of  the  wound"  (Fig.  862). 


I300 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


When  the  tube  has  been  exposed  it  is  opened  by  a  longitudinal  incision. 
The  stone  is  removed.  The  ureter  is  explored  by  means  of  a  sound  to  see  if  it  is 
free.  After  removing  the  stone,  close  the  wound  in  the  ureter  with  sutures  of 
ver}'-  fine  chromic  gut.  Deep  sutures  pass  through  all  the  coats  and  are  tied. 
Over  this  a  layer  of  superficial  sutures  are  inserted.  Close  the  tissues  about  the 
ureter  and  drain  by  rubber  tissue.  Never  drain  by  gauze.  To  do  so  will  cause 
a  urinary  fistula.  In  a  woman  a  stone  near  the  vesical  opening  can  be  reached 
by  a  vaginal  incision.  Stone  in  the  vesical  portion  of  the  ureter  may  perhaps 
be  removed  by  aid  of  an  operating  cystoscope  or  by  forceps  after  the  perform- 
ance of  a  suprapubic  cystotomy. 

My  colleague,  Prof.  John  H.  Gibbon,  advocates  a  combined  intra-  and 
extraperitoneal  route  for  stones  anywhere  in  the  lower  two- thirds  of  the 
ureter.  The  peritoneal  incision  permits  of  exploration  and  exact  localization 
of  the  stone,  allows  the  surgeon  to  push  the  calculus  from  an  inaccessible  into 
an  easily  reachable  position,  and  makes  the  removal  vastly  easier.  The  stone 
is  removed  by  extraperitoneal  incision  of  the  ureter,  and  the  peritoneum  is 
closed  (Gibbon,  in  "Annals  of  Surg.,  Gynec,  and  Obstet.,"  May,  1908). 


Fig.  863. — Van  Hook's  method  of  ureteral  anastomosis. 

Uretero-ureterostomy  {Van  Hookas  Operation). — In  this  operation  ligate 
the  lower  end  of  the  divided  ureter  with  silk  or  catgut.  About  j  inch  below 
the  ligature  make  an  incision  in  the  long  axis  of  the  tube.  This  incision  is  in 
length  equal  to  twice  the  diameter  of  the  tube.  Each  end  of  a  piece  of  fine 
catgut  is  threaded  to  a  fine  needle.  This  thread  is  passed  through  the  upper 
end  of  the  ureter  (Fig.  863) .  The  needles  are  made  to  enter  the  lower  end  of  the 
tube  through  the  door  made  by  the  surgeon.  They  are  pushed  through  the 
wall  of  the  ureter  |  inch  below  the  door  (Fig.  863).  Traction  upon  the  strings 
causes  invagination,  and  the  ligature  ends  are  tied.  If  the  operation  is  intra- 
peritoneal the  ureter  is  wrapped  about  with  peritoneum. 

Intestinal  Implantation  of  the  Ureters. — This  operation  may  be  em- 
ployed in  exstrophy  of  the  bladder  and  in  vesical  cancer  in  which  it  is  neces- 
sary to  remove  the  bladder.  After  this  operation  there  is  danger  of  infection 
of  the  ureters  and  consequent  ascending  ureteritis  and  pyelonephritis,  and 
the  presence  of  urine  in  the  bowel  usually  causes  inflammation  of  the  rectum 
and  incontinence  of  urine  may  take  place. 

Maydl  asserts  that  a  piece  of  the  bas-fond  should  be  removed  with  the 
ureter,  and  implanted  with  it  into  the  intestine,  the  flange  hanging  free  in 


Cystoscopy  1301 

the  lumen  of  the  gut.  If  this  is  done,  the  relations  of  the  ureter  to  the  mus- 
cular coat  of  the  bladder  are  not  interfered  with,  stricture  is  less  likely  to 
occur,  ascending  infection  is  antagonized,  and  suppurative  conditions  arise 
at  the  margin  of  the  flange  rather  than,  as  in  other  methods,  directly  in  the 
cut  ureter.  Maydl  has  collected  the  records  of  14  cases  operated  upon  by  this 
method,  with  2  deaths.^  I  performed  it  twice,  -^dth  i  death.  In  vesical  ex- 
strophy Peterson  transplants  a  vesical  flap  containing  both  ureteral  orifices 
into  the  descending  colon. 

Cystoscopy  is  the  emplo\Tnent  of  the  cystoscope  for  the  study  of  the 
interior  of  the  bladder,  the  prostate,  the  ureteral  orifices,  and  the  appearance 
of  the  fluid  coming  from  each  kidney. 

The  cystoscope  is  an  instrument  of  great  value  in  the  hands  of  a  skilful 
and  experienced  man,  but  is  practically  useless  when  employed  by  a  no\dce. 
All  of  my  cystoscopic  examinations  are  made  for  me  by  Dr.  Stellwagen  or  some 
other  expert.  In  using  a  cystoscope  the  mucous  membrane  may  be  burned  ^\ith 
a  hot  lamp.  This  causes  inflammation,  and  if  an  eschar  forms,  it  wiU  be  cast  off, 
exposing  a  granulating  surface.  Schmidt  caUs  attention  to  this  injiur^-,  speaks  of 
the  condition  as  ulcer  cystoscopicum,  says  it  is  in  the  fundus,  has  the  shape  of 
the  instrument,  and  heals  in  from  fourteen  to  twenty-one  days  ('"'Jour.  Amer. 
Med.  Assoc.,''  July  19,  1902). 

Cystoscopic  examination  of  the  bladder  owes  its  present  position  to  ^Messrs. 
;Max  Xitze  and  Joseph  Leiter,  who  were  the  first  to  introduce  practical  in- 
stnmients:  Xitze  in  1S76  and  Leiter  in  1S79.  The  great  obstacle  in  former 
years  was  the  danger  of  burning  the  mucous  membrane  by  overheating  of  the 
lamp.  The  invention  of  the  cold  lamp  by  E.  C.  Preston  eliminated  that  danger, 
and  was  a  great  step  for^'ard.  Xitze  was  the  first  to  recognize  the  futility  of 
examination  by  reflected  light  and  constructed  an  instrument  with  the  light 
on  the  end  which  to-day  is  copied  by  all  of  the  modern  instruments. 

Cystoscopes  may  be  di\-ided  into  several  t^-pes:  (i)  The  examining  instru- 
ment: (2)  the  instrument  carr\-ing  ureteral  catheters  or  the  catheterizing  cysto- 
scope; (3)  the  operating  cystoscope.  They  all  have  certain  mechanical  features 
in  common,  but  differ  in  their  construction  and  lens  arrangement. 

The  examining  instruments  are  of  two  fimdamental  t^-pes — the  direct  and 
the  indirect.  In  the  direct  there  is  a  straight  telescope  with  a  series  of  wide 
angle  lens  that  give  the  picture  of  the  bladder  in  front  and  shghth-  to  the  side. 
In  the  indirect  the  lens  is  so  ground  and  set  as  to  enable  the  operator  to  look 
toward  the  prostate. 

Catheterizing  cystoscopes  are  also  of  two  kinds — the  direct  catheterizing 
and  the  indirect.  In  the  direct  catheterizing  cystoscope  the  catheters  are 
passed  directly  from  the  carrying  tubes  into  the  ureters.  In  the  indirect 
catheterizing  cystoscope  the  catheter  is  bent  or  directed  by  a  lever  on  the 
end  of  the  instrument  operated  by  a  thumb-screw  on  the  penile  end.  By 
raising  or  lowering  the  lever  the  angle  of  the  catheter  is  altered  to  facilitate  its 
introduction  into  the  ureteral  orifice. 

It  is  obA-ious  that  the  bladder  should  be  distended  in  order  to  permit  of 
c>'stoscopic  examination.  For  this  purpose  air  and  water  have  been  utihzed. 
The  modern  tendency  is  in  favor  of  water  distention.  Some  of  the  operating 
instnunents.  notably  that  of  Prof.  Le-^is.  require  air. 

Water  as  a  dilating  medium  is  superior  to  air.  unless  operative  work  is  to 
be  done  through  the  mstrument,  in  which  case  the  ine^-itable  hemorrhage  pre- 
cludes the  use  of  water.  The  air  instruments  show  but  a  smaU  field,  the  dis- 
tention causes  pain  and  is  often  followed  b}^  mild  cystitis. 

From  the  foregoing  it  is  plain  that  one  tspe  of  instnmient  is  not  suited  to  all 
cases',  and  each  has  its  claim  to  practical  utflity.  Some  cases  can  be  most 
1  Editorial  in  "Jour.  Amer.  Med.  Assoc,"  May  6.  1899. 


1302 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


readily  catheterized  by  the  direct,  while  others  are  only  reached  by  the  indi- 
rect, plan.  It  is  my  conviction  that  if  the  ureteral  orifices  are  normally 
placed,  the  direct  method  is  quicker  and  more  readily  learned  by  the  beginner. 
Men  who  have  had  training  had  best  use  the  A.  C.  M.  I.  cystoscope  (Figs.  864, 
865).  It  is  an  indirect  or  oblique  cystoscope,  but  has  a  corrected  image  field 
which  enables  the  operator  to  work  as  he  sees  and  not  the  reverse  (as  is  neces- 
sary with  the  uncorrected  image  field) .  These  new  instruments  cause  less  pain 
than  direct  instnunents,  and  give  a  very  wide  field.  When  from  any  cause  the 
ureteral  orifice  turns  backward  (which  only  happens  in  a  very  small  percentage 
of  cases)  the  indirect  cystoscope  is  indispensable,  it  being  practically  impossible 
to  reach  the  ureteral  orifice  by  the  direct  instrument. 


Fig.  864. — ^The  A.  C.  M.  I.  double  catheterizing  cystoscope. 

There  are  at  present  many  different  forms  of  cystoscopes  on  the  market, 
notable  among  them  are  the  Nitze,  Casper,  Tilden  Brown,  Cabot's  modifica- 
tion of  the  Tilden  Brown,  Buerger,  Albarran,  Bransford  Lewis,  and  the  so-called 
Universal.  The  universal  instruments  of  Bransford  Lewis  and  Tilden  Brown 
possess  features  of  great  practical  utility. 

Sterilization  of  Cystoscopes  and  Ureteral  Catheters. — In  order  to  sterilize 
the  cystoscope  before  using,  place  it  for  five  minutes  in  a  solution  of  mercury 
oxycyanid  (i :  1000)  or  formaldehyd  (i :  500) .  The  steriUzing  power  of  formalde- 
hyd  gas  is  not  to  be  relied  on.  Some  operators  use  a  5  per  cent,  solution  of 
phenol,  in  which  the  instrument  is  immersed  for  twenty-four  horn's,  after  which 
it  is  dipped  into  glycerin,  which  both  neutralizes  the  phenol  and  lubricates  the 


Fig.  865. — The  A.  C.  M.  I.  operating  cystoscope. 

tube.  The  mercury  oxycyanid  solution  is  easily  used  and  is  thoroughly  satis- 
factory. Should  formaldehyd  solution  or  formahn  gas  be  used,  always  wash 
the  instrument  thoroughly  with  salt  solution  before  using  to  prevent  irritation 
by  the  sterilizing  medium. 

Dr.  M.  P.  Willard,  of  San  Francisco,  in  ''Jour.  Amer.  Med.  Assoc,"  Octo- 
ber 4,  19 13,  advocates  the  following  method  for  sterilizing  ureteral  catheters: 
The  ureteral  catheter  is  placed  in  a  muslin  bag  2  cm.  wide  by  75  cm.  long.  The 
bag  is  enclosed,  with  the  catheter  in  it,  in  parafl&n  paper,  and  secured  by  encir- 
cling strips  of  adhesive  plaster.  As  many  may  be  prepared  as  is  thought  neces- 
sary. The  package  is  placed  for  twenty  minutes  in  an  autoclave  with  a  pres- 
sure of  8  to  ID  pounds.  When  the  catheter  is  to  be  used  the  paper  is  rerrioved 
and  the  end  of  the  instrument  is  exposed  by  pulling  back  the  Hnen  bag  and  the 


Technic  of  Cystoscopy 


1303 


/ 


tip  of  the  catheter  is  engaged  in  the  carrying  tube  of  the  cystoscopy  As  the 
catheter  is  fed  through  the  cystoscope  the  Unen  bag  is  pulled  back;  in  this  way 
the  fingers  do  not  come  in  contact  with  the  catheter. 

Ureteral  catheters  can  be  steril- 
ized by  placing  them  in  an  open 
shallow  djsh  containing  a  saturated 
solution  of  ammonium  sulphate  or 
sodium  chlorid  and  boiling  them  for 
five  or  ten  minutes.  The  following 
precautions  must  be  obser^^ed:  Each 
catheter  should  be  \\Tapped  in  gauze 
and  the  bottom  of  the  pan  covered 
wath  gauze.  If  the  catheters  are 
allowed  to  touch  each  other  or  curl 
upon  themselves  the  shellac  coating 
will  melt  and  ruin  the  instruments. 
They  may  also  be  sterilized  in  the 
same  manner  as  the  cystoscope,  care 
being  taken  if  formalin  was  used  to 
carefully  wash  away  the  germicide, 
especially  from  the  limien  of  the 
catheter. 

Centra-indications  to  Cystoscopy. 
— ^The  bladder  must  hold  at  the 
very  least  50  c.c.  of  fluid.  If  it 
holds  less  cystoscopy  is  useless.  Ex- 
amination is  either  impossible  or  un- 
satisfactor}^  if  the  prostate  is  greatly 
enlarged.  Contracted  meatus  urin- 
arius  and  stricture  of  less  caliber 
than  No.  24  of  the  French  scale  are 
correctible  contra-indications.  Pap- 
illomata  and  other  tumors  and  foreign 
bodies  of  the  urethra  are  impedi- 
ments. In  acute  Bright's  disease  in- 
strmnentation  is  dangerous,  because 
it  may  be  followed  by  suppression 
of  lu-ine.  The  following  are  further 
contra-indications,  as  suggested  by 
FoUen  Cabot  and  Henr\^  G.  Spooner, 
in  "Med.  Record,"  July  11,  1903: 
When  it  is  ob\dous  that  operative 
inter\"ention  would  be  useless;  when 
there  is  a  large  tumor;  in  acute 
cystitis;  in  tuberculosis  in  which 
the  diagnosis  is  e\ddent  without  the 
cystoscope.  In  women,  pelvic  adhe- 
sions and  large  exudates  may  inter- 
fere with  CN^stoscopy. 

Technic  of  Cystoscopy. — ^The  patient  should,  if  possible,  be  carefully  sounded 
once  a  day  for  several  days  previous  to  the  cystoscopic  examination;  this  estab- 
lishes tolerance  of  the  urethra.  He  should  be  placed  upon  a  suitable  table, 
such  as  that  de\ised  by  Tilden  Brown  or  Bransford  Lewis,  as  sho-vsTi  in  Fig.  868. 

The  urethra  is  cleaned  by  irrigation  with  salt  solution.  General  anesthe- 
sia is  rarely  necessary  provided  the  operator  is  gentle  in  his  manipiilations. 


Fig.  866. — Different  types  of  ureteral  cathe- 
ters: a,  Blasucci;  b,  return  flow  for  irrigation; 
c,  Garceau;  d,  another  type  of  Blasucci;  e,  Cun- 
ningham; /,  olivary  tipped;  g,  x-ray  whistle  tip. 


1304 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


There  are,  however,  some  hypersensitive  urethras  which  it  is  necessary  to 
anesthetize.  Cocainization  of  the  urethra  will  usually  be  efi&cient.  This  is 
carried  out  by  instillation  through  the  Keyes-Ultzmann  syringe  or,  better, 
through  a  soft-rubber  catheter  into  the  posterior  portion  of   the  canal  of 


U2- 


Fig.  867. — Buerger's  rongeur  forceps  with  flexible  shank  for  use  with  Buerger's  operating  cystoscope. 

I  dram  of  a  4  per  cent,  solution  of  cocain.  Alypin,  placed  in  the  canal  at  the 
points  of  greatest  tenderness  by  means  of  Dr.  Lewis's  repositor,  answers  very 
well.  These  tablets  are  allowed  to  dissolve  in  the  urethral  mucus.  The  points 
of  greatest  tenderness  are  the  fossa  navicularis,  the  bulbo  membranous  junction, 
and  the  prostatic  urethra  about  the  verumontanum.    In  cases  complicated  by 


Fig.  868. — Tilden  Brown's  cystoscopic  table  with  patient  in  position  for  examination. 

cystitis,  preliminary  lavage  of  the  bladder  should  be  practised.  This  may  be 
given  through  the  cystoscope  sheath  or  through  a  soft-rubber  catheter.  If  the 
bladder  is  not  diseased,  it  is  merely  necessary  to  draw  off  the  urine.  After  the 
urine  has  been  withdrawn,  the  cystoscope  sheath  should  be  firmly  but  gently 
held  in  place.     The  thumb  of  the  left  hand  presses  downward  while  the  index- 


Technic  of   Cystoscopy 


1305 


finger  presses  upward  on  the  under  surface  of  the  sheath.  This  procedure 
raises  the  beak  of  the  instrument  from  the  sensitive  trigone,  where  most  of 
the  pain  and  hemorrhage  are  produced  by  vesical  tenesmus. 

In  regard  to  the  selection  of  the  distending  medium,  the  operator  may  use 
sterile  water,  normal  salt  solution,  boric  acid  solution,  or  mercury  oxycyanid 
solution  (1:5000).  The  bladder  should  be  moderately  distended  and,  if  pos- 
sible, from  8  to  10  oimces  of  fluid  are  allowed  to  remain  in  the  viscus.  In  con- 
tracted or  h^^Dersensitive  bladders  it  is  well  to  elevate  the  hips  and  so  relieve 
the  pressure  on  the  sensitive  vesical  neck  and  trigone. 

The  temperature  of  the  distending  fluid  is  of  great  importance,  particularly 
if  there  is  difficulty  in  finding  the  ureteral  outlet.  If  this  is  the  case,  the  temper- 
ature of  the  fluid  should  be  about  60°  F.  This  enables  the  operator  to  see  a 
so-called  swhirl  wnen  the  warm  jet  of  urine  mixes  with  the  cold  water  in  the 
bladder.  It  is  sometimes  ad\'isable  to  give  methylene-blue  before  examining 
for  the  same  reason.  The  blue 
stream  from  the  ureter  at  once 
identifies  the  tube. 

After  the  bladder  has  been 
filled  the  telescope  containing  the 
catheters  is  inserted  and  the  light 
is  turned  on.  The  instrument, 
then  held  in  the  median  line,  is 
pushed  gently  back,  well  into  the 
bladder,  pressure  being  always 
made  to  keep  the  beak  from  im- 
pinging upon  the  floor  of  the 
viscus.  The  cystoscope  is  now 
slowly  withdrawn,  a  careful 
watch  being  maintained  through 
the  telescope  for  the  internreteral 
bar  (Fig.  869).  This  structure 
(there  has  been  much  argument 
as  to  whether  this  structure  really 
exists)  marks  the  posterior  border 
of  the  trigone.  The  examiner  has 
still  another  guide  to  the  trigone 
in  the  blood-vessels,  which  in  a 

general  wa}'  run  anteroposteriorly.  There  is  a  distinct  line  of  demarcation 
between  the  fish-net  loop  arrangement  of  the  mucous  membrane  of  the  sides 
and  base  of  the  bladder  and  the  mucous  membrane  in  the  trigone.  Fig.  869 
gives  a  general  idea  of  the  vascular  arrangement.  WTien  the  interureteral  bar 
or  posterior  border  of  the  trigone  has  been  located,  the  instnmient  is  gently 
and  slowly  moved  laterally,  so  that  the  border  of  the  cystoscope  is  kept  in  the 
field  until  the  end  of  the  bar  is  reached.  The  instrument  is  then  held  stationary 
for  a  moment  and  a  sharp  lookout  is  kept  for  the  jet  of  urme  or  the  swirl.  The 
ureteral  orifice  is  thus  indicated.  Should  the  field  become  blurred  by  blood  on 
the  lens,  or  should  the  solution  In  the  bladder  become  mixed  with  blood,  con- 
tinuous irrigation  must  be  kept  up  through  the  cystoscope. 

The  Ureteral  Orifices. — As  before  mentioned,  the  ureteral  orifices  are  usually 
located  at  the  terminations  of  the  interureteral  bar,  and  occupy  the  basal  angles 
of  a  triangle  formed  by  the  vesical  outlet  and  the  base  of  the  trigone.  They  are 
usually  about  i  to  i^  cm.  from  the  median  fine  and  about  2I  cm.  from  the 
vesical  end  of  the  urethra.  They  are  recognized  as  smaU  slits  or  as  tubercles 
on  the  surface  of  the  mucous  membrane.  Their  position  is  not  always  the  same. 
Some  of  the  abnormal  positions  more  commonly  met  with  are  as  follows:   one 


Fig.    86g. — The    interior 
arrangement    of    the    vessels 
interureteral  bar. 


of    the    bladder,    showing 
of    the    trigone:     A,    B, 


1306  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ureter  closer  to  or  further  removed  from  the  median  line,  both  ureters  emptying 
into  the  bladder  close  to  the  median  line,  generally  about  one-quarter  or  one- 
half  the  length  of  the  bar.  Malposition  toward  the  vesical  outlet  and  in  some 
very  rare  instances  both  emptying  on  the  same  side.  Sacculation  and  pocket- 
ing of  the  bladder  with  swelling  of  the  mucous  membrane  often  make  localiza- 
tion of  the  ureteral  orifices  difficult.  It  is  then  that  the  administration  of 
methylene-blue  or  indigo-carmin  may  enable  the  investigator  to  more  readily 
locate  the  ureters. 

After  locating  a  ureteral  orifice  the  vesical  end  of  the  cystoscope  is  carried 
directly  over  the  opening  and  the  catheter  is  projected  against  the  opening, 
where  it  is  allowed  to  remain  for  a  moment  in  order  to  overcome  the  spasm 
of  the  sphincteric  muscular  fibers.  The  patient  is  instructed  to  hold  his  breath 
and  the  opening  is  carefully  watched  until  a  jet  of  urine  is  forced  through,  during 
which  act  the  catheter  is  gently  inserted  into  the  ureter.  The  passing  of  the 
urine  is  accompanied  by  dilatation  of  the  opening  and  greatly  facilitates  the 
passage  of  the  instrument.  After  the  catheter  has  passed  the  sphincter 
muscle  it  should  be  carried  up  the  canal  by  very  gentle  pressure.  The  prac- 
tice of  passing  the  instriunent  quickly,  so  commonly  resorted  to  by  the  novice 
in  order  to  gain  time,  is  pernicious,  and  almost  invariably  causes  laceration 
and  hemorrhage.  Before  inserting  the  catheter  some  operators  prefer  to  coat 
it  with  paraffin  in  order  to  render  it  absolutely  smooth  and  further  to  assist 
in  the  detection  of  calculus.  This  is  not  necessary.  Any  instrument  with  an 
imperfect  eye  should  be  discarded. 

The  roimd-pointed  catheter  should  be  used  wherever  possible,  as  with 
it  there  is  less  danger  of  injuring  the  delicate  mucous  lining  of  the  canal. 
The  sharp-pointed  oHvary  tipped  instrument  often  causes  blood  to  appear. 
If  possible,  insert  the  catheter  into  the  renal  pelvis,  for  then  hemorrhage  from 
trauma  is  less  likely  to  invalidate  the  examination,  and  spasm  of  the  ureter, 
with  sucking  of  the  mucous  membrane  into  the  eye  of  the  catheter,  will  not 
occiir.  Having  finished  the  catheterization  of  one  side,  the  catheter  is  left  in 
place,  the  instriunent  handle  is  swimg  to  the  opposite  side  and  a  similar  pro- 
cedure is  carried  out.  Always  have  a  distinguishing  mark  upon  the  catheters. 
A  very  good  method  is  to  use  different  colored  instruments,  so  that  there  may 
be  no  confusion  after  withdrawal  of  the  cystoscope.  In  some  cases  only  one 
ureter  can  be  catheterized.  In  such  a  case  the  bladder  should  be  thoroughly 
washed,  and  the  other  catheter,  left  on  the  floor  of  the  bladder,  wiU.  collect  the 
urine  from  the  uncatheterized  side  and  give  a  fair  idea  of  the  condition  of  that 
kidney. 

Removal  of  the  Cystoscope. — The  light  should  be  turned  off  and  a  small 
amount  of  fluid  allowed  to  escape  through  the  barrel.  The  lens  system  carry- 
ing the  catheter  is  then  loosened  and  gently  rotated  from  side  to  side  to  free 
the  catheters.  During  this  procedure  the  catheters  are  drawn  gently  backward, 
but  not  with  sufficient  force  to  cause  kinking,  and  the  lens  system  is  removed. 
Next  the  sheath  is  withdrawn  by  carrying  it  straight  up  over  the  abdomen. 

Collection  of  the  Urine. — ^The  protruding  catheters  are  carefully  wiped  with 
sterile  gauze  and  are  permitted  to  drain  into  separate  bottles  or  test-tubes, 
marked  respectively  right  and  left.  The  orifices  of  the  receivers  should  be 
plugged  with  sterile  absorbent  cotton,  which  will  collect  and  prevent  any  admix- 
ture of  urine  or  water  coming  from  the  bladder  by  capillary  drainage.  The 
bottles  should  also  be  held  in  such  position  as  to  prevent  such  capillary  drainage 
reaching  them.  With  regard  to  the  collection  of  the  samples,  there  are  certain 
precautions  that  should  be  observed:  (i)  The  samples  should,  if  possible,  be  col- 
lected in  three  separate  bottles  from  each  side,  allowing  each  set  to  remain  in 
position  a  definite  time,  generally  one-half  hour.  These  should  be  carefully 
watched  and  marked  first,  second,  and  third  half-hours.     They  should  each  be 


The  Operating  Cystoscope 


1307 


examined  separately,  and  by  a  summation  of  the  examinations  the  opinion 
should  be  reached.  Almost  invariably  microscopical  blood  can  be  found  in  the 
urine  drawn  by  catheterization  of  the  ureters.  In  a  study  of  15  cases  of 
normal  ureters,  blood  not  being  present  before  catheterization  after  catheter- 
izing  with  the  greatest  care,  microscopical  blood  was  present  in  all  but  3.  The 
erythrocytes  are  usually  most  numerous  in  the  first  bottle,  gradually  diminish- 
ing, until  in  the  third  there  are  very  few  or  none.  Should  the  blood  increase 
in  amount  in  the  second  or  third  bottle,  it  is  an  important  clinical  fact. 

In  some  instances  one  or  both  catheters  fail  to  drain.  This  may  be  due  to  a 
bubble  of  air  in  the  instrument,  impinging  of  the  mucous  membrane  upon 
the  eye,  plugging  by  blood-clot,  mucus,  pus,  or  particles  of  gravel.  A  syringe 
is  then  essential.  The  blunt  hollow  needle  should  be  inserted  into  the  cath- 
eter and  suction  applied;  should  this  fail,  not  over  4  c.c.  of  sterile  normal  salt 
solution  may  be  injected  through  the  catheter.  This  procedure,  however,  must 
be  carried  out  very  gently,  because  of  the  danger  of  overdilating  the  renal  pel- 
vis and  thus  producing  coKc. 

The  carrying  capacity  of  the  pelvis  of  the  kidney  is  uncertain.  Careful 
observations  indicate  that  there  is  no  definite  carrying  capacity  that  may  be 


j^^SS 


M  r        1 

Ih   _ — /^l 

Fig.  870. — Bulbs  and  bottle  for  distending  bladder  and  collecting  washings. 

called  normal.  The  range  of  difference  is  great  and  even  differs  at  certain 
times  in  the  same  kidney.  In  many  kidneys  it  is  about  8  to  10  c.c,  but,  on 
the  other  hand,  it  may  be  as  high  as  20  c.c.  and  still  be  normal.  It  would  seem 
as  though  the  blood-supply  of  the  organ  had  something  to  do  with  the  pelvic 
capacity,  for  a  congested  circulation  means  distended  vessels,  and  they  prob- 
ably impinge  upon  the  pelvis.  Again,  the  question  of  producing  renal  coHc 
by  overdilatation  of  the  pelvis  is  a  very  imcertain  gmde  as  to  the  capacity,  for 
in  many  instances  the  ureteral  and  pelvic  musculature  is  sufficient  to  force  the 
fluid  doTvm  the  ureter  with  the  catheter  in  situ  and  yet  produce  no  evidence  of 
colic.  This  has  been  seen  in  many  instances  in  making  a  pyelographic  study 
by  means  of  a  solution  of  collargol,  which  is  much  thicker  than  urine  or  water. 

A  uropyknometer  is  used  for  taking  the  specific  gravity  of  small  quantities 
of  urine  removed  by  the  ureteral  catheter. 

The  Operating  Cystoscope. — ^The  most  practical  operating  cystoscopes  are 
Bransford  Lewis's  and  the  A.  C.  M.  I.  instrtunent  (see  Fig.  865).  These  instru- 
ments greatly  facilitate  the  removal  of  small  portions  of  stone  and  foreign  bodies 
from  the  bladder  and  the  ureteral  orifices.    They  are  also  useful  for  making  ap- 


i3o8 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


plications  to  ulcerated  areas.  It  is  not  wise  to  remove  papillomatous  timiors 
by  them,  as  most  villous  papillomatous  growths  sooner  or  later  exhibit  the 
elements  of  malignancy  and  should  have  their  pedicles  removed  with  a  portion 
of  the  vesical  wall,  which  can  only  be  safely  done  after  suprapubic  cystotomy. 
We  have  succeeded  in  fulguration  of  intravesical  papillomata  of  a  benign  type 


Fig.  871. — I,  Scissors;  2,  tweezers;  3,  forceps;  and  4,  puncli  for  use  with  the  Lewis's  cystoscope. 

by  means  of  the  high-frequency  current,  and  Prof.  Hiram  R.  Loux  has  had 
several  such  cases  that  have  remained  well  for  over  two  years. 

Practical  Value  of  Cystoscopy  and  Ureteral  Catheterization. — The  cysto- 
scope has  attained  a  very  important  position  in  the  surgeon's  armamentarium. 
It  undoubtedly  affords  the  best  method  of  establishing  an  accurate  diagnosis 


Fig.  872. — "Universal"  cystoscope  with  wire  snare. 

founded  on  pathological  findings.  By  it  one  is  enabled  to  determine  the  pres- 
ence and  character  of  cystitis,  stone,  foreign  bodies,  and  malformations.  With- 
out it  the  presence  of  ulcerations  could  merely  be  guessed  at  by  the  clinical 
history.  Its  greatest  field  is  in  the  early  diagnosis  of  the  cause  of  renal  and 
vesical  hemorrhages.  In  the  detection  of  renal  neoplasms  it  may  be  said 
to  have  revolutionized  surgery.     It  makes  possible  the  early  removal  of  such 


Fig.  873. — Lewis's  repositor. 


growths  before  malignancy  has  signed  the  patient's  death  warrant.  Cases  of 
prostatic  hypertrophy,  in  which  the  lobes  project  backward,  cannot  be  accu- 
rately diagnosticated  without  the  cystoscope;  with  it  the  parts  can  be  seen  and 
the  clinical  diagnosis  positively  confirmed.  It  makes  possible  the  removal  of 
small  foreign  bodies,  such  as  stone,  pieces  of  cotton,  or  filiform  bougie  through 
the  urethra,  thus  saving  formidable  cutting  operations.  It  is  needless  to  mention 
the  great  difficulty  found  by  surgeons  in  former  years  in  determining  the  source 


Practical  Value  of  Cystoscopy  and  Ureteral  Catheterization      1309 


of  symptomless  hemorrhage,  a  problem  which  is  now  comparatively  easy  of 
solution. 

Ureteral  catheterization  makes  possible  the  irrigation  of  the  ureter  and 
pelvis  of  the  kidney  in  cases  of  ureteritis  and  pyelitis. 

The  technic  of  lavage  is  as  follows:  The  gravity  tubes  for  instilling  fluid, 
shown  in  Fig.  874,  are  carefully  sterilized  and  the  metal  nozzles  arranged  so  as 
to  fit  correctly  the  lumen  of  the  ureteral  catheters.  It  is  always  necessary  to 
make  certain  that  the  nozzles  will  fit  and  that  they  and  the  catheters  are  free. 
This  should  never  be  neglected.  It  has  been  found 
on  several  occasions  that  one  or  the  other  was 
blocked,  and,  again,  any  particles  of  catheter  or 
other  material  that  might  form  a  nidus  for  stone 
formation  should  be  washed  out.  We  advise  the 
irrigation  to  be  done  by  means  of  gravity  in  prefer- 
ence to  a  syringe,  as  the  fluid  may  be  delivered 
more  evenly  and,  so  to  speak,  may  be  "sneaked" 
into  the  pelvis  of  the  kidney.  This  gentle  trickle 
of  warmed  fluid  does  not  seem  to  excite  acutely  the 
musculature  of  the  ureter  and  pelvis;  in  consequence 
there  is  not  so  much  coHc,  and  when  colic  occurs  it 
does  not  persist  so  long.  About  this  point  there  has 
been  some  difference  of  opinion,  but  the  evidence  is 
in  favor  of  the  gravity  method  both  for  lavage  and 
pyelography. 

There  are  several  solutions  that  may  be  used. 
We  beHeve  that  normal  salt  solution  is  the  best  for 
mere  cleansing  purposes.  Saturated  solution  of 
boric  acid  may  be  used  if  a  mild  antiseptic  is  needed. 
Either  of  these  solutions  may  be  followed  by  the 
different  silver  solutions  in  strengths  calculated  to 
suit  the  case  in  hand.  The  nitrate  of  silver  is 
generally  used  in  a  strength  of  i :  8000,  but  a  much 
stronger  solution  may  be  resorted  to.  In  the  clinic 
of  Prof.  Loux  excellent  results  have  been  obtained 
from  a  10  per  cent,  solution  of  argyrol. 

The  catheters  are  passed  into  one  or  both  ureters 
and  the  fluid  is  permitted  to  pass  very  slowly  into 
the  pelvis  or  ureter,  as  the  case  may  be.  Overdis- 
tention  must  be  guarded  against,  and  a  safe  rule  is 
not  to  allow  over  8  c.c.  to  be  used  at  any  one  time. 

The  type  of  catheter  to  be  used  may  be  according 
to  the  fancy  of  the  operator.  There  is  at  present  a 
very  excellent  two-way  pelvic  irrigating  ureteral 
catheter,  or  the  single  tube  instrument  may  be 
used  and  the  flmd  aUowed  to  escape  after  filling  the  pelvis.  This  procedure 
should  be  repeated  until  the  return  fluid  is  clear.  Should  hemorrhage  com- 
plicate the  procedure,  an  irrigation  of  adrenalin  may  be  used.  (This  has  been 
known  to  apparently  cure  essential  renal  hematuria.) 

After  completion  of  the  irrigation  the  bladder  should  be  thoroughly  washed 
and  the  patient  put  upon  some  mfld  genito-urinary  antiseptic,  of  which  there  are 
several  to  choose  from.     Uro tropin  is  the  one  usuaUy  given. 

It  wovdd  seem  a  wise  plan  to  thoroughly  irrigate  the  kidney,  pelvis,  and 
ureter  before  certain  surgical  operations.  When  a  surgeon  is  going  to  open  the 
kidney  in  the  presence  of  pus  or  infected  iirine,  before  cutting  down  upon  the 
kidney  it  is  well  to  wash  away  as  much  as  possible  of  the  purulent  matter 


Fig.  874. — Apparatus  for 
filling  pelves  in  pyelography; 
also  for  doing  lavage  of  ureters 
and  pelves. 


I3IO 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


through  a  ureteral  catheter  and  then  instil  some  nitrate  of  silver  or  coUargol, 
which  is  the  silver  preparation  used  in  making  pyelographic  studies. 

Irrigation  of  the  pelvis  and  ureter  has  come  to  be  a  rational  surgical  pro- 
cedure and  in  many  cases  is  followed  by  a  marked  improvement  in  the  general 
health  of  the  individual,  making  operative  procedure  safer  and  not  complicated 
by  so  marked  a  toxemia.  In  all  cases  when  operative  work  is  to  be  done  on  a 
kidney  with  a  large  pus  sac  of  other  than  tuberculous  origin,  irrigation  of  the 
pelvis  by  means  of  one  of  the  milder  antiseptic  silver  solutions  would  seem  to 
be  a  proper  surgical  procedure.  It  is  especially  so  when  the  necessity  may 
arise  for  opening  the  peritoneal  cavity. 

A  differential  diagnosis  must  sometimes  be  made  between  gall-bladder  dis- 
ease, appendicitis,  and  movable  kidney  with  dilated  pelvis.  This  is  done  by 
determining  the  carrying  capacity  of  the  pelvis  by  means  of  the  injection  of 


Fig.  875. — A,  Dilated  kidney  pelvis  lillid  with  lollargol  solution;  B,  kink  in  ureter;  C,  dilated 
ureter  filled  with  collargol  solution;  D,  constriction  of  ureter;  E,  ureteral  catheter.  (Taken  by  Dr. 
W.  F.  Manges.) 

salt  solution  and  by  making  a  pyelograph  (Fig.  875).  If  the  trouble  is  with  the 
kidney,  pain  caused  by  injection  of  salt  solution  will  be  similar  in  character  and 
situation  to  the  pain  of  the  attacks.  As  a  rule,  in  movable  kidney  producing 
marked  symptoms  the  renal  pelvis  is  dilated.  When  the  trouble  is  due  to  the 
kidney  the  pain  induced  by  the  distention  is  similar  to  that  from  which  the 
patient  has  suffered  (Howard  A.  Kelly).  If  a  stone  is  present  in  the  ureter 
the  x-ray  picture  will  usually  reveal  it,  but  here  again  there  may  arise  doubt  as  to 
the  exact  course  of  the  canal.  Catheters  passed  into  the  ureters,  each  catheter 
with  a  lead  wire  in  it,  can  be  skiagraphed,  and  the  radiographer  will  be  able  to 
determine  the  exact  course  of  the  ureters.  Instead  of  a  catheter  containing  a 
wire  the  x-ray  catheter  of  Eynard  may  be  used.  Figure  876  demonstrates  the 
practical  utility  of  such  manipulation.  Phleboliths,  fecal  masses,  appendoliths, 
concretions,  and  calcified  lymph-nodes  have  been  mistaken  for  ureteral  stone 


Disinfection  of  Urethral  Catheters 


1311 


even  after  a  study  of  skiagraphs.  Appendices  have  been  removed  when  the 
source  of  trouble  has  been  impacted  stone  in  the  right  ureter.  In  3  cases 
seen  by  Stellwagen  appendectomy  had  failed  to  cure.  In  each  case  a  stone  was 
subsequently  removed  from  the  ureter  and  the  patient  cured.  An  impacted 
stone  in  the  ureter  may  often  be  dislodged  by  passing  a  catheter  into  the  ureter 
and,  if  possible,  beyond  the  stone.  A  few  minims  of  sterile  olive  oil  are  then 
injected  through  the  catheter,  which  act  as  a  lubricant  and  assist  in  the  passage 
of  the  stone.  Dilatation  of  the  ureteral'orifice,  by  leaving  the  catheter  in  sUu 
or  passing  a  second  instrument  alongside  of  the  first,  will  often  cause  the  stone 
to  pass  into  the  bladder. 

Disinfection  of  Urethral  Catheters. — Metallic  instruments  are  cleansed 
by  boiling.  Soft-rubber  and  elastic  catheters  can  be  sterilized  by  mechanical 
cleansing  with  soap  and  water  and  boiling  for  five  minutes.  The  common 
custom  of  immersing  a  soft- rubber  or  elastic  catheter  for  five  minutes  in  a 
I  :  2000  solution  of  corrosive  sublimate  is  a  useless  waste  of  time,  as  such  a 


Fig.  876.- 


-X-ray  photograph,  showing  the  course  of  the  ureters  by  wires  in  the  catheters, 
by  Dr.  W.  F.  Manges.) 


(Taken 


procedure  will  not  sterilize  an  infected  instrument.  Formalin  vapor  is  not  re- 
liable. A  catheter  coated  with  varnish  or  resin  cannot  be  placed  in  steam,  and 
cannot  be  boiled  in  water  if  it  is  allowed  to  touch  the  metal  of  the  boiler  or 
another  catheter.  Woven  and  varnished  instruments  can  be  boiled  in  salt 
water  (3  drams  of  salt  to  i  pint  of  water) ,  provided  each  instrmnent  is  wrapped 
in  a  piece  of  gauze  so  that  it  cannot  touch  another  instrmnent  or  the  side  or 
bottom  of  the  metal  sterilizer.  This  plan  secures  the  most  certain  sterilization. 
Catheters,  after  being  cleansed  mechanically  and  disinfected,  may  be  kept  ready 
for  use  in  a  glass  cylinder  containing  calcium  chlorid  (R.  W.  Frank,  in  "Berliner 
klin.  Woch.,"  No.  44,  1895).  By  this  plan  the  catheters  can  be  kept  straight. 
Some  prefer  to  keep  them  in  a  glass  cylinder  containing  a  few  formalin  tablets. 
An  excellent  way  to  keep  sterile  catheters  clean  is  to  place  each  catheter  in 
an  individual  bag  of  linen  or  waxed  paper.  Stellwagen  boils  a  number  of 
rubber  condoms  at  the  time  he  boils  the  catheters.     When  the  instruments 


13 1 2  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  condoms  are  dry  he  encloses  an  instrument  in  each  condom.  Before  using 
catheters  which  have  been  in  formalin  vapor  they  must  be  washed  in  sterile 
water  or  salt  solution. 

Diseases  and  Injuries  of  the  Bladder 

Retention  of  Urine  in  the  Male.— Retention  of  urine  is  not,  of  course, 
a  disease;  it  is  rather  a  result  of  one  of  a  number  of  different  diseases.  By 
this  term  is  meant  an  absolute  inability  to  micturate  voluntarily.  The 
retention  may  be  complete,  not  a  drop  emerging,  or  it  may  have  been  complete, 
a  dribbling  setting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which  viscus 
becomes  unable  to  contain  more  fluid,  expulsion  of  the  overflow  from  the 
ureters  being  produced  by  atmospherical  pressure.  This  condition  is  known 
as  the  engorgement,  the  overflow,  or  the  incontinence  of  retention.  There  may  be 
retained  urine  in  a  man  with  enlarged  prostate,  a  portion  only  of  the  urine 
being  voided.  This  is  not  retention,  and  the  urine  so  retained  is  called  re- 
sidual urine.  Of  course,  true  retention  may  arise  in  a  person  with  enlarged 
prostate.  Retention  may  be  caused  by:  (i)  Obstruction,  resulting  from 
urethral  stricture,  hypertrophied  prostate,  inflamed  prostate,  occluded  meatus, 
impacted  calculus  or  foreign  body,  urethral  tumor,  rupture  of  the  urethra, 
perineal  abscess,  imperforate  prepuce,  congenital  phimosis,  tumor  of  the  penis, 
timior  of  the  prostate,  prostatic  abscess,  abscess  of  the  penis,  ischiorectal 
abscess,  and  pressure  from  a  large  pelvic  tumor.  The  commonest  obstructive 
cause  is  spasm  of  the  membranous  urethra  arising  during  the  existence  of 
stricture,  acute  gonorrhea,  or  gleet.  (2)  Defective  expulsion,  resulting  from 
impairment  of  the  nervous  apparatus  for  inducing  micturition.  Hysteria  is 
a  rare  cause  in  men.  We  see  retention  without  obstruction  after  vertebral 
fractures  or  spinal  concussion,  in  certain  diseases  of  the  spinal  cord,  some- 
times in  shock  and  peritonitis,  often  in  the  continued  fevers  and  diseases 
characterized  by  muscular  wasting,  from  the  action  of  certain  drugs  (bella- 
donna, opium,  or  cantharides) ,  and  after  certain  surgical  operations  upon  or 
about  the  rectum.  The  last-named  form  of  retention  is  due  either  to  reflex 
inhibition  of  the  expulsor  muscle  or  to  reflex  stimulation  of  the  sphincter 
vesicae,  causing  it  to  remain  firmly  contracted.  Acute  retention  comes  on 
suddenly  and  is  sometimes  the  first  thing  that  causes  a  sufferer  from  urethral 
stricture  to  seek  a  surgeon. 

Symptoms. — In  acute  retention  there  is  an  agony  of  desire  to  urinate,  the 
patient  making  acutely  painful  straining  efforts,  during  which  feces  are  often 
passed.  There  are  severe  pain  and  aching  in  the  abdomen,  thighs,  perineum, 
and  penis.  All  the  symptoms  rapidly  increase,  a  typhoid  state  is  inaugurated 
eventually,  and  death  closes  the  scene  unless  relief  be  given.  If  retention 
is  from  time  to  time  alleviated  by  the  passage  of  a  little  water,  the  symptoms 
are  slower  in  evolution  and  are  less  intense,  and  the  case  is  said  to  be  chronic. 
Some  cases  of  gradual  onset  due  to  atony  are  very  insidious,  the  patient 
feeling  no  particular  pain  and  complaining  only  of  the  dribbling,  which  is 
really  the  overflow  of  retention,  and  is  not  a  sign  that  the  bladder  is  success- 
fully emptying  itself.  In  any  case  of  retention  the  bladder  rises  above  the 
pubes,  and  there  is  found  a  pyriform,  elastic,  fluctuating  mass  in  the  hypo- 
gastrium,  which  mass  is  dull  on  percussion  and  gradually  enlarges  until  the 
bladder  is  evacuated  or  incontinence  sets  in.  The  flanks  give  a  clear  percus- 
sion-note, and  the  tumor  is  more  prominent  when  the  patient  is  erect  than 
when  he  is  recumbent.  Long  continuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  retention,  disorganizes 
the  kidneys.  Acute  and  complete  retention  may  induce  rupture  of  the  ure- 
thra or  urinary  suppression. 


Treatment  of  Retention  of  Urine 


1313 


Treatment  of  Retention  of  Urine. — Place  the  patient  upon  his  back  and, 
if  possible,  upon  a  hard  mattress.  If  the  bed  is  so  soft  that  the  hips  sink  do"WTi 
in  it,  put  an  ironing  board  or  some  other  support  beneath  the  mattress 
at  the  level  of  the  buttocks.  This  will  greatly  facilitate  catheterization. 
Never  attempt  to  use  a  catheter  when  the  patient  is  erect;  to  do  so  may 
cause  serious  or  even  fatal  shock.  Always  keep  the  patient  protected  from 
cold.  Obtain  a  full  history  of  the  case  and  always  make  a  gentle  rectal  ex- 
amination of  the  prostate;  also  examine  the  external  genitalia.  Failure  is 
often  traceable  to  a  lack  of  thorough  examination.  It  is  evident  that  retention 
due  to  prostatic  disturbance  is  not  to  be  dealt  vnth.  in  the  same  manner  as 
retention  due  to  stricture,  impacted  stone,  etc.  If  instrumentation  does  not 
rapidly  succeed,  give  an  anesthetic.  Be  sure  that  every  instrument  is 
aseptic,  and  irrigate  the  urethra  before  and  after  instrumentation.  Grease 
the  instrvmients  with  Hquid  cosmolin.  Prolonged  attempts  to  introduce  a 
catheter  and  excessive  instrumentation  are  highly  dangerous,  especially  in 
prostatic  cases.  Dreadful  damage  may  be  inflicted.  There  is  no  operation  in 
surgery"  that  requires  a  gentler  touch.  Haste,  eagerness,  carelessness,  rough- 
ness are,  alike,  taboo.  If  a  non-medical  person  knew  the  facts  he  would  give 
more  thought  in  the  selection  of  a  surgeon  to  reheve  him  of  retention  of  urine 
than  of  a  surgeon  to  amputate  his  leg.  A  surgeon  with  retention  would  give 
grave  thought  to  the  question.  WTien  the  instrument  enters  the  bladder, 
draw  off  but  hah  of  the  mine, 
withdraw  the  instrument,  wait 
a  few  hours,  insert  it  again,  and 
then  empty  the  bladder  and 
wash  out  the  \dscus  with  warm 
boric  acid  solution.  To  draw  off 
aU  of  the  urine  at  once  is  danger- 
ous, because  the  sudden  relief  of 
the  pressure  upon  distended  veins 
leads  to  bleeding  from  the  mucous 
membrane  and  hemorrhage  into 
the  bladder  walls.  After  the 
bladder  has  been  emptied  the 
patient  is  wrapped  in  blankets,  a 
bag  of  hot  water  is  placed  against  the  perineimi,  and  a  hot-water  bag  is  laid  upon 
the  hypogastric  region.  If  no  anesthetic  was  used,  he  is  given,  at  once  after 
the  operation,  a  suppository  of  opiiun  and  belladonna.  If  an  anesthetic  was 
used,  he  is  given  the  suppositon,^  when  he  recovers  from  the  effect  of  the  anes- 
thetic. Tablets  of  salol  and  boric  acid  are  administered  during  the  several 
days  which  immediately  foUow  the  operation.  If  the  cause  of  retention  is 
organic  stricture,  tr}^  to  pass  an  elastic,  olivary  pointed  catheter  (Fig.  877,  a). 
Do  not  use  any  force  imtil  the  neck  of  the  elastic  catheter  is  well  engaged  in 
the  stricture.  Then  an  experienced  operator  may  warily  use  a  certain  amount 
of  force,  but  never  an  amount  which  much  exceeds  the  slightest.  If  it  is  found 
impossible  to  pass  an  elastic  instrimient,  make  an  attempt  to  carr}'  a  fiHform 
whalebone  bougie  into  the  bladder.  Fig.  878  shows  filiform  bougies.  If  the 
history  shows  that  the  man  has  long  had  an  organic  stricture,  do  not  waste 
time  with  the  gum  catheter,  but  at  once  proceed  to  use  the  filiform  bougie. 
On  this  bougie,  after  it  has  been  inserted,  Gouley's  tunnelled  catheter  can 
perhaps  be  threaded  (Fig.  879)  and  carried  into  the  bladder.  Instead  of  carry- 
ing in  the  catheter,  we  can  simply  leave  the  filiform  bougie  in  place  and  fasten 
it.  The  filiform  bougie  will  act  as  a  capillary  drain,  and  in  a  few  horn's  will 
empty  the  bladder  and  will  also  dilate  the  stricture.  Then  insert  another 
bougie  beside  the  first,  and  so  on  for  several  days,  using  also  opium,  order- 
83 


Fig.  877. — a,  French  olivarj-  gum  catheter;  b,  Aler- 
cier's  elbowed  catheter  (.coude);  c,  !Merder's  double- 
elbowed  catheter  (bicoude);  d,  cur\-ed  gum  catheter. 


I3I4 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


ing  rest  in  bed,  and  making  no  attempt  to  dilate  the  stricture  forcibly  until 
retention  has  ceased  and  inflammation  has  subsided.  Perhaps  Phillips's 
catheter  (Fig.  883)  can  be  passed.  If  no  instrument  can  be  passed,  aspirate 
above  the  pubes  or  perform  cystotomy  (suprapubic  or  perineal).  In  spas- 
modic stricture  hold  a  good-sized  metal  catheter  firmly  against  the  face  of 
the  spasmed  area;  relaxation  will  occur  and  the  instrument  will  eventually 


\. 


Fig.  878.— Points  of 
Gouley's  whalebone  guides 
(filiform  bougies). 


Fig.  879. — Gouley's  tunnelled  catheter  threaded  on  a  fiHfonn  bougie. 


pass.  Fig.  880  shows  the  proper  curve  of  a  metal  instrimient.  An  individ- 
ual who  has  an  organic  stricture  which  has  given  but  little  trouble  may 
develop  attacks  of  retention  because  of  inflammatory  edema  of  the  mucous 
membrane  and  spasm  of  the  urethral  muscles.  These  attacks  are  tempo- 
rary, and  an  instrument  can  usually  be  inserted  when  employed  as  above 
directed.  In  inflammation  give  a  hot  hip-bath  and  suppositories  of  opium  and 
belladonna,  and  then  use  a  hot  sand-bag  to  the  perineum  and  a  hot-water  bag 


Fig.  880. — ^4 -£-E  shows  the  proper  curve  (reduced  in  size)  for  unyielding  male  urethral  instruments; 
C—B-D  shows  an  improper  curve. 

over  the  hypogastrium.  If  these  fail  or  if  the  symptoms  are  urgent,  pass  a 
soft  catheter.  In  the  occluded  meatus  of  the  newborn  incise  with  a  tenotome. 
In  a  congenital  cyst  of  the  sinus  pocularis  pass  a  steel  bougie,  which  will  rupture 
the  cyst.  In  complete  phimosis  spUt  up  the  prepuce.  In  impacted  stone  try 
to  pull  out  the  calculus  with  urethral  forceps;  if  this  fails,  cut  the  urethra  or, 
in  rare  cases,  push  the  stone  back  into  the  bladder.     In  fecal  impaction  scrape 


Fig.  881. — English  silk-web  catheter. 

out  the  rectum  with  a  spoon.  In  enlarged  prostate  the  rectal  examination  gives 
information  as  to  the  type  of  enlargement.  If  there  is  moderate  enlargement 
of  the  middle  lobe  the  coude  (Fig.  877,  h)  or  the  bicoude  catheter  (Fig.  877, 
c)  will  probably  pass.  If  these  instruments  fail,  try  the  overcurved  silver 
catheter  of  Sir  Benjamin  Brodie.  This  metal  instrument  has  a  large  curve  and 
will  probably  succeed,  but  it  is  a  dangerous  tool  and  one  capable  of  inflicting 
grave  injury.     In  enlargement  of  one  lateral  lobe  with  possible  deflection  of  the 


Exstrophy  of  the  Bladder 


1315 


urethra  and  valve  formation  try,  in  order,  the  woven  silk  catheter  (Fig.  881), 
the  Nelaton  catheter  (Fig.  882),  strengthened  by  having  a  fihform  passed  in 
its  lumen  nearly  to  the  beak,  and  the  rat-tailed  silk  instrument.  In  enlarge- 
ment of  both  lobes  and  the  middle  lobe  try  the  coude,  then  the  bicoude,  then 
a  coude  and  a  bicoude  with  olivary  or  rat-tailed  tips.  If  all  of  these  faU,  the 
overcurv^ed  metal  catheter  of  Brodie  must  be  used  gently.  In  retention  from 
expulsive  defect  use  a  soft  catheter  (Fig.  882).  Cases  of  retention  after  cathe- 
terization require  warmth,  confinement  to  bed,  the  administration  of  laxatives, 
free  action  of  the  skin,  and  the  use  of  such  drugs  as  salol,  boric  acid,  urotropin, 


Nelaton's  catheter. 


and  quinin  to  asepticize  the  urine.  In  some  few  cases  no  instrument  can  be 
inserted  in  the  bladder.  In  most  of  such  cases  aspirate — which  may  be  done 
several  times  if  necessary — and  in  a  day  or  two,  when  swelling  and  congestion 
abate,  an  instrument  can  be  passed.  The  parts  are  asepticized.  A  small 
aseptic  trocar  or  aspirator  needle  is  pushed  into  the  bladder,  the  trocar  or 
needle  being  inserted  in  the  median  line,  just  above  the  pubes,  and  taking  a 
course  downward  and  backward.  After  the  completion  of  the  operation  the 
pimcture  is  dressed  with  iodoform  and  collodion.     Only  half  the  urine  is  with- 


Phillips's  catheter. 


drawn  at  a  first  aspiration.  Rectal  puncture  is  now  obsolete.  If  incision  is 
necessary  in  retention,  the  perineal  route  is  usually  chosen.  In  some  cases  the 
operation  is  done  with,  in  some  without,  a  guide.  In  prostatic  retention  not 
rehevable  by  a  catheter,  make  suprapubic  drainage  or  do  prostatectomy. 

Congenital  Defects  of  the  Bladder. — Exstrophy  of  the  bladder 
(ectopia  vesicce)  is  a  condition  of  defective  development  commoner  in  males 
than  in  females.  The  anterior  abdominal  wall  has  failed  to  close,  the  ante- 
rior wall  of  the  bladder  is  absent,  the  arch  of  the  pubes  has  not  developed, 


13 1 6  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

epispadias  exists,  and  in  many  cases  the  testicles  have  not  descended  into 
the  scrotum.  In  this  condition  the  posterior  wall  of  the  bladder  projects 
into  or  beyond  the  gap  in  the  abdominal  wall;  the  urine  constantly  flows  and 
renders  the  condition  of  the  patient  dreadful.  The  condition  shortens  life 
and  only  30  per  cent,  of  the  victims  live  beyond  the  twentieth  year,  death 
being  due  to  pyelonephritis. 

The  only  treatment  which  offers  hope  is  operation,  and  operation  often 
fails.  If  possible,  operate  when  the  patient  is  about  five  years  of  age.  Various 
operations  have  been  suggested  for  this  condition,  viz.:  covering  with  skin- 
flaps;  implanting  the  ureters  into  the  bowel  (Maydl,  Albert,  Roux,  Simon, 
and  others) ;  division  of  the  posterior  ligaments  of  the  sacro-iliac  joints,  bring- 
ing the  arch  of  the  pubes  forcibly  together,  the  patient  wearing  a  support 
until  the  parts  become  firm,  when  the  greatly  narrowed  defect  is  closed  in  by 
integumentary  flaps  and  suturing  the  bladder  edges  {Trendelenburg's  opera- 
tion or  synchondroseotomy) ;  osteotomy  through  one  ilium  or  both  ilia  instead 
of  separation  of  the  sacro-iliac  joints  {Berg's  operation) ,  or  after  extirpating  the 
bladder,  loosening  the  ureters  from  the  bladder,  drawing  them  down  and 
attaching  them  to  the  end  of  the  penis  {Sonnenberg's  operation) . 

A  bladder  closed  in  by  autoplasty,  by  Trendelenburg's  operation,  or  by 
Berg's  operation  is  never  really  continent,  although  when  the  patient  is  erect 
and  wears  a  light  compress  he  may  perhaps  be  able  to  hold  water  two  or  three 
hours.  The  above  methods  are  suited  to  young  children  and  are  far  safer 
than  ureteral  transplantation.  Tuffier  showed,  nearly  twenty  years  ago,  that 
transplantation  of  the  cut  ureters  into  the  bowel  was  certain  to  be  followed 
by  fatal  infection  of  the  kidney,  and  that  the  only  way  to  prevent  this  was  to 
retain  the  ureteral  orifices  which  contain  valves. 

Maydl  introduced  his  operation  in  1892.  He  implanted  the  trigone  with 
the  ureters  into  the  sigmoid  flexure,  extirpating  the  rest  of  the  bladder.  I 
have  twice  performed  a  modified  Maydl's  operation,  with  one  death  and  one 
recovery.  Buchanan  ("Surg.,  Gynecol.,  and  Obstet.,"  Feb.,  1909)  has  col- 
lected 80  cases.  In  this  collection  there  were  23  deaths  (28.7  per  cent.);  7 
died  of  peritonitis  and  9  of  pyelonephritis.  Bregenhem  in  1894  devised  extra- 
peritoneal implantation  of  the  ureters  and  a  portion  of  bladder  through  two 
separate  openings  into  the  rectiim. 

Diseases  and  Injuries  of  the  Bladder. — This  viscus  is  so  deeply 
situated,  and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely  injured  when 
empty.  If  the  bladder  is  fifll  and  the  abdomen  tense — which  is  common 
in  alcoholic  intoxication — ^force  appHed  upon  the  abdomen  may  injiire  the 
bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are  noted  vesical 
hematuria,  tenesmus,  severe  cystitis,  and  an  impediment  to  the  flow  of  water 
because  of  clots.  Hemorrhage  may  be  very  severe  and  sepsis  may  arise, 
even  causing  death.  When  contusion  exists  retention  is  relieved  by  means 
of  a  clean  soft  catheter;  if  this  fails  because  of  occlusion  of  the  eye  of  the 
catheter  with  blood-clot,  at  intervals  there  must  be  passed  through  the  cath- 
eter from  a  fountain-syringe  a  solution  of  sodium  bicarbonate  in  cooled  boiled 
water.  Gross's  blood-catheter  can  be  used  or  the  evacuator  of  Bigelow  may 
be  employed.  The  patient  is  put  to  bed,  a  hot-water  bag  is  applied  to  the 
hypogastrium,  morphin  is  adrninistered  in  moderate  doses,  the  bladder  is 
washed  out  several  times  a  day  with  boric  acid 'solution  or  a  solution  of  bicar- 
bonate of  sodium  to  disintegrate  and  remove  blood-clots,  and  the  urine  is 
diluted  and  rendered  aseptic  by  the  stomach  administration  of  salol,  boric  acid, 
and  the  free  use  of  bland  fluids.  Hemorrhage  usually  ceases  on  relieving  dis- 
tention; if  it  does  not,  some  more  radical  measure  must  be  employed  (see 
Hematuria) . 


Rupture  of  the  Bladder  131 7 

Wounds  of  the  Bladder. — Besides  being  contused,  the  bladder  may  be 
injured  by  bullets:  by  stabs  or  punctures  through  the  abdomen,  the  vagina, 
or  the  uterus:  or  by  penetration  by  a  fragment  of  a  fractured  pehdc  bone. 
The  S}Tnptom5  of  such  conditions  are  those  of  rupture  of  the  bladder  (q.  ?.). 
In  an  intraperitoneal  wound  at  once  open  the  abdomen,  sutiu-e  the  woimd 
in  the  bladder  wall,  irrigate  and  drain  the  peritoneal  ca\'ity,  and  drain  the 
bladder  by  means  of  a  retained  catheter,  perineal  section,  or  suprapubic  cys- 
totomy. In  an  extraperitoneal  wound  drain  the  wound  by  a  tube,  and  drain 
the  bladder  by  a  retained  catheter,  perineal  section,  or  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms:  (i)  intraperitoneal — a 
rupture  involving  the  peritoneal  coat;  (2)  extraperitoneal — a  rupture  of  a  por- 
tion of  the  bladder  not  covered  by  peritoneum:  and  (3^  subperitoneal — a 
rupture  of  the  mucous  and  muscular  coats,  the  urine  diffusing  under  the 
peritoneal  investment.  The  causes  are  of  two  kinds,  predisposing  and  ex- 
citing. Predisposing  causes  are:  distention  of  the  bladder:  drunkenness:  c}*3- 
titis;  ulceration;  degeneration  or  atony  of  the  bladder-coats:  prostatic  enlarge- 
ment, and  luethral  stricture.  Distention  of  the  bladder  is  the  great  predispos- 
ing cause.  It  causes  the  bladder  to  rise  from  the  peMs  and  so  become  exposed 
to  a  direct  blow,  it  places  the  organ  imder  tension,  and  force  tends  to  rupture  the 
weakest  point.  In  about  one-third  of  the  cases  collected  by  Bartels  the  in- 
di\ddual  was  intoxicated  at  the  time  of  the  accident.  Drunkenness  predisposes 
because  a  dnmken  man  is  ver\-  liable  to  injur}'  and  is  apt  to  have  a  distended 
bladder  and  a  rigid  belly  wall.  ISIales  are  much  more  liable  to  rupture  than 
females  (10  to  i).  Most  cases  are  between  the  ages  of  twentA'  and  forty.  Of 
Besley's  25  cases,  i  was  a  child  of  three,  i  a  man  of  forty-nine,  3  were  in  the  first 
and  second  decades,  5  were  between  twenty-  and  thirty,  7  between  thirty  and 
forty,  6  between  forty  and  fift\',  and  in  2  the  age  is  not  given  (paper  before 
Chicago  Surg.  Soc,  Feb.,  1907).  The  condition  is  ver}-  rare  in  children,  but 
I  of  Besley's  cases  was  three  years  of  age.  and  King  recorded  the  accident 
in  a  fetus  with  imperforate  urethra. 

Exciting  causes  are:  obstruction  to  the  outflow  of  urine  (by  stricture  or  en- 
larged prostate) ;  external  \T.olence;  falls  upon  the  feet  or  the  buttocks,  as  well  as 
upon  the  abdomen:  lifting:  straining  at  stool,  in  micturition,  or  during  partu- 
rition: and  the  forcing  of  injections  into  the  bladder.  A  distended  bladder  may 
be  ruptiued  by  a  concussion.  The  most  usual  cause  of  the  injur}-  is  a  crush. 
The  mechanism  of  the  injiu*}'  is  in  dispute.  It  is  certain  that  the  bladder  must 
have  lost  its  elasticity  by  distention.  \Mien  force  is  applied  to  fluid  i  fluid  is 
incompressible)  the  bladder  tears  at  its  weakest  point.  The  weakest  point 
is  not  identical  in  all  indi\-iduals.  It  may  be  weak  am-where  from  disease. 
The  most  common  site  of  the  tear  is  at  the  posterosuperior  aspect,  but  it  may 
be  in  front,  at  either  side,  or  at  the  pubic  or  prostatic  ligament  i  Staubenranch). 
The  mucous  membrane  or  the  peritoneum  may  give  way  lirst  and  the  tear  may 
be  anteroposterior,  oblique,  or  longitudinal.  Alexander  maintains  that  the 
most  usual  cause  of  the  injur}-  is  a  crush  which  forces  the  distended  bladder 
against  the  sacral  promontor}-,  but  Besley's  (Ibid.'i  experiments  do  not  indi- 
cate that  this  is  correct.  A  common  complication,  especially  of  extraperitoneal 
rupture,  is  fracture  of  the  pehis,  due  to  the  same  force  that  ruptiu-ed  the 
bladder. 

Symptoms,  Diagnosis,  and  Treatment. — The  s}Tnptoms  are  not  always 
definite,  and  ever}-  characteristic  one  may  be  for  a  time  absent,  the  patient 
seeming  in  some  rare  instances  of  extraperitoneal  and  intraperitoneal  rupture  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it.  As  a  rule,  however, 
there  are  foimd  some  or  all  of  the  following  s}-mptoms,  following  an  accident 
or  occurring  during  the  progress  of  a  causative  disease:  severe  pain  in  the  blad- 
der and  in  the  suprapubic  region,  coUapse:  inability  to  walk  or  great  diffic\flty 


1318  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

in  walking ;  excessive  desire  to  micturate,  but  inability  to  do  so  (sometimes  a  little 
pure  blood  or  bloody  water  is  squeezed  out  by  painful  effort) ;  a  catheter,  when 
used,  brings  away  piure  blood  or  a  very  little  bloody  urine ;  the  catheter  occa- 
sionally slips  through  the  tear  into  the  cavity,  and  more  bloody  water  comes 
away.  In  some  reported  cases  clear  water  has  been  withdrawn.  If  a  measured 
amount  of  boric  acid  solution  is  injected,  it  is  improbable  that  all  of  it  can  be 
withdrawn  by  the  catheter,  although  in  some  cases  it  may  all  come  away 
(Alexander,  in  "Annals  of  Surgery,"  August,  1901).  Injecting  fluid  fails  to 
lift  the  bladder  into  the  hypogastric  region  so  as  to  be  recognizable  on  percus- 
sion. In  a  patient  suffering  from  retention  of  urine  in  whom  rupture  occurs 
there  is  first  a  temporary  sense  of  relief  from  retention,  but  very  soon  severe 
h3^ogastric  pain  and  rectal  tenesmus.  In  intraperitoneal  rupture  reaction 
may  be  obtained  after  a  few  hours  or  a  number  of  hours.  The  evidences  of 
peritonitis  will  be  noted  soon  (rapid  pulse,  perhaps  vomiting,  rigidity,  disten- 
tion, obstruction  of  the  bowel,  elevated  temperature,  etc.).  Shock  in  vesical 
rupture  is  so  severe  that  death  may  ensue;  if  reaction  follows,  there  may  be 
delirium  and  often  septicemia;  extensive  infiltrations  of  urine  may  occur. 
In  intraperitoneal  rupture  general  peritonitis  is  certain  to  arise,  but  its  appear- 
ance may  be  postponed  for  several  days  if  the  urine  is  healthy.  In  these  cases 
the  extravasation  is  noted  as  a  simple  sweUing,  probably  on  one  side  only. 
In  extraperitoneal  rupture  the  urine  may  infiltrate  the  perineum,  the  scrotiun, 
the  thighs,  and  under  the  integuments  of  the  abdomen  and  the  back,  and 
may  soon  induce  sloughing.  In  subperitoneal  rupture  peritonitis  is  apt  to 
arise. 

In  doubtful  cases  some  surgeons  pump  air  or  hydrogen  into  the  bladder. 
To  insert  air  a  bicycle  pump  can  be  used  (Brown)  or  a  Davidson  syringe  (Keen). 
Keen's  directions  are  to  insert  a  catheter,  empty  the  bladder  of  urine,  and  con- 
nect to  the  catheter  a  disinfected  Davidson's  syringe,  a  mass  of  absorbent  cot- 
ton being  fastened  over  the  distal  end  of  the  syringe.  Air  after  it  has  filtered 
through  the  cotton  is  pumped  into  the  bladder;  an  unruptured  bladder  will 
rise  above  the  pubes  as  a  pyriform  tumor,  tympanitic  on  percussion.  A 
ruptured  bladder  will  not  so  rise.  In  intraperitoneal  rupture  the  air  will 
pass  into  the  general  peritoneal  cavity  and  distention  will  occur.  In  extra- 
peritoneal rupture  injection  will  produce  emphysema  of  the  extra  vesical 
connective  tissue.  On  removing  the  syringe  the  air  rushes  out  again  if  the 
bladder  is  unruptured,  but  little  if  any  comes  away  if  it  is  ruptured.  Alex- 
ander considers  gaseous  distention  unreliable,  and  claims  that  it  adds  to 
shock  and  disseminates  infection.  His  rule  is  the  wisest  to  follow;  that  is, 
in  a  case  of  suspected  rupture  of  the  bladder,  make  a  suprapubic  incision 
and  inspect  the  prevesical  space  for  signs  of  extraperitoneal  rupture.  If 
extraperitoneal  rupture  is  not  found,  open  the  belly  and  explore. 

Treatment. — In  extraperitoneal  rupture,  after  incision  down  to  the  blad- 
der insert  a  drainage-tube.  In  intraperitoneal  rupture,  place  the  patient  in 
the  Trendelenburg  positon,  expose  the  tear  in  the  bladder  by  abdominal  in- 
cision, and  suture  the  opening  in  the  viscus. 

Results. — Baron  Larrey  was  the  first  surgeon  to  state  that  a  wound  through 
all  the  coats  of  the  bladder  might  be  followed  by  recovery.  In  intraperitoneal 
ruptures  if  operation  is  not  performed  the  mortality  is  98  per  cent.  If  opera- 
tion is  performed  many  cases  recover.  Of  the  78  cases  collected  by  Dambriu 
and  Papin  in  1904,  34  died,  a  mortality  of  43  per  cent.  (Besley,  paper  before 
Chicago  Surg.  Soc,  Feb.,  1907).  Galactionoff  ("Rovssky  Vratch,"  Nov.  12, 
1 910)  reports  15  cases  operated  upon  for  intraperitoneal  rupture;  5  recovered 
(3  of  them  were  operated  upon  during  the  first  twenty- four  hours;  i,  after 
thirty-six  hours,  and  i,  after  forty-eight  hours).  In  extraperitoneal  rupture 
without  operation  there  are  11  per  cent,  cures  and  with  operation  30  per  cent. 


Treatment  of  True  Paralysis  of  the  Bladder  13 19 

(See  Daniel  N.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25,  1902;  Samuel 
Alexander,  "Annals  of  Surgery,"  Aug.,  1901.) 

Atony  of  the  bladder  is  a  condition  in  which  the  expulsive  power  of 
the  bladder  is  diminished  or  lost  because  of  impairment  of  muscular  tone. 
The  bladder  is  very  thin,  and  the  muscles  are  flaccid  and  often  the  seat  of 
fatty  degeneration.  Sometimes  the  viscus  is  very  large  and  sometimes  it  is 
very  small.     A  slight  degree  of  atony  is  physiological  after  middle  age. 

The  causes  are  senility,  distention  from  true  paralysis,  chronic  overdistention 
from  obstruction,  and  acute  overdistention.  In  most  cases  there  is  obstruction 
of  the  urethra.  In  that  rare  condition  known  as  idiopathic  atony  there  is  no 
evidence  of  obstruction.  Walker  ("Annals  of  Surgery,"  Nov.,  1910)  reports 
12  cases  of  idiopathic  atony.  He  says  the  patients  were  between  the  ages 
of  twenty-two  and  forty.  He  regards  the  condition  as  due  to  a  lesion  in  the 
reflex  centers. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes  water  frequently 
(a  symptom  probably  existing  for  some  years),  and  especially  at  night;  he 
may  even  do  so  while  asleep.  The  stream,  when  voluntarily  passed,  has  little 
projection,  but  seems  to  drop  at  once  from  the  end  of  the  penis.  Residual 
urine  exists  for  years  and  may  at  any  time  set  up  cystitis,  and  retention  with 
incontinence  is  apt  to  occiu*.  This  condition  is  not  vesical  paralysis  resulting 
from  a  lesion  of  the  nervous  system. 

Treatment. — In  treating  atony  of  the  bladder  measure  the  residual  urine: 
if  it  amovuits  to  4  oz.,  use  a  soft  catheter  night  and  morning;  if  it  amounts 
to  6  oz.,  use  the  catheter  every  eight  hours;  if  it  amounts  to  8  oz.,  use  the 
catheter  every  six  hoiu*s  (J  W.  White).  The  patient  should  be  taught  how  to 
use  the  catheter  and  how  to  keep  it  sterile.  (For  Methods  of  Disinfecting 
Catheters  see  article  on  page  13 n.)  The  bladder  is  from  time  to  time  washed 
out  with  3  gr.  to  the  ounce  of  boric  acid  solution  at  a  temperature  of  100°  F. 
Strychnin,  electricity,  ergot,  and  urotropin  may  be  ordered. 

True  Paralysis  of  the  Bladder. — Vesical  paralysis  results  from  a 
lesion  of  the  nervous  system  causing  paralysis  of  the  motor  nerves  or  of  the 
motor  paths  from  which  they  are  prolongations  (fracture  of  the  vertebrae, 
spinal  meningitis,  syphilis  of  the  cord,  myelitis,  and  hemorrhage  about  or  into 
the  spinal  cord).  A  traumatic  paralysis  comes  on  suddenly.  Hysteria  may 
be  responsible  for  temporary  palsy.  If  the  detrusor  muscles  alone  are  palsied 
there  is  complete  retention  of  urine.  If  the  sphincter  is  paralyzed  the  urine 
dribbles  constantly.  Even  when  there  is  dribbling  a  quantity  of  lU^ine  is  re- 
tained below  the  level  of  the  internal  meatus.  In  such  a  case  there  is  inconti- 
nence with  partial  retention  (the  overflow  of  Sir  Henry  Thompson).  If  the 
patient  sits  down  or  assumes  the  knee-chest  position  he  may  empty  the  bladder 
by  contracting  the  abdominal  muscles.  In  cases  of  real  retention  the  detrusors 
may  be  temporarily  paralyzed.  In  such  a  case  the  sphincter  may  finally  relax 
from  fluid  pressure,  and  atmospherical  pressure  or  contraction  of  abdominal 
muscles  may  cause  urine  to  dribble,  the  bladder  remaining  full  (the  overflow  of 
retention  of  the  elder  Gross).  In  some  cases  of  vesical  paralysis  there  is  re- 
tention; in  some  cases,  incontinence  of  urine.  If  the  sensory  as  well  as  the 
motor  path  is  involved  in  a  lesion,  the  patient  has  no  sensation  to  notify  him 
of  dribbling  or  of  retention. 

Treatment. — Treat  the  cause.  Employ  regular  aseptic  catheterization 
by  a  soft  instrument.  In  some  cases  the  bladder  may  be  subjected  to  faradism 
(one  electrode  in  the  bladder  and  one  in  the  perineum  or  on  the  abdomen  above 
the  pubes).  Kilvington  ("Brit.  Med.  Jour.,"  1907,  vol.  i)  pointed  out  that 
the  nerve-supply  of  the  bladder  and  rectum  is  from  the  second  and  third  and 
sometimes  also  from  the  first  sacral  nerves.  He  suggested  treating  some 
otherwise  incurable  cases  of  vesical  paralysis  by  anastomosing  a  nerve-root  above 


1320  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  lesion  to  certain  sacral  nerves  below  the  lesion.  Bird  did  the  first  operation, 
but  it  failed.  Mills  and  Frazier  (see  page  863)  performed  intradural  anasto- 
mosis of  the  last  lumbar  nerve  to  the  third  and  fourth  sacral  nerves.  The 
patient  was  much  benefited  ("Jour.  Amer.  Med.  Assoc,"  Dec.  21,  1912). 

Foreign  Bodies  in  the  Bladder. — The  term  "foreign  body"  is,  at  best, 
a  poor  one,  since  a  stone  is  a  foreign  body.  The  term,  however,  is  generally 
used  to  designate  material  held  within  the  viscus  and  of  purely  extraneous  ori- 
gin. There  have  been  a  great  variety  of  foreign  bodies  removed  from  both  the 
male  and  female  urinary  bladder.  We  have  seen  a  lead-pencil,  hair-pins,  a 
willow  twig,  a  glass  rod,  and  a  piece  of  chewing  gtun  removed,  as  well  as  por- 
tions of  catheters  and  filiform  bougies.  For  reports  of  foreign  bodies  found  in 
the  bladder  the  reader  is  referred  to  text-books  upon  genito-urinary  diseases. 

Most  of  the  foreign  bodies  are  foimd  in  the  bladders  of  masturbators.  In 
them  the  glans  penis  or  the  clitoris  have  become  so  inm*ed  to  friction  that  they 
must  seek  deeper  for  sensation,  and  consequently  men  resort  to  titillation  of 
the  verumontanum  and  posturethra,  and  women,  to  irritation  of  the  vesical 
neck.  The  object  used  to  stir  sensation  may  slip  from  the  grasp  and  pass  back- 
ward into  the  bladder.  The  careless  use  of  the  filiform  bougie  is  a  great  danger. 
Always  test  the  filiform  for  defects  and  for  tensile  strength  before  using  it. 
Should  you  be  using  the  Gouley  catheter,  see  that  the  tip  through  which  the 
filiform  must  lace  is  not  sharp  or  square,  else  it  may  shear  off  a  portion  of  the 
bougie.  All  foreign  bodies  sooner  or  later  induce  cystitis.  Every  foreign  body 
if  allowed  to  remain  will  become  encrusted  with  urinary  salts  and  form  a 
nucleus  for  stone  formation. 

Diagnosis,  Symptoms,  and  Treatment. — Diagnosis  is  made  by  the  history, 
if  given  correctly,  of  the  case.  The  stone-searcher,  the  x-ray,  and  the  cysto- 
scope  are  most  useful  in  diagnosis.  The  symptoms  are  similar  to  those  of 
stone  in  the  bladder.  The  treatment  is  removal,  with  subsequent  care  of  the 
resultant  cystitis. 

Vesical  Calculus,  or  Stone  in  the  Bladder. — ^The  salts  normally 
in  solution  in  the  urine  may  deposit  as  calcuH  and  may  be  imprisoned  in  any 
portion  of  the  urinary  tract.  The  commonest  primary  calculi  are  those  com- 
posed of  uric  acid,  urates,  calcium  oxalate,  and  fusible  phosphates.  In  80  per 
cent,  of  cases  primary  calculi  are  composed  of  uric  acid  and  urates.  A  primary 
calculus  may  become  coated  with  another  material  (secondary  calculus). 
The  formation  of  uric  acid  and  urate  calculi  is  explained  under  Renal  Calculus 
(see  page  1283).  Vesical  calcuU  are  usually  renal  calculi  that  have  passed  the 
ureter  and  become  enlarged  by  new  accretions.  New  accretions  from  an  alka- 
line urine  will  cause  the  formation  of  a  secondary  phosphatic  stone.  Phos- 
phatic  calculi  may  be  formed  in  the  bladder  when  chronic  cystitis  causes  and 
maintains  an  alkaline  urine.  Uric-acid  calculi  are  smooth,  round  or  oval,  and 
hard,  but  easily  broken.  On  section  they  present  the  color  of  brick-dust  and 
are  marked  by  concentric  rings.  Their  nuclei  are  dark  by  comparison.  They 
are  soluble  in  dilute  potassium  hydrate  and  in  nitric  acid.  They  are  com- 
bustible and  leave  scarcely  any  ash.  Urate  of  sodium  and  urate  of  ammonium 
often  occur  together  in  stones,  and  these  calculi  are  not  in  rings,  are  not  so 
hard  as  the  uric-acid  stones,  and  are  fawn  colored  on  section.  Oxalate  of  lime 
stones  are  round,  with  many  projecting  nodes  like  the  mulberry,  hence  the  term 
"mulberry  calculus."  They  are  very  hard,  and  section  shows  the  color  to  be 
brown  or  green  and  that  they  possess  wavy,  concentric  rings.  This  form  of 
calculus  is  soluble  in  hydrochloric  acid.  The  so-called  fusible  calculus  of  the 
early  writers,  which  is  composed  of  a  phosphate  of  magnesium,  ammonium, 
and  calcium  {triple  phosphate),  constitutes  the  commonest  form  of  phosphatic 
stone  and  of  large  stone.  It  is  light,  soft,  smooth  and  white,  and  shows  no 
laminae  on  section.     Some  rare  forms  of  primary  stone  are  composed  of  xan- 


Symptoms  of  Vesical  Calculus,  or  Stone  in  the  Bladder         13 21 

thin,  cystin,  indigo,  urostealith,  calcium  phosphate  or  calcium  carbonate,  or 
blood  concretions. 

A  stone  having  layers  of  different  substances  may  be  formed;  for  instance, 
there  is  often  found  a  uric-acid  nucleus  surrounded  by  phosphates,  the  latter 
surrounded  by  some  uric  acid  or  urates,  and  these  again  by  phosphates.  In 
some  cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or  phosphates 
(Bowlby).  Bowlby  states  that  the  alternating  uric-acid  and  phosphatic 
layers  are  due  to  the  altering  reactions  of  the  urine;  that  when  the  urine  is 
acid  uric  acid  is  deposited  on  the  stone,  but  when  cystitis  makes  the  urine 
alkahne  the  stone  receives  a  phosphatic  coat. 

Anything  that  favors  the  formation  of  an  excessive  urinar\'  deposit  may 
cause  vesical  calculus,  and  among  such  causes  are  defective  digestion,  failure 
in  processes  of  oxidation,  excess  of  solids  and  nitrogenous  elements  in  the  diet, 
deficient  exercise,  etc.  If  to  the  urinarv-  condition  established  by  the  above 
factors  catarrh  of  the  genito-urinar}--  tract  is  added,  pus  or  mucopus  in  the 


Fig.  884.^Stone  in  bladder  shown  by  .r-rays. 

concentrated  urine  may  induce  stone.  Children  are  predisposed  to  uric-acid 
stones,  and  old  people  to  phosphatic  stones.  In  an  old  man  with  enlarged 
prostate  and  chronic  cystitis  a  stone  forms  rapidly  about  any  accidental 
nucleus.  The  nucleus  ma}^  be  phosphate  crj'stals  glued  together  by  mucus, 
a  blood-clot,  uric-acid  gravel,  or  a  foreign  body.  Stone  is  rare  in  females 
because  of  the  shortness,  the  large  diameter,  and  the  ready  dilatabihty  of  the 
urethra.  Stone  is  very  rare  in  the  negro.  Gout,  rheumatism,  lithemia, 
enlarged  prostate,  vesical  atony,  urethral  stricture,  and  catarrhal  inflamma- 
tion of  the  kidney,  the  ureter,  and  the  bladder  are  predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are  antedated  by  an 
attack  of  nephritic  colic.  Hence  the  necessity  for  cystoscopy  after  renal  colic 
if  no  stone  passed  from  the  meatus,  and  the  removal  of  any  retained  stone  by 
the  evacuator  or  the  cystoscopy  The  severity  of  the  s>Tnptoms  of  stone  in  the 
bladder  depends  more  on  the  roughness  of  the  stone  than  on  its  size.  A  smaU, 
rough  calculus  will  produce  intolerable  anguish,  whereas  several  large,  smooth 


1322  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

stones  will  cause  but  moderate  pain.  A  patient  with  stone  in  the  bladder  com- 
plains of  frequency  of  micturition,  particularly  in  the  daytime,  the  desire  being 
sudden,  uncontrollable,  and  invoked  or  aggravated  by  exercise.  This  symp- 
tom is  more  positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning  char- 
acter is  experienced  at  the  end  of  micturition,  due  to  the  contraction  of  the 
empty  bladder  upon  the  stone  or  stones.  It  disappears  gradually  as  urine 
enters  and  distends  the  bladder.  The  usual  seat  of  this  pain  is  the  under  sur- 
face of  the  head  of  the  penis,  a  little  behind  the  meatus,  and  the  pain  may 
continue  for  some  time.  By  pulling  on  the  penis  to  relieve  this  pain  the  pre- 
puce of  a  child  may  become  pendulous.  The  pain  varies  in  severity,  being 
much  worse  during  an  attack  of  cystitis  and  after  exercise;  it  may  be  absent 
in  encysted  stone;  it  may  be  present  early  in  a  case,  but  almost  disappear 
as  a  case  progresses,  and  it  is  always  worse  in  the  young  than  in  the  old. 
Stone  in  chronic  cases  of  atony  and  in  cases  of  vesical  paralysis  causes  neither 
marked  pain  nor  frequency  of  micturition.^  In  a  case  of  enlarged  prostate  pain 
precedes  the  act  of  micturition,  in  urethral  stricture  it  accompanies  it,  and 
in  stone,  as  already  stated,  it  follows  it  (P.  J.  Freyer,  in  "The  Practitioner," 
Feb.,  1898).  The  symptoms  may  be  somewhat  confused  by  the  coexistence 
of  vesical  calculus  and  prostatic  hypertrophy.  Attacks  of  cystitis  in  a  man 
with  calculus  are  spoken  of  as  attacks  of  stone.  When  a  stone  is  small,  it 
may  during  micturition  roll  into  the  urethral  orifice,  and  so  cause  a  sudden 
interruption  of  the  flow  of  urine,  the  stream  again  starting  when  the  patient 
changes  his  position.  This  symptom  is  seldom  met  with  and  is  particularly 
rare  in  the  old,  the  stone  in  them  dropping  into  the  sac  back  of  the  prostate 


■mr»rm.i..ijj.i!d^ 


^ 


Fig.  885. — Thompson's  calculus  sound. 


and  helow  the  urethral  orifice.  Even  if  this  symptom  occurs,  it  is  not  con- 
clusive, as  a  stalked  tumor,  a  blood-clot,  or  a  mass  of  pus  or  mucus  may 
block  the  urethral  orifice  and  cut  off  the  stream.  Hematuria  may  or  may 
not  be  noted;  it  is  most  usual  after  exercise,  and  occurs  at  the  end  of  the 
urinary  act,  the  first  urine  passed  being  clear,  the  later  urine  being  blood- 
tinged,  and  at  the  end  of  the  act  some  drops  of  pure  blood  emerge.  It  is 
not  one  of  the  earliest  symptoms.  When  it  occurs  it  puts  the  patient  in  a 
great  fright.  It  does  not  appear  suddenly  and  profusely,  but  as  gradual  and 
trivial  bleeding  and  with  micturition.  Blood  appearing  between  acts  of  mic- 
turition comes  from  either  the  urethra  or  prostate  (P.  J.  Freyer).  The  bleed- 
ing from  a  bladder  tumor  is  profuse  and  the  urine  is  mixed  with  blood  and 
blood-clots  and  tumor  fragments.  Bleeding  from  a  tuberculous  ulcer  of  the 
bladder  often  resembles  the  bleeding  caused  by  stone.  Pus  or  mucopus  will  be 
observed  if  cystitis  occurs  with  calculus  disease.  Priapism  occurs  in  some 
cases.  Pain  of  a  reflex  nature  may  be  felt  in  the  rectum,  in  the  perineum,  or 
in  some  distant  part. 

The  above  symptoms,  even  if  all  are  present,  do  not  prove  that  an 
individual  has  a  stone  in  the  bladder.  To  prove  the  presence  of  a  stone 
the  object  must  be  pictured  by  the  a;-rays,  seen  through  a  cystoscope,  or 
be  touched  by  a  sound.  Simple  touching  by  a  sound  is  not  sufficient, 
the  contact  must  be  felt  and  heard.  To  sound  a  patient,  have  the 
bladder  well  filled  with  boric  acid  solution  or  salt  solution,  and  place 
him  recumbent,  with  the  knees  drawn  up.  Never  sound  a  person  while 
he  is  standing,  because  of  the  danger  of  syncope.  In  an  ordinary  case 
1 "  American  Text-Book  of  Surgery." 


Treatment  of  Vesical  Calculus,  or  Stone  in  the  Bladder        1323 

in  a  male  use  a  sound  with  a  very  slight  curve  (Fig.  885) ;  in  a  man 
with  h^-pertrophied  prostate  use  a  sound  with  a  short  and  decided  curve. 
The  caliber  of  a  stone-sound  is  No.  13  of  the  French  scale.  The  instrument 
is  carefully  boiled  and  anointed  with  yellow  liquid  cosmolin.  Examine  the 
entire  bladder  systematically,  and  be  sure  a  stone  is  present  only  when  contact 
with  the  sound  is  both  heard  and  felt.  The  stone  may  be  difficult  to  find,  or 
it  may  elude  the  instrument  entirely  when  it  is  encysted,  when  it  rests  in  a 
diverticulum,  when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  \'iscus,  or 
when  it  is  crusted  with  lymph  or  blood-clot.  In  doubtful  cases  always  insist 
on  a  second  examination,  giving  ether  if  the  first  was  very  painful.  Occa- 
sionally, as  Freyer  pointed  out  in  1884,  a  small  stone  will  be  foimd  by  using  a 
Bigelow  evacuator,  the  current  causing  the  calculus  to  knock  against  the  tube. 
In  many  cases  stone  in  the  bladder  may  be  detected  by  means  of  the  .T-rays 
(see  Fig.  884).  Use  the  cystoscope  in  all  cases  of  suspected  stone.  If  a  stone 
is  fixed  in  a  diverticulum  or  projects  from  the  ureter,  or  is  in  a  sac  back  of  the 
prostate,  it  may  be  missed  by  sound  and  evacuator  tube,  but  be  shown  by  the 
x-rays  and  the  cystoscope.  A  stone,  when  it  is  detected,  should  always  be 
measured  by  Thompson's  instrument,  an  arrangement  looking  something  Hke 
a  small  edition  of  a  hthotrite,  but  having  very  delicate  blades.  The  composi- 
tion of  the  stone  is  assumed  from  an  examination  of  fragments  which  pass  by 
the  urethra  or  which  adhere  to  the  measure.  Remember  that  the  outer  layer 
of  a  calculus  may  be  soft  phosphate  and  the  inner  portion  may  be  the  harder 
lu^ic  acid,  urate,  or  oxalate. 

Stone  in  Females. — Calculus  in  the  female  is  a  rare  complaint.  In  over  900 
patients  operated  upon  by  Freyer  for  stone  there  were  only  20  females.  Pain 
and  increased  frequency  of  micturition,  which  are  s^-Tnptoms  of  stone  in  men 
and  women,  are  in  women  commonly  caused  by  other  conditions,  notably  by 
uterine  disease  and  displacement.  A  straight  soimd  is  used  to  examine  a  female 
for  stone.  If  the  surgeon  is  still  uncertain  after  soimding,  he  uses  a  cysto- 
scope or  dilates  the  urethra  and  explores  the  bladder  with  his  little  finger. 

Stone  in  children  can  occur  at  any  age,  and  congenital  cases  have  been 
placed  on  record.  The  \u"ic-acid  stone  is  most  common.  The  s\Tnptoms 
are  like  those  of  the  adult.  The  pain  causes  the  male  child  to  pull  at  the 
penis  and  the  prepuce  becomes  pendulous.  If  in  a  child  with  stone  the  stream 
of  urine  is  blocked  from  time  to  time,  the  child  strains  to  empty  the  bladder, 
and  after  a  time  a  hernia  may  form  or  prolapse  of  the  rectum  take  place. 

Treatment. — In  people  predisposed  to  stone  (for  instance,  by  lithemia) 
the  physician  should  forsee  the  danger  and  antagonize  it.  Insist  on  the 
urine  being  kept  dilute  by  the  freest  use  of  water  and  of  milk,  and  re- 
duce to  a  minimiun  the  amount  of  alcohol,  meat,  sugar,  and  fat  which  is 
taken.  Let  the  patient  live  chiefly  on  green  vegetables,  salads,  bread,  fruit, 
eggs,  fish,  poultry,  weak  tea  or  coffee,  water,  milk,  and,  if  desired,  a  little  red 
■^ine.  Continued  purging  does  harm  by  concentrating  the  urine,  though  a 
laxative  may  be  employed  when  indicated.  Moderate  open-air  exercise  is 
of  immense  importance,  simshine  and  fresh  air  being  Nature's  correctives 
for  a  condition  of  imperfect  oxidation  power.  If  the  urine  be  very  acid,  use 
piperazin,  15  to  20  gr.  daily,  liquor  potassii  citratis,  phosphate  of  sodium, 
or  borocitrate  of  magnesiimi.  If  the  lu-ine  be  phosphatic  and  alkaline,  order 
mineral  acids  and  strychnin,  or,  what  seems  to  be  very  efficient,  lu-otropin. 
Urotropin  is  given  in  5-gr.  capsules  four  times  daily.  If  the  urine  be  filled 
with  oxalate,  use  the  mineral  acids  "^nth  an  occasional  course  of  phosphate 
of  sodimn.  Travel  and  rest  at  the  seaside  or  at  some  spa  are  often  of  servdce 
in  aU  forms.  Always  endeavor  to  prevent  cystitis,  and  treat  it  promptly 
when  it  does  occur.  When  a  stone  is  once  formed,  it  is  an  idle  dream  to  think 
of  dissolving  it.     An  operation  must  be  done.     Some  very  small  stones  may  be 


1324  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

crushed  in  view  through  the  cystoscope  by  one  of  the  several  intravesical 
forceps,  but  in  an  immense  majority  of  cases  a  very  much  more  formidable 
operation  is  required.  The  operation  selected  depends  upon  the  age,  the  state 
of  the  bladder  and  the  prostate,  the  dilatability  of  the  urethra,  the  kidney  con- 
dition, the  size  and  composition  of  the  stone,  and  the  nimiber  of  calculi  present 
(see  Operations  on  the  Bladder). 

Bacteriuria. — Most  urines  contain  bacteria.  If  bacilli  are  present  in 
nimibers,  the  condition  is  called  hacilluria.  The  variety  and  number  vary 
greatly  in  different  individuals.  In  typhoid  fever  typhoid  bacilli  are  found. 
In  many  cases  of  nephritis  bacteria  are  present.  In  pulmonary  tuberculosis, 
vesical  tuberculosis,  and  renal  tuberculosis  bacilli  may  be  found  in  the  urine. 
In  some  cases  niunerous  cplon  bacilH  are  found.  They  may  seem  to  do  no 
harm;  they  may  cause  nephritis;  they  may  cause  cystitis. 

If  a  urine  contains  bacteria,  inflammation  of  the  genito-m^inary  tract  may 
or  may  not  exist,  but  even  if  it  does  not  exist  it  is  apt  to  occur  at  any  time. 
In  some  persons  the  urine  is  found  swarming  with  colon  baciUi.  Colon  bacilli 
are  capable  of  causing  a  very  severe  t3^e  of  cystitis  and  nephritis.  Bacterial 
urine  explains  many  cases  of  urinary  fever  (see  page  1369). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a  compUcation 
of  some  other  disease  of  the  genito-urinary  tract,  but  it  may  arise  after  ex- 
posure to  cold  and  wet.  Traumatism  from  a  catheter,  the  presence  of  a  stone, 
the  spread  of  a  urethral  inflammation,  pus  infection,  vesical  tuberculosis  or 
cancer,  and  the  use  of  such  drugs  as  cantharides,  turpentine,  alcohol,  urotropin, 
and  sandalwood  oil  in  large  doses  may  produce  it.  It  appears  not  unusually 
during  an  exanthematous  fever  or  in  conditions  of  vesical  paralysis;  it  often 
follows  retention;  frequently  accompanies  enlarged  prostate  and  urethral  stric- 
ture, and  sometimes  arises  from  concentration  of  urine  or  accompanies  bladder 
growths.  Acute  cystitis  causes  discoloration  and  swelling  of  the  bladder  walls, 
and  there  is  present  a  catarrhal  discharge  which  is  mixed  with  urinary  elements, 
serimi,  mucus,  often  pus  and  epithelial  debris.  Ulceration,  sloughing,  or  false- 
membrane  formation  may  occur.  Chronic  cystitis  is  an  inflammatory  condi- 
tion always  due  to  bacteria.  We  frequently  speak  of  a  chronic  cystitis  as  due 
to  stone  in  the  bladder,  hypertrophy  of  the  prostate  gland,  or  tumor  of  the 
bladder.  These  conditions  do  not  cause  chronic  cystitis,  but  act  by  rendering 
the  bladder  vulnerable  to  micro-organisms.  Among  the  causative  organisms 
we  may  mention  the  Bacillus  coli  communis,  the  gonococcus,  the  Bacillus  tu- 
berculosis, the  Bacillus  typhosus,  the  Urobacillus  liquefaciens  septicus,  and  the 
various  pyogenic  bacteria  (Leonard  Freeman).  These  bacteria  may  gain 
entrance  on  instruments  or  by  way  of  the  ureter,  urethra,  the  lymph-vessels, 
and,  in  rare  instances,  by  the  blood. 

In  chronic  cystitis  there  is  an  enormous  production  of  thick,  sticky  mucus 
and  the  urine  becomes  alkaline.  The  excessive  secretion  of  mucus  and  the 
great  number  of  bacteria  convert  the  urea  into  carbonate  of  ammonium,  and 
this  product,  being  irritant  to  the  bladder  walls,  makes  the  inflammation 
worse.  In  chronic  cystitis  the  bladder  is  contracted  and  has  very  thick  walls, 
and  the  mucous  membrane  is  thick,  edematous,  congested,  and  filled  with 
large  veins.  The  bladder  may  be  ulcerated  or  encrusted  with  urinary  salts. 
The  urine  contains  bacteria,  triple  phosphate,  pus,  blood,  and  mucus,  the 
blood  emerging  with  the  last  drops  of  urine.  Pyelitis  may  arise  as  a  result 
of  chronic  cystitis. 

What  was  formerly  called  inflammation  of  the  neck  of  the  bladder  is  an 
inflammation  of  the  vesical  trigone  and  of  the  posterior  urethra.  It  is  now 
usually  called  urethrocystitis  or  trigonitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  micturition,  with  the 
passage,  at  each  act,  of  a  very  small  quantity  of  urine;  the  desire  to  urinate  is 


Treatment  of  Acute  Cystitis  1325 

almost  constant,  and  there  is  intensely  painful  straining  {tenesmus).  The 
pain  is  acute  and  scalding,  and  may  be  felt  in  the  head  of  the  penis,  above  the 
pubes  or  in  the  perineum ;  it  often  runs  into  the  loins  and  the  thighs  and  radi- 
ates over  the  sacrum.  Pain  above  the  pubes  indicates  involvement  of  the 
fundus,  and  pain  in  the  perineum  and  in  the  head  of  the  penis  points  to  in- 
flammation of  the  bladder  trigone.  The  urme,  at  first  clear,  loses  its  trans- 
parency, becomes  full  of  thick  mucus,  and  often  contains  a  httle  blood  or  pus. 
The  patient  not  unusually  has  some  fever.  A  rectal  examination  causes  violent 
pain.  If  retention  arises,  there  will  probably  be  a  chill  and  high  fever,  and 
anuria  may  occur. 

Treatment. — In  treating  acute  cystitis  endeavor  to  remove  the  cause. 
By  allaying  an  irritation  or  removing  an  obstruction  the  bladder  will  often 
become  able  to  empty  itself  of  retained  urine,  which  urine  causes  congestion 
of  the  bladder  and  thus  renders  infection  probable  or  may  be  itself  filled  with 
bacteria.  If  cystitis  arises  after  the  administration  of  cantharides,  put  the 
patient  in  bed  and  give  him  hquor  potassii  citratis.  If  it  arises  after  the  use 
of  a  clean  sound,  order  rest  in  bed,  suppositories  of  opium  and  belladonna, 
diluent  drinks,  and  ammonii  benzoas  or  lupulin.  If  the  inflammation  is 
septic  (as  from  the  use  of  a  dirty  sound)  or  is  very  acute,  put  the  patient  in 
bed,  keep  him  warm,  and  use  a  hot  sand-bag  to  the  perineum  and  hot  fomen- 
tations or  poultices  to  the  hypogastriiun.  Hot  hip-baths  may  be  used.  The 
hips  should  be  elevated,  and  the  bowels  should  be  emptied  by  the  adminis- 
tration of  salines  and  by  glycerin  enemata.  An  exclusive  milk-diet  is  de- 
sirable. The  patient  shoidd  drink  copiously  of  sweetened  water  containing  a 
few  drops  of  aromatic  sulphuric  acid  or  of  milk  of  almonds.  Sterilize  the 
urine  by  the  administration  of  urotropin,  giving  a  capsule  containing  7^  gr. 
of  the  drug  three  times  a  day.  Other  remedies  which  may  be  of  service  in 
sterilizing  the  urine  are  quinin,  boric  acid,  salol,  borocitrate  of  magnesium, 
and  salicylate  of  sodium.  A  valuable  remedy  consists  of  15  gr.  of  salicylate 
of  sodium  and  1 5  gr.  of  benzoic  acid,  given  three  times  a  day  in  a  little  chloro- 
form water.     If  the  pain  and  straining  still  continue,  order — 

I^.     Ext.  hyoscyami gr.  viij; 

Ext.  cannabis  indicae gr.  viij; 

Sacchar.  alba gr.  xlviij. — M. 

Div.  in  pulv.  No.  xxiv. 

Sig. — One  powder  every  four  hours. 

Or, 

I^.     Camphorae gr.  viij; 

Ext.  cannabis  indicae gr.  viij ; 

Sacchar.  alba gr.  xlviij. — M. 

Div.  in  pulv.  No.  xx. 

Sig. — One  powder  every  three  hours.  (Von  Zeissl.) 

Suppositories  of  extract  of  belladonna  are  of  great  value.  Suppositories  each  of 
which  contains  i  gr.  of  ichthyol  are  of  service,  and  one  may  be  used  every  four 
hours.  Opitmi,  unfortunately,  constipates;  when  it  is  given,  secure  evacuations 
by  the  use  of  glycerin  suppositories,  by  the  administration  of  saHne  cathartics, 
or  by  the  employment  of  enemata.  If  opiiun  is  necessary,  it  is  given  in  a 
suppository  containing  i  gr.  of  powdered  opitma  and  \  gr.  of  the  extract  of 
belladonna  every  three  or  four  hours.  Hypodermatic  injections  of  morpbin 
may  be  required.  Wash  the  bladder  out  daily  with  warm  normal  salt  solu- 
tion or  warm  boric  acid  solution.  This  can  be  done  through  a  soft  catheter 
or,  better,  by  hydrostatic  pressure.  If  retention  occurs,  use  a  soft  catheter. 
If  much  blood  is  passed,  give  internally  the  tinctura  ferri  chloridi  and  bhster 
the  perineum.     In  urethrocystitis  (trigonitis)  the  instillation  of  solutions  of 


1326  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

nitrate  of  silver  (5  to  10  gr.  to  the  ounce)  often  do  good.     A  very  acute  cystitis 
is  rarely  arrested  within  a  week  or  ten  days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be  a  legacy  from 
acute  cystitis  or  it  may  appear  without  any  acute  precursory  phenomena. 
There  will  be  found  frequency  of  micturition,  but  not  so  great  as  in  the  acute 
form.  There  will  be  slight  tenesmus  and  moderate  pain  from  time  to  time, 
usually  radiating  toward  the  head  of  the  penis.  Constitutional  symptoms 
may  arise  when  kidney  damage  has  become  pronounced  or  sepsis  has  occurred 
from  absorption.  The  urine  is  anmioniacal,  fetid,  and  turbid;  it  is  filled  with 
viscid,  tenacious  mucus  or  with  mucopus;  it  contains  a  great  excess  of  phos- 
phates, and  occasionally  clots  of  blood.  The  condition  of  chronic  cystitis 
with  the  production  of  immense  quantities  of  thick  mucus  is  often  called 
chronic  catarrh  of  the  bladder.  Chronic  cystitis  may  eventuate  in  the  for- 
mation of  stone  or  in  the  production  of  serious  disease  of  the  bladder,  the 
ureters,  and  the  kidneys.     It  is  very  apt  to  cause  retention  of  urine. 

Chronic  Tuberculous  Cystitis. — Chronic  cystitis  may  be  due  to  tuber- 
culosis. Primary  vesical  tuberculosis  is  very  uncommon.  When  it  does 
occur  it  will  often  be  found  that  it  was  preceded  by  gonorrheal  infection 
of  the  bladder.  Most  cases  of  vesical  tuberculosis  are  secondary  to  renal 
tuberculosis  or  to  tuberculosis  of  the  prostate,  seminal  vesicles,  or  epididy- 
mis. Some  cases  come  on  rapidly,  many  tubercle  bacilli  being  found  in 
the  urine.  Other  cases  come  on  more  gradually,  and  in  them  the  urine 
may  contain  few  tubercle  bacilli.  In  many  such  cases  no  tubercle  bacilH 
are  found.  The  tuberculous  products  caseate  and  ulcers  form  or  fibrous 
organization  takes  place.  A  cystitis  for  which  no  cause  can  be  found,  and 
which  is  accompanied  by  pyuria  and  severe  and  lasting  pain,  is  possibly 
tuberculous.  Pyuria  is  usually  present,  but  in  some  cases  the  urine  is  per- 
fectly clear.  In  some  cases  the  patient  has  painful  paroxysms  of  varying 
duration  and  feels  well  between  the  atacks.  Finding  tuberculosis  of  the 
kidney,  prostate,  vesicle,  or  epididymis,  increases  the  probability  that  tuber- 
culous cystitis  exists.  The  diagnosis  is  made  by  the  cystoscope.  Tubercu- 
lous ulceration  is  most  common  in  the  trigone  and  about  the  inner  orifice 
of  the  urethra.  A  tuberculous  ulcer  is  small.  The  adjacent  mucous  mem- 
brane is  not  inflamed,  but  contains  grayish-white  nodules  (Louis  E.  Schmidt, 
"Jour.  Amer.  Med.  Assoc,"  July  19,  1902). 

Treatment  of  Chronic  Cystitis. — In  treating  chronic  cystitis  remove  the 
cause,  if  possible  (get  rid  of  a  stone,  evacuate  frequently  residual  urine,  dilate  a 
stricture,  and  remove  a  tiraior) .  For  chronic  cystitis  certain  remedies  are  taken 
by  the  mouth.  Water  is  drunk  in  large  amounts,  also  iron  spring-water  (Ma- 
rienbad,  etc.).  Salol  and  boric  acid,  5  gr.  of  each  four  times  a  day,  are  very 
valuable.  Salol  in  fluidextract  of  triticum  repens  does  good;  so  does  chlorate  of 
potassium,  10  gr.  daily.  Either  borocitrate  of  magnesium,  quinin,  or  salicylate 
of  sodium  with  benzoic  acid  may  often  be  used  with  benefit.  Alum,  tannic 
acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  turpentine  have  all  been  recom- 
mended, and  possibly  may  be  of  some  benefit.  Urotropin  is  useful  in  many 
cases.  This  drug  prevents  the  development  of  bacteria  in  the  urine  (Nico- 
laier)  and  antagonizes  the  tendency  to  sepsis  and  urinary  poisoning.  It 
is  given  in  5-gr.  capsules,  from  four  to  six  being  given  daily.  Colon  bacillus 
cystitis  is  treated  by  giving  sodium  benzoate  and  urotropin  internally.  In 
obstinate  cases  a  vaccine  should  be  made  and  given.  In  cases  of  chronic  cystitis 
(even  the  tuberculous  form)  Stellwagen  has  had  excellent  results  from  the 
following  capsule:  3  min.  of  creosote,  6  min.  of  oil  of  sandalwood,  i  min.  of 
oil  of  cinnamon,  i  gr.  of  pepsin.  One  capsule  after  each  meal.  Whatever  rem- 
edy is  used,  see  that  the  bowels  move  once  a  day  and  that  the  skin  is  active. 
Champagne  and  beer  must  be  avoided.     If  residual  urine  gathers,  a  soft. 


Treatment  of  Chronic  Cystitis  1327 

catheter  must  be  regularly  employed.  If  it  is  possible  to  introduce  a  cath- 
eter of  considerable  size,  catheterization  may  be  all  that  is  needed  in  the  case. 
In  some  cases  of  chronic  cystitis  the  retention  of  a  catheter  from  three  to  five 
weeks  is  of  the  greatest  ser^dce.  If  the  case  is  very  severe,  the  bladder  must 
be  washed  out  daily  with  peroxid  of  hydrogen  (25  to  40  per  cent,  solution), 
nitrate  of  silver  (i  :  Sooo),  boric  acid  (5  to  10  per  cent.),  carbolic  acid  (i  :  500), 
corrosive  sublimate  (from  i  :  20,000  to  i  :  5000),  or  permanganate  of  potas- 
sium (i  :  4000).  If  nitrate  of  silver  or  permanganate  of  potassium  is  used,  first 
rinse  out  the  bladder  with  distilled  water.  If  any  other  agent  is  used,  first  wash 
out  the  bladder  with  either  boiled  water  or  normal  salt  solution.  The  daily  in- 
jection of  a  2  per  cent,  solution  of  ichthyol  may  prove  useful.  Collin  uses  a  i 
per  cent,  solution  of  guaiacol  carbonate  in  sterile  olive  oil.  Some  surgeons  oc- 
casionally employ,  at  inten.'als  of  a  number  of  days,  strong  silver  solutions  (30 
or  40  gr.  to  the  ounce).  If  a  strong  solution  is  used,  after  the  drug  flows  away 
wash  out  the  bladder  with  a  solution  of  common  salt.  The  bladder  is  usually 
washed  out  by  attaching  to  the  free  end  of  a  soft  catheter,  the  other  end  of 
which  is  in  the  bladder,  a  tube  which  is  connected  with  a  graduated  bottle, 
the  force  being  obtained  by  elevating  the  reservoir  {fountain  irrigation). 
The  bladder  can  be  irrigated  -s^ithout  using  a  catheter,  the  resistance  of  the 
compressor  muscle  of  the  urethra  being  overcome  by  the  pressure  of  a  column 
of  water.  The  reserv^oir  is  raised  to  the  height  of  6  feet.  The  patient  sits 
in  a  chair.  The  tube  of  the  reserv^oir  has  upon  it  a  clamp  to  control  the  flow, 
and  in  its  end  a  large  bulbous  tip  which  will  fill  the  meatus  (Valentine's  in- 
strument). The  tip  is  inserted  into  the  urethra,  the  clamp  on  the  tube  is 
loosened,  and  the  patient  is  directed  to  take  a  deep  inspiration.  In  a  short 
time  the  bladder  fills  wdth  water,  the  tube  is  removed,  and  the  patient  empties 
the  viscus  naturally.  In  some  cases  it  is  necessary  to  wait  quite  a  while  for 
the  column  of  water  to  tire  out  the  muscle.  ■  If  the  fluid  will  not  enter,  direct 
the  patient  to  make  efforts  as  in  micturating,  the  pressure  of  the  fluid  on 
the  anterior  surface  of  the  cut  off  muscles  being  kept  up.  If  this  fails,  direct 
him  to  urinate,  and  then  the  surgeon  makes  another  attempt  to  get  the  fluid 
to  enter.     After  a  little  practice  a  patient  learns  how  to  admit  the  fluid. 

If  the  cystoscope  discloses  tuberculosis  of  the  bladder  and  there  is  known 
to  be  tuberculosis  of  one  kidney,  cure  of  the  bladder  is  impossible  without 
preliminary  nephrectomy.  In  tuberculous  cystitis  coUargol  may  be  injected 
once  a  day.  A  i  per  cent,  solution  is  used  and  it  is  allowed  to  remain  for  a 
long  time.  The  method  is  painless.  Collin  ad\dses  the  instillation  of  30  min. 
of  the  following  mixture  into  the  bladder  and  posterior  urethra:  5  gm.  of 
guaiacol,  i  gm.  of  iodoform,  100  gm.  of  sterile  olive  oil.  About  30  min.  of  this 
are  injected  once  a  day.  Rovsing,  of  Copenhagen  (Meeting  of  French  Uro- 
logical  Assoc,  of  1910),  uses,  in  tuberculosis  of  the  bladder,  a  fresh  solution  of 
carbolic  acid  (3  to  6  per  cent.).  He  injects  from  25  to  50  c.c.  through  a  catheter, 
allows  it  to  remain  in  the  ^^scus  for  two  or  three  minutes,  lets  it  run  out,  and 
repeats  this  procedure  until  the  fluid  emerges  clear.  This  treatment  is  carried 
out  at  first  every  other  day.  When,  on  the  intervening  day,  the  urine  remains 
clear  the  interval  between  treatments  is  lengthened.  Rovsing  claims  to  have 
cured  28  cases  in  from  four  to  six  weeks.  Din-ing  treatment  he  makes  a  cysto- 
scopic  examintion  every  other  week  to  determine  the  progress  of  the  case. 
The  injections  are  usually  very  painful  and  would  be  intolerable  without  a 
preliminary  injection  of  a  local  anesthetic  (25  c.c.  of  a  i  per  cent,  solution  of 
eucain) .  Sometimes,  in  tuberculous  ulceration  of  the  bladder,  curetting  through 
a  cystoscope  is  usefiil.  In  other  cases  the  bladder  must  be  opened,  the  ulcer 
curetted,  and  the  \dscus  drained. 

If  the  ordinary  methods  of  treatment  fail  to  cure  chronic  cystitis;  if  the 
bladder  resents  catheterization  and  irrigation;  if  in  spite  of  irrigation  the 


1328  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

urine  does  not  become  clear;  and  if  there  are  evidences  of  infection  of  the 
patient  and  breaking  down  of  his  general  health,  drain  by  perineal  or  supra- 
pubic cystotomy  and  through  the  incision  wash  the  bladder  frequently  and 
thoroughly.  If  a  persisitent  cystitis  is  due  to  stricture  which  dilatation  fails 
to  ciire,  perform  external  perineal  urethrotomy  and  employ  perineal  drainage. 

Ulcer  of  the  bladder  may  be  due  to  injury,  cystitis,  tuberculosis, 
malignant  tumor,  or  gonorrhea.  A  form  of  ulceration  particularly  common 
in  anemic  women  is  a  solitary,  punched-out  ulcer  (Louis  E.  Schmidt,  "Jour. 
Amer.  Med.  Assoc,"  July  19,  1902).  Ulcers  may  be  single  or  multiple.  Per- 
foration may  occur. 

A  perforation  may  occur  into  the  peritoneal  cavity  or  into  the  perivesical 
cellular  tissue.  In  the  former  case,  after  the  onset  of  marked  hematuria, 
there  are  shock,  abdominal  pain,  and  peritonitis.  In  the  latter  case  there  is 
extravasation  of  urine  or  abscess  formation. 

Tuberculous  ulcer  is  discussed  on  page  1327  and  cystoscopic  ulcer  on  page 
1301. 

Schmidt  (Ibid.)  points  out  that  gonorrheal  ulceration  is  apt  to  be  multiple, 
and  causes  severe  pain  and  bloody,  turbid  urine.  As  a  rule,  when  the  bladder 
is  ulcerated,  the  urine  contains  blood,  blood-clots,  or  tissue  debris,  but  the  urine 
may  be  clear  when  there  is  a  tuberculous  ulcer  or  soUtary  ulcer. 

Diagnosis  is  usually  made  by  the  cystoscope.  In  some  cases  it  is  made 
by  exploratory  suprapubic  incision. 

Treatment. — If  there  is  one  ulcer,  or  if  there  are  a  few  ulcers,  curet  through 
an  operating  cystoscope,  use  irrigations,  and  keep  the  urine  aseptic.  In  wide- 
spread ulceration  perform  suprapubic  cystotomy,  curet  the  diseased  mucous 
membrane,  and  insert  a  drainage-tube.  In  some  cases  of  maUgnant  growth 
the  cautery  is  used  as  a  palliative  measure.  Perforation  is  treated  as  is 
rupture  of  the  bladder  (see  page  131 8). 

Tumors  of  the  Bladder. — ^These  growths  are  usually  said  to  be  ver}^ 
rare,  but  in  Guyon's  statistics  they  are  found  to  constitute  3.9  per  cent,  of  all 
cases  of  genito-urinary  disease.  They  are  almost  5  times  as  common  in 
males  as  in  females.  They  are  most  frequently  met  with  between  the  ages 
of  fifty  and  sixty,  although  myxoma  is  met  with  only  in  childhood  and  sarcoma 
is  most  common  in  the  young  (Lincoln  Davis,  in  "Annals  of  Surgery,"  April, 
1906).  Persistent  vesical  irritation  may,  perhaps,  be  an  element  in  causing 
tumor.  Tumors  of  the  bladder  may  be  either  innocent  or  mahgnant,  the  latter 
being  the  commonest.  Innocent  tumors  which  may  arise  from  the  bladder 
are  papillomata  or  villous  tumors,  adenomata,  mucous  polypi  (myxomata), 
fibrous  polypi,  myomata,  and  angiomata.  A  myoma  may  attain  a  great  size 
(even  that  of  a  child's  head).  The  common  form  is  intravesical.  There  is  an 
interstitial  form  and  a  peripheral  form.  Papilloma  is  far  and  away  the  most 
common  form  of  innocent  tumor.  Cysts  may  also  arise.  Mahgnant  tumors  are 
sarcoma  (comparatively  rare)  and  carcinoma  (encephaloid,  rare;  epithelioma, 
common).  Munwes  ("Zeit.  f.  Urology,"  Nov.,  1910)  collected  107  cases  of  sar- 
coma. Sarcoma  begins  in  the  submucosa.  The  majority  of  bladder  carcino- 
mata  are  secondary  to  growths  of  the  rectum,  prostate,  or  uterus.  Adenocar- 
cinoma and  scirrhous  carcinoma  are  practically  always  secondary  to  rectal, 
prostatic,  or  uterine  timiors.  Papillary  cancer  and  epithelioma  are  not  un- 
usually primary  (Mandlebaum,  in  "Surg.,  Gynecol.,  and  Obstet.,"  1907).  Pri- 
mary carcinoma,  like  primary  sarcoma,  most  commonly  arises  in  or  near  the 
trigone.  Any  timior  of  the  bladder,  innocent  or  malignant,  will  eventually  cause 
death  if  allowed  to  remain.     Papilloma  is  very  apt  to  become  cancerous. 

Symptoms. — The  innocent  timiors  rarely  cause  cystitis  or  irritation, 
though  by  obstructing  the  ureters  or  the  urethra  they  may  induce  disease  of 
the  kidneys.     Hematuria  is  almost  invariable  present  at  some  time  during  the 


Treatment  of  Tumors  of  the  Bladder  1329 

existence  of  a  bladder  tumor.  It  is  apt  to  be  profuse,  and  the  urine  contains 
blood,  blood-clots,  and  perhaps  fragments  of  tumor.  The  bleeding  is  intermit- 
tent, may  occur  even  when  the  patient  is  at  rest,  and,  except  in  malignant  dis- 
ease, is  seldom  preceded  or  accompanied  by  pain.  Bleeding  usually  occurs  at 
the  termination  of  micturition,  the  first  urine  being  clear  and  the  last  red  or 
clotted.  Often  hemorrhage  is  the  only  phenomenon  produced  by  a  papilloma 
or  a  mucous  polypus.  Hemorrhage  may  occur  from  a  myoma.  Malignant 
tumors  cause  cystitis,  and  the  urine  contains  mucus,  blood,  and  pus.  The 
growth  may  become  crusted  with  salts  from  the  urine.  Cancer  is  decidedly 
and  often  horribly  painful.  In  malignant  disease  the  rectum  usually  becomes 
involved.  Hydronephrosis  may  be  caused.  Metastases  to  the  lungs  are  com- 
mon. Ulceration  may  occur  into  the  peritoneal  cavity  or  rectum.  A  malig- 
nant tumor  progresses  much  more  rapidly  than  an  innocent  growth,  although 
in  vesical  cancer  metastases  are  not  formed  so  early  as  in  some  other  regions. 
Innocent  tumors  are  felt  with  difficulty  with  the  sound,  but  malignant  tumors 
are  easily  felt.  In  some  cases  a  tumor  can  be  detected  by  a  bimanual  examina- 
tion (a  finger  m  the  rectum  and  the  fingers  of  the  other  hand  on  the  abdo- 
men). Make  a  careful  study  to  determine  whether  or  not  a  growth  has 
infiltrated  the  prostate,  the  seminal  vesicles,  the  rectum,  or  the  perivesical 
tissues.  Bleeding  follows  the  use  of  a  sound.  There  may  be  difficulty  in 
starting  the  stream  in  mictiu-ition,  there  may  be  interruption  or  irregular  halts 
in  the  stream.  The  latter  condition  is  called  stammering  of  the  bladder.  The 
urine  should  be  examined  microscopically  to  see  if  it  contains  villi,  portions 
of  fibroma,  colonies  of  cancer-cells,  or  fragments  of  epithelioma.  A  cystoscope 
should  be  employed  in  order  to  reach  a  diagnosis.  If  the  urethra  is  too 
narrow  for  the  cystoscope,  this  channel  must  be  dilated.  If  there  is  profuse 
bleeding  an  irrigating  cystoscope  must  be  employed.  In  doubtful  cases  ex- 
ploratory suprapubic  cystotomy  is  advisable. 

Treatment. — Some  innocent  tumors  may  be  cured  by  fulguration.  Papil- 
lomata  are  particularly  amenable  to  this  treatment.  Recurrence  is  rare. 
Some  innocent  tiomors  (for  instance,  peripheral  myomata)  are  treated  by  supra- 
pubic incision  and  removal  of  the  growth  and  a  portion  of  the  bladder  wall.  A 
papilloma  which  recurs  after  fulguration  should  be  treated  by  excision  with 
a  portion  of  the  mucous  membrane  and  submucous  tissue  of  the  bladder  wall. 
The  perineal  operation  only  enables  the  surgeon  to  reach  and  remove  growths 
of  small  size,  pedunculated  growths,  and  growths  near  the  neck  of  the  bladder. 
(See  Operations  on  the  Bladder.) 

Among  the  operations  practised  for  mafignant  disease  are  partial  cys- 
tectomy with  resection  of  one  or  both  ureters,  partial  resection  of  the  bladder 
wall,  removal  of  the  growth  without  resection  of  the  wall  (a  useless  pro- 
cedure), ciiretting  (which  is  futile).  Complete  extirpation  of  the  bladder 
{total  cystectomy)  for  cancer  has  been  performed  by  Bardenheuer,  Heresco,  and 
others.  Goldenberg  reported  26  cases,  with  a  mortality  of  over  60  per  cent. 
It  is  usually  done  in  two  stages,  in  the  first  operation  the  ureters  of  a  man 
being  transplanted  into  the  rectimi,  the  ureters  of  a  woman  into  the  rectum 
or  vagina.  About  three  weeks  later  the  bladder  is  removed.  The  adjacent 
lymph-nodes  along  the  internal  iliac  vessels  and  in  front  of  the  sacrum  must 
be  removed  in  all  cases.  The  surgeon  should  bear  in  mind  that  vesical  scir- 
rhus  and  adenocarcinoma  are  practically  always  secondary  growths,  and  if  he 
cannot  remove  the  primary  growth  he  should  not  extirpate  the  bladder.  The 
complete  procedure  has  been  carried  out  successfully  at  one  operation  (Tuffier 
and  Dujarier,  "Rev.  de  Chir.,"  April,  1898) .  Some  surgeons  prefer  preliminary 
double  lumbar  nephrostomy;  others  transplant  the  ureters  to  the  skin  surface. 
The  operation  of  complete  extirpation  is  of  questionable  value.  In  most  cases 
it  has  proved  a  fatal  failure.  Munwes  ("Zeit.  f.  Urology,"  Nov.,  1910)  re- 
84 


1330  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ported  69  radical  operations  for  sarcoma.  Only  3  patients  lived  for  more 
than  a  brief  time. 

In  Rafin's  collection  of  30  cases  of  cancer  there  were  17  deaths.  One  case 
was  alive  five  years  after  operation,  i  fifteen  months,  and  i  seven  months  after. 
Watson's  table  of  25  cases  of  cancer  shows  14  deaths  and  only  2  of  the  survivors 
were  alive  and  free  from  recurrence  after  three  years. 

Complete  extirpation  should  be  employed  only  when  cancer  involves  the 
bladder  extensively.  I  agree  with  Berg  ("Annals  of  Surgery,"  Sept.,  1908),  that 
if  less  than  one-third  of  the  bladder  is  involved  the  operation  should  be  partial 
cystectomy  with  implantation  of  the  ureters  into  the  portion  of  bladder  remain- 
ing. The  surgeon  removes  the  anatomically  related  lymphatic  area  and  always 
bears  in  mind  that  vesical  adenocarcinoma  and  scirrhus  are  secondary  growths. 
Partial  cystectomy  saves  the  performance  of  the  fatal  operation  of  transplanting 
the  ureters  as  is  ordinarily  done,  or  the  questionable  operation  of  lumbar  neph- 
rostomy with  all  of  its  unpleasant  consequences.  In  Rafin's  collection  of  96 
cases  there  were  21  deaths  (a  mortality  one-half  that  of  complete  cystectomy) ; 
50  cases  were  traced — 5  were  welljover  three  years  and  16  over  six  months  (Berg, 
Ibid.).  Henry  Morris  lays  down  the  following  rule:  "When  an  infiltrating 
growth  is  felt,  per  rectum  or  per  vaginam,  or  with  the  soimd,  to  be  involving  a 
large  surface  of  the  bladder  wall,  to  be  infiltrating  its  coats,  especially  in  the 
neighborhood  of  the  ureters  and  neck  of  the  bladder,  no  operation  whatever 
should  be  proposed  unless  the  hemorrhage  is  copious  or  the  symptoms  of  cystitis 
severe,  and  then  an  incision  for  palliative  purposes  only  should  be  made" 
(Treves's  "System  of  Surgery"). 

Many  surgeons  content  themselves  in  vesical  cancer  with  suprapubic  cystot- 
omy, removing  the  growth  and  a  portion  of  the  bladder  wall.  If  removal 
is  not  possible,  they  curet,  cauterize,  and  drain. 

Operations  On  the  Bladder. — Lateral  Lithotomy. — Lithotomy  is  the  re- 
moval of  a  stone  from  the  bladder.  Lateral  lithotom,y  is  an  operation  which 
was  once  a  glory  of  surgery,  which  is  every  year  becoming  less  popular, 
but  which  is  still  at  times  employed  by  surgeons,  especially  for  stone 
in  children.  This  operation  should  not  be  performed  if  the  stone  is 
over  2  inches  in  its  short  diameter;  it  is  rarely  justifiable  if  the  stone 
weighs  3  oz.  or  more  (Cage);  and  it  must  not  be  performed  for  encysted 
stone,  or  on  a  person  with  a  deep  perineum,  a  narrow  pelvic  -outlet,  or  an 
enlarged  prostate.  For  one  week  before  the  operation  keep  the  patient  in 
bed,  wash  out  the  bladder  daily  with  hot  boric  acid  solution,  and  administer 
salol  and  boric  acid  by  the  mouth,  5  gr.  of  each  four  times  a«day.  The  night 
before  the  operation  give  a  saline,  order  a  hot  bath,  and  have  the  perineum, 
the  scrotum,  the  buttocks,  and  the  inner  sides  of  the  thighs  cleansed  and 
dressed  antiseptically.  In  the  morning  an  enema  is  to  be  given.  At  the  time 
of  operation  the  bladder  should  contain  several  ounces  of  boric  acid  solution. 
The  instruments  required  are  a  lithotomy  knife,  a  straight  probe-pointed  bis- 
toury, a  grooved  staff,  a  stone-sound,  stone-forceps  and  scoops,  a  tenaculum, 
an  aneurysm  needle,  a  fountain-syringe,  curved  needles  and  a  needle-holder, 
hemostatic  forceps,  a  tube  with  chemise  (see  Fig.  229),  a  Paquelin  cautery,  a 
Clover  crutch,  and  a  lithotrite. 

Place  the  patient  upon  his  back,  anesthetize  him,  and  find  the  stone  by 
sounding.  If  the  stone  is  not  discovered  by  the  sound  at  that  time,  do  not  operate. 
Place  the  buttocks  so  that  they  project  beyond  the  edge  of  the  table,  introduce 
the  staff  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten  the  patient  in  the 
lithotomy  position  with  a  crutch.  During  the  first  incision  the  handle  of  the 
staff  is  held  toward  the  belly ;  after  the  first  cut  the  staff  is  set  perpendicularly 
and  is  hooked  up  under  the  pubes.  An  incision  is  made,  starting  just  to  the 
left  of  the  raphe  of  the  perineum  and  i\  inches  in  front  of  the  edge  of  the 


Suprapubic  Lithotomy  133 1 

anus,  and  passing  downward  and  outward  to  between  the  anus  and  the  ischial 
tuberosity,  but  one-third  nearer  the  former  than  the  latter.  In  the  adult 
this  incision  is  3  inches  in  length.  The  first  incision  is  superficial  and  does  not 
reach  the  staff,  but  it  is  this  incision  which  may  cut  the  rectmn.  After  making 
the  first  cut  the  nail  of  the  left  index-finger  feels  for  the  groove  of  the  staff, 
the  staff  is  hooked  up,  the  knife  is  entered  into  the  groove  and  is  pushed  into 
the  bladder,  and  as  it  is  withdrawn  the  wound  is  enlarged.  As  the  knife 
enters  the  bladder  there  is  a  gush  of  fluid.  The  finger  follows  the  knife  and 
stretches  the  wound,  the  staff  is  withdrawn,  and  the  stone  is  felt  for  and 
extracted  with  forceps.  Liston  showed  years  ago  the  value  of  keeping  the 
finger  in  the  wound.  This  maneuver  retains  some  water  in  the  bladder, 
and  as  a  consequence  causes  the  stone  to  rest  at  the  lowest  part  of  the  viscus, 
and  when  the  forceps  are  introduced  they  at  once  come  upon  the  stone.  In 
withdrawing  the  stone  make  traction  in  the  axis  of  the  pelvis,  and  do  not  rotate 
the  calculus  imtil  it  is  entirely  out  of  the  prostatic  urethra.  Wash  or  scrape 
away  debris  or  incrustation  from  the  w^all  of  the  bladder,  see  that  no  other 
stone  is  present,  syringe  out  the  \dscus  with  warm  salt  solution,  insert  a  tube, 
apply  antiseptic  dressings  around  the  tube,  and  put  on  a  T-bandage.  The  end 
of  the  tube  which  is  external  to  the  dressings  is  fastened  to  the  tails  of  the 
T-bandage.  A  rubber  cloth  is  put  on  the  bed,  under  the  body  and  legs,  and 
the  patient's  buttocks  rest  upon  a  mass  of  old  linen,  the  scrotum  being  raised 
on  a  pad.  The  knees  are  bent  over  pillows.  Change  the  linen  as  soon  as 
it  becomes  wet.  Remove  the  tube  in  forty-eight  hours.  The  urine  begins 
to  come  by  the  urethra  from  the  eighth  to  the  twelfth  day.  In  children  the 
incision  is  not  so  long,  it  is  dilated  by  forceps  instead  of  by  the  finger,  and 
no  tube  is  required.  In  lateral  lithotomy  the  prostatic  and  membranous 
portions  <of  the  urethra  are  opened,  the  prostate  gland  is  partly  divided  by 
the  knife,  and  the  woimd  is  dilated  by  the  finger.  One  objection  to  the 
operation  is  that  it  is  possible  to  cut  the  rectum,  and  another  is  that  inflam- 
mation may  occlude  the  ejaculatory  ducts  and  cause  sterility. 

Suprapubic  Lithotomy. — This  operation  is  the  removal  of  a  stone  through 
an  opening  above  the  pubes.  It  is  in  many  instances  the  preferable  opera- 
tion. The  mortality  of  this  operation  is  higher  in  children  than  that  of  lateral 
lithotomy;  in  adults  and  in  individuals  beyond  middle  life  the  mortality  is 
decidedly  less  than  is  that  following  the  lateral  operation.  It  is  used  for  the 
removal  of  multiple  calculi,  for  very  hard  stones,  for  stones  above  2  inches  in 
their  short  diameter,  for  calcuH  in  men  with  enlargement  of  the  prostate,  for 
foreign  bodies  incrusted  with  sediment,  when  the  perineimi  is  deep,  when  the 
pelvic  outlet  is  narrow,  for  encysted  stones,  for  calculi  associated  with  a  vesical 
tumor,  and  when  the  urethra  will  not  permit  the  use  of  a  lithotrite.  Before 
doing  the  operation  determine  the  carrying  capacity  of  the  bladder  when  the 
patient  is  not  anesthetized.  This  gives  the  safe  limit  of  distention.  Under 
an  anesthetic  the  bladder  will  receive  3  or  4  more  oiuices  than  the  safe  amount. 
The  patient  is  prepared  as  for  lateral  lithotomy,  except  that  the  pubes  are 
shaved,  and  the  lower  part  of  the  abdomen  and  the  upper  part  of  the  thighs  are 
disinfected.  Dm"ing  the  operation  the  penis  is  kept  wrapped  in  a  piece  of  anti- 
septic gauze. 

In  performing  the  operation  place  the  patient  in  the  Trendelenburg  posi- 
tion. It  is  necessary"  to  distend  the  bladder  and  raise  it  in  order  to  have  the 
prevesical  space  imcovered  by  peritoneum.  In  most  cases  this  is  accomplished 
by  distention  of  the  bladder  and  the  Trendelenburg  position.  In  a  few  cases 
in  which  the  bladder  holds  very  Httle  fluid  a  rectal  bag  is  used  to  Uft  the 
bladder.  If  a  rectal  bag  is  to  be  used  an  assistant  ofls  it  and  pushes  it 
(empty)  above  the  sphincters.  It  is  filled  after  the  bladder  has  been  injected. 
Draw  off  the  urine  with  a  soft  catheter,  wash  out  the  bladder  mth  a  solution  of 


1332  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


silver  nitrate  (i  :  8000  to  i  :  5000),  and  inject  the  bladder  with  the  same  solu- 
tion. In  a  child  under  the  age  of  five  inject  3  to  4  oz. ;  in  an  adult  it  is  usual  to 
inject  10  to  12  oz.  Withdraw  the  catheter  and  tie  a  tube  around  the  penis  to 
prevent  the  escape  of  fluid.  After  injecting  the  bladder  with  fluid,  if  the  viscus 
is  not  well  Hfted,  inject  the  rectal  bag  with  water  and  clamp  its  tube  with  for- 
ceps. In  a  child  inject  from  2  to  4  oz.  of  warm  water  into  the  rectal  bag;  in 
an  adult  inject  10  oz.  Bristow  suggested  the  injection  of  air  into  the  bladder. 
Some  surgeons  simply  inject  air  by  means  of  a  catheter  and  a  brass  syringe  or  a 
Davidson  syringe.  Air  injection  is  not  recommended  if  fluid  can  be  used. 
In  operating  on  an  air-distended  bladder  there  is  greater  danger  of  trauma,  shock, 
and  postoperative  bleeding.  If  air  is  injected,  a  rectal  bag  is  never  used,  and 
the  patient  is  placed  on  his  back  rather  than  in  the  position  of  Trendelenburg. 
The  best  method  of  injecting  air  is  that  of  F.  Tilden  Brown,^  by  means  of  a 
bicycle  pump.     A  catheter  is  introduced,  the  bladder  is  washed  out,  the 

catheter  is  fastened  to  a  bandage, 
the  bicycle  pump  is  attached,  the 
operation  is  proceeded  with,  and 
when  the  transversalis  fascia  is  ex- 
posed the  bladder  is  filled  with  air, 
the  soft  catheter  is  clamped,  and 
the  bladder  is  opened.  Make  a  3- 
inch  longitudinal  incision  in  the 
median  line  of  the  hypogastric  re- 
gion, terminating  over  the  sym- 
physis. When  the  prevesical  con- 
nective tissue  is  reached  push  it  up 
with  a  gauze-covered  finger.  In 
close  association  with  this  tissue 
are  the  prevesical  fat  and  peri- 
toneum. The  pushing  up  must  be 
done  slowly  and  gently  with  a 
sweeping  motion.  Any  roughness 
may  be  responsible  for  disaster. 
If  the  peritoneum  should  appear, 
push  it  up.  Hold  the  wound  edges 
apart  by  retractors.  The  large  veins 
are  seen,  giving  the  bladder  a  blue 
color.  Avoid  these  veins  if  possible, 
but  even  if  they  should  be  cut  bleed- 
ing will  usually  cease  when  the  blad- 
der has  been  opened  and  the  rectal 
bag  has  been  emptied  and  removed. 
Clamp  bleeding  vessels.  Pass  a  stay  sutiu-e  of  strong  silk  on  each  side  of 
the  contemplated  incision  in  the  bladder.  Catch  each  suture  by  a  hemo- 
stat  and  let  it  hang.  Open  the  viscus  in  the  middle  line  above,  and  cut 
toward  the  pubes.  Explore  the  bladder,  remove  the  stone  or  stones,  scrape 
away  incrustations,  ligate  bleeding  vessels  outside  the  bladder,  and  irrigate  the 
viscus  with  hot  saline  solution.  Introduce  a  double  tube  into  the  bladder,  and 
attach  to  its  external  end  a  long  tube  to  siphon  off  the  urine.  The  bladder 
can  be  drained  very  satisfactorily  by  a  siphonage  apparatus  (Fig.  886).  Suture 
the  muscles  and  fascia  at  the  upper  part  of  the  wound.  Dress  with  dry  anti- 
septic gauze  and  a  rubber-dam,  the  dressings  and  binder  being  split  to  go 
around  the  tube.  Catch  the  urine  which  siphons  over  in  a  bottle  containing 
some  antiseptic  fluid.  Change  the  dressings  as  often  as  they  become  wet. 
'  "Annals  of  Surgery,"  Feb.,  1897. 


Fig.  886. — Cathcart  drainage.  The  Y-tube  is  of 
glass  and  is  darkened  in  order  to  be  shown  against 
a  white  background. 


Litholapaxy  1333 

Take  out  the  tube  in  four  or  five  days,  and  allow  the  wound  to  heal  bv  granu- 
lation. The  patient  may  get  up  in  two  weeks.  ]\Iany  Continental  surgeons 
advocate  immediate  suture  of  the  bladder  after  incision.  Albert,  Vincent, 
Bassini,  DeVlaccos,  and  others  advocate  immediate  suture.  The  suture  ma- 
terial should  be  catgut.  After  suturing  a  catheter  is  kept  in  the  bladder  to 
drain  the  viscus.  Immediate  suture  may  be  employed  in  patients  of  any  age, 
but  should  not  be  used  if  the  urine  is  very  septic  or  if  pyelonephritis  exists. 
In  some  cases  the  attempted  closure  wdll  fail ;  in  others  it  ■^'ill  only  partially 
succeed;  in  others  it  will  prove  successful;  but  even  if  it  only  partially  succeeds 
it  vnR  tend  to  prevent  dissemination  of  urine  in  the  prevesical  cellular  tissue. 
The  chief  causes  of  death  after  suprapubic  lithotomy  are  septicemia,  secondary 
hemorrhage,  cellulitis,  peritonitis,  and  suppression  of  urine.  J.  W.  \\'hite  esti- 
mates the  relative  mortality  of  suprapubic  and  lateral  lithotomy  as  follows: 
In  children  the  suprapubic  operation  gives  a  mortality  of  12  per  cent.;  the 
perineal,  of  3  per  cent.  In  adults  the  suprapubic  gives  a  mortality  of  12  per 
cent.;  the  perineal,  from  8  to  12  per  cent.  In  old  men  the  suprapubic  gives  a 
mortality  of  25  to  30  per  cent.;  the  perineal,  30  to  40  per  cent. 

Crushing  of  Vesical  Calculi. — This  is  now  done  in  one  sitting,  the  old 
operation  of  Civiale,  which  required  repeated  crushings,  being  obsolete.  In 
ever\^  case  of  suspected  stone  (as  before  stated)  the  cystoscope  should  be  used. 

Contra-indications  to  Litholapaxy. — Papilloma,  malignant  tumor,  projecting 
prostatic  lobes,  encysted  stone,  and  diverticuli. 

Litholapaxy  (Bigelow^s  operation,  or  rapid  lithotrity)  is  the  operation 
for  remo\dng  a  stone  from  the  bladder  in  one  sitting  by  thoroughly  crushing 
the  stone  and  completely  washing  away  the  fragments.  This  operation  is 
wonderfully  successful  if  done  by  an  expert.  Few  of  us  do  it  sufficiently 
often  to  learn  how  to  perform  it  "^'ith  great  rapidity,  certainty,  and  safety. 
It  is  the  best  operation  in  most  cases  if  performed  by  a  ver\-  skilful  man.  It  is 
the  operation  in  the  majority  of  cases  for  even  the  general  surgeon  to  select, 
but  the  general  surgeon  wiLl  have  better  results  in  certain  difficult  cases  after 
suprapubic  hthotomy  than  aftel"  htholapax}\  Sir  H.  Thompson  says  this 
method  is  suited  to  29  cases  out  of  30.  Litholapaxy-  should  be  employed  if 
the  bladder  will  hold  at  least  4  oz.  of  fluid  and  is  in  a  fairly  health}*  condition; 
if  the  urethra  is  tolerant  and  penetrable  by  instruments;  if  the  stone  is  not  too 
hard,  does  not  weigh  over  2^  oz.,  and  is  not  over  2  inches  in  diameter.  It  is 
not  suitable  for  multiple  calculi,  for  large  and  hard  calculi,  for  enc}'sted  stones, 
or  for  a  patient  with  marked  enlargement  of  the  prostate  gland,  with  vesical 
atony,  or  with  cystitis.  An  easily  dilatable  stricture  need  not  prevent  the  sur- 
geon doing  litholapaxA".  The  stricture  can  first  be  dilated,  and  later  Bigelow's 
operation  can  be  performed,  but  firm,  gristly  strictures  demand  a  cutting 
operation.  If  the  urethra  is  intolerant  to  instrumentation,  the  patient  being 
prone  to  febrile  attacks  when  it  is  attempted,  cut  instead  of  crushing.  An  in- 
di\ddual  laboring  under  kidney  disease  vnU  do  better  after  this  operation  than 
after  cutting  (Cage).  In  diabetes,  locomotor  ataxia,  and  conditions  of  exhaus- 
tion patients  are  best  treated  by  Bigelow's  operation,  unless  cystitis  exists. 

The  Indian  surgeons  have  had  the  most  admirable  results  from  lithol- 
apax\\  It  has  often  been  claimed  that  such  results  were  due  to  racial  pecu- 
liarities of  the  patients  and  various  factors  regarding  their  habits,  diet,  etc. 
The  fact,  however,  that  some  of  these  ver\-  surgeons  have  returned  to  England 
and  repeated  their  triumphs  in  London  shows  bow  large  a  part  masterly 
dexterity  played  in  obtaining  success. 

J.  A.  Cunningham  ("Brit.  Med.  Jour.,"  Aug.  7,  1887)  reports  upon  10,073 
Indian  cases  of  litholapaxy.     The  mortality  was  3^96  per  cent. 

Cabot,  of  Boston,  in  116  cases  had  but  4  deaths,  and  2  of  these  were  due  to 
pneumonia. 


1334 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


The  preparation  of  the  bladder  is  the  same  as  for  Hthotomy.  Be  sure  to 
measure  the  stone,  and  to  ascertain  also  whether  a  lithotrite  can  readily  be 
introduced  and  manipulated.  The  instruments  required  are  a  stone-soimd  (see 
Fig.  885),  lithotrites  (several  sizes,  Figs.  887-889),  an  evacuating  bulb  and  tubes 
(straight  and  curved.  Figs.  890, 891),  soft  catheters,  a  glass  irrigator  to  inject  the 
bladder,  and  instruments  in  case  the  surgeon  is  forced  to  cut.  The  patient  is 
anesthetized  and  is  placed  upon  his  back,  a  pillow  is  inserted 
under  the  pelvis,  and  he  is  well  wrapped  up.  The  urine 
is  drawn  and  a  measured  amoimt  of  warm  boric  acid  is 
allowed  to  flow  into  the  bladder.  This  plan  is  better  than 
having  the  patient  retain  bis  urine,  as  in  the  latter  case 
there  is  no  certainty  as  to  the  amoimt  of  fluid  in  the 
viscus.  It  is  well  to  introduce  at  least  5  or  6  oz.  of  fluid,  if 
possible.  If  the  bladder  ■v\ill  not  hold  4  oz.  the  opera- 
tion is  unsafe  (Thompson).  The  hthotrite,  preferably 
the   instrument  of  Forbes   (Fig.  889),  is  now  introduced, 


Fig.  887. — Bigelow's 
lithotrite. 


Fig.  888. — Thompson's 
hthotrite. 


Fig.  889. — Forbes's  litho- 
trite. 


the  handle  being  gradually  raised  to  a  vertical  position  as  the  penis  is  drawn 
up  on  the  shaft,  but  not  being  depressed  until  the  instrument  has  passed 
by  its  own  weight  into  the  prostatic  urethra.  Thompson's  plan  for  catching 
the  stone  is  as  follows:  After  introducing  the  lithotrite,  let  its  lower  end  rest  for 
a  few  seconds  on  the  bottom  of  the  bladder,  so  that  currents  will  subside;  then 
draw  back  the  male  blade,  wait  a  moment,  close  the  blades,  and  in  almost  every 


Litholapaxy 


1335 


Fig.  890. — Bigelow's  latest  evacuator. 


instance  the  stone  will  be  caught.  If  the  stone  is  caught,  press  firmly  to  see 
that  the  calculus  is  well  held,  lock  the  instrument,  and  break  tbe  foreign  body 
by  screwing.  WTien  resistance  suddenly  ceases  the  stone  has  either  slipped  or 
has  been  crushed;  if  crushed,  the  blades 
should  have  been  felt  forcing  through  the 
stone  and  the  calculus  should  have  been 
heard  to  break.  WTien  resistance  ceases 
catch  and  crush  again  as  above  directed. 
Rapid  movements  T\ath  the  lithotrite  are 
improper,  as  they  estabhsh  currents  which 
are  apt  to  push  away  the  stone.  If  the 
above  maneuver  does  not  catch  the  stone, 
see  if  the  calculus  be  near  the  neck  of  the 
bladder.  Pull  the  instrument  close  to  the 
vesical  neck,  and  open  it,  not  by  pulhng 
the  male  blade,  but  by  pushing  the  female 
blade.  If  the  operator  still  fails  to  catch 
the  stone,  or  if,  after  crushing,  a  large  frag- 
ment knocks  against  the  evacuator,  which 
fragment  cannot  pass,  conduct  a  careful 
search:  turn  the  blades  to  the  right  side, 
open,  and  close;  then  to  the  left  side,  open, 
and  close;  next  turn  the  point  around  be- 
hind the  prostate,  open,  and  close.  After 
catching  a  stone  with  the  lithotrite,  turn 
the  instrument  ver}-  slowly,  so  as  to  detect 
the  catching  of  the  bladder  wall  if  it  has  oc- 
curred, and  crush  the  stone  in  the  middle 
of  the  bladder  with  the  blades  up.  After 
crushing  several  times,  proceed  to  evacuate. 

saline  fluid.     Insert  an  evacuating  catheter,  its  point  being  in  the  center  of  the 
bladder,  let  the  fluid  and  fragments  run  out,  and  attach  the  aspirator  to  the 


I . — Thompson's  evacuator. 
Fill  the  aspirator  with  warm 


1336  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

catheter;  turn  the  valve,  and  compress  and  relax  the  bulb  so  that  an  ounce  or 
more  of  fluid  is  forced  in  at  each  squeeze,  the  compression  coinciding  with 
expiration.  The  debris  falls  into  a  bulb,  and  the  pumping  is  continued  until 
the  fragments  cease  to  pass,  whereupon  the  point  of  the  catheter  is  pushed 
against  the  floor  of  the  bladder  and  another  trial  is  made.  If  fragments  which 
cannot  gain  exit  are  felt  knocking  against  the  tube,  withdraw  the  evacuator, 
crush  again,  and  again  use  the  aspirator.  When  no  more  debris  comes  away 
and  no  more  fragments  are  felt,  withdraw  the  tube  and  carefully  sound  the  blad- 
der. Keyes  advises  the  operator  to  seek  .for  a  final  fragment  by  listening 
with  a  stethoscope  while  pumping  at  the  bulb  and  searching  the  bladder 
with  the  tube.  The  amount  of  blood  usually  obscures  a  cystoscopic  view. 
This  operation  will  rarely  occupy  over  forty  minutes,  though  Bigelow  has 
protracted  it  for  three  hours,  the  patient  recovering.  A  serious  compHcation 
is  severe  bleeding,  due  to  damage  done  with  the  instrument  or  to  the  pres- 
ence of  a  tumor  which  easily  bleeds.  The  injection  of  moderately  hot  water 
or  of  adrenalin  solution  (i  :  10,000)  usually  checks  hemorrhage,  but  if  bleeding 
is  dangerous  in  amount  the  operation  of  litholapaxy  should  be  abandoned  and 
suprapubic  lithotomy  be  performed. 

If  clogging  of  the  lithotrite  with  fragments  occiu"s,  forcible  pushing  of 
the  blades  together  repeatedly  will  probably  amend  it;  but  it  will  never  happen 
if  the  surgeon  uses  a  proper  form  of  instrument.  A  lithotrite  with  a  fenes- 
trated blade  will  not  lock.  Forbes's  lithotrite  is  a  very  powerful  instrument, 
the  blades  of  which  will  not  lock.  If  the  blades  of  a  lithotrite  should  become 
forcibly  and  hopelessly  locked,  make  a  perineal  section,  clear  out  the  blades, 
close  them,  and  then  withdraw  the  instrument. 

After-treatment. — Put  the  patient  to  bed,  apply  a  bag  of  hot  water  to  the 
hypogastrium,  and  give  him  a  hypodermatic  injection  of  morphin  as  he  re- 
covers from  ether.  Give  a  hot  hip-bath  every  night,  and  administer  liquor 
potassii  citratis  in  moderate  doses  every  day.  If  urethral  fever  occurs,  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily  with  warm 
boric  acid  solution,  and  tie  in  a  rubber  catheter.  If  retention  occurs,  use 
the  catheter.  If  cystitis  appears,  treat  as  in  an  ordinary  case.  The  urine 
ceases  to  be  bloody  in  two  or  three  days,  and  the  patient  may  g'et  up  in  a  week. 
Before  the  case  is  discharged  cystoscopy  should  be  practised  to  be  certain 
that  no  fragments  of  stone  remain. 

Litholapajfy  in  Male  Children. — It  used  to  be  the  teaching  that  a  child, 
because  of  the  small  size  of  the  bladder,  the  small  diameter  of  the  urethra, 
and  the  readiness  with  which  the  mucous  membrane  is  lacerated  by 
even  slight  violence,  is  a  poor  subject  for  crushing.  Lateral  lithotomy  is 
known  to  be  eminently  successful  when  performed  upon  children.  The 
elder  Gross  did  this  operation  upon  72  children,  with  only  2  deaths.  Keegan, 
however,  has  persuaded  the  profession  that  rapid  lithotrity  is  perfectly  applic- 
able to  children:  He  shows  that  the  bladder  of  a  child  of  even  less  than  two 
years  of  age  is  quite  large  enough  to  allow  the  surgeon  to  manipulate  an  in- 
strument; that  the  mucous  membrane  is  in  no  danger  if  the  operator  is  care- 
ful, and  that  the  urethra  is  by  no  means  so  small  as  was  supposed.  The 
urinary  meatus  must  often  be  incised,  and  after  doing  this,  Keegan  states, 
there  can  be  passed  in  a  boy  of  from  three  to  six  years  a  No.  7  or  8  lithotrite 
(English),  and  in  a  boy  of  from  eight  to  ten  years  a  No.  10  or  even  a  No.  14. 
It  is,  however,  just  to  state  that  the  operation  is  more  delicate  than  a  like 
procedure  on  older  persons,  and  that  no  one  is  justified  in  doing  it  who  has 
not  had  considerable  experience  in  adult  cases.  Furthermore,  it  should  be 
noted  that  Keegan's  mortality  by  this  operation  has  been  4.3  per  cent.,  while 
Gross's  mortality  from  lateral  lithotomy  on  children  was  under  3  per  cent. 

Special  points  relating  to  litholapaxy  on  male  children  are  as  follows:  use  well- 


Suprapubic  Cystotomy   (or  Cystostomy)  1337 

fenestrated  lithotrites;  have  a  stylet  to  punch  out  the  fragments  blocking  the 
evacuator;  and  crush  the  stone  to  a  fine  mass.  There  can  usually  be  em- 
ployed a  No.  8  lithotrite  and  a  No.  8  evacuating  tube  (English  scale). 

Perineal  Lithotrity  (Keith's  Operation). — This  operation  is  employed 
by  some  surgeons  in  dealing  -^ith  very  hard  or  very  large  calcuh  in  male 
adults,  or  in  cases  in  which  it  is  impossible  to  introduce  a  hthotrite  into  the 
bladder.  Keith's  operation  consists  in  opening  the  urethra  from  the  peri- 
neum, passing  a  Hthotrite  through  the  wound,  into  the  urethra  and  along  the 
mrethra  into  the  bladder,  and  crushing  the  stone,  introducing  an  evacuator 
and  remo\'ing  the  fragments.  In  Keith's  operation  the  incision  is  median 
and  opens  the  membranous  urethra.  In  very  large  stones  Milton  thinks 
the  surgeon  should  open  the  bladder  as  in  ordinar}^  lateral  lithotomy,  in- 
troduce a  lithotrite  through  the  incision,  and  crush  the  stone  before  extract- 
ing it,  thus  avoiding  the  mliiction  of  injun,'  upon  important  structures. 

Operation  for  Stone  in  Women. — If  the  stone  be  small,  give  the  patient 
ether,  place  her  in  the  lithotomy  position,  dilate  the  urethra  by  the  uterine 
dilator  imtil  it  admits  the  index-finger,  and  remove  the  stone  by  the  finger, 
the  scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too  large  to  pass,  crush 
it  by  a  lithotrite  and  get  rid  of  the  debris  by  the  evacuator.  Large  stones 
(2  oz.)  may  require  suprapubic  Hthotomy.  Vaginal  lithotomy  is  never  re- 
quired. If  done,  it  is  ver>'  Hkely  to  leave  as  a  legacy  a  vesicovaginal  fistula. 
In  female  children  dilate  the  lu'ethra,  crush  the  stone,  and  evacuate. 

Cystotomy  or  Cystostomy. — These  terms  mean  the  opening  of  the  bladder. 
If  the  opening  is  made  for  diagnosis  or  treatment  and  is  then  closed  or  allowed 
to  close,  the  operation  is  a  cystotomy.  If  the  woimd  is  deliberately  kept  open 
it  is  a  cystostomy.  The  bladder  may  be  opened  for  drainage,  for  diagnosis,  for 
the  removal  of  stones  or  tumors,  or  for  the  treatment  of  ulcers.  This  opening 
may  be  done  by  (i)  a  suprapubic  cut  (as  in  suprapubic  lithotomy),  (2)  a  lateral 
perineal  cut  (as  in  lateral  Hthotomy),  or  (3)  a  median  perineal  cut  (as  in 
median  lithotomy). 

The  operation  may  be  completed  in  one  sitting,  or  the  bladder  may  be 
only  exposed,  the  opening  of  it  being  delayed  for  several  days  imtil  it  becomes 
adherent  to  the  margins  of  the  w^oimd  (Senn's  operation).  Serm's  operation 
pi'eVents  infiltration  of  urine  into  the  prevesical  space,  and  it  is  advisable  to 
select  it  if  the  urine  is  verj^  foul. 

A  sinus  may  persist  after  suprapubic  cystotomy,  but  usuaUy  the  woimd 
heals  unless  it  is  kept  open  by  some  expedient. 

The  effects  of  suprapubic  drainage  are  very  beneficial  in  cases  of  chronic 
cystitis  associated  -^ith  hypertrophy  of  the  prostate  gland,  the  urine  being  foul. 
Drainage  causes  the  urine  to  become  clear  and  the  mucous  membrane  of  the 
bladder  to  become  normal.  If  the  opening  is  made  as  a  permanent  drain,  there 
will  usuaUy  be  incontinence,  as  the  new  channel  has  no  sphincter  action 
(Dandridge).     Figures  895  and  8g6  show  tubes  for  prolonged  drainage. 

Suprapubic  Cystotomy  (or  Cystostomy). — The  operation  is  employed  to 
aUow  the  sm-geon  to  explore  the  bladder,  to  treat  an  ulcer,  to  pro^dde  drainage, 
or  to  remove  a  tumor.  If  the  operation  is  for  calculi,  it  is  knowTi  as  suprapubic 
Hthotomy  (see  page  1331).  After  the  bladder  is  opened  its  interior  can  be 
illuminated  by  the  rays  of  an  electric  lamp,  which  appliance  is  fastened  with  a 
mirror  to  the  forehead  of  the  operator.  If  an  ulcer  is  foimd,  it  is  scraped  with 
a  curet  or  a  spoon.  Most  cases  of  tumor  require  suprapubic  cystotomy.  It  is 
true  that  a  small  single  growth  at  the  vesical  neck  is  accessible  by  median  cys- 
totomy, but  the  area  for  manipulation  is  very  narrow  and  the  growth  cannot 
be  seen.  Ever\^  large  growth,  aU  cases  of  multiple  tmnors,  and  ah  cases  of 
tumor  in  indi\'i'duals  -^-ith  great  depth  of  perineum  or  with  enlarged  prostate 
require  suprapubic  cystotomy,  an  operation  which  aUows  one  to  feel  and  to 


1338 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


see  the  growth,  which  gives  room  for  manipulation,  and  which  permits  thorough 
exploration  of  the  entire  bladder.  The  patient  is  put  in  the  Trendelenburg 
position  if  water  distention  is  used,  but  is  placed  horizontally  if  air  distention 
is  employed.  After  opening  the  bladder  as  for  stone  (see  page  1332),  hold 
the  edges  of  the  incision  apart  by  means  of  a  speculum  (speculum  of  Keen 
or  Watson)  or  by  retractors,  and  reflect  the  electric  Hght  into  the  woimd. 
Growths  when  seen  can  be  twisted  off,  a  pair  of  forceps  holding  the  base  and 
another  pair  being  used  to  twist,  but  after  removal  by  twisting  they  will  always 
recur  unless  the  base  and  the  mucous  membrane  about  the  base  is  removed. 
Broad  malignant  growths  may  require  partial  cystectomy.  Some  growths  (as 
inoperable  cancer)  are  removed  piece  by  piece  with  Thompson's  forceps  (Figs. 
892-894),  the  base  of  the  tumor  being  scraped.  Such  a  procedure  is  merely 
palliative.  Soft  growths  are  scraped  away  by  a  curet,  a  spoon,  or  the  finger- 
nail.    If  bleeding  is  severe,  check  it  by  pressure,  by  hot  water,  by  a  i  :  10,000 


Fig.  894. 

Figs.  892-894. — Thompson's  vesical  forceps  for  removing  growths  in  the  bladder;  for  growths  close  to 
the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the  neck  of  the  bladder. 


solution  of  adrenalin  chlorid,  or  even  by  the  actual  cautery.  In  some  cases  the 
wound  is  allowed  to  heal  rapidly.  In  others  the  bladder  is  drained  for  a  con- 
siderable time.  In  some  it  is  kept  open  permanently.  Permanent  drainage  is 
desirable  in  some  cases  of  enlarged  prostate,  and  in  such  cases  Senn's  tube  (Figs. 
895  and  897)  or  Stevenson's  tube  (Figs.  896  and  898)  may  be  employed. 

Median  Cystotomy  (or  Cystostomy). — The  same  incision  is  made  in  the 
perineal  raphe  for  median  cystotomy  as  for  median  lithotomy.  A  grooved 
staff  is  introduced  and  is  hooked  up  under  the  pubes ;  an  incision  is  made  into 
the  membranous  urethra,  and  is  extended  backward  for  f  inch,  and  a  finger 
is  carried  into  the  bladder.  If  searching  for  a  growth,  find  it  by  the  finger. 
The  usual  rule  has  been  to  catch  it  in  Thompson's  forceps  and  twist  it  off. 
Such  an  operation  is  totally  inefficient.  Soft  growths  may  be  scraped  away. 
Stop  bleeding  by  digital  pressure  or  by  injections  of  hot  water  or  adrenalin 


Injuries  of  the  Penis  and  Urethra 


1339 


chlorid  (i  :  10,000).  Median  cystotomy  does  not  allow  anything  like  the  free- 
dom of  access  given  by  suprapubic  cystotomy,  and  the  latter  operation  is  the 
best  for  tumor  cases.    The  median  operation  may  be  used  for  drainage. 


Fig.  895. — Senn's  silver  tube. 


Fig.  896. — Stevenson's  suprapubic  drainage- 
tube. 


Growths  In  the  Female  Bladder. — It  was  long  the  custom  to  dilate  the 
urethra  as  in  a  case  of  stone,  and  scrape,  twist,  or  pull  the  growth  away  or 
hgate  it.     This  plan  is  inefficient,  as  by  it  the  base  of  the  tumor  is  not  re- 


Fig.  897. — Senn's  tube  applied.     The  in- 


strument  does  not   press   upon   the  sensitive        Fig.  898. — Stevenson's  suprapubic  drainage-tube  in 
neck  of  the  bladder.  place  and  attached  to  a  receptacle  for  urine. 


moved.  It  is  usually  best,  if  fulguration  fails  or  will  evidently  be  useless,  to 
perform  a  suprapubic  operation.  If  the  growth  is  large  or  if  there  are  mul- 
tiple growths,  always  perform  suprapubic  cystotomy. 


Diseases  and  Injuries  of  the  Urethea,  Penis,  Testicle,  Prostate, 
Seminal  Vesicle,  Spermatic  Cord,  and  Tunica  Vaginalis 

Injuries  of  the  penis  and  uretlira  may  arise  from  traumatism  to  the 
perineimi  or  the  penis,  from  cuts  and  twists  of  the.  penis,  from  the  popular 
"breaking"  of  a  chordee,  from  t3dng  string  around  the  organ,  from  forcing  rings 


1340  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

over  it,  from  the  passage  of  instriiments,  or  from  the  impaction  of  calculi. 
Violence  inflicted  upon  an  erect  penis  may  fracture  the  corpora  cavernosa. 
The  writer  saw  one  man  with  a  glass  rod  broken  off  in  the  canal,  he  having 
been  in  the  habit  of  introducing  it  at  the  dictate  of  morbid  sexual  excitement. 
A  patient  in  the  Insane  Department  of  the  Philadelphia  Hospital  pushed  a 
ring  over  his  penis,  which  organ  ulcerated  into  the  urethra.  These  injuries 
are  treated  on  general  principles. 

Perineal  Bruises. — If  the  perineum  is  bruised  without  rupture  of  the 
urethra,  the  perineum  and  scrotum  swell  and  become  discolored;  water  is  passed 
with  difficulty  because  the  extravasated  mass  of  blood  in  the  periurethral  tis- 
sues compresses  the  canal  more  or  less;  the  water  is  not  bloody;  and  there  is 
severe  pairi  and  much  shock.  Some  authors  include  under  rupture  those  cases 
in  which  laceration  of  the  spongy  tissue  occurs,  without  involvement  of  the 
mucous  membrane  or  of  the  fibrous  coat,  but  they  are  properly  contusions. 

Treatment  of  Bruises  and  Wounds. — Place  the  patient  in  bed  and  establish 
reaction,  and  when  reaction  is  complete  employ  opiates  for  the  relief  of  pain. 
Apply  an  ice-bag  to  the  perineum.  If,  notwithstanding  these  measiu-es,  swell- 
ing continues,  introduce  a  silver  catheter  (No.  1 2  English) ,  tie  it  in,  and  make 
pressure  upon  the  perineum  by  a  firmly  applied  T-bandage  or  by  a  crutch  braced 
against  the  foot-board  of  the  bed.  Even  when  swelling  is  slight,  retention  of 
urine  may  occur  from  projection  of  a  submucous  blood-clot  into  the  canal  of 
the  urethra.  In  some  cases  it  may  become  necessary  to  incise  the  perineum  and 
evacuate  the  blood-clot.  After  twenty-four  hours  have  passed,  if  hemorrhage 
has  ceased,  substitute  a  hot-water  bag  for  the  ice-bag,  and  empty  the  bladder 
regularly  by  a  soft  catheter.  Occasionally,  though  rarely,  an  abscess  forms. 
Punctured  wounds  of  the  urethra  require  ordinary  dressings.  Incised  wounds  of 
the  urethra,  when  longitudinal,  are  closed  by  suture.  Healing  is  rapid  and  iU. 
consequences  are  not  to  be  feared.  Stricture  does  not  foUow.  When  the  wound 
is  transverse,  introduce  a  catheter,  suture  the  wound  over  the  instrument,  and 
remove  the  catheter  at  the  end  of  the  third  day.  If  a  catheter  cannot  be  in- 
troduced, employ  sutures,  but  at  the  first  evidence  of  extravasation  open  the 
wound,  and  if  drainage  is  not  free  perform  external  perineal  urethrotomy. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lacerated  or  a  con- 
tused wound  of  the  urethra,  destroying  partially  or  entirely  the  integrity  of 
the  canal.  A  lacerated  wound  may  be  induced  by  fracture  of  the  cavernous 
bodies  during  erection,  the  symptoms  being  severe  hemorrhage,  intense  pain, 
retention  of  urine,  and  inability  to  pass  an  instrument;  infiltration  of  urine 
occurs,  and  gangrene  is  a  common  result.  The  writer  has  seen  i  case  of 
rupture  of  the  penile  urethra  due  to  a  man's  slipping  while  shaving,  the  penis 
being  caught  in  a  partially  open  drawer,  the  drawer  being  shut  by  his  body 
coming  against  it.  Rupture,  however,  is  almost  invariably  located  in  the  peri- 
neum, and  it  arises  when  the  iirethra  is  suddenly  and  forcibly  pressed  against 
the  arch  of  the  pubes  by  a  blow,  by  a  kick,  or  by  falling  astride  a  beam  or  a 
fence-rail  or  on  a  wagon  wheel.  Retention  of  urine  due  to  stricture  may  lead 
to  extravasation  of  urine.  The  lesion  of  urethral  rupture  consists  in  some  cases 
of  laceration  of  the  spongy  tissue  and  the  mucous  membrane,  a  cavity  being 
formed  which  communicates  with  the  canal,  and  which  fills  with  urine  during 
micturition.  In  other  cases  not  only  the  spongy  tissue  and  the  urethral  mucous 
membrane  are  rent  asunder,  but  the  fibrous  coat  is  also  torn,  the  canal  opening 
directly  into  the  perineal  tissues,  among  which  a  huge  cavity  forms,  that 
fills  with  blood  and  later  with  urine  and  pus.  The  urethra  may  be  torn 
entirely  across,  but  in  most  cases  a  small  portion  at  least  of  its  circumference 
is  uninjured.  Rupture  never  occurs  primarily  and  alone  in  the  prostatic 
urethra.  Some  think  it  is  extremely  rare  in  the  membranous  urethra  unless 
due  to  pelvic  fracture.     I  beheve  that  it  occurs  not  unusually  in  the  membran- 


Treatment  of  Rupture  of  the  Urethra 


1341 


ous  urethra.  WTien  we  recall  that  this  is  the  fixed  portion  of  the  tube  we  would 
expect  rupture  here  rather  than  elsewhere.  It  is  very  unusual  in  the  penile 
urethra.  The  seat  of  rupture  in  the  great  majority  of  cases  is  in  the  region  of 
the  bulb.     Ver\^  rarely  is  the  skin  broken. 

The  symptoms  of  rupture  of  the  fixed  urethra  are  considerable  pain,  ag- 
gravated by  motion,  pressure,  and  attempts  to  pass  water;  decided  shock;  in 
some  cases  micturition  is  still  possible,  blood  preceding  and  also  discoloring 
the  stream,  for  some  blood  usually  runs  into  the  bladder;  retention  of  urine 
quickly  arises;  in  a  vast  majority  of  the  cases  retention  is  absolute  from  the 
ver\'  first,  and  it  is  due  to  the  interruption  in  the  integrity  of  the  canal  and  to 
the  occlusion  of  the  channel  by  blood-clots.  Bleeding,  which  is  usually  free, 
lasts  for  several  hours,  some  little  blood  generally  appearing  externally  and 
much  being  retained  in  the  perineum,  inducing  progressive  swelhng.  The 
presence  of  a  large  swelling  is  regarded  as  evidence  of  urethral  rupture. 
The  blood  which  is  effused  in  the  perineum  may  extend  under  the  fascia 
to  the  penis  and  scrotum.  The  swelhng  soon  becomes  reddish,  purple,  or 
even  black,  pressure  upon 
it  is  apt  to  cause  blood  to 
run  from  the  meatus,  and  it 
is  augmented  in  volume 
when  attempts  are  made  to 
urinate.  After  a  time,  if 
the  surgeon  does  not  act, 
the  urine  fills  the  perineal 
caxity  and  widely  infil- 
trates, and  there  ensue  gan- 
grene, sloughing,  and  sep- 
sis, life  being  endangered 
or  fistulge  being  left  as 
legacies.  The  course  of 
the  extravasated  urine  ^\ill 
often  enable  one  to  locate 
the  seat  of  injury.  In 
rupture  of  the  membran- 
ous urethra,  if  uncompK- 
cated,  the  urine  remains  be- 
tw^een  the  two  layers  of  the 
triangular  Hgament  until  a  channel  is  opened  for  it  by  sloughing  or  by  the  knife. 
When  extravasation  occurs  behind  the  posterior  layer  of  the  hgament  the 
urine  finds  its  way  to  the  perineum  in  the  neighborhood  of  the  anus.  When  the 
rupture  is  in  front  of  the  anterior  layer  of  the  ligament  the  urine,  directed  by 
the  deep  layer  of  the  superficial  fascia,  finds  it  way  into  the  scrotum  and  up 
on  the  belly,  but  does  not  pass  into  the  thighs  (Fig.  899).  A  contusion  is  dis- 
tinguished from  a  rupture  by  the  facts  that  in  the  former  the  perineal  swelling 
is  not  very  extensive  and  does  not  enlarge  on  attempting  micturition,  w^hile  in 
the  latter  it  is  extensive  and  does  enlarge  on  attempting  to  pass  water.  Further- 
more, contusion  does  not  cause  urethral  hemorrhage,  while  rupture  does.  A 
contusion  sometimes,  but  not  often,  prevents  the  passage  of  a  catheter;  a 
rupture  almost  always,  but  not  invariably,  does  so.  The  mortality  from 
severe  rupture  with  extravasation  is  about  14  per  cent.  (Kaufman). 

Treatment. — In  some  very  rare  cases  it  is  possible  to  suture  the  urethra,  and 
this  procedure  should  be  carried  out  when  possible.  In  order  to  suture,  per- 
form suprapubic  cystotomy  and  also  make  a  perineal  section.  Find  the  pos- 
terior end  of  the  ruptured  urethra  in  the  perineum  by  passing  a  catheter  from 
the  bladder  into  the  urethra.     Suture  by  way  of  the  perineum  and  with  silk. 


Fig.  Sgg. — Rupture  of  the  urethra  and  extravasation  of  urine. 


1342  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  sutures  pass  through  all  of  the  coats  of  the  urethra.  The  roof  of  the  canal 
is  sutured  first,  then  a  steel  sound  is  introduced  from  the  meatus,  and  the 
urethra  is  sutured  around  the  instrument.  The  sound  is  withdrawn  and  the 
bladder  is  drained  by  Cathcart's  siphon  as  illustrated  in  Fig.  886  or  by  a 
double  tube.  In  recent  cases  of  ruptiu'ed  urethra  the  usual  treatment  is  as 
follows:  Immediately  perform  median  perineal  section  and  turn  out  the  clot^ 
trim  off  lacerated  edges ;  find  the  proximal  end  of  the  urethra,  pass  a  catheter 
from  the  meatus  into  the  bladder,  and  leave  it  in  situ  until  healing  has  begim. 
aroimd  it.  If  the  catheter  cannot  be  passed  from  the  meatus,  open  the  blad- 
der above  the  pubes  and  find  the  proximal  end  of  the  torn  xirethra  by  retrograde 
catheterization.  In  retrograde  catheterization  we  push  an  instrimient  from  the 
bladder  into  the  wound  and  use  it  to  guide  a  catheter  from  the  meatus  into  the 
bladder.  When  rupture  occurs  back  of  a  strictiure  it  is  a  good  plan  to  excise 
the  cicatricial  tissue.  In  cases  with  extravasation  make  a  median  incision  and 
nimierous  transverse  cuts  to  secure  drainage  for  areas  of  retained  urine  or  pus. 
Then  at  once  perform  suprapubic  cystotomy.  Drain  suprapubically  and  from 
the  perineum  for  about  two  weeks,  by  which  time  sloughing  tissue  will  have 
separated.  Then  find  the  posterior  urethra  by  retrograde  catheterization  and 
do  a  perineal  operation  to  repair  the  damaged  urethra.  (See  Eugene  Fuller,  in 
"New  York  Med.  Jour.,"  Nov.  23,  1901.)  The  wound  is  packed  with  iodoform, 
gauze,  and  the  bowels  are  tied  up  with  opium  for  a  few  days.  Some  surgeons 
strongly  disapprove  of  the  custom  of  retaining  the  catheter,  beHeving  that  the 
instrimient  does  no  real  good,  as  urine  is  certain  to  get  between  the  catheter 
and  the  walls  of  the  iirethra.  They  think  it  is  quite  enough  to  stuff  the  woimd 
with  gauze,  the  patient  urinating  through  the  wound  for  the  first  few  days,  after 
which  time  a  catheter  is  used  at  regular  intervals.  Whatever  method  is  em- 
ployed, healing  will  require  from  six  to  eight  weeks,  and  the  patient  must 
during  the  rest  of  his  life,  from  time  to  time,  introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may  be  calcuh,  bodies 
introduced  by  injury,  as  shot,  bone,  etc.,  bodies  entering  from  a  fistiilous  open- 
ing into  the  rectum,  or  bodies  introduced  from  the  meatus,  as  broken  bits  of 
catheters,  straws,  pins,  etc. 

The  symptoms  and  treatment  vary  with  the  size  and  the  natine  of  the 
body.  Sometimes  there  are  almost  no  symptoms;  at  other  times  there  are 
foimd  great  pain,  retention  of  urine,  and  hemorrhage.  Examination  is  made 
by  the  urethroscope  by  feeling  carefully  with  a  finger  in  the  rectum  and  by 
searching  very  gently  with  a  sound,  taking  care  not  to  push  the  body  back. 
In  some  cases  the  body  can  be  removed  by  aid  of  the  urethroscope.  Employ 
this  plan  if  possible.  If  it  is  not  possible,  try  the  following  plans:  If  the 
bladder  is  well  filled  with  water  when  the  body  becomes  impacted,  inject  a 
little  oil  into  the  meatus,  close  the  lips  with  the  fingers,  and  direct  the  patient 
to  forcibly  attempt  urination,  the  surgeon  opening  the  meatus  when  the  urethra 
is  widely  distended,  the  foreign  body  being  often  forced  out.  If  this  maneuver 
fails,  and  the  foreign  body  is  impacted  in  the  pendulous  urethra,  prevent  its 
backward  passage  by  at  once  tying  a  rubber  tube  aroimd  the  penis.  Try  to 
squeeze  the  body  out,  and,  if  unsuccessful,  endeavor  to  catch  it  with  a  wire 
loop,  with  a  scoop,  or  with  the  long  urethral  forceps.  If  these  methods  fail, 
cut  down  upon  the  body  and  remove  it,  dividing  any  existing  stricture.  If  it  is 
lodged  just  back  of  the  meatus,  incision  of  the  meatus  will  permit  extraction. 
If  a  hairpin  is  in  the  canal,  the  points  of  the  pin  are  almost  always  pointing  to  the 
meatus;  to  prevent  them  catching  on  attempted  withdrawal,  the  penis  must 
be  squeezed  to  approximate  the  feet  of  the  pin,  and  when  they  are  adjacent  a 
part  of  a  silver  catheter  is  slipped  over  to  retain  them  in  this  position,  when  the 
pin  can  be  extracted.  If  this  fails,  drag  the  penis  against  the  belly,  by  rectal 
touch  force  the  sharp  ends  of  the  pin  out  through  the  integument,  cut  one 


Non-venereal,  Non-specific,  Pyogenic,  or  Simple  Urethritis       1343 

end  off,  and  then  withdraw  the  other.  An  ordinary  large-headed  pin  is  forced 
out  in  the  same  way,  and  when  the  head  is  turned  externally  it  is  extracted 
by  way  of  the  meatus.  If  a  hard  or  sharp  foreign  body  is  lodged  in  the  pros- 
tatic urethra,  do  not  catch  it  with  an  instrument  and  try  to  drag  it  forward. 
To  do  so  will  be  apt  to  tear  the  membranous  urethra.  It  is  better  to  push 
it  into  the  bladder  and  remove  it  later  by  cutting  or,  if  it  be  a  stone,  by  crush- 
ing (H.  Hartmann,  in  "La  Presse  Med.,"  July  24,  1901).  If  a  lithotrite  loaded 
with  fragments  be  caught  in  the  urethra,  the  surgeon  must  perform  a  perineal 
section,  to  enable  him  to  clean  and  close  the  blades.  After  the  blades  have 
been  closed  the  instrument  may  be  easily  withdrawn. 

Urethrorrhea  is  not  urethral  inflammation,  but  is  a  condition  of  sensi- 
tiveness of  the  urethra  and  oversecretion  of  the  glandular  elements.  It  may 
be  due  to  masturbation,  sexual  excess,  and  also,  as  Sturgis  points  out,  to  with- 
drawal during  sexual  intercourse,  and  to  ungratified  sexual  passion.  A  drop 
or  two  of  transparent  mucus  is  found  at  the  meatus  in  the  morning,  and  a 
considerable  amount  may  flow  away  while  straining  at  stool  or  upon  the  dimi- 
nution of  an  erection.  This  flow  at  stool  is  often  caUed  defecation  spermat- 
orrhea. This  discharge  stains,  but  does  not  stiffen  linen  (Sturgis).  The 
discharge  contains  mucus,  mucous  corpuscles,  epithehal  cells,  but  no  gonococci 
or  pus  organisms.  The  patient  may  be  weU  in  all  other  respects,  but  in  many 
cases  there  are  neurasthenic  symptoms,  sexual  weakness,  or  even  impotence. 
It  is  weU  to  explain  to  the  patient  that  the  overaction  of  the  muciparous  glands 
is  Nature's  effort  to  facflitate  the  passage  of  the  fluid  of  the  orgasm  and  to 
alkalinize  an  acid  urethra  which  would  inhibit  the  acti\dty  of  spermatozoids. 
Quacks  fatten  on  these  unfortunates.  This  condition  may  be  readily  distin- 
guished from  prostatorrhea  by  the  absence  of  Bottcher's  crystals  (see  page 
1377)  and  from  that  very  rare  condition  spermatorrhea  by  the  absence  of  sper- 
matozoids. 

Treatment. — In  an  uncompHcated  case  improvement  or  ciire  will  follow  upon 
the  abandonment  of  evil  habits  and  the  systematic  passage  of  steel  sounds. 
If  complications  arise,  they  must  be  treated. 

Urethritis,  or  Inflammation  of  the  Urethra. — Urethral  inflammations 
can  be  divided  into  two  classes:  (i)  simple  or  non-specific,  in  which  infection 
is  due  alone  to  pyogenic  cocci  (particularly  the  Bacillus  coli  communis  and  the 
Staphylococcus  pyogenes),  and  (2)  specific,  in  which  the  gonococcus  is  present. 

Non-venereal,  non-specific,  pyogenic,  or  simple  urethritis  may  be  due  to 
several  causes,  such  as  traumatism;  great  acidity  of  the  urine;  chancre  in  the 
urethra;  contact  with  menstrual  fluid,  leukorrheal  discharge,  the  discharge  from 
malignant  disease  of  the  uterus,  ordinar}^  pus,  or  acrid  vaginal  discharge;  the 
passage  of  instrimients;  the  administration  of  irritant  diuretics;  strong  injec- 
tions; worms  in  the  rectum;  a  febrfle  malady;  venereal  excess  and  masturbation; 
the  passage  or  impaction  of  foreign  bodies,  and  papfllomata  of  the  urethra. 
A  temporary  and  mild  urethritis  sometimes  accompanies  early  s>^hilitic  erup- 
tions. Simple  urethritis  is  less  severe  and  prolonged  than  gonorrheal  urethritis, 
though  clinically  in  the  early  stage  the  physician  cannot  invariably  distinguish 
between  the  tw^o  forms.  The  diplococci  of  gonorrhea  are  never  foimd  in  the 
discharge  of  simple  lurethritis,  although  there  may  be  numerous  other  diplococci. 
In  medicolegal  cases  testimony  is  not  admitted  as  to  the  presence  or  absence  of 
diplococci,  as  judges  do  not  admit  that  their  presence  proves  or  their  absence 
disproves  gonorrhea.  In  the  non-specific  inflammation  pus  is  not  always 
present,  many  cases  stopping  short  of  pus  formation  after  a  var}dng  period  of 
catarrh,  but  any  catarrh  may  become  purulent.  A  simple  urethritis  may  be 
caused  or  may  be  prolonged  for  an  indeflnite  period  by  the  presence  of  large 
amoimts  of  oxalate  in  the  urine  or  the  existence  of  the  uric-acid  diathesis  (see 
Gouty  Urethritis). 


1344  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Treatment. — Seek  for  the  cause  and  remove  it.  Correct  any  abnormal 
condition  of  the  urine  by  means  of  suitable  diet,  drugs,  and  mode  of  Ufe. 
Mild  astringent  injections  are  useful.  It  may  be  necessary  to  flush  the  urethra 
repeatedly  with  a  solution  of  silver  nitrate  (i  :  8000). 

Traumatic  Urethritis. — The  onset  of  pain  in  traumatic  urethritis  is  coinci- 
dent with  the  introduction  of  the  foreign  body.  The  discharge,  which  may  be 
bloody,  mucous,  mucopurulent,  or  purulent,  comes  on  within  twenty-four  hours. 

Treatment. — If  the  inflammation  is  sUght,  prescribe  diluent  drinks,  pare- 
goric, a  saline,  or  the  following: 

I^.     Tinct.  belladonna fSss; 

Sodii  bromid 5iv; 

Tinct.  opii  camphorat f  o  j; 

Syrupus  zingib f 5  ss; 

Aquae  destil q.  s.  ad.  fSvj. — M. 

Sig. — A  tablespoonful  every  six  hours. 

If  the  inflammation  is  severe,  put  the  patient  to  bed,  apply  hot  fomentations 
to  the  perineimi,  give  diluent  drinks,  employ  suppositories  of  opium  and 
belladonna,  and  watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in  the  posterior  ure- 
thra, not  in  the  anterior,  as  does  clap.  Its  symptoms  are  great  vesical  irrita- 
bility; pain  on  urination;  discharge,  usually  scanty,  associated  with  uric  acid  in 
the  urine  and  perhaps  joint  symptoms  of  gout.  The  treatment  comprises  dieting 
and  the  usual  remedies  for  gout.  Purgatives  are  given  freely,  and  full  doses 
of  coichicum,  piperazin,  urotropin,  or  the  alkaHs;  hot  baths,  low  diet,  diluent 
drinks,  and  diaphoretics  are  indicated.  A  chronic  discharge  from  the  pros- 
tatic region  is  apt  to  Hnger;  for  this  there  is  nothing  better  than  the  usual 
gouty  remedies  and  saline  waters  with  copaiba,  cubebs,  or  sandalwood  oil. 
In  many  cases  it  is  necessary  to  flush  the  urethra  once  a  day  with  a  solution 
of  silver  nitrate  (i  :  8000). 

Eczematous  Urethritis. — Berkley  Hill  states  that  this  disease  is  very 
obstinate,  is  probably  associated  with  gout,  and  is  met  with  in  adults  of  full 
habit  or  who  are  beer-drinkers  and  who  have  eczema  of  the  surface  of  the 
body.  He  states  also  that  the  glans  penis  near  the  meatus  is  red  and  tender, 
and  that  the  interior  of  the  urethra  is  in  the  same  condition.  Pain  is  constant, 
and  it  is  aggravated  by  micturition.  The  discharge  is  scanty.  The  treatment 
comprises  injections  of  cold  water  or  irrigation  with  iced  water,  and  internally 
the  administration  of  arsenic  with  the  alkahs. 

Tuberculous  urethritis  is  due  to  a  tuberculous  ulcer,  which  is  most  apt 
to  be  seated  near  the  vesical  neck.  There  is  a  little  pain  on  micturition,  but 
there  is  intense  pain  at  one  spot  on  passing  a  bougie.  The  discharge  is  sHght 
and  at  times  bloody.  The  bladder  is  very  irritable,  and  severe  cystitis  arises 
and  persists.  The  treatment  includes  warmth,  nutritious  diet,  and  cod-liver 
ofl,  curettement,  and  local  applications  of  iodoform  through  a  urethroscope, 
and  living  as  much  as  possible  out  of  doors.  The  climate  of  southern  California 
is  peculiarly  weU  suited  to  these  cases.  The  bladder  is  washed  out  once  a  day 
with  boric  acid  solution.  Iodoform  emulsion  is  injected  daily.  Tuberculin 
may  prove  of  value.  After  a  time  the  surgeon  will  probably  be  forced  to  drain 
by  perineal  or  suprapubic  cystotomy  (see  Tuberculous  Cystitis,  pages  1326 
and  1327). 

Pyogenic  Chancroidal  Urethritis. — This  condition  is  sometimes  seen  in 
association  with  chancroid  of  the  urinary  meatus. 

Pyogenic  Urethritis  of  Urethral  Chancre. — A  urethritis  may  occur  in  this 
condition. 

Pyogenic  Syphilitic  Urethritis. — A  temporary  and  mild  urethritis  sometimes 
accompanies  early  syphilitic  eruptions. 


Gonorrhea  1345 

Examination  of  a  Patient  in  Whom  a  Urethral  Discharge  Exists. — 

Learn  accurately  the  history.  Obtain  some  of  the  discharge  and  examine  an 
unstained  sHde  and  a  shde  stained  for  gonococci.  In  some  cases  take  cultures. 
Learn  the  amount  of  the  twenty-four-hour  urine  and  study  a  sample  chemically 
and  microscopically,  being  sure  to  determine  the  amount  of  urea.  Learn  if 
the  discharge  discolors  or  stiffens  linen;  if  it  is  only  found  in  the  morning; 
if  it  simply  glues  the  lips  of  the  meatus  together;  if  it  is  seen  during  the  day; 
if  it  is  noted  particularly  or  only  after  sexual  excitement  or  straining  at  stool. 
Inquire  as  to  pain,  frequency  of  micturition,  passage  of  blood,  nocturnal 
emissions,  manner  of  urinating,  etc.  In  many  cases  insert  a  finger  in  the 
rectum,  feel  the  prostate  and  vesicles,  massage  them,  and  see  if  discharge 
appears  at  the  meatus  after  stripping  the  penis.  If  discharge  does  appear, 
collect  a  specimen  and  examine  it.  In  some  cases  it  is  necessary  to  pass  a 
sound.  Carefully  cleanse  the  meatus,  glans,  prepuce,  and  urethra  before  pass- 
ing a  sound.  Cleanse  the  meatus,  glans,  and  prepuce  with  a  i  :  6000  solution 
of  corrosive  sublimate.  Irrigate  the  urethra  with  boric  acid  solution  and  fill 
and  clean  urethra  with  emulsion  of  iodoform  and  glycerin  (5  per  cent.),  and 
after  using  the  instrument  irrigate  again  with  boric  acid  solution  (Valentine's 
method) .     Examine  the  urine  by  the  three-glass  test. 

The  Three-glass  Test  {Valentine's  Plan). — Take  as  many  3-oz,  tubes 
as  are  required  to  receive  all  the  urine  from  the  bladder.  The  first  tube 
contains  the  washings  from  the  anterior  urethra.  The  second  and  other 
tubes,  additional  material  from  the  bladder.  The  last  tube  contains  material 
expressed  from  the  posterior  lurethra,  prostate,  and  seminal  vesicles.  Ex- 
amine the  urine  and  the  sediment  in  the  first  two  glasses  and  in  the  last  glass. 
Note  particularly  if  shreds  are  present.  The  shreds  of  gonorrhea  are  white 
in  color  and  of  variable  length,  and  float  in  the  urine.  They  are  composed  of 
pus-corpuscles  and  of  epithelial  cells  which  have  undergone  fatty  degeneration. 
Some  of  these  shreds  form  in  the  ducts  of  Cowper's  glands,  some  in  the  glands 
of  Littre,  some  in  the  prostatic  sinuses,  some  in  the  utricle,  some  in  the  folds 
around  the  verumontanum,  and  some  from  inflammatory  patches  along  the 
entire  length  of  the  urethra.  A  i  per  cent,  solution  of  methylene-blue  injected 
into  the  anterior  urethra  will  stain  the  urethral  shreds,  while  those  from  the 
bladder  will  not  be  stained  by  it. 

Gonorrhea  (Clap;  Specific  Urethritis;  Tripper;  Venereal  Catarrh). 
— Gonorrhea  is  an  acute  inflammation  of  the  genital  mucous  membrane, 
nearly  always  of  venereal  origin,  due  to  the  deposition  and  multiplica- 
tion of  gonococci  in  the  cells  of  the  membrane  and  a  mixed  infection  with 
the  cocci  of  suppuration.  The  disease  is  inaugurated  by  gonococci.  After  a 
few  days  or  more  secondary  pyogenic  infection  develops  and  complications 
may  result  from  the  gonococci  or  from  the  bacteria  causing  the  mixed  infection. 
The  disease  attacks  with  the  greatest  ease  surfaces  covered  with  squamous 
epithelium.  The  gonococci  enter  into  and  multiply  in  the  superficial  epithelial 
cells  and  pass  between  the  deeper  cells,  where  they  lodge  and  multiply  as  the 
superficial  cells  are  cast  off.  The  pus  from  the  urethra  contains  epithelial 
cells  with  gonococci  on  or  inside  of  them,  and  also  pus-cells  with  gonococci 
within  them  as  a  result  of  phagocytosis.  Cultures  are  made  with  difficulty. 
Gonococci  do  not  stain  by  Gram's  method,  but  stain  best  with  a  weak,  watery 
solution  of  an  anilin  dye.  These  bacteria  are  said  not  to  be  pathogenic  to 
animals,  although  some  observers  deny  this  assertion.  Gonorrhea  is  one  of  the 
most  common  and  widely  disseminated  diseases.  Probably  one-half  of  all 
sterile  women  and  many  sterile  men  have  been  rendered  so  by  this  disease. 
It  is  responsible  for  not  a  few  cases  of  abortion,  for  an  enormous  majority 
of  female  pelvic  diseases,  and  it  causes  many  cases  of  blindness  by  infection  of 
■children's  eyes  during  delivery. 

8s 


1346  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Gonorrhea  in  the  Male. — In  the  male,  clap  begins  within  the  meatus 
and  fossa  navicularis  and  extends  backward  throughout  the  length  of  the 
urethra.  The  mucous  membrane  swells  and  becomes  hyperemic,  and  there 
is  a  discharge,  first  of  mucus  and  serum,  and  then  of  pus.  In  severe  cases 
the  discharge  is  bloody  {black  gonorrhea)  or  green.  For  a  week  or  more  the  in- 
flammation increases,  then  becomes  stationary  for  a  time,  and  then  declines, 
the  discharge  growing  less  profuse  and  thinner,  a  watery  discharge  lasting 
for  a  considerable  time.  An  ordinary  case  of  genuine  gonorrhea  lasts  from  six 
to  ten  weeks,  and  even  a  case  limited  purely  to  the  anterior  urethra  will  rarely 
be  cured  within  four  or  five  weeks.  During  the  acute  stage  the  entire  penis 
swells  and  the  corpus  spongiosiun  becomes  infiltrated  with  inflammatory 
exudate.  An  interesting  fact  is  that  gonorrhea  may  induce  mild  septicemia 
without  demonstrable  complications,  the  condition  causing,  according  to 
Thayer  ("Amer.  Jour.  Med.  Sci.,"  Nov.,  1905),  a  continued  fever  which, 
perhaps,  lasts  a  number  of  weeks.  In  true  gonorrheal  septicemia  the  blood 
must  contain  gonococci  (gonococcemia) .  In  the  case  recorded  by  Thayer  and 
in  the  one  recorded  by  Blumer  and  Hayes,  and  in  the  one  recorded  by  Stell- 
wagen  ("Therapeutic  Gazette,"  April  16,  1910,  page  248)  cultures  were  ob- 
tained from  the  blood.  Gonorrhea  may  produce  grave  septicemia  with  sys- 
temic complications.  It  tends  particularly  to  attack  serous  membranes  or 
other  endothelial  structures  (joints,  pericardium,  endocardium,  pleura,  tendon- 
sheaths,  intima  of  vessels,  etc.).  Among  the  complications  are  gonorrheal 
arthritis,  myelitis,  poliomyeHtis,  and  multiple  neuritis.  There  are  3  cases  of 
gonorrheal  myositis  on  record  (Martin  W.  Ware,  "Amer.  Jour.  Med.  Sci.," 
July,  1 901).  Phlebitis  may  arise.  Mild  endocarditis  may  arise  or  severe 
endocarditis  may  occur,  identical  symptomatically  with  ulcerative  endocar- 
ditis due  to  other  bacteria.  In  6  reported  cases  of  endocarditis  gonococci 
were  obtained  by  cultures  from  the  blood  intra  vitam  (Thayer,  Loc.  cit.). 
Cerebral  embolism  may  result.  Cerebrospinal  meningitis  can  occur  (fluid  ob- 
tained by  lumbar  puncture  contains  gonococci). 

Gonorrheal  rheumatism  is  discussed  on  page  636.  Gonorrheal  peritonitis 
is  rare.  Infection  of  the  peritoneum  through  the  blood  is  very  rare.  The 
majority  of  cases  of  gonorrheal  peritonitis  occur  in  women  and  are  due  to 
direct  extension  from  the  Fallopian  tubes.  Gonococci  have  not  been  found 
in  the  exudates  of  cases  of  pleuritis  and  pericarditis  supposed  to  be  of  gonor- 
rheal origin.  A  child  may  contract  gonorrheal  ophthalmia  during  delivery, 
and  any  person  may  develop  it  by  getting  gonococci  into  the  eyes. 

Symptoms  of  Acute  Inflammatory  Gonorrhea. — The  period  of  incubation 
of  gonorrhea  is  from  a  few  hours  to  two  weeks.  The  usual  period  is  from  three 
to  five  days,  when  symptoms  of  the  prodromal  stage  or  stage  of  onset  begin. 
The  patient  notices  on  arising  a  drop  of  thin  fluid  which  glues  the  lips  of  the 
meatus  together,  and  he  feels  some  heat  and  itching  or  tickling  about  the  mea- 
tus or  in  the  navicular  fossa.  There  may  be  uneasiness  or  actual  pain  uncon- 
nected with  urination,  and  there  is  sure  to  be  scalding  pain  on  urination.  The 
meatus  is  red  and  swollen,  has  a  glazed  appearance,  may  be  covered  with  a  little 
mucopus,  and  the  lips  are  glued  together  by  the  discharge.  It  may  be  possi- 
ble to  squeeze  out  a  drop  or  two.  Even  so  early  the  fluid  contains  gonococci. 
The  urine  appears  clear,  but  on  shaking  some  flakes  are  noted.  They  are 
epithelial  cells.  Within  forty-eight  hours  the  first  stage,  the  florid  stage,  the 
acute  stage,  or  the  stage  of  increase,  becomes  established.  The  meatus  is 
now  red,  swollen,  and  everted  {fish-mouth  meatus);  the  entire  glans  may  be 
red  and  swollen;  if  the  prepuce  is  long,  it  becomes  swollen,  reddened,  and 
constricted,  and  in  many  cases  very  edematous ;  the  lymphatics  by  the  f remun 
and  on  the  dorsum  of  the  penis  may  be  red,  swollen,  tender,  and  cord-like; 
micturition  causes  severe  pain  {ardor  urines),  which  is  due  to  distention  of 


Examination  for  Gonococci  1347 

the  inflamed  urethra  and  to  stinging  by  the  acid  urine.  Bumstead  thus 
described  the  act  of  micturition  in  acute  gonorrhea:  "During  the  act  the 
patient  invokmtarily  relaxes  the  abdominal  walls,  holds  his  breath,  and 
keeps  the  diaphragm  elevated  in  order  to  diminish  the  pressure  on  the  bladder 
and  lessen  the  size  and  force  of  the  stream"  ("Venereal  Diseases,"  by  Robt.  W. 
Taylor).  Because  of  the  narrowing  of  the  canal  the  stream  of  urine  becomes 
narrow,  weak,  twisted,  forked,  or  is  delivered  in  little  bursts  or  drops.  Re- 
tention may  result  from  spasm  of  the  muscles.  When  the  acute  or  florid  stage 
is  fully  developed,  the  entire  urethra  is  inflamed  from  the  meatus  to  the  tri- 
angular ligament;  there  is  constant  mieasiness  or  actual  pain  in  the  penis  and 
perineum,  increased  by  walking  and  by  sitting  down  suddenly  or  carelessly. 
Insomnia  is  common;  chordee  occurs,  especially  when  the  patient  is  warm  in 
bed.  By  "chordee"  we  mean  a  condition  of  pamful  erection  in  which  the  penis 
is  markedly  bent.  The  rigid  infiltration  of  the  corpus  spongiosum  prevents 
it  distending  to  accommodate  itself  to  the  enlarged  corpora  cavernosa,  and  in 
consequence  the  organ  curves.  There  is  frequent  micturition,  with  tenesmus 
and  a  profuse  creamy  discharge,  which  is  yellow,  greenish,  or  even  bloody. 
The  discharge  soils  and  stains  the  victim's  linen  and  may  crust  upon  the 
linen,  the  meatus,  or  the  glans.  The  commonest  compHcations  of  this  stage 
are  balanitis  (inflammation  of  the  mucous  membrane  of  the  glans  penis), 
halano posthitis  (inflammation  of  the  surface  of  the  glans  and  the  mucous 
membrane  of  the  prepuce),  phimosis  (thickening  and  contraction  of  the  fore- 
skin, so  that  the  glans  cannot  be  imcovered),  and  paraphimosis  (catching 
and  fixation  of  the  retracted  prepuce  behind  the  corona  glandis,  with  such 
sweUing  of  the  glans  and  prepuce  that  it  is  impossible  to  bring  the  prepuce 
forv\'ard  over  the  glans).  This  is  a  dangerous  condition  and  it  should  be  re- 
duced at  once.  In  the  second  or  stationary  stage,  which  lasts  from  the  end  of 
the  first  to  the  end  of  the  second  week,  the  acute  symptoms  of  the  first  stage 
continue.  The  most  common  complications  of  this  stage  are  peri-urethral 
abscess  or  phlegmon  (infection  of  a  urethral  gland  or  of  submucous  structures) , 
folliculitis  (inflammation  of  the  follicles  of  Littre),  hemorrhage,  retention  of 
urine  (which  is  rare),  gonorrheal  arthritis,  lymphangitis,  and  diminutive 
bubo  on  the  dorsum  of  the  penis  (bubonulus) ,  sohtary  and  painful  bubo  of  the 
groin,  which  may  suppurate,  Cowperitis  (inflammation  of  Co^\'per's  glands), 
inflammation  of  the  prostate  or  of  the  bladder,  gonorrheal  ophthalmia,  and 
chordee  (painful  erection  with  downward  bending  of  the  penis).  In  the  third 
or  subsiding  stage  the  symptoms  gradually  abate,  the  discharge  becoming 
scantier  and  thinner,  and  finally  drying  up.  This  stage  is  of  uncertain  dura- 
tion, and  in  it  there  may  occur  epididymitis,  or  inflammation  of  the  epididvmis. 
Among  possible  complications  we  may  mention  peri-urethral  abscess  or 
phlegmon,  Co^\-peritis,  cystitis,  prostatitis,  bubonulus,  foUiculitis,  gonorrheal 
arthritis  (see  page  636),  infective  endocarditis,  tenosynovitis,  pyelitis,  puru- 
lent ophthalmia,  perichondritis,  and  peritonitis. 

Examination  for  Gonococci. — Every  urethral  discharge  should  be  examined 
for  gonococci  in  order  to  make  a  positive  diagnosis.  This  examination  is 
made  several  times  during  the  progress  of  the  case,  so  as  to  determine  when  the 
organisms  disappear.  Many  non-gonorrheal  conditions  are  due  to  cocci 
strongly  resembling  gonococci.  Free  pus  and  numerous  cocci  usually  mean 
gonorrhea.  So  do  complications.  The  examination  of  the  smear  is  not  abso- 
lutely conclusive.  Cifltures  are  conclusive.  If  there  is  a  free  discharge, 
fluid  for  examination  can  be  easfly  obtained.  If  the  discharge  is  scanty  or 
occasional,  have  the  patient  partiaUy  empty  the  bladder.  Then  the  surgeon 
massages  the  prostate  and  urethra  and  smears  fluid  on  the  slide.  Then  the 
patient  empties  his  bladder  into  two  glasses.  Each  specimen  is  to  be  centri- 
fuged  and  examined  for  pus  (Keyes,  "Amer.  Jour.  Med.  Sci.,"  Jan.,  1912). 


1348  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  taking  of  a  smear  and  its  examination  are  easy.  Place  a  drop  of  discharge 
upon  a  cover-glass,  lay  another  cover-glass  over  this,  and  slide  the  glasses  apart. 
Dry  and  fix  the  slides  in  the  flame  of  an  alcohol  lamp.  Bring  the  cover-glasses 
in  contact  with  a  saturated  solution  of  methylene-blue  in  5  per  cent,  carbolic 
acid  water.  The  staining  material  is  allowed  to  remain  in  contact  with  the 
slides  for  five  or  ten  minutes,  the  glasses  are  washed  with  water,  are  then  placed 
in  a  solution  of  5  drops  of  acetic  acid  to  20  c.c.  of  water,  and  kept  there  "long 
enough  to  count  one,  two,  three  slowly,"  and  are  again  washed  with  water.  Ex- 
amination with  the  microscope  shows  the  gonococci  stained  blue.^  In  doubtful 
cases,  especially  when  the  microscope  fails  to  show  gonococci,  make  cultures. 
Cultures  must  be  made  in  suspected  gonorrhea  in  a  child,  from  the  fluid  of  an 
inflamed  joint,  from  the  discharge  in  gleet  or  purulent  ophthalmia,  and  from 
the  blood  in  obscure  infections. 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who  have  previously 
had  gonorrhea,  as  a  result  of  prolonged  or  repeated  coition  or  of  contact  with 
menstrual  fluid  or  leukorrheal  discharge.  There  is  profuse  mucopurulent 
discharge,  but  very  little  pain  on  micturition,  and  seldom  chordee  or  marked 
irritability  of  the  bladder. 

Irritative  or  Abortive  Gonorrhea. — ^In  this  disease  the  symptoms,  which 
are  identical  with  those  of  beginning  clap,  do  not  increase,  but  disappear 
within  ten  days. 

Chronic  Urethral  Discharges. — Chronic  urethral  catarrh,  which  may 
follow  gonorrhea,  is  characterized  by  the  occasional  presence  of  a  drop  of 
clear,  tenacious  liquid.  This  discharge  becomes  more  profuse  as  a  result  of 
sexual  excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge,  because  of  locali- 
zation of  inflammation  in  one  spot  or  the  production  of  a  granular  patch  or  a 
superficial  ulcer,  characterizes  chronic  gonorrhea.  There  is  some  scalding 
on  urination;  erections  produce  aching  pain;  there  are  pain  in  the  back  and 
redness  and  swelling  of  the  meatus.  All  the  symptoms  are  intensified  by 
sexual  excitement,  by  coitus,  by  violent  exercise,  or  by  alcoholic  excess. 

Gleet. — If  a  chronic  gonorrheal  urethritis  lasts  over  ten  weeks,  it  is  called 
gleet.  In  gleet  the  lips  of  the  meatus  are  stuck  together  in  the  morning,  and 
squeezing  them  discloses  a  drop  of  opalescent  mucopurulent  fluid  (the  morning 
drop) .  During  the  day  the  discharge  is  rarely  found.  The  discharge  is  yellow  or 
has  a  yellowish  hue;  it  stains  the  linen  distinctly,  and  contains  pus  shreds,  epi- 
thelium, and  at  times  gonococci.  The  urine  is  clear  and  contains  pus,  gonorrheal 
shreds,  and  comma-shaped  hooks.  The  discharge  is  not  obviously  purulent, 
and  contains  amyloid  corpuscles.  There  are  frequency  of  micturition,  pains 
in  the  back,  and  dribbling  of  urine,  and  a  bougie  may  find  a  stricture  of  large 
caliber,  or  at  least  will  discover  that  the  urethra  is  rigid  from  inflammatory 
infiltration.  A  discharge  may  be  maintained  by  chronic  prostatitis.  In  this 
condition  there  are  frequency  of  micturition ;  a  sense  of  weight  or  dull  pain  in 
the  perineum;  diminished  projectile  force  of  the  stream  of  urine;  there  is  often 
a  tendency  to  sexual  excitement  and  premature  emission.  In  prostatorrhea  a 
milky  discharge  gathers  m  the  urethra  during  sleep  and  flow^s  during  muscular 
effort  or  while  the  patient  is  at  stool.  The  linen  is  stained  but  slightly  and  the 
lips  of  the  meatus  are  not  glued  together  on  wakmg.  There  is  a  history  of 
masturbation  or  sexual  excess.  The  condition  is  not  aggravated  particularly 
by  alcohol  or  sexual  intercourse.  In  chronic  anterior  inrethritis  there  is  a  dis- 
charge from  the  meatus  or  sticking  together  of  the  lips  in  the  morning.  In 
chronic  posterior  urethritis  there  is  no  discharge  of  pus  from  the  meatus. 
If  the  three-glass  test  is  made,  it  will  be  found  that  in  a  case  of  chronic  anterior 
urethritis  only  the  first  portion  wifl  be  cloudy  and  show  shreds;  if  there  is 
■  1  Schutz's  method,  as  set  forth  by  R.  W.  Taylor  in  his  work  upon  "Venereal  Diseases." 


Treatment  of  Acute  Gonorrhea  1349 

posterior  urethritis  of  not  ver\'  long  standing,  both  portions  will  be  a  Uttle 
clouded,  the  hrst  containing  clap  shreds,  the  last  hool-shaped  shreds.  In  a 
verv'  chronic  case  neither  sample  will  be  cloudy,  but  the  first  portion  will  con- 
tain shreds.  In  gleet  the  rigidity  of  the  urethra  causes  the  retention  of  small 
quantities  of  urine  after  each  act  of  micturition,  back  of  the  thickened  areas. 
This  retained  urine  decomposes  and  adds  to  inflammation.  Indulgence  in 
alcohol,  sexual  excitement,  or  sexual  intercourse  aggravates  the  condition. 

Treatment  of  Acute  Gonorrhea. — General  Care. — Wash  the  hands  after 
touching  the  parts  and  dry  them  on  an  individual  towel,  which  is  not  used 
upon  the  face.  Wear  a  suspensory  bandage.  Avoid  \dolent  exercise,  espe- 
cially bicycle  riding,  and  also  wet.  Moderate  exercise  is  allowable.  The 
patient  must  not  only  refrain  from  sexual  intercourse,  but  must  not  permit 
himself  to  indulge  in  sexual  excitement,  and  must  not  drink  a  drop  of  liquor, 
malt,  \-inous,  or  spiritous,  imless  he  is  a  heavy  or  a  regular  drinker,  in  w^hich 
case  we  should  permit  the  moderate  use  of  well  diluted  rye  or  Scotch  whisky. 
Some  men  become  actually  ill  without  their  regular  daily  stimulants  and  such 
men  should  have  them  in  moderation.  Some  surgeons  permit  the  moderate 
use  of  claret  to  all  patients.  At  least  twice  a  day  wash  the  penis  for  five  minutes 
in  a  cup  of  warm  water  containing  i  dram  of  salt.  Passing  the  urine  while  the 
penis  is  immersed  in  warm  fluid  lessens  ardor  urinae.  Cut  a  small  opening  in 
a  square  piece  of  old  linen,  slip  the  linen  over  the  glans,  catch  it  back  of  the 
corona,  and  bring  the  ends  forward  with  the  prepuce.  Never  permit  the 
cotton  or  linen  to  stick  fast  and  plug  up  the  lips  of  the  meatus.  If  the  lips 
tend  to  become  sealed  up,  grease  them  wdth  sterile  vaselin.  If  the  glans  is 
completely  naked,  pin  the  foot  of  an  old  stocking  upon  the  imdershirt,  put 
absorbent  cotton  in  the  toe,  and  place  the  penis  within  this  bag.  Never  tie 
or  fasten  any  material  about  the  penis.  The  patient  should  drink  freely  of 
plain  water  or  of  water  containing  a  Uttle  bicarbonate  of  sodium.  He  should 
obtain  one  bowel  movement  every  day. 

Diet  and  Instruction  List  (Dr.  T.  C.  Stellwagen,  Jr.). — Meats. — May  have 
white  meat  of  chicken,  boiled  fish,  lamb. 

Must  not  take  beef,  beef  steak,  veal,  pork,  liver,  kidney,  etc. ;  nor  salt  fish, 
meats,  smoked,  canned,  or  potted  foods. 

Vegetables. — May  have  rice,  hominy,  string  beans,  fresh  peas,  spinach,  beans, 
baked  potatoes  (sweet  and  white) ,  lentils,  etc. 

Must  not  take  rhubarb,  tomatoes,  asparagus  (Guiteras's  rule.  See  Begg, 
in  "Phila.  Med.  Jour.,"  June  7,  1902),  lemons,  oranges,  limes,  or  preserved 
fruits. 

Drinks. — Nothing  but  plain  water  and  milk. 

Must  not  take  alcoholic  beverages  or  carbonated  drinks. 

Must  not  take  salt,  spices,  condiments,  cheese  or  pickles. 

Desserts. — Only  of  the  simplest  kind,  made  from  milk  and  eggs,  and  take 
them  only  sparingly. 

General  Rules. — Put  on  a  suspensory'  bandage  and  wear  it  in  conjunction 
with  a  piece  of  linen  or  a  bag  to  catch  discharges. 

Wash  the  hands  after  handling  the  parts,  and  keep  the  fingers  away  from 
the  eyes. 

Keep  the  linen  from  contaminating  the  family  wash. 

Wash  the  organ  frequently  in  warm  salt  water  (i  teaspoonful  of  table  salt 
to  I  glass  of  water). 

WTien  urination  causes  biuming,  immerse  the  organ  in  a  basin  of  warm  water 
and  allow  the  urine  to  flow. 

Keep  the  body  warm  and  free  from  chilling. 

Should  not  go  about  on  rainy  or  snowy  days  without  ample  protection. 

Should  go  to  bed  early. 


1350  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Must  not  take  cold  baths.     May  take  warm  ones. 

Should  not  eat  between  meals — it  is  unwise  to  overload  the  stomach. 

Should  drink  freely  of  plain  water  or  milk. 

Should  urinate  when  the  desire  comes. 

Should  keep  away  from  females  socially  and  sexually — and  any  other 
exciting  influences,  such  as  erotic  sights,  thoughts,  and  literature. 

Must  keep  bowels  loose. 

A  smoker  should  decrease  the  consumption  of  tobacco. 

Never  put  pieces  of  cotton  over  the  end  of  organ,  as  cotton  so  used  prevents 
the  free  drainage  of  discharge.  Should  the  lips  of  the  opening  seal  together, 
wash  clean  in  warm  salt  water  and  grease  with  vaseHn. 

A  tea  or  coffee  drinker  may  have  a  small  amount  once  daily,  but  it  will  be 
better  not  to  partake  of  either. 

Should  the  patient  be  using  an  injection  and  find  that  the  desire  for  urina- 
tion becomes  frequent  at  night,  he  must  stop  the  injection  and  consult  his 
physician. 

The  injection  is  never  to  be  forced  into  the  organ;  it  is  to  be  introduced 
gently,  and  the  bladder  is  to  be  empty  when  an  injection  is  given. 

Abortive  treatment  may  be  tried  if  the  case  is  seen  early.  The  use  of  strong 
solutions  of  powerful  germicides  has  been  abandoned  because  of  the  great 
pain  they  produce  and  the  inevitable  subsequent  crippling  of  the  urethra. 

Abortive  treatment  is  applicable  only  to  specially  selected  cases  and  even 
then  usually  fails.  It  should  never  be  used  after  the  gonococci  have  invaded 
the  submucosa,  but  only  during  the  prodromal  stage,  when  it  is  hoped  that  the 
germs  are  upon  and  not  in  the  mucous  membrane.  This  stage  usually  lasts 
but  a  few  hours,  usually  not  over  forty-eight.  The  patient  generally  presents 
himself  after  this  period  has  passed.  When  the  symptoms  as  described  in  the 
prodromal  period  prevail,  the  abortive  treatment  may  be  tried,  after  explaining 
to  the  patient  that  it  will  cause  some  pain  and  discomfort  and  in  the  end  may 
fail  or  even  aggravate  the  inflammation. 

Germicides  may  be  used  and  with  some  chance  of  killing  the  infection,  for 
as  yet  the  organisms  are  growing  upon  the  superficial  strata  of  epithelium 
much  as  a  sod  of  grass  upon  soil.  When  the  deeper  structures  have  been 
invaded  it  is  folly  to  attempt  to  abort  the  disease. 

The  method  advocated  by  White  and  Martin  and  which  has  proved  success- 
ful in  Prof.  Hiram  Loux's  clinic  in  a  limited  number  of  selected  cases  is  as 
follows:  After  urination  4  drops  of  a  4  per  cent,  solution  of  eucain  are  injected 
into  the  urethra;  after  which  2  drams  of  \  per  cent,  solution  of  protargol  are 
instilled  and  retained  for  three  minutes.  The  injections  are  repeated  every 
two  hours  while  awake. 

Each  time  the  bottle  is  half  emptied  it  is  replenished  with  sterile  water  to 
its  full  capacity,  until  the  end  of  the  third  day.  If  successful,  recovery  is  ac- 
complished in  about  seven  days.  Should  a  mucoid  discharge  persist  an  anti- 
septic astringent  injection  is  employed  to  complete  the  cure.  During  the  treat- 
ment the  patient  must  be  kept  at  rest.  The  diet  should  be  bland  and  light  and 
the  usual  balsamic  remedies  are  administered.  If  the  symptoms  become  hyper- 
acute, stop  the  treatment  at  once  and  give  a  sedative. 

Another  abortive  method  is  the  use  of  hot  retro-injections  of  corrosive  subli- 
mate solution  (i  :  20,000),  2  pints  being  run  through  the  urethra  once  a  day. 
If  in  seventy-two  hours  the  symptoms  are  not  greatly  improved,  abortive 
treatment  should  be  abandoned.  Recent  studies  render  it  almost  certain  that 
there  is  no  real  abortive  treatment.  Abortive  treatment,  to  be  efficient,  would 
have  to  be  carried  out  before  the  gonococci  penetrated  the  epithelial  cells; 
in  other  words,  would  need  to  be  instituted  before  the  distinct  symptoms  of 
the  disease  appear.     Janet  says  that  we  must  alter  our  conception  as  to  what 


Treatment  of  Acute  Gonorrhea 


1351 


constitutes  abortive  treatment,  and  he  doubts  if  a  case  of  true  gonorrhea  was 
ever  really  aborted.^  The  method  of  irrigation  with  solutions  of  permanganate 
of  potassium  is  really  a  prophylactic  treatment.  Janet  applies  his  treatment  as 
evidences  of  trouble  present  themselves,  and  before  acute  symptoms  appear, 
and  claims  that  in  most  persons  the  disease  can  be  arrested  in  from  eight  to 
twelve  days.     The  same  plan  of  treatment  is  useful  in  a  well-developed  case. 

Irrigation  in  Gonorrhea. — Irrigation  can  be  used  in  an  incipient  or  in  a 
well-developed  case.  Janet's  method  is  as  follows:  An  irrigator  is  filled 
with  a  warm  solution  of  permanganate 
of  potassium  (i  :4ooo).  The  patient 
after  emptying  his  bladder  is  seated 
upon  a  chair  and  his  sacrum  rests  upon 
the  extreme  front  edge  of  the  chair 
(Valentine's  position).  The  reservoir 
is  joined  to  a  glass  nozzle  by  a  rubber 
tube.  The  nozzle  is  introduced  into 
the  meatus,  and  the  fluid  is  permitted 
to  run  gradually  at  first,  with  full  force 
later.  In  anterior  trouble  the  fluid  is 
allowed  to  run  out  of  the  meatus  by 
the  side  of  the  nozzle.  The  anterior 
urethra  is  always  irrigated  first,  the 
reservoir  being  2  feet  above  the  chair. 

In  posterior  urethritis,  after  the  an- 
terior urethra  has  been  irrigated,  the 
reservoir  is  raised  from  6  to  7  feet  above 
the  bed,  the  meatus  is  held  tight  about 
the  nozzle,  and  the  fluid  overcomes  the 
force  of  the  compressor  muscles  of  the 
urethra  and  the  bladder  sphincter  and 
enters  the  bladder.  If  the  muscles  do 
not  quickly  relax,  continue  the  hydro- 
static pressure  for  several  minutes,  when 
relaxation  will  usually  occur;  but  if  it 
does  not  do  so,  tell  the  patient  to 
breathe  slowly  and  deeply,  and  to  make 
efforts  at  urination  (Valentine's  plan). 
When  the  bladder  is  full  the  tube  is 
withdrawn  and  the  patient  micturates. 
This  procedure  is  practised  once  or 
twice  a  day  for  five  or  sLx  days,  or  even 
longer,  and  the  strength  of  the  solution 
is  gradually  increased  up  to  i  :  1000. 
It  has  been  claimed  that  after  one  or 
two  weeks  of  this  treatment  gonococci 
permanently  disappear  in  the  majority 
of  cases.  Figure  900  shows  the  ingeni- 
ous and  very  useful  irrigator  devised  by 

Ferd.  C.  Valentine,  of  New  York.  Valentine^  has  constructed  the  table  on 
page  1352,  which  is  of  use  to  a  practitioner  who  wishes  to  employ  irrigations 
with  permanganate  of  potassium  in  the  treatment  of  acute  gonorrhea.  I  fol- 
lowed the  method  set  forth  in  the  table  in  a  great  number  of  cases,  and  re- 
garded it  an  extremely  useful  systematic  plan. 

1  "Ann.  d.  mal.  d.  org.  gen.-urin.,"  1896,  p.  1031. 
^  "The  Irrigation  Treatment  of  Gonorrhea." 


Fig.  goo. — ^Valentine's  urethral  and  intravesi- 
cal irrigator:  a,  Board  with  attachments  to  be 
screwed  to  wall;  c,  open  collar;  d,  pulley;  e, 
cord;/,  ring  to  suspend  percolator;  g,  brass  rod; 
h,  percolator;  i,  rubber  tube;  j,  ring  for  fourth 
finger;  k,  flange  to  graduate  pressure;  I,  shield; 
m,  ring  to  suspend  shield;  n,  nozzle  attached. 


1352 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


First  day,  first  visit. 

First  day, 

7  p.  M. 

Second  day, 

9  A.  M. 

Second  day, 

7  p.  M. 

Third  day. 

9  A.  M. 

Third  day, 

7  p.  M 

Fotirth  day. 

9  A.  M. 

Fourth  day. 

7  p.  M 

Fifth  day, 

Noon. 

Sixth  day. 

Noon. 

Seventh  day 

Noon. 

Eighth  day. 

9  A.  M. 

Eighth  day. 

7  p.  M. 

Ninth  day,  9  A.  m. 

Ninth  day,  7  p.  m. 

Tenth  day,  9  A.  m. 

Tenth  day,  7  p.  m. 


Anterior  irrigation . 

Anterior 

Anterior 

Anterior 

Intravesical 

Anterior 

Intravesical 
/  Intravesical 
\  Anterior 

Intravesical 
■  Intravesical 

Intravesical 
f  Intravesical 
\  Anterior 
j  Intravesical 
I  Anterior 
/  Intravesical 
\  Anterior 
J  Intravesical 
I  Anterior 
f  Intravesical 
\  Anterior 
/  Intravesical 
1  Anterior 


3000 
4000 
3000 
4000 
6000 
5000 
5000 
5000 
2000 
5000 
5000 
5000 
5000 
3000 
5000 
2000 
4000 
1000 
4000 
1000 
4000 
1000 
5000 
500 


For  full  directions  regarding  this  method  see  Valentine's  book,  "The  Irri- 
gation Treatment  of  Gonorrhea."  If  a  stricttire  exists,  it  is  not  advisable 
to  employ  this  treatment.  Excellent  results  can  be  obtained  by  irrigations 
with  fluid  containing  silver  nitrate  (i  :  12,000  to  i  :  8000). 

When  a  patient  is  treated  by  irrigation,  after  the  entire  subsidence  of 
acute  symptoms,  a  thin,  colorless  discharge  may  persist.  This  can  be  cured 
by  the  use  of  astringents.  Two  or  three  times  a  day  an  astringent  is  injected 
by  means  of  a  ^-ounce  syringe.  Dalton's  formula  is  very  useful:  Zinc  oxid 
and  lead  acetate,  of  each,  ^  to  3  gr.;  tincture  of  catechu,  from  10  to  30  min. ; 
glycerin,  from  |  to  i  dram;  and  water  to  make  i  oz.  Ultzmann's  formula  is: 
Zinc  sulphate,  16  gr.;  pulverized  alum,  8  toi2gr.;  carbolic  acid,  3gr.;  and 
water  to  make  4  oz. 

Many  writers  oppose  the  irrigation  treatment,  claiming  that  it  increases 
the  liability  to  complications,  especially  prostatic  inflammation,  and  enhances 
the  danger  of  recurrence.  I  believe  in  the  method.  I  do  not  think  it  shortens 
materially  the  duration  of  the  disease,  but  do  believe  that  it  mitigates  its  inten- 
sity, makes  the  patient  much  more  comfortable,  and  quickly  causes  the  dis- 
charge to  become  mucopurulent.  That  it  increases  complications  and  the 
danger  of  reinfection  is  very  doubtful.  Much  of  the  trouble  which  has  fol- 
lowed its  use  has  been  due  to  raising  the  reservoir  to  too  great  a  height. 

Irritative  gonorrhea  will  subside  in  a  few  days.  The  above  directions 
should  be  followed,  and  the  anterior  urethra  should  be  washed  out  several 
times  daily  with  diluted  peroxid  of  hydrogen,  or  irrigated  once  a  day  with  a  hot 
solution  of  permanganate  of  potassimn  (i  :4ooo).  In  catarrhal  gonorrhea  at 
once  order  injections  (i  gr.  to  the  ounce  of  sulphate  of  zinc;  or  zinci  sulphas, 
8  gr.,  plumbi  acetas,  15  gr.,  water  8  oz. ;  or  5  gr.  of  sulphocarbolate  of  zinc 
to  I  oz.  of  water ;  or  White's  prescription  of  i  dram  each  of  acetate  of  zinc  and 
tannic  acid,  8  drams  of  boric  acid,  6  oz.  of  liq.  hydrogen  peroxid).  For  in- 
jecting use  a  blunt-pointed  hard-rubber  syringe  of  a  capacity  of  3  or  4  drams. 
Let  the  patient  urinate  and  then  sit  on  a  chair,  his  buttocks  hanging  over  the 
edge;  throw  a  syringeful  of  the  solution  into  the  urethra  and  let  it  run  out 
at  once,  and  throw  in  another  syringeful  and  hold  it  in  from  three  to  five 
minutes. 

In  ordinary  acute  gonorrhea  we  follow  an  old  rule  when  we  order  balsams. 
The  common  custom  is  to  give  two  capsules  three  times  a  day,  each  capsule 


Treatment   of  Acute  Gonorrhea 


L050 


containing  5  gr.  of  salol,  5  gr.  of  oleoresin  of  cubebs,  10  gr.  of  balsam  of 
copaiba,  and  i  gr.  of  pepsin.  Clinical  obser\-ation  indicates  that  the  bal- 
sams are  of  distinct  value  in  gonorrhea.  When  used  early,  the  discharge 
tends  to  become  mucopurulent  and  the  acute  s^Tnptoms  usually  soon  begin 
to  subside  (S.  Behrmann,  in  "Dermatologisches  Centralblatt.""  BerUn,  Xov. 
and  Dec,  1901).  Many  practitioners  will  not  use  balsams  until  the  third 
week.  Bacteriological  studies  indicate  that  copaiba,  when  eliminated  in  the 
urine,  has  a  certain  amount  of  power  in  inhibiting  the  growth  of  gonococci,  but 
that  cubebs  and  oil  of  sandal  have  not  such  power.  Yet  oil  of  sandal  is  more 
useful  than  copaiba  as  a  remedy.  Salol  is  distinctly  germicidal,  hence  it  is 
given  with  the  balsams.  In  a  case  treated  by  balsams  an  astringent  injec- 
tion is  usually  employed.  The  injection  is  used  two  or  three  times  a  day. 
immediately  after  micturition.  As  the  inflammation  subsides  the  strength 
of  the  injection  should  be  gradually  increased.  A  good  plan  is  to  order  an 
8-oz.  bottle  and  S  i-gr.  powders  of  sulphate  of  zinc.  Direct  the  patient 
to  fill  the  bottle  vriih.  water,  in  which  one  powder  is  dissolved:  when  this  is 
used  dissolve  2  powders  in  a  bottleful  of  water,  and  so  progressively  increase  the 
strength.  \Mien  the  discharge  ceases  stop  the  injections  gradually.  \Mien- 
e^-er  a  syringeful  is  taken  from  the  bottle  a  S}Tingeful  of  water  is  put  into  the 
bottle,  and  thus  pure  water  is  soon  obtained,  at  which  point  injection  is  dis- 
continued. If  a  simple  astringent  injection  causes  much  pain,  use  a  sedative 
injection — 2  drams  of  boric  acid,  S  gr.  of  aqueous  extract  of  opium,  and  8  oz.  of 
Hquor  plumbi  subacetatis  dilutis.  I  have  had  about  as  much  success  with  the 
above  simple  method  as  with  the  most  complicated  of  plans.  Complication 
and  complexity  are  not  criterions  of  usefulness. 

Argonin,  which  is  a  combination  of  albumin,  silver,  and  an  alkaH,  is  highly 
recommended  by  some  authors  as  a  local  remedy  for  gonorrhea  (Schaffer, 
Guthiel).  A  solution  of  this  material  is  non-irritant,  the  silver  is  not  pre- 
cipitated by  chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by  injec- 
tion or  irrigation.  If  used  by  irrigation,  employ  a  i  :  500  solution  twice  a 
day.  If  used  as  an  injection,  employ  a  i  :  200  solution  six  or  eight  times  a 
day.  When  the  discharge  is  found  free  from  gonococci  and  remains  free  for 
three  days,  stop  the  argonin  and  use  an  astringent  injection. 

Protargol,  metallic  silver  combined  with  a  protein,  is  a  yellow  powder  solu- 
ble in  water,  the  solution  not  being  acted  on  by  hght.  It  is  a  non-irritant 
germicide.  Xeisser,  after  demonstrating  the  presence  of  the  gonococcus, 
administers  protargol  by  injection,  the  first  injections  being  of  a  strength  of 
0.25  per  cent.,  the  strength  being  gradually  increased  to  0.5  per  cent.,  and 
finally  to  i  per  cent.  In  the  beginning  he  orders  three  injections  a  day, 
each  injection  being  retained  from  fifteen  to  thirty  minutes:  after  several 
days,  when  the  s}"mptoms  improve,  he  gives  only  one  or  two  injections  a  day, 
and  these  are  continued  for  ten  days  after  gonococci  disappear  from  the  dis- 
charge. After  protargol  is  abandoned  an  astringent  injection  should  be  used 
for  a  time.  Some  surgeons  use  a  i :  1000  solution  of  protargol,  and  irrigate 
the  anterior  urethra  and  flush  the  bladder  twice  a  day.  A  silver  salt  used  by 
many  is  arg\Tol,  or  silver  \'itellin.  The  injection  used  at  first  may  be  of  a 
strength  of  2  per  cent.  The  drug  should  be  retained  in  the  urethra  four  or 
five  minutes,  and  three  or  four  injections  should  be  given  each  day.  The 
strength  of  the  injection  can  be  gradually  increased  to  5  per  cent,  or  even  more. 
I  have  not  been  impressed  ■^-ith  the  value  of  this  preparation  except  in  the 
earhest  stages  of  gonorrhea.  Picric  acid  has  been  highly  commended  as  an 
injection.  The  strength  of  solution  is  i  :  200.  and  it  is  to  be  retained  in  the 
urethra  three  or  four  minutes  (de  Brun's  method). 

Methylene-blue  internally  is  occasionally  of  ser^-ice  in  gonorrhea.  A  cap- 
sule containing  i  or  2  gr.  of  the  drug  is  siven  three  times  a  dav.     It  makes  the 


1354  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

urine  greenish  blue  and  occasionally  induces  strangury.     Urotropin  renders 
the  urine  sterile.     Salicylate  of  sodium  may  be  of  value  late  in  the  case. 

In  his  clinic  in  Jefferson  Hospital  my  colleague,  the  late  Prof.  Horwitz, 
introduced  the  following  plan  of  treatment:  A  capsule  containing  balsam  of 
copaiba,  salol,  oil  of  sandal,  and  methylene-blue  is  given  half  an  hour  after 
each  meal: 

IJ.     Methylene-blue gr.  xxx; 

Balsami  copaibae  1  -     rr-         ^^ 

Oleisantali  / aa  l^iss.     M. 

Pone  in  capsulas  No.  xxx. 

Sig. — One  after  each  meal. 

The  patient  begins  at  once  to  take,  by  hand  injection,  a  lo  per  cent,  solu- 
tion of  argyrol.     He  takes  it  three  times  a  day, 

At  each  daytime  injection  the  fluid  is  retained  in  the  canal  for  five  minutes. 
At  the  bedtime  injection  the  fluid  is  retained  for  fifteen  minutes.  At  first 
only  about  i  dram  is  injected  at  a  time,  but  as  the  urethra  becomes  accustomed 
to  fluid  distention  the  amount  is  gradually  increased,  until  finally  4  drams  may 
be  given. 

When  the  stage  of  decline  begins  (toward  the  end  of  the  second  week)  a 
combined  astringent  and  antiseptic  treatment  is  used. 

The  capsules  of  methylene-blue,  copaiba,  and  sandal,  and  the  injections 
of  argyrol  are  discontinued.  A  capsule  containing  oleoresin  of  cubebs,  oil 
of  sandal,  and  balsam  of  copaiba  is  given  before  each  meal,  and  a  capsule  of 
urotropin  is  given  after  each  meal.  An  injection  of  protargol  (j  of  i  per  cent.) 
is  given  three  times  a  day.  This  remedy  is  germicidal  and  also  astringent. 
The  strength  is  gradually  increased  until  a  i  per  cent,  solution  is  used.  By  the 
end  of  the  fourth  week  the  patient  has  reached  the  terminal  stage.  Now 
capsules  of  sandal  and  salol  are  substituted  for  the  cubebs,  sandal  and  copaiba 
and  an  astringent  injection  is  ordered.  The  following  injection,  recommended 
by  J.  Wm.  White,  is  very  satisfactory: 

I^.     Hydrarg.  chlor.  corros gr-  I; 

Zinci  sulphocarbolas 5ss; 

Acidi  boraci 3 ij; 

Acidi  carbohci itUxv; 

Boroglycerid  (25  per  cent.) f  Sij; 

Aquae  destil q.  s.  ad.  f ovj. — M. 

Sig. — Inject.     Dilute  if  it  causes  much  pain. 

When  the  mucoid  condition  predominates  in  the  discharge  the  following  is 
useful: 

R.     Zinci  sulph ■ gr.  xv; 

Plumbi  acetati gr.  xxx; 

Glycerol  tannin         \  _  _  ^  ^ . 

Hydrastin  (Lloyd's)  / ^^  *^^^' 

Mucil.  acaciae f  o  iv; 

Aquae  destil q.  s.  ad.  f  §  vj. — ^M. 

Sig. — As  injection. 

The  formula  of  the  "injection  Brue"  is  as  follows: 

I^.    Plumbi  acetat gr.  xxx; 

Zinci  sulphat gr.  xvj; 

Ext.  krameriae  il f  3iv; 

Tinct.  opii f  3iij; 

Aquae  destil q.  s.  ad.  f  o  vj. — M. 

Sig. — As  injection. 


Treatment  of  Complications  1355 

WTien  all  s^Tnptoms  of  clap  have  disappeared,  any  injection  in  use  is 
gradually  diluted.  Whenever  a  s}Tingeful  of  the  fluid  is  taken  from  the  bot- 
tle, a  syringeful  of  water  is  put  in.  When  the  fluid  becomes  pure  water  the 
injection  is  discontinued.  Balsams  are  stopped  by  gradual  diminution  in  the 
number  of  daily  doses.  For  three  weeks  after  the  entire  disappearance  of  all 
S}Tnptoms  alcohol  is  forbidden  and  sexual  indulgence  is  prohibited.  Should  a 
relapse  occur  the  patient  is  at  once  placed  upon  treatment  as  for  the  acute 
stage,  and  when  the  stage  of  decline  again  ensues  he  is  placed  again  on  anti- 
septics and  astringents.  Relapses  are  caused  by  a  localized  lesion  or  lesions  in 
the  anterior  or  posterior  urethra,  hence  as  soon  as  all  acute  s\Tnptoms  subside 
an  endoscopic  examination  is  to  be  made  and  proper  treatment  is  to  be  appHed 
to  any  localized  lesion.  If  during  the  treatment  of  gonorrhea  a  complication 
develops,  local  treatment  of  the  urethra  is  at  once  discontinued  and  constitu- 
tional treatment  suited  to  the  new  condition  is  prescribed. 

If  the  onset  of  gonorrhea  is  marked  by  ^•iolent  inflammaton.-  symptoms 
(chordee.  hemorrhage,  severe  pain,  swelling,  profuse  purulent  discharge), 
local  treatment  of  the  urethra  is  contra-indicated. 

If  the  invasion  is  hyperacute,  no  local  treatment  of  the  urethra  is  permis- 
sible until  the  disease  assiomes  the  character  of  ordinar\^  gonorrhea. 

Not  unusually  gonorrhea  passes  into  a  low  grade  of  anteroposterior  ure- 
thritis that  proves  most  rebellious  to  treatment.  This  condition  is  especially 
common  when  too  stimulating  treatment  has  been  used.  A  mild  astringent 
injection  should  be  used  three  times  a  day.  Ever\-  second  or  third  day  an  in- 
jection of  nitrate  of  silver  (i  :  4000)  should  be  given.  If  the  silver  salt  sets  up 
an  acute  inflammation  the  treatment  used  in  the  acute  stage  of  gonorrhea  is 
given  until  the  s}Tnptoms  abate. 

A  valuable  plan  in  rebellious  anteroposterior  urethritis  is  daily  irrigation 
of  the  anterior  urethra  with  a  warm  solution  of  permanganate  of  potassium 
(i  :  6000),  followed  by  the  passage  of  a  soft  catheter  and  the  filling  of  the  blad- 
der with  a  like  solution.  The  patient  empties  his  bladder  after  the  catheter 
is  withdrawn  and  thus  flushes  the  entire  urethra  "oith  the  permanganate. 
The  strength  of  the  solution  is  gradually  increased  up  to  i  :  2000. 

Weiss  uses  corrosive  sublimate  ( i  :  20.000)  in  the  manner  just  described. 
It  is  particiflarly  valuable  in  cases  of  bacterial  contamination,  the  gonococci 
ha\'ing  disappeared. 

Treatment  of  Complications. — Ardor  urince  is  reHeved  by  urinating  while 
the  penis  is  immersed  in  hot  water  and  by  administering  alkaline  diuretics. 
Chordee  requires  a  bowel  movement  in  the  evening,  and  sleeping  in  a  cool 
room,  under  Hght  covers,  and  on  a  hard  mattress;  bromid  of  potassiimi  is 
given  several  times  daily,  and  a  considerable  dose  is  given  at  night :  it  may  be 
necessary-  to  use  suppositories  of  opiimi  and  camphor  or  to  give  hyoscin.  Bala- 
■jiitis  requires  frequent  washing  of  the  head  of  the  penis  and  prepuce  in  warm 
water,  dr\ing  with  cotton,  and  dusting  with  borated  talc,  stearate  of  zinc,  or 
boric  acid  and  subnitrate  of  bismuth  (1:6).  Balanopostliitis  requires  soaking 
in  hot  water,  and  injections  of  black  wash  under  the  prepuce  until  edema 
of  the  foreskin  subsides,  and  then  cleanliness  and  the  application  of  a  dr\-- 
ing  powder.  Phimosis  requires  soaking  the  penis  in  hot  water,  and  injec- 
tions of  hot  water  beneath  the  foreskin,  followed  by  black  wash.  If  this 
fails,  circumcision  must  be  performed.  If  paraphimosis  occurs,  grasp  the 
head  of  the  penis  with  the  left  hand,  squeeze  the  blood  out,  and  tr}-  to 
push  the  head  back,  whfle  -^-ith  the  right  hand  the  penis  is  pulled  upon  as  if 
the  surgeon  intended  to  lift  the  indi\-idual  by  the  organ.  If  this  fails,  cut  the 
collar  on  the  dorsum  -^-ith  scissors:  or,  what  is  better,  for  it  gives  free  expo- 
sure, incise  each  side  of  the  prepuce  between  the  middle  of  the  dorsum  and 
the  frenum.     Bubo  requires  the  appHcation  of  iodin,  ichthyol.  or  blue  oint- 


1356  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ment,  the  use  of  a  spica  bandage,  and  rest.  If  a  bubo  suppurates,  it  must  be 
opened  or  aspirated.  Acute  posterior  urethritis  is  treated  by  rest,  and  if  the 
symptoms  are  severe,  by  rest  in  bed.  If  the  balsams  do  not  irritate,  they  are 
given;  if  they  do,  they  are  withdrawn.  Uro tropin  or  salol  is  given  and  the 
patient  is  placed  upon  a  milk-diet  \nth  orders  to  drink  largely  of  flaxseed  tea. 
Alkaline  fluids  do  harm  by  favoring  ammoniacal  decomposition  of  the  urine. 
Injections  and  irrigations  are  abandoned.  Pain  and  vesical  spasm  are  con- 
trolled by  suppositories  of  opiimi  and  belladonna.  If  retention  of  urine 
occurs,  have  the  patient  urinate  while  in  a  hot  bath;  if  this  fafls,  use  a  soft 
catheter.  Acute  vesiculitis  is  treated  as  is  acute  prostatitis.  Chronic  vesicu- 
litis is  considered  on  page  1375.  Pyelitis  is  treated  by  rest  in  bed,  hot  baths, 
wet  cupping  of  the  loin,  milk-diet,  diuretics,  the  taking  of  a  large  quantity  of 
bland  liquid,  and  the  administration  of  salol  or  urotropin,  and  in  some  cases 
lavage  of  the  kidney  pelvis  through  a  ureteral  catheter  with  one  of  the  sflver 
preparations  (i  :  15,000  of  nitrate  of  silver).  Folliculitis  is  treated  by  rest  and 
the  application  of  a  hot-water  bag  to  the  perineum  (if  that  be  the  part  involved). 
If  pus  forms,  evacuate  by  incision.  Later  the  folHcle  may  be  dissected  out  or 
destroyed  by  cauterization.  If  the  follicle  opens  into  the  urethra  it  may  be 
cauterized  through  an  endoscope.  Peri-urethritis  is  treated  by  rest  and  hot 
applications.  If  pus  forms,  an  incision  must  be  made.  If  the  abscess  is 
permitted  to  break  into  the  urethra,  rest  and  hot  fomentations  may  be  used, 
but  at  the  first  sign  of  urinary  extravasation  make  an  external  incision.  Cow- 
peritis  is  treated  in  the  same  way  as  peri-urethritis.  Gonorrheal  rheumatism 
is  considered  on  page  636.  Acute  prostatitis  and  cystitis  require  confinement  to 
bed,  a  milk-diet,  the  use  of  diuretics,  hot  applications  to  the  perineum  and 
h3^pogastriimi  (bags  of  hot  sand),  suppositories  of  opium  and  belladonna  or  of 
ichthyol,  leeching  the  perineimi,  the  discontinuance  of  balsams  and  injections, 
and  the  administration  of  urotropin  or  salol.  Heat  can  be  applied  by  means 
of  a  stream  of  warm  water  which  circulates  through  a  metal  instrument  intro- 
duced in  the  rectum.  Abscess  of  the  prostate  requires  instant  incision.  In  reten- 
tion of  urine  the  patient  should  try  to  pass  the  urine  while  in  a  hot  bath;  if  this 
fafls,  a  soft  catheter  is  used.  After  relieving  the  bladder  put  the  patient  to  bed 
and  apply  hot  sand-bags  as  for  acute  prostatitis.  Chronic  prostatitis  requires 
cold  hip-baths,  cold-water  enemata,  deep  urethral  injections,  massage  of  the 
prostate,  plain  diet,  avoidance  of  alcohol  and  overexertion,  counterirritation 
of  the  perineimi,  and  the  relief  of  stricture  or  phimosis.  Great  benefit  is 
occasionally  derived  from  passing  a  soft  bougie  covered  with  blue  ointment 
or  with  a  i  per  cent,  ointment  of  silver  nitrate.  If  there  are  pus  pockets, 
gonorrheal  phylacogen  may  perhaps  be  of  service.  If  epididymitis  arises, 
put  the  patient  to  bed,  abandon  injections,  shave  the  hair  from  the  groin, 
leech  over  the  cord,  elevate  the  testicles,  and  early  in  the  case  appty  an  ice- 
bag.  Give  a  cathartic,  a  fever  mixture,  and  suitable  doses  of  bromid  of  potas- 
sium and  morphin.  The  local  application  twice  a  day  of  20  drops  of  guaiacol 
in  I  dram  of  cosmoHn  or  olive  oil  gives  relief.  When  sweUing  lingers,  after 
tenderness  subsides  strap  the  testicle  with  adhesive  plaster.  A  lingering  case 
is  benefited  by  the  internal  use  of  iodid  of  potassium  and  the  local  application 
of  ichthyol.  In  gonorrheal  ophthalmia  secure  a  watch-crystal  over  the  miaf- 
fected  eye,  put  the  patient  in  a  darkened  room,  rub  the  infected  conjunctival 
sac  with  cotton  soaked  in  a  2  per  cent,  solution  of  sflver  nitrate,  wash  out  the 
affected  eye  repeatedly  with  hot  boric  acid  solution,  keep  the  pupfl  dilated 
with  atropin,  leech  the  temple,  and  give  purgatives.  Always  send  for  an 
ophthalmologist. 

When  is  Gonorrhea  Cured? — It  is  said  that  Ricord  declared:  "We  know 
when  clap  begins,  but  God  alone  knows  when  it  ends."  When  actual  discharge 
ceases  a  patient  considers  himself  cured,  and  yet  he  may  have  residues  of 


Treatment  of  Chronic  Gonorrhea  1357 

infection  which  are  liable  at  any  time  to  awaken  into  activity  and  produce  anew 
an  acute  condition.  Gonococci  are  frequently  retained  in  the  urethral  glands 
and  follicles  or  in  areas  surrounded  by  indurated  mucous  membrane.  Gono- 
cocci may  linger  in  these  haunts  for  many  months,  some  say  for  years.  Keyes, 
however,  maintains  that  they  never  persist  in  the  male  lu-ethra  over  three 
years  and  that  in  90  per  cent,  of  cases,  with  or  without  treatment,  they  dis- 
appear within  one  year  (Edward  L.  Keyes,  Jr.,  in  "Amer.  Jour.  Med.  Sci.," 
Jan.,  1912).  It  is  customary  to  consider  a  man  well  when,  after  he  has  been 
^\dthout  treatment  for  one  week,  shreds  and  pus  disappear  from  the  urine, 
when  an  examination  of  expressed  mucus  on  three  successive  days  fails 
to  find  gonococci,  and  when  there  has  been  no  discharge  for  ten  days.  Fur- 
thermore, we  must  be  suje  that  the  prostate,  Cowper's  glands,  and  the  seminal 
^'esicles  are  free  from  disease.  Never  declare  a  man  well  under  three  months 
from  the  start  of  the  disease  unless  gonococci  are  positively  absent  from  the 
urine  and  the  expressed  discharge. 

If  a  patient  has  "no  morning  drop,"  has  been  apparently  well  for  three  or 
four  months,  has  no  pus  in  the  morning  urine  or  in  the  expressed  secretion  of 
the  urethra,  prostate,  and  seminal  vesicles,  we  can,  without  making  cultures, 
afl&rm  that  he  is  well  (Keyes,  Ibid.). 

Keyes  also  maintains  that  a  man  with  a  "pearly  morning  drop"  who  passes 
a  urine  containing  pus-shreds,  but  who  has  no  free  pus  in  expressed  secretions, 
is  probably  free  from  gonorrhea. 


goi . — Bougie-a-boule. 


Treatment  of  Chronic  Gonorrhea  and  of  Chronic  Urethritis  Following 
Gonorrhea. — ^The  first  thing  to  do  is  to  determine  the  cause  of  the  prolonga- 
tion of  the  discharge.  Valentine's  list  of  causes  should  be  borne  in  mind 
("Med.  Record,"  Jime  29,  1901).  They  are  as  follows:  (i)  Lack  of  treat- 
ment; (2)  misdirected  treatment;  (3)  insufficient  treatment;  (4)  overtreat- 
ment;  (5)  infraction  of  dietetic  or  hygienic  regulations;  (6)  constitutional  dis- 
turbances; (7)  congenital  or  acquired  deformities  and  complications;  (8)  in- 
volvement of  the  urethral  adnexa;  (9)  marital  reinfection.  In  a  case  in  which 
a  discharge  persists  or  recurs  the  symptoms  and  general  condition  must  be 
closely  studied,  the  discharge  must  be  examined  microscopically,  the  condition 
of  the  urine  must  be  determined,  and  the  urethra  must  be  explored. 

Exploration  of  the  urethra  is  inaugurated  by  inspection  and  external  pal- 
pation. Palpation  detects  induration,  peri-urethritis,  follicular  abscess  or 
inflammation,  Cow^eritis,  etc.  The  prostate  and  seminal  vesicles  are  ex- 
amined by  a  finger  in  the  rectum.  The  interior  of  the  urethra  is  explored 
by  a  soft  bougie-a-boule  (Fig.  901).  On  withdrawing  this  instrument  the 
shoulder  catches  in  any  contracture.  It  is  to  be  borne  in  mind  that  a  large 
steel  sound  can  often  be  introduced  wdth  ease  when  the  bougie-a-boule  makes 
evident  that  a  contracture  exists.     The  emergence  of  the  instriunent  is  arrested 


1358 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


by  a  patch  of  thickening,  a  granular  area,  a  zone  of  epithelial  proliferation, 
a  papilloma,  or  a  stricture.     In  fact,  anything  which  lessens  the  urethral 

caliber  interferes  with  the 
withdrawal  of  the  bougie- 
a-boule.  It  does  not  do 
to  conclude  that  stricture 
exists  simply  because  some 
lessening  of  caliber  is  ap- 
preciated. The  bougie-a- 
boule  finds  its  chief  use 
in  exploring  the  anterior 
urethra.  If  introduced 
into  the  deep  urethra  its 
emergence  will  be  normally 
checked  as  its  shoiilder 
comes  against  the  posterior 
layer  of  the  triangular  Hga- 
ment. 

In  most  cases  the  diag- 
nosis is  only  certainly  de- 
termined by  the  use  of 
the  iirethroscope.  This 
instrimient  has  been  per- 
Fig.  902.— Valentine's  urethroscope.  fected  of  recent  years  and 

is  now  an  absolutely  es- 
sential part  of  our  armamentarium.  I  have  long  used  Valentine's  instru- 
ments (Figs.  902-905).     Marks's  air-dilating  urethroscopes  (Figs.  906,  907) 


Fig.  903. — Valentine's  urethroscopic  tube. 

are  highly  satisfactory.     The  anterior  and  posterior  urethra   can  be  thor- 
oughly examined  and  with  the  utmost  ease.      Before  inserting  a  urethro- 


Fig.  904.- — Valentine's  obturator. 

scopic  tube  place  the  patient  recumbent  and  cleanse  the  foreskin,  glans,  and 
anterior  urethra  as  directed  in  the  section  on  Cystoscopy.     Insert  a  tube  which 


Fig.  905. — ^Valentine's  light  carrier. 


readily  passes  the  meatus,  first  cleansing  the  tube  and  obturator  by  burning 
alcohol  upon  them.     Carry  the  tube  to  the  anterior  layer  of  the  triangular  liga- 


Treatment  of  Chronic  Gonorrhea 


1359 


ment.  Withdraw  the  obturator  and  insert  the  Hght.  Turn  on  the  light,  mop 
the  virethra  with  bits  of  cotton  wrapped  on  a  stick,  and  slowly  withdraw  the 
tube,  examining  the  urethra  as  its  walls  fall  together  back  of  the  retracting 
tube.    After  withdrawal  of  the  tube  irrigate  the  anterior  urethra.     To  examine 


Fig.  906. — jNIarks's  air-dilating  urethroscope  for  examination  of  the  anterior  urethra. 


the  deep  urethra  carry  the  instrument  through  the  prostatic  urethra.      After 
the  examination  give  an  intravesical  irrigation. 

WTien  the  cause  of  a  discharge  is  once  determined,  rational  treatment  can 
be  instituted,  and  to  determine  the  cause  the  electric  urethroscope  is  indispen- 
sable.    An  erosion  of  the  mucous  membrane  or  a  granular  patch  requires 


Fig.  907. — ^Marks's  air-dilating  urethroscope  for  examination  of  the  posterior  urethra. 


touching  from  time  to  time  wdth  a  solution  of  silver  nitrate  (i  or  2  per  cent,  or 
even  much  stronger).  These  applications  are  made  through  the  tube  of  the 
urethroscope.  A  stricture  or  an  infiltration  is  treated  by  gradual  dilatation. 
This  combines  pressure  and  massage.     If  the  caliber  of  the  urethra  is  less  than 


1360 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


No.  21  of  the  French  scale,  conical  steel  sounds  are  used  twice  a  week.  If  there 
is  much  hyperesthesia  they  are  retained  but  a  brief  time;  but  as  hyperesthesia 
diminishes  the  period  of  retention  is  lengthened,  until  an  instrument  can  be  kept 
in  place  without  causing  severe  suffering  for  ten  or  fifteen  minutes.  It  is 
not  desirable  to  use  cocain.     Its  use  is  not  free  from  danger  and,  further,  it 


Fig.  911. — Oberlander's  anteroposterior  dilator. 

obtunds  the  sensibility  so  that  undue  violence  may  be  used,  and  it  increases 
postoperative  inflammation.  Before  and  after  using  an  instrument  the  ure- 
thra must  be  cleansed  by  irrigation  with  salt  solution  or  permanganate  of 
potassium. 

When  the  urethra  becomes  tolerant  to  instrumentation,  a  special  dilator 
is  employed  to  act  particularly  on  the  area  of  disease.  If  in  the  beginning  of 
treatment  the  caliber  of  the  urethra  is  equal  to  or  greater  than  No.  21  of  the 


gi2. — Kollmann's  gland  syringe. 


French  scale,  it  is  rarely  necessary  to  precede  the  dilator  by  the  use  of  conical 
sounds.  Figs.  908-911  show  various  dilators.  A  dilator  unless  of  a  very 
modern  type  should  be  inserted  in  a  sterile  rubber  cover  before  being  used, 
otherwise  it  will  cut,  tear,  or  pinch  the  urethra  when  closed  and  withdrawn. 
Kollmann's  dilator  (new  style)  will  not  injure  the  mucous  membrane  and  can 


Gonorrhea  of  the  Mouth  1361 

be  used  \\-ithout  a  cover  (Fig.  908).  A  dilator  should  be  lubricated  with  lubri- 
chondrin,  synol  soap,  or  liquid  cosmolin.  If  a  two-bladed  dilator  is  used  at 
first,  a  four-bladed  dilator  must  be  subsequently  employed. 

A  dilator  is  cleansed  by  scrubbing  its  blades  with  soap  and  water,  sticking 
them  in  alcohol,  \\ithdra\Ning,  and  burning  the  alcohol  retained  in  the  in- 
strument. 

The  following  rules  for  dilatation  are  of  the  first  importance  (Ferd.  C. 
Valentine,  in  "Med.  Record,"  June  29,  1901) : 

1.  The  first  dilatation  must  stop  at  that  point  at  which  the  first  resistance 
to  further  dilatation  is  felt  by  the  operator's  fingers  turning  the  screw  that 
separates  the  blades. 

2.  Dilatations,  if  done  by  a  novice,  must  in  the  beginning  of  treatment 
be  repeated  no  oftener  than  ever>-  three  or  four  days. 

3.  Each  dilatation,  in  point  of  time,  must  reach  no  greater  duration  than 
two  minutes  over  that  of  the  preceding  session. 

4.  No  dilatation  must  exceed  one-half  number  Chariere  above  the  number 
attained  at  the  next  prior  seance,  regardless  of  any  lack  of  resistance  that  may 
be  present. 

As  a  rule,  glandular  and  follicular  infiltrations  are  cured  by  the  use  of 
the  dilator.  If  they  are  not,  they  must  be  treated  through  the  tube  of  the 
urethroscope.  The'interior  of  a  follicle  may  be  cauterized  by  a  heated  electric 
wire,  subjected  to  electrolysis,  fulgurated  by  the  Oudin  current,  or  touched  with 
a  3  per  cent,  solution  of  silver  nitrate.  A  thickened  cr\-pt,  gland  follicle, 
or  an  area  of  induration  may  be  slit  by  a  knife.  A  polyp  can  be  removed 
by  a  snare,  the  cauter\-,  or  special  forceps.  In  a  chronic  inflammation  of 
the  urethra,  in  which  the  inflammation  is  superficial  and  in  which  the  glands 
are  not  involved,  irrigations,  urethral  and  intravesical,  constitute  the  best 
treatment.  (See  Valentine's  treatise  on  "The  Irrigation  Treatment  of  Gonor- 
rhea, its  Local  Complications  and  Sequels.") 

In  anv  lingering  case  of  gonorrhea  examine  the  urine,  and  direct  suitable 
treatment  for  oxaluria,  lithemia,  or  phosphaturia,  if  any  one  of  these  condi- 
tions exists.  Such  morbid  states  of  the  urine  are  occasionally  responsible  for 
great  prolongation  of  the  inflammation.  In  some  cases  a  discharge  is  kept 
up  by  inflammation  of  the  seminal  vesicles  (see  page  1375). 

Gonorrhea  of  the  anus  and  rectum  occasionally,  though  ver\-  rarely, 
occurs.  It  may  result  from  pederasty,  or  in  a  woman  from  a  flow  of  infectious 
material  from  the  genitalia  to  the  anus.  It  causes  severe  burning  pain,  aggra- 
vated by  defecation.  The  parts  are  red,  swollen,  and  tender.  The  discharge 
is  profuse,  being  at  first  cream  white,  and  then  thicker  and  greenish.  The 
diagnosis  rests  upon  the  histon.'  and  the  finding  of  gonococci  in  the  discharge. 
The  disease  rarely  extends  above  the  anus.  I  have  seen  one  undoubted  case 
of  rectal  gonorrhea. 

Treatment. — If  the  anus  only  is  involved,  spray  it  several  times  daily  with 
peroxid  of  hydrogen,  wash  \\ith  salt  solution,  irrigate  v^ith  permanganate  of 
potash  (i  :40oo),  dust  with  talc  powder,  and  interpose  a  piece  of  iodoform 
gauze  between  the  inflamed  surfaces.  An  iflcer,  a  fissure,  or  an  excoriation 
is  touched  with  limar  caustic.  If  the  rectum  becomes  involved,  secure  a 
daflv  bowel  movement  and  irrigate  the  rectmn  t^\-ice  a  day  ^ith  boric  acid 
solution  or  permanganate  of  potassium  (i  :  4000). 

Gonorrhea  of  the  Mouth. — This  is  a  vers-  uncommon  malady.  It 
occurs  in  infants  more  often  than  in  older  people.  Infection  in  infants  may 
take  place  during  birth  if  the  mother  has  gonorrhea.  The  s>-mptoms  are 
those  of  \-iolent  stomatitis.  The  diagnosis  is  suggested  by  the  condition  of 
the  mother  and  is  proved  by  finding  gonococci  in  the  discharges  from  the 
mouth. 


1362  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Treatment. — Wash  the  mouth  frequently  with  boric  acid  solution,  and 
swab  the  diseased  areas  at  intervals  with  a  10  per  cent,  solution  of  argyrol. 

Gonorrhea  of  the  Nose. — It  is  alleged  that  this  condition  can  arise, 
but  an  absolutely  authentic  case  does  not  seem  to  be  on  record. 

Gonorrhea  in  the  Female. — There  is  much  dispute  as  to  the  parts  in- 
fected. Some  observers  maintain  that  the  vaginal  epithelium  never  con- 
tains gonococci  and  that  gonococci  found  in  a  vaginal  discharge  have  come 
from  the  cervix  or  uterine  canal.  Beyond  a  doubt,  however,  when  young 
women  who  have  not  borne  children  contract  gonorrhea  the  vulva  and  vagina 
usually  suffer.  In  older  women  and  in  women  who  have  borne  children 
the  vaginal  tissues  are  altered  and  the  cells  are  not  nearly  so  prone  to  infec- 
tion; hence  in  such  subjects  the  vagina  usually  or  at  least  often  escapes.  The 
initial  infection  is  in  many  cases  in  the  cervical  canal,  in  some  in  the  vulva  or 
urethra.  No  matter  what  part  was  first  attacked,  other  parts  usually  become 
quickly  involved  in  the  acute  process.  The  urethra  is  involved  in  almost 
every  case.  Chronic  gonorrhea  is  prone  to  linger  in  the  urethra,  in  the  glands 
of  Bartholin,  in  the  cervical  canal,  or  within  the  uterus  or  in  the  Fallopian 
tubes.  The  great  danger  of  gonorrhea  in  the  female  is  the  development  of 
ascending  infection  of  the  lining  membrane  of  the  uterus,  which  may  reach  the 
tubes,  ovaries,  and  peritoneum. 

When  infection  occurs  during  pregnancy  or  when  pregnancy  occurs  during 
infection  of  the  cervical  or  uterine  canal,  abortion  may  take  place.  Again, 
a  pregnant  woman  may  not  abort,  but  may  go  on  to  term  and  the  child  may 
receive  a  conjunctival  infection  during  delivery  and  rapidly  develop  purulent 
ophthalmia. 

In  some  cases  when  pregnancy  occurs  during  the  existence  of  gonorrhea 
the  disease  seems  to  pass  away,  and  yet  the  child  gets  conjunctival  infection 
during  delivery  or  the  mother  subsequently  develops  pus-tubes. 

Treatment. — Place  the  patient  in  bed  during  the  acute  stage  of  the  dis- 
ease, give  hot  hip-baths,  keep  the  bowels  open  by  means  of  saline  purga- 
tives, insist  on  a  fluid  diet  consisting  chiefly  of  milk,  and  flush  out  the  ure- 
thra by  having  the  patient  drink  considerable  quantities  of  water.  The 
external  genital  organs  should  be  sprayed  with  peroxid  of  hydrogen  every 
two  or  three  hours,  and  after  spraying  should  be  dried  with  absorbent  cotton 
and  dusted  with  equal  parts  of  starch  and  powdered  oxid  of  zinc,  or  with 
powdered  stearate  of  zinc.  Pads  of  cotton  fixed  in  place  by  a  bandage  are 
used  to  catch  the  discharge.  If  urethritis  exists  in  this  stage,  we  may  give 
alkalis,  balsams,  and  astringent  urethral  injections. 

When  the  acute  symptoms  have  somewhat  abated  an  attempt  should  be 
made  to  prevent  ascending  infection  from  the  cervical  canal.  The  mucous 
membrane  of  the  canal  may  be  curetted  aw^ay  or  be  destroyed  by  pure  car- 
boHc  acid  or  nitrate  of  silver.  A  wiser  plan  is  to  paint  the  cervical  canal 
daily  with  iodin  or  a  10  per  cent,  solution  of  argyrol,  painting  the  vaginal 
portion  of  the  cervix  at  the  same  time  with  the  same  drug.  The  vagina  is 
irrigated  twice  a  day  with  a  warm  solution  of  permanganate  of  potash  (i  :  4000) 
and  is  lightly  packed  with  iodoform  gauze.  When  the  vulva  is  particularly 
involved,  treat  that  part  by  applying  acetate  of  aluminum  (2  per  cent.)  locally 
or  paint  the  vulva  with  silver  solution  (40  gr.  to  i  oz.).  If  the  vulvovaginal 
gland  suppurates,  open  it. 

If  vaginitis  exists  and  continues  in  spite  of  the  treatment  suggested  above, 
wash  out  the  vagina  every  two  hours,  first  with  i  pint  of  hot  solution  of  bi- 
carbonate of  sodium,  next  with  i  pint  of  hot  water,  and  finally  with  i  pint  of 
astringent  solution  (i  teaspoonful  of  lead  acetate,  i  teaspoonful  of  zinc  sul- 
phate, I  teaspoonful  of  alum,  or  4  teaspoonfuls  of  tannin  to  i  pint  of  hot 
water).     As  the  attack  subsides,  use  vaginal  suppositories,  each  containing 


Gonorrhea  in  Female  Children  1363 

5  gr.  of  tannic  acid.  In  some  cases  apply  solutions  of  silver  nitrate  (i  :  200) 
or  of  arg>Tol  (10  per  cent.),  and  insert  tampons  of  ichthyol  (8  per  cent.) 
moistened  with  boroglycerid  (Le  Blonde). 

In  chronic  cases  of  urethritis  use  strong  solutions  of  silver  nitrate  and 
irrigate  the  iirethra  and  bladder  with  silver  nitrate  (i  :  8000). 

For  uterine  gonorrhea  obser\-e  the  same  general  management.  Swab 
out  the  uterus  with  tincture  of  iodin  or  nitrate  of  silver  and  insert  tampons 
of  iodoform  gauze. 

Gonorrhea  in  Children. — Male  Children. — This  disease  is  not  very 
common.  When  it  affects  children  imder  twelve  it  is  usually  due  to  some 
abandoned  and  diseased  female  ha\ing  brought  the  child's  penis  in  contact 
with  her  sexual  organs.  It  may  result  from  introducing  infected  materials 
into  the  penis.  The  s>T3iptoms  are  similar  to,  but  more  acute  than,  those  met 
with  in  an  adult.  The  finding  of  the  gonococci  is  clinical  but  not  absolute 
legal  proof  of  the  existence  of  gonorrhea,  and  it  is  to  be  remembered  that 
boys  may  suffer  from  catarrhal  urethritis  as  a  result  of  introducing  irritants, 
from  balanoposthitis,  or  from  overacid  urine.  Legal  proof  is  afforded  by  the 
growth  of  the  suspected  micro-organisms  on  artificial  blood-serimi. 

The  treatment  consists  in  confinement  to  bed  during  the  acute  stage,  bland 
drinks,  light  diet,  etc.  Circumcision  is  necessan,'  if  phimosis  exists.  When  the 
acute  s\-mptoms  subside,  injections  are  used  as  in  an  adult. 

Female  Children. — Gonorrhea  is  more  common  in  female  children  than 
in  male  children,  and  the  vagina  is  involved  as  well  as  the  \ailva  and  urethra. 

A  female  child  may  suffer  from  catarrhal  inflammation  of  the  \ailva,  as  a 
result  of  the  contact  of  foul  urine,  of  feces,  of  the  presence  of  seat-worms,  or 
of  neglect  of  bathing.  In  such  a  case  the  vagina  and  urethra  escape.  Involve- 
ment of  the  vagina  and  urethra  strongly  suggests  gonorrhea.  A  recently  born 
child  or  a  young  infant  may  acquire  gonorrhea  directly  from  a  diseased  mother, 
or  indirectly,  by  pus  upon  linen,  from  the  mother's  fingers,  etc.  A  diseased 
nurse  may  infect  the  baby.  Older  children  who  have  ceased  to  nurse  may  get 
the  disease  from  infected  linen,  bathtubs,  etc.,  and  may  by  these  means  infect 
child  after  child  in  an  institution.  Now  and  then  the  disease  arises  by  a 
diseased  man  or  woman  deliberately  bringing  the  child's  private  parts  in  con- 
tact with  their  own  diseased  organ. 

The  disease  is  acute:  the  urethra,  vulva,  and  vagina  are  usually  involved; 
the  discharge  is  profuse,  purulent,  and  often  bloody.  During  the  first  day 
or  two  the  discharge  exhibits  leukocytes  but  no  gonococci,  and  the  normal  flora 
of  the  urethra  disappear;  later  gonococci  appear  (Harmsen,  "Zeits.  f.  Hyg. 
u.  Infektionskr.,"  1906,  vol.  iii).  Microscopical  examination  of  the  discharge 
is  absolutely  necessan,-.  Dr\-  cover-slip  preparations  are  made  so  as  to  ob- 
tain clap  shreds  from  the  discharge.  An  attempt  should  be  made  to  obtain 
cultures.  The  gonococcus  is  ver\^  difficult  to  maintain  in  culture;  it  must 
be  frequently  transferred,  and  it  grows  best  in  an  incubator  at  a  temperature 
of  36°  C.  No  attempt  is  made  to  grow  it  upon  ordinarv^  culture-media.  The 
finger  may  be  sterilized  and  punctured,  blood  thus  obtained  being  smeared 
upon  ordinary  agar.  Upon  this  composite  material  growth  can  be  obtained. 
Animal  blood-senim  is  not  a  good  medium,  but  human  blood-serum  is  (Leh- 
mann  and  Neumann).  Human  blood-serum  is  obtained  by  opening  a  vein 
or  from  a  fresh  placenta. 

Lehmann  and  Neumann  ("Atlas  and  Principles  of  Bacteriology")  find 
the  following  a  satisfactory  medium:  Agar,  containing  i  per  cent,  peptone 
and  5  per  cent,  glycerin,  which  has  been  liquefied  and  cooled  to  50°  C,  is 
mixed  ''with  one-haLf  its  volume  of  ascitic  fluid  or  the  fluid  from  ovarian 
C}^sts."  Plate  cifltures  and  streak  cultures  should  be  made.  This  excessive 
care  in  pro\"ing  the  presence  of  the  gonococcus  is  imperatively  necessar\^  in 


1364  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

female  children  because  of  the  medicolegal  questions  which  may  arise  in  such  a 
case  and  also  because  of  the  danger  there  is  of  the  case  infecting  other  persons. 

Surgeons  are  apt  to  be  doubtful  about  the  diagnosis  in  many  supposed 
cases  of  gonorrhea  in  female  children.  The  clinical  picture  may  simply  be 
that  of  catarrhal  vulvovaginitis,  it  may  be  that  of  gonorrhea.  The  finding 
of  the  gonococcus  is  regarded  as  conclusive  from  a  clinical  standpoint,  but  not 
from  the  legal  point  of  view.  Again,  as  Taylor  points  out,  in  some  cases  in 
which  the  clinical  and  microscopical  evidence  seem  to  prove  the  existence  of 
gonorrhea  no  proof  can  be  obtained  that  the  condition  is  of  venereal  origin, 
and  that  in  some  cases  in  which  everything  indicates  that  the  disease  began 
as  a  catarrhal  vulvovaginitis,  a  condition  seemingly  identical  with  gonorrhea 
has  arisen.  Obtaining  a  culture  of  gonococci  is  conclusive.  The  treatment 
consists  in  taking  every  care  to  prevent  diffusion  of  the  infection  to  others  and 
to  the  patient's  own  eyes.  She  is  put  to  bed,  given  frequent  baths,  and  fed 
upon  milk,  etc.  Irrigations  of  bicarbonate  of  sodium  are  employed,  followed 
by  protargol  (i  :  5000,  according  to  White  and  Martin).  Later  astringent 
injections  are  indicated. 

Treatment  oj Gonorrheal  Arthritis  and  Endocarditis .^in  a  communication  in 
the  "Jour.  Amer.  Med.  Assoc,"  Jan.  27,  1906,  pages  261-263,  Messrs.  Rogers 
and  Torrey  described  the  method  of  preparation  of  an  antigonococcic  serum 
for  the  treatment  of  gonorrheal  arthritis.  This  serum  in  its  present  form,  as 
manufactured  by  a  good  chemical  company,  seems  possibly  to  be  of  some  value 
in  the  treatment  of  gonorrheal  infections  of  joints,  tendon-sheaths,  and  allied 
structures.  Dr.  Thomas  C.  Stellwagen,  of  the  Genito-urinary  Department  of 
Jefferson  Hospital,  has  used  the  material  in  a  series  of  26  cases  of  acute  and 
chronic  gonorrheal  arthritis  with  encouraging  results  ("Therapeutic  Gazette," 
April  16,  1910,  page  248). 

Preparation  of  the  Serum. — To  quote  from  Messrs.  Rogers  and  Torrey's  re- 
ports (Loc.  cit.) :  "Rabbits  were  at  first  used  exclusively  in  producing  the  serum. 
Although  a  very  potent  serum  may  be  obtained  from  these  animals,  it  was 
found  that  the  serum  itself  is  decidedly  toxic  for  some  individuals  and  may  pro- 
duce a  rather  alarming  reaction.  In  order  to  obviate  this  serious  objection  we 
have  experimented  with  goats  and  sheep.  Similar  objectionable  properties, 
although  less  in  degree,  were  found  to  be  present  in  goat  seriun,  but  from  sheep 
serum  they  seem  to  be  entirely  absent.  Accordingly  in  later  work  only  these 
animals  have  been  used.  They  should  be  full  grown,  uncastrated  males.  In 
immunizing  these  animals  it  has  been  found  advantageous  to  pursue  the  follow- 
ing plan:  The  first  inoculation  may  consist  of  the  twenty-four-hour  surface 
growth  from  18  square  inches  of  solid  culture-medium,  emulsified  in  about 
30  c.c.  of  physiologic  saline  soution,  and  heated  for  one-half  hour  at  65°  C." 

In  Stellwagen's  studies  and  use  of  the  serum  it  was  found  that  the  best 
results  were  obtained  by  giving  the  injections  as  close  to  the  area  of  infection 
as  possible,  and,  further,  to  give  them  every  day.  The  only  untoward  results 
noticed  were  now  and  then  an  eruption  of  wheals  or  urticaria  accompanied  by 
slight  headache  and  itching,  with  a  trivial  rise  of  temperature.  The  acute 
cases  generally  showed  marked  improvement  after  about  the  seventh  injection. 
The  serum  also  seemed  to  be  of  use  in  other  complications,  such  as  orchitis, 
prostatitis,  and  epididymitis.  Stellwagen  maintains  that  the  serum  is  a  valu- 
able adjunct  in  treatment,  especially  where  the  older  standard  remedies  are 
slow  to  produce  a  result.  The  great'^claim  for  serum,  however,  has  been-  in 
arthritis  and  other  synovial  infections,  in  which  it  seems  to  be  distinctly 
valuable. 

The  serum  must  not  be  confused  with  the  vaccine,  which  is  decidedly 
uncertain.  When  the  vaccines  were  used  in  the  venereal  clinic  of  the  Jef- 
ferson Hospital  they  did  not  produce  the  happy  results  that  other  clinicians 


Symptoms  and  Results  of  Stricture  1365 

have  claimed  for  them.  Schiifer's  gonorrheal  phylacogen  possibly  furnishes  a 
useful  method  of  treatment  for  metastatic  gonorrheal  infections. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral  caliber,  is 
divided  into  inflammatory,  spasmodic,  and  organic.  The  so-called  inflam- 
matory or  congestive  stricture  is  not  a  stricture,  but  is  an  inflammatory  swell- 
ing of  the  mucous  membrane. 

Spasmodic  stricture  does  not  exist  alone,  but  complicates  organic  stricture, 
a  hyperesthetic  urethra,  or  an  inflamed  bladder. 

Organic  stricture  is  a  fibrous  narrowing  of  the  urethra,  due,  as  a  rule,  to 
chronic  gonorrheal  inflammation  or  to  traumatism.  True  organic  stricture 
is  very  rare  in  children,  but  can  occur.  Abbe  reported  a  case  of  impassable 
stricture  in  the  deep  urethra  of  a  male  child  two  and  one-half  years  of  age, 
due  to  urethral  gonorrhea.  There  were  also  two  strictures  of  the  anterior 
urethra.  External  urethrotomy  was  performed.  Traumatic  strictures  occur 
in  the  bulbous  or  membranous  urethra,  and  are  due  generally  to  force  apphed 
to  the  perineum,  the  urethra  being  squeezed  between  the  subpubic  ligament 
and  the  vulnerating  body.  Strictures  resulting  from  gonorrheal  inflamma- 
tion occur  in  the  penile,  bulbous,  or  membranous  urethra.  Stricture  never 
forms  in  the  prostatic  urethra  except  as  a  result  of  traumatism.  Recent 
non-traumatic  strictures  are  soft  and  are  easily  distended.  Old  strictures 
and  traumatic  strictures  are  very  dense.  A  resilient  stricture  is  one  which 
contracts  quickly  after  dilatation.  The  nearer  a  stricture  is  to  the  meatus, 
the  more  fibrous  it  is. 

A  congenital  stricture  is  congenital  narrowness  of  a  portion  of  the  urethra, 
usually  the  portion  near  the  meatus.  The  more  fibrous  a  stricture  is,  the  more 
it  narrows  the  urethra  and  the  less  dilatable  it  will  prove.  A  stricture  may  be 
annular  (forming  a  ring  aromid  the  urethra),  tubular  (surrounding  the  ure- 
thra for  a  considerable  distance),  or  bridle  (when  a  band  crosses  the  urethra 
from  wall  to  wall).  A  stricture  of  large  caliber  will  admit  an  instrument 
larger  than  a  No.  15  French  sound.  A  strictiu"e  of  small  cahber  will  not 
admit  a  No.  15  French  soimd.  An  impermeable  strictiu-e  will  not  admit  the 
passage  of  any  instrument.  "Impermeable"  is  more  or  less  a  relative  term. 
A  stricture  may  be  impermeable  when  an  anesthetic  is  not  used,  and  perme- 
able when  the  patient  is  anesthetized,  or  may  be  impermeable  to  one  surgeon, 
but  permeable  to  another.  Impermeability  is  often  a  temporary  condition 
due  to  spasm  or  to  inflammatory  edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually  a  history  of  repeated 
attacks  of  urethritis.  A  chronic  discharge  may  exist,  the  amoimt  of  which  is 
variable.  There  is  a  feeling  of  weight  in  the  perineum  and  soreness  of  the  back, 
and  frequency  of  micturition  is  complained  of.  Hypochondriacal  tendencies 
are  usual.  In  a  deep  stricture  there  is  difficulty  in  starting  the  stream  in 
micturition.  In  most  cases  the  stream  is  small,  twisted,  and  forked.  There 
is  often  interruption  or  "stammering"  of  the  stream,  and  it  dribbles  long 
after  the  conclusion  of  the  act,  so  that  the  penis  must  be  "milked"  before  it 
.  is  retiu"ned  within  the  clothing.  The  urethra  back  of  the  stricture  dilates, 
a  pouch  forms,  drops  of  urine  collect  and  decompose,  and  a  chronic  inflam- 
mation results  in  the  mucous  membrane  or  the  parts  adjacent,  which  inflam- 
mation may  go  on  to  ulceration  or  to  periurethral  abscess.  A  urinary'  fistula 
results  from  the  opening  externally  of  a  periurethral  abscess.  Retention 
of  urine  may  occur,  not  from  actual  obliteration  of  the  tube  by  the  growth 
of  the  stricture,  but  by  closure  of  the  lumen  of  the  urethra  by  musfcular  spasm 
and  by  edematous  swelling  in  the  neighborhood  of  the  stricture.  Edematous 
swelling  may  be  due  to  cold,  wet,  venereal  excitement,  the  use  of  alcohol, 
overexertion,  etc.  Spasm  of  the  muscles  results,  and  contact  of  the  urine 
increases  the  spasm,  and  spasm  plus  edema  of  the  mucous  membrane  closes 


1366  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  urethra.  Spasm  may  exist  in  the  urethra  itself  and  in  the  muscles  of  the 
neck  of  the  bladder,  but  is  only  a  temporary  condition.  In  old  strictures 
the  bladder  is  hypertrophied  and  often  fasciculated,  and  is  very  liable  to 
cystitis.  The  diagnosis  of  stricture  and  of  its  location  is  made  by  the  use 
of  exploratory  bougies.  In  this  examination  the  author  follows  to  a  great 
extent  the  plan  of  Ramon  Guiteras,^  which  is  as  follows:  Have  the  patient 
pass  urine  into  two  glasses.  Examine  the  urine  for  clap-shreds.  Cloudiness 
in  the  first  glass  shows  that  urethral  discharge  exists.  Cloudiness  in  the 
second  glass  points  to  cystitis.  The  patient  is  placed  recumbent  with  his 
shoulders  elevated,  and  the  urethra  is  washed  out  with  warm  salt  solution  or 
boric  acid.  Bulbous  sounds  are  inserted,  beginning  with  No.  15  French. 
If  this  passes  with  ease,  take  a  larger  size  and  note  where  strictures  are  situated 
by  the  catch  on  withdrawal.  If  No.  15  does  not  pass,  use  a  smaller  size. 
Remember  that  the  posterior  layer  of  the  triangular  ligament  catches  a  bulb- 
ous instrument  on  withdrawal.  If  the  meatus  is  too  small  to  permit  of  explo- 
ration, divide  it  by  a  curved  bistoury,  cutting  from  within  outward.  After 
cutting  the  meatus  bleeding  is  arrested  with  styptic  cotton,  and  a  piece  of 
absorbent  cotton  is  tucked  into  the  cut.  After  each  act  of  micturition  the 
patient  inserts  a  fresh  bit  of  cotton,  and  after  three  days  the  urethral  examina- 
tion may  be  proceeded  with. 

Treatment. — A  stricture  of  large  caKber  in  the  deep  urethra  requires  gradual 
dilatation.  A  steel  bougie  is  introduced  every  fifth  day,  the  size  being  gradually 
increased.  Never  anoint  a  bougie  with  vasehn,  as  it  may  become  a  nucleus  for  a 
stone  in  the  bladder;  use  liquid  cosmolin,  glycerin,  synol  soap,  or  lubrichondrin. 
Before  passing  an  instrument  the  patient  urinates  and  his  urethra  is  washed 
out  with  salt  solution  or  boric  acid  solution.  Glans,  meatus,  and  urethra 
are  cleansed  as  directed  on  page  i345-  The  sound  is  rendered  sterile  by  boiling 
before  using.  Gradual  dilatation  can  be  effected  by  the  use  of  the  dilator  of 
Oberlander,  the  tube  being  distended  to  the  extent  of  3  mm.  every  fifth  day. 
If  after  dilatation  there  is  urethral  spasm,  pain,  or  very  frequent  micturition, 
suspend  the  treatment  for  a  number  of  days  and  order  each  night  a  hot 
hip-bath  and  a  dose  of  paregoric.  During  gradual  dilatation  the  patient 
should  not  use  alcohol,  should  refrain  from  sexual  excitement,  should  avoid 
cold  and  damp,  and  should  take  internally  capsules  containing  boric  acid  and 
salol.  It  is  rarely  necessary  to  dilate  above  No.  32  French.  After  the  sur- 
geon finishes  treatment  he  teaches  the  patient  to  use  an  instrument  and 
directs  him  to  pass  it  once  a  month,  because  gradual  dilatation  rarely  cures  a 
stricture,  and  if  dilatation  is  permanently  abandoned  contraction  will  probably 
occur.  Strictures  in  the  pendulous  urethra,  if  soft,  are  treated  by  gradual  dila- 
tation; if  fibrous  and  contractile,  by  internal  urethrotomy.  For  fibrous  stric- 
ture in  or  near  the  bulb  external  urethrotomy  should  be  combined  with  internal 
division.  External  urethrotomy  secures  drainage,  and  the  doing  of  it  greatly 
lowers  mortality.  In  performing  internal  urethrotomy  prepare  the  patient 
carefully;  for  several  days  before  the  operation  give  salol  and  boric  acid  by 
the  mouth,  and  wash  out  the  bladder  repeatedly  with  boric  acid  solution. 
Be  thoroughly  aseptic.  Anesthetize  the  patient.  Before  cutting  irrigate  the 
urethra  with  warm  normal  salt  solution,  and  after  cutting  irrigate  again,  pass  a 
rubber  catheter  into  the  bladder  and  tie  it  in.  These  precautions  will  pre- 
vent urethral  fever.  In  cutting,  insert  Gross's  urethrotome  (Fig.  913)  back 
of  the  stricture,  spring  out  the  blade,  cut  the  stricture  on  the  roof  of  the 
urethra,  close  the  blade,  withdraw  the  instrument,  and  pass  a  full-sized 
bougie. 

Stricture  of  the  meatus  requires  incision  by  a  knife  and  the  use  of  a  meatus 
bougie  imtil  heahng  is  complete.  Strictures  of  small  caliber  in  front  of  the 
1  "Med.  Record,"  Nov.  14,  1896. 


Treatment  of  Stricture 


1367 


membranous  urethra  require  gradual  dilatation  and,  if  this  fails,  internal  ure- 
throtomy or  divulsion.  Internal  urethrotomy  can  be  performed  with  the  ure- 
throtome of  Maisonneuve  (Fig.  914)  or  the  Otis-Wyeth  instrument  (Fig.  916). 
The  instrument  of  Maisonneuve  is  shaped  like  a  sound,  has  a  groove  upon  its 
surface,  and  into  this  groove  a  shaft  carrying  a  triangular  knife  can  be  inserted. 
The  staff  is  screwed  to  a  guide,  the  guide  is  carried  into  the  bladder  and  the  staff 


<S 


Fig.  gi3. — S.  W.  Gross's  ex- 
ploratory urethrotome. 


Fig.  914. — Maisonneuve's  urethrotome. 


Fig.  915. — Horwitz's  modi- 
fication of  Maisonneuve's  ure- 
throtome. 


follows  it.  The  point  of  the  staff  is  carried  to  the  prostatic  urethra  and  the 
guide  curls  up  in  the  bladder.  The  penis  is  held  upon  the  stretch,  the  blade 
is  inserted  and  pushed  down  through  the  stricture.  This  instrument  cuts  the 
stricture,  but  not  the  healthy  urethra.  Stricture  within  i  inch  of  the  meatus 
is  divided  on  the  floor  of  the  urethra.  A  deeper  stricture  is  divided  on  the  roof, 
except  at  or  near  the  bulbomenbranous  junction.  In  such  a  stricture  the  roof 
is  divided  by  internal  urethrotomy  and  the  floor  by  external  urethrotomy.    In 


1368 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


using  a  urethrotome  do  not  overdilate  or  cut  deeply.  To  do  so  will  cause  de- 
formity of  the  penis.  For  divulsion  the  patient  is  prepared  as  for  internal  ure- 
throtomy. The  dilator  ,of  Gross  (Fig.  917),  or  divulsor  of  Sir  Henry  Thompson 
or  of  Gouley  (Figs.  918,  919)  is  introduced,  the  blades  are  separated,  the  instru- 
ment is  withdrawn,  a  large  bougie  is  passed,  and  a  catheter  is  tied  in  the  bladder. 
Strictures  of  small  caliber  in  the  deep  urethra  are  seldon  permanently  benefited 
by  gradual  dilatation.  The  best  method  is  combined 
internal  and  external  urethrotomy.  In  strictiures  of  the 
deep  urethra,  if  only  a  filiform  bougie  can  be  introduced, 
the  bougie  may  be  left  in  place,  and  in  a  day  or  two 
another  can  be  slipped  in  beside  it,  until  in  a  few  days 
the  channel  becomes  permeable  to  a 
metal  bougie.  A  tunneled  catheter  can 
be  slipped  over  the  filiform  bougie,  both 
be  withdrawn,  and  a  metal  bougie 
passed.  A  tunneled  and  grooved  staff 
can  be  carried  in  over  the  bougie  and 
external  urethrotomy  be  performed. 
Thompson's  dilator  can  be  carried  in 
over  the  fiHform  and  the  stricture  be 
divulsed.  What  is  known  as  modified 
rapid  dilatation  consists  in  first  dilat- 
ing as  described  above  by  the  Thomp- 
son dilator,  then  introducing  the 
powerful  dilator  of  Gross  (Fig.  917) 
and  distending  the  urethra  to  the  limit. 
This  operation  tears  and  lacerates 
rather  than  dilates  and  has  been  prac- 
tically abandoned.  In  impassable 
stricture  of  the  deep  urethra  perform 
external  perineal  urethrotomy  without 
a  guide  (the  operation  of  Wheelhouse). 
If  a  perineal  fistula  exists,  dilate, 
divulse,  or  cut  the  stricture  and  retain 
a  catheter  in  the  bladder  for  forty- 
eight  hours.  After  this  period  dilate 
the  urethra  every  fourth  or  fifth  day  by 
a  metal  instrument.  Every  morning 
and  evening  draw  the  urine  by  a  soft 
catheter,  introduce  boric  acid  solution 
into  the  bladder,  remove  the  catheter, 
and  let  the  man  empty  his  bladder 
naturally.  A  part  will  flow  from  the 
fistula  and  a  part  from  the  meatus. 
Day  by  day  the  quantity  which  comes 
from  the  fistula  lessens,  and  finally  the 
abnormal  opening  heals. 
Urethral  Fever. — Any  operation  upon  the  urethra  may  be  followed 
by  a  chill  owing  to  shock  (urethral  shock),  and  this  may  be  followed  by  a 
nervous  fever.  Urethral  fever  proper  is  sapremia  following  a  urethral  opera- 
tion. The  condition  is  due  to  absorption  of  toxic  elements  which  may  be 
in  the  urine,  may  have  been  in  the  urethra,  or  may  have  been  introduced  from 
without.  It  usually  follows  the  first  urinary  act  after  operation.  It  begins 
with  a  violent  chill  and  presents  the  characteristics  of  a  septic  fever.  It  is 
accompanied  by  a  marked  tendency  to  urinary  suppression,  and  may  eventuate 


Fig.  916. — Otis's  dilating 
urethrotome. 


Fig.    917.  —  Gross's 
urethral  dilator. 


Urinary  Fever 


1369 


in  septicemia  or  pyemia.  Urethral  fever  can  be  prevented  by  rigid  antisepsis. 
If  this  fever  should  arise,  a  catheter  must  be  tied  in  the  bladder,  the  bladder  and 
urethra  must  be  repeatedly  irrigated  with  aseptic  or  antiseptic  fluids,  and  the 
patient  must  be  given  urmary  antiseptics  and  stimulants  by  the  mouth. 

Urinary  Fever. — Sir  Benjamin  Brodie  pointed  out  that  the  with- 
drawal of  residual  urine  in  a  case  of  enlarged  prostate  may  be  followed  by 
very  serious  symptoms.  The  condition  is  spoken  of  as  urinary  fever,  and 
was  said  to  be  due  to  the  sudden  and  complete  emptying  of  a  bladder 
which  has  become  accustomed  to  retaining  permanently  a  considerable  quan- 
tity of  urine.  Modern  studies  prove  that  urinary  fever  is  due  to  infection 
of  the  bladder  and  kidneys,  and  not  simply  to  the  sudden  withdrawal  of  all  of 
the  urine  from  the  bladder,  although  such  a  procedure  leads  to  vesical  con- 


Fig.  918. — Thompson's  divulsor. 


gestion  and  probably  favors  infection.  The  bacteria  most  often  found  are 
pyogenic  cocci,  colon  bacilli,  and  micro-organisms  which  cause  putrefaction 
and  decomposition  of  urea. 

The  condition  does  not  arise  promptly,  suddenly,  and  violently,  as  does 
urethral  fever,  but  begins  rather  insidiously  after  several  days.  Mr.  C. 
Mansell  Moullin^  thus  describes  the  condition: 

"So  far  as  the  broader  features  are  concerned,  the  symptoms  that  present 
themselves  in  these  cases  are  remarkably  uniform.  They  do  not  begin  at 
once.  Nearly  always  some  few  days  elapse  before  there  is  anything  to  excite 
suspicion.  Then  the  urine  becomes  cloudy,  though  it  may  still  retain  its 
acid  reaction.  A  small  quantity  of  albumin,  more  than  can  be  accounted 
for  by  the  amount  of  pus  that  is  present,  makes  its  appearance.     Under  the 


Fig.  919. — Gouley's  divulsor. 

microscope  there  are  a  few  hyaline  casts,  perhaps  a  blood-corpuscle  or  two, 
numerous  pus-corpuscles,  and  myriads  of  bacteria.  The  specific  gravity  is 
lower  than  it  ought  to  be,  and  is  lower  than  it  was  before  the  catheter  was 
used.  The  total  amount  passed  in  the  twenty-four  hours  may  either  increase 
until  it  is  as  much  as  7  or  8  pints,  or  diminish  imtil  it  scarcely  reaches 
20  oz.  There  is  seldom  any  definite  rigor,  but  there  may  be  mmierous  slight 
chills.  The  pulse  grows  more  rapid  and  feeble.  The  tongue  becomes  red  and 
dry.  There  is  complete  anorexia.  Delirium  sets  in  at  night,  and  in  a  con- 
siderable proportion  of  cases  the  symptoms  rapidly  grow  worse  and  worse 
imtil,  at  the  end  of  a  few  days,  the  patient  sinks  into  a  semicomatose  condition 
from  which  he  seldom  rallies.  Postmortem  there  are  all  the  signs  of  recent 
acute  cystitis  and  pyelonephritis.    The  mucous  membrane  lining  the  pelvis 

1  "Lancet,"  Sept.  10,  1898. 


1370  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  calices  of  the  kidney,  the  ureters,  and  the  bladder  is  swollen  and  stained 
by  old  and  recent  hemorrhages,  and  here  and  there  a  thin  layer  of  pus  is  ad- 
herent to  it.  The  pelvis  and  the  ureters  are  dilated,  the  apices  of  the  pyramids 
are  eaten  away,  the  cortex  is  shrunken  and  hard,  the  capsule  is  adherent,  and 
in  places  between  the  tubules  are  minute  collections  of  pus  differing  in  shape  and 
outline  according  to  the  anatomical  arrangement." 

Treatment. — Aseptic  catheterization  is  necessary  if  we  would  avoid  urin- 
ary fever;  and  as  the  iirethra  contains  some  of  the  causative  organisms,  the 


Fig.  920. — Syme's  grooved  staff. 

prepuce,  glans,  and  meatus  should  be  washed  with  soap  and  water  and  irri- 
gated with  boric  acid  or  permanganate  of  potassiiun  solution,  and  the  urethra 
be  irrigated  with  boric  acid  solution  or  permanganate  of  potassium  before  the 
sterile  catheter  is  introduced  to  draw  the  urine. 

If  urinary  fever  arises,  it  may  be  possible  to  control  it  by  frequently  irri- 
gating the  bladder  with  warm  normal  salt  solution,  solution  of  nitrate  of 
silver  (i  :  8000)   or  boric  acid  solution,  and  by  administering  stimulants, 


Fig.  921. — Wheelhouse's  staff. 

diuretics,  diaphoretics,  saline  cathartics,  urotropin,  salol  or  boric  acid,  qui- 
nin,  and  nutritious  food.  In  severe  cases  perform  suprapubic  cystostomy  for 
drainage. 

Perineal  section  is  external  perineal  urethrotomy.  There  are  three 
methods — the  operation  of  Syme,  of  Wheelhouse,  and  of  Cock. 

Syme's  Operation. — This  operation  is  employed  if  a  stricture  is  very 
contractile,  if  dilatation  fails  to  cure,  or  if  urethral  instrumentation  invari- 
ably causes  pronounced  urethral  fever.    The  patient  is  anesthetized,  Syme's 


922. — Teale's  probe  gorget. 


staff  (Fig.  920)  is  introduced,  and  the  surgeon  makes  an  incision  in  the  mid- 
line of  the  perineum  and  exposes  the  staff  just  above  the  shoulder  of  the 
instrument.  The  knife  is  carried  along  the  groove  and  divides  the  stricture. 
A  catheter  is  passed  into  the  bladder  from  the  meatus  and  is  retained  for 
several  days,  and  the  woimd  is  dressed  antiseptically.  After  the  catheter  has 
been  removed  it  must  be  used  every  six  hours  until  the  urine  comes  entirely  by 
the  meatus.  During  the  rest  of  the  patient's  life  a  full-sized  sound  should 
be  passed  at  monthly  intervals. 


Hypospadias  1371 

Wheelhouse's  Operation, — This  operation  is  employed  for  the  treament  of 
impermeable  stricture.  Wheelhouse's  staff  (Fig.  921)  is  passed  into  the  urethra 
until  it  blocks  on  the  stricture.  The  perineum  is  incised  down  to  the  staff 
and  in  front  of  the  stricture.  The  edges  of  the  cut  urethra  are  held  apart 
by  forceps,  the  surgeon  seeks  for  the  opening  through  the  stricture,  passes 
a  fine  probe  through  it,  divides  the  stricture,  carries  into  the  bladder  from  the 
wound  an  instrument  known  as  a  probe  gorget  (Fig.  922)  to  dilate  the  canal 
and  furnish  a  solid  floor  to  facihtate  the  introduction  of  a  catheter.  With  the 
gorget  in  place  a  metal  catheter  is  carried  from  the  meatus  into  the  bladder. 
The  gorget  is  removed  and  the  catheter  is  tied  in  place.  After  three  or  four  days 
the  catheter  is  removed  and  is  then  passed  frequently.  The  perineal  wound  is, 
of  course,  dressed  antiseptically. 

Cock's  Operation. — This  operation  opens  the  urethra  back  of  the  stricture 
without  the  aid  of  a  guide  and  relieves  retention  of  urine.  The  surgeon  intro- 
duces into  the  rectum  the  index-finger  of  the  left  hand,  and  the  tip  of  the  finger 
is  rested  upon  the  apex  of  the  prostate  gland.  The  surgeon  incises  the  median 
line  of  the  perineum,  the  back  of  the  knife  being  toward  the  anus.  When 
the  point  of  the  knife  is  felt  to  be  near  the  finger  the  handle  is  lowered  slightly, 
the  blade  is  placed  a  little  oblique,  and  the  urethra  is  opened.  A  catheter  is 
passed  into  the  bladder  from  the  wound  and  retained  for  a  time,  and  the 
stricture  is  subsequently  treated. 

Gibson's  Operation  for  Impermeable  Stricture  (C.  L.  Gibson,  in  "Med. 
Record,"  Aug.  6,  1910). — Open  the  posterior  urethra  by  Cock's  operation  (see 
above).  In  most  cases  it  is  now  possible  to  pass  a  small  urethrotome  from 
the  urethral  wound  forward.  If  this  can  be  done  the  deep  stricture  is  at  once 
divided.  If  it  cannot  be  done  a  filiform  is  passed  from  the  urethral  wound 
out  through  the  urinary  meatus.  This  maneuver  may  require  the  aid  of  a 
special  instrument  (Gibson's  retrograde  filiform  carrier).  The  straight  staff 
of  the  Fliihrer  urethrotome  is  threaded  over  the  filiform  bougie  in  front  of  the 
meatus.  It  is  pushed  back  until  it  passes  through  the  stricture,  when  the  knife 
is  inserted  and  "pushed  home."  This  trivial  cut  permits  the  passage  of  a 
large  urethrotome  (for  instance,  Otis's).  The  stricture  is  now  freely  divided 
(up  to  No.  30  French).  After  division  of  the  stricture  a  No.  30  French  steel 
sound  is  carried  from  the  meatus  into  the  bladder.  A  tube  to  drain  the  blad- 
der is  introduced  through  the  wound. 

Epispadias  is  a  congenital  cleft  in  the  corpora  cavernosa,  the  roof  of 
the  urethra  being  completely  or  partly  absent.  In  complete  epispadias  there 
are  absence  of  the  pubic  arch  and  exstrophy  of  the  bladder. 

Partial  epispadias  may  sometimes  be  remedied  by  a  plastic  operation. 

Hypospadias  is  a  congenital  cleft  on  the  floor  of  the  urethra,  the  meatus 
opening  on  the  floor  at  some  point  between  the  scrotum  and  the  end  of  the 
glans  penis,  the  channel  in  front  of  the  meatus  being  a  gutter  and  not  a  tube. 

Hypospadias  of  the  glans  is  the  most  common  form.  In  this  condition 
the  urethra  has  no  floor  as  it  passes  beneath  the  glans,  the  site  of  the  urethra 
is  indicated  by  a  groove,  and  the  foreskin  is  absent  below.  Partial  hypo- 
spadias requires  no  treatment  except  possibly  dilatation  or  incision  of  the 
meatus.  People  who  suffer  from  it  are  very  prone  to  develop  chronic  urethral 
inflammation.  In  hypospadias  of  the  penis  the  ill-developed  cord-like  corpus 
spongiosum  draws  the  penis  to  the  scrotum.  In  this  variety  of  the  deformity 
the  penis  is  very  short. 

In  complete  hypospadias  the  opening  of  the  urethra  is  back  of  the  scrotum 
in  the  perineum,  the  penis  is  dwarfed  and  bound  down,  and  looks  not  unlike 
a  clitoris,  the  scrotum  is  divided  into  two  portions,  a  gap  existing  between 
them,  and  in  many  cases  the  testicles  have  not  descended.  Such  individuals 
are  occasionally  mistaken  for  females.     In  the  penile  complete  forms  of 


1372 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


hypospadias  a  plastic  operation  should  be  performed  between  the  eighth  and 
tenth  years  of  age.  Such  an  operation,  unfortunately,  may  faU.  Hypospadias 
is  rare  in  women,  but  it  may  occur.  In  such  a  case  the  urethra  opens  into 
the  vagina.  Figures  923-925  show  the  ingenious  operation  successfully  prac- 
tised by  Carl  Beck  for  penile  hypospadias. 

Chancroid  {soft  chancre;  the  local  venereal  sore)  is  an  ulcer,  usually  of 
venereal  origin.  The  name  "chancroid"  was  introduced  by  Clerc,  who  beheved 
that  a  soft  sore  resulted  from  inoculating  a  person  already  syphilitic  with  the 
products  of  a  hard  sore.  He  further  held  that  when  a  soft  sore  arose  the 
syphilitic  poison  lost  its  infective  properties,  and  "could  be  transmitted  as 
a  soft  sore  to  a  healthy  person,  and  not  cause  general  infection."^  The  chan- 
croidal ulcer  is  not  connected  with  the  syphilitic  poison,  but  is  developed 
by  inoculation  with  the  bacterium  of  Ducrey.  Until  recently  it  was  believed 
that  a  chancroid  was  not  produced  by  a  special  poison,  but  arose  after  in- 


Fig.  923.  Fig.  924.  Fig.  9?s. 

Figs.  923-925. — Beck's  operation  for  h5rpospadias. 

oculation  with  inflammatory  products  or  irritating  secretions.  It  seems  to 
have  been  proved,  however,  by  Krefting  and  Colombini  that  the  organism 
discovered  by  Ducrey  in  1889  is  the  real  cause.  This  organism  is  grown 
on  a  mediimi  of  fresh  blood  and  bouillon  or  in  "immixed  human  blood."  (See 
Lincoln  Davis,  "Observations  On  the  Distribution  and  Culture  of  the 
Chancroid  Bacillus,"  "Report  of  Research  Work,"  1902-03;  the  Division  of 
Surgery  of  the  Medical  School  of  Harvard  University.)  As  a  rule,  chan- 
croids are  of  venereal  origin,  and  result  from  contact  with  other  chancroids, 
pus,  mucopus,  or  areas  of  ulceration.  A  chancroid  appears  soon  after  inter- 
course, usually  within  five  days,  always  within  ten  days.  It  is  first  manifested 
by  a  pustule  which  ruptures  and  discloses  an  ulcer.  This  ulcer  has  sharply 
defined  and  undermined  margins;  it  looks  "punched  out";  the  base  is  gray 
and  sloughy;  the  discharge  is  jirofuse,  purulent,  foul  and  auto-inoculable,  and 
causes  fresh  chancroids  by  flowing  over  the  parts.  The  area  around  a  chan- 
1  "  Syphilis,"  by  Alfred  Cooper. 


Treatment  of  Chancroid 


1373 


croid  is  red  and  inflamed,  and  considerable  pain  is  apt  to  be  complained  of. 
The  original  chancroid  spreads  and  new  sores  appear.  The  edge  of  a  chan- 
croid is  rarely  indurated  imless  caustics  have  been  used  or  there  is  mixed 
infection  with  s}^hilis.  Inflammatory  induration  fades  gradually  into  the 
tissues,  but  the  induration  of  a  hard  chancre  is  sharply  defined.  Fournier  says 
that  a  chancroid  may  have  a  hard  base  if  the  sore  is  located  in  the  sulcus  back 
of  the  glans,  on  a  lip  of  the  meatus,  or  on  the  lower  border  of  the  prepuce  of  a 
man  with  phimosis,  or  when  the  ulcer  is  inflamed.  The  surgeon  should  always 
ask  if  the  sore  has  been  cauterized  and  how  it  has  been  treated.  When  a 
chancroid  after  a  time  displays  marked  and  sharply  outlmed  induration  it 
points  to  mixed  uif  ection  with  chancroidal  and  s^^philitic  organisms.  Chancroids 
are  not  followed  by  constitutional  s^Tnptoms,  but  are  apt  to  be  accompanied 
by  paiiiful  inflammator}'  buboes  which  are  prone  to  suppurate.  In  hospital 
practice  about  30  per  cent,  of  patients  with  chancroids  develop  buboes.  The 
bubo  may  be  either  unilateral  or  bilateral.  In  the  majority  of  cases  the  ade- 
nitis of  chancroid  is  due  to  the  absorption  of  toxins  alone  and  the  pus  may  be 
entirely  free  from  bacteria.     Cases  have  been  reported  in  which  non-indurated 


Fig.    926. — Buttonliole    perforation    of    the 
prepuce  foUoTi\-ing  phagedenic   chancroid    (Hor- 
witz). 


Fig.  927. — Buttonhole  perforation  of  the 
prepuce  following  phagedenic  chancroid  (Hor- 
w"itz). 


sores  were  followed  by  s^-phiHs.  It  is  probable  that  a  mixed  infection  existed, 
and  that  induration  was  overlooked,  because  a  papular  initial  lesion  was  beneath 
the  chancroidal  ulcer.  When  inflammation  in  chancroids  is  high,  a  rapidly 
destructive  ulceration  known  as  phagedena  may  arise  (Figs.  926  and  927),  but 
this  process  is  more  common  in  s^phiHtic  sores. 

Treatment, — Ordinar}^  cases  of  chancroid  are  treated  by  spraying  vdth 
peroxid  of  hydrogen,  dndng  with  cotton,  touching  each  sore  first  with  pure 
carboHc  acid  and  then  -vs-ith  pure  nitric  acid,  and  dressing  with  black  wash 
or  dusting  -^ith  iodoform  or  "^dth  calomel.  Ever\'  few  hours  the  patient 
soaks  the  penis  in  hot  salt  water  (a  teaspoonful  of  salt  to  a  pint  of  water), 
sprays  the  sores  \d\h.  peroxid  of  hydrogen,  dries  -^-ith  cotton,  and  dresses  with 
black  wash  or  dusts  with  iodoform  or  ■v\-ith  calomel.  As  soon  as  granulation 
begins  the  sores  should  be  dressed  "^^ith  i  part  of  ointment  of  nitrate  of  mer- 
CMTx  to  7  parts  of  cosmolin.  Mild  cases  do  well  without  cauterizing,  peroxid 
of  hydrogen  being  frequently  used  and  a  dr^-ing  powder  being  employed. 
In  chancroids  with  phimosis  slit  up  the  foreskin,  smear  the  raw  edges  of  the 
wound  with  pure  carbolic  acid,  and  treat  the  ulcers  by  cauterization.  A  reg- 
iflar  circumcision  usually  fafls  because  of  infection  of  the  stitch-holes.     Phage- 


1374  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

dena  requires  the  internal  use  of  iron,  quinin,  and  milk-punch,  and  the  local 
use  of  powerful  caustics  (bromin  or  nitric  acid  or  even  the  actual  cautery). 
In  some  cases  continuous  antiseptic  irrigation  is  valuable.  When  a  bubo  first 
begins,  order  rest,  apply  iodin  or  an  ointment  of  belladonna  or  ichthyol,  and 
make  pressure  by  a  spica  bandage  of  the  groin.  Some  surgeons  advise  the 
injection  of  20  to  40  min.  of  a  solution  of  carbolic  acid  (10  gr.  to  the  ounce), 
but  I  have  never  seen  any  benefit  from  it.  Some  inject  a  i  per  cent,  solution 
of  bichlorid  of  mercury,  but  the  proceeding  causes  intense  pain.  Welander 
recommends  the  injection  of  a  i  per  cent,  solution  of  benzoate  of  mercury. 
I  have  had  no  experience  with  this  method.  If  the  bubo  persists  though  it 
does  not  suppurate,  it  should  be  completely  excised.  If  pus  forms,  several 
methods  of  treatment  are  open  to  us:  aspiration,  injection  with  a  solution  of 
carbolic  acid,  squeezing  out  the  acid  and  injecting  10  per  cent,  ointment 
of  iodoform  and  glycerin,  and  sealing  the  opening  with  collodion  (Scott  Helms) . 
Hayden  makes  a  puncture,  squeezes  out  the  pus,  washes  out  the  cavity  with 
peroxid  of  hydrogen,  and  then  with  corrosive  sublimate  solution,  injects 
warm  iodoform  ointment,  and  dresses  with  cold,  moist,  corrosive  sublimate 
gauze  to  set  the  ointment.  Otis,  Fontain,  Perry,  and  others  commend  this 
plan.  We  have  sometimes  found  it  to  succeed.  If  the  above-mentioned 
plan  fails,  if  it  is  not  used,  or  if  an  ulcer  or  sinus  exists,  incise,  curet,  cauterize 
with  pure  carbolic  acid,  cut  away  hopelessly  infiltrated  skin,  and  pack  the 
wound  with  iodoform  gauze.  In  some  cases  it  will  be  necessary  to  extirpate 
fragments  of  gland. 

Phimosis  is  a  condition  of  the  prepuce  that  renders  retraction  over  the 
glans  impossible.     It  is  usually  congenital,  but  it  may  arise  from  inflamma- 
tion.    Congenital  phimosis  causes  retention  of  sebaceous  matter,  which  de- 
composes and  lights  up  inflammation  and  the  prepuce  is 
apt  to  grow  fast  to  the  glans.     Congenital  phimosis  may 
induce  irritability  of  the  bladder,  incontinence  of  urine, 
prolapse  of  the  rectum,  and  various  nervous  symptoms. 
The  treatment  is  circumcision.    Asepticize  the  parts. 
Grasp  the  foreskin  and  the  mucous  membrane  by  two 
pairs  of  forceps,  draw  the  prepuce  forward,  catch  the  skin 
Fig.  Q28  — -Circum-     r^^  ^]^g  point  it  is  desired  to  cut)  horizontally  between  the 

cision    completed    (Es-        ^  r  .1       i  n         r  •         r        •  i  re    ^ 

march  and  Kowalzig).  arms  oi  the  handle  01  a  pair  of  scissors,  and  cut  on  the  re- 
dundant prepuce.  Retrench  the  excess  of  mucous  mem- 
brane by  trimming  with  scissors  \  inch  from  the  glans,  stitch  the  skin  to 
the  mucous  membrane  with  catgut,  and  dress  with  sterile  gauze  (Fig.  928). 

Fracture  of  the  penis,  which  is  a  laceration  of  the  cavernous  bodies 
with  extravasation  of  blood,  occurs  occasionally  during  coition. 

The  treatment  consists  of  cold  and  bandaging  to  arrest  bleeding,  and  in 
some  cases  incisions  to  let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from  tying  constricting 
bands  around  the  organ,  from  fracture  with  excessive  hemorrhage,  and  from 
paraphimosis.     If  extensive,  it  requires  amputation. 

Cancer  of  the  penis  (Fig.  929)  is  commonest  in  persons  with  phimosis. 
In  a  limited  epithelioma  of  the  foreskin  circumcision  is  performed  and  the 
glands  of  the  groin  are  removed;  if  a  well-developed  cancer  affects  the  glans, 
amputation  of  the  penis  is  imperative  and  removal  of  the  inguinal  glands  is 
absolutely  necessary.  Certain  recent  superficial  cases  without  glandular  in- 
volvement may  apparently  be  cured  by  fulguration. 

Amputation  of  the  Penis. — Ricord  advised  cutting  off  the  organ  by 
a  single  stroke  of  the  knife,  making  four  slits  in  the  mucous  membrane  of 
the  urethra,  and  stitching  each  of  these  flaps  to  the  skin.  Treves  splits  the 
skin  of  the  scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum 


Chronic  Vesiculitis 


1375 


down  to  the  corpus  spongiosum,  passes  a  metal  catheter  down  to  the  tri- 
angular ligament,  inserts  a  knife  between  the  corpus  spongiosimi  and  the 
corpora  cavernosa,  withdraws  the  catheter,  cuts  the  urethra  across,  detaches 
the  urethra  from  the  penis  back  to  the  triangular  ligament,  cuts  around  the 
root  of  the  penis,  divides  the  suspensory  ligament,  detaches  each  crus  from 
the  pubes,  slits  up  the  corpus  spongiosum  |  inch,  stitches  its  edges  to  the 
rear  end  of  the  scrotal  incision,  introduces  a  drainage-tube,  ligates  the  vessels, 
and  sutures  the  wound. 

Seminal  Vesiculitis.  —  In- 
flammation of  the  seminal  vesicles 
is  due  to  the  extension  of  a  gonor- 
rheal inflammation,  to  a  pyogenic 
process,  or  to  tuberculosis. 

Acute  vesiculitis  is  made  evi- 
dent by  frequent  and  painful 
micturition,  pains  in  the  anus, 
rectum,  and  perineum,  and  pos- 
sibly the  hip-joint,  back,  and 
thighs.  Defecation  and  micturi- 
tion are  excessively  painful.  Per- 
sistent erections  may  take  place, 
and  in  some  cases  bloody  ejacula- 
tions occur.  Rectal  examination 
detects  the  enlarged  and  tender 
vesicles  external  to  the  lateral 
lobes  of  the  prostate  and  on  a 
higher  level. 

Treatment. — Abandon  local  urethral  treatment,  and  treat  the  patient  as 
for  acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may  develop  in- 
sidiously in  an  individual  with  gonorrhea.  It  is  one  of  the  possible  causes  of 
a  chronic  urethral  discharge.  The  patient  suffers  from  imperative  and  frequent 
demands  to  micturate,  and  he  has  a  gleety  discharge  which  becomes  irregularly 
worse  and  better,  but  does  not  disappear.  This  chronic  inflammation  is  be- 
heved  to  persist  because  of  narrowing  of  the  duct  and  consequent  incomplete 
drainage  of  the  vesicle.  In  chronic  seminal  vesiculitis  there  is  usually  sexual 
weakness,  nocturnal  emissions  occur,  and  the  semen  may  contain  blood. 


Fig.  92g. — Cancer  of  penis  (Horvvitz). 


Fig.  930. — Dufaux's  prostatic  masseur. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary  methods.  Use 
hot  rectal  enemata.  Milk  the  ducts  by  Fuller's  method  once  every  seven 
days.  During  massage  the  patient's  bladder  should  be  full.  He  leans  over 
a  chair-back,  the  knees  being  straight  and  the  body  at  a  right  angle  to  the 
thighs.  The  surgeon  covers  his  finger  with  a  rubber  stall,  anoints  it  with 
oil  or  synol  soap,  introduces  it  into  the  rectum,  and  makes  pressure  over 
the  pubes  with  the  fist  of  the  other  hand.  The  finger  comes  in  contact 
with  the  lower  half  of  the  vesicle;  it  makes  firm  pressure  for  a  moment  and 
is  then  drawn  slowly  toward  the  duct.  This  stroking  is  repeated  several 
times.     The  other  vesicle  is  treated  in  the  same  manner.     These  maneuvers 


1376  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

empty  the  vesicles  and  hasten  the  resolution  of  inflammation.  In  many 
cases  the  finger  reaches  only  the  very  lowest  part  of  the  vesicle.  In  such  a 
case  practice  massage  by  means  of  Dufaux's  rubber  masseur  (Fig.  930).  After 
the  completion  of  the  stripping  the  patient  should  micturate,  and  the  bladder 
and  urethra  should  be  irrigated. 

Tuberculosis  of  the  Seminal  Vesicles. — Primary  tuberculosis  is  very 
unusual.  As  a  rule,  there  is  evidence  of  antecedent  tuberculosis  of  the  testicle 
or  prostate  gland.  About  50  per  cent,  of  the  cases  occur  in  individuals  under 
forty  years  of  age.  The  diseased  vesicle  is  at  first  nodular  and  indurated, 
but  later  imdergoes  caseation  and  softening.  Finally  the  disease  passes  through 
the  capsule  and  invades  adjacent  structures.  Dreyer  collected  36  cases  and 
found  that  in  34  of  them  the  lungs  were  involved. 

Tuberculous  vesiculitis  may  be  imilateral  or  bilateral.  In  unilateral 
tuberculous  epididymitis  the  corresponding  vesicle  is  apt  to  become  diseased. 
In  bilateral  disease  of  the  testicles  both  vesicles  are  liable  to  become  victims. 
Peritoneal  tuberculosis  may  follow  tuberculous  vesiculitis.  In  very  imusual 
cases  spontaneous  cure  is  obtained  by  fibrous-tissue  formation.  On  palpa- 
tion a  tuberculous  vesicle  is  found  to  contain  here  and  there  hard  and  but 
slightly  tender  nodules. 

Treatment.^If  tuberculous  epididymitis  is  followed  by  tuberculous  vesicu- 
litis, it  is  justifiable  to  remove  the  vesicle  after  removing  the  epididymis  or 
testicle,  provided  the  prostate  and  other  parts  of  the  genito-urinary  tract  are 
free  from  disease  and  there  is  no  distant  lesion  of  tuberculosis.  If  both  tes- 
ticles or  epididymes  are  removed,  both  vesicles  can  be  extirpated.  If  a  vesicle 
or  both  vesicles  suffer  from  primary  tuberculosis,  operation  is  advised  by  some 
surgeons.     Reported  cases,  however,  do  not  seem  to  favor  operation. 

Kraske,  Schede,  and  Rydygier  have  removed  the  vesicles  after  preliminary 
resection  of  the  sacrum.  Zuckerkandl,  Diettl,  and  Schede  have  employed 
the  perineal  route.  Villeneuve  reached  them  by  way  of  the  inguinal  region. 
The  curved  perineal  incision  of  Zuckerkandl  is  the  method  usually  preferred. 
H.  H.  Young  makes  a  suprapubic  incision,  strips  the  peritoneum  from  the 
bladder,  and  reaches  the  vesicles  from  behind.  He  calls  it  the  suprapubic- 
retrocystic-extraperitoneal  method  (H.  H.  Youjig,  in  "Annals  of  Surgery," 
Nov.,  1901). 

Acute  Prostatitis. — Acute  inflammation  of  the  prostate  gland  may 
be  caused  by  inflammation  in  adjacent  structures,  the  use  of  instruments  or 
irritant  applications  in  the  deep  urethra,  injury  by  a  passing  or  impacted 
calculus,  various  infectious  diseases,  a  stricture  of  the  urethra,  but  particularly 
by  gonorrhea.  The  gland  enlarges  greatly,  the  prostatic  fluid  exudes  mixed 
with  blood  and  pus,  and  the  gland-ducts  become  distended  with  pus.  A 
distinct  abscess  may  form.  The  orifices  of  the  ejaculatory  ducts  become 
distended  and  filled  with  pus,  and  the  seminal  vesicles  or  epididymes  may 
also  suffer.  An  abscess  is  liable  to  form  in  the  cellular  tissue  outside  of  the 
prostate. 

Symptoms. — There  is  a  feeling  of  weight,  fulness,  or  soreness  in  the  peri- 
neimi;  a  persistent  pain  at  the  neck  of  the  bladder;  frequent  micturition,  pain 
being  present  and  becoming  most  severe  as  the  last  drops  are  voided ;  perineal 
tenderness;  painful  defecation;  and  bulging  of  the  anal  mucous  membrane.  If 
a  finger  is  introduced  into  the  rectum,  it  causes  severe  pain  and  palpates  the 
enlarged  and  tender  gland,  imless  the  outlines  are  destroyed  by  periprostatitis, 
in  which  case  there  will  be  felt  a  large,  boggy,  tender  mass.  (See  Henry 
Morris  on  "Injuries  and  Diseases  of  the  Genital  and  Urinary  Organs.")  These 
symptoms  are  accompanied  by  distinct  elevation  of  temperature.  The 
inflammation  may  abate  without  suppuration,  but,  as  a  rule,  pus  forms,  the 
temperature  becomes  characteristic,  the  pain  becomes  pulsatile,  micturition 


Prostatorrhea  1377 

causes  agony,  the  inflammatory  mass  is  felt  per  rectum  to  be  softening,  and 
sometimes  the  swollen  perineum  becomes  dusky  red.  Retention  of  urine  is 
almost  certain  to  occur.  The  abscess  may  rupture  into  the  urethra  or  the  rec- 
tiun,  or  may  diffuse  in  the  periprostatic  cellular  tissue  and  subsequently  may 
open  in  the  perineum.  Spontaneous  evacuation  may  be  followed  by  recovery 
or  by  the  development  of  annoying  or  dangerous  complications. 

Treatment. — Keep  a  hot-water  bag  on  the  perineum  and  three  or  four 
times  a  day  use  rectal  injections  of  hot  water.  Place  the  patient  on  a  milk- 
diet.  Leech  the  perineum.  Give  suppositories  of  opium  and  belladonna, 
and  also  suppositories  of  ichthyol,  and  administer  urotropin  by  the  mouth. 
Retention  of  urine  is  relieved  by  a  soft  catheter.  When  pus  forms  it  may  be 
possible  in  some  cases  to  rupture  the  abscess  into  the  urethra  by  the  passage 
of  a  steel  sound.  If  this  can  be  accomplished  it  will  be  fortunate.  Occasion- 
ally a  specialist  may  succeed  in  opening  the  abscess  through  an  operating 
cystoscope.  Most  cases  require  to  be  cut  externally.  What  is  known  as  the 
boiitonniere  operation  is  the  method  of  choice.  The  patient  is  placed  in  the 
extreme  lithotomy  position.  The  index-finger  of  the  left  hand  is  introduced 
into  the  rectum  and  carried  to  the  apex  of  the  prostate.  A  straight  bistoury  is 
entered  to  the  side  of  the  median  raphe  and  carried  into  the  abscess  cavity, 
and  the  opening  is  dilated  by  forceps.     The  urethra  is  not  to  be  opened. 

Chronic  prostatitis  may  arise  from  stricture,  venereal  excess,  chronic 
cystitis,  or  stone  in  the  bladder,  but  gonorrhea  is  the  common  cause.  The 
prostate  is  usually,  but  not  always,  enlarged,  is  somewhat  softened,  and  the 
ducts  contain  pus  and  blood. 

Sjrmptoms. — There  is  usually  a  mucopurulent  discharge  or  fluid  can  be 
obtained  by  massage  of  the  prostate.  There  is  a  feeling  of  weight  and  fulness 
in  the  perineum,  there  is  increased  frequency  of  micturition,  and  the  prostate 
is  very  sensitive  to  digital  pressure.  The  patients  are  neurotic,  frequently 
suffer  from  nocturnal  emissions,  and  have  but  feeble  power  of  erection.  The 
prostatic  urethra  is  extremely  hyperesthetic.  All  the  symptoms  are  aggra- 
vated by  worry,  sexual  excitement,  or  violent  exercise.  An  abscess  may  form 
and  rupture  into  the  urethra. 

Treatment. — Tonics  and  nutritious  food  are  essential.  Intravesical 
irrigations  with  nitrate  of  silver  solution  (i  :  8000)  do  good.  Massage  of 
the  prostate  is  useful.  Some  cases  are  benefited  by  touching  the  posterior 
urethra  through  a  urethroscope  tube  with  nitrate  of  silver  (3  gr.  to  the  ounce) 
or  by  injecting  by  means  of  Ultzman's  syringe  a  few  drops  of  silver  nitrate 
solution  (5  gr.  to  the  ounce) .  Rectal  suppositories  of  ichthyol  may  be  ordered. 
Blistering  the  perineum  at  intervals  may  prove  of  service.  At  intervals  of 
three  or  four  days  a  full-sized  cold  steel  sound  should  be  gently  introduced. 
If  an  abscess  forms,  open  it  through  the  perineum. 

Prostatorrhea. — Just  as  overaction  of  the  glands  of  the  urethra  con- 
stitutes urethrorrhea,  so  overaction  of  the  glandular  apparatus  of  the  prostate 
gland  constitutes  prostatorrhea.  Prostatorrhea  is  not  inflammatory,  although 
the  prostate  and  posterior  urethra  are  often  congested,  and  the  latter  region 
is  usually  h3^eresthetic.  In  some  cases  urethrorrhea  exists  with  prostator- 
rhea. Prostatorrhea  is  produced  by  sexual  excess,  masturbation,  ungratified 
sexual  desire,  riding  a  bicycle  with  an  improper  seat,  and  sometimes  by  riding 
horseback.  The  condition  is  usually  accompanied  by  marked  neurasthenia, 
and  may  be  associated  with  spermatorrhea  and  impotence. 

The  patient  notices  a  milky  or  gray  discharge  after  straining  at  stool 
{defecation  spermatorrhea) ,  after  violent  exercise,  sexual  excitement,  or  a 
bicycle  ride.  The  discharge  also  gathers  in  the  urethra  during  sleep.  Ex- 
amination of  the  discharge  shows  it  to  be  prostatic  fluid,  although  spermato- 
zoids  are  sometimes  found.  It  is  not  purulent  and  contains  amyloid  cor- 
87 


1378  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

puscles.  The  meatus  is  not  glued  up  in  the  morning  and  the  linen  is  very 
slightly  stained.  The  urine  is  clear  and  contains  small  comma-shaped  hooks. 
Sexual  excitement  and  alcohol  do  not  appreciably  aggravate  the  condition. 
The  bladder  is  irritable,  and  there  is  frequency  of  micturition  and  often 
some  pain  in  the  head  of  the  penis  at  the  termination  of  the  act.  Noc- 
turnal emissions  may  occur. 

Treatment. — The  patient  should  correct  bad  habits.  If  there  is  urethral 
hyperesthesia  or  prostatic  congestion,  irrigate  the  bladder  and  urethra  once  a 
day  with  a  solution  of  silver  nitrate  (i  :  4000),  and  every  fourth  or  fifth  day  intro- 
duce a  cold  sound.  In  some  cases  the  occasional  instillation  into  the  prostatic 
urethra  of  a  few  drops  of  a  i  per  cent,  solution  of  nitrate  of  silver  does  good. 

For  the  irritable  bladder  give  hot  hip-baths  at  night.  The  following 
prescription  is  of  service:  15  gr.  of  bromid  of  potassium,  |  dram  of  tincture 
of  hyoscyamus  in  |  oz.  of  cinnamon-water,  three  times  a  day.  Hot  enemata 
are  of  service. 

After  the  hyperesthesia  of  the  urethra  has  abated  and  nocturnal  emissions 
have  ceased,  the  neurasthenia  is  treated  by  cold  sponging  of  the  body  night 
and  morning,  the  continued  use,  at  intervals  of  several  days,  of  a  large-sized 
cold  sound,  irrigation  every  second  or  third  day  with  silver  nitrate  (i  :  4000), 
and  the  administration  of  strychnin  and  other  tonics. 

Hypertrophy  of  the  Prostate  Gland. — It  was  pointed  out  by  Mor- 
gagni  that  in  old  men  difficulty  of  micturition  is  due  to  obstruction  by  an 
enlarged  prostate  gland.  Enlargement  of  the  prostate  gland  may  be  brought 
about  by  different  forms  of  growth.  It  is,  as  a  general  thing,  a  senile  change, 
occurring  only  after  the  age  of  fifty,  and  being  most  likely  to  arise  after  the 
attainment  of  sixty  years.  It  is  very  rare  for  enlargement  of  the  prostate  to 
cause  symptoms  long  before  the  age  of  fifty  or  to  begin  after  the  age  of  seventy. 
Sir  Henry  Thompson  maintained  that  34  per  cent,  of  men  over  sixty  have 
prostatic  hypertrophy,  but  that  only  half  of  them  have  troublesome  symptoms. 
According  to  Freyer,  33  per  cent,  of  all  men  past  fifty-five  years  of  age  present 
some  enlargement  of  the  prostate. 

There  are  some  who  oppose  the  view  that  prostatic  enlargement  is  essen- 
tially a  senile  change.  For  instance,  Dr.  L.  Bolton  Bangs  ("Jour,  of  Der- 
matol, and  Gen.-urin.  Dis.,"  March,  1901)  maintains  that  the  change  is  not 
senile;  that  it  really  begins  early  in  life,  but  that  its  effects  do  not  become 
manifest  until  during  or  after  middle  age.  Lydston  asserts  that  it  begins 
during  the  third  decade  of  life,  but  the  gland  does  not  attain  sufficient  size  to 
cause  symptoms  till  beyond  middle  life.  Socin  and  Burckhardt,  as  a  result  of 
300  postmortem  examinations,  reached  the  following  conclusions:  Between  the 
ages  of  thirty-six  and  forty  the  gland  is  hypertrophied  in  13  per  cent,  of  cases, 
between  forty  and  fifty  in  25  per  cent.,  between  fifty  and  sixty  in  31  per  cent., 
between  sixty  and  seventy  in  56  per  cent.,  between  seventy  and  eighty  in 
50  per  cent.,  and  between  eighty  and  ninety  in  54  per  cent.  Undoubtedly,  the 
enlargement  begins  long  before  it  occasions  sufficient  obstruction  to  induce 
S3Tiiptoms,  and  the  growth  progresses  very  slowly.  Guyon  and  the  French 
school  in  general  maintain  that  hypertrophy  of  the  prostate  gland  is  always  the 
result  of  arteriosclerosis,  affecting  not  only  the  prostate,  but  also  the  entire 
urinary  tract.  The  hypertrophy  that  ensues  affects  the  bladder  walls  notably, 
as  well  as  the  prostate,  because  of  distinct  growth.  Caspar  has  apparently 
demonstrated  that  Guyon's  view  is  not  correct.  He  has  shown  that  in  many 
cases  there  is  no  sclerosis  of  the  prostatic  arteries,  and  that  frequently  there 
are  no  sclerotic  changes  in  other  portions  of  the  urinary  tract.  Another 
important  point  made  by  Caspar  is  that  arteriosclerosis  tends  to  cause  degen- 
eration, and  not  hypertrophy. 

Some  think  that  sexual  excess  is  a  cause  of  prostatic  enlargement;  some 


Symptoms  of  Hypertrophy  of  the  Prostate  Gland  1379 

assert  that  antecedent  gonorrhea  is  the  cause,  but  it  seems  very  improbable 
that  either  is  causal.  Bellield  blames  altered  testicular  secretion;  Hawley 
believes  the  cause  to  be  altered  prostatic  secretion  and  the  "chemical  action 
of  pathological  proteins  resulting  from  irregular  metabolism  or  derived  from 
disintegration  of  the  secretion,  or  in  the  usual  action  of  tissue  enzymes" 
("Amials  of  Surgery,"  Nov.,  1903). 

In  the  h\pertrophied  prostate  there  is  an  excessive  production  of  fibrous 
tissue  and  of  ill-formed  glandular  tissue,  the  mass  constituting  a  fibro-adenoma. 
Fibro-adenoma  is  the  common  cause  of  enlargement  (W.  Bruce  Clarke). 
T>-pical  adenoma,  according  to  Albarran  and  Halle,  is  found  in  14  per  cent, 
of  the  cases  ("Annales  des  Maladies  des  Organes  Genito-Urinaires,"  Feb.  and 
March,  1900).  Again,  in  not  a  few  prostates  there  is  no  real  enlargement, 
but  there  is  an  indurated  fibrous  mass  producing  obstruction.  Albarran  and 
Halle  (Ibid.,  1S98,  vol.  xvi)  point  out  that  in  an  enlargement  of  the  prostate 
different  elements  may  usually  be  recognized:  soft  hypertrophy  of  the  gland; 
indurated  enlargement  of  the  glandular  elements;  fibrous  enlargement;  cir- 
cimiscribed  tumor-masses;  distinct  fibromata  or  myomata;  or  adenofibromyo- 
mata.  The  real  cause  of  the  various  forms  of  prostatic  enlargement  is  not 
knoTNTi.  Nearly  10  per  cent,  of  cases  are  cancerous  (Oraison),  and  adenoma  is 
apt  to  be  transformed  into  cancer. 

All  the  lobes  may  be  enlarged  equally;  all  may  be  enlarged  unequally;  the 
enlarged  gland  may  siu-round  the  prostatic  urethra  like  a  horse-collar;  or 
one  lobe  only  may  be  enlarged.  Symmetrical  enlargement  of  the  entire  gland 
is  not  so  apt  to  produce  sjonptoms  as  is  non-s}Tnmetrical  enlargement.  In 
some  cases  the  chief  enlargement  is  into  the  bladder;  in  others,  into  the 
urethra.  An  enlarged  prostate  frequently  shows  a  circular  groove  about  it, 
due  to  the  constriction  exerted  by  the  rectovesical  fascia  at  the  vesical  neck. 

The  bridge  of  prostate  which  joins  the  two  lateral  lobes  behind  the  ure- 
thra is  known  as  the  lohe  of  Home  or  the  middle  lobe,  and  a  comparatively 
tri\dal  enlargement  of  the  middle  lobe  may  cause  obstruction.  Prostatic 
hypertrophy  causes  narro-oing  and  lengthening  of  the  urethra,  and  gives 
this  tube  a  tortuous  course.  The  opening  of  the  urethra  into  the  bladder 
is  usually  pushed  to  a  higher  level,  and  there  forms  behind  it  a  pouch  in  which 
urine  collects.  The  urine  that  gathers  in  this  pouch  is  known  as  residual 
urine.  It  cannot  be  voluntarily  expelled.  It  may,  therefore,  collect  in 
large  quantity,  and  it  is  likely  to  decompose,  producing  cystitis.  Residual 
urine  strongly  favors  calculus  formation.  The  mechanical  resistance  to 
the  expulsion  of  the  urine  causes  congestion  of  the  neck  of  the  bladder  and 
the  posterior  urethra  and  also  h^^Dertrophy  of  the  muscles  of  the  bladder. 
In  consequence  of  the  h^'pertrophy  the  bladder  enlarges,  thickens,  and  becomes 
fasciculated.  When  this  takes  place,  micturition  becomes  ver}^  difficult 
and  sometimes  impossible.  Enlargement  of  the  middle  lobe  inevitably 
blocks  the  flow  of  urine  and  causes  great  distention  of  the  bladder.  In  hyper- 
trophy of  the  prostate  gland  the  ureters  and  the  renal  pelves  and  calyces 
may  distend  and  surgical  kidney  may  develop. 

It  is  useful  to  di\dde  persons  -vN-ith  prostatic  hypertrophy  into  three 
groups:  (i)  those  in  whom  there  is  no  obstruction  or  in  whom,  the  urinary 
s>Tnptoms  are  ver\'  tri\dal;  (2)  those  in  whom  there  are  residual  urine  and 
(hsturbances  of  urinary  function,  who  depend  upon  the  catheter  for  relief, 
but  who  do  very  well  by  this  method;  and  (3)  those  that  suffer  a  complete 
breakdown  during  the  period  in  which  the  catheter  is  depended  upon  (Orsdlle 
Horwitz,  in  "Phila.  Med.  Jour.,"  Nov.  16,  1901). 

Symptoms. — In  90  per  cent,  of  the  cases  there  is  ver\'  tri^-ial  inconveni- 
ence, the  patient  merely  being  annoyed  somewhat  by  episodes  of  nocturnal  fre- 
quency of  micturition.     The  stream  of  lu^ine  is  slow  to  start  and  falls  feebly 


1380  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

from  the  end  of  the  penis.  In  some  cases  there  is  interruption  of  the  stream 
(stammering).  The  last  drops  fall  entirely  without  control.  If  the  patient  be- 
comes sexually  excited,  chilled,  or  worried,  or  indulges  inordinately  in  the  pleas- 
ures of  the  table  or  in  wine,  beer,  or  alcoholic  liquors,  nocturnal  frequency  of 
micturition  becomes  for  a  short  time  most  harassing.  In  10  per  cent,  of  all  cases 
the  bladder  cannot  be  emptied  entirely,  and  residual  urine  collects.  Frequency 
of  micturition  comes  on,  particularly  at  night;  the  patient  has  to  get  up  often; 
the  bladder  never  feels  empty;  and  cystitis  is  apt  to  arise.  The  urine,  at  first 
acid  and  clear,  becomes  neutral  and  cloudy,  and  finally  ammoniacal  and 
turbid,  and  contains  bacteria,  mucopus,  precipitates  of  phosphates,  and 
blood.  Above  the  pubes  there  is  aching  pain,  soon  spreading  to  the  peri- 
neum, which  pain  is  increased  when  the  bladder  is  distended  and  during 
micturition.  The  rectum  becomes  irritable,  and  piles  form  or  prolapse  of 
the  mucous  membrane  occurs,  because  of  straining  in  micturition.  Attacks 
of  retention  of  urine  may  occur.  In  about  one-third  of  all  cases  we  can  make 
a  diagnosis  by  rectal  palpation.  In  enlargement  of  the  middle  lobe  alone 
or  in  pure  intravesical  enlargement  rectal  touch  will  fail  to  make  the  diagnosis 
and  the  cystoscope  must  be  relied  upon.  The  bladder  becomes  thin  and 
distended,  or  hypertrophied,  rigid,  and  fasciculated.  In  rare  cases  true 
incontinence  is  caused  by  the  median  lobe  growing  toward  the  neck  of  the 
bladder  and  preventing  closure.  The  health  breaks  down  because  of  pain, 
restless  nights,  indigestion,  and  disorder  of  the  bowels.  The  kidneys  may 
become  involved  (inflammation  of  the  pelves  or  calices,  or  surgical  kidney) 
and  suppression  may  occur.  Septic  fever  may  arise.  Calculi  may  form  in 
the  bladder.  Death  is  due  to  exhaustion,  suppression  of  urine,  or  septic 
cystitis.  A  foul  catheter  is  the  usual  cause  of  septic  cystitis,  but  micro- 
organisms sometimes  enter  by  passing  along  the  urethral  mucous  membrane. 

A  patient  should  be  examined  by  rectal  touch,  by  a  sound,  and  by  a  cysto- 
scope, if  possible;  the  amount  of  residual  urine  must  be  determined,  and  the 
condition  of  the  urine  is  to  be  carefully  studied.  The  presence  or  absence  of 
stone  should  always  be  determined.  After  an  examination  by  instruments  the 
patient  must  remain  in  bed  for  twenty-four  hours. 

Treatment. — There  is  no  known  method  of  preventing  prostatic  hyper- 
trophy. Many  cases  of  enlargement  are  treated  by  regular  catheterization, 
and  if  this  is  conducted  with  careful  cleanliness,  and  if  the  patient  rigidly 
adheres  to  hygienic  rules,  he  may  be  kept  comfortable  in  this  way  for  a 
considerable  time.  When  a  man  must  depend  upon  a  catheter  to  empty  his 
bladder  he  is  said  to  be  in  catheter  life.  Alexander  has  formulated  several 
sound  rules  as  to  when  catheterization  is  the  proper  treatment.  He  says, 
if  the  patient  is  intelligent  and  dextrous,  if  cystitis  is  not  severe,  if  the 
amount  of  residual  urine  is  not  very  large,  if  obstruction  is  not  great,  if 
the  bladder  retains  considerable  expulsive  power,  and  if  catheterization  is 
easy  and  painless,  we  are  justified  in  relying  upon  this  simple  plan  of  treat- 
ment. Prevent  cystitis  by  emptying  the  bladder  each  evening  with  a  coude 
catheter.  If  there  is  trouble  in  passing  the  catheter,  strengthen  the  instru- 
ment by  inserting  a  filiform  bougie  as  a  stylet.  It  is  very  seldom  that  a 
metal  instrument  is  required,  but  if  it  is  necessary,  a  catheter  with  a  large 
curve  is  employed.  If  a  soft  or  semisolid  instrument  can  be  passed,  teach  the 
patient  how  to  clean  it,  how  to  use  it,  and  how  to  keep  it,  but  never  permit  the 
patient  to  use  a  metal  instrument  himself.  A  dirty  instrument  may  cause  fatal 
infection.  It  is  true  that  some  people  use  dirty  instruments  for  long  pe- 
riods without  trouble,  but  in  most  cases  there  will  be  trouble  if  it  -is  attempted. 
It  is  absolutely  necessary  to  use  only  perfectly  aseptic  instruments.  Metal 
instruments  are  sterilized  by  boiling  in  water.  Rubber  catheters  can  be  cleansed 
by  washing  with  soap  and  running  water,  wrapping  in  gauze,  and  boiling.    After 


Treatment  of  H>'pertrophy  of  the  Prostate  Gland  1381 

sterilization  the  instruments  are  kept  ready  for  use  in  a  glass  c\-linder  which 
contains  calcium  chlorid.^  The  cleansing  of  catheters  is  discussed  on  page 
131 1.  If  there  are  3  oz.  of  residual  urine,  use  the  catheter  only  at  night. 
If  there  are  6  oz.,  use  it  night  and  morning.  If  there  are  more  than  6  oz. 
of  residual  mine,  add  one  more  catheterization  a  day  for  even.-  additional 
2  oz.  present  until  the  catheter  is  used  sLx  times  in  the  twenty-fom  hours. 
It  should  never  be  used  oftener  than  this.  Gradual  dilatation  with  steel  sounds 
is  of  benefit,  but  forcible  dilatation  is  not  ad^•isable.  The  sound  mav  be 
passed  once  a  week.  Tell  the  patient  to  avoid  Niolent  exercise,  cold,  damp, 
sexual  excitement,  and  the  use  of  alcohoHc  Hquors;  prevent  constipation  and 
indigestion,  and  direct  him  to  drink  milk  and  plenty  of  water.  A  hot  hip-bath 
at  night  adds  to  his  comfort.  Hot  enemata  are  of  value.  If  a  large  quantity- 
of  residual  urine  exists,  or  if  cystitis  begins,  wash  out  the  bladder  daily  with 
boric  acid  solution,  or  normal  salt  solution,  or  nitrate  of  silver  1  from  i  :  10.000 
to  I  :  4000),  and  give  urotropin  or  salol  and  boric  acid  by  the  mouth  (see  Cys- 
titis, page  1324).  In  some  severe  cases,  if  a  large-sized  rubber  catheter  be  tied 
in  the  bladder  for  a  few  days,  great  rehef  is  obtained.  Retention  of  urine  can 
usually  be  relieved  by  the  introduction  of  a  coude  catheter  strengthened  with 
a  whalebone.  In  exceptional  cases  a  silver  instrument  with  a  prostatic  cur\-e 
must  be  employed  or  aspiration  must  be  practised.  ^lany  cases  occurring 
among  well-to-do  people  can  be  kept  comfortable  by  catheterization.  Some 
.  surgeons  still  think  that  only  when  this  fails  should  an  operation  be  performed. 
Unfortunately,  sooner  or  later  a  man  who  regularly  relies  upon  the  catheter  will 
develop  cystitis.  A  poor  man  cannot  give  the  necessarv-  time  and  attention  to 
make  catheter  life  safe  and  operation  must  be  thought  of  in  him  sooner  than  in 
others.  If  the  s^inptoms  grow  constantly  worse,  if  the  suffering  becomes  severe, 
if  the  patient  cannot  urinate  without  the  use  of  an  instrument,  if  catheterization 
is  painful  or  impossible,  if  the  patient  is  too  careless  or  ignorant  to  trust  with  a 
catheter,  if  only  a  catheter  of  ver\^  small  size  can  be  introduced,  if  attacks  of 
obstinate  retention  occur,  if  there  is  persistent  or  recurring  cystitis  or  hematuria, 
if  there  are  signs  of  beginning  infection  of  the  kidney,  if  the  residual  urine 
gradually  increases  in  amount,  operation  is  called  for.  Do  not  postpone 
operation  imtil  the  patient  becomes  reaUy  ill.  Give  palliative  measures 
a  reasonable  trial,  and  if  they  fail,  operate.  Before  determining  upon  any 
operation  make  a  o-^stoscopic  examination.  This  is  particularly  valuable 
before  a  Bottini  operation  and  before  a  perineal  operation.  It  shows  us  the 
condition  of  the  bladder:  the  natiu-e.  size,  and  situation  of  the  enlargement, 
the  median  lobe  if  present,  and  a  calculus  if  one  exists.  This  examination  may 
determine  the  form  of  operation  desirable.  Prostatectomy  is  not  to  be  regarded 
as  a  tri\-ial  affair  certain  to  result  in  cure.  It  is  a  grave  procedure,  with  a 
considerable  mortalitv;,  which  may  be  attended  by  disastrous  complications 
and  from  which  imfortunate  consequences  may  arise.  I  agree  with  James  E. 
Moore  that  "it  is  altogether  too  grave  an  operation  to  be  resorted  to  as  a 
routine  treatment  for  ever\-  enlarged  prostate,  and  is  applicable  only  to  properly 
selected  cases."  The  operation  is  contra-indicated  if  there  is  advanced  dis- 
ease of  the  kidneys,  and  if  it  is  pert'ormed  in  such  a  case,  fatal  uremia  is  to 
be  expected.  Age  is  not  in  itself  a  contra-indication  if  the  kidneys  and  car- 
diovascular system  are  soimd.  An  occasional  sequel  of  prostatectomy  is  in- 
continence of  urine  due  to  injiu-\-  of  the  neck  of  the  bladder  or  to  the  ner\-es  of 
the  part.  A  possible  sequel  is  sterility-,  but  most  of  the  subjects  have  been 
rendered  practically  sterile  before  operation  by  age. 

In  the  majority  of  cases  in  which  palliation  fails  the  operative  indication 
is  to  remove  an  obstructing  mass  and  depress  the  level  of  the  opening  from 
the  bladder  into  the  prostatic  urethra,  so  that  the  prostatic  pouch  is  abol- 
^R.  W.  Frank,  in  "Berliner  klin.  Woch.,"'  Xo.  44,  1805. 


1382  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ished  and  the  bladder  can  be  thoroughly  drained.  The  surgeon  chooses 
between  prostatotomy  and  prostatectomy.  Prostatotomy  is  usually  performed 
by  the  galvanocautery  (Bottini's  operation).  Prostatectomy  may  be  supra- 
pubic or  perineal,  and  the  latter  may  be  by  enucleation  without  the  aid  of 
sight  (as  in  the  operations  of  Nicoll  and  Alexander)  or  by  open  dissection 
(as  in  Young's  operation).  No  one  routine  plan  is  suitable  for  all  cases. 
The  patient  should  be  studied,  and  the  operation  chosen  which  is  safest  and 
best  for  that  individual  case.  The  surgeon  who  only  uses  one  method  must 
wrong  many  patients,  and  he  retains  consistency  at  the  expense  of  humanity. 
It  was  formerly  believed  that  any  operation  of  total  prostatectomy  must  of 
necessity  produce  impotence.  This  we  now  know  need  not  be  the  case.  The 
suprapubic  operation  is  proabaly  less  likely  to  be  followed  by  this  than  is  the 
perineal,  as  it  usually  spares  the  ejaculatory  ducts.  Young's  perineal  opera- 
tion spares  the  ejaculatory  ducts.  Destruction  of  the  ejaculatory  ducts 
certainly  produces  sterility  and  may,  but  does  not  of  necessity,  produce  impo- 
tence. Willy  Meyer  ("Med.  Record.,"  Oct.  7,  1905)  points  out  that  impotence 
may  be  caused  by  damaging  important  nerves  or  blood-vessels  in  advancing 
through  the  perineum,  and  also  by  the  operation  producing  relaxation  of  the 
verumontanum  and  prostatic  urethra,  parts  necessary  in  the  reflex  for  erection. 

The  perineal  operation  is  as  safe  as  the  suprapubic  or  safer,  and  can  be 
rapidly  performed.  It  is  the  desirable  route  when  the  gland  can  be  palpated 
per  rectum,  and  does  not  mount  high  up  when  we  are  dealing  with  the  early  - 
stages  "of  soft  hypertrophy  (Willy  Meyer,  Ibid.)  and  when  prolonged  drainage 
is  required.  According  to  Francis  S.  Watson  ("Annals  of  Surgery,"  June, 
1904),  the  mortality  in  203  cases  was  only  2.9  per  cent.  In  563  cases  of  removal 
through  the  perineum  by  dissection  the  mortality  was  5.5  per  cent.  Yoimg's 
cases  in  this  group  number  1 50  and  his  mortality  was  4.6  per  cent. ;  the  mor- 
tality of  Hartman  was  9  per  cent. ;  of  Albarran,  4  per  cent.,  and  of  Murphy,  3.9 
per  cent.  (Schachner,  in  "Annals  of  Surgery,"  August,  1908).  In  190  cases  of 
blind  enucleation  through  the  perineum  the  mortality  was  4.7  per  cent.  (Ibid.). 

After  the  performance  of  the  perineal  operation  the  drainage  is  at  the  lowest 
part  of  the  bladder.  In  a  perineal  operation  every  effort  should  be  made  to  do 
as  little  damage  as  possible  to  the  urethra.  If  we  destroy  the  entire  pros- 
tatic urethra  the  operation  becomes  easy  and  rapid  and  Nature  rapidly  re- 
pairs it,  but  a  traumatic  stricture  may  follow  and  may  make  the  patient's 
condition  worse  than  at  first.  As  Moore  says,  we  must  destroy  a  portion  of  the 
floor  of  the  urethra,  but  we  can  preserve  the  roof  and  the  side  walls.  Another 
point  in  the  perineal  operation  is  to  avoid  injuring  the  rectum.  A  tear  may 
enter  the  rectimi,  or,  even  if  the  gut  was  not  torn,  sloughing  of  the  rectimi 
resulting  in  recto-urethral  fistula  may  occur.  The  rectum  may  be  opened 
because  the  surgeon  fails  to  stick  close  to  the  urethra  in  his  dissection,  and 
sloughing  may  be  due  to  an  injudicious  use  of  the  retractors.  If  the  rectum 
is  opened,  it  should  be  at  once  sutured  with  catgut.  In  most  cases  it  takes 
about  three  weeks  for  the  wound  in  the  perineum  to  heal,  and  in  some  few 
cases  a  perineal  urinary  fistula  is  established.  Urinary  incontinence  may 
follow  this  operation.  By  simply  incising  the  prostate  gland  the  floor  of  the 
urethra  may  be  lowered  to  the  level  of  the  floor  of  the  bladder.  Simple  in- 
cision of  the  prostate  in  this  manner,  or  by  Bottini's  method,  is  known  as 
prostatotomy.  The  mortality  is  small  and  the  rehef  is  often  great.  Prosta- 
totomy is  performed  on  old  and  exhausted  patients  with  damaged  kidneys. 
A  large  tube  should  be  worn  during  the  healing  of  the  wound. 

The  suprapubic  operation  is  easier  than  the  perineal;  it  is  less  safe;  it 
gives  excellent  results  if  temporary  drainage  only  is  needed.  According 
to  Watson  ("Annals  of  Surgery,"  June,  1904),  the  mortality  in  69  cases  was 
8.6  per  cent.     P.  J.  Freyer  reports  600  cases  varying  in  age  from  forty-eight  to 


Treatment  of  Hypertrophy  of  the  Prostate  Gland  1383 

eighty-nine  years.  There  were  47  between  the  ages  of  eighty  and  eighty-nine, 
and  7  were  seventy-nine;  most  of  the  cases  had  been  entirely  dependent  on 
the  catheter  for  periods  up  to  twenty-four  years.  "Nearly  all  were  in  broken 
health  and  many  apparently  dying  before  operation.  Few  were  free  from 
one  or  more  grave  complications,  such  as  cystitis,  stone  in  the  bladder,  pye- 
Utis,  kidney  disease,  diabetes,  heart  disease,  chronic  bronchitis,  paralysis, 
hernia;  and  in  .a  few  instances  there  was  malignant  disease  of  some  other 
organ  than  the  prostate"  ("Archives  Internationales  de  Chirurgie,"  vol.  iv, 
Fascic.  4,  1909).  In  these  600  cases  there  were  37  deaths  in  periods  of  from  six 
hours  to  thirty-seven  days  after  operation,  a  mortality  of  6.15  per  cent.  Supra- 
pubic prostatectomy  is  indicated  in  rather  young  subjects  in  whom  we  greatly 
fear  impotence;  in  cases  in  which  the  gland  is  placed  high;  in  cases  in  which  the 
gland  is  not  palpable  per  rectum,  but  is  causing  serious  symptoms,  and  in  which 
the  h^-pertrophy  is  recognized  by  the  cystoscope  (IMeyer) ;  in  cases  in  which 
there  is  a  middle  lobe;  in  cases  in  which  cancer  exists,  or  in  which  calculus  com- 
plicates the  case.  It  is  the  most  useful  operation  when  the  gland  is  very  large 
and  intravesical.  It  is  not  a  suitable  method  if  the  bladder  is  markedly  con- 
tracted or  if  the  belly  walls  are  very  thick.  If  prolonged  drainage  (short  of 
permanent  drainage)  is  required,  as  it  is  sure  to  be  in  cases  with  advanced  cys- 
titis, the  opening  is  better  placed  in  the  perineal  operation.  If  when  a  supra- 
pubic operation  has  been  performed  it  is  found  that  prolonged  drainage  is 
indicated,  a  siphon  drain  (Fig.  886)  may  be  used.  If  permanent  drainage  is 
required  in  a  case,  the  suprapubic  method  is  the  best.  After  a  suprapubic 
cystostomy  has  been  performed  for  drainage,  the  opening  may  be  kept  per- 
manently patent  by  the  retention  of  a  tube  (Hunter  McGuire's  operation).  It 
is  only  in  ven,^  advanced  cases  or  in  cancer  that  permanent  suprapubic  drainage 
is  employed.  After  making  a  suprapubic  incision  the  floor  of  the  urethra  cannot 
be  brought  level  with  the  floor  of  the  bladder  by  a  simple  incision  of  the  prostate 
through  this  incision;  it  can  be  brought  level  only  by  the  performance  of  prosta- 
tectomy. In  the  suprapubic  operation  the  structures  divided  are  less  important, 
the  hemorrhage  is  less,  and  the  drainage  is  less  conveniently  placed  but  better 
than  in  the  perineal  operation.  Suprapubic  prostatectomy  inflicts  injury  upon 
the  bladder,  it  may  gravely  damage  the  sphincter  of  the  bladder,  and  is  some- 
times followed  by  incontinence  or  by  inability  to  expel  urine  (John  B.  Mur- 
phy, "Jour.  Amer.  Med.  Assoc,"  March  29,  1902),  but  disturbance  of  con- 
trol is  less  common  than  after  the  perineal  operation.  The  bladder  wall  may 
be  seriously  torn,  and  if  such  a  wound  should  be  inflicted,  it  ought  to  be 
sutured  with  catgut.  In  this  operation  if  the  bladder  is  contracted,  the 
surgeon  must  exercise  great  care  to  avoid  injuring  the  peritoneum.  The 
ureters  may  be  damaged  and  subsequently  become  obstructed  from  contrac- 
tion. If  death  occurs  after  prostatectomy  it  is  due  to  shock,  uremia,  sepsis,  or 
postoperative  complications,  usually  pulmonary.  Schachner  ("Annals  of 
Surger>%"  August,  1908)  uses  Watson's  figures  to  present  the  special  dangers 
of  each  operation.  The  figures  give  the  percentage  of  the  deaths  due  to  shock, 
uremia,  hemorrhage,  and  pulmonary  complications.    The  table  is  as  follows: 

Per  cent. 

Bottini 2.7  1 

Perineal  operations 35 -o  f  Uremia  (or  renal  insufficiency). 

Suprapubic  operations 34.0  j 

Bottini 52.0"! 

Perineal  operations 17-8  |-  Sepsis. 

Suprapubic  operations 8.6  J 

Bottini 5.0  S 

Perineal  operations 21.4  >  Shock. 

Suprapubic  operations 30.0  j 

^ottmi. o  I  Postoperative  pulmonary  compli- 

Permeal  operations 17.8  ^     ^^^j^^^ 

Suprapubic  operations 22.0  J 


1384  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

At  the  International  Urological  Congress  held  in  London  in  191 1  Young 
presented  the  records  of  484  cases  of  perineal  prostatectomy.  The  mortality 
in  simple  hypertrophy  (450  cases)  was  3.77  per  cent.;  34  cases  were  can- 
cerous, and  of  these  2  died.  Zuckerkandl's  mortality  from  perineal  opera- 
tions was  9.5  per  cent.,  from  suprapubic  operations,  18.7  per  cent.  ("Ann.  des 
Mai.  des  Org.  Gen.-Urin.,"  191 1,  ii).  Freyer  ("Amer.  Jour,  of  Dermatology 
and  Genito-Urinary  Diseases,"  191 2)  reports  1000  cases  of  suprapubic  prosta- 
tectomy since  1901 .  The  average  age  of  these  cases  was  sixty-nine.  The  young- 
est patient  was  forty-nine,  the  oldest  was  ninety.  There  were  55  deaths  (a 
mortality  of  5.5  per  cent.).  Freyer's  mortality  in  his  first  100  cases  was  10 
per  cent.,  in  his  last  100  cases  it  was  3  per  cent.  This  proves  the  great  value 
of  experience.  The  less  training  a  man  has  had,  the  higher  will  be  his  mor- 
tality.  Prostatectomy  is  distinctly  not  an  operation  for  a  surgical  juvenile. 

Suprapubic  Prostatectomy. — Freyer's  Method. — The  bladder  is  washed 
out  through  a  catheter  with  warm  boric  acid  solution  and  is  then  filled 
with  the  solution.  The  nozzle  of  a  large  syringe  filled  with  fluid  is  in- 
serted into  the  end  of  the  catheter.  This  keeps  the  bladder  fluid  from 
running  out  and  enables  the  surgeon  to  quickly  distend  the  viscus  more  if 
occasion  shall  arise.  The  bladder  is  exposed  and  opened  in  the  midline  and  in 
an  area  free  from  veins  (see  Suprapubic  Cystotomy,  page  1337).  The  incision 
is  vertical,  is  made  toward  the  symphysis,  and  is  about  i  inch  in  length  (it 
can  be  enlarged  later  if  necessary) .  If  any  calculi  are  found  they  are  at  once 
removed.  A  finger  is  placed  in  the  rectum  to  raise  up  the  prostate  and  keep 
it  steady.  The  finger  of  the  other  hand  is  introduced  into  the  bladder,  and  by 
means  of  the  finger-nail  the  mucous  membrane  is  scratched  through  over  "the 
most  prominent  portion  of  one  lateral  lobe,  or  over  the  so-called  middle  lobe, 
if  there  be  but  one  prominence"  (Freyer,  in  "Archiv.  Internat.  de  Chir.," 
Fascic.  4,  1909).  This  portion  of  the  gland  is  only  covered  by  mucous  mem- 
brane, and  when  this  is  scratched  through  the  true  prostatic  capsule  is  reached. 
In  doing  Freyer's  operation  the  author  passes  the  finger  to  the  extreme  anterior 
limit  of  the  trigone,  so  that  the  finger  is  really  within  the  urethra.  At  this  point 
he  splits  the  capsule  and  begins  the  enucleation,  being*  careful  to  injure  the 
trigone  as  little  as  possible.  This  precaution  greatly  lessens  the  danger  of 
incontinence.  The  finger  is  kept  in  close  contact  with  the  true  capsule  and 
enucleates  the  gland  by  passing  first  posterior,  next  outside,  and  finally  in  front 
of  one  lateral  lobe. 

"The  finger  is  then  swept  in  a  circular  fashion  from  without  inward,  in 
front  of  and  to  the  inner  side  of  the  lobe,  detaching  this  from  the  urethra, 
which  is  felt  covering  the  catheter,  and  pushed  forward  toward  the  symphysis 
between  the  lateral  lobes,  which  will,  as  a  rule,  have  separated  along  their 
anterior  commissure  in  the  course  of  the  manipulations.  The  other  lobe  is 
attacked  and  treated  in  the  same  manner.  The  finger  is  next  pushed  well 
downward  behind  the  prostate  and  the  inferior  surface  of  the  gland  is  peeled 
off  the  triangular  ligament.  When  the  prostate  is  felt  free  within  its  sheath 
and  separated  from  the  urethra,  with  the  finger  in  the  rectum,  aided  by  that 
in  the  bladder,  it  is  pushed  into  the  bladder  through  the  opening  in  the  mucous 
membrane,  which,  during  the  manipulations,  will  have  become  considerably 
enlarged"  (Freyer,  Ibid.).  The  prostate  is  removed  from  the  bladder  by 
forceps.  If  the  lobes  come  away  separately,  Freyer  believes  that  the  ejacu- 
latory  ducts  are  uninjured  and  remain  attached  to  the  urethra.  There  has 
been  an  active  controversy  as  to  whether  Freyer's  operation  does  or  does  not 
destroy  the  prostatic  urethra.  It  seems  certain  that  even  if  it  is  left  it  must 
slough  for  want  of  blood-supply.  In  my  operations  by  this  method  it  has 
come  away  with  the  prostate. 

In  Freyer's  earlier  operations  he  sought  to  leave  the  urethra  and  accom- 


Nicoll's  Operation  of  Perineal   Prostatectomy 


1385 


panying  structures  behind,  but  he  is  now  convinced  that  the  prostatic  urethra 
may  be  torn  or  removed  without  ill  results.  Figure  931  shows  the  drainage 
as  I  employ  it  after  suprapubic  prostatectomy.     P'igure  932  shows  the  drain. 

McGill's  Operation. — The  bladder  is  opened  by  a  suprapubic  incision, 
the  edges  of  the  cut  bladder  are  sutured  to  the  abdominal  wound  with  catgut, 
and  the  interior  of  the  viscus  is  carefully  explored  by  the  finger  and  by  sight, 
an  electric  light  being  used  for  illumination.  If  a  sessile  growth  exists,  the 
mucous  membrane  is  incised  and  the  growth  enucleated  by  finger  or  a  curet. 
A  pedunculated  growth  is  cut  away  by  sharp-edged  forceps.  If  a  mass 
projects  into  the  bladder,  an  incision  is  made  to  divide  it  into  two  portions 
and  each  half  is  enucleated.  Hemorrhage  is  arrested  by  irrigation  with  hot 
salt  solution  and  by  compression  with  gauze  pads.  In  some  cases  a  tampon 
must  be  inserted.  The  bladder  is  drained  for  several  days  or  a  number  of 
days.  As  a  matter  of  fact,  a  dense  fibrous  prostate  cannot  be  enucleated  and 
can  be  removed  only  by  scissors  or  cutting  forceps. 

Fuller's  Operation. — Open  the  bladder  above  thepubes;  have  an  assistant 
push  the  gland  up  by  means  of  a  fist  in  the  perineum.     The  gland  can  be 


Fig.  931.  Fig.  932. 

Figs.  931  and  932. — Showing  double-tube  drainage  for  suprapubic  operation.  Fig.  931  was  taken 
from  an  elevation  to  show  the  termination  of  the  drainage-tubes.  Fig.  932  shows  tubes  enlarged  in 
separate  view. 

lifted  by  two  fingers  in  the  rectimi.  The  surgeon  makes  a  small  incision 
through  the  mucous  membrane  over  the  prostate,  enucleates  the  gland  by 
means  of  the  finger,  and  drains  through  an  incision  in  the  membranous  ure- 
thra, as  well  as  through  the  suprapubic  opening. 

Belfield's  Operation. — Belfield  performs  suprapubic  cystotomy,  makes  a 
perineal  cut  to  enable  the  finger  to  approach  the  prostate,  pushes  the  prostate 
up  toward  the  belly,  and  enucleates  it  from  within  the  bladder. 

Perineal  prostatectomy  is  less  blood}^  than  suprapubic  prostatectomy. 
The  sphincter  of  the  bladder  is  not  damaged,  the  entire  prostate  can  be  brought 
into  view  and  removed,  and  perfect  drainage  is  obtainable  after  operation. 

Nicoll's  Operation. — Perform  suprapubic  cystotomy.  Then  incise  the  per- 
ineum down  to  the  prostate,  split  the  capsule  of  the  prostate,  insert  two  fingers 
of  the  left  hand  into  the  bladder,  and  push  the  prostate  into  the  perineum  so 


1386  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


as  to  bring  it  within  reach.     Enucletae  the  gland  from  the  perineal  woiind 
without  damaging  the  mucous  membrane  of  the  floor  of  the  bladder. 

Alexander's  Operation. — Alexander  makes  a  suprapubic  incision  and  uses 
it  for  the  same  purpose  as  does  Nicoll,  but  he  also  opens  the  membranous 
urethra  on  a  grooved  staff.  After  enucleating  the  gland  he  inserts  a  drainage- 
tube  through  the  incision  in  the  membranous  urethra.  In  a  very  thin  subject 
it  may  not  be  necessary  to  perform  suprapubic  cystotomy.  Alexander  has 
brought  the  gland  into  an  accessible  position  in  the  perineal  wound  by  supra- 
pubic pressiure,  and  Guiteras  has  done  so  by  making  an  incision  in  the  llnea 
alba  and  inserting  two  fingers  into  the  prevesical  space.  Syms  advocates 
opening  into  the  peritoneal  cavity,  inserting  the  hand,  and  pressing  the  pros- 
tate into  the  perineum  without  opening  the  bladder  above  the  pubes. 

Bryson's  Operation. — This  is  a  satisfactory  method  in  some  cases.  The 
bladder  is  irrigated  and  filled  with  warm  salt  solution.  A  grooved  staff  is  intro- 
duced and  a  median  perineal  section  is  made  to  open  the  urethra  just  in  front 
of  the  apex  of  the  prostate  gland.  The  knife  is  pushed  back  in  the  groove 
of  the  staff  sufficiently  far  to  incise  the  ring  at  the  apex  of  the  prostate;  the 
forefinger  is  passed  into  the  prostatic  urethra  and  the  staff  is  withdrawn. 
Then  a  short  tear  is  made  by  means  of  a  blunt  instrument  into  the  mass  of 
the  left  lobe  and  the  finger  is  introduced  and  enucleates  the  lobe.  The  same 
procedure  is  carried  out  on  the  right  lobe,  and,  finally,  if  necessary,  on  the 
middle  lobe.     If  the  middle  lobe  requires  removal,  but  cannot  be  reached,  a 

suprapubic  cut  is  made  into  the  cave  of 
Retzius,  two  fingers  are  inserted,  and  the  lobe 
is  pushed  within  reach  of  the  finger  below.  A 
large  perineal  tube  is  introduced  for  drainage, 
a  catheter  is  introduced  and  tied  in  place,  and 
bleeding  is  arrested  by  packing. 


Fig.  933. — Tractor  introduced;  blades 
separated;  traction  made,  exposing  poste- 
rior surface  of  prostate.  Incisions  in  cap- 
sular on  each  side  of  ejaculatory  ducts 
(Young). 


Fig.  g34.- 


-Enucleation  of  lobes. 
(Young). 


Forceps  in  position 


Young's  Operation. — This  surgeon  frequently  operates  under  spinal  anes- 
thesia. He  places  the  patient  in  an  exaggerated  lithotomy  position  and  in- 
troduces a  sound.  In  thin  subjects  the  incision  is  in  the  raphe  and  is  carried 
close  to  the  anus;  in  short  individuals  the  incision  is  an  inverted  V.  He  in- 
cises the  recto-urethralis  muscle  transversely,  exposes  the  membranous  ure- 
thra, opens  it,  and  inserts  his  tractor  into  the  opening  in  the  urethra  (Fig.  933). 
The  tractor  is  turned  180  degrees,  the  blades  are  opened,  and  traction  is  made. 


Bottini's  Galvanocaustic  Prostatotomy 


1387 


The  capsule  is  incised  on  each  side  of  the  ejaculatory  ducts  and  the  gland  is  re- 
moved by  blunt  dissection,  the  forceps  grasping  each  lobe  during  enucleation 
(Fig.  934).  Every  effort  is  made  to  save  the  urethra.  After  removing  the 
lateral  lobes  the  tractor  is  used  to  bring  a  middle  lobe,  if  one  exists,  into  the 
wound,  and  it  is  also  enucleated.     The  bladder  is  drained  for  about  one  week. 

Young's  punch  operation  was  devised  for  the  removal  of  small  prostatic 
bars  and  contractures  of  the  vesical  neck  involving  the  prostate.  Young 
reports  200  cases  with  no  mortality.  It  can  be  done  under  local  urethral  anes- 
thesia; 4  per  cent,  novocain  is  employed.  The  operation  is  performed  by 
means  of  a  special  prostatic  punch  devised  by  Young.  By  means  of  the 
pimch  a  portion  of  the  offending  bar  is  removed. 

Bottini's  Galvanocaustic  Prostatotomy. — Bottini,  of  Padula,  in  1874 
suggested  cauterizing  the  prostate  by  means  of  a  special  instrument.  He  sought 
to  burn  away  a  portion  of  the  gland  in  hope  that  the  contraction  of  the  scar 
would  cause  the  remainder  of  the  gland  to  shrink.  The  instrument  of  Bot- 
tini is  shaped  like  a  catheter,  and  carries  a  platinum  blade  which  is  heated 
by  an  electric  current.  Bottini's  early  instrument  was  not  satisfactory  and 
the  operation  never  became  popular  until  Freudenberg  improved  the  tools 
in  1897  (Fig.  935). 


Fig.  935. — Young's  modification  of  Freudenberg's  instrument  for  prostatotomy  by  galvanocautery, 

Bottini's  galvanocaustic  operation  is  performed  as  follows:  The  bladder 
should  be  emptied,  irrigated,  and  distended  with  air,  and  the  posterior  urethra 
must  be  anesthetized  by  instillation  of  cocain  or  eucain.  The  current  is  tried 
to  see  how  many  seconds  it  requires  to  heat  the  blade  sufficiently.  The  cur- 
rent is  broken,  the  instrument  is  introduced,  the  cooling  current  is  set  in  mo- 
tion, and  one  assistant  watches  this  and  nothing  else.  The  current  is  turned 
on  and  the  surgeon  waits  the  required  number  of  seconds  for  the  blade  to  become 
red  hot  (twelve  to  fifteen  seconds) ,  and  then  turns  the  screw  at  the  handle,  and 
burns  a  groove  in  the  prostate.  A  groove  should  be  burned  toward  the  rectum, 
one  to  the  side,  and,  if  it  is  thought  desirable,  one  to  the  opposite  side.  No 
groove  should  be  burned  toward  the  pubes.  When  a  groove  has  been  burned, 
the  blade  is  returned  into  its  sheath,  the  current  being  increased  while  doing 
so  in  order  to  keep  the  blade  from  adhering  to  the  tissue,  then  the  current  is 
shut  off.  After  withdrawing  the  instrument  it  is  not  necessary  to  introduce  and 
retain  a  catheter.  The  patient  is  confined  to  bed  only  twenty-four  hours,  there 
is  rarely  bleeding  or  fever,  and  the  results  are  fairly  good.  The  scars  contract 
and  the  gland  atrophies.  During  the  period  of  healing  a  steel  sound  should  be 
passed  from  time  to  time  (Bangs).  It  is  alleged  that  fibrous  stricture  of  the 
neck  of  the  bladder  may  follow  in  some  cases.^ 

^  For  description  of  this  operation  see  Freudenberg,  in  "Berliner  klin.  Woch.,"  No.  46, 
1897;  and  Willy  Meyer,  in  "Med.  Record"  of  March  5,  1898,  and  May  12,  1900. 


1388  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Bottini's  operation  is  the  procedure  to  be  selected  for  a  sclerotic  prostate 
and  for  hypertrophy  in  a  feeble  and  aged  individual  with  damaged  kidneys.  It 
is  not  probable  that  the  cautery  operation  will  ever  replace  prostatectomy.  The 
best  instrument  is  Yoimg's  modification  of  Freudenberg's  instrument  (Fig. 


\  / 


Fig.  936. — Incisions  of  the  middle  lobe  (Young). 

935).  Figures  936  and  937  show  various  methods  of  making  the  cuts  as  advised 
by  Hugh  H.  Young.  When  there  is  a  distinct  and  pedunculated  median  lobe 
the  ordinary  plan  of  burning  fails  entirely;  but,  as  Young  shows  (Figs.  936, 
938),  if  an  oblique  cut  is  made  on  each  side  across  the  base,  this  lobe  will  drop 


J  2  J  •^ 

Fig.  937. — Different  incisions  of  prostate  gland  in  Bottini's  operation  (after  Young). 

out  of  the  way  and  quickly  atrophy.     Bottini's  operation  does  not  gain  in 
pubHc  confidence. 

Castration  and  Vasectomy. — In  1886  Sanitzin  demonstrated  clinically 
the  shrinking  of  a  large  prostate  after  double  castration  (Hawley,  in  "Annals  of 

Surgery,"  Nov.,  1903).  In  1893  Ramm, 
of  Norway,  performed  double  castra- 
tion in  order  to  cause  shrinking  of  an 
enlarged  prostate.  In  1893,  after  a  long 
series  of  careful  experiments,  J.  William 
White  recommended  the  operation  of 
bilateral  orchidectomy  for  the  treat- 
ment of  prostatic  hypertrophy.  He 
proved  that  removal  of  the  testicles 
causes  a  rapid  shrinking  in  an  enlarged 
prostate.  Much  of  this  shrinking  may 
be  due  to  diminution  of  congestion  and 
edema,  but  true  atrophy  undoubtedly 
occurs  in  the  glandular  elements.  Very 
remarkable  results  have  been  recorded. 
In  some  cases  the  patients  become 
absolutely  comfortable  and  dispense 
entirely  with  the  catheter.  Cystitis 
ceases,  and  desire  to  urinate  frequently  becomes  less  marked.  Unilateral 
orchidectomy  has  been  employed,  but  it  is  not  satisfactory.  In  1894  Mears 
suggested  ligation  of  the  spermatic  cord.  In  1895  Lauenstein  suggested  divi- 
sion of  the  spermatic  cord.    In  1896  Tilden  Brown  suggested  ligation  of  the 


Fig.  938. — Incising  the  middle  lobe  (Young). 


Castration  and  Vasectomy  1389 

vas.  Reginald  Harrison  in  1S96  advised  section  of  the  vas.  Lennander  in 
1S97  proposed  exsection  of  the  vas  deferens  {vasectomy).  It  is  slower  in  its 
results,  but  just  as  certain  as  castration.  In  spite  of  the  great  simplicity  of 
orchidectomy  the  mortality  has  been  considerable  (from  11  to  18  per  cent., 
according  to  some  authors.  Socin  and  Burckhardt  say  16.2  per  cent.).  In 
several  instances  mental  disturbance  has  followed  the  operation.  Castration 
is  now  ver}"  seldom  performed,  as  vasectomy  is  just  as  useful  and  is  safer. 
Vasectomy  is  valueless  in  cases  of  fibroid  prostate,  does  some  good  in  adenoma, 
but  is  most  valuable  when  the  prostate  is  generally  h>-pertrophied  and  prone 
to  great  congestion,  causing  \-iolent  s}-mptoms.  The  testicle  does  not  atrophy 
after  vasectomy,  mental  disturbance  does  not  occur  because  the  internal 
secretion  of  the  testicle  is  still  furnished  to  the  organism,  and  impotence  may 
not  develop,  though  sterihty  must. 

Other  Methods. — Among  other  operations  which  have  been  suggested  are: 
Hgation  of  the  vascular  elements  of  the  cord;  resection  of  all  the  cord  ele- 
ments except  the  vas  and  its  arter}-  and  vein  {angionei<rectomy,  proposed  by 
Albarran  in  1897);  parenchimatous  injections  of  cocain  into  the  testicles;  and 
ligation  of  both  internal  ihac  arteries.  Angioneiirectomy  has  a  mortahty  of 
5.5  per  cent.  (Socin  and  Burckhardt^ 

Selection  of  Operation  and  Results. — The  relative  merits  of  these  various 
operations  aUuded  to  above  are  in  dispute.  It  is  certain  that  many  cases  of 
prostatic  h^-pertrophy  can  be  kept  comfortable  by  aseptic  catheterism.  If 
this  procedure  fails,  or  for  other  reasons  must  be  abandoned,  or  if  the  surgeon 
decides  not  to  employ  it,  a  careful  study  of  the  case  should  be  made  before 
selecting  a  special  operation.  The  Bottini  operation  for  a  time  had  somewhat 
extensive  use.  Some  apphed  it  to  almost  any  sort  of  case,  claiming  that  the 
operation  is  practicaUy  free  from  danger.  Meyer  used  it  for  any  case  of  im- 
comphcated  hypertrophy,  but  if  the  prostate  was  ver\'  large,  hgated  the  vasa 
deferentia  some  weeks  before  cauterizing  the  prostate,  in  order  to  lessen  the 
danger  of  thromboses. 

A  more  conserv-ative  \-iew  is  that  of  Eugene  FuUer,  who  doubts  the  perma- 
nence of  the  results  of  the  Bottuii  operation,  fears  that  stenosis  of  the  vesical 
neck  may  foUow,  and  would  restrict  the  operation  to  uncomphcated  cases  not 
of  a  grave  character,  and  in  which  the  bladder  has  not  been  seriously  damaged. 
It  is  the  operation  of  choice  if  the  prostate  is  fibrous.  It  is  the  preferable 
operation  if  the  patient  is  old,  debilitated,  or  the  \dctim  of  kidney  disease. 
Some  residual  urine  usually  remains  after  a  Bottini  operation.  In  over  10  per 
cent,  of  cases  no  benefit  follows.  \'asectomy  is  used  for  an  engorged  and  gener- 
aUv  enlarged  prostate.  It  may  do  great  good  or  may  fail  completely.  If  the 
urine  is  extremely  foul,  some  operation  permittmg  drainage  is  advisable.  In  an 
adenomatous  prostate  in  which  enucleation  is  easy  we  should  prefer  the  perineal 
method.  In  other  cases  in  which  it  is  probable  enucleation  will  be  hard;  in 
cases  of  imcertain  diagnosis;  in  cases  in  which  a  calculus  may  exist;  and  in 
cases  in  which  the  middle  lobe  is  at  fault,  do  a  suprapubic  operation,  although 
sometimes  a  perineal  incision  may  be  made,  and  a  cut  be  made  in  the  prostate 
to  bring  the  floor  of  the  urethra  level  "oith  the  trigone. 

In  old  men  with  great  obstruction  and  vrith  serious  disease  of  the  bladder 
and  involvement  of  the  kidneys,  and  in  indi^-iduals  vdih  prostatic  cancer,  per- 
manent suprapubic  drainage  is  sometimes  the  most  useful  procedure. 

The  mortahty  from  Bottini's  operation  is  over  5  per  cent.  Young  had 
3  deaths  in  41  operations. 

Vasectomy  done  early  gives  a  mortahty  of  from  3  to  5  per  cent.  If  per- 
formed later,  the  mortahty  is  10  to  15  per  cent.  Socin  and  Burckhardt  estimate 
the  mortahty  of  bilateral  vasectomy  as  8.3  per  cent.  The  mortahty  of  bilateral 
■orchidectomy  is  16.2  per  cent. 


1390  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  mortality  of  perineal  and  suprapubic  prostatectomy  has  been  con- 
sidered on  page  1382. 

Malignant  Disease  of  the  Prostate  Gland. — Primary  malignant 
growths  of  the  prostate  are  not  infrequently  encountered,  but  secondary 
growths  are  much  more  rare  than  primary  growths.  When  malignant  dis- 
ease does  occur,  it  is  usually  cancerous.  Secondary  cancer  of  the  pros- 
tate finds  its  most  usual  antecedent  in  cancer  of  the  rectum.  Epithelioma 
does  not  occur.  Scirrhus  occasionally  occurs;  but  the  most  frequent  form  is 
encephaloid.  Sarcoma  is  rare,  although  probably  not  quite  so  rare  as  has 
been  thought.  Some  cases  of  prostatic  tumor  obviously  inoperable  when  first 
seen  by  the  surgeon  are  probably  sarcomatous.  Round-celled,  spindle-celled, 
or  mixed-celled  sarcoma  may  develop.  Powers  says  there  have  been  but  31 
authenticated  cases  of  primary  sarcoma  reported  ("Annals  of  Surgery,"  Jan., 
1908).  According  to  Gibson  ("Jour.  Amer.  Med.  Assoc,"  April  23,  1910) 
there  are  on  record  36  absolutely  authenticated  cases  of  sarcoma  of  the  prostate. 
Sarcoma  is  most  frequent  in  childhood.  It  grows  rapidly,  is  usually  soft,  and 
causes  pain  in  the  rectum  and  perineum  or  pubic  region,  but  early  in  the  case, 
at  least,  there  is  seldom  residual  urine  (Powers,  Loc.  cit.).  No  real  cure  of 
sarcoma  has  yet  been  reported. 

Carcinoma  of  the  prostate  may  occur  at  an  earUer  age  than  ordinary 
hypertrophy  of  the  prostate.  The  latter  does  not  become  evident  until  after 
the  age  of  fifty;  but  carcinoma  of  the  prostate  may  begin  at  any  time  after 
the  age  of  forty,  and  sarcoma  of  the  prostate  may  commence  in  early 
youth. 

At  first  the  carcinomatous  growth  enlarges  slowly;  but  it  soon  begins  to 
grow  with  rapidity.  It  breaks  through  the  capsule  and  fungates  into  the 
bladder  or  into  the  urethra.  The  pelvic,  the  inguinal,  and  the  femoral  glands 
become  involved  early  in  the  course  of  the  disease.  It  is  unusual  to  find 
great  obstruction  to  urination  or  to  the  passage  of  a  catheter  at  an  early  period, 
but  later  both  these  conditions  are  noted.  Early  in  the  case  there  is  pain  only 
when  obstruction  to  urination  occurs;  later,  the  pain  in  the  neck  of  the  blad- 
der may  be  severe,  and  there  may  also  be  pain  in  the  loin  and  in  the  sciatic 
nerves.  Hemorrhage  usually  occurs.  In  the  beginning  the  hemorrhage  is 
trivial  and  intermittent,  but  when  fungation  exists,  large  hemorrhages  gen- 
erally take  place.  The  blood  is  usually  mixed  with  urine,  but  there  is  some- 
times a  large  hemorrhage  unassociated  with  micturition.  The  urine  is  not 
likely  to  contain  pus  or  any  large  quantity  of  mucus  unless  the  bladder  is  in- 
volved in  the  growth. 

When  the  prostate  gland  is  felt  by  means  of  a  finger  in  the  patient's  rectum, 
it  is  found  to  be  of  stony  hardness  and  to  be  firmly  anchored  in  place.  Regi- 
nald Harrison  points  out  that  an  ordinary  hypertrophied  gland  is  not  so  firmly 
anchored  as  a  carcinomatous  gland;  that  the  bowel  moves  over  it  with  free- 
dom; and  that,  although  it  is  firm  to  the  touch,  it  is  not  of  stony  hardness. 
The  patient  with  carcinoma  of  the  prostate  loses  flesh  rapidly  and  develops 
distinct  cachexia,  and  metastatic  deposits  are  likely  to  form  in  the  vertebral 
column,  in  the  kidneys,  and  in  other  organs  and  structures. 

In  making  a  diagnosis  Harrison  insists  upon  the  value  of  the  cystoscope. 
He  says  that  in  cancer  one  does  not  find  much  intravesical  projection,  and 
that  what  projection  there  is  is  uneven  and  irregular.  In  an  ordinary  adeno- 
matous prostate,  on  the  contrary,  the  surface  is  smooth  and  roimded  and 
projects  into  the  bladder. 

Treatment. — Radical  operation  is  out  of  the  question  in  these  cases. 
Permanent  suprapubic  drainage  is  made  in  most  instances,  and  usually  gives 
the  patient  great  relief.  (See  "Remarks  on  Cancer  of  the  Prostate,"  by 
Reginald  Harrison,  in  "Brit.  Med.  Jour.,"  July  4,  1903.) 


Retained  and  Malplaced  Testicle  1391 

Tuberculosis  of  the  prostate  gland  is  rarely  priman-.  It  is  usually 
secondan,-  to  tuberculosis  of  the  kidney.  It  may  follow  tuberculosis  of  the 
epidid^tnis.  In  the  majority  of  cases  of  tubergulosis  of  the  prostate  the  lungs 
are  involved  in  a  tuberculous  process  when  the  patient  is  first  seen  by  the 
surgeon.  The  disease  appears  particularly  between  the  ages  of  twenty  and 
thirty  years,  but  it  may  attack  elderly  men  and  even  the  aged.  It  begins  by 
the  formation  of  a  number  of  tuberciilous  nodules  in  the  immediate  neighbor- 
hood of  the  prostatic  tubules.  These  nodviles  caseate  and  run  together,  form- 
ing ca\ities  and,  eventually,  tuberculous  abscesses,  which  are  prone  to  rupture 
into  the  urethra.  In  ven,-  rare  instances  a  large  tuberculous  abscess  ruptures 
through  the  perineum,  into  the  rectum  or  into  the  peritoneimi. 

The  disease  occasionally  undergoes  spontaneous  cure  through  fibrous 
tissue  formation  or  calcification.  The  tuberculous  process  is  liable  to  spread 
to  the  seminal  vesicles,  the  bladder,  the  ureters,  and  possibly  the  peritoneum; 
and  in  some  cases  it  inaugurates  thrombophlebitis  and  pyemia. 

Symptoms. — ^^The  patient  suffers  from  pain  during  micturition;  there  i& 
frequent  micturition,  and  from  time  to  time  the  inrine  contains  blood.  Attacks 
of  cystitis  take  place,  and  weakness  and  a  loss  of  flesh  are  greater  than  is  com- 
mensurate with  any  ordinan.-  inflammation.  Tuberculosis  of  the  prostate 
alone  is  said  not  to  cause  marked  hectic  fever,  but  when  adjacent  structures 
become  involved  the  temperature  is  definiteh-  elevated  and  becomes  charac- 
teristic. Wlien  the  disease  has  advanced  there  is  not  imusuaUy  urinar\'  in- 
continence, on  account  of  the  involvement  of  the  circular  muscular  fibers 
about  the  neck  of  the  bladder.  Commonly,  there  is  a  mucopurulent  discharge, 
or  mucopurulent  matter  may  be  obtained  by  massaging  the  prostate.  This 
matter  may  contain  tubercle  bacilli,  and  in  some  cases  the  urine  also  con- 
tains baciUi.  Early  in  the  course  of  the  case  rectal  examination  detects  some 
enlargement  of  the  gland,  many  nodifles,  and  tenderness;  later  in  the  disease 
it  finds  marked  enlargement  and  areas  of  softening. 

Treatment. — Early  in  the  case  Senn  recommends  parench^Tnatous  in- 
jections of  iodoform  emulsion,  the  punctures  being  made  through  the  peri- 
neum. If  these  fail,  operation  must  be  considered.  WTien  one  takes  into 
account  how  rare  primar\-  tuberculosis  of  the  prostate  is,  one  is  impressed 
with  the  infrequencv-  with  which  a  radical  operation  should  be  attempted. 
If  there  is  absolutely  no  e\-idence  that  any  adjacent  organ  is  involved  or  that 
any  distant  focus  of  disease  exists,  it  is  justifiable  to  perform  perineal  pros- 
tatectomy. As  a  rule,  however,  the  only  surgical  operation  performed  con- 
sists in  making  a  curvilinear  incision  in  front  of  the  rectum,  which  exposes 
the  prostate,  and  permits  the  surgeon  to  open  and  curet  caseous  foci.  If  an 
abscess  forms,  it  shoifld  be  evacuated  by  means  of  a  perineal  incision  and 
ca\-ities  should  be  curetted  and  packed  with  iodoform  gauze. 

WTien  a  patient  is  convalescent  after  an  operation  or  if  it  is  determined 
that  no  operation  is  ad\'isable,  fuU  antituberculous  treatment  is  employed 
(see  page  230).  One  should  look  to  the  patient's  general  health,  administer 
urotropin,  and  avoid  using  instriunents  as  much  as  possible;  because,  as  Sir 
Henr\-  Thompson  has  shown,  instr-umentation  irritates  the  prostate,  causes  a 
great  deal  of  pain,  and  makes  the  disease  worse  in  ever\"  case. 

Retained  and  Malplaced  Testicle. — The  normaUy  descended  testicle  is 
entirely  within  the  scrotum.  In  i  person  of  1000  there  is  either  undescended 
or  ectopic  testis.  In  80  per  cent,  of  indi^'iduals  the  testicles  have  descended  at 
birth;  most  often  it  is  the  right  testicle  which  fails  to  descend.  Sometimes 
a  testicle  descends  after  being  retained  for  months  or  even  years.  In  Keyes's 
case  it  descended  in  the  thirtieth  year.  Late  descent  usually  causes  hernia, 
and  in  90  per  cent,  of  aU  cases  hernia  exists.  The  testicle  may  be  arrested  in 
its  passage  to  the  scrotum  (cryptorchism,  single  or  double) ;  it  may  remain  in 


1392  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  lumbar  region;  it  may  reach  the  internal  abdominal  ring;  it  may  lodge  in 
the  inguinal  canal;  it  may  emerge  from  the  external  ring,  but  fail  to  enter  the 
scrotum;  or  it  may  pass  into  an  unnatiual  position,  as  into  the  perineum  or  the 
crural  canal  (ectopia  of  the  testis) .  The  failure  of  descent  may  be  unilateral  or 
bilateral,  but  when  bilateral  the  degree  of  descent  is  seldom  the  same  on  the  two 
sides.  The  gland  may  be,  but  seldom  is,  functionally  active.  When  re- 
tained in  the  abdomen  it  never  has  the  power  of  spermatogenesis.  Before 
puberty  the  testicle  is  usually  normal,  but  after  puberty  there  is  practically 
always  more  or  less  atrophy.  In  about  i  case  out  of  5  there  is  spermatogenesis 
for  a  time.  A  retained  testicle  is  liable  to  attacks  of  orchitis  and  may  become 
tuberculous,  carcinomatous,  endotheliomatous,  or  sarcomatous.  In  most  cases 
there  is  neither  pain  nor  tenderness,  and  the  patient  presents  himself  for  treat- 
ment because  a  lump  has  appeared  in  the  groin.  In  some  cases  there  are  sudden 
attacks  of  violent  pain,  accompanied  by  nausea  (Rawling,  on  "Incompletely 
Descended  Testicle,"  in  "Practitioner,"  August,  1908).  A  testicle  in  the 
inguinal  or  crural  canal  or  in  the  perineum  is  far  more  apt  to  become  sarcoma- 
tous than  one  retained  within  the  abdomen.  Over  10  per  cent,  of  cases  of 
sarcoma  of  the  testicle  are  in  undescended  glands.  Russell  Howard  ("Prac- 
titioner," Dec,  1907),  out  of  57  cases  of  undescended  testicle,  found  15.7 
per  cent,  with  malignant  disease.  In  double  cryptorchism,  in  which  the 
testicular  function  has  been  abolished,  there  is  delayed  union  of  the  bony 
epiphyses  and  epiphyseal  fractures  are  common,  and  there  may  be  excessive 
growth  of  long  bones.  The  same  liability  is  noted  in  those  subjected  to  cas- 
tration in  infancy.  When  such  a  subject  reaches  manhood,  he  may  develop 
some  disease  of  the  skeleton  which  is  usually  seen  only  in  children  (Gross 
and  Sencert,  "Rev.  de  Chir.,"  No.  11,  1905).  In  operating  on  these  cases  we 
usually  find  a  well-developed  gubernaculum  and  a  vaginal  tunic  extending 
below  the  testicle. 

Treatment. — If  one  testicle  is  undescended  at  or  after  the  eighth  year  of  life 
and  before  puberty,  if  it  lies  in  the  canal,  and  if  the  other  testicle  is  sound, 
the  former  should  be  removed  if  it  is  found  impossible  to  draw  the  gland  into 
the  scrotum.  Both  testicles  should  not  be  removed  from  a  child:  one  should  be 
placed  within  the  abdomen.  I  would  save  one  testicle  in  order  to  have  the  child 
certainly  enter  and  remain  in  the  masculine  groove.  Removal  of  both  testicles  is 
permissible  in  an  adult,  because  he  has  definitely  become  and  will  remain  mascu- 
line, and  undescended  or  ectopic  testicles  in  an  adult  are  or  will  surely  become 
functionally  useless  and  menaces.  If  a  testicle  is  retained  in  the  abdomen  it 
should  not  be  operated  upon  unless  it  causes  trouble.  Always  try  to  get  a  re- 
tained gland  into  the  scrotimi  before  the  age  of  puberty.  If  it  is  retained  after 
puberty,  it  will  be  almost  certain  to  be  or  to  become  functionally  useless.  An 
ectopic  testicle  should  be  restored  to  the  scrotum  if  possible;  if  not,  it  should  be 
removed.  Even  when  operation  is  performed  to  replace  the  testicle,  success  is 
seldom  enduring.  In  Rawling's  29  cases  only  4  were  permanently  successful. 
Other  operators,  however,  claim  better  results.  For  instance,  Broca  reports  79 
cases  traced  from  one  to  six  years,  and  in  31  of  them  the  result  was  perfect  and 
permanent.  The  method  I  employ  is  that  advocated  by  Coley,  viz.,  Bassini's  in- 
cision through  the  aponeurosis,  separation  of  the  cord  from  the  peritoneum  (it 
is  usually  in  the  posterior  sac  wall) ;  removal  of  the  vaginal  process,  the  cre- 
master  and  fibrous  adhesions  around  the  cord;  the  making  of  a  scrotal  pouch 
by  the  fingers,  closure  of  the  canal  as  in  hernia;  suturing  of  the  cord  to  the  pillars 
of  the  external  ring,  as  advocated  by  Dowd.  This  is  practically  Broca's  method. 
Bevan  operates  for  a  testicle  within  the  canal  by  separating  and  dividing  the 
vaginal  process,  removing  all  the  coverings  of  the  cord,  and  leaving  the  testicle 
suspended  by  the  vas  and  spermatic  vessels  only.  This  proceeding  gives  the 
testicle  a  very  wide  range  of  mobility.    A  pocket  is  made  in  the  scrotum  by 


•Tuberculosis  of  the  Testicle  1393 

means  of  the  finger,  the  testicle  is  placed  in  the  pocket,  and  remains  there 
without  suturing.  The  canal  is  now  sutured  as  in  a  Bassini  operation  without 
cord  transplantation.  There  is  a  certain  though  small  risk  of  gangrene  of 
the  testicle  after  Bevan's  operation.  I  believe  Bevan's  method  should  be  em- 
ployed in  the  more  severe  cases.  If  there  is  no  hernia,  operation  should  not  be 
performed  imtil  between  the  eighth  and  tw^elfth  years  of  life. 

Orchitis  is  inflammation  of  the  testicle.  Acute  orchitis  may  follow  cold, 
wet,  traumatism  or  epididymitis,  and  may  follow  or  develop  during  gout, 
mumps,  rheiunatism,  or  a  specific  fever.  The  testicle  is  round,  swollen,  tender, 
and  very  painful,  the  scrotum  is  red  and  swollen,  the  tunica  vaginalis  is  filled 
with  fluid,  and  there  is  fever.  Chronic  orchitis  results  from  the  acute  form  or 
from  a  chronic  urethral  inflammation,  and  is  almost  always  combined  with 
epididymitis.  Gonorrheal  orchitis  is  rare  and  almost  certainly  results  in  slough- 
ing of  the  testicle. 

The  treatment  of  the  acute  form  consists  of  rest  in  bed  and  applications 
as  for  epidid^Tnitis  (see  page  1397).  The  chronic  form  requires  the  removal  of 
the  causative  lesion,  if  possible,  the  wearing  of  a  suspenson,^  bandage,  ap- 
plications of  ichthyol  or  mercurial  ointment,  and  the  administration  of  iodid 
of  potassiimi  by  the  mouth.  Strapping  with  zinc  oxid  adhesive  plaster  may 
do  good.     Castration  may  be  required. 

Tuberculosis  of  the  testicle  may  perhaps  be  primary,  but  in  the  vast 
majority  of  cases  is  secondary  to  tuberculosis  of  the  kidney,  prostate,  bladder,  or 
seminal  vesicles.  As  Keyes  ("Annals  of  Surgery,"  June,  1907)  says,  careful  exam- 
ination wiU  show  one  of  three  conditions — tubercle  bacilli  in  urine,  indurations 
in  the  prostate,  and  vesicles  or  "a  distinct  haze  in  the  urine  due  to  prostatic 
catarrh."  Tuberculosis  of  the  prostate  or  vesicles  exists  in  probably  one-half  the 
cases  (Barney,  in  "Boston  Med.  and  Surg.  Jour.,"  March  14,  191 2).  In  about 
one-third  of  the  cases  there  is  evidence  of  tuberculosis  distant  from  the  genito- 
urinary organs  (especially  in  the  lungs  or  bones) .  Patients  with  tuberculosis  of 
the  testicle  are  nearly  always  sterile.  The  disease  may  be  preceded  by  pulmonary 
tuberculosis,  lymphatic  tuberculosis,  peritoneal  tuberculosis,  anal  fistula,  renal 
tuberculosis,  or  tuberculous  disease  of  bones  or  joints;  and  primary  tuberculosis 
of  the  testicle  may  be  foUowed  by  near  or  distant  tuberculous  lesions.  In  some 
cases  involvement  of  the  prostate  exists,  but  cannot  be  detected  {latent  tuber- 
culosis of  the  prostate);  in  other  cases  the  prostate  is  in  a  state  of  subacute 
inflammation.  The  epididymis  is  usually  involved  before  the  testicle  and 
early  chronic  lesions  are  localized  there  for  some  time.  In  most  cases  the 
bacilli  reach  the  prostate  and  vesicles  by  way  of  the  blood,  and  reach  the 
epidid}Tnis  by  way  of  the  vas  deferens,  the  lesions  of  the  prostate  and  vesicles 
developing  first  or  remaining  latent.  In  some  cases  tuberculosis  of  the  kidney 
or  bladder  is  foUowed  by  tuberculosis  of  the  testicle.  The  spread  from  the 
prostate,  vas,  or  bladder  is  by  epithelial  infection.  There  is  no  e\ddence  con- 
firmatory of  the  idea  of  ascending  infection  from  the  urethra.  In  a  child 
with  an  open  vaginal  process,  tuberculous  peritonitis  may  directly  cause  tu- 
berculous epidid>Tnitis.  The  disease  begins  in  one  testicle,  but  in  the  vast 
majority  of  cases  the  other  testicle  becomes  involved  after  a  few  weeks  or 
months.  If  the  other  testicle  remains  free  for  three  years  its  chance  of  remain- 
ing free  is  good.  If  but  one  epidid\anis  is  involved  the  testicle  may  not 
be  affected  for  weeks  or  months.  Von  Bruns  says  that  in  18  per  cent,  of  such 
cases  the  testicle  is  not  involved  for  six  months;  in  40  per  cent.,  for  over  two 
mionths  ("Archiv.  f.  klin.  Chir.,"  Bd.  63,  H.  4).  It  usuaUy  comes  on  graduaUy, 
but  it  may  begin  acutely,  as  I  have  seen  in  two  instances  during  the  progress 
of  tuberculous  peritonitis.  An  acute  onset  or  an  acute  exacerbation  of  a 
chronic  case  usually  means  mixed  infection.  The  disease  may  follow  a  sHght 
injur}^  or  inflammation,  and  is  most  common  in  yoimg  men,  but  may  arise  at 


1394 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


any  age.  The  causal  influence  of  antecedent  or  existing  gonorrhea  is  doubtful. 
Some  maintain  that  sexual  excess  predisposes.  There  is  often  a  family  his- 
tory of  tuberculosis.  A  chronic  case  begins  by  swelling  of  the  epididymis. 
Palpation  detects  one  or  two  or  several  rounded  nodules,  or  a  diffuse  hardening. 
In  the  latter  case  the  epididymis  is  much  enlarged,  and  there  is  usually  a  slight 
hydrocele.  Rectal  examination  commonly  detects  nodules  in  the  prostate 
and  vesicles.  In  a  few  cases  there  are  frequency  of  micturition,  tenesmus, 
hematuria,  and  seropurulent  fluid  can  he  massaged  from  the  vesicles  and 
prostate  and  milked  from  the  urethra.  In  some  cases  bacilli  are  found  in  the 
urine.  In  others  the  urine  is  hazy.  In  about  80  per  cent,  of  cases  the  guinea- 
pig  test  will  prove  the  presence  of  bacilli.  In  some  cases  the  urine  is  normal. 
Sooner  or  later  nodules  appear  in  the  testicle.  The  vas  is  always  swollen  and 
may  or  may  not  be  palpable.  In  an  acute  case  one  testicle  is  involved.  The 
testicle  is  very  painful  and  the  epididymis  is  greatly  swollen  and  smooth.  The 
testicle  quickly  swells,  there  is  always  a  hydrocele,  and  the  scrotal  skin  becomes 


Fig.  gag. — Obstructive  hyperemia  for  the  testicles.  The  ends  of  the  elastic  tube  are  held  by 
the  patient,  crossed.  A  piece  of  tape  is  placed  beneath  to  be  tied  by  an  attendant  (Meyer  and  Schmie- 
den). 

reddened.  In  a  few  days  the  acuteness  of  the  symptoms  subsides,  but  suppu- 
ration occurs  soon.  In  any  case  of  tuberculosis  of  the  testicle  nodules  tend  to 
soften  and  run  together.  After  a  time  the  skin  may  become  red  and  adhe- 
rent, give  way,  and  expose  a  caseous  breaking-down  epididymis  or  testicle. 
Caseation  can  occur  without  mixed  infection,  but  in  many  cases  in  which  soften- 
ing and  sinus  formation  occur  there  is  mixed  infection.  The  duration  of  the 
disease  is  tmcertain;  10  per  cent,  of  the  100  cases  carefully  studied  by  Keyes 
were  known  to  be  alive  ten  years  after  the  beginning  of  the  trouble,  and  4  (and 
not  one  of  them  had  been  operated  upon)  seemed  free  from  tuberculous  le- 
lesions  anywhere.  One-third  of  the  cases  that  suppurated  were  apparently 
well  after  three  years  ("Annals  of  Surgery,"  June,  1907).  Except  in  the  acute 
cases  the  testicle  is  only  slightly,  if  at  all,  painful,  and  tenderness  is  trivial. 
In  one-sixth  of  the  cases  a  small  hydrocele  forms.  If  a  hydrocele  exists  the 
fluid  should  be  withdrawn  by  tapping  in  order  that  cultures  may  be  made  from  it. 
Treatment." — Before  attempting  any  operation  try  Bier's  method.     The 


Embryomata  1395 

patient  is  placed  recumbent,  the  diseased  testicle  is  lifted  upward,  cotton 
batting  is  placed  around  the  neck  of  the  scrotum,  and  a  rubber  drainage-tube 
of  a  caHber  of  25  of  the  French  scale  is  wound  twice  around  and  fastened  with 
a  string  or  clamp.  If  both  testicles  are  diseased,  both  are  held  up  and  the  neck 
of  the  scrotum  is  embraced  by  the  tube  with  the  required  firmness  (see  Fig. 
939).  The  treatment  is  applied  for  two  or  three  hours  a  day  or  longer.  The 
patient  had  best  be  recumbent  during  the  application.  In  the  intervals  he  wears 
a  suspensory  and  gets  about.  During  the  use  of  Bier's  method  full  antitubercu- 
lous  treatment  is  required  (see  page  230).  If  a  cold  abscess  forms,  open  it  and 
dress  the  part  antiseptically.  If  Bier's  treatment  fails,  consider  the  advisability 
of  operation.  An  acute  case  requires  unilateral  castration.  If,  in  a  chronic 
case  the  disease  is  limited  to  the  epididymis  or  to  the  epididymis  and  vas,  resect 
the  epididymis  (epididymectomy)  and  the  vas  deferens.  If  the  testicle  is  dis- 
eased, orchidectomy  is  performed.  It  was  long  believed  that  orchidectomy  was 
useless  if  the  vesicles  and  prostate  were  involved,  but  Koenig  and  others  main- 
tain that  vesiciilar  and  prostatic  tuberculosis  improves  after  removing  the  dis- 
eased testicle  or  epididymis.  If  tlie  epididymis  of  each  testicle  is  involved, 
bilateral  epididymectomy  should  be  performed.  When  both  testicles  are  dis- 
eased and  other  organs  and  structures  are  not  extensively  involved,  bilateral 
orchidectomy  is  performed  or,  better,  the  testicle  which  is  most  diseased  is 
removed  and  the  diseased  portion  of  the  other  is  extirpated.  Cumston  points 
out  that  when  the  testicle  is  diseased  the  disease  may  not  be  detectable  even 
on  operative  exposure.  Hence  in  doing  epididymectomy  he  splits  open  the 
testicle  to  see  if  it  is  diseased.  If  it  is  not  diseased  he  sutures  it  with  catgut 
and  removes  the  epididymis.  If  it  is  diseased  he  considers  the  advisability 
of  imilateral  orchidectomy  (Charles  Greene  Cumston,  in  "Annals  of  Surgery," 
June,  1909). 

In  many  cases  after  epididymectomy  sinuses  form.  They  may  remain  open 
for  months.  In  association  with  and  after  operation  employ  antituberculous 
remedies,  order  a  nourishing  diet,  send  the  patient  to  a  good  climate,  and  insist 
on  an  open-air  life.  Tuberculin  may  prove  useful.  A  considerable  percentage 
of  unilateral  cases  are  cured  by  operation  (over  40  per  cent.).  Some  few 
bilateral  cases  are  cured. 

Cysts  and  Tumors  of  the  Testicle. — Innocent  tumors  are  very  rare;  in 
fact,  some  dispute  their  existence.  The  elements  of  a  testicular  growth  are  very 
complex.  A  majority  of  growths  are  unquestionably  malignant.  Some  are 
wholly  maHgnant.  Many  show  a  mingling  of  benign  and  malignant  elements. 
Even  growths  which  are  not  malignant  in  the  beginning  have  an  irresistible 
tendency  to  become  so.  It  is  believed  by  many  surgeons  that  fibroma  and 
adenoma  can  arise  and  perhaps  remain  for  some  time  benign.  Embryomata 
are  at  first  benign,  but  tend,  perhaps  after  years,  to  become  malignant. 

Embryomata. — H.  Morriston  Davies  ("Lancet,"  Feb.  17,  191 2)  considers 
embryomata  to  be  "composite  tumors  containing  elements  derived  from  epi- 
blast,  mesoblast,  and  hypoblast."  They  are  "developed  in  the  body  of  the 
testicle"  and  not  in  the  epididymis,  though  that  structure  may  eventually  be 
involved.  Early  in  their  development  these  growths  are  benign,  but  any  or 
aU  the  layers  may  become  maUgnant  (Nicholson,  in  "Guy's  Hospital  Reports," 
vol.  bd,  1907). 

When  two  or  more  layers  become  malignant  "a  mixed  tumor  is  the  result; 
when  hypoblast  alone,  the  tmnor  assumes  the  character  of  a  columnar-celled 
carcinoma;  when  mesoblast  alone,  of  a  sarcoma  or  myxosarcoma"  (Davies, 
Loc.  cit.).  When  a  dermoid-Hke  growth  from  the  epiblast  becomes  malignant 
it  resembles  chorion  epithelioma.  Nicholson  (Loc.  cit.)  divides  embryomata 
into  solid  embryomata  (which  often  contain  cysts  and  are  common)  and  cys- 
tic embryomata  or  dermoids  (which  are  very  rare).      Many  surgeons  regard 


1396  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

sarcoma,  others  carcinoma,  as  the  commonest  form  of  malignant  disease. 
EndotheHoma  may  occur. 

Malignant  Disease  of  the  Testicle. — It  may  arise  from  an  embryoma  or 
may  be  malignant  from  the  start.  If  a  tumor  which  has  long  existed,  perhaps 
years,  begins  to  grow  rapidly,  we  may  assume  that  there  is  malignant  change  in 
an  embryoma.  It  is  seldom  possible  to  diagnosticate  the  form  of  a  malignant 
tumor.  Sarcoma  is  usually  of  the  small  round-celled  variety  (the  type  known  as 
lymphosarcoma).  The  other  testicle  soon  becomes  involved  in  malignancy. 
The  growths  disseminate  rapidly.  In  10  per  cent,  of  cases  the  testicle  is  im- 
descended.  Any  sarcoma  is  liable  to  sudden  increase  in  size  because  of 
hemorrhage. 

Nicholson  ("Guy's  Hospital  Reports,"  vol.  Ixi,  1907)  divides  carci- 
nomata  into  encephaloid  (which  is  commonest)  and  scirrhus  (which  is 
rare),  and  regards  so-caUed  columnar  carcinomata  as  teratomata.  Davies 
("Lancet,"  Feb.  17,  191 2)  admirably  sums  up  the  chnical  picture  of 
malignant  disease  of  the  testicle.  I  have  utilized  his  article  extensively 
below.  The  timior  may  attain  a  great  size  (that  of  a  cocoanut).  It  is 
usually  oval,  but  may  exhibit  a  few  roimded  projections  "due  to  the  pres- 
ence of  degeneration  in  the  timior  or  of  fluid  in  the  tunica  vaginaHs."  Early 
in  the  development  the  growth  is  smooth  (except  for  the  projections  men- 
tioned) ,  later  it  breaks  through  the  tunica  albuginea  and  so  comes  to  have  an 
irregular  surface.  The  epididymis  is  at  first  free,  but  sooner  or  later  be- 
comes part  of  the  timior.  The  consistence  of  malignant  tumors  is  very  vari- 
able (may  be  hard,  elastic,  soft,  or  fluctuating) ,  and  the  consistence  of  a  tumor 
may  vary  in  different  parts.  In  most  cases  there  is  an  associated  hydrocele, 
in  which  the  fluid  may  be  limited  or  may  be  distributed  throughout  the 
entire  sac.  The  hydrocele  may  be  translucent,  the  tumor  never  is.  Pain  is 
seldom  severe  and  tenderness  seldom  acute  in  the  testicle.  I  have  seen  ter- 
rible agony  when  the  lumbar  glands  are  involved.  The  tumor  when  raised 
on  the  hand  feels  very  heavy.  The  cord  becomes  enlarged  because  of  in- 
volvement. 

The  growth  finally  adheres  to  the  scrotum,  and  the  skin  reddens  and  gives 
way  and  fungation  occurs.  When  this  happens  there  is  severe  pain.  Sarcoma 
of  the  testicle,  unHke  sarcoma  in  most  other  regions,  causes  early  glandular 
involvement.  Carcinoma,  of  course,  involves  glands.  The  inguinal  glands 
are  not  involved  unless  the  scrotimi  is  attacked.  The  lumbar  glands  receive 
the  testicular  lymphatics.  Secondary  growths  are  early  and  widespread  and 
are  common  in  the  skin. 

H.  M.  Davies  emphasizes  the  great  fatality  of  mahgnant  disease  of  the  tes- 
ticle; quotes  Chevassu's  collection  of  100  cases  treated  by  castration,  of  which  81 
died  of  malignant  disease  and  only  19  were  cured,  and  insists  that  "early  diag- 
nosis and  the  removal  of  the  testicle  and  surrounding  fascia  and  the  glands  in 
the  lumbar  region  offer  the  only  hope  of  decreasing  so  appalHng  a  mortahty" 
("Lancet,"  Feb.  17,  1912). 

Orchidectomy,  or  Castration  (Excision  of  a  Testicle). — Bilateral  cas- 
tration should  never  be  performed  without  deliberate  consideration.  It  often 
produces  grave  mental  disorder.  This  is  in  part  the  result  of  the  mental  de- 
pression attendant  on  knowing  that  the  highly  prized  glands  are  gone  for 
ever,  and  in  part  the  loss  to  the  organism  of  the  internal  secretion  of 
the  testicles.  A  boy  castrated  before  puberty  never  becomes  potent. 
A  man  may  retain  potency  for  a  considerable  time  after  castration.  I 
removed  a  tuberculous  kidney  from  a  man  who  had  been  castrated  by  my 
colleague.  Dr.  Horwitz,  two  years  before,  yet  he  was  still  able  to  have 
intercourse.  Unilateral  orchidectomy  does  not  make  a  man  either  sterile  or 
impotent  and  does  not  produce  mental  disturbance.     In  orchidectomy  for 


Strangulation  of  the  Cord  by  Axial  Rotation  1397 

benign  disease  an  incision  is  made  over  the  cord,  commencing  just  outside  the 
external  ring  and  running  down  over  the  base  of  the  tumor.  Clamp  the  cord 
and  di\'ide  it  near  the  ring,  remove  the  testicle,  ligate  the  spermatic  artery 
alone,  and  then  ligate  the  entire  thickness  of  the  cord.  The  cord  is  Ugated  with 
chromic  gut.  The  skin  is  sutured  with  silkworm-gut.  Drainage  is  not  re- 
quired. It  is  often  advisable  to  remove  a  considerable  amount  of  scrotal  skin. 
Orchidectomy  for  mahgnant  disease  must  be  a  much  more  radical  procedure. 
After  the  cord  has  been  divided  and  the  testicle  removed,  as  in  the  ordinary 
operation,  the  incision  is  prolonged  along  and  through  the  roof  of  the  inguinal 
canal,  and  is  continued  in  the  same  direction  to  a  point  a  little  above  the  anterior 
superior  spine  of  the  ilium.  The  incision  is  then  curved  and  carried  up  to 
"the  costal  margin  at  the  level  of  the  tenth  rib"  (Davies,  in  "Lancet,"  Feb. 
17,  1912).  The  peritoneum  is  exposed.  The  cord  is  traced  well  into  the  true 
pehds,  is  tied,  and  divided.  The  fascia  over  the  iliacus  and  psoas  muscles  is 
dissected,  ''together  with  the  contained  spermatic  vessels  andhiiiphatics,''  and 
the  glands  upon  "the  inferior  vena  cava  and  aorta"  are  removed  (Da\'ies, 
Ibid.).  This  operation  was  first  performed  by  Gregoire  in  1905.  Da^-ies  did 
the  thirteenth  operation  on  record  (Ibid.). 

Epididymitis,  or  inflammation  of  the  epididymis,  is  usually  due  to  in- 
flammation of  the  urethra.  It  is  apt  to  occur  in  the  stage  of  decline  of  a 
gonorrhea,  and  in  such  a  case  is  announced  by  a  notable  diminution  or  a 
complete  cessation  of  discharge.  It  may  result  from  the  passage  of  a  urethral 
instrument,  the  voiding  of  urine  which  contains  fragments  of  calculi,  or  as  a 
compHcation  of  prostatic  hypertrophy.  Acute  epididymitis  is  characterized 
by  swelling  of  the  epidid}-mis,  severe  pain  in  the  groin,  and  tenderness  over  the 
posterior  part  of  the  testicle.  The  pain  becomes  acute,  swelling  rapidly  in- 
creases, and  the  constitution  s}-mpathizes.  The  swelling  is  due  partly  to 
engorgement  of  the  epididymis  and  partly  to  fluid  in  the  tunica  vaginalis 
{acute  hydrocele).  Chronic  epididymitis  is  usually  linked  \\-ith  orchitis,  and  it 
foUows  an  actue  exacerbation  of  a  chronic  urethral  inflammation. 

Treatment  by  aseptic  puncture  with  a  tenotome,  if  fluctuation  is  marked, 
will  reheve  tension  and  pain.  Hagner  makes  multiple  punctures  in  the  epididy- 
mis. Leeching  over  the  external  abdominal  ring,  the  use  of  an  ice-bag  early 
in  the  case,  elevation,  application  of  guaiacol,  and  administration  of  laxatives 
and  opium  constitute  the  usual  treatment  in  the  acute  stage.  Applications  of 
guaiacol  over  the  cord,  epidid>-mis,  and  testicle  seem  to  relieve  pain  and  dis- 
tinctlv  lessen  swelling.  Two  applications  a  day  should  be  made  for  one  week. 
At  each  application  paint  the  scrotum  and  over  the  external  ring  -^dth  1 5  drops 
of  guaiacol  in  i  dram  of  glycerin  or  olive  oil.  Strapping  is  employed  as  the 
inflammation  subsides.  The  treatment  of  the  chronic  form  is  the  same  as 
that  for  chronic  orchitis. 

Strangulation  of  the  Cord  by  Axial  Rotation. — In  nearly  one-half 
of  th,e  cases  the  testicle  is  undescended  or  only  partly  descended.  In  ever>^  case 
there  is  a  long  mesorchium,  and  if  a  normal  testicle  is  normally  placed  torsion 
of  the  cord  wiU  hardly  occur  (Chas.  L.  Scudder,  "Annals  of  'Surger\^,"  Aug., 
1901).  The  t-n-isting  may  be  toward  the  right  or  toward  the  left.  The  s>Tnp- 
toms  arise  suddenly,  and  usually  during  exertion.  In  some  cases  a  hernia  also 
exists.  WTien  the  rotation  occurs,  the  testicle  swells,  hemorrhages  take  place 
into  it,  and  gangrene  may  develop.  If  the  cord  of  an  imdescended  or  par- 
tially descended  testicle  twists,  swelling  and  tenderness  are  noted  in  the  abdo- 
men or  groin.  If  the  swollen  testicle  is  in  the  scrotum,  the  gland  feels  nodular 
and  the  epidid^-mis  is  found  to  be  anterior  instead  of  posterior,  as  it  is  in  a 
normaUv  placed  gland.  The  s\Tnptoms  are  sudden  pain,  vomiting,  moderate 
shock,  and  a  sweUing  in  the  groin  or  a  swollen  testicle  in  the  scrotmn.  The 
swelling  receives  no  impulse  on  coughing.     The  s^-mptoms  resemble  those  of 


1398  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Fig.  Q40. — Hydrocele  of  tunica  vaginalis  (Horwitz). 


strangulated  hernia,  but  are  less  violent,  and  the  bowels,  though  often  much 
constipated,  are  not  obstructed. 

Treatment. — An  incision  should  be  made,  and  if  the  twisting  was  recent 
and  the  testicle  is  not  gangrenous,  the  cord  may  be  untwisted  and  the  testicle 

fastened  to  the  scrotum  by  a  cat- 
>W'~^  gut  stitch.  If  the  testicle  is  gan- 
grenous it  should,  of  course,  be 
removed.  Scudder  tells  us  that 
in  88  per  cent,  of  cases  the  testicle 
is  found  to  be  gangrenous.  Ac- 
cording to  Scudder,  there  are  32 
cases  on  record:  31  were  operated 
upon  and  i  was  not,  but  all  re- 
covered ;  in  3  the  testicle  sloughed 
and  in  2  it  atrophied  ("Annals  of 
Surgery,"  Aug.,  1901). 

Vaginal  hydrocele  {chronic 
hydrocele)  (Figs.  940  and  942,  e) 
is  a  collection  of  fluid  in  the  tunica 
vaginalis  testis.  An  enlargement 
of  the  testis  may  cause  it  {sec- 
ondary hydrocele),  but  in  most 
instances  the  cause  is  unknown 
and  no  signs  of  inflammation  exist  {primary  hydrocele).  The  fluid  is  albumin- 
ous, but  it  does  not  coagulate  spontaneously;  it  is  thin,  straw  colored,  and 
may  contain  crystals  of  cholesterin.  The  testicle  is  at  the  lower  and  back 
part  of  the  sac.  The  pyriform  mass  fluctuates,  is  translucent,  grows  from 
below  upward,  and  the  introduc- 
tion of  an  exploring  needle  per- 
mits the  yellow  fluid  to  flow 
out.  Sometimes  a  hydrocele  has 
an  hour-glass  shape.  This  is 
the  hydrocele  "en  bissac"  of  the 
French.  In  this  condition  (Fig. 
941)  two  cavities  exist,  usually 
but  not  invariably  communicat- 
ing. The  constriction  between 
the  cavities  is  due  to  inflamma- 
tory thickening. 

Treatment.  —  In  secondary 
hydrocele  the  treatment  of  the 
diseased  testicle  is  the  essential 
plan.  We  discuss  here  the 
treatment  of  primary  hydrocele. 
Simply  tapping  the  sac  with  a 
trocar  is  only  palliative ;  air  must 
run  in  as  fluid  runs  out,  and  sup- 
puration may  occur,  which  will 
be  dangerous  without  drainage. 
Never  tap  a  rigid  sac.  The  in- 
jection   of    irritants    should    be 

abandoned,  as  it  exposes  the  patient  to  serious  danger  because  of  inflammation 
occurring  without  provision  for  drainage.  A  good  plan  is  to  incise  the  sac, 
dry  its  interior  by  bits  of  gauze,  swab  it  out  with  pure  carbolic  acid,  pack  it 
with  iodoform  gauze,  and  dress  it  antiseptically.     The  packing  is  removed  in 


Fig.  941. — ^Hydrocele  "en  bissac."  This  hydrocele 
extends  up  the  cord  into  the  inguinal  canal  and  to  the 
internal  abdominal  ring  (Horwitz). 


Treatment  of  Infantile  Hydrocele 


1399 


twenty-four  hours  and  the  wound  is  allowed  to  close.  In  most  cases  I  prefer 
this  method.  If  the  sac  is  rigid  and  will  not  collapse,  either  stitch  it  to  the 
skin  and  pack  it  or  excise  a  large  portion  of  its  parietal  layer  and  insert  a 
drainage-tube  (Volkmaiin's  operation).  Another  plan  is  to  tap  the  sac  with  a 
trocar  and  cannula,  leaving  the  cannula  in  place  as  a  drain  for  some  days,  and 
dressing  antiseptically. 

Longuet's  operation  is  easy  and  is  advocated  by  many  surgeons.  It  is 
called  extraserous  transposition  of  the  testicle.  It  was  introduced  by  Longuet 
in  1898  ("Progres  Med.,"  Sept.  21,  1901).  Doyen  and  Winklemann  do  a  simi- 
lar operation.  Jaboulay,  too,  advocates  splitting  the  sac  and  turning  it  inside 
out.  He  folds  it  around  both  the  testicle  and  cord  and  stitches  it  so  that  the 
•smooth  endotheUal  surface  of  the  tunic  will  be  in  contact  with  the  raw  scrotal 
tissue.  It  will  adhere  to  the  scrotal  tissue  ("Keen's  Surgery,"  vol.  iv).  A 
local  anesthetic  is  injected  and  an  incision  2  inches  in  length  is  made.  The 
testicle  is  lifted  from  the  scrotiun.  The  serous  and  all  the  other  coats  except 
the  skin  fall  together  behind  and  make  a  sheath  for  the  cord.  One  catgut 
suture  will  hold  them  behind  the  cord.  A  bed  is  made  for  the  testicle  beneath 
the  inner  edge  of  the  skin  wound  by  tearing  with  the  fingers.  The  testicle  is 
rotated  on  its  long  axis  and  inserted  into  this  cavity.  The  testicle  rests  against 
the  scrotal  septum,  and  in  front  of  the  gland  is  the  cord  covered  by  the  tunic. 
The  skin  is  sutured  and  the  wound  is  dressed.     E.  Wylly  Andrews  devised  the 


Tig.  942. — ^Varieties  of  hydrocele:  a,  Congenital;  b,  infantile;  c,  funicular;  d,  encysted;  e,  vaginal. 


iottle  operation  ("Keen's  Surgery,"  vol.  iv).  The  unopened  tunic  (with  the 
testicle)  is  separated  from  the  scrotum  and  dislocated  through  the  scrotal 
wound.  A  small  incision  is  made  near  the  stunmit  of  the  funnel-like  prolon- 
gation of  the  sac  upon  the  cord.  The  sac  empties  and  then  resembles  a  bottle  or 
bag  with  a  small  opening  at  the  top.  The  testicle  is  squeezed  through  the 
opening.  When  this  is  done  the  sac  is  inside  out  and  the  edges  of  the  small 
opening  lie  closely  about  the  cord.  The  skin  is  closed  without  drainage.  In 
some  cases  after  doing  any  one  of  the  operations  which  turn  the  sac  inside 
out  a  large  tender  mass  forms,  composed  of  swollen  testicle  and  thickened  sac. 
I  have  had  this  experience  several  times.  In  such  a  case  it  is  necessary  to 
excise  the  thickened  sac. 

Congenital  hydrocele  (Fig.  942,  a)  is  hydrocele  through  an  unclosed 
fimicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is  raised  the  fluid 
Tims  back  into  the  peritoneal  cavity,  from  which  it  originally  came. 

The  treatment  is  the  application  of  a  truss  to  obliterate  the  funicular 
process,  and  when  that  occurs,  if  the  counterpart  of  an  infantile  hydrocele 
persists,  puncture  and  scarification  of  the  walls  of  the  sac. 

Infantile  hydrocele  (Fig.  942,  b)  is  a  collection  of  fluid  in  a  funicular 
process  and  the  timica  vaginalis,  the  funicular  process  being  closed  above, 
but  not  below. 

The  treatment  is  to  puncture  the  sac  and  to  scarify  the  sac  wall  with 
a  needle. 


I400 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Funicular    Hydrocele   (Fig.  942,  c). — The  funicular  process  is  closed 

below,  but  is  open  above.     Raising  the  pelvis  causes  the  fluid  to  trickle  back 

into  the  peritoneal  cavity. 

The  treatment  is  the  application  of  a  truss. 

Encysted   Hydrocele  of  the  Cord  (Fig.  942,  d). — In  this  variety  the 

funicular  process  is  obliterated  above  and  below,  but  it  is  patent  between 

these  two  points  and  fluid  collects. 

The  treatment  is  the  same  as  that  for  infantile  hydrocele.     If  this  fails, 

incise  and  pack. 

Encysted  hydrocele  of  the  testicle  and  of  the  epididymis  may  occur.     Diffused 

hydrocele  of  the  cord  is  simply  edema  of  the  cord.     Hydrocele  of  a  hernia  is 

the  distention  of  a  hernial  sac  by 
peritoneal  fluid. 

Hematocele  (Fig.  943).— Fa- 
ginal  hematocele  is  blood  in  the  tunica 
vaginalis,  the  result  of  traumatism,  a 
tumor,  or  the  tapping  of  a  hydrocele. 
There  is  a  pyriform  swelling  which 
fluctuates,  but  which  gradually  be- 
comes firmer;  the  scrotum  is  Hvid 
and  the  testicle  is  below  and  pos- 
terior to  the  tumor.  The  encysted 
form  of  hematocele  of  the  cord  is  a 
hydrocele  of  the  cord  into  which 
bleeding  has  occurred.  The  diffused 
form  is  due  to  extravasation  of 
blood  into  the  cellular  substance  of 
the  cord.  Encysted  hematocele  of  the 
testicle  is  due  to  effusion  of  blood 
into  an  encysted  hydrocele  of  the 
testicle.  Parenchymatous  hematocele 
is  extravasation  of  blood  into  the 
substance  of  the  testicle. 

The  treatment  of  a  recent  case 
of  vaginal  hematocele  is  to  put  the 
patient  to  bed,  support  the  scrotum, 
If  the  swelling  does  not  soon  abate, 


Fig.  g43. — ^Acute  hematocele  of  tunica  vaginalis  the 
result  of  traumatism  (Horwitzj. 


and  apply  an  ice-bag  over  the  testicle 
incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the  venous  plexus 
of  the  spermatic  cord.  The  veins  are  thickened,  lengthened,  dilated,  and 
convoluted.  The  assigned  causes  are  straining,  cough,  constipation,  and  an 
occupation  requiring  prolonged  standing.  Some  believe  ungratified  sexual 
desire  is  a  cause.  Hereditary  predisposition  is  probable.  There  are  more 
left-sided  than  right-sided  varicoceles,  because  the  right  spermatic  vein  has 
valves  and  empties  into  the  vena  cava  at  an  acute  angle,  but  the  left  sper- 
matic vein  has  no  valves  and  empties  into  the  left  renal  vein  at  a  right 
angle.  Varicocele  is  a  very  common  condition.  The  elder  Senn  found  it  in 
21  per  cent,  of  10,000  recruits.  An  irregular  swelling  exists  in  the  scrotima 
and  extends  up  the  cord.  This  swelling  feels  like  "a  bag  of  earth-worms"; 
it  exhibits  a  slight  impulse  on  coughing;  the  scrotal  skin  and  cremaster  mus- 
cle are  attenuated;  the  testicle  lies  at  the  bottom  of  the  swelling  and  is  softer 
and  smaller  than  normal;  the  swelling  diminishes  on  lying  down  and  increases 
on  standing  or  on  making  pressure  over  the  external  ring.  The  scrotum  is 
pendulous  and  the  scrotal  skin  frequently  contains  varicose  veins.  The 
testicle  may  be  soft  and  shrunken.     There  is  usually  some  discomfort,  aching, 


Classification  of  Amputations  1401 

or  dragging  in  the  testicle  and  the  groin,  and  often  neuralgic  pain  in  the  cord. 
There  may  be  no  discomfort  of  any  sort.  A  large  varicocele  may  be  free  from 
discomfort  and  a  small  varicocele  may  produce  much  annoyance,  or  vice 
versa.  There  are  sometimes  mental  depression  and  h}-pochondriasis.  As  a 
man  reaches  middle  age  a  varicocele  usually  ceases  to  give  trouble. 

Treatment. — In  treating  varicocele,  reassure  the  patient:  tell  him  there 
is  no  real  danger  of  impotence;  order  cold  shower-baths,  correct  constipation 
and  mdigestion,  give  occasional  tonics,  and  order  the  patient  to  wear  a  sus- 
pensory- bandage.  If  the  testicle  is  undergoing  atrophy,  if  the  pain  and  the 
dragging  are  annoying,  or  if  the  mind  is  much  depressed,  operate. 

Operation  for  Varicocele. — Subcutaneous  hgation  is  no  longer  practised. 
The  open  operation  is  universally  employed. 

The  patient  is  placed  in  a  recumbent  position.  Local  anesthesia  is  very 
satisfactor}^  A  fold  of  skin  is  pinched  up  over  the  external  ring,  and  the 
surgeon  transfixes  it  on  the  line  of  the  cord,  so  that  he  will  have  an  incision 
about  i^  inches  long.  The  skin  and  fascia  are  cut  by  a  scalpel,  the  veins  are 
well  exposed,  and  the  cord  is  located  and  held  aside.  A  double  Hgature  of 
strong  catgut  or  chromicized  gut  is  passed  imder  the  veins  by  an  aneur\'sm 
needle.  The  threads  are  separated  i  inch,  tied  tightly,  and  the  ends  are  left 
long.  The  veins  between  the  ligatures  are  excised.  The  two  gut  ligatures 
are  tied  together  and  cut.  This  shortens  the  cord.  The  wound  is  sewed  up 
vdXh  silkworm-gut. 

Bloodgood  points  out  that  it  is  well  to  avoid  di^-iding  the  genital  branch 
of  the  genitocrural  ner\-e  which  supplies  the  cremaster  muscle.  If  this  ner\-e 
shoiild  be  di^ided,  the  cremaster  will  become  lax  and  return  of  the  varicocele 
will  be  favored.  Bloodgood  makes  the  incision  over  the  external  ring,  draws  the 
veins  up,  and  resects  them.  A  wound  so  placed  heals  more  certainly  and 
promptly  than  does  a  woimd  of  the  scrotum.  Of  late  years  I  have  always 
followed  this  plan. 

XXXVIII.  AMPUTATIONS 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion  of  a  limb.  Re- 
moval of  a  limb  or  a  portion  of  a  limb  at  a  joint  is  known  as  ''disarticulation.'' 
Amputation  may  be  necessar}-  because  of  the  existence  of  severe  mjiuy*,  of 
gangrene,  of  tumor,  of  intractable  disease  of  bones  or  joints,  of  ulcer  which 
will  not  heal,  of  traumatic  aneur^-sm,  etc.  A  re-amputation  may  be  required 
because  of  the  existence  of  a  defective  stump  or  disease  in  the  stimip. 

Classification. — Amputations  are  classified  as  follows:  (i)  As  to  time 
of  operation  after  the  injur}*:  a  primary  amputation  is  performed  soon  after 
the  occunence  of  the  accident — as  soon  as  the  suft"erer  reacts  from  shock,  and 
before  he  develops  fever;  a  secondary  amputation  is  performed  some  time 
after  the  accident,  suppuration  having  supervxned;  and  an  intermediate 
amputation  is  performed  during  the  existence  of  fever,  but  before  the  de- 
velopment of  suppuration.  (2)  As  to  the  situation,  where  the  bone  is  di\-ided 
or  according  to  which  joint  is  cut  through.  (3)  As  to  the  form  and  situation 
of  the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis;  completely  remove 
the  hopelessly  damaged  portion;  sacrifice  as  little  of  the  sound  tissue  as  possi- 
ble; prevent  hemorrhage  during  the  amputation,  and  carefully  arrest  it  after 
the  operation;  have  enough  sound  tissue  in  the  flap  to  cover  the  bone,  and 
enough  skin  to  cover  the  muscles;  and  secure  drainage  at  a  dependent  point. 

Hemorrhage  may  be  prevented  by  the  elastic  bandage  of  Esmarch  (Fig. 
944).  Ordinarily  we  can  apply  this  bandage  from  the  periphen,^  to  well  above 
the  line  of  prospective  incision,  encircle  the  limb  with  an  elastic  band  (not 


I402 


Amputations 


the  thin  tube  shown  in  the  cut),  and  remove  the  bandage.  The  bandage 
and  band,  asepticized  before  using,  are  appHed  to  the  Umb,  which  has  been 
carefully  sterilized.  After  the  band  has  been  applied  the  limb  should  not 
be  freely  or  forcibly  moved,  because  of  the  danger  of  tearing  muscles  which 
are  firmly  fixed  by  the  compressing  band.  When  elastic  compression  has  been 
used  in  an  operation  the  sujgeon,  after  removal  of  the  band,  should  be  very 
careful  to  tie  every  visible  vessel.  The  paralysis  of  the  small  vessels  induced  by 
pressure  often  prevents  bleeding,  and  unless  their  mouths  be  found  and  the 
vessels  be  tied  reactionary  hemorrhage  will  occur.  Reactionary  hemorrhage  is 
the  great  danger  after  the  use  of  the  Esmarch  bandage,  and  paralysis  or  slough- 
ing may  also  follow  its  employment.  If  there  be  an  area  of  suppuration  or  of 
gangrene  or  an  extra-osseous  malignant  growth,  do  not  apply  the  bandage  as 
directed  above.  One  bandage  can  be  applied  from  the  periphery  to  near  the 
lower  border  of  the  area  of  growth  or  infection,  and  another,  from  near  the 
upper  border  of  this  area,  up  the  limb.  If  the  bandages  are  applied  in  this 
manner  the  contents  of  the  diseased  area  (tumor-cells  and  fluid  or  septic  prod- 


Fig.  944. — Esmarch's  elastic  bandage. 


Fig.  945.— Application  of  tourniquet. 


ucts)  are  not  squeezed  into  the  circulation.  In  cases  like  the  above  the  best 
plan  is  to  hold  the  extremity  in  a  vertical  position  for  five  minutes,  lightly 
stroking  it  toward  the  body  with  the  hand,  and  then  apply  the  constricting 
band.  As  a  matter  of  fact,  this  plan  satisfactorily  empties  the  limb  of  blood, 
and  it  is  not  necessary  in  any  case  to  force  the  blood  out  by  elastic  compression. 
Some  surgeons  prefer  the  tourniquet.  Figures  946  and  947  show  two  forms  of 
tourniquet.  To  apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 
a  small,  firm*  compress  over  the  artery  and  a  broad  thick  compress  over  the 
outer  surface  of  the  limb,  buckle  the  tapes  around  the  limb  so  that  the  plate 
is  over  the  broad  pad,  and  tighten  the  tourniquet  by  separating  the  plates 
by  the  screw  (Fig.  945).  When  a  tourniquet  is  apphed  to  arrest  bleeding 
during  transportation,  bandage  the  limb,  sew  the  compress  pad  to  a  bandage, 
and  place  the  plates  of  the  instrument  over  the  pad.  Signorini's  horseshoe 
tourniquet  may  be  used  upon  the  brachial  artery.  In  hip-joint  and  shoulder- 
joint  disarticulations  Wyeth's  pins  may  be  passed,  and  after  the  limb  is  emptied 
of  blood  the  band  can  be  fastened  above  them.  These  pins  prevent  the  band 
from  shpping. 


Transverse  Circular  Method  of  Amputating 


1403 


The  instruments  and  appliances  required  for  amputation  are  Esmarch's 
apparatus  or  tourniquet,  amputating  knives  (Fig.  948),  a  bone-knife,  scalpels, 
saws  (Fig.  94S),  a  lion-jaw  forceps,  bone-cutting  forceps,  a  periosteum- 
elevator,  retractors  of  linen,  dissecting,  hemostatic,  and  toothed  forceps,  a 
tenaculum,  an  aneurysm-needle,  a  probe,  scissors,  needles,  Hgatures,  sutures 
of  silkworm-gut,  dressings,  bandages,  and  solutions.  A  retractor  has  two  tails 
for  the  thigh  and  arm  and  three  tails  for  the  leg  and  forearm:  it  is  made  by 
taking  a  piece  of  muslin  8  inches  wide  and  12  inches  long  and  cutting  tails  on 
one  side  8  inches  in  length. 


Fig.  Q46. — Petit's  spiral  tourniquet. 


Fig.  g4  7. — Charri6re's  tourniquet. 


Methods  of  Amputating. — The  transverse  circular  is  the  oldest  method 
of  amputating.  The  common  circular  incision  is  at  a  right  angle  to  the 
axis  of  the  limb.  Kocher  considers  also  as  a  circular  incision  an  obUque 
cut  around  the  limb  if  the  line  of  incision  "continues  in  one  direction" 
(Kocher's  "Text-Book  of  Operative  Surgery,"  translated  by  Harold  J.  Stiles). 
This  method  is  called  the  oblique  circular  amputation.  A  racket  incision  is 
formed  by  adding  a  longitudinal  cut  to  a  transverse  circular  cut.  If  the 
edges  are  rounded,  the  lanceolate  incision  is  formed.     Rectangular  flaps  are 


Fig.  948. — Catlin,  long  knife,  and  saws  for  amputation. 

formed  when  two  longitudinal  incisions  are  added  to  a  transverse  circular  cut. 
If  the  corners  of  a  rectangular  flap  are  trimmed,  rounded  flaps  are  formed. 
The  three  last-mentioned  plans  are  considered  under  the  head  of  the  Modified 
Circular  Amputation  (see  page  1404). 

Transverse  Circular  Method  (Figs.  949-952).— The  surgeon  should  stand 
to  the  right  of  the  limb  and  use  a  long  amputating  knife  which  cuts  from  heel  to 
point  (Fig.  949).  After  an  assistant  has  retracted  the  skin  the  operator  divides 
the  soft  parts  by  a  series  of  circular  cuts.  He  does  not  cut  at  once  to  the  bone, 
but  divides  the  skin  and  subcutaneous  tissues.     At  the  retracted  edge  of  the 


I404 


Amputations 


first  cut  the  superficial  muscles  are  divided,  and  after  these  muscles  retract  the 
deep  muscles  are  divided.  The  periosteum  is  incised  by  a  bone-knife  and  pushed 
up  by  an  elevator,  and  after  the  application  of  the  retractors  the  bone  is  then 
sawed,  the  saw  starting  from  heel  to  point.  A  periosteal  flap  can  be  made  to 
cover  the  end  of  the  bone,  but  it 
is  unnecessary.  In  this  amputa- 
tion is  formed  a  cone  whose  apex 
is  the  bone  and  whose  base  is  the 
skin  edge.  Figs.  950-952,  from 
Kocher,  show  the  steps  of  the 
operation  and  the  shape  of  the  re- 
sulting stimip.  In  one  form  of  cir- 
cular amputation  {amputation  a  la 
manchette)  the  retracted  skin  is  cut 
by  a  circular  sweep  of  the  knife,  a 
cuff  of  skin  and  subcutaneous  tis- 
sue is  freed  and  turned  up,  and  the 
muscles  are  cut  circularly  at  the 
edge  of  the  turned-up  cuff  (Fig. 
953).  The  pure  circular  amputa- 
tion is  performed  on  the  arm  and 
the  thigh;  the  amputation  a  la 
manchette  is  performed  chiefly 
through  the  wrist  and  the  lower 
forearm. 


Fig.  949. — Amputation  of  arm  by  the  cir- 
cular method  (Druitt). 


Fig.  952. 

Figs.  950-952. — ^The  steps  of  a  transverse  circular  am- 
putation (Kocher). 


If  there  is  more  sound  skin  upon  one  side  of  the  extremity  than  upon  the 
other,  the  transverse  circular  incision  sacrifices  more  of  the  limb  than  is  neces- 
sary and  the  oblique  circular  is  preferable.    An  objection  to  the  transverse 


Fig.  953. — Circular  amputation:  Dissecting  up  the  skin-flap  (Esmarch). 

circular  incision  is  that  the  cicatrix  hes  directly  at  the  end  of  the  stump  and 
is  liable  to  cause  pain  when  subjected  to  pressure. 

Modified  Circular  Method. — In  this  operation  the  circular  skin-cut  may 
be  modified  by  making  a  vertical  incision  to  join  the  first  wound,  the  muscles. 


Oblique  Circular  Method  of  Amputating 


140; 


being  cut  by  a  circular  sweep  (racket  incision)  or  by  making  two  venical 
skin  incisions  ^rectangular  flaps).    The  lanceolate  incision  is  made  by  round- 


Fig.  954.. — Modified  drcalar  amputatioii:  Skia-9aps  and  circular  cut  through  musdes  (Esnarch). 

ing  the  edges  of  the  flaps  which  result  from  a  racket  incision.    Liston's  modi- 
fication consists  in  dissecting  up  two  short  semilimar  integumentary^  flaps  and 

in  dividing  the  muscles  circularly  (Fig. 
954).  This  is  known  as  the  "mixed 
method.''  The  modified  circular 
method  can  be  used  upon  the  thigh, 
the  leg.  the  arm.  and  the  forearm. 

Oblique  Circular  Metiiod  (Elliptical 
Method  . — ZMark  the  upper  and  io~er 
ends  of  the  incision  as  shown  in  Figs. 
955-957.  The  lowest  incision  is  at  a 
right  angle  to  the  cutaneous  surface; 
the  highest  incision  is  parallel  to  the 
cutaneous  surface  (Kocher).  The  skin 
and  fascia  are  divided  so  that  an  obHque 
incision  to  the  muscles  surrounds  the 
Mmb.  The  distal  elliptical  portion  of 
skin  is  picked  up  and  drawn  toward  the 
body  and  the  muscles  are  divided  to  the 
bone,  the  knife  being  held  trans\*ersely 
(Figs.  955-957).  Kocher  points  out 
that  this  flap  increases   in   thickness 


Fig-  957- 
Figs.  955—957. — The  early  stef)s  of  an  obhque 
drcular  anq>utaticMi  (Kochor). 


Fig.  95S. — Amputation  of  t'-e  :ii:ri 
(Gre- 


toward  the  bone.    The  rest  of  the  muscles  are  di^dded  on  a  level  with  and  in 
the  direction  of  the  skin  edge.     The  periosteum  is  cut  transversely  and  is 


1406  Amputations 

treated  as  in  the  transverse  circular  operation.  The  flap  of  muscle  and  integu- 
ment is  brought  over  the  wound.  This  method  stands  midway  between  the 
circular  operation  and  the  operation  by  a  single  flap,  and  is  employed  par- 
ticularly in  certain  disarticulations. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or  of  both  skin 
and  muscle,  but  the  skin-flap  must  always  be  longer  than  the  muscle-flap,  so 
that  the  latter  will  be  covered  by  it.  A  flap  containing  much  muscle  heals 
badly,  but  the  best  flap  has  a  moderate  amount  of  muscle  (enough  skin  to 
cover  the  muscle  and  enough  muscle  to  cover  the  bone).  Flaps  may  be  single 
or  double.  Double  flaps  may  be  lateral  or  anteroposterior,  square  or  \J -shaped, 
equal  or  unequal,  and  they  may  be  cut  by  transfixion  (Fig.  958),  by  cutting  from 
without  inward,  by  dissection,  or  by  cutting  the  skin  from  without  inward 
and  the  muscles  by  transfixion. 

Racket  Method  (if  flaps  are  rounded,  is  known  as  the  "oval"  or  "lanceo- 
late" incision). — In  an  oval  amputation  the  incision  through  the  skin  and 
subcutaneous  tissue  is  an  oval  with  a  pointed  end  or  a  triangle;  and  the  other 
parts  down  to  the  bone  are  cut  from  without  inward.  When  a  longitudinal 
incision  down  to  the  bone  (see  Fig.  967,  a-b)  extends  from  the  point  of  the  oval, 
the  operation  is  called  the  "racket"  amputation.  If  the  longitudinal  cut  joins  a 
circular  cut,  the  operation  is  known  as  a  T-amputation.  The  oval  or  racket 
operation  is  performed  at  the  metacarpophalangeal,  metatarsophalangeal, 
and  shoulder-joints;  the  T-operation  may  be  performed  at  the  hip- joint. 

Completion  of  An  Amputation. — When  an  amputation  has  been  com- 
pleted, tie  the  main  vessels,  pull  down  the  nerves  and  cut  them  high  up,  smooth 
the  flaps,  take  off  the  constricting  band,  and  after  arresting  hemorrhage  apply 
sutures.  In  some  cases  the  deep  parts  are  stitched  with  a  continusous  catgut 
suture  and  the  superficial  parts  are  closed  with  silkworm-gut;  in  other  cases 
the  deep  parts  are  not  stitched  at  all,  the  skin  alone  being  sutured  with  silk- 
worm-gut. Drainage-tubes  should  be  used  except  in  amputations  of  the 
fingers  and  toes. 

Special  Amputations 

Fingers  and  Hand. — In  amputating  the  thumb  and  index-finger  save 
every  possible  scrap  of  tissue.  If  it  is  necessary  to  amputate  a  finger 
above  the  middle  of  the  middle  phalanx,  the  attachment  of  the  flexor 
tendons  will  be  cut  off  and  the  finger  will  be  liable  to  project  directly 
backward,  so  that  it  is  better  either  to  disarticulate  at  the  metacarpal 
joints  or  to  stitch  the  flexor  tendons  to  the  periosteum.  The  flexor  ten- 
dons have  fibrous  sheaths  extending  from  the  proximal  end  of  the  distal 
phalanx  to  the  metacarpophalangeal  articulations,  these  sheaths  being  thin 
and  collapsible  opposite  the  joints,  but  being  thick  and  rigid  opposite  the  shafts 
of  the  bone.  The  fibrous  sheath  is  known  as  the  theca,  and  when  it  is  cut 
in  an  amputation  it  should  be  closed,  otherwise  it  may  carry  infection  to  the 
palm  of  the  hand.  The  theca  does  not  exist  over  the  distal  phalanx,  and  it  is 
not  distinctly  visible  over  the  joint  between  the  distal  and  middle  phalanges. 
To  effect  closure  over  the  shaft  of  a  bone,  strip  up  the  periosteum  and  pass 
catgut  sutures  vertically  through  the  theca  and  the  periosteum  (Treves). 
In  amputation  of  the  fingers  and  the  thumb  an  Esmarch  bandage  is  unneces- 
sary, though  pressure  may  be  made  upon  the  arteries  at  the  wrist.  Only  two 
or  three  ligatures  are  necessary.  Close  with  a  very  few  sutures,  so  as  to  favor 
drainage  between  the  threads. 

The  distal  phalanx  is  best  removed  by  a  long  palmar  flap  (Fig.  959,  a). 
The  plamar  flap  (a)  is  marked  out  by  cutting  through  the  skin  and  subcu- 
taneous tissue.  The  incisions  are  next  carried  to  the  bone,  the  flap  is  dis- 
sected from  the  bone,  the  finger  is  strongly  flexed,  a  transverse  incision  (b)  is 


Amputation  of  the  Thumb 


1407 


carried  across  the  dorsum  on  a  level  with  the  base  of  the  third  phalanx,  the 

soft  parts  are  pushed  back,  the  joint  is  opened,  the  lateral  ligaments  are 

cut  from  within  outward,  the   third 

phalanx    is    forcibly    extended,    and 

the   remaining    structures    are     cut 

from  below  upward.     Fig.  960  shows 

the    lines    of    the    joints    when    the 

finger  is  flexed.     The  middle  phalanx 

can  be  removed  by  the  same  method 

(Fig.  959,  c).     The  proximal  phalanx 

can   be  removed   by  a  long   palmar 

flap  or  by  a  long  palmar  and  a  short 

dorsal  flap  (Fig.  959,  D,  e). 


Fig.  960. — The  line  of  the  joints  in  the  flexed 
position  of  the  finger:  a,  Extensor  longus  digi- 
torum;  b,  interossei  and  lumbricals;  c,  extensor 
longus  digitorum  and  interossei;  g,  interossei  and 
lumbricals;  /,  flexor  subhmis;  e,  flexor  profundus 
(Kocher). 


A  O- 

Fig.  959. — .\inputation  of  the  finger. 


Disarticulation  at  a  metacarpophalangeal  joint  is  best  performed 
by  the  oval  method.  The  incision  upon  the  dorsum  (a)  is  begun  just  above 
the  head  of  the  metacarpal  bone,  is  carried  down  to  beyond  the  base  of  the 
phalanx,  and  involves  the  skin  only  (Figs.  961  and  962).  One  incision  sweeps 
around  the  finger  at  the  level  of  the  web,  going  only  through  the  skin  (b); 
the  finger  is  extended  and  the  palmar  cut  is  carried  to  the  bone;  each  lateral 
incision  is  carried  to  the  bone  while  the  finger  is  bent  in  the  opposite  direction, 
the  flaps  are  dissected  back  to  the 
joint,  the  finger  is  strongly  extended, 
the  joint  is  opened  from  the  palmar 
side,  and  disarticulation  is  effected. 
Cutting  off  the  head  of  the  meta- 
carpal bone  improves  the  appearance 


Fig.  961. — A,  Disarticulation  of  a  metacarpo- 
phalangeal joint;  C,  amputation  of  a  finger 
with  the  metacarpal  bone. 


Fig.  962. — Disarticulation  of  the  little  finger 
and  index-finger.  Disarticulation  of  the  ring 
finger  with  its  metacarpal  bone.  Disarticula- 
tion of  the  thumb  with  its  metacarpal  bone 
(Kocher). 


of  the  stump,  but  weakens  the  hand,  hence  in  a  workingman  it  must  not  be  done 
unnecessarily.  If  it  is  necessary'  to  remove  a  metacarpal  bone,  the  incision 
(c)  is  made  from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through  its  distal  or  proximal  phalanx  is 
performed  in  the  identical  way  employed  in  amputation  of  a  finger.  Ampu- 
tation of  the  thumb,  with  a  portion  or  the  whole  of  its  metacarpal  bone,  is 
performed  by  the  oval  or  racket  incision  (Fig.  962). 


1408  Amputations 

Disarticulation  at  the  wrist=joint  can  be  done  by  the  oblique  circu- 
lar method  (Fig.  963)  or  by  a  double  flap.  In  the  double-flap  amputation  a 
dorsal  flap  is  made  by  carrying  a  semilunar  skin  incision  between  the  styloid 
processes;  the  skin  is  lifted,  the  wrist  is  forcibly  flexed,  the  joint  is  opened 
by  a  transverse  cut,  and  a  long  semilunar  palmar  flap  which  includes  only  the 
skin  and  fascia  is  made  by  dissection.  Kocher  prefers  to  amputate  by  an 
obHque  incision.  The  lower  end  of  this  incision  is  about  the  middle  of  the 
palm  and  the  upper  end  is  in  the  line  of  the  w^rist-joint  (Fig.  963).  The  hand 
is  strongly  flexed,  the  extensor  tendons  are  divided,  the  posterior  ligament  of 


Pig.   g63.- 


-Disarticulation   of  the  middle  finger.     Disarticulation  at  the  wrist-joint, 
through  the  forearm  by  the  obhque  circular  method  (Kocher). 


Amputation 


the  joint  is  incised,  and  incisions  below  the  styloid  processes  di\ade  the  lateral 
Hgaments  and  certain  tendons.  The  flexor  tendons  are  separated  from  the 
bone  and  are  di^dded  so  as  to  remain  in  the  palmar  flap. 

Amputation  through  the  forearm  may  be  effected  by  the  obHque  circular 
method  (Fig.  963),  the  circular,  the  modified  circular,  or  the  flap  operation.  The 
modified  chrcular  is  an  excellent  plan.  A  semilunar  dorsal  skin-flap  and  a  semi- 
lunar skin-flap  on  the  flexor  surface  are  made.  The  flaps  are  raised,  the  muscles 
are  cut  circularly  (Fig.  964),  the  interosseous  space  is  cleared  by  the  knife,  a 
three-tailed  retractor  is  applied,  the  periosteum  is  pushed  up,  and  the  bones 
are  saw^n  I  inch  above  the  flap.  In 
sawing  the  bones,  start  the  saw 
upon  the  radius,  draw  it  from  heel 
to  point,  make  a  furrow  on  the  ra- 
dius and  ulna,  and  saw  both  bones 
at  the  same  time.  After  saw- 
ing, cut  away  any  irregular  edge 


Fig.  964.- 


—Modified  circular  amputation  of 
the  forearm  (Bryant). 


Fig.  965. — Disarticulation  of  the  elbow-joint  by  the 
obhque  circular  method  (Kocher). 


with  bone-pliers.  In  the  lower  third  Teale's  amputation  may  be  done,  the 
dorsal  flap  being  the  long  one.  In  Teale's  amputation  rectangular  flaps  are 
made.  The  long  flap  is  equal  in  wddth  and  length  to  one-half  the  circumference 
of  the  hmb  at  the  pomt  where  it  is  to  be  sawn.  The  short  flap  is  equal  in  width 
to  the  long  flap,  but  is  only  one-fourth  its  length.  The  two  longitudinal  cuts 
are  at  first  taken  only  through  the  skin,  but  the  two  transverse  cuts  go  at  once 
to  the  bone.  The  flaps  are  dissected  up  from  the  interosseous  membrane  and 
the  bone.     In  the  middle  or  the  upper  third  of  a  fleshy  arm  two  semilunar 


Larrey's  Operation  for  Disarticulation  at  Shoulder-joint         1409 

skin-flaps  can  be  cut  from  without  inward,  and  the  muscles  can  be  cut  by 
transfixion. 

Disarticulation  at  the  elbow=joint  can  be  done  by  the  elliptical 
method  or  by  a  long  anterior  and  short  posterior  flap.  In  Kocher's  oblique 
operation  the  incision  begins  anteriorly  over  the  joint-line  and  ends  posteriorly 
a  hand's  breadth  below  the  summit  of  the  olecranon  (Fig.  965).  A  posterior 
flap  which  contains  the  integument,  the  insertion  of  the  triceps,  the  anconeus, 
and  the  periosteum  is  dissected  up  until  the  posterior  surface  of  the  humerus 
is  reached.  The  joint  is  opened  anteriorly  by  a  transverse  incision,  and  the 
radiohumeral  articulation  is  opened  from  without  inward  (Kocher).  In  the 
double  flap  operation  the  forearm  is  partly  flexed  and  a  skin-cut  marks 
out  a  long  anterior  flap,  the  knife  being  entered  opposite  the  external  condyle 
and  being  withdrawn  i  inch  below  the  internal  condyle.  The  muscles,  which 
are  bunched  forward,  are  cut  by  transfixion.  A  posterior  semilunar  flap  is 
made,  which  separates  the  attachments  of  the  radius,  the  ulna  is  cleared,  and 
the  triceps  is  cut  at  its  insertion  (Bell).  Gross  advocated  sawing  through 
the  olecranon  and  the  inner  trochlear  surface. 


Tig.  966. — Use  of  Wyeth's  pins  in  amputation  at  the  shoulder-joint.      The  acromion  is  marked  by  a 

black  line  (Keen). 

Amputation  of  the  arm  is  best  performed  by  marking  out  with  a  knife 
two  equal  semilunar  anteroposterior  flaps,  the  first  cut  being  carried  through 
the  skin  alone,  the  muscles  being  then  transfixed  with  a  long  knife.  Teale's 
method  is  shown  in  Figs.  438  and  439.  The  circular  or  the  modified  circu- 
lar amputation  may  be  performed. 

Disarticulation  at  the  Shoulder=joint. — In  this  operation  some 
surgeons  use  Wyeth's  pins  to  hold  the  Esmarch  band  in  place.  The  an- 
terior pin  is  entered  at  the  middle  of  the  lower  margin  of  the  anterior  axillary 
fold,  and  emerges  i  inch  within  the  tip  of  the  acromion.  The  posterior  pin 
is  entered  at  a  corresponding  point  on  the  posterior  axillary  fold,  and  emerges 
more  posteriorly  than  the  first  pin  and  an  inch  within  the  tip  of  the  acromion. 
After  the  extremity  has  been  drained  of  blood  by  the  Esmarch  bandage  or  by 
stroking  and  a  vertical  position,  the  Esmarch  band  is  applied  above  the  pins 
(Fig.  966).  With  a  competent  assistant,  however,  the  pins  are  not  necessary, 
the  surgeon  divides  his  main  vessels  as  the  last  step  of  the  operation,  and  the 
assistant  controls  them,  before  they  are  cut  and  until  they  are  tied,  with  his 
thumbs  slipped  back  of  the  bone. 

Larrey's  Operation. — In  this  method  of  shoulder- joint  disarticulation  the 
limb  is  held  from  the  side  and  an  incision  is  made  down  to  the  bone,  the  incision 
beginning  just  below  and  in  front  of  the  acromion  and  running  vertically  for 


I4IO 


Amputations 


4  inches  down  the  outer  surface  of  the  arm  (Fig.  967,  a-b).  From  the  center 
of  this  incision  an  oval  incision  {c-d,  c~e)  is  carried  around  the  arm,  the  inner 
aspect  of  the  oval  reaching  as  low  as  the  lower  end  of  the  vertical  cut.  The 
oval  incision  at  first  involves  only  the  skin  and  subcutaneous  tissues.  The 
anterior  structures  are  divided  close  to  the  bone,  and  the  posterior  structures 
are  next  cut.  To  disarticulate,  cut  the  capsule  transversely  upon  the  head  of 
the  bone;  while  the  arm  is  rotated  outward  cut  the  subscapularis,  and  while 
the  arm  is  rotated  inward  cut  the  supraspinatus  and  infra- 
spinatus and  the  teres  minor.  Cut  away  any  tissue  holding 
the  humerus  to  the  body,  hanging  nerves,  capsule-fragments 
and  tissue-shreds,  insert  a  tube,  and  sew  up  the  wound  ver- 
tically. Bell  advises  an  oval,  incision  with  a  racket  handle. 
Spence  used  an  anterior  racket  incision. 

Kocher's  Operation. — Kocher  makes  an  anterior  lan- 
ceolate incision  (Fig.  968).  The  incision  begins  over  the 
clavicle  just  external  to  the  coracoid  process  of  the  scapula, 
and  is  carried  downward,  dividing,  as  it  advances,  the 
anterior  fibers  of  the  deltoid  muscle.  "Bleeding  vessels 
and  the  cephalic  vein  are  ligatured.  In  the  upper  part  of 
the  wound  the  acromial  branches  of  the  acromiothoracic 
artery  are  also  ligatured.  The  knife  is  carried  down  to  the 
bone  at  the  edge  of  the  deltoid  (only  the  upper  fibers  of  which  have  been 
divided).  The  capsule  is  divided  over  the  lesser  tuberosity  and  the  bicipital 
groove.  The  periosteum,  the  insertions  of  the  subscapularis,  pectoralis 
major,  latissimus  dorsi,  and  teres  major  are  detached  along  with  the  capsule. 
The  capsule,  along  with  the  insertions  of  the  supraspinatus,  infraspinatus, 
and  teres  minor  muscles,  is  also  detached  from  the  upper  part  of  the  head 


Fig.  967. — Ampu- 
tation at  the  shoul- 
der-joint: a-h,  c-d, 
c-e,  Larrey's  opera- 
tion; f-g,  Dupuy- 
tren's  operation. 


Fig.  968. — Disarticulation  at  the  shoulder-joint 
by  Kocher's  method  (Kocher). 


Fig.  969.- 


-Removal  of  the  entire  upper  extremity 
(Kocher) . 


and  from  the  great  tuberosity.  The  head  of  the  humerus  can  now  be  pro- 
truded from  the  wound.  In  cutting  down  over  the  surgical  neck  it  may  be 
necessary  to  ligature  the  circumflex  arteries;  in  any  case  the  anterior  vessel 
must  be  tied.  The  racket  incision  is  now  completed  by  dividing  the  skin 
circularly  at  the  level  of  the  axillary  folds.  The  vessels  and  nerves  are  then 
easily  isolated,  the  former  being  ligatured  and  the  latter  divided"  (Kocher's 
"Text-Book  of  Operative  Surgery,"  translated  by  Harold  J.  Stiles).     Kocher 


Amputation  of  the  Toes  and  the  Foot 


1411 


cautions  us  to  avoid  the  circumflex  nerve  which  suppHes  the  deltoid,  as  the 
deltoid  is  the  muscle  of  the  stump. 

Dupuytren's  Operation. — In  Dupuytren's  shoulder-joint  disarticulation 
a  U-shaped  dap  is  marked  out  by  a  skin-incision  (Fig.  967, /-g>.  If  the  am- 
putation is  "CO  be  at  the  right  shoulder,  the  arm  is  carried  across  the  chest;  the 
knife  is  entered  at  the  root  of  the  acromion,  follows  the  margin  of  the  deltoid, 
and  is  withdra\\Ti  at  the  coracoid  process,  the  arm  being  gradually  abducted 
and  pulled  oS  from  the  chest.  If  the  left  shoulder  is  to  be  amputated  the 
procedure  is  reversed  (Treves').  The  knife  next  cuts  through  the  deltoid 
and  raises  a  flap  composed  of  this  muscle,  the  shoulder-joint  is  exposed,  and 
disarticulation  is  effected  as  in  Larrey's  method.  The  knife  is  passed  down 
back  of  the  bone  and  a  short  internal  flap  is  cut. 

Lisfranc's  amputation  is  by  transfixion  v,-ith  the  formation  of  an  anterior 
and  a  posterior  flap,  and  can  be  performed  ver\-  rapidly  by  a  skilful  surgeon. 

Amputation  of  the  Entire  Upper  Extremity. — Berger's  Opera- 
tion.— The  Interscapulothorack  Amputation. — This  operation,  which  is  an 
amput:ation  above  the  shoulder- joint,  was  described  by  Berger  in  1S87.  By 
it  are  removed  the  arm,  the  scapula,  and  a  portion 
of  or  the  entire  cla\-icle.  It  is  occasionally  employed 
in  cases  of  maHgnant  disease  and  of  severe  injur}-. 
The  operation  is  attended  with  profuse  hemorrhage, 
and  as  a  preliminars-  the  subcla\'ian  vessels  should 
be  Hgated.  The  incisions  must  be  varied  according 
to  the  necessities  of  the  case.  In  this  operation 
Berger  di^'ides  the  cla\-icle  at  the  junction  of  its 
outer  and  middle  thirds,  and  resects  the  middle  third 
of  the  bone;  Hgates  and  di\ides  the  subcla^•ian  ves- 
sels; cuts  the  anterior  flap;  di^•ides  the  brachial 
plexus;  marks  out  the  posterior  flap;  and  completes 
the  operation  by  di\-iding  the  structures  which  hold 
the  shoulder-blade  to  the  chest.  It  is  in  this  last 
step  that  bleeding  is  profuse.  Figure  970  shows 
Berger's  incisions  for  the  operation.  Figure  969 
shows  Kocher's  incisions. 

The  usual  procedure  of  t}-ing  the  third  part  of  the 
preliminar}'  measure  possesses  certain  disadvantages. 
deeply  situated  at  this  point,  is  in  close  relation  -nith  the  pleura,  and  is  covered 
to  a  considerable  extent  by  the  vein,  and  the  phrenic  ner\-e  is  ver\-  near.  Le 
Conte  resects  the  entire  cla\'icle  before  t}"ing  the  vessels.  He  maintains  that 
then  one  ot"*  two  courses  may  be  taken:  The  veins  may  be  severed  first,  and 
aftem-ard  the  arter\-  may  be  exposed  and  tied.  When  this  is  done,  the  amount 
of  blood  remaining  in  the  arm  is  lost.  The  procedure  that  he  selects  as  the 
best,  however,  is  to  expose  the  axillar}-  arten,-  as  high  up  as  possible,  and  place 
a  temporary-  ligature  around  it ;  then  elevate  the  arm,  empty  it  of  blood,  place 
a  permanent  hgature  around  the  third  part  of  the  subcla\'ian  arten.-,  and  (il^ide 
the  arter}-  in  this  portion  of  its  course  (Robert  G.  LeConte,  ''Annals  of  Surgen.-," 
Oct.,  1902).  If  the  scapula  is  involved  in  the  tumor,  the  mortahty  is  something 
over  23  per  cent.  (Berger,  *'Re^-ue  de  Chir.,"  Aug.,  1905).  I  have  twice  per- 
formed the  operation  successfully  and  in  each  case  followed  LeConte's  plan. 

Amputation  of  the  Toes  and  the  Foot. — Only  through  the  great  toe 
is  partial  amputation  performed,  and  it  is  effected  by  the  formation  of  a  long 
plantar  flap,  just  as  a  long  pahnar  flap  is  formed  from  a  finger.  .Amputation 
at  a  metatarsophalangeal  joint  is  pert'ormed  by  an  oval  or  racket  incision 
(Fig.  971,  c,  c).  Amputation  of  a  toe  with  removal  of  its  metatarsal  bone  is 
shown  in  Fig.  971,  a-b  and  d—e. 


Fig.   970. — Removal  of  the 
whole  upper  extremin-. 

ubcla\-ian  artery  as  a 
The   arter\'  is  ven' 


I4I2 


Amputations 


Disarticulation   at  the   Tarsometatarsal   Articulation. — Lisfranc's 

Operation  {after  Treves). — In  order  to  amputate  the  right  foot  by  this  method 
begin  an  incision  on  the  outer  border  of  the  foot,  behind  the  tubercle  of  the 
fifth  metatarsal  bone;  carry  the  incision  forward  i  inch  and  sweep  it  across 
the  foot  I  inch  below  the  tarsometatarsal  articulations;  bring  the  incision 
to  the  inner  edge  of  the  foot,  ^  inch  in  front  of  the  articulation  of  the  tarsus 
with  the  first  metatarsal  bone,  and  carry  the  cut  straight  back  along  the 
inner  margin  of  the  foot  until  it  reaches  a  point  f  inch  above  the  articulation  of 


Fig.  g7i. — Amputation    of    the    toes    with    and 
without  the  metatarsal  bones. 


Fig.  972. — Lines    in    amputations    of    the    foot 
(Gross). 


the  metatarsal  bone  of  the  great  toe.  A  very  short  semilunar  dorsal  skin-flap 
is  thus  formed.  Figure  977  shows  the  flaps  as  cut  by  Kocher.  After  the  skin- 
flap  has  been  dissected  back  for  \  inch  the  tendons  are  divided,  and  the  flap, 
which  now  contains  aU  the  soft  parts,  is  dissected  back  to  above  the  joint.  A 
long  plantar  flap  is  cut,  reaching  from  the  origin  of  the  first  flap  to  the  necks 
of  the  metatarsal  bones.  The  skin-flap  is  dissected  up  until  the  hollow  behind 
the  heads  of  the  metatarsal  bones  is  reached,  when,  with  the  toes  in  extension, 
the  tendons  are  cut  across  and  a  flap  composed  of  all  the  soft  parts  is  dissected 
up  to  above  the  tarsometatarsal  joint.     Figures  972  and  977  show  the  Hne  of 


Fig.  973. — Lisfranc's  amputation:  First  step 
in  disarticulating  the  second  metatarsal  bone 
(Guerin). 


Fig.  974. — Lisfranc's  amputation:  Second  step. 
in  disarticulating  the  second  metatarsal  bone 
(Guerin). 


Lisfranc  at  the  tarsometatarsal  articulation.  The  joint  is  opened  from  the 
outer  side  according  to  the  following  rule :  in  separating  the  fifth  metatarsal  di- 
rect the  edge  of  the  knife  toward  the  distal  end  of  the  first  metatarsal;  in 
separating  the  fourth  metatarsal  direct  the  knife  toward  the  middle  of  the 
first  metatarsal ;  in  separating  the  third  metatarsal  carry  the  knife  almost  di- 
rectly across.  The  separation  is  faciUtated  by  bending  down  the  front  of  the 
foot,  and  at  the  same  time  the  tendons  of  the  peroneus  brevis  and  tertius  are 
divided.     Open  the  joint  between  the  first  metatarsal  and  the  inner  cuneiform 


Disarticulation  at  the  Tarsometatarsal  Articulation 


1413 


bone,  turning  the  knife  toward  the  middle  of  the  shaft  of  the  fifth  metatarsal, 
and  at  the  same  time  divide  the  tibiahs  anticus  muscle.  Treves  says  that  in 
disarticulation  of  the  second  metatarsal  the  knife  is  to  be  held  as  a  trocar,  it  is 
to  be  thrust  between  the  base  of  the  first  and  second  metatarsal  bone  until 
the  pomt  strikes  bone  (Fig.  973),  and  is  then  to  be  raised  to  a  perpendicular  and 
the  cut  is  to  be  made  toward  the  external  malleolus  to  sever  the  ligament  of 
Lisfranc  (Fig.  974).     Divide  any  remaining  ligaments,  and  also  the  tendon 


Fig.  075. — Anterior  intertarsal    Fig.  g76. — Chopart's  am-    Fig.  g^^. — ^Lisfranc's  ampu- 
disarticulation  (Kocher).  putation  (Kocher).  tation  (Kocher). 

of  the  peroneus  longus  muscle.  The  skin-incisions  in  the  left  foot  are  begun 
on  the  inner  side,  and  in  disarticulating  the  tarsal  joint  of  the  great  toe  is  first 
opened.  Figure  978  shows  the  parts  after  disarticulation  at  the  line  of  Lisfranc. 
Hey's  Operation. — In  Hey's  method  the  incision  is  practically  the  same 
as  that  for  Lisfranc's  amputation.    The  four  external  metatarsal  bones  are 


Fig.  978. — The  parts  after  Lisfranc's  amputa- 
tion  (Bernard  and  Huette). 


Fig.    979. — The    parts    after    amputation    by 
Chopart's  method  (Bernard  and  Huette). 


disarticulated,  but  the  first  metatarsal  is  removed  by  sawing  a  portion  of  the 
internal  cuneiform  bone.  Guerin  advised  sawing  all  the  bones  across.  Skey 
advised  the  division  of  the  head  of  the  second  metatarsal.  Figure  972  shows 
the  line  of  Hey. 


1414  Amputations 

Anterior  Intertarsal  Disarticulation  (Amputation  of  Forbes,  of  Toledo). 

— The  disarticulation  is  effected  between  the  three  cuneiform  bones  in  front 
and  the  scaphoid  behind,  and  the  cuboid  is  sawn  across.  Figure  972  shows 
the  Hne  of  Forbes.  The  incision  of  the  soft  parts  is  as  for  Lisfranc's  ampu- 
tation (Fig.  97s). 

Disarticulation  Through  the  Middle  Tarsal  Joint. — Chopart's 
Operation  {Posterior  Intertarsal  Disarticulation). — Make  a  transverse  in- 
cision through  the  skin  of  the  instep,  2  inches  below  the  ankle-joint;  cut  the 
tendons  and  muscles,  expose  the  tarsus,  and  make  on  each  side  a  small  longi- 
tudinal incision  reaching  to  below  and  in  front  of  the  corresponding  malleolus. 
The  flap  thus  formed  is  retracted.  The  plantar  flap  is  made  as  in  Lisfranc's 
amputation.  The  flaps  as  made  by  Kocher  are  shown  in  Fig.  976.  Open 
the  astragaloscaphoid  joint,  then  the  calcaneocuboid  joint,  and  disarticulate. 
Figures  972  and  976  show  the  line  of  Chopart.  Figure  979  shows  the  parts 
after  Chopart's  disarticulation. 

Subastragaloid  Disarticulation. — A  circular  incision  is  carried  around 
the  foot  at  the  level  of  the  middle  tarsal  joint  and  a  racket  incision  is  added  to 
it  running  below  and  posterior  to  the  tip  of  the  external  malleolus  (Fig.  980). 
"The  joint  between  the  astragalus  and  scaphoid  is  opened  upon  the  dorsum, 

without  opening  the  calcaneo- 
cuboid joint.  A  narrow  knife 
is  then  passed  backward  and 
slightly  upward  beneath  the 
head  of  the  astragalus  so  as  to 
divide  the  strong  interosseous 
ligament  between  it  and  the 
OS  calcis.  The  soft  parts  are 
then  dissected  off  the  os  calcis, 
first  from  its  upper  surface, 
then  from  its  outer  and  under 

Fig.  g8o.— Subastragaloid  disarticulation  (Kocher).  Surfaces,    and   lastly    from   its 

inner  and  posterior  surfaces. 
The  greatest  difficulty  is  met  with  at  the  inner  side  in  clearing  the  projecting 
sustentaculum  tah"  (Kocher's  "Text-Book  of  Operative  Surgery,"  translated 
by  Harold  J.  Stiles). 

Disarticulation  At  the  Ankle=joint. — Syme's  Method. — The  foot 
is  held  at  a  right  angle  to  the  leg,  and  a  skin-incision  is  carried,  from  just 
below  the  external  malleolus,  straight  across  or  a  little  backward  across  the 
sole  to  a  corresponding  point  on  the  opposite  side.  Do  not  take  this  incision 
near  to  the  inner  malleolus,  as  to  do  so  will  endanger  the  posterior  tibial  ar- 
tery. The  incision  is  carried  to  the  bone,  the  flap  being  pushed  back  and 
separated  from  the  bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot  is  now  extended 
and  a  transverse  cut  is  made  across  the  dorsum,  joining  the  two  ends  of  the 
first  incision;  the  ankle-joint  is  opened,  the  lateral  ligaments  are  cut,  disar- 
ticulation is  effected,  and  the  foot  is  finally  completely  removed  by  severing 
the  tendo  Achillis.  A  thin  piece  of  bone  including  both  malleoli  is  sawn 
from  the  tibia  and  fibula.  The  flap  is  perforated  posteriorly  to  secure  drain- 
age (Fig.  438). 

Pirogoflf's  Method. — Flex  the  foot  to  a  right  angle  with  the  leg.  "Make 
an  incision  from  the  tip  of  the  internal  malleolus  across  the  sole,  a  little  in 
front  of  the  long  axis  of  the  tibia,  to  a  point  in  front  of  the  apex  of  the  external 
malleolus  down  upon  the  bone."^  Dissect  the  flap  backward  from  the  cal- 
caneum  for  \  inch,  but  do  not  dissect  the  flap  from  the  posterior  portion  of  the 
1  "Operative  Surgery,"  by  Joseph  D.  Bryant. 


Sedillot's  Leg  Amputation 


1415 


Fig.  gSi.- 


-Lines  of  section  of  the  os  calcis  and  the  bones  of  the 
leg  in  Pirogoff's  amputation. 


OS  calcis.  Join  the  extremities  of  the  first  incision  by  another  cut  which 
reaches  to  the  bone,  and  which  is  "|  inch  in  front  of  the  lower  extremity  of  the 
tibia"  (Bryant) ;  but  saw  off  this  bony  projection  obliquely  and  leave  it  adhe- 
rent to  the  tissues.  The  saw  is  used  after  disarticulation  of  the  ankle-joint; 
it  is  passed  behind  the  astragalus,  cutting  downward  and  forward,  sawing  the  os 
calcis  obliquely,  and  leaving  a  considerable  portion  in  place  in  the  flap.  The 
lower  ends  of  the  tibia  and  fibula  are  well  exposed  by  raising  the  anterior  flap 
slightly;  the  sawing  is  begun  anteriorly  just  above  the  articular  surface,  and  is 
completed  h  inch  above  the  articular  surface  posteriorly.  The  lines  a  and  b 
(Fig.  98 1)  show  the  sections  made  by  the  saw.  The  sawn  surface  of  the  os 
calcis  is  brought  into  contact  with  the  sawn  surfaces  of  the  tibia  and  fibula,  and 
the  flaps  are  sutured. 

Amputations  of  the 
Leg. — The  so-called  "point 
of  election"  is  at  the  upper 
part  of  the  middle  third  of 
the  leg.  Se^■enty-five  years 
ago  Liston  advised  surgeons 
not  to  amputate  in  the  lower 
third  of  the  leg  because  of  the 
scantiness  of  the  soft  parts, 
because  the  stump  is  apt  to 
ulcerate,  and  because  it  is  un- 
comfortable in  an  artificial 
leg.  These  views  have  been 
much  modified.  The  ampu- 
tation near  the  ankle  is  safer 
than  the   amputation  near 

the  knee,  and  artificial  legs  are  now  made  which  may  be  worn  with  comfort.  In 
amputations  of  the  leg  by  the  long  anterior  flap,  cut  through  the  skin,  dissect  up 
the  anterior  muscles  with  the  flap,  and  cut  all  the  posterior  tissues  -^ith  a  single 
transverse  sweep.  Amputation  by  the  rectangular  flap,  Teale's  method,  is  ver>- 
useful  (see  page  140S).  The  long  flap  is  anterior,  and  is  in  length  and  breadth 
equal  to  one-half  the  circumference  of  the  limb.     The  short  flap  is  one-fourth 

the  length  of  the  long  flap.  The  flaps  are 
dissected  up,  the  bones  are  sawn,  the  long 
flap  is  turned  upon  itself,  and  its  edges  are 
sutured  to  the  edges  of  the  short  flap. 

Bier  suggests  a  plan  (Fig.  9S2)  to  in- 
crease the  supporting  power  of  the  stump 
after  a  leg  amputation.  After  the  wound 
has  healed,  a  wedge-shaped  piece  of  bone  is 
removed  above  the  level  of  the  stump. 
The  lower  extremity  is  turned  forward  and 
upward  through  an  arc  of  90  degrees,  and 
unites  in  this  position  (Zuckerkandl's  "Oper- 
ative Surgen,^' ') .  Thus  the  medullar^'  ca\-ity 
is  closed  and  the  skin  which  must  bear 
pressure  is  healthy  and  free  from  cicatrices;  and  as  the  muscles  are  still 
attached  to  the  bone,  they  do  not  undergo  atrophy. 

Sedillot's  leg  amputation  (Fig.  983)  is  by  a  long  external  flap.  A  longi- 
tudinal incision  is  made  along  the  inner  edge  of  the  tibia,  the  tissues  are  drawn 
toward  the  fibula,  a  knife  is  introduced  and  passed  to  the  outer  edge  of  the  tibia, 
just  touching  the  fibula,  and  is  brought  out  posteriorly,  thus  transfixing 
the  calf-muscles  and  cutting  an  external  flap.     A  convex  incision  is  made  on 


Fig.  g82. — Diagrammatic  representa- 
tion of  amputation  of  the  leg  after  the 
method  of  Bier. 


I4I6 


Amputations 


the  inner  side,  the  bones  are  cleared  and  are  sawn  i  inch  above  the  flaps, 
^  inch  more  being  taken  from  the  fibula  than  from  the  tibia,  and  the  tibia  being 
bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg. — Cut  semilunar  skin-flaps,  lay 
them  back,  and  cut  circularly  to  the  bone  at  the  edge  of  the  turned-up  flap. 
Another  method  of  modified  circular  amputation  is  by  adding  to  the  circular  cut 
a  vertical  incision  down  the  front  of  the  leg.  In  sawing  the  bones  of  the  leg  the 
surgeon,  who  stands  to  the  outer  side  of  the  right  leg  or 
to  the  inner  side  of  the  left  leg,  divides  the  fibula  first, 
and  at  a  higher  level  than  the  tibia,  and  bevels  the  an- 
terior surface  of  the  tibia.  In  sawing  the  left  fibula  the 
saw  points  to  the  floor;  in  sawing  the  right  fibula  it 
points  to  the  ceiling. 

Amputation  of  the  Leg  by  a  Long  Posterior  and  a 
Short  Anterior  Flap. — In  this  operation  a  posterior  U- 
shaped  flap  is  made  equal  in  length  and  breadth  to  the 
diameter  of  the  limb.  The  skin-incision  is  begun  i  inch 
below  the  point  where  the 
bone  is  to  be  sawn,  and 
behind  the  inner  edge  of 
the  tibia,  and  is  carried  to 
a  point  posterior  to  the 
peronei  muscles.  The  gas- 
trocnemius muscle  is  di- 
vided transversely  at  the 
level  of  the  flap,  the  soft 
parts  on  either  side  in  the  fine  of  the  flap  being  cut  to  the  bone.  Through 
these  vertical  cuts  the  muscles  are  lifted  from  the  bones  and  are  divided 
through  their  lower  part  by  cutting  from  within  outward.  The  anterior  flap 
is  formed  by  making  a  semflunar  skin-flap  and  by  cutting  the  muscles  across 
at  its  retracted  edge  (Fig.  984). 

Amputation  of  the  leg  by  lateral  flaps  is  not  a  popular  operation,  as  it  offers 
too  much  encouragement  to  subsequent  protrusion  of  the  bone. 


Fig.    Q83.— S^dillot's 
amputation    of   the    leg 

(Wyeth). 


Fig.  984. — Amputation  of  the  leg 
by  a  long  posterior  flap  (Gross). 


Fig.  985. — Kocher's  oblique  incision  for  disarticulation  at  the  knee-joint  (Kocher). 

Amputation  Just  Below  the  Knee. — The  seat  of  election  is  i  inch  below 
the  tuberosities.  No  muscle  is  needed  in  the  flap.  Cut  two  flaps  of  skin, 
equal  in  size  and  of  semilunar  shape,  these  flaps  beginning  anteriorly  2  inches 
below  the  tuberosity  of  the  tibia.  One  flap  is  antero-external  and  the  other  is 
postero-internal.  The  flaps  are  pulled  up,  the  anterior  muscles  are  cut  as  high 
up  as  possible,  and  the  posterior  muscles  are  cut  through  the  middle  of  the 
portion  exposed  (Bell).    The  bone  is  sawn  i  inch  below  the  tuberosity. 


Amputation  of  the  Thigh 


1417 


Disarticulation  At  the  Knee. — In  disarticulation  by  the  long  anterior 
flap,  make  a  long  anterior  skin-flap,  incise  the  ligament  of  the  patella,  turn  up 
a  flap  containing  the  patella,  open  the  joint,  and  complete  the  disarticulation 
by  cutting  from  within  outward  and  downward.  The  knee  may  be  disarticu- 
lated by  means  of  a  long  anterior  and  a  short  posterior  flap.  Kocher  prefers 
the  oblique  incision  (Fig.  985).  This  secures  an  anterior  flap.  The  leg  is  so 
held  that  it  makes  an  angle  with  the  thigh  of  135  degrees  and  "the  incision 
falls  in  the  continuation  of  the  long  axis  of  the  thigh"  (Kocher's  "Text-book 
of  Operative  Surgery,"  translated  by  Harold  J.  Stiles).  The  posterior  part 
of  the  incision  is  opposite  the  line  of  the  joint  and  the  anterior  part  of  the 
incision  ends  four  fingers-breadth  below  the  tibial  tubercle. 

Amputation  Through  the  Femoral  Condyles. — Syme's  Method  by  a  Long 
Posterior  Flap. — Carry  a  skin-incision,  with  a  very  slight  downward  curve  from 
one  condyle  to  the  other,  across  the  middle  of  the  patella.  Cut  down  to  the 
bone,  retract  the  flap,  and  cut  the  quadriceps  above  the  patella.  Insert  a 
long  knife  at  one  angle  of  the  wound,  pass  it  back  of  the  femur,  and  make  it 
emerge  at  the  opposite  angle,  cutting  a  posterior  flap  8  inches  long.  Retract 
the  posterior  flap,  clear  for  sawing,  and  section  the  condyles  horizontally. 
Carden  made  a  curved  section  of  the  condyles  at  their  widest  part.  In  children 
Buchanan  showed  that  we  can  easily  separate  the  lower  femoral  epiphysis. 


Fig.  986.- 


-Diagrammatic  representation  of  Grit- 
ti's  operation. 


Diagrammatic  representation  of  Sa- 
banejeff's  operation. 


In  Gritti's  supracondyloid  amputation  an  oblique  incision  is  made.  The  upper 
end  of  the  incision  is  posterior  and  just  above  the  condyles.  Its  lower  end  is 
anterior  and  two  fingers-breadth  below  the  patella  (Kocher).  The  ligament  of 
the  patella  is  cut,  the  flap  is  turned  up,  the  femur  is  sawn  at  the  base  of  the 
condyles,  the  articular  face  of  the  patella  is  sawn  off,  and  the  sawn  patella  is 
fastened  to  the  sawn  femur  and  the  flaps  are  sutured  (Fig.  986).  Sabanejeff 
makes  an  anterior  flap,  opens  the  knee-joint  from  behind,  saws  the  condyles 
at  their  broadest  part,  takes  a  bone-flap  from  the  anterior  portion  of  the  tibia, 
and  fastens  it  to  the  femur  (Fig.  987). 

Amputation  of  the  Thigh. — In  high  amputation  in  the  lower  third  either  a 
flap  or  a  circular  operation  may  be  performed.  In  a  double-flap  operation  a 
semilunar  skin-incision  should  be  made  from  without  inward,  and  the  muscles 
should  be  cut  by  transfixion  (Fig.  988).  In  the  lower  third  Teale's  flap  or  the 
long  anterior  flap  may  be  employed.  The  amputation  by  a  long  anterior  flap 
consists  in  making  a  lengthy  skin-flap,  reflecting  it,  cutting  the  anterior  struc- 
tures to  the  bone,  again  entering  the  long  knife  at  one  angle  of  the  incision, 
pushing  it  back  of  the  femur,  bringing  it  out  at  the  outer  angle,  and  cutting  the 
structures  behind  the  bone  directly  backward.  Bell  amputates  by  a  long  an- 
terior semilunar  flap  and  a  short  posterior  flap.  In  amputations  in  the  upper 
two-thirds  of  the  thigh  the  best  plan  is  to  mark  out  equal  anterior  and  posterior 


I4i8 


Amputations 


semilunar  skin-flaps,  divide  the  skin  with  a  scalpel,  enter  the  long  knife  at  one 
angle  of  the  anterior  flap,  bring  it  out  at  the  other  angle,  and  cut  the  muscles 
by  transfixion.  Cut  the  posterior  flap  in  the  same  manner.  Some  surgeons 
prefer  a  long  anterior  semilunar  flap  and  a  short  posterior  semilunar  flap.  The 
pure  circular  amputation  is  not  adapted  to  the  thigh. 

Disarticulation  At  the  Hip-joint. — Various  methods  have  been  employed  to 
prevent  or  limit  hemorrhage  during  this  formidable  operation.     Abernethy 
used  digital  compression  of  the  external  iliac  artery  or  of  the  femoral  artery. 
This  is  an  extremely  tiresome  procedure; 
the  finger  is  liable  to  slip;  and,  in    any 
case,    compression    so    situated    fails    to 
intercept  the  blood-current  in  a  number 
of  large  vessels. 


Fig.  g88. — Amputation  of  the  thigh  (Bryant). 


Fig.  989. — Pancoast's  aorta  tourniquet. 


Various  other  methods  have  been  employed.  It  was  formerly  the  custom 
to  compress  the  aorta  by  means  of  an  abdominal  compressor  (Figs.  989,  990). 
A  tourniquet  is  very  likely  to  be  displaced  during  the  operation.  The  intention 
is  to  compress  the  artery  against  the  spine,  but  in  effecting  this  the  circulation 
in  a  portion  of  the  intestine  may  be  impaired.     In  any  case,  as  Senn  says,  the 


Fig.  ggo. — ^Von  Esmarch's  aorta  tourniquet. 

circulation  is  cut  off  from  half  the  body,  and  the  patient  is  exposed  to  grave 
danger  from  "sudden  vascular  engorgement  of  important  internal  organs" 
(Senn).  Again,  an  abdominal  compressor  of  this  sort  does  not  arrest  venous 
bleediiig.  A  number  of  years  ago  Davy  suggested  that  a  suitable  cylindrical 
piece  of  wood,  about  25  inches  long,  and  shaped  like  a  cone  at  the  end,  might 
be  introduced  into  the  rectum  and  used  to  compress  the  common  iliac  artery 


Disarticulation   at   the  Hip-joint 


141Q 


upon  the  pel\"ic  brim.     This  appliance  is  known  as  Davy's  lever.     It  is  apt 
to  slip,  and  may  do  serious  damage  to  the  rectum. 

Some  surgeons  have  practised  preliminary-  ligation  of  the  common  femoral 
arter\-  or  of  the  external  iliac  arten*-.  and  others  have  tied  the  vessels  while 
making  the  flaps.  I  employed  preliminary-  Ugation  of  the  common  femoral  with 
perfect  satisfaction  in  2  of  my  4  cases  of  amputation  at  the  hip-joint  for 
sarcoma  of  the  femur.  If  any  form  of  compression  is  used,  that  recommended 
by  Macewen,  of  Glasgow,  is  the  most  successful  and  satisfactory-  (Fig.  991). 
The  weight  of  the  assistant's  body  is  thrown  upon  the  patient's  aorta  by  the 
right  nst.  placed  slightly  to  the  left  of  the  umbilicus.  McBurney  has  suggested 
the  prevention  of  bleeding  by  making  a  small  abdominal  incision  and  ha\-ing  an 
assistant  make  direct  digital  pressure  upon  the  iliac  arter\-.  I  employed  Mc- 
Bumey's  method  in  one  case  and  found  it  most  satisfactory-.  In  this  case  a 
sarcoma  of  the  thigh  reached  up  so  far  that  no  band  could  be  applied  above 


Fig.  Qg2. — Posterior  dap  in  author's  un- 
usual case  requiring  hip-joint  amputation: 
a—b.  The  anterior  itdsion;  a-c—d.  the  ex- 
Fig,  ggi. — ^Macewen's  method  for  compression  of  the  ab-       temal  incision  and  the  beginning  of  the 
dominal  aorta  ("American  Text-Book  of  Surger\-").  posterior  cut. 


it  and  I  was  obliged  to  make  the  posterior  flap  shown  in  Fig.  992.  If  the 
constricting  band  of  Esmarch  is  applied  by  the  ordinary-  method,  it  is  certain 
to  sHp.  It  may  remain  in  place  if  appHed  as  a  figure-of-S  of  the  thigh  and  the 
peMs,  but  even  then  it  is  uncertain. 

A  satisfactory-  method  in  many  cases  is  Wyeth's,  in  which  the  constrictor 
is  held  in  place  by  the  preliminary-  passage  of  two  steel  pins  (Fig.  993).  Tren- 
delenburg's method  consisted  in  passing  one  pin  and  winding  an  elastic 
tube  about  it.  Wyeth  applied  the  principle  and  greatly  improved  the 
method.  The  outer  pin  is  inserted  i^  inches  below  and  a  little  internal  to 
the  anterior  superior  spine  of  the  ilium,  and  is  brought  out  just  back  of  the  great 
trochanter.  The  inner  pin  is  entered  i  inch  below  the  level  of  the  crotch  and 
internal  to  the  saphenous  opening,  and  it  emerges  17  inches  ia  front  of  the  tuber- 
osity of  the  ischium.  A  sterile  cork  may  be  pushed  on  the  end  of  each  pin,  to 
save  the  surgeon  from  woimding  himself  upon  the  sharp  points.     A  cork  is 


I420 


Amputations 


apt  to  come  off  during  the  course  of  the  operation.  Because  of  the  insecurity  of 
the  cork  I  have  had  made  pins  with  removable  points.  After  a  pin  has  been 
passed,  the  point  is  unscrewed  and  a  knob  is  screwed  on  in  its  place.    After  the 

Umb  has  been  emptied  of 
blood  by  holding  it  in  a 
vertical  position  for  five 
minutes  and  stroking  it 
from  the  periphery  toward 
the  body,  the  constricting 
band  is  fastened  about  the 
limb  above  the  pins. 

In  the  bloodless  method 
of  Wyeth  (Figs.  993,  994), 
after  passing  the  pins, 
draining  the  limb  of  blood, 
and  applying  the  band  of 
the  Esmarch  apparatus, 
the  amputation  is  pro- 
ceeded with.  The  hip  is 
brought  well  over  the  edge 
of  the  table,  a  circular  incision  is  made  do"^Ti  to  the  deep  fascia,  6  inches  be- 
low the  constricting  band,  and  is  joined  by  a  longitudinal  skin-cut  reaching  from 
the  band  to  the  level  of  the  circular  incision,  and  the  cuff  is  reflected  to  the 
level  of  the  lesser  trochanter.    The  muscles  are  cut  by  a  circular  sweep  at  the 


Fig. 


993. — ^Amputation  at  the  bdp-joLat:  Wyeth's  bloodless 
method. 


Fig.  994. — Wyeth's  bloodless  amputation  at  the  hip-joint:  Ciiff  of  skin  and  subcutaneous  fat 
turned  back,  muscles  divided  at  level  of  small  trochanter,  bone  partly  stripped,  and  large  vessels  ex- 
posed for  deligation. 

level  of  the  retracted  cuff,  the  capsule  of  the  hip-joint  is  opened  freely,  the 
cotyloid  ligament  is  cut  posteriorly,  the  thigh  is  bent  upward,  forward,  and 
inward  to  dislocate  the  head  of  the  bone,  and,  using  the  thigh  as  a  handle,  the 
roimd  ligament  is  incised  and  the  limb  removed.     After  ligating  the  vessels 


Disarticulation   at   the  Hip-joint 


1421 


and  introducing  drainage-tubes  the  tlaps  are  sewn  together  vertically.     The 
old   transfixion   operation   is   practically   extinct.     A   J-amputation   may   be 


Fig.  095. — Seim's  method  of  pprtnrming  bloodless  amputation  at  the  hip-joint.  Dislocation  of 
head  of  femur  and  upper  portion  of  shaft  through  straight  external  incision.  Elastic  constrictor  in 
place,  the  anterior  one  tied  (Senn). 


Fig.  996. — Elastic  constriction  completed  by  constricting  the  posterior  segment  oi  the  thigh.     Flaps 
formed,  including  all  the  tissues  down  to  the  muscles  (Senn). 

employed.     It  consists  of  an  external  straight  incision  down  to  the  bone, 
starting  over  the  gjeat  trochanter,  down  the  outer  side  of  the  limb,  and  a 


1422 


Amputations 


circular  incision  through  the  skin  5  inches  below  the  constricting  band,  the 
muscles  being  cut  by  a  circular  sweep  at  the  level  of  the  retracted  skin.  This 
method  affords  easy  access  to  the  joint.  The  bloodless  method  of  Wyeth,  as 
applied  to  the  hip-joint  and  shoulder-joint,  is  a  notable  advance  in  the  art  of 
surgery. 

Senn's  Bloodless  Method. — The  elder  Senn  has  devised  a  method  for  pre- 
venting hemorrhage  during  amputations  of  the  hip-joint.  He  makes  a  straight 
incision,  about  8  inches  in  length,  in  the  direction  of  the  long  axis  of  the  femur 
and  directly  over  the  center  of  the  great  trochanter.  This  incision  reaches 
about  3  inches  above  the  upper  margin  of  the  great  trochanter.  The  muscular 
insertions  are  divided  close  to  the  bone,  and  the  thigh  is  flexed,  strongly  ad- 
ducted,  and  rotated  inward.  The  capsular  ligament  is  divided  at  its  upper  and 
posterior  aspect.  While  the  thigh  is  brought  into  a  position  of  slight  flexion, 
the  remaining  portion  of  the  capsular  ligament  is  cut.  Then  the  thigh  is 
dislocated  outward,  and  the  liga- 
mentum  teres  is  cut.  If  this  can- 
not be  accomplished,  the  head  of 
the  bone  is  forcibly  dislocated  upon 
the  dorsum  of  the  ilium.  After  dis- 
locating, the  lesser  trochanter  and 
the  upper  part  of  the  femoral  shaft 
are  cleared.  The  limb  is  now 
brought    down    in    a    straight    line 


Fig.  gg7. — Keen  and  DaCosta's  method  of 
interilio-abdominal  amputation  ("International 
Climes,"  vol.  iv,  13th  series). 


Fig.  998. — Keen  and  DaCosta's  case  of  inter- 
ilio-abdominal amputation.  The  shaded  portion 
of  the  bone  was  removed  ("International  Clin- 
ics," vol.  iv,  13th  series). 


with  the  body,  the  thigh  is  slightly  flexed,  a  long  and  stout  pair  of  forceps  is 
inserted  into  the  wound  behind  the  femur  and  on  a  level  with  the  normal 
situation  of  the  lesser  trochanter,  and  the  instrument  is  pushed  downward  and 
inward,  2  inches  below  the  ramus  of  the  ischium  and  just  behind  the  adductor 
muscles.  As  soon  as  the  point  can  be  felt  under  the  skin,  an  incision  2  inches 
in  length  is  made  upon  it,  and  the  instrument  is  forced  through  the  opening. 
The  tunnel  in  the  tissues  is  enlarged  by  opening  the  forceps.  A  piece  of  rub- 
ber tubing  f  inch  in  diameter  and  4  feet  in  length  is  caught  about  the  middle 
with  the  forceps  and  is  withdrawn.  The  rubber  tube  is  cut  in  two  at  about 
the  point  at  which  the  forceps  have  held  it,  and  half  of  the  tube  is  used  to  con- 
strict the  anterior  segment  of  the  thigh  (Fig.  995)  and  the  other  half  to  constrict 
the  remaining  portion  of  the  thigh  (Fig.  996).  Before  the  constricting  bands 
are  tied  the  limb  is  held  vertically  for  a  sufficient  length  of  time  to  make  it 
practically  bloodless;  the  amputation  is  then  completed  (Senn's  "Practical 
Surgery"). 


Mammillitis  and  Fissure  1423 

Other  Methods. — John  G.  Sheldon  (''.■Vmer.  Med.,''  April  19,  1902)  has 
modified  Senn's  method  as  follows:  He  disarticulates  the  head  of  the  femur 
and  frees  the  upper  part  of  the  femur  from  its  attachments.  He  then  intro- 
duces a  pair  of  long,  stout  artery-forceps  behind  the  femur  and  clamps  the 
femoral  vessels.  He  forms  the  flap,  removes  the  limb,  and  ligates  the  ves- 
sels. In  this  operation  the  surgeon  can  work  rapidly  and  can  make  a  flap 
of  any  size  or  shape,  and  is  not  hindered  by  a  constriction  apparatus;  but  this 
method  does  not  cut  oft"  the  bleeding  from  the  obturator  and  the  sciatic  arteries. 

Larrey  amputated  by  lateral  flaps,  and  Liston  by  anteroposterior  flaps. 
Fomeaux  Jordan's  method  consists  in  di\"iding  the  soft  parts  low  down,  txing 
the  blood-vessels  on  the  face  of  the  stump,  shelling  out  the  femur  from  the 
soft  parts,  and  disarticulating. 

Interilio-abdominal  Amputation. — This  very  formidable  operation  is  occa- 
sionally performed  for  sarcoma  of  the  ilium.  The  operation  was  first  performed 
by  Billroth  in  1891,  and  the  patient  died.  Prof.  Keen  and  I  collected  19  cases, 
including  i  of  our  own.  Five  of  these  cases  recovered  (W.  W.  Keen  and  J. 
Chalmers  DaCosta,  in  "International  Clinics,''  vol.  iv,  13th  series).  Our 
patient  perished  in  thirty-three  hours  from  suppression  of  urine  and  with 
gangrene  of  the  parts  supplied  by  the  internal  iliac  arten.'.  In  some  cases 
the  entire  innominate  bone  has  been  removed,  in  others  portions  of  it  have  been 
left.  In  our  cases  we  made  the  flap  sho\\Ti  in  Fig.  997,  tied  the  internal  iliac 
arten.-  after  rolling  up  the  peritoneum,  but  spared  the  external  iliac,  kept  the 
femoral  in  the  flap,  and  sawed  through  the  bones  as  indicated  in  Fig.  998, 
lea\-ing  in  place  the  portions  shown  in  white. 


XXXIX.  DISEASES   OF   THE   MAMMARY   GLAND 

Hypertrophy  of  the  Breast  (Fig.  999). — This  is  a  rare  condition.  It 
may  affect  one  breast  or  both.  It  is  most  apt  to  appear  at  the  age  of  puberty, 
but  it  may  appear  in  childhood,  adult  life,  or  old  age.  The  breast  may  attain 
enormous  size.  In  Porter's  case  the  breasts  of  a  woman  of  thirty-seven  were 
so  ver}-  large  that  they  were  carried  hung  upon  a  frame  ("Boston  Med.  and 
Surg.  Jour.,''  March  3,  1892). 

These  ver\'  large  breasts  are  not  composed  of  true  gland  tissue,  but  rather 
of  fat  and  connective  tissue  {"  Diseases  of  the  Breast,"  by  A.  !^Iarmaduke 
Sheild).  H^-pertrophy  may  also  occur  in  the  male  breast.  In  some  cases 
h}-pertrophy  occurs  so  rapidly  as  to  merit  the  name  acute.  Such  cases  may 
perhaps  be  sarcomatous. 

Treatment. — Be  sure  it  is  hypertrophy  and  not  sarcoma,  adenoma,  or 
lipoma.  Tr\-  recumbent  posture,  dr\-  diet,  pressure,  and  iodid  of  potash 
(Sheild,  Ibid'.).     If  these  means  fail,  amputation  is  the  only  resource. 

Mammillitis  and  Fissure. — The  nipple  may  inflame  as  a  result  of 
injur\',  but  the  condition  is  rarely  encountered  except  in  a  woman  who  is 
nursing  a  baby.  It  is  most  common  after  a  first  pregnancy,  when  the  nipple 
is  deformed  or  when  the  skin  is  dehcate.  The  nipple  is  slightly  injured  during 
nursing,  and  the  epithelium  is  macerated  by  the  milk  and  saliva.  If  the  in- 
flammation is  not  arrested,  a  spot  excoriates  or  an  irritable  ulcer  forms  (a 
fissure).  A  fissure  is  often  surrounded  by  an  area  of  acute  inflammation,  and 
nursing  causes  intense  agony.  Because  of  the  pain  the  mother  is  apt  to  extend 
the  inter\-als  between  nursing,  and  as  a  consequence  the  breasts  become  swollen 
with  retained  milk.  The  iilcer  not  unusually  bleeds  when  the  breast  is  taken  by 
the  child.  Besides  the  fact  that  a  fissure  causes  pain  to  the  mother,  it  often 
leads  to  grave  trouble.  It  is  a  suppurating  area,  and  as  such  may  lead  to  ab- 
scess of  the  mother's  breast,  or  may  impair  the  health  of  the  nursing  child. 


1424 


Diseases  of  the  Mammary  Gland 


Prevention  of  Fissure. — During  pregnancy  the  nipples  should  be  carefully 
attended  to.  They  should  be  washed  often  in  sterile  water  and  bathed  in 
alcohol,  and  if  retracted,  ought  to  be  drawn  out  repeatedly.  During  the  period 
of  lactation  the  nipples  are  washed  in  sterile  water,  dried,  and  dusted  with  ber- 
ated talc  powder  as  soon  as  an  act  of  nursing  is  completed.  Washing  the 
nipples  regularly  with  the  following  solution  tends  to  prevent  the  formation 
of  a  fissure:  iodid  of  mercury,  2  gr. ;  alcohol,  i|  oz.;  glycerin  and  distilled  water, 

of  each  a  pint  (Lepage).  If  a 
small  abrasion  appears,  order 
the  woman  to  wear  a  nipple- 
shield  during  nursing,  and  after 
each  act  of  nursing  to  wash 
the  part  with  hot  sterile  water, 
dry,  and  dust  borated  talc  over 
the  surface.  If  a  fissure  forms, 
wean  the  child  at  once,  and  dry 
up  the  milk  in  both  breasts. 
It  is  useless  to  try  and  dry  it 
up  in  one  breast.  Milk  may 
be  dried  up  by  applying  oint- 
ment of  belladonna  locally,  and 
administering  iodid  of  potassiima 
internally;  by  strapping  the 
breasts  with  adhesive  plaster 
(Parker) ;  or  by  applying  to  the 
nipples  six  times  a  day  a  5  per 
cent,  solution  of  cocain  in  equal 
parts  of  glycerin  and  water 
(Joise).  The  fissure  is  not 
treated  by  ointments.  These 
preparations  are  septic,  prevent 
drainage,  and  aggravate  macer- 
ation. Wash  the  fissure  twice 
a  day  with  peroxid  of  hydrogen, 
dress  it  with  gauze  wet  in  boric  acid  solution  (10  gr.  to  i  dram  of  water), 
and  cover  the  dressing  with  waxed  paper.  If  the  fissure  resists  treatment, 
touch  it  with  lunar  caustic. 

Acute  Mastitis  and  Abscess. — Acute  inflammation  of  the  breast,  as 
a  result  of  injury  of  the  breast  or  nipple,  may  occur  in  either  sex  at  any  time 
of  life.  Very  commonly  in  both  sexes  a  few  days  after  birth  the  breast  be- 
comes distended  with  a  material  which  in  reality  is  milk.  The  fluid  is  usually 
small  in  quantity.  The  process  is  physiological,  and,  as  a  rule,  ceases  spon- 
taneously (Guelliot).  If  it  lingers,  the  application  of  belladonna  ointment 
will  stop  secretion.  If  the  nurse  meddles  with  the  glands  and  tries  to  squeeze 
out  the  fluid,  acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in  both. 
The  skin  of  the  breast  reddens,  the  gland  swells  and  becomes  tender  and  pain- 
ful, the  child  loses  its  appetite  and  becomes  feverish,  restless,  and  sleepless. 
Such  a  condition  is  treated  by  the  local  use  of  alcohol.  If  pus  forms,  the 
local  signs  and  constitutional  symptoms  are  aggravated.  Evacuate  the  pus, 
dress  with  hot  antiseptic  fomentations,  and  be  sure  that  the  chfld  is  well 
nourished.     Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the  glands  of  the  new- 
born may  occur  in  either  sex  at  puberty.  The  methods  of  treatment  are  the 
same  in  both  cases.  As  a  matter  of  fact,  at  this  time  of  life  rarely  more  than 
one  lobule  inflames,  and  suppuration  is  most  unusual. 


Fig.  ggg. — Hypertrophy  of  breast. 


Chronic  Mastitis 


1425 


x\cute  mastitis  is  most  usually  met  with  in  a  woman  who  is  nursing  a  child, 
and  is  due  to  bacterial  infection.  Primipara  are  particularly  liable  to  develop 
mastitis.  So  are  women  with  deformed  nipples.  In  most  cases  an  abrasion 
of  the  nipple  exists,  and  through  this  breach  of  continuity  bacteria  gain  en- 
trance to  the  breast-tissue.  The  abrasion  may  be  so  slight  that  it  can  only 
be  detected  when  the  nipple  is  examined  through  a  magnifying-glass  (Marma- 
duke  Sheild).  Streptococcic  infections  are  very  generally  due  to  inoculation 
of  a  fissure  of  the  nipple.  Bacteria  may  pass  up  the  milk-ducts,  coagulat- 
ing the  milk  and  penetrating  through  the  walls  of  the  acini.  Staphylococci 
not  unusually  pursue  this  route  in  reaching  the  breast-tissue.  Occasionally 
causative  bacteria  reach  the  breast  through  the  arteries  (in  septicemia  and 
in  septic  wounds  of  the  genital  organs) . 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in  the  breast,  and 
in  most  cases  a  fissure  or  abrasion  exists.  There  is  a  febrUe  condition.  Occa- 
sionally a  chill  ushers  in  the  attack. 

If  a  case  supposed  to  be  acute  mastitis  proves  utterly  rebellious  to  treat- 
ment the  suspicion  should  arise  in  the  surgeon's  mind  that  the  condition  is 
acute  or  inflamed  cancer  (carcinoma  mastitoides,  see  page  1436).  If  such  a 
doubt  arises,  a  piece  of  tissue  must  be  excised  for  microscopical  study. 

Treatment. — Order  the  patient  to  suspend  nursing.  The  physician  en- 
deavors to  arrest  the  secretion  of  milk.  Treat  the  nipple  as  advised  on  page 
1424.     Support  the  breast  and  apply  ichthyol  ointment. 

Mastitis  may  undergo  resolution;  it  may  terminate  in  organization  and 
induration;  it  may  eventuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  acute  mastitis.  There  may  be 
but  one  area  of  suppuration,  or  multiple  foci  may  exist,  which  eventually 
fuse.  The  symptoms  of  mastitis,  local  and  constitutional,  are  greatly  aggra- 
vated. After  a  time  the  skin  becomes  dusky  and  edematous.  The  axillary 
and  superficial  cervical  glands  enlarge.  The  abscess  will  eventually  open 
spontaneously  at  one  or  more  points,  leaving  branching  fistulae.  A  super- 
ficial abscess  is  situated  just  beneath  the  nipple,  and  pus  may  flow  from  the 
nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland.  There  are  often 
nultiple  foci  of  suppuration.  Nodules  are  felt  in  the  gland,  pus  may  run  from 
the  nipple,  but  cutaneous  redness  is  late  in  appearing. 

Retromammary  abscess  is  a  rather  rare  condition.  It  may  occur  alone 
or  be  associated  and  connected  with  an  area  of  intramammary  suppuration. 
It  may  result  from  metastatis  or  from  caries  of  a  rib.  The  breast  is  lifted  up 
by  the  fluid  beneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision  radiating  from 
the  nipple.  Treat  as  any  other  acute  abscess.  An  intramammary  abscess 
should  be  opened  by  a  radiating  incision,  and  pockets  of  pus  should  be  broken 
into  with  the  finger.  An  examination  is  made  to  determine  if  a  retromammary 
abscess  also  exists  If  this  is  found  to  be  the  case,  an  incision  is  made  at  the 
point  of  junction  of  the  thorax  and  mammary  gland,  and  at  the  lower  border 
of  the  gland.  The  gland  is  raised  from  the  chest  wall,  the  pus  evacuated, 
a  drainage-tube  is  inserted,  and  a  few  sutures  are  introduced.  If  retromam- 
mary abscess  exists  alone,  make  the  last-named  incision  in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in  only  a  portion 
of  the  breast,  or  may  attack  many  lobules  (lobar  mastitis).  The  ordinary 
form  may  arise  after  weaning  a  child,  or  may  be  due  to  a  blow,  to  the  pressure 
of  corsets,  or  to  numerous  slight  traumatisms.  It  may  occur  in  the  young, 
the  middle  aged,  or  the  old.  The  patient  has  sHght  pain  at  times  in  the 
gland.  Examination  detects  a  firm,  elastic  area,  which  is  somewhat  tender 
and  does  not  possess  distinct  margins.  The  skin  is  not  adherent  to  the  mass 
90 


1426  Diseases  of  the  Mammary  Gland 

unless  suppuration  occurs.  If  the  mass  is  pressed  against  the  chest  by  the 
surgeon's  fingers,  it  becomes  evident  that  no  real  tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support  the  breast  by  a 
spica  bandage.  Apply  ichthyol  ointment  During  the  night  employ  a  hot- 
water  bag.     If  pus  forms,  treat  as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which  numerous  lobules 
become  indurated.  The  real  cause  of  this  condition  is  unknown.  It  may 
occur  at  any  age  after  puberty,  and  often  attacks  both  breasts.  Such  a 
breast  is  apt  to  be  painful,  especially  at  the  menstrual  periods;  it  feels  un- 
natural, solid,  and  careful  examination  detects  numerous  indurated  areas, 
each  of  which  is  of  small  size.  At  the  menstrual  period  the  breast  enlarges 
and  new  nodules  may  be  detected.  In  some  of  these  cases  violent  neuralgic 
pains  are  present  in  the  gland  (mastodynia) .  Chronic  lobular  mastitis  is  apt 
to  lead  to  cyst  formation.  When  cysts  form  fluid  may  occasionally  discharge 
from  the  nipple. 

Treatment. — Support  the  breast  and  apply  ichthyol  ointment  or  bella- 
donna ointment.  Examine  the  generative  organs  and  correct  any  existing 
abnormality.  Improve  the  general  health  by  good  food,  tonics,  and  open-air 
life.  In  cases  in  which  multiple  cysts  are  known  to  exist  the  question  of  treat- 
ment is  uncertain.  There  seems  to  be  little  doubt  that  such  cases  tend  in 
some  instances  to  eventuate  in  cancer.  I  believe  that  the  proper  treatment 
when  multiple  cysts  exist  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Gland. — Sir  Astley  Cooper  in  1829 
wrote  on  "scrofulous  swellings"  of  the  breast,  and  Velpeau  also  referred  to 
them.  Nevertheless,  Virchow,  in  his  treatise  on  tumors,  stated  that  the  mam- 
mary gland  was  not  subject  to  tuberculosis.  Durbar  first  proved  the  existence 
of  the  condition  by  histological  and  bacteriological  observations.  Primary 
tuberculosis  of  the  breast  is  a  rare  condition.  If  we  are  to  judge  from  English 
and  American  literature,  it  is  a  very  rare  condition.  In  1902  Bindo  de  Vecchi 
was  able  to  report  i  case  and  collect  77  from  literature  ( "Extra tis  della 
Clinica  Chirurgica,"  No.  8,  1902).  Braendle  in  1906  reported  11  cases  from 
the  Tubingen  clinic  ("Beit,  zur  klin.  Chir.,"  vol.  i,  1906).  Powers,  of  Denver, 
reported  4  cases  ("Annals  of  Surgery,"  Feb.,  1913).  About  80  cases  con- 
firmed by  bacteriological  findings  and  histological  study  have  been  reported. 
It  is  seldom  that  both  glands  are  involved.  Tuberculosis  of  the  breast  may  be 
secondary  to  tuberculosis  of  the  skin,  of  related  glands,  of  the  rib,  etc.  It  may 
result  from  some  distant  tuberculous  lesion  of  bone,  of  joint,  of  lung,  etc.  It 
may  be  a  part  of  general  miliary  tuberculosis.  We  consider  here  primary 
or,  as  Geissler  named  it,  solitary  tuberculosis,  tuberculosis  apparently  limited 
to  the  breast  in  an  individual  free  from  evidences  of  antecedent  tuberculosis, 
and  of  tuberculosis  elsewhere.  It  occurs  usually  in  those  of  excellent  general 
health.  The  route  of  infection  may  be  by  the  blood,  by  the  lymph-ducts,  and 
perhaps  by  the  lymphatics  from  the  skin  or  nipple.  The  lesion  begins  in  the 
periacinous  and  periductal  connective  tissue.  The  ducts  and  acini  become 
involved  later.  E.  M.  Von  Eberts  ("Amer.  Jour.  Med.  Sci.,"  July,  1909) 
states  that  there  is  no  reported  case  before  the  age  of  puberty,  that  the  most 
advanced  case  reported  was  fifty-three  years  of  age,  that  maturity  of  the  gland 
and  lactation  predispose,  and  that  the  reported  cases  show  the  proportion  of 
the  married  to  the  unmarried  as  4  to  i .  It  is  vastly  more  common  in  women 
than  in  men.  In  many  cases  there  is  a  history  of  antecedent  inflammation  or 
abscess  during  lactation.  In  some  cases  there  is  a  history  of  traumatism.  There 
are  two  forms  of  the  condition,  and  in  each  form,  sooner  or  later,  degenera- 
tion occurs,  and  fistulae  from  a  cold  abscess  arises  (see  page  242) ;  these  forms 
are  nodular  and  confluent  (Von  Eberts,  Ibid.).  In  the  nodular  form  a  nodule, 
several  nodules,  or  many  nodules  arise  in  the  glandular  tissue.     There  is  little 


Tumors  and  Cysts  of  the  Mammary  Gland  1427 

or  no  pain.  If  nodules  are  under  the  nipple  retraction  may  occur.  The  condi- 
tion is  very  slow  in  progress  and  a  year  or  several  years  may  elapse  before  degen- 
eration occurs.  Degeneration  results  in  cold  abscess  (see  page  236)  and  often  in 
fistula  formation.  Schley  has  pointed  out  that  cold  abscess  is  a  termination 
more  common  in  the  confluent  than  in  the  nodular  type  ("Annals  of  Surgery," 
1903).  In  the  confluent  form  the  condition  develops  much  more  rapidly,  is  as- 
sociated with  pain,  is  most  apt  to  arise  during  lactation,  is  particularly  prone 
to  abscess  and  fistula  formation,  and  is  liable  to  acute  exacerbation  from  second- 
ary pyogenic  infection.  The  axillary  glands  are  found  enlarged  in  three-fourths 
of  all  cases  of  primary  tuberculosis.  Cases  have  been  reported  of  carcinoma  and 
of  adenoma  associated  with  tuberculosis. 

Treatment. — In  a  very  slowly  developing  nodular  case,  in  which  it  is 
certain  lactation  will  not  arise,  it  may  be  considered  proper  to  treat  the  condition 
with  tuberculin,  etc.  (see  section  on  Tuberculosis).  In  the  confluent  form  and 
in  cases  of  the  nodular  form  in  which  tuberculin  treatment  has  failed,  or  in 
which  we  cannot  exclude  the  possibility  of  pregnancy,  the  breast  should  be 
removed  and  the  glands  and  fat  should  be  removed  from  the  axilla.  Most  of 
the  cases  recover  permanently  after  radical  operation  (Braendle,  of  Tubingen, 
in  "Beit,  zur  klin.  Chir.,"  1906,  Bd.  i).  Powers  ("Annals  of  Surgery,"  Feb., 
191 3)  advises  the  thorough  removal  of  the  breast,  pectoral  fascia,  and  axillary 
contents,  and  with  this  recommendation  I  am  in  accord. 

Cysts  and  Tumors  of  the  Nipple. — Tumors  are  rare  in  the  nipple, 
but  do  sometimes  occur.  The  following  growths  are  occasionally  seen:  fibroma, 
angeioma,  papilloma,  myxoma,  myoma,  and  epithelioma.  Sebaceous  cysts  of 
the  nipple  and  areola  are  not  very  unusual.  A  cancer  of  the  nipple  may  be 
a  primary  growth,  or  may  be  secondary  to  gland  cancer.  Primary  epithelioma 
of  the  nipple  presents  the  same  general  characters  as  epithelioma  in  any  other 
part.  It  begins  as  an  indurated  area  in  the  areola,  or  an  excoriation  of  the 
nipple.  Ulceration  soon  occurs.  The  ulcer  is  irregular  in  outline,  has  hard 
edges,  and  furnishes  a  foul,  red,  sanious,  and  fetid  discharge.  The  mammary 
gland  becomes  infiltrated  at  an  early  period.  The  subclavian  glands  enlarge, 
and  later  the  axillary  glands.  Such  a  growth  must  not  be  confounded  with  a 
chancre  of  the  nipple. 

Treatment  of  Tumors  of  the  Nipple. — Innocent  tumors  are  to  be  excised 
and  the  breast  need  not  be  removed. 

Epithelioma  of  the  nipple  requires  the  complete  extirpation  of  the  breast, 
and  also  the  clearing  out  of  the  lymphatic  contents  of  the  axilla,  and  possibly 
of  the  subclavian  triangle. 

Paget 's  Disease  of  the  Nipple  (Malignant  Dermatitis). — This  condition 
is  held  to  be  a  chronic  inflammation  of  the  epithelial  layer  of  the  nipple  and 
areola  occurring  in  women  beyond  middle  life,  and  is  regarded  as  a  not  unusual 
precursor  of  epithelioma  of  the  nipple  and  of  duct  cancer.  Paget's  disease  is 
not  a  simple  eczema,  it  is  not  associated  with  the  usual  causes  and  attendants 
of  eczema,  either  local  or  constitutional,  and  is  not  cured  by  remedies  which 
control  the  ordinary  disease. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes  copiously  a  thick, 
yellow  discharge.  In  some  cases  Paget's  disease  is  secondary  to  duct  cancer, 
auto-infection  of  the  nipple  having  been  effected  by  the  fluid  flowing  from 
the  ducts.  Investigations  have  shown  the  presence  of  psorosperms  in  areas 
of  Paget's  disease.  I  am  of  the  opinion  that  Paget's  disease  is  usually,  from 
the  very  beginning,  cancer. 

Treatment. — Removal  of  the  entire  breast  and  clearing  out  of  the  axilla. 

Tumors  and  Cysts  of  the  Mammary  Gland. — These  tumors  may  be 
innocent  or  malignant.  Tumors  may  occur  in  childhood  (angeioma,  sarcoma, 
fibro-adenoma) .     Malignant  tmnors  are  very  rare  before  the  age  of  twenty-five. 


1428  Diseases  of  the  Mammary  Gland 

Innocent  Tumors  of  the  Mammary  Gland. — The  innocent  tumors  are: 
Periductal  Jibroma,  fihrocystadenoma,  papillary  cystadenoma,  simple  adenoma, 
periductal  fibromyxoma,  myxoma,  angioma,  lipoma,  and  enchondrojna.  It  is 
maintained  by  most  authorities  that  any  innocent  tumor  of  the  gland  may  and 
is  apt  to  become  mahgnant. 

Periductal  Fibroma,  Fibro-adenoma. — The  nomenclature  of  fibro-ade- 
nomata  is  in  a  state  of  great  confusion.  The  name  fibro-adenoma  was  given 
by  Cornil  and  Ranvier  to  the  same  sort  of  growth  which  the  younger  Gross 
called  a  fibroma,  Billroth  an  adenofibroma,  and  Sir  Astley  Cooper  a  chronic 
mammar}^  tumor.  It  is  doubtful  if  a  pure  fibroma  ever  occurs  in  the  mammary 
gland.  A  fibro-adenoma  consists  of  acini  surrounded  by  fibrous  tissue.  Each 
of  these  structures  proliferates,  but  the  fibrous  tissue  does  so  much  more 
rapidly  than  the  glandular.  Bloodgood  ("Amer.  Jour.  Med.  Sci.,"  Feb., 
1908)  says,  "the  fibro-adenoma  microscopically  is  nothing  more  than  an 
encapsulated  area  of  normal  breast  tissue,  in  which  the  parenchyma,  in  the  early 
stage  of  the  tumor,  is  greater  in  amount  than  the  normal  breast.  Later  the 
parenchyma  undergoes  pressure  atrophy  and  the  tumor  may  become  cal- 
cified." A  growth  of  this  character  is  surrounded  by  a  capsule  and  is  movable. 
It  is  firm,  elastic,  lobulated,  superficially  situated,  and  of  slow  growth.  It  is 
unassociated  with  retracted  nipple,  glandular  enlargement,  adhesion  to  the 
skin,  or  cachexia,  and  may  occur  at  any  age  up  to  fifty,  but  is  most  common 
between  twenty  and  thirty  (Sir  J.  Bland-Sutton).  Such  a  tumor  is  rarely  very 
painful,  but  it  may  be  tender  on  rough  handling  and  may  be  painful  at  the 
menstrual  period.  As  a  rule,  there  is  but  one  of  these  tumors  in  a  mammary 
gland,  but  the  tumors  may  be  multiple  in  one  gland,  or  one  or  more  may  exist 
in  each  gland.     It  is  not  very  common  for  sarcoma  or  carcinoma  to  arise. 

Periductal  Fibromyxoma. — It  is  most  common  in  young  women.  It  may 
be  multiple  in  one  breast  or  both.  It  is  an  encapsulated,  lobuled,  and  elastic 
growth,  which  is  seldom  painful,  is  usually  small,  and  often  remains  quiescent 
indefinitely  or  even  disappears.  It  may  enlarge  and  even  attain  a  large 
size.     When  it  enlarges  it  is  apt  to  become  cystic  and  sarcomatous. 

Treatment  of  Periductal  Fibroma  and  Fibromyxoma. — Extirpation  of  the 
tumor.  If  a  supposedly  innocent  growth,  removed  by  a  limited  operation, 
was  really  the  seat  of  beginning  malignancy,  the  wotmd  will  soon  thicken  after 
healing  and  recurrence  will  be  rapid.  Halsted  has  shown  that  in  such  a  case 
re-operation,  however  extensive,  will  not  obtain  a  cure.  Hence,  it  behooves  us 
in  doubtful  cases,  if  we  err  at  all,  to  err  on  the  side  of  radicaHsm.  In  a  case 
recognized  as  doubtful,  when  the  growth  is  removed  a  frozen  section  should  be 
made  at  once  and  be  studied  then  and  there,  and  the  surgeon  should  suspend 
operation  while  he  waits  for  the  report.  If  the  report  shows  that  the  growth  is 
malignant,  at  once  remove  the  breast  radically  and  clean  out  the  axilla.  A 
tumor  known  to  be  innocent  may  be  removed  through  an  incision  made  along 
the  junction  of  the  mammary  gland  and  breast,  at  the  lower  margin  of  the  gland, 
as  Thomas  proposed,  or,  better,  at  the  edge  of  the  outer  hemisphere,  as  advo- 
cated by  Warren  ("Annals  of  Surgery,"  June,  1907).  The  incision  exposes 
the  fibers  of  the  great  pectoral  muscle,  the  gland  is  raised  from  the  muscle,  and 
its  posterior  surface  exposed.  Any  growth  is  exposed  by  an  incision  from  center 
to  peripher}^  and  this  incision  is  explorator^^  Warren  removes  an  innocent 
timior,  a  cyst,  or  cysts  by  a  V-shaped  incision,  the  apex  of  the  V  being  at  the 
center  of  the  gland,  and  he  wisely  insists  that  the  tumor  is  not  to  be  dissected 
out.  Several  radiating  incisions  may  be  necessary  to  explore  a  cystic  breast. 
The  V-shaped  space  from  which  the  tumor  or  cyst  was  removed  is  closed  by  a 
double  row  of  catgut  sutures.  Incisions  for  exploration  seldom  need  to  be 
closed  by  suture.  The  gland  is  sutured  to  the  outer  edge  of  the  pectoral  fascia, 
and  a  row  of  sutures  is  inserted  through  the  deep  layer  of  the  superficial  fascia. 


Cysts  of  the  Mammary  Gland  1429 

Warren  calls  this  operation  plastic  resection  of  the  breast.  It  leaves  the  patient 
free  from  deformity. 

Fibrocystadenoma  or  cystic  adenoma  (adenocele)  is  a  rare  form  of  slowly 
growing  timior,  which  is  apt  to  attain  a  large  size,  which  is  nodular  in  outline, 
hard  to  the  touch,  and  firmly  attached  to  the  mammary  gland,  but  mobile  upon 
the  chest.  A  cystic  adenoma  has  a  distinct  capsule.  This  form  of  tumor  is 
painless,  and  is  most  apt  to  occur  in  women  between  thirty  and  forty  who 
have  borne  children.  The  growth  is  adherent  to  the  skin,  but  the  cutaneous 
surface  is  not  discolored,  the  cutaneous  veins  are  not  distended,  the  axillary 
glands  are  not  enlarged,  and  the  nipple  is  not  retracted.  From  the  walls  of 
the  dilated  acini  papillomatous  growths  are  apt  to  arise  (intracystic  vege- 
tations).    The  growth  may  be  a  precursor  of  cancer. 

Treatment. — Radical  removal  of  breast  and  clearing  of  axilla. 

Papillary  Cystadenoma. — This  condition  is  often  called  \'illous  papilloma 
or  duct  papilloma.  There  is  much  more  epithehal  proliferation  than  in  the 
fibrocystadenoma,  and  the  warty  masses  project  into  the  c^'st  caA^ities.  These 
growths  are  firm,  grow  slowly  and  painlessly,  and  seldom  fluctuate.  They 
do  not  adhere  to  the  skin,  attain  a  large  size,  or  cause  glandiilar  enlargement. 
They  are  situated  near  or  under  the  nipple,  and  occur  particularly  in  middle 
life.  Discharge  of  serous  fluid  from  the  nipple  is  a  cormnon  s\Tnptom.  In 
many  cases  there  is  a  bloody  discharge.  The  condition  tends  to  become  can- 
cerous. 

Treatment. — ^The  danger  that  duct  cancer  will  arise  is  so  great  that  the 
old  operation  of  excision  of  the  timior  should  give  way  to  radical  removal  of  the 
breast.  In  any  duct  growth  with  a  serous  discharge  from  the  nipple  it  is  wise 
to  remove  the  breast  and  clear  the  axiUa.  If  the  discharge  is  bloody  that 
radical  procedure  is  imperative. 

Simple  Adenoma. — This  is  a  ver\-  rare  tumor.  It  occurs  in  yoimg  and 
middle-aged  women.  It  is  soft,  nodular,  and  freely  movable.  It  does  not 
adhere  to  the  skin  and  does  not  cause  hTnphatic  involvement.  It  consists 
of  glandular  acini  and  a  very  delicate  stroma  of  connective  tissue.  It  tends 
to  become  cancerous. 

Treatment. — Extirpation  of  the  timior.  Touch  the  wound  with  chlorid  of 
zinc  solution  (10  gr.  to  the  ounce)  in  order  to  destroy  cells  which  might  lodge 
and  grow. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of  middle  age  or  be- 
yond. The  growth  is  solitary,  is  soft,  may  be  round  or  lobulated,  and  occasion- 
ally fungates.  The  nipple  is  not  retracted,  the  superficial  veins  are  not  dis- 
tended, and  the  axillan.^  glands  are  not  enlarged. 

Treatment. — Removal  of  the  mammar\'  gland. 

Angioma. — This  form  of  tumor  is  very  rare.  It  may  arise  secondarily  to  a 
ne\-us  of  the  skin  (Sir  J.  Bland-Sutton) .  The  diagnosis  of  angioma  of  the  skin 
is  readily  made.  In  a  cavernous  angioma  of  the  breast  it  wfll  be  foimd  that 
the  timior  can  be  lessened  in  size  by  pressure,  and  will  be  increased  in  size 
by  coughing,  laughing,  and  holding  the  breath.  Pulsation  may  be  detected 
and  a  bruit  may  be  audible. 

Treatment. — For  treatment  of  ne^-us  see  page  366.  If  a  cavernous  angioma 
exists  in  the  mamman.^  gland,  it  will  be  necessary-  to  extirpate  the  gland. 

Lipoma  and  encJiondroma  occasionally  occur  in  the  breast. 

Cysts  of  the  Mammary  Gland.— Involution  cysts  {cystic  degenera- 
tion of  the  mamma)  occur  in  women  who  are  approaching  the  menopause. 
Such  cysts  occur  earlier  in  those  who  are  sterile  than  in  those  who  have  borne 
children,  and  may  arise  after  chronic  mastitis.  The  parench}Tna  of  the  gland 
undergoes  atrophic  change,  but  the  ducts  remain,  become  blocked  and  dflated. 
Numerous  small  cysts  form,  and  both  glands,  as  a  rule,  suffer.     Villous  growths 


I430  Diseases  of  the  Mammary  Gland 

may  arise  in  the  walls  of  the  ducts.  In  some  cases  there  is  much  white  fibrous 
tissue  between  the  cysts  (cystic  fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical,  and  despondent. 
One  or  more  ill-defined  indurations  are  detected.  Frequently  there  is  a  history 
of  discharge  from  the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cystic  breasts  are  dangerous,  because  the  intracystic  vegetations  are  Uable  to 
eventuate  in  duct  cancer.  One-fourth  of  these  cases  are  cancerous  when  first 
seen  (Speese,  quoted  by  Primrose  in  "Amer.  Jour.  Med.  Sci.,"  Jan.,  1913). 

Treatment. — In  such  cases,  after  confirming  the  diagnosis  by  an  exploratory 
incision,  remove  the  entire  breast. 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk  brought  about  by 
blocking  of  some  of  the  milk-ducts.  It  usually  arises  soon  after  the  delivery 
of  the  child,  but  may  not  be  noted  for  months  or  even  several  years  after 
child-bed.  It  grows  rapidly  from  the  time  it  is  first  detected.  A  large  quantity 
of  milk  may  collect,  and  rupture  of  the  cyst  walls  may  occur,  the  fluid  passing 
into  the  glandular  connective  tissue. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases  in  size  during 
nursing.  There  is  little  or  no  pain.  In  some  cases  the  contents  of  the  cyst 
coagulate  and  a  solid  mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur.  There  are  33  positive 
cases  on  record  (Le  Conte,  in  "Amer.  Jour.  Med.  Sci.,"  Sept.,  1901).  A 
small,  hard,  movable,  and  painless  mass  appears  in  the  mammary  gland. 
Usually  it  gradually  increases  in  size,  but  it  may  grow  rapidly  for  a  time 
and  then  remain  apparently  almost  stationary  for  a  period.  If  rapid  growth 
takes  place  there  is  always  pain,  and  pain  is  usual  in  any  case  when  the  cyst 
attains  considerable  size.  Fluctuation  is  often  absent  and  crepitation  is  never 
obtained  (Le  Conte).     Suppuration  is  apt  to  occur  and  sinuses  may  form. 

Treatment. — A  small  and  recent  cyst  may  be  extirpated.  If  the  cyst  is 
not  recent,  but  is  fairly  large  and  adherent,  incise,  evacuate,  and  pack  with 
gauze.  If  the  cyst  is  large  and  adherent,  but  is  surrounded  by  considera- 
ble breast  tissue,  partially  amputate  the  breast.  If  the  cyst  is  large  and  the 
breast  practically  destroyed,  or  if  the  nipple  adheres  to  the  cyst,  remove  the 
mammary  gland  (Le  Conte,  Ibid.). 

Malignant  tumors  of  the  mammary  gland  are  ten  times  more  com- 
mon than  innocent  tumors.  We  should  regard  every  palpable  tumor  in  the 
gland  as  malignant  until  it  is  proved  to  be  innocent.  In  other  words,  we 
reverse  the  riile  of  jurisprudence.  We  regard  every  tumor  as  guilty  of  malig- 
nancy until  its  innocence  is  proved.  If  the  mistake  is  made  of  regarding  an 
innocent  tumor  as  malignant,  the  woman  loses  her  breast  needlessly.  If  a 
malignant  tumor  is  regarded  as  innocent  the  woman  loses  her  life  needlessly. 
"The  fact  that  malignant  degeneration  of  benign  growths  in  the  breast  is  of 
frequent  occurrence  is  obviously  another  convincing  argument  for  the  removal 
of  all  breast  tumors.  A  recent  study  by  Speese  showed  that  no  less  than  26 
per  cent,  of  the  cases  of  chronic  cystic  mastitis  (that  is,  that  form  of  'abnormal 
involution'  occurring  at  the  menopause)  examined  by  him  showed  malignancy. 
So,  too,  cyst  adenomata  are  found  associated  with  carcinoma,  the  frequency 
of  such  association  being  placed  by  some  authors  as  high  as  15  per  cent.  In- 
flammatory conditions  of  the  breast  resulting  in  mastitis  are  often  found  in  the 
early  history  of  cancer  cases.  All  these  facts  point  conclusively  to  the  frequent 
occurrence  of  malignant  degeneration  in  benign  growths  of  the  breast"  (A, 
Primrose,  Loc.  cit.). 

Sarcoma  of  the  mammary  gland  is  a  very  rare  growth  (not  over  3  per 
cent,  of  breast  tumors).  It  may  occur  at  any  age  from  puberty  to  old  age. 
It  was  long  thought  to  be  most  common  from  twenty  to  thirty-five  years 


Sarcoma  of  the  Mammary  Gland 


143 1 


of  age,  but  Rodman's  investigations  show  that  one-half  the  cases  occur  in  the 
fifth  decade  of  life  (Rodman  on  "Diseases  of  the  Breast").  The  growth 
may  be  composed  of  round  cells  or  spindle  cells;  both  varieties  may  be  present, 
and  myeloid  cells  may  be  found.  Circumscribed  sarcoma  arises  usually 
between  the  ages  of  twenty  and  thirty;  it  is  firm  to  the  touch,  as  it  contains 
much  fibrous  tissue,  is  painless,  does  not  grow  very  rapidly,  glands  are  seldom 
involved,  and  there  is  no  cachexia.  The  nipple  is  not  retracted.  The  growth 
may  adhere  to  the  skin.  If  it  is  composed  of  giant  cells  or  spindle  cells  it  will 
rarely  return  after  extirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells,  arises  in  the  center 
of  the  breast,  and  grows  with  great  rapidity.     It  is  most  commonly  met  with 


Fia 


-Scirrhous  carcinoma  Q.  Collins  Warren). 


about  the  age  of  thirty-five,  and  a  history  of  injury  can  often  be  elicited. 
The  timior  is  soft,  some  parts  being  softer  than  others  because  of  cyst  forma- 
tion. It  is  usually  mobile  upon  the  thorax,  though  it  soon  becomes  adherent 
to  the  skin.  The'tumor  reaches  a  very  great  size,  and  soon  fungates  through 
the  skin.  There  is  little  or  no  pain.  The  cutaneous  veins  over  the  tumor  are 
distended,  the  nipple  is  not  retracted,  and  the  axillar>'  glands  are  not  often 
enlarged.     Diffuse  sarcoma  is  apt  to  recur  after  removal. 

Treatment. — Remove  the  breast,  and  if  the  muscles  of  the  chest  wall  are 
infiltrated,  remove  them.  The  axillary  glands  should  be  removed  whether 
they  are  enlarged  or  not.  Operation  will  not  cure  when  metastases  exist. 
If  the  case  is  inoperable,  we  can  try  the  use  of  Coley's  fluid.     If  the  toxins 


1432 


Diseases  of  the  Mammary  Gland 


of  erysipelas  faU  to  arrest  the  progress  of  the  disease,  keep  the  patient  as 
comfortable  as  possible  by  the  administration  of  cocain  and  morphin. 

Endothelioma. — This  is  a  very  rare  tumor.     I  have  had  i  case  of  it.     The 
diagnosis  cannot  be  made  from  carcinoma. 
Treatment. — As  for  cancer. 

Carcinoma  or  Cancer  of  the  Mammary  Gland  of  the  Female  (Fig.  looo). 
— The  great  majority  of  mammary  tumors  are  cancerous.  Cancer  is  due  to 
proliferation  of  the  epithelium  of  the  acini  (acinous  cancer)  or  of  the  ducts 
(duct  cancer). 

Acinous  cancer  is  vastly  more  common  than  duct  cancer.  Usually  there 
is  much  connective  tissue  and  but  little  parenchyma  in  the  growth  (scirrhous 
cancer).  In  some  cases  there  is  little  connective  tissue  and  much  paren- 
chyma (encephaloid  or  medullary  cancer).  If  colloid  degeneration  of  the 
parenchyma  or  stroma  occurs,  the  growth  is  spoken  of  as  colloid  cancer. 

Scirrhus  (Figs.  looo  and  looi),  the  common  form  of  acinous  cancer,  is  almost 
as  hard  as  stone.    On  section  it  is  concave,  and  Sutton  says  "resembles  an  unripe 

pear."  The  tumor  is  without  a 
capsule,  and  the  epithelial  cells 
are  surrounded  by  masses  of 
fibrous  tissue.  Portions  of  tissue 
even  some  distance  away  from 
the  tumor  proper  contain  foci  of 
proliferating  embryonic  epithe- 
lial cells.  In  atrophic  or  wither- 
ing scirrhus  the  fibrous  stroma 
contracts  and  epithelial  cells 
undergo  fatty  degeneration. 

Halsted  in  1898  described 
adenocarcinoma.  It  is  the  in,itial 
movement  in  the  direction  of 
unrestrained  epithelial  prolifera- 
tion, and  sections  of  the  tumor 
show  the  formation  of  tubular 
acini.  The  most  characteris- 
tic sections  resemble  adenoma. 
Adenocarcinoma  is  not  the  com- 
mon form  of  breast  cancer.  In 
the  common  form  the  proliferat- 
ing epithelium  attains  no  resemblance  to  glandular  structure,  but  multiplies 
irregularly  in  connective-tissue  spaces  or  lymph-spaces. 

Causes  and  Symptoms. — Scirrhus  is  more  common  among  women  who  have 
borne  children  than  among  those  who  have  not.  Heredity  is  manifest  in  only 
about  10  per  cent,  of  cases.  The  younger  Gross  found  it  in  i  case  out  of  9. 
Trauma  has  no  apparent  influence  in  producing  cancer.  The  disease  is  rare 
before  the  age  of  thirty-five,  and  is  most  common  between  forty-five  and  fifty. 
The  author  operated  for  scirrhus  of  the  breast  on  a  woman  only  twenty-seven 
years  of  age.  Henry  saw  a  woman  of  twenty-one  with  cancer.  It  is  fre- 
quently met  with  in  the  aged.  These  tumors  are  rare  in  the  negro  race.  A 
hard  nodule  is  found  in  the  breast,  usually  under  the  nipple,  but  possibly  far 
away  from  it.  The  growth  is  nodular,  and  is  immobile  from  the  beginning. 
In  a  large,  fat  breast  there  is  often  a  deceptive  sense  of  mobility,  because 
some  of  the  breast  tissue  moves  with  the  tumor.  The  cancer  may  have  been 
present  for  a  considerable  time  before  being  discovered.  Sometimes  wide- 
spread lesions  develop  from  a  small  or  an  undiscovered  breast  cancer  (pleural 
effusion,  enlarged  glands  of  the  neck,  disease  of  the  spinal  cord,  bones  of  the 


Fig.  looi. — Scirrhous  carcinoma  of  right  breast  showing 
retraction  of  nipple  (Dr.  Blanck's  patient). 


Acinous  Cancer  1433 

skull  or  brain).  In  obscure  lesions  of  bones  and  viscera  examine  the  mammary 
glands,  because  the  trouble  might  be  due  to  metastasis  from  an  undiscovered 
carcinoma  of  the  breast.  The  glands  of  the  armpit  always  and  soon  become 
diseased,  the  glands  above  the  clavicle  often  enlarge,  and  the  arm  may  swell. 
Growth  may  arise  within  the  chest,  either  by  lymph  regurgitation  from  the  a.xil- 
lary  and  subclavian  glands,  or  directly  through  the  chest  walls  to  pleura  and 
lung  or  to  mediastinal  glands.  Oelsner  and  Poirier  showed  that  there  is  a  lymph 
tract  running  from  the  breast  to  glands  within  the  thorax,  passing  through  the 
great  pectoral  muscle  and  "the  fourth  interspace  at  the  level  of  the  costochon- 
dral  articulation"  (Primrose,  in  "Amer.  Jour.  Med.  Sci.,"  Jan.,  19 13).  "For- 
tunately, these  glands  are  not  frequently  involved,  a  circumstance  which 
may  be  accounted  for  by  the  atrophy  of  this  channel  in  senUe  mammas, 
in  which  cancer  usually  develops  (Poirier)"  (Primrose,  Ibid.).  Retraction  of 
the  nipple  is  present  in  over  one-hal,f  of  the  cases.  It  occurs  when  the  growth 
is  near  the  nipple,  and  is  due  to  the  contracting  fibrous  tissues  of  the  tumor 
pulUng  on   the  milk-ducts.      If   the    growth  is  far  away  from  the  nipple, 


Fig.  1002. — Carcinoma  of  right  breast.    Lesion  first  noticed  sLx  months  before  photograph  was  made. 


a  dimple  is  apt  to  form  on  the  skin  of  the  breast  because  of  the  pulling  upon 
the  suspensory  fibers.  Neither  retraction  of  the  nipple  nor  a  cutaneous  dimple 
proves  the  existence  of  cancer.  One  or  both  may  be  noted  in  a  breast  con- 
taining a  scar  (from  a  wound  or  a  healed  abscess),  in  tuberculosis  of  the  breast, 
and  in  mammary  syphilis.  The  dimple  is  not  due  to  adhesion  between  the 
tumor  and  the  skin.  It  is  noted  even  when  the  tumor  is  far  away  from  the  skin. 
It  may  not  be  obvious  unless  the  gland  is  moved  to  and  fro  or  unless  the  skin 
over  the  breast  is  pushed  in  various  directions.  When  this  is  done  it  becomes 
evident  that  the  skin,  at  a  certain  point,  is  held  inward.  The  dimple  is  a 
very  valuable  early  symptom. 

Glandular  enlargement  in  the  axilla  soon  follows  the  appearance  of  a 
scirrhus;  the  glands  become  very  hard  and  adherent.  In  over  60  per  cent, 
of  persons  the  glands  of  the  axilla  are  felt  to  be  enlarged  when  the  patient 
first  comes  for  treatment.  Because  the  surgeon  cannot  feel  enlarged  glands 
is  no  proof  that  there  are  none.  As  a  matter  of  fact,  the  glands  are  usually 
involved  wathin  two  months  of  the  beginning  of  the  disease,  but  the  involve- 
ment can  rarely  be  detected  externally  until  months  later.     Enlargement  of 


1434 


Diseases  of  the  Mammary  Gland 


the  axillary  glands  is  followed  by  enlargement  of  the  glands  in  the  posterior 
cervical  triangle  and  in  the  mediastinum.  Herbert  Snow  has  shown  that 
the  blocking  of  the  axillary  glands  often  leads  to  regurgitation  of  lymph 
containing  cancer-cells,  the  cells  being  thus  deposited  in  the  head  of  the 
humerus  and  the  thymus  gland.  Cancer  in  the  thymus  and  in  the  medi- 
astinal lymph-glands  after  a  time  causes  a  projection  of  the  sternum 
(the  sternal  symptom).  When  the  axillary  honphatics  are  extensively  in- 
volved the  arm  swells  from  obstruction  to  the  lymph-flow  (lymphedema)  or 
pressure  upon  the  vein.  If  there  is  lymphatic  obstruction  the  skin  of  the 
breast  becomes  pitted  and  resembles  pig  skin.  The  skin  is  actually  can- 
cerous or  soon  becomes  so  by  infiltration.  Each  pit  is  the  opening  of  a  sweat- 
gland.  The  sweat-duct  is  held  down  by  contracting  fibrous  tissue.  This 
condition  is  termed  peau  d^ orange,  or  pigskin  saddle  appearance.  The  tumor 
usually  grows  rather  slowl}'  unless  lactation  is  established ;  then  it  grows  with 


Fig.  1003. — Recurrent  carcinoma.     Cancer  en  cuirasse. 

frightful  rapidity.  As  it  grows  it  infiltrates  adjacent  structures  (the  pectoral 
fascia,  pectoral  muscles,  subcutaneous  ceUular  tissue,  and  skin).  When  a  tumor 
becomes  adherent  to  the  skin  the  skin  becomes  congested  and  of  a  dark  purple 
hue.  When  the  skin  is  destroyed,  an  ulcer  forms,  and  around  this  ulcer  the 
skin  becomes  red  and  filled  with  cancerous  nodules,  which  feel  like  shot  in  the 
skin.  Metastases  are  apt  to  occur  into  the  bones,  liver,  brain,  pleura,  lung, 
spine,  th}Tiius  gland,  and  rarely  the  eye.  The  pleura  and  lung  may  be  attacked 
by  direct  spread  of  the  growth  through  the  chest  wall,  from  infected  medias- 
tinal glands,  or  by  lymph  regurgitation  from  the  axillar}^  and  subclavian  glands. 
Pain,  absent  at  the  start,  is  usually  present  later  in  scirrhous  carcinoma. 
It  is  lancinating  and  neuralgic  in  character,  and  not  brought  on  or  in- 
creased by  handling.  It  ceases  if  colloid  degeneration  begins.  The  gen- 
eral health  is  usually  unimpaired  until  ulceration  takes  place,  when  cachexia 
arises.      In    1792    Howard    described    the   condition    which  Velpeau   called 


Acinous  Cancer 


M33 


particular  attention  to  in  1838  as  a  deep  cancer  of  the  integument  due 
to  a  cancerous  state  of  the  deep  cutaneous  l\-mphatics.  Velpeau  named 
it  ligneous  cancer  and  also  cancer  en  cuirasse  (Figs.  1003  and  1004").  The 
cancer  en  cuirasse  of  \'elpeau  is  a  condition  in  which  the  hTnphatic  vessels 


Fig.  1004. — Cancer  en  cuirasse. 

of  the  skin  are  distended  because  of  obstruction.  The  skin  thickens  as  in  ele- 
phantiasis. The  blocked-up  hTQph  contains  cancer  cells  and  the  skin  early 
becomes  nodular  and  cancerous. 
In  most  cases  the  condition  is 
secondary-,  but  primary-  cases 
have  been  reported.  The  condi- 
tion may  arise  from  cancer  in  the 
breast  or  may  follow  an  operation 
for  cancer  of  the  breast.  The 
skin  of  the  chest  becomes  thick 
and  rigid  like  a  leather  cuirass. 
The  growth  adheres  and  the  soft 
parts  come  to  adhere  to  the  chest 
wall.  The  skin  is  ver}-  exten- 
sivelv  invaded.  In  this  condition 
the  chest  wall  is  fixed,  respiration 
is  dimcult,  temperature  is  com- 
monlv  somewhat  elevated,  and 
there  is  probably  a  pleural  effu- 
sion. The  corresponding  upper 
extremity-  is  usually  the  seat  of 
great  swelling  from  hard  edema. 

In  atrophic  or  unthering  scirrhus  the  breast  becomes  ver>-  small.  In  some 
cases  the  contraction  is  so  great  that  it  seems  as  though  the  mammar\-  gland 
had  been  removed.  The  duration  of  scirrhus,  when  left  to  run  its  course. 
varies,  but  the  disease  generallv  produces  death  within  two  and  a  hah  years. 


Fig.  1005. — Recurrent  carcinoma  of  the  breast. 


1436 


Diseases  of  the  Mammary   Gland 


Occasionally  it  causes  death  within  a  \-ear.  In  atrophic  scirrhus  the  patient 
may  live  for  many  years. 

Diict  cancer  is  not  a  common  growth.  It  arises  from  the  duct  walls  in 
conditions  of  cystic  degeneration  of  the  mammary  gland.  The  tumor  is 
softer  than  the  acinous  growth  and  is  not  nodular.  There  is  no  pain,  no 
retraction  of  the  nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often 
be  squeezed  from  the  nipple.  A  duct  cancer  grows  and  infiltrates  less  rapidly, 
and  involves  adjacent  glands  later  than  does  an  acinous  growth. 

Carcinoma  mastitoides,  acute  cancer,  hraivny  cancer,  or  inflamed  cancer 
is  a  condition  originally  described  by  Volkmann  in  1875  under  the  name  of 
mastitis  carcinoma.  It  comes  on  almost  suddenly,  grows  very-  rapidly,  causes 
\dolent  irritation,  and  hence  widespread  infiltration  by  small  cells.  The  condi- 
tion resembles  inflammation  (Edward  A.  Schumann,  in  "Annals  of  Surger\','' 
July,  191 1).  In  this  condition  the  surgeon  cannot  make  out  the  outlines  of  a 
distinct  tumor,  but  the  entire  breast  is  hardened  and  enlarged,  and  the  skin 
of  the  breast  is  reddened,  infiltrated  and  edematous,  and  adheres  to  the 
gland.     There  is  often  pain  and  heat. 


Fig.  1006. — Ulcerating  scirrhous  carcinoma. 

Anatomically  related  glands  enlarge.  The  disease  is  most  apt  to  arise  late 
in  pregnancy  or  during  lactation  and  is  most  common  in  rather  young  women. 
It  may  be  limited  to  one  breast,  but  both  breasts  may  be  involved,  successively 
or  simultaneously.  The  nipple  may  or  may  not  be  retracted.  Slight  eleva- 
tion of  temperature  is  usual. 

There  is  rapid  metastasis,  profound  toxemia,  and  early  death.  Death 
occurs  in  less  than  a  year,  perhaps  in  a  few  weeks.  Billroth's  case  died  in  sLx 
weeks  after  the  discovery  of  the  cancer. 

Any  persisting  case  of  supposed  acute  mastitis  shoifld  make  us  suspicious. 
In  such  a  case  excise  a  piece  of  tissue  for  examination.  In  cutting  out  the  piece 
small  abscess  cavities  may  be  discovered  even  when  the  condition  is  cancerous. 
Schumann  (Ibid.)  says  there  are  only  13  reported  cases  of  carcinoma  masti- 
toides. Since  Schumann's  paper  Morris  Booth  Miller  reported  a  case  ("An- 
nals of  Surgery,"  ]\Iay,  1913).  I  showed  a  case  to  the  class  at  Jeft"erson  Hos- 
pital in  the  winter  of  1912-13.  The  woman  was  pregnant  and  both  breasts 
were  involved.  She  perished  miserably  a  few  months  after  the  onset  of  the 
disease  and  a  few  weeks  after  her  confinement. 

Cancer  of  the  Male  Breast. — This  condition  is  seldom  met  with,  though 
I  believe  it  to  be  more  common  than  is  generally  supposed.     I  have  seen  4 


Treatment  of  Carcinoma  of  the  Mammary  Gland  1437 

cases  within  the  last  ten  years.  Each  patient  was  in  the  early  forties;  neither 
complained  of  pain.  In  one  the  breast  had  been  extremely  large  from  early 
years.  In  each  case  the  growth  was  indurated,  but  in  neither  was  there  any 
retraction  of  the  nipple.  The  condition  in  each  patient  was  scirrhous  carci- 
noma. Warfield  has  collected  32  cases  from  literature  and  has  added  5  others 
("Bull,  of  Johns  Hopkins  Hosp.,"  Oct.,  1901).  The  patients  were  between 
forty  and  seventy  years  of  age;  8  gave  a  history  of  injury;  in  9  cases  there  . 
was  pain,  and  in  12  the  nipple  was  retracted.  Palermo  has  collected  750 
cases  of  timior  of  the  male  breast  ("'Semaine  Medicale,"  May  20,  1908)  and 
649  of  them  were  cancerous. 

Treatment  of  Carcinoma  of  the  Mammary  Gland. — The  treatment  is 
early  and  thorough  operation;  the  earlier  and  the  more  thorough,  the  better. 
The  older  surgeons  operated  simply  to  prolong  life  a  few  months;  the  modern 
surgeon  operates  with  the  hope  of  curing  the  patient.  The  mortality  of  the 
operation  is  surprisingly  small.  It  is  certainly  under  2  per  cent.  Rodman's 
statistics  (2133  operations  performed  since  1893  by  twenty-one  American  sur- 
geons) show  a  mortality  of  less  than  i  per  cent.  I  have  personally  lost  5  pa- 
tients in  over  250  operations.  In  1878  BiHroth's  statistics  showed  only  8  cures 
in  143  cases.  In  1S96  W.  Watson  Che^Tie  reported  12  cures  out  of  21  cases 
(57  per  cent.).  His  cases  now  show  54.8  per  cent,  alive  and  well  from  six  to 
thirteen  years  after  operation.  Depage's  statistics  show  that  48  per  cent,  of 
cases  passed  the  three-year  limit  ("Presse  Medicale,"  Oct.  21,  1908).  Green- 
ough,  Simmons,  and  Burney  consider  3.20  cases  operated  upon  radically 
("Annals  of  Surger\\"  July,  1907);  88  cases  passed  the  three-year  limit. 

E.  S.  Judd  ("Jour.  Anier.  Med.  Assoc,"  April  27,  1912)  pubhshes  the  fol- 
lowing statistics  from  the  Mayo  Clinic.  He  says:  "The  prognosis  as  to  the 
probabilitv  of  a  cure  in  a  case  of  carcinoma  of  the  breast  will  depend — i,  on 
the  length  of  time  the  neoplasm  has  been  developing;  2,  on  the  degree  of  out- 
lying involvement:  3,  on  the  acti\-ity  of  the  gland,  which  will  be  determined 
by  the  age  of  the  patient  and  the  relation  to  a  period  of  lactation ;  and,  4,  on 
the  thoroughness  of  the  removal  of  the  gland-bearing  fascia. 

"Data  Collected  from  the  Mayo  Clixic  ox  518  Cases  of  Carcixoil^  of  the  Breast, 
From  Januar>-  i,  1S90,  to  January  i,  1900: 

Average  age 55  years,  6  months. 

Oldest 75  years. 

Youngest 2r  years. 

Number  of  cases  operated  on  over  ten  vears  before: 

AKve  and  well 21  (23.5  per  cent.). 

Dead 23 

Xot  heard  from 45 

Total 89 

Xumber  of  cases  operated  on'over  five  years  before: 

.\live  and  well 74  (30  per  cent.). 

Dead 76 

Not  heard  from 89 

Total 239 

Xumber  of  cases  operated  on  over  two  vears  before: 

-\Hve  and  weU 233  (44  per  cent.). 

Dead i34 

Xot  heard  from 151 

Total 518" 

Bloodgood  ("Amer.  Jour.  Med.  Sci.,"  Feb.,  1908)  sets  forth  Halsted's  statis- 
tics: "The  statistics  m  Halsted's  Clinic  up  to  the  present  time  show  that  among 
210  cases,  in  which  three  years  or  more  have  passed  since  the  operation,  42  per 
cent,  are  apparently  well.     If  we  consider  the  cases  in  which  the  axillary 


1438  Diseases  of  the  Mammary  Gland 

glands,  studied  microscopically,  showed  no  evidence  of  metastasis,  61  cases, 
or  85  per  cent.,  are  well.  In  cases  in  which  the  axillary  glands  showed  metas- 
tasis (no),  30  per  cent,  remained  free  from  recurrence  for  three  years.  When 
the  glands  in  the  neck  showed  metastasis  (40  cases),  only  10  per  cent,  remained 
well  for  three  years.  In  all  of  these  groups  metastasis  has  been  observed  after 
an  interval  of  three  years  of  apparent  cure.  Such  late  metastasis  may  take 
place  up  to  eight  years  after  operation.  Excluding  these  cases  of  late  recur- 
rence, the  definitely  cured  in  these  three  groups  is  reduced  to  75,  24,  and  7  per 
cent,  respectively,  or,  for  all  cases  together,  35  per  cent.  I  have  not  time  to  give 
the  facts,  but  there  is  evidence  to  indicate  that  when  the  microscope  fails  to 
demonstrate  metastatic  cancer  cells  in  the  lymphatic  glands  in  the  axilla,  this 
is  not  a  positive  proof  that  metastasis  has  not  taken  place,  and  for  this  reason 
and  others,  which  space  prevents  me  from  stating,  there  should  be  no  restriction 
in  the  complete  operation  for  carcinoma  of  the  breast."  It  will  be  observed 
that  of  these  40  cases,  with  involvement  of  neck  and  axilla,  only  4  passed 
the  three-year  limit.  If  they  had  not  been  operated  upon,  statistics  would 
have  been  bettered.  The  surgeon  who  would  not  operate  on  such  cases 
would  have  a  higher  percentage  of  cures  for  his  statistics,  but  he  would 
have  sacrificed  to  statistical  glory  these  4  cases.  If  there  is  the  slightest 
doubt  of  the  diagnosis,  make  an  exploratory  incision  before  making  the 
incisions  for  the  removal  of  the  breast  (see  Dawbarn's  remarks  on  the 
deceptive  signs  given  by  thick- walled  abscesses  in  the  "Annals  of  Surgery," 
March,  1908).  A  frozen  section  can  be  made  and  examined  in  a  few  min- 
utes, and  this  procedure  is  demanded  in  a  doubtful  case.  If  the  mass  proves 
to  be  cancer,  I  always  pack  in  a  piece  of  gauze  just  wrung  out  of  boiling  water 
and  go  on  at  once  with  the  removal  of  the  breast.  As  Dawbarn  shows,  this 
method  seals  up  the  open  mouths  of  lymphatics.  A  radical  operation  should 
remove  the  breast  and  much  of  the  skin  above  it,  the  pectoral  fascia,  the 
pectoral  muscles,  the  fat  and  glands  of  the  axilla,  and  the  fascia  over  the 
serratus  magnus.  As  Cheyne  says,  remove  all  the  glands  along  the  axillary 
vein  and  lift  up  the  vein  at  the  apex  of  the  axilla  and  remove  the  glands  and 
fat  behind  it.  The  sheath  of  the  vein  should  always  be  removed.  Cheyne 
points  out  that  the  line  of  spread  must  be  traced  upward  along  the  vessels  and 
nerves  and  downward  along  the  external  respiratory  nerve  of  Bell  ("Lancet," 
March  12,  1904).  If  three  years  after  an  operation  there  has  been  no  return, 
we  regard  the  case  as  cured  (Volkmann's  Hmit).  As  a  matter  of  fact,  recur- 
rences are  noted  after  five  years,  and  this  limit  should  be  used  instead  of  three 
years.  It  is  true  that  80  per  cent,  of  those  passing  the  three-year  limit  remain 
free  from  recurrence.  Over  90  per  cent,  of  those  passing  the  five-year  limit 
remain  free.  Coley  reported  65  cases  of  recurrence — 15  per  cent,  recurred 
after  three  years  and  6  per  cent,  after  fourteen  years.  Ransohoff  collected 
10  cases  of  recurrence  during  the  seventh  and  eighth  years,  2  each  after  the 
ninth,  tenth,  eleventh,  twelfth,  and  fifteenth  years,  and  i  each  after  various 
intervals,  from  fifteen  to  twenty-five  years.  Martin  suggests  that  these  later 
so-called  recurrences  are  really  new  growths  in  persons  predisposed  to  cancer 
("Annals  of  Surgery,"  Oct.,  1.908).  Certain  cases  are  unsuitable  for  a  radical 
operation:  cases  in  which  metastases  exist;  cases  of  cancer  en  cuirasse;  cases 
with  mediastinal  involvement;  cases  where  axillary  involvement  is  very  great. 
Cheyne  would  also  rule  out  cases  in  which  large  glands  may  be  felt  above  the 
clavicle,  believing  that  in  such  cases  the  mediastinal  glands  must  be  cancerous.^ 
Operation  is  well-nigh  useless  for  carcinoma  mastitoides. 

Halsted's  Operation. — Halsted  performs   a   very   radical   operation.     He 
removes  suspected  tissue  in  one  piece,  and  thus  prevents  carcinoma  cells 
falling  into  the  wound,  for  it  is  well  known  that  if  such  cells  should  fall 
^  See  "Objects  and  Limits  of  Operation  for  Cancer,"  by  W.  Watson  Cheyne. 


Halsted's  Operation   for  Carcinoma  of  the  Mammary  Gland       1439 

into  the  wound  they  may  grow  just  as  may  a  graft  of  healthy  epithelium. 
The  neck,  shoulder,  arm  to  the  elbow,  the  entire  surface  of  the  chest  down 
to  the  waist,  both  breasts,  the  axilla,  the  side  and  the  back  of  the  diseased 
side  must  be  sterilized.  It  is  necessary  to  have,  besides  scalpels  and  the 
ordinary  instruments  for  an  operation,  a  great  number  of  hemostatic  for- 
ceps (So  to  100).  Place  the  patient  recumbent,  with  a  sand-pillow  under 
the  shoulder  of  the  affected  side.  The  shoulder  is  right  at  the  edge  of 
the  bed,  and  a  nurse  holds  the  arm  from  the  side,  keeping  it  at  a  right 
angle  with  the  body.  Halsted's  operation  is  performed  as  follows:^  The  skin- 
incision  is  made  as  shown  in  Fig.  1007,  and  is  carried  at  once  through  the 
fat.  The  triangular  skin-flap  (a,  b,  c)  is  turned  down.  The  costal  insertions 
of  the  great  pectoral  muscle  and  the  muscle  are  split  between  the  clavicle  and 
costal  portions  and  up  to  a  point  opposite  to  the  scalene  tubercle,  and  at  this 
point  the  cla^'icular  portion  of  the  muscle  and  the  tissue  overhang  it  are  cut 
through  close  to  the  cla\'icle,  and  the  apex  of  the  axilla  is  at  once  exposed. 
The  cellular  tissue  under  the  cla\dcular  portion  of  the  muscle  is  dissected 


Fig.  1007. — Halsted's  operation  for  carcinoma  of  the  breast:  the  first  incision. 


from  the  muscle,  and  the  splitting  of  the  muscle  is  continued  on  to  the  humerus. 
The  part  of  the  muscle  to  be  removed  is  cut  through  close  to  its  himieral  in- 
sertion. The  whole  mass  circumscribed  by  the  first  incision  (skin,  breast, 
areolar  tissue,  and  fat)  is  raised  ■^'ith  considerable  force  in  order  to  put  the 
submuscular  fascia  on  the  stretch  as  it  is  stripped  from  the  thorax  close  to  the 
ribs.  It  is  well  to  include  the  delicate  sheath  of  the  pectoralis  minor  muscle. 
The  lower  and  outer  boundan,-  of  the  lesser  pectoral  having  been  passed  and 
exposed,  the  muscle  is  cut  at  a  right  angle  to  its  fibers  and  a  little  below  the 
middle.  The  tissue  over  the  pectoralis  minor  muscle  near  its  coracoid  inser- 
tion is  di\-ided  as  far  out  as  possible,  and  is  then  reflected  inward  to  prepare 
for  the  reflection  upward  of  this  part  of  the  minor  muscle.  The  upper  por- 
tion of  the  minor  muscle  is  retracted  upward.  Some  surgeons  do  not  remove 
the  lesser  pectoral  muscle.  I  believe  it  should  be  removed,  because  the  axilla 
can  then  be  more  easily  and  rapidly  cleared.  The  removal  of  the  muscle 
does  not  impair  arm  movements,  and  its  retention  leads  to  the  formation,  when 
healing  is  complete,  of  a  cord-like  band  in  front  of  the  axilla.  (See  Douglas 
Drew,  in  "Brit.  Med.  Jour.,"  May  17,  1902.)  The  small  blood-vessels  imder 
the  minor  muscle  are  carefully  separated  from  it,  are  dissected  out  Yery  clear, 
and  are  ligated  close  to  the  axillary  vessels.  Having  exposed  the  subcla\darL 
^  "Johns  Hopkins  Hosp.  Reports,"  vol.  iv;  "Annals  of  Surgery."  Nov.,  1894. 


1440 


Diseases  of  the  Mammary  Gland 


vein  at  the  highest  possible  point  below  the  clavicle,  the  contents  of  the  axilla 
are  dissected  away  with  a  sharp  knife  and  the  vein  and  its  branches  are  stripped 
absolutely  clean.  The  loose  tissue  about  the  artery  and  the  nerves  should 
also  be  removed.  When  the  vessels  are  cleared,  the  axillary  contents  are 
rapidly  stripped  from  the  inner  walls  of  the  axilla  and  the  lateral  wall  of  the 


f  lyh 


Fig.  1008. — Halsted's  operation  for  carcinoma  of  the  breast:  The  mass  turned  down. 

thorax  (Fig.  1008).  The  fascia  which  binds  the  mass  to  the  chest  is  cut  loose 
to  the  ribs  and  the  serratus  magnus  muscle.  Just  before  reaching  the  junction 
of  the  posterior  and  lateral  walls  of  the  axilla  an  assistant  draws  the  triangular 
flap  of  skin  outward  in  order  to  spread  out  the  tissue  which  lies  upon  the  sub- 
scapularis,  teres  major,  and  latissimus  dorsi  muscles.    The  operator  cleans  the 

posterior  wall  of  the  axilla  from  within  outward. 
The  subscapular  vessels  are  clearly  exposed,  and 
are  caught  before  they  are  cut.  In  some  cases 
the  subscapular  nerves  are  removed,  in  others  they 
are  permitted  to  remain.  Having  passed  these 
nerves,  the  mass  is  turned  back  into  its  normal 
position  and  severed  from  the  body  of  the  patient 
by  a  stroke  of  the  knife  from  h  to  c,  repeating  the 
first  cut  through  the  skin.  Every  bleeding  point, 
however  small,  is  tied  with  fine  silk.  From  60  to 
100  ligatures  or  even  more  may  be  required. 

After  the  completion  of  the  operation  the 
wound  into  the  axilla  is  closed  with  a  subcuti- 
cular stitch  of  silver  wire;  if  a  cut  has  been 
carried  above  the  clavicle,  it  is  closed  in  the  same 
manner,  and  the  edges  of  the  elliptical  opening  are 
brought  nearer  together  by  a  purse-string  sub- 
cuticular stitch.  Thiersch  grafts  cut  from  the 
patient's  thigh  are  used  to  cover  the  gap.  Silver- 
foil  is  placed  over  the  wound,  this  is  covered  with 
gauze,  bandages  are  applied,  and  the  dressing  is 
overlaid  by  a  plaster-of-Paris  bandage,  which  in- 
cludes the  head,  neck,  chest,  and  arm.  The  area  from  which  grafts  were  taken 
is  dressed  with  sterile  gauze  or  an  ointment  containing  boric  acid. 

Formerly  I  did  not  open  the  subclavian  triangle.  I  believed  that  these 
glands  were  involved  only  from  the  axillary  lymphatics,  that  when  they  were 
involved  the  mediastinal  glands  were  sure  to  be  affected  (the  route  to  them 


Fig.  loog. — The  younger  Senn's 
incision  for  amputation  of  the 
breast. 


Warren's  Operation  for  Carcinoma  of  the  Mammary  Gland 


1 441 


being  more  direct)  and  operation  was  certain  to  be  useless.  When  the  sub- 
claWan  glands  are  involved  from  the  axillary  lymphatics  this  is  true,  but  in 
some  cases  they  are  involved  by  way  of  the  chrect  lymph  paths  from  the  mam- 
mary gland.  In  such  a  case  the  mediastinal  glands  may  be  free,  and  cleaning 
out  the  subclavian  triangle  may  save  the  patient.  I  always  open  the  subclavian 
triangle  and  clear  out  fat  and  glands  if  no  glands  or  only  a  few  small  glands 
were  palpable  before  operation.     If  there  is  a  large  glandular  mass  in  the 


Fig.  loio. — ^Jabez  2s.  Jackson's  incision 
for  removal  of  the  mammarj^  gland. 


Fig.  loii. — Method  of  approximating  flaps  after  breast 
amputation. 


triangle,  operation  is  useless.  I  always  open  the  triangle  if  the  tumor  of  the 
mammar}-  gland  is  in  the  upper  hemisphere,  or  if  I  discover  enlarged  glands 
at  the  apex  of  the  axiHa,  whether  there  are  or  are  not  small  palpable  glands 
above  the  cla\dcle. 

The  Younger  Sennas  Incision. — A  ver\-  useful  incision  is  that  described 
by  the  yoimger  Senn,  and  shown  in  Fig.  1009.  The  breast  is  circumscribed 
by  two  cursHinear  incisions  which  meet 
above,  at  the  border  of  the  great  pectoral 
muscle.  The  incision  is  continued  a  little 
internal  to  the  outer  border  of  the  muscle 
to  about  I  inch  above  the  apex  of  the 
axiUa,  when  it  is  cur\*ed  outward  in  the 
deltoid  region,  and  terminates  at  the  level 
of  the  apex  of  the  axilla.  The  breast  is 
removed  from  the  wall  of  the  chest,  and 
is  then  suspended  by  axiQan,'  glands  and 
fat,  which  are  removed  en  viasse}  This 
incision  gives  a  free  exposure,  opens  the 
axilla  from  in  front,  enables  the  surgeon 
quickly  to  locate  and  freely  expose  the 
axillary  vein,  and  the  resulting  scar  does 
not  materially  limit  the  motions  of  the  arm. 

Jackson's   incision  (Jabez  X.  Jackson, 
"Jour.  Amer.  Med.  Assoc,"  March  5,  1906) 

is  shown  in  Fig.  loio.  The  axilla  is  entered  from  above,  a  quadrilateral  flap 
of  skin  is  raised,  and  is  subsequently  pulled  down  to  and  inclosing  the  wound 
(Fig.  ion). 

Warren's  incision  is  shown  in  Fig.  1012.    It  enables  the  surgeon  to  close  the 
wound. 

^  See  the  younger  Senn  in  '"Jour.  Amer.  Med.  Assoc,"  Ma\-  27,  1899. 

91 


Fig.  1012. — Warren's  incision  for  removal 
of  the  mammarv  gland. 


1442 


Diseases  of  the  Mammary  Gland 


Willy  Meyer's  Operation  ("Jour.  Amer.  Med.  Assoc,"  July  29,  1905). — 
For  the  last  few  years  I  have  been  performing  the  operation  devised  by 
Willy  Meyer.  I  consider  it  a  most  excellent  procedure,  with  distinct  points  of 
superiority  over  other  plans.  We  owe  to  Gerster  the  principal  of  opening  the 
axilla  in  the  beginning  of  the  operation  in  order  to  prevent  the  diffusion  of 
cancer  cells  and  so  diminish  the  chance  of  rapid  recurrence.  Gerster' s  paper 
was  published  in  the  "Amer.  Jour.  Med.  Sci."  in  1888.  The  younger  Gross, 
in  his  later  years,  used  to  open  the  axilla  first  when  there  was  an  axillary  mass, 
but  he  did  it  in  order  to  determine  in  the  beginning  of  the  operation  if  the 
axillary'  mass  was  really  removable.  Willy  Meyer  emphasizes  the  value  of  his 
procedure  in  lessening  hemorrhage.  In  Meyer's  operation  two  flaps  are  formed 
by  the  skin-incision  (Fig.  1013) — a  lower  and  an  upper  flap.  The  incision  for 
the  formation  of  the  lower  flap  begins  at  the  point  of  insertion  of  the  great 
pectoral  muscle  on  the  humerus,  and  is  carried  downward  and  inward  ^  inch 


Fig.  1013. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.   Skin  incision  as  practised  since  1898- 

above  the  border  of  the  muscle  and  parallel  to  it.  When  the  incision  reaches 
the  base  of  the  mammary  gland,  it  is  carried  along  the  lower  margin  of  the  gland, 
and  it  ends  over  the  sternum,  a  little  beyond  the  midline  (Fig.  1013) .  The  lower 
flap  is  separated  and  turned  down,  a  quantity  of  subcutaneous  fat  being  allowed 
to  remain  attached  to  the  breast.  This  turning  down  is  carried  to  the  border 
of  the  latissimus  dorsi  muscle,  to  the  axillary  cavity,  and  to  the  chest  wall. 
Meyer  then  directs  that  the  border  of  the  latissimus  dorsi  be  followed  down  to 
the  serratus  anticus  major,  and  upward  to  the  mass  of  fat  that  enters  the 
bicipital  sulcus  of  the  arm.  The  fat  is  removed  from  the  anterior  border  of  the 
muscle  by  blimt  dissection.  This  anterior  lower  wound  is  then  packed  with 
gauze. 

The  surgeon  next  forms  the  upper  flap  by  uniting  the  inner  and  outer  ends 
of  the  first  incision  vdih  another  incision  carried  along  the  upper  margin  of 
the  breast  (Fig.  1013).     In  this  flap,  as  in  the  other,  the  surgeon  leaves  as 


Meyer's  Operation  for  Carcinoma  of  the  Mammary  Gland      1443 

much  subcutaneous  fat  adhering  to  the  breast  as  he  can  spare  without  in- 
ducing the  danger  of  skin  necrosis.  This  upper  flap  is  raised  progressively 
until  the  cephalic  vein  is  reached  and  there  is  exposure  of  the  lower  surface 
of  the  clavicle  with  the  sternoclavicular  articulation.  Meyer  directs  that  the 
tissues  covering  this  articulation  shall  not  be  disturbed. 

After  the  formation  of  these  two  flaps  the  next  step  in  the  operation  is  the 
di\'ision  of  the  tendons  of  the  two  pectoral  muscles  and  the  exposure  of  the 
axillar}'  and  subcla\-ian  veins.  Meyer  ad\ases  that  the  cephaUc  vein  be  fol- 
lowed up  until  the  insertion  of  the  great  pectoral  muscle  into  the  humerus  is 
found.  The  tendon  is  fully  exposed,  care  being  taken  to  bare  it  of  axillary 
fat.  The  arm  is  then  carried  a  little  nearer  to  the  side  to  relax  the  great  pec- 
toral muscle.  This  tendon  is  cut  off  close  to  the  humerus  (Fig.  1014).  The 
muscle  is  pulled  downward  and  inward  and  is  loosened  from  the  cephalic 


Fig.  1014. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.    Insertion  of  pectoralis  major  muscle 
exposed.     Operator's  left  indes-finger  encircling  its  tendon. 

vein.  It  is  then  cut  off  near  the  lower  border  of  the  cla\-icle  and  the  sterno- 
clavicular articulation.  It  is  necessary-  to  di\'ide  the  nen,-es  that  enter  the  pec- 
toral muscle,  and  all  the  vessels  that  come  into  \ievr  are  di\'ided  between  two 
clamps  and  tied. 

The  next  step  is  to  di\dde  the  tendon  of  the  lesser  pectoral  muscle  near  the 
coracoid  process  (Fig.  1015).  Just  beneath  this  tendon  lies  the  subcla\dan 
vein.  The  surgeon  now  makes  a  transverse  di\-ision  of  the  fascia  over  the 
axilla,  and  thus  exposes  the  axillar}^  and  subcla\'ian  veins  (Fig.  1016). 

ISleyer's  third  step  is  to  split  the  axillarv^  fat  over  the  upper  portion  of  the 
latissimus  dorsi  up  to  the  axillary'  vein,  "thus  di\'iding  it  from  the  mass  of  fat 
that  enters  the  sulcus  bicipitaKs  brachii." 

Next,  the  axillary-  and  the  subclaAdan  veins  are  followed  up  to  where  the 
subcla^^an  passes  below  the  clavicle,  and  even,'  vessel  that  e\ddently  must  be 


1444  Diseases  of  the  Mammary  Gland 

cut  is  divided  between  two  ligatures  and  tied.  This  procedure  saves  a  great 
amount  of  hemorrhage.  Meyer  directs  us  to  be  careful  to  preserve  the  two 
superior  subscapular  nerves,  although  the  third  subscapular  must  be  sacrificed. 
The  next  step  in  the  operation  is  to  have  the  assistant  hold  up  the  mass  of 
partly  loosened  tissues  without  pulling  upon  them;  for  if  he  does  pull  upon 
them,  Meyer  truly  says,  he  is  apt  to  tear  off  pieces  of  periosteum  or  perichon- 
drium; and  such  bare  spots  are  liable  to  become  necrotic.  The  surgeon  now 
cuts  to  the  wall  of  the  chest,  being  careful  not  to  damage  the  great  serratus 
m.uscle.  Meyer  cautions  us  at  this  step  to  hold  the  blade  of  the  knife  horizon- 
tal; that  is,  "perpendicularly  toward  the  thorax."  "If  he  (the  surgeon) 
should  not  thus  turn  the  blade  of  his  knife,  but  cut  perpendicularly  downward 
toward  the  subscapular  muscle,  he  would  enter  the  fat  covering  and  enveloping 
the  nerves  and  blood-vessels  of  this  region,  thus  running  the  risk  of  unneces- 


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Fig.  loij. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.  Finger  undej  tendon  ofpectoralis 
minor  muscle.  Above,  cut  surface  of  clavicular  portion  of  pectoraUs  major  parallel  to  clavicle  is  \'is- 
ible  (in  the  living  the  belly  of  the  pectoralis  major  is  not  so  thoroughly  detached  from  that  of  the 
pectoralis  minor.     It  is  done  here  to  show  the  latter's  tendon). 

sarily  causing  considerable  hemorrhage  and  of  injuring  the  subscapular  nerves. 
In  the  general  run  of  cases  this  region  need  not  be  explored;  only  in  very  ad- 
vanced cases  did  I  find  a  few  injected  glands  in  this  area." 

The  pectoralis  major  muscle  is  now  di\dded  close  to  the  wall  of  the  chest, 
the  cuts  being  parallel  to  the  ribs,  and  almost  level  with  them;  and  the  mass 
being  gently  drawn  toward  the  sternum.  By  watching  carefully,  one  may 
see  the  perforating  arteries  and  veins  drawn  out  by  traction  before  cutting 
them,  and  may  usually  catch  each  of  them  with  two  clamps  and  divide  be- 
tween the  clamps.  If  this  is  impossible,  they  are  divided  and  quickly  picked 
up.  The  last  tissue  that  holds  the  mass  to  the  chest  wall  is  composed  of  the 
muscle-fibers  from  over  the  sternum.  These  are  di\dded  close  to  the  sternum 
(Fig.  1017).  The  final  steps  consist  in  tying  all  blood-vessels,  draining,  and 
suturing  the  wound.     The  draining  is  done  through  a  perforation  in  the 


Meyer's  Operation  for  Carcinoma  of  the  Mammary  Gland      1445 

posterior  flap.     It  may  be  tubal  or  by  gauze.     Gauze  has  the  advantage  of 
restraining  oozing  of  blood. 

This  operation  has  noteworthy  merits.  It  can  be  performed  far  more  rap- 
idly than  any  other  method  that  I  have  ever  employed.  The  loss  of  blood  is  com- 
paratively trivial,  because  in  this  operation  the  chief  blood-vessels  are  divided 
early,  are  cut  close  to  the  axillary  artery-,  and  are  tied.  In  removmg  the  mass 
from  the  chest  wall  there  is  httle  bleeding,  except  what  comes  from^'the  perfo- 
ratmg  vessels,  hemorrhage  from  the  branches  of  the  axillar>-  being  entirely 
absent;  and  even  many  of  these  perforatmg  vessels  are  tied  before  being 
divided.  We  are  far  less  apt  by  this  method  than  bv  the  usual  plan  to  milk 
hTnph  which  contains  cancer  cells  into  the  womid,  or  in  aberrant  directions 
through  the  h-mphatics.  As  Dawbarn  says,  the  squeezing  "of  the  breast  by  the 


Fig.  1016. — \\"\\\x  :Meyer"s  operation  for  carcinoma  of  the  breast.  Subcla\-ian  and  axillan-  veins 
fully  exposed.  So  far,  glands  and  fat  tissue  not  removed;  smaller  vessels  stiU  in  connection  with  main 
trunks.     Finger  imder  fat  toward  sulcus  bicipitahs,  its  nail  resting  on  asiUary  vein. 

retractors  during  its  oblation,  as  also  its  handling  when  separated,  save  for 
its  attachments  to  the  armpit,"  are  real  dangers  and  may  be  responsible 
for  rapid  recurrence  of  the  growth  (''.Innals  of  Surgery-,'''  :\Iarch,  1908). 
The  drain  is  removed  in  from  thirty-six  to  forty-eight  hours.  The  patient 
is  placed  in  a  sitting  posture  on  emerging  from  ether  and  is  allowed  out  of 
bed  on  the  fourth  or  nfth  day. 

Dressing  atid  After-treatment. — The  dressing  must  be  -nide  and  ample. 
Fluffed  up  gauze  is  pushed  into  the  axilla  to  obliterate  the  dead  space  and  the 
arm  is  bound  to  the  side  for  forty-eight  hours.  WTien  the  binding  is  removed, 
the  extremity  is  placed  on  a  pUlow  in  a  position  of  moderate  abduction,  and 
is  abducted  a  little  more  each  day.  If  the  incision  was  placed  well  above  the 
axillar>'  border  the  mobihtv  of  the  arm  will  be  such  that  in  two  weeks  the 


1446 


Diseases  of  the  Mammary  Gland 


patient  can  place  the  hand  on  the  back  of  the  head.  Of  late  I  have  been 
placing  the  arm  at  once  after  the  operation  in  abduction  (upon  a  pillow  or  a 
triangular  splint  which  rests  upon  the  side) .  This  is  unnecessary  if  the  incision 
does  not  run  on  to  the  arm  and  in  front  and  above  the  anterior  axillary  margin. 
If  the  old  incision  in  the  axilla  is  used,  abduction  and  all  other  plans  will  fail 
to  prevent  decided  limitation  of  movement. 

Inoperable  Malignant  Diseases  of  the  Breast. — This  term  implies 
that  a  radical  operation  looking  to  cure  is  impossible.  The  conditions  in 
which  it  is  impossible  have  already  been  specified  (see  page  1438).  Even  if  the 
case  is  judged  inoperable  from  the  radical  standpoint,  it  may  be  wise  to  re- 
move the  mammary  gland,  in  order  to  free  the  patient  from  a  hideous,  ulcer- 
ating area,  violent  pain,  or  harassing  hemorrhage. 


Fig.  1017. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.   Pedicle  of  mass  over  sternum  ready 

to  be  cut  off. 

It  has  been  suggested  that  some  cases  inoperable  by  ordinary  methods  may 
be  subjected  to  removal  of  the  entire  upper  extremity  or  to  disarticulation  at 
the  shoulder- joint  with  some  prospect  of  cure.  My  own  view  is  that  when 
a  case  has  advanced  so  far  that  it  is  not  amenable  to  ordinary  operative 
treatment,  neither  of  the  above-mentioned  procedures  offers  any  reasonable 
chance  of  success.  If  the  pain  is  extremely  violent  in  an  inoperable  case, 
the  surgeon  may  relieve  it  by  dividing  the  brachial  plexus,  or  perhaps  by 
disarticulating  at  the  shoulder-joint. 

Some  inoperable  cases  may  be  greatly  improved — for  a  time,  at  least — by  the 
use  of  the  :v-rays;  and  even  when  the  condition  is  not  benefited  in  other  ways, 
this  force  sometimes  mitigates  or  greatly  relieves  the  pain.  It  is  said  that  in 
some  cases  radium  is  more  efficient  than  the  :i:-rays,  but  it  is  probable  that 
most  improvements  by  radium  could  have  been  obtained  by  the  a:-rays.  In 
cases  of  lymphatic  recurrence  it  is  advisable  to  administer  thyroid  extract 
during  the  x-ray  course  (Woods,  in  "Brit.  Med.  Jour.,"  July  i,  1911). 


The  Rontgen  or  x-Rays  1447 

Beatson's  Operation,  or  Double  Oophorectomy. — It  has  been  pointed 
out  by  Sir  George  Thomas  Beatson  that  there  is  a  certain  similarity  between 
the  formation  of  cancer  in  the  mammary  gland  and  the  process  of  lactation. 
In  each  there  is  an  enormous  production  of  embryonal  epithelial  cells;  but 
in  lactation  the  epithelial  cells  undergo  fatty  degeneration,  and  in  cancer 
formation  they  do  not  do  so,  but  penetrate  into  the  tubules  and  the  acini  and 
infiltrate  the  gland  structure.  Beatson  further  points  out  that  when  a  lac- 
tating  cow  is  spayed,  it  continues  to  give  milk  indefinitely.  This  seems  to 
indicate  that  removing  the  ovaries  favors  the  fatty  degeneration  of  the  epi- 
thelial cells.  This  operation  has  been  performed  in  cases  of  inoperable  carci- 
noma of  the  breast  in  the  hope  of  bringing  about  degeneration  in  the  tumor 
mass.  In  the  great  majority  of  cases  it  fails  utterly;  but  now  and  then  it 
secures  a  notable  improvement,  and  in  a  very  few  cases  outward  evidence  of 
the  disease  disappeared,  the  general  health  improved,  and  there  was  gain  in 
weight.  The  cure  is  apparent,  but  not  real.  The  improvement  is  only  tem- 
porary'. Abbe  obtained  an  apparent  cure  in  2  patients.  It  was  at  first 
thought  that  the  operation  would  be  applicable  only  to  persons  that  have 
not  passed  the  menopause,  but  one  of  Abbe's  patients  was  over  seventy 
years  of  age.  Butlin,  however,  says  that  there  is  no  genuine  cure  secured  by 
this  operation  on  record,  and  Beatson  makes  the  same  statement.  The  opera- 
tion is  not  to  be  considered  if  visceral  deposits  exist.  My  own  view  is  that  the 
procedure  offers  but  little  prospect  of  success,  but  that,  as  it  does  offer  some, 
the  exact  facts  should  be  placed  before  the  patient,  and  she  should  be  per- 
mitted to  choose  whether  or  not  she  wishes  the  operation  performed. 


XL.  SKIAGRAPHY  OR  RONTQENOQRAPHY  (THE  EMPLOY= 
MENT  OF  THE  X=RAYS).  THE  FINSEN  LIGHT;  BEC= 
QUEREL'S   RAYS;    RADIUM    RAYS 

The  Rontgen  or  x=Rays. — The  cathode  rays  were  discovered  by  Hit- 
torf  in  1869,  while  passing  an  induction  current  through  a  vacuum  tube. 
Crookes,  of  London,  greatly  improved  the  vacuum  tube,  and  obtained  a 
rarefaction  which  left  in  the  tube  but  one-millionth  of  an  atmosphere.  This 
last-named  observer  found  that  when  an  interrupted  current  of  high  potential 
is  passed  through  a  vacuum  which  is  nearly  perfect,  fluorescence  takes  place. 
In  Crookes's  tube  the  positive  electrode  is  placed  at  some  indifferent  point, 
and  the  current  from  the  negative  electrode  flows  not  to  the  positive,  but  di- 
rectly to  the  wall  of  the  tube  opposite  the  cathode,  and  at  this  point  the  phos- 
phorescent glow  is  detected. 

In  1895  Rontgen,  of  Wurzburg,  while  making  a  study  of  cathode  rays  as 
developed  in  Crookes's  tubes,  discovered  the  energy  which  he  named  the  x- 
rays.  Rontgen  showed  that  at  the  wall  of  the  Crookes  tube  opposite  the 
negative  electrode  a  new  and  hitherto  unknown  energy  is  generated.  Be- 
cause of  the  uncertain  character  of  this  energy  he  gave  to  its  manifestation  the 
name  of  the  x-rays  or  unknown  rays. 

The  x-rays  are  invisible;  cannot  be  deflected,  refracted,  or  concentrated;  are 
not  influenced  by  the  magnet,  and  produce  none  of  the  ordinarily  recognized 
effects  of  heat.  The  rays  cannot  be  polarized,  travel  with  the  velocity  of  light, 
and  cause  fluorescence  in  certain  substances,  notably  in  the  tungstate  of 
calcium  (Edison),  platinocyanid  of  barium  (Rontgen),  and  the  platinocyanid  of 
potassium.  They  have  a  marvellous  power  of  penetration.  Freund  ("Radium 
Therapy")  says,  "Speaking  broadly,  one  may  say  that  the  lighter  the  specific 
gravity  of  a  body,  the  more  transparent  is  it  to  .r-rays.  On  the  other  hand, 
a  body's  opacity  for  the  rays  increases  with  its  density,  though  not  in  the  same 


1448  Skiagraphy  or  Rontgenography 

proportion."  "V.  Novak  and  0.  Sule,  also  VoUer  and  Walter,  proved  that  the 
transparency  of  a  body  to  x-rays  depends  less  upon  its  density  than  upon  its 
atomic  weight." 

The  x-rays  in  their  action  on  photographic  plates  or  films  exhibit  actinic 
effects.  If,  therefore,  an  object  whose  component  parts  are  of  unequal  den- 
sity— e.  g.,  the  hand — is  placed  on  a  photographic  plate  protected  from  or- 
dinary light,  and  exposed  to  the  action  of  x-rays,  the  plate  when  developed 
by  photographic  methods  will  exhibit  a  picture  of  the  shadows  cast  by  the  sev- 
eral parts  of  the  object.  Such  a  picture  is  known  as  a  skiagraph,  radiograph, 
or  a  Rontgenograph.  Similar  shadows  will  be  seen  on  a  fluorescent  screen  if 
the  object  is  between  an  excited  x-ray  tube  and  the  screen.  The  portion  of 
the  screen  free  from  shadow  glows  with  fluorescence.  Such  a  screen  is  known 
as  a  fluoroscope  or  Rontgenoscope. 

The  real  nature  of  the  rays  remains  unknown.  They  resemble  the  ultra- 
violet and  Becquerel  rays  in  their  action  on  a  charged  electroscope  and  in 
producing  fluorescence  in  certain  substances,  but  neither  the  Becquerel  nor  the 
ultraviolet  rays  have  the  penetrating  power  of  the  Rontgen  rays.  Many  the- 
ories have  been  advanced.  The  most  acceptable  has  been  on  the  electromag- 
netic theory  of  light.  The  difference  between  the  Rontgen  rays  and  a  beam 
of  sodium  light  is  said  to  be  that  the  thickness  of  the  Rontgen  ray  pulse  is 
very  small  compared  with  the  wave  length  of  sodium  light,  and  that  in  the 
Rontgen  rays  there  is  not  that  regular  periodic  character  which  occurs  in  a 
train  of  waves  of  constant  wave  length  (J.  J.  Thompson). 

Solid  bodies  which  are  struck  by  the  x-rays  emit  new  ra,ys  having  similar 
properties  (Saganic),  known  as  secondary  rays,  and  less  powerful  than  the 
primary  rays. 

For  practical  purposes  we  may  consider  that  the  x-rays  have  penetrating 
and  actinic  properties. 

For  the  production  of  the  Rontgen  rays  the  essential  is  to  have  an  electric 
current  pass  through  a  Crookes  tube  of  rather  high  vacuum.  The  state 
or  degree  of  vacuum  controls  the  nature  of  the  rays.  A  tube  of  low  vacuum 
will  emit  soft  rays  of  low  penetrating  power,  while  the  rays  from  a  tube  of  high 
vacuum  will  penetrate  even  pure  sheet  lead.  The  vacuum  of  a  given  tube  does 
not  remain  constant  with  use,  the  tendency  being  for  the  vacuum  to  become 
higher.  Some  get  so  high  that  they  cannot  be  used.  All  modern  tubes  have 
some  device  by  means  of  which  the  vacuum  may  be  regulated  and  controlled. 

The  soft  rays  are  rich  in  actinic  value,  but  because  of  their  feeble  penetrat- 
ing qualities  are  of  use  only  in  treating  superficial  conditions,  or  for  the  Ront- 
genography of  thin  parts,  and  in  conditions  in  which  much  contrast  of  shadows 
is  desired.  On  the  other  hand,  in  deep  and  dense  parts  satisfactory  results  can 
only  be  obtained  with  hard  rays.  In  the  hands  of  the  experienced  operator 
the  quality  of  the  rays  is  adapted  to  the  condition. 

To  excite  the  Crookes  tube  or,  as  it  is  more  commonly  called,  the  x-ray 
tube  it  is  necessary  to  have  an  electric  apparatus  capable  of  delivering  a  cur- 
rent of  high  tension  and  as  far  as  possible  unidirectional.  Rontgen  used  the 
induction-coil  of  Ruhmkorff .  The  fundamental  parts  of  an  induction-coil  are  a 
primary  winding,  which  receives  and  stores  up  the  electricity  from  its  origin  or 
from  its  source  of  supply,  an  interrupter,  to  make  and  break  the  current,  and  a 
secondary  winding,  which  receives  the  current  and  delivers  it  to  a  negative  and  a 
positive  pole.  Wires  carried  from  these  poles  to  their  respective  terminals  on 
the  x-ray  wiU  complete  the  circuit. 

A  static  machine  is  frequently  used  to  excite  Crookes's  tubes,  but  only  the 
most  powerful  are  of  practical  value  in  taking  skiagraphs.  The  static  machine 
is  ideal  for  Rontgen  ray  therapy,  for  the  reasons  that  the  current  is  without 
inverse  and  is  of  high  voltage,  hence  will  operate  tubes  of  high  degrees  of  vac- 


Physiological  Effects  of  the  Rontgen  Rays  1449 

uum;  it  is  a  current  of  constant  voltage,  that  is,  it  is  not  a  wave  form  of  current, 
and,  therefore,  all  of  the  current  is  efl&cient;  whereas  all  other  t\-pes  of  appa- 
ratus give  off  a  wave  form  of  current,  so  that  the  voltage  is  comparatively  low 
at  the  bottom  of  the  wave  and  ven,-  high  at  the  peak  of  the  wave,  fully  half  of 
the  wave  being  inefficient  in  the  operation  of  high  vacuum  tubes ;  and  the  rays 
from  a  tube  of  a  given  degree  of  vacuum  will  be  more  nearly  homogeneous,  and 
can  be  delivered  to  more  definite  purpose,  if  produced  by  a  static  machine. 
The  disadvantage  of  the  static  machine  is  that  it  will  not  deliver  a  sufficient 
quantity  of  current  for  rapid  Rontgenographic  work. 

The  induction  coil  has  three  disadvantages:  i,  its  current  is  not  always  uni- 
directional; 2,  some  form  of  mterrupter  is  necessar\^ — and  all  forms  are 
troublesome;  3,  the  output  is  not  sufficient  for  rapid  exposures.  It  is  largely 
used  for  therapeutic  exposures  and  for  exciting  the  .v-ray  tube  on  the  fluo- 
roscopic apparatus.  The  current  is  of  high  voltage,  though  low  in  amperage; 
it  is  easily  controlled  by  a  rheostat  and  switches,  and  operates  equally  well  high 
or  low  vacuum  tubes.  The  most  popular  machine  for  diagnostic  work  is  the 
transformer  t\pe,  the  first  of  which  was  installed  in  the  Jefferson  Hospital 
in  1907.  This  apparatus  is  buUt  either  for  direct  or  alternating  current.  \Mien 
the  current  supply  is  direct,  a  rotars'  converting  motor  delivers  an  alternating 
current  to  a  high  tension  transformer,  and  at  the  same  time  drives  a  rotating 
rectifying  s'^A'itch,  so  that  the  waves  of  opposite  direction  are  collected  and 
delivered  as  a  unidirectional  current.  When  the  supply  is  alternating  current 
the  transformer  receives  it  direct  from  the  line,  and  the  rectifj'ing  switch  is 
driven  b}'  a  s^Tichronous  motor.  The  output  of  the  direct  current  machine  is 
limited  to  the  capacity  of  the  rotary  converting  motor,  while  that  of  the 
alternating  current  t}-pe  is  limited  only  by  the  amperage  that  may  be  draT\Ti 
from  the  source  of  supply.  With  the  transformer  the  time  of  Rontgenographic 
exposure  has  been  reduced  from  minutes  and  fractions  of  a  minute  to  seconds 
and  fractions  of  a  second.  It  is  almost  free  from  inverse  current  in  the  tube 
circuit,  but  its  voltage  output  depends  upon  its  amperage  intake  to  such  an 
extent  that  a  tube  of  high  penetration  wiU  only  operate  well  when  a  compara- 
tively large  amount  of  current  is  delivered  to  it.  The  tube  heats  rapidly,  and 
thus  becomes  less  desirable  for  fluoroscopic  work  or  for  therapeutic  Rontgeniza- 
tion.  Recently  de\'ices  have  been  made  to  eliminate  from  the  tube  circuit  a 
portion  of  the  high  tension  waves,  so  that  the  transformer  bids  fair  to  become  of 
universal  appKcability.^ 

Physiological  Effects  of  the  Rontgen  Rays. — Clinical  obsen>-ations  have 
determined  that  in  small  or  moderate  intensity  the  Rontgen  rays  act  as  a 

^  A  new  tj'pe  of  x-ray  tube  has  recently  been  invented  by  Coolidge,  of  Tungsten  lamp 
fame.  A  detailed  description  of  this  can  be  found  in  the  '"Physical  Review"  for  De- 
cember, 191 3.  The  advantage  of  this  tube  over  our  present  standard  t>-pe  is  that  the 
negative  electrons  are  furnished  by  a  heated  cathode.  The  temperatiire  of  this  cathode 
determines  the  amount  of  electrons  to  be  given  off,  hence  the  amount  of  :c-ray  energy  that 
may  be  emitted  from  the  tube. 

The  cathode  is  heated  by  a  storage-batters'  having  a  rheostat  and  meter  in  circuit,  so 
that  the  temperature  of  the  cathode  can  be  definite!}'  regulated.  The  penetrating  qualities 
of  the  Rontgen  rays  given  off  by  this  tube  are  dependent  entirely  upon  the  voltage  of  cur- 
rent furnished  by  the  high  tension  transformer.  A  definite  quantity  of  .i;-rays  of  a  definite 
degree  of  penetration  can  be  given  for  any  desired  length  of  time.  Any  set  of  conditions  as 
to  hardness  of  rays  or  amount  of  rays  can  be  duplicated  accurately  at  will. 

The  vacuum  of  this  tube  is  at  least  a  thousand  times  greater  than  the  vacuum  of  our 
present  standard  tube  and  requires  no  regulation,  so  that  there  will  be  none  of  the  disadvan- 
tages due  to  regulation  of  the  vacuum. 

Dr.  Coolidge  believes  that  he  will  be  able  to  produce  an  a;-ray  tube  which  with  adequate 
exciting  apparatus  will  produce  .-c-rays  that  will  be  fully  as  penetrating,  if  not  more  so,  than 
the  most  penetrating  gamma-rays  of  radium. 

A  great  deal  is  to  be  expected  from  the  proper  use  of  this  new  type  of  a;-ray  tube  in  the 
field  of  therapeutics.     The  tube  is  not  yet  obtainable  cormnercially. 


I4SO  Skiagraphy  or  Rontgenography 

stimulant  to  cell-growth  and  metabolism,  while  prolonged  radiation  produces 
cell  destruction. 

Histological  study  shows  that  the  cellular  elements  of  the  integument  are 
first  afifected,  and  that  only  after  repeated  or  prolonged  exposures  are  the  normal 
connective-tissue  elements  acted  upon  noticeably. 

Cell  degeneration  occurs  and  is  followed  by  inflammatory  changes  in  the 
surrounding  tissues,  notably  in  the  blood-vessels. 

After  sufi&cient  irradiation  this  process  will  go  on  to  endarteritis  and  necrosis. 

The  cause  of  these  tissue  changes  under  x-ray  exposure  has  been  the  subject 
of  varied  conjectures,  viz. :  liberation  of  ozone  in  the  tissues  (Tesla) ;  interference 
with  cellular  nutrition  caused  by  static  electric  currents  "induced  by  the  intro- 
duction of  the  patient's  tissues  into  the  high  potential  induction-field  surround- 
ing the  tube"  (Leonard) ;  the  destruction  of  the  nerve  supply  of  the  tissue  (Hop- 
kins); irritation  of  the  peripheral  extremities  of  the  sensory  nerves,  causing 
vasomotor  paralysis  (Rudis-Jicinsky) ;  "no  doubt  there  is  some  chemical  action 
which  causes  metabolic  disturbances"  (Beck) ;  "the  effects  of  x-Ta,ys  upon  tissues 
and  upon  substances  sensitive  to  x-rays  are  due  to  actinic  properties  of  the 
same  character  as  those  of  light"  (Pusey). 

It  is  generally  admitted  that  the  rays  themselves  are  responsible  for  the 
tissue  changes,  and  not  some  external  agent,  such,  as  electric  discharges. 

The  earliest  noticeable  effect  of  exposure  to  x-rays  is  a  tanning  of  the  skin  in 
dark  people  or  reddening  of  the  skin  in  blondes.  Ormsby  has  noted  this 
analogy  between  the  action  of  x-rays  and  the  sun  rays. 

Glandular  structures  undergo  atrophic  changes  after  repeated  exposures. 
Its  action  on  the  nervous  mechanism  is  more  difficult  to  understand,  but  that 
it  has  anodyne  effects  in  certain  painful  conditions  is  beyond  question.  There 
is  also  testimony,  but  not  certain  evidence,  that  the  x-rays  have  an  inhibitory 
influence  on  the  sympathetic  nervous  system.  It  has  occurred  that  a  small 
ureteral  calculus,  lodged  in  the  lower  end  of  one  ureter  for  a  long  period,  has 
passed  into  the  bladder  within  a  few  days  after  x-ray  examination. 

The  influence  of  Rontgen  rays  is  in  many  cases  distinctly  inhibitory  to 
the  growth  of  bacteria. 

The  untoward  effects  from  overexposure  to  the  x-rays  may  range  from 
falling  out  of  the  hair  or  slight  irritation  of  the  skin  to  the  production  of  ster- 
ility, extensive  sloughing,  chronic  non-healing  and  painful  ulcers,  cancer,  and 
death.  These  effects  may  be  acute  or  chronic.  The  patient  is  more  apt  to 
develop  acute  conditions,  while  the  operator  or  investigator  is  constantly  in 
danger  of  the  remote  or  chronic  lesions. 

The  so-called  x-ray  burn  is  not  a  bum,  but  a  dermatitis  or  a  gangrenous 
process.  A  burn  results  from  heat,  begins  on  the  surface  and  at  once,  is  ac- 
companied by  pain  from  the  moment  of  its  origin,  and  is  followed  by  inflamma- 
tion starting  from  the  surface  biu^t.  An  x-ray  burn  does  not  come  in  evi- 
dence for  several  days  or  for  a  longer  time  after  the  application  of  the  cause, 
and  the  inflammation  begins  in  the  skin  rather  than  upon  its  surface.  So 
called  x-ray  bums  may  be  classified  by  stages  or  degrees.  In  a  bum  of  the 
first  degree  {x-ray  dermatitis)  the  skin  is  hyperemic,  more  or  less  tender,  and 
may  itch  or  burn,  there  is  increased  pigment  formation,  and  the  outer  layer  of 
the  skin  will  "pull  off"  as  in  simbum.  It  may  develop  any  time  after  a  few 
days,  but  usually  does  so  in  from  ten  to  twenty.  Such  a  condition  is  popidarly 
known  as  a  "reaction."  No  treatment  is  required  for  dermatitis  of  this  degree, 
unless  there  is  severe  itching  or  burning,  when  we  may  use  the  following  prepara- 
tion advised  by  Dr.  Martin  F.  Engman  ("Interstate  Med.  Jour.,"  July,  1903): 
It  consists  of  1 2  drams  of  boric  acid,  i  oz.  of  zinc  oxid,  i  oz.  of  starch,  i  cz.  of 
subnitrate  of  bismuth,  i  oz.  of  oHve  oil,  3  oz.  of  lime-water,  3  oz.  of  lanolin, 
and  1 2  drams  of  rose-water.     The  powder  is  rubbed  in  a  mortar,  the  lanolin  is 


Physiological  Effects  of  the  Rontgen  Rays  1451 

added.  The  olive  oil  and  lime-water,  mixed,  are  slowly  added  to  the  powder 
and  lanolin.  The  mixture  is  stirred,  the  rose-water  is  added,  and  the  prepara- 
tion is  beaten  into  a  creamy  paste.  If  itching  is  severe,  i  to  2  per  cent,  of  car- 
bolic acid  is  added.  The  paste  is  spread  on  se\'eral  thicknesses  of  gauze  and  the 
gauze  is  covered  with  a  rubber-dam. 

In  an  ".v-ray  burn"  of  the  second  degree  the  condition  becomes  more 
painful,  vesicles  or  even  bullae  form,  there  is  swelling,  and  if  the  blisters  are 
opened  the  denuded  cutis  will  weep.  The  raw  area  is  sensitive  to  touch  and 
to  direct  contact  with  air. 

This  condition  requires  Httle  treatment  beyond  aseptic  attention,  the  use 
of  the  above-mentioned  ointment,  and  protection  from  further  exposure  to 
.T-ray  or  air. 

The  ' 'x-ray  burn"  of  the  third  degree  involves  all  the  layers  of  the  skin 
and  more  or  less  of  the  underlying  tissue  in  a  process  of  sloughing.  The 
slough  is  white,  adherent,  tough,  and  stringy.  G.  G.  Hopkins  calls  the 
process  white  gangrene  ("Phila.  Med.  Jour.,"  Jan.  6,  1900).  The  pain  is 
excruciating  and  constant,  seeming  as  if  "red-hot  coals  were  held  against  the 
body."  Sloughing  may  continue  for  weeks  or  months,  and  the  exudate  is 
profuse  and  irritating.  The  process  may  eventuate  in  gangrene  of  a  large  area, 
even  of  a  Hmb.  Such  ulcers  require  months  to  heal,  if  they  heal  at  all,  and  are 
not  improved  by  the  treatment  which  reUeves  ordinary  burns.  Excision  with 
subsequent  skin-grafting  or  amputation  may  be  necessary.  In  the  early  stages 
alkaline  astringents  give  the  best  results,  e.  g.,  a  mixture  composed  of  2  drams 
each  of  zinc  oxid  and  bismuth  subnitrate,  ^  fiuidram  each  of  liquor  potassa 
and  Uquor  plumbi  subacetatis,  2  drams  of  glycerin,  and  sufficient  lime-water 
to  make  6  fluidounces. 

This  mixture  may  be  applied  twice  daily  and  will  relieve  much  of  the  itch- 
ing and  burning  as  well  as  control  the  exudate.  It  should  be  applied  over  a 
considerable  area  surroimding  the  seat  of  inflammation.  It  is  generally  taught 
that  ointments  should  not  be  used  to  relieve  the  pain  of  ulceration.  Leonard 
considers  them  conducive  to  malignant  changes.  Scarlet  red  ointment  has  been 
used  by  Manges  in  a  case  of  non-healing  ulcer  of  sLx  months'  duration.  The 
results  were  distinctly  encouraging  at  first,  but  the  ulcer,  being  in  the  region 
of  the  umbiUcus,  was  subjected  to  great  tension  by  a  coexisting  ascites,  and  ex- 
tended more  rapidly  in  one  direction  than  it  healed  in  another.  Then,  too,  the 
patient  was  cachectic  from  extensive  carcinoma  of  the  abdominal  viscera. 

In  extensive  ulceration  the  wound  must  be  kept  as  clean  as  possible  and 
free  from  irritants.  When  sloughing  ceases  and  granulation  tissue  forms, 
mild  stimulants  may  be  applied. 

The  patient's  general  health  should  be  improved  in  every  possible  manner. 

Skin-grafting  is  not  usually  successful  without  excision  of  the  floor  of  the 
ulcer,  but  should  be  tried.  In  spite  of  all  treatment  the  condition  may  remain 
a  chronic  ulcer  and  be  subject  to  malignant  change. 

Sometimes  the  results  of  an  .x-ray  burn  may  be  most  serious.  In  a  case 
reported  by  J.  P.  Tuttle  it  became  necessary  to  amputate  the  thigh  ("Med. 
Record,"  May  5,  1898). 

The  chronic  ".r-ray  burn"  or  chronic  .v-ray  dermatitis  is  seen  among  opera- 
tors or  men  working  more  or  less  constantly  with  the  rays.  The  onset  is  ver\' 
insidious.  Ulcers  may  not  form  for  a  year  or  more.  The  earliest  signs  of 
trouble  are  brittleness  of  the  finger-nails  and  itching  about  the  matrices. 
Scratches  on  the  fingers  heal  sluggishly.  The  skin  atrophies,  telangiectases 
form,  vesicles  appear  and  disappear,  keratoses  develop,  fall  off,  and  return. 
Small  ulcers  start  and  gradually  heal,  reappear,  become  more  extensive,  pain- 
ful, and  sluggish.  The  finger-nails  drop  off,  leave  sensitive  surfaces,  and 
grow  again  indifferently  or  in  a  misshapen  condition. 


1452  Skiagraphy  or  Rontgenography 

If  exposure  is  continued  the  ulceration  advances,  and  the  tendons  and  even 
phalanges  may  slough  away.  Usually  when  ulceration  of  this  kind  has  started, 
the  damage  is  irreparable  except  through  amputation  or  excision,  with,  of 
course,  absolute  protection  from  further  exposure. 

These  lesions  are  most  common  on  the  hands,  but  may  occur  elsewhere. 

That  mahgnant  changes  take  place  in  chronic  :r-ray  lesions  has  been  de- 
finitely shown  clinically  and  by  the  microscope.  Porter,  of  Boston,  has  made 
an  extensive  study  of  these  lesions,  and  emphasizes  the  importance  of  both 
excision'  and  skin-grafting  and  amputation  as  methods  of  treatment. 

His  results  were  excellent.  Palliative  treatment  should  be  limited  to  clean- 
liness and  care. 

Sterilization  of  either  sex  by  use  of  the  x-ray  is  possible  and  should  be 
guarded  against. 

Can  the  x-rays  cause  death?  The  x-rays  do  not  cause  death  directly,  but 
may  inaugurate  a  lesion  which  eventually  causes  death.  Death  may  follow 
a  burn  without  being  directly  due  to  it.  Carcinomata  have  developed  in 
chronic  x-ray  lesions  and  produced  death;  at  least  7  fatal  cases  from  multiple 
carcinomata  following  chronic  x-ray  dermatitis  are  known  to  have  occurred  in 
the  United  States.  Two  of  these  cases  occurred  in  Philadelphia,  and  one  of 
them  was  in  my  charge.  One  of  the  fatal  cases  was  from  Hartford,  Conn., 
and  I  was  consulted  by  him. 

Unnecessary  exposure  to  x-rays  is  to  be  avoided.  The  operator  should 
remain  as  far  away  from  the  excited  tube  as  possible,  and  have  between  it 
and  him  a  lead  screen  no  less  than  \  inch  in  thickness  and  of  dimensions  suf- 
ficient to  protect  his  entire  person.  The  patient  is  to  be  protected  from  undue 
irradiation  by  means  of  lead-glass  or  lead-covered  tube-holders  and  lead 
diaphragms.  In  the  treatment  of  lesions  beneath  the  skin  some  form  of  filter 
should  be  used  over  the  exposed  area.  Sheet  aluminum  is  commonly  used. 
Pfahler  has  suggested  the  use  of  sole  leather. 

The  function  of  the  filter  is  to  absorb  the  soft  rays,  which  would  be  otherwise 
taken  up  by  the  skin  and  would  irritate  that  structure.  With  proper  care  pa- 
tients may  be  treated  frequently  and  with  perfect  safety  for  a  long  time. 

The  Uses  of  the  Rontgen  Rays. — In  the  hands  of  trained  and  experienced 
workers  this  agent  is  a  most  valuable  aid  in  nearly  all  branches  of  medicine 
and  surgery;  whereas,  in  the  hands  of  the  untaught  and  inexperienced,  it 
may  lead  to  grave  error  in  diagnosis,  and  is,  even  at  the  present  day,  fraught 
with  all  the  dangers  of  its  early  use.  The  general  practitioner  should  not  at- 
tempt its  use  without  first  having  had  practical  training. 

For  diagnostic  purposes  studies  may  be  made  by  means  of  the  fluoro- 
scope  or  by  making  Rontgenographs  (skiagraphs,  radiographs). 

Edison's  fluoroscope  consists  of  four  sides  of  a  box,  one  end  being  open  and 
made  to  fit  tightly  over  the  observer's  eyes,  the  other  end  being  closed  with 
cardboard  made  fluorescent  by  smearing  it  with  mucilage,  and  before  the  muci- 
lage is  quite  dry  sprinkling  it  with  crystals  of  tungstate  of  calcium.  If  it  is 
desired  to  examine  the  hand  with  a  fluoroscope,  the  extremity  is  held  opposite 
an  excited  Crookes  tube  and  from  6  to  10  inches  away  from  it;  the  end  of  the 
fluoroscope,  which  is  covered  with  fluorescent  paper,  is  placed  near  the  surface 
of  the  hand  which  is  away  from  the  tube,  and  the  observer  looks  through  the 
other  end  of  the  instrument.  The  flesh  seems  but  a  dim  haze,  and  the  shadows 
of  the  bones  are  distinctly  outfined.  The  fluoroscope  is  of  advantage  in  the 
examination  of  the  movable  organs  of  the  chest  and  abdomen.  This  method, 
except  with  special  forms  of  apparatus,  endangers  both  the  patient  and  opera- 
tor. It  was  used  extensively  in  the  pioneer  days  and  caused  the  vast  majority 
of  injuries  to  the  early  workers.  The  fluoroscopic  method  has  gained  many 
American  adherents  in  the  last  few  years,  owing  to  the  development  of  appara- 


The  Uses  of  the  Rontgen  Rays  1453 

tus  which  enables  the  Rontgenologist  to  work  more  nearly  in  safety.  The 
American  fluoroscopes  are,  as  a  rule,  far  more  protective  than  the  foreign  t\pes. 
Quite  a  few  operators  have  apparatus  built  into  their  laboratories  to  suit  the 
local  conditions. 

All  modern  fluoroscopes  enable  the  operators  to  study  their  patients  by  the 
combined  method  of  liuoroscopy  and  Rontgenography  without  changing  the 
position  of  the  patient  or  .v-ray  tube. 

Rontgenographic  technic  has  been  wonderfully  developed  in  the  last  few 
years.  The  method  now  used  has  the  advantage  of  safety  to  patient  and  oper- 
ator, as  well  as  permanency  of  record.  With  the  most  improved  apparatus  a 
Rontgenograph  of  any  portion  of  an  average  sized  person  can  easily  be  made 
with  an  exposure  of  five  seconds  or  less,  so  that  the  motion  of  breathing  need 
not  interfere  as  it  did  in  former  years.  Children  are  skiagraphed  b}'  in- 
stantaneous exposure  and  seldom  require  an  anesthetic.  It  is  the  most  valu- 
able agent  we  have  for  the  study  of  bone  conditions.  In  fractures  the  rays 
enable  us  to  determine  the  nature  of  the  injur\',  the  amomit  of  splintering,  the 
existence  of  impaction,  the  question  whether  or  not  the  fragments  are  in  contact 
or  can  be  brought  in  contact,  the  direction  of  the  line  of  fracture,  the  variety 
of  deformity,  the  existence  of  more  than  one  fracture,  the  presence  of  epiphy- 
seal separation  or  dislocation  alone  or  with  a  fracture,  the  existence  of  an 
ununited  fracture,  the  presence  of  callus,  and  if  the  splints  are  holding  the 
fragments  in  apposition.  By  means  of  stereoscopic  Rontgenographs  fractures 
of  any  part  of  the  skull  can  be  detected:  and  the  actual  relations  of  the  parts 
in  fracture  or  dislocation  of  the  hip,  peMs,  or  shoulder  can  be  determined. 

Fractures  of  the  spine  in  the  lower  dorsal  region  are  difficult  to  demonstrate 
in  stout  persons.  In  bone  disease  the  experienced  Rontgenologist  can  greatly 
aid  the  surgeon  in  making  a  differential  diagnosis.  The  dissolved  appearance 
of  the  bone  in  myeloid  sarcoma  T^^thout  e\'idence  of  demarcation  difiers  from 
the  tuberculous  bone,  which  presents  a  picture  of  impoverishment  of  mineral 
matter,  but  with  more  or  less  distinctly  outlined  foci  of  destruction.  Bone 
atrophy  due  to  pressure  or  disuse  presents  still  another  picture.  Chronic 
periostitis,  osteoperiostitis,  necrosis,  chronic  osteomyeUtis,  and  osteosclerosis 
cast  shadows  more  or  less  characteristic.  The  bone  changes  iti  osteitis  de- 
formans {Pagefs  disease)  are  accurately  differentiated.  Bone-cysts,  osteo- 
sarcoma, osteoma,  and  osteophytes  show  clearly.  Conditions  about  the 
joints,  such  as  arthritis  deformans,  ossifying  bursitis,  tabetic  osteo-arthritis, 
and  foreign  substances  -n-ithin  the  joints,  the  character  of  deformity  and  whether 
due  to  disease  or  congenital  defect  can  be  determmed.  The  bone  changes  of 
rickets  and  scur\y  appear  in  distinguishable  manner.  Achondroplasia  pre- 
sents a  picture  unlike  anything  else. 

Pathological  processes  in  the  accessor}-  sinuses  of  the  skull  and  in  the  mastoid 
cells  are  capable  of  detection,  and  the  condition  as  well  as  position  of  the  teeth 
can  be  shown  "U"ith  great  clearness. 

Stereoscopic  Rontgenography  of  the  head  is  often  of  ver\-  positive  value  in 
obscmre  intracranial  lesions.  Variations  in  the  size  of  the  pituitary-  body  are 
determined  by  the  measurement  of  the  sella  turcica.  Likewise,  disease  of  this 
gland  or  tumors  in  this  region  are  sho-^-n  by  destruction  of  the  floor  of  the  sella 
turcica  and  the  clinoid  processes.  Brain  timaors  which  are  superficial  produce 
localized  atrophy  of  bone  by  pressure  on  the  inner  table  of  the  skull.  In  such 
cases  the  diagnosis  is  almost  positive  by  means  of  Rontgenographs.  Normally, 
the  inner  table  of  the  skuU  is  more  or  less  indented  by  the  convolutions  of  the 
brain.  These  indentations  become  striking  in  congenital  s^-philis,  in  which 
condition  the  skull  sutures  unite  early  and  the  bones  expand  less  rapidly  than 
the  brain,  and  the  ventricles  dilate.  This  same  condition  de\-elops  with  in- 
ternal hydrocephalus  from  other  causes,  but  in  the  latter  instance  the  sutures 


1454  Skiagraphy  or  Rontgenography 

are  ununited  and  even  separated.  On  the  other  hand,  in  acute  external  hydro- 
cephalus the  sutures  are  separated,  but  the  convolution  markings  on  the  in- 
ternal table  of  the  skull  are  absent. 

In  many  cases  of  epilepsy  there  are  hypertrophies  or  marked  variations  in 
size  of  the  sella  turcica,  and,  though  the  significance  is  not  apparent,  we  fre- 
quently find  evidence  of  calcareous  deposit  in  the  pineal  gland  from  the  size 
of  a  pin-head  to  a  match-head  or  larger.  They  are  usually  associated  with 
hypertrophies  of  the  clinoids,  are  foimd  occasionally  in  acromegalics  and  in 
cases  of  exophthalmic  goiter,  and  headache  or  other  nervous  manifestations 
are  sometimes  discovered. 

Intrathoracic  conditions  from  very  early  tuberculous  deposits  in  the  lungs 
to  generalized  involvement;  thickened  pleura;  effusion;  cavity  formation; 
consolidation;  the  excursions  and  relations  of  the  diaphragm  (Williams's  sign) 
to  fixation  of  this  organ ;  from  the  normal  heart  to  all  sorts  of  variations  in  size, 
shape,  and  position ;  dilated  aorta ;  aneurysm ;  the  presence  of  enlarged  medias- 
tinal or  peribronchial  glands ;  and  tumors  of  this  region  can  be  studied  to  great 
advantage  in  connection  with  physical  and  clinical  findings. 

Volumes  have  been  written  on  the  x-ray  study  of  gastro-intestinal  diseases. 
With  adequate  equipment  as  well  as  skill  in  technic  and  interpretation  the 
Rontgenologist  renders  most  efficient  aid  in  the  diagnosis. 

It  has  become  almost  a  matter  of  routine  hospital  practice  to  have  an  x-ray 
study  of  the  progress  of  a  bismuth  meal  in  patients  with  gastro-intestinal 
symptoms.  The  bismuth  meal  consists  of  from  2  to  4  oz.  of  bismuth  subcar- 
bonate  or  oxychlorid  suspended  in  a  pint  of  buttermilk,  one  of  the  bacillated 
preparations  of  milk,  or  some  especially  prepared  liquid  food.  "Kefir"  and 
"fermilac"  are  popular  in  this  country,  for  the  reason  that  they  keep  the  bis- 
muth in  suspension  for  a  long  time,  are  palatable,  and  are  articles  of  diet  suit- 
able for  most  patients.  Chemically  pure  barium  sulphate  has  replaced  bis- 
muth in  the  good  opinion  of  some  workers.  The  stomach  will  empty  a  barium 
meal  more  rapidly  than  a  bismuth  meal.  Bismuth  subnitrate  is  no  longer  used 
because  of  the  danger  of  nitrite  poisoning.  The  study  should  be  made  fluoro- 
scopically  as  well  as  by  means  of  Rontgenographs. 

The  normal  esophagus  varies  very  little  in  different  individuals,  so  that 
variations  from  a  normal  condition  are  due  to  functional  disorder  or  disease. 
The  stomach,  however,  does  vary  greatly  in  healthy  individuals,  and  the  study 
of  this  organ  is  complicated.  We  seldom  find  a  stomach  occupying  the  oblique 
position  high  in  the  abdomen,  as  described  in  medical  text-books.  In  a 
very  muscular,  healthy  person  the  stomach  is  usually  more  or  less  oblique, 
with  the  pylorus  extending  about  i  or  2  inches  to  the  right  of  the  median  line 
and  on  a  level,  slightly  above  the  umbilicus.  The  shape  of  this  stomach  is 
always  controlled  by  its  own  power  of  contraction,  or  its  resistance  to  expan- 
sion. The  other  extreme  is  the  low,  sagging,  atonic  stomach  of  the  muscularly 
weak  individual.  The  shape  of  the  stomach  depends  upon  the  amount  and 
weight  of  its  contents.  When  filled,  the  greater  curvature  is  several  inches 
below  the  umbilicus,  while  the  pylorus  remains  on  a  level  with  the  umbilicus  and 
is  usually  near  the  median  line.  This  stomach  is  normal  or,  at  least,  true  to  the 
type  of  the  individual.  Generally,  however,  we  speak  of  a  stomach  as  being 
normally  situated  when  the  cardiac  and  median  portions  lie  to  the  left  of  the 
median  line,  while  the  pyloric  portion  extends  i  inch  or  more  to  the  right  of 
the  vertebral  column,  and  when  comfortably  filled  the  pylorus  is  not  more  than 
2  inches  above  the  lowermost  point  of  the  greater  curvature.  Beyond  this 
we  find  different  degrees  of  ptosis  or  dilatation  from  congenital  defect  in  support, 
disease,  or  atony.  Schlessinger  classifies  the  variations  into  hypertonic,  or- 
thonic,  hypotonic,  and  atonic. 

Rontgen  ray  examination  should  be  preceded  by  chemical  analysis  of  the 


The  Uses  of  the  Rontgen  Rays  1455 

stomach  contents  and  careful  physical  examination  for  points  of  tenderness, 
with  markings  on  the  skin  to  guide  the  Rontgenologist.  The  examination 
should  be  made  with  the  patient  in  the  erect  posture,  since  the  recumbent  posi- 
tion is  essentially  a  natural  therapeutic  measure  for  the  relief  of  displacement 
producing  symptoms. 

The  process  of  deglutition  is  obser^-ed  on  the  fluoroscopic  screen.  Under 
normal  conditions  the  bismuth  mixture  makes  a  sinuous,  slowly  moving  shadow, 
and  enters  the  pars  cardiaca  without  hesitation,  showing  throughout  the  caliber 
of  the  esophagus.  Diverticula  will  retain  a  portion  of  the  bismuth  meal  and 
cast  a  localh'  enlarged  shadow,  smooth  in  outline.  Pressure  from  without  will 
cause  a  deviation  of  the  normal  line  in  one  or  more  planes,  but  not  necessarily 
narrow  the  normal  width  of  the  bismuth  shadow.  Functional  constriction  is 
differentiated  by  its  regularity  of  outline,  comparatively  slight  dilatation  above 
the  stricture,  and  a  more  or  less  sudden  relaxation,  permitting  the  meal  to  pass 
in  volume.  An  organic  stricture  retains  its  shape,  regular  or  irregular ;  the  bis- 
muth always  passes  in  a  thin  stream.  On  the  proximal  side  of  the  stricture, 
where  the  esophagus  is  dilated,  the  bismuth  is  retained  and  casts  a  broad 
shadow. 

Filling  of  Stomach. — The  normal  hypertonic  stomach  fills  slowly  from 
cardia  to  pylorus.  The  atonic  stomach  receives  the  bismuth  meal  and  lets  it 
drop  quickly  to  the  most  dependent  portion,  assuming  shape  only  when  filled. 
The  orthotonic  and  h}'potonic  t^-pes  present  intermediary  appearances.     A 

Rontgenograph  taken  at  this  stage  of  the  ex-  ,«r^^^^^^        

amination  will  serve  as  a  permanent  record  f^^^^^^^BAjj^^ 

of  size,  shape,  and  position  of  the  stomach.  ^^^^^^^^^^H^ 

The  picture  should  be  made  in  the  erect  pos-  H^^^^^^^^l^ 

ture  vdih  the  plate  on  the  abdominal  aspect  ^I^^^^^^^Hf 

of  the  patient,  but  without  pressure  against  J^^^^^^HP^ 

the  abdomen.  ^^^^^^^E^ 

Defects  in  filling  of  the  stomach  are  due  J^^^^^^HB^ 

to    external    pressure,    adhesions    to    other  i^^^^^^^^^HI^ 

organs,  or  to  functional  spasms,  contracted  ^^^^^^^^^^|Hw 

scar- tissue  in  the  stomach  wall,  or  invasion  '^^^^^^^^^^^^^K    ' 

of  the  stomach  wall  by  new  growth.     Ront-  ^^^^^^^B^l^^^K  1 

genographs  will  reveal  an   indentation  pro-  ,^^H|BP^   "^^^IB'! 

duced  by  the  spleen,  kidney,  or  colon;  and  ^HP-  ^^^^^^K  ' 

changing    the   position    of    the    patient    or      ^JaB^  "^^^^H 

making   pressure   over   the    abdomen   often 
determines  the   presence   or  absence  of  ex-       Fig.   loi 8— Marked    gastroptosis. 

,  ,         „       .        ^       .  ,  1       .  (.lakeii  bv  JJr.  W .  ir.  Manges.) 

temai    adhesions,    smce    the    stomach    is    a 

more  or  less  movable  organ.  Irritation  of  a  florid  ulcer  by  food  will  cause  a 
more  or  less  deep  contraction  of  the  transverse  muscular  fibers  at  the  level  of 
the  ulcer,  which  contraction  or  indentation  will  last  for  from  a  few  seconds  to 
several  minutes  or  longer. 

The  indentation  is  deeper  than  a  normal  peristaltic  contraction,  persists  for 
an  appreciable  time,  its  edges  are  smooth,  and  it  is  opposite  the  area  of  ulcer. 
It  can  usually  be  reproduced  by  pressure  over  the  stomach.  Sometimes  such 
a  contraction  persists  so  long  as  to  be  mistaken  for  an  organic  hour-glass  con- 
traction. It  is  usually  associated  with  h^-peracidity,  and  occurs  most  fre- 
quently in  the  middle  portion  of  the  stomach  along  the  greater  cur\'ature;  the 
stomach  empties  slowly.  Contracted  scar-tissue  from  healed  ulcer  ^ill  pro- 
duce permanent  defect  in  the  stomach  outline  in  extent  dependent  upon  the 
amount  of  cicatrization.  New  growth  invading  the  stomach  wall  will  pro- 
duce permanent  filling  defect  so  irregular  in  outline  as  not  to  be  mistaken  when 
extensive;  is  associated  with  absence  of  hydrochloric  acid,  and  rapid  empty- 


1456  Skiagraphy  or  Rontgenography 

ing  of  the  stomach  when  the  pylorus  is  not  obstructed.  The  character  of  peris- 
talsis is  in  itself  not  an  important  factor  in  diagnosis,  since  the  type  of  stomach 
usually  determines  the  depth  of  the  contraction.  Jonas  has  discovered  reverse 
peristalsis.  Haudek  considers  the  phenomenon  diagnostic  of  stenosis,  ulcer, 
erosion,  or  carcinoma. 

No  less  important  than  the  filling  is  the  emptying  of  the  stomach.  A 
normal  stomach,  that  is,  one  that  is  free  from  disease  within  or  obstructive 
influence  without,  except  when  it  is  of  the  extreme  atonic  type,  should  pass  the 
bismuth  meal  above  described  in  from  three  to  six  hours,  according  to  the  type 
or  tone  of  the  stomach.  Conditions  causing  rapid  emptying  of  the  stomach 
are  those  associated  with  decrease  in  hydrochloric  acid  or  increase  in  alkalinity 
of  the  duodenal  secretion,  and  occasionally  with  non-closure  of  the  pylorus. 
Those  causing  delay  are,  except  in  the  extreme  atonic  type,  associated  with 
increased  acidity  or  organic  changes  about  the  pylorus. 

Holzknecht  has  arranged  a  number  of  symptoms-complex  which,  though 
condensed,  are  very  instructive: 

"Symptom-complex  I:  Bismuth  residue  after  six  hours.  Normal  stomach 
shadow.     Achyha.     Diagnosis:  Small  carcinoma  of  pylorus." 

The  retention  is  due  to  pyloric  obstruction.  If  unobstructed,  the  presence 
of  achylia  alone  would  insure  rapid  empt3dng. 

In  symptom-complex  IV  he  states:  "Small  residue  after  six  hours.  Sen- 
sitive pressure  point  over  the  stomach.  Normal  stomach  shadow.  Diagno- 
sis: Simple  gastric  ulcer." 

He  continues:  "This  diagnosis  is  fairly  certain  and  simple.  In  all  cases  of 
gastric  ulcer  there  is  always  a  certain  amount  of  loss  of  motility.  Handek  has 
never  found  an  ulcus  ventriculi  without  this  delay  in  the  evacuation  of  the 
organ,  and  no  case  of  spasm  of  the  pylorus  without  some  lesion  of  the  stomach 
wall. 

"As  regards  pressure  point,  it  is  not  enough  merely  to  find  a  sensitive  point 
somewhere  in  the  epigastrium,  but  we  ought  to  demonstrate  radiographically 
that  the  pressure  point  falls  on  the  lesser  curvature  where  an  ulcer  is  most 
frequently  situated,  and  that  it  moves  with  the  stomach  by  pressure  or  indraw- 
ing  of  the  stomach  walls  (Jonas).  This  complete  diagnosis  requires  much 
experience  both  in  radiology  and  in  palpation;  happily,  there  are  a  number 
of  other  symptoms  which  confirm  the  diagnosis.     These  are : 

"i.  Antiperistalsis.  2.  Displacement  of  the  pylorus  upward  and  to  the 
left.  3.  Snail  form  of  the  lesser  curvature.  4.  Stabile  transverse  contractions. 
5.  Changing  transverse  contractions."     (We  would  add  hyperacidity.) 

"Symptom-complex  VII:  i.  Large  residue  after  six  hours.  2.  Dilatation. 
3.  Loss  of  tone.     Diagnosis:  Old  ulcer  stenosis. 

"Symptom-complex  VIII:  i.  Large  sickle-shaped  residue.  2.  Marked 
defect  in  filling  of  pars  pylorica.  Diagnosis :  Carcinoma  on  base  of  an  old  ulcer, 
with  stenosis.  This  picture  is  much  more  common  than  might  be  suspected. 
It  was  not  known  until  recently  that  advanced  stenosis  of  the  pylorus,  with 
dilatation  and  paralysis,  might  exist  without  vomiting  or  other  severe  symp- 
toms. Vomiting  may  set  in  later,  not  from  stenosis,  but  from  the  commencing 
carcinoma.  The  signs  of  dilatation  and  ^-omiting  and  the  previous  history 
of  ulcer  all  point  to  stenosis  of  the  pylorus,  and  do  not  in  any  way  interfere  with 
the  indications  for  operation." 

In  addition  to  the  above  groups  of  symptoms  depending  on  delay  in  emptying 
the  stomach  we  must  consider  mechanical  stenosis  due  to  external  adhesions. 
Manges  has  observed  2  cases,  in  each  of  which  a  pendulous  gall-bladder  filled 
with  gall-stones  was  in  close  relation  with  and  adherent  to  the  pylorus.  One 
stomach  was  of  the  orthotonic  type,  the  other  of  the  atonic  type  and  more  or 
less  dilated.     Both  retained  a  portion  of  the  bismuth  meal  long  after  six  hours. 


The  Uses  of  the  Riintgen  Rays 


1457 


At  operation,  after  freeing  adhesions  in  each  case,  the  pylorus  was  patulous  and 
no  evidence  of  organic  change  in  the  stomach  wall  was  found  by  palpation.  Both 
patients  have  made  good  recoveries,  further  substantiating  the  belief  that  dis- 
ease of  the  stomach  did  not  exist.  One  of  the  two  was  operated  on  by  DaCosta, 
the  other  by  Stellwagen,  and  the  diagnosis  of  gall-stones  in  each  instance  was 
only  made  after  incision.  Pericholecystitis  and  perihepatitis  are  common  con- 
ditions, and  frequently  involve  the  pylorus  and  first  portion  of  the  duodenum, 
nearly  always  producing  more  or  less  mechanical  obstruction.  Except  in 
the  case  of  pendulous  gall-bladder,  the  pyloric  end  of  the  stomach,  the  duo- 
denum, or  both  are  drawn  upward  and  to  the  right.  The  relations  between 
these  organs  cannot  be  altered  by  change  of  posture  or  pressure,  and  there  is 
usually  tenderness.  Again,  delay  in  empt^-ing  the  stomach  may  be  caused  by 
stricture  of  the  duodenum  from  old  ulcer. 

The  s^-mptom  of  a  sensitive  pressure  point  is  only  of  localizing  value,  per  se, 
when  a  gastric  ulcer  has  sufficient  depth  to  produce  inflammation  of  the  peri- 
toneum. It  is  always  present  in  perforating  ulcer,  and  is  suggestive  of  deep  ulcer 
when  accurately  traced  to  some  definite  point  with  relation  to  the  stomach. 

Organic  hour-glass  stomach  is  nearly  always  due  to  contracted  scar-tissue 
the  result  of  an  old  ulcer,  and  is  usually  situated  in  the  median  portion  of  the 
stomach.  Carcinoma  may  develop  secondarily,  and  when  present  usually  pro- 
duces more  or  less  rapid  cachexia.  Marked  hour-glass  contraction,  if  non- 
malignant,  may  exist  a  long  time  -without  loss  of  weight. 

Pfahler  (''American  Quarterly  of 
Rontgenolog}',''  Feb.,  19 13)  groups  Ront- 
genological  e\'idences  of  gastric  ulcer 
under  three  headings,  as  follows: 

■"I.  The  e\idence  of  perforation:  (a) 
A  projecting  shadow  outside  the  gas- 
tric shadow.  (6)  A  gas  bubble  h^ing 
above  this  collection  of  bismuth,  (c) 
Perigastric  adhesions  or  involvement 
of  other  organs,  {d)  A  palpable  tumor 
connected  with  the  stomach,  but  not 
affecting  the  lumen,  {e)  The  above  may 
be  associated  with  either  an  organic  or 
spasmodic  hour-glass  contraction  of  the 
stomach.  (/)  Retention  of  bismuth  in 
the  ulcer  after  the  remainder  of  the 
stomach  has  been  emptied.  {g)  Re- 
sistance corresponding  to  the  projecting 
shadow. 

''2.  The  e^-idence  of  irritation,  due  either  to  a  florid  ulcer  or  to  an  irritable 
scar  of  an  iflcer:  {a)  Spasmodic  contraction,  {b)  Retention  of  food  in  the 
stomach  after  sLx  hours,  {c)  Painful  pressure  point  corresponding  to  the  loca- 
tion of  the  ulcer,     {d)  Normal  outline  of  stomach. 

"3.  Secondary-  effects  usuaUy  associated  with  a  callous  ulcer:  {a)  Pyloric 
stenosis  and  gastrectasis.  ib)  Fixation,  {c)  Organic  contraction — hour-glass. 
{d^  Interference  with  peristalsis,  {e)  Reversed  peristalsis.  (/)  A  contracted 
lesser  cur\-atvu:e  with  retraction  of  the  pylorus  to  the  left." 

The  diagnosis  of  duodenal  conditions  requires  the  Rontgenologist's  best 
skill  in  technic  and  interpretation  of  both  the  fluorescent  screen  and  plates. 
The  principal  findings  are: 

1.  Rapid  emptying  of  the  stomach.  This  s}-mptom  is  only  of  practical 
value  when  achylia  or  non-obstructive  carcinoma  of  the  stomach  is  absent. 

2.  Irregularity  in  outline  at  all  times  of  the  first  portion  of  the  duodenimi. 


Fig.  1019. — A,  Functional  hour-glass  con- 
traction of  stomach.  i^Taken  by  Dr.  W.  F. 
Manges.) 


1458  Skiagraphy  or  Rontgenography 

familiarly  known  as  "the  cap."  The  value  of  this  symptom  depends  upon 
the  fact  that  the  first  portion  of  the  duodenum,  when  not  diseased,  is  a  very 
constant  anatomical  structure.  It  may,  however,  be  confused  with  defective 
outline  due  to  result  of  disease  in  adjacent  organs.  In  either  case  surgical 
interference  is  indicated. 

3.  The  majority  of  duodenal  ulcers  occur  in  the  first  portion. 

4.  Dilatation  of  the  duodenal  "cap"  indicates  obstruction  in  some  other 
portion  of  the  duodenum. 

5.  Penetrating  duodenal  ulcer  permits  small  projections  of  bismuth  beyond 
the  rest  of  the  mass.  These  small  portions  remain  for  some  time  and  occa- 
sionally contain  a  bubble  of  gas. 

6.  A  sensitive  pressure  point  is  found  in  many  cases  to  be  directly  over  some 
portion  of  the  duodenum,  and  when  there  are  no  external  bindings  the  tender 
spot  moves  with  the  organ. 

Cole's  method  of  serial  radiography  of  the  bismuth  meal  is  of  great  value  in 
duodenal  conditions.  He  makes  twelve  or  more  exposures  in  rapid  succession, 
after  the  proper  position  of  the  patient  has  been  determined  fluoroscopically 

("American  Quarterly  of  Rontgenology," 
March,  191 2).  George  and  Gerber  report 
only  three  partial  errors  in  the  Rontgen 
diagnosis  of  59  operated  cases  of  duodenal 
lesions  (Ibid.,  June,  1913). 

Adhesions  and  constrictions  of  the  rest 
of  the  small  intestine  cause  stasis  of  the 
bismuth  meal  and  gas  above  points  of  in- 
volvement. 

The  colon  is  studied  Rontgenologically 
after  ingestion  of  the  bismuth  meal,  and 
during  and  after  injection  of  bismuth  sus- 
pension per  rectum.  Also  both  in  the 
erect  and  recumbent  postures.  The  in- 
gested meal  under  normal  conditions  wiU 
have  passed  through  the  ileocecal  valve 
Fig.  1020.— Extreme  ptosis  of  colon:     in  from  eight   to   twelve   hours,   and  in 

A,    Hepatic    flexure;    B,    splenic    flexure.       r  ,  -       r  ^      ^r.-  ^        •      r.  mi 

(Taken  by  Dr.  w.  F.  Manges.)  from  twenty-iour  to  thirty-six  hours  will 

have  been  expelled.  The  injected  bis- 
muth suspension  should  be  studied  fluoroscopically.  The  findings  are  usually 
of  a  more  positive  nature  than  are  those  of  the  stomach  and  small  intestine. 

They  are,  briefly:  The  position  and  course  of  the  colon.  Evidence  of  ad- 
hesions, constrictions,  and  dilatation.  Incompetency  of  the  ileocecal  valve 
(Case,  "American  Quarterly  of  Rontgenology,"  Nov.,  191 2).  The  obstructive 
effect  of  gas  in  elongated  sigmoid  loops  (Pfahler,  "Jour.  Amer.  Med.  Assoc," 
Nov.  16,  191 2).  The  presence  of  impacted  feces.  The  extent  of  motility  of 
the  different  portions  of  the  colon ;  the  presence  and  extent  of  congenital  dila- 
tation.    And  often  the  location  and  extent  of  malignancy. 

Frequently  more  than  one  examination  is  necessary  before  attempting  a 
diagnosis.  It  is  not  essential  to  purge  prior  to  examination  of  the  ingested  meal, 
but  the  colon  should  be  thoroughly  emptied  by  irrigation  before  injection. 
Sedative  suppositories  may  be  used  before  injection  if  the  rectum  is  very'  irri- 
table, and  the  temperature  of  the  bismuth  mixture  should  be  a  little  above  that 
of  the  body. 

In  a  study  of  the  urinary  organs  the  Rontgenologist  should  be  able  to  deter- 
mine the  size  and  position  of  the  kidneys  in  a  normal  subject  weighing  160 
pounds  or  less.  In  larger  persons  only  the  best  skiagraphs  will  show  the  out- 
line of  the  kidneys.     In  patients  under  160  pounds  renal  calculi  from  the  size 


The  Uses  of  the  Rontgen  Rays  i4S9 

of  a  No.  2  shot  to  the  largest  found,  whether  smgle  or  multiple,  in  one  kidney 
or  both,  and  relatively  their  situation  in  the  kidneys  (except  in  stones  composed 
of  pure  uric  acid)  can  be  determined  in  Rontgenographs  of  the  best  quality. 

Ureteral  calculi  are  subject  to  the  same  display  as  renal  calculi.  The  course 
of  the  ureters  is  by  no  means  constant,  so  that  one  cannot  say  that  a  shadow 
lies  in  the  line  of  the  ureter  unless  this  line  is  determined  by  additional  means. 
However,  in  the  great  majority  of  instances  the  history  of  renal  colic;  a  point  of 
tenderness  on  deep  pressure;  the  presence  of  microscopical  Cjuantities  of  blood 
in  the  urine;  the  fact  that  ureteral  calculi  are  almost  never  round,  but  oval  or  ir- 
regular, in  contrast  to  the  small  round  shadows  cast  by  phleboliths,  or  calcareous 
deposits  in  the  mucous  membrane  of  the  female  genitalia;  and,  the  mulberry 
appearance  of  calcified  lymphatic  glands,  are  sufficient  to  confirm  a  Rontgeno- 
graphic  diagnosis  of  ureteral  calculus.  Vesical  calculi  are  more  apt  to  escape 
notice  since  they  are  not  infrequently  composed  entirely  of  uric  acid.  When 
they  do  contain  more  dense  material  the  Rontgen  diagnosis  is  usually  posi- 
tive as  to  size  and  number. 

In  the  past  few  years  great  progress  has  been  made  in  the  Rontgenographic 
study  of  surgical  conditions  of  the  urinar}^  organs  with  the  aid  of  ureteral 
catheterization  and  injection  of  solution  of  colloidal  silver.  The  study  de- 
mands the  assistance  of  one  skilled  in  the  use  of  the  ureteral  catheter,  and  this 
part  of  the  subject  is  treated  of  in  another  section  (see  page  1301). 

The  part  of  the  Rontgenologist  is,  to  be  prepared  to  make  Rontgenographs 
at  inter\^als  during  the  injection  and  with  the  patient  in  both  the  recumbent 
and  erect  postures  when  desired. 

The  points  of  information  gained  by  the  Rontgen  study  of  the  kidney  pelvis 
injected  with  collargol  {pyelography)  are:  the  position,  shape,  size,  and  the 
extent  of  mobility;  also  the  relation  of  the  kidney  pelvis  to  calculi  in  the  kid- 
ney, ureter,  or  gall-bladder. 

The  normal  kidney  pehds  will  hold  from  10  to  30  c.c.  of  the  solution,  and 
the  calices  are  sharp  in  outline,  branching  at  the  apices,  and  well  separated. 
The  hydronephrotic  kidney  may  hold  any  amount  above  this  to  500  c.c.  or  more. 
The  calices  are  less  separated,  the  apices  are  rounded  and  smooth,  and  all  the 
caHces  have  much  the  same  appearance.  The  pyonephrotic  kidney  may  hold 
small  or  large  quantities;  one  or  more  of  the  calices  may  be  involved,  and  the 
outline  is  irregular,  never  smooth,  as  in  hydronephrosis.  Tumors  invohdng 
the  kidney  produce  distortion,  but  usually  not  marked  enlargement  of  the 
pelvis  and  calices.  One  or  more  of  the  calices  may  be  long,  narrow,  and  irreg- 
ular in  outline.  Abscess  of  the  kidney  when  communicating  with  the  renal 
pelvis  permits  of  injection  with  collargol  solution,  and  shows  as  a  more  or  less 
large  shadow  external  to  the  shadow  of  the  renal  pehds. 

The  mobility  of  the  kidney  may  be  shown  in  some  cases  by  skiagraphing 
the  injected  kidney  before  and  after  manual  displacement  of  the  organ,  but 
when  possible  the  exposures  should  be  made  with  the  patient  recumbent  one 
instant  and  erect  the  next.  The  change  must  be  made  quickly,  as  the  collargol 
promptly  leaves  the  unobstructed  pelvis.  A  stone  in  any  portion  of  the  kidney 
pelvis  will  be  included  in  the  shadow  of  the  injected  peMs;  a  point  which  not 
only  serves  to  differentiate  stone  in  the  pelvis  from  stone  external  to  the 
pelvis,  but  shows  the  necessity  of  preliminary^  Rontgen  examination. 

The  study  of  the  ureters  by  this  method  requires  that  the  ureters  be  filled 
to  their  maximimi  capacity  throughout  their  entire  length  at  the  time  of 
exposure.  The  patient  may  be  placed  in  the  Trendelenburg  position  wdth  the 
ureteral  catheter  inserted  only  a  few  centimeters,  so  that  gravity  vnll  retain 
the  collargol  solution  in  the  ureter  and  kidney.  In  this  way  the  true  line 
of  the  ureter  and  diameter  of  the  Ivmien  will  be  shown.  In  a  case  of  hydro- 
nephrosis, due  to  ureteral  kink  associated  mth  a  movable  kidney,  to  pressure 


1460  Skiagraphy  or  Rontgenography 

from  without,  constriction  by  adhesions,  or  obstruction  within  the  ureter,  there 
will  be  shown  a  dilated  ureter  above  the  impediment  and  a  narrow  lumen  below. 
If  there  is  more  than  one  point  of  interference  the  ureter  will  show  a  corre- 
sponding number  of  areas  of  dilatation.  An  almost  completely  obstructed 
ureter  will  be  evident  by  the  presence  of  only  small  areas  of  collargol  shadow 
above  the  point  of  obstruction.  Here  again,  as  pointed  out  by  Fowler  and 
Stover  ("American  Quarterly  of  Rontgenology,"  Aug.,  191 2),  skiagraphing  the 
patient  very  promptly  after  putting  him  in  the  erect  posture  will  often  show 
the  nature  of  the  kink.  Stone  in  the  ureter  may  be  positively  diagnosticated 
by  finding  that  collargol  will  enter  the  diverticulum  occupied  by  the  stone; 
more  or  less  distortion  of  the  line  of  the  ureter  at  this  point  and  dilatation  above, 
if  the  stone  has  been  there  for  some  time  and  caused  obstruction.  A  stone 
acting  as  a  "ball  valve"  in  the  ureter  will  be  associated  with  dilatation  includ- 
ing the  stone  shadow. 

Kelly  has  used  a  water  suspension  of  small  quantities  of  bismuth  subnitrate 
injected  into  the  bladder  and  stereo-Rontgenographs  to  show  the  presence  of 
and  extent  of  tumors  involving  the  bladder. 


J 


Fig.  102 1. — Gunshot-wound  of  the  lung.  Rib  resection  for  secondary  hemorrhage  into  the  pleural 
sac  ten  days  after  the  injury;  bullet  not  removed.  Hemorrhage  arrested  by  packing  with  gauze. 
Skiagraph  taken  three  months  afterward  shows  the  bullet  (author's  case) . 

In  addition  to  the  above  pathological  findings,  all  sorts  of  anomalies  and 
anatomical  peculiarities  of  the  urinary  organs  are  plainly  shown.  Kelly  and 
Lewis  prefer  an  emulstion  of  silver  iodid  to  collargol  for  pyelographic  study, 
but  the  latter  is  more  generally  used. 

The  ureteral  catheter  containing  lead  shows  the  Course  of  the  ureter  less 
accurately  than  proper  injection  of  collargol,  but  does  have  the  advantage  of 
always  being  there  at  the  time  of  exposure. 

The  proper  preparation  of  the  patient  is  an  essential  requirement  in  any  x- 
ray  study  of  the  urinary  organs.  This  consists  of  thorough  purgation  and  ab- 
stinence from  food  or  drink  for  at  least  six  hours  prior  to  the  examination. 

The  liver  and  spleen  offer  but  a  small  field  for  useful  study.  Enlargement 
may  be  seen.  Biliary  calculi  are  not  often  seen  in  the  x-ray  negative,  because 
they  are  lacking  in  density  and  are  surrounded  by  thick  structures.  One  can- 
not make  a  negative  diagnosis  of  biliary  calculus  by  means  of  the  x-ray. 

Chronic  discharging  sinuses  may  be  outlined  and  studied  after  they  have 
been  injected  with  bismuth  paste.     This  study  is  best  made  by  means  of  stereo- 


Localization  of  Foreign  Bodies  1461 

scopic  negati\'es.  In  advanced  atheroma  the  outlines  of  the  arteries  of  the  ex- 
tremities are  seen  in  the  Rontgenograph. 

Localization  of  Foreign  Bodies. — Metallic  bodies,  such  as  bullets,  pieces 
of  steel  or  iron,  coins,  pins,  needles,  tin,  zinc,  brass,  etc.,  can  be  detected  in  any 
portion  of  the  body  and  accurately  localized.  Fragments  of  stone,  granite, 
marble,  and  lead-glass  can  be  skiagraphed  except  when  very  small  and  deeply 
situated.  Drainage-tubes  and  iodoform  gauze  can  be  found  if  lost  in  a  sinus 
or  cavity.  Anthracite  coal,  glass  other  than  lead-glass,  or  splinters  of  wood  are 
difficult  to  detect  unless  they  are  of  considerable  thickness,  are  not  superim- 
posed by  bone,  and  are  embedded  in  thin  structures  so  that  the  foreign  body 
can  be  brought  close  to  the  sensitive  plate.  When  the  fingers  are  the  seat  of 
injury,  anteroposterior  and  lateral  views  are  sufficient.  When  in  the  esoph- 
agus, trachea,  or  bronchi  the  fluoroscope  should  be  used  for  differentiation, 
after  which  a  Rontgenograph  will  assist. 

Foreign  bodies  elsewhere  should  be  localized.  If  near  a  joint  or  in  close 
relation  to  some  surgical  guide,  localization  is  accomplished  by  stereoscopic 


Pig.  1022. — Bullet  localized  by  means  of  stereoscope.     Removed  by  author. 

Rontgenographs.  (See  stereoscopic  skiagraph.  Fig.  1022,  of  bullet  in  a  shoulder 
case  of  mine.  The  bullet  lay  in  close  relation  to  the  anterior  surface  of  the 
glenoid  margin,  and  on  a  line  perpendicularly  below  the  coracoid  process. 
This  bullet  was  removed  with  ease.) 

Pieces  of  needle  in  the  palm  of  the  hand  or  soft  parts  near  the  surface  are 
best  localized  stereoscopically  when  a  definite  relation  between  some  known 
surface  mark  and  the  foreign  body  can  be  determined.  A  thin  coating  of 
bismuth  on  the  palm  of  the  hand  will  cause  every  line  in  the  skin  to  show  on  the 
Rontgenograph.  When  the  foreign  body  is  deeply  situated  and  not  in  close  rela- 
tion to  a  surgical  guide,  some  method  of  localization  must  be  used  to  indicate 
the  depth  and  direction  from  a  known  point  on  the  surface  in  which  the  body 
lies.  All  localizing  methods  are  based  upon  displacement  of  the  foreign  body 
shadow  bv  making  two  or  more  exposures  with  the  x-ray  tube  in  dift"erent  and 
known  positions,  while  the  part  containing  the  foreign  body  and  sensitive  plate 
remain  in  one  position.     This  has  been  called  the  triangulation  method. 

Mackenzie-Davidson  first  used  the  cross-threads,  from  the  known  positions 


1462 


Skiagraphy  or  Rontgenography 


of  the  focus  point  of  the  x-ray  tube  to  their  respective  shadows  on  the  negative, 
the  crossing  of  the  threads  representing  the  position  of  the  foreign  body  in 
relation  to  the  sensitive  plate  and  focus  tube.  Measurements  were  then  made 
from  some  point  on  the  skin  of  the  patient  that  had  registered  with  a  known 
position  on  the  negative.  The  Rontgenologist  could  then  say  that  the  foreign 
body  lay  perpendicularly  beneath  a  certain  point  to  a  definite  depth.  Nearly 
all  the  modern  localizing  schemes  are  modifications  of  this  general  plan,  and 
differ  mainly  in  the  manner  of  determining  the  position  of  the  focus  point  of  the 
fl;-ray  tube. 

A  foreign  body,  unless  it  be  large,  may  easily  lie  to  one  side  of  an  imaginary- 
line  as  drawn  by  the  scalpel  to  the  depth  of  2  or  more  inches;  again,  a  change 
in  position  of  the  patient  will  alter  the  relation  of  the  foreign  body  to  a  perpen- 
dicular line  from  the  indicated  surface  point.  A  modification  of  the  Mackenzie- 
Davidson  scheme  was  devised  by  Sweet.     Manges  improved  the  apparatus  by 


Fig.  1023. — Manges's  modified  Mackenzie-Davidson  localizer. 

limiting  the  possibility  of  error.  He  uses  the  apparatus  as  a  guide  during  the 
surgical  operation.  With  this  apparatus  all  relations  between  the  patient, 
foreign  body,  source  of  x-rays,  and  sensitive  plate  are  obtained,  maintained, 
and  regained  with  ease  and  mechanical  accuracy. 

The  localizer  is  a  detachable  part  of  the  tube  carriage  of  the  Rontgen- 
ographic  table,  and  consists  of  a  metal  frame  having  two  upright  bars  (a',  a"), 
connected  near  their  top  by  a  horizontal  bar  {h)  and  at  the  bottom  by  a 
curved  bar.  The  upper  bar  is  deeply  notched  to  a  scale  of  inches  on  each 
side  of  its  center.  To  the  curved  bar  are  attached  four  adjustable  clamps  and 
rods,  three  of  which  (c',  c" ,  c'")  are  used  to  estabhsh  a  relation  between  the 
localizer  and  the  patient,  the  fourth  {d)  to  indicate  the  depth  and  direction 
of  the  foreign  body.  The  fourth  rod  can  be  moved  through  a  sleeve  in  the 
direction  of  its  long  axis,  and  can  be  held  at  the  desired  depth  by  a  collar  and 
set-screw  attachment.     The  horizontal  bar  of  the  tube  carriage  is  graduated 


Localization  of  Foreisrn  Bodies 


1463 


on  one  side  to  correspond  with  the  notches  on  the  cross-bar  of  the  localizer. 
The  focus  point  on  the  target  of  the  tube  (the  source  of  the  rays)  is  accurately 
determined  by  sighting  from  cross-lines  on  one  side  of  the  lead-glass  tube  shield 
to  cross-lines  on  the  opposite  of  the  shield  (/),  and  is  exactly  6  inches  above 
the  level  of  the  notched  bar  of  the  localizer.  The  relation  between  the  focus 
point  and  the  sensitive  plate  is  obtained  by  means  of  a  clamp  on  the  edge  of 
the  table  (/).  This  clamp  has  two  flat  metallic  arms  projecting  over  the  sen- 
sitive plate  and  a  fixed  rod  externally,  against  which  the  upright  bar  of  the 
carriage  rests. 

In  making  the  localization  the  patient  is  placed  on  the  table  as  if  for  surgical 
operation.  i\  sensitive  plate,  10  by  12  or  11  by  14  inches  (g),  is  put  under  the 
part  containing  the  foreign  body,  the  tube  clamp  applied,  and  the  tube  carriage, 
localizer,  and  tube  are  adjusted  and  leveled.     Three  of  the  adjustable  rods  of 


Fig.  1024. — Bullet  localized  by  method  described  in  the  text.     Removed  by  author. 

the  localizer  are  made  to  touch  the  surface  of  the  patient  at  as  widely  separated 
points  as  possible,  in  which  positions  they  are  tightly  clamped.  These  three 
spots  are  touched  with  silver  nitrate. 

After  all  adjustments  are  examined,  and  the  height  of  the  tube  from  the 
plate  noted,  the  carriage  cross-bar  is  elevated  and  the  localizer  removed.  By 
lowering  the  tube-carrier  to  6  inches  below  its  original  position,  the  focus  point 
of  the  tube  will  be  at  the  level  formerly  occupied  by  the  cross-bar  of  the  local- 
izer, and  if  the  carriage  cross-bar  (z)  is  shifted  to  a  definite  distance  to  one  side 
of  zero,  the  focus-point  will  be  in  the  corresponding  position  held  before  by  a 
notch  on  the  cross-bar  of  the  localizer.  After  carefully  adjusting  the  tube- 
holder  an  exposure  is  made.  The  carriage  is  then  shifted  to  the  opposite  side 
of  zero  in  the  same  extent  and  manner  and  a  second  exposure  made.  The 
patient  is  removed,  the  plate  developed,  and  tracings  of  the  shadows  of  the 
foreign  bodv  and  arms  of  the  table  clamp  made  on  paper.     This  tracing  is 


1464  Skiagraphy  or  Rontgenography 

taken  to  the  table  and  put  in  relation  with  the  table  clamp  (h) .  The  localizer 
is  then  made  to  occupy  its  original  position,  and  threads  are  carried  from  the 
notches  on  its  cross-bar  to  the  tracings  of  the  foreign-body  shadows  {e).  At  the 
crossing  of  these  threads  is  the  position  of  the  foreign  body  in  relation  to  the 
localizer.  The  point  of  the  fourth  adjustable  rod  can  be  made  to  touch  the 
cross-threads  from  any  direction  {d).  If  the  Rontgenologist  cannot  determine 
the  best  direction  for  incision,  he  may  consult  the  surgeon,  and  when  this  is 
known,  the  point  of  the  rod  is  made  to  touch  the  crossing  of  the  threads,  and 
its  collar  and  set-screw  fixed. 

At  the  operation  for  removal  of  the  foreign  body  the  localizer  is  sterilized 
and  applied  to  the  patient,  preferably  by  the  Rontgenologist,  if  he  has  had 
sufficient  surgical  training  to  render  his  assistance  of  value  from  the  standpoint 
of  surgical  technic;  or  he  may  thoroughly  instruct  the  surgeon  in  the  manip- 
ulation of  the  apparatus.  The  following  precautions  are  to  be  observed: 
First,  the  localizer  must  be  handled  carefully  to  prevent  displacement  of  the 
rods;  and  second,  the  patient  should  be  placed  on  the  operating  table  in  about 
the  position  he  occupied  on  the  Rontgenographic  table,  so  that  the  three 
marked  spots  on  the  skin  receive  the  three  fixed  points  of  the  localizer.  With 
the  apparatus  in  position,  the  indicating  rod  is  placed  in  its  carrier  or  sleeve, 
and  when  its  point  touches  the  skin  the  long  axis  of  the  rod  indicates  the  direc- 
tion of  incision,  while  the  distance  between  the  collar  on  the  rod  and  the  sleeve 
shows  the  depth  at  which  the  foreign  body  lies.  During  the  course  of  the  opera- 
tion the  localizer  should  be  repeatedly  applied,  so  that  excessive  manipulation 
of  the  tissues  may  be  avoided. 

Manges  combined  the  localizing  process  above  described  with  stereo- 
Ron  tgenography,  and  devised  an  accurate  method  of  measuring  the  diameters 
of  the  female  pelvis. 

The  determination  of  the  localization  of  pieces  of  metal,  glass,  or  other 
substances  in  the  eye  or  immediately  adjacent  structures  by  means  of  the 
Rontgen  rays  requires  that  the  shadow  of  the  foreign  body,  as  shown  on  the 
radiograph,  be  studied  in  relation  to  the  shadow  of  one  or  more  opaque  objects 
of  known  position.  Dr.  William  M.  Sweet  has  designed  a  localizing  apparatus 
which  consists  of  two  ball-pointed  indicating  rods,  one  opposite  the  center  of 
the  cornea  and  the  other  situated  at  a  known  distance  from  the  first  to  the 
temporal  side.  The  patient  is  placed  recumbent,  with  the  photographic  plate 
to  the  side  of  the  head  corresponding  with  the  injured  eye.  Two  negatives 
are  made,  one  with  the  tube  horizontal  or  nearly  so  with  the  plane  of  the  two 
indicating  rods,  and  the  other  at  any  distance  below  this  plane.  A  special 
chart  is  employed,  containing  a  section  of  the  normal  adult  eyeball,  and  lines 
are  drawn  indicating  the  planes  of  shadow  at  the  two  exposures.  Where  these 
planes  cross  is  the  position  of  the  foreign  body  in  relation  to  the  structures  of 
the  eyeball  and  orbit. 

The  accuracy  of  this  method  of  localization  has  been  fully  demonstrated 
by  its  author  and  other  x-ray  workers,  but  the  learner  finds  so  much  diffi- 
culty in  understanding  the  lines  to  be  drawn  upon  the  chart  to  represent  the 
planes  of  shadow  at  the  two  exposures,  that  Dr.  Sweet  has  recently  de- 
signed an  entirely  new  apparatus,  in  which  a  single  indicator  is  employed. 
As  shown  in  the  illustration  (Fig.  1025)  the  tube-holder,  indicating-ball,  and 
plate-holder  are  upon  a  movable  stage,  and  the  tube  is  in  a  fixed  carrier,  so 
that  the  angle  of  the  rays  with  the  eyeball  and  the  distance  of  the  tube  from 
the  plate  are  always  the  same.  A  telescope  and  reflecting  mirror  permit 
the  observer  to  adjust  the  instrument  until  the  image  of  a  cross- wire  in  the 
tube  is  in  direct  contact  with  the  lateral  image  of  the  summit  of  the  cornea. 
After  this  adjustment  is  made,  the  indicating-ball  is  exactly  10  milimeters 
from  the  center  of  the  cornea. 


Localization  of  Foreign  Bodies  1465 

The  patient  fixes  with  the  good  eye  upon  a  circular  mirror  placed  1 2  inches 
above  the  injured  eye,  so  that  there  is  no  movement  of  the  eye  during  exposure, 
and  the  visual  hne  of  the  injured  eye  is  parallel  with  the  plate.  The  two 
exposures  are  made  upon  one  plate,  one  with  the  tube  in  the  zero  position  of  the 
apparatus,  so  that  the  rays  pass  in  a  direction  corresponding  with  the  horizon- 
tal plane  of  the  eyeball ;  and  the  second  exposure  with  the  tube  at  its  farthest 
point  on  the  graduated  rod  to  the  right  or  left  of  the  first  position,  depending 
upon  which  eye  is  to  be  examined.  Two  metal  shutters  are  used  to  uncover 
any  desired  portion  of  the  photographic  plate. 

Since  the  relative  position  of  the  tube  in  reference  to  the  indicating-ball  and 
the  photographic  plate  remains  fixed  and  known,  the  direction  of  the  rays  in 
passing  through  the  eyeball  follows  a  definite  course,  which  is  the  same  for  the 
two  separate  exposures.  Lines  have,  therefore,  been  drawn  upon  the  locahz- 
ing  chart  to  indicate  the  direction  of  the  rays  at  the  two  exposures,  each  line 


Fig.  1025. — Sweet's  apparatus  for  locating  foreign  bodies  in  the  eyeball  and  orbit. i 

having  the  required  amount  of  divergence  to  represent  rays  coming  from  a  point 
the  distance  of  the  tube  from  the  photographic  plate.  After  development 
the  photographic  plate  is  placed  in  a  frame  containing  cross-lines  indicating  the 
focal  coordinates  of  the  rays.  The  radiograph  is  moved  until  the  shadow  of 
the  indicating-ball  is  in  apposition  with  a  spot  representing  the  indicating-ball 
on  the  key-plate.  A  reading  is  then  made  of  both  the  vertical  and  horizontal 
coordinate  lines  which  pass  through  the  shadow  of  the  body  on  the  radiograph, 
and  this  is  transferred  to  the  corresponding  lines  on  the  localization  chart. 
Three  readings  are  taken,  and  after  having  been  transferred  to  the  chart,  the 
point  of  crossing  of  the  several  lines  indicates  the  location  of  the  foreign  body 
in  the  eyeball  or  orbit. 

The  accuracy  of  the  localization  depends  entirely  upon  the  care  with  which 

the  operator  adjusts  the  indicating-ball  opposite  the  center  of  the  cornea  and 

at  a  definite  and  fLxed  distance  from  it.     After  the  exposure  is  made  and  the 

plate  developed,  the  determination  of  the  situation  of  the  foreign  body  is 

'  "Transactions  of  the  American  Ophthalmological  Society,"  1909. 


1466  Skiagraphy  or  Rontgenography 

simply  a  question  of  reading  from  a  key-plate  and  transferring  these  readings 
to  a  localization  chart. 

The  x-Rays  in  the  Treatment  of  Diseases. — It  may  be  said  that  the 
beneficial  results  obtained  by  the  use  of  the  x-rays  is  in  direct  proportion 
to  the  skill  of  the  Rontgenologist.  No  two  Crookes's  tubes  are  alike  in  their 
behavior;  they  vary  widely  from  day  to  day,  and  even  during  one  operation. 

Unfortunately,  there  is  no  accurate  method  of  computing  dosage  either  in 
quality  or  quantity.^  The  quality  of  rays  may  be  fairly  well  estimated  by 
determining  the  electric  resistance  the  tube  manifests.  Tubes  of  high  vacumn 
offer  great  resistance  to  the  passage  of  the  electric  current  and  emit  hard  or 
highly  penetrating  rays,  while  tubes  of  lower  vacuum  offer  less  resistance  and 
emit  softer  rays.  The  quantity  of  a  certain  quality  of  rays  may  be  roughly 
estimated  by  the  amount  of  current  passing  through  a  tube  of  known  vacuum 
in  a  definite  period  of  time.  The  instrument  commonly  used  in  this  country 
for  this  purpose  is  known  as  the  milliamperemeter,  the  standard  of  measure- 
ment of  electric  units.  In  Europe  the  physiochemical  properties  of  the  rays 
are  more  in  vogue  as  a  means  of  measurement  of  dosage.  In  the  United 
States  most  Rontgenologists  give  repeated  short  exposures,  while  abroad  the 
tendency  is  to  use  infrequent  but  powerful  applications  of  the  rays. 

In  any  case,  ability  gained  by  experience  is  essential  for  the  proper  selec- 
tion and  control  of  the  Crookes  tube  in  the  treatment  of  a  given  condition. 

The  effects  of  x-rays  which  offer  possibilities  of  therapeutic  application  are, 
according  to  Pusey,  as  follows  ("The  Rontgen  Rays  in  Therapeutics  and  Diag- 
nosis," Pusey-Caldwell) :  "(i)  Their  effect  in  causing  atrophy  of  the  append- 
ages of  the  skin;  (2)  their  destructive  action  upon  organisms  in  hving  tissues; 
(3)  their  stimulative  action  upon  the  metabolism  of  tissues;  (4)  their  power 
of  destroying  certain  pathological  tissues;  (5)  their  anodyne  effect."  A  qual- 
itative generalization  may  be  made,  i.  e.,  superficial  diseases  should  be  treated 
in  most  instances  with  tubes  of  low  vacuum,  while  deeper-seated  lesions 
should  be  exposed  to  the  rays  from  tubes  of  higher  vacuum.  Quantitatively, 
for  causing  atrophy  of  the  skin  appendages,  stimulating  action  upon  metabolism, 
and  for  the  relief  of  pain  in  other  than  malignant  conditions,  mild  applica- 
tions or  short  exposures  should  be  given;  on  the  other  hand,  for  destructive 
action  maximum  exposures  are  demanded. 

In  diseases  of  the  skin  the  sin-rounding  healthy  parts  are  to  be  protected 
from  the  action  of  the  rays  by  means  of  sheet-lead,  while  the  diseased  portion 
is  directly  exposed.  In  treating  lesions  beneath  the  surface  it  may  be  necessary 
to  expose  an  area  beyond  the  evident  limits  of  the  disease,  but  all  overlying 
healthy  skin  must  be  protected  from  the  non-penetrating  rays  by  a  filter  of 
almninum  or  leather. 

Because  of  the  possible  untoward  effects  of  exposure  to  x-rays,  diseased  con- 
ditions amenable  to  other  forms  of  treatment  should  not  be  treated  by  the  rays 
imtil  after  the  simpler  treatment  has  failed.  In  such  conditions  the  rays  are 
the  "last  resort."  It  is  strikingly  true,  however,  that  the  most  signal  results 
of  x-ray  therapy  are  obtained  in  conditions  that  are  frequently  incurable  by 
other  means.  Many  of  the  chronic  diseases  of  the  skin  that  yield  but  slowly 
to  medication  may  be  found  to  be  safely  and  promptly  amenable  to  x-ray 
treatment.  Among  these  diseases  are  acne,  eczema,  lupus  vulgaris,  lupus  ery- 
thematosis,  psoriasis,  and  mycosis  fungoides.  The  treatment  is  also  beneficial 
in  tinea  tonsurans,  favus,  sycosis,  alopecia  areata,  hypertrichosis,  and  prurigo. 

In  the  treatment  of  malignant  growths  the  Rontgen  rays  find  their  greatest 
field  of  therapeutic  usefulness.  With  improved  technic,  permitting  of  massive 
doses  of  the  rays  with  safety  to  overlying  and  adjacent  healthy  tissue,  the 
results  are  far  more  favorable  than  in  the  earlier  x-ray  days. 

^  See  foot-note  on  page  1449. 


The  .v-Rays  in  the  Treatment  of  Diseases  1467 

In  superficial  epithelioma,  rodent  ulcer,  and  Marjolin's  ulcer,  without 
glandular  involvement,  cure  is  the  rule,  recurrence  is  becoming  less  frequent 
and  is  amenable  to  cure,  and  the  cosmetic  effect  is  good. 

When  deeper  structures  are  invaded  by  carcinoma  cure  becomes  less 
frequent  and  recurrence  more  frequent  in  direct  proportion  to  the  depth  of 
the  lesion  and  the  degree  of  glandular  involvement.  Even  in  advanced  cases, 
however,  for  instance,  when  the  entire  contents  of  an  orbit  are  involved,  large 
portions  of  the  nasal  structure  destroyed,  or  extensive  areas  of  subcutaneous 
tissue  the  seat  of  foul  and  painful  ulceration,  and  where  operative  interference 
is  contra-indicated,  the  .v-rays  reheve  pain  and  decrease  discharge.  Some 
reach  such  a  stage  of  improvement  that  surgical  procedure  may  be  instituted 
with  hope  of  success,  and  in  a  few  actual  cures  result  from  x-ray  treatment 
alone. 

Epitheliomata  involving  mucous  membranes,  particularly  of  the  lower  Up, 
anus,  or  vagina,  should  not  be  treated  by  .r-ray  until  after  surgical  methods 
have  been  exhausted.  The  rays  are  used  to  prevent  recurrence  after  oper- 
ation. The  reason  why  the  rays  should  be  regarded  as  a  last  resource  in 
these  cases  is  that  mucous  membrane  is  very  susceptible  to  the  action  of  the 
rays  and  is  as  apt  to  be  destroyed  as  is  the  cancer.  Further,  in  the  lower  lip, 
glandular  involvement  is  almost  sure  to  exist.  All  forms  of  carcinoma  with 
glandular  involvement,  if  operable,  should  be  subjected  to  radical  surgical 
extirpation,  and  the  rays  should  be  used  as  a  prophylactic  measure  against 
recurrence. 

All  cases  of  primary  inoperable  carcinoma,  regardless  of  situation,  extent, 
or  the  reason  for  being  inoperable,  should  be  exposed  to  \dgorous  irradiation. 
Likewise,  all  recurrences  after  operative  procedure  is  prohibited  ought  to  be 
afforded  the  possible  benefits  of  .r-ray  treatment. 

In  sarcoma  also  the  results  are  becoming  more  favorable,  but  this  form  of 
treatment  is  by  no  means  on  such  a  basis  of  hope  that  it  should  be  allowed 
to  interfere  with  or  supersede  surgical  methods.  It  is  a  fact,  however,  that  in 
some  cases  in  which  operation  was  not  agreed  to  by  the  patient  or  parents,  or 
in  which  the  condition  was  deemed  by  the  surgeon  to  be  inoperable,  surprising 
results  have  been  obtained  with  the  Rontgen  rays  alone  or  in  connection  with 
the  use  of  Coley's  toxins.  I  know"  of  a  case  of  rapidly  growing  periosteal  sarcoma 
of  the  himierus  in  a  yoimg  girl,  the  onset  of  which  was  so  rapid  that  the  mass 
■was  considered  to  be  a  subperiosteal  abscess,  but  which  was  proved  by  .T-ray 
examination  and  later  by  incision  to  be  sarcoma.  It  was  treated  at  first  by 
.T-rays  and  Coley's  toxins,  and  later  by  x-rays  alone.  It  has  remained  weU  for 
eighteen  months.  The  arm  is  strong  and  useful,  and  the  girl  is  robust.  At 
the  site  of  origin  there  remains  a  spur  of  bone  which  is  about  i  inch  in  length, 
h  inch  in  thickness,  and  has  a  density  equal  to  that  of  the  densest  portion  of 
the  himierus.  Isolated  cases  of  inoperable  retroperitoneal  sarcoma,  fibrosarcoma 
of  the  uterus,  and  other  deep-seated  tmnors,  clinically  or  after  exploratory- 
operation  considered  sarcomata,  have  been  reported  as  greatly  benefited,  con- 
trolled, or  cured. 

Good  results  in  .r-ray  treatment  of  inoperable  malignancies  can  be  obtained 
only  by  the  best  apparatus.  In  the  deep-seated  growths  hard,  penetrating  rays 
in  maximum  quantity  are  demanded.  The  treatment  must  extend  over  a 
period  of  months,  so  that  great  care  and  skill  are  required.  There  is  Httle 
reason  to  believe  that  .r-rays  cause  metastatic  involvement  in  other  parts. 

The  rays  have  been  extensively  used  in  European  countries  in  the  treat- 
ment of  selected  cases  of  uterine  myomata  and  menorrhagic  conditions. 

The  indications  for  this  plan  of  treatment  usually  mean  contra-indications 
for  surgical  procedures.  The  results,  as  reported  by  Hainisch,  Runge,  Bordier, 
and  others,  are  very  satisfactory  in  cases  during  or  near  the  menopause.     The 


1468  Skiagraphy  or  Rontgenography 

hemorrhage  is  stopped  and  fibroid  tumors  diminish  or  disappear.  Atrophic 
changes  occur  in  the  ovaries  and  the  menopause  is  terminated  promptly.  In 
women  under  forty  years  of  age  good  resiilts  are  not  constant. 

Tuberculous  sinuses  that  are  not  deep  seated  are  frequently  quickly  bene- 
fited, and  old  tuberculous  glands  in  which  ulceration  has  recurred  after  opera- 
tion should  always  receive  the  .T-ray  treatment,  as  some  remarkable  results  have 
been  obtained. 

Of  late  years  exophthalmic  goiter  has  been  treated  more  or  less  successfully 
by  Rontgen  rays.  The  rays  are  of  distinct  value  in  many  cases  that  are  not  oper- 
able or  amenable  to  other  forms  of  treatment.  The  Mayos  use  the  rays  for  a 
time  befure  operating.  Many  of  the  distressing  nervous  symptoms  may  be  re- 
lieved, the  pulse-rate  is  often  materially  lowered,  and  changes  favorable  to  future 
operation  take  place  in  the  gland  and  its  capsule.  Dr.  Manges,  the  Ront- 
genologist at  Jefi'erson  College  Hospital,  in  an  extreme  case  of  exophthalmic 
goiter,  obtained  a  remarkably  good  result  from  x-ray  treatment,  so  far  as 
rehef  of  the  nerv^ous  s^nnptoms,  tachycardia,  and  improvement  of  the  gen- 
eral health  of  the  patient  are  concerned.  There  is  not  a  marked  diminution 
in  the  size  of  the  goiter,  but  the  exophthalmus  is  distinctly  less.  The  patient 
has  been  following  for  nearly  four  years  and  without  inconvenience  her  occu- 
pation as  a  weaver. 

Here  again  more  data  is  to  be  desired  before  other  methods  of  treating 
this  disease,  especially  surgery,  are  to  be  replaced  by  Rontgenization.  These 
rays  are  perhaps  the  most  valuable  therapeutic  agent  we  have  in  the  treatment 
of  myelogenic  or  splenomedullar}^  leukemia  and  lymphatic  leukemia.  Since 
Senn's  report  some  years  ago  this  plan  of  treatment  has  been  widely  used  in 
connection  with  other  remedies.  A  spleen  of  enormous  size  will  sometimes  go 
back  to  normal,  high  leukocyte  counts  may  disappear,  red  cells  and  hemoglobin 
may  increase,  and  the  general  health  of  the  patient  is  apt  to  improve.  Stengel 
and  Pancoast  have  improved  the  technic  of  x-ray  treatment  in  their  system- 
atic exposures  of  the  bony  skeleton,  particularly  the  long  bones,  -^dth  com- 
paratively Httle  irradiation  of  the  spleen  imtil  late  in  the  course  of  treatment. 
Even  very  advanced  cases  are  apt  to  improve  greatly  for  a  tune,  but  even  in 
the  early  cases  recurrence  usually  appears  sooner  or  later,  and  becomes  less 
responsive  to  treatment.  Life  may  be  prolonged  for  many  years,  but  perma- 
nent cure  is  very  rare,  if  it  ever  occurs. 

Chronic  suppurating  sinuses  sometimes  heal  under  the  influence  of  these 
rays,  and  varicose  ulcers  are  benefited  by  moderate  exposures.  The  pain  in 
rheumatic  affections  and  neuralgias  is  often  greatly  relieved. 

THE   FINSEN    LIGHT 

It  is  known  that  below  the  spectrum  of  red  Hght  are  heat  rays,  and  above 
the  spectrimi  of  violet  Hght  are  short  \dolet,  actinic,  or  chemical  rays.  The 
short  violet,  with  the  indigo  rays  and  blue  rays,  constitute  the  Finsen  light. 
Ultraviolet  rays  cause  an  electrified  body  to  discharge,  excite  fluorescence  in 
certain  substances,  affect  a  photographic  plate,  and  are  bactericidal,  but  have 
little  power  of  penetrating  tissues  and,  it  is  said,  do  not  inflame  tissues.  Ultra- 
violet rays  pass  readily  through  rock  salt  or  ice,  which  will  not  transmit  heat- 
rays. 

Finsen  taught  us  to  use  these  rays  therapeutically.  He  first  obtamed 
the  rays  from  sunlight,  intercepting  the  heat-rays  by  ice  or  rock  crystal. 
Later  he  obtained  them  from  the  arc  Hght. 

Blood  in  part  prevents  the  passage  of  the  Finsen  light,  hence  in  using 
the  light  we  must  make  the  area  on  which  the  rays  are  to  act  nearly  bloodless. 
This  is  done  by  pressing  firmly  upon  the  part  with  a  rock  cr\^stal  through 


Becquerel's  Rays,  Radium  Rays  1469 

which  water  passes.     The  rays  pass  through  the  crystal  and  the  water  ab- 
sorbs the  heat-rays.     The  rays  are  especially  serviceable  in  lupus. 

BECQUEREL'S   RAYS 

Becquerel  discovered  in  1896  that  uranium  and  some  of  its  compounds  give 
off  a  radiation  similar  to  but  much  weaker  than  the  x-rays.  Among  these 
radiant  substances  are  pitchblende,  radium,  and  uranium.  These  rays  are 
luminous,  actinic,  and  skiagraphic  (McFarland),  and  may  produce,  by  pro- 
longed action,  dermatitis  similar  to  x-ray  dermatitis. 

RADIUM   RAYS 

Monsieur  and  Madame  Currie,  after  prolonged  research,  found  that  thorium 
and  certain  ores  of  thorium  and  uranium  (pitchblende)  are  radio-active,  pitch- 
blende being  more  strongly  so  than  uranium  itself.  The  conclusion  was  that 
pitchblende  contained  a  strongly  radio-active  element  and  that  it  was  not 
uranium.  In  1903  they  discovered  the  sources  of  radio-activity  to  be  two 
hitherto  unknown  elements,  radium  and  polonium  (Dawson  Turner,  in  "Brit. 
Med.  Jour.,"  Dec.  12,  1903). 

Turner  (Ibid.)  tells  us  that  radium  gives  of¥  a  radio-active  emanation  and 
three  kinds  of  rays  (alpha-rays,  beta-rays,  and  gamma-rays).  It  also  emits 
heat,  and  is  itself  at  a  higher  temperature  than  the  medium  in  which  it  rests. 
The  emanation  from  radium  is  a  luminous  gas,  which  can  be  condensed  by 
great  cold,  and  which  imparts  radio-activity  to  certain  bodies.  It  is  to  this 
gas  that  most  of  the  curative  effects  of  radium  can  be  attributed. 

Alpha-rays  consist  of  a  stream  of  positively  charged  gaseous  particles.  Tur- 
ner points  out  tliat  these  particles  are  each  about  twice  the  size  of  a  hydrogen 
atom,  travel  at  a  velocity  of  20,000  miles  a  second,  and  have  little  power  of 
penetration.  In  fact,  the  penetrating  power  of  the  alpha-rays  is  so  slight  that 
they  do  not  pass  through  the  glass  of  a  tube  (Robert  Abbe,  in  "Med.  Record," 
Oct.  12,  1907).  The  beta-rays  consist  of  particles  each  being  one  one- thou- 
sandth the  size  of  a  hydrogen  atom  and  being  strongly  actinic.  These  rays 
are  said  by  Turner  to  resemble  cathode  rays  and  to  be  far  more  penetrating 
than  alpha-rays.  Gamma-rays  resemble  x-rays  and  have  great  penetrating 
power  (Dawson  Turner,  Loc.  cit.).  According  to  Abbe  ("N.  Y.  Med.  Jour.," 
Feb.  10,  1912),  the  soft  beta-rays  and  the  alpha-rays  irritate  and  stimulate; 
the  hard  beta-rays  and  gamma-rays  destroy.  It  is  probable  that  radivun 
also  generates  or  helps  to  generate  a  gas  called  helium,  which  has  no  action 
on  tissues. 

The  actions  of  radium  are  extraordinary.  A  man  entirely  blind  cannot 
perceive  light  when  radium  is  brought  near  him,  but  one  not  quite  but  almost 
blind  can,  and  one  quite  blind  to  form  but  with  retention  of  some  light  percep- 
tion can  actually  see  the  shapes  of  objects  near  a  screen  rendered  luminous 
by  radium.  Turner  tells  us  that  a  man  retaining  vision,  who  covers  his 
eyes,  can  detect  radium  held  in  a  box  behind  his  head.  If  dry  seeds  before 
planting  are  exposed  to  radium  rays  sprouting  will  be  retarded  in  proportion 
to  the  time  of  exposure.  When  meal  worms  are  exposed  to  the  rays  "they  go 
on  living  as  meal  worms,  'veritable  Methuselahs,'  as  it  has  been  said,  while 
their  sisters  and  brothers,  unradiumized,  progress  for  generations,  completing 
several  cycles  of  beetles,  eggs,  meal  worms,  etc."  (Abbe,  in  "Med.  Record," 
Oct.  12,  1907).  Radium  rays  are  germicidal,  but  act  very  slowly  and  feebly. 
Skiagraphs  can  be  taken  with  the  rays.  Water  and  other  materials  may  be 
rendered  radio-active  by  exposure  to  radium  rays.  Probably  certain  natural 
waters  have  subtle  powers  due  to  radio-activity.     On  the  tissues  radium  may 


1470  Skiagraphy  or  Rontgenography 

act  to  produce  a  retrogressive  effect;  may  increase  self-digestion;  may  cause 
irritation  and  inflammation,  and  so  block  blood-vessels.  Severe  reaction  may 
result  in  ulceration.  On  a  tumor  radium  produces  inflammation,  first  of  the 
fibrous  stroma,  then  of  the  tumor-cells,  or  a  primary  necrosis  (Sticker,  in 
"  Presse  Medicale,"  May  18,  1912).  It  seems  to  have  a  selective  action  on 
cancerous  tissue.  Sometimes  a  spreading  eruption,  like  that  of  scarlet  fever, 
follows  overaction.  Abbe  says  that  when  an  ulcerated  surface  is  treated 
or  when  a  tube  of  radium  is  inserted  in  a  wound  for  twenty-four  hours,  a 
"specific  toxemia"  frequently  arises.  "The  symptoms  will  be  headache,  chill, 
general  aching,  coated  tongue,  fever  up  to  from  103°  to  106°  F.,  and  an  occa- 
sional rash-like  scarlatina."  Some  hold  that  radium  acts  similarly  to  the 
ic-rays  and  that  the  x-rays  can  do  anything  radium  can  do.  Other  observers 
believe  that  the  radium  rays  have  a  specific  action  and  can  accomplish  some 
few  things  impossible  to  the  x-rays. 

Radium  therapy  is  commanding  profound  and  widespread  public  in- 
terest. How  real  its  claims  are  and  how  great  its  future  is  to  be  we 
can  only  guess.  Sir  Frederick  Treves  bids  us  be  cautious  in  our  esti- 
mates, although  he  thinks  there  may  be  a  great  future  for  radium  therapy 
in  surgery  ("Brit.  Med.  Jour.,"  Jan.  30,  1909).  It  has  cured  many  surface 
carcinomata  and  sarcomata,  keloids,  angeiomata,  moles,  pigmented  moles, 
and  warts.  It  is  particularly  valuable  in  lesions  about  the  face  when  it 
is  desirable  to  avoid  scars;  in  lesions  of  the  nostril,  mouth,  and  other  cavi- 
ties. It  has  a  very  powerful  action  on  angeiomata.  So  far  radium  has 
been  used  chiefly  for  inoperable  cancer.  It  has  been  used  most  advan- 
tageously for  epithelioma  of  the  eyelid  (see  the  striking  cases  reported  by 
Abbe,  in  "Med.  Record,"  Oct.  12,  1907).  When  treating  a  surface  lesion  the 
rays  are  obtained  from  radium  bromid,  which  material  is  kept  in  a  hermetically 
sealed  platinum  or  lead  tube.  In  a  deep-seated  tumor  an  incision  may  be  made 
and  a  tube  of  radium  bromid  be  inserted  in  the  wound  and  allowed  to  remain 
for  forty-eight  hours.  Attempts  are  being  made  to  treat  internal  conditions 
by  the  inhalation  of  radium  emanations  or  by  the  administration  of  materials 
which  have  been  rendered  radio-active  and  contain,  so  to  speak,  radium  ema- 
nations in  solution.  Radio-active  water  has  been  tried  for  cancer  of  the  stom- 
ach. Treatment  by  radium  is  called  radium  therapy;  treatment  by  radio- 
active substances,  radiotherapy.  It  is  extraordinary  how  even  very  brief 
applications  of  radium  may  be  followed  by  notable  changes.  In  one  of  Abbe's 
cases  an  epithelioma  of  the  forehead  disappeared  after  one  exposure  of  an 
hour's  duration.  Another  on  the  side  of  the  nose  disappeared  in  four  weeks 
after  one  exposure  of  an  hour's  duration.  A  cancer  involving  one-third  of  the 
upper  eyelid  entirely  disappeared  in  two  weeks  after  three  five-minute  expos- 
ures. After  an  exposure  no  changes  are  apparent  for  several  days  or  a  week. 
The  skin  at  the  site  of  application  then  begins  to  burn  and  itch  and  becomes 
reddened.     The  irritation  endures  for  about  two  weeks. 

Confusion  has  arisen  because  of  the  varying  strengths  and  amounts  used 
by  different  operators.  Bromid  of  radium  is  the  salt  usually  employed. 
Abbe  takes  as  a  standard  10  mg.  of  bromid  of  radium  and  tests  other  specimens 
by  this.  He  calls  the  10  mg.  of  strong  German  bromid  of  radium  "the  work- 
ing unit."  In  malignant  disease  the  best  results  have  followed  one  hour's  exhi- 
bition of  the  "working  unit"  to  small  growths  and  three  or  four  hours  to  large 
growths,  "with  an  interval  of  one  month  for  study  of  the  effect"  (Abbe,  Ibid.). 
Ischemia  favors  powerful  action  of  radium  rays. 

In  order  to  obtain  the  best  results  from  radium  heavy  "doses"  seem  to  be 
necessary,  and  heavy  "doses"  are  very  apt  to  burn  the  skin.  The  penetrating 
rays  are  the  gamma-rays,  and  in  order  to  make  them  reach  a  deep  growth  in 
sufficient  intensity  to  do  good  the  superficial  parts  are  endangered. 


Effects  Produced  by  Lightning  147 1 

So  far  radium  has  found  its  chief  use  in  inoperable  cases  and  in  superficial 
lesions.  Abbe  ("New  York  Med.  Jour.,"  Feb.  10,  191 2)  says,  we  may  suppress 
the  short  rays  which  burn,  and  yet  use  the  deeply  penetrating  rays  by  placing 
a  considerable  amount  of  radium  in  lead  which  is  from  y\  to  2  mm.  in  thickness. 

Macdonald  ("Brit.  Med.  Jour.,"  Dec.  9,  191 1)  uses  for  a  deep  growth  at 
least  250  mg.  of  bromid  of  radium  in  platinum  2  J  mm.  thick.  He  keeps  the 
tube  applied  from  twenty-four  to  forty-eight  hours.  In  some  cases  he  inserts 
the  tube  in  the  tumor  and  leaves  it  in  place  for  forty-eight  hours.  A  long 
application  is  not  to  be  repeated  for  five  or  six  weeks.  For  a  superficial 
growth  he  uses  radium  in  a  glass  tube  every  other  day  for  a  week. 

It  may  develop  that  radium  has  decided  power  in  preventing  recurrence 
after  operation.  In  some  few  cases  of  cancer  radium  may  convert  an  inoper- 
able into  an  operable  case. 

A  serious  bar  to  the  extensive  use  of  radium  is  its  immense  cost.  The 
little  there  is  in  the  world  is  in  the  hands  of  a  few  men  and  a  few  institutions. 
Altruistic  persons  in  many  lands  are  striving  to  give  greater  numbers  access 
to  the  supposedly  beneficent  influence  of  that  wonderful  element.  No  proc- 
ess ever  was  so  thoroughly  and  dramatically  advertised  as  the  radium  treat- 
ment of  cancer.  There  is  a  hideous  cruelty  in  the  newspaper  exploitation  of 
radium  therapy,  because  great  numbers  of  persons  who  are  victims  of  cancer 
have  been  caused  to  believe  that  they  could  certainly  be  cured  if  they  could 
gain  access  to  radium.  Such  hopes  cannot  be  realized.  Any  statement  that 
an  extensive  cancer  can  usually  or  even  often  be  cured  by  radium  is  a  stupid 
mistake  or  a  heartless  deception.  At  the  present  time  the  real  truth  of  the 
matter  is  being  slowly  and  carefully  studied  out  by  earnest  men  who  are  not 
seeking  profitable  notoriety.  There  is  little  evidence  at  present  that  radium, 
except  in  certain  exceptional  cases,  has  greater  curative  power  than  the  x-rays, 
and  the  Coolidge  .x*-ray  tube  may  remove  even  these  exceptional  cases  from 
the  radium  side  of  the  scale. 

XLI.  INJURIES   BY   ELECTRICITY 

Effects  Produced  by  Lightning. — Every  year  in  the  United  States 
about  224  persons  are  killed  by  lightning  (McAdie,  as  quoted  in  Draper's 
"Legal  Medicine").  An  individual  may  be  struck  directly  or  he  may  be  shocked 
by  the  Hghtning  having  struck  a  nearby  object.  A  person  can  be  struck  while 
in  a  room,  but  there  is  more  danger  when  he  is  exposed,  especially  in  the  open 
country.  To  be  under  a  single  tree  or  under  a  tree  at  the  margin  of  a  forest 
during  a  thunder-storm  is  dangerous,  but  to  be  in  a  wood  or  imder  a  hedge 
is  reasonably  safe.  The  oak  is  struck  more  often  and  the  beech  less  often 
than  other  trees.  During  a  thunder-storm  it  is  not  safe  to  stand  by  a  chim- 
ney or  fireplace,  in  an  open  doorway,  or  close  to  cattle  (McAdie,  Ibid.).  One 
should  not  use  a  telephone  or  ring  a  bell  during  a  storm.  It  is  vmwise  to 
nm,  as  the  current  of  air  thus  created  is  a  danger.  Telegraph  posts  should 
be  avoided.  A  pool  of  water  is  a  dangerous  neighbor.  Horses  and  other 
animals  shoiild  be  given  a  wide  berth.  The  victim  of  lightning  may  be 
killed  instantly.  The  body  may  show  no  mark,  but  there  are  usually  bums. 
Burns  may  be  superficial,  or  a  large  area  (as  a  limb)  may  be  caj"bonized. 
Death  is  the  fate  of  over  one-third  of  those  struck.  Tidy  ("Legal  Medicine") 
states  that  out  of  54  cases,  21  died  and  2,3  recovered.  Recovery  may  follow 
even  when  there  has  been  severe  burning.  Postmortem  examination  may  fail 
to  reveal  a  lesion,  but  in  many  cases  severe  burns  are  discovered;  in  some  there 
are  laceration  of  tissue,  crushing  of  bones,  and  fearful  injury.  Burns  are  espe- 
cially apt  to  occur  at  the  points  where  the  current  entered  and  emerged.  The 
clothes  are  usually  singed  or  torn,  shoes  are  especially  apt  to  be  torn  apart  or 


1472  Injuries  by  Electricity 

destroyed.  Yet  a  man  may  be  burned  or  killed  and  the  clothing  be  undamaged, 
or  the  underclothing  may  be  destroyed  and  the  outer  garments  escape  unin- 
jured. A  person's  clothing  may  be  destroyed,  he  may  be  left  naked,  and  yet 
he  may  not  be  injured.  Clothing  may  be  cast  far  off,  and  in  some  cases  is 
said  to  have  utterly  disappeared.  The  typical  lightning-marks  are  arborescent 
tracings,  representing  the  course  of  blood-vessels,  produced  by  disorganization 
and  effusion  of  blood  as  the  fluid  travels  through  it.  Occasionally  metal  ob- 
jects, such  as  buttons,  knives,  money,  keys,  etc.,  are  fused,  and  spread  as  a 
metallic  film  over  a  considerable  portion  of  the  surface  of  the  body.  Bichat 
stated  that  in  death  from  lightning  rigor  mortis  does  not  occur.  This  state- 
ment is  now  known  to  be  an  error  (see  the  3  cases  reported  by  M.  Tourdes). 
As  a  rule,  there  are  early  but  perhaps  brief  rigor  mortis,  retained  fluidity  of 
blood,  and  distention  of  the  brain  with  venous  blood.  Putrefaction  is  early 
and  rapid.  A  man  killed  by  lightning  may  remain  in  the  exact  attitude  in 
which  he  was  struck  dead.  He  may  not  be  disfigured,  his  clothing  may  be 
intact,  and  yet,  almost  at  a  touch,  he  may  crumble  to  ashes  because  the  body 
was  practically  incinerated  (see  the  apparently  authentic  cases  •  quoted  by 
Flammarion  in  "Thunder  and  Lightning").  In  most  cases  killed  the  body 
shows  burns.  The  cause  of  death  by  lightning  was  supposed  by  Hunter  to 
be  destruction  of  muscular  contractility,  and  by  Richardson  the  resolution  of 
the  blood  into  gases.  It  is  asserted  that  some  deaths  are  due  to  actual  dis- 
organization of  vital  structure  and  that  others  are  due  to  shock  or  inhibition. 
Spitzka  believes  that  death  from  electric  shock  is  due  to  asphyxia,  to  paralysis 
of  the  heart  with  fibrillary  contractions  of  that  organ,  or  to  a  combination  of 
these  conditions.  An  individual  struck  by  lightning  may  recover  even  when 
he  is  apparently  dead.  Sestier^  collected  reports  of  77  persons  struck  by  light- 
ning; 7  of  them  were  apparently  dead  for  a  number  of  hours,  but  finally  reacted. 
Brouardel  says  in  such  cases  the  death-like  state  may  be  ascribed  to  inhibition, 
caused  by  a  maximum  degree  of  stimulus."  When  death  from  lightning  is 
not  immediate,  the  condition  may  be  as  above  outlined,  the  individual  being 
apparently  dead,  without  obvious  respiration  or  pulse.  He  may  be  insensible, 
with  slow  and  labored  respiration,  a  weak  and  irregular  pulse,  and  dilated 
pupils,  and  may  remain  in  this  condition  for  a  few  minutes  or  for  several  hours. 
The  above  condition  is  scarcely  to  be  distinguished  from  severe  concussion  of 
the  brain.  Every  individual  suffering  from  the  effect  of  lightning  should  have 
his  entire  body  carefully  examined  to  see  if  physical  injures  exist  (fractures, 
wounds,  burns,  ecchymoses,  arborescent  tracings).  The  consequences  of 
lightning-stroke  are  many  and  various.  There  may  be  rapid  and  complete 
recovery,  gradual  recovery,  traumatic  neurasthenia,  sloughing  burns,  partial 
paralysis,  which  is  usually  recovered  from  (Nothnagel),  but  which  may  be 
permanent;  hysteria,  blindness,  change  of  character,  and  actual  insanity. 

Treatment.— Do  not  pronounce  a  person  dead  until  a  thorough  attempt 
at  resuscitation  has  been  made.  Raise  the  head  a  little,  draw  the  tongue 
forward.  Make  artificial  respiration  in  the  prone  position  (Schafer's  method). 
Occasionally  tickle  the  epiglottis,  apply  external  heat,  massage  over  the 
heart,  and,  if  the  means  are  at  hand  and  the  man  is  apparently  dead 
or  all  but  dead,  throw  salt  solution  and  adrenalin  into  a  large  artery  and 
toward  the  heart,  as  advised  by  Crile  and  Dolley  (see  page  468).  Do  not 
give  alcoholic  stimulants.  If  the  respiration  is  feeble,  make  tongue  tr-action 
and  employ  artificial  respiration.  Apply  the  stream  of  a  hot  douche  to  the 
head,  rub  the  limbs  with  mustard,  put  a  mustard  plaster  over  the  heart 
and  another  to  the  back  of  the  neck,  wrap  the  individual  in  hot  blankets,  give 

1  Sestier,  "De  la  Foudre,"  Paris,  1866.  Quoted  by  Brouardel  in  his  lectures  upon 
""Death  and  Sudden  Death." 

^  Beaham's  translation  of  Brouardel's  lectures  upon  "  Death  and  Sudden  Death." 


Effects  of  Artificial  Currents  1473 

enemata  of  hot  saline  fluid,  and  strychnin  hypodermatically.  In  some  cases 
venesection  has  seemed  to  be  of  benefit.  Lumbar  puncture  may  be  tried. 
When  the  individual  reacts,  treat  any  existing  condition  symptomatically, 
and  treat  particular  physical  injuries  according  to  their  character. 

Effects  of  Artificial  Currents. — Individuals  may  receive  dangerous 
or  fatal  shocks  by  contact  with  wires  carrying  a  powerful  electric  current,  by 
contact  with  a  dynamo,  or  with  some  metal  object  which  has  become  accident- 
ally charged  by  a  powerful  current.  The  shock  may  be  from  contact  with  both 
poles  of  a  circuit  (while  standing  on  the  ground  and  touching  one  pole  of  a 
"grounded"  circuit);  when  actual  contact  has  not  occurred,  but  a  person  has 
been  very  close  to  a  high-tension  current  and  the  current  has  junped  an  inch 
or  several  inches  through  the  air;  when  a  person  insulated  from  the  ground 
grasps  the  conductor  with  both  hands  (Spitzka,  "Jour.  Med.  Soc.  of  New  Jer- 
sey," 1909).  Workmen  for  electric  companies,  pedestrians  in  the  streets  of  a 
city  which  is  lighted  by  electricity  or  in  which  trolley  cars  are  employed, 
roofers,  and  firemen  are  liable  to  be  injured  by  electricity.  During  many 
fires  in  cities  live  electric  wires  fall  and  charge  the  rails  of  a  street-car  track, 
the  iron  of  a  hook-and-ladder  truck,  water-tower,  or  a  fire-escape.  Firemen 
who  come  in  contact  with  such  charged  materials  are  shocked.  I  have  seen 
dozens  of  men  thus  shocked,  but  have  as  yet  seen  no  fatal  case.  There  are 
enormous  differences  in  individual  resistance  and  susceptibility.  Spitzka  points 
out  that  in  i  case  death  followed  a  shock  of  65  volts,  and  others  have  sur- 
vived shocks  of  many  thousand  volts.  The  amount  of  current  the  indi- 
vidual gets  from  the  circuit  is  influenced  by  the  tension  of  the  current;  the 
ground  he  stands  on  (metal  floors  and  wet  floors  are  most  dangerous);  the 
area  of  contact  (limited  area  of  contact  means  serious  burning  and  less  gen- 
eral shock,  broad  area  means  little  or  no  burning  and  severe  shock) ;  the  nature 
of  the  tissue  (the  thick  palm  offers  more  resistance  than  the  lip,  and  the  more 
callous  the  palm  of  the  hand  the  greater  the  resistance),  and  the  duration 
of  the  contact.  An  alternating  current  is  decidedly  more  dangerous  than  a 
continuous  current  of  equal  strength.  The  constant  current  causes  a  shock 
only  as  the  circuit  is  opened  and  closed.  While  the  current  is  passing  con- 
tinuously there  is  no  shock,  although  dreadful  burns  may  be  caused  at  this  time. 
The  alternating  current  causes  rapidly  repeated  violent  shocks.  The  arc  light 
is  either  an  alternating  or  a  direct  current.  "Low  tension  currents  with  30  to 
150  alternations  are  more  dangerous  to  the  heart  than  if  of  more  than  500  fre- 
quency. Greater  frequencies,  as  in  Tesla's  currents,  are  practically  harmless" 
(Spitzka,  Ibid.).  An  artificial  current  acts  like  lightning.  It  may  produce 
instant  death,  it  may  produce  unconsciousness,  delirium,  stertorous  respi- 
ration, Cheyne-Stokes  breathing,  or  clonic  spasms.  Its  effects  can  be  often 
recovered  from.  Not  unusually  the  victim  is  apparently  dead,  but  subse- 
quently recovers.  D' Arson val  reports  the  case  of  a  man  who  was  appar- 
ently killed  by  the  passage  of  4500  volts.  No  attempt  at  resuscitation  was 
made  for  one-half  hour,  and  yet  he  recovered  when  artificial  respiration  was 
employed.  DonneUan  reports  a  case  of  recovery  after  the  passage  of  1000 
volts.  Slight  shocks  may  cause  temporary  numbness  and  even  motor  paral- 
ysis. An  electric  shock  frequently  causes  burns  or  ecchymoses  and,  occa- 
sionally, wounds.  Wounds  caused  by  electricity  bleed  profusely  and  are  apt 
to  slough.     Spitzka  (Ibid.)  sets  forth  the  effects  of  electric  shock  as  follows: 

"I.  Local  Signs:  (a)  Burns  of  the  skin  and  hair,  (b)  Puncture  and  rupture 
of  tissues,  (c)  Superficial  necroses,  (d)  MetalHc  impregantion  of  the  surface 
tissues,     (e)  Hemorrhages.     (/)  Edema,  erythemas,  'hghtning'  figures. 

"11.  General  Effects:  (a)  Loss  of  consciousness  and  of  nerve-fimctions  gen- 
erally,    (b)  Paralyses  or  spasms  of  muscles,     (c)  Disturbances  of  respiration 
and  cardiac  action;  high  temperature. 
93 


1474  Injuries  by  Electricity 

'^ Later:  Affections  of  the  bowel  activity:  meteorism,  constipation,  albu- 
minuria, icterus,  incontinence  or  retention  of  urine,  bloody  urine,  arterial 
rigor  or  spasms  of  arterioles,  acute  edema  of  various  parts  (joints) ;  eye-symp- 
toms of  various  kinds:  blinding,  conjimctivitis,  keratitis,  iritis,  cataract, 
dislocation  of  lens,  etc.;  ear-symptoms:  rupture  of  tympanic  membranes, 
deafness,  bleeding,  epistaxis;  thermal  symptoms:  usually  a  rise  of  temperature 
to  38°  to  39°  C,  amnesia,  neuritis,  etc." 

If  death  occurs  it  is  due  to  asphyxia,  to  cardiac  paralysis  with  fibrillary 
contractions  of  the  heart,  or  to  both  conditions  (Spitzka,  "Jour.  Med.  Soc.  of 
New  Jersey,"  1909).  An  electric  burn  looks  like  a  blackened  crust;  it  is  sur- 
roimded  by  pale  skin,  and  for  twenty-four  hours  remains  dry,  when  inflamma- 
tory oozing  begins  and  the  skin  around  it  reddens.  These  burns  are  seldom 
as  painful  as  ordinary  bums,  but  sometimes  cause  severe  pain,  and  recovery 
requires  a  long  time.  When  inflammation  begins  and  suppuration  occurs,  tis- 
sue is  extensively  destroyed;  tendons,  bones,  and  joints  may  sufl'er;  some  por- 
tions become  deeply  excavated,  and  other  portions  show  dry  adherent  masses 
of  dead  and  dying  tissue,  and  a  burn  which  was  at  first  small  may  be  followed 
by  a  large  area  of  moist  gangrene;^  lack  of  tissue  resistance,  due  to  trophic 
disturbance,  is  largely  responsible  for  the  progress  of  the  sloughing.  Even  an 
apparently  trivial  burn  may  be  followed  by  extensive  sloughing. 

Treatment. — If  a  person  is  in  contact  with  a  live  wire,  the  first  thing  to  do 
is,  if  possible,  to  shut  off  the  current.  If  it  is  not  possible  to  shut  off  the  cur- 
rent, catch  a  portion  of  the  clothing  of  the  victim  and  pull  him  away  from  the 
wire,  but  do  not  touch  his  body  with  the  bare  hand.  If  a  pair  of  rubber 
gloves  can  be  obtained,  the  subject  can  be  moved  with  impunity  and  the  AAires 
can  be  safely  cut.  If  it  is  not  possible  to  drag  a  person  away  from  electric 
wires,  an  individual  can  wTap  his  hands  in  dry  woolen  material  and  safely  Hft 
the  portion  of  the  body  in  contact  with  earth  or  wire,  and  thus  break  the 
circuit  and  permit  removal  of  the  body.^  A  dry  cloth  can  be  pushed  between 
the  body  and  the  ground,  and  the  body  can  then  be  removed  from  the  wires. 
It  may  be  possible  to  push  the  wares  away  by  means  of  a  dry  piece  of  wood, 
or  to  cut  them  with  shears  which  have  wooden  handles  and  which  are  perfectly 
dry,  or  to  push  or  draw  the  body  away  from  the  wire  by  the  employment  of 
sticks  of  dry  wood.  Spitzka  warns  us  to  be  careful  in  using  shears  "as  the 
momentary  arc  formed  between  the  separated  ends  may  blind  the  rescuers." 
Treat  the  general  condition  in  the  manner  set  forth  in  the  article  on  Light- 
ning-stroke (seepage  1472).  Raise  the  head  a  little,  draw  the  tongue  for^^ard, 
and  tickle  the  epiglottis.  If  he  does  not  breathe,  place  the  patient  prone  and 
make  artificial  respiration  by  Schafer's  method.  Artificial  respiration  may  be 
carried  out  wdth  the  patient  supine  by  Meltzer's  method  of  tracheal  insufflation 
or  by  the  pulmotor  (see  "Report  of  the  Commission  on  Resuscitation  from 
Electric  Shock,"  June,  1913).  Always  apply  external  heat  and  massage  over 
the  cardiac  region.  If  facihties  are  at  hand  and  the  victim  is  apparently  dead, 
inject  at  once  adrenahn  and  salt  solution  into  a  large  artery  (see  page  468). 
While  any  heart  action  remains  there  is  a  chance  of  resuscitation.  When  heart 
action  and  respiration  are  present  the  prognosis  is  good.  Very  severe  bums 
may  be  caused.  The  author  has  dressed  many  electric  burns  with  hot  fomen- 
tations of  salt  solution  during  the  first  few  days.  This  facilitates  the  sep- 
aration of  the  sloughs  and  seems  to  aid  the  weakened  tissues  in  resisting 
microbic  invasion;  after  sloughs  separate,  the  part  is  dressed  with  dry  sterile 
gauze.  Antiseptic  dressings  can  be  used  from  the  beginning,  but  they  often 
fail  entirely  to  arrest  the  sloughing.     Iodoform  produces  much  irritation  and 

1  See  the  article  by  N.  W.  Sharpe  on  "Peculiarities  and  Treatment  of  Electrical  Injuries," 
in  "Phila.  Med.  Jour.,"  Jan.  29,  1898. 

2  See  the  directions  in  "Med.  Record,"  Dec.  28,  1895,  from  "Med.  Press." 


Treatment  of  Effects  of  Artificial  Currents  1475 

should  not  be  employed.  Ointments  are  ver\'  unsatisfacton,-.  WTien  the 
dressings  are  changed,  the  part  should  not  be  washed  with  corrosive  sublimate, 
as  this  agent  produces  irritation;  peroxid  of  hydrogen  should  be  employed, 
followed  by  warm  normal  salt  solution.  Sharpe  removes  sloughs  by  applying 
the  following  mixture:  2  parts  of  scale  pepsin,  i  part  of  hydrochloric  acid,  U.  S. 
P.,  1 20  parts  of  distilled  water.  This  mixture  is  washed  off  after  two  hours  with 
peroxid  of  hydrogen.  The  same  surgeon  treats  necrosis  of  bone  by  injecting 
ever\-  few  hours  a  3  per  cent,  solution  of  hydrochloric  acid,  using  exery  second 
day  the  pepsin  solution,  and  when  necrotic  areas  come  away,  packing  with 
gauze.  When  repair  begins,  the  raw  surface  should  be  covered  with  silver-foil. 
Skin-grafting  by  Reverdin's  method  or  Thiersch's  method  is  rarely  successful. 
In  some  regions  it  is  possible  to  slide  a  large  flap  in  place  to  cover  a  raw  area 
which  will  not  heal.  In  a  ven.-  severe  case  amputation  or  resection  may  be 
necessar}-. 

In  Xew  York,  Pennsylvania,  Xew  Jersey,  and  several  other  states  electricity 
is  employed  to  execute  criminals  con\-icted  of  capital  offenses.  The  infliction 
of  death  by  electricity  is  popularly  spoken  of  as  electrocution.  It  is  beyond 
doubt,  in  the  words  of  my  colleague,  Professor  Spitzka,  ''the  most  humane 
method  of  executing  criminals."  The  first  electrocution  in  Xew  York  was  in 
Auburn  Prison  in  1S90,  and  since  then  over  100  criminals  have  been  executed 
by  electricity  in  Xew  York  state  alone.  Dr.  Spitzka  has  witnessed  36  electro- 
cutions and  made  autopsies  on  27  of  the  \-ictims  ("Jour.  Med.  Soc.  of  Xew 
Jersey,"'  1909).  The  apparatus  used  is  "an  alternating  dynamo  capable  of 
generating  2000  volts,  a  'death-chair'  with  adjustable  head-rest,  binding  straps, 
and  adjustable  electrodes.  (At  Trenton  a  2400-volt  cmrent  is  taken  from  the 
public  service  vrixe  and  lowered  to  the  desired  tension  by  a  rheostat.)  The 
notch  to  control  the  current  is  in  the  death-chamber  and  the  d^mamo  is  in 
another  apartment,  commimication  being  had  by  electric  signals.  The 
prisoner  (usually  without  fetters)  walks  in  when  ever^'thing  is  ready  and  sits 
down  in  the  chair,  and  his  arms,  legs,  head,  and  chest  are  strapped  to  the  chair. 
An  electrode  moist  with  salt  solution  is  fastened  to  the  head  and  another  to 
the  bare  calf  of  the  leg.     The  head  need  not  be  shaved. 

"The  application  of  the  current  is  usually  as  follows:  The  contact  is  made 
with  a  high  potential — 1800  volts — for  five  to  seven  seconds,  reduced  to 
250  volts  until  a  half -minute  has  elapsed:  raised  to  high  voltage  for  three 
to  five  seconds:  again  reduced  to  low  voltage  until  one  minute  has  elapsed, 
when  it  is  again  raised  to  the  high  voltage  for  a  few  seconds,  and  the  contact 
is  broken.  The  ammeter  usually  shows  that  from  7  to  10  amperes  have 
passed  through  the  criminal's  body. 

"A  second  or  even  a  third  brief  contact  is  sometimes  made,  partly  as  a 
precautionary  measiure,  but  more  to  completely  abolish  reflexes  in  the  dead 
body. 

"The  time  consumed  by  the  strapping-in  process  is  iisually  about  fort>'-five 
seconds  and  the  first  contact  is  made  a  few  seconds  later.  In  all,  about  sixty 
to  seventy  seconds  elapse  from  the  moment  the  comict  leaves  his  cell  until 
he  is  shocked  to  death"'  (Spitzka,  Ibid.V 

After  electrocution  the  temperature  of  the  body  rises  and  may  reach 
129.5°  F.  Dr.  Spitzka  finds  that  after  remo\-iQg  the  brain  the  temperature 
in  the  vertebral  canal  is  often  over  120°  F.  The  brain  shows  capillar}- hemor- 
rhages, arterial  anemia,  and  venous  congestion.  In  some  of  Spitzka"s  cases 
sections  of  the  pons,  oblongata,  and  spinal  cord  showed  areas  resembling  gas- 
eous emphysema,  which  were  perhaps  caused  by  "electrolytic  hberation  of  gas." 

In  electrocution  there  is  no  pain,  consciousness  is  at  once  abolished,  death 
is  certain,  and  resuscitation  is  impossible.  The  Imid  stories  about  criminals 
being  killed  by  the  necropsy  and  not  by  the  electric  current  are  nonsense. 


NDEX 


Abbe's  method  of  lateral  intestinal 

anastomosis,  1114 
operation  for  stricture  of  esopha- 
gus, 936 

of  intracranial  neurectomy,  767 
Abbott's  treatment  of  scoliosis,  843 
Abdomen,    contusion    of,    muscular 

rupture  from,  94s 
diseases  and  injuries,  943 
foreign  bodies  in,  944 
gunstiot-wounds  of,  954 
operations  on,  1066 
Abdominal  actinomycosis,  310 
aorta,  compression  of,  447 

ligation,  492 

Macewen's  method  of  compress- 
ing, 1419 
hernia,  1133.    See  also  Hernia. 
nephrectomy,  1295 
operation,  hemorrhage  after,  457 

iliac  thrombosis  after,  187 

in  insanity,  825 
section,  io66 

after-treatment,  1070 

hemorrhage  in,  control  of,  453 

ligation   of   iliac   arteries   after, 
489 

suture  of  wound  after,  1069 

toilet  of  peritoneum  after,  1068 
type  of  pneumonia,  1012 
wall,    contusion,    without    injury 
of  viscera,  944 

wounds  of,  953 
Abernethy's  fascia,  489 

method  of  ligating  external  iliac 
artery,  491 

of    preventing    hemorrhage    in 
amputation  of  hip-joint,  1418 
Abortive  gonorrhea,  1348 
Abscess,  132 
acute,  140,  141 

in  various  regions,  143 

symptoms  of,  142 
alveolar,  145,  913 

treatment  of,  148 
appendiceal,  143,  1005 

treatment  of,  149,  1075 
axillary,  144 
Bezold's,  146,  80s 

treatment  of,  149 
Brodie's,  142,  497 
caseous,  141 
cervical,  deep,  144 
cheesy,  141 
chronic,  141,  235,  239 
circumscribed,  142 
cold,  141,  235 
congestive,  142,  235 
consecutive,  142 
critical,  142 
deep,  142 

Hilton's  method  of  opening,  149, 
ISO 

of  neck,  144 

treatment  of,  iso 
diagnosis  of,  147 
diathetic,  142 
diffused,  142 
dorsal,  tuberculous,  241 

treatment  of,  246 
Dubois's,  1248 
embolic,  142,  197 
emphysematous,  142 
encysted,  142 
epiploic,  957 
extradural,  805 


Abscess,  fecal,  142 
follicular,  142 
forms  of,  141 
gravitating,  142,  235 
hematic,  142 
hypostatic,  142 
iUac,  tuberculous,  241 
intramammary,  142s 
ischiorectal,  145,  1172 

treatment  of,  149 
lumbar,  tuberculous,  242 

treatment  of,  246 
lymphatic,  141,  235 
marginal,  142 
metastatic,  142,  197 
migrating,  235 
milk,  142 
mushroom,  802 
of  antrum  of  Highmore,  145,  878 

treatment,  149 
of  bone,  chronic,  497 

tuberculous,  treatment  of,  245 
of  brain,  143,  802 

from  ear  disease,  805 

treatment,  149 
of  breast,  146,  1424 

acute,  1425 

treatment,  149 

tuberculous,  242 
treatment  of,  24s 
of  frontal  sinus,  878 
of  groin,  146 
of  hip,  626 

of  joints,  tuberculous,  242 
of  kidney,  1287 
of  larynx,  14s 

treatment,  149 
of  liver,  144,  1035 

pyemic,  1036 

treatment  of,  1039 

traumatic,  1036 
treatment  of,  1039 

treatment,  148 

tropical,  1036 

treatment  of,  1038 
of  lung,  14s,  901 

pneumotomy  for,  901,  912 

treatment,  148 
of  lymphatic  glands,  tuberculous, 

treatment  of,  24s 
of  mediastinum,  145 

treatment,  148 

tuberculous,  242 
treatment  of,  24s 
of  neck,  deep,  144 

tuberculous,  242 
of  popliteal  space,  146 
of  prostate,  146 

treatment,  150 
of  rib,  tuberculous,  242 

treatment  of,  245 
of  scalp,  774 
of  spine,  847 
of  spleen,  1064 
orbital,  146 

treatment  of,  149 
ossifluent,  142 
Paget's,  142,  239,  2SO 
palmar,  146,  721 
pericystic,  104s 
perigastric,  965 
perinephric,  14s,  1288 

treatment  of,  149 
perirenal,  1288 

peri-urethral,  in  gonorrhea,  1347 
pointing  of,  135,  141 


Abscess,    postpharyngeal,    tubercu- 
lous, 241 
treatment  of,  246 
prognosis  of,  148 

of   prostate   in   gonorrhea,    treat- 
ment, 1356 
psoas,  142 

tuberculous,  241 
treatment  of,  246 
pyemic,  142 
residual,  142,  237,  239 
rest  in,  95,  isi 
retromammary,  142s 
retropharyngeal,  acute,  144 

treatment  of,  149 

tuberculous,  241 
scrofulous,  23s 
secondary,  197 
shirt-stud,  151,  239 

treatment  of,  243 
spontaneous  evacuation,  141 
stercoraceous,  142 
strumous,  141,  235 
subdiaphragmatic,  144 
subphrenic,  144,  892,  1030 

after  appendicitis,  1030,  1031 

treatment  of,  149,  1032 
superficial,  142 

treatment  of,  150 
sympathetic,  142 
syphihtic,  142 
thecal,  142,  721 
treatment  of,  148 
tropical,  142,  1036 

treatment  of,  1038 
tuberculous,  141,  23s 

age  occurring,  236 

albuminoid  disease  from,  239 

amyloid  disease  from,  239 

contents,   236 

diagnosis  of,  240 

formation,  236 

in  various  regions,  240 

lardaceous  disease  from,  239 

large,  treatment  of,  245 

of  considerable  size,  treatment, 
243,  244 

of  head  of  bone,  240 

pointing  of,  239 

prognosis  of,  240 

results  of,  239 

secondary    infection    with   bac- 
teria of,  putrefaction 
from,  238 
suppuration  from,  237 

signs,  238 

situations,  236 

small      superficial,     treatment, 
243 

symptoms,  238 

terminations,  237 

treatment  of,  243 
general,  244 

wall  of,  237 

waxy  disease  from,  239 
tympanitic,  142 
urinary,  142 
verminous,  142 
von  Bezold's,  146,  80s 

treatment  of,  149 
wandering,  142,  235 
Absence,  congenital,  of  gall-bladder, 

1123 
of  thyroid  gland,  1228 
Absorbent  cotton,    sterile,    prepara- 
tion of,  7S 

1477 


1478 


Index 


Absorptive  power  of  stomach,  test- 
ing. 974 
Accessory  adrenals,  379 
Accidental  fistula,  993 
A.  C.  E.  mixture,  1209 
Acetabulum,  fractures   of,  of  brim, 
586 
of  fundus,  586 
Acetanilid,  32 
Acetate  of  aluminum,  29 
Acetonuria,  175 

after  anesthesia,  1207 
Achard  and  Castaign's  test  for  ex- 
cretory capacity  of  kidneys,  1272 
Achillodynia,  360 
Acid,  boric,  29 
carbolic,  28 

gangrene  from,  182 
in  tetanus,  213 
poisoning  from,  29 
intoxication  after  anesthesia,  1207 
nucleinic,  34 

picric,  treatment  of  burns  by,  314 
Acidosis,  17s 

after  anesthesia,  1207 
A.  C.  M.  I.  cystoscope,  1302 
Acne,  syphilitic,  325  ^ 
Aconite  in  inflammation,  106 
Acromegaly,  509 
Acromion  process,  fractures,  554 
Actinomyces,  19,  309 

bovis,  309 
Actinomycosis,  19,  309 
abdominal,  3ro 
cutaneous,  310 
of  bone,  310,  494 
of  brain,  809 
treatment,  311 
Actol,  32 

Acupressure  in  hemorrhage,  445 
Acupuncture  in  aneurysrn,  430 
Acute  miliary  tuberculosis,  252 
Adams's  operation  of  osteotomy,  690 

saw,  688 
Adelmann's  method  of  compression 

in  hemorrhage.  447 
Adenitis,  tuberculous,  250 
Adenocarcinoma,  392 
Adenocele  of  breast,  1429,  1432 
Adenofibroma  of  breast,  1428 
Adenoma,  381 
cystic,  381 
of  breast.  1429 
multiple,  of  Virchow,  982 
of  brain,  810 
of  breast,  1429 
cystic,  1429 
of  intestine,  1000 
Adenomatous  goiter,  1230 
Adherent  tongue,  925 
Adhesion-dyspepsia  ,972 
Adhesions,  perigastric,  971 
Adiposis  dolorosa,  509 
Adrenalin  chlorid  in  shock,  263 
Adrenals,  accessory,  379 
rests  of,  379 
tuberculosis  of,  252 
tumors  of,  379 
Agglutination    test   in   diagnosis   of 

tuberculosis,  229 
Agglutinins,  39 

Agnew's      operation      for     webbed 
fingers,  738 
splint   in   transverse   fractures   of 

patella,  604 
treatment  of  fracture  of  femur  at 
upper  third,  595 
Agraphia  in  tumor  of  brain,  815 
Air-embolism,  193 
Airol,  32 

Air-passages,  foreign  bodies  in,  880 
Air-pressure,    positive    or    negative, 
intrathoracic     operations     under, 

Air-resistance,  influence  of,  on  pro- 
jectiles, 286 
Albee's  method  of  bone-grafting  in 
Pott's  disease,  847,  860 
operation    for    osteo-arthritis    of 

hip-joint,  643 
treatment  of  fractures  of  anatom- 
ical neck  of  humerus,  555 


Albert's  disease,  360,  726 
Albuminoid  disease  from  tuberculous 

abscess,  239 
Albuminous  expectoration,  907 
Albuminuria  obstructing  repair,  116 

of  secondary  syphilis,  327 
Alcohol,  29 

and  chloroform  anesthesia,  1209 
in  inflammation,  109 
in  neuralgia  of  fifth  nerve,  763 
Alcoholic  coma,  785 
Alden    and    Allen's    treatment    of 

pyogenic  arthritis,  636 
Aleppo  boil,  138,  1226 
Alexander's    method    of    diagnosing 
rupture  of  bladder,  1318 
of  perineal  prostatectomy,  1386 
Alexin,  38 
Alexinsky's   treatment   for   avulsion 

of  brachial  plexus,  751 
Alimentary    canal,    tuberculosis    of. 

248 
Alkaloidal  toxins,  37 
Allen    and    Alden's    treatment    of 

pyogenic  arthritis,  636 
Allingham's  operation  for  piles,  1181 
AUis's  ether  inhaler,  1198 
method  of  nerve-suture,  760 
of    reducing   dislocation   occur- 
ring with  fracture,  531 
sign  in  intracapsular  fractures  of 
femur,  584 
in    traumatic  dislocation  of  fe- 
mur, 678 
treatment  of  dislocation  of  femur 
into   obturator   foramen, 
679 
upon  dorsum  of  ilium,  678 
with  catching  up  of  sciatic 
nerve,  681 
of  head  of  femur  with  frac- 
ture of  shaft,  681 
of  fractures  in  or  near  elbow- 
joint,  566 
Almen's  test  for  hematuria,  1267 
Alopecia,  syphilitic,  326 
Alpha-rays,  1469 
Aluminum,  acetate  of,  29 
Alveolar  abscess,  145,  913 
treatment,  148 
sarcoma,  372 
Amboceptor,  332 
American  bandage  of  foot,  1255 
Amputation,  1401 
^  la  manchette,  1404 
at  ankle,  1414 
Pirogoff's,  1414 
Syme's,  1414 
at  elbow,  1409 
at  forearm,  1408 
at  hip-joint,  1418 
Jordan's,  1423 
Larrey's,  1423 
Liston's,  1423 
Senn's,  1422 
Sheldon's,  1423 
T-,  1421 
Wyeth's,  1420 
at  knee,  141 7 
at      metacarpophalangeal      joint, 

1407  ,  .  . 

at  middle  tarsal  jomt,  1414 
at  shoulder,  1409 
Dupuytren's.  141 1 
Kocher's,  1410 
Larrey's,  1409 
Lisfranc's,  1411 
at     tarsometatarsal     articulation, 

1412 
at  wrist,  1408 

Berger's,  of  upper  extremity,  141 1 
Bier's,  of  leg,  1415 
Chopart's,  of  foot,  1414 
circular,  1403 
classification,  i4or 
completion  of,  1406 
eUiptical,  1405 
flap  method,  1406 
for  aneurysm,  430 
for  gangrene,  rules,  183 
Forbes's,  T414 
Gritti's  supracondyloid,  1417 


Amputation,  hemorrhage  in,  r40i 
Hey's,  of  foot,  i4r3 
in  gunshot-wounds,  282 
interilio-abdominal,  1423 
interscapulothoracic,  141 1 
intertarsal,  anterior,  1414 
Kocher's,  of  knee,  1417 
lanceolate  incision,  1403,  1406 
Lisfranc's,  of  foot,  141 2 
Liston's  modified  circular,  1405 
methods  of,  1403 
mixed  method,  1405 
modified  circular,  1404 
oblique  circular,  1403,  r405 
of  arm,  1409 
of  fingers,  1406 
of  foot,  1411 
of  hand,  1406 
of  leg,  1415 

below  knee,  141 6 
by  lateral  flaps,  1416 
by  long  anterior  flap,  141S 
posterior  and  short   anterior 
flap,  1416 
by  rectangular  flap,  1415 
modified  circular,  1416 
point  of  election,  1415 
of  penis,  1374 
of  thigh,  141 7 
of  thumb,  1407 
of  toes,  1411 
of  upper  extremity,  1411 
oval,  1406 
racket,  1403,  1406 
rectangular  flaps,  1403 
rounded  flaps,  1403 
Sedillot's,  of  leg,  1415 
special,  1406 
subastragaloid,  1414 
Syme's,     through     femoral     con- 
dyles, 141 7 
T-,  1406 

of  hip-joint,  r42i 
Teale's,  of  forearm,  1408 

of  leg,  1415 
through  femoral  condyles,  1417 
transverse  circular,  1403 
AmyeUa,  835 
Amyloform,  32 
Amyloid    disease   from    tuberculous 

abscess,  239 
Anaphylaxis,  46 

Anastomosis,  aneurysm  by,  366,  417, 
434 
arteriovenous,    for   prevention   or 
treatment  of  gangrene  of  ex- 
tremity, 183 
for  transfusion  of  blood,  463 
facio-accessory,  768 
faciohypoglossal,  768 
intestinal,    by    Murphy's   button, 
1107 
Connell's  method,  mi 
consideration  of  methods,  11 16 
end-to-side,  11 07 
Halsted's  method,  iiii 
Harrington  and  Gould's  method, 

mo 
Kocher's  method,  mo 
Laplace's  forceps  for,  1112 
lateral,  1107,  1113 
Abbe's  method,  11 14 
Halsted's  method,  1115 
Horsley's  method,  iirs 
Laplace's  forceps  for,  11 16 
with  rings,  1113 
Maunsell's  method,  mo 
Moynihan's  method,  mi 
O'Hara's  forceps  for,  1112 
Robson's  method,  mo 
Senn's  method,  1107,  1113 
with  Frank's  coupler,  1109 
intradural  root,  in  vesical  paral- 
ysis, 862 
of  nerves,  760 

vein-to-vein,  transfusion  of  blood 
by,  464 
Anatomical  snuff-box,  471 

tubercle,  247 
Anderson's      method      of      tendon- 
lengthening,  734 


Index 


1479 


Andrews's   operation  for  hydrocele, 

130Q 
Ancl's  operation  for  aneurysm,  424 
Anemic  gangrene,  164 
Anesthesia,   iiQi 

acetonuria  after,  1207 

acid  intoxication  after,  1207 

acidosis  after,  1207 

after-effects,  1205 

backache  after,  1206 

bronchopneumonia  after,  1206 

closure  of  epiglottis  in,  treatment, 
1204 

cyanosis  in,  1202 
treatment,  1204 

death-rate,  1192 

delayed  poisoning  after,  1207 

edema  of  lungs  in,  treatment,  1204 

forgetting  to  breathe  in,  1204 

heart  massage  in  collapse  during, 
1203 

hypnotic,  1215 

infusion,  1201 

intratracheal  insufSation,  1199 

local,  1 215 

paralysis  after,  1208 

preparation  of  patient,  1192 

primary,  1208 

reaction  from,  1205 

regional,  1218 

renal  complications  after,  1206 

respiratory  disorders  after,  1206 

shock  in,  treatment,  1203 

spinal,  1223 

swallowing  tongue  in,  1202 
treatment,  1204 

syncope  in,  treatment,  1203 

terminal,  1218 

treatment  of  complications,  1202 

vomiting  in,  1205 
treatment,  1202 
Anesthetic  successions,  12 13 
Anesthetist,  psychic,  1220 
Aneurysm,  416 

acute,  417 

Anel's  operation  for,  424 

aneurysmectomy,  424 

aneurysmorrhaphy,  426 

aneurysmotomy,  423 

Antyllus's  operation  for,  423 

arteriovenous,  417,  432 
treatment  of,  433 

Brasdor's  operation  for,  425 

by  anastomosis,  366,  417,  434 

capillary,  417 

Carnot's  solution  in,  422 

causes,  418 

circumscribed,  417 

cirsoid,  366,  417,  432 

consecutive,  416 

constituent  parts,  419 

Corradi's  operation  for,  430 

cyhndrical,  417 

diagnosis,  421 

diffused,  416 

traumatic,  416,  431 

dissecting,  417,  418 

embolic,  417 

false,  416 

forms  of,  416 

fusiform,  416 

gelatin  treatment,  422 

Halsted's  operation  for,  429 

Hunter's  operation  for,  424 

Lister's  tourniquet  in,  422 

Matas's  operation  for,  426 

miUary,  417 

needles,  Dupuytren's,  469 
Saviard's,  468 

of  bone,  417 

Pott's,  432 

Reid's  treatment,  423 

rest  in,  95 

ruptured,  416 

sacculated,  416 

secondary,  417 

Shekelton's,  417 

spontaneous,  417 

Strongylus  armatus  as  cause,  419 

Syme's  operation  for,  423 

symptoms,  419 

traumatic,  291,  293,  417 


Aneurysm,  traumatic,  diffused,  416, 
431 
treatment,  421 

after  operation,  429 

by  acupuncture,  430 

by  amputation,  430 

by  distal  ligation,  425 

by  electrolysis,  430 

by  extirpation,  424 

by  injecting  coagulating  agents, 

■^?° 
by  introduction  of  wire,  430 

by  ligature  and  suture,  423 
by  manipulation,  430 
by  pressure,  422,  423 
following     wound     of     healthy 

artery,  431 
operative,  423 
true,  416 
tubulated,  416 
Tuffnell's  compress  in,  422 

treatment,  421 
varicose,  432 

symptoms  of,  433 
treatment  of,  433 
verminous,  417 
Wardrop's  operation  for,  426 
«-rays  in  diagnosis,  420,  421 
Aneurysmal  varix,  432 
symptoms,  433 
treatment,  433 
Aneurysmectomy,  424 
Aneurysmorrhaphy,  426 
Aneurysmotomy,  423 
Angeiosarcoma,  373 
Angelic  scrofula,  225 
Angina,  Ludwig's,  181 
treatment  of,  182 
Angioma,  365 
capillary,  365 
cavernous,  366 
of  brain,  809 
of  breast,  1429 
plexiform.  366 
simple,  365 
Angioneurectomy  for  hypertrophy  of 

prostate,  1389 
Angiosarcoma  of  brain,  809 
Animal  inoculations  in  diagnosis  of 

tuberculosis,  229 
Ankle-joint,  disarticulation  at,  1414 
disease,  632 
excision  of,  704 

Hancock's  method,  704 
traumatic    dislocation,    686.     See 
also    Dislocation,    traumatic,    of 
ankle-joint. 
tuberculosis  of,  632 
Ankyloglossia,  congenital,  92 
Ankylosis,  650 

Baer's  treatment,  653 
bony,  650 

Chlumsky's  treatment,  653 
complete,  650 
extra-articular,  650 
treatment  of,  654 
false,  650 

after  fractures  of  elbow,  567 
inulty,  of  hip-joint,  osteotomy  for, 
689 
of  knee-joint,  osteotomy  for,  690 
fibrous,  650 

Helferich's  treatment,  652,  653 
Huguier  and  Murphy's  treatment, 

652 
incomplete,  650 
intra-articular,  650 
treatment  of,  651 
Lexer's  treatment,  652 
Mikulicz's  treatment,  653 
Taylor's  treatment,  653 
temporomaxiUary,  912 
Thorn's  treatment,  653 
true,  650 

after  fractures  of  elbow,  567 
Verneuil's  treatment,  652 
Weglowski's  treatment,  652 
Anoci-association  operation  of  Crile, 

262,  1218 
Anodynes  in  inflammation,  107 
Anosacral  cysts,  837 
Antemortem  thrombus,  185 


Anthrax,  300 
bacillus  of,  54 
in  blood,  302 
benign,  138 
carbuncle,  302 
edema,  302 
external,  302 

treatment  of,  303 
forms  of,  302 
internal,  302 
prevention  of,  303 
prognosis,  303 
salvarsan  in,  304 
Sclavo's  serum  in,  304 
Antibiosis,  25 
Antibodies,  39 
bacteriolytic,  39 
lytic,  39 
Antigen,  40 
Antinosin,  32 

Antiphlogistic    regimen    in    inflam- 
mation, no 
Antipyretics  in  inflammation,  107 
Antisepsis,  56 

dry,  57 
Antiseptic,  chemical,  26 

fomentation  in  inflammation,  102 
gauze,  preparation,  75 
Antistreptococcic  serum  in  cutaneous 

erysipelas,  201 
Antitoxin  serum  in  tetanus,  208,  211 
Antitoxins,  39,  42 
Antivenene  serum,  300 
Antrum    of   Highmore,   abscess   of, 
145,  878 
treatment,  149 
inflammation,  878 
sarcoma  of,  369,  371 
Antyllus's   operation  for  aneurysm, 

423 
Anuria,  postoperative,  treatment  of, 

265,  266 
Anus,  artificial,  993 
making  of,  11 20 
diseases  and  injuries,  1165 
examination  of,  1166 
fissure  of,  11 77 
fistula  of,  1 1 73 

tuberculous,  248 
gonorrhea  of,  1361 
imperforate,  11 73 
inflammation  of,  pain  in,  89 
prolapse  of,  1182 
pruritus  of,  11 76 
tumors  of,  benign,  1185 
Aorta,    abdominal,   compression   of, 
447 
ligation  of,  492 

Macewen's  method  of  compress- 
ing, 1419 
Apathetic  shock,  261 
Aphasia,  motor,  in  tumor  of  brain, 

81S 
Aplastic  lymph,  87,  120 
Apnea,  863 

Apoplexy,  coma  of,  785 
Appendiceal  abscess,  143,  1005 
treatment,  149,  1075 
colic,  1003,  1004,  1005,  1006 
dyspepsia,  1013 
lithiasis,  1003 
Appendicitis,  looi 

Barker's  operation  for,  1074 

Battle's  incision  in,  1072 

blood-count  in  diagnosis  of,  1012 

catarrhal,  1005 

Davis's  incision  in,  1072 

Dawbarn's  operation  for,  1074 

diagnosis,  loio 

etiology,  1003 

following  childbirth,  1014 

foreign-body,  1004 

forms  of,  loos 

fulminating,  iocs 

gangrenous,  1005 

hematuria  in,  ion 

hepatic  infection  after,  loog 

in  children,  1013 

treatment,  1018 
in  pregnancy,  1014 
treatment,  1018 
lymphatic  infection  after,  1009 


1480 


Index 


Appendicitis,    McBurney's    incision 
in,  1071 
interval  operation  in,  1075 
point  in,  1002,  1007 
rule  in,  1017 
obliterative,  1005 
operation  for,  107 1 

mortality  after,  1076 
Parker's  incision  in,  1075 
patholoKy,  1003 
prognosis,  1008 
recurrent,  1005 
simple  parietal,  1005 
stercoral,  1004 
subphrenic    abscess    after,    1030, 

1031 
suppurative,  1005 
symptoms  and  signs,  1006 
terminations,  1008 
thrombosis  in,  188 
traumatic,  1004 
treatment,  1015 
tuberculous,  1014 
treatment  of,  1018 
Appendicostomy,  Weir's,  1077 
Appendix,   vermiform.     See    Vermi- 

form  appendix. 
Apraxia  in  tumor  of  brain,  815 
Arachnitis,  798 
Ardor  urinre  in  gonorrhea,  1346 

treatment,  1355 
Argyrol,  33 
Aristol,  32 

Arm,  amputation  of,  1409 
glass,  718 
lawn-tennis,  718 
spiral  reversed  bandage  of,  1253 
Amot's    method    of    skin-grafting, 

1262 
Arrow-wounds,  274 
Arsenic  cancer,  388 
Arterial  piles,  1179 
pyemia,  198 

sedatives  in  inflammation,  106 
transfusion  and  infusion  of  saline 
fluid,  467 
centripetal,  in  shock,  263 
Arteries,  ligation  of.     See  Ligation. 
Arteriocapillary  fibrosis,  414 
Arteriorrhaphy,  441 

Bickham's  method,  443 
Gluck's  method,  443 
Halsted's  method,  444 
Lexer's  method,  444 
Murphy's  method,  443 
Salomoni  and  Tomaselli's  method, 
443 
Arteriosclerosis,  414 
Arteriovenous  anastomosis  for  pre- 
vention or  treatment  of  gan- 
grene of  extremity,  183 
for  transfusion  of  blood,  463 
aneurysm,  417,  432 
treatment,  433 
Arteritis,  413 
acute,  413 

Ford's  treatment,  414 
chronic,  414 

treatment  of,  415 
syphilitic,  415 
Artery,  inflammation  of,  413.      See 

also  Arteritis. 
Arthrectomy,  696,  697 
Arthritis,  617,  619 
acute  rheumatic,  639 

suppurative,  63s 
deformans,  640 
gonorrheal,  636 

treatment  of,  638,  1364 
gouty,  640 
hemophilic,  458 
infective,  634 
neuropathic,  643 
non-tuberculous,  634 
ossificans,  650 
pneumococcus,  638 
Poncet's,  619 
pyogenic,  63s 
rheumatoid,  640 
traumatic,  634 
tuberculous,  620 
fistula  in,  Beck's  treatment,  623 


Arthritis,    tuberculous,   gelatiniform 
degeneration  in,  621 
treatment  of,  622 

typhoid,  636 
Arthrodesis,  697 
Arthropathie  deformant,  344 
Arthropathies,  643 
Arthropathy,  tabetic,  643 
Arthrospores,  23 
Arthrotomy  in    pyogenic    arthritis, 

63s 
Articular  rheumatism,   tuberculous, 

619 
Artificial  anus,  993 
making  of,  11 20 

immunity,  38 

leech,  96,  97 

pneumothorax  in   pulmonary   tu- 
berculosis, 903 
operation  for  creating,  907 

respiration,  864.    See  also  Respira- 
tion, artificial. 
Sylvester's  method,  865 

stimulation  of  phagocytosis,  42 
Asch    tube    in    fractures    of    nasal 

bones,  537 
Ascites  from  hepatic  cirrhosis,  sur- 
gical treatment,  11 18 
Ascitic  peritonitis,  1028 
Ascococci,  21 

Asemia  in  tumor  of  brain,  815 
Asepsis,  56 

dry,  57 
Aseptic  agents,  26 

fever,  117 

gauze,  preparation  of,  75 

peritonitis,  102 1 

pus,  133 

traumatic  fever,  129 
Ashhurst's    method    of    excision    of 

knee-joint,  703 
Ashton's  gauze  pads,  77 
Asphyxia,  863 

local,  173 

smoke,  871 

traumatic,  890 
Aspiration  in  empyema,  893 

of  joints,  695 

of  pleural  sac,  906 
Aspirator  and  injector,  693 
Asthma,  thymic,  1247 
Astragaiectomy,  705 

Barker's  method,  706 

by  subperiosteal  plan,  706 

in  paralytic  calcaneus,  706 
Whitman's  method,  706 

in  talipes,  741 
Astragalus,  excision  of,  705 

fractures  of,  615 

traumatic  dislocation,  687 

forward  or  backward,  687 
lateral  and  rotary,  687 
Astringents  in  inflammation,  100 
Atheroma,  414,  415 
Atony  of  bladder,  1319 

idiopathic,  1319 
Atrophy,   muscular,   ischemic,   with 
contractures  and  paralysis,  714 

of  bone,  493 

of  muscles,  713 

of  thyroid  gland,  1228 
Atropin  in  inflammation,  no 

in  shock,  265 
Auditory    nerve,    division    of,    for 

tinnitus  aurium  and  aural  vertigo, 

767 
Auer  and  Meltzer's  method  of  in- 
tratracheal insufflation  anesthesia, 

1199 
Aural  vertigo,  division  of  auditory 

nerve  for,  767 
Auricle,  cancer  of,  390 

cervical,  400 
Auscultation     in     examination     of 

esophagus,  931 
Autogenous  vaccine,  47 
Auto-intoxication,  37 
Autotoxins,  23 

Autotransfusion  in  shock,  265 
Avulsion  of  brachial  plexus,  750 
Alexinsky's  treatment,  751 
Frazier's  treatment,  751 


Avulsion  of  limb,  272 

of  scalp,  272 

of  spine  of  tibia,  610 
Axillary  abscess,  144 

artery,  ligation  of,  473,  474 


Babes-Ernst  granules,  20 
Bacelli's  treatment  of  tetanus,  213 
Bacilluria,  1324 
Bacillus,  21 

anthracis,  52 

aerogenes  capsulatus  of  Welch,  54 

branching,  21 

coli  communis,  53 

colon,  so,  53 

comma,  21 

dichotomy,  21 

Eberth's,  54 

Frankel's,  53 

Koch's,  52 

leptothrix  forms,  21 

mallei,  52 

Nicolaier's,  51 

cedematis  maligni,  54 

of  anthrax,  52 

of  Escherich,  53 

of  glanders,  52 

of  mahgnant  edema,  54 

of  Neisser,  50 

of  tetanus,  51,  205 

pseudodichotomy,  22 

pyocyaneus,  50 

pyogenes  fetidus,  50 

tetani,  51,  205 

tuberculosis,  52,  216 
distribution,  217 
extracellular  poisons,  220 
intracellular  poisons,  220 
products,  220 
resistance,  221 

typhoid,  54 
Back,  injuries  of,  849 

litigation,  851 

saddle-,  844 

sarcoma  of,  377 

strain  of,  718 
Backache  after  anesthesia,  1206 
Bacteremia,  36 
Bacteria,  19 

aerobic,  24 

amotile,  20 

anaerobic,  24 

as  cause  of  infection,  35 

Brownian  movement,  20 

Brunonian  movement,  20 

capsule  of,  20 

carrier,  35,  38 

chemical  composition,  24 

distribution,  34 

effect  of  bacteria  on,  25 
of  cold  on,  24 
of  heat  on,  24 
of  motion  on,  24 
of  oxygen  on,  24 
of  radium  on,  24 
of  sunlight  on,  24 
of  «-rays  on,  24,  1450 

forms,  21 

in  fission,  22 

in  segmentation,  22 

in  urine,  1324 

latent,  25 

life-conditions,  24 

motile,  20 

multiplication,  22 

non-pathogenic,  20 

parasitic,  20 

pathogenic,  20 

products,  21 

pus,  48 

putrefactive,  20,  55 

pyogenic,  48 

resistance  to,  37 

saprophytic,  20 

special  surgical,  48 
Bacterial  ferments,  36 

products,  21 

protein,  37 

vaccines,  treatment  of  infections 
by,  47 
Bacterines,  47 


Index 


1481 


Bacteriology,  17 
Bacteriolytic  antibodies,  39 
Bacterium  coli  commune,  53 
drumstick,  23 
facultative-anaerobic,  24 
t>-phi,  54 
Bacteriuria,  1324 

Baer's  treatment  of  ankylosis,  653 
Balanitis  in  gonorrhea,  1347 

treatment,  135s 
Balanoposthitis  in  gonorrhea,  1347 

treatment.  1355 
Bald  patch,  323 

Ballance's    method    of    di\Tsion    of 
auditorj'  nerve,  768 
mushroom  abscess,  802 
Ballooning,  rectal,  985 
Ball-valve  gall-stone,  1031 
Bandage.  78,  1235 

American,  of  foot,  1235 

Barton's,  1256 

Borsch's,  of  eye,  1256 

circular,  1253 

crossed,  of  angle  of  jaw,  1256 

of  both  eyes.  1256 
demigauntlet,  1254 
Desault's.  1258 
Esmarch's  elastic,  1402 
figure-of-S,  1253 
of  both  eyes,  1256 
of  breast,  1239 
of  elbow,  125S 
of  jaw  and  occiput.  1256 
of  neck  and  axilla.  1259 
of  shoulders.  12 58 
of  thigh  and  pehas,  1257 
French,  of  foot,  1255 
gauntlet,   1254 
gauze,  78 
Gibson's.  1256 
Hamilton's,  541 
handkerchief,  1260 
Martin's,  in  ulcer,  156 
oblique,  of  jaw,  1256 
of  foot  covering  heel,  1255 
not  covering  heel,  1255 
T-,  of  perineum,  1260 
plaster-of -Paris,  1260 
recurrent,  of  head,  1260 

of  stump,  1260 
Scudder's.    in    fractures    of    ana- 
tomical  neck   of   humerus, 
556 
of  shaft  of  humerus,  560 
Selva's,  of  thumb,  1254 
siUcate  of  sodium,  1261 
spica,  1253 
of  groin,  1257 
of  instep,  1255 
of  shoulder,  1257 
of  thumb,  1254 
spiral,  1252 
of  fingers,  1254 
of  foot  covering  heel,  1235 
of  palm  or  dorsum  of  hand,  1254 
reversed.  1253 

of  lower  extremity,  1255 
of  upper  extremity,  1253 
Velpeau's.  1258 

in  fractures  of  clavicle,  352 
Barbadoes  leg.  1251 
Barker's  curet,  244 

method  of  astragalectomy,  706 
of  excision  of  hip-joint,  702 
of  osteotomy  in  talipes  equino- 

varus,  691 
of  spinal  anesthesia,  1223 
needle.  605 

operation  for  appendicitis,  1074 
for  dislocation  of  semilunar  car- 
tilages of  knee-joint,  709 
for  transverse  fractures  of  pa- 
tella, 605 
point,  772 
Barlow's  disease,  237 
Barton's  bandage,  1256 

fracture,  575 
Basedowified  goiter,  1231 
Basedow's  disease,  1235 
Basin,  dressing,  77 
Bassini's     operation     for     femoral 
hernia,  11 50 


Bassini's  operation  for  oblique  in- 
guinal hernia.  11 40 
for  undescended  testicle,  1392 
Bath,    hot- water,    in    inflammation, 

i°3  .      .  ,.  .  . 

Battle  s  mcision  m  appendicitis,  1072 
sign  in  fracture  of  base  of  skull,  792 
Beads,  rachitic,  254 
Beast-mimicry  in  hysteria,  306 
Beatson's    operation    of    oophorec- 
tomy, 395,  1447 
Bechterew's  disease.  848 
Beck's    operation    for    hypospadias, 
1372 
treatment  of  empyema,  894 

of  fistula  in  tuberculous  arthritis, 
623 
Becquerel's  rays,  1469 
Bed-sore,  160,  164,  180 

Charcot's,  180  | 

treatment.  180 
Beebe's     serum     in     exophthalmic 

goiter,  1238 
Bees,  stings  of,  296 
Belfield's     method     of     suprapubic  ■ 

prostatectomy.  1385 
Bell's  induction  balance  in  locating 
bullet.  2S1 
treatment  of  empj^ema,  S94 
Bennett's  fracture.  580 

operation  for  varix  of  leg.  462 
Benzidin  test  for  hematuria,  1267 
Berger's   amputation   of   upper   ex- 
tremity. 1411 
Berg's    operation   for   exstrophy   of 

bladder,  13 16 
Beny's  operation  for  cleft-palate,  921 
Bertomier's  treatment  of  injuries  of 
elbow-joint  in  young  children,  567 
Beta-rays,  1469 
^-eucain  anesthesia,  12 18 
Bevan's  incision  for  svu-geiy  of  bile- 
ducts,  1123 
operation  for  vmdescended  testicle, 
1392 
Beyea's   operation  for  gastroptosis, 

1104 
Bezold's  abscess,  146,  803 

treatment,  149 
Biceps  flexor  cubiti  or  tendon,  rup- 
ture of.  718 
long  head,  dislocation  of,  720 
rupture  of,  718 
Bichat's  fissure,  769 
Bichlorid  of  merciuy.  2  7_ 

of  methylene  anesthesia.  1213 
Bickham's  method  of  arteriorrhaphy. 

443 
Bier's  amputation  of  leg,  141 5 
hyperemia  in  inflammation,  112 
in  tuberculosis,  234 

of  testicle,  1394 
in  tuberculous  arthritis,  623 
intravenous  method  of  local  anes- 
thesia, 1222 
Bigelow's  evacuator,  1335 
Bthotrite,  1334 
operation  of  litholapaxy,  1333 
Bigg's  apparattis  for  bunion,  732 
Bile-ducts,  1032 

catarrhal  inflammation,  1042 
croupous  inflammadon,  1043 
incision  for  operations  on,  1123 
rupture  of,  952 

suppurative  inflammation.  1043 
Biliarj'     fistula     after    cholecystos- 

tomy.  II 26 
BiUroth's    method    of    gastro-enter- 
ostomy,  1 09 1 
of  pylorectomy,  1083 
mixture,  1209 
BUocular  stomach.  972 
Biological  theor>'  of  cancer,  386 
Bircher's  method  of  gastropDcation, 

1103 
Birth  palsy,  brachial.  751 
operation  for,  769 
Bismuth,  subgallate  of,  32 

subiodid  of.  32 
Bismuth-vasehn  paste  in  fistula  in 
tuberculous  arthritis,  623 
poisoning  from,  624 


Bites  and  stings  of  insects,  296 
of  centipedes,  296 
of  chigger,  297 
of  cobra,  297,  299 
of  copperhead,  297 
of  coral  snake,  298 
of  Gila  monster,  300 
of  leech,   hemorrhage   from,   con- 
trol, 454 
of  poisonous  lizard.  300 

spider.  296 
of  rattlesnake,  297,  299 
of  reptiles,  296,  297 
of  sand  flea,  297 
of  scorpion,  296 
of  snakes,  296,  297 

treatment,  299 
of  tarantula,  296 
of  tick,  296 
Black  gonorrhea,  1346 

sarcoma.  373 
Bladder,  atony  of,  1319 
idiopathic,  1319 
calculus  in,   1320.     See  also  Cal- 

cidus  in  bladder. 
cancer  of.  1328 
chronic  catarrh.  1326 
congenital  defects.  1315 
contusion  of,  13 16 
cj'stoscopic  examination,  1301 
diseases  and  injuries,  1312,  1316 
exstrophy  of,  13 15 
female,  growths  in,  1339 
foreign  bodies  in,  1320 
hemorrhage  from,  1270 

control,  455 
hernia  of,  1163 
inflammation  of,   1324.     See  also 

Cystitis. 
mucous   membrane   of,   removal, 

1128 
neck  of,  inflammation,  pain  in,  89 
operations  on,  1330 
overflow  of.  1319 

of  retention,  1319 
papilloma  of.  132S 
paralj'sis  of.  1319 

intradural  root  anastomosis  in,- 
862 
rupture  of,  1317 
sarcoma  of,  1328 
stammering  of,  1329 
stone  in,  1320.     See  also  Calculus^ 

in  bladder. 
tumors  of.  1328 
ulcer  of,  1328 
wounds  of.  1317 
Blake's  method  of  preparing  silver- 

ized  catgut.  71 
Blandin  and  Xuhn's  mucous  glands^ 

926 
Blank-cartridge  wounds,  277 
Blastomycetes,  18 

dermatitis.  19 
Blastomycetic  dermatitis,  311 
Blastomycosis,  311 
cutaneous,  311 
systemic,  311 
treatment,  312 
Blasucci's  ureteral  catheters,  1303 
Bleljs  in  fractures,  530 
Bleeders,  458 

Bleeding.     See  Hemorrhage. 
Blind  boU.  137 

Blister  fluid  from  suspected  tuber- 
culosis, injecting  tuberculous  ani- 
mal with,  221,  229 
Blistering  in  diagnosis   of  tubercu- 
losis, 221.  229 
Blisters  in  inflammation.  104 
Block,  physiological.  260,  262 
Blood,  carbon  monoxid  in,  tests  for, 
876 
changes  in  cancer,  390 
cryoscopy  of,  1273 
freezing-point.  1273 
loss  of.  436.     See  also  Hemorrhage^ 
transfusion  of.  463 
Brewer's  method,  464 
Crile's  operation,  463 
Fauntleroy's  vein-to-vein  anas- 
tomosis for,  464 


1482 


Index 


Blood,  transfusion  of,  in  shock,  264 
Blood-clot,  healing  by,  117 
Blood-count  in  diagnosis  of  appendi- 
citis, 1012 
Blood-cyst,  258 

Bloodgood's  modification  of  Hal- 
sted's  operation  for  inguinal 
hernia,  11 44 

operation  for  varicocele,  1401 
Blood-plaques  in  inflammation,  84 
Blood-plates  in  inflammation,  84 
Blood-serum  in  hemophilia,  4Sg 

in  hemorrhage,  448 
Blood-vessels,  repair  of,  127 

tuberculosis  of,  248 
Blue  ointment  in  inflammation,  loi 

pus,  135 
Bodine's  method  of  inguinal  colos- 
tomy, 1 1 22 
Boeckman's    method    of    preparing 

catgut,  72 
Boil,  137 

Aleppo,  138,  1226 

blind,  137 

Delhi,  140,  1226 

endemic,  of  tropics,  138,  1226 

gum-,  i4S>  913 
Boiled  water,  30 
Boldt's  operating-table,  60 
Bond's  splint  in  CoUes's  fracture,  578 
Bone,  abscess  of,  chronic,  497 

tuberculous,  treatment  of,  245 

actinomycosis  of,  310,  494 

aneurysm  of,  417 

atrophy  of,  493 

cystoma  of,  494 

cysts  of,  494 

diseases  of,  493 
typhoid,  501 

excision  of,  696 

felon,  725 

fissure  of,  514 

head  of,  tuberculous  abscess,  240 

hypertrophy  of,  493 

inflammation  of,  495 

necrosis  of,  495,  499 
acute,  496 
central,  500 
postfebrile,  501 
quiet,  500,  SOI 

node  of,  496 

operations  on,  688 

riders',  496,  713 

repair  of,  126 

syphilis  of,  494 

syphilitic  affections,  326 

tertiary  syphihs  of,  330 

tuberculosis  of,  249,  494 
infiltrating  progressive,  494 

tumors  of,  493 
Bone-cavities,  bone-grafting  for,  503 

decalcified  bone-chips  for,  502 

Dressman's  treatment,  502 

Neuber's  treatment,  502 

Schede's  treatment,  503 

Schleich's  treatment,  502 

Senn's  treatment,  502 

Sherman's  treatment,  502 

treatment  of,  502 

von  Mosetig-Moorhof 's  treatment, 
502 
Bone-chips,    decalcified,    for    bone- 
cavities,  502 
Bone-drill,  Richter's,  535 
Bone-grafting  for  bone-cavities,  503 

in  Pott's  disease,  847,  860 

in  ununited  fractures,  536 
Bone-holding  forceps,  536 
Borborygmi  in  intestinal  obstruction, 

985 
Borchardt's     method     of     reaching 

pituitary  body,  833 
Boric  acid,  29 

Borsch's  eye-bandage,  1256 
Bottini's    galvanocaustic  prostatot- 

omy,  1387 
Bottle  operation  for  hydrocele,  1399 
Bottom,  weavers',  731 
Bougie-i-boule,  1357 
Bougies,  esophageal,  930 
Boutonniere    operation    for    acute 

prostatitis,  1377 


Bow-legs,  740 
Boyer's  cysts,  728 

Brachial  artery,  compression  of,  446 
ligation,  472,  473 
birth  palsy,  751 

operation  for,  769 
plexus,  avulsion  of,  750 

Alexinsky's  treatment,  751 
Frazier's  treatment,  751 
rupture  of,  750 
Braided  silk,  73 
Brain,  abscess  of,  143,  802 
from  ear  disease,  805 
treatment,  149 
actinomycosis  of,  809 
adenoma  of,  810 
angioma  of,  809 
angiosarcoma  of,  809 
cancer  of,  810 
cholesteatoma  of,  810 
compression  of,  782 

treatment,  786 
concussions  of,  780 
contusions  of,  780 
cysts  of,  810 

diseases  and  malformations,  776 
from    suppurative    ear    disease, 
804 
enchondroma  of,  810 
endothelioma  of,  809 
fibroma  of,  810 
gUoma  of,  809 
gliosarcoma  of,  809 
hernia  of,  797 
laceration  of,  780 
lipoma  of,  810 
neuroma  of,  810 
operations  on,  825 

technic,  828 
osteoma  of,  810 
pearl  tumor  of,  810 
prolapse  of,  797 
psammoma  of,  809 
repair  of,  124 
sarcoma  of,  809 
sinus  of,  rupture,  788 
syphihs  of,  331,  332 
syphiloma  of,  809 
traumatic  inflammation,  798 
tuberculoma  of,  809 
tuberculosis  of,  249 
tuberculous  gumma  of,  809 
tumors  of,  808 

consecutive  bulging  in,  819 
Cushing's  decompression  opera- 
tion in,  820,  831 
decompression     operation     for, 

820 
diagnosis,  812 
gummatous,  809 
initial  bulging  in,  819 
localization,  814 
palliative  trephining  in,  820 
symptoms,  810 
treatment,  817 
tuberculous,  809 
two-stage  operation,  819 
water  on,  801 
wounds  of,  794 

from  revolver  bullets,  796 
in  war,  794 
Brainard's  drills,  692 
Brain-matter  in  tetanus,  213 
Brain-sand  tumor,  357 
Branchial  cysts,  399 
fistula,  399 
complete,  399 
incomplete,  400 
sinus,  400 
Branching  of  bacilli,  21 
Brandt's     operation     of     stomach- 
reefing  for  dilated  stomach,  1103 
Brasdor's   operation   for   aneurysm, 

42s 
Brass  wire,  preparation,  74 
Brauer  and  Spengler's  modification 
of  Murphy's  apparatus  for  nitro- 
gen injections,  go8 
Brauer's  method  of  cardiolysis,  461 
Braun's   method   of   gastro-enteros- 

tomy,  1092 
Brawny  cancer  of  breast,  1436 


Breast,  abscess  of,  146,  1424 
acute,  1425 
treatment,  149 
tuberculous,  242 
treatment  of,  245 
adenocarcinoma  of,  1432 
adenocele  of,  1429 
adenofibroma  of,  1428 
adenoma  of,  1429 
angioma  of,  1429 
cancer  of,  1432.     See  also  Cancer 

of  breast. 
cystadenoma  of,  1429 
cystic  adenoma,  1429 
degeneration,  1429 
fibroma,  1430 
cysts  of,  1427,  1429 
diseases  of,  1423 
enchondroma  of,  1429 
endothelioma  of,  1432 
fibro-adenoma  of,  1428 
fibrocystadenoma  -^f,  1429 
fibroma  of,  1428 
fibromyxoma  of,  1418 
figure-of-8  bandage,  1259 
fissure  of,  1423 

prevention,  1424 
hydatid  cysts,  1430 
hypertrophy  of,  1423 
inflammation  of,  1423 
inoperable     malignant     diseases, 

1446 
involution  cysts,  1429 
lacteal  cysts,  1430 
lipoma  of,  1429 
myxoma  of,  1429 
papilloma  of,  1429 
plastic  resection,  1429 
sarcoma  of,  1430 
scirrhus  of,  1432 

atrophic  or  withering,  1435 
tuberculosis  of,  1426 
confluent,  1426 
nodular,  1426 
tumors  of,  1427 
innocent,  1428 
malignant,  1430 
Breathing,  Cheyne-Stokes,  784 
Bregenhem's      operation      for      ex- 
strophy of  bladder,  1316 
Brewer's  method  of  transfusion  of 
blood,  464 
treatment  of  hydrocephalus,  779 
tubes,  464 
Brick's  pile  clamp,  1180 
Brinkerhoff's  speculum,  1167 
Brinton's   treatment   of  fracture   of 

both  bones  of  leg,  615 
Brisement  force  in  ankylosis,  651 
Broca's   operation  for   undescended 

testicle,  1392 
Brodie's  abscess,  142,  497 

joint,  644 
Bronchocele,  1231 
Bronchopneumonia  after  anesthesia, 

1206 
Bronchus,  foreign  bodies  in,  881 
Bronze  wire,  preparation,  74 
Brophy's  operation  for  cleft-palate, 

922 
Brownian  movement  of  bacteria,  20 
Brown's  cystoscopic  table,  1304 
method  of  injecting  air  into  blad- 
der, 1332 
Bruises,  258 

perineal,  1340 
Brunonian  movement  of  bacteria,  20 
Brush-bum,  272 

Bryant's   extension   in   fractures   of 
shaft  of  femur  in  children,  597, 
598 
splint  in  Pott's  fracture,  613 
triangle,  584 
Bryson's   method  of  perineal   pros- 
tatectomy, 1386 
Bubo  in  chancroid,  1373 
treatment,  1374 
in  gonorrhea,  treatment,  1355 
indolent,  321 
pyogenic,  146 
syphilitic,  321 
Bubonulus  in  gonorrhea,  1347 


Index 


1483 


Buchanan's  oi>eration  for  talipes,  741 
Buck's    apparatus    in    intracapsular 

fractures  of  femur,  5S6 
Budding  fungi,  iS 
Buechner's    treatment    of    delayed 

union  in  fractures,  535 
Buerger's  rongeur  forceps.  1304 
test    of    patency   of    deep   veins, 
416 
Buffy  coat  of  inflammation.  q2 
Bullet.     See  also  Pr&jectiles. 
Dumdum,  288 
explosive.  288 
fluoroscope  in  locating.  281 
induction  balance  in  locating,  281 
Krag-Jorgensen,  2S5 
mushroom,  2S8 
skiagraph  in  locating,  281 
soft  nose,  288 
Springfield,  285 
x-rays  for  locating,  281 
BuUet-forceps,  281 
BuUet-probe.  Fluhrer's,  280 
Girdner's,  281 
Lilienthal's,  281 
N^aton's.  280 
Senn's.  281,  ^g^ 
Bunion,  732 

Bigg's  apparatus  for,  732 
Mayo's  operation  for,  732 
Bums  and  scalds.  312 
of  epiglottis.  315 
of  esophagus,  313,  940 
of  glottis,  315 
of  pharynx,  315 
of  tongue.  315 
picric  acid  treatment,  314 
treatment.  313 
brush-,  272 
electric.  1474 
.r-ray,  1450,  1431 
Burrs,  Hudson's,  826 
Bursa,  diseases  and  injuries.  712 
of  semimembranosus  muscle.  731 
retrocalcaneal,  osteophj'tes  of,  359 
Bursitis,  726 
acute,  726 
chronic,  726 
gluteal,  727 
iliac,  727 
iliopsoas,  727 
infrapatellar,  731 
olecranon.  727,  731 
retrocalcaneal,  726 
subacromial.  728 

Codman's  treatment,  730 
Dawbarn's  sign  in.  729 
Monk's  treatment,  729 
subdeltoid,  727 
treatment.  728,  731 
Butcher's    method    of    excision    of 

metatarsal  bone  of  great  toe,  705 
Buttock,  sarcoma  of,  378 
Button  suture,  272 

Cachexia,  cancerous,  383 
of  malignant  disease,  351 
stnimipriva.  122S 
Calcaneum,  fractures  of,  615 
Calcaneus,     paraljTic,     astragalec- 

tomy  in.  706 
Calcium  chlorid  in  hemorrhage,  448 
Calculus  in  bladder.  1320 
attacks  of,  1322 
crushing,  1333 
in  children,  1323 
in  female,  1323,  1337 
mulberry,  1320 
operation  for.  1330 
phosphatic,  1320 
rest  in,  95 
treatment,  1323 
in  ureter.  1285 
pancreatic.  1061 
renal,  1283 

operation  for,  1 294 
pain  of,  89 
salivary-,  915 

sound,  Thompson's,  1322 
urethral,  treatment  of,  1314 
Callus,  bending  of,  526 


Callus,  central.  525 
definitive,  525 
ensheathing.  525 
formation  of,  524 
intermediate,  525 
permanent,  525 
pro\nsional,  525 
temporary,  525 
Calmette's  antivenene  serum,  300 
ophthalmotuberculin   reaction    in 

tuberculosis,   2 28 
Calomel  ointment  in  prevention  of 

syphilis,  334 
Calor  cmntumore  et  dolore,  88 
Cammidge's   reaction   in  pancreatic 

disease,  1058 
Camphor  in  chronic  ulcer  of  leg,  155 
Cancer.  381 
acute,  of  breast,  1436 
k  deux.  350,  390 
arsenic,  388 
biological  theory'.  386 
blood  changes  in,  390 
bra^Tiy.  of  breast,  1436 
cachexia  in.  3S3 
causes  of.  theories,  384 
chemotherapy  of,  395 
chimney-sweeps's.   390 
classification  of.  390 
colloid.  393 
conjugal.  350 
contact.  349,  390,  938 
contusion  as  cause,  384 
cuirass.  390.  1435 
dissemination  of.  389 
distribution  of.  388 
emboli,  389 
encephaloid.  393 
en  cuirasse.  390,  1435 
endotheUal.  374 
eosin  and  selenium  in.  395 
extension  of.  389 
fulguration  in.  394 
glandular.  392 
hematoid.  393 

hereditarj'  influence,  347,  387 
houses,  348,  3SS 
immunity  to,  347.  3S7 
inclusion  theorj'  of  Cohnheim,  385 
increase  of.  386 
inflamed,  of  breast.  1436 
influence  of  diet,  388 
inoperable,  treatment  of.  394 
irritation  as  cause,  384 
ligneous.  1435 

lymphatic  involvement,  389 
mastoides.  1436 
medullary".  393 
melanotic.  391,  393 
metastasis,  389 
mouse.  385,  386 

eosin-selenium  in.  395 
of  axiricle.  390 
of  bladder,  132S 
of  brain,  810 
of  breast.  1432 

acinous.  1432 

acute.  1436 

Beatson's  operation  in,  393, 1447 

brawny,  1436 

causes,  1432 

dressing     and     after-treatment 
after  operation  for,  1445 

duct.  1432,  1436 

Halsted's  operation.  1438 

hard.  1432 

inflamed.  1436 

inoperable.  1446 

Jackson's  operation.  1441 

Meyer's  operation.  1442 

oophorectomy  in,  1447 

scirrhous,  1432 

Senn's  operation.  1441 

sternal  symptom,  1434 

symptoms.  1432 

treatment.  394.  1437 

Warren's  operarion,  1441 
of  esophagus.  937 

treatment.  394.  938 
of  gall-bladder,  1054 
of  intestine.  1000 

treatment,  394 


Cancer  of  kidney,  1274 
of  lip.  923 

Grant's  operation  for,  394,  924 
of  Uver,  1033 
of  male  breast,  1436 
of  nipple,  1427 
of  penis,  1374 

treatment,  394 
of  prostate,  1390 
of  pylorus,  treatment,  394 
of  rectum.  1187 

Cripps's  operation,  1189 
Kxaske's  operation,  1190 
palliaUve  colostomy  in,  1189 
preUminary  colostomy  in,  1188 
Quenu-Mayo  operation  for,  1190 
rest  in.  95 

treatment.  394,  1188 
Weir's  operation  for,  1190 
of  stomach,  958 

coffee-ground  vomit  in,  959 
treatment.  960 
of  testicle.  1396 
of  thymus  gland.  124S 
of  thyroid  gland,  1229 
of  tongue.  927 

complete  removal  of  tongue  in, 

929 
Kocher  s  operation  for,  929 
partial  removal  of  tongue  in,  928 
treatment.  394.  928 
■Uliitehead's  operation  for,  930 
of  vermiform  appendix,  1013 
opium  in.  395 
paraffin  workers'.  390 
parasitic  theorj",  385 
precancerous  stage,  384 
prevalence  of.  386 
radium  in.  395.  1470,  1471 
recurrence  of.  after  operative  re- 
moval. 3S8 
Dawbarn's  operation  in,  395 
regions,  388 
scirrhous.  392 
serum  reacdon  in,  384 
sex  incidence,  387 
spontaneous  disappearance,  389 
telangiectatic.  393 
theories  as  to  cause.  384 
Thiersch's  h\"pothesis.  383 
transplantarion  of.  349 
treatment  of.  393 
.r-rays  in.  388.  394.  395,  1467 
Cancerous  cachexia,  383 
cirrhosis  of  liver,  1033 
ulcer,  true.  391 
Cancroid,  392 

ulcer.  139 
Cancrum  oris,  178 
Cannon-balls,  wounds  by,  282 
Cannula  i  chemise,  453 
Capillarj-  aneurj"sm,  417 
angioma.  365 
drains,  77 

hemorrhage,  control,  433 
piles,  1179 
Capsule  of  bacteria,  20 
Capsulorrhaphy  in  habitual  disloca- 
tions of  humerus.  669 
Caput  medusK.  411 
succedaneum.  772 
Carbolic  acid,  28 
gangrene,  1S2 
in  pfles,  1 180 
in  tetanus.  213 
poisoning,  29 
Carboluria,  29 

Carbon  monoxid  in  blood,  tests  for, 
876 
poisoning,  874 
Carbonic-acid  snow  in  nevus,  368 
Carbuncle,  138 
anthrax,  302 
of  lip,  923 
treatment,  140 
Carcinoma.  381.    See  also  Cancer. 
Cardiolysis.  461 

Brauer's  method.  461 
Delorme's  method,  461 
Cardiospasm,  939 
Cardiovascular  degeneration,  414 
Carditis,  traumatic,  405 


1484 


Index 


Cargile  membrane,  76 
Caries,  495,  498 
excision  of  rib  in,  707 
necrotica.  498 

of  lumbar  and  last  dorsal  vertebrae, 
with  abscess  in  psoas  magnus  or 
quadratus     lumborum     muscle, 
Treves's  operation  for,  695 
sicca,  498 
spinal,  844 

treatment  of,  846 
strumous,  495,  498 
tuberculous,  495,  498 
Camot's  solution  in  aneurysm,  422 
Carotid  artery,  common,  ligation  of, 
479.  480 
external,  ligation  of,  481 
preliminary  closure,  707 

by  median  incision,  707 
Weber's  incision,  707 
internal,  ligation  of,  481 
body,  1246 

tumors  of,  1246 
triangle,  inferior,  475,  478 
superior,  475.  479 
Carpal  bones,  traumatic  dislocation, 
673 
scaphoid,  fractures,  580 
Carpus,  fractures  of,  579 
Carrier,  bacteria,  35,  38 

typhoid,  38 
Carrying  angle  in  fractures  of  hu- 
merus, 561,  562 
Cartilages,  costal,  fractures  of,  545 
Malgaigne's  treatment,  545 
traumatic  dislocation,  675 
floating,  654 
inflammation  of,  86 
laryngeal,  fractures  of,  543 
loose,  in  osteo-arthritis,  641 
semilunar,  of  knee-joint,  disloca- 
tion. Barker's  operation  for, 
709 
traumatic  dislocation,  684 
inflammation  of,  618 
Caseous  abscess,  141 
osteitis,  498 
peritonitis,  1028 
puS;  236 
Castration,  1396 

for  hypertrophy  of  prostate,  1388 
Cataplasm  in  inflammation,  103 
Catarrh,  chronic,  of  bladder,  1326 
suppurative,  of  gall-bladder,  1044 
urethral,  chronic,  1348 
venereal,  1345 
Catarrhal  appendicitis,  1005 
cholecystitis,  1042 
gonorrhea,  1348 

treatment,  1352 
inflammation,  86,  87 

of  gall-bladder  and  bile-ducts, 
1042 
Catgut,  JO 
chromicized,  preparation  of,  72 
method  of  tying,  72 
preparation  of,  Boeckman's  meth- 
od, 72 
boiling  in  alcohol,  71 
Claudius's  method,  71 

Salkindsohn's  modification, 
71 
corrosive  sublimate  method,  72 
cumol  method,  71 
dry  heat  method,  72 
formalin  method,  72 
Johnston's  method,  72 
Kronig's  method,  71 
Senn's  method,  72 
silverized,  Blake's  method  of  pre- 
paring, 71 
Cathartics  in  inflammation,  106 
Cathcart  drainage,  1332 
Catheter,  Blasucci's,  1303 
Cunningham's,  1303 
Enghsh,  13 14 
French,  13 13 
Gouley's,  1314 
Mercier's,  13 13 
Nelaton's,  13 15 
PhiUips's,  13 15 
ureteral,  1303 


Catheter,   ureteral,    disinfection    of, 
1311 
sterilization  of,  1302 
Catheterization  in  prostatic  hyper- 
trophy, 1380 

of  ureters,  1268 

practical  value,  1308 
Cathode  rays,  1447 
Cautery,  actual,  in  hemorrhage,  449 

in  inflammation,  105 

Paquehn,  449 
Cavernous  angioma,  366 

lymphangioma,  368 

sinus,  infective  thrombosis  of,  807 
Cecal  hernia,  1160 
Cecostomy,  valvular,  1121 
Celiotomy,  1066 

Cell  proHferation  in  inflammation,  84 
Cell-division,  122 

direct,  122 

indirect,  122 
Cells,  epithelioid,  214 
Cellular  emphysema,  544 
Cellulitis,  136,  200,  202 

crab,  198 

diffuse,  136 

gangrenous,  202 
CeUulocutaneous  erysipelas,   202 
Celluloid  thread,  74 
preparation  of,  74 

yam,  74 
Cementome,  361 
Centipedes,  bites  of,  296 
Centripetal    arterial    transfusion    in 

shock.  263 
Cephalhematoma,  773 
CephaUc  tetanus,  208 
Cephalocele,  776 

frontal,  776 

occipital,  776 

Robson's  treatment,  777 
Cephalodynia,  712 
CerebelUtis,  798 
CerebeUopontile    angle,    tumors    of. 

817 
Cerebellum,  tumors  of,  816 
Cerebral  concussion,  rest  in,  94 

hemorrhage,  788 

irritability.  781 

paralysis,    infantile,    epilepsy   fol- 
lowing, operative  treatment,  823 

sinus,  hemorrhage  from,  control  of, 
452 

tetanus,  208 
Cerebritis,  798 

Cerebrospinal  fluid,  bacteriology  of, 
862_ 
cytodiagnosis  of,  862 
Cervical  abscess,  deep,  144 

auricle,  400 

esophagostomy  for  stricture,  937 

fistula,  complete  congenital,  400 
median,  927 
congenital  lateral,  400 
incomplete  median,  927 

lymphadenitis,  tuberculous,  252 

lymph-glands,  tuberculosis,  250 

rib,  840 

method  of  removing,  707 
Cervicodorsal  lump,  510 
Chain  coccus,  49 
Chalk-stone,  640 
Chancre.  319 

and    chancroid,    mixed    infection, 
320 

diagnosis,  320 

Hunterian,  320 

redux,  321 

relapsing,  321 

soft,  1372 

urethral,    pyogenic    urethritis    of, 
1344 
Chancroid,   1372 

and  chancre,  mixed  infection,  320 
Charbon,  300 
Charcot's  acute  bed-sores,  180 

artery  of  cerebral  hemorrhage,  786 

disease,  643 

fever,  1046,  1051 

steeple  chart  of,  1052 

joint,  643 
Charriere's  tourniquet,  1403 


Chauveau's  theory  of  immunity,  38 
Cheesy  abscess,  141 
Chemical  antiseptic,  26 
Chemiotaxis,  negative,  20,  41,  83 

positive,  20,  41,  83 
Chest,  concussion  of,  896 

contusions  of,  896 
treatment,  897 

diseases  and  injuries,  890 

mobihzation     of,     in     pulmonary 
tuberculosis,  903 

tapping  of,  906 

wall,    plastic    operations    on,    for 
pulmonary  tuberculosis,  903 

wounds  of.  898 

involving  diaphragm,  899 
Cheyne's  operation  for  femoral  her- 
nia, 1 1 50 
Cheyne-Stokes  breathing,  784 
Chiene's  method  of  finding  fissure  of 

Rolando.  770 
Chigger,  bites  of,  297 
Chilblain,  315 

treatment,  316 
Childbirth,    appendicitis    following, 

1014 
Chimney-sweeps's  cancer,  390 
Chinese  syphihs,  318 
Chlorid  of  ethyl  anesthesia,  12 10 
for  freezing  anesthesia,  1216 
Chloroform,  administration  of,  1196 

and  oxygen  anesthesia,  1198 

anesthesia,  1195,  1201 
followed  by  ether,  12 13 
Chloroma,  371 
Chlumsky's  treatment  of  ankylosis,- 

653 
Choked  disk,  784 

as    symptom    of    brain-tumors, 
811 
Cholangitis,  1052 

infective,  1046 

suppurative,  1046 
Cholecystectomy,  11 28 

for  gall-stones,  1054 
Cholecystendysis      for      gall-stones, 

1053 
Cholecystenterostomy,  1126,  1127 

for  gall-stones,  1054 

Murphy's  method,  11 28 
Cholecystitis,   104T 

acute  phlegmonous,  1045 

bacteriology  of,  1041 

catarrhal.  1042 

simple  suppurative,  1044 

typhoid,  1047 
Cholecystostomy,  11 25 

bihary  fistula  after,  11 26 

for  gall-stones,  1053,  1125 
Cholecystotomy,  1125 

for  gaU-stones,  1053 

ideal,  11 26 

for  gaU-stones,  1053 
Choledochoduodenostomy,   internal, 

1131 
Choledocho-enterostomy     for     gall- 
stones. io_S4 
CholedochoUthotomy,  11 29 
Choledochohthotrity  for  gaU-stones, 

1034 
Choledochostomy,  1129,  1130 

for  gaU-stones,  1054 
Choledochotomy      for      gall-stones, 
1054 

retroduodenal,  1131 

supraduodenal,  1129 
Cholelithiasis,  1048 
Cholesteatoma,  357 

of  brain,  810 
Chondroma,  357 

treatment  of,  358 
Chondrosarcoma,  373 
Chopart's  amputation  of  foot,  1414. 
Chordee  in  gonorrhea,  1347 

treatment,  1353 
Chromicized  catgut,  preparation,  72 
Chvostek's  sign  in  tetany,  1246 
Chyle  cysts,  402 
Cicatrices,  121 

vicious,  121 
Cicatricial    stenosis    of    orifices    of 

stomach,  969 


Index 


148: 


Cicatricial  stricture  of  intestine,  in- 
testinal obstruction  from,  982 
tissue,  119 
Cicatrization,  116,  120 

scarlet  red  in,  120 
Cigarette  drain,  77 
Circulation,  retardation,   in  inflam- 
mation. So 
Circumcision  in  phimosis.  1374 
Cirrhosis,  cancerous,  of  liver,  1033 
Cirsoid  aneurysm.  366,  417,  434 
Cistema  magna,  drainage  of.  832 
Clamp    and    cauter>'    operation    in 

piles.  1 1  So 
Clap,  J34S 
Claret  stains,  36s 

Claudication,    intermittent,   in   pre- 
senile spontaneous  gangrene,  166 
Claudius's  method  of  preparation  of 
catgut,  71 
Salkindsohn's  modification, 
71 
Clavicle,  excision  of,  706 

fractures  of,  550 
of  acromial  end,  552 
Fox"s  apparatus,  552 
Moore's  dressing,  552 
of  shaft,  550 
of  sternal  end,  553 
Sajrre's  dressing,  552 
Velpeau's  bandage,  552 

gumma  of.  329 

traumatic  dislocation.  660 

Rhoad's  apparatus  for,  662 
Clavus,  1227 
Claw-hand,  754 
Cleft-palate.  916 

Berr>-'s  operation  for.  921 

Brophy's  operation  for,  922 

Fergusson's  operation  for,  922 

operation  for,  giS 
Cloaca.  500 
Cloquet's  hernia.  11 60 

tabatiere  anatomique,  471 
Clostridium.  23 
Closure  of  jaws,  912 
Clot,  active,  418 

external,  435 

internal,  435 

passive.  41S 
Clove-hitch  knot.  658 
Clover's  ether  inhaler.  1198 
Club-foot.  740.    See  also  Talipes. 
Club-hand,  740 
Coagulable  lymph,  117 
Coal-gas.  poisoning  from,  874 
Cobra,  bite  of.  297,  299 
Cocain  hydrochlorate  h>'podemiatic 

injection.  12 16 
Cocainization  of  nerve-trunk,  1217 

of  spinal  cord.  1223 
Cocain-poisoning,  121 7 

fever  of,  131 
Coccus,  21 

chain,  49 

Fehleisen's,  50 

plate,  21 

pj'ogenic,  21 

wool-sack.  21 
Coccygodynia,  550 
Coccyx,  fractures  of,  549 

traumatic  dislocation,  676 
Cock's    method    of    reducing    dislo- 
cated humerus,  668 

operation  of  perineal  section,  1371 
Codman's  treatment  of  subacromial 

bursitis,  730 
Coffee-ground    vomit   in   cancer    of 

stomach.  959 
Cohnheim's     inclusion     theory     of 

tumors.  346 
Coin-catcher,  942 
Cold  abscess,  141,  235 

effects  of.  315 
on  bacteria.  24 

gangrene,  164 

in  inflammation,  97 
Cole's  method  of  serial  radiography 

of  bismuth  meal.  1458 
Coley's  dressing  in  oblique  inguinal 
hernia,  1142 

fluid  in  sarcoma,  377 


Colic,     appendicular,     1003,     1004, 
1005.  1006 
in  gall-stones.  1050 
nephritic,  1283 
pain  of,  90 
Collapse,  260 
in  anesthesia,  heart  massage  for, 
1203 
CoUargolum.  32 
Colles's  fracture.  573 

Bond's  splint  in,  578 
Levis's  treatment,  577 
Maisonneuve's  symptom  in.  577 
Moore's  treatment.  578 
Pitcher's  treatment.  578 
reversed  deformity  in.  577 
Roberts's  splint  in,  578 
Storp's  treatment,  578 
law  in  syphilis.  317,  343 
CoUey's    operation    in    Volkmann's 

contracture,  717 
CoUin's  apparatus  for  salt  solution, 

466 
CoUins's  incision  for  surgery  of  bile- 
ducts,  1 1 24 
Collodion,  iodoform,  76 
Colloid  cancer,  393 

goiter,  1231 
Colloidal  silver.  32 
Colon  bacillus,  50,  53 
congenital  idiopathic  dilatation  of. 

1019 
diseases  of,  «-rays  in  diagnosis  of, 

1458 
fibromatosis  of.  1018 
Colopexy  in  rectal  prolapse,  1184 
Colostomy.  11 20 
ingmnal.  11 21 

Bodine's  method.  1122 
Maydl's  method,  112 1 
lumbar,  11 23 
paUiative.    in    cancer    of    rectum. 

1189 
preliminary",  in  cancer  of  rectum. 
11S8 
Colubrine  venom,  298 
Columns  adiposae.  138 
Coma,  alcoholic,  785 

determination  of  cause,  785 
diabetic.  173.  785 
hysterical,  785 
of  apople.xy.  785 
of  opium-poisoning.  785 
postepileptic.  785 
of  uremia.  785 
Comma  bacillus.  21 
Commercial  gasolene,  a 
Complement.  332 
Compound  ganglion,  722 
Compression  in  hemorrhage,  443 
in  inflammation,  100 

of  joint.  100   ■ 
of  brain,  782 

treatment,  786 
of  spinal  cord,  852 
stenosis  of  esophagus.  934 
Concretions,  fecal,  intestinal  obstruc- 
tion from.  981 
saUvary.  915 
Concussions  of  brain,  780 
rest  in,  94 
of  chest,  896 
of  spinal  cord,  851 
Condyloma,  325 

flat,  324 
Congestion  bj'  recoil,  907 
of  thyroid  gland,  1229 
Cormective- tissue     tumors,     mahg- 

nant.  368 
ConneU's      method      of      intestinal 
anastomosis,  mi 
suture,  1079 
Constipation  of  appendix,  1005 
Constitution,  lymphatic,  223 
Contact  cancer,  349,  390,  958 
Continuous  suture,  270 
Contour  gunshot-wounds,  279 
Contraction.  Dupuytren's,  737.    See 

also  Diipuylren's  contraction. 
Contracdons  of  muscles.  720 
Contracture,  Volkmann's,  714 
Colley's  operation  in,  717 


Contracture,  Jones's  treatment,  716 
Contused  wound,  272 
Contusions,  258 

of    abdomen,     muscular    rupture 
from,  945 

of    abdominal    wall    without    in- 
jury of  viscera,  944 

of  bladder,  13 16 

of  brain,  780 

of  chest,  896 
treatment,  897 

of  head,  779 

of  lung,  896 

of  muscles.  717 

of  nerves,  758 

of  spinal  cord.  851 

symptoms,  238 

treatment.  259 

wind,  from  projectiles,  291 
Cook's  speculum,  11 68 
Coohdge's  «-ray  tube,  1449 
Cooper's  hemiotome.  1156 

method    of     reducing    dislocated 
humerus,  667 

operation  for  Ugating  abdominal 
aoru,  493 

rule  in  old  traumatic  dislocations. 
658 

treatment  of  dislocation  of  lower 
jaw,  660 
Copper  wire,  preparation,  74 
Copperhead,  bite  of.  297,  298 
Coracoid  process,  fractures.  554 
Coral  snake,  "bite  of.  298 
Com,  1227 

Cornea,  inflammation  of,  85 
Corneal  corpuscles.  85 
Coming's     method     of     preventing 

nerve  regeneration.  760 
Corona  veneris.  324 
Corpora    quadrigemina.    tumors   of, 

816 
Corpus  caUosum,  tumors  of,  815 

striatum,  tumors  of,  816 
Corpuscles,  corneal.  85 

educated.  42 

third,  in  inflammation,  84 
Corradi's    operation    for   aneurj'sm, 

430 
Corrosive  sublimate,  27 

method  of  preparing  catgut,  72 
poisoning,  28 
Corset,  Gallant's,  for  movable  kid- 
ney, 1278 
Costal  cartilages,  fractures.  545 

Malgaigne's  treatment,  345 
traumatic  dislocation.  675 
Costotome.  707 

Cotton,    sterile   absorbent,  prepara- 
tion of.  75 
Cours'oisier's  law  in  gaU-stones.  1052 
Cowperitis  in  gonorrhea.  1347 

treatment,  1356 
Coxa  valga.  745.  746 

Galeazzi's  treatment.  747 

vara.  745 
Coxalgia,  623.    See  also  Tuberculosis 

of  hip-joint. 
Crab  cellulitis.  19S 
Crampton's  hne.  489 
Cranial  pneumatocele.  774 
Craniocerebral  topography,  768 
Cranioschisis.  777 
Craniotabes,  253 
Craniotomy,  Unear.  831 
CrawUng  paralysis.  852 
Crede's  ointment  of  silver.  32 
Creolin.  30 

Crepitus  in  fractures,  521 
Crequy's  plan  of  remo\ing  foreign 

bodies  from  esophagus.  942 
Cretinism,  12  28 

Crile's    anoci-association    operation, 
262.  1218 

method  of  injection  of  saline  solu- 
tion and  adrenalin.  467.  46S 
of  transfusion  of  blood,  463 

rubber  suit  in  shock,  263 
Cripps's  operation  for  rectal  cancer. 

1189 
Crises,  Dietl's,  1276 
Crookes's  tube,  1447 


I486 


Index 


Crossed  paralysis,  8i6 
Croupous  inflammation,  86,  87 

of  gall-bladder  and   bile-ducts, 
1043 
Crucial  ligaments  of  knee,  rupture, 

649 
Crus.  tumors  of,  815 
Crushing  vesical  calculi.  1333 
Cryoscopy,  1273 
Cryptitis,  1186 
Cryptorchism,  1391 
Crypts  of  Morgagni,  inflammation, 

1186 
Cuboid,  fractures  of,  615 
Cuirass  cancer,  390,  1435 
Culminating  point  of  bullet,  287 
Cumol    method    of    preparation    of 

catgut,  71 
Cimeiform  bones,  fractures,  615 
Cunningham's      ureteral     catheter, 

1303 
Cupping  in  inflammation,  96 
Cups,  dry,  96 

wet,  96 
Curdy  pus,  236 
Curet,  Barker's,  244 
Curling's  ulcer,  162,  313,  994 
Curvature,    spinal,    840.      See    also 

Spinal  curoature. 
Cushing's    decompression    operation 
in  tumors  of  brain,  820,  831 

electrode,  829 

method  of  osteoplastic  resection  of 
skull,  828 
of  reaching  pituitary  body,  834 
of   removal   of    Gasserian   gan- 
glion, 767 

right-angled  suture,  1079 

treatment  of  hydrocephalus,  779 
Cut  throat,  879 
Cutaneous  erysipelas,  199,  200 

tuberculin    reaction,     Moro's,    in 
tuberculosis,  229 
von  Pirquet's,  in  tuberculosis, 
229 
Cyanid  gauze,  preparation  of,  75 
Cyanosis  in  anesthesia,  1202 

treatment,  1204 
Cylindrical-celled  epithelioma,  391 
Cylindroma,  373 
Cyrtometer,  Horsley's,  772 
Cystadenoma  of  breast,  1429 
Cystectomy,  partial,  for  tumors   of 
bladder,  1329 

total,     for     tumors     of     bladder, 
1329 
Cystic  adenoma,  381 
of  breast,  1429 

degeneration  of  breast,  1429 

fibroma  of  breast,  1430 

goiter,  1231 

tximors,  multilociilar,  361 
Cysticotomy,  1054 
Cystitis,  1324 

acute,  1324 

chronic,  1324,  1326 
treatment  of,  1326 
tuberculous,  1326 

in  gonorrhea,  treatment,  1356 

rest  in,  95 

tenesmus  in,  1325 

treatment,  1325 
Cystocele,  11 34 
Cystoma,  396,  400 

atheromatous,  396,  398 

mesoblastic,  397 

mucous,  397 

of  bone,  494 

traumatic  epithelial,  396 

varieties  of,  396 
Cystoscope,  1301 

A.  C.  M.  I.,  1302 

collection  of  urine  by,  1306 

Lewis's,  1307 

operating,  1307 

removal  of,  1306 

sterilization  of,  1302 

universal,  1308 
Cystoscopic  table,  Brown's,  1304 

ulcer,  1301 
Cystoscopy,    contra-indications    to, 

1303 


Cystoscopy,  location  of  interureteral 
bar  in,  1305 
of  ureteral  orifices  in,  1305 

practical  value,  1308 

technic  of,  1303 
Cystostomy,  1337 
Cystotomy,  1337 

median,  1338 

suprapubic,  1337 
Cysts,  400 

anosacral,  837 

blood-,  258 

Boyer's,  728 

branchial,  399 

chyle,  402 

dentigerous,  361 

dermoid,  398 

sequestration,  398 

epithelial  traumatic,  398 

from  softening,  401 

hydatid,  402 
of  breast,  1430 
of  liver,  1034 

involution,  of  breast,  1429 

lacteal,  401 
of  breast,  1430 

mesenteric,  402,  956 

milk,  401 

mucous,  401 
of  mouth,  926 

of  bone,  494 

of  brain,  810 

of  breast,  1427,  1429 

of  incisive  gland,  926' 

of  liver,  1033 

of  nipple,  1427 

of  pancreas,  1055 

of  sinus  pocularis,  treatment,  1314 

of  spleen,  1065 

of  testicle,  1395 

of  vitello-intestinal  duct,  402 

on,  401 

omental,  955 

pancreatic,  1061 

parasitic,  402 

retention-,  400 

salivary,  401 

sebaceous,  400 

soUtary,  358 

subhyoid,  927 

thyroglossal,  926 

thyroUngual,  926 

tubulo-,  401 

urachal,  402 

vein,  412 
Cytodiagnosis  of  cerebrospinal  fluid, 

862 
Czemy-Lembert  suture,  1079 
Czerny's  method  of   tendon-length- 
ening, 734 


DaCosta's  method  of  bowel  identi- 
fication, 949 
modification  of   Senn's   operation 
for  fixing  kidney,  1296 
Dactylitis     in    hereditary    syphihs, 
344 
tertiary,  330 
Dalton's    formula    in    acute    gonor- 
rhea, 1352 
Dangerous  area,  774 
Danger-zone  of  projectiles,  286.  287 
Davis's  incision  in  appendicitis,  1072 
Davy's  director,  6gi 
lever,  447,  1419 

method   of   osteotomy   in   talipes 
equinus,  691 
Dawbam's  method  of  arterial  saline 
transfusion,  468 
of  sealing  up  open   mouths  of 
lymphatics,  1438 
operation  for  appendicitis,  1074 
for  recurrent  cancer,  39s 
for  sarcoma  of  tonsils,  377 
sign  in  subacromial  bursitis,  729 
Dead  space,  57 
Death  by  inhibition,  260 
from  a;-rays,  1452 
thymic,  1247 
D6coUement   of   parietal   pleura   m 
abscess,  912 


Decompression     for     heart     hyper- 
trophy, 461 

spinal,  863 
Decompressive  trephining,  820,  831 
Decortication,  pulmonary.  Fowler's 

operation,  911 
Decubital  gangrene,  164,  180 
Decubitus,  160,  164,  180 
Defecation,    spermatorrhea,      1343, 

1377 
Defensive  protein,  38 
Deformity,  reversed,  in  Colles's  frac- 
ture, 577 

silver-fork,  577 
Degeneration,  cardiovascular,  414 

cystic,  of  breast,  1429 

gelatiniform,    in    tuberculous    ar- 
thritis, 621 

of  muscles,  713 

pulpy,  of  synovial  membrane,  250, 
618,  620 

Wallerian,  123 
De    Guise's   operation    for   salivary 

fistula,  914 
Delbet's  operation  for  varix  of  leg, 

462 
Delhi  boil,  138,  1226 
Delirious  shock,  261 
Delorme's  method  of  cardiolysis,  461 

treatment  of  ununited  fractures, 
536 
Delusions,   hypochondriacal,    opera- 
tive treatment,  824 
Demarcation,  line  of,  167 

in  gangrene,  164 
Dental  nerve,  inferior,  neurectomy 

of,  762 
Dentigerous  cysts,  361 
Deodorizer,  26 
Depression-fracture,  514 
Depressions,  obstetric,  of  skuU,  794 
Dermatitis,  blastomycetes,  19 

blastomycetic,  311 

gangraenosa  infantum,  164 

malignant,  of  nipple,  1427 

venenata,  1226 

a;-ray,  1450,  145 1 
Dermatol,  32 

Dermoid     associated     with     sacro- 
coccygeal region,  1165 

cysts,  398 

sequestration,  398 

sacrococcygeal,  836 

subungual,  926 

traumatic,  396 
Desault's  bandage,  1258 

sign   in  intracapsular  fracture  of 
femur,  584 
Desmoid  tumors,  355 
Diabetes  obstructing  repair,  116 
Diabetic  coma,  175.  785 

gangrene,  164,  174 
of  foot,  treatment,  175 
treatment,  175,  176 
Diabetics,  operations  on,  69 
Diaphoretics  in  inflammation,  107 
Diaphragm,  eventration  of,  1164 

rupture  of,  897 

wounds  of  chest  involving,  899 
Diaphragmatic  hernia,  1164 
Diastasis,  517 
Diathesis,  hemorrhagic,  456 
Dichotomy  of  bacilU.  21 
Diday's  operation  for  syndactylism, 

738,  739 
Diet  in  inflammation,  1:0 
Dietl's  crises,  1276 
Diffenbach's  treatment  of  old  trau- 
matic dislocations,  659 
Digestive  tract,  upper,  diseases  and 

injuries,  912 
Digits,  supernumerary,  739 
Dilatation,  congenital  idiopathic,  of 
colon,  1019 

digital,  of  pylorus,  for  cicatricial 
stenosis.  loSo 

of  stomach,  acute,  974 

Brandt's  operation  for,  1103 
chronic,  973 

of    urethra,    modified    rapid,    for 
stricture,  1368 
Dimple,  postanal,  836 


Index 


1487 


Dioxid  of  hydrogen,  30 
Diphtheric  inflammation,  86,  87 
Diplococcus,  21 

pneumoniae,  53 
Disarticulation,  1401 
at  ankle-joint,  1414 
at  elbow- joint,  1409 
at  hip-joint,  1418 
at  knee,  141 7 
at      metacarpophalangeal      joint, 

1407 
at  middle  tarsal  joint,  1414 
at  shoulder-joint,  1409 
at     tarsometatarsal     articulation, 

1412 
at  wrist- joint,  1408 
intertarsal,  anteiior,  1414 

posterior,  1414 
subastragaloid,  1414 
Discission     of     pulmonary     pleura, 

Ransohoff's  operation,  893,  912 
Disease    production    from  bacteria, 

35  , 
Dismfectant,  26 
Disinfection,  26 

of  mucous  membranes,  68 
of  skin,  iodin  for,  68 
of  ureteral  catheters,  13 11 
Dislocation,  655 
congenital,  656 
consecutive,  655 
internal,  of  femur,  549 
Monteggia's,  680 
Nekton's,  686 

occurring  with  fractures,  531 
of  hip,  congenital,  Hoflfa's  opera- 
tion, 711 
Lorenz's  bloodless  method  of 
reduction,  710 
operation,  711 
operation  for,  710 
reduction    by    means  of  me- 
chanical appliances,  711 
in  typhoid  fever,  655 
of  kidney,  1275 
of  long  head  of  biceps,  720 
of  muscles,  720 

of   semilunar   cartilages   of   knee- 
joint,    Barker's    operation    for, 
709 
of  spine,  852 
of  tendons,  720 
of  ulnar  nerve  at  elbow,  758 
pathological,  655 
spontaneous,  655 
traumatic,  655,  656 

at  inferior  radio-ulnar  articula- 
tion, 673 
causes,  656 
compound,  658 
diagnosis,  657 
of  ankle-joint,  686 
anteroposterior,  686 
lateral,  686 
upward,  686 
of  astragalus,  687 

forward  or  backward,  687 
lateral  and  rotary,  687 
of  carpal  bones,  673 
of  clavicle,  660 

Rhoads's  apparatus  for,  662 
of  coccyx,  676 
of  elbow-joint,  670 
of  femur,  676 

AlUs's  sign  in,  678 

anomalous,  680 

central,  680 

internal,  680 

into  obturator  foramen,  679 

of    head,    with    fracture    of 

shaft,  681 
on  to  border  of  sciatic  notch, 

678 
upon  dorusm  of  ilium,  677 
upon  pubis,  679 
with   catching   up   of   sciatic 
nerve  during  reduction,  681 
of    fibula    at     superior     tibio- 
fibular articulation,  685 
of    hip-joint,     676.       See    also 
Dislocation,   Iraumaiic,    of  fe- 
mur. 


Dislocation,  traumatic,  of  humerus, 
663.     See  also  Humerus,  Irau- 
maiic dislocalion. 
of  knee,  682 
backward,  682 
forward,  682 
inward,  683 
outward,  683 
of  lower  jaw,  659 

Cooper's  treatment,  660 
Ndlaton's  treatment,  660 
Young's  treatment,  660 
of  mandible.  659 
of  metacarpal  bones,  674 
of  metacarpophalangeal  articu- 
lation, 674 
joint  of  thumb,  674 
of  metatarsal  bones,  688 
of  OS  magnum  backward,  674 
of  patella,  683 
edgewise,  684 
inward,  683 
outward,  683 
of  pelvis,  67s 
of  phalanges,  688 
of  phalanx,  675 
of  radius,  67 r,  672 

and  ulna,  670,  671 
of  ribs  and  costal  cartilages,  675 
of  scapula,  662 

of  semilunar  cartilages  of  knee- 
joint,  684 
of  shoulder-joint,  663.     See  also 
Humerus,    Iraumaiic    disloca- 
lion. 
of  sternum,  675 
of  tarsal  bones,  687 
of  ulna,  671 

and  radius,  670,  671 
of  wrist,  673 
old,  658 

pathological  conditions,  656 
subastragaloid,  687 
symptoms,  657 
treatment,  657 
Displacement  of  pancreas,  1057 

in  plastic  surgery,  1261 
Dissection-wounds,  295 
Diuretics  in  inflammation,  107 
Diver  goiter,  1231 

Diverticulitis,  intestinal,  acute,  1018 
Diverticulum,  intestinal,  1018 
Meckel's,  402,  971 
hernia  of,  1155,  1163 
intestinal  obstruction  from,  982 
of  esophagus,  939 
pharyngeal,  400 
Divulsion  in  rectal  stricture,  1187 

of  urethra  for  stricture,  1368 
Dorsal  abscess,  tuberculous,  241 

treatment  of,  246 
Dorsahs  pedis  artery,  ligation,  483 
Douche  in  inflammation,  loi 

Scotch,  in  inflammation,  101 
Dowd    and    McBurney's    fracture- 
hook,  531 
Dowd's   operation  for  undescended 

testicle,  1392 
Downe's  method  of  controlling  hem- 
orrhage, 449 
Doyen's  vasotribe,  440 
Drain,  capillary,  77 

cigarette,  77 
Drainage,  76 
Cathcart,  1332 

intracranif  1,  in  hydrocephalus,  778 
of  cisterna  magna,  832 
of  hepatic  duct,  11 28 
of  wounds,  267 
Drainage-tubes,  76 
Dressing  of  wounds,  267 
Dressings,  75 
change  of,  77 
fixed,  1260 

impermeable  material  over,  76 
Dressman's  treatment  of  bone-cavi- 
ties, 502 
Drip,  Matas's,  1127 

McArthur,  11 26 
Drop-finger,  739 
Dropsy,  618 
Drowning,  869 


Drumstick  bacterium,  23 
Dubois's  abscess,  1248 
Dufaux's  prostatic  masseur,  1375 
Dugas's  sign  in  dislocation  of  shoul- 

der-jomt,  665 
Dumdum  bullet,  288 
Dunham's  iodoform  emulsion,  31 

treatment  of  fractures  of  shaft  of 
femur  in  children,  598 
Duodenocholedochotomy,  1130 

for  gall-stones,  1054 

transduodenal  route,  1130 
Duodenostomy,  1105 

for  cancer,  960 
Duodenum,  peptic  ulcer  of,  994 

ulcer  of,  994 
Duplay's  treatment  of  ganglion,  724 
Dupuytren's   amputation   at   shoul- 
der-joint, 141 1 

aneurysm  needles,  469 

contraction,  737 

Keen's  operation  for,  738 
Lexer's  operation  for,  738 
McCurdy's  operation  for,  738 

fracture,  686 

splint  in  Pott's  fracture,  613 

suture,  1078 
Dura  mater,  hematoma  of,  799 
Duret's   operation   for  gastroptosis> 

1104 
Dysenteric  ulcer  of  rectum,  1185 
Dyspepsia,  adhesion-,  972 

appendiceal,  1013 


Ear  disease,  cerebral  abscess  from,. 
805 
suppurative,  brain  disease  from, 
804 
hemorrhage  from,  control,  454 
sign  in  erysipelas,  200 
syphilitic  affections,  326 
Eberth's  bacillus,  54 
Ecchondroses,  358 
Ecchymosis,  258 
Ecchymotic  mask,  8go 
Echinococcus  cysts,  402 
Ecthyma,  gangrenous,  164 

syphilitic,  325 
Ectopia  of  testis,  1392 

vesicK,  131S 
Eczema    compUcating    ulcer,    treat- 
ment, iss 
Eczematous  urethritis,  1344 
Edebohl's   method   of   nephrotomy, 
1293 
operation    for    chronic    nephritis^ 
1292 
for  movable  kidney,  1279 
Edema,  anthrax,  302 
gangrenous,  acute,  170 
in  fractures,  530 
malignant,  295 
bacillus  of,  54 
treatment  of,  296 
of  glottis,  879 
of  larynx,  879 
of  lungs  in  anesthesia,  treatment, 

1204 
of  spermatic  cord,  1400 
Edematous  erysipelas,  200 
granulations,  120 
ulcer,  159 
Edison's  fluoroscope,  1452 
Educated  corpuscle,  42 
Effusion,  pericardial,  operation  for, 
460 
pleuritic,  890 
purulent,  140 
Ehrlich's  theory  of  immunity,  40 
Elbow,  figure-of-8  bandage,  1258 
fractures  of,  561 
miners',  731 
Elbow-joint,  disarticulation  at,  1409 
disease,  633 
excision  of,  699 

fractures  in  or  near,  Allis's  treat- 
ment, 566 
false  ankylosis  after,  567 
in  young  children,    Berto- 
mier's  treatment,  567 
treatment,  566 


1488 


Index 


Elbow-joint,  fractures   in   or   near, 
Jones's  dressing  for,  566 
prognosis,  564 
treatment,  564 
true  ankylosis  after,  567 
traumatic  dislocation,  670 
tuberculosis  of,  633 
Electricity,  burns  from,  1474 

effects  of  artilicial  currents,  1473 

injuries  by,  1471 
Electrocution,  1475 
Electrode,  Cushing's,  829 
Electrohemostasis     in     hemorrhage, 

44Q 
Electrolysis  in  aneurysm,  430 
Elephantiasis,  1250 

Arabum,  1250 

of  leg,  1251 

of  scrotum,  1251 

spurious,  1 25 1 
Elevation  in  hemorrhage,  445 
Elsberg's    apparatus    for    intratra- 
cheal insulBation,  906 
Embohc  abscess,  142,  197 

aneurysm,  417 

gangrene,  164 
treatment,  165 

pneumonia,  septic,  igo 
Embolism,  188 

air-,  193 

fat-,  191 

treatment  of,  193 

of  mesenteric  arteries,  190 

intestinal    obstruction    from, 
,       983 

pulmonary,  190 
occluding,  899 

symptoms,  189 
Embolus,  188 

aseptic,  188 

bland,  188 

cancer,  389 

infectious,  188 

septic,  188 

simple,  188 

toxic,  188 
Embryoma  of  testicle,  1395 
Embryonic  tissue,  84 
Emergencies,  intra-abdominal,  diag- 
nosis of,  943 
Emetics  in  inflammation,  108 
Emotional  fever,  131 
Emphysema,  cellular,  5/].] 

gangrenous.  170,  295 
Emphysematous  gangrene,  163,  170 
Emprosthotonos,  207 
Empyema,  146,  891 

acute,  892 

Beck's  treatment,  894 

Bell's  treatment,  894 

chronic,  892 

closed,  892 

double,  892 

excision  of  rib  in,  707 

locab'zed.  892 

necessitatus,  892 

of  antrum  of  Highmore,  145 

of  gaD-bladder,  1041,  1044,  1052 
acute,  1045 
recurrent,  1045 
of  mastoid,  805 

open,  892 

partial,  892 

pulsating,  892 

Thiersch's  treatment,  893 

total,  892 

treatment  of,  893 
Encephalitis,  798,  800 

chronic.  801 
Encephalocele,  776 
Encephaloid  cancer,  393 
Enchondroma,  357 

of  brain.  810 

of  breast,  1429 
Endarteritis,  chronic,  414 
treatment  of,  415 

obliterative,  415 
End-bulb.  124 
Endemic  boil  of  tropics,  138,  1226 

goiter,  1 23 1 
Endo-aneurysmorrhaphy,     oblitera- 
tive, without  arterioplasty,  426 


Endo-aneurysmorrhaphy  with  com- 
plete arterioplasty,  426 
with  partial  arterioplasty,  426 
Endocarditis,  gonorrheal,  treatment 
of,  1364 
malignant.  198 
Endocardium,  tuberculosis  of,  249 
Endospore,  23 
Endothelial  cancer,  374 
Endothelioma,  374 
of  brain,  809 
of  breast,  1432 
Endoto.xins,  37 
Endotracheal  goiter,  1235 
Endspore,  23 
End-to-side   intestinal   anastomosis, 

1107 
English  catheter,  1314 
Enterectomy,  1105 
Enteritis,  rest  in,  95 
Enterocele,  1134 

partial,  1135,  1162 
Entero-epiplocele,  1134 
Enterohths,    intestinal     obstruction 

from,  981 
Enteroperitoneal  tuberculosis,  999 
Enteroptosis,  1020 
Enterorrhaphy,  1077 

circular,  1105 
Enterostenosis,   977.      See   also   In- 
testinal obstruction. 
Enterostomy,  11 20 

Stewart's  method,  992 
Enucleation  in  goiter,  1235 

of  thyroid  gland,  1240 
Enzymes,  36 

Eosin-selenium  in  cancer,  39s 
Epidemic  goiter,  1231 
Epidermization,  120 
Epididymectomy  in  tuberculosis  of 

testicle,  1395 
Epididymis,  encysted  hydrocele  of, 

1400 
Epididymitis,  1397 
compression  in,  100 
in  gonorrhea,  1347 
treatment,  1356 
pain  in,  89 
Epigastric  hernia,  1160 
Epiglottis,  burns  and  scalds,  315 
closure    of,    in    anesthesia,    treat- 
ment, 1204 
Epilepsy,  essential,  operative  treat- 
ment, 821 
focal,  operative  treatment,  822 
following  infantile  cerebral  palsy, 

operative  treatment,  823 
idiopathic,    operative    treatment, 
821 
with    local    onset    of    attacks, 
operative  treatment,  822 
Jacksonian,  814 

due  to  gross  brain  disease,  opera- 
tive treatment,  823 
operative  treatment,  822 
operative  treatment,  820 
pleural,  909 

posthemiplegic,   of  adults,  opera- 
tive treatment,  823 
reflex,  operative  treatment,  821 
traumatic,    operative    treatment. 
.  822 
Epileptic  insanity,   operative  treat- 
ment, 824 
Epiphyseal  separation,  517 
Epiphysitis,  acute,  504 
Epiplocele,  1134 
Epiploic  abscess,  957 
Epiplopexy,  11 18 
Epispadias,   1371 
Epistaxis,  control  of,  453 
Epithehal  cystoma,  traumatic,  396 
cysts,  traumatic,  398 
odontomes,  361 
tumors,  malignant,  381 
Epithelioid  cells,  214 
Epithehoma,  159,  391 
cylindrical-celled,  391 
exedens,  392 
of  nipple,  1427 

of  tongue,  927.    See  also  Cancer  of 
tongue. 


Epithelioma,  radium  in,  1470 
squamous-celled,  391 
*-rays  in,  1467 
Epsom  salts,  saturated  watery  solu- 
tion, in  inflammation,  loo 
solution  of,  for  spinal  analgesia, 
1226 
EpuUdes,  fibrous,  354 
Epulis,  fibrous,  355 
Equinia,  307 
Erasion,  696,  697 

of  knee-joint,  697 
Erb's  sign  in  tetany,  1246 
Erectile  tumors,  365 
Erector  spinae  muscle,  strain  of,  851 
Erethistic  shock,  261 
Ergot  in  pulmonary  hemorrhage,  456 
Ergotism,  gangrene  from,  176 
Erichsen's    signs    in    dislocation    of 
shoulder-joint,  665 
suture  for  nevus,  367 
Erysipelas,  199 
ambulant,  199 
bullous,  199 
ceUulocutaneous,  202 
cHnical  forms,  200 
compression  in,  100 
cutaneous,  199,  200 
diffused,  199 
ear  sign,  200 
edematous,  200 
effect  of,  on  sarcoma,  377 
erj'thematous,  199 
faucial,  200 
forms,  199 
idiopathic,  199 

law  of  centrifugal  maximum,  200 
lymphatic,  200 
metastatic,  199 
migratory,  199 
mucous,  200 
neonatorum,  199,  200 
phlegmonous,  200,  202 
puerperal,  199 
serum  in  sarcoma,  378 
simplex,  199 
streptococcus  of,  50 
typhoid,  200 
venous,  200 
wandering.  199 
Erysipele  .salutaire.  200 
Erysipeloid,  198,  1249 
Erythema  serpens,  198 

syphihtic,  323 
Erythromelagia    in    presenile    spon- 
taneous gangrene,  166 
Escherich's  bacillus.  53 
Esmarch's  cooUng  coil,  99 
elastic  bandage,  1402 
splint.  700.  702 
tourniquet.  1418 
Esophageal  bougies,  930 
forceps,  942 
instruments,  942 
sounds.  930,  942 
Esophagismus,  938 
Esophagoplication    in    cardiospasm, 

939 
Esophagoscope,  931 
Esophagoscopy,  888 

MikuKcz's  instruments  for,  931 
Esophagostomy,  cer\ical,   for  stric- 
ture, 937 
Esophagotomy,  external,  for  foreign 
bodies,  943 
in  stricture,  935 
Esophagus,  bums  and  scalds,  940 
bums  of.  315 
cancer  of,  937 

treatment,  394,  938 
diverticula  of,  939 
examination  of,  930 

a;-rays  for,  930 
foreign  bodies  in,  941 
injuries  and  diseases,  912 
from  within,  940 
from  without,  940 
stricture  of.  932.    See  also  5/ric/Mre 

of  esophagus. 
wounds  of,  940 
Essential  epilepsy,  operative  treat- 
ment, 821 


Index 


1489 


Essential  hematuria.  1268 
Estlander's  method  of  thoracoplasty, 

gio 
Ether,  administration  of,  irgS 
drop  method,  1198 
and  chloroform  anesthesia,  1209 
and  oxj-gen  anesthesia,  11 99 
anesthesia.  1195.  1201 

followed  by  chloroform.  1213 
inhaler.  Allis's.  119S 
Clover's,  119S 
Etherization,  intravenous,  1201 

rectal,  1200 
Ether-pneumonia.  1206 
Ether-spray  anesthesia.  1216 
Ethyl  bromid  anesthesia.  1209 
chlorid  anesthesia.  1210 

for  freezing  anesthesia,  1216 
Eucain     hydrochlorate     anesthesia, 

I2l8 

Euphoren,  32 

Eventration  of  diaphragm.  1164 

Ewald's    method    of    testing    motor 

power  of  stomach.  974 
Excision  in  gunshot-wounds.  2S2 
of  ankle-joint.  704 

Hancock's  method.  704 
of  astragalus.  705 
of  bones.  696 
of  clavicle.  706 
of  elbow-joint.  699 
of  half  of  lower  jaw,  708 

of  upper  jaw,  707 
of  head  of  radius.  700 
of  hip-joint,  702 

Barker's  method.  702 
by  anterior  incision.  702 
by  lateral  incision.  703 
Gross's  method,  703 
Langenbeck's  method,  703 
of  joints.  696 
of  knee-joint,  703 

Ashhurst's  method,  703 
by  anterior  semilunar  flap,  703 
of  lower  jaw,  partial,  709 

Stillman's  operation  to  pre- 
vent   contraction    after, 
709 
of  metacarpal  bones,  702 
of  metatarsal  bone  of  great  toe,  706 

Butcher's  method.  706 
of    metatarsophalangeal    articula- 
tion of  great  toe,  706 
of  OS  calcis.  705 

by  subperiosteal  method,  705 
of  phalanges.  702 
of  pylorus,  1082 
of  rib,  707 
in  caries,  707 
in  empyema,  707 
of  scapula,  706 

Syme's  method,  706 
Treves's  method,  706 
of  shoulder-joint.  697 
by  anterior  incision.  698 
by  deltoid  flap,  698 
Senn's  method,  698 
of  testicle,  1396 
of  wrist-joint.  700 
Lister's  method,  700 
radial  incision,  700 
ulnar  incision,  701 
Esfob'ation,  500 

Exhaustion  theory  of  immunity.  38 
Exophthalmic  goiter,  1231.  1235 
exophthalmus  in,  1237 
ligation  of  thyroid  arteries  in, 

1243 
Moebius's  sign  in,  1237 
operation  for,  1243 
partial  thyroidectomy  in,  1239 
SteUwag's  sign  in,  1237 
tachycardia  in,  1237 
thyroidectin  in.  1238 
thyroidectomy  in.  1243 
treatment.  1238 
von  Graefe's  sign  in,  1237 
r-rays  in,  1468 
Exophthalmus  in  exophthalmic  goi- 
ter, 1237 
Exostosis,  359 
multiple.  360 

94 


Exostosis,  subungual.  359 
Exothymopex>-,  1248 
Exothyrope.xy,  1235 
Expectoration,  albuminous,  907 
Experimental  tetany,  1244 
Explosive  bullets.  28S 
Expression  in  pain.  90 
Exstrophy  of  bladder.  1313 
Extensor  tendon,  rupture  of,  739 
Extirpation,   e.xtracapsular,   of   thy- 
roid gland,  1240 
in  goiter,  1235 
intracapsular,    of    thyroid    gland, 

1242 
of  sac  in  treatment  of  aneurysm, 
424 
Extracellular  toxins.  37 
Extradural  abscess.  80s 

hemorrhage,  control.  452 
Extravasation.  25S 
Exuberant  granulations.  120 
Exudation  of  fluids  in  inflammation. 
Si 
plastic,  82 
Eyes,  crossed  bandage.  1256 
figure-of-S  bandage,  1236 
foreign  bodies  in.  Sweet's  appara- 
tus for  locating,  1464,  1465 
inflammation  of,  pain  in.  89 

rest  in,  95 
symptoms  in  hereditary  syphilis, 

344 
s\'philitic  affections,  326 


F.iBRiciTJs's    operadon   for  femoral 

hernia,  1150 
Face,  Hippocratic,  in  intestinal  ob- 
struction. 9S4.  983 

injuries  and  diseases,  912 
Facial  arterj',  ligation.  482 

paralysis,  operation  for,  768 
Facio-accessory  anastomosis,  768 
Faciohypoglossal  anastomosis,  768 
Facultative-anaerobic  bacterium,  24 
Fallopian  tubes,  inflammation,  pain 
in,  89 
tuberculosis,  232 
False  joint  in  fractures,  527 

neuroma,  364 
Farcy,  307 

acute.  308 

chronic.  308 

diagnosis,  308 
Farcy-buds,  308 
Fascia,  Abemethy's,  489 

plantar,  subcutaneous  fasciotomy 
of.  733 

tuberculosis  of,  249 
Fasciotomy,  subcutaneous,  of  plan- 
tar fascia,  733 
Fat-embolism,  191 

treatment,  193 
Fat-hemia,  353,  1134 
Fat-necrosis  of  pancreas,  1057 
Faucial  er\"sipelas.  200 
Fauntleroy's  tubes,  465 

vein-to-vein  anastomosis  for  trans- 
fusion of  blood.  464 
Fear  as  cause  of  shock.  260 
Fecal  abscess,  142 

accumulation,   intestinal   obstruc- 
tion from.  9S3 

concretions,     intestinal     obstruc- 
tion from,  981 

fistula.  993 

Senn's  operation  for,  11 20 

impaction,  treatment.  1314 

incontinence    after    operation   for 
fistula  in  ano.  treatment,  11 76 

vomiting  in  strangulated  hernia, 
1154 
Fehleisen's  coccus.  50 
FeU-0'Dwyer  apparatus.  896 
Felon.  146.  724 

bone.  725 

deep.  725 

elevation  in.  95 

painless.  724 

superficial,  724 

White's  treatment,  725 


Femoral  artery,  compression  ol,  447 
ligation,  487,  488 

condyles,     amputation     through, 
14.17 

hernia.     See  Hernia,  femoral. 

vein,    hemorrhage    from,    control, 
452 
Femur,  chronic  osteomyelitis,  508 

fractures  of,  582.     See  also  Frac- 
tures of  femur. 

incurvation  of  neck,  745 

infraction  of  neck,  745 

internal  dislocation,  549 

osteoma  of,  358 

osteotomy    of    shaft    below    tro- 
chanters, 6go 
Gant's  operation,  690 
through  neck,  690 

Adams's  operation,  690 
with  osteotome,  690 

sarcoma  of,  374 

traumatic   dislocation,    676.      See 
also    Dislocation,    traumatic,    of 
femur. 
Ferguson's    operation    for    inguinal 

hernia,  1146 
Fergusson's     operation     for     cleft- 
palate,  922 
for  varix  of  leg,  462 
Ferments,  bacterial,  36 
Fetal  rests.  347 
Fetus,  parasitic,  398 

suppressed,  398 
Fever,  92 

aseptic,  117 

due  to  awakening  of  area  of  pul- 
monary tuberculosis,  130 

emotional,  131 

hectic,  130.  143 

hepatic.  131 

hysterical.  131 

inflammatory.  92 

mercurial,  130 

neurotic,  131 

of  cocain-poisoning.  131 

of  iodoform  absorption,  130 

of  malignant  disease,  132 

of  morphinism,  131 

of  ptyalism.  130 

of  tension,  130 

splenic,  300 

suppurative,  130 

surgical.  128.  194 

essential  phenomena.  129 
genuine.  130 

symptomatic,  92 

syphilitic.  322 

traumatic.  129 

typhoid,  dislocation  of  hip  in,  6s5 
thrombosis  in,  188 
Fibrinoplastic  peritonitis.  1028 
Fibro-adenoma,  3S1 

of  breast,  1428 
Fibroblasts.  116,  117 

of  inflammation.  84 
Fibrocystadenoma  of  breast,  1429 
Fibrofatty  tumor.  352 
Fibroid  tumor,  recurrent,  373 

uterine.  362 
Fibroma,  354 

cellular.  355 

cystic,  of  breast,  1430 

hard.  354 

nasopharjTigeal.  354 

of  brain,  810 

of  breast.  1428 

soft.  354 

treatment  of.  357 
Fibromatosis  of  colon.  101 8 

of  stomach.  957,  965 
Fibromyoma  of  breast.  1428 
Fibrosarcoma,  372.  373 
Fibrosis,  arteriocapillary,  414 
Fibrospindle-cell  sarcoma,  372 
Fibrous  epulides,  354 

epulis.  3SS 

goiter.  1 23 1 

odontome,  361 

tissue.  119 

tubercle,  215 
Fibula,  fractures  of,  610.     See  aiaa 
Fractures  of  fibula. 


I490 


Index 


Fibula,  sarcoma  of,  376 

traumatic  dislocation,  at  superior 
tibiofibular  articulation,  685 
Fifth  nerve,  neuralgia  of,  762.     See 

also  Neuralgia  of  fifth  nerve. 
Figure-of-8  bandage,  1253.    See  also 

Bandage,  figure-oj-H. 
Filamentous  fungi,  19 
Filaria  sanguinis  hominis,  368 
Filarial  worms,  1250 
Fingers,  amputation  of,  1406 
drop-,  739 
jerk-,  739 
lock-,  739 
mallet-,  739 
snapping-,  739 
spiral  bandage,  1254 
trigger-,  739 
webbed,  738 
Finney's  method  of  gastroduodenos- 
tomy,  1081 
in  cicatricial  stenosis,  970 
Finsen  light,  1468 

in  tuberculosis,  235 
First  intention,  healing  by,  116 
First-aid   package   in   warfare,    293, 

294 
Fish  stings,  297 
Fish-mouth    meatus    in    gonorrhea, 

1346 
Fiske's  plan  for  detecting  effusion  in 

knee,  617 
Fission,  bacteria  in,  22 

fungi,  23 
Fissure,  intraparietal,  771 
of  anus,  1177 
of  Bichat,  769 
of  bone,  514 
of  breast,  1423 

prevention,  1424 
of  Rolando,  769 
of  Sylvius,  770 
Fistula,  162 
accidental,  993 
biliary,     after     cholecystostomy, 

1126 
branchial,  399 
complete,  399 
incomplete,  400 
cervical,  complete  congenital,  400 
median,  927 
congenital  lateral,  400 
incomplete  median,  927 
fecal,  993 

Senn's  operation  for,  11 20 
horseshoe,  1174 
in  ano,  11 73 

fecal  incontinence  after  opera- 
tion for,  treatment,  11 76 
tuberculous,  248 
in    tuberculous    arthritis.    Beck's 

treatment,  623 
intentional,  993 
of  Steno's  duct,  914 
pancreatic,  1056 
perineal,   in  stricture  of  urethra, 

treatment,  1368 
pleural,  892,  893 
salivary,  914 

De  Guise's  operation  for,  914 
Flagella,  20 
Flail-joints,  747 
Flat  condyloma,  324 
Flat-foot,  742 

Gleich's  treatment,  744 
Golding-Bird  and  Davy's  opera- 
tion for,  744 
Goldthwait's  operation  for,  742 
inflammatory,  742 
Miiller's  treatment,  744 
Ogston's  operation  for,  744 
paralytic,  742 
Rugh's  operation  for,  744 
Stokes's  operation  for,  744 
spurious,  742 
Whitman's  plate  in,  743 
Wilson's  correction  screw  for,  743 
Flea,  sand,  bites  of,  297 
Flesh,  proud,  120 
Fleshy  polyps,  363 
Floating  cartilages,  654 
kidney,  1275 


Floating  liver,  1039 

patella,  617 
Floss  silk,  73 
Fluhrer's  probe,  280 
Fluoroscope,  1448,  1452 
Edison's,  1452 
in  locating  bullet,  281 
Focal  epilepsy,  operative  treatment, 

822 
Foerster-Mingazzini     operation     in 

tabes,  862 
Follicular  abscess,  142 
Folliculitis  in  gonorrhea,  1347 

treatment,  1356 
Fomentations  in  inflammation,  102 
Foot,  American  bandage,  1255 
amputation  of.  141 1 
bandage  of,  covering  heel,  1255 

not  covering  heel,  1255 
club-,  740.    See  also  Talipes. 
diabetic   gangrene   of,   treatment. 

17s 
flat-,  742 
fractures  of,  615 
French  bandage,  1255 
hollow,  744 
Madura-,  19 

spiral  bandage,  covering  heel,  1255 
Foramen   of  Winslow,   hernia   into, 

1162 
Forbes's  amputation,  1414 

lithotrite,  1334 
Forceps,  bone-holding,  536 
Buerger's,  1304 
bullet-,  281 
esophageal,  942 
Halsted's,  438 
hemostatic,  438 

Hudson's  modified  De  Vilbiss,  827 
Laplace's,  for  intestinal  anastomo- 
sis, 1112 
lateral     intestinal    anastomosis 
with,  1 1 16 
O'Hara's,  for  intestinal  anastomo- 
sis, 1112 
Thompson's  vesical,  1338 
Ford's  suture,  270,  1079 

treatment  of  acute  arteritis,  414 
Forearm,  amputation  of,  1408 
and  hand,  sterilization  of,  63 
Fiirbringer's  method,  63 
mechanical,  62 

sublimate-alcohol  method,  64 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 
Foreign  bodies  in  abdomen,  944 
in  air-passages,  880 
in  bladder,  1320 
in  bronchus,  881 
in  esophagus,  941 
in   eye.    Sweet's   apparatus   for 

locating,  1464,  1465 
in  intestines,  956 
in  larynx,  880 
in  nose,  877 
in  pharynx,  880 
in  rectum,  11 71 
in  stomach,  956 
in  trachea,  880 
in  urethra,  1342 
in  wounds,  removal,  266 
intestinal  obstruction  from,  981 
a;-rays  in  localizing,  1461 
Foreign-body  appendicitis,  1004 
Formaldehyd,  a 
Formalin,  33 

method  of  preparing  catgut,  72 
Formalin-gelatin,  33 
Formalin-glycerin  in  acute  synovitis, 
618 
in  elbow-joint  disease,  633 
in  gonorrheal  arthritis,  638 
in  infective  arthritis,  635 
in  knee-joint  disease,  632 
in  pyogenic  arthritis,  63s 
in  shoulder-joint  disease,  633 
in  tuberculosis  of  hip-joint,  630 
in  tuberculous  arthritis,  622 
in  wrist-joint  disease,  634 
Formic  aldehyd,  33 
Fossa,  intersigmoid,  hernia  into,  1162 
retrocecal,  hernia  into,  1162 


Fossa,   retrodudodenal,  hernia  into, 

1162 
Foudroyant  gangrene,  170 
Fourth  of  July  tetanus,  204,  277 
Fowler's    method    of    gastro-enter- 
ostomy,  1097 

of  pulmonary  decortication,  911 
operation  for  inguinal  hernia,  1146 
position  in  peritonitis,  1025 
Fox's  apparatus  for  fracture  of  clav- 
icle, 552 
Fractura  acetabuli  perforans,  680 

perforata,  680 
Fracture-box,  611 
Fracture-dislocation  of  spine,  852 

treatment,  856 
Fracture-hook    of     McBurney    and 

Dowd,  531 
Fractures,  513 

ambulatory  treatment,  529 

Barton's,  575 

bending  of  callus,  526 

Bennett's,  580 

bent,  514 

blebs  in,  530 

by  contrecoup,  517 

capillary,  514 

causes,  518 

CoUes's,  57S 

Bond's  splint  in,  578 

Levis's  treatment,  577 

Maisonneuve's  symptom  in,  577 

Moore's  treatment,  578 

Pilcher's  treatment,  578 

reversed  deformity  in,  577 

Roberts's  splint  in,  578 

Storp's  treatment,  578 
comminuted,  515,  516 
complete,  514 
complicated,  514 
compUcations,  523 

prevention  and  treatment,  532 
composite,  516 
compound,  513 

of  patella,  treatment,  533 

primary,  513 

repair  of,  525 

secondary,  514 

treatment  of,  531 
compression  in,  100 
consequences,  523 
crepitus  in,  521 
cuneated,  515 
cuneiform,  515 
definition,  513 
delayed  union,  525 
treatment,  534 
dentate,  515 
depression-,  514 

designation  according  to  seat,  517 
diagnosis,  522 

by  a-ray,  523 
direct,  S17 

dislocations  occurring  with,  S3i 
Dupuytren's,  686 
edema  in,  530 
en  coin,  515 
en  rave,  515 
en  V,  515 
extracapsular,  518 
extravasation  of  blood,  520 
false  joint  in,  527 
faulty  union,  526 
fibrous  union,  527 
fissured,  514 

from  muscular  action,  518 
from  violence,  direct,  518 

indirect,  51S 
functional  result  of  non-operative 

treatment,  531 
Gosselin's,  515 
green-stick,  514 
gutter-,  of  skull,  796 
hair,  514 
helicoid,  517 
hickory-stick,  514 
impacted,  516 
incomplete,  514 
indirect,  517 
inflammation  in,  531 
intra-articular,  517 
intracapsular,  517 


Index 


1491 


Fractures,  intra-uterine,  517 
ligamentous  union,  5J7 
linear,  514 
longitudinal,  515 
loss  of  function,  520 
massage  in,  52g 
membranous  union,  527 
multiple,  516 
muscular  spasm  in,  531 
non-operative     treatment,     func- 
tional result,  531 
non-union,  527 
oblique,  515 

spiroide,  515 
of  acetabulum,  of  brim,  586 

of  fundus,  586 
of  acromion  process,  554 
of  astragalus,  6is 
of  bones  of  tarsus,  615,  616 
of  both  bones  of  leg,  614 

compound,  615 
of  brim  of  acetabulum,  586 
of  calcaneum,  615 
of  carpal  scaphoid,  580 
of  carpus,  570 
of  clavicle,  550 

of  acromial  end,  552 
Fox's  apparatus,  552 
Moore's  dressing,  552 
of  shaft,  550 
of  sternal  end,  553 
Sayre's  dressing,  552 
Velpeau's  bandage,  552 
of  coccyx,  549 
of  coracoid  process,  554 
of  costal  cartilages,  545 

Malgaigne's  treatment,  545 
of  cuboid,  615 
of  cuneiform  bones,  615 
of  elbow,  561 
of  false  pelvis,  547 
of  femur,  582 

examination  of  hip  in,  582 
extracapsular,  590 
impacted,  590 
Southam's  treatment,  590 
Hodgen's  splint  for,  596,  597 
intracapsular,  582 
AUis's  sign  in-,  584 
Buck's  apparatus  in,  586 
Desault's  sign  in,  584 
diagnosis  of,  585 
Jones's  treatment,  589 
Lagoria's  sign  in,  584 
Morris's  measurement  in,  584 
prognosis  of,  586 
Senn's  treatment,  588 
symptoms  of,  583 
Thomas's  splint  in,  589 
treatment  of,  586 
Whitman's  treatment,  589 
just  above  condyles,  601 
longitudinal,  601 
Mclntyre's  splint  in,  597 
near  knee-joint,  S97 
of  base  of  neck,  590 
of  lower  part  of  lower  third,  597 
of  middle  third,  596 
of  neck,  in  children,  590 
operative  treatment,  592 
ununited     Freeman's    opera- 
tion for,  693 
operative  treatment,  693 
of  shaft,  593 
in  children,  597 

Bryant's  extension  in,  597, 

598 
Dunham's  treatment,  598 
Jones's  abduction  frame  in, 

598 
Van  Arsdale's  splint  in,  598 
Ware's  splint  in,  S99,  600 
Wyeth's  dressing  in,  599 
of  upper  extremity,  582 
part  of  lower  third,  596 
third,  595 

Agnew's  treatment,  595 
Smith's  splint  in,  595,  596 
separating  either  condyle,  601 
separation    of   lower   epiphysis, 
601 
of  upper  epiphysis,  592 


Fractures  of  fibula,  610 
of  lower  third,  611 
of  upper  two-thirds,  611 
of  foot,  61S 

of  fundus  of  acetabulum,  586 
of  glenoid  cavity,  553 
of  great  trochanter,  593 
of  humerus,  554 

above  condyles,  563 
at  anatomical  neck,  554 
Albee's  treatment,  555 
Scudder's  bandage  in,  556 
at  base  of  condyles,  562 
at  external  condyle,  561 
at  head,  557 
at  inner  epicondyle,  561 
at  internal  condyle,  562 
at  lower  extremity,  561 

Gerster's  method  of  reduc- 
ing swelling,  561 
at  shaft,  558 

injury  of  musculospiral  nerve 

in,  559 
Scudder's  bandage  in,  560 
at  surgical  neck,  556 
at  upper  extremity,  554 
carrying  angle  in,  561,  562 
gunstock  deformity  in,  562 
in  or  near  elbow-joint,  564.    See 
also  Elbow-joint,  fractures  in 
or  near. 
intracapsular,  554 
linear,  558 

separation   at   lower   epiphysis, 
567 
at  upper  epiphysis,  558 
supracondylar,  563 
T-fractures,  562 
of  hyoid  bone,  542 
of  inferior  maxillary  bone,  541 
of  inner  malleolus,  610 
of  lachrymal  bone,  538 
of  laryngeal  cartilages,  543 
of  leg,  609 
of  malar  bone,  540 
of  metacarpal  bones,  580 
Russ's  splint  in,  581 
of  metatarsal  bones,  616 
of  nasal  bones,  536 
Asch  tube  in,  537 
Jones's  splint  in,  538 
Mason's  pin  in,  537 
of  OS  calcis,  615 
of  patella,  601,  602 
by  direct  force,  608 
compound,  608 
transverse,  602 

Agnew's  splint  in,  604 
Barker's  operation  in,  60s 
treatment  of,  604 
wiring  in,  605 
ununited  and  badly  united,  608 
operative  treatment,  694 
of  pelvis,  547 
of  penis,  1374 
of  phalanges,  581 

of  toes,  616 
of  radius,  571 

and  ulna  near  wrist,  579 

of  both  forearms,  574 

of  head,  571 

of  lower  extremity,  575 

of  neck,  572 

of  shaft,  573 

above   insertion   of   pronator 

radii  teres  muscle,  573 
below    insertion    of    pronator 
radii  teres  muscle,  574 
separation  of  lower  radial  epiph- 
ysis, S79 
of  ribs,  543 
of  sacrum,  549 
of  scaphoid,  615 
of  scapula,  553 
of  body,  553 
of  neck,  553 
of  spine,  553 
of  skull,  789 

by  contrecoup,  789 
of  base.  789,  791 

Battle's  sign  in,  792 
of  vault,  789 


Fractures    of  skull,   trephining   for, 
826 
of  spine,  852 
of  sternum,  546 

of  superior  maxillary  bone,  538 
of  tibia,  609 

of  lower  end,  610 
of  shaft,  610 
of  upper  end,  609 
separation   of   lower   epiphysis, 
610 
of  tubercle,  609 
of  upper  epiphysis,  610 
of  true  pelvis,  547 

Wood's  rule  in,  548 
of  ulna,  567 

and  radius  near  wrist,  579 
of  coronoid  process,  567 
of  olecranon  process,  568 

Murphy's     operation     for, 

569,  570 
Pick's  treatment,  569 
of  shaft,  570 
of  styloid  process,  571 
of  zygomatic  arch,  540 

Matas's  operation  for,  541 
par  irradiation,  517 
pathological,  516 
Pott's,     612.       See     also     Pott's 

fracture. 
preternatural  mobility,  521 
pseudo-arthrosis  in,  527 
radish-,  515 
recent,  operative  treatment,  533 

simple  operation  for,  692 
repair,  523 
rest  in,  94 
rupture  in,  531 
secondary,  516 
simple,  513 

recent,  operation  for,  692 
repair  of,  523 
special,  536 
spiral,  517 
sphnter-,  515 
spontaneous,  516 
sprain-,  515 
starred,  517 
stellate,  517 
strain-,  515 
symptoms,  519 
toothed,  515 
torsion,  517 
transverse,  515 
treatment,  527 
T-shaped.  515 
ununited,  516 

Delorme's  treatment,  536 
Lannelongue      and      Menard's 

treatment,  535 
of     femoral     neck.     Freeman's 
treatment,  693 

operative  treatment,  693 
operative  treatment,  692 
Senn's  treatment,  693 

treatment  of,  534 
varieties,  513 

of  displacement,  521 
vicious  union,  526 

osteotomy  for,  691 
treatment,  536 
V-shaped,  515 
wedge-shaped,  515 
willow,  514 

with  crushing  or  penetration,  516 
Fragilitas  ossium.  519 
Fragility,  hereditary,  519 
Frankel's  bacillus,  53 
Frank's   coupler,    intestinal   anasto- 
mosis with,  1109 
method  of  examination  in  movable 
kidney,  1277 
Frazier    and    Mill's    operation    for 

paralysis  of  bladder,  1320 
Frazier's  treatment  for  avulsion  of 

brachial  plexus,  751 
Frazier-Spiller    operation    of    intra- 
cranial neurotomy,  767 
Freeman's  clamp,  693 

treatment  of  ununited  fractures  of 
femoral  neck,  693 
Freezing  for  anesthesia,  1216 


1492 


Index 


Freezing-point  of  blood,  1273 

of  urine,  1273 
Fremitus,  hydatid,  403 
French  bandage  of  foot,  1255 

catheter,  1313 
Freudenberg's  instrument  for  pros- 

tatotomy      by      galvanocautery. 

Young's  modification,  1387 
Freyer's  method  of  suprapubic  pros- 
tatectomy, 1384 
Friedreich's  operation  in  pulmonary 

tuberculosis,  Q04 
Frontal    sinus,    distention    and    ab- 
scess, 878 
trephining,  828 
Frost-bite,  177,  315 

gangrene  from,  177 
Fulguration  in  cancer,  394 
Fuller's  method  of  milking  seminal 
ducts,  1375 
of    suprapubic    prostatectomy, 
1385 
Fulminating  appendicitis,  1005 

gangrene,  170 
Fungous  ulcer,  157 
Fungus  as  cause  of  skin  diseases,  19 

budding,  18 

cerebri,  798 

filamentous,  19 

fission,  23 

of  testicle,  252 

ray,  19,  309 
Funicular  hydrocele,  r4oo 

process,  hernia  into,  1159 
Fiirbringer's  method  of  sterilization 

of  hands  and  forearms,  63 
Furuncle,  137.     See  also  Boil. 
Furunculosis,  138 


Gaxactocele,  401,  1430 
Galeazzi's  treatment  of  coxa  valga, 

747 
Gallant's  corset  for  movable  kidney, 

1278 
Gall-bladder,  1032 

cancer  of,  1054 

catarrhal  inflammation,   1042 

congenital  absence,  11 23 

croupous  inflammation,  1043 

empyema  of,  1041,  1044,  1052 
acute,  1045 
recurrent,  1045 

healthy,  11 23 

hydrops  of,  1041,  1052 

incision  for  operations  on,  1123 

inflammation  of,  1041 

rupture  of,  952 

suppurative  catarrh,  1044 
inflammation,  1043 
Gall-stones,  1048 

ball-valve,  1051 

colic  in,  1050 

Courvoisier's  law  in,  1052 

Hamel's  test  for  jaundice  in,  1051 

intestinal  obstruction  from,  981 

prodromal  state,  1049 

symptoms,  1049 

treatment,  1053 
Gait's  trephine,  826 
Gamma-rays,  1469 
Ganglion,  723 

compound,  722 

Gasserian,  removal  of,  765 

Cushing's  method,  767 

Hartley's  method,  766 

Horsley's  method,  767 

Gangrene,  163 

acute,  169 
microbic,  170 

amputation  for,  rules,  183 

anemic,  164 

carbolic  acid,  182 

chronic.   166 

classification,  163 

cold,  164 

congenital,  163 

constitutional,  163 

cutaneous,  163 

decubital,  164,  180 

diabetic,  164,  174 

of  foot,  treatment,  175 


Gangrene,   diabetic,    treatment    of, 

17s,  176 
dry,  163,  164 
embolic,  164 

treatment  of,  165 
emphysematous,  163,  170 
for  ergotism,  176 
foudroyant.  170 
from  frost-bite,  177 
from  3c-rays,  1451 
fulminating,  170 
gaseous,  163 
glycemic,  164 
hospital,  164,  171 

treatment  of,  172 
hot,  164 
idiopathic,  164 

symmetrical,   164 
line  of  demarcation,  164,  167 
microbic,  163 

acute,  170 
mixed,  164 
moist,  163,  169 

from  inflammation,  170 

of  leg,  169 

treatment  of,  170 
Moskowicz's     method    of    deter- 
mining viable  area  in,  168 
multiple,  164 

cachectic,  164 
of  leg,  arteriovenous  anastomosis 

for  prevention  or  treatment,  183 
of  lung,  901 

pneumotomy  for,  912 
of  penis,  1374 
postfebrile,  183 
Pott's,  166 

presenile  spontaneous,  165 
pressure,  164 
primary,  164 
purpuric.  164 
Raynaud's,  164,  173 

treatment  of,  174 
scorbutic,  164 
secondary,  164 
senile,  166 

Moskowicz's   method  of  deter- 
mining viable  area  in,  168 

prevention   of,    in   predisposed, 
168 

symptoms  of,  167 

treatment  of,  168 
static.  164 
symmetrical,  172 
thrombotic,  164 

treatment  of,  165 
traumatic  spreading,  170 
trophic,  164 
venous,  164 

white,  from  ac-rays,  1451 
Gangrenous  appendicitis,  1005 
celluhtis,  202 
ecthyma,  164 
edema,  acute,  170 
emphysema,  170,  295 
induration  of  neck,  181 
inflammation,  87 
masses,  179 
Gant's  osteotomy  of  shaft  of  femur 

below  trochanters,  690 
Garceau's  ureteral  catheter,  1303 
Garel's  sign  in  abscess  of  antrum  of 

Highmore,  145 
Gas,  coal-,  poisoning  from,  874 

illuminating,  poisoning  from,  874 
Gaseous  gangrene,  163 

phlegmon,  170 
Gasolene,  commercial,  33 
Gasserian  ganglion,  removal,  765 
Cushing's  method,  767 
Hartley's  method,  766 
Horsley's  method,  767 
Gastrectomy,  complete,  for  cancer. 

960 
partial,  for  cancer,  960 
subtotal,  for  cancer,  960 
total,  io8s 

for  cancer,  960 
Gastro-anastomosis,  1102 
Watson's  method,  1102 
Wolfler's  method,  1102 
Gastroduodenostomy,  Finney's,  1081 


Gastroduodenostomy    in    cicatricial 

stenosis,  970 

Jaboulay's,  1096 
Gastro-enterostomy,  1088 

anterior,  1093 

Kocher's  method,  1094 
Mayo's  method,  1093 
Senn's  method,  1093 

BiUroth's  method,  1091 

Braun's  method,  1092 

by  Murphy  button,  1096 

complications  after,  1089 

for  cancer,  961 

Fowler's  method,  1097 

Jaboulay's  method,  1092 

Liicke's  method,  1091 

Mayo's  method,  iioi 

McGraw's  method,  1095 

Moynihan's  method,  1099 

peptic  ulcer  of  jejunum  after,  1089 

posterior,  1096 

treatment  after,  1089 

vicious    circle    and    regurgitation 
after,  1090 

vomiting  after,  1089,  1091 
treatment,  1092 

von  Hacker's  method,  1092 

with  entero-anastomosis,  1092 

'Wolfler-Liicke  method,  1091 

Wolfler's  method,  1091 
Gastrogastrostomy,  1102 
Gastrojejunostomy,  1088 
Gastropexy,  1104 
Gastroplication,  1103 

Bircher's  method,  IT03 

Brandt's  method,  1103 
Gastroptosis,  976 

Beyea's  operation  for,  1104 

Buret's  operation  for,  1104 

Ransohoff's  omentopexy  for,  1104 
Gastrorrhagia  in  ulcer  of  stomach, 

operation  for,  968 
Gastrostomy,  1086 

for  cancer,  960 

Kader's  method,  1087 

Senn's  method.  1088 

Ssabanajew-Frank  method,  1087 

Witzel's  method,  1086 
Gastrotomy,  1085 
Gauntlet  bandage,  T254 
Gauze,  antiseptic,  preparation  of,  75 

aseptic,  preparation  of,  75 

bandages,  78 

cyanid,  preparation  of,  75 

iodoform,  preparation  of,  75 

packs,  77 

pads.  77 

sterilized,  preparation  of,  75 
Gebauer's  ethyl-chlorid  tube,  1216 
Gelatin,  formalin-,  33 

in  hemorrhage,  447 

injection  of,  tetanus  after,  204 

treatment  of  aneurysm,  422 
Gelatiniform  degeneration  in  tuber- 
culous arthritis,  621 
Gelatinous  polyps,  362 
Gelsemium  in  inflammation,  106 
Genito-urinary     diseases,     pain    in, 
1271 

operations  in  insanity,  825 

organs,  diseases  and  injuries,  1266 
Genu  valgum,  739 

Macewen's  operation  for,  688 
Ogston's  operation  for,  689 
osteotomy  for,  688 

varum,  740 
Germicides,  26 

Gerster's  method  of  reducing  swell- 
ing in  fracture  of  lower  extremity 

of  humerus,  561 
Giant-cell  sarcoma,  372 
Gibbon's    method  of    ureterolithot- 
omy, 1300 
Gibney's  method  of  treating  sprains 

of  ankle,  648 
Gibson's  bandage,  1256 

incision   for   operations   on   lower 
ureter,  1299 

operation   for   impermeable   stric- 
ture of  urethra,  1371 

valvular  cecostomy,  ir2i 
Gigantism,  509 


Index 


1493 


Gila  monster,  bite  of,  300 
Gillette's     treatment     of    shoulder- 
joint  disease,  633 
Girdle  pain  in  tetanus,  207 
Girdner's  telephonic  probe,  281 
Glabella,  769 
Glanders,  307 

acute,  308 

bacillus  of,  52 

chronic,  308 

diagnosis,  308 

treatment,  309 

tuberculous,  250 
treatment  of,  245 
Glands,  tuberculous,  250 
Glandula;  Pleiades,  322 
Glandular  cancer,  392 
Glass  arm,  718 
Gleet,  1348 

Glcich's  treatment  of  fiat-foot,  744 
Glfoard's  disease,  1020 

sign,  1040 
Glenoid  cavity,  fractures,  553 
Glioma,  364,  371 

of  brain,  809 
Gliosarcoma,  373 

of  brain,  809 
Gliosis,  364 
Glottis,  burns  and  scalds,  315 

edema  of,  879 
Gloves  for  operation,  preparation,  65 

use  of,  64 
Gluck's   method   of   arteriorrhaphy, 

443 
Gluteal  artery,  ligation  of,  491 

bursitis,  727 

hernia,  1162 
Glutei,  33 

Glycemic  gangrene,  164 
Goelet's  method  of  examination  in 
movable  kidney,  1277 

operation    for    movable    kidney, 
1280 
Goiter,  1230 

acute,  1229,  1231 

adenomatous,  1230 

Basedowified,  1 231 

causes,  1232 

colloid,  1 231 

cystic,  1 231 

diver,  1231 

endotracheal,  1235 

endemic,  1231 

enucleation  in,  1235 

epidemic.  1231 

exophthalmic,     1235.       See     also 
Exophthalmic  goiter. 

extirpation  in,  1235 

fibrous,  1 23 1 

hemorrhagic,  1231 

inflammatory,  1229 

intrathoracic,  1231 

lobectomy  for,  1235 

malignant,  1231 

non-malignant,  metastasis  of,  1234 

of  adolescence,  1 230 

operations,  dangers  in,  1242 

parenchymatous,  1230 

pulsating,  1235 

retro-esophageal,  1231 

retrosternal,  1231 

retrotracheal,  1231 

sporadic,  1232 

substernal,  1231 

suffocating,  1231 

symptoms,  1232 

thyroidectomy  in,  1235 

treatment,  1234 

wandering,  1231 
Gold-beaters'  skin  as  protective,  76 
Golding-Bird  and  Davy's  operation 

for  flat-foot,  744 
Goldthwait's  operation  for  flat-foot, 

742 
Gonococcemia,  1346 
Gonococcus,  50 

examination  for,  1347 
Gonorrhea,  134s,  1346 

abortive,  1348 

acute  inflammatory,  complications 
in,  treatment,  1355 
symptoms,  1346 


Gonorrhea,     acute      inflammatory, 
treatment  of,  1349 

black,  1346 

catarrhal,  1348 
treatment  of,  1352 

chronic,  1348 

treatment  of,  1357 
urethritis  following,  treatment, 
I3S7 

examination  for  gonococci,  1347 

in  children,  1363 

in  female,  1362 
children,  1363 

irrigation  in,  135 1 

irritative,  1348 
treatment  of,  1352 

of  anus  and  rectum,  1361 

of  mouth,  1361 

of  nose,  1362 

of  uterus,  treatment,  1363 

subacute,  1348 

when  cured,  1356 
Gonorrheal  arthritis,  636 
treatment,  638,  1364 

endocarditis,  treatment,  1364 

ophthalmia,  1346 
treatment,  1356 

orchitis,  1393 

peritonitis,  1346 

rheumatism.  636 
GosseUn's  fractures,  515 
Gouley's  catheter,  1314 

divulsor,  1369 
Gout,  chronic.  640 

partial  rheumatic,  642 
of  hip-joint,  642 

progressive  rheumatic,  641 

rheumatic,  640 
Gouty  arthritis,  640 

inflammation,  elevation  in,  95 

urethritis,  1344 
Graefe's  sign  in  exophthalmic  goiter, 

1237 
Graft,  omental,  1079 
Grafting,     skin-,     1262.       See    also 
Skin-grafting. 

bone-,  for  bone-cavities,  503 
in  Pott's  disease,  847,  860 
in  unimited  fractures,  536 

nerve-,  760 

tendon-,  734 

thyroid,  1228 
Graham's  treatment  of  metatarsal- 

gia,  745 
Granny-knot,  439 
Grant's  operation  for  cancer  of  lip, 

394.  924 
Granulations,  rig 

edematous,  120 

exuberant,  120 

healing  by,  117 

pale,  120 

tissue,  141 

in  inflammation,  85 
Granules,  Babfe-Ernst,  20 
Granuloma  fungoides,  374 
Graves'  disease,  1235 
Gravity,  influence  of,  on  projectiles, 

286 
Green-stick  fracture,  514 
Grenades,  wounds  by,  282 
Gritti's  supracondyloid  amputation, 

1417 
Groin,  abscess  of,  146 

spica  bandage,  1257 
Gross's  method  of  excision  of  hip- 
joint,  703 

probang,  942 

treatment  of  cutaneous  erysipelas, 
201 

urethral  dilator,  1368 

urethrotome,  1367 
Guaiac  test  for  hematuria,  1267 
Gum-boil.  145,  913 
Gumma,  328 

of  clavicle,  329 

tuberculous,  247 
of  brain,  809 
Gummatous  inflammation,  329 

synovitis.  331 

tumors  of  brain,  809 

uicer,  329 


Gummy  pus,  135 

Gunpowder,  black,  as  compared  with 

smokeless  powder,  283 
Gunshot-wounds,  274 

amputation  in,  282 

contour,  279 

excision  in,  282 

from  shotgun,  276 

from  sporting  rifle,  276 

hemorrhage  from,  280 
control  of,  454 

in  civil  life,  276 

of  abdomen,  954 

of  arteries,  435 

of  pancreas,  1054 

of  pregnant  uterus,  935 

penetrating,  278 

perforating,  278 

symptoms,  280 

tattooing  in,  278 

tissue  track,  278 

treatment,  280 

wound  of  entrance,  278 
of  exit,  278 
Gunstock  deformity  in  fractures  of 

humerus,  562 
Gussenbauer's    clamp    in    unimited 
fractures,  536 

operation  for  stricture  of  esopha- 
gus, 936 

suture,  1079 
Guthrie's  rule  in  hemorrhage,  449 
Gutta-percha  tissue  as  protective,  76 
Gutter-fracture  of  skull,  796 
Gwathmey-Woolsey     nitrous     oxid 

oxygen  apparatus,  1213 
Gynecological  operations  in  insanity, 

825 


Habit  fits,  824 

Hacker's    method    of    gastro-enter- 

ostomy,  1092 
Hagedom's  needles,  440 
Hair,  ss^philitic  affections,  326 
Hall's   method  of  artificial   respira- 
tion, 867 
Hallus  valgus,  744 

osteotomy  for,  691 
Wilson's  operation  for,  744 
varus,  744 
Halsted's  band  roller,  429 
forceps,  438 
hammer,  11 29 

method  of  arteriorrhaphy,  444 
of  intestinal  anastomosis,  iiii 
of  lateral  intestinal  anastomosis, 
1115 
operation  for  aneurysm,  429 
for  cancer  of  breast,  1438 
for  inguinal  hernia,  1142 
modified,  1 144 
packs,  77 

suture,  57,  75,  271,  1079 
Hamel's   test   for  jaundice   in  gall- 
stones, 1051 
Hamilton's  bandage,  S4i 

bone-drills,  692 
Hammer-toe,  745 

Terrier's  treatment,  745 
Hanch's     treatment     of     obstetric 

depressions  of  skull,  794 
Hancock's    method    of    excision    of 

ankle-joint,  704 
Handkerchief  bandages,  1260 
Hands,  amputation  of,  1406 
and  forearms,  sterilization  of,  63 
Fiirbringer's  method,  63 
mechanical.  62 

sublimate-alcohol  method,  64 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 
claw-,  754 
club-,  740 
palm  or  dorsum,  spiral  bandage  of, 

1254 
sterilization  of,  62 
Hanging,  870 
Harelip.  916 
double,  operation  for,  917 

Owen's  operation  for,  918 
Malgaigne's  operation  for,  917 


1494 


Index- 


Harelip,  operation  for,  gi7 

single,  Mirault's  operation  for,  917 
operation  for,  916 

suture,  272 
Harrington  and  Gould's  method  of 

intestinal  anastomosis,  11 10 
Harris's  urine  segregator,  1269 
Harrison's  renipuncture,  1296 
Hartley's    method    of    removal    of 

Gasserian  ganglion,  766 
Hayden's     treatment    of    bubo    in 

chancroid,  1374 
Haynes's  method  of  drainage  of  cis- 

tema  magna,  832 
Head,  contusions  of,  779 

diseases  of,  769 

injuries  of,  769,  779 
during  labor,  772 

recurrent  bandage,  1260 

tetanus,  208 
Headache,  elevation  in,  95 
Healing,  116.     See  also  Repair. 
Heart,  diseases  and  injuries,  404 

hypertrophy     of,     decompression 
for,  461 

in  inflammation,  112 

massage   in   anesthetic   poisoning, 
1203 

muscle,  tuberculosis  of,  249 

rupture  of,  404 

tamponade,  404,  405 

wounds  of,  404 
operation  for,  460 
Rotter's  incision  in,  460 
Heart-cavity,  tapping,  439 
Heat,  34 

effect  on  bacteria,  24 

in  inflammation,  88,  100,  loi,  103 
Heath    and    Selby's    treatment    of 

Pott's  fracture,  614 
Heberden's  nodosities,  641 
Hectic  fever,  130,  143 
Hedonal  for  infusion  anesthesia,  1201 
Heineke-Mikulicz's  method  of  pylo- 
roplasty, 1080 

operation  for  cicatricial  stenosis  of 
stomach,  970 
HeUerich's   treatment   of   ankylosis, 
632,  653 
of  delayed  umon  in  fractures, 
S3S 
Heliotherapy  in  tuberculosis,  231 
HeDer's  test  for  hematuria,  1266 
Hemangeiosarcoma,  373 
Hemangioma,  365 
Hematemesis,  control  of,  455 
Hematic  abscess,  142 
Hematocele,  1400 

of  spermatic  cord,  diffused,  1400 
encysted,  1400 
of  testicle,  1400 

of  tunica  vaginalis,  1400 

parenchymatous,  of  testicle,  1400 

vaginal,  1400 
Hematoid  cancer,  393 
Hematoma,  258 

of  dura  mater,  799 

of  scalp,  780 

of  stemomastoid,  736 
Hematorayelia,  851 
Hematuria,  1266 

Almen's  test,  1267 

benzidin  test,  1267 

determination  of  source  of  blood, 
1267 

essential,  1268 

guaiac  test,  1267 

Heller's  test,  1266 

in  appendicitis,  ion 

microscopical  test,  1267 

renal,  1267 

Rosenthal's  test,  1266 

spectroscope  test,  1266 

Struve's  test,  1267 

unilateral,  1268 
Hemianopsia  in  tumor  of  brain,  815 
Hemoglobinuria,  1266 
Hemophilia,  457 

treatment  of,  438 
Hemophilic  arthritis,  438 
Hemoptysis,  control  of,  436 
Hemorrhage,  436 


Hemorrhage,  actual  cautery  in,  449 
acupressure  in,  445 
after  abdominal  operation,  457 
after    lateral    lithotomy,    control, 

455 
after     operation     in     obstructive 

jaundice,  436 
blood-serum  in,  448 
calcium  chlorid  in,  448 
capillary,  control  of,  433 
cerebral,  788 
compression  in,  443 
consecutive,  436 
Downes's  method  of  controlling, 

44Q 
electrohemostasis  in,  449 
elevation  in,  445 
extradural,  control  of,  452 

mefiin.geal.  786 
extramedullary,  832 
forced  flexion  in,  447 
from  bladder,  1270 

control,  455 
from  cerebral  sinus,  control,  432 
from  ear,  control,  434 
from  femoral  vein,  control,  432 
from  gunshot-wounds,  280 

control,  434 
from    intercostal    artery,    control, 

451  . 
from    internal    mammary   artery, 

control,  431 
from  intestine,  control,  433,  436 
from  kidney,  control,  433 
from  kidney-substance,  1267 
from  leech-bite,  control,  454 
from  lung,  control,  436 
from  nose,  control,  4S3 
from  palmar  arch,  rules  for  arrest- 
ing, 450 
from  pelvis  of  kidney,  1267 
from  prostate,  1270 

control,  434 
from  rectum,  control,  434 
from  stomach,  control,  455 
from  tooth-socket,  control,  432 
from  ureter,  1267 
from  urethra,  1270 

control,  454 
from  uterus,  control,  433 
from  vagina,  control,  435 
gelatin  in,  446 
Guthrie's  rule  in,  449 
Horsley's  wax  in  controlling,  431 
in  abdominal  section,  control,  433 
in  amputation,  1401 
in  inflammation,  94,  103 
in  pancreatitis,  1038 
in  ulcer  of  stomach,  operation  for, 

968 
in  wounds  from  rifle-bullets,  291 
intercurrent,  456 
intermediate,  436 
intra-abdominal,  437,  943 

control  of,  432 
intracranial,  786 

in  newborn,  788 

traumatic,  786 
intramedullary,  832 
ligature  for,  438 
meningeal,  extradural,  786 

subdural,  787 
of  wounds,  239 

arrest,  266 
primary,  rules  for  arresting,  449 
reactionary,  436 
recurrent,  436 
secondary,  436 

treatment  of,  437 
Skene's  method  of  controlling,  449 
spinal,  control  of,  432 
spontaneous,  into  kidney,  1268 
styptics  in,  447 
subcutaneous,  436 

treatment  of,  454 
subdural  meningeal,  787 
suprarenal  extract  in,  448 
syncope  after,  436 
torsion  in,  444 
treatment,  437 

hemostatic  agents.  438 
umbilical,  control  of,  434 


Hemorrhage,   Vaughan's   method  of 

controlling,  451 
Hemorrhagic  diathesis,  457 
disease,  437 
goiter,  1231 
infarction.  189 
inflammation,  84,  87 
sarcoma,  373 
ulcer,  139 
Hemorrhoids,  411,  1177 

AlUngham's  operation  for,  1181 

arterial,  1179 

capillarj',  11 79 

clamp  and  cautery  operation  in, 

1180 
excision  for,  1181 
external,  1177,  1178 
connective-tissue,  11 79 
thrombotic,  11 78 
varicose,  11 78 
inflammatory,  11 78 
internal,  11 77,  11 79 
hgature  operation  for,  1181 
mixed,  11 77 

treatment  of,  operative,  1180 
venoiis,  1 1 79 

Whitehead's  operation  for,  1181 
Hemostasis,  Simpson's  method,  445 
Hemostatic  agents,  438 

forceps,  438 
Hepatic  duct,  drainage  of,  1128 
fever,  131,  1046,  1031 
infection  after  appendicitis,  1009 
lobe,  floating,  1040 
Hepaticotomy,  1130 
Hepatitis,  pain  of,  89 
Hepatopexy,  1040 
Hepatoptosis.  1039 
hepatopexy  in,  1040 
laparectomy  in,  1040 
partial,  1040 
Heredity  as  cause  of  cancer,  347,  387 
Hernia,  1133 
abdominal,  11 33 

adherent,    of    ascending    and   de- 
scending     colon,      operative 
treatment,  11 30 
of  large  intestine,  1161 
causes  of,  1134 
cecal,  1160 
cerebri,  797,  798 
Cloquet's.  1160 
diaphragmatic,  1164 
director,  1139 
epigastric,  11 60 
fat-,  333,  1 134 
femoral,  1160 

Bassini's  operation  for,  1130 
Cheyne's  operation  for,  1150 
Fabricius's  operation  for,  1150 
herniotomy  in,  1137 
prevascular,  11 60 
radical  cure,  11 30 
gluteal.  1 162 
Hesselbach's,  1160 
hydrocele  of,  1400 
in  childhood,  1138 
incarcerated.  1152 
infantile,  1159 

encysted,  11 60 
inflamed,  1152 
ingiiinal,  congenital,  1159 
direct,  11 39 

radical  cure,  1148 
Ferguson's  operation  for,  1146 
Fowler's  operation  for,  1146 
Halsted's  operation  for,  1142 
modified,  1144 
plus  Bloodgood's  method  of 
transplanting  rectus  mus- 
cle, 1144 
indirect,  1159 
interparietal,  1162 
interstitial,  1162 
Kocher's  operation  for,  1146 
Macewen's  operation.  1139 
obUque,  Bassini's  operation  for, 
1 140 
Coley's  dressing  in.  1142 
herniotomy  in,  1156 
superficial,  1162 
internal,  1162 


Index 


1495 


Hernia,  internal,  intestinal  obstruc- 
tion from,  9S1 
into  foramen  of  Winslow,  1162 
into  funicular  process.  1159 
into  intersigmoid  fossa.  1162 
into  retrocecal  fossie.  11 62 
into  retroduodenal  fossse,  1162 
intra-abdominal,  1162 
irreducible.  1152 
labial.  11 59 
Laugier's.  1160 
Littr6"s,  iiss,  1163 
lumbar,  1162 
needles,  1139 
obstructed,  1152 
obturator.  1162 
of  appendix,  1161 
of  bladder,  1163 
of  brain.  797 
of  intestinal  wall.  1162 
of  linea  alba.  11 60 
of    Meckel's    diverticulum,    1155, 

1163 
of  muscles,  720 
of  ovar>%  1 1 64 
of  uterus,  1164 
perineal.  1162 
preperitoneal,  1162 
pudendal,  1162 
reducible.  1135 

Lannelongue's  treatment,  1139 
treatment  of,  1136 
rest  in,  95 

retroperitoneal,  1162 
Richter's.  1155,  1162 
Rokitansky's  diverticular,  1163 
sciatic.  1162 
scrotal.  1 159 

sliding,  of  ascending  and  descend- 
ing   colon,    operative     treat- 
ment, 1 1 50 
of  large  intestine,  11 61 
strangulated,  1152 
delusive  calm  in,  1154 
elastic.  1133 
fecal,  1 153 

vomiting  in,  1154 
herniotomy  in,  11 56 
reduction  en  bissac,  1155 
en  bloc,  1155 
en  masse,  1155 
retrograde,  1153 
taxis  in,  1155 
treatment  of,  1155 
traumatic,  1135 
tuberculosis  of,  1135 
umbilical,  1160 

herniotomy  in.  1157 
Mayo's  operation  for,  1148 
radical  cure,  1148 
vaginal.  1162 
varieties  of.  1159 
ventral,  1160 
with  incomplete  sac,  1161 
Hemiotome.  Cooper's,  1156 
Herniotomy.  1156 
Herxheimer's    reaction    in    syphilis, 

33S 
Hesselbach's  hernia,  1160 
Heurteloup's  artificial  leech,  97 
Hewitt's   nitrous   oxid   and   oxygen 
apparatus,  1212 
apparatus.  1211 
Hey's  amputation  of  foot.  1413 

internal  derangement,  6S4 
Hibb's  method  of  bone-grafting  in 
Pott's  disease.  860 
of  tendon-lengthening.  734 
operation    for    osteo-arthjitis    of 
knee-joint.  643 
Hickorj^-stick  fracture,  314 
Highmore.  antrum  of,  abscess,  145, 
878 
treatment  of,  149 
inflammation,  878 
Hilton's    method    of    opening    deep 

abscess.  149.  150 
Hip,  abscess  of.  626 

congenital      dislocation,      Hoffa's 
operation,  711 
Lorenz's  bloodless  method  of 
reduction,  710 


Hip,  congenital  dislocation,  Lorenz's 
operation,  711 
operation  for,  710 
reduction    by   means   of   me- 
chanical appliances,  711 
disease,  625 
dislocation   of,   in   typhoid   fever, 

635 
examination    of,    in    fractures    of 
femur,  382 
Hip;-joint,  disarticulation  at,  1418 
disease,  625 

excision  of,   702.     See  also  Exci- 
sion of  hip-joint. 
faulty    ankj'losis,    osteotomy   for, 

689 
osteo-arthritis  of.  642 
partial  rheumatic  gout,  642 
traumatic    dislocation,    676.      See 
also    Dislocation,    irauifuUic,    of 
femur. 
tuberculosis    of,    625.      See    also 
Tuberculosis  of  hip-joint. 
Hippocratic    face    in    intestinal    ob- 
struction, 984.  985 
Hirschsprung's  disease,  1019 
Hodgen's    splint    for    fractures    of 

femur,  596 
Hodgkin's  disease.  1251 
Hofia's  operation  for  congenital  dis- 
location of  hip.  711 
Hoflfmann's  sign  in  tetany,  1246 
Hollow  foot,  744 
Holzknecht's         symptom-complex. 

r-t56 
Home's  lobe,  1379 
Hoppe-Se^der  test  for  carbon  mon- 

oxid  in  blood,  876 
Horn,  400 
Horsehair,  73 

preparation  of,  73 
Horseshoe  fistula,  11 74 
Horsley's  cjTtometer,  772 

method     of     finding     fissure     of 
Rolando,  770 
of  lateral  intestinal  anastomosis, 

of   removal   of    Gasserian   gan- 
glion, 767 
operation      for      chronic      spinal 

meningitis.  863 
wax    in    controlling    hemorrhage, 

Horwitz's   modification   of   Maison- 
neuve's  urethrotome,  1367 
treatment     of     acute    gonorrhea, 
1354 
Hospital  gangrene,  164,  171 

treatment,  172 
Hot  gangrene,  164 
Hot-water  bath  in  inflammation,  103 
Hour-glass  stomach.  972,  1103 
Housemaids'  knee,  728,  730 
Houses,  cancer.  388 
Howard's  method  of  artificial  respi- 
ration. 866 
Hudson's  burrs,  826 

modified      De     Vilbiss      forceps, 
827 
Huguier  and  Murphy's  treatment  of 

ankylosis.  652 
Humerus,  fractures  of,  554.    See  also 
Fractures  of  humerus. 
osteoma  of,  359 
sarcoma  of,  375 
subluxation  of.  720 
traumatic  dislocation,  663 
axillary,  664 
Cock's  reduction,  668 
Cooper's  reduction,  667 
diagnosis.  665 
Dugas's  sign  in.  665 
Erichsen's  signs  in.  665 
habitual.  669 

capsulorrhaphy  in,  669 
Thomas's  operation  for,  669 
Keetley's  reduction,  666 
Kocher's  reduction.  666 
La  Mothe's  reduction,  668 
recurrent,  669 
reduction  by  extension,  667 
Smith's  reduction,  667 


Humerus,  traumatic  dislocation,  sub- 
clavicular, 664 
subcoracoid,  664 
subglenoid,  664 
subspinous,  664 
supracoracoid,  664 
symptoms,  665 
treatment,  666 
unreduced.  668 

McBumey's  treatment,  669 
upward  extension  in,  668 
Humoral  theorj'  of  immunity,  38 
Hunger-pain     in     peptic     ulcer     of 
duodenum.  995 
in  ulcer  of  stomach.  963 
Hunterian  chancre,  320 
Hunter's  canal.  487 

operation  for  aneurysm,  424 
Huntington's  treatment  of  tubercu- 
losis of  hip-joint,  630 
Hutchinson's  splint,  631 

teeth.  344 
Hiiter's  sign.  718 
Hyaline  tubercle.  215 
Hydatid  cysts.  402 
of  breast,  1430 
of  liver,  1034 
fremitus.  403 
moles  of  pregnancy,  362 
toxemia.  403.  1034 
Hydrarthrosis  in  osteo-arthritis,  641 
HydrencephaUc  cr>-,  801 
Hydrencephalocele,  776 
Hydrocele,  acute,  1397 
chronic.  1398 
congenital.  1399 

diffused,  of  spermatic  cord.  1400 
en  bissac,  1398 
encysted,  of  epididymis,  1400 
of  spermatic  cord,  1400 
of  testicle,  1400 
funicular,  1400 
infantile,  1399 
of  hernia,  1400 
of  neck,  397 
of  tunica  vaginalis,  1398 
primary-,  1398 
secondary,  1398 
vaginal.  1398 
Hydrocephalus.  778 
acute.  778.  801 
chronic.  778 
external,  778 
internal,  778 
Hydrogen  peroxid,  30 

rectal  insufflation,  948 
Hydronephrosis.  401,  1289 
Hydrophobia,  304 

Pasteur's  treatment,  306 
spurious,  306 

tetanus  and,  differentiation.  208 
treatment.  306 
Hydrophobic  tetanus,  208 
Hydrops,  401 
articuH.  618 

of  gall-bladder.  1041,  1032 
Hydrosalpinx.  401 
Hyoid  bone,  fractures,  542 
Hj-perchlorhydria.  962 
Hyperemia,  active.  79 
clinical  signs.  80 
Bier's,  in  inflammation,  112 
in  tuberculosis,  234 
of  testicle,  1394 
passive.  79 
Hyperesthesia,  91 
Hypernephroma.  379 

of  kidney.  1273 
Hyperostosis  cranii,  510 
Hj-perpituitarism,  510 
Hyperplastic  tuberculosis.  999 
H>-perthymi2ation,  1247 
HyperthjToidism,  1236,  1243 
Hypertrophy  of  bone,  493 
of  breast.  1423 

of  heart,  decompression  for,  461 
of  muscles.  713 
of  prostate.  1378 

catheterization  in.  1380 
cystoscopic  examination  before 

operation  in.  1381 
middle  lobe,  1379 


1496 


Index 


Hypertrophy  of  prostate,  operations 
for,  1381 
results,  i38g 
selection,  i38g 
symptoms,  i37g 
treatment,  1314,  1380 
Hyphomycetes,  18,  19 
Hypnotic  anesthesia,  1215 
Hypnotics  in  inflammation,  107 
Hypochondriacal    delusions,    opera- 
tive treatment,  824 
Hypodermoclysis  in  shock,  263,  264 
Hypoparathyroidism,  1245 
Hypophysis  cerebri,  tumors  of,  817 
Hypopituitarism,  510 
Hypospadias,  13  71 

Beck's  operation  for,  1372 
Hypothyroidism,  1228 
Hysteria,  beast-mimicry  in,  306 

stigmata  of,  850 

tetanus  and,  differentiation,  209 

traumatic,  850 
Hysterical  coma,  785 

fever,  131 

joint,  644 

stricture,  938 


Ice  and  salt  anesthesia,  1216 
Ice-bag,  99 

Ichthyol  in  inflammation,  loi 
Beus,  977.     See  also  Intestinal  ob- 
struction. 
niac  abscess,  tuberculous,  241 

artery,  common,  compression  of, 
447 
ligation  of,  488 
external,  ligation  of,  491 
internal,  ligation  of,  490 
ligation,  488 

after  abdominal  section,  489 

bursitis,  727 

thrombosis  after  abdominal  oper- 
ations, 187 
Iliopsoas  bursitis,  727 
Illuminating  gas-poisoning,  874 
Immediate  union,  116 
Immimity,  37,  42 

acquired,  38 

active,  38 

artificial,  38 

Chauveau's  theory,  38 

CoUes's,  in  syphilis,  317 

Ehrlich's  theory,  40 

exhaustion  theory,  38 

humoral  theory,  38 

natural,  37 

passive,  38 

Profeta's,  in  syphilis,  317 

retention  theory,  38 

to  cancer,  387 

to  tuberculosis,  221 
Imperforate  anus,  1173 
Impermeable    material    over    dress- 
ings, 76 
Impetigo,  syphilitic,  325 
Implantation,  intestinal,  of  ureters, 
1300 

of  nerves,  760 
Incarcerated  hernia,  1152 
Incision  in  inflammation,  95 
Incisive  gland,  cyst  of,  926 
Incontinence,  fecal,   after  operation 
for   fistula    in   ano,   treatment, 
1176 

of  retention  of  urine,  1312 
Index,  opsonic,  41 
Indian  method  of  rhinoplasty,  1265 
Indifferent  tissue  in  inflammation,  85 
Indigo-carmin     test    for     excretory 

capacity  of  kidneys,  1272 
Indolent  buboes,  321 

ulcer  of  leg,  157 
Induction  balance  in  locating  bullet, 

281 
Infantile  hydrocele,  1399 

paralysis,    cerebral,    epilepsy    fol- 
lowing, operative  treatment,  823 

scurvy,  257 
Infarction,  189 

hemorrhagic,  189 

red,  189 


Infarction,  white,  189 
Infected  wounds,  295 
Infection,  bacteria  as  cause,  35 

intra-uterine.  26 

mixed,  26 

placental,  26 

septic,  195 

treatment,  by  bacterial  vaccines, 

47 
vital  resistance  to,  42,  43 
Infiltration  anesthesia,  1218 

with  sterile  water,  1223 
purulent,  136,  140,  202 
Inflamed  hernia,  1152 
Inflammation,  78 
aconite,  in  106 
acute,  86 

symptoms,  88 

treatment,  94 
adhesive,  86 
adynamic,  86,  92 
alcohol  in,  109 
alkaUne  iodids  in,  109 
anodynes  in,  107 
antiphlogistic  regimen,  no 
antipyretics  in,  107 
antiseptic  fomentation  in,  102 
arterial  sedatives  in,  106 
asthenic,  86_,  92 
astringents  in,  100 
atropin  in,  no 

Bier's  hyperemic  treatment,  112 
bleeding  in,  95,  105 
blisters  in,  104 
blood-plaques,  84 
blood-plates,  84 
blue  ointment  in,  loi 
buffy  coat,  92 
cataplasm  in,  103 
catarrhal,  86,  87 

of  gall-bladder  and   bile-ducts, 
1042 
cathartics  in,  106 
causes,  87,  88 
cautery  in,  105 
cell  proUferation,  84 
changes  in  perivascular  tissue,  84 
chronic,  86,  93 

causes,  93 

symptoms,  93 

tissue  changes,  93 

treatment  of,  112 
circulatory  changes,  79 
classification,  86 
cleanliness  in,  112 
cold  in,  97 
common,  86 
compression  in,  100 
contagious.  87 
counterirritants  in,  104 
croupous,  86,  87 

of  gaU-bladder  and  bile-ducts, 
1043 
cupping  in,  96 
definition,  78 
dehtescence,  87 
depletion  in,  95 
derangement  of  absorbents,  92 

of  secretions,  92 
diapedesis  and  migration,  83 
diaphoretics  in,  107 
diet  in,  no 
diphtheric.  86,  87 
discoloration,  90 
disordered  function,  91 
diuretics  in,  107 
douche  in,  loi 
dry,  87 

elevation  in  treatment,  95 
embiyonic  tissue,  84 
emetics  in,  108 
extension,  87 
exudation  of  fluids,  81 
fibrinous,  86 
fibroblasts,  84 
fomentations  in,  102 
gangrenous.  87 
gelsemium  in,  106 
gouty,  elevation  in,  95 
granulation  tissue,  85 
gummatous,  329 
healthy,  87 


Inflammation,  heart  in,  112 
heat  in.  8S.  100,  loi,  103 
hemorrhagic,  84,  87 
hot-water  bath  in,  103 
hyperesthesia,  91 
hypnotics  in.  107 
hypostatic,  87 
ichthyol  in,  loi 
idiopathic,  86 

impairment  of  special  function,  92: 
in  fractures,  531 
in  non-vascular  tissue,  83 
incision  in,  95 
increased  irritability,  91 

tenderness.  91 
indifferent  tissue,  85 
infective,  86 
interstitial,  86 
iodids  in,  108 
irritants  in,  105 
juvenile  tissue,  85 
latent,  87,  89 
lead-water  in,  100 
leeching  in,  95 
leukocytes,  81 
leukocytosis,  84,  92 
malignant,  87 
massage  in,  loi 
mercurials  in,  loi 
mercury  in,  108 
migration  and  diapedesis,  83 
moist  gangrene  from,  170 
multiple  puncture  in,  95 
muscular,  relaxation  in,  95 

rigidity,  92 
neuropathic,  87 
new  growth,  87 
nitrate  of  silver  in,  loi 
obstructive  hyperemia  by  means 
of  cupping  glass  in,  113 
of  elastic  bandage  in,  112 
of  antrum  of  Highmore,  878 
of  anus,  pain  in,  89 
of  artery,  413 
of     bladder,      1324.        See     also 

Cystitis. 
of  bone,  495 
of  breast,  1423 
of  cartilage,  86 
of  cornea,  85 

of  crypts  of  Morgagni,  1186 
of  epididymis,  1397 

pain  in,  89 
of  eye,  pain  in,  89 

rest  in.  95 
of  Fallopian  tubes,  pain  in,  89 
of  joint,  compression  in,  100 

rest  in,  94 
of  mucous  membrane,  86 

rest  in,  94 
of  neck  of  bladder,  pain  in,  89 
of  nerves,  747 
of  ovaries,  pain  in,  89 
of  prostate,  1376,  1377 

pain  in,  89 
of  rectum,  1172 

pain  in.  89 
of  sacro-iUac  joint,  pain  in,  89 
of  semilunar  cartilages,  618 
of  seminal  vesicles,  137s 
of  sigmoid,  1172 
of  testicle,  1393 

pain  in,  89 
of  thyroid  gland,  1229 
of     urethra,     1343.       See     also 

Urethritis. 
of  uterus,  pain  in,  89 
of  vein,  408 

oscillation  and  stagnation,  81 
pain,  88 

Paquelin  cautery  in,  105 
parenchymatous,  86 
peri-anal,  1172 
perirectal,  1172 
phlebotomy  in,  105 
phlegmonous,  86 
plastic,  82,  86 
poultice  in,  103 
piflse  in,  112 
puncture  in,  95 
purgation  in,  106 
purulent,  86 


Index 


1497 


Inflammation,  redness  as  sign,  91 

referred  pain,  89 

reflex,  87 

relaxation  in,  95 

remedies  directed  against  special 
morbid  states.  109 

resolution,  87 

rest  in  treatment,  94 

retardation  of  circulation,  80 

rouleaux  formation,  81 

saturated     water>'     solution      of 
Epsom  salt  in,  100 

scarification  in,  05 

Scotch  douche  in,  loi 

sedative  poultice  in,  103 

serous,  81,  86 

simple,  86 

sorbefacients  in,  100 

specific,  86 

stagnation,  81 

and  oscillation,  81 

stasis.  Si 

sthenic,  86,  92 

stimulants  in,  109 

strychnin  in,  no 

stupe  in,  102 

subacute,  86 

suppurative,  86 

of  gall-bladder  and  bile-ducts, 
1043 

sweating  in,  107 

swelling  or  tumefaction,  91 

sympathetic,  87 
pain,  89 

tartar  emetic  in,  106 

temperature  in,  in 

tenderness,  89 

terminations.  87 

third  corpuscles,  84 

tincture  of  iodin  in,  loi 

tonics  in,  no 

traimiatic,  86 
of  brain,  70S 

treatment,  constitutional,  105 
local,  94 

turpentine  stupe  in,  102 

typhoid,  92 

liJiealthy,  87 

urine  in,  in 

vascular  changes,  79 
resume.  81 

venesection  in,  10s 

ventilation  in.  112 

veratrum  %'iride  in,  106 

Wright's  \iews  on,  115 
Inflammatory  flat-foot,  742 

goiter,  1229 

pUes,  1178 
Infra-orbital  nerve,  neurectomy  of, 

762 
Infrapatellar  bursitis,  731 
Infusion  anesthesia.  1201 
Ingestion  tuberculosis.  218 
Ingrowing  toe-nail.  157,  1227 
Inguinal  colostomy,  1121 
Bodine's  method,  1122 
Maydl's  method,  1121 

hernia.    See  Hernia,  inguinal. 
Inhalation  tuberculosis,  217 
Inhibition,  death  by,  260 
Inion,  769 
Injection  Brue  in  acute  gonorrhea, 

I3S4 
Innocent  sj-phiUs,  317 
Innominate  artery,  ligation,  478 
Inoculation  tuberculosis,  218 
Inoculations,  preventive,  43 

protective,  43 
Insanity,   abdominal  operations  in. 
8^5  . 

epileptic,  operative  treatment,  824 

genito-urinary  operations  in,  825 

gynecological  operations  in,  825 

non-traumatic,     operative     treat- 
ment, 824 

opierative  treatment,  824 

postoperative,  807 

traumatic,  operations  for,  824 
Insects,  bites  and  stings.  296 
Insomnia,  syphilitic.  332 
Instep,  spica  bandage,  1255 
Instruments,  sterilization  of,  65 


Insufflation      anesthesia,      intratra- 
cheal, 1199 
intratracheal,  Meltzer  and  Auer's 
method.  905 
Insusceptibility.  42 
Intentional  fistula.  993 
Intercostal  artery,  hemorrhage  from, 
control  of,  451 
neuralgia.  712 
Interdental  splint,  542 
Interilio-abdominal         amputation, 

^+23. 
Intermittent    claudication    in    pre- 
senile spontaneous  gangrene,  166 
Internal  dislocation  of  femiir,  549 
Interpolation  in  plastic  surgery,  1261 
Interrupted  suture,  270 
Interscapulo  thoracic       amputation, 

1411 
Intersigmoid  fossa,  hernia  into,  1162 
Intertarsal  disarticulation,  anterior, 
1414 
posterior,  1414 
Interureteral  bar  in  cystoscopy,  1305 
Intestinal  anastomosis.     See  Anas- 
tomosis, intestinal. 
diverticulitis,  acute.  1018 
diverticulum,  1018 
exclusion,  local.  1118 
implantation  of  ureters,  1300 
obstruction.  977 
acute.  978 

ssonptoms  of,  984 
chronic,  978 

symptoms  of,  985 
complete,  9 78 
diagnosis.  985 
from  adhesions.  979 
from  bands  and  abnormal  open- 
ings. 0S2 
from  cicatricial  stricture.  982 
from  embolism  or  thrombosis  of 

mesenteric  vessels,  983 
from  enteroliths,  981 
from  fecal  accumulation,  983 

concretions.  gSi 
from  foreign  bodies.  981 
from  gall-stones.  9S1 
from  internal  hernia,  981 
from  intussusception,  979 
from     Meckel's     diverticulum, 

981,  982 
from  strangulation,  97S 
from  tumors.  982,  983 
from  volvT-ilus,  979 
gradual,  978 
partial.  978 
postoperative,  983 
prognosis.  989 
pseudo-.  9S3 
treatment.  989 
stasis,  chronic,  977 
tuberculosis.  24S 
perforation  in,  1000 
primary.  999 
wall,  hernia  of,  1162 
Intestine,  956 
adenoma  of,  1000 
cancer  of,  1000 

treatment,  394 
foreign  bodies  in,  956 
hemorrhage    from,    control,    455, 

456 
large,  identification  of,  949 
phantom  tumor  of,  983,  988 
polyp  of.  1000 
pseudo-obstruction  of,  983 
resection  of,  with  approximation 
by  circular  enterorrhaphy,  1105 
rupture      of,      without     external 

wound.  947 
sarcoma  of.  1000 
small,  identification  of,  949 

location  of  loop,  951 
strangulation    of.    intestinal    ob- 
struction from.  978 
structure  of,  cicasricial,  intestinal 

obstruction  from,  982 
suture  of,  1077 
tumors  of,  1000 

intestinal  obstruction  from,  982 
ulcer  of,  993 


Intoxication,  acid,  after  anesthesia, 
1207 

auto-.  37 

putrid,  194 

septic,  194 
Intra-abdominal  emergencies,   diag- 
nosis, 943 

hemorrhage,  437,  945 
control,  452 
Intra-articular  fracture,  517 
Intracapsular  fracture,  517 
Intracellular  toxins,  37 
Intramamman,'  abscess,  1425 
Intraparietal  fissure,  771 
Intrathoracic  goiter,  1231 

operations  under  positive  or  nega- 
tive air-pressure.  904 
Intratracheal  insufflation  anesthesia, 
1199 
Meltzer  and  Auer's  method,  905 
Intra-uterine  fractures.  517 

infection,  26 
Intravenous  etherization,  1201 

infusion  of  saline  fluid,  465 
in  shock,  263 

method  of  local  anesthesia,  1222 
Intubation  of  larynx,  884 
Intussusception,  979 

cecal,  981 

coUc,  gSi 

diverticular,  981 

Heal,  9S1 

ileo-appendiceal,  981 

ileocecal,  979 

ileocolic,  981 

operation  for,  1120 

retrograde,  981 
Intussusceptum.  981 
Intussuscipiens,  981 
Involucrum.  500 
Involution  cysts  of  breast,  1429 
lodids  in  inflammation,  108 
Iodin.  $5 

as  skin  disinfectant.  68 

tincture  of,  in  inflammation,  lor 
lodism.  109 

in  syphilis,  340 
Iodoform,  30 

absorption,  fever  of,  130 

collodion,  76 

emulsion,  31 

gauze,  preparation,  75 

poisoning,  31 

wax,  31 
lodol,  32 

Iritis,  syphflitic,  326 
Irrigarion  in  gonorrhea,  1351 

in  septic  wounds,  69 

of  ureter,  1309 
Irritability,  cerebral.  7S1 
Ischemia.  79 
Ischiorectal  abscess,  145,  117  2 

treatment.  149 
Italian  method  of  rhinoplasty,  1265 
Itrol,  32 
I\-y  poisoning,  1226 


J.ajbotjXay's  method  of  gastroduode- 
nostomy,  1096 
of  gastro-enterostomy,  1092 
operation  for  hydrocele,  1399 
Jacksonian  epilepsy,  814 

due     to     gross     brain    disease, 

operative  treatment,  823 
operative  treatment,  822 
Jackson's     instruments     for    laryn- 
goscopy,     bronchoscopy,     and 
esophagoscopy,  888 
operation  for  cancer  of  breast,  1441 
tracheobronchoscop3',  885 
veil.  977 
Jacob's   treatment  in   dislocation  of 
semilunar  cartilages  of  knee,  685 
ulcer,  159,  392 
Janet's   treatment   of   acute   gonor- 
rhea, 1351 
Jaundice     in    gall-stones,     Hamel's 
test  for,  1051 
obstrucdve  hemorrhage  after  oper- 
ation in,  436 


1498 


Index 


Jaw  and  occiput,  figure-of-8  bandage, 
1256 
angle  of  crossed  bandage,  1256 
closure  of,  Q12 
injuries  and  diseases,  912 
lower,  excision  of  half,  708 
partial  excision  of,  709 

Stillman's  operation  to  pre- 
vent   contraction    after, 
709 
lumpy,  309 
necrosis  of,  913 

phosphorus,  913 
oblique  bandage,  1256 
phosphorus  necrosis  of,  91.3 
traumatic  dislocation,  659 
Cooper's  treatment,  660 
Nekton's  treatment,  660 
Young's  treatment,  660 
upper,  excision  of  half,  707 
Jejunostomy,  1105 

for  cancer,  960 
Jejunum,     peptic     ulcer     of,     after 

gastro-enterostomy,  1089 
Jerk-finger,  739 

Johnston's  method  of  preparing  cat- 
gut, 72 
Joints,  abscess  of  tuberculous,  242 
aspiration  of,  695 
Brodie's,  644 
Charcot's,  643 
diseases  of,  493,  617 
excision  of,  696 
false,  in  fractures,  527 
flail-,  747 
hysterical,  644 

inflammation  of,  compression   in, 
100 
rest  in,  94 
loose  bodies  in,  654 
neuralgia  of,  645 
operations  on,  688 
strumous,  620 
syphilitic  affections,  326 
tertiary  syphilis,  331 
trophic  affections,  643 
tuberculosis  of,  250 
wounds  and  injuries,  646 
Jones's  abduction  frame  in  fractures 
of   shaft  of   femur  in  children, 
598 
dressing  for  injuries  of  elbow-joint, 

S66 
splint  in  fracture  of  nasal  bones, 

538 
treatment   of   intracapsular   frac- 
tures of  femur,  589 
of  Volkmann's  contracture,  716 
Joimesco's    method    of    sympathec- 
tomy, 761 
Jordan's    amputation    at    hip-joint, 
1423 
treatment  of  spinal  caries,  846 
Jugular  vein,  thrombosis,  186 
Junker's  inhaler,  1197 
Justus's  test  for  syphihs,  332 
Juvenile  tissue  in  inflammation,  83 


Kader's    method    of    gastrostomy, 

1087 
Kangaroo-tendon,  72 
preparation  of,  72 
Truax's  method,  73 
Karyokinesis,  122 
Katagama's  test  for  carbon  monoxid 

in  blood,  876 
Katzenstein's  operation  for  serratus 

palsy,  663 
Keen's  method  of  diagnosing  rupture 
of  bladder,  13 18 
operation    for    Dupuytren's    con- 
traction, 738 
Keetley's   method   of   reducing  dis- 
located humerus,  666 
treatment  of  dislocation  of  meta- 
carpophalangeal joint  of  thumb, 
674 
Kehr's  sign  in  rupture  of  spleen,  1063 
Keith's  method  of  lithotrity,  1337 
Kelly's  method  of  catheterization  of 
ureters  in  women,  1268 


Kelly's  method  of  differentiating  be- 
tween appendicular  pain  and 
pain  of  movable  kidney,  1276 
of  examining  rectum,  1168 
operation  for  movable  kidney,  1280 
speculum,  1169 
Keloid,  355 
spontaneous,  357 
treatment  of,  357 
true,  357 
Kemig's  sign  in   acute  leptomenin- 
gitis, 800 
Kidney,  abscess  of,  1287 
cancer  of,  1274 
complications     after     anesthesia, 

1206 
determination  of  excretory  capac- 
ity, 1272 
diseases  and  injuries,  1273 
dislocated,  1275 
floating,  1275 

hemorrhage  from,  control,  455 
hypernephroma  of,  1273 
injuries  of,  1280 
laceration  of,  1280 
movable,  1275 
operations  on,  1291 
pelvis  of,  bleeding  from,  1267 
perforating  wounds,  1281 
prolapse  of,  1275 
repair  of,  128 
rupture  of,  1280 
sarcoma  of,  1274 
spontaneous      hemorrhage      into, 

1268 
stone  in,  1283 

operation  for,  1294 
pain  in,  89 
surgical.  1289 
suture  of,  1282 
tuberculosis  of,  252 

chronic,  1290 
tumors  of,  1273 
wandering,  1275 
Kidney-substance,     bleeding     from, 

1267 
Kilvington's  operation  for  paralysis 

of  bladder,  13 19 
Kissing  ulcer,  962 
Klemperer's  method  of  testing  motor 

power  of  stomach,  973 
Knee,  crucial  ligaments,  rupture  of, 
.649 
disarticulation  at,  141 7 
housemaids',  728,  730 
semilunar  cartilages,    dislocation. 
Barker's  operation  for,  709 
traumatic  dislocation,  684 
subluxation  of,  684 
traumatic   dislocation,    682.      See 
also    Dislocation,   traumatic,    of 
knee. 
Knee-joint  disease,  631 
erasion  of,  697 
excision  of,  703 

Ashhurst's  method,  703 
by  anterior  semilunar  flap,  703 
faulty   ankylosis,    osteotomy   for, 

690 
fractures  of  femur  near,  597 
tuberculosis  of,  631 
Knock-knee,    739.      See    also    Genu 

valgum. 
Kocher's    amputation    at    shoulder- 
joint,  1410 
of  knee,  141 7 
incision  for  nephrectomy,  1295 
for  nephrotomy,  1293 
for  surgery  of  bile-ducts,  11 24 
method   of  anterior  gastro-enter- 
ostomy, 1094 
of  disarticulation  at  wrist-joint, 

1408 
of  intestinal  anastomosis,  mo 
of  reducing  dislocated  humerus, 
666 
of  thyroidectomy,  1 240-1 242 
operation  for  cancer  of  tongue,  929 
for  inguinal  hernia,  1146 
Koch's  bacillus,  52 
circuit  as  proof  of  microbe  as  cause 
of  disease,  35 


KoUmann's  dilators,  1360 
gland  syringe,  1360 

Konig's    incision    for    nephrectomy, 
1295 
tracheotomy  tube,  1235 

Koranyi's  method  of  cryoscopy,  1273 

Krag-Jorgensen  bullet,  285 

Kraske's     method     of     preventing 
spread  of  cutaneous  erysipelas, 
201 
operation  for  rectal  cancer,  1 190 

Kronig's    method  of   preparation  of 
catgut,  71 

Kronlein's  method  of  locating  brain- 
areas,  772 

Kyphosis,  843 


La  Mothe's  method  of  reducing  dis- 
located humerus,  668 

Labial  hernia,  1159 

Labor,  injuries  of  head  during,  772 

Laborde's      method      of      artificial 
respiration,  867 

Lacerated  wound,  272 

Laceration  of  brain,  780 
of  kidney,  1280 
palsy,  751 

Lachrymal     and     sahvary     glands, 
lymphoma  of,  915 
bone,  fractures,  538 

Lacing  lobe  of  liver,  1041 

Lacteal  cysts,  401 
of  breast,  1430 

Lagoria's  sign  in  intracapsular  frac- 
tures of  femur,  584 

Lambotte's   operation    for   enterop- 
tosis,  102 1 

Laminectomy,  860 
for  spinal  caries,  848 

Landerer's  dry  method  of  operating, 
69 

Lane's  operation  for  chronic  intes- 
tinal stasis,  977 
of  extirpation  of  large  intestine 
to  arrest  ost'eo-arthritis,  642 
steel  plates  for  fractures,  534 

Langenbeck's    incision    in    nephrec- 
tomy, 1295 
method   of   excision   of   hip-joint, 

703 
treatment  of  imunited  fractures, 
S36 

Lannelongue    and    Menard's    treat- 
ment of  ununited  fractures,  535 

Lannelongue 's  plan  of  reaching  liver, 
1033 
treatment  of  reducible  hernia,  1139 

Lannier-Hackerman  area,  939 

Laparectomy  in  hepatoptosis,  1040 

Laparotomy,  1066 

Laplace's  forceps  for  intestinal  anas- 
tomosis, 1112,  1116 

Lardaceous  disease  from  tuberculous 
abscess,  239 

Larrey's    amputation    at    shoulder- 
joint,  1409 
of  hip-joint,  1423 

Laryngeal  cartilages,  fractures,  543 

Laryngoscopy,  direct,  885 

Laryngotomy,  quick,  884 

Laryngotracheotomy,  884 

Larynx,  abscess  of,  145 
treatment,  149 
diseases  and  injuries,  879 
edema  of,  879 
foreign  bodies  in,  880 
intubation  of,  884 
operations  on,  883 
wounds  and  injuries,  879 

Laudable  pus,  135 

Laugier's  hernia,  1160 

Lautenschlager's  sterilizer,  75 

Lavage  of  ureter,  1309 

Law,  Colles's,  in  syphilis,  317,  343 
Courvoisier's,  in  gall-stones,  1052 
Miiller's,  of  tumors,  346 
of  centrifugal   maximum   in   ery- 
sipelas, 200 
Profeta's,  in  syphilis,  317 
Virchow's,  of  tumors,  346 

Lawn-tennis  arm,  718 


Index 


1499 


Le    Conte's    amputation    of    upper 

extremity,  141 1 
Le  Dentu's  tendon-suture.  734 
Le  Fort's  tendon-suture,  734 
Le  tour  de  poignet,  558 
Lead-water  in  inflammation,  100 
Leather-bottle  stomach,  958 
Leech,  artificial,  96,  97 
Leech-bite,   hemorrhage   from,   con- 
trol, 454 
Leeching  in  inflammation,  95 
Leg,  amputation  of,  1415.     See  also 
Amputation  of  leg. 
Barbadoes,  1251 
bow-,  740 
fractures  of,  609 
of  both  bones,  614 
compound,  613 
gangrene  of,   arteriovenous  anas- 
tomosis    for     prevention     and 
treatment,  183 
milk-,  186,  409 
moist  gangrene  of,  169 
riders',  718 

spiral  reversed  bandage,  1255 
ulcer  of,  acute,  152 
treatment,  153 
callous,  159 
chronic,  153 

treatment,  154 
exuberant,  157 
fungous,  157 
indolent,  157 
inflamed,  152 
varicose,  157 
varix  complicating,  157 
varicose  veins  of,  461.     See  also 
Varix  of  leg. 
treatment,  412 
Leiomyoma,  362 
Leiter's  tubes,  99 
Lejar's  tendon-suture,  734 
Lembert's  suture,  1077 
Leontiasis  ossea,  510 
Leptomeningitis,  798 
acute,  800 
chronic,  801 
primary,  800 
secondary,  800 
Leti^vant's  method  of  implantation 

of  nerves,  760 
Leukemia,  1251 

^c-rays  in,  1468 
Leukocytes  in  inflammation,  8r 
Leukocytosis,  42 

in  inflammation,  84,  92 
Leukolysin,  48 
Leukomains,  37 
Levis 's  splint,  675 

treatment  of  Colles'  fracture,  577 
Lewis's  cystoscope,  1307 

repositor,  1308 
Lexer's   method    of   arteriorrhaphy, 
444 
operation    for    Dupuytren's    con- 
traction, 738 
treatment  of  ankylosis,  652 
Lichen,  syphilitic,  325 
Ligament  of  Treitz,  1102 
Ligaments,  crucial,  of  knee,  rupture, 
649 
spinal,  injuries  of,  849 
Ligation  in  tabatiere,  471 
of  abdominal  aorta,  492 
of  anterior  tibial  artery,  484,  485 
of  arteries  in  continuity,  468 
of  axillary  artery,  473,  474 
of  brachial  artery,  472,  473 
of  common  carotid  artery,  479,  480 

ihac  artery,  489 
of  dorsahs  pedis  artery,  483 
of  external  carotid  artery,  481 

iliac  artery,  491 
of  facial  artery.  482 
of  femoral  artery,  487,  488 
of  gluteal  artery,  491 
of  iliac  arteries,  488 

after  abdominal  section,  489 
of  inferior  thyroid  artery,  477 
of  innominate  artery,  478 
of  internal  carotid  artery,  481 
Uiac  artery,  490 


Ligation  of  internal  pudic  artery,  492 
of  lingual  artery,  482 
of  occipital  artery,  483 
of  popliteal  artery,  486,  487 
of  posterior  tibial  artery,  485,  486 
of  radial  artery,  470,  471 
of  sciatic  artery,  492 
of  subclavian  artery,  475,  476 
of  superior  thyroid  artery,  482 
of  temporal  artery,  483 
of  thyroid  arteries  in  exophthalmic 

goiter.  1243 
of  ulnar  artery,  471,  472 
of  vertebral  artery,  476,  477 
Ligature  and  suture,  70,  439 
for  hemorrhage,  438 
operation  for  piles,  1181 
suture-,  439 
Lightning,  effects  produced  by,  147 1 
Ligneous  cancer,  1435 

phlegmon,  136 
Lilienthal's  operating  table,  59 

probe,  2S1 
Line,  Crampton's,  489 
McKee's,  489 
Nelaton's,  584 
of  demarcation  in  gangrene,  164, 

167 
omphalospinous,  1007 
Linea  alba,  hernia  of,  1160 
Lingual  artery,  ligation,  482 
Linguiform  lobe  of  liver,  1041 
Lip,  cancer  of,  923 

Grant's  operation  for,  394    924 
carbuncle  of,  925 
Lipoma,  352 
cavernous,  353 
diffuse,  353 
nevoid,  366 
of  brain,  810 
of  breast,  1429 
telangiectodes,  353 
treatment  of.  354 
Liquor  formaldehydi,  33 
Lisfranc's  amputation  at  shoulder- 
joint.  141 1 
of  foot,  1412 
Lister's  cyanid  gauze,   preparation, 
75 
method  of  excision  of  wrist-joint, 

700 
protective,  76 

tourniquet  in  aneurysm,  422 
treatment   of   old   traumatic   dis- 
locations. 659 
Liston's    amputation    at    hip-joint, 
1423 
modified  circular  amputation,  1405 
Lithiasis,  appendicular,  1003 
Lithiomercuric  iodid,  28 
Litholapaxy,  1333 
after-treatment,  1336 
contra-indications  to,  1333 
in  male  children,  1336 
Lithotomy,  1330 
lateral,  1330 

hemorrhage  after,  control,  455 
suprapubic,  1331 
Lithotrite,  Bigelow's,  1334 
Forbes's,  1334 
Thornpson's.  1334 
Lithotrity.  perineal,  1337 

rapid,  1333 
Litigation  backs,  851 
Littrd's  hernia,  1155,  1163 
Liver,  1032 

abscess  of,    144,    1035.     See  also 

Abscess  of  liver. 
cancer  of,  1033 
cancerous  cirrhosis  of,  1033 
cysts  of,  1033 
floating.  1039 
hydatid  cysts,  1034 
lacing  lobe  of,  1041 
linguiform  lobe  of,  1041 
lobe  of,  floating,  1040 
lacing,  1 04 1 
linguiform,  1041 
movable,  1039 
repair  of,  128 
rupture  of,  1032 
sarcoma  of,  1034 


Liver,  syphilis  of,  1034 

tuberculosis  of,  248 

tumors  of,  1033 

wounds  of,  1032 
Lizard,  poisonous,  bite  of,  300 
Lloyd's  rules  for  detecting  rigidity 

of  spine,  845 
Lobectomy,  1240 

for  goiter,  1235 
Lobular  mastitis,  chronic,  1426 
Lock -finger,  739 

Lockjaw.  203.     See  also  Tetanus. 
Locus  minoris  resistentiae,  36 
Longuet's   operation   for   hydrocele, 

1399 
Loose  bodies  in  joints,  654 

cartilages  in  osteo-arthritis,  641 
Lordosis,  844 

Lorenz's   bloodless   method   of  con- 
genital dislocation  of  hip,  710 

method  of  treatment  of  tubercu- 
losis of  hip-joint,  630 

operation   for   congenital   disloca- 
tion of  hip,  711 
Loreta's     operation     for    cicatricial 
stenosis  of  stomach,  970 
for  digital  dilatation  of  pylorus, 
1080 
Loretin,  32 

Lowman-Lambotte  bone-holding  for- 
ceps, 536 
Lowman's    combination    bone    and 

plate  holder,  536 
Liicke's    method    of   gastro-enteros- 

tomy,  1 09 1 
Lud wig's  angina,  181 

treatment,  182 
Luetin,  333 
Lumbago,  712 

Lumbar  abscess,  tuberculous,  242 
treatment  of,  246 

and  last  dorsal  vertebrae,  caries  of, 
Treves's  operation  for,  695 

colostomy,  11 23 

hernia,  1162 

nephrectomy,  1295 

puncture,  861 

in  hydrocephalus,  778 

triangle,  superior,  1162 
Lumpy  jaw,  309 
Lung,  abscess  of,  145,  901 

pneumotomy  for,  901,  912 
treatment,  148 

contusion  of,  896 

diseases  and  injuries,  890 

edema    of,    in    anesthesia,    treat- 
ment, 1204 

gangrene  of,  901 

pneumotomy  for,  912 

hemorrhage  from  control,  456 

operations  on,  904 

protrusion  of,  898 

rupture  of,  897 
Lund's  treatment  of  iliopsoas  bur- 
sitis, 731 
Lupus,  247 

exedens,  247 

hypertrophicus,  247 

syphilitic,  328 

vulgaris,  247 
Luxatio  erecta,  664 
Luxation.  655.    See  also  Dislocation, 
Luys's  urine  separator,  1270 
Lymph,  82 

aplastic,  87,  120 

coagulable,  117 

scrotum,  368 
Lymphadenitis,  1249 

acute,  1250 

cervical,  tuberculous,  250 

chronic,  1250 

compression  in,  100 

infective,  1249 

septic.  1249 
Lymphadenoma,  1251 
Lymphangiectasis,  368,  1250 

varicose,  1250 
Lymphangioma,  368,  1250 

cavernous,  368 

circumscriptum,  1250 
Lymphangitis,  1249 

capillary,  1249 


I500 


Index 


Lymphangitis,  reticular,  igS,  1249 

tubular,  1249 
Lymphatic  abscess,  141,  23s 
constitution,  225 
erysipelas,  200 

glands,    abscess    of,    tuberculous, 
treatment  of,  245 
cervical,  tuberculosis  of,  250 
diseases  and  injuries,  1248 
tuberculosis,  250 
varicose,  1250 
infection  after  appendicitis,  1009 
nevus,  368 
scrofula,  225 
thrombosis,  186 
tissue,  repair,  128 
warts,  1250 
Lymphatism,  225 
Lymphedema,  1250 
Lymphoma,  351 
malignant,  1251 
of  salivary  and  lachrymal  glands, 

915 
Lymphorrhea,  1250 
Lymphosarcoma,  370 

of  testicle,  1396 
Lymph-scrotum,  1251 
Lysins,  39 
Lysol,  33 
Lyssa,  304 
Lytic  antibodies,  39 


Macewen's  method  of  preventing 
hemorrhage   in   amputation    at 
hip-joint,  1419 
operation  for  genu  valgum,  688 

for  inguinal  hernia,  1139 
treatment      in      contractions      of 

muscles,  720 
triangle,  772,  830 
Mackenzie-Davidson   a;-ray   appara- 
tus, 1462 
Mackenzie's  operation  for  fistula  in 

ano,  117s 
Macroglossia,  368 
Maculae,  syphilitic,  323 
Madelung's   operation   for  varix   of 

leg,  462 
Madura-foot,  19 

Magazine  rifles  of  small  caliber,  284 
Maggots  in  wounds,  297 
Magnesium  sulphate  in  tetanus,  213 
Maisonneuve's  symptom  in  CoUes's 
fracture,  577 
urethrotome,  1367 

Horwitz's  modification,  1367 
Malar  bone,  fracture,  540 
Malaria,  131 

Malgaigne's    operation    for    harelip, 
917 
pads,  634 

treatment   of   fractures   of   costal 
cartilages,  545 
Malignant  disease,  fever  of,  132 
of  vermiform  appendix,  1014 
edema,  bacillus  of,  54 
endocarditis,  198 
Malingering  in  spinal  diseases,  851 
Mallein,  308 

Malleolus,  inner,  fracture  of,  610 
MaUet-finger,  739 
Malleus,  307 
Malplaced  testicle,  1391 
Mammary   artery,  internal,  hemor- 
rhage from,  control  of,  451 
gland,  1423.     See  also  Breast. 
Mammillitis,  1423 

Mandible,  traumatic  dislocation,  659 
Manges's   modified    Mackenzie-Da- 
vidson a;-ray  apparatus,  1462  _ 
Mannkopf's    sign    of    back    injury, 

849 
Maragliano's  serum  in  tuberculosis, 

234  .       ,  ,, 

Marchands  s  operation  for  movable 

liver,  1040 
Marcy's  buried  tendon  sutures,  75 
Marginal  abscess,  142 
Marie's  disease,  509,  644 
Marjolin's  ulcer,  159,  391 


Marks's  urethroscope,  1359 
Marmion's  treatment  of  hydroceph- 
alus, 779 
Marriage  in  syphilis,  34r 
Marsupialization,  403,  1034 
Martin's  bandage  in  ulcer,  156 
method  of  proctoscopy,  11 70 
speculum,  1167 
Marwedel's  incision  for  nephrotomy, 

1293 
Mask,  ecchymotic,  890 

Skinner's,  1197 
Mason's   pin   in   fractures   of   nasal 

bones,  537 
Massage,  heart,  in  anesthetic  poison- 
ing, 1203 
in  fractures,  529 
in  inflammation,  loi 
of  tuberculous  focus  in  diagnosis 
of  tuberculosis,  229 
Mastitis,  acute,  1424 
carcinoma,  1436 
chronic,  1425 
lobular,  1426 
Mastodynia,  1426 
Mastoid,  empyema  of,_  805 

suppuration,  operation  for,  830 
trephining,  828 
Matas's  drip,  1127 

operation  for  aneurysm,  426 

for  fractures  of  zygomatic  arch, 
541 
Mathews's  speculum,  11 66 

treatment  of  thrombotic  external 
hemorrhoids,  11 78 
MaunseU's     method     of     intestinal 
anastomosis,  mo 
operation  for  intussusception,  11 20 
Maxillary  antrum,  inflammation  and 
abscess,  878 
bone,  inferior,  fractures  of,  541 
superior,  fracture  of,  538 
Maydl's  method  of  inguinal  colos- 
tomy, 1 1 21 
of    intestinal    implantation    of 
ureters,  1300 
operation  for  exstrophy  of  bladder, 

1316  .       ,, 

Mayer's     dressing     for     Thiersch  s 

method  of  skin-grafting,  1264 
Mayo-Quenu    operation    for    rectal 

cancer,  1190 
Mayo's  method  of  anterior  gastro- 
enterostomy, 1093 
of      gastro-enterostomy,     iioi, 

1102 
of  nephrotomy,  1293 
of  pylorectomy,  1083 
operation  for  bunion,  732 

for  umbilical  hernia,  1148 
transgastric    method    of    excising 
ulcer     of     posterior     wall     of 
stomach,  968 
McArthur  drip,  11 26 
McArthur's     method     of     reaching 

pituitary  body,  834 
McBurney    and    Dowd's    fracture- 
hook,  531  .  . 
McBurney's  incision  in  appendicitis, 
1071 
interval  operation  in  appendicitis, 

1075 
method  of     duodenocholedochot- 
omy,  1130 
of  preventing  hemorrhage  in  am- 
putation at  hip-joint,  1419 
of   treating   unreduced   disloca- 
tions of  shoulder,  669 
point  in  appendicitis,  1002,  1007 
rule  in  appendicitis,  1017 
McCurdy's    operation    for    Dupuy- 

tren's  contraction,  738 
McGraw's  method  of  gastro-enter- 
ostomy, 109  s 
Mclntyre's    spHnt    in    fractures    of 
femur,  597 
>  of  leg,  61S 

McKee's  line,  489 

Meatus,   fish-mouth,   in   gonorrhea, 
1346 
I      occluded,  of  newborn,  treatment, 
I  1314 


Meatus  urinarius,  stricture  of,  treat- 
ment. 1366 
Meckel's  diverticulum,  402,  981 
hernia  of,  1155,  1163 
intestinal  obstruction  from,  982 
Mediastinum,  abscess  of,  145 
treatment,  148 
tuberculous,  242 
treatment  of,  245 
surgical  invasion,  943 
Medulla,  tumors  of,  816 
Medullary  cancer,  393 

sarcoma,  372 
Megacolon,  true,  1019 
Melanosis,  393 
Melanotic  cancer,  391,  393 

sarcoma,  373 
Meltzer  and  Auer's  method  of  intra- 
tracheal insufflation,  90s,  1199 
Membranous  perienteritis,  977 
Menard    and    Lannelongue's    treat- 
ment of  ununited  fractures,  535 
Meningeal   hemorrhage,   extradural, 
786 
subdural.  787 
Meninges,  spinal,  puncture  of,  861 
Meningitis,  798 
otitic,  804 

spinal,   chronic,   Horsley's  opera- 
tion for,  863 
tuberculous.  801 
Meningocele,  776,  835 
Robson's  treatment,  777 
spurious,  777 
Meningomyelocele,  835 
Mercier's  catheter,  1313 
Mercurial  fever,  130 
Mercurials  in  inflammation,  loi 
Mercury,  bichlorid  of,  27 
in  inflammation,  108 
in  syphilis,  336 
Mesenteric  arteries,  embolism  of,  190 
intestinal    obstruction    from, 
983 
rupture  of,  952 

thrombosis    of,    intestinal    ob- 
struction from,  983 
cysts.  402.  956 
glands,  tuberculosis  of,  in  children, 

1000 
vessels,  thrombosis  of,  187 
Mesoblastic  cystoma.  397 
Metacarpal  bones,  e.xcision  of,  702 
fractures,  580 

Russ's  splint  in,  581 
traumatic  dislocation,  674 
Metacarpophalangeal      articulation, 
traumatic  dislocation,  674 
joint,  disarticulation  at,  1407 
of  thumb,  traumatic  dislocation, 
674  _ 

Metachromatic  bodies,  20 
Metatarsal  bone  of  great  toe,  exci- 
sion of,  706 
Butcher's  method,  706 
bones,  fractures,  616 

traumatic  dislocation,  688 
Metatarsalgia,  74s 

Graham's  treatment  74s 
Metatarsophalangeal  articulation  of 

great  toe.  excision,  706 
Methylene-blue    test    for    excretory 

capacity  of  kidneys,  1272 
Meyer's    operation    for    cancer    of 
breast.  1442 
treatment  of  cardiospasm,  939 
Microbes,  17,  18 
Microbic  gangrene,  163 

acute,  170 
Microcephalus,  775 
Micrococcus,  21 
gonorrhoeae,  50 
pyogenes,  48 
teniiis,  49 
tetragenus,  49 
Micro-organisms,  17 
Microphyta,  18 
Microscopical    test    for    hematuna; 

1267 
Microzoaria,  18 
Micturition,  frequency  of,  1271 
slowness  of,  1271 


Index 


1501 


Middle  lobe,  362 
Migrating  abscess,  235 
Mikulicz's  bag,  78 

disease,  915 

instruments    for    esophagoscopy, 
931 

method  of  operatmg  for  gangrene 
in  intestinal  obstruction,  992 

operation  for  rectal  prolapse,  11 84 

treatment  of  ankylosis,  653 
Miliary  aneurysm,  417 

tuberculosis,  acute,  252 
Milk  abscess,  142 

cysts,  401 
Milk-leg,  186.  409 
Mills    and    Frazier's    operation    for 

paralysis  of  bladder,  1320 
Milzbrand,  300 
Mind-blindness  in  tumor  of  brain, 

81S 
Miners'  elbow,  731 
Mingazzini-Foerster     operation     in 

tabes,  862 
Mirault's  operation  for  single  hare- 
lip, 917 
Mitchell's    mixture    for    infiltration 

anesthesia,  1219 
Mixed  infection,  26 

spindle-cell  sarcoma,  372 

tumors,  373 
Mixter's  apparatus  for  skin-grafting, 
1263 

treatment  of  stricture  of  esopha- 
gus, 935 
Mobilization  of  thorax  in  pulmonary 

tuberculosis,  903 
Moebius's    sign     in     exophthalmic 

goiter,  1237 
Moist  gangrene,  163,  169 
from  inflammation,  170 
of  leg,  169 
treatment,  170 
Molds,  19 
Mole,  355 

congenital   pigmented,   malignant 
growth  from,  39s 

hydatid,  of  pregnancy,  362 

treatment  of,  357 
MoUities  ossium,  508 
MoUuscum  fibrosum,  355,  364 
Monks 's  method  of  locating  loop  of 
small  intestine,  951 

treatment  of  subacromial  bursitis, 
729 
Monococci,  21 
Monteggia's  dislocation,  680 
Moore's    dressing    in    fractures    of 
clavicle,  552 

treatment  of  CoUes's  fracture,  578 
Morbid  growths,  345 
Morbus  coxae,  625 
senilis,  642 

coxarius,  625 
senilis,  613 
Morgagni,   crypts  of  inflammation, 

1186 
Morning  drop  in  gonorrhea,  1348 
Moro's   cutaneous   tuberculin   reac- 
tion in  tuberculosis,  229 
Morphea,  357 
Morphinism,  fever  of,  131 
Morris's  measurement  in  fractures- of 
femur,  584 

method    of    palpating    vermiform 
appendix,  1009 

rule  in  operations  on  tumors  of 
bladder,  1330 
Mortification,  163 
Morton's  disease,  74s 

method  of  spinal  anesthesia,  1223 
Morvan's  disease,  724 
Moschchowitz's  operation  for  rectal 

prolapse,  11 84 
Mosetig-Moorhof's      treatment      of 

bone-cavities,  502 
Moskowicz's  method  of  determining 

viable  area  in  senile  gangrene,  168 
Mother's  marks,  365 
Motile  bacteria,  20 
Motion,  effect  on  bacteria,  24 
Motor  aphasia  in  tumor  of  brain,  815 

power  of  stomach,  testing,  973 


Motor   power  of    stomach,   testing, 
Ewald's  method,  974 
Klemperer's  method,  973 
Mouse  cancer,  385,  386 

eosin-selenium  in,  395 
Mouth,  gonorrhea  of,  1361 
injuries  and  diseases,  912 
mucous  cysts  of,  926 
preparation  of,  for  operation,  68 
Mouth-to-mouth  inflation,  864 
Movable  kidney,  1275 

liver,  1039 
Moynihan's  clamp,  1097 

method     of     gastro-enterostomy, 
1099 
of  intestinal  anastomosis,  iiii 
plan  of  treatment  in  intestinal  ob- 
struction, 991 
Mucopus,  13s 
Mucous  cystoma,  397 
cysts,  401 

of  mouth,  926 
erosions  of  stomach,  962 
erysipelas,  200 

glands  of  Nuhn  and  Blandin,  926 
membranes,  disinfection  of,  68 
inflammation,  86 

rest  in,  95 
of  bladder,  removal,  1128 
syphilitic  affections,  325 
wounds  of.  271 
patches,  syphilitic,  325 
polyps,  362 
Mulberry  calculus  in  bladder,  1320 
Muller's  law  of  tumors,  346 
treatment  of  flat-foot,  744 
Multiple  adenoma  of  Virchow,  982 
myeloma,  513 
neuritis,  747 
Mummification,  167 
Mumps,  914 
Murphy  and  Huguier's  treatment  of 

ankylosis,  652 
Murphy's   button,   anastomosis   by, 
1107 
gastro-enterostomy  by,  1096 
method  of  arteriorrhaphy,  443 

of  cholecystenterostomy,  1128 
operation    for    fractures    of  olec- 
ranon process  of  ulna,  569,  570 
plan  to  protect  nerves  from  scar 

invasion  after  suture,  760 
treatment  of  peritonitis,  1025 
Murray's  operation  for  ligating  ab- 
dominal aorta,  492 
Muscles,  atrophy  of,  713 
contractions  of,  720 
contusions  of,  717 
degeneration  of,  713 
diseases  and  injuries,  712 
dislocations  of,  720 
hernia  of,  720 
hypertrophy  of,  713 
operations  on,  732 
ossification  of,  713 
repair  of,  125 
rupture  of,  718 
spinal,  injuries  of,  849 
strains  of,  717 
syphilis  of,  713 
trichinosis  of,  713 
tuberculosis  of,  249 
tumors  of,  713 
wounds  of,  717 
Muscular    atrophy,    ischemic,    with 
contractures  and  paralysis,  714 
inflammation,  relaxation  in,  95 
rheumatism,  712 

rigidity  as  sign  of  inflammation,  92 
rupture     from     abdominal     con- 
tusion, 945 
spasm  in  fractures,  531 
Musculospiral     nerve,     injury,     in 
fractures  of  shaft  of  humerus,  559 
Musculus  sardonicus,  207 
Mushroom  abscess,  802 

bullet,  288 
Mustard,  33 
Myalgia,  712 
Mycelial  threads,  18 
Mycetoma,  19 
Mycosis,  19 


Mycosis  fungoides,  374 
Myelocele,  835 
Myeloid  sarcoma,  372 
Myeloma,  multiple,  513 
Myiasis,  297 
Myoma,  362 

intramural,  362 

submucous,  362 

subserous,  363 

treatment  of,  363 

uterine,  362 
Myositis,  713 

infective,  713 

ischemic,  714 

ossificans,  713 
Myxedema,  1228 

operative,  1228 
Myxoma,  361 

of  breast,  1429 

treatment  of,  362 
Myxosarcoma,  362,  373 


Nails,  diseases  of,  1226 

syphiUtic  affections,  326 
Narcosis  paralysis,  1208 
Nasal  bones,  fractures,  536 
Asch  tube  in,  537 
Jones's  spHnt  in,  538 
Mason's  pin  in,  537 
Nasopharyngeal  fibroma,  354 
Natiform  skull,  343 
Neck,  abscess  of,  deep,  144 
tuberculous,  242 

and    axilla,    figure-of-8    bandage, 
I2S9 

gangrenous  induration,  181 

hydrocele  of,  397 

region  of,  anatomy,  478 

sarcoma  of,  369,  370,  371 

triangles  of,  475 

anterior,  478 

posterior,  479 

Necrosis,  152,  167 

fat-,  of  pancreas,  1057 

of  bone,  495,  499 
acute,  496 
central,  500 
postfebrile,  501 
quiet,  SCO,  501 

of  jaw,  913 

phosphorus,  of  jaw,  913 

specific  serpiginous,  164 
Negri  bodies,  304 
Neisser's  bacillus,  50 

treatment  of  acute  gonorrhea,  1353 
Nekton's  catheter,  1315 

dislocation,  686 

line,  584 

probe,  280 

treatment  of  dislocation  of  lower 
jaw,  660 
Neoplasms,  345 
Neosalvarsan  in  syphilis,  341 
Nephrectomy,  1294 

abdominal,  1295 

for  movable  kidney,  1279 

in  children,  1296 

lumbar,  1295 

partial,  1296 
Nephrite     toxique     appendiculaire, 

ion 
Nephritic  colic,  1283 
Nephritis,    chronic,    operation    for, 

1 291 
Nephrolithotomy,  1294 
Nephropexy,  1279,  1296 
Nephroptosis,  127s 
Nephrorrhaphy,  1296 
Nephrostomy,  1292 
Nephrotomy,   1292 

for  calculus,  1294 
Nerve-grafting,  760 
Nerves,  anastomosis  of,  760 

contusion  of,  758 

diseases  of,  747 

implantation  of,  760 

inflammation  of,  747 

injuries  of,  747,  749 

of)erations  on,  758 

pressure  on,  758 

punctured  wounds,  758 


I502 


Index 


Nerves,  regeneration  of,  123,  124 
repair  of,  122 
section  of,  749 

symptoms,  749,  750 
in  anterior  crural,  755 
in  brachial  plexus,  750 
in  circumflex,  752 
in  external  popliteal,  736 
in  facial,  757 
in  great  sciatic,  75s 
in  internal  popliteal,  756 
in  lumbar  plexus,  755 
in  median,  753 
in  musculocutaneous,  752 
in  musculospiral,  752 
in  obturator,  755 
in  plantar,  756 
in  posterior  thoracic,  751 
in  radial,  752 
in  sacral  plexus,  7S5 
in  small  sciatic,  755 
in  superior  gluteal,  75s 
in  suprascapular,  752 
in  ulnar,  753 
treatment,  757 
tuberculosis  of,  248 
tubulization  of,  760 
wounds  of,  749 
Nerve-suture,  7s8 
Allis's  method,  760 
secondary,  759 
Nerve-trunk,  cocainization  of,  121 7 
Nervous  system,  syphilis  of,  327,  331 
Neuber's  treatment  of  bone-cavities, 
502 
of  knee-joint  disease,  632 
Neuralgia,  74 
intercostal,  712 
of  fifth  nerve,  alcohol  in,  763 

extracranial  operation  for,  762 
osmic  acid  in,  762 
removal    of    Gasserian    gan- 
glion   for,    765.      See    also 
Gasserian  ganglion. 
Rose's  method  of  neurectomy 
in,  764 
of  joints,  645 

of  stumps,  Senn's  treatment,  748 
treatment,  748 
Neurasthenia,  traumatic,  849 
Neurectasy,  760 
Neurectomy,  760,  761 

intracranial.  Abbe's  operation,  767 
of  inferior  dental  nerve,  762 
of  infra-orbital  nerve,  762 
of  supra-orbital  nerve,  762 
Rose's    method,    in    neuralgia    of 
fifth  nerve,  764 
Neuritis,  747    . 
multiple,  747 
optic.    See  Choked  disk. 
Neurofibroma,  364 
Neuroma,  364 
false,  364 
malignant,  364 
of  brain,  810 
plexiform,  364 
traumatic,  364 
Neuroparalytic  ulcer,  161 
Neuropathic  arthritis,  643 
Neuroplasty  by  flap  method,  759 
Neurorrhaphy,  758 
Neurotic  fever,  131 
Neurotomy,  760 

intracranial,  Frazier-Spiller  meth- 
od, 767 
Nevoid  lipoma,  366 
Nevohpoma,  353 
Nevus,  365,  413 
lymphatic,  368 
venous,  366 
Newborn,    intracranial    hemorrhage 
in,  788 
tetanus  of,  208 
Nicolaier's  bacillus,  %x 
NicoU's    method    of    perineal    pros- 
tatectomy, 1385 
Nipple,  cancer  of,  1427 
cysts  of,  1427 
epithelioma  of,  1427 
maUgnant  dermatitis,  1427 
Paget's  disease  of,  1427 


Nipple,  tumors  of,  1427 

Nitrogen    injection,    production    of 

artificial     pneumothorax     by,     in 

pulmonary  tuberculosis,  903 
Nitrous  oxid  gas  and  oxygen  anes- 
thesia, 1211 
as  anesthetic,  1211 

followed  by  ether,  1214 
Noci  influences  in  shock,  260 
Nodes  of  bone,  496 
Nodosities,  Heberden's,  641 
Noguchi's     cutaneous     reaction    in 

syphiHs,  333 
Noli  me  tangere,  159,  392 
Noma,  178 

pudendi,  178 

streptococcus  in,  51 

treatment,  179 
Nose  and  antrum,  diseases  and  in- 
juries, 877 

foreign  bodies  in,  877 

gonorrhea  of,  1362  '■ 

hemorrhage  from,  control,  453 

injuries  and  diseases,  912 

saddle-,  correction  of,  by  insertion 
of  plate,  1265 

syphilis  of,  329 
Nosophen,  32 
Novocain  anesthesia,  1218 
Nucleinic  acid,  34 
Nucleins,  34 
Nuhn  and  Blandin's  mucous  glands, 

926 
Nussbaum's  treatment  of  cutaneous 

erysipelas,  201 


Oberlander's  dilators,  1360 
ObUterative  appendicitis,  1005 

endarteritis,  415 

endo-aneurysmorrhaphy     without 
arterioplasty_,  426 
Obstetric  depressions  of  skull,  794 
Obturator  hernia,  1162 
Occipital  artery,  ligation,  483 

lobe,  tumors  of,  815 

triangle,  475,  479 
Ochsner's  operation  for  stricture  of 

esophagus,  937 
Odontoma,  360 

composite,  361 

epithelial,  361 

fibrous,  361 

follicular,  compound,  361 

radicular,  361 

treatment  of,  361 
O'Dwyer's  operation  of  intubation  of 

larynx,  884 
Ogston's  operation  for  flat-foot,  744 

for  genu  valgum,  68g 
O'Hara's  forceps  for  intestinal  anas- 
tomosis, II 12 
Oidiomycosis  of  skin,  311 
Oi'dium  albicans,  19 
Oil  cysts,  401 

Ointment,  Credo's,  of  silver,  32 
Olecranon  bursitis,  727,  731 
OOier-Thiersch     method     of     skin- 
grafting,  1263 
Omental  cysts,  955 

graft,  1079 
Omentopexy,   RansohoS's,   for  gas- 

troptosis,  1 1 04 
Omentum,  great,  torsion  of,  956 
Omphalectomy,  1148 
Omphalospinous  Une,  1007 
Onychia,  i?!27 

malignant,  1227 

syphilitic,  326 
Oophorectomy  in  cancer  of  breast, 

395,  1447 
Operating  table,  Boldt's,  60 

Lilienthal's,  59 

Operation,  gloves  for,  64 

preparation,  6s 

Landerer's  dry  method,  69 

on  diabetics,  6g 

preparation,  s8 
of  mouth,  68 
of  patient,  66 
of  rectum,  68 
of  urethra,  68 


Operation,    preparation  of     vagina, 
68 
prevention  of  shock  in,  261 
sterilization  of  hands,  62 
and  forearms,  63 
mechanical,  62 
time  of  day  for,  68 
Ophthalmia,  gonorrheal,  1346 

treatment  of,  1356 
Ophthalmo-tuberculin  reaction,  Cal- 

mette's,  in  tuberculosis,  228 
Opisthotonos,  207 
Opium  in  cancer,  395 
Opium-poisoning,  coma  of,  785 
Opsonic  index,  41 
Opsonins,  39,  41 
Optic  neuritis.    See  Choked  disk. 

thalamus,  tumors  of,  81  s 
Orange  pus,  135 
Orbital  abscess,  146 
treatment,  149 
Orchidectomy,  1396 

in  tuberculosis,  1395 
Orchitis,  1393 

gonorrheal,   1393 
Oriental  sore,  138,  1226 
Orrhotherapy,  44 
Orthopedic  surgery,  736 
Orthotonos,  207 
Os  calcis,  excision  of,  705 

by      subperiosteal      method, 
705 
fractures,  615 
osteophyte  of,  339 
magnum,    traumatic    dislocation, 
backward,  674 
Oscillation    and    stagnation    in    in- 
flammation, 81 
Osmic    acid    in    neuralgia    of    fifth 

nerve,  762 
Ossification  of  muscles,  713 
Osteitis,  495 
caseous,  498 
deformans,  510 
pearl  workers',  495 
Osteo-arthritis,  640 
of  hip-joint,  642 
treatment  of,  642 
Osteo-arthropathie    hypertrophiante 

pneumique,  644 
Osteoma,  358 
cancellous,  358 
compact,  358 
of  brain,  810 
of  femur,  358 
of  humerus.  359 
treatment  of,  360 
Osteomalacia,  508 
Osteomyelitis.  503 
acute  infective,  503 
of  vertebrae,  839 
chronic,  507 
of  femur,  508 
of  tibia,  507 
pyogenic,  503 
tuberculous,  249,  494 
Osteoperiostitis,  495 
diffuse,  496 
syphilitic,  330 
Osteophyte,  359 
of  OS  calcis,  359 
of  retrocalcaneal  bursa,  359 
Osteoplastic  periostitis,  496 

resection  of  skull,  827.     See  also 
Skull,  osteoplastic  resection. 
Osteopsathyrosis,  519 
Osteosarcoma,  371,  372,  373 
Osteotome,  688 
Osteotomy,  688 
cuneiform.  688 
for  bent  tibia,  689 
for  faulty  ankylosis  of  hip-joint, 
689 
of  knee-joint,  6go 
for  genu  valgum,  688 
for  hallux  valgus,  691 
for  talipes  equinovarus,  691 
Barker's  operation,  691 
equinus,  691. 

Davy's  method,  691 
for  vicious  union  of  fracture,  691 
linear,  688 


Index 


1503 


Osteotomy  of  shaft  of  femur  below 
trochanters,  690 
Gant's  operation,  6go 
through  neck  of  femur,  6go 

Adams's  operation,  690 
with  osteotome,  690 
Otis's  urethrotome,  1308 
Otitic  meningitis,  804 
Otitis  media,  brain  disease  from,  804 
Oval  amputation,  1406 
Ovary,  hernia  of,  1164 

inflammation  of,  pain  in,  89 
tuberculosis  of,  252 
Owen's  operation  for  double  harelip, 

918 
Oxygen,  effect  on  bacteria,  24 
Ozena,  syphilitic,  329 


Pachymeningitis,  798 
externa,  799 
interna,  799 

haemorrhagica,  799 
Packs,  77 
gauze,  77 
Halsted's,  77 
Pads,  77 
Ashton's,  77 
gauze,  77 
of  Malgaigne,  634 
Paget's  abscess,  142,  239,  250 
disease,  391,  510 

of  nipple,  1427 
Pain,  expression  in,  90 

hunger-,  in   peptic  ulcer  of  duo- 
denum, 995 

in  ulcer  of  stomach,  963 
in  fractures,  519 
in  genito-urinary  diseases,  1271 
in  wounds,  259 

from  rifle-bullets,  291 
of  colic,  go 
of  coxalgia,  89 
of  hepatitis,  89 
of  inflammation,  88 

of  anus.  89 

of  epididymis,  89 

of  eye,  8q 

of  Fallopian  tubes,  89 

of  neck  of  bladder,  89 

of  ovaries,  8g 

of  prostate,  89 

of  pyelitis,  8g 

of  rectum,  89 

of  renal  calculus,  89 

of  sacro-iliac  joint,  89 

of  testicle,  89 

of  uterus,  89 

referred,  89 

sympathetic,  89 
Palate,  cleft-,  916.     See  also  Cleft- 
palate. 
hard,  closure  of  clefts  in,  921 
soft,  suture  of,  operation  for,  920 
Pale  granulations,  120 
Palmar  abscess,  146,  721 

arch,  hemorrhage  from,  rules  for 

arresting,  450 
psoriasis,  324 
Pancoast's  tourniquet,  1418 
Pancreas,  cyst  of,  1055 
diseases  of,  1054 

Cammidge's  reaction  in,  1058 
displacement  of,  1057 
fat-necrosis  of,  1057 
gunshot-wounds,  1054 
injuries  of,  1054 
pseudocysts  of,  1061 
rupture  of,  1054 
tuberculosis  of,  249 
tumors  of,  1062 
wounds  of,  1054 

during   operations   on   stomach 
and  spleen,  1056 
Pancreatic  calculi,  1061 
cysts,  1061 
fistula,  1056 
Pancreatitis,  1057 
acute,  1058 
chronic,  1060 
forms  of,  1058 
hemorrhage  in,  1058 


Pancreatitis,  subacute,  1059 
Pannous  synovitis,  621 
Pantophobia,  305 
Papilloma,  379.    See  also  Warts. 
of  bladder,  1328 
of  breast,  1429 
Papular  syphilids,  324 
Papules,  humid,  324 

moist,  324 
Paquelin  cautery,  449 

in  inflammation,  105 
Paracentesis  auriculi,  459 
pericardii,  459 
thoracis,  906 
Paraffin,  subcutaneous  injection,  for 
prosthetic  purposes,  1264 
worker's  cancer,  390 
Paraffinoma,  1264 
Paralysis,  brachial  birth,  751 
operation  for,  769 
crawling,  852 
crossed,  816 

facial,  operation  for,  768 
in  Pott's  disease,  847 
in  spinal  injury,  853 
infantile    cerebral,    epilepsy    fol- 
lowing, operative  treatment,  823 
ischemic,  714 
laceration,  751 
narcotic,  1208 
of  bladder,  1319 

intradural  root  anastomosis  in, 
862 
of  serratus  magnus  muscle,  663 
postanesthetic,  1208 
pseudohypertrophic,  713 
Volkmann's,  714 
Paralytic  calcaneus,  astragalectomy 
in,  706 
flat-foot,  742 
rabies,  305 
Paranoia,   non-traumatic,   operative 

treatment,  824 
Paraphimosis  in  gonorrhea,  1347 

treatment,  1355 
Paraphlebitis,  409 
Parasites,  facultative,  20 
obligate,  20 
potential,  67 
Parasitic  bacteria,  20 
cysts,  402 
fetus,  398 

theory  of  cancer,  385 

of  tumors,  348 

Parasyphilitic  lesions,  332 

phenomena,  344 
Parathyroid  glands,  1244 
accessory,  1244 
tetany  after  removal,  1244 
transplantation  of,  1245 
tumor  of,  1245 
Paratrimma,  181 

Paresis,  operative  treatment,  824 
Parietal  lobe,  tumors  of,  815 

pleura,  decollement  of,  in  abscess, 
912 
Parietocolic  sinus,  103 1 
Parker's    incision    in    appendicitis, 

1075 
Parkhill's  clamp  for  ununited  frac- 
ture, 536 
Paronychia,  724,  1227 

syphilitic,  326 
Parotitis,  914 
epidemic,  914 
sympathetic,  915 
Pasteur's     method     of    vaccinating 
animals  against  anthrax,  301 
treatment  of  hydrophobia,  306 
Patella,   compound   fracture,   treat- 
ment, 533 
floating,  617 
fractures  of,   601,   602.     See  also 

Fractures  of  patella. 
traumatic   dislocation,    683.      See 
also    Dislocation,    traumatic,    of 
patella. 
Patient,  preparation  of,  for  opera- 
tion, 66 
Paul's  tube,  1121 

Payr's  treatment  of  hydrocephalus, 
779 


Pearl  tumor,  357 
of  brain,  810 

workers'  osteitis,  49s 
Peau  d'orange,  1434 
Pelvis,  false,  fractures  of,  547 

fractures  of,  547 

of  kidney,  bleeding  from,  1267 

traumatic  dislocation,  67.'; 

true,  fractures  of,  547 
Wood's  rule  in,  548 
Penis,  amputation  of,  1374 

cancer  of,  1374 
treatment,  394 

diseases  and  injuries,  1339 

fracture  of,  1374 

gangrene  of,  1374 
Peptic  ulcer  of  duodenum,  994 

of  jejunum  after  gastro-enteros- 

tomy,  1089 
of  stomach,  961 
Perforated  typhoid  ulcer,  997 
Perforating    sigmoiditis,    treatment, 
1018 

ulcer,  i6i 
Perforation  in  gastric  ulcer,  965,  966 
operation  for,  968 

in  intestinal  tuberculosis,  1000 

in  peptic  ulcer  of  duodenum,  996 
Perforative  peritonitis,  1023 
Perhydrol,  30 

Peri-anal  inflammation,  1172 
Periarteritis,  415 

Pericardial   effusion,    operation    for,, 
460 

sac,  tapping,  459 

suppuration,  operation  for,  460 
Pericardiotomy  in  pericarditis,  408 
Pericarditis,  407 

traumatic,  405 
Pericardium,  tuberculosis  of,  249 

wounds  of.  404 
Pericystic  abscess,  104s 
Perienteritis,  membranous,  977 
Perigastric  abscess,  965 

adhesions,  971 
Perineal  bruises,  1340 

fistula    in    stricture    of    urethra, 
treatment,  1368 

hernia,  11 62 

lithotrity,  1337 

prostatectomy,    1382,    1385.     See 
also  Prostatectomy,  perineal. 

section,  1370 

Cock's  operation,  1371 
Syme's  operation,  1370 
_  Wheelhouse's  operation,  1371 
Perinephric  abscess,  145,  1288 

treatment,  149 
Perinephritis.  1288. 
Perineum,  T-bandage,  1260 
Periosteal  bridge,  523 
Periostitis,  495 

acute,  simple,  496 

chronic,  496 

in  tertiary  syphilis,  329 

osteoplastic,  496 
Perirectal  inflammation,  1172 
Perirenal  abscess,  1288 
Peritoneal  shock,  945 
Peritoneum,  1021 

rupture  of,  94s 

toilet  of,  after  abdominal  section,. 
1068 

tuberculosis  of,  248 
Peritonism,  945 
Peritonitis,  acute,  1021 

ascitic,  1028 

aseptic,  102 1 

caseous,  1028 

circumscribed  suppurative,  1022- 
treatment.  1027 

diffuse  septic,  1023 
suppurative,  1023 

fibrinoplastic,  1028 

forms,  1022 

Fowler's  position  in,  1025 

gonorrheal,  1346 

Murphy's  treatment,  1025 

perforative,  1023 

pneumococcus,  1030 

treatment,  1024 

tuberculous,  248,  1027 


I504 


Index 


Peritonitis,  tuberculous,  acute  form, 
1029 
chronic  form,  1028 

Peri-urethritis   in   gonorrhea,   treat- 
ment, 1350 

Perivascular  tissues,  changes  in,  in 
inflammation,  84 

Pernio,  315 

Peroneus     brevis     muscle,     subcu- 
taneous tenotomy  of  tendon  of, 
733 
longus  muscle,  subcutaneous  ten- 
otomy of  tendon  of,  733 

Peroxid  of  hydrogen,  30 

Pes  cavus,  744 

planus,  742.     See  also  Plat-fool. 

Petechia,  258 

Petit 's  tourniquet,  1402,  1403 
triangle,  1162 

Petrosal  sinus,  infective  thrombosis 
of,  807 

Phagedena,  180,  321,  1373 
sloughing,  171 

Phagedenic  ulcer,  153,  159 

Phagocytes.  40,  41 

Phagocytosis,  38,  41 
artificial  stimulation,  42 

Phalanges,  excision  of,  702 
fractures  of,  581 
of  toes,  fractures,  616 
traumatic  dislocation,  675,  688 

Phantom    tumor   of   intestine,  983, 
988 

Pharyngeal  diverticulum,  400 

Pharynx,  burns  and  scalds,  313 
foreign  bodies  in,  880 

Phelps's  operation  for  talipes,  741 
for  varix  of  leg,  462 

Phenolsulphonephthalein  test  for  ex- 
cretory capacity  of  kidneys,  1273 

Phillips's  catheter,  1315 

Philogenetic  association,  261 

Phimosis,  1374 

complete,  treatment  of,  1314 
in  gonorrhea,  1347 
treatment,  135s 

Phlebectasia,  410.    See  also  Varicose 
veins. 

Phlebectasis,  410.    See  also  Varicose 
veins. 

Phlebitis,  408 
acute,  408 
chronic,  410 
infective,  408 
plastic,  408 
postoperative,  409 

Phlebolith,  186,  412 

Phleborrhaphy,  440 

Phlebosclerosis,  410 

Phlebotomy,  462 

in  inflammation,  105 

Phlegmasia  alba  dolens,  186,  409 

Phlegmatic  scrofula,  225 

Phlegmon,  gaseous,  170 
ligneous,  136 
of  tendon-sheaths,  721 
peri-urethral,  in  gonorrhea,  1347 
wooden,  136 

Phlegmonous     cholecystitis,     acute, 
104s 
suppuration,  136 

Phloridzin  test  for  excretory  capac- 
ity of  kidneys,  1272 

Phosphorus  necrosis  of  jaw,  913 

Phthisis,  syphilitic,  331 

Physiological  block,  260,  262,  1196 

Pick's  treatment  of  fractures  of  olec- 
ranon process  of  ulna,  569 

Picric  acid  treatment  of  bums,  314 

Pig  skin,  1434 

Pilcher's  treatment  of  CoUes's  frac- 
true,  578 

Piles,  411,  1177.     See  also  Hemor- 
rhoids. 

Pirogoflf's  amputation  at  ankle-joint, 
1414 

Pirquet's  cutaneous  tuberculin  reac- 
tion in  tuberculosis,  229 

Pitchblende,  1469 

Pituitary  body,  methods  of  reaching, 
833 

Placental  infection,  26 


Plantar   fascia,   subcutaneous   fasci- 
otomy  of,  733 

psoriasis,  324 
Plantaris  muscle,  rupture  of.  719 
Plaster-of-Paris  bandage,  1260 
Plastic  exudation,  82 

inflammation,  86 

operations  on  chest  wall  for  pul- 
monary tuberculosis,  903 

phlebitis,  408 

resection  of  breast,  1429 

surgery,  1261 
Plate  cocci,  21 
Pleura,  diseases  and  injuries,  890 

operations  on,  904 

parietal,  decoUement  of,  in  abscess, 
912 

pulmonary,   discission  of,   Ranso- 
hoff's  operation,  893,  912 

tuberculosis  of,  248 
Pleural  epilepsy,  909 

fistula,  892,  893 

sac,  aspiration  of.  906 
exploratory  puncture,  906 
Pleurectomy,  total,  911 
Pleuritic  effusion,  890 
Pleuritis,  rest  in,  94 

traumatic,  896 
Pleurodynia,  712 
Pleuropneumo lysis .  thoracicoplastic , 

with  subcostal  apicolysis,  904 
Pleurosthotonos,  207 
Plexiform  angioma,  366 

neuroma,  364 

sarcoma,  373 
Plexus,  brachial,  avulsion  of,  750 
Alexinsky's  treatment,  751 
Frazier's  treatment,  751 
rupture  of.  750 
Plummer's  test  for  diverticulum  of 

esophagus,  940 
Pneumatocele,  cranial,  774 
Pneumectomy  in  pulmonary  tuber- 
culosis, 903 
Pneumococcemia,  53 
Pneumococcus,  53 

arthritis,  638 

peritonitis,  1030 

septicemia,  1030 
Pneumonia,  abdominal  type,  1012 

embol'c,  septic,  190 

ether-,  1206 

postoperative,  1206 

traumatic,  896 
Pneumothorax,  acute  traumatic,  895 

artificial,   in   pulmonary   tubercu- 
losis. 903 
operation  for  creating,  907 

non-traumatic,  894 
Pneumotomy   for   abscess    of   lung, 
901,  912 

for  gangrene  of  lung,  91 2 _ 

in  pulmonary  tuberculosis,  902 
Point.  Barker's.  772 

McBumey's,  in  appendicitis,  1002, 
1007 

of  least  resistance,  36 
Pointing  of  abscess,  135.  141 

of  tuberculous  abscess,  239 
Points  douloureux,  90 
Poisoned  wounds,  294 
Poisoning,  anesthetic,  heart  massage 
in,  1203 

bismuth-,  624 

cocain-,  1217 
fever  of,  131 

corrosive  sublimate,  28 

delayed,  after  anesthesia,  1207 

from  carbolic  acid.  29 

from  carbon  monoxid,  874 

from  coal-gas,  874 

from  illuminating  gas,  874 

iodoform-,  31 

ivy-,  1226 

opium-,  coma  of,  78s 

ptomain-,  37 

strychnin-,    tetanus    and,    difier- 
entiation,  209 
Poisonous  lizard,  bite  of,  300 

spider,  bites  of,  296 
Polydactylism,  739 
Polyps,  fleshy,  363 


Polyps,  gelatinous,  362 

mucous,  362 

of  intestine,  1000 
Poncet's   method  of   tendon-length- 
ening, 734 

rheumatism,  250 

tuberculous  arthritis,  619 
Pons,  tumors  of,  816 
Popliteal  artery,  ligation,  486,  487 

space,  abscess  of,  146 
Portal  pyemia,  197,  1036 
Port-wine  stains,  365 
Position,  Starck's,  932 

Trendelenburg,  1067 
Positive  pressure  apparatus,  90s 
Postanal  dimple,  836 

gut,  1165 
Postanesthetic  paralysis,  1208 
Postfebrile  gangrene,  183 
Postepileptic  coma,  785 
Postfebrile  necrosis  of  bone,  501 
Posthemiplegic    epilepsy   oJE    adults, 

operative  treatment,  823 
Postoperative  insanity,  807 

intestinal  obstruction,  983 

phlebitis,  409 

rise  of  temperature,  129 
Postpharyngeal  abscess,  tuberculous, 
241 
treatment  of,  246 
Potential  parasites,  67 
Pott's  aneurysm,  432 

disease,  844 

bone-grafting  in,  860 
paralysis  in,  847 

fracture,  612 

Bryant's  splint  in,  613 
compound,  614 
Dupuytren's  splint  in,  613 
Heath   and    Selby's   treatment, 

614 
Stimson's  splint  in,  613 

gangrene,  166 

puffy  tumor,  774 
Poultice,  antiseptic,  in  inflammation, 
102 

in  inflammation,  103 

sedative,  in  inflammation,  103 
Pox,  316.    See  also  Syphilis. 
Precancerous  stage  of  cancer,  384 
Precentral  sulcus,  771 
Precipitins.  39 

Prefrontal  region,  tumors  of,  814,  815 
Pregnancy,  appendicitis  in,  1014 
treatment.  .1018 

hydatid  moles  of.  362 
Pregnant    uterus,    gunshot-wounds, 

955 
Presenile  spontaneous  gangrene,  165 
Pressure  apparatus,  positive,  905 

gangrene,  164 

on  nerves,  758 

stasis,  890 
Preventive  inoculations,  43 
Primary  union,  116 
Probang,  Gross's,  942 
Procidentia,  1183 
Proctitis,  1172 
Proctoclysis,  1025 

apparatus,  1025 

in  shock,  263,  264 
Proctoscope,  Tuttle's,  1169 
Proctoscopy,  1166 

Martin's  method,  11 70 
Proctotomy  in  rectal  stricture,  1187 
Profeta's  immunity  in  syphUis,  317 
Projectiles,  283 

culminating  point,  287 

danger-zone,  286,  287 

drift  of,  286 

explosive  effect,  290 

influence  of  air-resistance  on,  286 
of  gravity  on,  286 

initial  velocity,  285 

mechanics  of,  285  _ 

motion  of  translation,  28s 

movement  of  rotation,  286 

muzzle  velocity,  285 

point  of  first  catch  for  cavalry,  287 
for  infantry,  287 

power  of,  to  wound,  288 

remaining  velocity,  286 


Index 


1505 


Projectiles,  resistance    encountered, 
288 
sectional  density,  286 
small,  nature  of  wounds  inflicted 

by,  2S8 
spin  of,  286 
trajectorj'  of,  286 
velocity  of,  2S5 
wind  contusions  from,  291 
Prolapse  of  anus,  1182 
of  brain,  797 
of  kidney,  1275 
of      rectal     mucous     membrane, 

1182 
of  rectum,  1182 
complete,  11  S3 
incomplete,  1182 
Prostate,  abscess  of,  146 

in  gonorrhea,  treatment,  1356 
treatment,  150 
cancer  of,  1390 
diseases  and  injuries,  1339 
hemorrhage  from,  1270 

control,  454 
hypertrophy  of,   1378.     See  also 

Hypertrophy  of  prostate. 
inflammation  of,  1376,  1377.     See 

also  Prostatitis. 
malignant  disease,  1390 
sarcoma  of,  1390 
tuberculosis  of,  1391 
latent,  1393 
Prostatectomy,  perineal,  1382,  1385 
Alexander's  method,  1386 
Bryson's  method,  1386 
NicoU's  method,  1385 
Young's  method,  1386 
suprapubic,  1382,  1384 
Belfield's  method,  1385 
Freyer's  method,  1384 
Fuller's  method,  13S5 
Prostatic  masseur,  Dufaux's,  1375 
Prostatitis,  acute,  1376 
chronic,  1348,  1377 
in  gonorrhea,  treatment,  1356 
pain  in,  8g 
Prostatorrhea,  1348,  1377 
Prostatotomy,  1382 

Bottini's  galvanocaustic,  1387 
Protargol,  33 
Protective,  76 
inoculations,  43 
Lister's,  76 
Protein,  bacterial,  37 

defensive,  38 
Protonuclein.  34 
Protozoa,  infections  by,  55 
Protrusion  of  lung,  898 
Proud  flesh,  120 
Pruritus  of  anus,  11 76 
Psammoma,  357,  374 
Pseudo-arthrosis  in  fractures,  527 
Pseudocysts  of  pancreas,  1061 
Pseudodichotomy  of  bacilli,  22 
Pseudo-elephantiasis,  1231 
Pseudohypertrophic  paralysis,  713 
Pseudoleukemia,  1251 
Pseudo-obstruction  of  intestine,  983 

of  brain,  809 
Psoas  abscess,  142 
tuberculous,  241 
treatment  of,  246 
muscle,  strain  of,  717 
Psoriasis,  palmar,  324 

plantar,  324 
Psorosperm,  350 
Psorospermosis,  350 
Psychic  anesthetist,  1220 
Pterion,  769 
Ptomain-poisoning,  37 
Ptomains.  37 
Ptyahsm,  fever  of,  130 

in  syphilis,  338 
Pudendal  hernia,  1162 
Pudic  artery,   internal,   ligation   of, 

492 
Puerperal  erysipelas,  199 
Puffy  tumor.  Pott's,  774 
Puknonary    decortication.    Fowler's 
operation,  911 
embohsm,  190 
occluding,  Sgg 

95 


Pulmonary  pleura,  discission  of  Ran 
sohoff's  operation,  893,  912 

tuberculosis,  248 

fever  due  to  awakening  of  area 

of,  130 
surgical  treatment,  902 
Pulmotor,   artificial   respiration   by, 

867 
Pulpy     degeneration     of     synovial 

membrane,  250,  618,  620 
Pulsating  empyema,  892 

goiter,  1235 
Pulse  in  inflammation,  112 
Puncture,    exploratory,    of    pleural 
sac,  906 

in  inflammation,  95 

lumbar,  861 

in  hydrocephalus,  778 

of  spinal  meninges,  861 
Punctured  wounds,  273 
Purpuric  gangrene,  164 
Purulent  effusion,  140 

infiltration,  136,  140,  202 
Pus,  133 

aseptic,  133 

blue,  135 

caseous,  133,  236 

concrete,  135 

curdy,  135,  236 

fibrinous,  135 

forms  of,  135 

gummy,  135 

healthy,  135 

ichorous,  135 

in  general,  134 

laudable,  133 

malignant,  135 

microbes,  48 

orange,  135 

red,  13s 

sanious,  135 

scrofulous,  133,  236 

serous,  13s 

spurious,  133 

stinking,  135 

tuberculous,  135,  214 

watery,  13  s 
Pustular  syphilids,  325 
Pustule,  maUgnant,  300,  302 
Putrefaction,  34,  194 
Putrefactive  bacteria,  20,  55 
Putrid  intoxication,  194 
Pyelitis,  1287 

in  gonorrhea,  treatment,  1356 

pain  of,  89 
Pyelography,  1459 

in  movable  kidney,  1278 
Pyelolithotomy,  1294 
Pyelonephritis,  1287 
Pyelotomy  for  renal  calculus,  1294 
Pyemia,  197 

arterial,  198 

portal,  197,  1036 

streptococcus  of,  50 

symptoms,  198 

treatment,  198 
Pyemic  abscess,  142 
Pylephlebitis,  septic,  188 
Pylorectomy,  1082 

Billroth's  method,  1083 

for  cancer,  961 

Mayo's  method,  1083 
Pylorodiosis,  1080 
Pyloroplasty,  Finney's,  1081 

Heineke-MLkulicz,  1080 
in  cicatricial  stenosis,  970 
Pylorus,  cancer  of,  treatment,  394 

congenital   hypertrophic   stenosis, 
970 

digital    dilatation,    for    cicatricial 
stenosis,  1080 

excision  of,  1082 
Pyogenic  bubo,  146 

osteomyelitis,  503 
Pyonephrosis,  1289 


Quadriceps  extensor  femoris  ten- 
don, rupture  of,  719 

Quenu-Mayo  operation  for  rectal 
cancer,  1190 

Quiet  necrosis  of  bone,  500,  501 


Quilled  suture,  271 
Quincke's  lumbar  puncture,  861 
Quinin-urea  hydrochlorid  anesthesia, 
1218 


Rabic  tubercle,  305 

Rabies,  304 

paralytic,  305 
Rachischisis,  835 
partial,  835 
total,  83s 
Rachitic  beads,  254 
Rachitis,  252.    See  also  Rickets. 
Racket  amputation,- 1403,  1406 
Radial  arter>',  ligation,  470,  471 
Radiotherapy,  1470 
Radio-ulnar     articulation,     inferior, 

traumatic  dislocation  at,  673 
Radish-fracture,  515 
Radium,  1469 
actions  of.  1469 
effect  of,  on  bacteria,  24 
on  tissues,  1469,  1470 
in  cancer,  395,  1470,  1471 
in  epithelioma,  1470 
in  sarcoma,  379 
rays,  1469 
therapy,  1470 
working  unit,  1470 
Radius  and  ulna,  traumatic  disloca- 
tion, 670,  671 
fractures  of,  571.     See  also  Frac- 
tures of  radius. 
head  of,  excision,  700 

subluxation.  672 
traumatic  dislocation,  671,  672 
Railway  spine,  850 
Ransohoff's  method  of   discission  of 
pulmonary  pleura,  893,  912 
omentopexy  for  gastroptosis,  1104 
Ranula,  401.  926 
Rattlesnake,  bite  of,  297,  299 
Ray-fungus,  19,  309 
Raynaud's  disease,  172 
treatment,  174 
gangrene,  164,   173 
treatment,  174 
Reaction,  Herxheimer's,  in  syphilis, 

338 
Receptaculum  chyli,  rupture  of,  1248 
Rectal  ballooning,  985 
etherization,  1200 
insufflation  of  hydrogen,  948 
mucous    membrane,    prolapse    of, 

1182 
speculum,  Brinkerhofi's,  1167 
Cook's,  1x58 
Kelly's,  1169 
Martin's,  11 67 
Mathews's,  1166 
Sims',  1167 
tubes,  passage  of,  1171 
Rectitis,  rest  in,  93 
Rectum,  cancer  of,  1187.     See  also 
Cancer  of  rectum. 
diseases  and  injuries,  1165 
examination  of,  1166 
foreign  bodies  in,  1171 
gonorrhea  of,  1361 
hemorrhage  from,  control,  454 
inflammation  of,  1172 

pain  in,  89 
Kelly's  method  of  examining,  1168 
preparation  of,  for  operation,  68 
prolapse  of,  1182 
complete,  1183 
incomplete,  1182 
stricture  of.  non-cancerous,  1186 
tumors  of,  benign,  1185 
ulcer  of,  1185 
dysenteric,  1185 
simple,  1185 
sjrphilitic,  1185 
tuberculous,  1185 
wounds  and  injuries,  11 71 
Red  infarction,  189 
pepper  grains,  309 
pus,  13s 
thrombus,  185 
Redressement  in  ankylosis,  651 
Reef-knot,  439,  469 


i5o6 


Index 


Reflex  epilepsy,  operative  treatment, 

821 
Regeneration  of  nerves,  123,  124 
Regional  anesthesia,  1218 
Regurgitation    after   gastro-enteros- 

tomy,  1090 
Reid's  treatment  of  aneurysm,  423 
Reminders,  syphilitic,  317,  327 
Renal.     See  Kidney. 
Renipuncture,  1296 
Repair,  us 

albuminuria  obstructing,  116 

by  blood-clot,  117 

by  first  intention,  116 

by  granulation,  117 

by  second  intention,  117 

by  third  intention,  120 

diabetes  obstructing,  116 

of  blood-vessels,  127 

of  bone,  126 

of  brain,  124 

of  compound  fractures,  S25 

of  fractures,  523 

of  kidney,  128 

of  liver,  128 

of  lymphatic  tissue,  128 

of  muscle,  125 

of  nerves,  122 

of  simple  fractiires,  523 

of  skin,  128 

of  spinal  cord,  1 24 

of  spleen,  128 

of  subcutaneous  wounds,  121 

of  tendon,  126 

of  testicle,  128 

of  wounds  in  non-vascular  tissues. 

122 
primary  union,  116 
Reptiles,  bites  of,  296,  297 
Resection  of  intestine  with  approx- 
imation    by    circular    enteror- 
rhaphy, 1105 
of  rib,  707 
osteoplastic,  of  skull,  827.    See  also 

Skull,  osteoplastic  resection. 
plastic,  of  breast,  1429 
Residual  abscess,  142,  237,  239 
of  Paget,  239,  250 
urine,  1312 

in  prostatic  hypertrophy,  1379 
Resistance  to  bacteria,  37 
vital,  to  infection,  42,  43 
Respiration,  artificial,  864 
by  pulmotor,  867 
Hall's  method,  867 
Howard's  method,  866 
Laborde's  method,  867 
mouth-to-mouth,  864 
prone  method,  866 
Schafer's  method,  866 
Sylvester's  method,  865 
Respiratory    disorders    after    anes- 
thesia, 1206 
organs,  surgery  of,  863 
Rests,  adrenal,  379 

fetal,  347 
Retained  testicle,  1391 
Retention  of  urine,  131 2 
acute,  131 2 

from    expulsive    defect,    treat- 
ment, 1315 
in  gonorrhea,  treatment,  1356 
incontinence  of,  1312 
theory  of  immunity,  38 
Retention-cysts,  400 
Retrenchment,  1262 
Retrocalcaneal  bursa,  osteophytes  of, 
359 
bursitis,  726 
Retrocecal  fossae,  hernia  into,  1162 
Retroduodenal         choledochotomy, 
1131 
fossae,  hernia  into,  11 62 
Retromammary  abscess,  1425 
Retroperineal  hernia,  1162 
Retropharyngeal  abscess,  acute,  144 
treatment,  149 
tuberculous,  241 
Reverdin's  method  of  skin-grafting, 

1262 
Revolver  bullet,  wounds  from,  277 
of  brain  from,  796 


Rhabdomyoma,  362,  372  1 

Rheumatic  arthritis,  acute,  639 
fever,  639 
gout,  640 
partial,  642 

of  hip-joint,  642 
progressive,  641 
torticollis,  712 
Rheumatism,  acute,  639 
chronic,  639 
gonorrheal,  636 
monarticular,  642 
muscular,  712 
Poncet's.  250 
syphilitic,  326 
tuberculous  articular,  619 
Rheumatoid  arthritis,  640 
Rhigolene  anesthesia,  1216 
Rhinoplasty,  1265 
Indian  method,  1265 
Italian  method,  1265 
Tagh'acotian  method,  1265 
Rhoads's    apparatus    for  dislocated 
clavicle,  662 
method  of  tendon-lengthening,  734 
Rhus-poisoning,  1226 
Rib,  abscess  of,  tuberculous,  242 
treatment  of,  245 
and    costal    cartilage,    traumatic 

dislocation,  675 
cervical,  840 

method  of  removing,  707 
excision  of,  707 
in  caries,  707 
in  empyema,  707 
fractures  of,  S43 
resection  of,  707 
Richter's  bone-driU,  535 

hernia,  1155,  1162 
Rickets,  252 
acute,  254 
congenital,  253 
evidences  of,  253 
late,  254 
scurvy,  253,  257 
treatment,  254 
Ricord's     method     of     amputating 

penis,  1374 
Riders'  bone,  496,  713 

leg,  718 
Rifle,  sporting,  wounds  from,  276 
Rifle-buUets,   wounds  in  war  from, 
282 
symptoms,  291 
treatment,  292 
Rifles,  magazine,  of  small  caliber,  284 
Ring  around,  724 

Ringer's  treatment  of  erysipelas,  201 
Risus  sardonicus,  207 
Roberts'   splint  in  CoUes's  fracture, 

578 
Robson's  incision  for  surgery  of  bile- 
ducts,  1 1 24 
method  of  intestinal  anastomosis, 

IIIO 

of    preventing    hemorrhage    in 
choledochotomy,  1129 

operation  for  fecal  incontinence 
after  operation  for  fistula  in  ano, 
1176 

treatment     of     cephalocele     and 
meningocele,  777 
Rodent  ulcer,  159,  392 
Rogers  and  Torrey's  antigonococcic 

serum,  1364 
Rogers's     serum     in    exophthalmic 

goiter,  1238 
Rokitansky's     diverticular     hernia. 

1163 
Rolando's  fissure,  769 
Rontgen     rays,     1447.       See     also 

X-rays. 
Rontgenography,    1447  ■      See    also 

X-rays. 
Rosenthal's  test  for  hematuria,  1266 
Roseola,  syphihtic,  323 
Rose's    method    of    neurectomy    in 

neuralgia  of  fifth  nerve,  764 
Rotter's  incision  in  wounds  of  heart. 

460 
Rouge's  operation  in  myxoma,  362 
Rouleaux  formation,  81 


Round-celled  sarcoma,  370,  372 

Rubor,  88 

Rugh's  operation  for  flat-foot,  744 

splint  for  VoLkmann's  contracture, 
716 

treatment    of    pains    of    chronic 
rheumatism,  640 
Run-around,  1227 
Rupia,  syphilitic,  325,  328 
Rupture,  abdominal,  1133 

in  fractures,  531 

muscular,    from    abdominal    con- 
tusion, 945 

of  biceps  flexor  cubiti  or  tendon, 
718 

of  bile-ducts,  952 

of  bladder,  13 17 

of  brachial  plexus,  750 

of  crucial  hgaments  of  knee,  649 

of  diaphragm,  897 

of  extensor  tendon,  739 

of  gall-bladder,  952 

of  heart,  404 

of     intestine     without     external 
wound,  947 

of  kidney,  1280 

of  left  thoracic  duct,  1248 

of  Uver,  1032 

of  long  head  of  biceps,  718 

of  lung,  897 

of  mesenteric  arteries,  952 

of  muscles,  718 

of  pancreas,  1054 

of  peritoneum,  94s 

of  plantaris  muscle,  719 

of    quadriceps    extensor    femoris 
tendon,  719 

of  receptaculum  chyli,  1248 

of  sinus  of  brain,  788 

of  spleen,  1063 

Kehr's  sign  in,  1063 

of     stomach      without      external 
wound,  946 

of  tendons,  718,  721 

of  urethra,  1340 

of  varicose  veins,  control,  453 

small,  1162 
Ruptured  aneurysm,  416 
Russ's   splint   in  fractures  of   meta- 
carpal bones,  581 
Russell's  treatment  of  cardiospasm, 

939 


Saccharomyces,  18 
Sacrococcygeal  dermoids,  836 
region,     teratoids    and    dermoids 

associated  with,  1165 
tumors,  836 
Sacro-iHac    articulation,   sprain    of, 
648 
disease,  624 
joint,  inflammation  of,  pain  in,  89 

tuberculosis  of,  624 
relaxation,  649 
Sacrum,  fractures  of,  549 
Saddle-back,  844 

Saddle-nose,  correction  of,  by  inser- 
tion of  plate,  1265 
Saline  fluid,  arterial  transfusion  and 
infusion,  467 
intravenous  infusion,  465 
in  shock,  263 
solution,  29 
Salivary     and     lachrymal     glands, 
lymphoma  of,  915 
concretions,  915 
cysts,  401 
fistula,  914 

De  Guise's  operation  for,  914 
glands,  injuries  and  diseases,  912 
wounds  of,  914 
Salivation  in  syphilis,  338 
Salkindsohn's  modification  of  Clau- 
dius's method  of  preparing  catgut, 
71 
Salomoni  and  Tomaselli's  method  of 

arteriorrhaphy,  443 
Salvarsan,  effect  of,  on  Wassermann 
reaction,  342 
in  anthrax,  304 
in  syphilis,  341 


Index 


1507 


Salzer's    local    intestinal    exclusion. 

1118 
Sand  flea,  bites  of,  2g7 
Sanious  pus,  135 
Sapremia.  194 
Saprophytes,  20 

facultative,  20 

obligate.  20 
Saprophytic  microbes,  20 
Sarcinae,  21.  22 
Sarcocele.  syphilitic.  327 
Sarcoma.  36S 

alveolar.  372 

black.  373 

Coley's  fluid  in.  377 

effect  of  er>-sipelas  on,  377 
of  suppuration  on,  377 

er>-5ipelas  serum  in,  377,  378 

fibrospindle-cell,  372 

giant-cell.  372 

hemorrhagic.  373 

medullap',  372 

melanotic.  373 

metastasis.  368 

mixed  spindle-cell,  372 

myeloid.  372 

of  antrum.  369,  371 

of  back.  377 

of  bladder.  1328 

of  brain,  809 

of  breast.  1430 

of  buttock.  378 

of  femur.  374 

of  fibula.  376 

of  humerus.  375 

of  intestine,  1000 

of  kidney,  1274 

of  liver,  1034 

of  neck.  360.  370,  371 

of  prostate.  1390 

of  stomach,  961 

of  sternum.  374 

of  testicle.  1396 

of  th\-inus  gland,  1248 

of  thyroid  gland,  1229 

of  tonsil,  Dawbam's  operation  in. 
377 

of  vermiform  appendix,  1015 

plexiform.  373 

radium  in.  379 

round-celled.  370,  372 

spindle-ceUed,  371 

telangiectatic,  373 

treatment  of,  375 

varieties  of.  370 

i-rays  in.  379.  1467 
Sarcomatosis.  369 
Sauerbruch  chamber,  905 
Saviard's  aneiuysm  needle,  468 
Saw,  Adams's.  688 
Sayre's    dressing    for    fractures    of 
cla\-icle.  352 

plaster-of-Paris  jacket   and  jurj-- 
mast.  8  46 

splint.  629.  631 
Scalds,    312.     See    also    Burns    and 

scalds. 
Scalp,  abscess  of,  774 

a\TiIsion  of,  272 

diseases  of.  774 

hematoma  of.  780 

wounds  of.  779 
Scaphoid,  carpal,  fractures  of.  580 

fractures  of.  615 
Scapula,  excision  of.  706 
Syme's  method.  706 
Treves's  method,  706 

fractures  of,  533 
of  body,  553 
of  neck,  553 
of  spine,  553 

traumatic  dislocation,  662 
wing-like,  751 
Scar  tissue,  119 

Scarification  in  inflammation,  95 
Scarificator.  97 

Scarlet   red   in   acute   ulcer   of   leg, 
153 
in  cicatrization.  120 

fever  surgical,  131 
Scarpa's  triangle,  487 
Scars,  121 


Schafer's     gonorrheal     phylacogen, 
1365 
method    of    artificial    respiration, 
866 
Schede's   method   of   thoracoplasty, 

QIC 

operation  for  varix  of  leg,  462 

treatment  of  bone-ca%'ities,  503 
Schimmelbusch's  sterilizer,  65 
Schizomycetes.  19 

Schleich's     infiltration     anesthesia, 
1218 

mixture    for    general    anesthesia, 
1209 

treatment  of  bone-ca\"ities,  502 
Schloffer's      method      of      reaching 

pituitarj'  body.  834 
Sch6sser"s      alcohol      injection      in 

neuralgia  of  fifth  ner\-e,  763 
Schultze's  sign  in  tetany,  1246 
Sciatic  arterj',  Hgation  of,  492 

hernia.  1162 

nen.'e  stretching,  761 
Scirrhous  cancer,  392 
Scirrhus  of  breast.  1432 

atrophic  or  withering,  1435 
Sclavo's  serum  in  anthrax,  304 
Scolices.  403 
Scoliosis.  841 
Scopolamin-morphin  anesthesia. 

1213 
Scorbutic  gangrene,  164 

ulcer,  161 
Scorbutus,  255.     See  also  Scuny. 
Scorpion,  bites  of,  296 
Scotch     douche     in     inflammation, 

lOI 

Scrofula,  225 

angelic,  225 

lymphatic,  225 

phlegmatic,  225 

sanguine,  225 
Scrofulodermata,  247 
Scrofulous  abscess,  235 

pus.  236 
Scrotal  hernia.  11 39 
Scrotum,  lymph.  368.  1251 
Scudder's   bandage   in   fractures    of 
anatomical     neck     of     hu- 
merus. 556 
of  shaft  of  humerus,  560 
Scurvy,  255 

infantile,  257 

prevention,  257 

rickets,  253,  257 

treatment,  237 
Sebaceous  cj'sts,  400 
Second  intention,  healing  by,  117 
Sedative    poultice   in  inflammation, 

^°^ 
Sedatives,  arterial,  in  inflammation, 

106 
Sedillot's  amputation  of  leg,  1415 
Segmentation,  bacteria  in.  22 
Selby    and    Heath's    treatment    of 

Pott's  fracture.  614 
Selva's  thumb  bandage,  1254 
Semilunar    cartilages,  inflammation. 
618 
of  knee-joint,  dislocation.  Bar- 
ker's operation  for,  709 
traumatic  dislocation,  684 
Semimembranosus  muscle,  bursa  of, 

"3.1 
Seminal    vesicle,    diseases    and    m- 
juries.  1339 
inflammation  of,  1375 
tuberculosis  of,  1376 
vesiculitis,  1375 
Senile  gangrene,  166 

Moskowicz's    method  of   deter- 
mining %-iable  area  in,  168 
prevention,  in  predisposed,  168 
s3Tnptoms,  167 
treatment.  168 
Senkungsabscess ,  235 
Senn's  amputation  of  hip-joint.  1422 
buUet-probe.  281,  797 
injection  sjTinge.  243 
method  of   anterior  gastro-enter- 
ostomy,  1093 
of  excision  of  shoulder-joint,  698 


Senn's  method  of  fixing  kidney  with- 
out sutures.  Da  Costa's  modi- 
fication, 1296 
of  gastrostomy,  1088 
of  intestinal  anastomosis,  1107, 

1113 
of  preparing  catgut,  72 
operation  for  cancer  of  breast,  1441 

for  fecal  fistula,  11 20 
powder  in  bums,  313 
silver  tube,  1339 
treatment  of  bone-ca\'ities,  502 
of  hydrocephalus,  779 
of     intracapsular     fracture     of 

femur,  588 
of  stump  neuralgia,  748 
of  imunited  fractures,  693 
Sepsis,  194 

Septic  embohc  pneumonia,  190 
infection.   195 
intoxication,  194 
pylephlebitis,  188 
wounds.  295 
irrigation  in,  69 
Septicemia.  194 

pneumococcus,  1030 
streptococcus  of,  50 
true.  193 
Sequestrectomy.  501 
Sequestrum.  300 
Serous  inflammation,  81.  86 
Serratus   magnus   muscle,   paralysis 

of,  663 
Serum,  antistreptococcic,  in  cutane- 
eous  er>-sipelas.  201 
antitoxin,  in  tetanus,  208,  211  ^ 
Beebe's,   in   exophthalmic   goiter, 

1238 
blood-,  in  hemophilia.  439 

in  hemorrhage,  448 
Calmette's  antivenene,  300 
diagnosis  of  sj^philis.  332 
disease.  46 

erysipelas,  in  sarcoma,  378 
hypersusceptibilitv'  to,  46 
injections,  iintoward  effects,  46 
MaragUano's,  in  tuberculosis,  234 
reaction  in  cancer,  384 
Rogers    and    Torrey's    antigono- 

coccic.  1364 
Rogers's,  in   exophthalmic  goiter, 

1238 
Sclavo's,  in  anthrax,  304 
Serum-therapy,  44 
Shekelton's  aneurysm.  417 
Sheldon's   amputation   of  hipHJoint, 

1423 
Shells,  wounds  by,  2S2 
Sherman's  bone-bolts  and  nut-driver, 
536 
treatment  of  bone-ca\'ities,  502 
Shirt-stud  abscess,  151,  239 

treatment,  243 
Shock,  259 

adrenalin  chlorid  in,  263 
apathetic.  261 
atropin  in.  263 
autotransfusion  in,  265 
centripetal  arterial  transfusion  in. 

263 
Crile's  anoci-association  operation, 
262 
rubber  suit  in,  263 
delayed.  261 
delirious,  261 
diagnosis,  261 
erethistic.  261 
fear  as  cause.  260 
hypodermoclysis.  in  263.  264 
in  anesthesia,  treatment.  1203 
in  wounds  from  rifle-bvfllets,  291 
intravenous  salt  infusion  in,  263 
noci  influences  in.  260 
operation  during.  263 
peritoneal.  943 
philogenetic  association.  261 
prevention,  in  operations,  261 
proctoclysis  in.  263.  264 
resuscitation  in.  263 
secondary'.  261 
str>"chnin  in.  264,  265 
symptoms.  261 


i5o8 


Index 


Shock, torpid,  261 

transfusion  of  blood  in,  264 
treatment,  262 
urethral,  1368 
Shoemaker's   symptom   in   ulcer   of 

stomach,  g66 
Shotgun,  wounds  from,  276 
Shoulder,  figure-of-8  bandage,  1258 

spica  bandage,  1257 
Shoulder-joint,    disarticulation     at, 
1409 
disease,  632 
excision  of,  697.    See  also  Excision 

of  shoulder-joint. 
traumatic   dislocation,    663.      See 
also   Humerus,  traumatic  dislo- 
cation. 
tuberculosis  of,  632 
Sigmoid,  inflammation  of,  1172 
Sigmoiditis,  1172 

perforating,  treatment  of,  1018 
Sign,  AUis's,  in  intracapsular  frac- 
tures of  femur,  584 
in   traumatic  dislocation  of  fe- 
mur, 678 
Battle's,    in   fracture   of    base   of 

skull,  792 
Chvostek's,  in  tetany,  1246 
Dawbarn's,    in   subacromial   bur- 
sitis, 729 
Desault's,   in   intracapsular   frac- 
tures of  femur.  584 
Dugas's,  in  dislocation   of   shoul- 
der-joint, 665 
ear,  in  erysipelas,  200 
Erb's,  in  tetany,  1246 
ErJchsen's,  in  dislocation  of  shoul- 
der-joint 66s 
Garel's,  in  abscess  of  antrum  of 

Highmore,  145 
Glenard's,  1040 
Hoffmann's,  in  tetany,  1246 
Hiiter's,  718 

Kehr's,  in  rupture  of  spleen,  1063 
Kernig's,  in  acute  leptomeningitis, 

800  _ 
Lagoria's,    in    intracapsular  frac- 
tures of  femur,  584 
Mannkopf's,  of  back  injury,  849 
Moebius's,  in  exophthalmic  goiter, 

1237 
Stellwag's,  in  exophthalmic  goiter, 

1237 
StiUer's,  1020 

Trousseau's,  in  tetany,  1246 
von     Graefe's,     in     exophthalmic 

goiter,  1237 
Williams's,  1454 
Silicate  of  sodium  dressing,  1261 
Silk,  braided,  73 
floss,  73 

for  ligatures  and  sutures,  73 
inserts,  734 
preparation  of,  73 
Tait's,  73 
Silkworm-gut,  73 

preparation  of,  73 
Silver,  32 
citrate,  32 
colloidal,  32 
Credo's  ointment  of,  32 
foil  as  protective,  76 

for  dressings,  75 
lactate,  32 

nitrate  in  inflammation,  101 
vitelline,  33 
wire,  preparation,  74 
Silver-fork  deformity,  577 
Silverized  catgut,  Blake's  method  of 

preparing,  71 
Simpson's  method  01  hemostasis,  44s 
Sims's  speculum,  1167 
Sinus,  162 

branchial,  400 

cavernous,  infective  thrombosis  of, 

807 
cerebral,   hemorrhage   from,   con- 
trol of,  452 
chronic    suppurating,  «-rays    in, 

1468 
frontal,  distention  and  abscess,  878 
trephining  of,  828 


Sinus,  lateral,  infective  thrombosis  of, 

806 
of  brain,  rupture,  788 
parietocolic,  103 1 
petrosal,  infective  thrombosis  of, 

807 
pocuiaris,  cyst  of,  treatment,  13 14 
postanal,  836 
thyroglossal,  926 
thyroBngual,  926 
tuberculous,  jc-rays  in,  1468 
Sinus-thrombosis,  infective,  80s 
Siphon,  98 

Skene's  method  of  controlling  hemor- 
rhage, 449 
Skiagraphy,  1447.  _  See  also  a;-rays. 
Skin,  actinomycosis  of,  310 
blastomycosis  of,  311 
diseases  of,  1226 
fungi  as  cause,  ig 
in  tertiary  syphilis,  328 
syphiHtic,  323 
x-rays  in,  1466 
disinfection  of,  iodin  for,  68 
gold-beaters',  as  protective,  76 
oidiomycosis  of,  311 
pis,  1434 
reaction,    Noguchi's,    in    syphilis, 

333 
repair  of,  128 
tabs,  1 1 79 
tuberculosis  of,  246 
Skin-grafting,  1262 
Arnot's  method,  1262 
Mixter's  apparatus  for,   1263 
Ollier-Thiersch  method,  1263 
Reverdin's  method,  1262 
Wolfe's  method,  1264 
Skinner's  mask,  1197 
Skull,   bones   of,  diseases  and   mal- 
formations, 774 
fractures  of,  789.     See  also  Frac- 
tures of  skull. 
gutter-fracture  of.  796 
natiform,  343 

obstetric  depressions  of,  794 
operations  on,  825 
osteoplastic  resection,  827 
Cushing's  method,  828 
with  Hudson's  burrs,  828 
Sleeping  sweats  in  tropical  abscess 

of  Hver,  1038 
Sliding  hernia  of  ascending  and  de- 
scending   colon,    operative    treat- 
ment, 1150 
Sloughing,  179 

phagedena.  171 
Sloughs,  179 
Smith's  dressing  basin,  77 

head-rest  for  operations  on  cere- 
bellum, 834 
method    of    reducing    dislocated 

humerus.  667 
splint    in    fracture    of    femur    at 
upper  third,  sgs,  596 
of  leg,  615 
Smoke  asphyxia.  871 
Smokeless  powder  as  compared  with 

black  gunpowder,  283 
Smothering,  864 
Snakes,  bites  of,  296,  297 

treatment,  299 
Snapping-finger.  739 
Snow,  carbonic-acid,  in  nevus,  368 
Snuff-box,  anatomical,  471 
Socin's  operation  on  thyroid,  1240 
Sodium  chlorid  solution,  29 
Soft  nose  bullet,  288 
Solitary  cyst,  3s8 
Sonnenberg's  operation  for  exstrophy 

of  bladder,  1316 
Sorbefacients  in  inflammation,  100 
Sore,  splint-,  715 
Souchon's  inhaler,  1197 
Sounds,  esophageal,  930.  942 
Southam's   treatment   in    Charcot's 
disease,  644 
of    extracapsular    fractures    of 
femur.  $0° 
Spangaro's    incision    in    wounds    of 

heart,  406 
Spasm,  muscular,  in  fractures,  531 


Spasmodic   stricture   of   esophagus, 
938 
of  urethra,  136s 
torticolhs,  736 
Spectroscope     test    for    hematuria, 

1266 
Speculum,  Brinkerhoff's,  1167 
Cook's,  1 168 
Kelly's,  1169 
Martin's,  1167 
Matthews's,  1166 
Sims's,  1 167 
Spencer's  apparatus  for  salt  solution, 

466 
Spermatic  cord,  diffused  hematocele, 
1400 
hydrocele,  1400 
diseases  and  injuries,  1339 
edema  of,  1400 
encysted  hematocele,  1400 

hydrocele,  1400 
strangulation  of,  1397 
varix  of,  411 
Spermatorrhea,     defecation,     1343, 

1377 
Sphacelus,  163 

Spider,  poisonous,  bites  of,  296 
Spina  bifida,  83s 

occulta,  83s,  836 
operation  for,  8s9 
yentosa.  258 
Spinal  analgesia,  1223 
caries,  844 

treatment,  846 
cord,  cocainization  of,  1223 
compression  of,  852 
concussion  of,  851 
contusion  of,  851 
repair,  124 
tuberculosis  of,  249 
tumors  of,  837 

extrameduUary,  837 
intramedullary,  838 
wounds  of,  8s I 
curvature,  840 
angular,  844 
anterior,  844 
anteroposterior,  843 
forcible  correction,  848 
gradual  correction,  848 
posterior,  843 
decompression,  863 
excurvation,  843 
hemorrhage,  control  of,  452 
ligaments   and   muscles,    injuries, 

849 
meninges,  puncture  of,  861 
meningitis,      chronic,      Horsley's 

operation  for,  863 
syphilis.  331,  332 
Spindle-celled  sarcoma,  371 
Spine,  abscess  of,  847 
congenital  deformities,  83s 
curves  of,  841 
dislocations  of,  852 
fracture-dislocation  of,  852 

treatment,  8s6 
fractures  of,  852 
operations  on,  859 
railway,  8so 
surgery  of,  835 
typhoid,  839 
Spirillum,  21 
Spirochseta  pallida,  55,  317 

in  diagnosis  of  syphilis,  334 
Splanchnoptosis,  1020 
Spleen,  abscess  of,  1064 
cysts  of,  1065 
enlargement  of,  1065 
injuries  and  diseases,  1063 
operations  on,    wounds    of   pan- 
creas during,  1056 
removal  of,  1131 
repair  of,  128 
rupture  of,  1063 

Kehr's  sign  in,  1063 
tuberculosis  of,  249 
tumors  of,  io6s 
wandering,  1065 
wounds  of,  1063 
Splenectomy,  changes  after,  1133 
total,  113 1 


Index 


1509 


Splenic  fever,  300 
Splenopexy,  1065,  1133 
Splenoptosis,  1065 
Splenorrhaphy,  1064 
Splint,  Agnew's,  in  transverse  frac- 
tures of  patella,  604 

anterior  anguhir,  565 

Bond's,  in  Colles's  fracture,  578 

bracketed.  532 

Bryant's,  in  Pott's  fracture,  613 

Dupuytren's,  613 

Esmarch's,  700,  702 

fenestrated,  532 

hard-rubber,  53g 

Hodgen's,  in  fractures  of  femur, 
S96,  597 

Hutchinson's,  631 

interdental,  542 

internal  angular,  556 

Jones's  nasal,  538 

Levis's,  578,  67s 

Mclntyre's,  in  fractures  of  femur, 
S97 
of  leg,  615 

Roberts's,  in  Colles's  fracture,  578 

Rugh's,  for  Volkmann's  contrac- 
ture, 716 

Russ's,  in  fractures  of  metacarpal 
bones,  581 

Sayre's,  629,  631 

Smith's,  in  fracture  of  femur  at 
upper  third,  595,  596 
of  leg,  61  s 

Stimson's,  in  Pott's  fracture,  613 

Stromeyer's,  633 

Thomas's,  628 

in     intracapsular     fracture     of 
femur,  589 

Van    Arsdale's,    in    fractures    of 
shaft  of  femur  in  children,  598 

Volkmann's,  705 

vulcam'te,  542 

Ware's,   in  fractures   of  shaft  of 
femur  in  children,  599,  600 

Watson's,  704 

Wyeth's,  629 
Splint-sore,  180,  715 
Spondyhtis,  844 

deformans,  642,  650,  848 

rhizomelique,  849 

syphilitic,  330 
Sponges,  77 

Spontaneous  gangrene,  presenile,  165 
Spores,  23 

Sporting  rifle,  wounds  from,  276 
Spots,  syphilitic,  323 
Sprague  hot  dry-air  apparatus,  619 
Sprain-fracture,  515 
Sprains,  646 

of  sacro-iliac  articulation,  648 
Springfield  bullet.  285 
Spurious  elephantiasis,  1251 

flat-foot,  742 

hydrophobia,  306 

meningocele,  777 

pus,  133 
Squamous-ceUed  epithelioma,  391 
Ssabanajew-Frank   method   of   gas- 
trostomy, 1087 
St.  Anthony's  fire,  199 
Stab-wounds,  274 

Stagnation    and    oscillation    in    in- 
flammation, 81 
Stains,  claret,  365 

port-wine,  365 
Stammering  of  bladder,  1329 
Staphylococcus,  21 

cereus  albus,  49 
flavus,  49 

epidermidis  albus,  49 

flavescens,  49 

pyogenes  albus,  49 

aureus,  2r,  48 

citreus,  49 

Staphylorrhaphy,  920 

Starck's  position,  932 

Stasis  in  inflammation,  81 

intestinal,  chronic,  977 

pressure,  890 
Static  flat-foot,  742 
Status  lymphaticus,  225 

thymicus,  1248 


Stave  of  thumb,  580 
Stay-knot,  470 
Steam-pressure  sterilizer,  74 
Steeple  chart  of  Charcot's  fever,  1052 
Stellwagen's  suture  of  kidney  to  pre- 
vent cutting  after  tying,  1282 
Stellwag's     sign     in     exophthalmic 

goiter,  1237 
Steno's  duct,  fistula  of,  914 

wounds  of,  914 
Stenosis,    cicatricial,    or    orifices    of 
stomach,  969 

congenital    hypertrophic,    of    py- 
lorus, 970 
Stercoraceous  abscess,  142 

vomiting,  984 
Stercoral  appendicitis,  1004 
Stereo-arthrolysis  in  ankylosis,  651 
Sterility  from  «-rays,  1452 
Sterilization,  26 

of  cystoscope,  1302 

of  hands,  62 

and  forearms.  63 

Fiirbringer's  method,  63 
mechanical,  62 

sublimate-alcohol  method,  64 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 

of  instruments,  65 

of  ureteral  catheters,  1302 
Sterilized  gauze,  preparation  of,  75 
Sterihzer,  Lautenschlager's,  75 

portable,  66 

Schimmelbusch's,  65 

steam-pressure,  74 
Sternocleidomastoid     muscle,     open 

division,  for  wry-neck,  732 
Sternomastoid,  hematoma  of,  736 
Sternum,  fractures  of,  546 

sarcoma  of,  374 

traumatic  dislocation,  675 
Stevenson's  bag  for  inguinal  colos- 
tomy, 1122 

suprapubic  drainage-tube,  1333 
Stewart's   method    of   enterostomy, 

992 
Stifling,  864 

Stigmata  of  hysteria,  850 
Stilier's  sign,  1020 

Stillman's  operation  to  prevent  con- 
traction   after    excision    of    jaw, 

709 
Stimson's  splint  in  Pott's  fracture. 

613 
Stimulation,  artificial,  of  phagocy- 
tosis, 42 
Stings  and  bites  of  insects,  296 

of  bees,  296 

of  fish.  297 

of  wasps,  296 
Stinking  pus,  135 

Stokes's  operation  for  flat-foot,  744 
Stomach,  956 

absorptive  power  of,  testing,  974 

bilocular,  972 

cancer  of.  958.    See  also  Cancer  of 
stomach. 

cardiac  orifice,  constriction  of.  969 

cicatricial  stenosis,  of  orifices,  969 

dilatation  of,  acute.  974 

Brandt's  operation  for,  1103 
chronic,  973 

fibromatosis  of.  957,  965 

foreign  bodies  in,  956 

hemorrhage  from,  control,  455 

hour-glass.  972,  1103 

leather-bottle,  958 

motor  power  of,  testing,  973 
Ewald's  method.  974 
Klemperer's  method,  973 

mucous  erosions,  962 

operations  on,  1079 

wounds  of  pancreas  during,  1056 

peptid  ulcer  of,  961 

pyloric  orifice,  constriction  of.  969 

rupture      of,      without     external 
wound,  946 

sarcoma  of.  961 

tuberculosis  of,  248 

ulcer  of.  g6i.     See  also  Ulcer  of 
stomach. 

volvulus  of,  957 


Stomach-reefing,  Brandt's  operation, 

for  dilatation,  1103 
Stone,  vein-,  412 

Storp's  treatment  of   Colles's   frac- 
ture, 578 
Stovain  anesthesia,  12 18 
Strain,  muscular,  717 
of  back,  718 

of  erector  spinae  muscle,  851 
of  psoas  muscle,  717 
of  vertebral  ligaments,  851 
Strain-fracture,  515 
Strangulated  hernia,  1152.    See  also 

Hernia,  strangulate'! . 
Strangulation  of  intestine,  intestinal 
obstruction  from,  978 
of  spermatic  cord,  1397 
Strapping  ulcer  of  leg,  156 
Streptobacillus,  21 
Streptococcus,  21 
articulorum,  50 
in  noma,  51 
lanceolatus,  53 
of  erysipelas,  so 
of  pyemia,  50 
of  septicemia,  50 
pyogenes,  49,  50 

malignus,  50 
septicus,  so 
Streptothrices,  19 
Streptothrix  madurae,  19 
StreptotrichosiS;  19,  309 
Stretching  sciatic  nerve,  761 
Stricture,  hysterical,  938 
of  esophagus,  932 

Abbe's  operation  for,  936 
cancerous,  937 
cicatricial,  932 
compression,  934 
fibrous,  932 

Gussenbauer's  operation,  936 
Mixter's  treatment,  935 
Ochsner's  operation  for,  937 
spasmodic,  938 
Symond's  treatment,  935 
treatment,  934 
of  intestine,  cicatricial,  intestinal 

obstruction  from,  982 
of    meatus    urinarius,    treatment, 

1366 
of  rectum,  non-cancerous,  1186 
of  ureter,  1288 
of  urethra.  1365 
congestive,  1365 
impermeable,  1365 

Gibson's  operation  for,  1371 
inflammatory,  136s 
organic.  136s 
perineal    fistula   in,    treatment, 

1368 
spasmodic,  1365 

treatment  of,  1314 
symptoms  and  results,  1365 
treatment.  1366 
Stromeyer's  splint.  633 
Strongylus    armatus    as    cause    of 

aneurysm.  419 
Strurnous  abscess,  141 
caries,  49s,  498 
joint.  620 
Struve's  test  for  hematuria,  1267 
Strychnin  in  inflammation,  no 

in  shock,  264.  265 
Strychnin-poisoning,     tetanus    and, 

differentiation,  209 
Stump,  neuralgia   of,    Senn's   treat- 
ment, 74S 
treatment.  748 
recurrent  bandage,  1260 
Stupe  in  inflammation,  102 

turpentine,  in  inflammation,  102 
Stupor,  784 

Styptics  in  hemorrhage,  447 
Subacromial  bursitis,  728 

Codman's  treatment,  730 
Dawbarn's  sign  in,  729 
Monk's  treatment,  729 
Subastragaloid  disarticulation,  1414 

dislocation,  traumatic,  687 
Subclavian  artery,  compression   of, 
446 
ligation,  47s,  476 


I5I0 


Index 


Subclavian  triangle,  475,  479 
Subcutaneous  injection  of  paraffin 
for  prosthetic  purposes,  1264 
wounds,  healing,  121 
Subdeltoid  bursitis,  727 
Subdiaphragmatic  abscess,  144 
Subgallate  of  bismuth,  32 
Subhyoid  cyst,  927 
Subiodid  of  bismuth,  32 
Sublimate-alcohol  method  of  sterili- 
zation of  hands  and  forearms,  64 
Subungual  dermoid,  926 
Subluxation  of  head  of  radius,  672 
of  humerus,  720 
of  knee-joint,  684 
Submaxillary  triangle,  473,  479 
Submental  triangle,  475,  479 
Subphrenic  abscess,  144,  892,  1030 
after  appendicitis,  1030,  1031 
treatment,  149,  1032 
Subungual  exostosis,  339 
Suffocating  goiter,  1231 
Suffocation,  864 
Suffusion,  258 
Sulcus,  precentral,  771 
Sulphur  grains,  309 
Sunlight,  effect  of,  on  bacteria,  24 
Sunshine  in  tuberculosis,  231 
Supernumerary  digits,  739 
Suppuration,  48,  132 

effect  of,  on  sarcoma,  377 

mastoid  operation  for,  830 

pericardial,  operation  for,  460 

phlegmonous,  136 

signs  of,  135 

sjrmptoms  of,  133 

threatened,  treatment,  103 
Suppurative  fever,  130 

inflammation,  86 
Supraduodenal         choledochotomy, 

1129 
Suprameatal  triangle,  772,  830 
Supra-orbital   nerve,  neurectomy  of, 

762 
Suprapubic  cystotomy,  1337 

lithotomy,  1331 

prostatectomy,    1382,    1384.     See 
also  Prostatectomy,  suprapubic. 
Suprarenal   extract   in   hemorrhage. 

448 
Surgeon's  knot,  439 
Surgical  fevers.  128,  194 

essential  phenomena,  129 
genuine,  130 

kidney,  1289 

scarlet  fever,  131 
Sutherland  and  Cheyne's  treatment 

of  hj'drocephalus,  778 
Suture  a  distance,  759 

button.  272 

ConneU's,  1079 

continuous,  270 

Cushing's  right-angled,  1079 

Czemy-Lembert,  1079 

Dupuytren's,  1078 

Erichsen's,  for  nevus,  363 

Ford's.  270.  1079 

Gussenbauer's,  1079 

Halsted's,  37,  73,  271,  1079 

hare-lip,  272 

interrupted,  270 

Lembert's,  1077 

ligature  and,  70 

nerve-,  758.    See  also  Nerve-suture. 

of  artery,  441 

of  intestine,  1077 

of  kidney,  1282 

of  soft  palate,  operation  for,  920 

of  vein,  440 

of  wound  after  abdominal  section, 
1069 

quilled,  271 

removal  of,  77 

tendon-,   734.     See  also   Tendon- 
suture. 

twisted,  272 

Wolfler's.  1079 
Suture-ligature.  439 
Suturing,  secondary,  120 
Swallowing  of  tongue  in  anesthesia, 
1202 
treatment,  1204 


Sweats,  sleeping,  in  tropical  abscess 

of  liver,  1038 
Sweet's  apparatus  for  locating  for- 
eign bodies  in  eyeball  and  orbit, 
1464.,  1463 
Swelhng,  white,  250,  620,  631 
Sylvester's     method     of     artificial 

respiration,  863 
Sylvius,  fissure  of,  770 
Symbiosis,  23 

Syme's   amputation   at   ankle-joint, 
1414 
through  femoral  condyles,  1417 
grooved  staff,  1370 
method  of  excision  of  scapula,  706 
operation  for  aneurysm,  423 
of  perineal  section,  1370 
Symmetrical  gangrene,  172 
Symond's  treatment  of  stricture  of 

esophagus,  933 
Sympathectomy,  761 

Tonnesco's  operation,  761 
Sympathetic  parotitis,  913 
Synchondroseotomy  for  exstrophy  of 

bladder,  1316 
Syncope  after  hemorrhage,  436 
in  anesthesia,  treatment,  1203 
local,  172 
S>Ticytioma  malignum,  393 
Syndactylism,  738 
Agnew's  operation  for,  738 
Diday's  operation  for,  738,  739 
Synovial  membrane,  pulpy  degenera- 
tion, 250,  618,  620 
Synovitis,  617 
acute,  617 
chronic,  618 
gummatous,  331 
pannous,  621 
relaxation  in,  93 
subacute,  617 
Syphilids,  323 
papular,  324 
pustular,  325 

secondary  and  tertiary,  differen- 
tiation, 325 
tubercular,  323 
Syphilis,  316 
acquired,  317 

and  tuberculosis,  coexistence,  318 
Chinese,  318 
CoUes's  law  in,  317,  343 
definition  of,  316 
duality  theory,  319 
effect  of,  upon  longe\aty,  318 
general,  322 
hereditary,  317,  342 
dactylitis  in,  344 
diagnosis  of,  344 
eye  symptoms  in,  344 
treatment  of.  345 
Herxheimer's  reaction  in,  338 
Hutchinson's  teeth  in,  344 
infection  in  utero,  343 
initial  lesions,  319 
intermediate  period,  319,  327 
iodism  in,  340 
Justus's  test  for,  332 
marriage  in.  341 
mercury  in,  336 
neosalvarsan  in,  341 
Noguchi's  cutaneous  reaction  in, 

333 
of  bone,  326,  494 
of  brain,  331,  332 
of  innocent,  317 
of  liver,  1034 
of  muscles,  713 
of  nervous  system,  327,  331 
of  nose,  329 
of  thyroid  gland,  1229 
osteocopic  pains  in,  326 
period, 319 

intermediate,  319 

of  primary  incubation,  319 

symptoms,  319 
of  secondary  incubation,  319 

symptoms,  319 
of  tertiary  symptoms,  319 
prevention  of,  334 
primary,  318,  319 
treatment  of,  334 


Syphilis,  Profeta's  immunity  in,  317 
ptyalism  in,  338 
reminders,  317,  327 
salivation  in,  338 
salvarsan  in,  341 
secondary,  318,  322 

albuminuria  of,  327 

complications  in,  treatment,  339 

treatment  of,  335 
serum  diagnosis,  332 
spinal.  331,  332 
spirochaeta  pallida  in  diagnosis  of, 

334 
Stages  of,  318 
tertiary,  318,  328 

lesions  of,  329 

of  bones,  330 

of  joints,  331 

periostitis  in,  329 

serpiginous  ulcer  in,  328 

skin  diseases  in.  328 

treatment  of,  340 
transmission  of,  317 
transmitted  congenital,  343 
treatment  of,  abortive,  334 
unity  theory,  319 
\Hsceral,  331 
Wassermann's  test  for  diagnosis, 

332 
Syphihtic  abscess,  142 
acne.  323 
affections  of  bones  and  joints,  326 

of  ear,  326 

of  eye,  326 

of  hair,  326 

of  mucous  membranes,  325 

of  naUs,  326 

of  testes,  327 
alopecia,  326 
arteritis,  413 
bubo,  321 
ecthyma,  325 
erythema,  323 
fever.  322 
impetigo,  325 
insomnia,  332 
iritis.  326 
lichen,  323 
lupus.  328 
maculse,  323 
mucous  patches,  325 
onychia,  326 
osteoperiostitis,  330 
ozena.  329 
paronychia,  326 
phthisis,  331 
rheumatism,  326 
roseola,  323 
rupia,  325,  328 
sarcocele,  327 
skin  diseases,  323 
spondylitis,  330 
spots,  323 
ijcers,  133 

of  rectum,  1185 
urethritis,  pyogenic,  1344 
warts.  323 
SyphUoderm,  323 
annular.  324 
circinate.  324 
Syphiloma  of  brain,  809 
SjTinge,  Senn's,  243 
Syringomyelocele,  833 
Szumann's  solution,  466 


Tabatiere  anatomique  of  Cloquet, 
471 

ligation  in.  471 
Tabes,  mesenterica  250,  1000 

Mingazzini-Foerster  operation  in, 
862 
Tabetic  arthropathy,  643 
Table,  Boldt's  operating,  60 

Brown's  cystoscopic,  1304 

Lilienthal's  operating,  59 
Tache  cerebrate,  800.  801 
Tachj'cardia  in  exophthalmic  goiter, 

1237 
Tagliacotian  method  of  rhinoplasty, 

1263 
Tait's  silk,  73 


Index 


1511 


Talipes,  740 

astniKalectomy  in,  74.1 
Buchanan's  operation  for,  741 
calcaneovalgus,  741 
calcaneovarus,  741 
calcaneus,  740,  741 
equinovalgus,  741 
equinovarus,  741 
osteotomy  for,  6gi 

Barker's  operation,  691 
equinus,  740,  741 
osteotomy  for,  691 
Davy's  method,  691 
Phelps's  operation  for,  741 
valgus,  740,  741 
varus,  740,  741 
Talma's  operation  for  ascites,  1118 
Tamponade,  heart,  404,  405 
T-amputation,  1406 
of  hip-joint,  1421 
Tarantula,  bites  of,  296 
Tarsal  bones,  fractures,  615,  616 
traumatic  dislocation,  687 
joint,   middle,   disarticulation   at, 

Tarsometatarsal  articulation,  disar- 
ticulation at,  1412 
Tartar     emetic     in     inflammation, 

106 
Tattooing  in  gunshot-wounds,  278 
Taxis  in  strangulated  hernia,  1x55 
Taylor's  treatment  of  ankylosis,  653 

of  hydrocephalus.  779 
T-bandage  of  perineum,  1260 
Teale's  amputation  of  leg,  1415 

method    of    amputation    through 
forearm,  1408 

probe  gorget,  1370 
Teeth,  Hutchinson's,  344 
Telangiectasis,  365 
Telangiectatic  cancer,  393 

sarcoma,  373 
Telephonic  probe,  281 
Temperature  in  inflammation,  11 1 

postoperative  rise,  129 
Temporal  artery,  ligation,  483 
Temporomaxillary  ankylosis,  912 
Temporosphenoidal  lobe,  tumors  of, 

81S 
Tenaculum,  439 
Tenderness  of  inflammation,  89 
Tendo  Achillis,  subcutaneous  tenot- 
omy of,  733 
Tendon,  diseases  and  injuries,  712 

dislocations  of.  720 

operations  on,  732 

repair  of,  126 

rupture  of,  718,  721 

wounds  of,  720 
Tendon-grafting,  734 
Tendon-lengthening,  734 

Anderson's  method,  734 

Czerny's  method,  734 

Hibb's  method,  734 

Poncet's  method,  734 

Rhoads's  method,  734 
Tendon-sheaths,  phlegmon  of,  721 

tuberculosis  of,  252 
Tendon-suture,  734 

Le  Dentu's,  734 

Le  Fort's,  734 

Lejars's,  734 
Tendon-transplantation,  734 
Tenesmus  in  cystitis,  1325 
Tenosynovitis,  721 

tuberculous,  252 
Tenotomy,  732 

open,  732 

subcutaneous,  732 
of  tendo  Achillis,  733 
of  tendons  of  peroneus  longus 

and  brevis  muscles,  733 
of    tendon    of    tibialis    anticus 
muscle,  733 
posticus  muscle,  733 
Tension,  fever  of.  130 
Teratoids     associated     with     sacro- 
coccygeal region,  1165 
Teratoma,  397 

external,  398 

internal,  398 
Terminal  anesthesia,  1218 


Terrier's  treatment  for  hammer-toe, 

745 
Test,  Achard  and  Castaign's,  for  ex- 
cretory   capacity    of    kidneys, 
1272 

agglutination,  in  diagnosis  of 
tuberculosis,  229 

Almcn's,  for  hematuria,  1267 

benzidin,  for  hematuria,  1267 

Calmette's  ophthalmo-tuberculin, 
in  tuberculosis,  228 

Cammidge's,  in  pancreatic  disease, 
1058 

Ewald's,  for  motor  power  of 
stomach,  974 

guaiac.  for  hematuria,  1267 

Hamel's,  for  jaundice  in  gall- 
stones, 1051 

Heller's,  for  hematuria,  1266 

Hoppe-Seyler,  for  carbon  monoxid 
in  blood,  876 

indigo-carmin,  for  excretory  capac- 
ity of  kidneys,  1272 

Justus's,  for  syphilis,  332 

Katagama's,  for  carbon  monoxid 
in  blood,  876 

Klemperer's,  for  motor  power  of 
stomach,  973 

methylene-blue,  for  excretory 
capacity  of  kidneys,  1272 

microscopical,  for  hematuria,  1267 

Moro's  cutaneous  tuberculin,  in 
tuberculosis,  229 

Noguchi's  cutaneous,  in  syphilis, 
333 

phenolsulphonephthalein,  for  ex- 
cretory capacity  of  kidneys, 
1273 

phloridzin,  for  excretory  capacity 
of  kidneys,  1272 

Plummer's,  for  diverticulum  of 
esophagus,  940 

Rosenthal's,  for  hematuria,  1266 

spectroscope,  for  hematuria,  1266 

Struve's.  for  hematuria,  1267 

three-glass,  of  urethral  discharge, 
^345 

tuberculin,  in  tuberculosis,  227 

von  Pirquet's  cutaneous  tubercu- 
lin, in  tuberculosis,  229 

Wassermann,   effect  of  salvarsan 
on.  342 
for  diagnosis  of  syphilis,  332 
Testicle,  cancer  of,  1396 

cysts  of,  139s 

diseases  and  injuries,  1339 

ectopia  of,  1392 

embryoma  of,  1395 

encysted  hematocele,  1400 
hydrocele,  1400 

excision  of,  1396 

extraserous  transposition,  1399 

fungus  of,  252 

inflammation  of,  1393 
pain  in,  89 

lymphosarcoma  of,  1396 

malignant  disease,  1396 

malplaced,  1391 

parenchymatous  hematocele,  1400 

repair  of,  128 

retained,  1391 

sarcoma  of,  1396 

syphilitic  affections,  327 

tuberculosis  of,  252,  1393 

tumors  of,  1395 

undescended,  1391 
Tetanus,  203 

acute,  symptoms  of,  206 

antitoxin  serum  in,  208.  211 

Bacelli's  treatment,  213 

bacillus,  51,  205 

brain-matter  in,  213 

carbolic  acid  in,  213 

cephalic,  208 

cerebral,  208 

chronic.  208 

diagnosis,  208 

differential,  20S,  209 

dolorosa,  208 

following  injection  of  gelatin,  204 
vaccination,  204 

Fourth  of  July,  204,  277 


Tetanus,  girdle  pain,  207 
head,  208 
hydrophobia  and,  differentiation, 

208 

hydrophobic,  208 

hysteria  and,  differentiation,  209 

idiopathic,  203 

local,  206 

magnesium  sulphate  in,  213 

mortality,  206 

of  newborn,  208 

strychnin-poisoning  and,  differen- 
tiation, 209 

symptoms,  206 

tetany  and,  differentiation,  208 

treatment,  208 
Tetany  after  removal  of  parathyroid 
glands.  1244 
of  thyroid  gland,  1228 

Chvostek's  sign  in,  1246 

Erb's  sign  in,  1246 

experimental,  1244 

from   removal   of   thyroid   gland, 
1228 

Hoffmann's  sign  in,  1246 

Schultze's  sign  in,  1246 

tetanus  and,  differentiation,  208 

Trousseau's  sign  in,  1246 
Tetracoccus,  21,  22 
T-fractures  of  humerus,  563 
Theca,  1406 
Thecal  abscess,  142,  721 
Thecitis,  721 

acute,  721 

chronic,  722 

suppurative,  146 

traumatic,  723 

tuberculous,  722 
Thiersch's  fluid,  29 

hypothesis  of  cancer,  385 

treatment  of  empyema,  893 
Thigh,  amputation  of,  141 7 

and    pelvis,    figure-of-8    bandage, 
1257 
Third  corpuscles  in  inflammation,  84 

intention,  healing  by,  120 
Thomas's  operation  for  habitual  dis- 
location of  humerus,  669 

splint,  628 

in     intracapsular     fracture     of 
femur,  589 
Thompson's  calculus  sound,  1322 

diagnostic   questions   on    micturi- 
tion, 1 271 

divulsor,  1369 

evacuator,  1335 

lithotrite,  1334 

vesical  forceps,  1338 
Thoracic    duct,    left,    wounds,    rup- 
tures, and  occlusions,  1248 
Thoracicoplastic    pleuropneumolysis 

with  subcostal  apicolysis,  904 
Thoracoplasty,  910 

Estlander's  method,  910 

Schede's  operation,  910 
Thoracotomy,  908 
Thorax.     See  Chest. 
Thorium,  1469 

Thorn's  treatment  of  ankylosis,  653 
Threads,  mycelial,  18 
Three-glass    test    of    urethral    dis- 
charge, 134s 
Throat,  cut,  879 
Thrombin,  458 
Thrombo-angiitis     obliterans,     165, 

Thrombo-arteritis,  186 
Thrombogen,  458 
Thrombokinase,  458 

method  of  obtaining,  459 
Thrombophlebitis,  infective,  186,  409 
Thrombosis,  184 

causes.  185 

iliac,  after  abdominal  operations, 
187 

in  appendicitis,  188 

in  general  infections,  188 

in  typhoid  fever,  188 

infective,  of  cavernous  sinus,  807 
of  lateral  sinus.  806 
of  petrosal  sinus,  807 

lymphatic,  186 


I5I2 


Index 


Thrombosis  of  jugular  vein,  186 
of   mesenteric   arteries,   intestinal 
obstruction  from,  983 
vessels,  187 
sinus-,  infective,  805 
symptoms,  186 
treatment,  188 
Thrombotic  gangrene,  164 

treatment,  165 
Thrombus,  184 
antemortem,  185 
aseptic,  184 
bland,  184 
infectious,  184 
mixed,  185 
primarj-,  185 
propagating,  185 
red,  18s 
secondary,  iSs 
simple,  184 
spreading,  185 
white,  185 
Throttling,  871 
Thrush,  19 
Thumb,  amputation  of,  1407 

metacarpophalangeal      joint      of, 

traumatic  dislocation,  674 
Selva's  bandage,  1254 
spica  bandage,  1254 
stave  of,  580 
Thymectomy,  1248 
Thymic  asthma,  1247 

death,  1247 
Thymus  gland,  1247 
cancer  of,  1248 
enlargement  of,  1247 
sarcoma  of,  1248 
tumors  of,  1248 
Thyroglossal  cysts,  926 
duct,  926 
sinus,  926 
Thyroid  arteries,  Ugation,  in  exoph- 
thalmic goiter,  1243 
artery,  inferior,  hgation  of,  477 

superior,  ligation  of,  482 
extract  in  hemophilia,  459 
fever,  1243 
gland,  aberrant,  1232 
absence  of,  1228 
accessory,  1232 
atrophy  of,  1228 
cancer  of,  1229 
congestion  of,  1229 
diseases  and  injuries,  1227 
effect  of  removal  of,  1228 
enucleation  of,  1240 
extirpation     of,     extracapsular, 
1240 
intracapsular,  1242 
feeding  of,  1228 
grafting  of,  1228 
inflammation  of,  1229 
maUgnant  disease  of,  1229 
operations  on,  1239 
sarcoma  of,  1229 
Socin's  operation  on,  1240 
syphilis  of,  1229 
tetany  after  removal  of,  1228 
tuberculosis  of,  1229 
tumors  of,  1229 
wounds  of,  1228 
Thyroidectin  in  exophthalmic  goiter, 

1238 
Thyroidectomy,  complete,  1240 
in  exophthalmic  goiter,  1243 
in  goiter,  123  s 

Kocher's  method,  1 240-1 242 
partial,  1240 

in  exophthalmic  goiter,  1239 
Throidism,  acute,  1243 
ThyroUngual  cysts,  926 
duct,  926 
sinus,  926 
Thyrotomy,  882 
Tibia,  bent,  osteotomy  for,  689 
chronic  osteomyelitis  of,  507 
fractures  of,  609.     See  also  Frac- 
tures of  tibia. 
spine  of,  avulsion,  610 
Tibial  artery,  antenor,  ligation  of, 
484,  48s 
posterior,  ligation  of,  485,  486 


Tibialis  anticus  muscle,  subcutane- 
ous tenotomy  of  tendon  of,  733 

posticus     muscle,     subcutaneous 
tenotomy  of,  733 
Tic  douloureux,  748 

bites  of,  296 
Tinnitus  aurium,   division  of  audi- 
tory nerve  for,  767 
Tissue  changes  from  «-rays,  1450 
Toe,  amputation  of,  141 1 

great,   metatarsal    bone,   excision 
ot,  706 
Butcher's  method,  706 
metatarsophalangeal      articula- 
tion, excision  of,  706 

hammer-,  745 

phalanges  of,  fractures,  616 
Toe-nail,  ingrowing,  157,  1227 
Tongue,  adherent,  925 

bums  and  scalds,  313 

cancer  of,  927.     See  also  Cancer 
of  tongue. 

injuries  and  diseases,  912 

swallowing  of,  in  anesthesia,  1202 
treatment,  1204 
Tongue-tie,  925 
Tonics  in  inflammation,  no 
Tonsil,  sarcoma  of,  Dawbam's  oper- 
ation in,  377 
Toothache,  elevation  in,  95 
Tooth-socket,      hemorrhage      from, 

control,  452 
Torpid  shock,  261 
Torsion,  free,  in  hemorrhage,  445 

in  hemorrhage,  444 

of  great  omentum,  956 
TorticoUis,  736 

acute,  736 

chronic,  736 

congenital,  736 

open     division     of     sternocleido- 
mastoid muscle  for,  732 

rheumatic,  712 

spasmodic,  736 
Tourniquet,  appHcation  of,  1402 

Charriere's,  1403 

impromptu,  446 

Lister's,  in  aneurysm,  422 

Pancoast's,  1418 

Petit's,  1402.  1403 

von  Esmarch's,  1418 
Toxalbumins,  37 
Toxemia,  36 

hydatid,  403,  1034 
Toxins,  36 

alkaloidal,  37 

extracellular,  37 

intracellular,  37 
Trachea,  diseases  and  injuries,  879 

foreign  bodies  in.  880 

operations  on,  883 
Tracheobronchoscopy,  882 

Jackson's,  885 
Tracheotomy,  883 

high,  883 
Trajectory  of  projectiles,  286 
Transfusion,  arterial,  of  saline  fluid, 
467 

centripetal  arterial,  in  shock,  263 

of  blood,  463 

Brewer's  method,  464 
Crile's  operation,  463 
Fauntleroy's  vein-to-vein  anas- 
tomosis for,  464 

of  blood  in  shock,  264 
Transplantation  of  cancer,  349 

of  parathyroids,  1245 

tendon-,  734 

with  pedicle,  1261 

without  pedicle,  1261 
Trauma,  tuberculosis  and,  relation, 

223 
Traumatic  abscess  of  hver,  1036 
treatment,  1039 

aneurysm,  291,  293,  417 
diffuse,  431 

appendicitis,  1004 

arthritis,  634 

asphyxia,  8go 

carditis,  405 

dermoids,  396 

diffused  aneurysm,  416 


Traumatic   dislocations,   655.      See 
also  Dislocation,  traumatic. 
epilepsy,  operative  treatment,  822 
epithelial  cystoma,  396 

cysts,  398 
fevers,  129 
aseptic,  129 
benign,  129 
septic,  129 
true,  730 
hernia,  1135 
hysteria.  850 
inflammation,  85 

of  brain  and  membranes,  798 
Insanity.  ODerations  for,  824 
intracranial  hemorrhage,  786 
neurasthenia.  849 
neuroma,  364 
pericarditis,  405 
pleuritis,  896 
pneumonia,  896 
pneumothorax,  acute,  89s 
spreading  gangrene,  170 
thecitis,  723 
urethritis,  1344 
Treitz's  ligament,  1102 
Trendelenburg's    operation    for    es- 
strophy  of  bladder,  13 16 
for  varix  of  leg,  462 
position,  1067 
Trephine,  Gait's,  826 
Trephining,  826 

decompressive,  820,  831 
frontal  sinus,  828 
mastoid,  828 

palliative,  in  tumors  of  brain,  820 
preventive,  790 
Treponema  pallidum,  55 
Treves's      method    of     amputating 
penis,  1374 
of  excision  of  scapula,  706 
operation  for  caries  of  lumbar  and 
last  dorsal  vertebrae,  with  ab- 
scess in  psoas  magnus  or  quadra- 
tus  lumborum  muscle,  695 
treatment  of  perforating  ulcer,  161 
Triangle,  Bryant's,  584 
carotid,  inferior,  475,  478 

superior,  47s,  479 
lumbar,  superior,  1162 
Macewen's,  830 
occipital,  475,  479 
of  election,  475,  479 
of  necessity,  475,  478 
of  neck,  475.  478 
anterior,  478 
posterior,  479 
of  Petit,  1162 
Scarpa's,  487 
subclavian,  47s,  479 
submaxillary,  475,  479 
submental.  475,  479 
suprameatal,  772 
Trichinosis  of  muscles,  713 
Trigeminal  neuralgia,  762.    See  also 

Neuralgia  of  fifth  nerve. 
Trigeminus,  sensory  root  of,  Frazier- 
Spiller    operation    of    intracranial 
neurotomy  of,  767 
Trigger-finger.  739 
Trigonitis.  1324 
Tripper.  1345 
Trismus.  207 
nascentium,  208 
neonatorum,  208 
Trochanter,  great,  fractures  of,  593 

separation  of  epiphysis,  593 
Trophic  gangrene,  164 
joint  affections,  643 
ulcer.  161 
Tropical  abscess.  142,  1036 

treatment.  1038 
Tropics,  endemic  boil  of,  138 
Trousseau's  sign  in  tetany,  1246 
Truax's  method  of  preparing  kanga- 
roo-tendon, 73 
Tubercle,  214 
anatomical,  247 
diffuse,  214 
fibrous,  215 
hyaline,  215 
painful  subcutaneous,  355 


Index 


1513 


Tubercle,  primitive,  214,  236 
rabic,  305 
reticulated,  215 
Tuberculin,  220 
BE.,  220 

dangers  from  injecting,  221 
in  prognosis  of  tuberculosis,  230 
in  treatment  of  tuberculosis,  232 
OT.,  220 

reaction  in  non-tuberculous,  221 
test  in  tuberculosis,  227 
TO.,  220 
TR.,  220 
Tuberculoma  of  brain,  S09 
Tuberculosis,  213 
acute  miliary,  252 
agglutination  test  in  diagnosis,  229 
and  syphilis,  coexistence,  318 
animal  inoculations  in  diagnosis, 

229 
bacillus  of,  216 

distribution,  217 

extracellular  poisons,  220 

intracellular  poisons,  220 

products,  220 

resistance,  221 
Bier's  treatment,  234 
blistering  in  idiagnosis,  221,  229  _ 
Calmette's    ophthalmo-tuberculin 

reaction  in,  2 28 
diagnosis,  226 
disseminata,  247 
enteroperitoneal,  999 
Finsen  light  in,  235 
heb'otherapy  in,  231 
hereditary  predisposition  to,  222 
hyperplastic,  999 
immunity  to,  221 
incidence,  215 
ingestion,  218 
inhalation,  217 
inoculation,  218 
intestinal,  248 

perforation  in,  1000 

primary,  999 
latent  lesions,  219 
massage  of  focus  in  diagnosis,  229 
miliary,  acute,  252 
Moro's  cutaneous  tubercuhn  reac- 
tion in,  229 
of  adrenals,  252 
of  ahmentary  canal,  248 
of  ankle-joint,  632 
of  blood-vessels,  248 
of  bone,  249,  494 

infiltrating  progressive,  494 
of  brain,  249 
of  breast,  1426 

confluent,  1426 

nodular,  1426 
of  cervical  lymph-glands,  250 
of  elbow-joint,  633 
of  endocardium,  249 
of  Fallopian  tubes,  252 
of  fascia,  249 
of  heart  muscle,  249 
of  hernia,  1134 
of  hip-joint,  625 

by  weight-bearing  and  fixation, 
630 

complications,  628 

formalin-glycerin  in,  630 

Huntington's  treatment,  630 

intra-articular     injections     and 
operation  in,  630 

Lorenz's  treatment,  630 

pain  of,  89 

treatment,  628 
of  joints,  250 
of  kidney,  252 

chronic.  1290 
of  knee-joint,  631 
of  liver,  248 

of  lymphatic  glands,  230 
of  mesenteric  glandis  in  children, 

1000 
of  muscle,  249 
of  nerves,  248 
of  ovaries,  252 
of  pancreas,  249 
of  pericardium,  249 
of  peritoneum,  248,  1027 


Tuberculosis  of  pleura,  248 
of  prostate,  1391 

latent,  1393 
of  sacro-iliac  joint,  624 
of  seminal  vesicles,  1376 
of  shoulder-joint,  632 
of  skin,  246 
of  spinal  cord,  249 
of  spleen,  249 
of  stomach,  248 
of  subcutaneous  connective  tissue, 

247 
of  tendon-sheaths,  252 
of  testicle,  252,  1393 
of  thyroid  gland,  1229 
of  uterus,  252 
of  vertebrze,  624 
of  wrist-joint,  633 
predisposition  to,  222 
prognosis,  229 
pulmonary,  248 
fever  due  to  awakening  of  area 

of,  130 
surgical  treatment,  902 
routes  of  infection,  217 
sunshine  in,  231 
trauma  and,  relation,  223 
treatment,  230 
local,  234 

surgical,  special  methods,  234 
tuberculin  in  prognosis,  230 
test  in,  227 
treatment,  232 
ulcerosa,  246 
verrucosa,  247 

von  Pirquet's  cutaneous  tubercu- 
lin reaction  in,  229 
3C-rays  in  diagnosis,  227 
in  treatment,  235 
Tuberculous  glands,  250 
Tubulization  of  nerves,  760 
Tubulocysts,  401 
Tubulodermoid,  398 
Tucked  back  ulcer,  994 
TuiSer's  method  of  exploring  for  ab- 
scess of  lung,  912 
Tuffnell's  compress  in  aneurysm,  422 

treatment  of  aneurysm,  421 
Tumors,  345 
causes  of,  346 
classes  of,  346 
classification  of,  351 
connective-tissue,  malignant,  368 
cystic,  multilocular,  361 
desmoid,  355 
division  of,  34s 
heredity  as  cause,  347 
heterologous,  346 
inclusion  theory  of  Cohnheim,  346 
injury  and  inflammation  as  causes, 

348 
innocent,  350 

connective-tissue,  352 
malignant,  350 
epithelial,  381 

from  congenital  pigmented  mole, 
395 
mixed,  373 
Miiller's  law,  346 
parasitic  theory,  348 
peari,  357 
physiological  activity  as  cause,  348 

decline  as  cause,  348 
Virchow's  law,  346 
Tunica   vaginalis,   diseases   and   in- 
juries, 1339 
hematocele  of,  1400 
hydrocele  of,  1398 
Turpentine  stupe   in  inflammation, 

102 
Tuttle's  proctoscope,  1169 
Twisted  suture,  272 
Typhobacillosis,  252 
Typhoid  arthritis,  636 
bacillus,  S4 
bone  disease,  301 
carrier,  38 
cholecystitis,  1047 
erysipelas,  200 
fever,  dislocation  of  hip  in,  655 

thrombosis  in,  188 
spine,  839 


Typhoid  ulcer,  perforated,  997 
vaccination,  44 


Ulcer,  151 
acute,  152 
callous,  of  leg,  159 
cancerous,  true,  391 
cancroid,  159 
chronic,  152 
classification,  152 
complications  of,  treatment,  155 
compression  in,  100 
Curling's,  162,  313,  994 
cystoscopicum,  1301 
eczema   complicating,   treatment, 

iSS 
edematous,  159 
erethistic,  157 
exuberant,  of  leg,  157 
fungous,  of  leg,  157 
gummatous,  329 
healthy,  157 
hemorrhagic,  159 
indolent,  of  leg,  157 
irritable,  157 
Jacob's,  159,  392 
kissing,  962 
Marjolin's,  159,  391 
Martin's  bandage  in,  156 
neuroparalytic,  i6i 
of  bladder,  1328 
of  duodenum,  994 
of  intestine,  993 
of  leg,  acute,  152 
treatment,  153 

callous,  159 

chronic,  153 
treatment,  154 

exuberant,  157 

fungous,  137 

indolent,  157 

inflamed,  132 

varicose,  157 
of  rectum,  1185.    See  also  Rectum, 

ulcer  of. 
of  stomach,  961 

acute,  962 

chronic,  962 

hemorrhage    in,    operation   for, 
968 

hunger-pain  in,  963 

indurated,  962 

latent,  963 

non-indurated,  962 

perforation  in,  965,  966 
operation  for,  968 

Shoemaker's  symptom,  966 

symptoms,  963 

treatment.  966 

x-TSLys  in  diagnosis  of,  1456, 1457 
painful,  157 
peptic,  of  duodenum,  994 

of  jejunum,  after  gastro-enteros- 
tomy,  1089 

of  stomach,  961 
perforating,  161 
phagedenic,  133,  iS9 
rodent,  159,  392 
scorbutic,  161 
serpiginous,  in  syphilis,  321 

in  tertiary  syphilis,  328 
syphilitic,  153 
trophic,  r6i 
tuberculous,  132,  247 
tucked  back,  994 
typhoid,  perforated,  997 
varicose,  of  leg,  137 
varix  complicating,  treatment,  155 
Vesigne's,  161 
Ulna  and  radius,  traumatic  disloca- 
tion, 670.  671 
fractures  of,  567.     See  also  Frac- 
tures of  ulna. 
traumatic  dislocation,  671 
Ulnar  artery,  ligation,  471,  472 

nerve,  dislocation  of,  at  elbow,  758 
Ultzmann's  formula  in  acute  gonor- 
rhea, 1352 
Umbilical  hemorrhage,  control,  454 

hernia.     See  Hernia,  umbilical. 
Unconsciousness.     See  Coma. 


I5I4 


Index 


Undescended  testicle,  1301 
Union,  immediate,  116 

primary,  116 
Unna's  dressing  in  chronic  ulcer  of 

leg,  154 
Urachal  cysts,  402 
Uranium,  1469 
Uranoplastj',  921 
Uremia,  coma  of,  785 
Ureter,  bleeding  from,  1267 
calculus  in,  1283 
catheterization  of,  1268 

practical  value,  1308 
diseases  and  injuries,  1273 
intestinal  implantation,  1300 
irrigation  of,  1309 
lavage  of,  1309 
operations  on,  1291 
stricture  of,  1288 
wounds  of.  1283 
Ureteral  catheters,  1303 
disinfection  of,  131 1 
sterilization  of,  1302 
orifices,    location,    in    cystoscopy, 
1303 
Ureterohthotomy,  1285,  1298 
Uretero-ureterostomy,  1300 
Urethra,     dilatation     of,     modified 
rapid,  for  stricture,  1368 
diseases  and  injuries,  1339 
divulsion  of,  for  stricture,  1368 
foreign  bodies  in,  1342 
hemorrhage  from,  1270 

control,  434 
inflammation  of,   1343.     See  also 

Urethritis. 
preparation  of,  for  operation,  68 
rupture  of,  1340 

stricture  of,  1365.     See  also  Stric- 
ture of  urethra. 
spasmodic,  treatment,  1314 
wounds  of,  1339 
Urethral  calculus,  treatment,  1314 
catarrh,  chronic,  1348 
chancre,    pyogenic    urethritis    of, 

1344 
discharge,  chronic,  1348 
examination  in,  1345 
three-glass  test  of,  1345 
fever,  1368 
shock,  1368 
Urethritis,  1343 

acute     posterior,     in     gonorrhea, 

treatment,  1356 
anteroposterior,  treatment  of,  1355 
chronic,  following  gonorrhea,  treat- 
ment, 1337 
eczematous,  1344 
gouty,  1344 
non-specific.  1343 
non-venereal.  1343 
pyogenic,  1343 
chancroidal,  1344 
of  urethral  chancre,  1344 
syphilitic,  1344 
simple,  1343 
specific,  1345 
traumatic,  1344 
treatment,  1314 
tuberculous,  1344 
Urethrocystitis,  1324 
Urethrorrhea.  1343 
Urethroscope,  Marks's,  1359 

Valentine's,  1358 
Urethrotome,  Gross's,  1367 
Maisonneuve's,  1367 

Horwitz's  modification,  1367 
Otis',  1368 
Urinary  abscess,  142 
fever,  1369 

organs,  diseases  of,  a;-rays  in  diag- 
nosis of,  1438 
Urination,  frequency  of,  1271 

slowness  of,  12 71 
Urine,  bacteria  in,  1324 

collection  of,  by  cystoscope,  1306 
cryoscopy  of,  1273 
defective  expulsion,  13 12 
freezing-point,  1273 
in  inflammation,  iii 
postoperative  suppression  of  treat- 
ment, 265,  266 


Urine,  residual,  1312 

in  prostatic  hypertrophy,  1379 
retention  of,  1312 

acute,  1312 

from    expulsive    defect,    treat- 
ment, 131S 

in  gonorrhea,  treatment,  1356 

incontinence  of,  1312 
segregation  of,  1269 
segregator,  Harris's,  1269 
separator,  Luys's,  1270 
Uterine  fibroid,  362 

myoma,  362 
Uterus,    gonorrhea    of,    treatment, 

1363 
hemorrhage  from,  control,  455 
hernia  of.  1164 
inflammation  of,  pain  in,  89 
pregnant,  gunshot-wounds  of,  953 
tuberculosis  of,  232 


Vaccination,  44 

tetanus  following,  204 
typhoid,  44 
Vaccine.  44 

therapy,  47 
Vaccines,  autogenous,  47 

bacterial,  treatment  of  infections 
by,  47 
Vagina,   hemorrhage  from,   control, 
455 
preparation  of,  for  operation,  68 
Vaginal  hematocele,  1400 
hernia,  1162 
hydrocele,  1398 
Vagolysis  in  cardiospasm,  939 
Valentine's  irrigator,  1351 
light  carrier,  1338 
method  of  examination  in  urethral 

discharges,  134s 
obturator,  1338 
rules    for    cGlatation    in    chronic 

gonorrhea,  1361 
treatment    of    acute    gonorrhea, 

1331, 1352 
urethroscope,  1358 
VaUeix's  points  douloureux,  90 
Valvular  cecostomy,  1121 
Van   Arsdale's   method   of   treating 
sprains,  648 
splint  in  fractures  of  shaft  of 
femur  in  children,  598 
Van   Hook's   operation   of   uretero- 
ureterostomy, 1300 
Varicocele,  411,  1400 

Bloodgood's  operation  for,  1401 
open  operation  for,  1401 
Varicose  aneurysm,  432 
symptoms,  433 
treatment,  433 
external  hemorrhoids,  11 78 
lymphatics,  1230 
uilcer  of  leg,  157 
veins.    See  also  Varix. 
Varix,  410 

aneurysmal,  432 
symptoms  of,  433 
treatment  of,  433 
complicating  ulcer  of  leg,  137 

treatment,  133 
of  leg,  Bennett's  operation  for,  462 
Delbet's  operation  for,  462 
Fergusson's  operation  for,  462 
Madelung's  operation  for,  462 
operation  for.  461 
Phelps's  operation  for,  462 
Schede's  operation  for,  462 
treatment.  412 

Trendelenburg's   operation   for. 
462 
of  spermatic  cord.  411 
ruptured,  control  of,  453 
Vascular  system,  operations  on,  439 
Vasectomy  for  hypertrophy  of  pros- 
tate. 1388 
Vasotribe,  Doyen's.  440 
Vaughan's    method    of    controlling 

hemorrhage,  431 
Veins,  cyst  of,  412 
inflammation  of,  408 
suture  of,  440 


Veins,  varicose.  410.    See  also  Varix. 

wounds  of,  436 
Vein-stone,  412 
Vein-to-vein    transfusion    of    blood, 

464 
Velpeau's  bandage,  1238 

for  fractures  of  clavicle,  552 
Venae  comites,  469 
Venereal  catarrh.  1343 
sore,  local,  1372 
warts,  380 
Venesection,  462 

in  inflammation,  103 
Venom,  colubrine,  299 

viperine,  298 
Venom-globulin,  298 
Venom-peptone,  298 
Venous  circle,  vicious,  412 
erysipelas,  200 
gangrene,  164 
nevus,  366 
piles,  1 1 79 
Ventilation  in  inflammation,  1112 
Ventral  hernia.  11 60 
Veratrum  viride  in  inflammation,  106 
Vermiform  appendix,  cancer  of,  1015 
constipation  of,  1003 
hernia  of,  1161 
malignant  disease  of,  1014 
Morris's  method  of  palpating, 

1009 
removal    of.    under   infiltration 

anesthesia,  1220 
sarcoma  of,  1015 
Vemeuil's   treatment   of    ankylosis, 

632 
Verruca  necrogenica.  247 
\"ertebr£e,  acute  osteomyelitis  of,  839 

tuberculosis  of.  624 
Vertebral  artery,  ligation,  476,  477 

ligaments,  strain  of,  851 
Vertigo,  aural,  division  of  auditory 

nerve  for,  767 
Vesical.     See  Bladder. 
Vesiculitis,     acute,     in     gonorrhea, 
treatment,  1336 
seminal,  1373 

tuberculous,  1376 
Vesigne's  ulcer,  161 
Vestiges,  fetal,  347 
Vibrio,  21 

Vibrione  septique,  34 
Vicious  cicatrix,  121 
circle     after    gastro-enterostomy. 

1090 
venous  circle,  412 
Vienna  mixture,  1209 
Villous  papilloma,  380 
Viperine  venom,  298 
Virchow's  disease,  310 
law  of  tumors,  346 
multiple  adenoma,  982 
Visceral  syphilis,  331 
Visceroptosis,  1020 
Vischer's  case  for  culture-tubes,  147 
Vitello-intestinal  duct,  cysts  of,  402 
Volkmann's  contracture,  714 
CoUey's  operation  in,  717 
Jones's  treatment,  716 
membrane,  237 
operation  for  hydrocele,  1399 
paralysis,  714 
spUnt,  703 
Volvulus,  979 

of  stomach,  937 
\'omiting  after  gastro-enterostomy, 
1089,  1091 
treatment,  1092 
fecal,  in  strangulated  hernia,  1154 
in  anesthesia,  1205 
treatment,  1202 
stercoraceous,  984 

in  strangulated  hernia,  1x54 
von  Bezold's  abscess,  146,  805 

treatment,  149 
von  Esmarch's  tourniquet,  1418 
von  Graefe's  sign  in  exophthalmic 

goiter,  1237 
von    Hacker's    method    of    gastro- 
enterostomy, 1092 
von  Mosetig-iloorhof 's  treatment  of 
bone-cavities,  502 


Index 


151S 


von  Nussbaum's  treatment  of  cuta- 
neous erysipelas.  201 

von  Pirquet's  cutaneous  tuberculin 
reaction  in  tuberculosis,  229 

Vulcanite  splint,  542 

Vulva,  noma  of,  17S 

Wallerian  degeneration,  123 
Wandering  abscess,  142,  235 

erysipelas,  199 

goiter.  1231 

kidney,  1275 

spleen.  1065 
War.  wounds  of  brain  in,  794 
Wardrop's  operation  for  aneurysm. 

426 
Ware's  splint  in  fractures  of  shaft 

of  femur  in  children,  599,  600 
Warren's    operation    for    cancer    of 
breast,  1441 
for  fibroma  of  breast,  1428 
Wart-horn,  380 
Warts,  379 

lymphatic,  1250 

syphilitic.  325 

venereal.  380 

villous,  380 
Wash-stand.  61 
Wasps,  stings  of,  296 
Wassermann  test,  effect  of  salvarsan 
on,  342 
for  diagnosis  of  syphilis,  332 
Water,  boiled,  30 

on  brain,  801 

sterile,  infiltration  anesthesia  with, 
1223 
Watson's  method  of  gastro-anasto- 
mosis.  1 102 

splint,  704 
Wax,  Horsley's,  in  controlling  hem- 
orrhage, 451 

iodoform,  31 
Waxy  disease  from  tuberculous  ab- 
scess, 239 
Weavers'  bottom.  731 
Webbed  fingers.  738 
Weber's    incision     for    prelinunary 

closure  of  external  carotid  artery, 

707 
Weglowski's  treatment  of  ankylosis. 

652 
Weir's  appendicostomy,  1077 

operation  for  rectal  cancer,  1190 
Weir-Stimson  method  of  sterilization 

of  forearms  and  hands,  63 
Welanders    treatment  of   bu'-o     in 

chancroid,  1374 
Welch-Kelly  method  of  sterilization 

of  hands  and  forearms,  63 
Welch's  bacillus  aerogenes  capsula- 

tus.  54 
Wens.  400 
West's    rules    as    to    treatment    m 

pneumothorax.  895 
Wheelhouse's  operation  of  perineal 
section,  1371 
staff.  1370 
White   and   Martin's   treatment   of 

gonorrhea.  1350 
White  gangrene  from  ;c-rays,  1451 
infarction.  189 
swelling,  250,  620,  631 
thrombus,  185 
Whitehead's  operation  for  cancer  of 
tongue,  930 
for  piles.  1181 
White's  treatment  of  acute  gonor- 
rhea, 1354 
of  catarrhal  gonorrhea,  1352 
of  felon.  725 
Whitlow.  724.     See  also  Felon. 
Whitman's    method    of    astragalec- 
tomy  in  paralytic  calcaneus,  706 
plate  in  flat-foot,  743 
treatment   of   intracapsular   frac- 
tures of  femur,  589 
Willard's     method     of     sterilizing 

ureteral  catheters,  1302 
Williams's  sign,  1454 
Wilson's  flat-foot  correction  screw, 
743 
operation  for  hallus  valgus,  744 


Wind  contusion  from  projectiles,  291 

Wing-like  scapula.  751 

Winslovv,   foramen   of,    hernia  into. 

1162 
Wire,  brass,  preparation  of,  74 
bronze,  preparation  of,  74 
copper,  preparation  of,  74 
in  treatment  of  aneurysm,  430 
silver,  preparation  of,  74 
Witte's  treatment  of  hemophilia,  459 
Witzel's    method    of    gastrostomy, 

1086 
Wolfe's  method    of    skin-grafting, 

1264 
Wolfler-Liicke  method    of    gastro- 
enterostomy, 1091 
Wolfler's    method    of    gastro-anas- 
tomosis,  1102 
of  gastro-enterostomy,  logi 
suture,  1079 
Wooden  phlegmon.  136 
Wood's    rule    in    fractures  of     true 

pelvis,  548 
Wool-sack  cocci,  21 
Wool-sorters'  disease,  300 
Word-blindness  in  tumor  of  brain ,815 
Word-deafness  in  tumor  of  brain,  815 
Worms,  filarial,  1250 
Wounds,  259 
arrow-,  274 
blank-cartridge,  277 
bringing  about  reaction,  266 
by  cannon-baUs.  282 
by  grenades,  282 
by  shells.  282 
cleansing  of,  266 
closure  of,  267 

constitutional  condition  after,  259 
contused,  272 
dissection-.  295 
drainage  of,  267 
dressing  of,  267 

foreign  bodies  in,  removal,  266 
from  revolver,  277 
gaping  or  retraction  of  edges,  259 
gunshot-,  275.     See  also  Gunshot- 
wounds. 
healing  of,  122 
hemorrhage  of,  259 

arrest,  266 
in  war  from  rifle-bullets,  282 
symptoms,  291 
treatment,  292 
incised,  268 
infected.  29s 
lacerated.  272 
local  phenomena,  259 
loss  of  function  in,  259 
maggots  in,  297 
of  abdominal  wall,  953 
of  arteries,  434,  435 

gunshot,  43 s 
of  bladder,  1317 
of  brain,  794 

from  revolver  bullets,  796 
in  war,  794 
of  chest,  898,  899 
of  esophagus,  940 
of  heart.  404 

operation  for,  460 
Rotter's  incision  in,  460 
of  joints,  646 
of  larynx,  879 
of  left  thoracic  duct,  1248 
of  liver,  1032 

of  mucous  membranes,  271 
of  muscles.  717 
of  nerves,  749,  758 
of  pancreas,  1054 

during   operations  on  stomach 
and  spleen,  1056 
of  pericardium,  404 
of  rectum.  1171 
of  salivary  glands,  914 
of  scalp.  779 
of  spleen.  1063 
of  spinal  cord.  851 
of  Steno's  duct,  914 
of  tendons,  720 
of  thyroid  gland,  1228 
of  ureters,  1282 
of  urethra,  1339 


Wounds  of  veins,  436 
pain  in.  259 

perforating,  of  kidney,  1280 
poisoned,  294 
punctured,  273 
rest  in,  268 
septic,  29s 

irrigation  in,  69 
stab-,  274 

subcutaneous,  healing  of,  121 
treatment,  266 
constitutional,  268 
Wright's  views  upon  inflammation 

and  its  treatment,  iis 
Wrist,  traumatic  dislocation,  673 
Wrist-joint,  disarticulation  at,  1408 
disease,  633 
excision  of,  700.    See  also  Excision 

of  wrist-joint. 
tuberculosis  of.  633 
Wry-neck,  736.    See  also  Torticollis. 
Wyeth's    amputation    of    hip-joint, 
1420 
dressing  in  fractures  of  shaft  of 

femur  in  children,  599 
method  of  preventing  hemorrhage 
in  amputation  at  hip- joint.  1419 
pins  in  amputation  at  shoulder- 
joint,  1409 
splint,  629 

Xanthoma,  353 
X-rays,  1447  . 

apparatus,    Mackenzie-Davidson,^ 
1462 

•  Sweet's,    for    locating    foreign. 

bodies,  1464,  1465 
burn  from,  1450   14S1 
cancer,  388 
death  from,  1452 
dermatitis  from,  1450,  14S1 
effect  on  bacteria,  24,  1450 
for  locating  bullet,  281 
in  cancer,  394,  395.  1467 
in  diagnosis  of  aneurysm,  420,  421 

of  diseases  of  colon,  1458 
of  urinary  organs,  1458 

of  duodenal  conditions,  1457 

of  fractures.  523 

of  gastric  ulcer.  1456,  I4S7 

of  gastro-intestinal  diseases, 1454. 

•  of  tuberculosis,  227 

of  ureteral  calculi,  1459 
in  diseases,  1466 

of  skin,  1466 
in  epithelioma,  1467 
in  examination  of  esophagus,  930 
in  exophthalmic  goiter,  1468 
in  leukemia,  1468 
in  localizing  foreign  bodies,  14611 
in  locating  bullet,  281 
in  malignant  growths,  1466 
in  sarcoma,  379,  1467 
in  tuberculosis,  235 
in  tuberculous  sinuses,  1468 
malignant  changes  from,  1452 
physiological  effects,  i449 
reaction  from,  1450 
sterility  from,  1452 
tissue  changes  from.  1450 
uses  of,  1452 
white  gangrene  from,  1451 

Yeasts.  18 

Young's  method  of  perineal  prosta- 
tectomy, 1386 

modification  of  Freudenberg's 
instrument  for  prostatotomy  by 
galvanocautery,  1387 

operation  for  tuberculosis  of  semi- 
nal vesicles,  1376 

punch  operation  on  prostate,  1387 

treatment  of  dislocation  of  lower 
jaw,  660 

Zone    of    election    of    pathological 
processes,  505 

Zooglea  masses,  21 

Zuckerkandl's   incision   in   tubercu- 
losis of  seminal  vesicles,  1376 

Zygomatic  arch,  fracture,  540 

Matas's  operation  for.  ^ii 


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Dercum's   Mental   Diseases 

Clinical  Manual  of  Mental  Diseases.  By  Francis  X.  Dercum, 
Ph.  D.,  ]\I.  D.,  Professor  of  Nervous  and  Mental  Diseases  at  Jefferson 
Medical  College,  Philadelphia.     Octavo  of  425  pages.     Cloth,  $3.00  net. 

TWO  PRINTINGS  IN  FIVE  MONTHS 

This  is  a  book  really  useful  to  the  family  physician — a  book  that  tells  you 
definitely  how  to  diagnose,  how  to  treat — either  at  home  or  in  an  institution — all 
classes  of  mental  diseases.  First,  Dr.  Dercum  takes  up  the  various  primars^ 
forms  of  mental  disease,  giving  emphasis  to  those  you  meet  in  your  daily  practice 
as  general  practitioner — -delirium,  confusion,  stupor..  Then  melancholia,  mania, 
the  insanities  of  early  life,  paranoia,  the  neurasthenic-neuropathic  disorders,  and 
the  dementias  follow.  The  mental  disturbances  of  the  infections  (syphilis,  tubercu- 
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The  Medical  World 

'•  This  book  gives  iust  the  information  necessary,  and  gives  it  in  a  style  studiously  adapted 
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Church  and  Peterson's 
Nervous  and  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Medical  Jurisprudence, 
Northwestern  University  Medical  School,  Chicago;  and  Frederick 
Peterson,  M.  D.,  formerly  Professor  of  Psychiatry  at  the  College  of 
Physicians  and  Surgeons,  N.  Y.  Handsome  octavo,  944  pages;  350 
illustrations.     Cloth,  ^5.00  net ;   Half  Morocco,  ^6.50  net. 

EIGHTH    EDITION 

For  this  new  {8th)  edition  this  standard  work  has  undergone  a  thorough  re- 
vision. Vertigo  and  its  labyrinthine  relations,  as  developed  by  Barany,  has 
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It  is  more  than  ever  the  standard. 

American  Journal  of  the  Medical  Sciences 

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and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 


Kaplan's  Serology  of  Nervous  and 
Mental  Diseases 

Serology  of  Nervous  and  Mental  Diseases.  By  D.  M.  Kaplan, 
M.  D.,  Director  of  Clinical  and  Research  Laboratories,  Neurological 
Institute,  New  York  City.  Octavo  of  346  pages,  illustrated.  Cloth, 
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This  is  an  entirely  new  work,  giving  you  the  indications,  contra-indications, 
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fluids  obtained  by  lumbar  puncture.  You  get  a  full  discussion  of  the  serology  of 
all  nervous  and  mental  diseases  of  non-lnetic  etiology  (including  disorders  of 
internal  secretion),  and  of  every  type  of  luetic  nervous  and  mental  disease,  giv- 
ing the  Wasserinann  reaction  in  detail,  the  use  of  salvarsan  and  neosalvarsan,  etc. 


MENTAL   DISEASES  AND   HYGIENE 


Herrick's  Neurology 

Introduction  to  Neurology.  By  C.  Judsox  Herrick,  Ph.  D.,  Pro- 
fessor of  Neurology  in  the  Univ^ersit\-  of  Chicago.  1 2mo  of  360  pages, 
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RECENTLY   ISSUED 

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of  elementar}'-  psychology  in  colleges  and  normal  schools,  by  students  of  general 
zoology  and  comparative  anatomy  in  college  classes,  and  by  medical  students  as 
a  guide  and  key  to  the  interpretation  of  the  larger  works  on  neurology. 


Brill's  Psychanalysis  second  Edition 

Psychanalysis  :  Its  Theories  and  Practical  Application.  By  A.  A. 
Brill,  Ph.  B.,  ^I.  D.,  Clinical  Assistant  in  Neurology  at  Columbia 
Univ^ersit}-  Medical  School.     Octavo  of  392  pages.        Cloth,  S3. 25  net. 

To  the  general  practitioner,  who  first  sees  these  ' '  borderline ' '  cases  (the 
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work.  Dr.  Brill's  work  will  prove  most  valuable.  Dr.  Brill  has  had  wide  clinical 
experience,  both  in  America  and  in  Europe.  The  results  of  this  experience  you 
get  in  this  book.  Here  you  get  the  practical  application  of  all  Freud's  theories — 
and  from  the  pen  of  a  man  thoroughly  competent  to  write. 

Hunt's  Diagnostic  Symptoms  of  Nervous  Diseases 

Diagnostic  Symptoms  of  Nervous  Diseases.  By  Edward  L. 
Hunt,  M.  D.,  formerly  Instructor  in  Neurology  and  Assistant  Chief  of 
Clinic,  College  of  Physicians  and  Surgeons,  New  York.  i2mo  of  229 
pages,  illustrated.     Cloth,  $\.^o  net. 

Stiles  on  the  Nervous  System 

The  Nervous  System  and  its  Conservation.  By  Percy  G.  Stiles, 
Instructor  in  Physiology  at  Harvard  University.  i2mo  of  230  pages, 
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Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  lOO  new  and  elaborate  tables  and  many  hand- 
some illustrations.  By  W.  A.  Newman  Borland,  M.  D.  Large 
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Owen's  Treatment  of  Emergencies 

The  Treatment  of  Emergencies.  By  Hubley  R.  Owen,  M.  D., 
Surgeon  to  the  Philadelphia  General  Hospital.  i2mo  of  350  pages, 
with  249  illustrations.  Just  Issued. 

Dr.  Owen's  book  is  a  complete  treatment  of  emergencies.  It  gives  you  not 
only  the  actical  technic  of  the  procedures,  but,  what  is  equally  important,  the  un- 
derlying principles  of  the  treatments,  and  the  reason  wJiy  a  particular  method  is 
advised.  You  get  treatments  of  fractures,  of  contusions,  of  wounds.  Particularly 
strong  is  the  chapter  on  giin-s-Jwt  wounds,  which  gives  the  new  treatments  that  the 
great  European  War  has  developed.  You  get  the  principles  of  hemorrhage,  to- 
gether with  its  constitutional  and  local  treatments.  You  get  chapters  on  sprains, 
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apoplexy,  exhaustion,  opium  poisoning,  uremia,  electric  shock,  bandages,  and 
a  complete  discussion  of  artificial  respiration,   including  mechanical  devices. 


DISEASES    OF   CHILDREN. 


Kerley*s  Pediatrics 

Practice  of  Pediatrics.  By  Charles  Gilmore  Kerley,  M.  D., 
Professor  of  Diseases  of  Children,  New  York  Polyclinic  Medical  School 
and  Hospital.  Octavo  of  878  pages,  illustrated.  Cloth,  ^6.00  net; 
Half  Morocco,  ;$7.50  net. 

FOURTH  LARGE  PRINTING 

This  work  is  not  a  cut-and-dried  treatise — but  the  practice  of  pediatrics,  giving 
fullest  attention  to  diagnosis  and  treatment.  The  chapters  on  the  newborn  and  its 
diseases,  the  feeding  and  growth  of  the  baby,  the  care  of  the  mother's  breasts, 
artificial  feeding,  milk  modification  and  sterilization,  diet  for  older  children — from 
a  monograph  of  125  pages.  Then  are  discussed  in  detail  every  disease  of  child- 
hood, telluig  just  what  measures  shoiild  be  instituted,  what  drugs  given,  60  valu- 
able prescriptions  being  included.  The  chapter  on  vaccina  therapy  is  right  down  to 
the  minute,  including  every  new  method  of  proved  value — with  the  exact  technic. 
There  is  an  excellent  chapter  on  Gymnastic  Therapeutics.  Another  feature  con- 
sists of  the  16 J  illustrative  cases — case  teaching  of  the  most  practical  sort. 

Dr.  A.  D.  Blackader,  McGill  University,  Montreal 

"  Dr.  Kerley  is  a  pediatrician  of  large  experience  who  thinks  for  himself  and  is  never  con- 
tent to  accept,  without  testing,  the  experiences  or  statements  of  previous  writers.  His  book  has 
a  very  definite  value." 


Bandler's  The  Expectant  Mother 

Just  Out 

This  is  decidedly  a  book  for  the  woman  preparing  for  childbirth.  It  has 
chapters  on  menstruation,  nourishment  of  mother  during  pregnancy,  nausea, 
care  of  breasts,  examination  of  urine,  preparations  for  labor,  care  of  mother  and 
child  after  delivery,  twilight  sleep,  and  dozens  of  other  matters  of  great  interest 
to  the  expectant  mother. 

i2mo  of  213  pages,  illustrated.  By  S.  Wyllis  Bandler,  M.  D.,  Professor  of  Diseases  of  Women,  New 
York  Post-Graduate  Medical  School  and  Hospital.  Cloth,  %\.2%  net. 

Winslow's  Prevention  of  Disease 

Just  Ready 

This  book  is  a  practical  guide  for  the  layman,  giving  him  briefly  the  means 
to  avoid  the  various  diseases  described.  The  chapters  on  diet,  exercise,  tea, 
coffee,  and  alcohol  are  of  special  interest,  as  is  that  on  the  prevention  of  cancer. 
There  are  chapters  on  the  prevention  of  malaria,  colds,  constipation,  obesity, 
nervous  disorders,  tuberculosis,  etc.  The  work  is  a  record  of  twenty-five 
years'  active  practice. 

i2mo  of  348  pages,  illustrated.  By  Kenelm  Winslow,  M.  D.,  formerly  Assistant  Professor  of  Com- 
parative Therapeutics,  Harvard  University.  Cloth,  $1.75  net. 

Kerr's  Diagnostics  of  Children's  Diseases 

Dr.  Kerr's  work  is  written  absolutely  for  the  general  practitioner — to  aid  him 
in  diagnosing  disease  in  his  child  patients.  He  approaches  his  subject  as  the 
child  is  approached  in  the  sick-room.  It  is  strictly  a  clinical  work — a  first  aid 
in  the  diagnosis  of  disease  in  children. 

Octavo  of  542  pages,  illustrated.  By  Le  Grand  Kerr,  M.  D.,  Professor  of  Diseases  of  Children  in  the 
Brooklyn  Postgraduate  Medical  School.  Brooklyn.  Cloth,  $5.00  net;    Half  Morocco,  $6.50  net. 


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Hill  and  Gerstley's  Infant  Feeding  Ready  soon 

Clinical  Lectures  in  Infant  Feeding.  By  Lewis  Webb  Hill, 
M.  D.,  Alumni  Assistant  in  Pediatrics,  Harvard  Medical  School,  and 
Jesse  R.  Gerstley,  M.  D.,  Clinical  Assistant  in  Pediatrics,  North- 
western University  Medical  School.     i2mo  of  300  pages,  illustrated. 

In  these  climes  you  are  given  the  full  details  of  the  Boston  method  of  infant 
feeding  as  developed  by  Dr.  Rotch,  and  of  the  Chicago  method.  You  are  given  the 
theory,  use  in  both  normal  and  abnormal  cases,  exact  quantities  and  percentages, 
and  concrete  clinical  examples.  The  book  is  equivalent  to  a  postgraduate  course 
in  infant  feeding.     It  brings  these  two  systems  right  to  your  door. 

Abt's  Preparation  of  Infants'  Foods         Ready  soon 

The  Preparation  of  Infants'  Foods.  By  Isaac  A.  Abt,  M.D., 
Professor  of  Diseases  of  Children,  Northwestern  University  Medical 
School.     i2mo  of  100  pages. 

This  is  a  practical  guide  for  infant  feeding,  giving  to  young  mothers,  nurses,  and 
caretakers  minute  directions  on  the  preparation  of  food  for  infants  and  young 
children.  You  get  weights  and  measures;  the  mineral  constituents  and  caloric 
values  of  foods.  You  get  such  practical  material  as  diet-lists  for  constipation  in 
older  children,  an  outline  of  a  plan  for  feeding  babies,  care  of  nipples  and  bottles, 
etc.,  and  a  great  host  of  recipes  for  beverages  of  all  kinds,  milk  preparations,  soups 
and  broths,  puddings  and  cereal  preparations,  custards,  eggs,  vegetables,  fruits, 
meats,  sea  foods,  and  breads. 

Aikens'  Home  Nurse's  Hand-Book  ^ew  (zd/EdS 

Home  Nurse's  Hand-Book.  By  Charlotte  A.  Aikens.  i2mo  of 
303  pages,  illustrated.  Cloth,  $1.50  net. 

The  point  about  this  work  is  this :  It  tells  you  and  shows  you  just  how  to  do  those 
little  but  important  things  often  omitted  from  other  nursing  books.  "Home  Treat- 
ments" and  "Points  to  be  Remembered" — terse,  crisp  reminders — stand  out  as  par- 
ticularly practical.     Just  the  book  for  those  who  have  the  home-care  of  the  sick. 

Galbraith's  Personal  Hygiene  for  Women  '^^Edlt^n 

Personal  Hygiene  and  Physical  Training  for  Women.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  New  York  Academy  of  Medicine. 
i2mo  of  393  pages,  with  original  illustrations.  Cloth,  $2.25  net. 

"  It  contains  just  the  sort  of  information  which  is  very  greatly  needed  by  the  weaker 
sex.     Its  illustrations  are  excellent." — Dietetic  and  Hygienic  Gazette. 

Galbraith's  Four  Epochs  of  Woman's  Life  ''^^dition 

The  Four  Epochs  or  Woman's  Life.  By  Anna  M.  Galbraith, 
M.  D.  With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  Uni- 
versity of  Pennsylvania.     1 2mo  of  296  pages.  Cloth,  $1.50  net. 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public  ; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and  whole- 
some."— Birmingham  Medical  Review. 


CHILD  REX  AXD    HYGIENE 


Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Professor 
of  Pediatrics  in  the  University  of  Pennsylvania.  i2mo  of  455  pages, 
illustrated.     Cloth,  $1.50  net. 

THE  NEW  (6th)  EDITION 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  so  that  the  volume  will  be  of 
service  to  mothers  and  nurses. 

New  York  MediceJ  Journal 

"We  are  confident  if  this  Itttle  work  could  find  its  wa/  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 


Grulee's   Inf&nt  Feeding 

Infant  Feeding.  By  Clifford  G.  Grulee,  M.  D.,  Assistant  Pro- 
fessor of  Pediatrics  at  Rush  Medical  College.  Octavo  of  3 16  pages,  illus- 
trated, including  8  in  colors.     Cloth,  $3.00  net. 

NEW  r2d)   EDITION 

Dr.  Grulee  tells  you  how  to  feed  the  infant.  He  tells  you — and  shows  by  clear 
illustrations — the  techntc  of  giving  the  child  the  breast.  Then  artificial  feeding  is 
thoughtfully  presented,  including  a  number  of  simple  formulas.  The  colored  illus- 
trations showing  the  actual  shapes  and  appearances  of  stools  are  extremely 
valuable. 


Ruhrah's   Diseases   of   Children 

A  Manual  of    Diseases  of    Children.     By  John  Ruhrah,  M.  D., 

Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 

Baltimore.      i2mo  of  552  pages,    fulh'    illustrated.     Flexible    leather, 
$2.75  net. 

FOURTH   EDITION 

In  revising  this  work  for  the  fourth  edition  Dr.  Ruhrah  has  carefully  in- 
corporated all  the  latest  knowledge  on  the  subject.  All  the  important  facts  are 
given  concisely  and  explicitly,  the  therapeutics  of  infancy  and  childhood  being 
outlined  wery  carefully  and  clearly.  There  are  also  directions  for  dosage  and 
prescribing,  and  many  useful  prescriptions  are  included. 

American  Joumed  of  the  Medical  Sciences 

"Treatment  has  been  satisfactorily  covered,  being  qukte  in  accord  with   the  best  teaching, 
yet  withal  broadly  general  and  free  from  stock  prescriptions." 


SAUNDERS'     BOOKS    ON 


Keefer*s  Military  Hygfiene 

Military    Hygiene   and   Sanitation.     By  Lieut.-Col.    Frank   R. 

Keeper,  Professor  of  Military  Hygiene,  United  States  Military  Academy, 

West  Point.      i2mo  of  305  pages,  illustrated.     Cloth,  $i.'-^o  net. 

ILLUSTRATED 

This  is  a  concise,  though  complete  text-book  on  this  subject,  containing 
chapters  on  the  care  of  troops,  recruits  and  recruiting,  personal  hygiene,  physical 
training,  preventable  diseases,  clothing,  equipment,  water-supply,  foods  and  their 
preparation,  hvgiene  and  sanitation  of  posts  and  barracks,  the  troopship,  hygiene 
and  sanitation  of  marches,  camps,  and  battlefields,  disposal  of  wastes,  tropical  and 
arctic  ser\dce,  venereal  diseases,  alcohol  and  other  narcotics,  and  a  glossary. 

Bergey*s   Hygiene 

The  Principles  of  Hygiene;  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  531  pages,  illustrated.  Cloth,  $3.00  net. 

FIFTH   EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  fifth  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  MediceJ  Journal 

■'  It  %vill  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 

Pyle*s  Personal  Hygiene  The  New  (6th}  Edition 

A  Manual  of  Personal  Hygiene  :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  541  pages,  fully  illustrated.  Cloth,  $1.50  net. 

The  book  has  been  thoroughly  re\'ised  for  this  new  edition,  and  a  new  chapter  on 
Food  Adulteration  by  Dr.  Harvey  W.  Wiley  added.  There  are  important  chapters 
on  Domestic  Hygiene  and  Home  Gymnastics,  Hydrotherapy,  Mechanotherapy,  and 
First  Aid  Measures. 

"The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge." — Boston  Medical  and  Surgical  Journal. 


LEGAL   MEDICINE 


Bohm  and  Painter's  Massage 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  Germany.  Edited,  with  an 
Introduction,  by  Charles  F.  Painter,  M,  D.,  Professor  of  Orthopedic  Sur- 
gery at  Tufts  College  Medical  School,  Boston.  Octavo  of  91  pages,  with  97 
;7raf//ir«/ illustrations.  Cloth,  )?i.75  net. 

Draper's  Legal  Medicine 

A  Text-Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper,  A.  M., 
M.  D.,  Late  Professor  of  Legal  Medicine  in  Harvard  University,  Boston. 
Octavo  of  573  pages,  illustrated.      Cloth,  ^4.00  net  ;  Half  Morocco,  ^5.50  net, 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.      By   Dr.   Ed. 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey,  M.  D., 
Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York.  With  71  colored 
illustrations  on  40  plates,  143  text  illustrations,  and  549  pages  of  text.  Cloth, 
$4.00  net.      hi  Saunders'  Hand- Atlas  Series, 

Hofmann   and   Peterson's   Legal   Medicine      Hand-Atiies 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited  by  Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates  and  193  half-tone  illustrations.      Cloth,  $3.50  net. 

Jakob  and  Fisher's  Nervous  System  ^^'JSiSi 

Atlas  and   Epitome  of  the  Nervous   System  and  its  Diseases.      By 

Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  Ed- 
ward D.  Fisher,  M.  D.,  University  and  Bellevue  Hospital  Medical  College. 
With  83  plates  and  copious  text.      Cloth,  $3.50  net. 

Spear's  Nervous  Diseases  J«st  out 

A  Manual  of  Nervous  Diseases.  By  Irving  J.  Spear,  M.  D,.  Professor 
of  Neurology  at  the  University  of  Maryland,  Baltimore.  i2mo  of  660  pages- 
illustrated.  Cloth,  $2.75  net. 

This  is  a  comprehensive  digest,  supptying  the  means  to  a  clear  understanding  of 
neurology,  and  robbing  that  subject  of  much  of  its  difficulty.  You  are  given,  first, 
a  brief  description  of  the  practical  anatomy  and  physiology,  with  those  facts  and 
theories  that  bear  on  the  mechanism  of  organic  nervous  diseases.  Then  pathologj' 
is  given,  the  simpler  diseases  being  considered  first,  gradually  preparing  the  reader 
to  grasp  the  more  difficult  ones.  The  descriptions  are  clear  and  brief,  diferential 
diagnoses  and  treatments  being  brought  out  verj'  definitely.  Only  the  most  recent 
accepted  facts  have  been  considered.  For  the  treatments  recommended,  no  special 
apparatus  is  required  beyond  a  galvanic  and  faradic  battery;  they  demand  no 
special  training,  and  they  are  easily  remembered. 


SAUiYDERS'   BOOKS  ON  CHILDREN. 


American  Pocket  Dictionary  New  (9th)  Edition 

American  Pocket  ^Medical  Dictionary.  Edited  by  W.  A.  New- 
man Borland,  ]\I.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
Avords  used  in  medicine  and  kindred  sciences,  with  75  extensive  tables. 
With  693  pages.  Flexible  leather,  with  gold  edges,  Si. 25  net;  with 
patent  thum.b  index,  Si. 50  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  ^^^^"^  ^*^'**°" 

Immediate  Care  of  the  Injured.  By  Albert  S.  Morrow,  M.  D., 
Adjunct  Professor  of  Surgery  at  the  New  York  Polyclinic.  Octavo  of  360 
pages,  with  242  illustrations.      Cloth,  S2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practicaJ  book  for  every 
dav  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.    Physicians  and  nurses  will  find  it  indispensible. 

Powell's  Diseases  of  Children  Third  Edition.  Revised 

Essentials  of  the  Diseases  of  Children.  By  William  M.  Powell, 
M.  D.  Revised  by  Alfred  Hand,  Jr.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.25  net.  //;  Saunders^ 
Question-  Compend  Series. 

Shaw  on  Nervous  Diseases  and  Insanity        Fifth  Edition 

Essentials  of  Nervous  Diseases  and  Insanity  :  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  ^1.25  net.  In  Saunders''  Question- Com- 
pend Series. 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted.' 
— Boston  Medical  and  Surgical  Joiirnal. 

Brady's  Personal  Health  just  out 

Personal  Health:  A  Doctor  Book  for  Discriminating  People.  By 
Willia:\i  Brady,  M.D.,  Elmira,  X.  Y.  i2mo  of  406  pages.  Cloth,  Si -50  net. 

Hecker,  Trumpp,  and  Abt  on  Children 

Atlas  .and  Epitome  of  Diseases  of  Children.  By  Dr.  R.  Hecker 
and  Dr.  J.  TRUiLPP,  of  Munich.  Edited,  with  additions,  by  Isaac  A. 
Abt,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 
of  text.     Cloth,  $5.00  net. 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  chnics.  and 
have  been  selected  with  great  care,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor.  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 


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